The feasibility, acceptability and outcomes of exergaming among individuals with cancer: a systematic review

Cancer is the second leading cause of deaths worldwide, with 8.8 million cancer-related deaths in 2015 alone [1, 2]. Cancer patients commonly experience symptoms such as cancer-related fatigue (CRF), decreased functionality and range of motion (ROM), decreased strength, pain, insomnia and mood disturbances, leading to a decrease in quality of life (QOL), following surgery or pharmaceutical treatments [3‐7]. The American College of Sports Medicine recommend that individuals with cancer should avoid inactivity and return to normal daily activities as soon as possible if they undergo surgery, or continue daily routines and exercise if undergoing non-surgical treatments [8]. The National Comprehensive Cancer Network [9] supports this and recommends starting rehabilitation upon diagnosis, continuing up to, and following, completion of treatment.

A lack of physical activity has been associated with an increase in mortality rates [10‐12] and a higher disease recurrence [13]. Previous systematic reviews indicate that exercise interventions, consisting of aerobic and resistance training, delivered to individuals with a diagnosis of cancer significantly alleviates some side-effects of surgery, including CRF, and improves exercise capacity and QOL [14‐17]. Adherence to such exercise interventions is poor (< 50% of prescribed sessions attended on occasions) [16, 18], potentially due to exercises being monotonous [19]. Current rehabilitation strategies for those with cancer advocate exercises such as stretching, ROM exercises, fine motor training, yoga, aerobic and resistance training exercises [7, 20]. In one study, supervised exercise sessions had an adherence rate of 73%, compared to only 8.7% in a home-based program [21]. Adherence to an exergaming intervention has shown to be greater than among those undergoing pulmonary rehabilitation [22] and dementia [23].

Exergaming, defined as the combination of exercise and gaming, is a relatively new intervention idea, whereby the user must use physical movements in order to interact with a game [24]. Such games can be played through hand-held controllers (Nintendo Wii), physical movement captured through video-cameras (Sony EyeToy and Microsoft Xbox Kinect) or weight-sensing platforms (Dance Dance Revolution [DDR] and Nintendo Wii Fit) [25]. Exergaming has been found to be an acceptable method for exercising among older adults [26, 27]. It has also been found to be safe [28‐30], easy to use [26] and enjoyable [26, 27]. Exergaming consoles are relatively inexpensive, with the Nintendo Wii and Microsoft Xbox Kinect currently costing less than £250 and £300, respectively. Recent systematic reviews have demonstrated the feasibility, acceptability and effectiveness of exergaming at improving balance, functionality, cognition and QOL in individuals with chronic conditions, including Parkinson’s disease (PD) [24], multiple sclerosis (MS) [31], cystic fibrosis [32] and those who have recently suffered a stroke [33]. Exergaming has also been found to be a fun and enjoyable method of physical activity, potentially increasing one’s motivation to partake in exercise programs [34]. The benefits of exergaming in other clinical populations are becoming increasingly recognised, however there is limited research assessing the feasibility, acceptability and effectiveness of exergaming interventions amongst patients with a current or previous cancer diagnosis.

To our knowledge, no systematic review has synthesised the evidence of exergaming among adults with a current or previous cancer diagnosis. It is therefore important to review the current literature to examine whether an exergaming intervention can indeed support cancer rehabilitation. It will also help to identify the best mode of intervention delivery for this clinical population, guiding future studies. The aim of this systematic review is three-fold; 1) To describe exergaming interventions applied in individuals with cancer, 2) To assess the feasibility and acceptability of an exergaming intervention delivered to adults (18+ years) with a current or previous cancer diagnosis, and 3) To explore the outcomes of such an intervention in this clinical population. Gathering such evidence in a systematic way may help to inform early exergaming interventions for individuals with cancer, within a hospital or home environment, as an alternative to standard mobilisation and exercise therapy.

The systematic review is registered with PROSPERO: CRD42017054615. The reporting of the review is consistent with PRISMA guidelines [35].

A total of 4276 articles were screened (excluding duplicates). 17 full text articles were identified and reviewed. Nine studies were excluded from the review; three didn’t involve exergaming, two weren’t available in English, in two articles the cancer patients weren’t segregated from the other participants, one was a review of the literature which wasn’t cancer specific and also didn’t involve exergaming and the final article didn’t explore the feasibility, acceptability or outcomes of an exergaming intervention (Fig. 1). Of the eight remaining studies, one intervention [44] was a continuation of a previous intervention [45] by the same authors the previous year; therefore, these two were combined so as not to allocate unfair weighting to this study.

This is the first systematic review to synthesise current evidence in order to describe exergaming interventions delivered to individuals with a current or previous diagnosis of cancer and to explore the feasibility, acceptability and outcomes of such interventions. The interventions found through this review showed great variability to one another.

Due to the variability of the interventions included, it is difficult to conclude which method of delivery would prove most advantageous. No one mode of intervention appeared to be most beneficial, although the majority used the Nintendo Wii. Almost half of the interventions were delivered within the hospital, with two delivered at home, indicating the suitability of exergaming interventions within both environments. Interventions showing significant improvements in health outcomes were delivered by an occupational therapist. The only other intervention to report an improvement was delivered by an exercise physiologist. It would appear exergaming interventions are most successful when delivered by a qualified healthcare professional or a professional with knowledge of exercise prescription. Duration and frequency of interventions varied greatly, however longer and more frequent interventions didn’t incur greater improvements. Balance, function, emotions and fatigue were the health outcomes most frequently assessed and targeted by exergaming interventions.

Exergaming interventions appear to be feasible and acceptable to individuals with cancer. It is difficult, however, to draw firm conclusions regarding its benefits due to the heterogeneity in the delivery of interventions and the outcome measures assessed within the included studies.

Adherence to interventions delivered to individuals with cancer and consisting of exercise, is relatively low [16, 18, 21] potentially due to the monotonous nature of aerobic and resistance training [50]. Numerous other factors have been shown to be associated with adherence rates among cancer patients, including, but not limited to, exercise history, fatigue levels, body mass index and level of education [51, 52]. Adherence percentages within this review [44, 45, 47, 48] were positive, with the lowest being 62%; however only one drop-out in this study wasn’t due to ill health, displaying high feasibility among those who are well, but also highlighting a challenge of delivering exercise interventions to a vulnerable group of individuals. Only one study within this review assessed the safety of the intervention using a set of criteria to grade any adverse events. No musculoskeletal or adverse events occurred [48].

Exergaming interventions have been shown to be acceptable to older adults [53], and those with chronic conditions, including PD [24], MS [54], chronic obstructive pulmonary disease (COPD) [55] and stroke [56] patients, concurring with results from the current review. Older adults [53], PD [24] and post-stroke patients [56] found the interventions to be fun and enjoyable, whilst older adults [53], PD [24] and MS patients [54] were motivated to participate. MS patients [54] showed greater intrinsic motivation through the Flow State Scale than those undertaking traditional training. Post-stroke patients [56] also found the exergaming intervention to be useful, if not better, than conventional rehabilitation, and would recommend its use to other patients. Conversely, COPD patients [55] accepted a pulmonary rehabilitation program (PRP) more than the exergaming intervention, albeit non-significantly. Barry, et al. [24] found that fast-paced and complex games caused difficulties and that games should be tailored according to the needs of the clinical population.

Exergaming has already been shown to be an effective method to increase physical activity in chronic disease populations, including PD [24], MS [31], cystic fibrosis [32] and those who have recently suffered a stroke [33], with little research assessing exergaming in a cancer population. Through this review, exergaming appears to improve several health aspects, such as balance, function, physical activity, strength, fatigue, emotions, cognition and pain among cancer patients.

Balance was shown to improve through two interventions within this review [44, 45, 49]. Fall counts and postural sway decreased in one study [49], whilst Hoffman, et al. [44, 45] found that participants’ balance self-efficacy increased. Exergaming has also been shown to improve balance among older adults [27, 53] and clinical populations, including PD [24], MS [54, 57] and post-stroke [33] patients. A study among older participants found a Wii intervention to significantly improve results of the Berg Balance Scale, between baseline and week four compared to standard care alone [27].

Function was assessed in four interventions [20, 46‐48] within this review, and was shown to improve, whether this was improved arm movements, hand grasp repetitions or functional dexterity. Exergaming interventions have been shown to have mixed results on functionality among older adults and clinical populations. Among older participants, dual-task function has been shown to improve in some studies, following a systematic review; however, many significant findings weren’t in comparison to a control group [34]. PD patients showed an increase in functionality following a variety in exergaming intervention, through a variety of tests as shown through a systematic review [24], whilst MS patients displayed mixed results, with non-significant improvements in the TUG and 25 ft walk test, and significant improvements for both the exergaming and control group during the Dynamic Gait Index [31]. PD patients’ function has shown to improve, which coincides with the findings from the current review. MS and older participants’ function meanwhile is not as conclusive.

Physical activity was assessed within two interventions in this review [44‐46]. Steps per day were shown to increase among those who partook in an exergaming intervention within this review; however, not as much as a standard exercise group. Although little research exists in exergaming interventions, standard exercise interventions have shown improvements in exercise capacity among COPD patients, potentially allowing for an improvement in physical activity [58, 59].

Exergaming interventions were shown to improve several measures of strength, assessed during three interventions [46‐48], throughout this review. One study found that despite improvements, a standard exercise group improved more than the exergaming group [46]. PD patients have shown significant improvements in their strength following an exergaming intervention [60]. These improvements were seen for both the exercise and exergaming group within the study, with no significant difference between the two. Post-stroke patients saw a significant improvement of strength following an exergaming intervention, whilst recreation therapy showed a non-significant increase [61]. This previous literature coincides with the findings from the current review. Despite improvements, it is inconclusive as to whether exergaming is more beneficial than a standard exercise intervention.

Exergaming was seen to decrease levels of fatigue in the one intervention [44, 45] where it was assessed through the current review. This finding concurs with findings of exergaming interventions among PD [62], MS [63] and COPD [64] patients, along with those who were undergoing a PRP [65].

Four interventions [26, 47‐49] in this systematic review found that exergaming had a positive impact on the emotions and cognition of cancer patients. Depression, mood and relaxation all improved following the interventions. Older participants have shown an increase in emotions and cognition following an exergaming intervention. A scoping review carried out by Klompstra, et al. [53] found that three studies reported an increase in cognitive function [66‐68], with one showing a decrease in depressive symptoms [68]. Likewise, PD [69] patients have also shown to have an improved mood, whilst COPD [55] patients have shown a significant decrease in depressive symptoms and a non-significant decrease in anxiety among the exergaming group. Changes were however less than the PRP alone, which seen significant decreases among both outcomes. The findings of the current review coincide with this previous literature.

Pain was only assessed in one intervention in this review [47], showing a slight decrease following an exergaming intervention. These findings are in keeping with other studies which have implemented exergaming, conducted in post-stroke patients [56], those having undergone a knee replacement [70] and also with UE dysfunction [71]. A systematic review also revealed that four of seven studies found significant improvements in musculoskeletal pain following exergaming interventions [72].

This systematic review is not without its limitations. The studies which were included within this review were vastly different from one another in terms of the console used, game played, the diagnosis of cancer and the outcomes assessed, which made analyses of the effects of exergaming difficult to derive, and a meta-analyses unable to be performed. Therefore no conclusion could be made on a single exergame or specific console, rather exergaming generically as a whole. Due to the relatively small number of studies included, conclusions drawn are tentative, however this review offers important insights regarding the delivery of exergaming to individuals with cancer. This review only found one study which assessed the safety of the intervention which is an important factor in determining feasibility. The safety of interventions should be considered in future studies applying exergaming interventions in a cancer population by reporting adverse events using set criteria. Other threats to internal and external validity exist within the included studies. Only one of the studies included was a randomised control trial thus conclusions on the outcomes of exergaming are taken with caution. Reviews with few or no randomised controlled trials are still valuable for inclusion within systematic reviews as they provide information regarding the feasibility of an intervention [73]. They can also prove to be of high value and of high interest to patients, healthcare professionals and stakeholders [74, 75]. The sample sizes within the studies were also relatively small, in one case with only one eligible participant. Due to this, it is difficult to draw firm conclusions from the results of the analyses due to the limited statistical power. The criteria of any cancer patients meant that a variety of cancers were researched, meaning no conclusion could be made on a specific diagnosis or disease severity. The lack of control group in many of the studies meant that it was difficult to determine whether the exergaming interventions were the cause of improvement, or whether these would have been shown following a standard exercise based regime. The inclusion criterion for this review was very broad which allowed for a range of studies to be included. In doing so, it provides a general insight into how exergaming has been used for patients with a current or previous diagnosis of cancer.

It is clear, through this review, that due to the scarcity of literature within this field, more research is required. Future research should explore common outcome variables during exergaming interventions, suitable to all cancer groups. It is also recommended that a control group, using standard exercise therapy, should be included in order to determine whether improvements are solely due to the exergaming intervention. Studies should also look to implement longer follow-ups in order to assess the feasibility, acceptability and outcomes of an exergaming intervention over a prolonged period of time.

In conclusion, the content of the interventions delivered to cancer patients show great heterogeneity, along with a wide variety of health outcomes assessed, therefore it is difficult to conclude its effectiveness. However, adherence rates and enjoyment appear greater during exergaming interventions compared to standard care, highlighting the feasibility and acceptability of this type of intervention delivery for adults with cancer.