Can spiders use the Web? The use of technology to support neurological

rehabilitation Dr Lorna Paul

Reader in Rehabilitation University of Glasgow

@RehabResearchGU

Plan

• Background to technological supported rehabilitation (focus on web and app based)

• Evidence base

• Two example: webbasedphysio.com STARFISH

Evolution of mobile technology

Times have changed!

Internet usage

http://www.internetworldstats.com/stats.htm

• 86% of the adult population of the UK used the internet •73% (36 million adults) used it on a daily basis (Office of National Statistics 2013) More people in the UK use the internet than have a car More people have a mobile phone than a toothbrush

Terminology

Increased demand on NHS

Unable to access

‘conventional’ treatment

Effort outweighs benefits

Timing (pt and therapist)

Cost of travel

24 hour day access

Seen by an expert

Add remote monitoring

Cost

Confidentiality

Governance

Technology

Skills (staff and pts)

Attitudes

Challenge on role

Scope of practise

DRIVERS BARRIERS

Key factors for successful internet interventions

• Use of educational components (structured educational

material) 2

• Tailoring of the intervention to participants needs 4

• Behaviour change techniques: goal setting, action planning, barrier identification, feedback on performance, facilitation of social comparison 1

• Theoretical basis: social cognitive theory, Transtheoretical Model, Theory of planned behavior 1

• Mode of delivery: automated functions (tailored feedback, multimedia use) communicative functions (with advisor/peers), supplementary modes (SMS/Email/ telephone) 1

• Programme utilization (More frequent use, participant engagement) 2,3

1Webb et al. 2012; 2Davies 2012; 3Norman 2007; 4Aalbers 2011

Background

• Some participants couldn’t access the community based programme due to problems with transport, work, family commitments etc

• Community programme resource intensive

Internet usage in MS In 2010, the Multiple Sclerosis Society undertook a survey of its members to inform their Web Accessibility Policy (v1.0). • 92% used the internet three times or more per week • only 20% had problems in using the internet. • visual and dexterity problems were most commonly reported • generally no modifications or ‘access technologies’ were required (many increased the font size).

webbasedphyiso.com

• Developed with patient advisory group

• Patients assessed face to face

• Individualised programme which is remotely reviewed and altered by physiotherapist

The website has 3 sections 1) exercise pages; each page has a video clip, written description, audio explanation of each exercise, timer and exercise diary 2) information/advice section [3) discussion forum] Library for around 30 exercises at four levels, warm up and cool down

Participants 30 people with Multiple Sclerosis and EDSS 5-6.5 Intervention (n=15) 12 weeks of twice weekly, web-based exercise Weekly phone calls from physiotherapist Remote alterations in programme as required Control (n=15) Usual care

Total sample Intervention

(Group 1) Control

(Group 2)

Number of participants

30 15 15

Gender M:F

6:24 3:12 3:12

Age (years)

51.7 [11.2] 50.8 [7.4] 52.5 [14.3]

EDSS 5.9 [0.5] 6.0 [0.5] 5.8 [0.5]

BMI 26.1 [5.1] 25.9 [4.6] 26.3 [5.7]

Time since diagnosis

(years) 12.7 [9.05] 12.5 [7.1] 12.8 [10.9]

Type of MS

Benign 2 PPMS 4

RRMS 17 SPMS 5

Not known 2

Benign 0 PPMS 1

RRMS 11 SPMS 2

Not known 1

Benign 2 PPMS 3 RRMS 6 SPMS 3

Not known 1

Outcome Measures (face to face) 25ft Walk Berg Balance Scale Timed Up and Go MS Symptom Checklist Multiple Sclerosis Impact Scale Hospital Anxiety and Depression Scale Leeds MS Quality of Life Scale Telephone Interviews

Variable/

Group

Pre

Mean [sd]

Post

Mean [sd]

Mean

Difference

[Pre-Post]

95%

Confidence

Interval

Effect Size

Cohen’s

d

25FW

Control 0.91 [0.45] 0.91 [0.43] 0.00 -0.06, 0.06 0

Intervention 0.75 [0.36] 0.80 [0.36] -0.05 -0.13, 0.02 0.44

BBS

Control 43.86 [12.71] 44.21 [11.82] -0.36 -1.78, 1.07 0.03

Intervention 40.80 [14.79] 42.07 [13.36] 2.29 -3.13, 7.72 0.09

TUG

Control 17.01 [8.11] 15.10 [5.37] 1.91 -0.05, 3.87 0.28

Intervention 26.61 [27.84] 24.32 [21.85] 2.29 -3.13, 7.72 0.09

MS Symptom

Control 34.14 [17.27] 32.64 [13.85] 1.50 -3.94, 6.94 0.10

Intervention 37.07 [11.93] 32.00 [13.58] 5.07 -0.55, 10.68 0.40

MSIS-PHY

Control 43.04 [20.87] 40.98 [20.44] 2.05 -6.04, 10.15 0.10

Intervention 48.42 [15.83] 39.83 [19.87] 8.59 0.09, 17.07 0.48

MSIS-PSY

Control 34.32 [22.48] 28.77 [16.97] 5.56 -2.62, 13.73 0.28

Intervention 35.74 [17.12] 29.44 [17.56] 6.30 -1.83, 14.42 0.36

HADS-A

Control 6.43 [4.11] 4.50 [2.79] 1.93 0.42, 3.44 0.55

Intervention 5.80 [3.88] 5.87 [4.05] -0.07 -1.16, 1.03 0.02

HADS-D

Control 6.07 [2.62] 5.79 [3.26] 0.29 -0.79, 1.34 0.10

Intervention 5.73 [3.73] 5.67 [2.90] 0.06 -1.20, 1.33 0.02

LEEDS QoL

Control 11.71 [3.60] 10.71 [4.53] 1.00 -0.54, 2.54 0.24

Intervention 10.13 [4.52] 10.20 [4.71] -0.07 -1.67, 1.53 0.01

Results - quantitative

Themes Subthemes Indicative quotes

Using of the Website

Ease of use “pretty easy and straightforward” wbp1 “not the best person on the computer but I did manage” wpb2

Using the programme

“if I have had a really tiring day I pick out certain ones... then at least I am doing something, rather than nothing” wbp8

Suggested improvements

Ability to review previous diary entries “would have given an indication if I was feeling better one day than the other at doing the exercises” wbp10

Physical and psychological change

“my walking got a lot better” wbp5 “it opened my eyes to what I can do and its made me a bit more confident” wbp10

Web-based physiotherapy as a mode of delivery

Enjoyment “I enjoyed doing it” wbp10 “I enjoyed it the way it was” wbp1

Practical convenience

“I don’t have to get dressed, get my jacket on and go in the car” wbp1 “it was a better option for me to do the exercises at home because I don’t drive any more and I would be relying on my poor old dad to drive me” wbp9

Exercising alone “I’ve went to a couple of classes since I had my MS, it’s quite embarrassing sometimes because you can’t do... in my own home I didn’t have the embarrassment factor” wbp10

Supported exercise

“I knew I could phone her [the physio] or text her, or mention it in the diary... it was all the support that you would want” wbp13

Future plans “I have went and joined the local gym” wbp10

Results - qualitative

Results - compliance • Participants logged on to the website an average 1.3 times per week.

• There was a reduction in the average number of log-ins over the 12 week intervention period from 2.1 to 0.9

0

1

2

3

1 2 3 4 5 6 7 8 9 10 11 12

Mean number of log-ins

Satisfaction questionnaire

16 Would you like to use this program in the future?

Certainly yes 13

To a large extent 1

To some extent 1

No 0

17 Would you advise other patients to use this program?

Certainly yes 14

To a large extent 1

To some extent 0

No 0

18 Overall how would you grade this program?

Needs serious improvement 0

Needs some improvement 0

Good 5

Excellent 10

Label Definition How the technique is operationalised in WEB BASED PHYSIO

GOALS AND PLANNING

Goal setting (behaviour) Set or agree on a goal defined in terms of the

behaviour to be achieve

Following initial assessment goals are agreed between the patient and physiotherapist. The

exercise programme is then set up with a number of exercises to address these agreed goals.

Review behaviour goals Review behaviour goal(s) jointly with the

person and consider modifying goal(s) or

behaviour change strategy in light of

achievement

The exercise programme is reviewed every two weeks and modified by the physiotherapist

as appropriate depending on the patient’s feedback within their exercise diary. Patients can

also request modifications to their programme depending on whether they find specific

exercise too easy or difficult.

FEEDBACK AND MONITORING

Monitoring of behaviour by

others without feedback

Observe or record behaviour with the

person’s knowledge as part of a behaviour

change strategy

As patients are completing their programme they complete their exercise diary online. This

is seen by their physiotherapist.

Self-monitoring of behaviour Establish a method for the person to monitor

and record the outcome(s) of their behaviour

as part of a behaviour change strategy

As patients are completing their programme they complete their exercise diary online.

Patients can review their previously completed diaries.

SHAPING KNOWLEDGE

Instruction on how to perform

behaviour

Advise or agree on how to perform the

behaviour

As patients log on to the website they view videos of each exercise assigned to them.

Patients can watch the exercise and listen to the audio and written instructions.

NATURAL CONSEQUENCES

Information about health

consequences

Provide information (eg. written, verbal, or

visual) about health consequences of

performing the behaviour

Patients are provided with advice and education on the website. Within this section there is

advice specific to their condition and advice regarding health consequences of performing

the behaviour.

Information about emotional

consequences

Provide information (eg. written, verbal, or

visual) about emotional consequences of

performing the behaviour

Patients are provided with advice and education section on the website. Within this section

there is advice specific to their condition and advice regarding emotional consequences of

performing the behaviour.

COMPARISON OF BEHAVIOUR

Demonstration of the

behaviour

Provide an observational sample of the

performance of the behaviour, directly in the

person or indirectly eg. via film, pictures, or

for the person to aspire to or imitate

Patients are provided with video demonstrations of each exercise within their individualised

exercise programme.

REPETITION AND SUBSTITUTION

Graded tasks Set easy-to-perform tasks, making them

increasingly difficult, but achievable, until

the behaviour is performed

Patients are assessed and exercises are prescribed based on their goals and ability. Exercises

within patients exercise programmes are gradually progressed in intensity or difficulty.

ANTECEDENTS

Adding objects to the

environment

Add objects to the environment in order to

facilitate the performance of the behaviour

The website is available to patients to access using their computer or tablet. Patients may

also be advised to use resistance (e.g. water bottles or resistance bands) to progress exercises

Body changes Alter body structure, functioning or support

directly to facilitate behaviour change

Patients may notice body changes or improved function in their daily life after taking part in

their exercise programme

Mapping of Behaviour Change Techniques (BCTs) to those of the International Taxonomy for BCTs (Michie et al 2013)

• Studies on-going comparing class and web-based

physio in pulmonary rehab • Customisation and pilot study for Spinal Cord Injury • Multicentre study in MS (with health economics),

funded by MS Society (Ayrshire, Lothian, Plymouth) • PhD student starting at University of Otago, New

Zealand • Investigating possibility of spin out company

• Applications pending for cohort study for people

with axial spondyloarthritis (ankylosing spondylitis)

Current activity and Future Plans

Digitisation of exercises • Working with MSc Medical Visualisation student • “Seeing the muscle group working is so much more effective and

empowering and would make me more inclined to keep doing it than not seeing it”

• “I felt very unhappy the first time I was sent away with exercises, not long after I had been diagnosed, and I was given the care-based exercises for the elderly video. But I thought, I’m young, I think I was about 40 and thought this isn’t good enough and that really was dispiriting…but this feels like you’re in the 21st century” and that you are so worthy that you’ve actually got this to do”

http://www.webbasedphysio.com

email address mstestphysiopatient@gmail.com

password: password

Collaborators: Linda Renfrew, Dr Elaine Coulter, Dr Paul Mattison, Dr Angus McFadyen

Web-based physiotherapy for people moderately affected with Multiple Sclerosis;

results from a randomised, controlled pilot study and the patient experience. Paul L, et al Clinical Rehabilitation 2014 28: 924-935

Demonstration Page

STARFISH, a facilitated, behavioural change programme to encourage physical activities delivered via a

mobile phone app

Dr Lorna Paul,

Prof S Wyke

Prof S Brewster

Dr Aleksandra Dybus

Dr Jason Gill

Gill Alexander

STARFISH • STARFISH is a smart phone app designed as a

behavioural change intervention to encourage physical activity

• The sensors within a standard smart phone record the number of steps taken per day by the individual

• Each person is represented by a fish within a fish tank.

• When the participant is active their fish blows bubbles and swims faster

• As the participant reaches their target number of steps per day, their fish’s fins and tail grow.

Key features – Social Facilitation and Targets

• STARFISH is undertaken in groups of four

• Each fish is distinguishable by colour thus each participant gets feedback on the activity of each member of the group

• Physical activity targets are individual

• Each person can access their daily or weekly step counts

Key Features - Feedback

• Each week the fish fins grow if the person achieves their daily target

• Individualised feedback for motivation

Physical activity targets - Group

• Each week a new creature comes to swim in the tank if the group achieve 90% of the group goal (seahorse, octopus, final creature is a Starfish)

• Group reward for motivation

STARFISH pilot studies

• One week baseline activity measure

• Baseline measures; medications, BMI, blood pressure, HR, Functional measures, Blood sample for blood lipids, LFTs, CRP, HBA1c

• Use the app for 6 weeks

• Repeat measures

• Focus group

STARFISH Studies

Starfish in older people

• Funded by BUPA Foundation

• Coproduction

• 16 older people

• 32% increase in steps/day

• Technological challenges ++

• One broken leg (fall)

Starfish in stroke

• Funded by Chest, Heart and Stroke Scotland

• Coproduction

• 24 people after stroke (4.2yrs)

• 16 intervention/8 control

• 40% increase in steps/day

• Significant increase in gait speed

• One person suffered second stroke

Examples of quotes from focus groups

Friends asking about the phone

generated discussion on PA

Realised how much I was

sitting at night

Can walk up the stairs without

getting so breathless

Could only plan one day at time – weather

dependent

I think I lost a

wee bit of weight

Certainly made me walk more

Gave me something

to look forward to

Lorna.Paul@glasgow.ac.uk 0141 330 6876

@RehabResearchGU

http://www.webbasedphysio.com

email address mstestphysiopatient@gmail.com

password: password

Collaborators: Linda Renfrew, Dr Elaine Coulter, Dr Paul Mattison, Dr Angus McFadyen

Web-based physiotherapy for people moderately affected with Multiple Sclerosis;

results from a randomised, controlled pilot study and the patient experience. Paul L, et al Clinical Rehabilitation 2014 28: 924-935

Demonstration Page