Disability and Rehabilitation

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Activity and MObility UsiNg Technology (AMOUNT)

rehabilitation trial – description of device use and
physiotherapy support in the post-hospital phase

Leanne Hassett , Maayken van den Berg , Heather Weber , Sakina Chagpar ,
Siobhan Wong , Ashley Rabie , Annie McCluskey , Richard I. Lindley , Maria
Crotty & Catherine Sherrington

To cite this article: Leanne Hassett , Maayken van den Berg , Heather Weber , Sakina Chagpar ,
Siobhan Wong , Ashley Rabie , Annie McCluskey , Richard I. Lindley , Maria Crotty & Catherine
Sherrington (2020): Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial –
description of device use and physiotherapy support in the post-hospital phase, Disability and
Rehabilitation, DOI: 10.1080/09638288.2020.1790679

To link to this article: https://doi.org/10.1080/09638288.2020.1790679

Published online: 14 Jul 2020.

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2020.1790679

ORIGINAL ARTICLE

Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial –

description of device use and physiotherapy support in the post-hospital phase
Leanne Hassetta,b,c,d
, Maayken van den Berge,f
, Heather Webere, Sakina Chagpara,b , Siobhan Wonga,b,d,
Ashley Rabied, Annie McCluskeyc,g , Richard I. Lindleyh , Maria Crottye and Catherine Sherringtona,b
a
Institute for Musculoskeletal Health, The University of Sydney/Sydney Local Health District, Sydney, Australia; bSchool of Public Health, Faculty
of Medicine & Health, University of Sydney, Sydney, Australia; cSydney School of Health Sciences, Faculty of Medicine & Health, The University
of Sydney, Sydney, Australia; dLiverpool Hospital, South Western Sydney Local Health District, Sydney, Australia; eRehabilitation, Aged and
Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia; fClinical Rehabilitation, College of Nursing and
Health Sciences, Flinders University, Adelaide, Australia; gStrokeEd Collaboration, Sydney, Australia; hWestmead Clinical School, Faculty of
Medicine and Health, University of Sydney, Sydney, Australia

ABSTRACT ARTICLE HISTORY

Purpose: To describe device use and physiotherapy support in the post-hospital phase of the AMOUNT Received 1 July 2019
rehabilitation trial. Revised 24 March 2020
Methods: We performed an evaluation of the support required for device use by participants randomised Accepted 29 June 2020
to the intervention group who received digitally-enabled rehabilitation in the post-hospital phase (n ¼ 144).
KEYWORDS
Intervention, additional to standard rehabilitation, utilised eight digital devices (virtual reality videogames, Physical therapy;
activity monitors and handheld computer devices) to improve mobility and increase physical activity. technology; mobility
Participants were taught to use devices during inpatient rehabilitation and were then discharged home to limitation; physical activity;
use the devices for the remainder of the 6-month trial. Physiotherapist-participant contact occurred every wearable electronic devices;
1–2 weeks using a health coaching approach, including technology support when required. Intervention smartphone; exercise
datasheets were audited, and descriptive statistics used to report device use and support required. therapy; virtual reality
Results: Participants (mean (SD) age 70 (18) years; 49% neurological health conditions) used an average
of 2 (SD 1) devices (98% used an activity monitor). Eight percent of physiotherapy contact included tech-
nology support with 30% provided remotely. Support addressed 845 issues categorised under initial set-
up and instruction (27%), education and training (31%), maintenance (23%) and trouble-shooting (19%).
Conclusion: Digital devices can be used for home-based rehabilitation, but ongoing technology support
is essential.

Clinical Trials Registry: ACTRN12614000936628

ä IMPLICATIONS FOR REHABILITATION

 Digital device use at home to support long-term management of health conditions is likely to
become increasingly important as the need for rehabilitation increases and rehabilitation resources
become more limited.
 Technology support for set-up and ongoing device use is a critical enabler of home-based digital
interventions.
 Health professionals delivering home-based digital interventions require sufficient training and equip-
ment and may need to vary the mode (e.g., home visit vs. telephone or video conference) depending
on the technology support required.

Introduction supports this shift of rehabilitation from the inpatient to home-

An estimated one billion people worldwide experience long-term
or residual disabilities, for which rehabilitation is an essential com-
ponent of care [1,2]. Due to population growth, population age-
ing, as well as increased survival of people with a disability, these
global rehabilitation needs are growing [1,3,4]. In response to this,
there is an increasing focus on rehabilitation services and ongoing
support away from the acute and subacute settings. Evidence
based settings [5,6], not only in terms of economic benefits [7]
but also from the patient’s perspective with rehabilitation poten-
tially being more relevant [8]. However, for home-based rehabili-
tation to be effective, sufficient support must be provided [6].
A potentially efficient way to provide supported physical
rehabilitation in the home is by using digital devices. Devices
such as virtual reality videogames, activity monitors and handheld

CONTACT Leanne Hassett leanne.hassett@sydney.edu.au Institute for Musculoskeletal Health, Faculty of Medicine and Health; The University of Sydney, Level
10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box 179, Missenden Rd, Camperdown, Sydney, NSW 2050, Australia

These two authors contributed equally to this article.
Supplemental data for this article can be accessed here.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 L. HASSETT ET AL.
devices can be low cost, portable, enable practice of functional
tasks while increasing dose [9,10], enhance enjoyment of exercise
[11] and can be used as part of telerehabilitation to enable
healthcare professionals to remotely monitor exercise adherence
and communicate for longer-term goal achievement and behavior
change [12]. Although sounding promising, the exponential
growth in available devices and the heightened interest in the
use of digital devices for healthcare has meant that many digital
health interventions have been rolled out into practice with little
evaluation of their benefits or harms [13]. The recent WHO guide-
lines on digital health have highlighted the need for more rigor-
ous evaluation of implementing digital devices into practice to
ensure the investment is worthwhile and that it is meeting the
needs of all stakeholders [13].
The Activity and MObility UsiNg Technology (AMOUNT)
rehabilitation trial evaluated a tailored prescription of a range of
digital devices provided, in addition to standard rehabilitation
care, to improve mobility and physical activity in adults with a
range of health conditions, delivered in the hospital and post-hos-
pital setting [14,15]. Within the context of this trial, we collected
data on device usage and the type of support required to enable
participants to use these devices at home. To the best of our
knowledge no study has evaluated the pragmatics of providing
this type of intervention in post-hospital discharge settings.
Therefore, this study aimed to describe digital device use and
physiotherapy support required by participants in the post-hos-
pital phase of the AMOUNT rehabilitation trial.
Methods
Design
The presented study evaluates the physiotherapy support
required for participants to use digital devices at home to
improve mobility and physical activity as part of the AMOUNT
rehabilitation trial (Australian New Zealand Trials Registry number
ACTRN12614000936628). The AMOUNT trial, a large (n ¼ 300)
multi-centre randomised controlled trial, assessed the effective-
ness of using affordable digital devices, in addition to usual care,
to improve physical activity and mobility in people with mobility
limitations admitted to hospital for aged care and neurological
rehabilitation, compared to usual care alone. The study design,
methods and trial results have been previously reported [14,15].
This study was approved by two human research ethics commit-
tees (HRECs) (Southern Adelaide Clinical HREC and South Western
Sydney Local Health District HREC) prior to commencement.
Sites, staff and participants
The AMOUNT trial was conducted across three trial sites in the
states of South Australia and New South Wales in Australia, with
participants recruited from the rehabilitation wards. Additional
physiotherapists were employed by the research funds to work
on the trial and were based in the rehabilitation wards. The trial
physiotherapists had experience working in rehabilitation, were
responsible for recruitment and intervention delivery, and
received comprehensive training in the prescription and use of
the different devices, according to the intervention protocol.
Research Managers provided ongoing training and support to the
physiotherapists within and between sites utilising clinical reason-
ing sessions and ongoing practice using devices.
Participants included adults admitted to the recruiting wards
at the trial sites who provided consent and met the following cri-
teria: reduced mobility (Short Physical Performance Battery score
<12) [16] with clinician assessed capacity for improvement; life
expectancy >12 months; anticipated length of stay in inpatient
rehabilitation 10 days from randomisation; able to maintain a
standing position (with assistance of one person if necessary).
Patients were excluded if they had significant cognitive or visual
impairment likely to interfere with device use; insufficient English
language skills; medical condition(s) precluding exercise (e.g.,
unstable cardiac disease, uncontrolled hypertension, uncontrolled
metabolic diseases or a weight-bearing restriction); no interest in
using devices; anticipated discharge to high care residential facil-
ity or discharge location too distant for follow-up in the post-hos-
pital phase.
Intervention
The AMOUNT intervention was prescribed according to a protocol
which matched games/exercises from eight devices to partici-
pants’ current mobility limitations, whilst taking into account par-
ticipant preferences, impairments and contextual factors. The
devices included virtual reality videogames (Nintendo Wii
(Nintendo, Kyoto, Japan); Xbox Kinect (Microsoft, Redmond,
Washington, US); Humac Balance System (CSMi Solutions,
Stoughton, Massachusetts, US); Fysiogaming (Doctor Kinetic,
Amsterdam, the Netherlands); Stepping Tiles (University of
Technology Sydney, Sydney, Australia)), activity monitors (Fitbit
Zip, One, and Alta (Fitbit, San Francisco, California, US);
Garmin Vivofit (Garmin, Olathe, Kansas, US)), and exercise and
physical activity applications on handheld devices (T-Rex iPad
exercise application (Repatriation General Hospital, Adelaide,
Australia); AMOUNT iPad exercise application (University of
Sydney, Sydney, Australia); Walk Forward iPhone application (The
George Institute for Global Health and Telstra Health, Sydney,
Australia) Runkeeper mobile phone application (FitnessKeeper,
Boston, Massachusetts, US)). The devices were tested and chosen
by the investigator team (including our consumer investigator)
based on the criteria that they were low cost, enabled practice of
mobility tasks or promoted physical activity, provided feedback
about performance or dose of practice and facilitated individual-
ised tailoring and progression of mobility exercise or physical
activity. For the duration of the participants’ inpatient rehabilita-
tion stay, supervised intervention sessions, lasting between 30
and 60 min, occurred in addition to usual care, five times a week.
During this period participants were also taught how to inde-
pendently and safely use the digital devices that they would be
taking home, such as learning how to charge handheld devices
and synchronise activity monitors to companion apps on hand-
held devices. Upon hospital discharge participants were loaned
the necessary intervention devices and asked to continue to exer-
cise, five times a week, for 30–60 min, for the remainder of the 6-
month period. Six of the eight included digital devices in the
AMOUNT trial were suitable for home-based use (Humac and
Stepping Tiles systems were developed for clinic or hospital use
only) and used in the post-hospital phase (see full intervention
protocol in [15], S1 Text).
Virtual reality videogames used in the post-hospital phase
included the Nintendo Wii, the Xbox Kinect, and Fysiogaming. The
Nintendo Wii and Xbox Kinect are two commonly used commer-
cially-available recreational gaming devices which both use body
motion to control game play. The Wii uses haptic sensor-based
handheld controllers, which measure changes in direction and
acceleration, plus a balance board which translate the movement
of the player onto the screen. The Xbox Kinect uses cameras and
depth sensors to enable gesture recognition, using full-body 3 D
 AMOUNT POST-HOSPITAL PHASE EVALUATION 3

motion data, and does not require handheld controllers or a bal- support only, mainly technology support with some health coach-
ance board. The user interacts with the games through a virtual ing, mainly health coaching with some technology support);
avatar created by the system. Fysiogaming is a commercially-avail- mode of technology support (face-to-face: home, hospital or tran-
able rehabilitation-specific device using a virtual trainer/avatar to sition care visits; remote: telephone, SMS, email, video confer-
guide the completion of a range of gamified rehabilitation exer- ence); duration of technology support; and whether the contact
cises (e.g., a submarine game of sit to stand), and a Kinect sensor was scheduled.
for movement detection. The home-based version of this system Device use: total number of devices used per participant; spe-
only became available towards the end of the AMOUNT trial. cific devices used per participant; physiotherapist-rated adherence
Exercise applications were prescribed on iPads with onboard to using each device (1 ¼ 0%; 2 ¼ 1% to 24%; 3 ¼ 25% to 49%;
data sim cards, including the investigator developed AMOUNT app 4 ¼ 50% to 74%; 5 ¼ 75% to 100%); total number of participants
and the T-Rex app. The AMOUNT app utilises exercises with per- who required technology support for each device; frequency of
mission from physiotherapy exercises (www.physiotherapyexer- physiotherapy contact for supporting use of each device.
cises.com) as a mobile version of this website was not available at Reasons for technology support per device: categorised under (1)
the time the AMOUNT trial commenced. The AMOUNT app is a initial set-up and instruction; (2) education and training; (3) main-
native physiotherapy exercise app, with functions to schedule an tenance; (4) trouble-shooting.
exercise program, upload own exercise videos and a messenger Descriptive statistics were used to determine the frequency,
function allowing sharing of dosage data and email contact mode and duration of contact, which devices were used, as well
between therapist and participant. T-Rex, is a web-based physio- as the reason for support to use these devices.
therapy exercise app with exercise videos accompanied by per-
sonalised written instructions. The application allows the
Results
physiotherapist to modify the exercise program remotely and in
real-time by customising the videos, instructions, number of repe- Flow of participants and therapists through the study
titions and sets. Physical activity applications were prescribed on One hundred and forty-nine participants were randomised to the
participants’ personal smartphones, including Runkeeper, and intervention group. Five participants withdrew or died during the
WalkForward to encourage outdoor walking activities. Runkeeper is inpatient phase of the intervention and were excluded from this
a commercially available GPS fitness monitor app allowing track- evaluation. In addition, technology support data was missing for
ing of walking and other activities. WalkForward is an investiga- one participant. Therefore, device use data is presented for 144
tor-developed app allowing participants to track and view shorter participants and technology support data for 143 participants.
walks (presented in metres) and compete with other participants Table 1 describes participant characteristics. Participants were
or trial physiotherapists through a leaderboard. on average in their early 70 s and just over half were males. Just
Finally, commercially available activity monitors were pre- under half of participants had been admitted to rehabilitation
scribed, including Fitbit Zip, One and Alta (Fitbit Inc., San because of a neurological health condition such as a stroke and
Francisco, California, United States) and Garmin Vivofit (Garmin 42% of participants had not used a computer, tablet, smartphone,
Ltd., Lenexa, Kansas, United States). Different models were pre- gaming console or activity monitor in the month prior to hospital-
scribed depending on participants’ needs and preferences. Fitbit isation. Over the duration of the trial, 13 physiotherapists deliv-
Zip and One were often attached to the participant’s shoe or ered the trial intervention, with 10 providing the post-hospital
around their ankle if they walked more slowly (<0.8 m/s) or had phase intervention.
an impaired gait pattern [17]. The monitors provide direct feed-
back on the monitor screen as well as on a companion app on an
Table 1. Characteristics of participants at baseline randomised to the interven-
iPad or smartphone, enabling self-monitoring of activity data such tion group who participated in post-hospital phase of the AMOUNT trial.
as step count, distance travelled, time spent active and goal Intervention
achievement. n ¼ 144
The trial protocol required the physiotherapist to contact par- Age (yrs), mean (SD); range 70 (18); 18–101
ticipants every 1–2 weeks in the post-hospital phase using a <50, n (%) 21 (15)
health coaching approach to support and encourage ongoing 50–69, n (%) 42 (29)
device use to improve mobility and increase physical activity as 70–89, n (%) 70 (49)
90þ, n (%) 11 (8)
well as technology support when technical issues arose. This sup- Gender (female), n (%) 68 (47)
port was provided mostly remotely (via telephone), but also via Primary diagnostic grouping, n (%)
home visits as required. In addition, the participants contacted neurological 71 (49)
the physiotherapist for additional support as required. Prescribed cardiopulmonary 14 (10)
musculoskeletal 40 (28)
devices, exercise programs and goals were progressed and restorative care/other 19 (13)
changed as needed throughout the 6-month intervention phase. English primary language at home, n (%) 124 (86)
Physiotherapists completed intervention data sheets including Cognition–MMSE
score (0–30), mean (SD); range 27 (3); 15–30
health coaching, technology support, device loan, goal setting Number of co-morbidities (0–26), mean (SD); range 5 (3); 0–14
Walking status prior to hospitalisation, n (%)
and post-hospital summary sheets (see Supplementary Did not walk 0 (0)
E-Appendices). Indoor walker only 17 (12)
Community walker 127 (88)
Devices used in month prior to hospitalisation, n (%)
Data extraction, outcome measures and analysis Computer 58 (40)
Tablet 42 (29)
The following outcome measures were determined from data Smartphone 52 (36)
extracted from intervention sheets: Gaming console 6 (4)
Technology support per participant: frequency of physiotherapy Activity monitor 7 (5)
contacts where technology support was provided (technology
MMSE: Mini Mental State Examination.
4 L. HASSETT ET AL.

Table 2. Frequency and duration of technology support provided in different modes as part of the
post-hospital phase of the AMOUNT trial.
Mean (SD) frequency
per participant receiving Mean (SD) duration
Total frequency, n (%) technology support per session, min
All occasions providing technical support
Face-to-face 436 (70) 3.3 (1.8) 46.6 (18.3)
Home visit 347 (56) 2.8 (1.8) 51.1 (20.8)
Hospital visit 45 (7) 1.5 (0.7) 21.8 (14.4)
Transition care 44 (7) 3.1 (1.5) 41.7 (16.9)
Non face-to-face 188 (30) 2.0 (1.3) 13.0 (6.9)
Phone call 179 (29) 2.0 (1.4) 13.0 (7.0)
SMS 4 (0.6) 1.3 (0.6) 6.7 (2.9)
Email 4 (0.6) 1.3 (0.6) 10.8 (5.2)
Video call 1 (0.2) – 10.0 (0)
Occasions in which solely technical support was provided
Face-to-face 89 (49) 1.9 (1.3) 22.1 (18.1)
Home visit 57 (31) 2.0 (1.5) 24.9 (8.5)
Hospital visit 32 (18) 1.4 (0.6) 13.5 (6.2)
Transition care 8 (4) 1.6 (1.3) 32.8 (32.2)
Non face-to-face 92 (51) 2.0 (1.4) 11.3 (8.3)
Phone call 83 (46) 1.9 (1.4) 11.5 (8.5)
SMS 4 (2) 1.3 (0.6) 6.7 (2.9)
Email 4 (2) 1.3 (0.6) 10.8 (5.2)
Video call 1 (1) – 10.0 (0)

Technology support during the post-hospital phase
As has been previously reported, participants spent on average
161 days (SD 18) in the post-hospital setting, typically at home,
and during this time trial physiotherapists provided on average
15 (SD 5) contacts per participant, and of those, 8% (624 contacts)
were either solely for or included technology support [15]. Of the
contacts that included technology support, 29% were for technol-
ogy support only, 8% were predominantly for technology support
but also incorporated some health coaching, 63% were predomin-
antly health coaching with some technology support provided,
and 0.3% were unclear. Seventy percent of technology support
was provided face-to-face (e.g., home visit) with 30% provided
remotely (Table 2), although remote support increased to 51%
when the contact was solely for technology support. The majority
(82%) of technology support was scheduled with only 14%
unscheduled (e.g., participant contact physiotherapist with an
issue) and 4% was not recorded. Table 2 provides further details
on the frequency, mode and duration of technology support.
Technology use and support for each device during the post-
hospital phase
Table 3 provides the number and percentage of participants who
used the different devices during the post-hospital phase as well
as the therapist-rated adherence to device use and the amount of
support required for each device. Participants used on average 2
(SD 1; range 1–5) devices during the post-hospital phase with
most participants using an activity monitor followed by exercise
apps on iPad, virtual reality videogames and a small number used
physical activity apps on their own smartphones. Fysiogaming
and Fitbit had the best participant adherence as rated by thera-
pists (100% and 62% respectively), although Fysiogaming was
only used by a small number of participants. Ninety four percent
of participants required technology support to use the prescribed
devices with support for use of activity monitors the most fre-
quent support required, matching that it was also the most used
device (Table 3).
Table 4 provides details of the reasons for technology support
for each type of device. There were 845 support reasons coded
with 53% related to using activity monitors. The reasons for sup-
port were spread across the four categories of initial set-up and
instruction, education and training, maintenance and trouble-
shooting with the highest number being categorised into educa-
tion and training, with 18% of these for learning and practicing to
synchronise, charge, wear and utilise features of the activity moni-
tor and/or companion app.
Discussion
This evaluation of the support required to enable digital device
use in the post-hospital phase of the AMOUNT rehabilitation trial,
showed that participants on average used more than one device
with most participants using an activity monitor to enable self-
monitoring and motivation to increase their physical activity.
Physiotherapy support to set-up and use the devices was pro-
vided to nearly all participants and ongoing support included fur-
ther education and training to use the devices, maintenance and
replacement of faulty or misused devices or batteries, and trou-
ble-shooting use issues often to do with connectivity and integra-
tion with participants’ own devices. Although some support could
be provided remotely, home visits were still required to manage
half of technology only issues. These findings suggest that health
professionals delivering a home-based digital intervention require
sufficient training and equipment and may need to vary the
mode (e.g., home visit vs. telephone) depending on the sup-
port required.
The high number of participants requiring technology support
may be explained in part by the participant characteristics as well
as the devices themselves. Many participants were novice users of
technology with 42% having not used any of the devices we pre-
scribed in the month prior to hospitalisation. To overcome this,
staff provided the planned home devices as early as possible
while in hospital and developed participant education resources
and started practicing using device features. This issue is likely to
reduce over time given older people are increasingly embracing
technologies such as smartphones [18]. Another factor perhaps
explaining the need for technology support was the use of
rehabilitation systems, particularly investigator developed systems.
These are often less well tested, developed with less money and
 AMOUNT POST-HOSPITAL PHASE EVALUATION 5

Table 3. Frequencies of device use, and support required, and average therapist rated adherence for each device as part of the post-hospital phase of the
AMOUNT trial.
Number participants rated by Number of participants who Total number of technology
Number of participants who therapist as  50% adherence required technology support, support sessions for each
Devices used each device, n (%) for each device, n (%) n (%) device (624 sessions), n (%)
VR videogames
Nintendo Wiia 23 (16) 7 (30) 17 (74) 24 (4)
Xbox Kinecta 24 (17) 14 (58) 19 (79) 38 (6)
Fysiogaminga 5 (3) 4 (100) 4 (80) 15 (2)
Activity monitors
Fitbita 141 (98) 87 (62) 120 (85) 401 (64)
Garmina 10 (7) 10 (100) 29 (5)
Exercise apps on iPad
AMOUNT appb 57 (40) 27 (47) 48 (84) 151 (24)
T-Rex appb 70 (49) 33 (47) 59 (84) 144 (23)
PA apps on Smartphones
Runkeepera 4 (3) 3 (38) 4 (100) 3 (0.5)
WalkForwardb 4 (3) 4 (100) 8 (1)
VR: Virtual reality; PA: Physical Activity. aCommercially available devices. bInvestigator developed devices.

Table 4. Total number (%) reasons for technology support for each type of device as part of the post-hospital phase of the AMOUNT trial.
VR videogames Exercise apps on iPads PA apps on
Activity monitors Smartphones
Nintendo Wiia; Fitbita; T-Rex appb; Runkeepera;
Total Xbox Kinecta Fysiogaminga Garmina iPada AMOUNT appb WalkForwardb
Total number issues managed 845 (100) 62 (7) 18 (2) 448 (53) 83 (10) 223 (26) 11 (1)
1) Initial set-up & instruction 225 (27)
-loaned device 29 5 86 97 6
-purchase own device 2
2) Education & training 259 (31)
-navigate through 7 1 25
menus/exercises
-syncing, charging, 154 4 68
wearing, features
3) Maintenance 200 (24)
-batteries flat 3 69
-replace faulty/misused/ lost 7 2 84 20
device or charger
-faulty participant technology 1 1
e.g., TV
-software/device update 1 10 2
4) Trouble-shooting 161 (19)
-syncing/camera issues 7 1
-linking loaned and 7 3 4
participant devices
-internet access/security 5 40 1
-accuracy feedback 23
-use/deletion of 30 31
companion app
-changed settings/locked 9
VR: virtual reality; PA: physical activity. aCommercially available devices. bInvestigator developed devices.

less well supported, and therefore can suffer from technical
glitches. Given the known importance of ease of use for adopting
and embracing new digital devices both for patients and for
therapists [19–21], it is important to ensure that future rehabilita-
tion-specific devices are well tested to meet all user needs prior
to implementation, particularly in home settings.
An interesting finding was the low use of physical activity
apps in the post-hospital setting. For some participants this was
probably because they were already using a Fitbit which recorded
indoor and outdoor walking, and thus the physical activity app
(tracking outdoor walking only) offered little additional benefit.
However, use of these apps required participants to have their
own smartphone and given only 36% reported using a smart-
phone in the month prior to hospitalisation, this may have also
been a factor. A further issue even when participants did have
their own smartphone was that it was not always compatible
with the apps due to phone brand or the operating system being
too old. Given the new WHO guidelines on digital health specific-
ally target mobile phone interventions as a more accessible tech-
nology in low resource settings, the actual practicalities of how
this may work may require further investigation.
Digital health is of particular interest in rehabilitation with the
recognition of the need for longer-term management of health
conditions [22], and the potential for digital health interventions
to support self-management and behavior change [12]. However
little work has been done evaluating the pragmatics of delivering
digitally-enabled rehabilitation in the home setting. Mountain
et al. [23] developed a prototype for a telerehabilitation system in
the home for people after stroke with extensive user testing and
feedback [23]. Similar to our findings, including what was
6 L. HASSETT ET AL.
reported by our participants in qualitative interviews [21], they
also identified the need for ongoing health professional support
during device use and recommended a whole system infrastruc-
ture being necessary before launching a new device in practice,
something that is not currently in place in many health services
around the world. These considerations are echoed in the WHO
digital health guidelines as sufficient training, infrastructure and
access to equipment being necessary for implementation and
scalability [13].
There are some limitations to consider with this evaluation.
The analysis relied on therapists correctly documenting when and
what technology support was provided and as such they may not
have recorded all support, especially when it was piggy-backed
onto the primary reason for physiotherapy contact which was
health coaching to support exercise adherence and goal achieve-
ment. However, intervention datasheets were set up to capture
this data easily with specific technology support sheets and tick
boxes on the summary sheet for when technology support was
provided, thus most technology support should have been cap-
tured. Secondly, some of the support provided was specific to
devices not currently commercially available and some devices
that have already been superseded, thus limiting generalisability
of results. However, by categorising technology support provided
it is likely similar types of support will be required for many differ-
ent devices. Finally, only 51% of technology only support was
provided remotely indicating at least some technology support is
required face-to-face. Therapists did not document specifically
why they chose a home visit over a phone call, however anec-
dotally stated that at times when participants lived near the hos-
pital it was just as easy to visit than to ring. As such, the true
amount of remote vs. face-to-face requirements for technology
support requires further evaluation in future studies.
In conclusion, this analysis of the AMOUNT trial demonstrates
that people with mixed health conditions undergoing rehabilita-
tion were able to use a range of digital devices in the home set-
ting to address mobility limitations and increase physical activity.
However, technology support was a critical enabler and staff
required training, resources and sufficient equipment to deal with
the technology issues that arose. These findings provide evidence
of the most commonly experienced technical problems and the
type and frequency of technology support needed as a critical
feature of any digital health interventions implemented and
scaled up in clinical practice, with either additional training
required for health professionals and/or information technology
staff included within rehabilitation teams.
Acknowledgements
The authors are grateful to Mr Ross Pearson for consumer advice
and testing different devices. We are also grateful to the study
participants, hospital staff, and the AMOUNT rehabilitation trial
study staff, other investigators and students.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work is financially supported by the National Health and
Medical Research Council.
ORCID
Leanne Hassett http://orcid.org/0000-0002-3546-1822
Sakina Chagpar http://orcid.org/0000-0002-9395-3243
Annie McCluskey http://orcid.org/0000-0002-9719-6657
Richard I. Lindley http://orcid.org/0000-0002-0104-5679
Catherine Sherrington http://orcid.org/0000-0001-8934-4368
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AMOUNT POST-HOSPITAL PHASE EVALUATION 7
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