MedBike: Virtual Reality for Remote Cardiac Rehabilitation

*Pierre Boulanger, William Mott, Stephanie Schaeffer, Peter W. Wood, Raj Padwal and Paolo Raggi*

### **Abstract**

Exercise-based cardiac rehabilitation (exCR) is a key element of a multidisciplinary cardiac rehabilitation program towards the care of patients with acute or chronic cardiac disease. Many studies have shown that patient's adherence to these programs is low despite evidence that such programs can improve outcomes and critical cardiac event reduction. New strategies to improve adherence to exCR programs are now being tested using non-hospital solutions that relies on VR gaming technologies. This paper presents such a system called MedBike which allows patients to perform an exCR program at home while being monitored in real-time by a remote clinician. The paper describes the technical aspects of the system, its pros and cons, various gamification strategies, and a recent usability study.

**Keywords:** virtual reality, haptics, telemonitoring, cardiac rehabilitation

## **1. Introduction**

Exercise-based cardiac rehabilitation (exCR) is a key component of a multidisciplinary cardiac rehabilitation program. Advances in medical and surgical cardiac treatments have improved the outcome for patients with acute or chronic cardiac diseases. In addition to those treatments, cardiac rehabilitation can provide great improvements to patient's outcome by reducing cardiovascular mortality, rehospitalization, and improving patient's quality of life [1]. Patient's adherence to these programs is low despite evidence that such programs can improve outcomes and reduce critical cardiac events. These low adherence rates have been shown to be between 15 and 30% [2–4]. A recent analysis of a large United States study (*n* = 74, 798) have shown that only 5.4% of eligible patients finished an exCR program [5]. Adherence to an exCR is critical as non-participants exhibit a 30% lower survival rate compare to patient's following a complete rehabilitation program [6].

Many factors improving the adherence to an exCR program have been identified. These factors include lack of physician endorsement, traveling distance from the patient's home to the hospital, lack of transportation, cost (e.g., parking fees), low self-motivation, poor social support, low self-esteem, fear of precipitating a cardiac event, and lack of enjoyment [4–9]. If one could improve the enjoyment of exCR activities using VR gaming technologies, one could increase program adherence as patients who have a positive view of exercise are more likely to continue [10, 11]. A recent study by Taylor et al. [12] reported that simply placing exCR in a home was not enough to improve program compliance. There are increasing interests in

exploring how VR gaming technology can improve CR participation by decentralizing the exCR process, increasing accessibility to rehabilitation, and increasing its comfort and enjoyment. This approach follows a recommendation by the American Heart Association's that internet-based techniques can be used to improve cardiac rehabilitation for both patients and healthcare providers [13].

Cardiac rehabilitation therapy is a long-term and tedious treatment. In recent years, virtual reality (VR) technologies have reduced in price and increased in visual quality and is now being used for many medical applications such as: therapies in CR [14], pain reduction [15, 16], stress reduction and skill training [17], telerehabilitation [18], and education [19]. Virtual rehabilitation applications using gaming technologies to improve interests to a rehabilitation program and the ability for a therapist to adapt a patient specific exercise program locally or remotely using the internet is currently being explored. By using VR technologies, a therapist can set a variety of controlled stimuli, monitor patients' responses during the exercise program, and offer clinical assessment and options [20, 21]. Using these VR systems, patients are immersed in a virtual environment, allowing them to perform safely physical activities [22]. Research [23] in the human physiological response to immersive VR systems was able to demonstrate that a significant increase in cycling time, distance, and caloric expenditure can be observed in healthy seniors and

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*MedBike: Virtual Reality for Remote Cardiac Rehabilitation*

performance, enjoyment, and dissociation can be found in [24].

then conclude by discussing the pros and cons of the system.

juniors using such systems. A review on how VR system can help enhance exercise

This paper describes the MedBike cardiac rehabilitation system (see **Figure 1**) which consists of a mountain bike mounted on a wirelessly controlled programmable resistance machine connected to a Unity 3D based VR game engine. Using this system patients can cycle through a virtual landscape where the bicycle resistance is modulated by the virtual world terrain and maximum/minimum forces set by a clinician. During the exercise program, the patients are monitored remotely by an exCR clinician in real-time using wireless biometric sensors (ECG, blood pressure, and pulse oximetry) and a bidirectional audio-video Internet connection. Section 2 describes the basic element of the MedBike system design specifications and implementation. Section 3 describes our current attempt to improve adherence to exCR programs through VR gamification. Section 4 describes MedBike effectiveness to improve exCR from a usability, adherence, and fitness point-of-view. We

Numerous designs for instrumented bikes have been proposed in the literature and in industry; additionally, a number of patents have also been awarded. The closest to our system, in which a VR controllable resistance system was developed for a cardio fitness application was proposed in [25, 26]. Commercial virtual reality cycling systems that use VR and instrumented bicycles have appeared on the market. The Italian company Widerun [27] offers clients to connect a normal bike to their resistance device, put on a VR headset, and cycle across a virtual terrain representing world-class cycling circuits. Their system can provide variable resistance based on the in-game environment. The overall visual quality is good but is not equal to the image quality produced by Unity 3D game engine. Their system uses a Head Mounted Displays (HMD) for immersion but as demonstrated in our lab, HMD are highly disorientating which may result in falls. Their system also does not provide free steering/breaking capabilities. The American company Zwift [28] is the one that closely resembles the VR aspects of MedBike. Contrary to our system, Zwift's worlds are static and not very engaging and cannot be modified easily for gamification. Zwift's graphics rendering suffers from many visual anomalies like aliasing and poor level of details via pop-up. Most of these commercial systems target the pro-cycling niche market focusing mainly on exercise performance and training, not medical applications. Most are them are dedicated cycling systems and cannot be easily modified for gamification. None of these systems offers patient sensor-based telemonitoring. Following numerous discussions with CR clinicians, we came up with design

*DOI: http://dx.doi.org/10.5772/intechopen.85651*

**2. MedBike system overview**

specifications for the system that are as follows:

• Privacy and data transmission integrity are critical;

• All patient's telemetry sensors should be medical grade;

• Telemetry sensors must be easy to install by the patient;

necessitate computer technical knowledge;

• VR experience does not need to be stereo or use HMDs because of concerns for

• Patient's interface must be intuitive and must be easy to use and should not

patient's balance and the loss of awareness of his/her environment;

**Figure 1.** *MedBike the VR-based telemonitored exercise cardiac rehabilitation system.*

#### *MedBike: Virtual Reality for Remote Cardiac Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.85651*

*Assistive and Rehabilitation Engineering*

exploring how VR gaming technology can improve CR participation by decentralizing the exCR process, increasing accessibility to rehabilitation, and increasing its comfort and enjoyment. This approach follows a recommendation by the American Heart Association's that internet-based techniques can be used to improve cardiac

Cardiac rehabilitation therapy is a long-term and tedious treatment. In recent years, virtual reality (VR) technologies have reduced in price and increased in visual quality and is now being used for many medical applications such as: therapies in CR [14], pain reduction [15, 16], stress reduction and skill training [17], telerehabilitation [18], and education [19]. Virtual rehabilitation applications using gaming technologies to improve interests to a rehabilitation program and the ability for a therapist to adapt a patient specific exercise program locally or remotely using the internet is currently being explored. By using VR technologies, a therapist can set a variety of controlled stimuli, monitor patients' responses during the exercise program, and offer clinical assessment and options [20, 21]. Using these VR systems, patients are immersed in a virtual environment, allowing them to perform safely physical activities [22]. Research [23] in the human physiological response to immersive VR systems was able to demonstrate that a significant increase in cycling time, distance, and caloric expenditure can be observed in healthy seniors and

rehabilitation for both patients and healthcare providers [13].

**96**

**Figure 1.**

*MedBike the VR-based telemonitored exercise cardiac rehabilitation system.*

juniors using such systems. A review on how VR system can help enhance exercise performance, enjoyment, and dissociation can be found in [24].

This paper describes the MedBike cardiac rehabilitation system (see **Figure 1**) which consists of a mountain bike mounted on a wirelessly controlled programmable resistance machine connected to a Unity 3D based VR game engine. Using this system patients can cycle through a virtual landscape where the bicycle resistance is modulated by the virtual world terrain and maximum/minimum forces set by a clinician. During the exercise program, the patients are monitored remotely by an exCR clinician in real-time using wireless biometric sensors (ECG, blood pressure, and pulse oximetry) and a bidirectional audio-video Internet connection. Section 2 describes the basic element of the MedBike system design specifications and implementation. Section 3 describes our current attempt to improve adherence to exCR programs through VR gamification. Section 4 describes MedBike effectiveness to improve exCR from a usability, adherence, and fitness point-of-view. We then conclude by discussing the pros and cons of the system.
