The effect of different virtual reality-based exercise trainings on pulmonary function, respiratory and peripheral muscle strength, functional capacity and balance in children with bronchiectasis

Bronchiectasis is a chronic lung disease that is characterized by irreversible dilatation and destruction of one or more bronchi due to the damage caused by chronic inflammation and infection in the bronchial walls. Bronchiectasis, which has a widespread prevalence especially in developing countries with low socioeconomic status; It is an important risk factor for mortality in its severe forms and late stages. Permanent obstruction of the airways by impaired gas exchange mechanism and secretion; It causes losses in respiratory function, respiratory and peripheral muscle strength and functional capacity. In addition, balance as an extrapulmonary symptom is a current research topic that needs to be investigated in chronic respiratory diseases. Guidelines for the treatment and management of the disease emphasize the importance of airway clearance techniques and exercise training. In the literature, it is stated that patient compliance and participation are the main factors in determining the effectiveness of an exercise program, but poor patient compliance and low participation rate are reported as common problems encountered in patients with bronchiectasis. Video game-based virtual reality applications, which are increasingly used in chronic respiratory system patients, are defined as an alternative and innovative physiotherapy and rehabilitation approach; It is stated as an effective and useful method as it increases the motivation, interest, exercise compliance and active participation of patients. Despite its known benefits, there are limited studies examining the effects of virtual reality-based exercise training in patients with bronchiectasis. For this reason, we planned this study to investigate the effects of different virtual reality-based exercise trainings on respiratory function, respiratory and peripheral muscle strength, functional capacity and balance. Thirty-nine pediatric patients with bronchiectasis aged 8-18 years were randomly divided into 3 groups as the control group (Group 1), the "Wii Fit" exercise group (Group 2) and the "Breathing Games" exercise group (Group 3). Pulmonary function test (PFT), respiratory and peripheral muscle strentgth assessments, 6-min walk test (6MWT) and, postural stability, limits of stability and sensory integration of balance tests in Biodex Balance System® (BBS) were applied to all patients. A home-based chest physiotherapy program including diaphragmatic breathing exercise, thoracic expansion exercises, incentive spirometer, oscillatory positive pressure device, postural drainage and percussion, techniques for improving the effectiveness of cough and physical activity counselling was given to the all patients in all three groups to be repeated twice a day, five days a week for 8 weeks. In addition to the home-based chest physiotherapy program; the patients in Group 2 were included in the "Wii Fit" exercise program consisting of aerobic exercises supervised by a physiotherapist, 2 days a week for 8 weeks. In addition to the home-based chest physiotherapy program; the patients in Group 3 were included in the "Breathing Games" exercise program consisting of breathing exercises supervised by a physiotherapist, 2 days a week for 8 weeks. All assessments were repeated at the end of the eighth week. IBM SPSS v.26 program was used for data analysis. The normality of the data were analyzed using the Shapiro-Wilk test. The Paired Sample T-test was used for data which were normally distributed and the Wilcoxon test was used for data which were not normally distributed. The One Way Anova test was used to compare data between groups which were normally distributed, and Tukey HSD test was used as a post hoc test to determine between which groups the difference was for variables with significant difference. The Kruskal Wallis test was used to compare data between groups which were not normally distributed. The Mann Whitney U test was used as two comparisons for three groups to determine between which groups the variables found to be significantly different in nonparametric tests. The significance level for all statistical tests was set at p<0.05. After eight weeks of training, statistically significant improvement was obtained in Group 1 in both measured and percent predictive values of all PFT parameters, maximum inspiratory and expiratory pressure (MIP and MEP) values, and 6MWT distance compared to pre-treatment values (p<0.05). In Group 2, a statistically significant improvement was obtained in the values of both measured and percent predictive values of all PFT parameters, MIP and MEP values, right and left M. Quadriceps and M. Biceps muscle strength, dominant and non-dominant side grip strength, 6MWT distance and values of all the postural stability test and the stability limits test and the sensory integration test of BBS parameters compared to pre-treatment values (p<0.05). In Group 3, a statistically significant improvement was obtained in the values of both actual and % predictive values of all PFT parameters, MIP and MEP values, 6MWT distance and values of all the postural stability test and the stability limits test and the sensory integration test of BBS parameters compared to pre-treatment values (p<0.05). When the post-treatment changes between Group 1 and Group 2 were compared; in % predictive values of forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), and forced expiratory flow 25-75% (FEF25-75) parameters of PFT, MEP value, all parameters of peripheral muscle strength, 6MWT distance and all parameters of BBS tests, the changes in Group 2 compared to Group 1 was statistically significant (p<0.05). When the post-treatment changes between Group 1 and Group 3 were compared; in % predictive values of FVC, FEV1, PEF and FEF25-75 parameters of PFT, MIP and MEP values, all parameters of postural stability test and sensory integration test, and all parameters of stability limits test except "left", "right" and "forward/left" values of BBS tests, the changes in Group 3 compared to Group 1 was statistically significant (p<0.05). When the post-treatment changes between Group 2 and Group 3 were compared; in all parameters of peripheral muscle strength and 6MWT distance, the changes in Group 2 compared to Group 3 was statistically significant (p<0.05). In conclusion, our study showed that virtual reality-based exercise approaches provide similar improvements with traditional exercise approaches in pediatric patients with bronchiectasis. Game-based virtual reality applications, especially in pediatric patients; it was showed that it is an approach that can be preferred because it ensures that the exercises are carried out in a goal-oriented, high motivation and entertaining way with full participation. In addition, according to the results of our study; virtual reality-based aerobic exercise training is a preferable approach for providing additional benefit to the development of functional capacity and peripheral muscle strength and also virtual reality-based breathing exercise training is a preferable approach for providing additional benefit to the development of respiratory muscle strength.