Efficacy of Augmented Reality-based Virtual Hiking in

Cardiorespiratory Endurance: A Pilot Study

Muhammad Asif Ahmad

1,2,3 a

, Honorato Sousa

, Élvio Rúbio Quintal

4,5 c,

and Sergi Bermúdez i Badia

1,2,3 d

Madeira Interactive Technologies Institute, Universidade da Madeira, Funchal, Portugal

Faculdade de Ciências Exatas e da Engenharia, Universidade da Madeira, Funchal, Portugal

NOVA Laboratory for Computer Science and Informatics, Universidade da Madeira, Funchal, Portugal

ITI/LARSyS, ARDITI, Funchal, Portugal

Department of Physical Education and Sport, University of Madeira, Funchal, Portugal

Keywords: Hiking Simulator, VR

Environments, User Experience, Heart Rate, Exertion Level, Virtual Reality, Exergames.

Abstract: Exergames can be used to overcome a sedentary lifestyle. Virtual Reality (VR) has made exergames

successful, and they can be used to increase heart rate, but some limitations are found, such as the adaptation

of the heart rate in exergames to the player's fitness profile. VR technology has been used to simulate virtual

cycling and walking experiences. We designed and developed an exergame' Virtual Levadas' in a cave-based

VR environment to simulate the Levadas hiking tracks. They are the main attraction for tourists in Madeira

Island, Portugal. This study's main objective was to assess player exertion, usability, participation, and realism

of the simulation of the Levadas tracks. We performed this study with 13 participants who played Virtual

Levadas for 6 minutes and found a significant increase in player's average physical activity and heart rate.

Overall, our results demonstrate that Virtual Levada's exergame provides a higher exertion level, immersion,

and realism of the virtual environment than the literature.

1 INTRODUCTION

Exergames (video games with physical activity) are

becoming more popular because of their reported

benefits (Ketcheson et al., 2015). The main goal in the

design of exergames is to keep players motivated

during gameplay and physical activity (Yue Gao and

Regan L. Mandryk, 2011) (Knights et al., 2014). An

exercise session of ten minutes can increase

concentration and provides cognitive incentives

(Klein and Simmers, 2009). The combination of

physical activity and video games increases player

interest and motivation (Yoo and Kay, 2016).

Exergames can help to overcome a sedentary lifestyle

(Klein and Simmers, 2009). According to the US

National Heart, Lung Blood Institute, the limitations

of inadequate physical activity levels include

https://orcid.org/0000-0002-9091-9381

https://orcid.org/0000-0002-7434-643X

https://orcid.org/0000-0003-0927-692X

https://orcid.org/0000-0003-4452-0414

lifestyle, fewer recreational facilities, age, and health

conditions (NIH, 2012).

In recent progress, virtual reality (VR) technology

has made exergames successful (Yoo and Kay, 2016).

The most common VR setups are large screen

displays (Cave systems) and head-mounted displays

(HMDs). Nintendo Wii (Park et al., 2014) and the

Microsoft Kinect (Chan et al., 2011) introduced

exergames and confirmed high interest and physical

activity. Wii Fit (wiifit.com) has been commercially

recognized and promoting Mircosoft Kinect

(microsoft.com) as an input device. However, the

exergames' immersion and motivation were observed

low with less involvement (Bolton et al., 2014). Some

exergames may elevate high physical activity levels

(PA) and adherence (Staiano et al., 2018). However,

traditional physical exercises induce higher PA than

in exergames (Schneekloth and Brown, 2018). More

Ahmad, M., Sousa, H., Quintal, É. and Bermúdez i Badia, S.

Efﬁcacy of Augmented Reality-based Virtual Hiking in Cardiorespiratory Endurance: A Pilot Study.

DOI: 10.5220/0010312405750582

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 575-582

ISBN: 978-989-758-490-9

575

research is required that the regular use of the

exergames can make players physical active (Soltani

et al., 2020).

In this study, we developed an application using

VR to simulate hiking on Levadas and Veredas tracks

and promote physical activity while enjoying

Madeira's unique hiking trails. Madeira (Portugal) is

one of Europe's leading island destinations (World

Travel Awards [WTA], 2019) and has 2/3 of the area

cataloged as a Natural Park. There are more than 28

hiking-tracks recommended by the local government

and municipalities to visit the park. Hiking is very

popular in Levadas and Veredas (Madeira's Hiking

trails) because of increased tourism (Roque et al.,

2018).

In this work, we modified the 2-minute step test

(TMST), introduced by Rikli and Jones, as part of the

Senior Fitness Test in 1999 (Rikli and Jones, 1999).

TMST may be used as an alternative to a six-minute

walk test to measure of aerobic endurance. We

hypothesized that a six-minute stepping exercise

would induce physical activity by elevating the

player's heart rate. An augmented reality-based setup

may simulate Levadas tracks with a higher sense of

presence, realism, and usability. In our virtual Levada

simulation, participants need to march-in-place as fast

as possible for 2 minutes while lifting knees at a

criterion height. A six-minute stepping exercise was

performed by the participants with three variations of

the knee height to walk in a VR environment, and

exertion of the physical activity was assessed through

heart rate to address the following research questions:

RQ1. Does a cave-based VR system provide a

high presence and usability to simulate virtual

Levadas?

RQ2. Can a stepping exercise in Virtual Levada's

exergame be used to induce adequate physical

activity?

2 RELATED WORK

The physical activity component of video games

defines exergames. Christos Ioannou and co-authors

proposed virtual performance augmentation of in-

place running and jumping and assessed a VR

exergame effect. They found that in-place running

and jumping in a VR can be used to create a natural

experience and induce moderate to high physical

activity (Ioannou et al., 2019). Another developed a

VR table tennis exergame and compared the

participants' heart rate generated through traditional

and VR-based table tennis (Varela Aldás et al., 2020).

They reported a decrease in the participants' heart rate

in the VR version, which indicated that VR-based

table tennis was not suitable to induce physical

activity (PA). A recent study built a bike 'Greedy

Rabbit' adopting a design-based exergame approach

to assess young adults' physical activity and

situational interest. They found that a design-based

exergame approach is an excellent method to elevate

the player's physical activity and situational interest

(Cédric Roure et al., 2020). Another study created an

exergame VRun in which players physically run on

the spot to interact with the virtual environment. They

compared laptop display and large screen display

setups and reported large-screen display had high

immersion (Yoo and Kay, 2016).

Similarly, Mallory Ketcheson and co-authors

introduced and assessed heart rate power-ups' novel

game concept to induce higher physical activity

during gameplay. The heart rate power-ups endorse

players to elevate their heart rate to the target level by

providing those rewards in the game. They developed

three exergames and found a significant increase in

the players' exertion level and enjoyment level

(Ketcheson et al., 2015). Gao et al. (2017) reported

that a school-based exergaming program induced

children's moderate-to-vigorous PA (7–10 years old)

over two years in overweight and obese adolescents.

Staiano et al. (2017) found an increase in PA during

a 12 weeks dance exergaming intervention program

in overweight and obese adolescent girls. Grab apple

exergame elevated 72% of the maximum heart in ten

minutes, making players play at different intervals of

the day (Yue Gao and Regan L. Mandryk, 2011). This

exergame was considered useful for those people who

were not able to perform a long exercise.

Moreover, Shaw et al. used an HMD environment

to simulate an exercycle game in which players have

to pedal to move in a virtual environment. The

authors reported a statistically significant increase in

exertion and motivation when playing the game.

However, a small increase in motivation and no

difference in exertion level were found in the HMD

environment (Shaw et al., 2015).

Sinclair stated that one limitation of designing

physical activity exergames is that gameplay and

exercise may not be synchronized to acquire a desired

target heart rate (Sinclair, 2011). Finkelstein and

Suma developed the immersive VR exergame

"Astrojumper" and reported a significantly increased

heart rate of users after gameplay. The participants'

exertion level was correlated with their motivation

level (Finkelstein and Suma, 2011).

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3 METHOD

Our study's main objective was to recreate Levadas

hiking-tracks' experience to develop a virtual

simulation scenario. For that, we designed and

created the "Virtual Levadas" exergame in a mixed

reality-based setup. We assessed users' physical

responses and usability, fidelity, and perceived level

of presence during the experience. The participants

were provided an informed consent that is compiled

with Helsinki and Portugues laws. The study was

conducted at the facilities of the Madeira Interactive

Technologies Institute in Funchal, Portugal.

3.1 Experiment Setup

3.1.1 Hardware

The KAVE is a unity plugin for CAVE systems

previously developed at our research lab. It comprises

scripts, objects, and prefabs that use a 140$ Kinect V2

tracking sensor (Microsoft, Redmond, USA) to add

parallax effect and full-body tracking for interaction

with virtual objects. The latest Azure Kinect DK can

be used with the Kave plugin because Kinect V2 is

out of production. The height and width of the CAVE

walls were 2.2 and 2.8 meters, respectively. A Kinect

V2 sensor was installed at the front wall to detect full-

body gestures. External speakers and four HD

projectors were positioned in a way as to project on

walls and floors (Figure 2). The price of the CAVE

(structure, projectors, and Kinect) was just under

3,800€ (projectors costing 3,200€). However, it

requires a computer capable of displaying in 4

screens. For more details on the KAVE, refer to

(Gonçalves and Bermúdez I Badia, Sergi, 2018).

Physical activity was assessed by ActiGraph

WGT3X-BT (Actigraph Corporation, Pensacola, FL,

USA), a tri-axial accelerometer (size: 3.5 × 3.5 ×

1 cm, weight: ~14 g). ActiGraph's WGT3X-BT

activity tracker is a validated small, lightweight,

portable device that measures body acceleration and

energy expenditure associated with movement

("ActiLife 6 User’s Manual", 2020). Also, the

WGT3X-BT was paired with a heart rate chest band

Polar H10 (Polar Electro Oy, Kempele, Finland), and

hence heart rate data were collected synchronously

with the ActiGraph system. ActiLife6 software

(version 6.13.4, ActiGraph, Cary, NC, USA) was

used to process data and calculate the vector

magnitude.

Figure 1: Schematic diagram of our KAVE Setup.

3.1.2 Software

Three types of Levada tracks were created in Unity

3D to simulate a six-minute hiking experience. The

VR environment contains computer-generated 3D

objects such as mountains, trees, grass, birds,

irrigation canals, etc., created in Unity3D and the

Blender creation suite (Blender Foundation,

Amsterdam, Netherlands) (Figure 2). The user moves

through the hiking trail by stepping-in-place. The

Kinect V2 is used to detect the knee height and trigger

the virtual movement. Three different difficulty levels

were created by modulating the required stepping

height of the knee.

Figure 2: Design of Virtual Levada and Six-minute hiking

simulation in Augmented Reality.

Efﬁcacy of Augmented Reality-based Virtual Hiking in Cardiorespiratory Endurance: A Pilot Study

577

3.2 Instruments

3.2.1 User Experience

Witmer and Singer's Presence Questionnaire (WSPQ)

was used. It includes 24 items addressing

Involvement, Immersion, Visual Fidelity, Interface

Quality, and Sound (Witmer et al., 2005). Items 1-22

are rated on a 7-point scale. Sound items (20-22) were

not considered for the overall WSPQ score's

computation, consistent with other studies (Witmer et

al., 2005). Items 23 and 24 are not applicable, as the

application does not have haptic feedback.

Our study also used the System Usability Scale

(SUS), created by (John Brooke, 1996), to assess the

application's usability. SUS comprises ten items with

five response options from strongly disagree to

strongly agree. It allows a quick evaluation of the

usability of a wide variety of products and services,

including hardware and software.

3.2.2 Fitness

Senior fitness tests (SFT) were introduced to assess

lower-body strength, agility and dynamic balance,

and aerobic endurance among the elderly (Rikli &

Jones, 1999). The SFTs have been used in many

clinical trials as a tool to assess the physical function

of older adults (Yang et al., 2019). The SFTs are easy

to use and do not require any special technical skills,

infrastructure, or setup (Birgitta Langhammer and

Johan K. Stanghelle, 2019). We used the two-minute

step test (TMST) to assess aerobic endurance. The

TMST was modified to use as a six-minute stepping

exercise to simulate virtual Levadas. The number of

steps was recorded through the exergame.

3.3 Protocol

Before starting, the study's protocol was provided,

and participants provided informed consent, and all

were randomly assigned to one group. Repeated

measures experimental design was used, and a two-

minute demo session was provided to familiarize

them with the application and task. After the demo

session, participants were asked to wear the

Actigraph accelerometer and the heart rate chest

band. Participants executed three consecutive 2-

minute marching at the same place trials of the Virtual

Levada, each with a different and increasing

difficulty level (easy, medium, and hard), based on

the knee’s high. One minute rest was provided to

participants after each trial. After the Virtual Levada

experience, participants answered the WSPQ and

SUS questionnaires.

3.4 Participants

The participants were a convenience sample recruited

at the Madeira Interactive Technologies Institute and

the University campus. It consisted of 13 participants

(females =8, ages: M=30.29 SD =6.4). Sample was

composed by graduate students and research

assistants, that had no physical disabilities, were able

to understand and speak English, and received no

compensation for their participation. Three

participants were removed because of technical

problems with the accelerometer.

3.5 Statistical Analysis

The number of steps, magnitude vector, and heart rate

was computed as median and standard deviation,

Mdn (IQR). For the WSPQ and SUS, we calculated

the total mean score and standard deviation M (SD)

to compare with related work. The normality of the

distributions was assessed using the Kolmogorov-

Smirnov test. Data were considered not normal for all

three parameters, and nonparametric tests were used.

The Friedman test was used to evaluate the impact of

different experimental conditions. The threshold for

significance was set at 5% (α=0.5). The post hoc 2-

tailed Wilcoxon signed-rank test was used for

pairwise comparisons. Because of multiple com-

parisons, Bonferroni correction was applied. Analysis

of data was performed using SPSS version 26.

4 RESULTS

4.1 User Experience

The virtual environment was created in a virtual

Levada exergame using VR technology to simulate

real Levadas. The hiking tracks with irrigation canals,

trees, birds, grass, and plants, audio, and visual effects

were added in the virtual environment to achieve high

visual fidelity, immersion, and presence. The total

mean score of the user perception of presence in

WSPQ was M=99.6 (20.3), which indicates a higher

sense of presence. The high average score for the

subdomains of the WSPQ, such as involvement,

immersion, visual fidelity, interface quality, and

sound, indicates that the user-perceived high

presence, realistic environment, reliable, and user-

friendly (Table 2). The high mean score reported in

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the SUS (M=79.2(16.3)) suggests that virtual Levada

exergame can simulate real Levadas and assess the

user's exercise exertion level.

Table 1: Mean (SD) scores.

WSPQ Items Scores

Total score All execpt 20,21,22 99.6 (20.3)

Involvement 1,2,3,4,5,6,7,10,13 5.1 (0.98)

Immersion 8,9,14

,15,16,19 5.0 (0.98)

Visual Fidelity 11,12 4.2 (1.5)

Interface Quality 17

,18

5.8 (1.5)

Sound

20,21,22 4.6 (1.7)

Reversed items

4.2 Fitness

We implemented and modified a 2-minute step test of

SFTs in virtual Levada exergame to induce adequate

physical activity level. Three levels (conditions) of

difficulty in exergame were added to elevate the user

heart rate and analyze the number of the steps and

vector magnitude. There was a statistical difference

in all parameters over three conditions of Levada

FR(2)=0.20, p<0.001. Post hoc analysis with the

Wilcoxon signed-rank test was used with a

Bonferroni correction applied, resulting in a

significance level set at p < 0.017, which indicates

that we found variation in physical activity. Mdns

(IQR) number of steps for the easy, medium, and hard

were 113.0 (27), 96.0 (19), and 83.5 (24),

respectively. There were significant differences in all

three conditions for the number of steps, which were

easy and medium (Z = -3.29, p = 0.0005), easy and

hard (Z = -3.29, p < 0.001), and medium and hard (Z

= -2.22, p = 0.013). The number of steps decreased at

each difficulty level, which suggests that our

exergame impacts the participant's exertion level.

Similarly, Mdns (IQR) average magnitude vectors for

the easy, medium, and hard were 371.1 (253.15),

394.4 (327.52), and 789.6 (360.18), respectively.

There were no significant differences in the average

magnitude vector between easy and medium (Z = -

1.97, p = 0.024). However, statistical significant

differences were found between the easy and hard (Z

= -2.73, p = 0.003), and medium and hard (Z = -2.85,

p = 0.002). Mdns (IQR) heart rates for the easy,

medium, and hard were 125.0 (54), 126.5 (53) and

138.0 (40), respectively. The significant differences

were found in all three conditions for the heart rate,

which were easy and medium (Z = -3.11, p = 0.001),

medium and hard (Z = -2.27, p = 0.011), and easy and

hard (Z =-2.41, p = 0.008) (Figure3). The participant's

heart rate suggests that the adaptation of the

participant heart rate to the exergame can induce

different physical activity levels.

Figure 3: Boxplot from post hoc results of Heart Rate,

Magnitude Vector, and number of steps.

DISCUSSION AND

CONCLUSIONS

5.1 Fitness

We assessed the efficacy of the application by

Efﬁcacy of Augmented Reality-based Virtual Hiking in Cardiorespiratory Endurance: A Pilot Study

579

measuring heart rate variability at different difficulty

levels. We observed a significant increase in heart

rate in each difficulty level of application from the

results, which may acquire the target heart by

modulating the application's duration and difficulty

levels. The difficulty level of the application was

associated with the participant's knee height during

the stepping exercise. The stepping activity was the

modification of a two-minute step test.

A recent study compared the two-minute step test

with a six-minute walk test, and they reported higher

fatigue and leg fatigue after the two-minute step test

than the six-minute walk test (Węgrzynowska-

Teodorczyk K et al., 2016). We expected that our

exergame would increase the exertion level of the

participants. They performed a six-minute stepping

exercise with three levels of difficulty and one-minute

rest after each difficulty level. Another recent study

assessed the average exertion level of multiple

exergames through the participant's heart rate and

found an elevation in the heart rate (Ketcheson et al.,

2015). They measured the exertion level of the

exergame through heart rate. The virtual Levada

exergame significantly increased the player's heart

rate and exertion level. Our results suggest that virtual

Levada exergame can induce adequate physical

activity level to answer our second research question.

5.2 User Experience

The usability and user perception of the application's

presence was also assessed using SUS and WSPQ

instruments. The average SUS score is 68, and our

study reported a SUS score (M=79.2(16.3)), which

indicates high usability of the application. Some other

studies also reported SUS scores; for example, Yoo

and Kay reported SUS to score 75 and 65 for HMD

and large-screen display, respectively (Yoo and Kay,

2016). Another study reported the highest SUS score

(M=87.0(11.1)) of the Mole exergame developed by

SilverFit (Nawaz et al., 2014). The subjective

measures such as high usability score answer our

second research question that virtual Levada can

induce physical activity. The total score (M=99.6

(20.3)) over the 19-item presence questionnaire

WSPQ (Witmer et al., 2005) was considered

significantly higher when compared to literature,

which indicates that our application had higher

immersion and involvement. For example, a recent

study reported a mean score of 109.35 (13.65) using

an HMD (Deb et a, 2017). In another study, Feldstein

et al. reported 93 (1.23) presence scores in an HMD

setup (Feldstein et al., 2016). The high score for

subdomains of involvement and immersion indicates

that participants perceived high presence and realistic

environment, whereas fidelity suggests the

application's reliability. The mean score of interface

quality informs that the interface of the application

was user-friendly. The average score for sound was

measured separately (M= 4.6(1.7)) indicated a

realistic ambient sound of Levadas. The high score of

fidelity and immersion answers our first research

question and suggests that our exergame can simulate

virtual Levadas using immersive VR technology.

In this study, we designed and developed an

exergame in a cave-based VR environment to provide

a virtual simulation of Levadas. They are the main

attraction for tourists in Madeira, and our exergame

would bring more awareness and promote tourism.

We also assessed the exergame's average exertion

level through a player's average heart rate and found

a significant heart rate increase. However, there are

still limitations such as portability of the application,

small sample size, space constraints, and consistent

heart rate data acquisition in real-time. In future work,

we will assess the target heart rate according to

ACSM recommendations (Mitchell et al., 2006) by

adapting the user heart rate to the exergame's

difficulty level in real-time. We would include more

challenging tasks and rewards in this application to

increase the player's motivation and interest. Hiking

could be a more challenging task for the elderly

because of their physical balance and fitness. We will

conduct further studies with a large sample size of the

elderly.

ACKNOWLEDGEMENTS

This work is supported by NOVA LINCS

(UIDB/04516/2020) with the financial support of

FCT- Fundação para a Ciência e a Tecnologia,

through national funds

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