Revolution in Cancer Rehabilitation – Innovative Treatment Methods with Virtual Reality

The side effects caused by cancer and its treatments, such as pain, anxiety, nausea, or neuropathy, make it difficult for patients to carry out daily activities and planned exercises. These side effects lower the quality of life for patients and can lead to inactivity and muscle loss.

Cancer rehabilitation (oncological rehabilitation) is a process aimed at improving the physical, psychological, and social well-being of patients undergoing cancer treatment. This rehabilitation is crucial for enhancing the quality of life, minimizing side effects, and enabling patients to continue their daily activities more comfortably during and after treatment.

With the advancement of technology, we are now better equipped to minimize the side effects that may occur during cancer rehabilitation. One such technological advancement is virtual reality (VR).

In recent years, VR technology has attracted attention as an innovative approach in the field of medicine. The use of virtual reality in cancer rehabilitation offers significant potential to support patients' physical, psychological, and social recovery processes.

VR applications can help patients through virtual environments with:

• exercise,
• stress management, and
• pain control.

This technology stands out as a new and effective tool aimed at improving the quality of life for individuals undergoing cancer treatment, contributing to overcoming the challenges encountered during the treatment process. For instance, thanks to virtual environments, patients can experience a more motivating rehabilitation process by overcoming the limitations of traditional rehabilitation methods. Additionally, the interactive and personalized experiences offered by Virtual Reality can enhance treatment adherence and encourage patients to actively participate in their recovery processes. In this context, the role of VR in cancer rehabilitation will become more significant in the future and holds the potential to revolutionize healthcare services.

FDA Approval of Virtual Reality Program for Chronic Pain Treatment

The approval of the EaseVRx virtual reality program by the FDA in November 2021 for the treatment of chronic pain has garnered significant attention and proven the efficacy of virtual reality technology. EaseVRx helps reduce pain in patients with chronic low back pain by using cognitive-behavioral therapy and other behavioral methods, with clinical studies showing successful results in pain management. This approval highlights the potential of VR-based treatment methods and has led to the adoption of a new and effective approach to chronic pain treatment.

EaseVRx is also an example of gamification. This technology aims to distract users and increase adherence to treatment by offering interactive and entertaining content. Thus, the pain management and rehabilitation process becomes more bearable and motivating.

General Working Principle of VR Glasses

VR is an innovative technology that operates through a computer simulation system, allowing users to experience and perform activities in a virtual/artificial environment. Its mechanism includes sensory stimuli such as sounds, visuals, and tactile stimulation in a three-dimensional virtual world. It creates a sense of physical presence, enabling users to interact with their surroundings.

In healthcare, VR is utilized as a non-invasive method to manage symptoms and complaints associated with cancer treatment. VR systems are available as head-mounted devices (HMDs) with stereographic potential and headsets, 3D glasses, body tracking sensors, and other somatosensory devices like gloves and joysticks. This helps bridge the gap between the real and virtual worlds, providing an opportunity for interactive feedback between the user and the virtual environment.

Recently, VR has emerged as a promising technological tool to support patients undergoing cancer treatment and minimize their pain. It functions as a distracting intervention to alleviate pain, fatigue, anxiety, depression, and cognitive dysfunction by playing relaxing scenes, creating virtual interactions and feedback, engaging in task-based activities, or even combining with music therapy. VR-guided sessions can also be used for mind relaxation or meditation. VR has significant applications in physical rehabilitation to enhance functionality and promote activities of daily living.

Functional Impairments Caused by Cancer Treatment and the Importance of Exercise Rehabilitation

Studies show that cancer treatment leads to varying degrees of functional impairments, with nearly 20% of pediatric patients and over 50% of adult patients experiencing such impairments. Common functional impairments include:

• Neuropathy caused by chemotherapy,
• Sexual dysfunction,
• Cancer-related fatigue,
• Cancer-related sleep disorders,
• Cognitive dysfunction,
• Postoperative syndromes in breast cancer,
• Cardiopulmonary dysfunction.

These functional impairments significantly reduce the quality of life for patients and increase the economic burden on the healthcare system. Exercise rehabilitation, which includes aerobic resistance, flexibility, and neuromuscular training, is widely discussed as a treatment method.

Virtual Reality-Based Exercise Rehabilitation (VR-ER)

Virtual Reality-based Exercise Rehabilitation (VR-ER) is a promising initiative that combines VR and exercise rehabilitation. VR-ER uses virtual reality to create a three-dimensional environment with body tracking to provide safe and realistic scenarios. Studies have suggested that VR-ER effectively improves functional impairments resulting from various diseases. For patients with balance and coordination problems, VR technology offers virtual scenarios for gait and balance rehabilitation through multisensory VR-based exercise rehabilitation programs, adding to the benefits of physical therapy. VR-based exercises are promising in cases where traditional rehabilitation methods fall short.

VR Applications in Oncology

Various studies and articles discuss the use of virtual reality glasses in the rehabilitation of cancer patients. This technology has the potential to improve the rehabilitation experience for patients in several ways:

• Physical Rehabilitation: VR-based exercise programs are used to make rehabilitation exercises more engaging and effective. For example, VR sessions may include activities such as virtual rafting, cross-country running, and other interactive games (gamification). These exercises are usually supervised by physiotherapists to ensure safety and efficacy, helping patients increase muscle strength, balance, and overall physical endurance. Studies on patients with Chronic Obstructive Pulmonary Disease (COPD) have shown similar benefits for lung cancer rehabilitation. Studies have reported that exercise rehabilitation, such as pelvic floor muscle exercises, can improve sexual function; and an 8-week exercise rehabilitation program that includes endurance, resistance, and balance training has shown significant improvement in chemotherapy-induced neuropathy.

• Psychological Benefits: VR can help reduce anxiety and improve the overall psychological well-being of cancer patients. By offering experiences that distract from pain and stress, VR helps patients manage the psychological burden of their illness. A study conducted by Cancer Research UK investigated whether VR experiences could help reduce stress and anxiety in people undergoing cancer treatment. The results showed that VR had positive effects on participants' stress, anxiety, fatigue, and overall quality of life.

• Patient Education and Engagement: VR also allows patients to receive education about their condition and treatments. For instance, patients can visualize their lungs and understand how treatments like radiation affect their tumors. This educational aspect enables patients to be more informed and involved in their treatment processes, improving adherence and outcomes. A blog post by the Association of Community Cancer Centers (ACCC) examined how VR is used as an innovative tool in patient education, helping patients better understand their diagnoses and participate in shared decision-making processes with healthcare providers. A study published in Practical Radiation Oncology aimed to develop and evaluate the effectiveness of an affordable smartphone-based VR patient education platform. The study found that VR videos, which provided a first-person perspective of standard radiotherapy appointments, were effective in reducing patient anxiety and increasing familiarity with the treatment process.

• Pain Management: VR technology plays a significant role in pain management. It can alleviate the discomfort associated with painful treatment processes like chemotherapy and radiotherapy by reducing patients' perception of pain. VR is also used during painful medical procedures to reduce acute pain and alleviate symptoms in palliative care for terminal patients. A study published in the Journal of Clinical Medicine evaluated the effectiveness of VR in reducing anxiety and pain during colonoscopy procedures. The study found that VR was as effective as conventional sedation and significantly reduced pain in patients who did not use sedation. Additionally, VR-based patient education was effective in reducing pre-colonoscopy anxiety and improving the quality of bowel preparation.

• Overall Quality of Life: The various activities and relaxing environments provided by VR enhance the overall quality of life for patients. Patients can relieve stress, have fun in virtual environments, and maintain high morale and motivation during the treatment process.

In conclusion, VR glasses offer multifaceted benefits in cancer rehabilitation. The contributions they provide in physical, psychological, and educational areas make this technology an integral part of cancer treatment. In addition to these benefits, VR can be used to ensure correct positioning and determine treatment targets during radiotherapy, particularly for cancer types requiring radiotherapy, such as prostate and breast cancer.

Use of VR in Managing Sleep Problems Due to Cancer

Another common issue among cancer patients is sleep problems. Chemotherapy, radiotherapy, and other cancer treatments can cause side effects such as nausea, fatigue, and hormonal imbalances, disrupting sleep patterns. In addition to these, stress, anxiety, pain, and discomfort experienced by the patient also contribute to sleep problems.

There have been some studies using VR technology to manage the sleep problems of cancer patients. In one pilot trial with women having metastatic breast cancer, VR therapies were observed to improve sleep quality by reducing anxiety and depression symptoms. In this study, participants regularly used VR experiences in their home environment, and the results showed that VR was effective in symptom management.

Another study indicated that VR could be used to manage physical and emotional symptoms such as pain and stress in terminal cancer patients, thus providing a more comfortable sleep experience.

Such studies demonstrate that VR technology can potentially be a beneficial tool for managing sleep problems in cancer patients. However, it is recommended to consult healthcare professionals to gain more information on the appropriate use of this technology and create a treatment plan suitable for your individual situation.

Use of VR in Breast Cancer Patients

The use of VR in cancer treatment has been most commonly researched in breast cancer. The reason for this is the high prevalence of breast cancer and the prolonged treatment process, which necessitates substantial physical and psychological support for patients.

Rehabilitative measures in breast cancer patients primarily aim to improve upper extremity mobility, which can be offered through various methods such as traditional physiotherapy, kinesiotherapy, and massage techniques. On the other hand, task-oriented programs offer better adaptability to daily life activities than traditional repetitive motion exercises. Recent advances in technology have significantly contributed to changing rehabilitation and offering non-invasive techniques for managing cancer-related symptoms and complaints. Virtual reality is one such tool that functions as an effective technique to minimize the psychological and physical outcomes of breast cancer treatment. It is as effective as traditional physiotherapy in improving functionality in the upper extremities and daily life activities.

VR-based interventions have introduced a new perspective in the rehabilitative management of breast cancer. It has proven to be an excellent non-invasive approach to overcoming the challenges of symptoms following breast cancer treatment, such as pain, fatigue, anxiety, depression, cognitive dysfunction, and joint mobility restrictions that hinder daily life activities. Numerous VR-based rehabilitation tools and devices, including computers, TVs, and mobile phones, are available. However, some limitations still hinder the widespread availability and use of VR. These include cybersickness, uncomfortable headsets, user discomfort and reluctance, and high equipment costs.

Considerations for Using VR – Potential Side Effects

The use of VR technology in cancer rehabilitation stands out as an innovative and effective method to support patients' physical, emotional, and psychological recovery. However, there are some important considerations to keep in mind when implementing this technology.

• Potential Side Effects: The possible side effects of virtual reality use, including cybersickness, have been measured in the literature using the Virtual Reality Symptom Questionnaire. These side effects can include symptoms such as dizziness, nausea, and balance issues.
• Patient Safety: It must be ensured that VR applications are safe for patients. This is particularly important in VR experiences that may cause dizziness, nausea, or balance problems. Additionally, the cleanliness and hygiene of VR devices (glasses or headsets) should be maintained.
• Personalized Applications: Every patient's rehabilitation needs are different. Therefore, VR programs should be customized according to the specific needs and health status of the patients. Regular patient feedback should be collected to continuously evaluate the effectiveness and suitability of VR applications.
• Expert Supervision: VR therapies should always be guided by healthcare professionals specialized in the field. Experts such as physiotherapists, psychologists, or oncology specialists ensure that patients benefit correctly and effectively from VR therapies. Patients' conditions should be closely monitored throughout the rehabilitation process, and interventions should be made when necessary.

By paying attention to these considerations, it is possible to ensure that VR technology is used most effectively and safely in cancer rehabilitation.