Differences in Use of a Exercise-based Tele-rehabilitation Service

Delivered as Substitute of or Supplement to Conventional Care

S. M. Jansen-Kosterink, M. H. A. Huis in ‘t Veld

Roessingh Research and Development, Telemedicine group, Roessinghsbleekweg 33b, Enschede, The Nederlands

D. Wever

Roessingh Centre of Rehabilitation, Roessinghsbleekweg 33, Enschede, The Netherlands

H. J. Hermens, M. M. R. Vollenbroek-Hutten

Roessingh Research and Development,Telemedicine group, Roessinghsbleekweg 33b, Enschede, The Nederlands

University of Twente, Faculty of Electrical Engineering, Mathematics and computer Science

Telemedicine group, Enschede, The Netherlands

Keywords: Tele-rehabilitation, Service Configuration, Compliance, Use, Usability.

Abstract: The aim of this paper is to explore the use of an exercise-based tele-rehabilitation service in patients with

mild or severe chronic obstructive pulmonary disorder (COPD). The service is delivered to the patients in

two ways: as substitute of (a part of) their pulmonary rehabilitation or as supplement to their pulmonary

rehabilitation. Given their reduced amount of conventional pulmonary rehabilitation, it is likely to assume

that the use of the service is higher in the substitute group compared to the supplement group. Use is

parameterized as the time between log-in and log-out time of patients interacting with the tele-rehabilitation

service for each week. Next to this the number of weeks patients used the service to exercise as well as the

average frequency of use per week and average duration of use per week were determined. Analyses were

performed on a group and individual level. Results showed that patients of the substitute group (n=29) used

the tele-rehabilitation service slightly more than the patients (n=15) of the supplement group, but these

differences were not significant.

1 INTRODUCTION

It is know that compliance, defined as the extent to

which a patient’s behaviour coincides with the

healthcare professional advice (Sackett & Haynes,

1976) to exercise treatment, has a positive effect on

clinical outcomes (Cramer, Benedict, Muszbek,

Keskinaslan, & Khan, 2008). To specify patient’s

compliance with a tele-rehabilitation service it is

important to know if patients used the tele-

rehabilitation for a sufficient amount of time

(frequency and duration). The use of a tele-

rehabilitation service by patients is easily to monitor,

by investigating the time between log-in and log-out.

The use of exercise-based tele-rehabilitation is

investigated in various papers. Van den Berg et al.

(van den Berg et al., 2006; van den Berg et al., 2007)

showed that for a home-based physical activity

intervention for patients with rheumatoid arthritis,

the number of patients who logged on to the website

declines during treatment. However, no information

is given about the duration of use and whether

patients used the website for the same amount of

time during treatment despite of the decline of

frequency of use. In addition Huis in ’t Veld et al.

(Huis in 't Veld et al., 2010) who examined the use

of a tele-treatment application for chronic pain

patients, showed a decline in use over time. They

used the average time the service was used, as

measure for use. In the first week the average use

was 14.3 hours and this declined to 9.5 hours in the

final week.

Wever D., Vollenbroek M., Jansen-Kosterink S., Hermens H. and Huis in ’t Veld R. (2012).

Differences in Use of a Exercise-based Tele-rehabilitation Service Delivered as Substitute of or Supplement to Conventional Care.

In Proceedings of the Sixth International Symposium on e-Health Services and Technologies and the Third International Conference on Green IT

Solutions, pages 44-51

DOI: 10.5220/0004473900440051

 SciTePress

In both studies the tele-rehabilitation service is

delivered to the patients as an autonomous

treatment. Is the decline in use for this service

configuration a pattern or a coincidence? And is this

decline in use also shown in tele-rehabilitation

service once integrated as a partially substitute of or

supplement to conventional care? Information about

the use of the tele-rehabilitation services is important

and should be addressed properly since it could

influence the results found for clinical effectiveness.

To the best of our knowledge the use of a tele-

rehabilitation service for the various service

configurations, i.e. as substitute of or as supplement

to conventional care has not been investigated yet.

However, information about differences in use for

different service configurations could provide

valuable knowledge on how to optimally implement

the service in conventional care.

In this paper the use of two different service

configurations of an exercise-based tele-

rehabilitation service will be investigated. This

service, designed within the CLEAR (= Clinical

Leading Environment for the Assessment of

Rehabilitation protocols in home care) project

(http://www.habiliseurope.eu), is implemented in the

pulmonary rehabilitation of patients with

mild/severe or severe chronic obstructive pulmonary

disorder (COPD). The service is delivered to the

patients in two ways: [1] as a substitute (of a part) of

conventional rehabilitation for patients with

mild/severe COPD. After an introduction period of

four weeks, the service substitutes one of the three

treatment days per week (group substitute) for ten

weeks. Or [2] as supplement to conventional

rehabilitation care in patients with severe COPD.

After an introduction period of four weeks, the

service was a supplement of the two treatment days

per week (group supplement) for ten weeks.

It is our empirical hypothesis that patients are

more willing to rehabilitate at home using the tele-

rehabilitation services when the service is delivered

to them as substitute of the pulmonary rehabilitation

compared to when the service is delivered

supplementary to their conventional pulmonary

rehabilitation. For the first service configuration, we

think that patients will use the tele-rehabilitation

service for a sufficient amount of hours to deal with

the substituted hours. For the second service

configuration, we think that the service is maybe

considered to be too much for patients next to their

already intensive pulmonary rehabilitation program.

The aim of this paper is to explore the use

(frequency and duration) of an exercise-based tele-

rehabilitation service in patients suffering from

pulmonary disease and to explore the difference

between the two service configurations (substitute or

supplement).

2 METHODS

Subjects were recruited between September 2010

and December 2011, by rehabilitation centre Het

Roessingh, Enschede, the Netherlands. Patients

directed, by their rehabilitation physician, to the

outpatient pulmonary rehabilitation for COPD

patients were asked to use the exercise tele-

rehabilitation service during their three months of

rehabilitation. Subjects with COPD were included if

they had sufficient understanding of the Dutch

language and were aged above 18 years.

The study was approved by the appropriate

ethics committee. All participants gave their

informed consent prior to participation.

2.1 Exercise Tele-rehabilitation Service

The exercise tele-rehabilitation service is facilitated

by a notebook with webcam, with newly developed

software giving access to a database of exercise

videos and a teleconference service to facilitate

contact between the patient and healthcare

professional. With this new service the healthcare

professional can compose a tailored exercise

program for his patient. The patient can carry out the

program on a self-scheduled time at home. Every

week the patient records an exercise with the

webcam and the recorded exercise will be assessed

by the healthcare professional. Patient and

healthcare professional can contact each other by

teleconference to discuss the rehabilitation progress.

The healthcare professional can schedule, add and

delete exercises in the exercise program of the

patient during the rehabilitation. The exercise tele-

rehabilitation service enables patients to exercise at

home at moments preferred by patients, which fits in

the current trend of self management of patients

(Kennedy, Rogers, & Bower, 2007).

During the instruction period, four weeks, all

subjects received an extended training on how to use

the exercise tele-rehabilitation service.

The demographic characteristics of the two

groups will be measured by means of a

questionnaire asking for age, gender, height, weight,

education level and the availability of a computer

with internet access. In addition, symptoms

(shortness of breath) prior to participation are

measured by means of VAS scales (Gift, 1989).

Differences in Use of a Exercise-based Tele-rehabilitation Service Delivered as Substitute of or Supplement to

Conventional Care

Figure 1: The exercise tele-rehabilitation service (1).

Figure 2: The exercise tele-rehabilitation service (2).

Patients are asked to rate their experienced level of

shortness of breath during the past week. The VAS

consists of a 10 cm horizontal line with ‘no

discomfort at al’ on the left and ‘as much discomfort

as possible’ on the right extremity of the line.

Psychometric properties have proven to be

sufficient.

2.2 Measurements

Use of the Service: Frequency and Duration

The use of the service was determined by various

parameters:

• The time between log-in and log-out of each

single session, this is registered by the service

automatically. Interval smaller than two minutes

were excluded, because the average duration of

an exercise video was two minutes and in

smaller intervals patients were not able to

exercise. The intervals larger than two hours

were also excluded, because it is unlikely that

patients will exercise longer than two hours in

one session. It was assumed that in these cases

patients forgot to log-out.

• The number of weeks the patients used the

service during their three months period

conventional rehabilitation program.

• The average frequency and duration of use per

week (in minutes).

Usability

It is likely to assume that the actual use of the tele-

rehabilitation service is influenced by the perceived

usability of the service. Differences in perceived

usability, between the two groups, might cause

differences in use irrespective of the type of service

configuration. For this reason we investigate the

perceived usability of the exercise-based tele-

rehabilitation service. All patients are asked to

complete the System Usability Scale (SUS) (Brooke,

1995) after their pulmonary rehabilitation. This

questionnaire includes 10 items which provide a

global view of subjective assessment of service’s

usability. Each item was rated on a five-point scale

form one (disagree totally) to five (agree totally).

The items score were calculated to give an overall

score ranging from 10 to 100 points. The SUS has

been shown by the author to be a robust and reliable

evaluation tool, but its psychometric properties are

still under investigation. There is no validated Dutch

version of the SUS. For this study the SUS is

translated to Dutch.

2.3 Statistical Analyses

Analyses were performed using standard software

(SPSS version 17). The normality of variables was

evaluated by the Kolmogorov-Smirnov test.

Descriptive statistics (means and SD) were

calculated for all socio-demographic variables,

shortness of breath and SUS score.

Group Level

Differences in frequency and duration of use of the

tele-rehabilitation service between groups were

investigated by means of an independent t-test or

Chi-square test in case of percentage. To investigate

the use (duration and frequency) of the service per

week, for the two groups, mixed-model analysis for

repeated measures will be used. Treatment week was

used as a within-subjects factor and type of service

delivery as a between-subject factor. Post hoc

comparisons were made when required and Sidak

adjustments were used to correct for multiple test.

EHST/ICGREEN 2012

Individual Level

To investigate difference in use of the service

between the groups on an individual level the

parameters number of weeks, frequency and

duration are categorized. Based on this

categorization the percentages of patients in the

various categories were assessed.

The categories for number of weeks used during

treatment are: often (more than 8 weeks) regularly

(between 7 and 4 week) and sometimes (less than 3

weeks). The categories for average frequency of use

per week are: often (more than 1.5 times a week),

regularly (between 1.4-1 time(s) a week) and

sporadic (less than once a week). The categories for

average duration of use per week are: long-term

(more than 60 minutes a week), regularly (between

30-59 minutes a week), sometimes (between 10-29

minutes a week) and short-term (less than 10

minutes a week). These categories are arbitrary

chosen and discussed with the health-care

professionals. Group differences in category

distribution are assessed by Chi-square testing.

3 RESULTS

In total, 85 COPD patients are informed about tele-

rehabilitation service and 58 patients (68%) gave

written informed consent to participate. Patients

were instructed how to work with the tele-

rehabilitation service. After this instruction period of

four weeks, 54 patients started to use the tele-

rehabilitation service as substitute of (group

substitute, n=20) or as supplement of (group

supplement, n=34) their rehabilitation program. In

the time period between the start to use the tele-

rehabilitation service and the end of the

rehabilitation program 10 patients (19%) dropped

out because of technical problems with the

equipment or personal circumstances, such as lack

of time or motivation. Thus, 44 patients used the

tele-rehabilitation service during the full length (10

weeks) of their rehabilitation program.

Of the 44 patients, 15 patients suffered from

severe COPD and used the tele-rehabilitation as

supplement of their rehabilitation program. Twenty-

nine patients suffered from mild/severe COPD and

used the tele-rehabilitation as substitute of their

rehabilitation program. The demographic

characteristic, shortness of breath and SUS score of

the two groups (group substitute and group

supplement) are shown in Table 1. Patients of group

substitute are significant younger (p=0.045) than the

patients of group supplement. Beyond, there are no

significant differences between the two groups.

Patients in both groups rated the usability of the

exercise tele-rehabilitation service as acceptable

with a SUS score of 70. For a product with a SUS

score in the 60s and 70s, although promising, but do

not guarantee high acceptability of the product in the

field (Brooke, 1995). On usability there are also no

differences between the two groups.

Use of the Tele-rehabilitation Service

In total, 293 interval blocks (time between log-in

and log-out time) were available on the server of the

tele-rehabilitation service. Fourteen (5%) of the

interval blocks were excluded, 11 blocks were

smaller than two minutes and three blocks were

larger than two hours.

Table 1: Demographic characteristic, shortness of breath and SUS score of the two groups.

Group substitute Group supplement p-value

Number 29 15

Pathology mild/severe COPD severe COPD

Age 55 years (SD 11) 62 years(SD 9) p=0.045

Height 177 cm (SD 11) 172 cm (SD 10) p=0.131

Weight 87 kg (SD 19) 82 kg (SD 26) p=0.482

Gender

Male: 66%

Female: 34%

Male: 47%

Female: 53%

p=0.228

Education

- primary

- secondary

- higher

69%

28%

79%

14%

p=0.517

PC with internet available at home Yes: 97% Yes: 80% p=0.107

Shortness of breath last week (VAS) 5.3 cm (SD 1.9) 6.1 cm (SD 2.0) p=0.224

SUS score post-test 70 (SD 17) 70 (SD 20) p=0.985

Differences in Use of a Exercise-based Tele-rehabilitation Service Delivered as Substitute of or Supplement to

Conventional Care

Figure 3: Frequency of use of the tele-rehabilitation service during the treatment weeks.

Figure 4: Duration of use of the tele-rehabilitation service during the treatment weeks.

Group Level Analyses

Patients of group substitute used the service average

6.6 weeks (SD2.4) out of the maximum of 10 weeks.

The average frequency of use is 1.7 times a week

(SD1.1) with an average duration of 33 minutes per

week (SD22). Patients of group supplement used the

service average 6.2 weeks (SD2.6) with an average

frequency of 1.4 times a week (SD1.1) and with an

average duration of 24 minutes per week (SD16). In

line with our hypothesis the average use of the tele-

rehabilitation service of the group substitute is

higher than the use of the tele-rehabilitation service

of the group supplement. However this difference

failed to reach significance (p≥0.155).

Figure 3 shows the average frequency of use

during the treatment weeks of the two groups over

the treatment weeks. The average frequency of the

use of the service declines in both groups. The

frequency of use declines for group substitute from

1.9 times a week for the first week to 0.9 times a

week for the final week of treatment. The frequency

of use declines for group supplement from 2.2 times

a week for the first week to 1.9 times a week for the

final week of treatment, notice the frequency of use

in the pre final treatment week was only 0.4 times a

week.

Mixed-model analysis for repeated measures

showed that frequency of use declines significant

over time (p=0.002), without additional effects for

service configurations (substitute or supplement)

(0.424).

Figure 4 shows the average duration of use

during the treatment weeks of the two groups. The

average duration of the use of the service declines

during treatment for both groups. The duration of

use declines for group substitute from 30 minutes a

week for the first week to 13 minutes times a week

for the final week of treatment. The duration of use

EHST/ICGREEN 2012

Table 2: Use of the tele-rehabilitation service in total number of days, average frequency per week and average duration per

week in percentages of patients.

Group substitute

n=29

Group supplement

n=15

p-value

Number of weeks of

use during treatment

period

Often 48% 47%

p=0.957

Regularly 42% 40%

Sometimes 10% 13%

Average frequency

per week

Often 24% 33%

p=0.382

Regularly 55% 33%

Sporadic 21% 33%

Average duration per

week

Long-term 7% 0%

p=0.703

Regularly 45% 40%

Sometimes 34% 40%

Short-term 14% 20%

declines for group supplement from 30 minutes a

week for the first week to 23 minutes a week for the

final week of treatment, notice the duration of use in

the pre final treatment week was only 7 minutes a

week.

Mixed-model analysis for repeated measures

showed that duration of use declines significant over

time (p=0.001), without additional effects for service

configurations (p=0.273).

Individual Level Analyses

Table 2 shows that approximately 50% of the

patients used the tele-rehabilitation service eight or

more weeks during their treatment period of three

months. 40% of the patients used the tele-

rehabilitation service four to seven weeks during

their treatment period. Only a small amount of

patients (10%) seem to have used the tele-

rehabilitation sporadically, i.e. less than three week

during their treatment period of three months.

About one-third of the patients (24-33%) used the

tele-rehabilitation service more than 1.5 times a

week; 33-55% of the patients used the tele-

rehabilitation service between 1.4 and 1 time(s) a

week; and 21-33% of the patients used the tele-

rehabilitation service less than 1 time a week.

Only 7% of the patients of group substitute used

the tele-rehabilitation service more than 60 minutes

per week. None of the patients of the group

supplement used the tele-rehabilitation service for

this amount of time. Most patients (40-45%) used

the tele-rehabilitation service between 30-59 minutes

per week. 34-40% of the patients used the used the

tele-rehabilitation service between 29-10 minutes

per week and 14-20% of the patients used the tele-

rehabilitation service less than 10 minutes per week.

However, the differences between the two groups

could not be supported by statistical analysis

(p≥0.382).

4 CONCLUSIONS

The aim of the current paper was to explore use

(frequency and duration) of an exercise-based tele-

rehabilitation service in patients suffering from

pulmonary disease and to explore the difference

between the two service configurations (substitute or

supplement). Almost 50% of all patients (both

groups) used the tele-rehabilitation service during

most weeks of their rehabilitation program, with a

frequency of at least once a week and an average

duration of more than 30 minutes on a basis of

voluntariness of use.

In line with our hypothesis, the patients where

the tele-rehabilitation service was delivered as

substitute of their pulmonary rehabilitation,

substitute group (n=29), used the tele-rehabilitation

service slightly more than the patients of the

supplement group (n=15). The difference between

the two groups is small, on average frequency per

week the delta score between the groups is 0.3 and

on duration this delta score is 9 minutes per week

and failed to reach significance. Furthermore, it is

beyond our expectations to think that these small

differences will be addressed as clinically relevant

by health-care professional either.

A decline in use, frequency and duration of use

per week, is observed in the results of the current

study. The decline of use of our tele-rehabilitation

service can be clarified in two ways. A first

clarification is the possibility that patients’

motivation to use the tele-rehabilitation service

declines. For instance after a couple of weeks

patients are not motivated the use the service and

Differences in Use of a Exercise-based Tele-rehabilitation Service Delivered as Substitute of or Supplement to

Conventional Care

reduce the amount of use or do not use the service

anymore. A second clarification is the possibility

that the patients’ need to use the tele-rehabilitation

service declines. After a couple of weeks using the

tele-rehabilitation service patients are aware of the

various exercises and do not need the exercise

videos to perform those exercises. In other words,

thanks to the service patients have become very well

capable of performing their exercises independently

and no longer have to rely on the service. There are

only a small number of papers addressing the use of

exercise-based tele-rehabilitation service. As

described in the introduction of the current paper,

the results of these papers show also a decline in use

(Huis in 't Veld, et al., 2010; van den Berg, et al.,

2006; van den Berg, et al., 2007).

In the current study the use of the service by the

patients was based on voluntariness of use. Patients

were not asked by their healthcare professionals to

use the tele-rehabilitation for a certain amount of

time. Following the Unified Theory of Acceptance

and Use of Technology (UTUAT) (Venkatesh,

Morris, Davis, & Davis, 2003), voluntariness of use

is a key moderator to the determinant social

influence and influences the behavioural intention of

patients to use a tele-rehabilitation service.

Non-mandatory use could be an explanation of

finding no significant differences in the use of the

tele-rehabilitation service between the two service

configurations. Replacing one treatment day (three

hours) of the pulmonary rehabilitation by the tele-

rehabilitation service does not motivate patients to

exercise for the same amount of time per week. So,

patients need an extra motivation, like minimum use

thresholds imposed by the healthcare professional, to

use the tele-rehabilitation service for a sufficient

amount of time.

These thresholds for minimum use should be

determined based on the empirical knowledge of

healthcare professionals or based on the relation

between use and clinical outcome.

Concerning the patient groups in this paper, the

two groups significantly differed on age. Patients of

group supplement were proximally seven years older

than the patients of group substitute. It is unknown if

in the current study age influenced the use of the

tele-rehabilitation service. Despite of this age

differences it can be stated that both patient groups

belong to the same generation 55 to 65 years. Based

on UTUAT (Venkatesh, et al., 2003), age is one of

the mediators that influence the use intention and

actual use of the tele-rehabilitation.

In addition, the two groups also differ in severity

of pathology; mild/severe versus severe COPD.

Prior to use of the service the shortness of breath

score of group supplement are slightly higher than

the score of group substitute. However this

difference did not reach significance

Other limitations of the current paper were the

relatively small sample size (n=43) and the

imbalance in groups size (n=29 vs. n=15) of the two

groups.

Given the results of the current paper clinical

implications can be made. First, healthcare

professionals should be aware of the fact that

different configurations of the same tele-

rehabilitation service do not result in different

patterns of use. Second, the amount of use of a tele-

rehabilitation service can explain possible

disappointing clinical outcome of tele-rehabilitation

services. Third, to find the cause, decline of use

should be addressed between healthcare professional

and patient, to result in optimization of the tele-

rehabilitation service.

This paper focused on the use of the tele-

rehabilitation service but for a future paper it is

recommendable to investigate the relation between

use of this tele-rehabilitation service and the clinical

outcome.

In conclusion, the use (frequency and duration)

of the exercise-based tele-rehabilitation service

declines during treatment. In contrast to our

expectations, there is no difference in use between

two different configurations of the same tele-

rehabilitation service in patients suffering from

pulmonary diseases.

ACKNOWLEDGEMENTS

This work was undertaken with financial support

from the European commission (ICT-PSP CLEAR

224985).

REFERENCES

Brooke, J. (1995). SUS - a quick and dirty usability scale.

In P. W. Jordan, B. Thoma & B. A. Weerdmeester

(Eds.), Usability Evaluation in Industry (pp. 189-194).

Lodon: Taylor & Francis.

Cramer, J. A., Benedict, A., Muszbek, N., Keskinaslan,

A., & Khan, Z. M. (2008). The significance of

compliance and persistence in the treatment of

diabetes, hypertension and dyslipidaemia: a review. Int

J Clin Pract, 62(1), 76-87.

Gift, A. (1989). Visual Analogue Scales: Measurement of

subjective phenomena. Nurs Res, 38, 286-288.

EHST/ICGREEN 2012

Huis in 't Veld, R. M., Kosterink, S. M., Barbe, T.,

Lindegard, A., Marecek, T., & Vollenbroek-Hutten,

M. M. (2010). Relation between patient satisfaction,

compliance and the clinical benefit of a teletreatment

application for chronic pain. J Telemed Telecare,

16(6), 322-328.

Kennedy, A., Rogers, A., & Bower, P. (2007). Support for

self care for patients with chronic disease. BMJ,

335(7627), 968-970.

Sackett, D., & Haynes, R. (1976). Compliance with

therapeutic regimens. Baltimore: Johns Hopkins Univ

Pr.

van den Berg, M. H., Ronday, H. K., Peeters, A. J., le

Cessie, S., van der Giesen, F. J., Breedveld, F. C., et

al. (2006). Using internet technology to deliver a

home-based physical activity intervention for patients

with rheumatoid arthritis: A randomized controlled

trial. Arthritis Rheum, 55(6), 935-945.

van den Berg, M. H., Ronday, H. K., Peeters, A. J., Voogt-

van der Harst, E. M., Munneke, M., Breedveld, F. C.,

et al. (2007). Engagement and satisfaction with an

Internet-based physical activity intervention in patients

with rheumatoid arthritis. Rheumatology (Oxford),

46(3), 545-552.

Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. B.

(2003). User acceptance of information technology:

Toward a unified view MIS Quarterly, 27(3), 425-478.

Differences in Use of a Exercise-based Tele-rehabilitation Service Delivered as Substitute of or Supplement to

Conventional Care