Review question
What are the benefits and risks of using digital interventions for delivering or monitoring, or both, physical activity in people with cystic fibrosis (CF)?
Key messages
Taken together, the results of these trials suggest the following.
– Using a web-based application to record, monitor, and set goals on physical activity plus usual care may result in little to no difference on physical activity and pulmonary exacerbations (flare up of disease) compared to usual care alone.
– The evidence is very uncertain about the effects of an exercise program plus the use of a wearable fitness tracker integrated with a social media platform plus exercise prescription, compared with exercise prescription alone, and on the effects of receiving a wearable fitness tracker plus text message for personalized feedback and goal setting, compared to a wearable fitness tracker alone.
– We are very uncertain about the effects of web-based compared to face-to-face exercise delivery.
What is digital health technology?
When we talk about digital interventions, we mean using technology to allow communication and the sending of information between an individual and a healthcare provider to help manage a person's condition remotely. This can be done by mobile phone, tablet computer applications, or other types of technologies.
What is CF?
CF is an inherited disease that causes problems with the lungs, digestive system, and other organs. People with CF have thick and sticky mucus that blocks airways, leads to lung damage, and makes infections more likely. Most people with CF have respiratory symptoms such as coughing with more mucus and shortness of breath.
How digital health technologies can help people with CF?
A sedentary lifestyle may contribute to the progression of physical and functional impairment in people with CF, so exercise is recommended as part of the CF treatment plan. However, not everyone sticks to the exercise plan as they should. We wanted to see if digital technology can help people with CF to exercise and if it can keep track of the exercise they do.
What did we want to find out?
How can digital health technologies help deliver and monitor exercise programs in adults and children with CF?
What did we do?
To answer this question, we searched medical databases for all relevant trials on the topic. We collected and analyzed all the data currently available from the trials.
What did we find?
We found four trials involving 231 participants (aged six years or older). The trials lasted from three months to one year. These trials used different types of digital interventions. While one trial used a digital intervention to deliver an exercise program, the other three used a digital intervention to monitor people's physical activity.
Main results
One trial used a web-based application to record, monitor, and set goals on physical activity plus usual care and investigators found there may be little to no difference on the amount of physical activity undertaken or on the number of pulmonary exacerbations that people experienced compared to usual care alone.
We are not confident in the results of the trial looking at whether a wearable fitness tracker with an exercise prescription can provide important benefits to people with CF compared to using only exercise prescription. We also cannot be sure whether using a wearable fitness tracker plus text message for personalized feedback and goal setting is effective compared to a wearable fitness tracker alone.
Furthermore, we are very uncertain on the effects of web-based compared to face-to-face exercise delivery.
No trials formally evaluated whether digital interventions could lead to harms and we found little or no data on other important outcomes such as participation in physical activity, self-management behavior (the ability to manage our actions), and the occurrence of pulmonary exacerbations.
There is no information on the effectiveness of other types of digital health technologies for monitoring physical activity or delivering exercise programs in people with CF, and on their long-term effects (more than one year).
What are the limitations of the evidence?
We included only four trials, each with a small number of participants. The authors of these trials reported little information on how they were conducted. This decreased our confidence in their results. There may be bias when the people assessing a person's test results know which treatment the person received. In the included trials, it was not clear if the investigators tried to prevent the outcome assessors from knowing each person's treatment. Some trials also did not report in full the results that they planned in their protocol and this may also introduce bias. Therefore, we are uncertain about the effects of digital interventions for monitoring and delivering exercise in people with CF, and further better-quality trials are needed to clarify its effects. Overall, we had only low to very low confidence in the results.
How up to date is this evidence?
The evidence is current to 21 November 2022.
The evidence is very uncertain about the effects of an exercise program plus the use of a wearable fitness tracker integrated with a social media platform compared with exercise prescription alone and on the effects of receiving a wearable fitness tracker plus text message for personalized feedback and goal setting, compared to a wearable fitness tracker alone. Low-certainty evidence suggests that using a web-based application to record, monitor, and set goals on physical activity plus usual care may result in little to no difference in time spent in moderate-to-vigorous physical activity, total time spent in activity, pulmonary exacerbations, quality of life, lung function, and exercise capacity compared to usual care alone. Regarding the use of digital health technologies for delivering exercise programs in CF, the evidence is very uncertain about the effects of using a wearable fitness tracker plus personalized exercise prescription compared to personalized exercise prescription alone.
Further high-quality RCTs, with blinded outcome assessors, reporting the effects of digital health technologies on clinically important outcome measures, such as physical activity participation and intensity, self-management behavior, and the occurrence of pulmonary exacerbations in the long term are needed. The results of six ongoing RCTs identified through our searches may help clarify the effects of different modes of digital health technologies for delivering and monitoring exercise programs in people with CF.
Although exercise is recommended as part of the cystic fibrosis (CF) therapeutic routine, adherence to exercise is still limited. Digital health technologies can provide easy-to-access health information and may help improve healthcare and outcomes in individuals with long-term conditions. However, its effects for delivering and monitoring exercise programs in CF have not yet been synthesized.
To evaluate the benefits and harms of digital health technologies for delivering and monitoring exercise programs, increasing adherence to exercise regimens, and improving key clinical outcomes in people with CF.
We used standard, extensive Cochrane search methods. The latest search date was 21 November 2022.
We included randomized controlled trials (RCTs) or quasi-RCTs of digital health technologies for delivering or monitoring exercise programs in CF.
We used standard Cochrane methods. Our primary outcomes were 1. physical activity, 2. self-management behavior, and 3. pulmonary exacerbations. Our secondary outcomes were 4. usability of technologies, 5. quality of life, 6. lung function, 7. muscle strength, 8. exercise capacity, 9. physiologic parameters, and 10. adverse events. We used GRADE to assess certainty of evidence.
We identified four parallel RCTs (three single-center and one multicenter with 231 participants aged six years or older). The RCTs evaluated different modes of digital health technologies with distinct purposes, combined with diverse interventions.
We identified important methodologic concerns in the RCTs, including insufficient information on the randomization process, blinding of outcome assessors, balance of non-protocol interventions across groups, and whether the analyses performed corrected for bias due to missing outcome data. Non-reporting of results may also be a concern, especially because some planned outcome results were reported incompletely. Furthermore, each trial had a small number of participants, resulting in imprecise effects. These limitations on the risk of bias, and on the precision of effect estimates resulted in overall low- to very low-certainty evidence. We undertook four comparisons and present the findings for our primary outcomes below. There is no information on the effectiveness of other modes of digital health technologies for monitoring physical activity or delivering exercise programs in people with CF, on adverse events related to the use of digital health technologies either for delivering or monitoring exercise programs in CF, and on their long-term effects (more than one year).
Digital health technologies for monitoring physical activity
Wearable fitness tracker plus personalized exercise prescription compared to personalized exercise prescription alone
One trial (40 adults with CF) evaluated this outcome, but did not report data for any of our primary outcomes.
Wearable fitness tracker plus text message for personalized feedback and goal setting compared to wearable fitness tracker alone
The evidence is very uncertain about the effects of a wearable fitness tracker plus text message for personalized feedback and goal setting, compared to wearable technology alone on physical activity measured by step count at six-month follow-up (mean difference [MD] 675.00 steps, 95% confidence interval [CI] −2406.37 to 3756.37; 1 trial, 32 participants). The same study measured pulmonary exacerbation rates and reported finding no difference between groups.
Web-based application to record, monitor, and set goals on physical activity plus usual care compared to usual care alone
Using a web-based application to record, monitor, and set goals on physical activity plus usual care may result in little to no difference on time spent in moderate-to-vigorous physical activity measured via accelerometry compared to usual care alone at six-month follow-up (MD −4 minutes/day, 95% CI −37 to 29; 1 trial, 63 participants). Low certainty-evidence from the same trial suggests that the intervention may result in little to no difference on pulmonary exacerbations during 12 months of follow-up (median 1 respiratory hospitalization, interquartile range [IQR] 0 to 3) versus control (median 1 respiratory hospitalization, IQR 0 to 2; P = 0.6).
Digital health technologies for delivering exercise programs
Web-based versus face-to-face exercise delivery
The evidence is very uncertain about the effects of web-based compared to face-to-face exercise delivery on adherence to physical activity as assessed by the number of participants who completed all exercise sessions after three months of intervention (risk ratio 0.92, 95% CI 0.69 to 1.23; 1 trial, 51 participants).