# Use of a Smartphone for Improved Self-Management of Pulmonary Rehabilitation

Authors: A. Marshall; O. Medvedev; A. Antonov
Journal: International Journal of Telemedicine and Applications
 (2008)

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## Abstract

Patients suffering from chronic respiratory disease need to follow a rehabilitative exercise programme, in order to self-manage their illness and improve quality of life. Adherence to the programme is highly dependent on professional support from a physiotherapist and hence declines when patients seek to self-manage in the home. A number of requirements were identified for a Smartphone-based application in which patients are supported remotely and given automatic feedback during exercise. An application is described which will improve adherence during pulmonary rehabilitation.


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## Body

## 1. Introduction

One of the  most serious challenges in healthcare today is how to
support chronic disease patients to manage their lifestyle and/or therapeutic
programme. Chronic diseases are on the increase [1]. Current healthcare policy
considers that it is more effective clinically, economically, and socially for
healthcare services to support self-management in the home, than to bring
patients into hospital or clinics for regular treatment [2–4]. Self-management
may involve adhering to drug therapy or another intervention, but also normally
requires lifestyle changes, particularly exercise or dietary changes and in
some cases cessation of smoking, alcohol consumption, and so forth [5].
Appropriate support has to be provided by community health workers, such as
nurses, physiotherapists, and occupational therapists. The Smartphone
application described in this article provides a tool to be used by both
patients and community health workers to improve this process.One of the major chronic illnesses today is chronic obstructive pulmonary
disease (COPD), which affects an estimated 210 million people worldwide.
According to the World Health Organisation’s latest estimates (2007), COPD will
become the fourth most significant cause of death worldwide by 2030. In 2005, 3
million died from COPD [6]. COPD patients suffer breathlessness, shortness of
breath, and chronic cough. If patients suffer an acute episode, which includes
a hospital admission, they are usually advised to join a rehabilitation
programme, in which they are trained to carry out a daily exercise programme.
If they adhere to the exercise programme, they should improve their health
significantly. The difficulty arises once they are discharged from the
supervised exercise stage and expected to continue the programme at home,
within their normal lifestyle [7].We propose a support system in which the reduced level of the
community health worker’s time can be maximised in value, using wireless
communications and personalised computing platforms. A number of telemedicine
or e-health applications for respiratory medicine have already been developed
and piloted [8–12]. Most pilot
systems use personal home computers or provide portable devices to health
workers. A system using mobile phone technology has been developed to early
commercial stage, using peak flow monitors to support the self-management of
asthma [8, 9]. Chronic care of COPD has been found to be made more effective by
provision of 24-hour telephone support and a web-based patient self-management
module [12]. The system described here
is slightly different in emphasising patient motivation and management, rather
than focusing on monitoring.


## 2. Smartphone Pulmonary Rehabilitation System

A pilot application has been developed, based on a standard
rehabilitation programme used within Wakefield Primary Care Trust, within the
UK National Health Service. Patients are trained to undertake a series of 12
gentle exercises, each typically for a period of 5 minutes, per day.


### 2.1. User Requirements

A stakeholder analysis was conducted to develop an understanding of
the problems and issues, which the Smartphone application should address. This
involved several discussions with a community physiotherapist, community respiratory
nurse, and public health physician, which took place at different stages of
development of the application, using an earlier demonstration version of the
programme. Consultations with approximately 15 patients were conducted
indirectly through the physiotherapist, who described the application in
general terms and by asked for feedback on the current regime. From this, a set
of user requirements were developed and are summarised in Table1.Table 1
Stakeholder/user
requirements.
COPD patient– Reminder to do exercises– Convenient (does not interfere
excessively with daily lifestyle)– Easy to use– Feedback available from
physiotherapist– Confidence that exercise activity is safePhysiotherapist– Ability to see if patients are
adhering to programme– Can provide care in a shorter time
than conventionally– Easy to use, convenientHealth service– Reduced number of acute episodes
due to failure of adherence to exercise programme– Management information to evaluate
and monitor community care programmeOne issue that was identified was lack of confidence by patients in
the safety of exercising. Many patients became concerned that they were short
of breath, although they were actually in a completely safe state. When
exercising under supervision of the physiotherapist, monitoring equipment could
be connected to show that their heart rate was stable. The use of home
monitoring during exercise was, therefore, identified as a desirable feature of
the Smartphone application.It was also found that motivation was a key issue in adherence to a
home exercise programme, which is supported by findings reported by Calverley
[5] who reports that rehabilitation programmes, whilst effective at all stages
of the disease, are most successful if patients are well motivated.


### 2.2. Elements of the Smartphone Application

The application has been developed using Microsoft Visual Studio for
a Windows Mobile Smartphone and has been deployed on a Qtek 8300 and an O2
Graphite XDA phone for testing purposes. The monitoring sensor is a Nonin 4100
Bluetooth Pulse Oximeter [13]. The sensor is connected to the Smartphone by
Bluetooth, prior to starting the application. The connection and pairing
functions within the Smartphone operating system are used. Once this has been done the application must
be launched.The design goal for the rehabilitation application was to simplify
the main user routines, which will be used on a daily basis, and provide more
complex functions in separate menus. The user routines and menus are described
in more detail in Section2.3.Daily exercise results (including times and durations of exercise,
physiological data) are saved to the phone memory card. Data is sampled every 30
seconds, recording the heart rate and the blood oxygen saturation (SpO2).
The Nonin 4100 Bluetooth sensor sends 5 bytes of data 75 times per second. In
this application, data is only sampled twice per second, and for a typical
exercise period of 12 exercises each of 1–5 minutes
duration, the total file size is 100–200 kB. The
manufacturer’s claimed accuracy is ±2 digits for SpO2 and ±3% for heart rate. In this application, it
is the relative change of the data that is important, with absolute figures not
being required to a high accuracy. Only the heart rate data is shown to the
patient, as this is more variable and directly related to the rate of
exercising. The blood oxygen saturation is kept for reference by the clinical
users, but is generally constant throughout the exercise session. The data can
be transferred using the mobile networks on a daily basis, or by data cable to
a local laptop. The latter procedure, although less automated, was preferred
for the population under study as it could be done weekly by the physiotherapist during a home
visit. Many chronic COPD patients have limited computer skills and hence find
this procedure preferable.Clinical professionals are able to examine the data in Microsoft
Excel or in a bespoke PC application, linked to patient records.These elements are summarised in Figure1, which shows the main
components and data transfer processes.Figure 1
Elements of the Smartphone application.


### 2.3. User Feedback and Interactivity

Users enter the application to a simple main menu, shown in Figure2, and will normally select “Start exercise,” to go directly to exercise mode. They may also select “Resume exercise” if they
had taken a break between exercises. They are then advised to connect the pulse
oximeter and to start exercising. During exercise, the application provides
users with real-time feedback, summarised in Table 2. The heart rate and time
remaining are displayed in real time, with a green/amber/red background to
denote normal/borderline/danger (STOP). In addition, audible signals are
provided. A loud siren-like sound is emitted if the patient’s heart rate
exceeds safe limits. A different signal is emitted at the end of each
individual exercise period (normally 1–5 minutes).Table 2
Feedback
to users during exercise programme.
StatusScreen
shotOther
details– Normal physiological conditions
– Heart rate within acceptable range specified by
clinical professional– Heart rate shown
– Time remaining in seconds shown – Green background– Normal  physiological
conditions, but near acceptable limits
– Heart rate higher or lower than normal, but still within
acceptable range– Heart rate shown
– Time remaining in seconds shown – Amber background– Dangerous physiological conditions – Heart rate excessively high or low
– Exercise should cease now– LOUD AUDIBLE WARNING
SIGNAL
– Heart rate shown – Red background
– STOP displayed – Display freezes and remains in this state until the
Stop button is pressed– Exercise completeDisplay clearsAudible signalFigure 2
The main menu.Users may also access information screens, from the main menu, to
see diagrams and text describing the exercise to be done (see Figure3).Information screens for users.


### 2.4. Configuration of the Application

The  application may be configured to set the acceptable limits for
the individual, in terms of minimum and maximum heart rates. The first item on
the main menu, personal settings, should be selected. Basic data is recorded,
as shown in Figure4(a). The up setting and the down setting determine the
limits for the feedback screen. If the user’s heart rate increases to within
10% of the “Up” figure, an amber signal will be shown. When it reaches this
figure, the red signal plus the alarm sound will be activated. Similarly, if
the user’s heart rate falls to the “Down” figure, signals will be given in the
same way. The length of each exercise may also be configured, through “Setup
exercise regime” and edited in “View exercise settings” (see Figure 4(b)). Configuration
would normally be done by the physiotherapist or community health worker, but
could be done by the users themselves.Screen shots to show configuration of application to
individual user.
(a)(b)


## 2.1. User Requirements

A stakeholder analysis was conducted to develop an understanding of
the problems and issues, which the Smartphone application should address. This
involved several discussions with a community physiotherapist, community respiratory
nurse, and public health physician, which took place at different stages of
development of the application, using an earlier demonstration version of the
programme. Consultations with approximately 15 patients were conducted
indirectly through the physiotherapist, who described the application in
general terms and by asked for feedback on the current regime. From this, a set
of user requirements were developed and are summarised in Table1.Table 1
Stakeholder/user
requirements.
COPD patient– Reminder to do exercises– Convenient (does not interfere
excessively with daily lifestyle)– Easy to use– Feedback available from
physiotherapist– Confidence that exercise activity is safePhysiotherapist– Ability to see if patients are
adhering to programme– Can provide care in a shorter time
than conventionally– Easy to use, convenientHealth service– Reduced number of acute episodes
due to failure of adherence to exercise programme– Management information to evaluate
and monitor community care programmeOne issue that was identified was lack of confidence by patients in
the safety of exercising. Many patients became concerned that they were short
of breath, although they were actually in a completely safe state. When
exercising under supervision of the physiotherapist, monitoring equipment could
be connected to show that their heart rate was stable. The use of home
monitoring during exercise was, therefore, identified as a desirable feature of
the Smartphone application.It was also found that motivation was a key issue in adherence to a
home exercise programme, which is supported by findings reported by Calverley
[5] who reports that rehabilitation programmes, whilst effective at all stages
of the disease, are most successful if patients are well motivated.


## 2.2. Elements of the Smartphone Application

The application has been developed using Microsoft Visual Studio for
a Windows Mobile Smartphone and has been deployed on a Qtek 8300 and an O2
Graphite XDA phone for testing purposes. The monitoring sensor is a Nonin 4100
Bluetooth Pulse Oximeter [13]. The sensor is connected to the Smartphone by
Bluetooth, prior to starting the application. The connection and pairing
functions within the Smartphone operating system are used. Once this has been done the application must
be launched.The design goal for the rehabilitation application was to simplify
the main user routines, which will be used on a daily basis, and provide more
complex functions in separate menus. The user routines and menus are described
in more detail in Section2.3.Daily exercise results (including times and durations of exercise,
physiological data) are saved to the phone memory card. Data is sampled every 30
seconds, recording the heart rate and the blood oxygen saturation (SpO2).
The Nonin 4100 Bluetooth sensor sends 5 bytes of data 75 times per second. In
this application, data is only sampled twice per second, and for a typical
exercise period of 12 exercises each of 1–5 minutes
duration, the total file size is 100–200 kB. The
manufacturer’s claimed accuracy is ±2 digits for SpO2 and ±3% for heart rate. In this application, it
is the relative change of the data that is important, with absolute figures not
being required to a high accuracy. Only the heart rate data is shown to the
patient, as this is more variable and directly related to the rate of
exercising. The blood oxygen saturation is kept for reference by the clinical
users, but is generally constant throughout the exercise session. The data can
be transferred using the mobile networks on a daily basis, or by data cable to
a local laptop. The latter procedure, although less automated, was preferred
for the population under study as it could be done weekly by the physiotherapist during a home
visit. Many chronic COPD patients have limited computer skills and hence find
this procedure preferable.Clinical professionals are able to examine the data in Microsoft
Excel or in a bespoke PC application, linked to patient records.These elements are summarised in Figure1, which shows the main
components and data transfer processes.Figure 1
Elements of the Smartphone application.


## 2.3. User Feedback and Interactivity

Users enter the application to a simple main menu, shown in Figure2, and will normally select “Start exercise,” to go directly to exercise mode. They may also select “Resume exercise” if they
had taken a break between exercises. They are then advised to connect the pulse
oximeter and to start exercising. During exercise, the application provides
users with real-time feedback, summarised in Table 2. The heart rate and time
remaining are displayed in real time, with a green/amber/red background to
denote normal/borderline/danger (STOP). In addition, audible signals are
provided. A loud siren-like sound is emitted if the patient’s heart rate
exceeds safe limits. A different signal is emitted at the end of each
individual exercise period (normally 1–5 minutes).Table 2
Feedback
to users during exercise programme.
StatusScreen
shotOther
details– Normal physiological conditions
– Heart rate within acceptable range specified by
clinical professional– Heart rate shown
– Time remaining in seconds shown – Green background– Normal  physiological
conditions, but near acceptable limits
– Heart rate higher or lower than normal, but still within
acceptable range– Heart rate shown
– Time remaining in seconds shown – Amber background– Dangerous physiological conditions – Heart rate excessively high or low
– Exercise should cease now– LOUD AUDIBLE WARNING
SIGNAL
– Heart rate shown – Red background
– STOP displayed – Display freezes and remains in this state until the
Stop button is pressed– Exercise completeDisplay clearsAudible signalFigure 2
The main menu.Users may also access information screens, from the main menu, to
see diagrams and text describing the exercise to be done (see Figure3).Information screens for users.


## 2.4. Configuration of the Application

The  application may be configured to set the acceptable limits for
the individual, in terms of minimum and maximum heart rates. The first item on
the main menu, personal settings, should be selected. Basic data is recorded,
as shown in Figure4(a). The up setting and the down setting determine the
limits for the feedback screen. If the user’s heart rate increases to within
10% of the “Up” figure, an amber signal will be shown. When it reaches this
figure, the red signal plus the alarm sound will be activated. Similarly, if
the user’s heart rate falls to the “Down” figure, signals will be given in the
same way. The length of each exercise may also be configured, through “Setup
exercise regime” and edited in “View exercise settings” (see Figure 4(b)). Configuration
would normally be done by the physiotherapist or community health worker, but
could be done by the users themselves.Screen shots to show configuration of application to
individual user.
(a)(b)


## 3. Discussion and Conclusion

The pulmonary rehabilitation Smartphone application has been
designed for a very specific exercise programme undertaken by chronic COPD
patients. The objectives were to provide users with a tool to reduce dependence
on the conventional, labour intensive services and to enable improved
management of their rehabilitation programme through better self-involvement.
In other words, we seek to provide a “personal physiotherapist” who is always
available. The application could easily be adapted to other patient groups, who
need to undertake a regular exercise programme, such as stroke patients. The
use of a mobile device platform enables users to leave the home and to use a
technology which is familiar. This offers significant advantages over PC-based
systems, to which many individuals do not have sufficient access or proficiency
to be comfortable in using for healthcare monitoring. A full patient trial has
not yet been undertaken. In the UK,
it is not permissible to allow patients to evaluate a new device at any level
prior to approval from a local ethics committee, which has not yet been
obtained. Patients were consulted indirectly via the physiotherapist, who was
able to describe the application and ask questions about their views on the
current rehabilitation procedure. A full user assessment and clinical evaluation
are currently being planned.



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*Source: 753064-2008-07-03.xml*