Perceptions from People Aging with a Mobility Impairment towards using Tele-Technology for Exercise
George Mois
3, Taylor E. Mackin
3, Amber Datta
2, Lyndsie M. Koon
4, Wendy A. Rogers
4, Tracy L. Mitzner
5, & Jenay M. Beer
1.
1University of Georgia, Institute of Gerontology
2University of Georgia, College of Public Health
3University of Georgia, School of Social Work
4University of Illinois, College of Applied Health Sciences
5Georgia Institute of Technology, Center for Assistive Technology and Environmental Access
Persons aging with a mobility disability encounter barriers to exercise engagement including accessibility to transportation, facilities, and adequately trained instructors. A tele-exercise platform could reduce these barriers as it utilizes video conferencing to enable remote exercise classes. For this feasibility study, participants (N = 19; 40+ years of age) who identified as aging with a mobility impairment for at least five years or longer, participated in a seated, one-on-one, gentle movement exercise class via web-based video conferencing (OneClick.chat). We present data from semi-structured interviews regarding participants’
perceptions of the tele-exercise class. Participants discussed their perceptions of benefits, concerns, technology usability, and intent to adopt. Participants expressed positive attitudes, overall, stating that they would likely benefit physically, emotionally, and socially from regular participation in a tele-exercise exercise program, and most expressed an interest in adopting such a program. Participants also expressed concern about the usability of the technology platform. We provide design recommendations to address participants’ concerns. These findings provide guidance for how to improve the design of a remote tele- exercise class for adults aging with mobility disability.
INTRODUCTION Older Adults and Lower Body Disability
The population of adults age 65+ is growing at an accelerated rate across the world (Connelly, Laghari, Mokhtari,
& Falk, 2014). Many older adults are living longer lives and some are aging with lifelong disabilities which can affect their quality of life. According to the Disability Statistics Annual Report, 35.2% of older adults age 65+ report having experienced a disability (Kraus, Lauer, Coleman, &
Houtenville, 2018). The most prevalent disability reported by older adults is ambulatory (Kraus, Lauer, Coleman, &
Houtenville, 2018). Older adults often experience a mobility disability due to an inability to perform or engage in activities as a result of a lower body impairment (LBI; Power, 2011). The presence of an unattended LBI, over an extensive period of time, can lead to the onset of a mobility disability. Furthermore, it is important to note that the challenges that often accompany longevity, such as functional or cognitive declines, can amplify the level of difficulty experienced in everyday activity engagement by adults aging with a mobility disability and/or a lower body impairment.
The prevalence of mobility disability among older adults draws concerns regarding their ability to be mobile, as well as concerns for overall health and wellbeing. According to Conway et al. (2011) and Ferrucci et al. (2016) poor physical function is associated with a decrease in well-being and quality of life in aging adults. Older adults living with LBI may experience limitations in their lower body strength and ability to lift, balance, and walk (Pope & Tarlov, 1991; Verbrugge &
Jette, 1994). For example, older adults with LBI are more likely to be less mobile, experience greater disability, and suffer premature death when compared to those without a LBI (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995, Santariano et al., 2014). These implications can have an adverse effect on older adults’ ability to engage in physical activity, which plays an essential role in healthy aging.
Addressing LBI through Physical Activity
Physical Activity is defined as any bodily movement that results in energy expenditure. Forms of physical activity include occupational, household, sport, community, leisure, and exercise-related activities (Carl et al., 1985). Physical activity has been shown to mitigate negative health outcomes and secondary health conditions including cardiovascular disease, stroke, hypertension, colon and breast cancer, osteoporosis, and obesity (Rosenberg et al., 2011). Engagement in physical activity can enhance physical functioning, and prevent further declines in functioning and further mobility losses (Rosenberg et al., 2011). Furthermore, physical activity can reduce the risk of falls, injury from falls, and functional limitations in those with LBI (Froehlich-Grobe et al., 2012). Despite the value of exercise, persons aging with LBI and disability face many barriers to adopt and maintain regular exercise behavior. These barriers include compounding attitudinal, financial, social, and environmental factors that must be considered in the development of an exercise intervention to be successful for this population (Cavil et. al, 2018; Malone et al, 2015; Rimmer et al., 2004; Wu et al., 2010).
Copyright 2019 by Human Factors and Ergonomics Society. DOI 10.1177/1071181319631040
Please see Table 1 for a summary of the barriers experienced by older adults with a LBI.
Table 1. Barriers Experienced by Older Adults with Lower Body Impairment in Adopting Exercise Interventions
Level Barrier Citations
Individual Physical Psychological
• Health conditions
• Emotional
• Safety
• Lack of Knowledge
(Cavil et. al, 2018;
Malone et al, 2015;
Rimmer et al., 2004)
Social • Support (Cavil et. al, 2018;
Rimmer et al., 2004) Environmental • Access Difficulties
• Travel
• Affordability
(Cavil et. al, 2018;
Malone et al, 2015;
Rimmer et al., 2004; Wu et al., 2010)
Using Tai Chi to engage Older adults in Physical Activity Considering the benefits of exercise in promoting physical activity in adults aging with disability, selection of an effective exercise program to help overcome perceived, and actual, barriers is crucial in ensuring an intervention’s success. Tai Chi has been well-known as an effective exercise modality for aging adults (Day et al., 2012; Hsu et al., 2016; Li et al., 2003;
Mortimer et al., 2012; Wang et al., 2016; Wu et al., 2010). Tai Chi is promising for those aging with disability as it has been shown to moderate disability by positively influencing aspects of functional limitations such as balance, functional performance, and cardiovascular function (Day et al., 2012).
Seated Tai Chi is an adapted version of Tai Chi frequently used with individuals who have lower body impairment as it allows for seated participation of the movements. These programs typically utilize a variety of slow, extensive upper- body movements (Yong et al., 2015).
Tai Chi has been shown to facilitate improvements for participants in the following areas: balance control, muscle strength, functional status, aerobic capacity (Day et al., 2012), pain (Kwai-Sang et al., 2002), quality of sleep, grip, strength, lower body flexibility, and cardiorespiratory function (Chen et al., 2007). Tai Chi prevents joint stiffness, reduces symptoms of osteoarthritis, and improves posture and balance (Kwai-Sang et al., 2002). Emotional and cognitive benefits include decreased dysphoric moods, improvements in self-esteem and emotional/physical well-being, increased QOL (Shem et al., 2016), decreased symptoms of depression (Chi et al., 2013), positive effect on mood, and improved alertness and concentration (Kwai-Sang et al., 2002). Finally, Tai Chi has positive social impacts, including broadening social networks, decreasing loneliness, and increasing satisfaction with perceived social support (Kawi-Sang & Parker, 2002).
Tele-Technology to Facilitate Engagement in Exercise Tele-technologies such as Skype, Facetime, and other video-conferencing software show great potential to promote exercise in those aging with disability. More specifically, “tele- exercise” is exercise facilitated through the use of video conferencing technology where individuals “meet” live via a laptop/television, and exercise with an instructor and classmates (Wu et al., 2010). Tele-exercise holds potential to facilitate access to exercise programs for those aging with
disability within their own homes, while also providing the individualized, and professional exercise instruction.
The use of Tai Chi exercise in conjunction with tele- technology for aging adults has shown great promise.
Technology-facilitated programs have been beneficial for older with mobility decline (Ni et al., 2017), pre-frail older adults (Marit Dekker-van et al., 2017), and those living in geographically rural areas (Elder et al., 2016). Previous findings indicate that study participants demonstrate approving views of tai chi tele-exercise classes and interest in long-term use (Wu et al., 2010; Wu et al., 2006; Mitzner et al., 2017).
While the benefits of a tailored Tai Chi tele-exercise program for older adults aging with disability are well supported, the specific environmental, technological, and personal requirements to develop a successful long-term tele- exercise intervention for this population are less well-known.
For example, the unknown environmental requirements include space requirements in the user’s home, safety considerations, and technical requirements for the instructor’s studio (e.g., software/hardware, auditory and visual, and network/
wifi components). Therefore, the goal of the current research is to investigate the benefits, concerns, technological considerations, resource needs, and interest to adopt, to determine the feasibility of a Tai Chi tele-exercise intervention for persons aging with a lower body impairment. Our aim is to provide guidance for the design of remote tele- exercise classes for adults aging with mobility disability.
METHODS Design
Most commonly used Tai Chi exercise interventions require multiple sessions spanning weeks and even months to learn and perform correctly (Fox, Dyer, Mathew, Van Camp, Ke, Hall, & Wang, 2011). Given that our investigation was a feasibility study, participants only attended a single 15-minute exercise session. Therefore, we used a simple, seated Tai Chi inspired gentle movement series that our participants could learn and perform for the purposes of the study. Our gentle movements demo exercises are outlined in Figure 1.
Figure 1. Gentle Movement Exercises Warm
Up Carrying the
Ball Wild Flying
Goose Wave
Hands Cool
Down Deep
Breathing
Tense and Relax
Participants
Our study took place at two research sites located in the Southeast and Midwestern regions of the United States.
Participants were recruited through the use of flyers which were posted in local social agencies, hospitals, rehabilitation and community centers. In total, 19 community dwelling adults aged 40+ who self-reported LBI participated in the study (Table 2). Participants were screened through a brief phone
interview to ensure they met the eligibility criteria for our study (Table 3).
Table 2. Demographic Data
n %
Mean Age - 62 (SD 10.18; range 43) 19 Sex
Males 8 42
Females 11 57
Race
Caucasian 13 68
African American 4 21
American Indian/Asian/Native Hawaii 2 10
Hispanic 0 0
Other 0 0
Mobility Aid
Cane 5 26
Manual Wheelchair 5 26
Walker 2 10
Electric Wheelchair 4 21
Orthotic Devices 1 5
Grab Bars 6 31
Scooters 1 5
Table 3. Participant Inclusion Criteria 1. Aged 40 years or older
2. Self-identified as having a lower body impairment 3. Experienced impairment for 5 years or more 4. No upper body impairment
5. Access to transportation to the study site
6. Pass gentle movement readiness scale (variation of the PAR-Q) 7. Score 24+ Telephone Interview for Cognitive Status (TICS)
Protocol
Prior to the study, participants were mailed a packet with the consent agreement and a demographics survey. Upon arrival, the participant was greeted by the primary researcher, and led to a private interviewing room. The secondary researcher was located in a remote location to act as the exercise instructor. The exercise instructor did not have in-person contact with the participant at any time during the study. The participant was than introduced to the study with an overview of the tele-exercise project including funding sources, goals, and background information.
Researchers administered the Montreal Cognitive Assessment (MOCA; Nasreddine et al., 2005), and participants completed the Technology Acceptance (Davis, 1989), Self- Efficacy for Exercise (Resnick & Jenkins, 2000), and Physical Activity Affect questionnaires (Lox et al., 2000). The primary researcher then set up the hardware and video-conferencing software (OneClick.chat), establishing the connection with the remote researcher, which provided the exercise instructions.
The primary researcher guided the participant to a chair located several feet from the laptop and webcam (Figure 2). The researcher then configured the technology until the participant was centered in the webcam view visible from the knees up.
The remotely located researcher was positioned the same way within the webcam view for the participant to see. Both were seated in chairs with armrests and no wheels and positioned in front of a solid background for visibility purposes.
The secondary researcher then proceeded with the demonstration of the gentle movements exercise training (Figure 1). Following the demonstration, the participant was then asked to complete the second set of questionnaires which
included: NASA TLX (Hart et al., 2011) and Post-Physical Activity Affect questionnaires (Craig et al., 2017). Once the questionnaires were completed, the primary researcher proceeded to conduct a semi-structured interview. Interview questions were developed to identify participants’ thoughts and opinions of the tele-exercise demonstration (questions available by request). After the interview was completed, the participant was asked to complete the final set of questionnaires which included: Post-Self-Efficacy for Exercise (Resnick &
Jenkins, 2000), Technology Acceptance (Davis, 1989), and System Usability Scale questionnaire (Brooke, 1996). All participants were compensated $40.
Figure 2. Tele-Exercise Set Up for Study Participant
Segmentation and Coding Scheme
All audio recordings were professionally transcribed.
Transcripts were segmented into meaningful data units, defined as any attitudinal statements participants made about use of tele-exercise. A coding scheme was developed through the use of thematic analysis, using a qualitative data analysis software, MAXQDA (Verbi Software, 2010). Two transcripts were coded by two researchers and with intercoder agreement of 84%
(Saldana, 2012), all remaining inconsistencies were discussed and the scheme was revised until consensus was reached. This final coding scheme was utilized to analyze all remaining transcripts which were divided and coded by the researchers.
RESULTS
This publication focuses on the interview data, specifically addressing issues that can inform design recommendations. The five most relevant categories were:
perceptions of benefits, concerns, technology considerations, and intent to adopt. Due to audio recorder technical issues, 2 interviews were not properly recorded. Therefore, interview data reflect a sample size of n=17.
Benefits
When prompted to discuss first impression on using the technology, study participants noted on average more likes than dislikes. Participants mentioned a total of 44 benefits. These mentions were nearly evenly split between physical, social, and emotional benefits. One participant noted “Sure, you might meet somebody or ... I mean we don't know where these people are right? Yeah it would be nice to meet people in other remote locations or other home bound people.” Participants mentioned other benefits such as convenience, easy to understand the movement instructions, and the personal attention from the instructor. One participant stated “I think it's time saving, you don't have to go and leave your home and rush to go to the
exercise center”. Participants indicated that they felt like active, rather than passive, participants in the demonstration. Some participants highlighted the convenience of a tele-exercise class, “…I could be at home, so this would be more readily available then you know, you don’t have to go somewhere.”
Concerns
In general, concerns arose in the discussion pertaining to technology use and privacy. Visual difficulty (e.g., due to the small computer displays, software split-screen design) was mentioned by 13% of the study participants and some participants (47%) mentioned difficulty hearing. Furthermore, 25% of study participants stated that they would be concerned about the instructor being able to see inside their home. When prompted to discuss how they felt about being in an exercise class with others, some participants noted discomfort, stating that they would not want the class members to see inside their home. One participant stated, “if you’re not sure who the other participants are, I think they would also not be comfortable because we might not have met face to face and we don’t know who the other people are, so that might be an issue.” Although most participants were open to a remote instructor, a few stated that they would feel more comfortable if an instructor was physically present in the room. One participant noted “Well it's difficult to mirror. When you're looking at a television set, you're looking at a reflection of a reflection, and you're dealing with mirroring”. Participant comments for preferring an in- person instructor were related to the challenges presented by the technology and concerns about privacy. One participant stated
“There would be another risk of security of privacy with me.”
Technology Considerations
The majority of participants (71%) were comfortable with using a computer, webcam, and video conferencing software.
However, some participants (29%) expressed that they might have difficulty setting up these technology components. As mentioned earlier, some participants expressed concerns about the usability of the technology pertaining to one’s ability to hear and see. One participant noted, “What I disliked about it was the split screen was hard. And it was small. It was not large. So, someone that has a vision problem would not be able to see as clear as if the screen was larger. The other thing that I didn't like was the buffering. Like the muffling sound, because it kept interrupting, and when you're trying to focus on exercising and it keeps muffling, you lose your train of thought.”
During the interview participants were asked about the availability of resources such as web camera, computer, along with other items that may be necessary for the implementation of a tele-exercise intervention. Participants indicated that they had the resources necessary to partake in a tele-exercise class.
Specifically, 88% of participants indicated that they had access to a chair and Wi-Fi; 82% had access to a webcam, computer, and space suitable to participate in tele-exercise.
Intent to Adopt
Overall study participants expressed intention to adopt the technology, they perceived many benefits to tele-exercise, and described it as being useful. When asked if they would be
interested in participating in a tele-exercise class if it was free, 88% of participants stated that they would.
DISCUSSION Summary of findings
Our study aim was to investigate the benefits, concerns, technology considerations, resources, and interest to adopt, to assess the feasibility of a Tai Chi tele-exercise intervention for persons aging with LBI. Our study findings indicate that tele- exercise classes hold a great potential in helping address the challenges experienced by persons aging with LBI which may limit their ability to engage in physical activity. Furthermore, our findings suggest that this population will perceive the physical, emotional, and social benefits of tele-exercise.
Participants indicated that they have the technical and support resources available to participate in remote exercise from their home. Some participants had mixed opinions about whether an instructor should always be remote; this data suggest that perhaps a hybrid course (a mix of in-person and remote) exercise classes may be of most benefit.
Design recommendations
The current study provides insight into potential design improvements for hardware and software utilized in tele- exercise. The hardware used in our study were 13-inch Windows laptops with built in web-camera, speakers, and microphone. Participants reported difficulty seeing and hearing the exercise instructor and at times described poor image quality. Furthermore, participants experienced difficulty with depth perception during the demonstration as the three- dimensional exercise was being displayed two dimensionally.
Future tele-exercise interventions should use a larger display to help improve visibility. Utilizing multiple external web-cameras, 3D cameras, depth sensors, or virtual reality may also help improve image quality, and give users a more comprehensive visualization of the exercise movement.
However, it is important to note that these suggestions may not be feasible in some older adults’ homes, where space may be limited, or the older adults may not have access to large computer screens. Therefore, it is crucial to utilize available resources to their full potential.
The telepresence software used in our study (OneClick.chat) used a split screen design, which divides the webcam views into two equal halves. The software also incorporated a chat-box feature. Participants had mixed input regarding the software interface, as some noted that they had difficulty seeing the instructor whereas others enjoyed being able to see themselves exercise. In future studies, it is recommended that software used in tele-exercise interventions allow for user customization, thus giving the user the ability to modify between a full and split screen interface. Furthermore, the option to remove chat-box may help increase picture size.
We found that participants had a difficult time hearing the instructor, thus using external microphones and speakers may help improve sound quality and clarity. Additionally, internet network speed should be considered, as it may have an effect on image and sound quality. This is particularly important for
interventions in rural communities, where network speeds are often slower than urban areas.
The results of our study provide encouraging support for the feasibility of tele-exercise interventions for persons aging with a lower body impairment. Future tele-exercise interventions need to consider the diverse functional abilities of adults aging with LBI. These individuals had positive attitudes towards this technology option and could benefit from having this exercise option in their homes.
ACKNOWLEDGMENTS
Funding Acknowledgements: The contents of this proceeding were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90REGE0006-01-00) under the auspices of the Rehabilitation and Engineering Research Center on Technologies to Support Aging-in-Place for People with Long- Term Disabilities (TechSAge; www.rerctechsage.org) NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this proceedings do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.”
This research was conducted utilizing the OneClick.chat system, an innovative web-based video chat platform that allows users to easily join and participate in video-based meetings and events.
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