Motivational cues as real-time feedback for changing daily activity behavior of patients with COPD

Technological features of smartphone apps for physical activity promotion in patients with CxsOPD: A systematic review

INTRODUCTION

Low physical activity (PA) levels have a negative impact on the health status of patients with Chronic Obstructive Pulmonary Disease (COPD). Smartphone applications (apps) focused on PA promotion may mitigate this problem; however, their effectiveness depends on patient adherence, which can be influenced by the technological features of the apps. This systematic review identified the technological features of smartphone apps aiming to promote PA in patients with COPD.

METHODS

A literature search was performed in the databases ACM Digital Library, IEEE Xplore, PubMed, Scopus and Web of Science. Papers including the description of a smartphone app for PA promotion in patients with COPD were included. Two researchers independently selected studies and scored the apps features based on a previously developed framework (38 possible features).

RESULTS

Twenty-three studies were included and 19 apps identified, with an average of 10 technological features implemented. Eight apps could be connected to wearables to collect data. The categories 'Measuring and monitoring' and 'Support and Feedback' were present in all apps. Overall, the most implemented features were 'progress in visual format' (n = 13), 'advice on PA' (n = 14) and 'data in visual format' (n = 10). Only three apps included social features, and two included a web-based version of the app.

CONCLUSIONS

The existing smartphone apps include a relatively small number of features to promote PA, which are mostly related to monitoring and providing feedback. Further research is warranted to explore the relationship between the presence/absence of specific features and the impact of interventions on patients' PA levels.

Just-in-Time Adaptive Interventions for Behavior Change in Physiological Health Outcomes and the Use Case for Knee Osteoarthritis: Systematic Review

BACKGROUND

The prevalence of knee osteoarthritis (KOA) in the adult population is high and patients profit from individualized therapy approaches. Just-in-time adaptive interventions (JITAIs) are upcoming digital interventions for behavior change.

OBJECTIVE

This systematic review summarizes the features and effectiveness of existing JITAIs regarding important physiological health outcomes and derives the most promising features for the use case of KOA.

METHODS

The electronic databases PubMed, Web of Science, Scopus, and EBSCO were searched using keywords related to JITAIs, physical activity (PA), sedentary behavior (SB), physical function, quality of life, pain, and stiffness. JITAIs for adults that focused on the effectiveness of at least 1 of the selected outcomes were included and synthesized qualitatively. Study quality was assessed with the Quality Assessment Tool Effective Public Health Practice Project.

RESULTS

A total of 45 studies with mainly weak overall quality were included in this review. The studies were mostly focused on PA and SB and no study examined stiffness. The design of JITAIs varied, with a frequency of decision points from a minute to a day, device-based measured and self-reported tailoring variables, intervention options including audible or vibration prompts and tailored feedback, and decision rules from simple if-then conditions based on 1 variable to more complex algorithms including contextual variables.

CONCLUSIONS

The use of frequent decision points, device-based measured tailoring variables accompanied by user input, intervention options tailored to user preferences, and simple decision rules showed the most promising results in previous studies. This can be transferred to a JITAI for the use case of KOA by using target variables that include breaks in SB and an optimum of PA considering individual knee load for the health benefits of patients.

What kind of non-pharmacological strategy for reducing sedentary behavior in COPD? Data from a scoping review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is usually associated with sedentary behavior (SB). Literature reports a harmful impact of SB on the physical, mental, and social health of individuals with COPD. However, Pulmonary Rehabilitation (PR) programs seem to have no clear effect on changing SB. Therefore, our study aimed to identify the strategies used in the literature to reduce SB among individuals with COPD.

METHOD

A scoping review was conducted to summarize the current literature regarding the proposed strategies to reduce SB in individuals with COPD. Searches were conducted in PUBMED; SCOPUS and COCHRANE LIBRARY for studies published from 2010 to march 2024.

RESULTS

Twenty four articles were retained for our review. Most of the identified strategies in the literature (21/24 articles) are based on behavioral approaches, with various forms: promoting self-efficacy, self-management and self-regulation of one's own behavior (12 articles), goal setting (10 articles), constant feedback (11 articles), therapeutic education (8 articles), motivational strategies (6 articles), re-engagement in meaningful activities (4 articles), promoting light intensity physical activity (LPA) (6 articles) and social support (6 articles). In association with the behavioral strategies, wearable connected technologies have been used in 4 articles, alone or combined with physical exercise programs included or not in a PR program. The home is associated with 83 % of interventions as a place for initial and continuous implementation of behavioral strategies.

CONCLUSION

It would seem appropriate to focus on combined strategies to reduce SB in individuals with COPD (improvement of physical abilities and behavioral strategies). Further research is needed to only target the reduction of SB and to evaluate the effects of various interventions.

Smartphone-Based Interventions to Reduce Sedentary Behavior and Promote Physical Activity Using Integrated Dynamic Models: Systematic Review

BACKGROUND

Traditional psychological theories are inadequate to fully leverage the potential of smartphones and improve the effectiveness of physical activity (PA) and sedentary behavior (SB) change interventions. Future interventions need to consider dynamic models taken from other disciplines, such as engineering (eg, control systems). The extent to which such dynamic models have been incorporated in the development of interventions for PA and SB remains unclear.

OBJECTIVE

This review aims to quantify the number of studies that have used dynamic models to develop smartphone-based interventions to promote PA and reduce SB, describe their features, and evaluate their effectiveness where possible.

METHODS

Databases including PubMed, PsycINFO, IEEE Xplore, Cochrane, and Scopus were searched from inception to May 15, 2019, using terms related to mobile health, dynamic models, SB, and PA. The included studies involved the following: PA or SB interventions involving human adults; either developed or evaluated integrated psychological theory with dynamic theories; used smartphones for the intervention delivery; the interventions were adaptive or just-in-time adaptive; included randomized controlled trials (RCTs), pilot RCTs, quasi-experimental, and pre-post study designs; and were published from 2000 onward. Outcomes included general characteristics, dynamic models, theory or construct integration, and measured SB and PA behaviors. Data were synthesized narratively. There was limited scope for meta-analysis because of the variability in the study results.

RESULTS

A total of 1087 publications were screened, with 11 publications describing 8 studies included in the review. All studies targeted PA; 4 also included SB. Social cognitive theory was the major psychological theory upon which the studies were based. Behavioral intervention technology, control systems, computational agent model, exploit-explore strategy, behavioral analytic algorithm, and dynamic decision network were the dynamic models used in the included studies. The effectiveness of quasi-experimental studies involved reduced SB (1 study; P=.08), increased light PA (1 study; P=.002), walking steps (2 studies; P=.06 and P<.001), walking time (1 study; P=.02), moderate-to-vigorous PA (2 studies; P=.08 and P=.81), and nonwalking exercise time (1 study; P=.31). RCT studies showed increased walking steps (1 study; P=.003) and walking time (1 study; P=.06). To measure activity, 5 studies used built-in smartphone sensors (ie, accelerometers), 3 of which used the phone's GPS, and 3 studies used wearable activity trackers.

CONCLUSIONS

To our knowledge, this is the first systematic review to report on smartphone-based studies to reduce SB and promote PA with a focus on integrated dynamic models. These findings highlight the scarcity of dynamic model-based smartphone studies to reduce SB or promote PA. The limited number of studies that incorporate these models shows promising findings. Future research is required to assess the effectiveness of dynamic models in promoting PA and reducing SB.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42020139350; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=139350.

Systematic review of context-aware digital behavior change interventions to improve health

Health risk behaviors are leading contributors to morbidity, premature mortality associated with chronic diseases, and escalating health costs. However, traditional interventions to change health behaviors often have modest effects, and limited applicability and scale. To better support health improvement goals across the care continuum, new approaches incorporating various smart technologies are being utilized to create more individualized digital behavior change interventions (DBCIs). The purpose of this study is to identify context-aware DBCIs that provide individualized interventions to improve health. A systematic review of published literature (2013-2020) was conducted from multiple databases and manual searches. All included DBCIs were context-aware, automated digital health technologies, whereby user input, activity, or location influenced the intervention. Included studies addressed explicit health behaviors and reported data of behavior change outcomes. Data extracted from studies included study design, type of intervention, including its functions and technologies used, behavior change techniques, and target health behavior and outcomes data. Thirty-three articles were included, comprising mobile health (mHealth) applications, Internet of Things wearables/sensors, and internet-based web applications. The most frequently adopted behavior change techniques were in the groupings of feedback and monitoring, shaping knowledge, associations, and goals and planning. Technologies used to apply these in a context-aware, automated fashion included analytic and artificial intelligence (e.g., machine learning and symbolic reasoning) methods requiring various degrees of access to data. Studies demonstrated improvements in physical activity, dietary behaviors, medication adherence, and sun protection practices. Context-aware DBCIs effectively supported behavior change to improve users' health behaviors.

Objectively measured physical activity as a COPD clinical trial outcome

BACKGROUND

Reduced physical activity is common in COPD and is associated with poor outcomes. Physical activity is therefore a worthy target for intervention in clinical trials, however, trials evaluating physical activity have used heterogeneous methodologies.

RESEARCH QUESTION

What is the available evidence on the efficacy and/or effectiveness of various interventions to enhance objectively measured physical activity in patients with COPD, taking into account minimal preferred methodological quality of physical activity assessment?

STUDY DESIGN AND METHODS

In this narrative review, the COPD Biomarker Qualification Consortium (CBQC) task force searched three scientific databases for articles that reported the effect of an intervention on objectively-measured physical activity in COPD. Based on scientific literature and expert consensus, only studies with ≥7 measurement days and ≥4 valid days of ≥8 hours of monitoring were included in the primary analysis.

RESULTS

37 of 110 (34%) identified studies fulfilled the criteria, investigating the efficacy and/or effectiveness of physical activity behavior change programs (n=7), mobile health or eHealth interventions (n=9), rehabilitative exercise (n=9), bronchodilation (n=6), lung volume reduction procedures (n=3) and other interventions (n=3). Results are generally variable, reflecting the large variation in study characteristics and outcomes. Few studies show an increase beyond the proposed minimal important change of 600-1100 daily steps, indicating that enhancing physical activity levels is a challenge.

INTERPRETATION

Only a third of clinical trials measuring objective physical activity in people with COPD fulfilled the pre-set criteria regarding physical activity assessment. Studies showed variable effects on physical activity even when investigating similar interventions.

Telerehabilitation for chronic respiratory disease

BACKGROUND

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth. Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

OBJECTIVES

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

MAIN RESULTS

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

AUTHORS' CONCLUSIONS

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

What matters the adherence with BP 24-hr self-monitoring wearable device among hypertensive patients? A population-based survey

Wearable mobile health (mHealth) technologies are a convenient and cost-effective community-based intervention to improve management of hypertension in resource-limited populations. This study was designed to evaluate user characteristics of blood pressure (BP) wearable technology among a community-based population in a rural area of China. During the period of April through July 2018, a self-monitoring intervention program for hypertension control was implemented in a remote area of central China. Participants completed a cross-sectional survey which included demographic characteristics, Technology Fluency, the Compliance of Hypertensive Patients' Scale, and the Health-related Quality of Life Survey. Participants were given a wearable BP-monitoring device which wirelessly uploaded data and monitored for 1 month. Participants (n = 317) were 64.57 years (SD = 11.68), 53.94% were male. During the 30-day monitoring, 52.68% of the sample uploaded BP wristband data daily were identified as "BP device users." No differences existed between device users and nonusers related to cardiovascular health measurements, technology fluency, and health-related quality of life. Device users were more likely to report a higher level of hypertension compliance. Individuals reporting a higher level of compliance in hypertension management are more likely to interact with a wearable BP-monitoring device than persons with lower levels of compliance. Further evaluation of mobile health systems involving a wearable device as part of a hypertension management program is needed in a resource-limited community-based setting.

Promoting Behavioral Change in Mobile Health Interventions for Older Adults: A Scoping Review

The current study reviewed the effectiveness of mobile health interventions in eliciting behavioral change across a range of health conditions and examined integration of behavioral change theory, techniques, and agents in interventions among people age ≥60. The initial search returned 1,929 articles: 779 in PubMed, 522 in CINAHL, 633 in PsycINFO, and 131 in EMBASE. The final sample included 20 articles. Most interventions targeted and reported increases in physical activity and disease and medication management. Some studies were informed by behavioral change theories and included behavioral change agents. The most commonly used behavior change techniques were in the form of self- or external-monitoring and receiving tailored feedback on a person's progress. As the National Institutes of Health currently calls for an increased focus on mechanisms of change, future studies should specify features promoting behavioral change and consider whether interventions worked by engaging the hypothesized change mechanisms. [Research in Gerontological Nursing, 13(2), 102-116.].

Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study

BACKGROUND

The use of mobile health (mHealth) interventions has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management.

AIM

The aim of this study was to explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD. It could inform the development and successful implementation of mHealth interventions for COPD management.

METHODS

This was a qualitative study. We conducted semi-structured individual interviews with HCPs, including nurses, pharmacists and physicians who work directly with patients with COPD. Interviews were also conducted with a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management.

RESULTS

A total of 40 people, including nurses, physicians and pharmacists, participated. The main recommendations for the proposed mHealth intervention were categorised into two categories: patient interface and HCP interface. The prevalent features suggested for the patient interface include educating patients, collecting baseline data, collecting subjective data, collecting objective data via compatible medical devices, providing a digital action plan, allowing patients to track their progress, enabling family members to access the mHealth intervention, tailoring the features based on the patient's unique needs, reminding patients about critical management tasks and rewarding patients for their positive behaviours. The most common features of the HCP interface include allowing HCPs to track their patients' progress, allowing HCPs to communicate with their patients, educating HCPs and rewarding HCPs.

CONCLUSION

This study identifies important potential features so that the most effective, efficient and feasible mHealth intervention can be developed to improve the management of COPD.The reviews of this paper are available via the supplemental material section.

Mobile Health Interventions for Physical Activity, Sedentary Behavior, and Sleep in Adults Aged 50 Years and Older: A Systematic Literature Review

We provide a systematic review of interventions utilizing mobile technology to alter physical activity, sedentary behavior, and sleep among adults aged 50 years and older. A systematic search identified 52 relevant articles (randomized control trial [RCT], quasi-experimental, pre/post single-group design). Of 50 trials assessing physical activity, 17 out of 29 RCTs and 13 out of 21 trials assessed for pre/post changes only supported the effectiveness of mobile interventions to improve physical activity, and 9 studies (five out of 10 RCTs and all four pre/post studies) out of 14 reduced sedentary behavior. Only two of five interventions improved sleep (one out of two RCTs and one out of three pre/post studies). Text messaging was the most frequently used intervention (60% of all studies) but was usually used in combination with other components (79% of hybrid interventions included SMS, plus either web or app components). Although more high-quality RCTs are needed, there is evidence supporting the effectiveness of mHealth approaches in those aged 50 years and older.

Older Adults' Attitudes Toward Ambulatory Technology to Support Monitoring and Coaching of Healthy Behaviors: Qualitative Study

Background

Prevention of functional decline demands a holistic perspective of health management. Older adults are becoming avid users of technology; however, technology is not yet largely used in supporting self-management of health in daily life. Previous research suggests that the low adherence to these technologies is likely to be associated with the fact that opinions and wishes of the older population are not always taken into consideration when designing new technology.

Objective

The aim of this study was to investigate the attitudes of older adults living independently regarding technology to support healthy behaviors, addressing nutrition, physical and cognitive function, and well-being.

Methods

In-depth semistructured interviews were performed with 12 older adults addressing 4 themes: (1) current practices in health management, (2) attitudes toward using technology to support health management, (3) wishes from technology, and (4) change in attitudes after actual use of technology. The fourth theme was investigated with a follow-up interview after participants had used a step counter, a smart scale, and a mobile app for 1 month. Data collected were analyzed using inductive thematic analysis.

Results

Participants were active in self-managing their health and foresaw an added value on using technology to support them in adopting healthier behaviors in everyday life. Attitudes and wishes differed considerably per health domain, with cognitive function being the most sensitive topic. Fears from technology mentioned were attention theft, replacement of human touch, and disuse of existing abilities. Poststudy interviews suggest that attitudes toward technology improve after a short period of use.

Conclusions

Technology to support aging in place must target health literacy, allow personalization in the design but also in the use of the technology, and tackle existing fears concerning technology. Further research should investigate the effect of these strategies on the adherence to technology to be used in daily life. We outline a set of recommendations of interest to those involved in developing and implementing technology to support aging in place, focusing on acceptance, barriers, and ethical concerns.

Key Elements of mHealth Interventions to Successfully Increase Physical Activity: Meta-Regression

Background

Mobile technology gives researchers unimagined opportunities to design new interventions to increase physical activity. Unfortunately, it is still unclear which elements are useful to initiate and maintain behavior change.

Objective

In this meta-analysis, we investigated randomized controlled trials of physical activity interventions that were delivered via mobile phone. We analyzed which elements contributed to intervention success.

Methods

After searching four databases and science networks for eligible studies, we entered 50 studies with N=5997 participants into a random-effects meta-analysis, controlling for baseline group differences. We also calculated meta-regressions with the most frequently used behavior change techniques (behavioral goals, general information, self-monitoring, information on where and when, and instructions on how to) as moderators.

Results

We found a small overall effect of the Hedges g=0.29, (95% CI 0.20 to 0.37) which reduced to g=0.22 after correcting for publication bias. In the moderator analyses, behavioral goals and self-monitoring each led to more intervention success. Interventions that used neither behavioral goals nor self-monitoring had a negligible effect of g=0.01, whereas utilizing either technique increased effectiveness by Δg=0.31, but combining them did not provide additional benefits (Δg=0.36).

Conclusions

Overall, mHealth interventions to increase physical activity have a small to moderate effect. However, including behavioral goals or self-monitoring can lead to greater intervention success. More research is needed to look at more behavior change techniques and their interactions. Reporting interventions in trial registrations and articles need to be structured and thorough to gain accurate insights. This can be achieved by basing the design or reporting of interventions on taxonomies of behavior change.

Text Messages Promoting Mental Imagery Increase Self-Reported Physical Activity in Older Adults: A Randomized Controlled Study

OBJECTIVE

This study tested whether text messages prompting adults 50 years of age and older to perform mental imagery would increase aerobic physical activity (APA) duration using a randomized parallel trial design.

METHOD

Participants were assigned to an Imagery 1, Imagery 2, or placebo group. For 4 weeks, each group was exposed to two conditions (morning text message vs. no morning text message). In the morning message condition, the imagery groups received a text message with the instruction to mentally imagine performing an APA, and the placebo group received a placebo message. All participants received an evening text message of "Did you do your cardio today? If yes, what did you do?" for 3 days per week.

RESULTS

Participants of the imagery groups reported significantly more weekly minutes of APA in the morning text message condition compared with the no morning message condition.

CONCLUSION

Electronic messages were effective at increasing minutes of APA.

Evaluating the Impact of Physical Activity Apps and Wearables: Interdisciplinary Review

Background

Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work.

Objectives

This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed.

Method

An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis.

Results

A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance).

Conclusions

The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines.

Adherence with physical activity monitoring wearable devices in a community-based population: observations from the Washington, D.C., Cardiovascular Health and Needs Assessment

Wearable mobile health (mHealth) technologies offer approaches for targeting physical activity (PA) in resource-limited, community-based interventions. We sought to explore user characteristics of PA tracking, wearable technology among a community-based population within a health and needs assessment. In 2014-2015, we conducted the Washington, D.C., Cardiovascular Health and Needs Assessment in predominantly African-American churches among communities with higher obesity rates and lower household incomes. Participants received a mHealth PA monitor and wirelessly uploaded PA data weekly to church data collection hubs. Participants (n = 99) were 59 ± 12 years, 79% female, and 99% African-American, with a mean body mass index of 33 ± 7 kg/m2. Eighty-one percent of participants uploaded PA data to the hub and were termed "PA device users." Though PA device users were more likely to report lower household incomes, no differences existed between device users and non-users for device ownership or technology fluency. Findings suggest that mHealth systems with a wearable device and data collection hub may feasibly target PA in resource-limited communities.

The role of smartphones in encouraging physical activity in adults

Lack of physical activity is a global public health issue. Behavioral change interventions utilizing smartphone applications (apps) are considered a potential solution. The purpose of this literature review was to: 1) determine whether smartphone-based interventions encourage the initiation of, and participation in, physical activity; 2) explore the success of interventions in different populations; and 3) examine the key factors of the interventions that successfully encouraged physical activity. Eight databases (Medline, Scopus, EBM Reviews–Cochrane Central Register of Controlled Trials, EBM Reviews–Cochrane Database of Systematic Reviews, PsycInfo, SportDISCUS, CINAHL, and EMBASE) were searched and studies reporting physical activity outcomes following interventions using smartphone apps in adults were included in the narrative review. Results were mixed with eight studies reporting increased physical activity and ten reporting no change. Interventions did not appear to be successful in specific populations defined by age, sex, country, or clinical diagnosis. There was no conclusive evidence that a specific behavioral theory or behavioral change technique was superior in eliciting behavioral change. The literature remains limited primarily to short-term studies, many of which are underpowered feasibility or pilot studies; therefore, many knowledge gaps regarding the effectiveness of smartphone apps in encouraging physical activity remain. Robust studies that can accommodate the fast pace of the technology industry are needed to examine outcomes in large populations.

Effectiveness of Smartphone Devices in Promoting Physical Activity and Exercise in Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review

The objectives of this systematic review were to analyse existing evidence on the efficacy of smartphone devices in promoting physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) and to identify the validity and precision of their measurements. A systematic review was undertaken across nine electronic databases: WOS Core Collection, PubMed, CINAHL, AMED, Academic Search Complete, Cochrane Central Register of Controlled Trials, SciELO, LILACS and ScienceDirect. Randomized and non-randomized controlled clinical trials were identified. To obtain additional eligible articles, the reference lists of the selected studies were also checked. Eligibility criteria and risk of bias were assessed by two independent authors. A total of eight articles met eligibility criteria. The studies were focused on promoting PA (n  =  5) and the precision of device measurements (n = 3). The effectiveness of smartphones in increasing PA level (steps/day) at short and long term is very limited. Mobile-based exercise programs reported improvements in exercise capacity (i.e. incremental Shuttle-Walk-Test) at short and long term (18.3% and 21%, respectively). The precision of device measurements was good-to-excellent (r = 0.69-0.99); however, these data should be interpreted with caution due to methodological limitations of studies. The effectiveness of smartphone devices in promoting PA levels in patients with COPD is scarce. Further high-quality studies are needed to evaluate the effectiveness of smartphone devices in promoting PA levels. Registration number: CRD42016050048.

The feasibility and RE-AIM evaluation of the TAME health pilot study

Background

Conducting 5 A’s counseling in clinic and utilizing technology-based resources are recommended to promote physical activity but little is known about how to implement such an intervention. This investigation aimed to determine the feasibility and acceptability, using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, of a pragmatic, primary care-based intervention that incorporated 5 A’s counseling and self-control through an activity monitor.

Methods

Primary care patients (n = 40) 55–74 years of age were recruited and randomized to receive a pedometer or an electronic activity monitor (EAM), Jawbone UP24, to monitor activity for 12 weeks. Participants were also invited to a focus group after completing the intervention. Stakeholders (n = 36) were recruited to provide feedback.

Results

The intervention recruitment rate was 24.7%. The attrition rate was 20% with a significantly higher rate for the pedometer group (p = 0.02). The EAM group increased their minutes of physical activity by 11.1 min/day while the pedometer maintained their activity (0.2 min/day), with no significant group difference. EAM participants liked using their monitor and would continue wearing it while the pedometer group was neutral to these statements (p < 0.05). Over the 12 weeks there were 490 comments and 1094 “likes” given to study peers in the corresponding application for the UP24 monitor. Some EAM participants enjoyed the social interaction feature while others were uncomfortable talking to strangers. Participants stated they would want counseling from a counselor and not their physician or a nurse. Other notable comments included incorporating multiple health behaviors, more in-person counseling with a counselor, and having a funding source for sustainability.

Conclusions

Overall, the study was well-received but the results raise a number of considerations. Practitioners, counselors, and researchers should consider the following before implementing a similar intervention: 1) utilize PA counselors, 2) target multiple health behaviors, 3) form a social support group, 4) identify a funding source for sustainability, and 5) be mindful of concerns with technology.

Trial registration

clinicaltrials.gov- NCT02554435. Registered 24 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0560-5) contains supplementary material, which is available to authorized users.

Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review

BACKGROUND

The emergence of smartphones and tablets featuring vastly advancing functionalities (eg, sensors, computing power, interactivity) has transformed the way mHealth interventions support chronic disease management for older adults. Baby boomers have begun to widely adopt smart devices and have expressed their desire to incorporate technologies into their chronic care. Although smart devices are actively used in research, little is known about the extent, characteristics, and range of smart device-based interventions.

OBJECTIVE

We conducted a scoping review to (1) understand the nature, extent, and range of smart device-based research activities, (2) identify the limitations of the current research and knowledge gap, and (3) recommend future research directions.

METHODS

We used the Arksey and O'Malley framework to conduct a scoping review. We identified relevant studies from MEDLINE, Embase, CINAHL, and Web of Science databases using search terms related to mobile health, chronic disease, and older adults. Selected studies used smart devices, sampled older adults, and were published in 2010 or after. The exclusion criteria were sole reliance on text messaging (short message service, SMS) or interactive voice response, validation of an electronic version of a questionnaire, postoperative monitoring, and evaluation of usability. We reviewed references. We charted quantitative data and analyzed qualitative studies using thematic synthesis. To collate and summarize the data, we used the chronic care model.

RESULTS

A total of 51 articles met the eligibility criteria. Research activity increased steeply in 2014 (17/51, 33%) and preexperimental design predominated (16/50, 32%). Diabetes (16/46, 35%) and heart failure management (9/46, 20%) were most frequently studied. We identified diversity and heterogeneity in the collection of biometrics and patient-reported outcome measures within and between chronic diseases. Across studies, we found 8 self-management supporting strategies and 4 distinct communication channels for supporting the decision-making process. In particular, self-monitoring (38/40, 95%), automated feedback (15/40, 38%), and patient education (13/40, 38%) were commonly used as self-management support strategies. Of the 23 studies that implemented decision support strategies, clinical decision making was delegated to patients in 10 studies (43%). The impact on patient outcomes was consistent with studies that used cellular phones. Patients with heart failure and asthma reported improved quality of life. Qualitative analysis yielded 2 themes of facilitating technology adoption for older adults and 3 themes of barriers.

CONCLUSIONS

Limitations of current research included a lack of gerontological focus, dominance of preexperimental design, narrow research scope, inadequate support for participants, and insufficient evidence for clinical outcome. Recommendations for future research include generating evidence for smart device-based programs, using patient-generated data for advanced data mining techniques, validating patient decision support systems, and expanding mHealth practice through innovative technologies.

An exploratory study on the impact of daily activities on the pleasure and physical activity of older adults

Background

Pleasure is one determinant of intrinsic motivation and yet a dimension often forgotten when promoting physical activity among the older population. In this study we investigate the relation between daily activities and physical activity, experience of pleasure, and the interaction between pleasure and physical activity in the daily lives of community-dwelling older adults.

Methods

Participants carried a hip-worn accelerometer during 30 consecutive days resulting in a total of 320 days of data collection. Current activity, location, companion and experience of pleasure during each activity were assessed through experience sampling on a smartphone every 1–2 h. Between- and within-individual differences were analysed with multi-level models and 10xN = 1 regression analysis.

Results

Outdoor activities were associated with higher physical activity than indoor activities (p < 0.001). Performing leisure activities, outdoors and not alone significantly predicted pleasure in daily life (all p’s < 0.05). Being more active while performing leisure activities resulted in higher experiences of pleasure (p < 0.001). However, when performing basic activities of daily living (e.g. commuting or households) this relation was inverted. Results provide meaningful indication for individual variance. The 30 days of data collected from each participant allow for identification of individual differences.

Conclusions

Daily activities and their contexts do influence the experience of pleasure and physical activity of older adults in daily life of older adults, although similar research with larger population is recommended. Results are in accordance with the literature, indicating that the method adopted (accelerometry combined with experience sampling) provides reliable representation of daily life. Identification of individual differences can eventually be automatically performed through data mining techniques. Further research could look at innovative approaches to promote Active Ageing using mobile technology in the daily life, by promoting physical activity through recommendation of pleasurable activities, and thus likely to increase the intrinsic motivation to become physically active.

Patient-Reported Safety Events in Chronic Kidney Disease Recorded With an Interactive Voice-Inquiry Dial-Response System: Monthly Report Analysis

BACKGROUND

Monitoring patient-reported outcomes (PROs) may improve safety of chronic kidney disease (CKD) patients.

OBJECTIVE

Evaluate the performance of an interactive voice-inquiry dial-response system (IVRDS) in detecting CKD-pertinent adverse safety events outside of the clinical environment and compare the incidence of events using the IVDRS to that detected by paper diary.

METHODS

This was a 6-month study of Stage III-V CKD patients in the Safe Kidney Care (SKC) study. Participants crossed over from a paper diary to the IVDRS for recording patient-reported safety events defined as symptoms or events attributable to medications or care. The IVDRS was adapted from the SKC paper diary to record event frequency and remediation. Participants were auto-called weekly and permitted to self-initiate calls. Monthly reports were reviewed by two physician adjudicators for their clinical significance.

RESULTS

52 participants were followed over a total of 1384 weeks. 28 out of 52 participants (54%) reported events using the IVDRS versus 8 out of 52 (15%) with the paper diary; hypoglycemia was the most common event for both methods. All IVDRS menu options were selected at least once except for confusion and rash. Events were reported on 121 calls, with 8 calls reporting event remediation by ambulance or emergency room (ER) visit. The event rate with the IVDRS and paper diary, with and without hypoglycemia, was 26.7 versus 4.7 and 18.3 versus 0.8 per 100 person weeks, respectively (P=.002 and P<.001). The frequent users (ie, >10 events) largely differed by method, and event rates excluding the most frequent user of each were 16.9 versus 2.5 per 100 person weeks, respectively (P<.001). Adjudicators found approximately half the 80 reports clinically significant, with about a quarter judged as actionable. Hypoglycemia was often associated with additional reports of fatigue and falling. Participants expressed favorable satisfaction with the IVDRS.

CONCLUSIONS

Use of the IVDRS among CKD patients reveals a high frequency of clinically significant safety events and has the potential to be used as an important supplement to clinical care for improving patient safety.

Effect of Electronic Messaging on Physical Activity Participation among Older Adults

The purpose of this study was to determine if electronic messaging would increase min of aerobic physical activity (PA) among older adults. Participants were active older adults (n = 28; M age = 60 years, SD = 5.99, and range = 51–74 years). Using an incomplete within-subjects crossover design, participants were randomly assigned to begin the 4-week study receiving the treatment condition (a morning and evening text message) or the control condition (an evening text message). Participants self-reported min of completed aerobic PA by cell phone text. The 1-way within-subjects ANOVA showed significant group differences (p < 0.05). Specifically, when participants were in the treatment condition, they reported significantly greater average weekly min of aerobic PA (M = 96.88 min, SD = 62.9) compared to when they completed the control condition (M = 71.68 min, SD = 40.98). Electronic messaging delivered via cell phones was effective at increasing min of aerobic PA among older adults.

The relationship between electronic goal reminders and subsequent drug use and treatment initiation in a criminal justice setting

INTRODUCTION

Opportunities to influence behavior through the use of electronic reminders has not been examined in a criminal justice population. The purpose of this study was to assess probationer preferences for short-term goals from a web-based program and evaluate the role of voluntary electronic reminders (e.g., text messaging, email) in achieving early treatment and probation tasks.

METHODS

We used data from drug-involved offenders (n=76) participating in a clinical trial of a 2-session motivational computer program. As part of the program, participants could choose to receive text or email reminders about their probation and treatment goals for the next month. Poisson regression models were utilized to evaluate goal and reminder selection in relation to the days of substance use and treatment attendance at two-month follow-up.

RESULTS

The most common goals were related to probation and treatment tasks, relationships, and cognitive reappraisals. Forty-five percent of probationers elected to receive electronic goal reminders at Session 1 with a slight increase at Session two (49%). Probationers who opted to receive electronic goal reminders at Session one selected significantly more goals on average (M=4.4, SD=2.1) than probationers who did not want reminders (M=3.4, SD=1.8), (t=2.41, p=.019). Reminder selection and total number of goals selected predicted days of substance use and treatment attendance at a two-month follow-up. Probationers who opted not to receive electronic reminders and those who only chose to receive reminders at one visit had more days of substance use compared to those who chose to receive reminders at both visits, 1.66 and 2.31 times respectively. Probationers who chose not to receive electronic reminders attended 56% fewer days of treatment compared to those who chose to receive reminders at both visits.

CONCLUSIONS

People's choice of short-term goals and reminders can provide advance notification of the likelihood of substance use and treatment initiation. Probation systems might use such information to triage at-risk probationers to a higher level of service, before problems have emerged.

Promoting Daily Physical Activity by Means of Mobile Gaming: A Review of the State of the Art

OBJECTIVES

To review mobile games and gaming applications that claim to improve physical activity behavior in daily life.

SEARCH METHODS

We searched PubMed, Web of Science, and the ACM Digital Library and performed a manual search of relevant journals and reference lists. Studies that reported on a mobile game that requires players to perform physical activity in daily life and where the game has specific goals, rules, and feedback mechanisms were included. This excludes non-mobile exergames. Theoretical foundations, game characteristics, and evaluation methodologies were assessed.

RESULTS

In total, 797 articles were identified through the search, of which 11 articles were included. The reviewed studies show that there is limited theoretical foundation for the game development, and most studies used goal setting as a motivation strategy to engage people in playing the game. There was a large variety in game characteristics found, although the majority of the studies used metaphors or avatars to visualize activity, whereas feedback was mostly provided in relation to the goal. Rewards and competition were the most commonly incorporated game elements. The evaluations were focused on feasibility, and clinical evidence is lacking with only two randomized controlled studies found.

CONCLUSIONS

This review provides a first overview of mobile gaming applications to promote daily life physical activity and shows this as a new research area with demonstration of its acceptability and feasibility among the users. Clinical effectiveness and the added value of gaming in changing daily activity behavior have by far not yet been established.

Prediction of Domain Behavior through Dynamic Well-Being Domain Model Analysis

As the concept of context-awareness is becoming more popular the demand for improved quality of context-aware systems increases too. Due to the inherent challenges posed by context-awareness, it is harder to predict what the behavior of the systems and their context will be once provided to the end-user than is the case for non-context-aware systems. A domain where such upfront knowledge is highly important is that of well-being. In this paper, we introduce a method to model the well-being domain and to predict the effects the system will have on its context when implemented. This analysis can be performed at design time. Using these predictions, the design can be fine-tuned to increase the chance that systems will have the desired effect. The method has been tested using three existing well-being applications. For these applications, domain models were created in the Dynamic Well-being Domain Model language. This language allows for causal reasoning over the application domain. The models created were used to perform the analysis and behavior prediction. The analysis results were compared to existing application end-user evaluation studies. Results showed that our analysis could accurately predict success and possible problems in the focus of the systems, although certain limitation regarding the predictions should be kept into consideration.

Personalized Coaching Systems to support healthy behavior in people with chronic conditions

Chronic conditions cannot be cured but daily behavior has a major effect on the severity of secondary problems and quality of life. Changing behavior however requires intensive support in daily life, which is not feasible with a human coach. A new coaching approach - so-called Personal Coaching Systems (PCSs) - use on-body sensing, combined with smart reasoning and context-aware feedback to support users in developing and maintaining a healthier behavior. Three different PCSs will be used to illustrate the different aspects of this approach: (1) Treatment of neck/shoulder pain. EMG patterns of the Trapezius muscles are used to estimate their level of relaxation. Personal vibrotactile feedback is given, to create awareness and enable learning when muscles are insufficiently relaxed. (2) Promoting a healthy activity pattern. Using a 3D accelerometer to measure activity and a smartphone to provide feedback. Timing and content of the feedback are adapted real-time, using machine-learning techniques, to optimize adherence. (3) Management of stress during daily living. The level of stress is quantified using a personal model involving a combination of different sensor signals (EMG, ECG, skin conductance, respiration). Results show that Personal Coaching Systems are feasible and a promising and challenging way forward to coach people with chronic conditions.

Using an electronic activity monitor system as an intervention modality: A systematic review

BACKGROUND

Obesity is a growing global health concern that may lead to cardiovascular disease, type II diabetes, and cancer. Several systematic reviews have shown that technology is successful in combating obesity through increased physical activity, but there is no known review on interventions that use an electronic activity monitor system (EAMS). EAMSs are defined as a wearable device that objectively measures lifestyle physical activity and can provide feedback, beyond the display of basic activity count information, via the monitor display or through a partnering application to elicit continual self-monitoring of activity behavior. These devices improve upon standard pedometers because they have the ability to provide visual feedback on activity progression, verbal encouragement, and social comparison. This systematic review aimed to synthesize the efficacy and feasibility results of EAMSs within published physical activity interventions.

METHODS

Electronic databases and journal references were searched for relevant articles. Data sources included CINAHL, Cochrane CENTRAL, Medline Ovid, PsycINFO, and clinicaltrials.gov. Out of the 1,574 retrieved, 11 articles met the inclusion criteria. These articles were reviewed for quality and content based on a risk of bias tool and intervention components.

RESULTS

Most articles were determined to be of medium quality while two were of low quality, and one of high quality. Significant pre-post improvements in the EAMS group were found in five of nine studies for physical activity and in four of five studies for weight. One found a significant increase in physical activity and two studies found significant weight loss in the intervention group compared with the comparator group. The EAMS interventions appear to be feasible with most studies reporting continual wear of the device during waking hours and a higher retention rate of participants in the EAMS groups.

CONCLUSION

These studies provide preliminary evidence suggesting that EAMS can increase physical activity and decrease weight significantly, but their efficacy compared to other interventions has not yet been demonstrated. More high-quality randomized controlled trials are needed to evaluate the overall effect of EAMS, examine which EAMS features are most effective, and determine which populations are most receptive to an EAMS.

Tailored motivational message generation: A model and practical framework for real-time physical activity coaching

This paper presents a comprehensive and practical framework for automatic generation of real-time tailored messages in behavior change applications. Basic aspects of motivational messages are time, intention, content and presentation. Tailoring of messages to the individual user may involve all aspects of communication. A linear modular system is presented for generating such messages. It is explained how properties of user and context are taken into account in each of the modules of the system and how they affect the linguistic presentation of the generated messages. The model of motivational messages presented is based on an analysis of existing literature as well as the analysis of a corpus of motivational messages used in previous studies. The model extends existing 'ontology-based' approaches to message generation for real-time coaching systems found in the literature. Practical examples are given on how simple tailoring rules can be implemented throughout the various stages of the framework. Such examples can guide further research by clarifying what it means to use e.g. user targeting to tailor a message. As primary example we look at the issue of promoting daily physical activity. Future work is pointed out in applying the present model and framework, defining efficient ways of evaluating individual tailoring components, and improving effectiveness through the creation of accurate and complete user- and context models.

mHealth App for Cannabis Users: Satisfaction and Perceived Usefulness

OBJECTIVE

The aim of this study was to describe the characteristics of cannabis users and their levels of satisfaction with Stop-cannabis, an app intended for cannabis users who want to stop or reduce their cannabis use or prevent relapse.

METHODS

A cross-sectional online survey was administered to users of Stop-cannabis, a French-language app for iOS and Android devices. All app users were invited to participate in the survey via a message sent to the app.

RESULTS

For hundred and eighty-two users answered the survey. The app was used daily by 348 of the participants (around 70%). More than 80% of participants (397) considered the app to have helped them "a little" or "a lot" to stop or reduce cannabis consumption. Most of the users' suggestions were related to the number or the quality of the messages sent by, or displayed in, the app.

CONCLUSION

This pilot study supports the feasibility of such an app and its perceived usefulness. A self-selection bias, however, limits the conclusions of the study. The efficacy of the app should be evaluated in a randomized controlled trial.

Psychosocial outcomes of e-feedback of radiotherapy for breast cancer patients: a randomized controlled trial

OBJECTIVE

This study aims to test the effectiveness on psychosocial outcomes of electronic feedback knowledge of radiotherapy intervention (e-Re-Know) for breast cancer patients.

METHOD

Randomized controlled trial in one university hospital in Finland was carried out. Breast cancer patients (n = 126) in the radiotherapy (RT) department were randomly assigned into two groups: intervention (the e-Re-Know and standard education) and control group (standard education). The e-Re-Know intervention consisted of e-feedback after response to the knowledge test delivered by e-mail. Instruments were completed before commencing first RT (M1), after concluding last RT (M2) and 3 months after last RT (M3). The main outcomes were anxiety and QOL.

RESULTS

Compared with the control group, the patients in the intervention group reported a marginally significant improvement in anxiety and significant improvement in QOL over time.

CONCLUSION

The e-Re-Know seems to have positive effects on psychosocial outcomes for breast cancer patients. They might gain additional value from the e-Re-Know over a longer time period. Further research needs to focus more on development of e-feedback in patient education.

A telehealth program for self-management of COPD exacerbations and promotion of an active lifestyle: a pilot randomized controlled trial

The objective of this pilot study was to investigate the use of and satisfaction with a chronic obstructive pulmonary disease (COPD) telehealth program applied in both primary and secondary care. The program consisted of four modules: 1) activity coach for ambulant activity monitoring and real-time coaching of daily activity behavior, 2) web-based exercise program for home exercising, 3) self-management of COPD exacerbations via a triage diary on the web portal, including self-treatment of exacerbations, and 4) teleconsultation. Twenty-nine COPD patients were randomly assigned to either the intervention group (telehealth program for 9 months) or the control group (usual care). Page hits on the web portal showed the use of the program, and the Client Satisfaction Questionnaire showed satisfaction with received care. The telehealth program with decision support showed good satisfaction (mean 26.4, maximum score 32). The program was accessed on 86% of the treatment days, especially the diary. Patient adherence with the exercise scheme was low (21%). Health care providers seem to play an important role in patients’ adherence to telehealth in usual care. Future research should focus on full-scale implementation in daily care and investigating technological advances, like gaming, to increase adherence.