Jonathan C. Rawstorn

A mobile phone intervention increases physical activity in people with cardiovascular disease: Results from the HEART randomized controlled trial

Aim To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease (IHD). Methods and results In this single-blind, parallel, two-arm, randomized controlled trial adults (n = 171) with IHD were randomized to receive a mobile phone delivered intervention (HEART; n = 85) plus usual care, or usual care alone (n = 86). Adult participants aged 18 years or more, with a diagnosis of IHD, were clinically stable as outpatients, able to perform exercise, able to understand and write English, and had access to the Internet. The HEART (Heart Exercise And Remote Technologies) intervention involved a personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behaviour, delivered over 24 weeks. All participants were able to access usual community-based cardiac rehabilitation, which involves encouragement of physical activity and an offer to join a local cardiac support club. All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake (PVO2; primary outcome), self-reported physical activity, health-related quality of life, self-efficacy and motivation (secondary outcomes). Results showed no differences in PVO2 between the two groups (difference −0.21 ml kg−1 min−1, 95% CI: −1.1, 0.7; p = 0.65) at 24 weeks. However significant treatment effects were observed for selected secondary outcomes, including leisure time physical activity (difference 110.2 min/week, 95% CI: −0.8, 221.3; p = 0.05) and walking (difference 151.4 min/week, 95% CI: 27.6, 275.2; p = 0.02). There were also significant improvements in self-efficacy to be active (difference 6.2%, 95% CI: 0.2, 12.2; p = 0.04) and the general health domain of the SF36 (difference 2.1, 95% CI: 0.1, 4.1; p = 0.03) at 24 weeks. The HEART programme was considered likely to be cost-effective for leisure time activity and walking. Conclusions A mobile phone intervention was not effective at increasing exercise capacity over and above usual care. The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

Objective Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD). Methods CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence. Results 11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors. Conclusions Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

Rapid directional change degrades GPS distance measurement validity during intermittent intensity running.

Use of the Global Positioning System (GPS) for quantifying athletic performance is common in many team sports. The effect of running velocity on measurement validity is well established, but the influence of rapid directional change is not well understood in team sport applications. This effect was systematically evaluated using multidirectional and curvilinear adaptations of a validated soccer simulation protocol that maintained identical velocity profiles. Team sport athletes completed 90 min trials of the Loughborough Intermittent Shuttle-running Test movement pattern on curvilinear, and multidirectional shuttle running tracks while wearing a 5 Hz (with interpolated 15 Hz output) GPS device. Reference total distance (13 200 m) was systematically over- and underestimated during curvilinear (2.61±0.80%) and shuttle (−3.17±2.46%) trials, respectively. Within-epoch measurement uncertainty dispersion was widest during the shuttle trial, particularly during the jog and run phases. Relative measurement reliability was excellent during both trials (Curvilinear r = 1.00, slope = 1.03, ICC = 1.00; Shuttle r = 0.99, slope = 0.97, ICC = 0.99). Absolute measurement reliability was superior during the curvilinear trial (Curvilinear SEM = 0 m, CV = 2.16%, LOA ± 223 m; Shuttle SEM = 119 m, CV = 2.44%, LOA ± 453 m). Rapid directional change degrades the accuracy and absolute reliability of GPS distance measurement, and caution is recommended when using GPS to quantify rapid multidirectional movement patterns.

Remotely Delivered Exercise-Based Cardiac Rehabilitation: Design and Content Development of a Novel mHealth Platform

Background Participation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on. Objective We aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location. Methods An iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support. Results The REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients’ exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription. Conclusions The REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.

The remote exercise monitoring trial for exercise-based cardiac rehabilitation (REMOTE-CR): a randomised controlled trial protocol

BackgroundExercise is an essential component of contemporary cardiac rehabilitation programs for the secondary prevention of coronary heart disease. Despite the benefits associated with regular exercise, adherence with supervised exercise-based cardiac rehabilitation remains low. Increasingly powerful mobile technologies, such as smartphones and wireless physiological sensors, may extend the capability of exercise-based cardiac rehabilitation by enabling real-time exercise monitoring for those with coronary heart disease. This study compares the effectiveness of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (REMOTE) to standard supervised exercise-based cardiac rehabilitation in New Zealand adults with a diagnosis of coronary heart disease.Methods/DesignA two-arm, parallel, non-inferiority, randomised controlled trial will be conducted at two sites in New Zealand. One hundred and sixty two participants will be randomised at a 1:1 ratio to receive a 12-week program of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (intervention), or an 8-12 program of standard supervised exercise-based cardiac rehabilitation (control).The primary outcome is post-treatment maximal oxygen uptake (V̇O2max). Secondary outcomes include cardiovascular risk factors (blood lipid and glucose concentrations, blood pressure, anthropometry), self-efficacy, intentions and motivation to be active, objectively measured physical activity, self-reported leisure time exercise and health-related quality of life. Cost information will also be collected to compare the two modes of delivery. All outcomes are assessed at baseline, post-treatment, and 6 months, except for V̇O2max, blood lipid and glucose concentrations, which are assessed at baseline and post-treatment only.DiscussionThis novel study will compare the effectiveness of technology-supported exercise-based cardiac rehabilitation to a traditional supervised approach. If the REMOTE program proves to be as effective as traditional cardiac rehabilitation, it has potential to augment current practice by increasing access for those who cannot utilise existing services.Trial registrationAustralian New Zealand Clinical Trials RegistryStudy ID number: ACTRN12614000843651. Registered 7 August 2014

Measurement and Data Transmission Validity of a Multi-Biosensor System for Real-Time Remote Exercise Monitoring Among Cardiac Patients

Background Remote telemonitoring holds great potential to augment management of patients with coronary heart disease (CHD) and atrial fibrillation (AF) by enabling regular physiological monitoring during physical activity. Remote physiological monitoring may improve home and community exercise-based cardiac rehabilitation (exCR) programs and could improve assessment of the impact and management of pharmacological interventions for heart rate control in individuals with AF. Objective Our aim was to evaluate the measurement validity and data transmission reliability of a remote telemonitoring system comprising a wireless multi-parameter physiological sensor, custom mobile app, and middleware platform, among individuals in sinus rhythm and AF. Methods Participants in sinus rhythm and with AF undertook simulated daily activities, low, moderate, and/or high intensity exercise. Remote monitoring system heart rate and respiratory rate were compared to reference measures (12-lead ECG and indirect calorimeter). Wireless data transmission loss was calculated between the sensor, mobile app, and remote Internet server. Results Median heart rate (-0.30 to 1.10 b∙min-1) and respiratory rate (-1.25 to 0.39 br∙min-1) measurement biases were small, yet statistically significant (all P≤.003) due to the large number of observations. Measurement reliability was generally excellent (rho=.87-.97, all P<.001; intraclass correlation coefficient [ICC]=.94-.98, all P<.001; coefficient of variation [CV]=2.24-7.94%), although respiratory rate measurement reliability was poor among AF participants (rho=.43, P<.001; ICC=.55, P<.001; CV=16.61%). Data loss was minimal (<5%) when all system components were active; however, instability of the network hosting the remote data capture server resulted in data loss at the remote Internet server during some trials. Conclusions System validity was sufficient for remote monitoring of heart and respiratory rates across a range of exercise intensities. Remote exercise monitoring has potential to augment current exCR and heart rate control management approaches by enabling the provision of individually tailored care to individuals outside traditional clinical environments.

Quantifying Human Movement Using the Movn Smartphone App: Validation and Field Study

Background The use of embedded smartphone sensors offers opportunities to measure physical activity (PA) and human movement. Big data—which includes billions of digital traces—offers scientists a new lens to examine PA in fine-grained detail and allows us to track people’s geocoded movement patterns to determine their interaction with the environment. Objective The objective of this study was to examine the validity of the Movn smartphone app (Moving Analytics) for collecting PA and human movement data. Methods The criterion and convergent validity of the Movn smartphone app for estimating energy expenditure (EE) were assessed in both laboratory and free-living settings, compared with indirect calorimetry (criterion reference) and a stand-alone accelerometer that is commonly used in PA research (GT1m, ActiGraph Corp, convergent reference). A supporting cross-validation study assessed the consistency of activity data when collected across different smartphone devices. Global positioning system (GPS) and accelerometer data were integrated with geographical information software to demonstrate the feasibility of geospatial analysis of human movement. Results A total of 21 participants contributed to linear regression analysis to estimate EE from Movn activity counts (standard error of estimation [SEE]=1.94 kcal/min). The equation was cross-validated in an independent sample (N=42, SEE=1.10 kcal/min). During laboratory-based treadmill exercise, EE from Movn was comparable to calorimetry (bias=0.36 [−0.07 to 0.78] kcal/min, t82=1.66, P=.10) but overestimated as compared with the ActiGraph accelerometer (bias=0.93 [0.58-1.29] kcal/min, t89=5.27, P<.001). The absolute magnitude of criterion biases increased as a function of locomotive speed (F1,4=7.54, P<.001) but was relatively consistent for the convergent comparison (F1,4=1.26, P<.29). Furthermore, 95% limits of agreement were consistent for criterion and convergent biases, and EE from Movn was strongly correlated with both reference measures (criterion r=.91, convergent r=.92, both P<.001). Movn overestimated EE during free-living activities (bias=1.00 [0.98-1.02] kcal/min, t6123=101.49, P<.001), and biases were larger during high-intensity activities (F3,6120=1550.51, P<.001). In addition, 95% limits of agreement for convergent biases were heterogeneous across free-living activity intensity levels, but Movn and ActiGraph measures were strongly correlated (r=.87, P<.001). Integration of GPS and accelerometer data within a geographic information system (GIS) enabled creation of individual temporospatial maps. Conclusions The Movn smartphone app can provide valid passive measurement of EE and can enrich these data with contextualizing temporospatial information. Although enhanced understanding of geographic and temporal variation in human movement patterns could inform intervention development, it also presents challenges for data processing and analytics.

Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial

Objective Compare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD). Methods Participants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O2max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O2max at 12 weeks (inferiority margin=−1.25 mL/kg/min); inferiority margins were not set for secondary outcomes. Results 162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O2 max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI −0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=−61.5 (95% CI −117.8 to −5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20). Conclusion REMOTE-CR is an effective, cost-efficient alternative delivery model that could—as a complement to existing services—improve overall utilisation rates by increasing reach and satisfying unique participant preferences.

End Users Want Alternative Intervention Delivery Models: Usability and Acceptability of the REMOTE-CR Exercise-Based Cardiac Telerehabilitation Program

OBJECTIVE Evaluate user experiences of an exercise-based cardiac telerehabilitation intervention (REMOTE-CR) that provided near universal access to real-time remote coaching and behavioral support from exercise specialists. DESIGN Secondary analysis (12-week follow-up) of a parallel group, single blind, randomized controlled noninferiority trial (ACTRN12614000843651). SETTING Community-based cardiac rehabilitation. PARTICIPANTS Adults (N=162) with coronary heart disease who were eligible for outpatient cardiac rehabilitation. Eighty-two of 162 trial participants were randomized to receive REMOTE-CR; 67 completed usability and acceptability assessment at 12-week follow-up. INTERVENTION REMOTE-CR comprised 12 weeks of individualized exercise prescription, real-time physiological monitoring, coaching, and behavioral support, delivered via a bespoke telerehabilitation platform. OUTCOMES Ease of use, satisfaction with the technology platform and intervention content, and demand for real-world implementation as an alternative to traditional center-based programs were assessed at 12-week follow-up. RESULTS Components of usability and acceptability were positively evaluated by most participants (44-66 of 67, 66%-99%). Fifty-eight of 67 (87%) would choose REMOTE-CR if it was available as a usual care service, primarily because it provides convenient and flexible access to real-time individualized support from exercise specialists. Technology challenges were rare and had little effect on user experiences or demand for REMOTE-CR. CONCLUSIONS REMOTE-CR can extend the reach and impact of existing cardiac rehabilitation services by overcoming traditional participation barriers while preserving expert oversight. Adoption of emerging technologies should be accelerated to support dynamic, engaging, individualized intervention delivery models, but optimizing overall cardiac rehabilitation participation rates will require multiple delivery models that are tailored to satisfy diverse participant preferences.