1. Measuring Exercise and Motivating Spine Patients Christy C. Tomkins-Lane, PhD Visiting Associate Professor Department of Orthopedic Surgery Stanford University

2. Primary goals for intervention Patient Satisfaction Decreased pain/symptoms Improved function

3. Associated Outcomes Patient Satisfaction - Satisfaction/QOL scales Decreased pain/symptoms - Pain and symptom scales Improved function - Physical function scales

4. Associated Outcomes Patient Satisfaction - Satisfaction/QOL scales Decreased pain/symptoms - Pain and symptom scales Improved function - Physical function scales

5.  Inaccurate and imprecise  Subject to multiple biases and external influences  Measures often highly inter-related  Demand for ways to quantify change & value

6. Associated Outcomes Patient Satisfaction - Satisfaction/QOL scales Decreased pain/symptoms - Pain and symptom scales Improved function - Accelerometry, VO2max testing

7. Function Complex concept Historically challenging to measure When measuring function, it is important to assess the two distinct components: performance and capacity.

8. Performance and Capacity Capacity reflects the ability to complete a given task in a controlled environment (e.g. a walking test, strength). Performance reflects actual physical activity in the context of one’s day to day life. Performance:  Identifies barriers to function  Impact of pathology on real life

10. Measuring Performance Performance has historically been measured with inaccurate self-report instruments. We are now able to objectively measure performance -Mobile technology -Physical activity monitors

11. How are we using these monitors? Until recently, primarily limited to fitness Clinical applications have begun: Assess outcomes of interventions Monitor rehabilitation programs Gait analysis Balance and falls risk assessment Sleep, heart rate, skin temperature  Limited application so far in clinical care!

13. Evaluating limitations  Evaluate performance in LSS, hip and knee OA  Patients with degenerative musculoskeletal disorders suffer limitations in performance compared to healthy controls  Objective assessment is feasible  More precise information vs. self-report Winter et al. BMC Musculoskelet Disord.Winter et al. BMC Musculoskelet Disord. 2010 Oct 12;11

14. Evaluating outcomes: epidural  Changes in performance following epidural injection for LSS  Significant improvements in self-reported physical function, general health, symptoms  No significant improvements in performance  Perceived change > objective change  Identify need for post-intervention rehabilitation? Tomkins-Lane et al. Arch Phys Med Rehabil.Tomkins-Lane et al. Arch Phys Med Rehabil. 2012 Nov;93(11):2008-14

15. Predicting performance  Predictors of performance in LSS, low back pain and controls  Body mass index  Pain  Female gender  Age  Predictors of performance were independent of pathology – implications for management? Tomkins-Lane et al. Arch Phys Med Rehabil.Tomkins-Lane et al. Arch Phys Med Rehabil. 2012 Apr;93(4):647-53.

16. Risk assessment  Relationship between low back pain, performance and obesity  Increased BMI is a risk factor for low back pain  Physical activity (performance) mitigates back pain risk – more so in overweight and obese Smuck et al. NASS 2013

17. How else can we use mobile tech?

18. Motivating Change

19. Successful e-health interventions Tailoring (individual) and targeting (group) Self-management (use of personal information for reflective self-management and monitoring of health behaviour) Social context and support Contacts with intervention Entertainment Aesthetics Usability What is common here???? Morrison et al. 2012

20. All can be accomplished using mobile tech!

21. Spinal Stenosis Pedometer and Nutrition Lifestyle Intervention

22. Spinal stenosis example….  Pedometer and nutrition lifestyle intervention for overweight and obese LSS patients  Objective assessment through accelerometers as bio-feedback to motivate lifestyle change

23. Lifestyle Intervention Assess physical activity at baseline using accelerometry and VO 2max test Provide personalized physical activity recommendations (e.g. steps per day) Provide activity monitor (pedometer, phone application, accelerometer) Ongoing prompts, biofeedback and contests (if desire) Ongoing assessment and adjustment

24. Self-management at home! People love tech Constant feedback At your fingertips Multiple variables can be tracked Puts people in charge of their own care

25. Other applications…..

26. Timing of intervention

27. Predicting success

28. Goals for intervention Patient Satisfaction Decreased pain/symptoms Improved function

29. Using mobile technology…. Change Measure Motivate MeasureMotivate

30. Thank you! Christy C. Tomkins-Lane, PhD clane@mtroyal.ca