Lactate Kinetics After Multimodal Exercise and Adjunctive Virtual Reality Exercise in Hospitalized Geriatric Patients

Fatigue, Frailty, Lactate, Quality of Life, Sarcopenia in Elderly

Exercise, Geriatric, Lactate, Virtual Reality, frailty, quality of life, sarcopenia

The goal of this clinical trial is to determine whether adding virtual reality exercise to conventional multimodal exercise affects exercise-related lactate kinetics, functional status, frailty, sarcopenia risk, perceived exertion, and health-related quality of life in adults aged 60 years or older who are hospitalized in an acute geriatric ward. The main questions it aims to answer are: 1. are there any difference in post exercise lactate at day 1 and 7 between the two groups? 2. does the lactate concentration reduces after low intensity resistance exercise in subject with high resting lactate? 3. Does virtual reality-assisted multimodal exercise improve functional independence, frailty status, sarcopenia risk, perceived exertion, and health-related quality of life from baseline to Day 7? Researchers will compare participants receiving conventional multimodal exercise plus virtual reality exercise with participants receiving conventional multimodal exercise alone to evaluate the additional effects of the virtual reality intervention. Participants will: * Undergo functional and medical assessments before starting the exercise program. * Receive an individualized conventional multimodal exercise program during hospitalization. * If assigned to the intervention group, perform additional virtual reality exercise using the VRAGMENT program. * Have capillary blood lactate concentrations measured immediately before and after standardized low-intensity resistance exercise on Day 1 and Day 7. * Complete the following assessments at baseline and on Day 7: * Barthel Index to assess functional independence. * Frailty Index-40 (FI-40) to assess frailty. * SARC-F to assess the risk of sarcopenia. * Borg Rating of Perceived Exertion (RPE) Scale to assess perceived exercise intensity. * EQ-5D-5L to assess health-related quality of life. * Have vital signs, exercise tolerance, and adverse events monitored throughout the intervention.

153 hospitalized older adults were enrolled from the acute geriatric ward at RSUPN Dr. Cipto Mangunkusumo (RSCM). Participants were randomly allocated to either a control group or an intervention group. The control group received conventional multimodal exercise, while the intervention group received the same conventional exercise program with additional virtual reality exercise (VRE) as an adjunctive therapy. Before beginning the exercise program, each participant underwent a comprehensive medical and functional assessment performed by a physical medicine and rehabilitation specialist. An individualized exercise prescription was then developed according to the participant's clinical and functional condition. The prescription specified the frequency, intensity, duration, and type of exercise. Conventional multimodal exercise could include breathing, resistance, aerobic, mobility, and other clinically indicated exercises. Participants assigned to the intervention group additionally performed VRE using the VRAGMENT software. VRAGMENT simulates instrumental activities of daily living, including making telephone calls, selecting grocery items, and completing payment transactions. Activities performed in the virtual environment were designed to elicit movements of the neck, trunk, upper limbs, and lower limbs according to each participant's functional capacity. VRAGMENT itself is a daily shopping simulation game.To align safely with mobilization levels 3 and 4, the virtual mechanics replaced physical walking with manual controller manipulation and virtual locomotion. VRAGMENT Training Procedure: 1. Before each training session, the researchers reviewed the indications and contraindications for mobilization. Training was conducted only when the participant had no contraindications to mobilization. 2. Participants received a detailed explanation of the activities to be performed during the VRAGMENT training and the final objective of the game. 3. Participants underwent familiarization with the Oculus Quest 2 headset, which served as the hardware platform for VRAGMENT. The virtual play area was also calibrated according to each participant's position, range of motion, and clinical condition. 4. Vital signs were assessed immediately before and after each training session to monitor the participant's physiological response and safety. 5. Participants initiated the game and completed the VRAGMENT activities sequentially. Throughout the session, the healthcare staff and attending physician were permitted to provide instructions, feedback, and verbal encouragement without directly performing the activities for the participant. 6. The level of difficulty was progressively increased when the participant was able to complete the entire sequence of activities within a given level in at least 50% less time than their initial completion time for that level. 7. The duration of each training session was recorded. Participants were expected to complete 30 minutes of training per day, either continuously or in divided sessions according to their tolerance and clinical condition. Training was conducted five times. Evaluation was performed within seven days after the first session.Instructions, supervision, and feedback were provided throughout the sessions. Vital signs, exercise tolerance, symptoms of virtual reality sickness, and other adverse events were monitored. The primary outcome was the change in exercise-related capillary blood lactate concentration. Lactate was measured using the StatStrip® Lactate Meter from Nova Biomedical, which has a measurement range of 0.3-20.0 mmol/L. Blood samples were collected immediately before and after standardized low-intensity resistance exercise at baseline (Day 1) and following the seven-day intervention period (Day 7). These measurements were used to evaluate acute exercise-related lactate responses and changes in lactate kinetics between Day 1 and Day 7. Secondary and exploratory outcomes were assessed at baseline and Day 7 and included: * Functional independence measured using the Barthel Index. * Frailty measured using the 40-item Frailty Index (FI-40). * Sarcopenia risk measured using SARC-F. * Perceived exercise intensity measured using the Borg Rating of Perceived Exertion Scale. * Health-related quality of life measured using the EQ-5D-5L. The analyses evaluated changes in the measured outcomes over time and compared the intervention and control groups. Statistical analyses were performed using IBM SPSS Statistics version 24.0.

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