Feasibility of a tele-game-based exercise (Tele-exergame) program to prevent deconditioning in hospitalized COVID-19 patients

Conventional face-to-face in-hospital mobility program (MP) is impractical for COVID-19 patients because of its associated risk of infection to hospital staff as well as other hospitalized patients. To address the gap, we propose a novel game-based virtually supervised (contactless) foot and ankle exercise, called Tele-Exergame, as an alternative and practical option. The primary goal of this SPiRE application is to test feasibility, acceptability, and proof of concept effectiveness of Exergame in COVID-19 patients as an alternative to conventional in-hospital MP to reduce the loss of mobility during hospitalization and decline in mental health. Exergames are digital or web-based games that use body movement to promote physical activity and generally involve strength, balance, and flexibility exercises. The tele-exergame MP, developed by our team, uses a remotely supervised and game-based approach, which helps to increase patient motivation and engagement in a cognitively demanding exercise program. For example, the Tele-Exergame MP includes foot and ankle exercise tasks with explicit augmented visual feedback (i.e., the patient's movement controls an object on the screen, thus providing real-time visual and audio feedback that is critical for motor learning). Monitoring and feedback are achieved by using wearable sensors worn on feet. Our game-based exercise includes a wide range of safe non-weight bearing exercise tasks, suitable for bedbound patients, and is inspired by an evidence-based exercise program. A popular game (flight shooter game) that could be played either while sitting or lying in bed by rapid, alternating ankle dorsiflexion and plantarflexion will be used. The motion of foot is translated into the movement of an avatar to play the game; for example, to "shoot" targets on a screen. The sensor on the foot can quantify motor and cognitive performance (e.g., slowness, weakness, exhaustion, and working memory), defined as cognitive frailty, using a validated algorithm developed by our team. Exercises are demonstrated remotely using a tele-medicine tablet, and the movement of subjects is monitored in real-time by research staff. To demonstrate the feasibility of Tele-Exergame MP, COVID-19 or PUI (persons under investigation) participants admitted to the MEDVAMC (n=60), with an anticipated length of stay at least 3 days will be recruited. Participants will be randomized (n=1:1) to either intervention (IG) or control (CG) groups. Both groups will receive standard of care. IG will additionally receive Tele-Exergame MP therapy. Tele-Exergame sessions will range from 3-10 minutes based on patient ability and completed twice daily. Primary outcomes include acceptability, deconditioning (cognitive-frailty), and mental health (e.g., depression and anxiety) assessed at baseline, at discharge, and at 1-month post-discharge. Secondary outcomes include adverse events (e.g., venous thromboembolism (VTE), falls, etc), instrumental activities of daily living, and community mobility, which will be assessed at baseline and at one-month post-hospital discharge. Our main hypotheses are H1) Tele-Exergame in hospital setting is feasible with less than 15% drop out and over 70% compliance; H2) The perceived ease of use, acceptability, and benefit is high as assessed using a validated technology acceptance model survey; H3) IG has less deconditioning and better mental health outcomes compared to CG at the time of discharge; H3) At 4 weeks post-discharge, the self-reported activity of daily living (ADL) and life space (LSA) would be higher in IG compared to CG. Impact: There is no existing contact-less in-hospital MP that is available for hospitalized COVID-19 population. If the feasibility and effectiveness of the proposed tele-exergame MP is demonstrated, it will address the current challenges for implementing in-hospital MP for COVID-19 patients and also open new avenues to deliver personalized exercise for non-COVID-19 patients with limited mobility including bedbound and hospitalized patients.