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\begin{document}

\title{EFFECT OF RESPIRATORY TRAINING DIGITAL GAME ON RESPIRATORY FUNCTIONS,
AND PSYCHOLOGICAL STATUS IN CHILDHOOD ASTHMA}



\author[1]{Ozden Gokcek}%
\author[2]{Esra Dogru Huzmeli}%
\author[1]{Nuray Elibol}%
\author[3]{Yagmur Tugral}%
\author[2]{Eren Lekesiz}%
\author[4]{Çiğdem El}%
\author[5]{Ahmet Kan}%
\author[2]{Basak Yılmaz}%
\author[1]{Miray Baser}%
\affil[1]{Ege University}%
\affil[2]{Hatay Mustafa Kemal University}%
\affil[3]{İzmir Democracy University}%
\affil[4]{Mustafa Kemal University}%
\affil[5]{Dicle University Training and Research Hospital}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
\textbf{Objective:} Asthma is a chronic obstructive disease that is
common in children worldwide. This study aims to examine the effects of
a digital game designed for respiratory training in childhood asthma.
\textbf{Methods:} Fifteen children aged 8-14 years with asthma were
included in the study. There were two groups a digital game group (n=9)
and a control group (n=6). Demographic information of the children was
recorded. Pulmonary function test (PFT) was evaluated with a portable
spirometer (Spirobank MIR), the quality of life of the children was
evaluated with the Paediatric Asthma Quality of Life Questionnaire and
psychological status was evaluated with the child depression scale.
Respiratory training was given to the digital game group with a digital
game. The control group was followed with medication. Both groups were
evaluated at baseline and after 3 weeks. \textbf{Results:} In the
digital game group; It was observed that there was an increase in PFT,
sub-parameters of the PAQLQ questionnaire, and the total score after the
treatment (p\textless{}0.05). In addition, it was determined that there
was a significant decrease after the treatment according to the
questionnaire used for the change in the psychological status of the
children (p\textless{}0.05). \textbf{Conclusion:} It was determined that
respiratory training given with digital games had a positive effect on
children's psychological state, pulmonary function test, and quality of
life.%
\end{abstract}%



\sloppy


\textbf{EFFECT OF RESPIRATORY TRAINING DIGITAL GAME ON RESPIRATORY
FUNCTIONS, AND PSYCHOLOGICAL STATUS IN CHILDHOOD ASTHMA}

\selectlanguage{polish}\textbf{Ozden Gokcek\textsuperscript{1}, Esra Dogru
Huzmeli\textsuperscript{2}, Nuray Elibol\textsuperscript{3}, Yagmur
Tugral\textsuperscript{4}, Eren Lekesiz\textsuperscript{5}, Cigdem
El\textsuperscript{6}, Ahmet Kan\textsuperscript{7}, Basak
Yılmaz\textsuperscript{8}, Miray Baser\textsuperscript{9}}\selectlanguage{english}

\textsuperscript{1}Ozden Gokcek,

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Ege University, \selectlanguage{polish}İ\selectlanguage{english}zmir, Turkey

Address: Ege University, Health Science Faculty, Department of
Physiotherapy and Rehabilitation Kars\selectlanguage{polish}ı\selectlanguage{english}yaka/Izmir/Turkey

E-mail: ozdencanbay@hotmail.com

\textsuperscript{2}Esra Dogru Huzmeli

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Hatay Mustafa Kemal University, Hatay, Turkey

Address: Hatay Mustafa Kemal University, Health Science Faculty,
Department of Physiotherapy and Rehabilitation Serinyol/Hatay/Turkey

E-mail: esradogru001@hotmail.com

\textsuperscript{3}Nuray Elibol

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Ege University, \selectlanguage{polish}İ\selectlanguage{english}zmir, Turkey

Address: Ege University, Health Science Faculty, Department of
Physiotherapy and Rehabilitation Kars\selectlanguage{polish}ı\selectlanguage{english}yaka/Izmir/Turkey

E-mail: elibol.nuray@gmail.com

\textsuperscript{4}Yagmur Tugral

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Izmir Democracy University, \selectlanguage{polish}İ\selectlanguage{english}zmir, Turkey

Address: Izmir Democracy University, Health Science Faculty, Department
of Physiotherapy and Rehabilitation Izmir/Turkey

E-mail: yyagmurcam@gmail.com

\textsuperscript{5}Eren Lekesiz

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Hatay Mustafa Kemal University, Hatay, Turkey

Address: Hatay Mustafa Kemal University, Health Science Faculty,
Department of Physiotherapy and Rehabilitation Serinyol/Hatay/Turkey

E-mail: fzt.erenlekesiz@gmail.com

\textsuperscript{6}Cigdem El

Department of Child Health and Diseases, Tayfur Ata S\selectlanguage{ngerman}ökmen Medicine
Faculty Hatay Mustafa Kemal University, Hatay, Turkey

Address: Hatay Mustafa Kemal University, Tayfur Ata Sökmen Medicine
Faculty, Department of Child Health and Diseases, Serinyol/Hatay/Turkey

E-mail: cigdem.el@hotmail.com

\textsuperscript{7}Ahmet Kan

Department of Allergy and Immunology, Dicle University Training and
Research Hospital, Dicle University Diyarbak\selectlanguage{polish}ı\selectlanguage{english}r/Turkey

Address: Dicle University Dicle University Training and Research
Hospital, Department of Allergy and Immunology Diyarbak\selectlanguage{polish}ı\selectlanguage{english}r/Turkey

E-mail: rodmerrod1980@gmail.com

\textsuperscript{8}Basak Y\selectlanguage{polish}ı\selectlanguage{english}lmaz

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Hatay Mustafa Kemal University, Hatay, Turkey

Address: Hatay Mustafa Kemal University, Health Science Faculty,
Department of Physiotherapy and Rehabilitation Serinyol/Hatay/Turkey

E-mail: basak.mirac.ayse@gmail.com

\textsuperscript{9}Miray Baser

Department of Physiotherapy and Rehabilitation, Health Science Faculty,
Ege University, \selectlanguage{polish}İ\selectlanguage{english}zmir, Turkey

Address: Ege University, Health Science Faculty, Department of
Physiotherapy and Rehabilitation Kars\selectlanguage{polish}ı\selectlanguage{english}yaka/Izmir/Turkey

E-mail: miraybaser1@gmail.com

\textbf{Corresponding author:} Ozden GOKCEK

\textbf{E-mail address:}
ozdencanbay@hotmail.com\textbf{;}ozden.gokcek@ege.edu.tr

\textbf{Orcid ID:} 0000-0003-3396-4108

Address: Ege University, School of Physiotherapy and Rehabilitation,
\selectlanguage{polish}İ\selectlanguage{english}zmir, Turkey

Gsm: 00905066754729

\textbf{Abstract}

\textbf{Objective:} Asthma is a chronic obstructive disease that is
common in children worldwide. This study aims to examine the effects of
a digital game designed for respiratory training in childhood asthma.

\textbf{Methods:} Fifteen children aged 8-14 years with asthma were
included in the study. There were two groups a digital game group (n=9)
and a control group (n=6). Demographic information of the children was
recorded. Pulmonary function test (PFT) was evaluated with a portable
spirometer (Spirobank MIR), the quality of life of the children was
evaluated with the Paediatric Asthma Quality of Life Questionnaire and
psychological status was evaluated with the child depression scale.
Respiratory training was given to the digital game group with a digital
game. The control group was followed with medication. Both groups were
evaluated at baseline and after 3 weeks.

\textbf{Results:} In the digital game group; It was observed that there
was an increase in PFT, sub-parameters of the PAQLQ questionnaire, and
the total score after the treatment (p\textless{}0.05). In addition, it
was determined that there was a significant decrease after the treatment
according to the questionnaire used for the change in the psychological
status of the children (p\textless{}0.05).

\textbf{Conclusion:} It was determined that respiratory training given
with digital games had a positive effect on children's psychological
state, pulmonary function test, and quality of life.

\textbf{Keywords:} Digital game, pediatric asthma, quality of life,
respiratory training, psychological status

\textbf{Statements and Declarations}

Funding Source: None

Trial registration: Not applicable

Conflicts of interest: None

Word Count: 2304

Figures: 6

Tables: 3

\textbf{Abbreviations}

PFT: Pulmonary function test

PAQLQ: Paediatric Asthma Quality of Life Questionnaire

ATS/ERS: American Thoracic Society/ European Respiratory Society

FVC: Forced vital capacity

FEV1: Forced expiratory volume in one second

FEF 25-75: Forced expiratory flow between 25-75\% of vital capacity.

\textbf{1. INTRODUCTION}

Asthma is a disease characterized by increased airway sensitivity to
various stimuli and reversible airway obstruction\textsuperscript{1}.
Asthma, the most common chronic disease of childhood, has become a
disease with increasing prevalence, morbidity, and mortality over the
years.

In cases where increased air trapping in the lungs is accompanied by a
bronchial obstruction, great effort is required for breathing.
Therefore, there is an increase in respiratory workload due to bronchial
obstruction in asthma. In asthma patients, the central nervous system is
exposed to hypoxia during attacks\textsuperscript{2}. Depending on
hypoxemia and hypoxia, there is an increase in blood viscosity and
pulmonary vascular resistance and a decrease in cerebral perfusion.
Deterioration in brain perfusion with hypoxemia causes the patients to
be negatively affected psychologically due to the decrease in their
cognitive functions. It negatively affects the quality of life due to
the negative impact on the psychological state\textsuperscript{3,4}.
Respiratory exercises are used in chest physiotherapy to increase lung
volume and prevent hypoxia. With breathing exercises, tidal volume,
mobility of the thoracic cage, and inspiratory capacity are
increased\textsuperscript{5}.

Assisted and unassisted breathing exercises can be applied to children
older than two years. Deep breathing can be taught after the age of two
through bubble-making games or a weather vane\textsuperscript{6}.
Another purpose of this breathing exercise is to introduce the family
and the child to inspiration and expiration, to help them distinguish
between deep and shallow breathing. This technique includes breathing
control, thoracic expansion exercises, and forced expansion technique.
Thoracic expansion exercise is a deep breathing exercise that emphasizes
inspiration. In this way, it is applied 3-4 times together with
respiratory control. Usually, a few seconds (approximately 3 seconds)
are waited at the end of inspiration to reduce airway
collapse\textsuperscript{7}. Inspiration is active and expiration is
passive and relaxed. Increasing lung volume reduces resistance to
airflow in the distal airways and collateral channels. From 4-6,
breathing controls in the active breathing techniques cycle; respiratory
control prevents the development of airway obstruction and
fatigue\textsuperscript{8}. As with all types of exercise, exercise
compliance and participation in respiratory exercises are important for
the effectiveness of exercise. As repetitive therapeutic procedures can
be boring for the participants, it can be difficult to maintain the
child's participation. In order to cope with this situation, it is
appropriate to apply the exercises through games developed in accordance
with the purpose. In the literature, gamification and active video games
are shown as methods that can be used to motivate children and help them
gain healthy habits\textsuperscript{9}.

This study aims to examine the effects of a digital game designed for
respiratory training on respiratory functions, quality of life, and
psychological state in childhood asthma.

\textbf{2. PATIENTS AND METHODS}

\textbf{2.1 Study design and population}

A total of 15 children aged 8-14 years diagnosed with asthma were
included in the study. Ethical and informed consent was obtained in
accordance with the Declaration of Helsinki (Approve no: 2022/02). The
informed consent form was signed by the children and their parents for
the study. Children diagnosed with asthma were divided into two groups
as digital game and control by simple random randomization method. There
were 9 children in the digital game group, and 6 children in the control
group. In addition to routine drug use, children of the digital game
group were followed up with 15 sessions of 15 minutes of digital games
for respiratory training. Children of the control group were followed up
with routine drug use (Figure 1).

\textbf{2.2 Evaluation and Measurement Methods}

Demographic information of the children; sex, age, body weight, height,
age at diagnosis, and medications used were recorded. Pulmonary function
tests were evaluated with a portable spirometer (Spirobank MIR, Italy).
The Asthmatic Child Quality of Life Questionnaire was used to evaluate
the quality of life of children, and the Child Depression Scale was used
to evaluate their psychological state. All measurements were repeated at
baseline and after 3 weeks and evaluated.

\textbf{2.2.1 Pulmonary Function Test}

The respiratory function of the children was evaluated with a portable
spirometer (Spirobank MIR, Italy) according to the ATS/ERS criteria.
Each measurement was repeated three times and forced vital capacity
(FVC), forced expiratory volume in one second (FEV1), FEV1/FVC values,
and forced expiratory flow FEF 25-75 values were
recorded\textsuperscript{10}.

\textbf{2.2.2 Asthmatic Child Quality of Life Questionnaire}

It is used to evaluate the quality of life of children aged 7-17 years
by measuring the physical, mental, and social impairment specific to
asthma. It is a 23-item quality-of-life scale developed to measure the
physical, mental, and social disorders of children with asthma. This
scale comprises; Symptoms (items 4, 6, 8, 10, 12, 14, 16, 18, 20, 23),
Activity Limitation (items 1, 2, 3, 19, 22), and Emotional Function
(items 5, 7, 9, 11, 13, 15, 17, 21). The answers to the questions in the
scale consist of different propositions on two cards, the blue, and the
green card, and the answers on the two cards are made according to a
Likert classification of 1-7 points. ''1'' point for the lowest degree
and ''7'' point for the highest degree. The total score for all items is
23-161. Higher scores suggest a better quality of
life\textsuperscript{11}. Turkish validity and reliability were
performed by Bozkurt\textsuperscript{12}.

\textbf{2.2.3 Depression Scale for Children}

Children's depression status was evaluated with the Child Depression
Scale, which was developed by Kovacs et al. On this scale, which
consists of 27 items, 1,2,3 items are specified for each question, and
the score is 0 for 1, 1 for 2, and 2 for 3, with a maximum of 54 points.
A cut-off score of 19 is recommended, and as the score increases, the
severity of depression increases\textsuperscript{13,14}. The Turkish
reliability and validity of the scale were performed by
Oy\textsuperscript{15}.

\textbf{2.3 Digital Game Application}

Respiratory training was given with a digital game for children, which
is open to free access via the internet
https://play.google.com/store/apps/details?id=air.HappyLungs link
designed by Gokcek et al. The digital game contains brief information
about the respiratory system adapted to children, and it is a game whose
duration can be adjusted manually to follow the treatment process of the
patient, taking into account the \selectlanguage{ngerman}½ ratio in the inhalation and
exhalation process in the clinic. In this game with male and female
figures, the voice is used as a female voice for girls, a male voice for
boys, and a flower figure for breathing and blowing out the candle on
the cake during exhalation (Figures 2,3,4,5,6). The training was given 5
days a week for 15 minutes for 3 weeks.

\textbf{2.4 Statistical Analysis}

SPSS Windows 22.0 version was used in this study. As descriptive
statistics, mean ± standard deviation was given for numerical variables,
and number and \% values were given for categorical variables. The
conformity of the data to the normal distribution was tested with the
Shaphiro wilk test, 2 independent groups were compared with the
Mann-Whitney U test in nonparametric data. In addition, Intergroup was
compared with Wilcoxon Test in non-parametric for parametric data. The
significance level was determined as p\textless{}0.05.

\textbf{3. RESULTS}

\textbf{3.1 Demographic and clinical characteristics}

Children of the digital game group age were 12.44±1.50 years, their body
mass index was 22.65±7.20 kg/m\textsuperscript{2}, age at diagnosis was
6.77±3.88 years. The control group's age was 12.83±2.48 years, the mean
body mass index was 22.10±4.78 kg/m\textsuperscript{2}, age at diagnosis
was 6.00±4.85 years (Table 1).

The respiratory parameters of the digital game group were determined as
FVC\% (p=0.033), FEV1\% (p=0.044), FEV1/FVC\% (p= 0.593), FEF 25-75\%
(p= 0.327) after the training compared to before the training, while the
respiratory parameters of the control group after routine drug use were
as follows: FEV1\% (p=0.599), FEV1/FVC\% (p= 0.075), FEF 25-75\% (p=
0.753). There was a significant difference in FEV\textsubscript{1}\% and
FEV\textsubscript{1}/FVC\% values between the two groups
(p\textless{}0.05). It was observed that children who received digital
game respiratory training had an improvement in respiratory function
sub-parameters (Table 2).

\textbf{3.2 Quality of life and depression level of children with asthma
with the digital game application}

There was a statistically significant difference in the symptoms and
emotional functioning of the asthmatic children's quality of life
scale's sub-parameters, in the total scale score, and in the depression
status scale between pre- and post-training in the digital game group
(p\textless{}0.05). On the other hand, a significant difference was
found in symptom evaluation and total score in the sub-parameters of the
quality-of-life scale in the control group (p\textless{}0.05), while no
significant difference was found in mood (p\textgreater{}0.05). However,
no significant difference was found in the depression scale for children
in the control group (p\textgreater{}0.05). A significant difference was
found between the two groups in the post-training total scale scores and
the depression scale results for children (p\textless{}0.05). It was
found that the digital game group significantly increased the quality of
life in the field and had a positive effect on the psychological state
(Table 3).

\textbf{4. DISCUSSION}

In this study, respiratory training was given using digital media in
children diagnosed with asthma. With this training, it is aimed to
reduce the symptoms of asthma, has a positive effect on the
psychological state, and increases lung capacity and quality of life.

We found that lung training with digital games in asthma contributes
positively to pulmonary function test parameters, improves the quality
of life, and positively affects the psychological state.

Asthma is a disease that requires an application to health institutions
most frequently due to chronic respiratory diseases in our country and
worldwide. In asthma; diagnosis, chronic follow-up, and attack process
constitute a serious burden in terms of health insurance in our
country\textsuperscript{16}.

In the literature, it has been stated that asthma is more common in boys
than girls in childhood, and boys are admitted to the hospital about
twice as often as girls due to an attack\textsuperscript{17}. In our
study, 66.7\% of the digital game group was female, 33.3\% were male,
and 100\% of the control group was male.

Asthma symptoms include coughing, wheezing, shortness of breath, and
chest tightness\textsuperscript{18}. A pulmonary function test is one of
the diagnostic criteria for asthma, which is an obstructive disease.

Ghaffar et al. included 24 asthma patients in the 20-40 age range and
group A; divided them into two groups inspiratory muscle training and
group B conventional rehabilitation. They trained 3 sessions a week for
6 weeks. At the end of 6 weeks, there was no statistically significant
difference in pulmonary function test results between the two
groups\textsuperscript{19}. In our study, while there was no significant
difference in FVC\% between the digital game group and the control
group, it was determined that there was a significant difference in
FEV\textsubscript{1} and FEV\textsubscript{1}/FVC\% after training, and
there was a positive improvement in respiratory function sub-parameters
in the digital game group.

Quality of life is significantly reduced in children with asthma
compared to their peers\textsuperscript{20}. In order to control the
disease, it is stated in the literature that besides the treatment, the
training of the patients is necessary and important for regular
follow-up. It is emphasized that patient training significantly
increases the quality of life\textsuperscript{21}.

In addition to pharmacological applications to reduce symptom control in
the treatment of asthma, the importance of non-pharmacological
recommendations (patient training, physical activity,
etc.)\textsuperscript{22}. Breathing exercise, which plays an active
role in increasing the efficiency of respiratory muscles, providing
airway cleaning, and enlarging the parenchyma, is an integral part of
chest physiotherapy\textsuperscript{23}. In our study, it was determined
that the digital game containing respiratory training increased the
quality of life of children with asthma. Although the quality of life of
the children increased only with the use of drugs in the control group,
it was observed that respiratory training in the digital game supported
medical treatment and provided a significant increase compared to the
control group.

Having an attack, absenteeism from school, and hospitalization due to
chronic diseases are common in children with asthma\textsuperscript{24}.
Baek et al. included 290 children with asthma in the study. The 130
children included in the study were given a 60-90-minute face-to-face
home-based asthma training program by healthcare professionals, and the
control group received only basic information material without any
direct information. As a result of the 3-month follow-up, there was no
statistically significant difference between the groups, although there
were positive developments in the physical health of the two groups, the
activity of the child, and the emotional health of the
child\textsuperscript{25}. In our study, 9 children with asthma were
given respiratory training with digital games at home, and 6 control
groups were followed up with routine drug use. It was observed that the
children in our digital game group contributed positively to the
symptoms of illness and emotional function.

Asthma, which is common in childhood, is a chronic disease that causes
significant limitations in children's movements and significantly
affects children's quality of life. Along with physical limitations, the
disease causes negative social and emotional
effects\textsuperscript{26,27}. In this study, it was observed that the
digital game containing respiratory training had a positive effect on
the psychological state of children and a decrease in the level of
depression.

\textbf{4.1 Limitation}

The small number of individuals participating in the study and the lack
of a suitable sex distribution is the limitations of our study. In order
to generalize the study, it is predicted that the inclusion and
evaluation of more individuals are important in terms of the
effectiveness of the digital game.

\textbf{5. CONCLUSION}

Children in our digital game group showed statistically significant
improvements after treatment compared to pre-treatment, and it was
determined that it had a positive effect on the quality of life and
depression after treatment compared to the control group. In this case,
it was determined that the application of physiotherapy in technological
environments, which is widely used as a support for medical treatment,
has a positive effect on the patient.

\textbf{CONFLICT OF INTERESTS}

The authors declare that there are no conflicts of interest.

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\end{enumerate}

\textbf{Hosted file}

\verb`figure 1 consort flow diagram_2.doc`  available at \url{https://authorea.com/users/605261/articles/634812-effect-of-respiratory-training-digital-game-on-respiratory-functions-and-psychological-status-in-childhood-asthma}

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\verb`figure 2,3,4,5,6.docx`  available at \url{https://authorea.com/users/605261/articles/634812-effect-of-respiratory-training-digital-game-on-respiratory-functions-and-psychological-status-in-childhood-asthma}

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\verb`Table 1.docx`  available at \url{https://authorea.com/users/605261/articles/634812-effect-of-respiratory-training-digital-game-on-respiratory-functions-and-psychological-status-in-childhood-asthma}

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\verb`Table 2.docx`  available at \url{https://authorea.com/users/605261/articles/634812-effect-of-respiratory-training-digital-game-on-respiratory-functions-and-psychological-status-in-childhood-asthma}

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\verb`Table 3.docx`  available at \url{https://authorea.com/users/605261/articles/634812-effect-of-respiratory-training-digital-game-on-respiratory-functions-and-psychological-status-in-childhood-asthma}

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