**3. VR gamification to encourage adherence**

Gamification has already been used in other telerehab programs for improving motor movement following surgical intervention [28, 29] and have shown to improve greatly adherence.

The first version of the VR simulation was built to represent a real-world outdoor biking experience. This virtual world consisted of beautiful trees, lakes, and mountains (see **Figure 5**) that the patient could explore at their own leisure alone or with another participant represented as a virtual avatar. No gaming aspect was added to this first version. Extremely positive feedback was received toward the experience, particularly being connected with a guiding clinician during weekly sessions. However, this VR world was limited in its ability to provide entertainment to the patient, an element we believe is truly important for establishing ongoing compliance to exercise CR programs. Two new VR worlds were developed to leverage the advantages of gamification.

Game for Pediatric Cardiac Patients: A VR world was developed for a pediatric cardiac rehabilitation program with a gaming environment specifically designed to engage child users into following a rehabilitation program (see **Figure 12**). The new game was designed for children with single heart ventricles who have undergone a corrective Fontan procedure and are severely deconditioned. Because of the high intensity interval training required for those patients, the game has two modes that alternate from a rest period to high-intensity exercise period. During the rest periods, the game requires that the patient explore the virtual world and collect strange roaming animals in order to acquire points. During the high intensity exercise periods, the patient must chase an animal into a wormhole by increasing their cadence to a specific level that if reached will eventually transport the user to a new world. The game for this project was created to integrate flawlessly into an exercise program designed specifically to train individuals with this condition. Furthermore, with the other inclusive features, such as remote monitoring (ECG and SpO2), one can suggest the safety of higher exercise exertion in these children, which may convince parents to encourage more aggressive uptake of daily physical activity for their children. Exercise tolerance is strongly correlated with long term health outcomes; thus, individuals with significantly reduced capabilities such as Fontan patients, should be directed to improve their baseline exercise levels [30]. This project is of particular importance, as there is currently no cardiac rehabilitation standard protocol for pediatric patients, particular those with a history of a Fontan procedure. Thus, this project will assist in providing an evidence base for pediatric cardiac rehabilitation programs.

Virtual Spin-Class: With the great ability of Unity 3D to develop rapidly various game scenarios, a third application of MedBike was developed for encouraging exercise for mild cardiac disease and others who would benefit from exercise participation. Using the multiplayer capability of Unity 3D, a *spin-class* version of the system was developed. The game consists of numerous bikes (currently max six bikes) to be connected via the internet to a central cloud-based game engine that allows registered participants to chase moving targets, or each other, and to score points depending on their physical performance measured by wireless ECG sensors. Each participant is represented by an avatar (like **Figure 11**) that can be

**107**

program.

**Figure 12.**

*MedBike: Virtual Reality for Remote Cardiac Rehabilitation*

personalized at the beginning of the game. The virtual landscape is an island where participants must discover special targets that if collided with will cumulate points. The spin-class instructor can change the island level of difficulties by increasing the programmable bike resistance. The winner of the game will be the participant with the most points and with the best physical condition as measured by the sensors. In this version there is no clinician online. Instead, the sensor data is automatically analyzed by an advanced machine learning algorithm to determine exercise level performance and to detect from the ECG any abnormal condition that should be reported to the spin-class instructor and the participant. This version of MedBike will be deployed this summer at a local sports facility at the University of Alberta where it will be tested for usability and how it improves adherence to an exercise

*Patient virtual reality experience for the pediatric rehabilitation game. The top image is during the rest phase* 

**4. Is MedBike effective for exercise-based cardiac rehabilitation?**

In 2017–2018, we conducted a small medical pilot project to assess:

1.The feasibility to perform home-based CR exercise using the MedBike system;

**4.1 A randomized pilot feasibility study**

*and the bottom image is during the high intensity interval phase.*

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

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

#### **Figure 12.**

*Assistive and Rehabilitation Engineering*

improve greatly adherence.

age the advantages of gamification.

pediatric cardiac rehabilitation programs.

multiplayer capabilities of Unity 3D. At each patient's location, the avatars are fully animated and allow each patient to cycle and communicate with the other patients as a group. One can see at **Figure 11** a typical avatar representation. Each patient is

Gamification has already been used in other telerehab programs for improving motor movement following surgical intervention [28, 29] and have shown to

The first version of the VR simulation was built to represent a real-world outdoor biking experience. This virtual world consisted of beautiful trees, lakes, and mountains (see **Figure 5**) that the patient could explore at their own leisure alone or with another participant represented as a virtual avatar. No gaming aspect was added to this first version. Extremely positive feedback was received toward the experience, particularly being connected with a guiding clinician during weekly sessions. However, this VR world was limited in its ability to provide entertainment to the patient, an element we believe is truly important for establishing ongoing compliance to exercise CR programs. Two new VR worlds were developed to lever-

Game for Pediatric Cardiac Patients: A VR world was developed for a pediatric cardiac rehabilitation program with a gaming environment specifically designed to engage child users into following a rehabilitation program (see **Figure 12**). The new game was designed for children with single heart ventricles who have undergone a corrective Fontan procedure and are severely deconditioned. Because of the high intensity interval training required for those patients, the game has two modes that alternate from a rest period to high-intensity exercise period. During the rest periods, the game requires that the patient explore the virtual world and collect strange roaming animals in order to acquire points. During the high intensity exercise periods, the patient must chase an animal into a wormhole by increasing their cadence to a specific level that if reached will eventually transport the user to a new world. The game for this project was created to integrate flawlessly into an exercise program designed specifically to train individuals with this condition. Furthermore, with the other inclusive features, such as remote monitoring (ECG and SpO2), one can suggest the safety of higher exercise exertion in these children, which may convince parents to encourage more aggressive uptake of daily physical activity for their children. Exercise tolerance is strongly correlated with long term health outcomes; thus, individuals with significantly reduced capabilities such as Fontan patients, should be directed to improve their baseline exercise levels [30]. This project is of particular importance, as there is currently no cardiac rehabilitation standard protocol for pediatric patients, particular those with a history of a Fontan procedure. Thus, this project will assist in providing an evidence base for

Virtual Spin-Class: With the great ability of Unity 3D to develop rapidly various

game scenarios, a third application of MedBike was developed for encouraging exercise for mild cardiac disease and others who would benefit from exercise participation. Using the multiplayer capability of Unity 3D, a *spin-class* version of the system was developed. The game consists of numerous bikes (currently max six bikes) to be connected via the internet to a central cloud-based game engine that allows registered participants to chase moving targets, or each other, and to score points depending on their physical performance measured by wireless ECG sensors. Each participant is represented by an avatar (like **Figure 11**) that can be

personalized by changing the avatar's bike and cycling garment colors.

**3. VR gamification to encourage adherence**

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*Patient virtual reality experience for the pediatric rehabilitation game. The top image is during the rest phase and the bottom image is during the high intensity interval phase.*

personalized at the beginning of the game. The virtual landscape is an island where participants must discover special targets that if collided with will cumulate points. The spin-class instructor can change the island level of difficulties by increasing the programmable bike resistance. The winner of the game will be the participant with the most points and with the best physical condition as measured by the sensors. In this version there is no clinician online. Instead, the sensor data is automatically analyzed by an advanced machine learning algorithm to determine exercise level performance and to detect from the ECG any abnormal condition that should be reported to the spin-class instructor and the participant. This version of MedBike will be deployed this summer at a local sports facility at the University of Alberta where it will be tested for usability and how it improves adherence to an exercise program.
