Missing Data Statistics Provide Causal Insights into Data Loss in Diabetes Health Monitoring by Wearable Sensors.

BACKGROUND: Data loss in wearable sensors is an inevitable problem that leads to misrepresentation during diabetes health monitoring. We systematically investigated missing wearable sensors data to get causal insight into the mechanisms leading to missing data. METHODS: Two-week-long data from a continuous glucose monitor and a Fitbit activity tracker recording heart rate (HR) and step count in free-living patients with type 2 diabetes mellitus were used. The gap size distribution was fitted with a Planck distribution to test for missing not at random (MNAR) and a difference between distributions was tested with a Chi-squared test. Significant missing data dispersion over time was tested with the Kruskal-Wallis test and Dunn post hoc analysis. RESULTS: Data from 77 subjects resulted in 73 cleaned glucose, 70 HR and 68 step count recordings. The glucose gap sizes followed a Planck distribution. HR and step count gap frequency differed significantly (p < 0.001), and the missing data were therefore MNAR. In glucose, more missing data were found in the night (23:00-01:00), and in step count, more at measurement days 6 and 7 (p < 0.001). In both cases, missing data were caused by insufficient frequency of data synchronization. CONCLUSIONS: Our novel approach of investigating missing data statistics revealed the mechanisms for missing data in Fitbit and CGM data.

Missing data imputation techniques for wireless continuous vital signs monitoring.

Wireless vital signs sensors are increasingly used for remote patient monitoring, but data analysis is often challenged by missing data periods. This study explored the performance of various imputation techniques for continuous vital signs measurements. Wireless vital signs measurements (heart rate, respiratory rate, blood oxygen saturation, axillary temperature) from surgical ward patients were used for repeated random simulation of missing data periods (gaps) of 5-60 min in two-hour windows. Gaps were imputed using linear interpolation, spline interpolation, last observation- and mean carried forwards technique, and cluster-based prognosis. Imputation performance was evaluated using the mean absolute error (MAE) between original and imputed gap samples. Besides, effects on signal features (window's slope, mean) and early warning scores (EWS) were explored. Gaps were simulated in 1743 data windows, obtained from 52 patients. Although MAE ranges overlapped, median MAE was structurally lowest for linear interpolation (heart rate: 0.9-2.6 beats/min, respiratory rate: 0.8-1.8 breaths/min, temperature: 0.04-0.17 °C, oxygen saturation: 0.3-0.7% for 5-60 min gaps) but up to twice as high for other techniques. Three techniques resulted in larger ranges of signal feature bias compared to no imputation. Imputation led to EWS misclassification in 1-8% of all simulations. Imputation error ranges vary between imputation techniques and increase with gap length. Imputation may result in larger signal feature bias compared to performing no imputation, and can affect patient risk assessment as illustrated by the EWS. Accordingly, careful implementation and selection of imputation techniques is warranted.

Adaptive threshold-based alarm strategies for continuous vital signs monitoring.

Continuous vital signs monitoring in post-surgical ward patients may support early detection of clinical deterioration, but novel alarm approaches are required to ensure timely notification of abnormalities and prevent alarm-fatigue. The current study explored the performance of classical and various adaptive threshold-based alarm strategies to warn for vital sign abnormalities observed during development of an adverse event. A classical threshold-based alarm strategy used for continuous vital signs monitoring in surgical ward patients was evaluated retrospectively. Next, (combinations of) six methods to adapt alarm thresholds to personal or situational factors were simulated in the same dataset. Alarm performance was assessed using the overall alarm rate and sensitivity to detect adverse events. Using a wireless patch-based monitoring system, 3999 h of vital signs data was obtained in 39 patients. The clinically used classical alarm system produced 0.49 alarms/patient/day, and alarms were generated for 11 out of 18 observed adverse events. Each of the tested adaptive strategies either increased sensitivity to detect adverse events or reduced overall alarm rate. Combining specific strategies improved overall performance most and resulted in earlier presentation of alarms in case of adverse events. Strategies that adapt vital sign alarm thresholds to personal or situational factors may improve early detection of adverse events or reduce alarm rates as compared to classical alarm strategies. Accordingly, further investigation of the potential of adaptive alarms for continuous vital signs monitoring in ward patients is warranted.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review.

BACKGROUND: Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature. METHODS: Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system. RESULTS: In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings - particularly for levels L4-S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases. DISCUSSION: Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas. CONCLUSIONS: We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

Sensory Interactive Table (SIT)-Development of a Measurement Instrument to Support Healthy Eating in a Social Dining Setting.

This paper presents the Sensory Interactive Table (SIT): an instrumented, interactive dining table. Through the use of load cells and LEDs that are embedded in the table surface, SIT allows us to study: (1) the eating behaviors of people in a social setting, (2) the social interactions around the eating behaviors of people in a social setting, and (3) the continuous cycle of feedback through LEDs on people's eating behavior and their response to this feedback in real time, to ultimately create an effective dietary support system. This paper presents the hard- and software specifications of the system, and it shows the potential of the system to capture mass-related dimensions in real time and with high accuracy and spatial resolution.

Persuasive technology to support active and healthy ageing: An exploration of past, present, and future.

The age of the population worldwide is rapidly increasing, bringing social and economic challenges. Persuasive technology can alleviate the burden on traditional healthcare services when used to support healthy behaviors, for instance in the prevention and treatment of chronic diseases. Additionally, healthy behaviors are key factors for active and healthy ageing by delaying or even reversing functional decline. In this manuscript, we present a multi-perspective analysis of technologies that can be used in the support of active and healthy ageing in the daily life. First, we take the perspective of physical and mental health, by focusing on the promotion of physical activity and emotional wellbeing. From a temporal perspective, we look at how technology evolved from past, present and future. The overview of the literature is structured in four main sections: (1) measurement of current behavior (monitoring), (2) analysis of the data gathered to derive meaningful information (analyzing & reasoning), (3) support the individual in the adoption or maintenance of a behavior (coaching), and (4) tools or interfaces that provide the information to the individual to stimulate the desired behavior (applications). Finally, we provide recommendations for the design, development and implementation of future technological innovations to support Active and Healthy Ageing in daily life.

Six-month effects of early or delayed provision of an ankle-foot orthosis in patients with (sub)acute stroke: a randomized controlled trial.

OBJECTIVE: To study the six-month clinical effects of providing ankle-foot orthoses at different moments (early or delayed) in (sub)acute stroke; this is a follow-up to a published trial. DESIGN: Randomized controlled trial. SETTING: Rehabilitation centre. SUBJECTS: Unilateral hemiparetic stroke subjects maximal six weeks post-stroke with indication for ankle-foot orthosis use. INTERVENTIONS: Subjects were randomly assigned to early (at inclusion; week 1) or delayed provision (eight weeks later; week 9). OUTCOME MEASURES: Functional tests assessing balance and mobility were performed bi-weekly for 17 weeks and at week 26. RESULTS: In all, 33 subjects were randomized. No differences at week 26 were found between both groups for any of the outcome measures. However, results suggest that early provision leads to better outcomes in the first 11-13 weeks. Berg Balance Scale ( P = 0.006), Functional Ambulation Categories ( P = 0.033) and 6-minute walk test ( P < 0.001) showed significantly different patterns over time. Clinically relevant but statistically non-significant differences of 4-10 weeks in reaching independent walking with higher balance levels were found, favouring early provision. CONCLUSION: No six-month differences in functional outcomes of providing ankle-foot orthoses at different moments in the early rehabilitation after stroke were found. Results suggest that there is a period of 11-13 weeks in which early provision may be beneficial, possibly resulting in early independent and safe walking. However, our study was underpowered. Further research including larger numbers of subjects is warranted.

Early or delayed provision of an ankle-foot orthosis in patients with acute and subacute stroke: a randomized controlled trial.

OBJECTIVE: (1) To study the effects of providing ankle-foot orthoses in subjects with (sub)acute stroke; and (2) to study whether the point in time at which an ankle-foot orthosis is provided post-stroke (early or delayed) influences these effects. DESIGN: Randomized controlled trial. SETTING: Rehabilitation centre. SUBJECTS: Unilateral hemiparetic stroke subjects with indication for use of an ankle-foot orthosis and maximal six weeks post-stroke. INTERVENTIONS: Subjects were randomly assigned to: early provision (at inclusion; Week 1) or delayed provision (eight weeks later; Week 9). OUTCOME MEASURES: 10-metre walk test, 6-minute walk test, Timed Up and Go Test, stairs test, Functional Ambulation Categories, Berg Balance Scale, Rivermead Mobility Index and Barthel Index; assessed in Weeks 1, 3, 9 and 11. RESULTS: A total of 33 subjects were randomized (16 early, 17 delayed). Positive effects of ankle-foot orthoses were found two weeks after provision, both when provided early (significant effects on all outcomes) or delayed (Berg Balance Scale p = 0.011, Functional Ambulation Categories p = 0.008, 6-minute walk test p = 0.005, Timed Up and Go Test p = 0.028). Comparing effects after early and delayed provision showed that early provision resulted in increased levels of improvement on Berg Balance Scale (+5.1 points, p = 0.002), Barthel Index (+1.9 points, p = 0.002) and non-significant improvements on 10-metre walk test (+0.14 m/s, p = 0.093) and Timed Up and Go Test (-5.4 seconds, p = 0.087), compared with delayed provision. CONCLUSIONS: We found positive effects of providing ankle-foot orthoses in (sub)acute stroke subjects that had not used these orthoses before.

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.

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.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke.

BACKGROUND: Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke. METHODS: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up. RESULTS: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log. CONCLUSIONS: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings. TRIAL REGISTRATION: This study has been registered at the Netherlands Trial Registry (NTR): NTR3669 .

Sedentary Behaviour Profiling of Office Workers: A Sensitivity Analysis of Sedentary Cut-Points.

Measuring sedentary behaviour and physical activity with wearable sensors provides detailed information on activity patterns and can serve health interventions. At the basis of activity analysis stands the ability to distinguish sedentary from active time. As there is no consensus regarding the optimal cut-point for classifying sedentary behaviour, we studied the consequences of using different cut-points for this type of analysis. We conducted a battery of sitting and walking activities with 14 office workers, wearing the Promove 3D activity sensor to determine the optimal cut-point (in counts per minute (m·s(-2))) for classifying sedentary behaviour. Then, 27 office workers wore the sensor for five days. We evaluated the sensitivity of five sedentary pattern measures for various sedentary cut-points and found an optimal cut-point for sedentary behaviour of 1660 × 10(-3) m·s(-2). Total sedentary time was not sensitive to cut-point changes within ±10% of this optimal cut-point; other sedentary pattern measures were not sensitive to changes within the ±20% interval. The results from studies analyzing sedentary patterns, using different cut-points, can be compared within these boundaries. Furthermore, commercial, hip-worn activity trackers can implement feedback and interventions on sedentary behaviour patterns, using these cut-points.

A telerehabilitation intervention for patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot trial.

OBJECTIVE: First, to investigate the effects of a telerehabilitation intervention on health status and activity level of patients with Chronic Obstructive Pulmonary Disease (COPD), compared to usual care. Second, to investigate how patients comply with the intervention and whether compliance is related to treatment outcomes. DESIGN: a randomized controlled pilot trial SUBJECTS: Thirty-four patients diagnosed with COPD. INTERVENTION: The telerehabilitation application consists of an activity coach (3D-accelerometer with smartphone) for ambulant activity registration and real-time feedback, complemented by a web portal with a symptom diary for self-treatment of exacerbations. The intervention group used the application for 4 weeks. The control group received usual care. MAIN MEASURES: Activity level measured by a pedometer (in steps/day), health status by the Clinical COPD Questionnaire at baseline and after intervention. Compliance was expressed as the time the activity coach was worn. RESULTS: Fourteen intervention and 16 control patients completed the study. Activity level (steps/day) was not significantly affected by the intervention over time. There was a non-significant difference in improvement in health status between the intervention (-0.34±0.55) and control group (0.02±0.57, p=0.10). Health status significantly improved within the intervention group (p=0.05). The activity coach was used more than prescribed (108%) and compliance was related to the increase in activity level for the first two feedback weeks (r=0.62, p=0.03). CONCLUSIONS: This pilot study shows the potential of the telerehabilitation intervention: compliance with the activity coach was high, which directly related to an improvement in activity levels.

Optimal sensor placement for measuring physical activity with a 3D accelerometer.

Accelerometer-based activity monitors are popular for monitoring physical activity. In this study, we investigated optimal sensor placement for increasing the quality of studies that utilize accelerometer data to assess physical activity. We performed a two-staged study, focused on sensor location and type of mounting. Ten subjects walked at various walking speeds on a treadmill, performed a deskwork protocol, and walked on level ground, while simultaneously wearing five ProMove2 sensors with a snug fit on an elastic waist belt. We found that sensor location, type of activity, and their interaction-effect affected sensor output. The most lateral positions on the waist belt were the least sensitive for interference. The effect of mounting was explored, by making two subjects repeat the experimental protocol with sensors more loosely fitted to the elastic belt. The loose fit resulted in lower sensor output, except for the deskwork protocol, where output was higher. In order to increase the reliability and to reduce the variability of sensor output, researchers should place activity sensors on the most lateral position of a participant's waist belt. If the sensor hampers free movement, it may be positioned slightly more forward on the belt. Finally, sensors should be fitted tightly to the body.

Automatic identification of inertial sensor placement on human body segments during walking.

BACKGROUND: Current inertial motion capture systems are rarely used in biomedical applications. The attachment and connection of the sensors with cables is often a complex and time consuming task. Moreover, it is prone to errors, because each sensor has to be attached to a predefined body segment. By using wireless inertial sensors and automatic identification of their positions on the human body, the complexity of the set-up can be reduced and incorrect attachments are avoided.We present a novel method for the automatic identification of inertial sensors on human body segments during walking. This method allows the user to place (wireless) inertial sensors on arbitrary body segments. Next, the user walks for just a few seconds and the segment to which each sensor is attached is identified automatically. METHODS: Walking data was recorded from ten healthy subjects using an Xsens MVN Biomech system with full-body configuration (17 inertial sensors). Subjects were asked to walk for about 6 seconds at normal walking speed (about 5 km/h). After rotating the sensor data to a global coordinate frame with x-axis in walking direction, y-axis pointing left and z-axis vertical, RMS, mean, and correlation coefficient features were extracted from x-, y- and z-components and magnitudes of the accelerations, angular velocities and angular accelerations. As a classifier, a decision tree based on the C4.5 algorithm was developed using Weka (Waikato Environment for Knowledge Analysis). RESULTS AND CONCLUSIONS: After testing the algorithm with 10-fold cross-validation using 31 walking trials (involving 527 sensors), 514 sensors were correctly classified (97.5%). When a decision tree for a lower body plus trunk configuration (8 inertial sensors) was trained and tested using 10-fold cross-validation, 100% of the sensors were correctly identified. This decision tree was also tested on walking trials of 7 patients (17 walking trials) after anterior cruciate ligament reconstruction, which also resulted in 100% correct identification, thus illustrating the robustness of the method.

Early Warning Scores to Support Continuous Wireless Vital Sign Monitoring for Complication Prediction in Patients on Surgical Wards: Retrospective Observational Study.

BACKGROUND: Wireless vital sign sensors are increasingly being used to monitor patients on surgical wards. Although early warning scores (EWSs) are the current standard for the identification of patient deterioration in a ward setting, their usefulness for continuous monitoring is unknown. OBJECTIVE: This study aimed to explore the usability and predictive value of high-rate EWSs obtained from continuous vital sign recordings for early identification of postoperative complications and compares the performance of a sensor-based EWS alarm system with manual intermittent EWS measurements and threshold alarms applied to individual vital sign recordings (single-parameter alarms). METHODS: Continuous vital sign measurements (heart rate, respiratory rate, blood oxygen saturation, and axillary temperature) collected with wireless sensors in patients on surgical wards were used for retrospective simulation of EWSs (sensor EWSs) for different time windows (1-240 min), adopting criteria similar to EWSs based on manual vital signs measurements (nurse EWSs). Hourly sensor EWS measurements were compared between patients with (event group: 14/46, 30%) and without (control group: 32/46, 70%) postoperative complications. In addition, alarms were simulated for the sensor EWSs using a range of alarm thresholds (1-9) and compared with alarms based on nurse EWSs and single-parameter alarms. Alarm performance was evaluated using the sensitivity to predict complications within 24 hours, daily alarm rate, and false discovery rate (FDR). RESULTS: The hourly sensor EWSs of the event group (median 3.4, IQR 3.1-4.1) was significantly higher (P<.004) compared with the control group (median 2.8, IQR 2.4-3.2). The alarm sensitivity of the hourly sensor EWSs was the highest (80%-67%) for thresholds of 3 to 5, which was associated with alarm rates of 2 (FDR=85%) to 1.2 (FDR=83%) alarms per patient per day respectively. The sensitivity of sensor EWS-based alarms was higher than that of nurse EWS-based alarms (maximum=40%) but lower than that of single-parameter alarms (87%) for all thresholds. In contrast, the (false) alarm rates of sensor EWS-based alarms were higher than that of nurse EWS-based alarms (maximum=0.6 alarm/patient/d; FDR=80%) but lower than that of single-parameter alarms (2 alarms/patient/d; FDR=84%) for most thresholds. Alarm rates for sensor EWSs increased for shorter time windows, reaching 70 alarms per patient per day when calculated every minute. CONCLUSIONS: EWSs obtained using wireless vital sign sensors may contribute to the early recognition of postoperative complications in a ward setting, with higher alarm sensitivity compared with manual EWS measurements. Although hourly sensor EWSs provide fewer alarms compared with single-parameter alarms, high false alarm rates can be expected when calculated over shorter time spans. Further studies are recommended to optimize care escalation criteria for continuous monitoring of vital signs in a ward setting and to evaluate the effects on patient outcomes.

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.

Game not over: Explaining older adults' use and intention to continue using a gamified eHealth service.

BACKGROUND: Gamification within eHealth services can increase eHealth adoption. However, little is known about factors affecting adoption of gamified eHealth among older adults. In this study, we sought to explain the (continued) use of a gamified eHealth service among older adults (55+). METHODS: Participants used a gamified eHealth service, focusing on falls prevention, for 4 weeks and completed a post-test questionnaire based on the Technology Acceptance Model. We used Partial Least Squares Structural Equation Modeling to analyse our data. RESULTS: Seventy-two older adults participated with a mean age of 65.1 years (SD = 7.0). Our results show that first, perceived ease of use affected use of the service (use duration: ß = 0.303, R2 = 0.130, and use frequency: ß = 0.304, R2 = 0.107). Second, perceived usefulness affected the intention to continue using the service (ß = 0.754, R2 = 0.640). Third, use of the service did not predict the intention to continue using it. Furthermore, enjoyment affected perceived usefulness (ß = 0.783, R2 = 0.563) and aesthetics affected perceived ease of use (ß = 0.634, R2 = 0.652). CONCLUSIONS: This study refutes the expected relation between use and intention to continue use a gamified eHealth service. Additionally, we learned that using theoretical approaches focusing on technology acceptance, are not suitable for explaining (continued) use of gamified eHealth services.

Evaluation of a virtual coaching system eHealth intervention: A mixed methods observational cohort study in the Netherlands.

BACKGROUND: With the rise in human life expectancy, the prevalence of chronic disease has increased significantly. Adopting a healthy lifestyle can decrease the risk of chronic disease. Virtual coaching systems can help older adults adopt a healthy lifestyle.AimThe primary objective of this study was to assess the use, user experience and potential health effects of a conversational agent-based eHealth platform (Council of Coaches) implemented in a real-world setting among older adults. METHODS: An observational cohort study was conducted with older adults aged 55 years or older in the Netherlands. Participants were enrolled for 5-9 weeks during which they had access to Council of Coaches. They completed three questionnaires: pre-test, post-test, and at follow-up. After five weeks, an interview was conducted, and participants chose whether they wanted to use the eHealth intervention for another four weeks during the facultative phase. RESULTS: The study population consisted of 51 older adults (70.6% female) with a mean age of 65.3 years (SD = 7.4). Of these, 94.1% started interacting with Council of Coaches, and most participants interacted once per week. During the facultative phase, 21 participants were still interacting with Council of Coaches. Minimal clinical important differences in quality of life were found among the study population after interacting with Council of Coaches. CONCLUSION: Our results demonstrate that eHealth interventions with virtual coaching can be used among older adults. This may increase quality of life for older adults, and decrease their healthcare needs. Future research into such eHealth interventions should take into account the inclusion of sufficient personalised content and the use of a mixed methods study for assessing the eHealth intervention.

Feasibility and patient's experiences of perioperative telemonitoring in major abdominal surgery: an observational pilot study.

BACKGROUND: Telemonitoring during the perioperative trajectory may improve patient outcomes and self-management. The aim of this study is to assess the feasibility of and patient's experiences with telemonitoring before and after major abdominal surgery to inform future study design. METHODS: Patients planned for elective major abdominal surgery wore a sensor and answered well-being questions on a tablet daily for at least 2 weeks preoperatively up to 30-days postoperatively. Feasibility was assessed by participation and completion rate, compliance per day, weekly satisfaction scores, and reasons for nonscheduled contact. RESULTS: Twenty-three patients were included (participation rate of 54.5%) with a completion rate of 69.6%. Median compliance with the wearable sensor and well-being questions was respectively: 94.7% and 83.3% preoperatively at home; 100% and 66.7% postoperatively in-hospital; and 95.4% and 85.8% postoperatively at home. Median weekly satisfaction scores for both wearing the sensor and well-being questions were 5 (IQR, 4-5). Contact moments were related to absence of sensor data and technological issues (76.0%) or patient discomfort and insecurity (24.0%). CONCLUSIONS: In this study, telemonitoring showed high satisfaction and compliance during the perioperative trajectory. Future trial design regarding the effectiveness of telemonitoring requires embedding in clinical practice and support for patients, relatives, and healthcare personnel.