Exergames rehabilitation program for postoperative cancer patients undergoing abdominal surgery: A quasi-experimental study

Abstract

Objectives

This study aimed to describe and test a program implemented by a nurse for cancer patients in the postoperative period of abdominal surgery using Wii Fit games. It explored the relationship between the type of game, its duration, and the score obtained with variables such as quality of life, fatigue, balance, anxiety, and depression.

Methods

A quasi-experimental project was conducted using a one-group pretest-posttest design to assess the effects of a rehabilitation program utilizing Nintendo Wii Fit. The games included were Wii Fit Aerobics - Basic Step, Wii Fit - Balance Games Penguin Slide, Wii Fit Training Plus - Birds Eye Bulls Eye, and Wii Fit - Hula Hoop. Data were collected 48 h post-surgery and on the 7th day post-surgery.

Results

Thirty-five patients participated in the study. The evaluation revealed that the scores and durations of the games had significantly related to the outcomes on the scales, with the “Wii Fit Aerobics - Basic Step” and “Wii Fit - Hula Hoop” games having the most significant impact across multiple aspects.

Conclusions

The study demonstrated that the rehabilitation program had a positive effect on the study population, administered by a rehabilitation nurse. The use of exergames may offer a viable solution to the challenges of traditional rehabilitation methods, particularly for cancer patients in the postoperative period.

Resumen

Objetivos

Este estudio tuvo como objetivo describir y probar un programa implementado por una enfermera para pacientes con cáncer en el período posoperatorio de cirugía abdominal utilizando juegos de Wii Fit. Exploró la relación entre el tipo de juego, su duración y la puntuación obtenida con variables como la calidad de vida, la fatiga, el equilibrio, la ansiedad y la depresión.

Métodos

Se llevó a cabo un proyecto cuasiexperimental utilizando un diseño de preprueba y posprueba en un solo grupo para evaluar los efectos de un programa de rehabilitación utilizando Nintendo Wii Fit. Los juegos incluidos fueron Wii Fit Aerobics - Basic Step, Wii Fit - Balance Games Penguin Slide, Wii Fit Training Plus - Birds Eye Bulls Eye y Wii Fit - Hula Hoop. Los datos se recopilaron 48 horas después de la cirugía y el séptimo día después de la cirugía.

Resultados

Treinta y cinco pacientes participaron en el estudio. La evaluación reveló que las puntuaciones y duraciones de los juegos estaban significativamente relacionadas con los resultados en las escalas, siendo los juegos Wii Fit Aerobics - Basic Step y Wii Fit - Hula Hoop los que tuvieron el impacto más significativo en múltiples aspectos.

Conclusiones

El estudio demostró que el programa de rehabilitación tuvo un efecto positivo en la población de estudio, administrado por una enfermera de rehabilitación. El uso de exergames puede ofrecer una solución viable a los desafíos de los métodos de rehabilitación tradicionales, particularmente para pacientes con cáncer en el período posoperatorio.

What is known:

• -

  The early postoperative recovery phase immediately follows surgery and is essential for promoting post-surgical rehabilitation.

What it contributes:

• -

  Exergames may be an effective solution for overcoming the challenges of traditional rehabilitation methods, especially for cancer patients.

• -

  Games such as Wii Fit Aerobics, Balance Games, Training Plus, and Hula Hoop have been utilized, illustrating that games can be integrated into rehabilitation programs.

Introduction

Exergames are electronic games that require physical interaction from the user and involve movements. They are performed in connection with a device (console) equipped with sensors that capture the user's movements and render them in a virtual context.¹ Currently, several motion-based electronic gaming consoles are commercially available, such as the Nintendo Wii®, the Sony PlayStation® 3 Move, the Sony PlayStation® 2 EyeToy, the Xbox 360 Kinect®, and the XaviX.² These features are characterized by a combination of exercise and motion.^3,4

Exergames gained more prominence with the release of the Nintendo Wii console in 2006.⁵ These significant advancements in gaming technology, such as the introduction of the Nintendo Wii's balance board in 2008 and the Microsoft Kinect camera in 2010, led to a new way of controlling and playing games. This new approach involves standing up and moving one's body to control an avatar displayed on a television screen and was termed ‘exergaming’.⁶ The Wii Balance Board, a platform with four force transducers that capture weight distribution information as the player moves, enables games that involve balance and specific movements.^7,8 Additionally, the Wii itself features a wireless pointing device with built-in sensors that detect changes in direction, speed, and acceleration in three dimensions, making the games more interactive and enjoyable.⁵

This type of device has proven to be a useful tool in the rehabilitation of various pathologies, particularly in cancer patients.^9–13 However, as of the date of this publication, its use in the postoperative rehabilitation of major abdominal surgery remains unknown. In the rehabilitation of oncology patients, the focus should be on improving their quality of life and helping them return as closely as possible to the life they were accustomed to before the illness.¹⁴ In this context, it is also noted that participants experienced a reduction in negative emotions such as stress and felt more relaxed and had an improved mood state after the intervention.¹³ The use of exergames facilitates the development of personalized rehabilitation programs, which is crucial in the context of nursing and early rehabilitation. This approach allows rehabilitation professionals to effectively use exergames to meet the specific needs of cancer survivors, for example, by promoting recovery and improving quality of life immediately after treatment.⁹ Evidence supports that Wii exergames are a safe and feasible tool, demonstrating that they can be used by nursing in rehabilitation programs.^2–4,9 Nursing can utilize these resources to implement and promote targeted exercise programs, helping cancer patients manage symptoms such as fatigue, pain, insomnia, and dyspnea, which are common among oncology patients.^15–17 In addition to improving the quality of life of these patients, such programs can be essential in preventing the worsening of existing conditions and reducing the incidence of new complications.¹⁶

Strategies should be employed to reduce the numerous potential postoperative complications, especially in the oncological context.¹⁵ Patients undergoing abdominal surgery for solid tumors often develop postoperative complications that can negatively impact their quality of life and survival.¹⁶ This is because, in addition to the clinical condition necessitating surgery, cancer patients may have pre-existing complications resulting from the progression of the disease and the various treatments they undergo, leading to numerous associated symptoms.^17,18

The first phase, or early postoperative recovery phase, encompasses the initial 7 days following surgery, during which promoting post-surgical recovery is crucial.¹¹ Lack of motivation and emotional impact are the primary limitations for participation in rehabilitation programs.¹⁹ It is in this context that exergames can assume significant relevance. It is no surprise that Wii Fit has garnered a lot of attention among healthcare professionals for its use in rehabilitation, included for nurse rehabilitation. The specificities of Wii Fit games, combined with the technical features of the Wii Balance Board, tend to promote medio-lateral and antero-posterior movements, resembling exercises commonly used in rehabilitation programs.²⁰

Given the absence of previous studies directly addressing the integration of exergames in nurse-led rehabilitation for this specific population—postoperative abdominal cancer patients—this study represents a new and significant contribution to the field. Furthermore, the programs presented in existing studies do not discuss the type of game used or its effectiveness.

Recognizing the potential of these resources, we have developed a rehabilitation program for patients following abdominal oncological surgery, utilizing Wii Fit games with the Wii Balance Board. This study aims to describe and test a rehabilitation program using Wii Fit games, correlating the type of game, duration, and score achieved with variables such as quality of life, fatigue, balance, anxiety, and depression. To explore this further, the research question formulated is: For cancer survivors participating in a rehabilitation program (Population), how does the type of Wii Fit game, duration of gameplay, and score achieved (Intervention) correlate with improvements in quality of life, fatigue, balance, anxiety, and depression (Outcomes)?

Methods

Design

We conducted a quasi-experimental project with a One-Group Pretest-Posttest Design to assess the effects of a rehabilitation program using an exergame. This study was conducted at a Northern Portugal Oncology Hospital within two surgery departments. CONSORT for pilot and feasibility trials was followed to guide the reporting of results.²¹ This study followed an intervention group undergoing a specific rehabilitation intervention program using exergames in the postoperative period, spanning 7 days (Fig. 1).

Figure 1.

Study design.

Participants

The study was conducted in two Oncology surgery departments. Patients undergoing major abdominal surgery were recruited between January 2023 and May 2023. The following inclusion criteria were considered for patient recruitment: individuals with scheduled abdominal surgery and an expected hospital stay starting the day before surgery, who were conscious and oriented in time and space, and who agreed to participate in the study with informed consent. Participants with the following criteria were excluded: those with cognitive deficits, motor deficits, severe visual impairment, patients clinically not indicated for lifting or mobilization, patients requiring admission to the Intensive Care Unit (ICU) or Intermediate Care Unit (IMCU), and patients undergoing abdominal surgery for diagnostic/staging purposes. Randomization took place on patient admission, including only patients admitted on odd-numbered days. Participant selection in this study was conducted through a rigorous randomization process to minimize the risk of bias. A diverse sample of patients was chosen based on age, pathology, treatment, and the presence of metastases, thus reflecting the typical heterogeneity of the patient population in real-world conditions. This strategy ensures that the influence of confounding variables is controlled and evenly distributed.

Participants’ characteristics

In total, 35 participants completed the pre- and post-intervention survey, while 3 patients declined to participate and 2 experienced complications that required a return to the operating room. Regarding sociodemographic characteristics, most individuals were male (n = 25), with ages ranging from 30 to 78 years (mean = 63.1). The admission diagnoses were as follows: 57.1% (n = 20) had intestinal neoplasms, 34% (n = 12) had gastric neoplasms, and 8.6% (n = 3) had other types of cancer. The majority did not have metastatic disease (82.9%, n = 29), and only 11 patients had undergone chemotherapy, with 6 patients receiving radiation therapy. On average, patients were hospitalized for 7.7 days, with a minimum stay of 7 days and a maximum of 21 days.

Intervention

Participants underwent the intervention and were monitored over a period of 7 days. For the intervention group, the Nintendo Wii® was utilized, involving the selection of 4 games (Wii Fit Aerobics - Basic Step, Wii Fit – Balance Games Penguin Slide, Wii Fit Super Hula Hoop, and Wii Fit Training Plus – Birds Eye Bulls Eye). In each session, patients completed all 4 games. On the 2nd and 3rd postoperative days, the total intervention time was 15 min, on the 4th and 5th postoperative days, it was extended to 20 min, and on the 6th and 7th days, it was further increased to 30 min. The 2nd and 7th postoperative days were used as cutoff points based on clinical practice and historical data. The 2nd day was chosen because all patients undergo postoperative mobilization on this day, marking an essential step in their recovery. The 7th day was selected based on a prior analysis of hospital records, which showed that the average length of stay for this patient population was approximately seven days.

The intervention process followed the stages outlined in Table 1. The intervention was implemented by a rehabilitation nurse in an oncological surgery unit. The rehabilitation program and the selection of specific Wii Fit games were meticulously designed based on the program's objectives, as outlined in Table 1. To ensure the effectiveness and suitability of these games for the intended rehabilitation outcomes, a pre-test was conducted with 5 patients. This preliminary testing phase allowed for adjustments and validation of the game choices to better align with the therapeutic goals.

Table 1.

Rehabilitation program.

	Rehabilitation program
	Wii Fit Aerobics - Basic Step	Wii Fit – Balance Games Penguin Slide	Wi Fit Training Plus – Birds Eye Bulls Eye	Wii Fit - Hula Hoop
	Game 1	Game 2	Game 3	Game 4
Game	The player performs rhythmic movements resembling climbing up and down stairs coordinated on the Balance Board.	The player has to fish for fish on an ice platform using lateral body movements to balance the penguin.	The player controls a bird that makes flying movements to reach various platforms.	The player must keep hula hoops in motion around the waist by making circular movements.
Time	6 min (2nd and 3rd day)	3 min (2nd and 3rd day)	3 min (2nd and 3rd day)	3 min (2nd and 3rd day)
	6 min (4th and 5th day)	6 min (4th and 5th day)	5 min (4th and 5th day)	3 min (4th and 5th day)
	10 min (6th and 7th day)	6 min (6th and 7th day)	8 min (6th and 7th day)	6 min (6th and 7th day)
Objectives	- Increased muscular strength	- Maintaining proper body posture.	- Active mobilization of the upper limbs.	- Increased muscular strength
	- Improved balance	- Control, coordination, and balance.	- Control, coordination, and balance.	- Improved balance
	- Awareness of breath	- Muscular strengthening of the lower limbs.	- Reduction of pulmonary complications (atelectasis, pneumonia, respiratory failure, pulmonary thromboembolism).	- Minimizing the effects of immobility on the cardiovascular and musculoskeletal systems
	- Minimization of the effects of cardiovascular and musculoskeletal immobility			- Greater mobility of the abdominal and thoracic walls.
	- Enhanced abdominal wall mobility

Study outcomes

The instrument was structured into two distinct parts. The first part pertained to sociodemographic and clinical characterization, while the second part involved the use of various scales: quality of life (WHOQOL Bref Scale), depression and anxiety (HADS scale), balance (Berg scale), and fatigue (FAS Scale). These instruments were administered on the 2nd and 7th postoperative days.

We used the WHOQOL Bref - Quality of Life scale. The WHOQOL Bref assesses the quality of life through 26 items. It uses a Likert scale with 5 response options for each item, where the patient chooses the option that best suits them. The higher the score assigned to each item, the better the quality of life. This scale encompasses 4 domains: physical, psychological, social relationships, and environment. The scale has been validated for the Portuguese population.²²

The Hospital Anxiety and Depression Scale (HADS) was used to assess the level of anxiety and depression.²³ It is a self-report scale that asks the patient about their state of mind over the past week. It consists of 14 questions, 7 related to depression and another 7 related to anxiety. Each item is scored from 0 to 3, with a maximum possible score of 21 points for each symptom. Scores from 0 to 7 are classified as “Unlikely,” scores from 8 to 11 as “Possible” (questionable or doubtful), and scores from 12 to 21 as “Probable”.

The Fatigue Assessment Scale (FAS) was used to assess physical and psychological fatigue.²⁴ This scale consists of 10 items, with each item rated on a five-point Likert scale, where 1 corresponds to “Never” and 5 corresponds to “Always”. Higher scores indicate higher levels of fatigue.

The Berg Balance Scale was used to evaluate static, functional, and dynamic balance.²⁵ The scale comprises 14 items, with scores ranging from 0 to 4. A score of 0 indicates “unable to perform the task,” while 4 indicates “able to perform the task independently”.²⁵ These scales were completed by one of the researchers, as their completion required direct observation or access to information records. In addition to these data, the score obtained in each game and its duration were also monitored (Fig. 1).

Statistical analysis

Statistical analysis of the data was conducted using the SPSS statistical package, version 26. Initially, descriptive characteristics of the participants were presented using frequencies, percentages, means, and standard deviations. Homogeneity tests for the variables studied were conducted, and the Shapiro-Wilk test was applied to verify the normal distribution of the quantitative data. All data were described as mean ± standard deviation (SD). In cases of non-normal distributions, non-parametric tests were used to analyze differences in means.

To assess the efficacy of the exergames, intragroup comparisons before and after the intervention were made using the Wilcoxon test for paired data, due to the non-normal distribution of the data. Additionally, a regression model was established to evaluate potential relationships between scores of different scales and the duration or score of each game. In this model, the dependent variable is the score of each scale and the independent variables are the duration or score of the four games used in the study. Statistical tests were considered significant at the 95% level (P < .05), for both parametric and non-parametric analyses.

Ethics statement

This study was approved by the ethics committee (Code: CES. 171/022). Additionally, written approval was obtained from the institution's board of directors and the Data Protection Commission. All participants were thoroughly informed about the research before obtaining their informed consent. Written informed consent was obtained from all study participants, and patient participation was voluntary. Throughout the study, confidentiality and anonymity of participants were ensured.

Results

Regarding the program's effectiveness, it was observed that from the 2nd postoperative day to the 7th postoperative day, it was effective in improving quality of life, anxiety and depression, balance, and fatigue. Through the analysis of the mean total scores of the different scales—WHOQOL Breath Scale, HADS scale, Berg scale, and FAS scale—the test results were significant (P < .005).

Wii Fit games

We characterized the analysis of different games based on their scores and durations. The specific Wii Fit games analyzed included: Wii Fit Aerobics - Basic Step, Wii Fit – Penguin Slide Balance Game, Wii Fit Training Plus – Bird's-Eye Bullseye, and Wii Fit - Hula Hoop.

In the context of depression, an increase of 1 min in the duration of “Wii Fit Aerobics - Basic Step” leads to an increase of 1.902 in the average depression score. For anxiety and depression, the same 1-min increase results in a 3.756 increase in the combined score, indicating that longer game time with this game reduces both depression and anxiety. Regarding balance, a 1-min increase in the duration of “Wii Fit - Hula Hoop” results in a 0.495 increase in the average balance score. These results suggest that only “Wii Fit Aerobics - Basic Step” and “Wii Fit - Hula Hoop” influence these scales, while the scores of other scales appear independent of game duration.

For quality of life, “Wii Fit - Hula Hoop” positively impacts the psychological, physical, and social relationship domains, as well as the overall scale. An increase of 1 point in its score improves these domains. On the other hand, higher scores in “Wii Fit Aerobics - Basic Step” reduce the psychological and social relationships domains of the WHOQOL Bref scale.

In the evaluation of balance using the Berg Balance Scale, only “Wii Fit - Hula Hoop” showed significant results, with higher scores improving balance. For fatigue, “Wii Fit Aerobics - Basic Step” reduces fatigue, while “Wii Fit - Hula Hoop” increases it. Again, only these two games influence the evaluated scales.

These results suggest that “Wii Fit - Hula Hoop” is the most effective game, impacting multiple health aspects, while “Wii Fit Aerobics - Basic Step” shows mixed effects. The lack of significant relationships for “Wii Fit Balance Games - Penguin Slide” and “Wii Fit Training Plus - Bird's-Eye Bullseye” does not necessarily indicate an absence of effect. A comparison between the 2nd and 7th postoperative days highlights the overall positive impact of the program, suggesting that engagement with the games is beneficial, regardless of duration or score.

However, to detect more significant relationships between the duration and scores of the games and the scales, it may be necessary to apply the games more frequently, which means that the intervention period should be extended. Indeed, the period used may be considered short, despite observing highly significant and favorable effects.

Next, we will characterize the analysis of each of the four games based on their duration and final score (Table 2). For each game, we considered the daily average value.

Table 2.

Characterization of the duration and score of the games.

	Game 1		Game 2		Game 3		Game 4
Coefficients	Duration	Score	Duration	Score	Duration	Score	Duration	Score
Minimum	3.6	131.1	2.1	79.8	1.6	354.4	0.0	0.0
Maximum	6.3	651.4	4.3	218.7	4.6	3582.6	3.4	663.7
Mean	5.6	360.9	4.0	146.0	3.7	2135.4	2.2	275.4
Standard Deviation	0.65	120.1	0.47	30.4	0.87	703.2	1.1	201.8
Coefficient of Variation (%)	11.5	33.3	11.9	20.8	23.5	32.9	48.2	73.3

Duration

In Game 1 – The minimum duration was 3.6 min, but there were very few people with a duration of shorter than 5.7 min. Indeed, durations mostly started from this latter value, with a maximum of 6.3 min. Therefore, longer durations closer to 6 min were predominant. The average duration was 5.6 min. The prevalence of longer durations resulted in low dispersion (the coefficient of variation was only 11.5%).

In Game 2 – The minimum duration was 2.1 min, but this was a single case. Predominantly, durations started from 3.6 min, with a maximum of 4.3 min. Therefore, longer durations were predominant. The average duration was 4 min. The prevalence of longer durations resulted in low dispersion (the coefficient of variation was only 11.9%).

In Game 3 – The minimum duration was 1.6 min, but only two cases exist. Indeed, durations above 3.5 min predominate, with a notable range between 3.6 and 4.4 min. Some durations also exceeded the latter, with a maximum of 4.6 min. The average duration was 3.7 min. Despite the prevalence of longer durations, the presence of a few shorter durations led to a somewhat low dispersion (the coefficient of variation was 23.5%).

In Game 4 – The minimum duration was 0 min, but this was a single case. Although there was a considerable number of durations up to 1.2 min, the vast majority fell within the range of 2.2–3.4 min, which was the maximum duration. Therefore, longer durations predominated, with a notable concentration in the 2.7–3-min range. The average duration was 2.2 min. Despite the prevalence of longer durations, the presence of a few much shorter durations led to a somewhat high dispersion (the coefficient of variation was 48.2%).

Score

In Game 1 – The minimum score was 131.1, but only three people had a score lower than 200. Scores predominantly fell in the range from just over 200 to around 500, with values between just over 400 and around 500 standing out. On the contrary, few scores were above 500, with the maximum being 651.4. Therefore, moderate and high scores were predominant. The average score was 360.9. Despite the prevalence of moderate (central) scores, the presence of both low and high scores led to moderate dispersion (the coefficient of variation was 33.3%).

In Game 2 – The minimum score was 79.8, but only two scores were below 104. There was a substantial increase in the number of people as the score rose up to 160, after which there were gradual declines in the number of participants, with the maximum score being 218.7. Consequently, scores between 120.5 and 160 predominated, but the number of scores below or above this range was considerable. The average score was 146. The predominance of moderate (central) scores alongside the presence of both lower and higher values led to a somewhat low dispersion (the coefficient of variation was 20.8%).

In Game 3 – The minimum score was 354.4 (only one person), but the next score was 809. There were only a few scores below 1600, and there was a strong predominance of values between 1851 and around 3000, with only two people having higher scores. The maximum was 3582.6. Therefore, high scores predominated. The average score was 2135.4. Despite the predominance of high scores, the presence of much lower values led to moderate dispersion (the coefficient of variation was 32.9%).

In Game 4 – The minimum score was 0 (only one person), and there was a considerable number of people with very low scores (up to 45.5). The number of people gradually decreased as higher scores were considered, with the maximum being 663.7. Therefore, low and moderate scores were predominant. The average score was 275.4. The presence of both very low and high scores resulted in significant dispersion (the coefficient of variation was 73.3%).

Relationship between scales and games

We also aimed to identify potential relationships between the scores on the different scales and the duration and score of each game, as observed in Table 3.

Table 3.

Influence of the games on the scores scales: Regression results.

Scale/Subscale	Game/Duration	Effect Estimate	P-value
HADS Scale
- Subscale Depression	Game 1- Wii Fit Aerobics - Basic Step	1.902	.021
- Total Scale	Game 1- Wii Fit Aerobics - Basic Step	3.756	.024
Berg Scale
- Total Scale	Game 4- Wii Fit - Hula Hoop	0.495	.032

Scale/Subscale	Game/Score	Score	P-value
WHOQOL Bref
- Subscale Physical Domain	Game 4- Wii Fit - Hula Hoop	0.020	.047
- Subscale Psychological Domain	Game 1- Wii Fit Aerobics - Basic Step	−0.033	.046
	Game 4- Wii Fit - Hula Hoop	0.025	.012
- Subscale Social Relations Domain	Game 1- Wii Fit Aerobics - Basic Step	−0.038	.027
	Game 4- Wii Fit - Hula Hoop	0.022	.028
- Total Scale	Game 1- Wii Fit Aerobics - Basic Step	−0.027	.037
	Game 4 - Wii Fit - Hula Hoop	0.018	.021
FAS Scale
- Total Scale	Game 1- Wii Fit Aerobics - Basic Step	0.026	.014
	Game 4- Wii Fit - Hula Hoop	−0.011	.056
Berg scale
- Total Scale	Game 4- Wii Fit - Hula Hoop	0.003	.017

Non-normal data were analyzed using non-parametric tests. Intragroup efficacy was evaluated using the Wilcoxon test, and regression models assessed relationships between game performance and scale scores, with significance set at P < .05.

Duration

In the Depression dimension of the HADS scale, the only significant estimate pertains to Game 1. Similarly, for the scale in its entirety (Anxiety and Depression), the only significant estimate also relates to Game 1. Regarding the assessment of balance using the Berg scale, the only significant estimate was associated with Game 4.

Score

In the case of the WHOQOL Bref - Physical domain, the only significant estimate is related to Game 4. For WHOQOL Bref - Psychological domain, significant estimates are associated with Games 1 and 4. In the case of the psychological domain of the same scale, significant estimates are also related to Games 1 and 4. The same estimates are obtained for the domain of social relationships and for the scale, using Games 1 and 4.

For the assessment of balance using the Berg scale, the only significant estimate is linked to Game 4. Finally, through the application of the Fatigue scale (HADS), the estimates are also related to Games 1 and 4.

Discussion

The primary objective of this study was to describe and test a nurse-led rehabilitation program using Wii Fit games, specifically aiming to correlate the type of game, duration, and scores achieved with critical health variables such as quality of life, fatigue, balance, anxiety, and depression. By exploring these correlations, the study seeks to determine how specific aspects of rehabilitation with exergames can directly impact the rehabilitation outcomes for cancer survivors. Exergames may prove to be useful tools for clinical populations of varying ages and conditions, given their positive effects described in symptoms of depression, quality of life, physical and cognitive performance, and motivation.²

A distinguishing aspect of the Wii, introduced in 2006, was the inclusion of an accessory, the Wii Balance Board, a platform equipped with four force transducers that capture information related to the player's weight distribution as they move. This allows for games involving balance and specific movements to be applied, making it an excellent resource for rehabilitation programs.⁸ As these authors indicate in a review study on the use of exergames in rehabilitation protocols for various clinical populations, there is a predominance in the use of the Nintendo Wii® and its game bundles, Wii Fit® and Wii Sports®, for treatment and rehabilitation among commercially available exergames.²

There has been a high rate of acceptance of Wii games among adult cancer patients during hospitalization.^26–29 By integrating this technology into nurse-led rehabilitation programs, the study highlights the potential of exergames to make a significant impact on patient care. However, for rehabilitation protocols involving exergames to be safe and effective, it is recommended that they be validated and carefully planned to identify which types of games are used, for what purposes they are intended, and their effectiveness.

The results demonstrated that specific games, notably “Wii Fit Aerobics - Basic Step” and “Wii Fit - Hula Hoop,” had a significant impact on improving multiple health dimensions of the participants, aligning with literature that suggests benefits of exergames in rehabilitation contexts. It is also worth noting that there are no studies that describe and evaluate the use of each game, which prevented the comparison of these results.

It was observed that the program was effective in improving quality of life, anxiety and depression, balance, and fatigue. Although not specific for patients undergoing abdominal surgery, other studies involving oncological patients emphasize the effectiveness of using exergames in this population.^{2,3,6,10–13}

Previous studies have reported that the use of exergames can enhance patient motivation and offer a fun and engaging way to perform physical exercises, which is crucial for maintaining adherence to rehabilitation programs, especially in populations with physical limitations or decreased motivation, such as postoperative oncological patients.^1,2 The results of the present study corroborate these observations, suggesting that Wii Fit games can serve as a useful tool in postoperative recovery, promoting not only physical activity but also improving the emotional state of patients.^11,13

Rehabilitation is a complex and variable domain that can be facilitated through creative and motivating strategies such as exergames. The rehabilitation process can be lengthy, challenging, and monotonous, which may lead to program dropout, particularly in oncological patients who have pre-existing fatigue due to multiple treatments.^2–4 Despite the growing popularity of these resources, reflected in numerous review studies,^3–5,11 no published report discusses the development and evaluation of a rehabilitation program for patients after abdominal oncological surgery, specifically identifying which types of games are most suitable and for what purposes they are indicated. A distinctive and crucial aspect of our study, often underestimated in many publications, is the meticulous description of how the rehabilitation program was implemented. Unlike other studies that do not detail the games used, sometimes alluding only to the total duration of the sessions and the frequency of the interventions, our study provides detailed information on all these parameters for their validation. This transparency is essential to allow the replication of programs and the validation of results by other professionals and researchers, significantly contributing to the robustness and practical applicability of the findings.

Limitations

One of the main limitations of this study is the size and diversity of the sample, which consisted of only 35 participants. The limited number may not provide sufficient statistical power to detect differences in the effects of the games, which is particularly significant given the goal of validating the rehabilitation program and verifying the suitability of the selected games for this specific population. The choice of a small sample was motivated by restrictions of the clinical setting and the availability of eligible patients within the study timeline. Future studies should aim to include a larger and more pathologically specific sample to increase the reliability and applicability of the results.

Another limitation falls on the study design, which utilized a quasi-experimental design without a control group, primarily due to ethical considerations surrounding the withholding of potentially beneficial treatments from patients who otherwise could not benefit from participation. This design limits our ability to definitively attribute the observed improvements in patient outcomes directly to the exergame intervention. Thus, future research is proposed with this integration.

Another limitation lies in the fact that the suitability of the specific games chosen for the program focused mainly on quantitative outcomes and did not deeply explore the subjective experience of the patients with the games. While this approach provides objective and measurable data to support the effectiveness of the intervention, it overlooks qualitative aspects that could inform about patient engagement and satisfaction.

Conclusion

Based on the findings, it was demonstrated that exergames are a viable rehabilitation tool for patients following major abdominal oncological surgery, to be implemented by a rehabilitation nurse. It was observed that the designed rehabilitation program was effective in improving the quality of life, reducing anxiety and depression, enhancing balance, and decreasing fatigue by the 7th day post-surgery. Particularly, games 1 (“Wii Fit Aerobics - Basic Step”) and 4 (“Wii Fit - Hula Hoop”) were found to have the most significant impact, influencing multiple outcome measures such as anxiety, depression, and balance. As the objective of this study, it was also possible to analyze the different Wii Fit® games used in the program and their durations, observing how these factors related to changes in the evaluated variables. However, the study acknowledges the need for further research with larger samples and longer intervention periods that can provide deeper insights.

CRediT authorship contribution statement

All authors have agreed on the final version of the article and have met at least one of the criteria: contributions to conception, data collection, analysis, and interpretation, and drafting the article or critically revising.

Funding information

This study has not received any funding.