SAN DIEGO—Technology advances like smartphone apps and virtual reality games may help rheumatology patients better adhere to treatment plans and even lead healthier lifestyles, said Maura Iversen, PT, DPT, at the at the 2013 ACR/ARHP Annual Meeting, held October 26–30. Dr. Iversen spoke as the 2013 ARHP Distinguished Lecturer. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.]
Mobile technology has greatly enhanced access to patients, overcoming barriers of time and inconvenience, said Dr. Iversen, professor and chair of the department of physical therapy at Northeastern University in Boston. A health professional might send a customized text message to remind a patient to take a medication or get daily physical activity, for example. Messaging can be programmed to suit an individual patient’s treatment plan. “Right now, we are looking at a concept of personalized medicine. Mobile health may be one of the key parameters in global intervention” for health promotion, she said.
Access to technology has also greatly increased in recent years, Dr. Iversen said. Currently, more than 3.2 billion individuals worldwide have mobile phones, so access through mobile technologies is a key area of growth for health care. According to the Pew Internet and American Life Project, 34% of U.S. adults 18 and older now own a tablet computer. Mobile health technologies include text messaging, video messaging, voice messaging, and mobile monitoring devices like accelerometers, which can monitor vital signs as well as the speed and distance of physical activity like walking. Interactive apps allow an individual to record personal health information on their phones, tracking symptoms, dietary intake, or physical activity, for example. There are estimated to be between 30,000 and 90,000 mobile health apps now available for smartphones, but only a few hundred have been formally evaluated, Dr. Iversen noted.
Exercise as Play
Virtual reality, a technology first popularized in arcade games, is now used for behavioral intervention as well. “Virtual reality is allowing both measurement and motivation of human behavior,” said Dr. Iversen. Virtual reality includes screens displayed on stationary bikes that allow riders to envision themselves biking through scenic locations, as well as information on how many calories were burned during the workout. A more advanced form of the technology is immersion virtual reality, where a participant uses a special mask and smart gloves to manipulate an avatar, or stand-in, as it moves through a virtual scenario. Immersion virtual reality games are popular with individuals who have suffered a stroke, who practice physical movements through a virtual environment and track their progress over time, Dr. Iversen continued.
One popular video game that uses some virtual reality technology is Wii Fit. The game allows the user to grasp handheld tools to manipulate images on a television screen as they exercise. Wii Fit games include yoga, tennis, and bowling. Three studies have explored the efficacy of Wii Fit games, including a 2011 study of women with systemic lupus erythematosus that showed users had some improvement in fatigue scores and body weight, Dr. Iversen noted.1 However, the effects of the game declined over time as people played it less frequently. Most Wii Fit users don’t achieve a vigorous energy expenditure level during their workouts, she added. She also recommended adding heart rate monitors to physical activity games.
There are new biosensor devices that use touch technology to allow people with physical disabilities to play video games or communicate more easily on their laptop computers, Dr. Iversen noted. This technology may be useful in the rheumatoid arthritis (RA) population, she said.
Online health behavior interventions are becoming more common. Most of these tools and programs focus on weight loss, and a number have been studied for efficacy. A report in the Journal of Medical Internet Research in 2013 looked at relevant literature on these online behavior interventions published between 2005 and 2012 and found 41 eligible reviews.2 Overall, the effects of these interventions were small, variable, and not sustainable, Dr. Iversen noted. Most of the users of online health behavior interventions were white, female, and well educated, she added.
Text messaging is a promising area of growth, she said. In 2010, researchers at the Yale University School of Epidemiology and Public Health reported in Epidemiological Reviews that in eight of nine well-powered studies of text-based behavior interventions, there was evidence of success for behavioral change.3 Most of these text-based interventions focused on weight management in diabetes patients.
Text messaging has benefits and disadvantages, Dr. Iversen noted. It is widely used, low cost, and communication is instant. Texting does not require much technical expertise for use. It is applicable to many health conditions, and the patient may retrieve the text at his or her convenience, she noted. However, text messaging may marginalize people who have low literacy, don’t read English, don’t have mobile phones, or don’t have a text messaging feature. Mobile phones are often lost or broken, she noted.
Smartphone technology allows patients to interact with each other, sharing information about their health behaviors and encouraging each other to stick with a diet or exercise program, Dr. Iversen said. Patients may upload photos of a meal and ask their peers to comment on its dietary value, for example. “E-communities and social feedback is important,” she said. “Health and technology are more likely to be adopted when they have greater versatility.”
Despite exciting new technology, there are still barriers for health professionals to overcome in behavior intervention. In one study, Dr. Iversen and her colleagues followed 1,108 adults with RA for four years and found that even when some patients had low disease activity, they did not engage in physical activity. Technology may offer health professionals more tools to reach these patients with reminders, she said.
So, what factors may influence the success of a web-based or mobile health program? “Trust in the program is important. Reliability and functionality needs to be addressed up front or you lose participation and they don’t rejoin the program,” Dr. Iversen said. It is important for the development of new health technology to be a collaborative effort, so the tools are more effective, she concluded.
“Usually, at the point when they are designing prototypes is when the patient and clinician are brought in to give feedback,” she said. Evaluations of the products after launch are needed as well, she added. “Healthcare professionals need to be involved in development early in the process, before the prototype and testing stage.”
Susan Bernstein is a writer based in Atlanta.
- Yuen HK, Holthaus K, Kamen DL, Sword DO, Breland HL. Using Wii Fit to reduce fatigue among African American women with systemic lupus erythematosus: A pilot study. Lupus. 2011;20:1293-1299.
- Kohl LF, Crutzen R, de Vries NK. Online prevention aimed at lifestyle behaviors: A systematic review of reviews. J Med Internet Res. 2013;15:e146.
- Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010;32:56-69.