Therapeutic game-based exercise during hemodialysis to improve balance and mobility

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Abstract Chronic kidney disease (CKD) disproportionately impacts older adults(1). Balance, mobility, and falls are serious problems for CKD patients due to associated peripheral neuropathy and peripheral arterial disease, which also contribute to foot ulcers and other foot problems in this population. Among older adults these problems are often compounded by other comorbid conditions leaving older adults with CKD at a particularly high risk for falls (2-4). Patients with CKD require hemodialysis unless and until they can receive a liver transplant. These patients visit clinics multiple times a week and must sit or lie still for hours (~4 hours) at a time while receiving hemodialysis. This, coupled with generally low activity levels, leads to further deconditioning of the lower extremities, muscle wasting, and an increased risk of falls. Exercise interventions have been shown to improve mobility and balance, reduce the incidence of falls, and improve peripheral blood flow, which is essential to reduce foot problems and peripheral arterial disease (5-8). However, uptake of exercise programs for individuals who are undergoing hemodialysis (HD) process has been limited (9). The three main factors limiting uptake and adherence among HD patients are time availability, post- dialysis fatigue, and transportation to exercise programs, which are usually offered in rehabilitation departments or cardiovascular centers but not in nephrology departments or in free-standing dialysis clinics (9) To address the factors limiting uptake and adherence of therapeutic exercise among HD individuals we have developed a game-based exercise program (Exergame platform) that can be performed while receiving HD. The exergaming system consists of a wireless inertial sensor worn on the dorsum of each foot and a laptop computer. The sensors track 3D motion while patients move their feet (ankle joint rotations) to navigate a computer cursor to execute motor-cognitive exercise tasks. This real-time ankle/foot motion biofeedback exercises sensorimotor control. Patients do not need to be supervised during the exercise session because the exergames are computerized, low risk (patients remain seated or recumbent), and performance is tracked automatically. We have developed a prototype and tested its feasibility. In summary, 11 HD patients were randomly assigned to either the intervention group with Exergame platform (IG: n=7) or the control group without exergame platform (CG: n=4). Both groups underwent a 4 weeks lower extremities exercise program during HD sessions, twice per week for duration of 30-min. Significant improvement in gait and balance was observed in the IG group after 8 sessions of exercise compared to the baseline measurements. These preliminary results support the scientific premise and feasibility to implement exergame intervention in HD clinics. Through this STTR project we will transfer our exergame platform from Baylor College of Medicine to BioSensics LLC for further development and commercialization. In Phase I we will improve the industrial design of the sensor and evaluate the efficacy of the intervention program for hemodialysis patients in a convenience sample of 15 HD individuals. We will investigate the effects of the proposed exergaming program on gait, balance, lower extremity vascular performance, daily physical activity, and fatigue. The clinical effectiveness of the proposed platform will be further examined during Phase II based on a randomized controlled trial that will be powered based on the results of the Phase I pilot study.