Name: Pulmoner Rehabilitasyon Egzersiz Bağlılık Eğitim Sürekli Veri İzleme Teknolojisi Kullanımı (Video) | JoVE Journal
Uploaded: 2013-11-08T23:00:00.000+00:00
Duration: 9 min 42 s
Description: Keşfedin, sürekli veri izleme teknolojisi kullanarak pulmoner rehabilitasyonda aerobik egzersiz bağlılığını nasıl ölçebilirsiniz. Bu yöntem, hedef kalp atış hızında geçirilen sürenin yüzdesi olarak bağlılık oranını hesaplar.

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Canadian Lung Association &ndash; Canadian Respiratory Health Professionals; Fonds de recherche du Qu&eacute;bec - Sant&eacute; (FRQS)

Once data is collected, a single file per subject per session of raw data is obtained. Using statistical software, all sessions per subject are combined into a single file. Subsequently, the target intensity must be calculated for each subject. The adherence rate to that target intensity can then be calculated per session per subject, for each session for all subjects combined, or per group.
1. Data Collection (carried out by personnel supervising the training session)
<ol>
	<li>Minimize electrical interference by turning off wireless devices (e.g. cell phones, Wi-Fi, etc.) and minimize crosstalk by ensuring the heart rate monitors and equipment are at least 1 meter apart. Refer to Figure 1 for placement of heart rate transmitter.</li>
	<li>Turn on the data tracking software. Press start on the aerobic equipment and train the participant at the target intensity. For example, in our studies, participants are asked to train within &#177; 5 beats/min of their target heart rate. Refer to Figure 2 for CardioMemory.</li>
	<li>Collect data second-by-second for each participant for each rehabilitation session. Collected data includes the following: subject ID, duration (hhmmss), level of intensity (1-30), workload (watts), pedaling speed (revolutions/minute), distance (km), pace (mm:ss/km), heart rate (beats/minute), estimated oxygen consumption (VO2, ml/min/kg), metabolic equivalent of physical effort (METs), estimated energy expenditure (kcal/hour), and estimated energy consumed (kcal). See Figure 3.</li>
	<li>Press stop on the aerobic equipment. Click &#34;save&#34; to upload the data to CardioMemory. Click &#34;export&#34; to save the document outside of CardioMemory. The document will be in .cvs format and will automatically include the date of the session.</li>
</ol>
2. Data Extraction
CardioMemory software does not allow for the distinction of various exercise-training phases. As such, the data obtained must be exported to a statistical software in order to eliminate the phases that are not of interest (e.g. warm-up and cool-down), merge the data files, and compare achieved against target intensity.
<ol>
	<li>Open statistical analysis software to import excel file. Procedure: File &#8594; Open &#8594; Data &#8594; In &#34;Open Data&#34; window, select All Files in the dropdown menu of &#34;Files of Types&#34; &#8594; Select Excel. xls file &#8594; Open &#8594; In &#34;Opening Excel Data Source&#34; window click OK.</li>
	<li>Save the data file in a statistical analysis software. See Figure 4 for a sample database.</li>
	<li>Eliminate the nontraining phases, i.e.&#160;warm-up and cool-down, if the interest is time spent at the target intensity during the training phase.
	<ol>
		<li>Eliminate warm-up phase (e.g. first 10 min):
		<ol>
			<li>To recode duration, create a variable to identify every second as 1. Procedure: 
Transform 
&#8594; 
Recode into Different variables&#8230; 
&#8594;
 In &#34;Recode into Different Variables&#34; window, select 
Duration_A 
img alt="Arrow" fo:content-width=".2in" src="/files/ftp_upload/50643/arrow.jpg" width="20px" />
 click arrow 
&#8594; Identify &#34;Output Variable Name&#34; (e.g. tempo) &#8594; Change &#8594; Click on Old and New Values &#8594; Under &#34;Old Value&#34;, select Value: and enter 0 &#8594; Under &#34;New Value&#34;, Select Value: and enter 0 &#8594; Add &#8594; Under &#34;Old Value&#34;, select All other values then click on Value:, under &#34;New Value&#34; and enter 1 &#8594; Add &#8594; Continue &#8594; OK.
			<ul>
				<li>RECODE Duration_A (0=0) (ELSE=1) INTO Tempo.</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>Create a second temporary variable. Procedure: Transform &#8594; Shift Values &#8594; Select tempo &#8594; Click arrow &#8594; Under &#34;Name:&#34; type temporary variable (e.g. tempo2) &#8594; Change &#8594; OK.
			<ul>
				<li>SHIFT VALUES VARIABLE=Tempo RESULT=Tempo2 LAG=1.</li>
			</ul>
			</li>
			<li>To start tempo2 at 0, it must be recoded. Procedure: Transform &#8594; Recode into Same Variables &#8594; Select tempo2 &#8594; Click arrow &#8594; Click Old and New Values &#8594; Under &#34;Old Value&#34;, select System-Missing &#8594; Under &#34;New Value&#34;, select Value: and enter 0 &#8594; Add &#8594; Continue &#8594; OK.
			<ul>
				<li>RECODE Tempo2 (SYSMIS=0).</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>Sum the seconds starting from zero. Procedure: Transform &#8594; Compute Variable &#8594; Under &#34;Target Variable:&#34; type tempo &#8594; Under &#34;Numeric Expression&#34; type lag (tempo) +1 &#8594; IF... &#8594; Select Include if case satisfies condition: &#8594; Type tempo2 &#62; 0 &#8594; Continue &#8594; OK.
			<ul>
				<li>IF (Tempo2 &#62; 0) Tempo=Lag (tempo) + 1.</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>To eliminate the first 10 min&#160;of warm-up, remove tempo data that precedes 599 seconds. Procedure: Data &#8594; Select cases&#8230; &#8594; In &#34;Select Cases&#34; window, under &#34;Select&#34;, choose &#34;If condition is satisfied&#34; &#8594; If&#8230; &#8594; In &#34;Select Cases: If&#34; window, insert equation tempo &#62; 599 &#8594; Continue &#8594; Under &#34;Output&#34;, choose Delete unselected cases &#8594; OK. See Figure 5.
			<ul>
				<li>FILTER OFF.</li>
				<li>USE ALL.</li>
				<li>SELECT IF (tempo &#62; 599).</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
		</ol>
		</li>
		<li>Eliminate cool-down phase (e.g. last 5 minutes):
		<ol>
			<li>Sort data in descending order for Duration_A to bring the cool-down phase to the top of the database, as SPSS removes data from the top of the file onwards. Procedure: Data &#8594; Sort Cases &#8594; In &#34;Sort Cases&#34; window, select Duration_A &#8594; click arrow &#8594; In &#34;Sort Order&#34; menu select Descending &#8594; OK.
			<ul>
				<li>SORT CASES BY Duration_A(D).</li>
			</ul>
			</li>
			<li>Recode Duration_A to identify every second as 1. Procedure: Transform &#8594; Recode Into Different variables&#8230; &#8594; In &#34;Recode into Different Variables&#34; window, select Duration_A &#8594; click arrow &#8594; Identify &#34;Output Variable Name&#34; (e.g. tempoA) &#8594; Change &#8594; Click Old and New Values &#8594; Under &#34;Old Value&#34;, select Value: and enter 0 &#8594; Under &#34;New Value&#34;, select Value: and enter 0 &#8594; Add &#8594; Select All other values under &#34;Old Value&#34;, then click on Value: under &#34;New Value&#34; and enter 1 &#8594; Add &#8594; Continue &#8594; OK.
			<ul>
				<li>RECODE Duration_A (0=0) (ELSE=1) INTO TempoA.</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>Create a second temporary variable. Procedure: Transform &#8594; Shift Values &#8594; Select tempoA &#8594; Click arrow &#8594; Under &#34;Name:&#34; type temporary variable (e.g. tempoA2) &#8594; Change &#8594; OK.
			<ul>
				<li>SHIFT VALUES VARIABLE=TempoA RESULT=TempoA2 LAG=1.</li>
			</ul>
			</li>
			<li>To start tempoA2 at 0, it must be recoded. Procedure: Transform &#8594; Recode into Same Variables &#8594; Select tempoA2 &#8594; Click arrow &#8594; Click Old and New Values &#8594; Under &#34;Old Value&#34;, select System-Missing &#8594; Under &#34;New Value&#34;, select Value: and enter 0 &#8594; Add &#8594; Continue &#8594; OK.
			<ul>
				<li>RECODE TempoA2 (SYSMIS=0).</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>Sum the seconds of the tempoA variable. Procedure: Transform &#8594; Compute Variable &#8594; Under &#34;Target Variable:&#34; type tempoA &#8594; Under &#34;Numeric Expression&#34; type lag (tempoA)+1 &#8594; IF... &#8594; Select Include if case satisfies condition: &#8594; Type tempoA2&#62; 0 &#8594; Continue &#8594; OK.
			<ul>
				<li>IF (TempoA2 &#62; 0) TempoA=Lag (tempoA) + 1.</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
			<li>To eliminate the cool-down phase (i.e. 5 min), remove tempo data that precedes 299 seconds. Procedure: Data &#8594; Select cases&#8230; &#8594; In &#34;Select Cases&#34; window, under &#34;Select&#34;, choose &#34;If condition is satisfied&#34; &#8594; If&#8230; &#8594; In &#34;Select Cases: If&#34; window, insert equation tempoA &#62; 299 &#8594; Continue &#8594; under &#34;Output&#34;, choose Delete unselected cases &#8594; OK. See Figure 6.
			<ul>
				<li>FILTER OFF.</li>
				<li>USE ALL.</li>
				<li>SELECT IF (tempoA &#62; 299).</li>
				<li>EXECUTE.</li>
			</ul>
			</li>
		</ol>
		</li>
		<li>Identify the session number (or date) associated with the dataset. Create and name a new variable (e.g. Session). Procedure: Transform &#8594; Compute Variable &#8594; In compute variable window under Target Variable, type Session &#8594; click Type &#38; Label to open &#34;Compute Variable: Type an...&#34; window &#8594; under &#34;Type&#34; select String &#8594; Continue &#8594; under String Expression type &#39;1&#39; &#8594; OK. See Figure 7.
		<ul>
			<li>STRING Session (A8).</li>
			<li>COMPUTE Session= &#39;1&#39;.</li>
			<li>EXECUTE.</li>
		</ul>
		</li>
		<li>Save the modified SPSS document in a new file (example: subjectID_session#).</li>
		<li>Repeat the above procedure for all remaining sessions for the same subject.</li>
	</ol>
	</li>
</ol>
3. Data Merging - Single Participant
<ol>
	<li>To merge all sessions into a single SPSS database, open participant&#39;s first session (i.e. subjectID_session1).</li>
	<li>Merge remaining sessions to the current file. Procedure: Data &#8594; Merge Files &#8594; Add Cases &#8594; in &#34;Add Cases to subjectID_session1.sav&#34; window, click Browse and choose file subjectID_session2 &#8594; Open &#8594; Continue &#8594; in the &#34;Add Cases from ...&#34; window click OK. Repeat for all remaining sessions. See Figure 8.
	<ul>
		<li>ADD FILES /FILE=*</li>
		<li>/FILE=&#39;SubjectAB001_Session1.sav&#39;.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>Add a column which contains the subject&#39;s ID number. Procedure: Transform &#8594; Compute Variable &#8594; In &#34;Compute Variable&#34; window under Target Variable, type SubjectID &#8594; click Type &#38; Label to open &#34;Compute Variable: Type an...&#34; window &#8594; under &#34;Type&#34; select String &#8594; Continue &#8594; under String Expression type &#39;SubjectID&#39; (e.g.&#160;&#39;AB001&#39;) &#8594; OK. See Figure 9.
	<ul>
		<li>STRING Subject_ID (A8).</li>
		<li>COMPUTE Subject_ID=&#39;AB001&#39;.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>Add a column that contains the subject&#8217;s target intensity (e.g. target heart rate [THR]). Procedure: Transform &#8594; Compute Variable &#8594; In &#34;Compute Variable&#34; window under Target Variable, type THR &#8594; click Type &#38; Label to open &#34;Compute Variable: Type an...&#34; window &#8594; under &#34;Type&#34; select Numeric &#8594; Continue &#8594; under Numeric Expression type THR (e.g. 110) &#8594; OK. See Figure 10.
	<ul>
		<li>STRING THR (A8).</li>
		<li>COMPUTE THR=&#39;110&#39;.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>Save database under a different file name (e.g. SubjectAB001_session1-36).</li>
	<li>Repeat for all remaining participants. At this point, each participant will have a database containing all sessions.</li>
</ol>
4. Data Merging - Grouping Participants
<ol>
	<li>To group several participants into a single database, open participant&#39;s file (i.e. subjectID_session1-36).</li>
	<li>Merge the remaining participants to the current file. Procedure: Data &#8594; Merge Files &#8594; Add Cases &#8594; in &#34;Add Cases to SubjectAB001_session1-36.sav&#34; window, click Browse and choose file SubjectCD002_session1-36 &#8594; Open &#8594; Continue &#8594; in the &#34;Add Cases from ...&#34; window click OK. Repeat for all participants that you wish to group. See Figure 11.
	<ul>
		<li>ADD FILES /FILE=*</li>
		<li>/RENAME (AB001=d0)</li>
		<li>/FILE=&#39;SubjectAB001_Session1-36.sav&#39;</li>
		<li>/RENAME (CD002=d1)</li>
		<li>/DROP=d0 d1.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>Save new database (e.g.Group01_Subjects001-010).</li>
</ol>
5. Identification of Target Intensity (e.g. THR Range)
<ol>
	<li>Identify a THR range; click Transform &#8594; Compute Variable &#8594; in the &#34;Compute Variable&#34; window under &#34;Target Variable&#34; enter a new variable name (e.g. Diff_HR_THR) &#8594; &#34;Type &#38; Label...&#34; &#8594; in the &#34;Compute Variable: Type an....&#34; select Numeric &#8594; Continue &#8594; Under &#34;Numeric Expression&#34; enter equation: HR - THR &#8594; OK. This provides us with a new variable.
	<ul>
		<li>COMPUTE Diff_HR_THR=HR - THR.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>Recode variables to identify whether the HR lies below, above, or within the THR range. Procedure:Transform &#8594; Recode Into Different Variables... &#8594; select Diff_HR_THR &#8594; click arrow &#8594; under &#34;Output Variable&#34; under &#34;Name&#34; type Diff_HR_THR _recoded &#8594; Change &#8594; Old and New Values... &#8594; in &#34;Recode Into Different Variables: Old and New Values&#34; window:</li>
</ol>
<table border="1">
	<tbody>
		<tr>
			<td align="center">Old Value</td>
			<td align="center">New Value</td>
			<td></td>
			<td align="center">Old--&#62;New:</td>
		</tr>
		<tr>
			<td align="center">Range: -5 through 5</td>
			<td align="center">1</td>
			<td align="center" rowspan="4">Add</td>
			<td align="center">-5 thru 5 --&#62; 1</td>
		</tr>
		<tr>
			<td align="center">Range, LOWEST through value: -5</td>
			<td align="center">0</td>
			<td align="center">Lowest thru -5 --&#62; 0</td>
		</tr>
		<tr>
			<td align="center">Range, value through HIGHEST: 5</td>
			<td align="center">0</td>
			<td align="center">5 thru Highest --&#62; 0</td>
		</tr>
		<tr>
			<td align="center">System-missing</td>
			<td align="center">System-missing</td>
			<td align="center">SYSMIS--&#62; SYSMIS</td>
		</tr>
	</tbody>
</table>
&#8594; Continue &#8594; OK. See Figure 12.
<ul style="margin-left: 80px;">
	<li>RECODE Diff_HR_THR (SYSMIS=SYSMIS) (-5 thru 5=1) (Lowest thru -5=0) (5 thru Highest=0) INTO</li>
	<li>Diff_HR_THR_Recoded.</li>
	<li>EXECUTE.</li>
</ul>
6. Calculation of Percent Adherence
<ol>
	<li>In Group01_Subjects001-010 file, calculate all seconds that patients were within the THR range by doing the following: Data &#8594; Aggregate &#8594; in &#34;Aggregate Data&#34; window, under &#34;Break Variable(s):&#34; select subjectID and session &#8594; click arrow &#8594; under &#34;Summaries of Variable(s):&#34; select Diff_HR_THR _recoded &#8594; click arrow &#8594; OK. A new variable is created with the name Diff_HR_THR _recoded_mean.
	<ul>
		<li>AGGREGATE</li>
		<li>/OUTFILE=* MODE=ADDVARIABLES</li>
		<li>/BREAK=Subject_ID Session</li>
		<li>/Diff_HR_THR_Recoded_mean=MEAN(Diff_HR_THR_Recoded).</li>
	</ul>
	</li>
	<li>Convert the obtained value into a percentage; click Transform &#8594; Compute Variable &#8594; under &#34;Target Variable&#34; enter variable name (e.g. Perc_THR) &#8594; under &#34;Numeric Expression&#34; select Diff_HR_THR _recoded_mean &#8594; click arrow &#8594; multiply the value by 100 (Diff_HR_THR _recoded_mean * 100) &#8594; OK. We then obtain adherence as a percentage of time spent within the THR for each subject for each session. See Figure 13
	<ul>
		<li>COMPUTE Perc_THR=Diff_HR_THR_Recoded_mean * 100.</li>
		<li>EXECUTE.</li>
	</ul>
	</li>
	<li>To obtain adherence for the percentage of time spent within the THR for each subject for all sessions combined, in &#34;Aggregate Data&#34; window, under &#34;Break Variable(s):&#34; substitute subjectID and session with only subjectID. See Figure 14.</li>
	<li>To obtain adherence for the percentage of time spent within the THR for each session for all subjects combined, in &#34;Aggregate Data&#34; window, under &#34;Break Variable(s):&#34; substitute subjectID and session with only session.</li>
	<li>Save the database under a different file name (e.g.&#160;Group01_Subjects001-010_Aggregate).</li>
</ol>

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<li>George, J., Kong, D. C. M., Stewart, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adherence+to+disease+management+programs+in+patients+with+COPD%5BTitle%5D)+AND+%22International+Journal+of+COPD%22%5BJournal%5D)">Adherence to disease management programs in patients with COPD.</a> International Journal of COPD. 2 (3), 253-262 (2007).</li>
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<li>Hogg, L., Garrod, R., Thornton, H., McDonnell, L., Bellas, H. &, White, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effectiveness%2C+attendance%2C+and+completion+of+an+integrated%2C+system-wide+pulmonary+rehabilitation+service+for+COPD%3A+prospective+observational+study%5BTitle%5D)+AND+%22COPD%22%5BJournal%5D)">Effectiveness, attendance, and completion of an integrated, system-wide pulmonary rehabilitation service for COPD: prospective observational study.</a> COPD. 9 (5), 546-554 (2012).</li>
<li>Singh, S. J., Smith, D. L., Hyland, M. E., Morgan, M. D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+short+outpatient+pulmonary+rehabilitation+programme%3A+immediate+and+longer+term+effects+on+exercise+performance+and+quality+of+life%5BTitle%5D)+AND+%22Respir.+Med%22%5BJournal%5D)">A short outpatient pulmonary rehabilitation programme: immediate and longer term effects on exercise performance and quality of life.</a> Respir. Med. 92, 1146-1154 (1998).</li>
<li>Young, P., Dewse, M., Fergusson, W., Kolbe, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Respiratory+rehabilitation+in+chronic+obstructive+pulmonary+disease%3A+predictors+of+nonadherence%5BTitle%5D)+AND+%22Eur.+Respir.+J%22%5BJournal%5D)">Respiratory rehabilitation in chronic obstructive pulmonary disease: predictors of nonadherence.</a> Eur. Respir. J. 13, 855-859 (1999).</li>
<li>Brooks, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Characterization+of+pulmonary+rehabilitation+programs+in+Canada+in%5BTitle%5D)+AND+%22Can.+Respir.+J%22%5BJournal%5D)">Characterization of pulmonary rehabilitation programs in Canada in.</a> Can. Respir. J. 14 (2), 87-92 (2005).</li>
<li>Fischer, M. J., Scharloo, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Drop-out+and+attendance+in+pulmonary+rehabilitation%3A+the+role+of+clinical+and+psychosocial+variables%5BTitle%5D)+AND+%22Respir.+Med%22%5BJournal%5D)">Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables.</a> Respir. Med. 103 (10), 1564-1571 Forthcoming.</li>
<li>Sabit, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predictors+of+poor+attendance+at+an+outpatient+pulmonary+rehabilitation+programme%5BTitle%5D)+AND+%22Respir.+Med%22%5BJournal%5D)">Predictors of poor attendance at an outpatient pulmonary rehabilitation programme.</a> Respir. Med. 102 (6), 819-824 Forthcoming.</li>
<li>Polar Wearlink + Transmitter [Internet]. USA: Nike + Support;. 15, Available from:
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The authors declare that they have no competing financial interests.

Continuous data tracking technology enables for a very precise measurement of exercise adherence. This procedure can be easily adapted to other definitions of adherence by replacing target heart rate range with target wattage, level, speed, or MET level. In the present example, the warm-up and cool-down phases were eliminated to isolate the exercise phase because of our specific research objective. Should the warm-up and cool-down phases be of interest to other researchers, step 2.3 (&#34;Eliminate the nontraining phases&#34;) can be eliminated from the protocol. Furthermore, the hardware and software is also available to measure adherence to other modes of training, such as the treadmill, elliptical, stepper, and arm ergometer.
When following the above protocol, certain simple steps are critical. First, the CardioMemory software must be started before the exercise equipment (e.g. cycle ergometer) for exercise data to be tracked and subsequently recorded. Should data be lost at this initial step, the data extraction protocol will need to be adjusted accordingly. Secondly, sources of interference must be minimized to reduce the risk of crosstalk and/or lost data. The heart rate monitors communicate wirelessly with the equipment and software. Thus, interference is especially detrimental if using target heart rate to calculate adherence. Finally, it is imperative to select statistical software for the database that has the capacity to permit for large quantities of data. For example, in a study with 10 participants completing 36 sessions at 40 min&#160;each, 864,000 rows of data points will be generated. Excel 2007 and later versions have the capacity to contain 1,048,576 rows in a worksheet23, whereas SAS24 and SPSS25 have no limit for the number of rows. Depending on the total number of data points expected for a given study, the software needs to be selected accordingly.
Despite the notable advantages of this technology, two main limitations exist. The first is data loss, which can result from equipment and/or software failure. As mentioned above, data loss can be due to electrical interference with wireless devices (i.e.&#160;cell phones or Wi-Fi), and more specifically interference with the wireless data transmission of heart rate. However, at times, data loss can also be due to unidentifiable causes. A second limitation is that the software does not provide the option of marking or splitting the exercise protocol systematically in order to differentiate/identify different phases. If this option were available, the extraction of the exercise phase of interest could be performed directly in the software, which would limit steps in the adherence calculation protocol. As well, the option of placing markers would be practical for the study of adherence to interval or intermittent training protocols as it would allow for the differentiation of the different phases (e.g. low versus high intensity).
For future perspectives, the use of continuous data tracking technology to precisely quantify adherence will enable researchers to investigate patterns of exercise response to different interventions, identify determinants of adherence, and characterize good and poor adherers. Ultimately, a better understanding of exercise adherence will allow for the optimization of exercise rehabilitation programs.

Pulmonary rehabilitation (PR) combines exercise training, patient education and psychosocial support, and is widely recognized as a cornerstone in the management of pulmonary disease1-5. The goals of PR are to reduce symptoms, optimize functional status, improve health-related quality of life, and reduce health care costs4,5. In a meta-analysis of 31 randomized controlled trials in chronic obstructive pulmonary disease (COPD), PR was shown to significantly improve exercise capacity, reduce dyspnea and fatigue, improve emotional function and enhance patients&#8217; sense of control over their condition6. Furthermore, evidence documents its effectiveness in reducing respiratory exacerbations7 and days spent in hospital8-13. Exercise training is considered the key to successful PR since it is responsible for much of the benefits associated with this intervention3-5. However, a major issue for several patients is adhering to the recommended amount or level of exercise. Nonadherence to recommended treatment may result in the failure of therapeutic interventions as well as inefficient use of health resources14.
According to the World Health Organization, the term &#39;&#39;adherence&#39;&#39; refers to the extent to which a person&#8217;s behavior coincides with recommendations given by a health care professional15. To date, adherence to exercise training in rehabilitation settings has been largely assessed as either the rate of participation (i.e registration to the program), the rate of completion (i.e. finishing the program), or the rate of attendance (i.e. number of exercise sessions attended)16-18. At present, no &#34;gold standard&#34; exists for measuring adherence15 and current methods do not allow for great precision. Furthermore, depending on the selected method, rates of adherence to PR have shown large variability16-19. For example, Hogg et al.16 measured adherence in COPD patients as the ratio between those who completed the program to those referred and found a low adherence of approximately 40%. However, other PR studies that have used attendance rates demonstrated, on average, a 90% adherence10,20,21. The lack of homogeneity in calculating adherence makes it difficult to compare results between studies. Another concern is the lack of precision with the existing calculation methods; attendance to an exercise training session does not guarantee adherence to the prescribed intensity. This gap in information led us to investigate how adherence could be calculated in a more precise way.
Recent advances in fitness equipment technology have allowed for continuous data tracking, which can be used to monitor adherence to a prescribed aerobic training intensity during individual exercise sessions in a PR context. More specifically, data tracking hardware and software permits for second-by-second recording of duration, speed, level, wattage, pace, heart rate, distance, calorie consumption, VO2, METS, and calories, and provides averages of all variables with the exception of level and VO2. The main advantage of this technology is the ability to record continuous detailed measures, which allows for the precise calculation of adherence to prescribed exercise versus previously reported general attendance or completion rates. This procedure can be of value for any study examining the impact of one or several aerobic exercise training programs. Using this technology, patient adherence to a prescribed intensity can be assessed by the percent time spent at a specified wattage, level, speed, or heart rate during the training phase of each session. For our investigations, adherence to an exercise training protocol has been defined as the percent time spent within a specified target heart rate range. Since heart rate response at a given submaximal workload decreases as cardiorespiratory fitness increases, this approach ensures that patients remain at the same relative (versus absolute) training intensity throughout the program. The present protocol describes in detail how continuous data tracking technology can be used to precisely measure adherence to a prescribed target heart rate range.

<table><tbody><tr><td>Bike Excite Med 700</td><td>Technogym - www.technogym.com</td><td></td><td>SCIFIT (http://scifit.com/)</td></tr><tr><td>CardioMemory software&amp;nbsp;</td><td>Technogym - www.technogym.com</td><td>Version 1.0</td><td>SCIFIT (http://scifit.com/)</td></tr><tr><td>Polar heart rate monitor</td><td>Polar - www.polarca.com</td><td>T31 coded Transmitter</td><td>&amp;nbsp;</td></tr><tr><td>SPSS Statistical Software</td><td>SPSS Inc. - www.spss.com/</td><td>Version 16.0</td><td>SAS/STAT software (http://www.sas.com/)</td></tr></tbody></table>

using continuous data tracking technology to study exercise adherence in pulmonary rehabilitation

Using Continuous Data Tracking Technology to Study Exercise Adherence in Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is an important component in the management of respiratory diseases. The effectiveness of PR is dependent upon adherence to exercise training recommendations. The study of exercise adherence is thus a key step towards the optimization of PR programs. To date, mostly indirect measures, such as rates of participation, completion, and attendance, have been used to determine adherence to PR. The purpose of the present protocol is to describe how continuous data tracking technology can be used to measure adherence to a prescribed aerobic training intensity on a second-by-second basis.
In our investigations, adherence has been defined as the percent time spent within a specified target heart rate range. As such, using a combination of hardware and software, heart rate is measured, tracked, and recorded during cycling second-by-second for each participant, for each exercise session. Using statistical software, the data is subsequently extracted and analyzed. The same protocol can be applied to determine adherence to other measures of exercise intensity, such as time spent at a specified wattage, level, or speed on the cycle ergometer. Furthermore, the hardware and software is also available to measure adherence to other modes of training, such as the treadmill, elliptical, stepper, and arm ergometer. The present protocol, therefore, has a vast applicability to directly measure adherence to aerobic exercise.

When the protocol is performed correctly, an adherence rate is obtained for each subject for each session (Figure 13), for each subject for all sessions (Figure 14), and for each session for all subjects combined. An estimate of the time required to complete the above protocol for a single session of one subject is approximately 5 min. Results for adherence can range from 0-100%. Using this information, additional analyses can be performed to determine differences between subjects (i.e. sex differences, disease severity, etc.),to identify changes over time, and to reveal patterns in adherence. Moreover, the comparison of adherence between groups can be performed; for example, different exercise training programs can be compared. Finally, through further investigation, causes of nonadherence can be identified at specific time points during PR.
<img alt="Heart rate monitor diagram showing chest strap in use for physiological data tracking." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig1.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 1"> 
Figure 1. Heart rate transmitter placement. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig1highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Exercise performance graph, data analysis of heart rate, speed, and VO2 during cycling session." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig2.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 2"> 
Figure 2. Sample of data collected using data tracking software. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig2highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Exercise data analysis chart; cycling stats; columns: speed, calories, HR, VO2; performance metrics." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig3.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 3"> 
Figure 3. Sample of data tracking software output. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig3highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data analysis table showing statistical variables and metrics for fitness tracking study." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig4.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 4"> 
Figure 4. Sample database illustrating a sample of statistical software database. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig4highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Statistical data analysis table in SPSS software, displaying various variables and results." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig5.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 5"> 
Figure 5. Sample database illustrating the eliminated warm-up phase. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig5highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Statistical data analysis table in SPSS software, showing various metrics for experimental results." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig6.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 6"> 
Figure 6. Sample database illustrating the eliminated cool-down phase. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig6highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data sheet; statistical data analysis, tabular student experiment results, variable sorting." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig7.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 7"> 
Figure 7. Sample database illustrating a column added for session number. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig7highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data analysis; spreadsheet; variable examination; research statistics; IBM SPSS Statistics." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig8.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 8"> 
Figure 8. Sample database illustrating the merged sessions for a single participant. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig8highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Statistical data analysis in SPSS; table of variables; data entry screen; experiment results." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig9.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 9"> 
Figure 9. Sample database illustrating a column added for subject identification number. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig9highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Statistical data table in SPSS software, showing variables and participant IDs." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig10.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 10"> 
Figure 10. Sample database illustrating a column added for target heart rate. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig10highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data analysis spreadsheet, showing variables, data rows, and statistical results." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig11.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 11"> 
Figure 11. Sample database illustrating the merged participants' files. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig11highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="Data analysis in SPSS, showing statistical variables table, used for health metrics evaluation." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig12.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 12"> 
Figure 12. Sample database illustrating the recoded heart rate variables. <a href="https://www.jove.com/files/ftp_upload/50643/50643fig12highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data analysis table, statistical software interface showing columns of calculated metrics and statistics." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig13.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 13"> 
Figure 13. Sample database illustrating adherence as a percentage of time spent within the target heart rate range for each subject for each session (horizontal red line highlights the change in adherence between sessions for the same subject). <a href="https://www.jove.com/files/ftp_upload/50643/50643fig13highres.jpg" target="_blank">Click here to view larger image</a>.
<img alt="SPSS data analysis, statistical table, variables, research, software interface, data processing." fo:content-width="5in" src="/files/ftp_upload/50643/50643fig14.jpg" width="600px" data-altupdatedat="1787630408000" data-alt="Figure 14"> 
Figure 14. Sample database illustrating adherence for the percentage of time spent within the target heart rate range for each subject for all sessions (horizontal red line highlights the difference between subjects). <a href="https://www.jove.com/files/ftp_upload/50643/50643fig14highres.jpg" target="_blank">Click here to view larger image</a>.

Pulmonary rehabilitation is widely recognized in the management of respiratory diseases. A key component to successful pulmonary rehabilitation is adherence to the recommended exercise training. The purpose of the present protocol is to describe how continuous data tracking technology can be used to precisely measure adherence to a prescribed aerobic training intensity.

Pulmonary rehabilitation (PR) is an important component in the management of respiratory diseases. The effectiveness of PR is dependent upon adherence to ...

The overall goal of the following protocol is to describe how continuous data tracking technology can be used to precisely measure adherence to a prescribed aerobic training intensity. This is achieved by first collecting the data using continuous data tracking technology. During an aerobic exercise training session, using data tracking software, a single file of raw data is obtained for each subject, for each training session, and then converted into an Excel format.Next, statistical software is used to extract and combine data for a single file per subject, which allows for the achieved intensity to be compared to the target intensity results are obtained the show an adherence rate expressed as the percentage of time spent at the target intensity for a given individual or for a group session by session, or for the entire program. The main advantage of using this technique over existing methods like general attendance or completion rate, is the ability to record continuous measures of exercise intensity, which allows for a precise calculation of adherence to the prescribed training program. So this method can help answer key questions in the pulmonary rehabilitation field, such as which exercise training approach is associated with the best adherence rate in patients with obstructive lung disease.Though this method can provide insight into adherence to exercise training using a target heart rate range. It can also be easily adapted to other definitions of adherence by replacing target heart rate range with target wattage level speed, or met level. Before beginning, turn off all wireless devices that may cause electrical interference and ensure that the heart rate monitors and equipment are at least one meter apart to minimize crosstalk.When ready, place the heart rate transmitter onto the patient and turn on the data tracking software. Next, start the aerobic equipment and instruct the participant to reach their target intensity. In this example, participants are asked to train within plus or minus five beats per minute of their target heart rate.Some examples of the data collected by CardioMEM include the subject ID, duration, level of intensity, distance, pace, heart rate, and metabolic equivalent of physical effort. After data collection, press stop on the aerobic equipment, save the data to cardio memory, in addition to exporting the document for further analysis. Since the CardioMEM software does not track distinct exercise training phases, the data obtained must be processed To eliminate the phases that are not of interest, merge the data files and determine the target intensity.Open the statistical analysis software to import the newly created Excel file and save the data file before proceeding with the analysis to focus on the data collected during the training phase, the warmup phase needs to be eliminated. The first step is to recode the duration, make the necessary changes to create a variable to identify every second as one. The next step is to create a second temporary variable.Name this variable tempo two. Once created, recode the new variable to begin at zero. After the variable has been recoded, sum the seconds starting from zero.Once the sum is obtained, the first 10 minutes of the warmup phase can be eliminated by removing the tempo data that proceeds 599 seconds. Next, the cool down phase needs to be eliminated To do so, sort data in descending order for duration. A to bring the cool down phase to the top of the database.Recode duration A to identify every second as one. Next, create a second temporary variable named tempo. A two recode the newly created variable to start at zero with the start point defined some the seconds of the tempo, a variable to eliminate the cool down phase, remove tempo data that proceeds 299 seconds.Next, identify the session number associated with the data set by creating a new variable. Finally, save the modified SPSS document as a new file to merge all sessions for a single patient into a single SPSS database. Open the participant's first session.Next, merge the remaining sessions into the current file. Once merged, add a column which contains the subject's id. Number next, add a column that contains the subject's target intensity.Save the database under a different file name. Repeat this procedure for all of the remaining participants. At this point, each participant will have a database containing all sessions.To group several participants into a single database, open the participant's file, merge the remaining participants to the current file, and save this information as a new database. After the data is prepared, the target intensity can be identified. To do this first, add a column that contains the difference between the heart rate and the target heart rate.Then recode the variables to determine whether the heart rate lies below, above, or within the target heart rate range. The percent adherence is calculated by determining all seconds that patients were within the target range. Once a value is obtained, convert this into a percentage to obtain the adherence rate as the percentage of time spent within the target heart rate.For each subject, for all sessions combined, substitute subject ID and session with only subject ID in the aggregate data window to obtain an adherence rate for each session. For all subjects combined, substitute subject ID and session with only session. Lastly, save the database under a different file name.Ultimately, the data can be used to look at patterns of adherence over time in a given individual or in different groups, or to look at the mean adherence rate throughout the training program for individuals or groups. Once mastered, this procedure can be done in approximately five minutes per session for one subject. While attempting this procedure, it's important to remember to start the cardio memory software before the exercise equipment so that data can be tracked and subsequently recorded.Secondly, sources of interference must be minimized to reduce the risk of crosstalk and or loss data. After watching this video, you should have a good understanding of how to use continuous data tracking technology to precisely measure adherence to prescribed aerobic training.Intensity.

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Using Continuous Data Tracking Technology to Study Exercise Adherence in Pulmonary Rehabilitation

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