'Exergaming' a Good Workout for Less-Active Heart Failure Patients: HF-Wii Trial

May 28, 2018

VIENNA — When patients regularly included simulated sports activities using a video-game console into their daily routine in a randomized trial, overall their self-perception of well-being improved along with functional capacity.

But not every patient with heart failure who exercised using the Wii Sports (Nintendo) gaming console reaped the benefits. Some defied expectations that high adherence would translate to bigger gains.

Those assigned to use the gaming console showed better improvements in 6-minute walk distance over 3 months compared with patients given "motivational support" to increase their activity levels. But there wasn't a strong correlation between gaming time and functional response.

That might have something to say about how an "exergaming" strategy in patients with heart failure in practice might or might not effectively complement more traditional approaches to promoting exercise, researchers speculate.

The primary finding of the HF-Wii study, reported at the European Society of Cardiology 2017 Congress, showed that patients assigned to exergaming had better 6-minute walk test (6MWT) results than the control group.

The new findings of improved self-perceived well-being as well as the unexpected relationship between exergaming adherence and functional outcomes were reported here this week at the European Society of Cardiology (ESC HF) Heart Failure 2018 by principal investigator Tiny Jaarsma, PhD, of Linköping University, Sweden.

Exergaming as done in the trial "requires rigorous physical exercise" and consists of simulated sports activities like golfing, bowling, or playing tennis by the patient, alone or with other participants, said Jaarsma during her presentation. 

Addressing those audience members who seemed unfamiliar with Wii Sports and exergaming in general, Jaarsma explained, "It's not doing a Sudoku on your phone, it is really being physically active and intended as a workout."

Experience in patients with heart failure, she said, suggests that "it increases motivation, increases activity, promotes better health behaviors, and improves exercise capacity and health."

In 2010, the American Heart Association (AHA) controversially entered a partnership with Nintendo in which the company donated $1.5 million to the organization, which for its part allowed its "heart check" emblem to be displayed on the packaging of Wii exergaming systems. The emblem was in use to identify consumer products the AHA certified as healthy lifestyle choices.

To be sure, the benefits of increased activity levels in heart failure are well recognized; often the challenges are patient engagement in and continued adherence to an exercise program. Exergaming seems to meet those challenges in various ways, Jaarsma pointed out for theheart.org | Medscape Cardiology. Most of the patients had fun playing the simulated sports, which can be done conveniently at home.

Also, exergaming can be performed alone or as a family activity, the latter of which was a big draw for some patients. "When we did a pilot study several years ago, we saw that the amount of time playing was related to having grandchildren," Jaarsma said. Their support and participation, it was thought, helped encourage the grandparents with heart failure to use the gaming device more often.

HF-Wii assigned 605 patients with heart failure to a recommendation to use the Wii Sport console for at least 30 minutes a day or to receive "motivational support only" and standard advice about exercise.

Wii consoles were provided to patients and installed in their homes for free. Patients received introductory lessons on their use and were given continued access to technical support, Jaarsma said.

There were no requirements for study entry based on NYHA functional class or left-ventricular ejection fraction. The patients were primarily in Sweden but also the Netherlands, Germany, Italy, Israel, and the United States.

Adherence to the exergaming time recommendation varied. Just over a third of patients, 34.8%, achieved more than 90% of the prescribed usage time. About half, 49.5%, fulfilled more than 60% of the exergaming prescription.

But a surprisingly large 17% of the exergaming group never used the console. They showed significantly less 6MWT improvement over 3 months compared with either the control group or those who actually used the Wii console regardless of adherence level.

Otherwise, there was no observed dose-response effect; those achieving all or nearly 100% of the recommended usage showed about as much 6MWT improvement as users with lower adherence.

"Those people who were really highly adherent, they were of course the people who had already been exercising — younger, fitter — so they could easily do 80%" of the recommended level, Jaarsma said. Put another way, she said, patients who used the Wii system the most were those with the least to gain from it.

Pointing in part to the 17% of patients in the exergaming group who didn't use the system, Christopher M. O'Connor, MD, of the Inova Heart & Vascular Institute, Falls Church, Virginia, said he'd been hoping that adherence in the trial would be "a little bit better, because adherence is the big thing with exercise."

Patients in the HF-ACTION trial adhered to their exercise protocol at about the same level that HF-Wii patients adhered to their exergaming recommendation, O'Connor told theheart.org | Medscape Cardiology. That's "curious" because in the earlier trial, "we were asking people to exercise on a treadmill 200 minutes a week for two-and-a-half years."

O'Connor isn't involved in HF-Wii but co-chaired HF-ACTION, which had randomly assigned about 2300 patients with heart failure to usual care with or without supervised exercise-training sessions plus a home-based exercise regimen. Patients in the intervention group showed dose-response relationships between exercise and functional capacity, quality of life, and 90-day survival.

If exergaming could be shown to produce gains like those seen in HF-ACTION, he said, it could be recommended as offering benefits similar to those from conventional exercise. It could then serve as one exercise option among many for individual patients, and choice itself, O'Connor said, might improve compliance.

As assigned discussant following Jaarsma's presentation, Loreena M. Hill, PhD, of Queen's University Belfast, UK, said the study "really demonstrates very positive results" and shows that the exergaming option is acceptable to patients. But it would be prudent to explore its long-term impact, she said, before exergaming should be recommended in clinical practice.

The previously reported functional benefits from exergaming in the trial included a 33-meter longer 6MWT distance (P = .002) at 3 months compared with the control group.

Table. Mean Current and Expected Well-Being Scoresa at 3 Months in HF-Wii

Endpoints Exergame Group Control Group P
Current well-being 6.6 6.2 < .05
Expected well-being 7.6 7.4 < .05
a. Cantril Ladder of Life scales ranging from 1 to 10.

In the new HF-Wii secondary analysis, patients in the exergaming group compared with controls showed significantly better responses from baseline to 3 months on Cantril Ladder of Life scales for current and expected well-being.

But there were no significant differences in responses based on the Hospital Anxiety and Depression Scale or in quality of life by the Minnesota Living With Heart Failure Questionnaire.

Jaarsma agreed that exergaming would likely serve as one exercise option among many for most patients, but it likely won't provide substantial functional gains for heart failure patients who are already active. If they walk a dog three times a week or bike for an hour, for example, "the Wii won't add to that."

Nintendo did not provide Wii systems or other support for the trial. Jaarsma and Hill have reported no relevant financial relationships. O'Connor discloses consulting fees from Novella and Amgen; ownership or partnership or being a principal in BisCardia; and research support from Otsuka, Roche Diagnostics, BG Medicine, Critical Diagnostics, Astellas, Gilead, GE Healthcare, and ResMed.

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook


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