Ⅰ. Introduction
Lifestyle medicine (LSM) is a concept that has recently attracted attention in relation to the knowledge for establishing a new rehabilitation strategy . LSM deals with lifestyle-related health issues; provides principles of environment, behavior, medicine, and incentives; and includes various physical activities, nutrition, sleep, stress, social connection, and substance abuse (An et al, 2015).
LSM provides basic recommendations that improve the quality of life and health of patients with less disability (Bodai et al, 2018). The intervention strategies in LSM are active living, healthy weight, healthy eating, and emotional stability (Bodai et al, 2018). These intervention strategies can change an unhealthy lifestyle to a healthy lifestyle and provide the right information for health care.
Most chronic conditions such as musculoskeletal diseases and cardiovascular diseases are the outcome of an unhealthy lifestyle and wrong health information (Bodai, & Tuso, 2015). Healthcare workers must therefore provide appropriate information on how to identify these chronic health problems and implement effective long-term plans to manage patients’ health. Furthermore, providing this lifestyle medical information can lead not only to paradigm shifts in health-care provision but also to positive effects on chronic diseases. Recent research reports suggest the importance of maintaining a healthy body mass index (BMI), increased physical activity, healthy food, and stress management associated with lifestyle interventions (LSIs) for chronic disease management (Bodai, & Tuso, 2015;Wang, & Beydoun, 2009;Farmer et al, 2011;Butler, Yan, & Fraser, 2009;Polednak, 2008).
LSI represents the importance of physical activity among LSM health management concepts. Rosengren reported a study that suggested that moderate physical activity per day for at least 30 minutes once a week reduces health risks among adults (Rosengren, Wedel, & Wilhelmsen, 1999). In addition, by increasing physical activity levels, the risks of Alzheimer disease, dementia, and cognitive impairment are reduced (Wright, & Musini, 2009). Increased physical activity levels can improve the physical inactivity of modern humans, thereby reducing health risks. The American College of Sports Medicine (ACSM) also reported that intervention through the application and implementation of lifestyle physical activity is beneficial to adults when the daily routine is applied in a modified form (Heesch et al, 2003). Consequentially, enhancement of physical activity levels can be achieved through a continuous and self-initiated form of exercise with which daily life can be modified.
However, as the conventional treatment method itself is difficult to manage, the modified forms of physical activity in daily life emphasized in the ACSM recommendation for physical function of the knee are difficult to apply. Therefore, rehabilitation strategies based on new concepts are necessary for applying the latest trends in intervention methods, using the devices developed during the fourth industrial revolution, in LSI rehabilitation strategies according to the changing lifestyle trends of subjects. With the suggested new-concept exercise program, substantive knowledge and information presented in lifestyle medicine must be provided along with a new LSI-based knee rehabilitation protocol in addition to the home-based rehabilitation virtual reality self-exercise program. Through provision of comprehensive rehabilitation information, it can be aimed at enhancing the self-management ability of subjects so that they can improve and maintain their overall physical health condition and knee function, which can contribute to the prevention of diseases and rehabilitation intervention effect. Ultimately, to establish effective rehabilitation strategies, a LSI-based strategy for knee rehabilitation and further study of the exercise method must be proposed.
Recently, LSI-based virtual reality (VR) has become one of the rehabilitation methods that can overcome the limitations of the existing formal exercise program because it has the advantage of allowing patients to exercise according to their own ability. It is already used in the field of rehabilitation science according to social demands. The rehabilitation exercise methods using the VR-based program consist of a wide range of assistive devices and techniques for rehabilitation through technically based therapies, including VR technology, cognitive retraining, and real-time database evaluation (Chute, 2002). Previous studies have reported that the range of motion increases when immersion and non-immersion VR exercise programs are applied with CyberGlove for 3 weeks (Merians et al, 2006). In addition, Yavuzer et al reported that improvement in motor performance was observed when the immersive VR exercise program was applied for 30 minutes for 4 weeks (Yavuzer et al, 2008). Owing to these effects, the new rehabilitation strategies through the development of science and clinical application have the advantage of providing patientcentered customized rehabilitation intervention according to the symptoms, characteristics, and environment of the patient without limitation of time and space (Lee et al., 2016). Therefore, people who exercise through the LSI-based VR exercise program can control the level of difficulty according to their individual ability to exercise, and motivation and participation in the exercise can be increased.
In a similar concept, a home-based exercise program has the advantage of rehabilitation according to the patient’s schedule or life pattern regardless of time and place. In addition, it includes self-directed exercise and has the advantage of recovering exercise physical function in daily life. The results of previous studies have showed that when a home-based exercise program was applied in elderly women for 6 months, physical function, prevention of falls, maintenance of bone density, and balance ability were improved (Tunay Baltaci, & Atay, 2010). In addition, a home-based muscle strengthening exercise program for 6 weeks in patients with knee osteoarthritis was also reported to reduce pain and improve knee functional ability (Park, & Kim, 2014). On the basis of this evidence, from the perspective of cost-effectiveness and feasibility, the home-based exercise program is considered to be better than the hospital-based exercise program for improving physical function.
Most chronic conditions such as musculoskeletal and cardiovascular diseases are the outcomes of an unhealthy lifestyle and wrong healthy information (Bodai, & Tuso, 2015). Healthcare workers should therefore provide appropriate information on how to identify these chronic health problems and implement effective long-term plans to manage patients’ health. Furthermore, providing lifestyle medical information can lead not only to paradigm shifts in health-care provision but also to positive effects on chronic diseases. Recent research reports have indicated the importance of maintaining a healthy body mass index (BMI), increased physical activity, healthy food, and stress management associated with lifestyle interventions (LSI) in chronic disease management (Bodai, & Tuso, 2015;Wang, & Beydoun, 2009;Farmer et al, 2011;Tonstad et al, 2009;Polednak, 2008).
In this study, we researched and suggested a new personalized exercise program based on rehabilitation strategies by introducing the LSI concept. In particular, the LSI-based rehabilitation strategies were established with emphasis on physical activity items related to exercise among the concepts of lifestyle medicine. To provide accurate health information to subjects, LSI rehabilitation strategies were constructed on the basis of evidence-based research data and were applicable without restriction of time and place according to the characteristics, symptoms, and environment of the subjects.
In addition, the LSI exercise program is composed of a complex exercise program that includes strengthening, balance, stretching, and aerobic exercises and is implemented as a customized program to enable personalized health management. One of the important points to be considered is that the LSI exercise program should be approached as a modified form of daily life and that guidelines for exercise should first be provided.
The purposes of this study were (1) to investigate the effect of the LSI-based complex exercise VR program, including muscle strength, endurance, flexibility, and balance exercises on isokinetic knee muscle strength, endurance, and dynamic postural stability in the elderly; (2) to determine differences in improvements in isokinetic knee strength, endurance, and proprioception between patients who participated in the LSI- and home-based rehabilitation and those who underwent supervised rehabilitation; and (3) to suggest new rehabilitation strategies based on the two above-mentioned objectives.
The present study investigated the results of integrated interventions, including knee muscle strengthening and physical function, in elderly and knee surgery patients by using the conventionally conceptualized LSM and LSI.
Ⅱ. Main issue
One experiment aimed to determine the effects of virtual reality exercise using Wii-Fit Plus on knee muscle strength and balance in the elderly. The complex exercise group that was provided with a balance, stretching, muscle strength, and aerobic exercise program showed a more significant improvement in knee muscle strength and balance than the group just provided with a balance exercise program (p<0.05). This result is consistent with the finding from a literature review (Yatar & Yildirim, 2015) that even the same exercise program can be implemented to vary in difficulty according to the game. This is significant in that it is a new rehabilitation strategy that can overcome the limitations of the existing standardized exercise program by allowing patients to adapt the exercise to their own ability (Broadbent et al, 2014;Molina, et al, 2014;Toulotte, Toursel, & Olivier, 2012) (Table 1).
While the existing self-exercise intervention program failed to induce patients to participate fully in exercise simply by listing several types of exercise to perform, not by reflecting the degree of their motivation, virtual-reality exercise using Wii-Fit Plus is significant in that it can overcome the limitations of the self-exercise intervention program by inducing motivation of fun through the element of games, making exercise more efficient within the same period and motivating patients to participate actively (Jack et al., 2001;Laver, et al, 2012;Yatar & Yildirim, 2015).
As physicians provide advice about how to improve lifestyle and exercise simply on the basis of basic information, patients may have no knowledge about how to exercise in daily life space; even if they are given in-depth guidance by a professional in the relevant field, they may actually doubt if they are doing the correct exercise for themselves in a separate space. On the contrary, virtual reality exercise, which allows an ordinary person to give a personal advice and provides immediate feedback with scores after the program ends, allows patients to learn how to exercise and see an improvement in their ability with ease and immediacy (Saposnik et al., 2010;Toulotte, Toursel, & Olivier, 2012;Yatar & Yildirim, 2015). This can be proposed as the first utilization factor of the new concept of the LSI-based knee rehabilitation strategy protocol.
In the other experiment, a comparison was made in terms of knee muscle strength and proprioception between the group of knee disease patients with ACL reconstruction implemented in a standardized, four-stage, home-based self-exercise program under a therapist’s supervision and the control group that applied it independently. Knee muscle strength improved significantly in both groups (p<0.05), regardless of a therapist's supervision (p>0.05). Proprioception improved significantly in the supervised group alone (p<0.05) and varied insignificantly between before and after the intervention in the control group (p>0.05). Although the difference in proprioception was significant in the supervised group, no significant differences in knee strength and endurance, which are important in the physical function of the knee, were found between the two groups. Therefore, the conventional progressive therapy in the home-based self-exercise program can be proposed as an application factor in establishing the knee rehabilitation strategy (Table 1).
What is certain is that a standardized exercise program is adapted to the patient’s condition, consistent with the purpose of rehabilitation but can hardly be generalized to every patient with the same condition (Yatar & Yildirim, 2015). These two experiments confirmed that both virtual reality exercise and the standardized exercise intervention have strengths and weaknesses. Therefore, subjects should take into consideration their characteristics and the characteristics of their diseases so that they can choose the most suitable exercise for themselves (Figure 1).
This study has the following limitations: It focused on patients with knee disease alone; thus, it results can hardly be generalized to other types of disease. It focused only on exercise while there are many other factors that can affect health in lifestyle intervention. More specific research on the home-based rehabilitation virtual reality self-exercise program and comprehensive research in patients with stroke and other musculoskeletal and knee diseases should be conducted.
Ⅲ. Perspective
Lifestyle intervention deals with the issue of health maintenance and promotion, giving priority to exercise (Bodai et al., 2018; Saposnik et al, 2010). On the basis of this concept, which focuses on developing patients’ ability to manage the right exercise methods themselves, the ACSM promotes the recent fitness trends (exercise as therapy, wearable technology, and fitness programs for older adults) and the role of prescribing and managing the appropriate exercise for individuals. Through the LSI-based researches 1 and 2, we demonstrated the effects of exercise by providing information and managing self-exercise methods quantitatively and qualitatively, without knowing how much exercise the subjects should perform in daily life after discharge. Therefore, the home-based selfexercise prescribed by the therapist on the basis of the LSI concept is considered effective.
Because the strategy for monitoring LSI is still lacking, constructing a system for monitoring is necessary, and a technology approach in connection with ICT (Information and Communications Technologies) U-health should be dealt with in a future study. Moreover, more specific research on the home-based rehabilitation VR self-exercise program and comprehensive research in exercise participants with stroke and other musculoskeletal diseases, as well as with knee diseases should be conducted. In addition, fusion research on “when to start intervention” will be needed in connection with the development of artificial intelligence (AI) technology.
Practical knowledge and information on the home-based rehabilitation self-exercise program with the LSI-based new knee rehabilitation protocol are suggested in this study. So that participants, including patients, can improve and maintain their health conditions and knee function to improve their self-care ability, significant contributions to prevent recurrence, decrease mortality, and improve quality of life, physical function, and fitness are needed. Clinical significance can be suggested by the LSI-related fact that by continuing the rehabilitation process, effective rehabilitation and prevention of recurrence can be achieved by prescribing appropriate exercise for patient after discharge.
