Identification of community-dwelling older adults at risk of frailty using the PERSSILAA screening pathway: a methodological guide and results of a large-scale deployment in the Netherlands.

BACKGROUND: Among community-dwelling older adults, frailty is highly prevalent and recognized as a major public health concern. To prevent frailty it is important to identify those at risk of becoming frail, but at present, no accepted screening procedure is available. METHODS: The screening process developed as part of the PERSSILAA project is a two-step screening pathway. First, older adults are asked to complete a self-screening questionnaire to assess their general health status and their level of decline on physical, cognitive and nutritional domains. Second, older adults who, according to step one, are at risk of becoming frail, are invited for a face-to-face assessment focusing on the domains in depth. We deployed the PERSSILAA screening procedure in primary care in the Netherlands. RESULTS: In total, baseline data were available for 3777 community-dwelling older adults (mean age 69.9 (SD ± 3.8)) who completed first step screening. Based on predefined cut-off scores, 16.8% of the sample were classified as frail (n = 634), 20.6% as pre-frail (n = 777), and 62.3% as robust (n = 2353). Frail subjects were referred back to their GP without going through the second step. Of the pre-frail older adults, 69.7% had evidence of functional decline on the physical domain, 67% were overweight or obese and 31.0% had evidence of cognitive decline. CONCLUSION: Pre-frailty is common among community-dwelling older adults. The PERSSILAA screening approach is a multi-factor, two-step screening process, potentially useful for primary prevention to identify those at risk of frailty and who will benefit most from preventive strategies.

Patient acceptance of a telemedicine service for rehabilitation care: A focus group study.

BACKGROUND AND PURPOSE: Despite positive outcomes, widespread implementation of telemedicine services in rehabilitation care is lacking. This could, for a large part, be attributed to a lack of end-user acceptance. The aim of this article is to look beyond the common theoretical approaches towards end-user acceptance (like the Technology Acceptance Model and the Unified Theory of Acceptance and Use of Technology), and to explore the factors that contribute to or hinder the acceptance of a telemedicine service for rehabilitation care by patients with a chronic disease. METHODS: A qualitative, exploratory focus group approach was applied. We involved 188 patients in 22 focus groups. A guide was developed to provoke a discussion among participants of a rehabilitation clinic on the topic of using an online portal with a wide range of telemedicine features (e.g., an exercise module and a teleconference module). Three coders, using thematic analysis, coded the focus group transcripts simultaneously. RESULTS: The focus groups resulted in a wide range of factors that drive or hinder patient acceptance. Facilitators included the possibility to exercise from the comfort of home, the ability to work on one's recovery, irrespective of the time schedule of care professionals, and improved quality of exercise instruction, due to the provision of exercise videos on the portal. Barriers included a lack of intrinsically motivation, experiencing portal-mediated communication with care professionals as 'impersonal', and the lack of physical space and rest to properly exercise at home. Generally speaking, participants were enthusiastic about the idea to provide the telemedicine service as a follow-up treatment as they liked to be in contact with their therapist and to continue training. CONCLUSION: Acceptance of telemedicine services depends on many factors that are not part of well-established theories that explain technology acceptance. These factors are more specific than general determinants, such as ease of use and usefulness, and focus mainly on contextual factors, such as a fit between the service configuration and daily life, personal motivation and the associated psychological burden.

Strategies to improve effectiveness of physical activity coaching systems: Development of personas for providing tailored feedback.

Mobile physical activity interventions can be improved by incorporating behavioural change theories. Relations between self-efficacy, stage of change, and physical activity are investigated, enabling development of feedback strategies that can be used to improve their effectiveness. A total of 325 healthy control participants and 82 patients wore an activity monitor. Participants completed a self-efficacy or stage of change questionnaire. Results show that higher self-efficacy is related to higher activity levels. Patients are less active than healthy controls and show a larger drop in physical activity over the day. Patients in the maintenance stage of change are more active than patients in lower stages of change, but show an equally large drop in level of physical activity. Findings suggest that coaching should at least be tailored to level of self-efficacy, stage of change, and physical activity pattern. Tailored coaching strategies are developed, which suggest that increasing self-efficacy of users is most important. Guidelines are provided.

The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review.

Introduction The aim of this study was to systematically review the evidence on the effectiveness of exercise-based telemedicine in chronic pain. Methods We searched the Cochrane, PubMed, MEDLINE, EMBASE, CINAHL and PEDRO databases from 2000 to 2015 for randomised controlled trials, comparing exercise-based telemedicine intervention to no intervention or usual care in adults with chronic pain. Primary outcome data were pooled using random effect meta-analysis. Primary outcomes were pain, physical activity (PA), limitations in activities of daily living (ADL) and quality of life (QoL). Secondary outcomes were barriers, facilitators and usability of telemedicine. Results Sixteen studies were included. Meta-analyses were performed in three subgroups of studies with comparable control conditions. Telemedicine versus no intervention showed significantly lower pain scores (MD -0.57, 95% CI -0.81; -0.34), but not for telemedicine versus usual care (MD -0.08, 95% CI -0.41; 0.26) or in addition to usual care (MD -0.25, 95% CI -1.50; 1.00). Telemedicine compared to no intervention showed non-significant effects for PA (MD 19.93 min/week, 95% CI -5.20; 45.06) and significantly diminished ADL limitations (SMD -0.20, 95% CI -0.29; -0.12). No differences were found for telemedicine in addition to usual care for PA or for ADL (SMD 0.16, 95% CI -0.66; 0.34). Telemedicine versus usual care showed no differences for ADL (SMD 0.08, 95% CI -0.37; 0.53). No differences were found for telemedicine compared to the three control groups for QoL. Limited information was found on the secondary outcomes. Conclusions Exercise-based telemedicine interventions do not seem to have added value to usual care. As substitution of usual care, telemedicine might be applicable but due to limited quality of the evidence, further exploration is needed for the rapidly developing field of telemedicine.

User Experience, Actual Use, and Effectiveness of an Information Communication Technology-Supported Home Exercise Program for Pre-Frail Older Adults.

OBJECTIVE: The main objective of this study was to investigate the use and user experience of an Information Communication Technology-supported home exercise program when offered for independent use to pre-frail older adults. Our secondary aim was to explore whether the program improved quality of life and health status compared to a control group. METHODS: A cohort multiple randomized controlled trail is being performed. Physically pre-frail older adults (65-75 years) living independently at home were included and randomly assigned to a control group or an intervention group. The intervention group received a home exercise program (strength, balance, and flexibility exercises) for a minimal duration of 12 weeks. The control group received usual care. Primary outcomes were: use of the intervention (frequency and duration), adherence to a 3-day exercise protocol and user experience [System Usability Scale (SUS); rating 1-10]. Secondary outcomes were quality of life measured with the SF12 (Physical Component Scale and Mental Component Scale) and health status (EQ-5D), assessed before the study starts and after 12 weeks of exercising. RESULTS: Thirty-seven independently living older adults participated in the study. Sixteen participants were allocated to the intervention group and 21 to the control group. The average score on the SUS was 84.2 (±13.3), almost reaching an excellent score. Participants rated the intervention with an 8.5. Eighty percent of the participants finished the 12 week exercise protocol. The adherence to the 3-day exercise protocol was 68%. Participants in the intervention group trained on average 2.2 times (±1.3) each week. The mean duration of login for each exercise session was 24 min. The Mental Component Scale of the SF12 was significantly higher in the intervention group compared to the control group. A trend was seen in the change over time in the health status between groups. CONCLUSIONS: This study provides evidence that a home-based exercise program is easy to use and has potential in improving quality of life and health status of pre-frail older adults who live at home. However, further refinement of the program is required to improve adherence and maximize the benefits and potential of exercising in the home environment. TRIAL REGISTRATION: Unique Identifier: NTR5304. URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5304.

Co-creation of an ICT-supported cancer rehabilitation application for resected lung cancer survivors: design and evaluation.

BACKGROUND: Lung cancer (LC) patients experience high symptom burden and significant decline of physical fitness and quality of life following lung resection. Good quality of survivorship care post-surgery is essential to optimize recovery and prevent unscheduled healthcare use. The use of Information and Communication Technology (ICT) can improve post-surgery care, as it enables frequent monitoring of health status in daily life, provides timely and personalized feedback to patients and professionals, and improves accessibility to rehabilitation programs. Despite its promises, implementation of telehealthcare applications is challenging, often hampered by non-acceptance of the developed service by its end-users. A promising approach is to involve the end-users early and continuously during the developmental process through a so-called user-centred design approach. The aim of this article is to report on this process of co-creation and evaluation of a multimodal ICT-supported cancer rehabilitation program with and for lung cancer patients treated with lung resection and their healthcare professionals (HCPs). METHODS: A user-centered design approach was used. Through semi-structured interviews (n = 10 LC patients and 6 HCPs), focus groups (n = 5 HCPs), and scenarios (n = 5 HCPs), user needs and requirements were elicited. Semi-structured interviews and the System Usability Scale (SUS) were used to evaluate usability of the telehealthcare application with 7 LC patients and 10 HCPs. RESULTS: The developed application consists of: 1) self-monitoring of symptoms and physical activity using on-body sensors and a smartphone, and 2) a web based physical exercise program. 71 % of LC patients and 78 % of HCPs were willing to use the application as part of lung cancer treatment. Accessibility of data via electronic patient records was essential for HCPs. LC patients regarded a positive attitude of the HCP towards the application essential. Overall, the usability (SUS median score = 70, range 35-95) was rated acceptable. CONCLUSIONS: A telehealthcare application that facilitates symptom monitoring and physical fitness training is considered a useful tool to further improve recovery following surgery of resected lung cancer (LC) patients. Involvement of end users in the design process appears to be necessary to optimize chances of adoption, compliance and implementation of telemedicine.

Engaging Elderly People in Telemedicine Through Gamification.

BACKGROUND: Telemedicine can alleviate the increasing demand for elderly care caused by the rapidly aging population. However, user adherence to technology in telemedicine interventions is low and decreases over time. Therefore, there is a need for methods to increase adherence, specifically of the elderly user. A strategy that has recently emerged to address this problem is gamification. It is the application of game elements to nongame fields to motivate and increase user activity and retention. OBJECTIVE: This research aims to (1) provide an overview of existing theoretical frameworks for gamification and explore methods that specifically target the elderly user and (2) explore user classification theories for tailoring game content to the elderly user. This knowledge will provide a foundation for creating a new framework for applying gamification in telemedicine applications to effectively engage the elderly user by increasing and maintaining adherence. METHODS: We performed a broad Internet search using scientific and nonscientific search engines and included information that described either of the following subjects: the conceptualization of gamification, methods to engage elderly users through gamification, or user classification theories for tailored game content. RESULTS: Our search showed two main approaches concerning frameworks for gamification: from business practices, which mostly aim for more revenue, emerge an applied approach, while academia frameworks are developed incorporating theories on motivation while often aiming for lasting engagement. The search provided limited information regarding the application of gamification to engage elderly users, and a significant gap in knowledge on the effectiveness of a gamified application in practice. Several approaches for classifying users in general were found, based on archetypes and reasons to play, and we present them along with their corresponding taxonomies. The overview we created indicates great connectivity between these taxonomies. CONCLUSIONS: Gamification frameworks have been developed from different backgrounds-business and academia-but rarely target the elderly user. The effectiveness of user classifications for tailored game content in this context is not yet known. As a next step, we propose the development of a framework based on the hypothesized existence of a relation between preference for game content and personality.

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.

A pilot study - the potential value of an activity-based feedback system for treatment of individuals with chronic lower back pain.

PURPOSE: The aim of this pilot study was to evaluate the potential value of a new personalized activity-based feedback treatment. METHOD: A prognostic cohort study was carried out in the daily environment of the patients. Seventeen individuals with chronic lower back pain (CLBP) symptoms for >3 months were included. Patients were from the Netherlands, aged 18-65 years. Patients wore an accelerometer and a Personal Digital Assistant (PDA) for 15 d. Patients received continuous and time-related personalized feedback and were instructed to follow the activity pattern as displayed on the PDA. Technical performance and compliance with the system were rated. Objective and subjective activity scores were compared for exploring awareness. The absolute difference between the activity pattern of the patient and the norm value used was calculated and expressed as mean difference. Pain intensity was measured using the VAS. RESULTS: The technical performance and compliance with the system were rated moderate. More than half of the patients were aware of their activity level during the feedback days (67%). A positive effect of the feedback was seen in a trend which showed a decrease in the absolute difference between the activity pattern of the patient and the norm value (p = 0.149) and a significant decrease in pain intensity levels (p = 0.005). CONCLUSIONS: This pilot study suggested that an individual-tailored feedback system that focuses on the activity behavior of the patient has potential as the treatment of individuals with CLBP. Implications for Rehabilitation Activity-based feedback for individuals with chronic low back pain: Many patients are not aware of their activity patterns. The activity patterns of patients differ from those of healthy controls. It is important to make patients aware of their activity patterns in order to change activity behavior. An individual-tailored feedback system seems promising in decreasing pain intensity levels for a subgroup of patients.

Do personalized feedback messages about activity patterns stimulate patients with chronic low back pain to change their activity behavior on a short term notice?

The aim of this study was to explore whether patients responded to personalized messages on top of continuous visual feedback by changes in activity patterns and whether this response is related to the stages of change and the pain intensity levels. Patients wore a movement sensor and a PDA for 2 weeks and received continuously feedback and time-related messages to influence activity behavior. The response was calculated by calculating the activity 30 min before and after a message. In addition, the readiness to change was measured with the Stage of Change questionnaire and pain intensity was measured on a visual analogue scale. Sixteen patients participated, receiving a total of 517 messages. Overall, patients responded to personalized messages (p < .049), with a higher response in the morning. Patients in different stages of change responded differently to the messages (p = .009) and the response was significantly related to the pain intensity levels (Pearson correlation -.226) in the second week of feedback. This study suggests that personalized messages have the potential to influence activity behavior. It seems relevant to take time of the day, the stages of change and pain intensity levels of the patient into account to further optimize the feedback strategy used.