Reliability and Usability of the eChez-Soi In-home Telerehabilitation

Platform: A New Internet-based Communication and Real-time

Monitoring Software Solution Combined with Interactive Exercises

Results of a Longitudinal Pilot Study in Four Patients with Lung Cancer

Hélène Moffet

1,2

, Didier Saey

1,3

, Valérie Coats

, Claude Vincent

1,2

Fanny Choinière

and François Comeau

Department of Rehabilitation, Faculty of Medicine, 1050 avenue de la Médecine, Université Laval, Québec (QC), Canada

Center for Interdisciplinary Research in Rehabilitation and Social Integration,

Institut de Réadaptation en Déficience Physique de Québec, 525 Boulevard Hamel, Québec (QC), Canada

Research Center of the Institut Universitaire de Cardiologie et Pneumologie de Québec,

2725 Chemin Sainte-Foy, Québec (QC), Canada

Keywords: Telehealth, Technology, User Perception, Exercise, Video Games.

Abstract: This longitudinal pilot study aims to describe the components and functionalities of the eChez-Soi home-

based telerehabilitation platform, and present preliminary results on its technological reliability and

usability. Four patients receiving chemotherapy treatments for lung cancer followed an 8 week home-based

telerehabilitation program using the new eChez-Soi platform. All 60 planned sessions supervised by a

clinician occurred with few technological problems. Only one session had to be rescheduled because of

unresolved audiovisual communication problems. In 20 sessions, temporary problems were experienced,

mostly related to the audiovisual signal (n=16), while few technical problems were associated with the

sensors (n=1) and the interactive exercise software (n=1). The usability of the platform was very good, with

an overall satisfaction rating of 4.63±0.43 (max. score=5) for all aspects evaluated, namely its dimension,

safety, effectiveness, ease of use and game environment. These preliminary results support the reliability

and usability of our new platform as a whole but highlight the challenges encountered in ensuring a stable

audiovisual signal when delivering services via a standard home-based Internet connection.

1 INTRODUCTION

Implementation of home-based telerehabilitation is

challenging. In combination with the development of

user-friendly and economical platforms that provide

quality audiovisual communication between

clinician and client, it may also be necessary to

allow real-time measurement of biomechanical and

physiological parameters (Theodoros and Russell,

2008). This is particularly essential in prescribing

safe, individually adapted exercises, as well as in

progressively increasing the intensity of exercises to

reach the goal of the intervention, especially in at-

risk populations.

Moreover, there is growing scientific evidence

that a gaming environment, and/or interactive

exercises, adaptable to the needs of users promote

better adherence to prescribed exercises

(Baranowski et al., 2008, Plow et al., 2011). To our

knowledge, however, few telerehabilitation

platforms combining one or more of these

functionalities have been developed; moreover, they

were not widely implemented (Kairy et al., 2009).

They were designed to meet specific rehabilitation

needs of various populations and mainly to retrain

balance and upper limb motor function of patients

with neurodegenerative diseases, acquired brain

injury or post-surgical deficits (Gonzalez-Fernandez

et al., 2010, Parmanto et al., 2010, Gil-Gómez et al.,

2011, Bento et al., 2012, Cikajlo et al., 2012, Kuusik

et al., 2013, Krpic et al., 2013, Eguiluz-Perez and

Garcia-Zapirain, 2014).

This pilot study provides preliminary results

concerning the reliability and usability of the eChez-

137

Moffet H., Saey D., Coats V., Vincent C., Choinière F. and Comeau F..

Reliability and Usability of the eChez-Soi In-home Telerehabilitation Platform: A New Internet-based Communication and Real-time Monitoring Software

Solution Combined with Interactive Exercises - Results of a Longitudinal Pilot Study in Four Patients with Lung Cancer.

DOI: 10.5220/0005476701370142

In Proceedings of the 1st International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AgeingWell-

2015), pages 137-142

ISBN: 978-989-758-102-1

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

Soi platform in the rehabilitation of patients with

lung cancer. The eChez-soi platform is a new

platform for home-based telerehabilitation which

combines interactive exercises with real-time

biomechanical and physiological parameter

acquisition and transmission to the clinician during

telerehabilitation sessions.

The aims of this study were: 1) to describe the

components and functionalities of the eChez-Soi

platform; 2) to describe the reliability of its

technological components and its software solution

designed for real-time acquisition, transmission and

visualization of biomechanical and physiological

signals, and for the creation of a gaming

environment with interactive exercises; and 3) to

collect four patients' perceptions of the usability of

this new platform.

2 METHODS

This pilot study was conducted at the Institut

universitaire de cardiologie et de pneumologie de

Québec (IUCPQ), in collaboration with the Centre

for Interdisciplinary Research in Rehabilitation and

Social Integration in Quebec City. The research

protocol was approved by the institutional ethics

committees. All participants provided written

informed consent before enrollment in the study.

2.1 Participants

Potentially eligible patients (men or women),

between 40 and 80 years of age, diagnosed with lung

cancer and receiving chemotherapy treatments, were

recruited from the Clinique d’oncologie thoracique

de l’IUCPQ. Patients had to have an ECOG

functional status (Scale of the Eastern Cooperative

Oncology Group, see Oken et al., 1982) of 0

(Asymptomatic) or 1(Symptomatic but completely

ambulatory); have a sufficient understanding of

verbal and written instructions; and live in a

geographic region served by a high speed Internet

connection. Exclusion criteria were as follows:

oxygen-pulsed saturation (SpO

) <80% during the

cardiopulmonary exercise test; contraindications to

exercise testing according to the American Thoracic

Society and American College of Chest Physicians

Exercise Testing Guidelines (2003); cerebral or bone

metastasis, a history of significant cardiovascular

disease, hypertension, diabetes or musculoskeletal

concerns that might limit their ability to perform

active exercises; and severe psychiatric illness

compromising adherence to the rehabilitation

training routine.

2.2 Study Design

Following their inclusion in the study and a baseline

evaluation, a technician installed the eChez-Soi

platform in the patient's home, and the eight-week

telerehabilitation program was initiated. The

proposed telerehabilitation program included

strengthening exercises for upper and lower body

and cardiovascular exercises, as well as

recommendations to increase the daily physical

activity level. Following the eight-week

telerehabilitation program, participants were

evaluated again and the telerehabilitation platform

was uninstalled. Clinical tests were performed at

both pre- and post-program evaluation times.

Usability of the eChez-Soi platform was assessed

during the post-program evaluation while its

reliability was evaluated throughout the program

delivery period (Figure 1).

Figure 1: Time Line of the Study.

2.3 Telerehabilitation Platform

Through a unique software interface, the eChez-Soi

telerehabilitation platform allows for the

combination of the following three technological

aspects: 1- continuous data acquisition and recording

from commercial biometric sensors and other

instruments used by patients during rehabilitation

sessions; 2- continuous transmission of the collected

data via the Internet to the clinician's computer,

allowing the clinician to visualize the biomechanical

and physiological parameters in real time; and 3- a

challenging gaming environment with interactive

exercises performed on musical rhythms using a

dance mat and a Wii Balance Board. This gaming

environment permits the clinician to create exercise

routines adapted to the patient's condition and to

export them remotely to the patient's platform. At

the end of each routine, a score is provided to the

patient, offering immediate feedback on their

performance in order to encourage them to improve.

Biometric sensors used were: a wrist-worn pulse

oximeter (Nonin WristOx

™

, Model 3150), wireless

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wearable accelerometers (LEGSys

™

, BioSensics),

and a Wii Balance Board (Nintendo

Wii Fit

™

), all

using Bluetooth-based communication, as well as an

Xbox Dance Mat connected by a USB cable. The

following parameters were also collected regularly

with these instruments: blood pressure (A&D

Medical Blood Pressure Monitor), weight (Aria

™

Wi-Fi Smart Scale) and daily physical activity

(Fitbit Flex

™

). These sensors and devices were

chosen because of their proven technology, ease of

use, and portability, as well as the availability of

Bluetooth or wireless communication.

The audiovisual communication between the

patient and the clinician was supported by the

videoconferencing solution Vidyo (Vidyo

™

Desktop

Software). This solution was chosen as a

videoconferencing platform for its ease of

deployment, its security, and its quality in a standard

network environment.

Figure 2: eChez-Soi Telerehabilitation Platform on the

Clinician side (top) and Patient side (bottom).

The home-based telerehabilitation station for the

patients includes an "all-in-one" computer with a

touch screen and Windows 8 friendly user interface,

as well as a small external screen, a webcam, all

sensors and instruments for biomechanical and

physiological measurement and the software

solution. The clinician’s technological station

includes an "all-in-one" computer with a touch

screen and Windows 8 friendly user interface,

combined with a webcam and a large LCD screen

for a good view of the patient (Figure 2).

2.4 Outcome Measures

2.4.1 Clinical Assessment

In order to provide a safe individualized exercise

prescription, a complete clinical evaluation was

made at baseline. It included assessments of

pulmonary functions, body composition, muscle

strength, functional exercise capacity and a

screening for abnormal cardiovascular and

pulmonary response to exercise. Clinical effects of

the program are reported elsewhere.

2.4.2 Reliability and Usability Assessment

Reliability of the eChez-Soi platform was assessed

by documenting the number, type, duration and

transient or permanent nature of the technological

problems encountered during supervised

telerehabilitation sessions. In addition, recordings’

reliability, with respect to the parameters observed

in real time by the clinicians during prescribed

routines of interactive exercises, was verified.

Usability was evaluated using a questionnaire

adapted from the Québec User Evaluation of

Satisfaction with Assistive Technology

questionnaire (QUEST 2.0) that calculates both

satisfaction scores for technological aspects and

services, and the overall scores. It consists of 12

items rated on a scale from 1 to 5 (1: not satisfied at

all to 5: very satisfied) (Demers et al., 2002). The

QUEST has good construct validity (factorial: two

dimensions), good to very good test-retest reliability

(ICC = 0.82, 0.82 and 0.91) and good internal

reliability (alpha: 0.76 to 0.82) (Demers et al., 1999,

Demers et al., 2000). For the present project, five

original technological aspects were preserved (items

1 to 5, Table 2) and seven new aspects (items 6 to

12, Table 2) were added.

2.5 Intervention

The planned intervention was an 8-week supervised

home-based program (3sessions per week with an

average duration of 75 minutes each). Over time, the

ratio of supervised/unsupervised training sessions

was progressively reduced from 3 supervised

ReliabilityandUsabilityoftheeChez-SoiIn-homeTelerehabilitationPlatform:ANewInternet-basedCommunicationand

Real-timeMonitoringSoftwareSolutionCombinedwithInteractiveExercises-ResultsofaLongitudinalPilotStudyin

FourPatientswithLungCancer

139

sessions per week to one, in order to develop the

patient’s autonomy. In total, 15 supervised sessions

and 9 unsupervised sessions were planned for a total

of 24 exercise sessions.

Throughout the program, training modalities and

intensity were adapted to the patient's condition. The

training included: 1) warm-up and stretching

exercises; 2) cardiorespiratory training and 3)

resistance training of the upper and lower limbs.

Exercises were executed using the Xbox Dance Mat

and the Wii Balance Board via a game software

environment developed for this purpose.

Before each supervised session, a short

assessment was conducted to detect any significant

changes in the participant’s health condition. In

addition, the participant's weight and blood pressure

were measured using the platform instruments.

Throughout the exercise session, participants used

the pulse oximeter to assess the components of the

physiological response (heart rate and

oxyhemoglobin saturation). Data were transmitted in

real time to the caregiver by the eChez-Soi platform.

In order to ensure the security of the intervention,

saturation should remain higher than 88%

throughout the session.

3 RESULTS

3.1 Subject Characteristics

Four subjects were recruited between May and

November 2014. Their personal and clinical

characteristics are presented in Table 1.

Table 1: Subject Characteristics.

ID Sex Age

(years)

BMI

(Kg/m

)

Stage Tumor

Type

01 Male 56 26.3 IV ADK

02 Female 60 20.6 IIIA ADK

03 Female 64 22.1 IV ADK

04 Male 57 24.2 IV ADK

*ADK: Adenocarcinoma

All patients received chemotherapy treatment during

the intervention period, and two had concomitant

radiotherapy during this period.

3.2 Compliance with the Intervention

All patients completed 100% of the supervised

prescribed exercise sessions (15/15 sessions). No

adverse event occurred during the entire

intervention. Only one training session had to be

postponed following the pre-training evaluation.

(The patient had a high level of psychological

distress and fatigue.) Also, the prescribed intensity

had to be adjusted for one patient who showed a

significant drop in oxyhemoglobin saturation during

a supervised training session. The mean duration of

supervised sessions was 67.5±12.9 minutes, and the

total duration of all 61 sessions was 68.6 hours.

Given some familiarity with the telerehabilitation

platform, due to its previous use in some supervised

sessions, all four patients were able to easily use it

during unsupervised sessions, following brief

instructions from the clinician.

3.3 Reliability of eChez-Soi Platform

3.3.1 Reliability of the Technology

Of the 60 sessions of telerehabilitation offered to the

four patients, only one session had to be delayed due

to an inability to establish audiovisual

communication between the patient and the

clinician. Three other sessions were cut short

because of technical problems.

Temporary problems (n=20) were observed and

resolved during 13 sessions. Most of these problems

were related to audiovisual communication (n=16).

The other difficulties were due to the poor

functioning of a sensor (n=1, pulse oximeter, and

n=1, Wii Balance) or the software solution

(synchronization of a sensor, n=1; interactive

exercises, n=1). 186 minutes in total (4.5% of the

entire duration of the sessions) were used to resolve

these temporary problems. Half of the sessions with

technical problem and the time spent resolving them

occurred during the follow-up care of the first

patient in this study (patient 01; 7 sessions with

temporary technical problems and 91 minutes spent

resolving them).

3.3.2 Real-time Measurements and

Recordings

Data from the pulse oximeter (heart rate and

oxyhemoglobin saturation), the accelerometers and

the Wii Balance were recorded for all interactive

exercise routines (n=331) performed during the 61

supervised sessions without problems, with the

exception of 24 routines (7% of the routines) where

data from at least one sensor, mainly the oximeter

(n=10), were not recorded.

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3.4 Usability of eChez-Soi Platform

All four patients were quite satisfied (score of 4) or

very satisfied (score of 5) with all aspects of the

home-based telerehabilitation platform, for a mean

score of 4.63 (Table 2). No 1 to 3 scores were

reported for any of the assessed items. Ease of use

and effectiveness of the telerehabilitation platform,

and audiovisual communication between the client

and the clinician were identified by the patients as

the three most important elements related to the

usability of the platform.

Table 2: Usability of the Telerehabilitation Platform (TP)

measured with an adaptation of the Quebec User

Evaluation of Satisfaction with assistive technology.

Item How satisfied are you with the… Score

dimension of your TP?

4.75 (0.50)

safety of your TP?

4.75 (0.50)

durability of your TP?

4.50 (0.58)

* ease of use of your TP?

4.50 (0.58)

* effectiveness of your TP?

4.75 (0.50)

biometric sensors of the TP for taking

data in real time (e.g. Nonin

oximeter)?

4.25 (0.50)

devices used by the patient for reading

automatic data (e.g. Fitbit Flex)?

4.75 (0.50)

visualization in real time of biometric

data collected by sensors on the client

workstation and transferred to the

clinician’s computer?

4.75 (0.50)

game environment, enabling

customers to perform exercises

tailored to their condition?

4.75 (0.50)

10.

* audiovisual communication between

the client and the clinician?

4.75 (0.50)

11.

touch screen and user-friendly

interface (Windows 8)?

4.50 (0.58)

12.

illustrated procedures accompanying

the user of the TP?

4.50 (0.58)

Overall score (SD): 4.63 (0.43)

Mean QUEST score (standard deviation) for the 4 patients (1:

not satisfied at all; 2: not very satisfied; 3: more or less satisfied;

4: quite satisfied; 5: very satisfied)

* 3 items reported as most important.

4 CONCLUSIONS

These preliminary results support the technical

reliability and usability of the eChez-soi

telerehabilitation platform. During the entire period

of this pilot study, relatively few technical problems

were experienced by the users (4.5% of the time).

Almost all technical difficulties were transient and

addressed rapidly within the same session. Lastly,

most of the problems (50%) were experienced by the

first participant, thus demonstrating our capacity to

prevent the repetition of previous technical

problems. However, some problems with the

audiovisual connection or signal quality were

experienced by all participants, thereby illustrating

the challenges of delivering services at home

through a standard home-based Internet connection.

All users were satisfied with the different aspects

of the new platform, with the highest score (4.75/5)

being found for dimension, safety, effectiveness,

devices, visualization in real time of biometric data

collected by sensors, the game environment and the

audiovisual communication between the client and

the clinician, even though most of the technical

problems (80%) were related to this last aspect.

Future studies are needed to confirm the present

results obtained with only four patients, although the

platform was tested during a significant number of

sessions and periods of time (61 sessions lasting 68

hours). This platform's potential should also be

tested in other contexts and populations.

ACKNOWLEDGEMENTS

The authors thank all participants. They also would

like to acknowledge the Clinique d’oncologie

thoracique de l’IUCPQ, including Dr. Lise

Tremblay, for their help in recruiting participants,

and Mr Steve Forest for his technical support with

the eChez-Soi Platform. This pilot study was

supported by the Canadian Lung Association and the

Québec INTER Research Network.

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Real-timeMonitoringSoftwareSolutionCombinedwithInteractiveExercises-ResultsofaLongitudinalPilotStudyin

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