Introduction
Breast cancer is the most leading cause of malignancy
among women in the world. The survival rate of breast
cancer has increased by 20-30% in the past 5-10 years.
As a result of this increase, it is necessary to focus on the problems that the patients suffered after the surgery
or other cancer treatments.[]
Treatment approaches after breast cancer surgery are
adjuvant chemotherapy, radiotherapy, and endocrine
therapy.[] Adjuvant therapies such as chemotherapy
and endocrin therapy are effective in reducing the risk of cancer recurrence,[] but lead to impairments in physical
functions.[] Cancer and treatment-related symptoms
become a major stress factor and studies have shown
that the rate of depression is higher in patients receiving
chemotherapy.[] Depression and fatigue as a result of
the systemic effects of chemotherapy cause poor quality
of life.[] Another side effect of chemotherapy which is
commonly seen in muscles, joints, and bones.[] Postsurgical
acute pain sometimes cannot be suppressed and
turns into persistent and chronic pain, caused by infection,
seroma, and hematoma caused by surgery.[]
Multimodal therapy methods have been used to
increase range of motion (ROM) of the shoulder joint
and to achieve pain relief. Strengthening and stretching
exercises and self-mobilization techniques that started
4-6 weeks after surgery have revealed significant improvements
in pain and ROM.[] Task-oriented therapy
approaches involving repetitive multiple movement
patterns are also superior to exercises only in
patients with musculoskeletal disorders.[]
The importance of technology in the rehabilitation
field is increasing rapidly and new technologies provide
more engagement of patients in their usual care and
therapy programs.[] Virtual reality provides better
upper limb functionality at least as good results of usual
care which results in improving daily life activities.[]
Xbox 360 Kinect™ (Redmond, WA) is a virtual
reality method that can be easily adapted in clinical
practice. The most basic feature of Xbox Kinect™ is interpreting
and transmitting sound, image and depth
stream data to the interface with its microphone and
three-dimensional depth sensors. Xbox Kinect™ captures
the movements of the human body and transfers
them to the computer.[] As a product of rapidly developing
video games technologies that do not require
a controller, Xbox 360 Kinect™ contributes to the current
physiotherapy programs.[]
To the best of our knowledge, no study has been
planned to investigate the acute effects of the video basedexercise
program on the upper extremity functionality
and fatigue in patients who received chemotherapy after
breast cancer surgery. This study was planned to investigate
the acute effects of the video game-based physiotherapy
program after breast cancer surgery on upper
extremity dysfunction, pain, and fatigue.
Methods
Study Type
The study has been conducted between November 2019
and May 2020 in patients who had surgery and chemotherapy in Ministry of Health Prof. Dr. Cemil Taşçıoğlu
City Hospital Departments of Radiation Oncology and
General Surgery. This study has been approved by Acıbadem
Mehmet Ali Aydınlar University Ethics Committee
on 07.02.2019 (Number: 2019-3/15). In addition, permission
was obtained from the hospital where the study
was conducted. The participants gave their written and
verbal consent. Our study was carried out in accordance
with the 2008 Principles of the Declaration of Helsinki.
Participants
A total of 24 patients were evaluated and nine patients
who did not meet the inclusion criteria were excluded
from the study. Fifteen patients aged between 30 and
60 years who had undergone unilateral mastectomy and
completed 12 weeks after surgery were included in the
study by simple randomization. All patients were received
neoadjuvant chemotherapy. In addition, after the
surgery all patients were received at least two cycles of
chemotherapy or receiving chemotherapy and were able
to continue their usual daily life activities. The exclusion
criteria were as; complications due to the surgery,
participation in a post-surgical physiotherapy program,
neurological diseases that would affect balance and coordination,
the existence of vision problems.
Treatment
Xbox Kinect 360 video games were selected considering
the functional limitations experienced by the patients.
The selected video games were qualified to increase
the functionality of the upper extremities and
especially consisted of shoulder flexion, abduction,
internal, and external rotation movements. In line with
the literature, we chose Kinect Sports I Beach volleyball,
Bowling, Boxing, and Fruit Ninja were played. The
effectiveness of the games have been seen in another
our study where we conducted 6 weeks of video gamebased
exercise training.[] Since the patients had not
experienced video games before, they had a warm-up
and adaptation session with a different video game for
5 min. Later, the patients had a total of 30 min of video
game-based exercises under the supervision of an experienced
physiotherapist. Patients were excluded if
they felt tired to complete the exercises.
Outcome Measures
Patients were evaluated before and after a single session
video game-based exercise. The demographic and
clinical data were recorded on an information form.
Shoulder abduction muscle strength was assessed with
a hand-held dynamometer; shoulder joint ROM with a digital goniometer, pain level with visual analog scale
(VAS), the perceived fatigue level with Modified Borg
Scale and the degree of exercise pleasure with "Modified
Visual Analog Scale."
Pain Severity
Visual analog scale (VAS) was used to determine the
pain severity. Patients were asked to rate their current
pain level on a 10-cm horizontal line in which "0" indicates
no pain and "10" indicates the worst possible
pain.[,]
ROM
Shoulder joint flexion, abduction, and external rotation
ROM were assessed with a digital goniometer (Baseline
Digital Goniometer).[,] The assessments were carried
out in the supine position. All measurements were
performed 3 times, the mean value was recorded and
the same physiotherapist conducted all measurements.
Muscle Strength
The strength of shoulder abductor muscles was evaluated
with J Tech Commender Muscle Tester® (Salt Lake
City, Utah, USA) hand-held dynamometer. The patients
were asked to position their shoulder at 90° and to hold
their arms against the applied force. The strength value
was recorded as kilograms. Muscle contraction was
continued for 5 s and 30 s of rest were given to prevent
fatigue. Each measurement was repeated 3 times, the
mean value was considered for analysis.[]
The Pleasure of Exercise
The perceived pleasure of exercise was determined
with Modified VAS which is graded from 0 to 5 and
"0" indicates "disagree" and "5" indicates "completely
agree." The patients were asked to answer "Do you feel
pleasure when you are exercising?" and rate their level
of pleasure.[]
Perceived Fatigue Level
Perceived fatigue was assessed to observe the exercise
tolerance and Borg Scale was used to determine the fatigue
level. Borg Scale was ranged the fatigue with "6"
indicates none, "7-8" very very light, "9-10" very light,
"11-12" fairly light," "13-14" somewhat hard, "15-16"
hard, "17-18" very hard, and "19-20" very very hard.[]
Sample Size and Statistical Analysis
Sample size was determined based on pain severity
from a study performed by Aguirre-Carvajal et al.[]
Based on this study, t-test was used to determine the sample size. At least 13 persons were found to be necessary
for strength of 0.80 with an alpha level of 0.05.
We included 15 subjects in our study. Statistical analysis
was performed using the Statistical Package for the
Social Sciences version 21.0 software package (IBM
Corp., Armonk, NY, USA). Descriptive data were presented
as mean±standard deviation, frequency and
percentage (%). The Shapiro-Wilk test was used to
check the normality of the data.
The paired t-test was used to determine whether the
differences between pre- and post-intervention measurements
in the treatment group. P<0.05 was considered
statistically significant.
Results
Fifteen patients with a mean age of 50.12±8.79 were
included in the study. Of all participants, 46.6% were
diagnosed with the right side and 53.4% were left side
breast cancer. Breast conserving surgery and axillary
curettage were performed in 53% of the patients, while
mastectomy and axillary curettage surgery were performed
in 46% of the patients. The mean number of
lymph nodes removed was 14.3 and none of the patients
had distant tissue metastases. More half of the
patients had Stage IIB tumor. Baseline demographic
characteristics of the participants are shown in Table 1.
Table 1 Demographic variables
Comparison of the outcome measures before and
after the single session video game-based exercise
program is summarized in Table 2. There were significant
differences for shoulder joint flexion, abduction,
and external rotation ROM (p<0.05). The pain severity
significantly increased after the treatment (p>0.05)
and no difference was detected for shoulder abduction
muscle strength (p>0.05). Mean perceived fatigue was
11.13±2.69 and mean pleasure of exercise of participants
value was 4.5±0.5.
Table 2 Mean and standart deviation of outcome variables at pre- treatment and post-treatment
Discussion
This study investigated the acute effects of video gamebased
exercise program in patients who had undergone
breast cancer surgery and were receiving chemotherapy
on the upper extremity functionality pain and fatigue.
Our results showed that video game-based exercises
improved shoulder ROM and fatigue level, however,
increased pain severity. Furthermore, patients performed
the exercises without getting bored.
Virtual reality-based therapy approaches are getting
more attention in both clinical practice and researches
and studies with long follow-up periods have shown their effectiveness with strong evidence.[]
Xbox Kinect 360 has been utilized to conduct kinematic
analysis of upper extremity and to evaluate functionality
in patients with breast cancer.[] Our study has the potential to contribute evidence about acute effects
of video game-based exercises on the upper extremity
functionality in patients with breast cancer.
Due to the decrease in mortality related to breast
cancer over the years, clinicians should focus on the
short- and long-term side effects of the treatment approaches.
Especially, mobility of the shoulder joint
complex decreases between 12% and 16% in patients
who had undergone breast cancer surgery compared
to healthy individuals.[] Post-surgical exercise program
resulted in 9.72° increase in shoulder abduction
ROM in patients receiving adjuvant therapy.[] In our
study despite single-session, shoulder abduction ROM
increased with an average of 4.24°. Future studies with
longer treatment periods may show more improvement
in shoulder joint ROM.[]
Pain is the most common complication during the
post-surgical period. When the painful surgical and
chemotherapy process is handled successfully, the
chronic pain that occurs in patients will not be associated
with chemotherapy.[] Although different treatment
modalities have been used to suppress chemotherapy-
induced pain, it has been reported that virtual
reality that applied during the chemotherapy sessions is
the most effective method in coping with pain.[,]
In our study, there was a significant increase in pain severity
after video game-based exercises. We think that
the reason for this increase may be related to the application
of virtual reality not on the day which patients
receive chemotherapy drugs rather during the disturbing
chemotherapy sessions. Because the distracting effect
of the virtual reality application could not be utilized.
Furthermore, an increase in pain severity may
be caused by the design of our treatment program in
which the games were planned to move the upper extremity
in all directions and the treatment duration was 30 min. Most of the studies were planned with patients
who were in a static position in the literature.
According to the American Society of Clinical Oncology
data, shoulder muscle strength decreases after mastectomy.[] Especially, a decrease in muscle strength is
more prominent in patients receiving chemotherapy due
to the decline in the mitochondrial capacity of muscle
cells. Decreased muscle strength causes impairment
in functionality and poor quality of life. Therefore, the
most important goal in cancer treatment is to increase
muscle strength.[] In our study, no significant change
was found in shoulder abduction muscle strength. The
single-session virtual reality treatment seems not effective
in increasing muscle strength, it is necessary to
prescribe more treatment sessions to achieve this goal.
Patients' pleasure of exercise is related to the level of exercise.
Furthermore, experiencing and learning different
exercises make exercising more enjoyable.[,]
Pleasure of exercise plays a key role in encouraging
sedentary women for exercise and physical activity
diagnosed with breast cancer.[] Our patients enjoyed
when performing video game-based exercises (Average:
4.5/5). Despite the increased pain severity during
the exercises, the high rate of exercise pleasure indicates
that the patients had a high level of exercise tolerance
and exercise tolerance can be improved in this
patient group.
Schmidt et al.[] reported that the perceived fatigue
level should be between 11 and 14 according to
the Borg Scale during endurance and resistive exercises.
It was also stated that the duration of the exercises
was associated with fatigue. The perceived fatigue
level of 12 and above was defined as a medium or high
level of fatigue.[] The perceived level of fatigue during
the 30-min virtual game-based exercise program
was 11.13±2.69 which was below 12. Considering the
level of fatigue, it has been observed that the participants
were performed exercises comfortably. The exercise
program was completed without any fatigue that
would require stopping the program. Therefore, breast
cancer patients receiving adjuvant chemotherapy can
participate in a virtual game-based exercise program
and complete the exercises with pleasure.
The study is not without limitations. First, our study
did not include a control group performing usual care
or conventional physiotherapy. Second, this is a singlesession
pilot study since we did not conduct our study
with larger sample size.
This is the first study investigating the acute effects
of video game-based exercises applied to patients receiving
chemotherapy drugs with breast cancer.
Conclusion
This pilot single-session study has shown that commercially
available Xbox 360 Kinect video games can be
used to increase upper extremity functionality and to
provide high level of exercise pleasure without causing
fatigue. More studies are needed to determine the optimal
duration and frequency of this method to improve
functionality without increasing pain.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by
the Acıbadem Mehmet Ali Aydınlar University Medical Research
Ethics Committee (No: 2019-3/15, Date: 07/02/2019).
Financial Support: This study has received no financial
support.
Authorship contributions: Concept - Ö.F., Ö.Ö., S.D.,
A.A.; Design - Ö.F., Ö.Ö., S.D., A.A.; Supervision - Ö.F.,
Ö.Ö., S.D., A.A.; Funding - S.D.; Materials - S.D., A.A.; Data
collection and/or processing - Ö.F., Ö.Ö.; Data analysis and/
or interpretation - Ö.F., Ö.Ö.; Literature search - Ö.F., Ö.Ö.,
S.D., A.A.; Writing - Ö.F., Ö.Ö., S.D.; Critical review - Ö.F.,
Ö.Ö., S.D., A.A.
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