Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial

What attributes of digital devices are important to clinicians in rehabilitation? A cross-cultural best-worst scaling study

BACKGROUND

Digital interventions are becoming increasingly popular in rehabilitation. Understanding of device features which impact clinician adoption and satisfaction is limited. Research in the field should be conducted across diverse settings to ensure digital interventions do not exacerbate healthcare inequities.

OBJECTIVE

This study aimed to understand rehabilitation clinicians' preferences regarding device attributes and included a cross-cultural comparison.

MATERIALS AND METHODS

Choice experiment methodology (best-worst scaling) was used to survey rehabilitation clinicians across Australia and Brazil. Participants completed 10 best-worst questions, choosing the most and least important device attributes from subsets of 31 attributes in a partially balanced block design. Results were analysed using multinomial models by country and latent class. Attribute preference scores (PS) were scaled to 0-100 (least to most important).

RESULTS

A total of 122 clinicians from Brazil and 104 clinicians from Australia completed the survey. Most respondents were physiotherapists (83%) working with neurological populations (51%) in the private/self-employed sector (51%) who had experience using rehabilitation devices (87%). Despite preference heterogeneity across country and work sector (public/not-for-profit versus private/self-employed/other), clinicians consistently prioritised patient outcomes (PS 100.0, 95%CI: 86.2-100.0), patient engagement (PS 93.9, 95%CI: 80.6-94.2), usability (PS 81.3, 95%CI: 68.8-82.5), research evidence (PS 80.4, 95%CI: 68.1-81.7) and risk (PS 75.7, 95%CI: 63.8-77.3). In Australia, clinicians favoured device attributes which facilitate increased therapy dosage (PS 79.2, 95%CI: 62.6-81.1) and encourage patient independent practice (PS 66.8, 95%CI: 52.0-69.2). In Brazil, clinicians preferred attributes enabling device use for providing clinical data (PS 67.6, 95%CI: 51.8-70.9) and conducting clinical assessments (PS 65.6, 95%CI: 50.2-68.8).

CONCLUSION

Clinicians prioritise patients' needs and practical application over technical aspects of digital rehabilitation devices. Contextual factors shape clinician preferences rather than individual clinician characteristics. Future device design and research should consider preferences and influences, involving diverse stakeholders to account for context-driven variations across cultures and healthcare settings.

Current experience and future potential of facilitating access to digital NHS primary care services in England: the Di-Facto mixed-methods study

Background

Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate 'digital facilitation' - that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services.

Objectives

Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support.

Design

Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings.

Setting

General practice in four regions of England.

Participants

Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants.

Intervention

Digital facilitation as undertaken in general practice.

Main outcome measures

Patient and practice staff reported use of, and views of, digital facilitation.

Data sources

Surveys, qualitative research; national General Practitioner Patient Survey (2019-22).

Review methods

Scoping-review methodology applied to academic and grey literature published 2015-20.

Results

While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of 'others'. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients.

Limitations

The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork.

Conclusions

Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution.

Future work

We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention.

Study registration

This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.

Digital Apps to Improve Mobility in Adults with Neurological Conditions: A Health App-Focused Systematic Review

The provision of mobility exercises through a smartphone application (app) for people undertaking neurological rehabilitation may improve mobility outcomes. However, it is difficult for clinicians and consumers to select high-quality, appropriate apps. This review aimed to identify (1) which mobile health (mHealth) apps are suitable for prescribing mobility exercises for adults with neurological health conditions, (2) how well these apps incorporate telehealth strategies, and (3) how well these apps rate in terms of quality and capacity for behaviour change. The Australian Apple iTunes Store was systematically searched, by using a search code and manually, for apps suitable for training mobility in neurological rehabilitation. Additional searches were conducted in known app repositories and for web-based apps. Trained reviewers extracted data from the included apps, including population-specific characteristics; quality, by using the Mobile App Rating Scale (MARS); and behaviour change potential, by using the App Behaviour Change Scale (ABACUS). The included apps (n = 18) provided <50 to >10,000 exercises, many incurred a subscription fee (n = 13), and half included telehealth features. App quality was moderate (mean MARS score of 3.2/5 and SD of 0.5), and potential for behaviour change was poor (mean ABACUS score of 5.7/21 and SD of 2.1). A limited number of high-quality apps are available for the prescription of mobility exercises in people with neurological conditions.

Responsiveness of Patient-Reported and Device-Based Physical Activity Measures: Secondary Analysis of Four Randomized Trials

PURPOSE

This study aimed to compare the responsiveness of patient-reported and device-based instruments within four physical activity trials.

METHODS

This was a secondary analysis of four randomized trials that used both a patient-reported outcome measure (the Incidental and Planned Exercise Questionnaire (IPEQ)) and a device-based instrument (ActiGraph or ActivPAL) to measure physical activity. The four trials included were (i) Activity and MObility UsiNg Technology (AMOUNT), digitally enabled exercises in those undertaking aged care and neurological rehabilitation; (ii) Balance Exercise Strength Training at Home, home-based balance and strength exercises in community-dwelling people 65 yr or older; (iii) Coaching for Healthy Ageing (CHAnGE), physical activity coaching and fall prevention intervention in community-dwelling people 60 yr or older; and (iv) Fitbit trial, fall prevention and physical activity promotion with health coaching and activity monitor in community-dwelling people 60 yr or older. We estimated treatment effects for all variables within each physical activity instrument using regression analyses and expressed results as effect sizes (ES).

RESULTS

Overall, device-based instruments were more responsive among healthy older adults (ES range, 0.01 to 0.32), whereas the IPEQ was more responsive among adults requiring rehabilitation (ES range, -0.06 to 0.35). Both the IPEQ and device-based instruments were more responsive in trials that promoted walking via coaching participants to increase their daily steps (AMOUNT (ES range, -0.06 to 0.35), CHAnGE (ES range, -0.24 to 0.22), and Fitbit trial (ES range, -0.23 to 0.32)). Individual variables within the IPEQ and device-based instruments varied in their responsiveness (ES range, -0.13 to 0.20).

CONCLUSIONS

Both the IPEQ and device-based instruments are able to detect small changes in physical activity levels. However, responsiveness varies across different interventions and populations. Our findings provide guidance for researchers and clinicians in selecting an appropriate instrument to measure changes in physical activity.

Physiotherapy-led telehealth and exercise intervention to improve mobility in older people receiving aged care services (TOP UP): protocol for a randomised controlled type 1 hybrid effectiveness-implementation trial

Introduction

Deteriorating mobility and falls reduce independence and quality of life for older people receiving aged care services. This trial aims to establish effectiveness on the mobility of older people, and explore cost-effectiveness and implementation of a telehealth physiotherapy programme.

Method and analysis

This type 1 hybrid effectiveness-implementation randomised controlled trial will involve 240 people aged 65+ years receiving aged care services in community or residential settings. Participants will be randomised to either: (1) the Telehealth Physiotherapy for Older People (TOP UP) Program or (2) a wait-list control group. The 6-month intervention includes 10 physiotherapy sessions delivered by videocall (Zoom). The intervention will include the local support of an aged care worker and online exercise resources. Primary outcome is mobility at 6 months post randomisation measured by the Short Physical Performance Battery. Secondary outcomes include rate of falls, sit-to-stand, quality of life, and goal attainment at 6 months after randomisation. Regression models will assess the effect of group allocation on mobility and the other continuously scored secondary outcomes, adjusting for baseline scores. The number of falls per person over 6 months will be analysed using negative binomial regression models to estimate between-group differences. An economic analysis will explore the cost-effectiveness of the TOP UP programme compared with usual care. Implementation outcomes and determinants relating to the intervention's reach, fidelity, exercise dose delivered, adoption, feasibility, acceptability, barriers and facilitators will be explored using mixed methods.

Conclusion

This is the first trial to investigate the effectiveness, cost-effectiveness and implementation of a physiotherapy intervention in aged care delivered solely by telehealth internationally. The study has strong aged care co-design and governance and is guided by steering and advisory committees that include staff from aged care service providers and end-users. Trial results will be disseminated via peer-reviewed articles, conference presentations and lay summaries.

Trial registration number

The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12621000734864).

Implementation of digital health interventions in rehabilitation: A scoping review

OBJECTIVE

Digital health interventions have potential to enhance rehabilitation services by increasing accessibility, affordability and scalability. However, implementation of digital interventions in rehabilitation is poorly understood. This scoping review aims to map current strategies, research designs, frameworks, outcomes and determinants used to support and evaluate the implementation of digital interventions in rehabilitation.

DATA SOURCES

Comprehensive searches from inception until October 2022 of MEDLINE, CINAHL, PsycINFO, PEDro, SpeechBITE, NeuroBITE, REHABDATA, WHO International Clinical Trial Registry and the Cochrane Library.

METHODS

Two reviewers screened studies against the eligibility criteria. Implementation science taxonomies and methods, including Powell et al.'s compilation of implementation strategies, were used to guide analysis and synthesis of findings.

RESULTS

The search retrieved 13,833 papers and 23 studies were included. Only 4 studies were randomised controlled trials and 9 studies (39%) were feasibility studies. Thirty-seven discrete implementation strategies were reported across studies. Strategies related to training and educating clinicians (91%), providing interactive assistance (61%), and developing stakeholder interrelationships (43%) were most frequently reported. Few studies adequately described implementation strategies and methods for selecting strategies. Almost all studies measured implementation outcomes and determinants; most commonly, acceptability, compatibility and dose delivered of digital interventions.

CONCLUSION

The rigour of implementation methods in the field is currently poor. Digital interventions require carefully planned and tailored implementation to facilitate successful adoption into rehabilitation practice. To keep pace with rapidly advancing technology, future rehabilitation research should prioritise using implementation science methods to explore and evaluate implementation while testing effectiveness of digital interventions.

Clinician experiences with using assistive technology in brain injury rehabilitation: a survey of clinician capability, attitudes, and barriers

BACKGROUND

The rise in assistive technology (AT) solutions to support people with an acquired brain injury (ABI) has warranted clinicians to build capability in assisting clients to select goal-centred AT. The study explored, amongst ABI clinicians, (a) capability, attitudes, and barriers with AT implementation, (b) age-related differences in technology self-efficacy and capability (c) strategies to support AT use in rehabilitation and (d) thematic analysis of AT-related experiences.

METHOD

Mixed methods design. Online survey circulated to ABI clinicians across New South Wales, Australia, comprising purpose-designed items as well as the Modified Computer Self-Efficacy Scale (MCSES; range 0-100).

RESULTS

Clinicians (n = 123) were evenly distributed across decadal age groups. The majority were female (90%, n = 111) and one-third were occupational therapists.Clinicians scored strongly on the MCSES (Mdn = 76, IQR = 19), with younger age groups significantly associated with higher scores (H[3] = 9.667, p = .022). Most clinicians (92%) were knowledgeable of mainstream technology for personal use, but over half (65%) reported insufficient knowledge of suitable AT for clients. Clinicians reported positive attitudes towards AT, however, time to research and develop proficiency with a range of AT was the primary barrier (81%).Thematic analysis suggested that whilst the ideal AT experience is client-motivated requiring multidisciplinary guidance, the clinician role and experience with AT is evolving, influenced by rapid technological advancement and extrinsic opportunities to access AT.

CONCLUSIONS

Whilst clinicians have positive attitudes towards AT, there is a gap in clinician implementation. There is need to support further resources to build clinician capability and access to AT.

Interventions Using Wearable Activity Trackers to Improve Patient Physical Activity and Other Outcomes in Adults Who Are Hospitalized: A Systematic Review and Meta-analysis

Importance

Low levels of physical activity during hospitalization are thought to contribute to a range of poor outcomes for patients. Using wearable activity trackers during hospitalization may help improve patient activity, sedentary behavior, and other outcomes.

Objective

To evaluate the association of interventions that use wearable activity trackers during hospitalization with patient physical activity, sedentary behavior, clinical outcomes, and hospital efficiency outcomes.

Data Sources

OVID MEDLINE, CINAHL, Embase, EmCare, PEDro, SportDiscuss, and Scopus databases were searched from inception to March 2022. The Cochrane Central Register for Controlled trials, ClinicalTrials.gov, and World Health Organization Clinical Trials Registry were also searched for registered protocols. No language restrictions were imposed.

Study Selection

Randomized clinical trials and nonrandomized clinical trials of interventions that used wearable activity trackers to increase physical activity or reduce sedentary behavior in adults (aged 18 years or older) who were hospitalized were included.

Data Extraction and Synthesis

Study selection, data extraction, and critical appraisal were conducted in duplicate. Data were pooled for meta-analysis using random-effects models. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed.

Main Outcomes and Measures

The primary outcomes were objectively measured physical activity or sedentary behavior. Secondary outcomes included clinical outcomes (eg, physical function, pain, mental health), and hospital efficiency outcomes (eg, length of stay, readmission).

Results

Fifteen studies with a total of 1911 participants were included, representing various surgical cohorts (4 studies), stroke rehabilitation (3 studies), orthopedic rehabilitation (3 studies), mixed rehabilitation (3 studies), and mixed medical (2 studies). All studies were included in meta-analyses. There was a significant association between wearable activity tracker interventions with higher overall physical activity (standardized mean difference, 0.35; 95% CI, 0.15 to 0.54; I2 = 72%; P < .002) and less sedentary behavior (mean difference, -35.46 min/d; 95% CI, -57.43 to -13.48 min/d; I2 = 0; P = .002), and a significant association between wearable activity tracker interventions with improvements in physical function (standardized mean difference, 0.27; 95% CI, 0.08 to 0.46; I2 = 0; P = .006) compared with usual care. There was no significant association between wearable activity tracker interventions with pain, mental health, length of stay, or readmission risk.

Conclusions and Relevance

In this systematic review and meta-analysis, interventions that used wearable activity trackers with patients who are hospitalized were associated with higher physical activity levels, less sedentary behavior, and better physical functioning compared with usual care.

Economic evaluation of digitally enabled aged and neurological rehabilitation care in the Activity and MObility UsiNg Technology (AMOUNT) trial

OBJECTIVE

To investigate the trial-based cost-effectiveness of the addition of a tailored digitally enabled exercise intervention to usual care shown to be clinically effective in improving mobility in the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial compared to usual care alone.

DESIGN

Economic evaluation alongside a pragmatic randomized controlled trial.

PARTICIPANTS

300 people receiving inpatient aged and neurological rehabilitation were randomized to the intervention (n = 149) or usual care control group (n = 151).

MAIN MEASURES

Incremental cost effectiveness ratios were calculated for the additional costs per additional person demonstrating a meaningful improvement in mobility (3-point in Short Physical Performance Battery) and quality-adjusted life years gained at 6 months (primary analysis). The joint probability distribution of costs and outcomes was examined using bootstrapping.

RESULTS

The mean cost saving for the intervention group at 6 months was AU$2286 (95% Bootstrapped cost CI: -$11,190 to $6410) per participant; 68% and 67% of bootstraps showed the intervention to be dominant (i.e. more effective and cost saving) for mobility and quality-adjusted life years, respectively. The probability of the intervention being cost-effective considering a willingness to pay threshold of AU$50,000 per additional person with a meaningful improvement in mobility or quality-adjusted life year gained was 93% and 77%, respectively.

CONCLUSIONS

The AMOUNT intervention had a high probability of being cost-effective if decision makers are willing to pay AU$50,000 per meaningful improvement in mobility or per quality-adjusted life year gained, and a moderate probability of being cost-saving and effective considering both outcomes at 6 months post randomization.

Implementing digital devices to increase mobility training for people receiving inpatient rehabilitation: protocol for a feasibility hybrid type II randomized controlled trial

BACKGROUND

People with mobility limitations can benefit from rehabilitation programs incorporating intensive, repetitive, and task-specific exercises using digital devices such as virtual reality gaming systems, tablet and smartphone applications, and wearable devices. The Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial (n = 300) showed improvements in mobility in people using these types of digital devices in addition to their usual rehabilitation care when the intervention was provided by an additional study-funded physiotherapist. However, it is not clear if this intervention can be implemented by hospital physiotherapists with a usual clinical load. The AMOUNT Implementation trial aims to explore the feasibility of conducting a large-scale implementation trial.

METHODS

A pragmatic, assessor blinded, feasibility hybrid type II randomized controlled trial will be undertaken at a public hospital in Australia. There will be two phases. Phase I (Implementation phase) will involve implementing the digital devices into physiotherapy practice. Physiotherapists from the rehabilitation ward will receive a multifaceted implementation strategy guided by the Capabilities, Opportunities, Motivation-Behaviour (COM-B) theoretical model. The implementation strategy includes identifying and training a clinical champion; providing digital devices and education and training; facilitating use of the devices through clinical reasoning sessions and journal clubs; and audit and feedback of exercise dosage documentation. Phase II (Trial phase) will involve randomising 30 eligible inpatients from the same ward into either usual care or usual care plus an additional 30 min or more of exercises using digital devices. This intervention will be provided by the physiotherapists who took part in the implementation phase. We will collect data on feasibility, implementation, and patient-level clinical outcomes. The three primary outcome measures are the extent to which physiotherapists document the dosage of exercises provided to participants (feasibility criteria: exercise practice sheets complete for ≥85% of all participants); ability to recruit participants; and fidelity to the protocol of using digital devices to prescribe exercises (feasibility criteria: average of ≥ 30mins per day for > 50% intervention participants).

DISCUSSION

This feasibility study will provide important information to guide the planning and conduct of a future large-scale implementation trial.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry; ACTRN12621000938808; registered 19/07/2021. Trial sponsor: Prince of Wales Hospital. 320-346 Barker Street, Randwick, NSW, 2031, Australia.

PROTOCOL VERSION

6.2 7th April 2021.

"It's been a long hard road": challenges faced in the first three years following traumatic brain injury

PURPOSE

There is limited qualitative research exploring challenges experienced following severe traumatic brain injury (TBI). We investigated challenges to recovery identified by individuals who sustained severe TBI three years earlier or their close others (COs), as well as suggestions for managing these challenges.

MATERIALS AND METHODS

Nine participants with TBI and 16 COs completed semi-structured interviews. Using reflexive thematic analysis, challenges were identified across several timeframes (i.e., at the injury, acute care, inpatient rehabilitation, outpatient rehabilitation, and at home/other location).

RESULTS

Challenges experienced across all timeframes included: lack of information and poor communication, pre-existing conditions, missed injuries, and issues with medical staff, and continuity of care. From acute care onwards, there were TBI-related consequences, issues with coping and emotional adjustment, negative outlook, insufficient treatment, lack of support for COs, and issues with compensation and funding for rehabilitation needs. Some challenges were unique to a specific timeframe (e.g., over-stimulating ward setting during acute care, and limited or unsupportive families once injured individuals went home). Suggestions for managing some of the challenges were provided (e.g., information provision, having peer supports).

CONCLUSION

Suggestions should be considered to promote successful outcomes following severe TBI.IMPLICATIONS FOR REHABILITATIONRecovery following a severe traumatic brain injury can be hindered by challenges, such as poor communication, limited information provision, injury-related consequences, limited services and emotional support for the injured individual and their Close Others, and a need for education of the broader community about traumatic brain injury.Suggestions for managing these challenges (e.g., peer supports; services closer to home) could be used to inform clinical guidelines that could be used in a rehabilitation context.These suggestions ultimately aim to improve the post-injury experience and outcomes of individuals with traumatic brain injury and their Close Others.

Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

BACKGROUND

The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.

OBJECTIVE

This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.

METHODS

Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.

RESULTS

A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.

CONCLUSIONS

Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.

The effectiveness of physical activity interventions using activity trackers during or after inpatient care: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Promoting physical activity (PA) in patients during and/or after an inpatient stay appears important but challenging. Interventions using activity trackers seem promising to increase PA and enhance recovery of physical functioning.

OBJECTIVE

To review the effectiveness of physical activity interventions using activity trackers on improving PA and physical functioning, compared to usual care in patients during and/or after inpatient care. In addition, it was determined whether the following intervention characteristics increase the effectiveness of these interventions: the number of behaviour change techniques (BCTs) used, the use of a theoretical model or the addition of coaching by a health professional.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Cinahl, SportDiscus and Web of Science databases were searched in March 2020 and updated in March 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomized controlled trials (RCTs) including interventions using activity trackers and feedback on PA in adult patients during, or less than 3 months after, hospitalization or inpatient rehabilitation.

METHODS

Following database search and title and abstract screening, articles were screened on full text for eligibility and then assessed for risk of bias by using the Physiotherapy Evidence Database (PEDro) scale. Meta-analyses, including subgroup analysis on intervention characteristics, were conducted for the outcomes PA and physical functioning.

RESULTS

Overall, 21 RCTs totalling 2355 patients were included. The trials covered a variety of clinical areas. There was considerable heterogeneity between studies. For the 13 studies that measured PA as an outcome variable(N = 1435), a significant small positive effect in favour of the intervention was found (standardized mean difference (SMD) = 0.34; 95%CI 0.12-0.56). For the 13 studies that measured physical functioning as an outcome variable (N = 1415) no significant effect was found (SMD = 0.09; 95%CI -0.02 - 0.19). Effectiveness on PA seems to improve by providing the intervention both during and after the inpatient period and by using a theoretical model, multiple BCTs and coaching by a health professional.

CONCLUSION

Interventions using activity trackers during and/or after inpatient care can be effective in increasing the level of PA. However, these improvements did not necessarily translate into improvements in physical functioning. Several intervention characteristics were found to increase the effectiveness of PA interventions.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42020175977 ) on March 23th, 2020.

Brief physical activity counselling by physiotherapists (BEHAVIOUR): protocol for an effectiveness-implementation hybrid type II cluster randomised controlled trial

BACKGROUND

Physical inactivity is a leading risk factor for chronic disease. Brief physical activity counselling delivered within healthcare systems has been shown to increase physical activity levels; however, implementation efforts have mostly targeted primary healthcare and uptake has been sub-optimal. The Brief Physical Activity Counselling by Physiotherapists (BEHAVIOUR) trial aims to address this evidence-practice gap by evaluating (i) the effectiveness of a multi-faceted implementation strategy, relative to usual practice for improving the proportion of patients receiving brief physical activity counselling as part of their routine hospital-based physiotherapy care and (ii) effectiveness of brief physical activity counselling embedded in routine physiotherapy care, relative to routine physiotherapy care, at improving physical activity levels among patients receiving physiotherapy care.

METHODS

Effectiveness-implementation hybrid type II cluster randomised controlled trial with embedded economic evaluation, qualitative study and culturally adapted patient-level outcome measures. The trial will be conducted across five hospitals in a local health district in Sydney, Australia, with a lower socioeconomic and culturally diverse population. The evidence-based intervention is brief physical activity counselling informed by the 5As counselling model and behavioural theory, embedded into routine physiotherapy care. The multi-faceted strategy to support the implementation of the counselling intervention was developed with key stakeholders guided by the Consolidated Framework for Implementation Research and the Capabilities, Opportunities, Motivation-Behaviour (COM-B) theoretical model, and consists of clinician education and training, creating a learning collaborative, tailored strategies to address community referral barriers, team facilitation, and audit and feedback. Thirty teams of physiotherapists will be randomised to receive the multi-faceted implementation strategy immediately or after a 9-month delay. Each physiotherapy team will recruit an average of 10 patients (n=300) to collect effectiveness outcomes at baseline and 6 months. The primary effectiveness outcome is self-reported planned physical activity using the Incidental and Planned Exercise Questionnaire, and the primary implementation outcome is reach (proportion of eligible new physiotherapy patients who receive brief physical activity counselling). Secondary effectiveness and implementation outcomes will also be collected.

DISCUSSION

This project focuses on physiotherapists as health professionals with the requisite skills and patterns of practice to tackle the increasing burden of chronic disease in a high-risk population.

TRIAL REGISTRATION

ANZCTR, ACTRN12621000194864 . Registered on 23 February 2021.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment

Background

Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity.

Methods

Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team.

Results

Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually “gave up” trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC.

Conclusions

Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study.

Trial registration

ClinicalTrials.gov NCT 04045054 05/08/2019.

Usability of affordable feedback-based technologies to improve mobility and physical activity in rehabilitation: a mixed methods study

PURPOSE

To explore physiotherapists' views on the usability of feedback-based technologies used in physical rehabilitation.

MATERIALS AND METHODS

A mixed methods study which was nested within a randomised controlled trial to investigate the effectiveness of affordable feedback-based technologies to improve mobility and physical activity within aged care and neurological rehabilitation. Technologies included virtual reality systems, handheld device apps and wearable devices. Physiotherapists (n = 11) who were involved in prescribing technologies during the trial rated the usability of 11 different devices using the System Usability Scale (SUS), then attended a focus group. Descriptive statistics and framework analysis were used for analysis.

RESULTS

Fitbit devices (mean 89.8, SD 9.3), Fysiogaming (mean 75.6, SD 15.3) and Xbox Kinect (mean 75.5, SD 11.2) rated in the acceptable range (>70) on the SUS. Three key factors on usability emerged from the focus groups: (1) Key device features relating to practicalities (ease of set up and use, reliability, safety) and therapeutic benefit (customisation, high active practice time, useful feedback) are important for usability; (2) Usability depends on the context of use; and (3) Usability can be enhanced with technical, clinical, environmental and financial support.

CONCLUSIONS

Health service managers and clinicians should consider key device features identified, contextual factors of their service, and supports available when selecting technologies for use in clinical practice. Further collaboration between clinicians, researchers and technology developers would benefit future technology development, particularly taking into consideration the identified key device features from this study.IMPLICATIONS FOR REHABILITATIONTechnology selection should be based on key device features relating to both practicalities and therapeutic benefit.Contextual factors and available supports should also be considered when selecting technologies.Key usability features identified in this study such as ease of set up, reliability and customisability should be considered in the design of future feedback-based technologies to optimise usability in physical rehabilitation.

Perspectives of older adults with chronic disease on the use of wearable technology and video games for physical activity

BACKGROUND

There is increasing interest in technology to deliver physical rehabilitation and allow clinicians to monitor progress. Examples include wearable activity trackers and active video games (AVGs), where physical activity is required to play the game. However, few studies have explored what may influence the effectiveness of these as technology-based physical activity interventions in older adults with chronic diseases.

OBJECTIVE

This study aimed to explore: 1) perceptions about wearable physical activity trackers; 2) perceptions about using technology to share physical activity information with clinicians; 3) barriers and motivators to playing games, including AVGs for rehabilitation.

METHODS

Qualitative study based on semi-structured interviews with older adults (n = 19) with chronic obstructive pulmonary disease (COPD).

RESULTS

Wearable activity trackers were perceived as useful to quantify activity, facilitate goal-setting, visualize long-term improvements and provide reminders. Participants generally wished to share data with their clinicians to gain greater accountability, receive useful feedback and improve the quality of clinical care. Participants were motivated to play games (including AVGs) by seeking fun, social interaction and health benefits. Some felt that AVGs were of no benefit or were too difficult. Competition was both a motivator and a barrier.

CONCLUSIONS

The findings of the present study seek to inform the design of technology to encourage physical activity in older adults with chronic diseases.

Haptic Nudges Increase Affected Upper Limb Movement During Inpatient Stroke Rehabilitation: Multiple-Period Randomized Crossover Study

BACKGROUND

As many as 80% of stroke survivors experience upper limb (UL) disability. The strong relationships between disability, lost productivity, and ongoing health care costs mean reducing disability after stroke is critical at both individual and society levels. Unfortunately, the amount of UL-focused rehabilitation received by people with stroke is extremely low. Activity monitoring and promotion using wearable devices offer a potential technology-based solution to address this gap. Commonly, wearable devices are used to deliver a haptic nudge to the wearer with the aim of promoting a particular behavior. However, little is known about the effectiveness of haptic nudging in promoting behaviors in patient populations.

OBJECTIVE

This study aimed to estimate the effect of haptic nudging delivered via a wrist-worn wearable device on UL movement in people with UL disability following stroke undertaking inpatient rehabilitation.

METHODS

A multiple-period randomized crossover design was used to measure the association of UL movement with the occurrence of haptic nudge reminders to move the affected UL in 20 people with stroke undertaking inpatient rehabilitation. UL movement was observed and classified using movement taxonomy across 72 one-minute observation periods from 7:00 AM to 7:00 PM on a single weekday. On 36 occasions, a haptic nudge to move the affected UL was provided just before the observation period. On the other 36 occasions, no haptic nudge was given. The timing of the haptic nudge was randomized across the observation period for each participant. Statistical analysis was performed using mixed logistic regression. The effect of a haptic nudge was evaluated from the intention-to-treat dataset as the ratio of the odds of affected UL movement during the observation period following a "Planned Nudge" to the odds of affected limb movement during the observation period following "No Nudge."

RESULTS

The primary intention-to-treat analysis showed the odds ratio (OR) of affected UL movement following a haptic nudge was 1.44 (95% CI 1.28-1.63, P<.001). The secondary analysis revealed an increased odds of affected UL movement following a Planned Nudge was predominantly due to increased odds of spontaneous affected UL movement (OR 2.03, 95% CI 1.65-2.51, P<.001) rather than affected UL movement in conjunction with unaffected UL movement (OR 1.13, 95% CI 0.99-1.29, P=.07).

CONCLUSIONS

Haptic nudging delivered via a wrist-worn wearable device increases affected UL movement in people with UL disability following stroke undertaking inpatient rehabilitation. The promoted movement appears to be specific to the instructions given.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry 12616000654459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370687&isReview=true.

Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial - description of device use and physiotherapy support in the post-hospital phase

PURPOSE

To describe device use and physiotherapy support in the post-hospital phase of the AMOUNT rehabilitation trial.

METHODS

We performed an evaluation of the support required for device use by participants randomised to the intervention group who received digitally-enabled rehabilitation in the post-hospital phase (n = 144). Intervention, additional to standard rehabilitation, utilised eight digital devices (virtual reality videogames, activity monitors and handheld computer devices) to improve mobility and increase physical activity. Participants were taught to use devices during inpatient rehabilitation and were then discharged home to use the devices for the remainder of the 6-month trial. Physiotherapist-participant contact occurred every 1-2 weeks using a health coaching approach, including technology support when required. Intervention datasheets were audited, and descriptive statistics used to report device use and support required.

RESULTS

Participants (mean (SD) age 70 (18) years; 49% neurological health conditions) used an average of 2 (SD 1) devices (98% used an activity monitor). Eight percent of physiotherapy contact included technology support with 30% provided remotely. Support addressed 845 issues categorised under initial set-up and instruction (27%), education and training (31%), maintenance (23%) and trouble-shooting (19%).

CONCLUSION

Digital devices can be used for home-based rehabilitation, but ongoing technology support is essential. Clinical Trials Registry: ACTRN12614000936628IMPLICATIONS FOR REHABILITATIONDigital device use at home to support long-term management of health conditions is likely to become increasingly important as the need for rehabilitation increases and rehabilitation resources become more limited.Technology support for set-up and ongoing device use is a critical enabler of home-based digital interventions.Health professionals delivering home-based digital interventions require sufficient training and equipment and may need to vary the mode (e.g., home visit vs. telephone or video conference) depending on the technology support required.

App-based supplemental exercise in rehabilitation, adherence, and effect on outcomes: a randomized controlled trial

QUESTION

To determine the uptake of an app-based supplemental exercise programme in a rehabilitation setting and the effect of such a programme on length of stay and function compared to usual care physiotherapy.

DESIGN

Randomized controlled trial with random allocation and assessor blinding.

PARTICIPANTS

A total of 144 individuals with mixed diagnoses (orthopaedic, neurological, reconditioning) admitted for inpatient sub-acute rehabilitation.

INTERVENTIONS

Participants were randomly allocated to usual care physiotherapy (control group) or usual care physiotherapy with the addition of an app-based supplemental exercise programme (intervention group).

OUTCOME MEASURES

The primary measure of interest was total supplementary exercise dosage completed by the intervention group. The primary between-group outcome measure was length of stay with secondary measures including walking endurance (Six-Minute Walk Test), walking speed (10-Metre Walk Test), functional mobility (Timed Up and Go Test) and level of disability (Functional Independence Measure).

RESULTS

Participants in the intervention group performed 7 minutes (SD: 9) or 49 repetitions (SD: 48) of supplementary exercise using the app each day. There were no differences between the groups for length of stay (mean difference (MD): -0.5 days, 95% confidence interval (CI): -3.2 to 2.2) or change in any secondary functional outcome measures, including walking speed (MD: -0.1 m/s, 95% CI: -0.2 to 0.0) and disability (MD: -0.9, 95% CI: -3.6 to 1.8).

CONCLUSION

A small supplementary exercise dose was achieved by participants in the intervention group. However, such a programme did not affect length of stay or functional outcomes when compared to usual care.