Designing to Support Prescribed Home Exercises:
Understanding the Needs of Physiotherapy Patients
Hitee Chandra
Carnegie Mellon University /University of Madeira
15213 Pittsburgh, PA, USA
hitee.c@gmail.com(412)805-3364

Ian Oakley
University of Madeira
9020-105 Funchal, Portugal
ian.r.oakley@gmail.com

ABSTRACT

Musculoskeletal disorders are a globally significant healthproblem affecting millions. Physiotherapy, including
prescribed exercises performed independently by patients intheir homes, is a key treatment for many sufferers.
However, many patients fail to complete home exercises,
prolonging recovery periods or accelerating decline.
Pervasive health technologies, capable of monitoring users
in their homes, are ideally suited to address this problem.
This paper describes user research with a group of threephysiotherapists and eleven current physiotherapy patientsto understand the problems and user needs underlying noncompliance with home exercise regimes. The research
adopted a speed dating approach and culminated with six
insights and design recommendations relating to the form
and type of feedback that should be used in such systems, tohow scheduling and therapist-patient communication
systems should be designed and to the role of privacy.
Author Keywords

Health, Physiotherapy, bio-monitoring, EMG, user-centered
design.
ACM Classification Keywords

H5.m. Information interfaces and presentation: Misc.
General Terms

DesignINTRODUCTION

Musculoskeletal disorders (MSDs) are a highly significant
global health problem. Many are work related; acrossEurope, 40 million workers, or one in seven, are affected bywork-related MSDs, with an estimated total economic costof €240 billion [33]. Time away from work is a key
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Hugo Silva
PLUX - Wireless Biosignals /IT/IST - Instituto de
Telecomunicacoes
Lisbon, Portugal
hsilva@plux.info

contributor to these costs. In the USA, 2010 figures indicatethat 1.2 million injuries (each leading to a median of eightdays off work) were ascribed to MSDs, representing a totalof approximately 76 million lost work hours per annum[25]. Indeed the prevalence of MSDs cannot be understated;in the UK, they represent 44% of all work-related injuries[23].
However, MSDs are not only a work issue. The prevalenceof such problems also increases with age, making them apressing concern across the rapidly graying developed
world [18]. For example, in the US, statistics indicate a
13% population share for senior citizens (65 or older) in2010 with a projected proportion approaching 20% by 2030
[29]. These demographic changes will lead to a greatly
increased occurrence rate of MSDs and place significant
strain on existing, labor intensive treatment paradigms.
These facts suggest that new techniques for the prompt
diagnosis and efficient and effective treatment of MSDs
will be critical to maintain current levels of care and a highquality of life in the rapidly ageing societies of thedeveloped world [36]Physiotherapy is a key part of current treatment methods formany MSDs. It is labor intensive, typically involving aseries of consultations with practitioners who diagnoseconditions and recommend exercise regimes as therapies.
Treatment programs last months and involve bi-weekly (ormore) clinical sessions supported by daily exercises
performed independently by patients at home [e.g. 16].
Performance of exercises at home is key to achieving
treatment goals. However, despite this health incentive, it
has been long acknowledged that many patients fail toperform home therapies; one study reports non-compliancewith prescribed exercises to be as high as 70% [32], anotherthat 14% of physiotherapy patients fail to return for followup outpatient appointments [34]. The result of noncompliance is non-effective (or unnecessarily prolonged)
treatments, resulting in extra costs and increased levels of
pain and impairment.
This paper addresses this problem space. It explores how
pervasive health systems might support patients in thepatients collaboratively setting treatment goals andmonitoring progress can lead to substantially higher levelsof treatment compliance compared to physiotherapistmandated goals [4].

Figure 1. bioPLUX biosignal acquisition device

performance of prescribed exercises at home. In particular,
it is inspired by recent developments in bio-monitoring forphysiotherapy such as the bioPLUX Clinical system (Figure
1, www.plux.info). This is a compact wireless biosignal
acquisition unit capable of streaming live data in real-time
to a base station. Sold as a clinical analysis service, it
enables therapists to use Electromyography (EMG) tomeasure and display muscular activity during clinicalsessions. The system’s compact and robust form factor also
makes the underlying technology ideal for home healthmonitoring, such as continuous monitoring in ambientassisted living scenarios [31].
This paper describes user research exploring how this kindof system, a muscle activity sensor, could be combined withexisting connected consumer technologies, such as
smartphones, to tackle the problem of non-compliance withprescribed exercises. To achieve this objective, it describes
a series of interviews with physiotherapists and patients tounderstand non-compliance behaviors and explore howhome bio-monitoring technologies might support
performance of exercises at home. The paper concludes
with design recommendations for this application space.
The remainder of this paper is structured as follows: areview of related work in the field of physiotherapy,
pervasive health and motivation; a description of the user
research and concept development; conclusions and future
work.
RELATED WORK

Non-compliance with prescribed physical therapy regimes
often results from patients’ explicit, reasoned decisions.
Factors contributing to these non-compliance choices
include: low perceived severity of symptoms; perceived
ineffectiveness of the intervention; and unwillingness andinability to incorporate the treatment into everyday life [6].
Individual factors such as attitudes towards exercise, pastexperiences, availability of facilities and social environment
also play a role [27, 32]. However, interventions to
overcome non-compliance can be highly effective. For
example, concordance, a term referring to practitioners andPervasive, persuasive health technologies are ideally suited
to address problems of non-compliance with prescribed
exercise routines. Indeed, there is a diverse body of work
demonstrating that personal digital technology can motivateand support users in performing exercises and other healthrelated activities. Many recent systems rely on theaccelerometer sensors in smartphones to count steps [e.g.
28] or GPS data to track jogging and running performance[e.g. 15]. A wide range of visualizations of this material
have also been explored. For example, in Fish’n’Steps. Lin
et al. [19] measured step count and tied this to theappearance, development and activity of a cartoon avatar
representing the user; over a 14-week study they reported
increases in participant activity levels. Buttussi [5], on theother hand, measured GPS location around an outdoor
fitness trail and provided specific advice and exercise
guidelines to users via a sophisticated embodied virtual
trainer, or agent. One of the goals of this instructional
feedback was to tackle problems of uncertainty – a common
reason for avoiding exercise is concern about incorrect
performance resulting in pain or aggravating problems [13].
Games and entertainment have also attracted muchattention as motivational tools to support exercise
performance. In many systems, physical activities areintegrated into game play, such that performing exercises
results in progress in the game world [e.g. 35]. A key
enabler of these approaches has been the advanced sensing
solutions shipping with current home entertainment
consoles: the Nintendo Wii, Sony Playstation and Microsoft
Xbox all come with powerful motion tracking peripherals.
Using these commercial technologies, researchers havedesigned games to support rehabilitation from stroke [20],rehabilitation of wrist flexion and extension [10], in training
individuals with cerebral palsy [11] and to support specificskills such as balance [14]. In general, exercise video games
have been shown to be a valuable tool to improve overall
muscular strength and bodily performance in clinicalsettings.
Other applications, and indeed commercial systems [e.g. 7,30], keep track of a user’s exercise performance over time,
providing longitudinal visualizations of this material. The
goal of this approach is to provide improved access to theresults and impact of the exercise program, typicallyunobservable in a single session and only meaningful over a
period of weeks or months [27]. Such applications are also
often combined with scheduling and coordination tools.
One example is the Wellness Diary [1], a mobile tool that
integrates exercise planning, tracking and sharing. Studies
show users struggled to enter exercise data manually but
appreciated features such as reminders to exercise, rewards

and achievements, recording exercise progress
automatic data analysis showing long term trends.

andResearchers have also explored social approaches tomotivation, such as sharing of progress to a peer group [19]or more widely via online social network services [21].
Although promising results are reported from these studies,
introducing highly personal health and wellness information
into the social sphere clearly also taps into issues ofprivacy. Perhaps unsurprisingly, some research suggeststhat users are reluctant to share health related information[21]. Further research is required to fully clarify theseissues.
While valuable and comprehensive, this work falls broadly
into two categories. It relates to either user’s embarking on
self-motivated and planned health and wellness activity
programs [e.g. 15, 28] or relies on high end equipment
better suited to clinical settings [e.g. 20]. Work at theintersection of these two spheres, in which medical
professionals impact on patient activities outside the clinic
is less comprehensively explored and has tended to focus
on monitoring scenarios. For example, remote monitoring
applications to keep track of vital signs (e.g., blood pressure[24]), or to detect non-medical emergencies (e.g., fallingincidents [8]) or to report on performance of the activities
of daily living (e.g., feeding [26]) have been widely
discussed and the benefits of these communication channels(chiefly in terms of timely alerts and early problem
diagnosis) are well established [3].
The work is this paper explores another intersection oftechnologies for home monitoring and clinical practice.
Specifically, it examines how technology can support theperformance of specific exercise routines in the home aspart of a prescribed program of physiotherapy. While it isexpected that many of the motivational approaches used inprior work are pertinent to this application domain, thispaper argues the bio-monitor's roles as a sophisticatedsensing and computational tool, as an intermediary between
practitioner and patient and indeed the fundamentally
therapeutic nature of the exercises themselves will impact
on optimal design choices. This paper explores this space,essentially that of technology mediating the relationshipbetween practitioner and patient, with the goal of creating
systems to lower patient non-compliance with prescribed
exercise regimes.
FIELD WORK

User research to achieve this objective took place in two
distinct stages. In the first stage, interviews were conductedwith three practicing physiotherapists. The insights
captured from this process were used to generate materials(in the form of scenarios and storyboard) for a speed dating
concept exploration and validation process [9] that was
conducted with eleven current physiotherapy patients.
These stages are described in more detail below.

Practitioner Interviews

60-90 minute interviews were conducted with threephysiotherapists working in Funchal, Portugal. Their mean
age was 30 and time in practice was 3-12 years. Two had
direct experience (1-2 years) of using bioPLUX EMG
biofeedback devices in clinical settings. The goal of thesesessions was to explore issues and problems inphysiotherapy treatment regimes, in particular focusing on
exercise performance in home settings, on patient
motivation and non-compliance, and on how biofeedback
technology might add value.
The results highlighted findings from the literature. The
physiotherapists emphasized the importance of both clinicaltreatment and also the development of a personal exercise
or series of exercises to address patient needs and support
rapid recovery. They reported that during initial sessions
time was spent demonstrating exercises and explaining their
purpose and benefits. On subsequent clinical sessions,home exercise feedback is captured from patients. The
physiotherapists indicate that typical responses are thatpatients are too busy to perform exercises, had forgotten to
do so, or that they volunteered no reason for noncompletion. Although it was not possible to capture an
accurate non-compliance rate in the interviews, thephysiotherapists stated it was commonplace and a major
frustration in their work. Underlying reasons were
attributed to patients’ perceived lack of immediate benefit
from the exercises, lack of motivation as many patientswere financially supported to attend the clinic (e.g. via
socially provided healthcare) and a lack of willingness, orability, to accommodate exercises into the routines ofeveryday life.
Some responses also fleshed out the literature review. One
therapist reported that understanding the impact of theexercises was the most important motivator, particularly incases where they cause discomfort or pain. He highlighted
the importance of credible, understandable information andsuggested that “understanding should be achieved bymaking sure patients get high-quality advice about their
medical condition, and that any fears are addressed by thetherapist”. Another backed this up, suggesting that
relatively few patients are motivated to perform exercise forenjoyment of physical activity; results are the mostimportant driving force. They also needed to be explicit andquantified. She stated: “just knowing that the exercise is…
[beneficial] …is not good enough for the patient” andindicated that regular subjective and objective evaluations
to show progress and provide feedback are vital. Finally,
several of the therapists expressed doubts about theappropriateness of social motivators. They stressed thehighly individual nature of their patients and the fact thatproblems, progress and prognosis varied greatly –comparisons of any sort may not be meaningful. One
reported: “what is good for one patient may not be good foranother. All patients are different and their problems aredifferent too”.

CONCEPT GENERATION

Synthesizing the results of these interviews (using
techniques such as affinity diagramming) with the literature
on motivation and pervasive health led to the generation of
six user scenarios expressing different approaches tomotivating physiotherapy patients to perform exercises athome. Each was based around the core idea of EMG based
bio-monitoring hardware linked to a smartphone andultimately expressed as short storyboards. The storyboards
are shown in Figure 2 and the six scenarios were as follows:

Daniel’s physiotherapist,in his first session,
explains his problem and
how
doing
exercises
would help him.

On reaching home Daniel While performing the At the end of the exercise
opens an application that exercises,
thebio- a message is displayed
reiterates
what
the monitoring
application giving him some more
physiotherapist explained detects
Daniel’s facts about his problem
through illustrations
movements and gives him and how today’s exercise
real time understanding of helped.
the muscle being exercise
through animations

It is time for Daniel’s
daily exercise. He browses
a game to play while
performing his exercise.

He selects the balancing At the end of the exercise Daniel looks back at hisball game and starts his Daniel receives a gold star stars to check his progress
exercise. The ball acts as a for doing a good job.
over time.
metaphor for the muscle
being
exercised. Thebalancing display gives
real time feedback onwhether he is performing
his exercise correctly.

Danielhas
been
performing his exercises
on a regular basis, just likethephysiotherapist
advised.

Alongside, Daniel has also However, Daniel does not He looks over various
been answering certain see
any
noticeable charts that compare andsubjective
questions improvementin
his contrast the results of therelated to level of pain and condition since the past few exercise and answers tofunctionality.
the subjective questions.
days.
The chart gives Daniel thebigger picture and he isable to see his progressover time.

Daniel’s physiotherapist
advises him to perform hishome exercises regularly
in order to recoverquickly.

Danielschedules
hisregularexercises
toprovide alerts at the
programmed
timewhenever he is home.

One day Daniel is latefrom work and fails toreachhome athis
scheduled exercise time.
The system detects his
location and the alerts aresuppressed for the time
being.

When Daniel reaches
home, he receives an alert
reminding him that hemissed his exercise andmust do it soon.

At his next session, Daniel
and the physiotherapist sit
together and list down aset of exercises Daniel
should perform at home.

Uponcommit,thesecollaboratively
decidedexercises
along
with
details of the duration andlength appear as a set ofgoals.

As Daniel performs his
exercises on a daily basis
the goals are checked off
and a report of theexercise routine is sent to
the physiotherapist.

The physiotherapist looks
over the report in his clinicand sends Daniel feedback
about his performance. He
also informs Daniel if heshould schedule anotherclinical session.

Daniel looks up otherpeople who have similar
problems as him. The
search reveals two suchpeople - Ana and João.

Daniel requests Ana and One day Daniel misses his In
addition,
DanielJoão to collaborate and regular exercise. Ana and receives a notification
help each other with their João are notified of the indicating that both Ana
exercises. Ana and João same. They send a ‘nudge’ and João have completedagree to the request.
to Daniel asking him to their exercises for the day.
perform his exercise.

Motivation by Understanding: Home regimes can appear

counter-productive to patients, particularly due to perceived
ineffectiveness of exercises or discomfort [6]. This scenario
explored the presentation of real time feedback illustrating
the problem and effect of exercises. This was shown as live
visualizations (muscles activating on a stylized body) of
EMG data.
Motivation by Enjoyment: Games have been frequently

explored as a mechanism to support and motivate
rehabilitation activities [2]. This scenario explored the useof simple “mini-games” driven by exercise performanceand interactively displayed on a smartphone.
Motivation by Results: Physiotherapy treatments work

incrementally and gradually; patients experience difficultyin observing improvements in such prolonged processes[27]. This scenario explored allowing users to visualize andexplore bio-sensed data charting their performance andprogress over time.
Motivation by Scheduling: Willingness and ability toaccommodate prescribed exercises regimes into everyday
life is a key to the success of a treatment program [6]. This
scenario explored the use of technology to prompt patients
to complete exercise sessions (based on contextual cues
such as arrival at home), to track completion (via biosignal
monitoring) and to manage and mediate clinicalappointments.
Motivation by Support: Bio-monitoring technology has thepotential to increase levels of clinical support. This scenario
explored online connections that transferred data recorded
from home exercise sessions immediately to therapists who
could monitor, evaluate and give feedback on performance
immediately and outside of regular clinical appointments.
Motivation by Peers: Although the interviewed practitioners

doubted the importance of social motivators, research has
shown social factors such as peer pressure, public
commitment and group membership are strong motivating
influences [22]. Consequently, this scenario explored therole of sharing of biofeedback based exercise performancedata with peer-patients.
Each storyboard focused on its overarching motivational
theme, as listed above, but did this through the introductionof a number of specific, well-defined examples. For
instance in the ‘motivation by support’ storyboard, multiple

Figure 2. Storyboards used in speed boarding tests. From top tobottom, these are: Motivation by Understanding, Motivation byEntertainment, Motivation by Results, Motivation by
Scheduling, Motivation by Support and Motivation by Peers.

means of practitioner support were presented, including
collaborative goal setting, remote reporting of objective
exercise performance and personalized feedback.
Technical and logistical details were not included in thestoryboards or the discussions surrounding them. For
instance in the ‘motivation by understanding’ storyboard, areal world patient would be required to connect a biomonitoring device to specific muscle groups on his or her
body in order to sense real time data and display feedback
on a mobile device. While such issues are clearly importantto any real world system design and deployment, thestoryboards in the current work intentionally avoided thislevel of detail in order to focus on motivational factors
rather than practical feasibility issues.
Concept Exploration

The six concepts were explored with the speed dating
method, a rapid, low-cost technique intended to let
designers and researchers quickly identify and understandthe user needs and critical contextual aspects of a design
space [9]. Speed Dating consists of two stages: Speed
Boards and Speed Enactments. Speed Boards is a needvalidation process that explores the intersection between
researcher-observed and user-perceived needs. In Speed
Enactments, researchers organize key factors that emerge
from this process into a Speed Dating Matrix, essentially amulti-dimensional grid of possible design spaces. Concepts
are generated for each cell in this grid and experience
prototyping techniques are used to elicit user feedback
about the full range of possible options. Speed dating wasselected as a method for this stage of the research in part
because of its focus on contextual factors and in part
because it is suitable for exploring a wide range of ideas
and possibilities in a single session. Given the complexityof systems depicted in the scenarios (involving a biomonitoring machine linked to a mobile phone) the relianceof speed dating on structured reference material(storyboards and mocked up spaces or applications) was
also valuable in ensuring sessions were grounded on
relevant issues.
A total of 11 physiotherapy patients participated in thisstage of the work. The youngest was of age 16, the oldest
75 and all had been in physiotherapy for at least one year.
All attended the same practice and all had previous
experience of EMG based biofeedback during clinicalsessions. The choice of patients with prior exposure to thisclinical treatment paradigm was intentional. Theirexperience with the technology gave them an accurate
understanding of its capabilities and use. We believe thismade the sessions more informative as participants had abasic understanding of the benefits provided by thistreatment paradigm. The patients were in therapy for a wide
range of conditions including muscle strain (due to sporting
injuries), upper and lower back pain (due to overexertion),paraplegia (due to stroke or spine injury) and osteoarthritis(associated with age).

Speed Boarding Process

Eight of the participants completed a speed boarding
process while the remainder completed follow-up user
enactments. Speed boarding took the form of semistructured interviews in which participants were exposed tothe six storyboards. An experimenter led a discussion ofeach scenario in turn, eliciting opinions, comments andcomparisons with the goal of extracting user needs. The
discussions were 1 to 2 hours long and were centered onparticipant impressions of the scenario, including
identifying the best and worst aspects, whether the service
described would be useful or motivating and how it could
be adjusted to better suit their needs. At the end of thesession participants were asked to individually rate eachscenario on a scale of 1-5 (1 being least appealing, 5 being
most appealing) and also rank the scenarios based on orderof importance to them. Such ratings and rankings were used
as a tool to elicit additional user commentary rather thansimply to provide explicit preference information.
In order to synthesize outcomes from these sessions, we
divided the interview transcripts into individual statements
and used a clustering process that bucketed each response
into a set of emergent categories. Efforts were expended toensure that statements that confirmed, negated or related to
one another were appropriately sorted. Particular attention
was paid to novel statements. Initially, this process
identified 15 categories, but these were eventually refined
to a pair of closely related overarching themes: reliance andprivacy. At heart, both related to patient trust duringperformance of home exercises. Reliance referred to trust in
the veracity of the feedback and information received in
response to the exercise, whereas privacy related to thewillingness and extent to which patients would share thisinformation: to a digital system, to their therapist or tofamily or peer group members.
These themes were broken down into two further
dimensions. Both were temporally based. The firstconsidered interventions to support exercises that take place
before, during or after exercise completion. The second
related to the proactive or reactive nature of system features- whether or not the system monitors and attempts to guideand prompt a patient towards desired performance, or
simply responds to events and data recorded. For example,
a proactive system would remind a user to perform
exercises, whereas a reactive system would inform a patientthat an exercise session had been missed.
Two other dimensions also emerged strongly from thetranscripts. Both related to individual differences across a
range of patient conditions and characteristics. The
condition dimension related to severity (in terms ofsymptoms and functional limitations) and prognosis of apatient’s ailment. On the other hand, the characteristics
dimension covered exercise history, self-efficacy, exercise
beliefs, age and lifestyle. These important and complex
factors were excluded from further analysis as they havePre-exercise

During exercise

Post-exercise

AlertsCorrectness feedback

Encouragement feedback

Proactive

You set alerts on the bio-monitoring
device as reminders to perform
exercises on time

You rely on your own judgment ofright or wrong when performing
exercises

You give yourself a “star” rating basedon your satisfaction with today’s
exercise

Reactive

You keep track of the exercises you
have missed on the bio-monitoring
device

You record your pain and functionality
on the bio-monitor to understand if
you are performing the exercises
correctly

You look up charts comparing andcontrasting the results of exercise andanswers to subjective questions

Proactive

The device observes and keeps
track of your routine; it decides when
the best time for you to exercise isand sets an alert

The bio-monitor shows visualizations(metaphors for the exercise being
performed) to indicate if it is being
done correctly

The device awards “stars” for doing wellat today’s exercises

Reactive

The device keeps track of yourroutine and missed exercises; it
provides a history of missed
exercises

Afterwards, the bio-monitor provides
a summary status that indicates
whether the exercise was performed
correctly or not

The bio-monitor provides feedback on
how you can perform the exercise betterand changes your exercise set if you
are not showing improvement

You share your calendar with yourtherapist and she/he sends you analert when you have to perform an
exercise

The bio-monitor captures yourexercises performance and sends it
to your therapist for immediate
analysis

The therapist monitors your exercise
through the bio-monitor and provides
you real time encouragement throughsupportive messages (e.g. “Good job!”,“You can do better”, “Good
improvement”)

Reactive

Your therapist keeps track of when
you miss an exercise and sends you
friendly reminders

The bio-monitor keeps track of theexercises and sends summary
information of where you went wrong
to the therapist

The therapist looks over your report andgives you feedback on correctness andperformance and also recommends
other exercises

Proactive

You share your calendar with apeer/family member and they send
you an alert when you have toperform your exercise

The bio-monitor captures the exercise
being performed and sends real time
information to your peers/familyYour family member monitors yourexercise through the bio-monitor andsends supportive messages (e.g. “Goodjob!”, “You can do better”, “Good
improvement”)

Your peer/family member keeps
track of when you miss an exercise
and sends you friendly reminders

The bio-monitor keeps track of theexercises and sends summary
information of where you went wrong
to your peer/familyYour family member looks over yourreport and gives you feedback on
correctness and performance and also
recommends other exercises

Reliance &Privacy

Self

DeviceProactive
Therapist

Peers/
FamilyReactive

AND
Your peer (also a physiotherapy patient)shares reports with you to help you
compare your progress

Table 1. Speed Matrix generated for Speed Enactment process.

received considerable attention from previous authors [e.g.
6, 27, 32] Attempting to understand the relationshipbetween them and the design space of bio-monitoring
technology was considered infeasible due to the small sizeand diverse ailments of our participant pool.
•
Speed Enactments Process

After identifying these key dimensions, we created a matrix
for carrying out speed enactments and future breachingexperiments. This took the form of a three-dimensional grid
integrating the following factors:•

Trust level: Reliance and Privacy were collapsed intoa single dimension of trust with the following fourlevels: Self; Device; Therapist and; Family/Peers. It
encapsulated elements of whom (or what) a patient
would rely on for motivational support for exercise
performance and also to whom (or what) they would be
willing to share this information with.
Intervention Time: This dimension referred to thetime at which motivational support was provided: preexercise;duringexerciseor;post-exercise.
Respectively, these temporal stages broadly
corresponded to support in the form of alerts or
warnings, in the form of live feedback on performanceand in the form of post-exercise comments andencouragement.

•Proactive/Reactive:Thisbinarydimension
encapsulated the difference between prompting for andresponding to events.

The cells in this matrix were then populated with fictional
scenes reflecting the combination of issues described bycolumn and row labels. A summary of this material can beseen in Table 1.
All 24 cells were explored through speed enactments using
experience prototyping and future breaching experiments.
Essentially, this process involved physiotherapy patients
being presented with short scenarios based on each category
and illustrated through simple low fidelity wireframes
displayed on a mobile device. Real-time engagement withand reactions to this material were then observed. Figure 3
shows one user interacting with a mockup on a mobile
device during an enactment session. Speed enactments werehighly effective in revealing the attitudes patients havetowards the involvement of the device, doctor and peers orfamily to support their motivational needs.

real time visualization of the muscles being exercised via ananimation. Users reported that this highly direct feedback
would increase comprehension of the impact of their
exercises, addressing problems in understanding how
specific movements related to particular health outcomes.
Similarly, in the “motivation by enjoyment” scenario, users
reported valuing the association between success in thegame and correctly performing the physical exercises. For
example, in the game depicted, balancing a ball acts as a
metaphor for the muscle being exercised; when the ball isbalanced, the exercise is being correctly performed.
Although the game play is trivial, its simple,
comprehendible depiction of correctness was highlymeaningful. One participant commented: “When I firststarted performing home exercises, I was very afraid ofoverexerting and was always stipulating my limits, so I
really like the idea of knowing [in] real time [that] what I
am doing is right.” Another, commenting on both theunderstanding and enjoyment scenarios, said: “The twocomplement each other very well. The muscle animation
helps form clear understanding about the exercise and thebalancing ball game gives information of right and wrong”.
In summary, physiotherapy patients struggle to relate their
exercises to their conditions and worry they do not perform
home activities correctly. These lacks can be addressed bybio-monitoring feedback designs that explicitly target
patients’ understanding of effectiveness of exercises and thecorrectness of their performance.

Figure 3. Physiotherapy patient enacts the scenario
where their family member/ peer ‘Ana’ keeps trackof missed exercises and sends a friendly reminder.
DESIGN INSIGHTS AND GUIDELINES

The results from both stages of the speed dating process
were analyzed to uncover insights and design guidelines
relating to the introduction of sophisticated homemonitoring technologies to physiotherapist practice. A
particular focus was on how bio-monitors coupled with
Internet connected mobile technology (such as
Smartphones) could support patient motivation and exercise
regime compliance. Ultimately, six findings emerged fromthis synthesis process. Each is described below, both interms of the opinions and comments upon which it is based
and also in terms of its implications for design. The
findings were as follows:
Effectiveness and Correctness: Participants had much tosay about the value and form that feedback from the device
should take. Clear user needs revolved around difficulties
understanding if exercises were genuinely helping toachieve therapeutic goals and whether or not exercises werebeing performed correctly. For example, in the “motivation
by understanding” scenario, the bio-monitoring application
detects a physiotherapy patient’s movements and provides a

Results are Rewards: Participants reported difficulties
understanding their progress through long-term therapy, inwhich efforts and outcomes can be separated by months.
They responded positively to tracking features in the“motivation by entertainment” scenario. For example, anumber of participants indicated that a record of gameachievements (stars awarded) would be highly beneficial.
One remarked: “Stars are the best aspect of this scenario,
because the credit provides motivation.” He later added: “Ialso like the ‘star’ and the ‘history of stars’, because it
indicates if [the patient] has been doing the exercise rightor wrong now and in the past too.”

But such things are not ends in themselves and their value(and credibility) lies in their correspondence with real
progress towards therapeutic goals. As one patient put it,“the rewards provide satisfaction, although a better
satisfaction would be observing improvement itself”.
Comments on the “motivation by results” scenario
reinforced this point. In this narrative, the patient explores
charts and graphs of his historical performance andsubjective report (e.g. pain levels, functionality) data to
gain a wider perspective on his treatment. Participants
reported that such visualizations would help them gauge
progress and appreciate the value and impact of home
exercises. One stated: “This is most important because it
explains why the problem still exists and how exercise canhelp reduce the problem”.

Future applications in this space should present simple
visualizations providing overviews of both short-term andlong-term performance, but must ensure they accurately
represent real health outcomes. At the same time, moredetailed statistical data covering both subjective evaluations(e.g. self report) and objective evaluations (e.g. derived
from a bio-monitor) should be available for users to
explore.
Exercise is not Entertainment: All participants valued the“motivation by entertainment” scenario, in which exercise
is supported by a simple mini-game, for its simplicity,
directness and understandable feedback. This stands in stark
contrast to the widespread premise that engagement or fun
is the primary motivating factor in gaming for exercise or
rehabilitation scenarios [e.g. 2]. One patient stated:“Exercises are not enjoyment even when coupled with agame”. Reinforcing this comment, another reported: “thepart that doing exercise is like playing a game, makes you
feel like there is less work but it is still not enjoyment assuch”. This argues against generalizing the success ofcommercial games with a physical component such as
Dance Dance Revolution and Wii Sports [35] to the domainof prescribed home exercise performance. The data fromparticipants in this study indicates that tying compellingentertainment experiences to exercises will have little effecton patient non-compliance rates. This is largely because
patients strongly indicated they did not seek to enjoy theirtreatment; making and understanding progress was more
important.
Games were not viewed as sufficiently motivating toencourage exercise compliance, possibly because of thewidespread
availabilityofalternative
dedicatedentertainment options. Instead, they were useful in that they
provide clear and immediate feedback relating to exercise
correctness and long term tracking of results. Future
designs for gaming for physiotherapy rehabilitation should
focus on accurate and informative depiction of data, notengagement or fun.
Scheduling: Participants reported noncompliance behaviors due to forgetfulness and difficulty inintegrating exercises with other tasks (e.g. work or schooltasks). One said: “I respect the treatment; never fail tocome to the therapist, but sometimes forget to perform
exercises or put [on] the ice pack. I feel like there is no time
because I [re]started work right after the problem.”
Attempting to unpack these challenges, the speed
enactments session explored techniques to support patients
who differ in how they manage exercise scheduling, fromself-reliance through to external reliance, either via a third
party or fully digital service.

Contextual

In response, many patients reported irritation with the ideaof external parties (therapists, family members or a mobile
device) mandating their routines. One indicated: “Thismakes sense for young kids but not for grownups like me. I
like to have control of my agenda”. In general, patients

responded most positively to notions of limited contextaware autonomy: a mobile device that would remind themto perform exercises at suitable places or times of day (suchas reminders to perform exercises upon arrival at home).
In sum, scheduling is a key factor in physiotherapy exercise
non-compliance and future designs in this space should
include for reminder and scheduling systems for exercise
regime compliance that are context aware [e.g. 12].
Lightweight Communications: Practitioners and patientsboth expressed a strong desire for improved communication
relating to home exercise performance. This came acrossclearly in the “motivation by support” scenario, in which
the patient checks off daily exercise goals in order to send a
progress report to the therapist who responds with coaching
feedback. Patients viewed this kind of sharing of exercise
results very positively. One stated: “It is very important tomaintain communication with the therapist - the doctor has
to be good for patient to get better soon”. Underlying thisopinion is appreciation for idea that care would be more
personalized. Another participant suggested: “I like the idea
because it is important to give the doctor right information
so that they can treat you well. The collaboration will help
make a fast recovery.” In the initial interviews, thephysiotherapists were cautiously positive about this kind ofcollaboration. They suggested organizing one hour per day
to monitor patients remotely could lead to fewer patients todeal with at the clinic, increasing productivity. On the other
hand, they voiced concern about the potential for increased
workload to remote monitoring commitments.
On the other hand, although patients felt communication
would definitely aid recovery, they doubted thatpractitioners would review or respond to it. Speed
enactments further highlighted complexities in thiscommunication. In one speed enactment, patients wereasked to perform their regular exercises. A bio-monitor
captured the exercise and sent real-time information to thedoctor for analysis. Patients liked that the physiotherapist
has access to their data but did not expect the doctor tofollow up. They had strong concerns about the therapist’s
availability and time constraints. Critical and low frequency
messages were viewed as more likely to receive attention.
One commented: “I feel the message will be ignored by thedoctor if it is not important. So it is more practical to send a
notification to doctor only if things are wrong”.
In summary, future designs in this space should focus on
enhancing communication channels between patients andtherapists. But, if real-time monitoring applications are toeffectively motivate users, they should emphasize thesignificance of the data they transmit. Communications totherapists should remain lightweight in order to be credible.
Communications that do not receive responses will rapidly
lose their motivational power.
Health Information is Private Information: All
participants viewed social motivating factors negatively.

This was explored in the “motivation by peers” scenario in
which a patient requests that two others collaborate forexercise support. The three patients are notified of eachother’s exercise performance and can send prompts andreminders to one another. Participants responded negatively
to these ideas of social feedback and sharing of their healthand exercise information. Many reported appreciating how
the idea would be motivating but that they would simply
opt out. One derided the idea as: “Facebook for the sick!”
The idea of sharing data with peer-patients, who wereperceived to be strangers, was particularly disliked. One
participant commented: “I will not like to share personal
information with strangers even though the doctor will help
establish connections.” The speed enactments fleshed out
reasons for these opinions. These were diverse andincluded: that the social aspects would lead to a lack ofcontrol; that sharing would be intrusive and impact theirprivacy; that the health information of others was of little
interest and; a general reluctance to socialize around what
they viewed as a negative aspect of their lives. Overall,participants were strongly negative about sharing even
abstracted information relating to their medical condition,
progress and prognosis. These results suggest that data
captured by biosignal monitors is viewed as too personalfor sharing with anyone except therapists.
DISCUSSION AND CONCLUSIONSThis paper highlights the problem of treatment noncompliance in physiotherapy and suggests thatappropriately designed technology may be able to support
patients and reduce the negative impact of this behavior. In
particular it focuses on sophisticated EMG bio-monitors
suitable for home use. To understand how suchtechnologies might be able to support physiotherapy
treatment routines, interviews with three practitioners and11 patients were conducted using a speed dating approach.
The resultant data was analyzed into six insights intended to
guide future application and service designs in this space.
The findings covered: the importance of feedback andrewards based on exercise effectiveness and correctness;
the fact that patients do not seek to be entertained during
their exercise sessions; the need for improved exercise
scheduling systems and credible communication channels
between patients and therapists and; the fact that biomonitor based health information is viewed as too private toshare. We believe these findings represent valuable
guidelines that can inform future designs in this space.
A key limitation to this study lies in its sample of users.
Physiotherapy patients are inherently a highly diverse
group, not only because the full spectrum of individuals cansuffer from such conditions, but also because the conditions
themselves vary substantially in their causes, severity,
duration, treatment goals and ultimate prognosis. The 11
patients in this study represented only a small sub-sectionof this diversity. Compounding this problem are the facts
that all participants were of a single nationality(Portuguese), attended a single clinic and, barring one
therapist, had prior experience with clinical EMG
technology but not pervasive home health technology.
While we believe the conclusions of this work to bevaluable, extending it to broader and more representative
user groups is a current priority. Considering a larger
population will extend, refine and improve the scope andgeneralizability of the findings. Fieldwork that addresses
the novice and/or novelty effects that may have influenced
the participant group studied in this paper would be of
immediate interest.
However, the main area for future work developing thisresearch will be in the creation, implementation and fieldtesting of functional prototypes that support performance ofprescribed home exercises. Factors such as how to combine
the various features introduced in the scenarios anddiscussed in the insights would be an important focus – it islikely that patients would seek to use aspects that cut across
how they have been framed in this paper, for instance by
combining the muscle monitoring with reward systems.
Furthermore, a particular topic of interest will be on
customizable approaches to motivating users [17] in orderto adapt to the different needs and demands of patients.
Overall, this paper argues that pervasive health technologies
have much to offer their users, but must be designed tomatch lifestyles and genuine needs. Comprehensively
capturing and understanding such information will be along and complex process and the work presented here
represents a small step towards this objective.
ACKNOWLEDGMENTS

We thank our participants for their time and input, Augusto
Esteves for translation and the Reabilitesse clinic in
Funchal, Portugal for supporting the fieldwork.
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