Virtual Reality–Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

Background Virtual reality–based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent. Objective We aimed to review the application of VRER in patients with CRDs. Methods This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety. Results We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event. Conclusions We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.


Introduction
VR is a technology that integrates visual and auditory stimuli through devices such as head-mounted displays, virtual headsets, and virtual glasses.While wearing a VR device, users can interact with the virtual environment through hand controllers and expanded usage of in health care in recent years and continues to be investigated.
Cancer-related dysfunctions (CRDs), caused by cancer and related treatments, showed significantly reduce the quality of life of patients and increase the economic burden on the healthcare system.Exercise rehabilitation, including aerobic, resistance, flexibility, and neuromuscular training, has been shown effective in improving CRDs VR is a broad concept with many different types of interventions can be developed.
Based on this reason, virtual reality-based exercise rehabilitation (VRER) was reported.VRER is a promising intervention that combines virtual reality (VR) and exercise rehabilitation.Studies have suggested that VRER effectively improves dysfunctions in patients with Parkinson's disease, stroke, and cardiovascular disease Unfortunately, little research has been carried out on the application of VRER in patients with cancer, and the results of the available research have been inconsistent patients.

Objective
We conducted a scoping review to review the application of VRER in CRDs, including 4 aspects:  The types of cancers and CRDs were studied in VRER;  Models and contents of VRER in CRDs;  The effective of VRER;  The safety, patients`compliance and satisfaction of VRER in CRDs.
We are also going to analyze the mechanism of action through which VRER caused these improvements to provide a reference for clinical oncology practices.

Research sources and strategy
We searched both English and Chinese database to catch needed studies included in this review.
 English database (n=9) PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv  Chinese database (n=4) CNKI, Wanfang Data, VIP and SinoMed Reference lists were also select to explore the further studies of interest.
Taking the form of a combination of Medical Subject Healings (MeSH) terms and free words to build our strategy, so as to make strategy perfect and optimized.Two researchers (Su and Guan) independently constructed the search terms based on the PICOS framework and previous research.If the opinions differed, the search terms were decided by another professor.
The search terms used of all database for the are presented in

Selection of studies
All search results were exported to Endnote X9, and screened and eliminated the duplication manually with it.
Study selection process started in two steps.
 First, we eliminated the irrelevant studies by reading titles and abstracts.
 Then, reading the full text of the remaining studies to determine the included studies by the same 2 researchers.

Data extraction and results synthesis
The extracted content included 4 parts.Tables 3

Results
The literature search was planned to be undertaken around September to October 2023.

Discussion
The scoping review would provide further information on the suitable type of VR device for VRER, VRER intervention methods, and the effect and patient attitudes.As healthcare evolves and technology advances, electronic interventions such as VR have become increasingly popular tools to support clinical management.The chronic development of cancer drives the digitalization of dysfunction management.Since 2013, VRER has begun to develop rapidly in CRDs, and the main studies are RCTs, aiming to study its effects and safety.While the number of VRER interventions in cancer patients is gradually increasing, it is important to consider the use of VRER and the effectiveness of the intervention to guide future development.By collating current research researchers can determine how VRER is being used in intervention and the current limitations.Furthermore, the scoping review identifies promising research and current research gaps that require further investigation.

Table 3 . Summary table shell example for clinical studies (study details)
present example table shells.
f VRER: virtual reality-based exercise rehabilitation