Internet and smartphone delivery of core trunk exercises for a randomised clinical trial: protocol

Margaret Agnes Perrott, M Sports Physio, M App Sci¹, Tania Pizzari, PhD², Jill Cook, PhD³

¹Department of Physiotherapy, La Trobe University, Bundoora, Vic. 3086; ²Department of Physiotherapy, La Trobe University, Bundoora, Vic. 3086; ³Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Vic. 3199

Corresponding author m.perrott@latrobe.edu.au

Journal MTM 3:2:46–54, 2014

doi:10.7309/jmtm.3.2.8

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Background

Lumbopelvic stability (LPS) has been defined as the ability of an individual to maintain optimal alignment of the spine, pelvis, and the thigh in both a static position and during dynamic activity¹. Clinically, there is a perception that LPS is an essential component of injury prevention, and training LPS is thought to aid recovery from injury and improve performance². Deficits in LPS have been associated with injury or pain in the back, groin and knee^3–10 and exercise for the lumbopelvic region can reduce the risk of muscle strain injury¹¹ and improve the gold standard quantitative measure of movement: three dimensional kinematics^12,13.

Although evidence demonstrates that the performance of single leg squat (SLS), a key measure of LPS, can be changed by exercise¹², it is uncertain if a training program focused solely on LPS can improve an athlete’s qualitative clinical rating of LPS when assessed by physiotherapists or will be validated by improved kinematic measures. It is also uncertain if isolated LPS training reduces the risk of injury. This trial aims to establish whether an LPS exercise program improves an athlete’s qualitative and quantitative performance of specific LPS tests and whether injury is reduced by improvement in LPS.

A barrier to implementing randomised controlled clinical exercise trials is the time consuming and costly nature of teaching exercises directly to research participants¹⁴. The use of mobile technology has the potential to overcome these barriers and to standardise the exercises that are taught¹⁵. This trial will use mobile technology, both internet and smartphone, in delivery of exercise programs, for providing feedback on exercise technique and for injury monitoring.

Methods

A single-blinded parallel randomised controlled trial (Figure 1) will compare the effect of two exercise programs in participants who have deficient LPS. The trial protocol has been approved by the La Trobe University Faculty Human Ethics Committee and all participants will give informed consent before taking part (Reference: FHC13/121) and registered with Australian New Zealand Clinical Trials Registry (ACTRN12614000095662).

Figure 1: Participant flow chart

Rating of Lumbopelvic Stability

One hundred and fifty healthy male and female recreational athletes will be recruited for a randomised controlled clinical trial. They will complete baseline movement testing of eight movement tests. Performance of two tests: SLS and dip test will be videoed by the lead researcher (MP) and uploaded to a Dropbox™ shared with two other researchers (T.P., J.C.). To protect the security of data, Dropbox uses Secure Sockets Layer (SSL) and AES-256 bit encryption to transfer and store data¹⁶, making this an ethically acceptable way for the researchers to view the video performance.

The researchers will rate the individual’s LPS as good, poor or neither good nor poor. The rating classification system has been previously validated¹⁷. Rating LPS using video eliminates the need for the raters to be present at each movement test or for the participants to perform the tests multiple times for individual raters. This method has been used previously by these researchers^17,18 Individuals classified as having good lumbopelvic stability will continue their usual training. All other participants will be randomly allocated to one of two exercise groups focused on the lumbopelvic region: stability training or stretching program. The exercise programs run for 12 weeks and are performed 3 times per week at home. The exercises take less than 15 minutes to perform. Allocation to exercise groups will be performed immediately after the clinical rating of LPS. Group allocation will be concealed by using an off-site trial administrator who holds the randomisation schedule. This administrator will not have any other role in the trial.

Randomisation

Stratified-block randomisation in groups of 20 will be performed using a random sequence generator at http://www.random.org/sequences. Stratification will be based on clinical rating of LPS: poor or neither good nor poor. This randomisation will ensure that similar numbers of participants with poor LPS or neither good nor poor LPS will be randomised to each exercise group. Differences in baseline LPS may influence the outcome of the trial rather than the intervention alone¹⁹.

Blinding

The researchers rating the LPS of participants at the 12 week and 12 month post intervention testing will be blinded to group allocation. The researchers assessing the outcomes and analysing the results data will also be blinded to group allocation.

Movement testing

Participants will attend three testing sessions, baseline, at the completion of the intervention at 12 weeks, and 12 months after baseline testing, to evaluate movement patterns in eight movement tests. This testing will be performed using the Organic Motion system (Organic Motion, New York, USA). This system records movement with gray scale cameras (120 Hz), develops a morphological and kinematic model of the participant, generates a body shape and matches it with a joint centre model from which angular changes in body segments can be extracted²⁰. The system can report details of movement characteristics known to discriminate between good and poor LPS¹⁷.

Movement Tests

Eight movement tests have been chosen for the trial as they challenge control of the lumbopelvic region and their performance may be influenced by improvement in LPS. Six have previously been described: balance on one leg with eyes closed^21,22, SLS²³, dip test²⁴, hurdle step and in-line lunge²⁵ and side-to-side hopping²⁶. Two additional tests will be performed: a turning manoeuvre and a pelvic leveling test. The turning manoeuvre will replicate typical sporting activity²⁷ with the participants performing a running v-shaped turn. The pelvic leveling test is based on tests of postural control ²⁸ where the participant stands on one leg, raises and lowers one side of their pelvis and attempts to return their pelvis to a level position. Participants will warm-up with 5 minutes walking at a comfortable speed on a treadmill while watching a video on correct performance of the tests, and then practice each test. The tests will be performed on each leg in random order.

Baseline Testing

1. Clinical assessment

The performance of SLS and dip test will be rated for LPS. Three other tests: balance, hurdle step and in-line lunge will be videoed and a clinical score recorded using validated rating systems. The balance test is scored with a point for each of 6 possible error types using the Balance Error Scoring System (BESS), with zero being the best possible score²¹. Hurdle step and in-line lunge are both scored from zero to three, with three being the best possible score²⁵.

2. Kinematic assessment

Kinematic measures of three planes of movement of the back, pelvis and thigh will be recorded during the eight movement tests using the Organic Motion markerless motion capture system.

Follow-Up Testing

The same assessment of clinical rating of LPS, clinical scores from 5 movement tests and kinematic measures from all movement tests will be performed for all participants at 12 weeks and 12 months after their inclusion in the trial, including those with good LPS who are continuing their usual training.

Adherence and Injury Monitoring with Mobile Technology

Mobile telephone technology (text messaging) will be used to collect data on exercise adherence and to monitor sporting injuries during the 12 months of the trial. Weekly text messages will be sent to all participants. During the exercise programs the participants will be asked via text message how many times they have performed the exercises that week, with the options of replying “0”, “1”, “2”, or “3”. Also throughout the trial they will be asked if they have sustained a sports injury during the week, with the option to reply “injury” or “no injury”. Therefore, for example, they may reply “3 no injury”. This simple text message response mechanism will assist in keeping participants engaged in the trial with encouragement for prompt reply being rewarded by entry into a weekly prize draw. External observation by text message communication is expected to increase the commitment of participants to perform the exercises²⁹. If participants reply that they have been injured the lead researcher will contact them via phone to identify the nature of the injury and refer them to an appropriate health practitioner for treatment.

Mobile Delivery of Exercise Programs and Feedback

After LPS rating, participants will be randomised to an exercise group. The exercise programs will be delivered to the participants with a link to one of two Dropbox internet sites: one for stability exercise and one for stretching exercise. At the site participants will access two types of video file: first, preliminary instructions and second, video of each exercise routine. The preliminary instructions include examples of correct technique and the number of repetitions to be performed. The stability exercise video also includes instructions on how to progress the exercises through four levels of difficulty. The exercise routine videos show exact timing and technique and allow the participant to exercise in conjunction with the video, providing a model to match. Participants will also be given written instructions and a poster showing either the stability exercises or the stretching exercises and the numbers of exercises and sets to be performed.

Feedback on correct exercise technique will be provided using an app, Coach’s Eye (TechSmith Corporation, Michigan, USA), that can be downloaded to smartphones, iPad and tablets. This app provides visual and verbal feedback on exercise technique that is provided directly to the participant’s smart phone. The system is operational on iOS, android and windows operating systems. The app provider has established a list of recommended devices on which the app is fully operational. If a participant has a smart phone that does not function correctly with the app, the participant will be able to video their performance on their phone, send to the lead researcher and receive visual feedback via email image that is indistinguishable from the Coach’s eye app. Written feedback will also be given in the email. Consistency of feedback across participants is regarded as important so that participants are able to access the same level of involvement in the project²⁹. Feedback on exercise technique will be available at any time during the 12 week exercise program and will give participants the opportunity to report difficulty with performance of the exercises.

Stability Training Program

The participants allocated to this group will be asked to perform a 12 week LPS training program 3 times per week at home (Table 1). They will perform 1–2 sets of 5–12 repetitions of the exercises.

Table 1: Stability training program

The stability training program comprises four exercises, each of which has four levels. The exercises are SLS, arabesque, side plank and prone plank (Figures 2a–d).The exercises commence in well-supported positions, performing only small movements and progress to increasingly challenging exercises with larger ranges of movement in positions that challenge LPS. Each exercise has criteria describing competent performance. The participants will progress at their own rate to the next level when competent at that level. Participants may not reach the highest level of each exercise during the 12 weeks.

Figure 2: Stability exercises a. Single leg squat, b. Arabesque, c. Side plank, d. Prone plank

Stretching Training Program

The participants allocated to this group will be asked to perform a 12 week stretching training program 3 times per week at home. The stretching training program comprises stretches for six muscle groups attached to the lumbopelvic region: hamstrings, quadriceps, adductors, gluteals, trunk rotators and hip flexors (Figures 3a–f) and have been described previously³⁰. The participants should feel a strong but comfortable stretch and hold each stretch for 30 seconds. The stretches will be performed on each side.

Figure 3: Stretching exercises a. Hamstrings, b. Quadriceps, c. Adductors, d. Gluteals, e. Trunk rotators, f. Hip flexors

Power calculation: sample size

One hundred and fifty recreational athletes will be recruited. The sample size is based on the clinically relevant ability to detect change in lumbopelvic stability after stability training in those with poor stability. Previous research shows a range of sample sizes from 21–42 where stability training changed isolated aspects of LPS^{7, 31, 32}, or reduced pain and disability³³.

This sample size range is supported by a power calculation based on research investigating the effect of a stability and agility program compared to a stretching program on recurrent hamstring strain³⁴. To detect differences between the two interventions in the current study and achieve a power of 0.8 at an alpha level of 0.05, df = 1, using chi square, a sample size of 19 with poor LPS would be required³⁵. This sample size is likely to be insufficient for the current study since the hamstring study was limited to a specific population with a high risk of re-injury who were closely supervised in their performance of their exercise program. Therefore a larger sample size will be chosen for the current trial.

A sample size of 150 participants should yield 34 participants with poor LPS. This is based on a study by the current researchers that yielded 14 individuals with poor LPS, 9 with good LPS and 39 with neither good nor poor stability from a population of 62 recreational athletes¹⁷. This should ensure a large enough sample size to detect change in LPS in those with poor LPS. The power of the trial is increased by basing the sample size only on detecting change in those with poor LPS, as change in LPS in those with neither good nor poor stability will also be examined in this trial.

Data analysis: clinical rating

Clinical rating of LPS (good, poor or neither good nor poor) will be compared before and after intervention using Chi square. Performance scores for balance, hurdle step and in-line lunge will be compared before and after intervention using Friedman two-way analysis of variance by ranks.

The correlation between clinical LPS rating and performance scores will be analysed using Spearman rho at baseline, 12 weeks and 12 months to establish if there is an association between clinical rating and performance scores on other tests. The alpha level will be set at p ≤ 0.05 for all statistical tests.

Data analysis: kinematic measures

Kinematic measures related to lumbopelvic stability will be compared before and after intervention using mixed two-way ANOVA (group by time). This comparison will be made at baseline, 12 weeks and 12 months to determine if an exercise program changes the amount that athletes move. Movement patterns will be analysed on each leg with skill and stance legs³⁶ analysed separately.

Data analysis: injury rate and adherence

The association between baseline rating of LPS and subsequent sports injury will be analysed using Chi square. Adherence to the exercise programs will be reported as a percentage of the 36 expected exercise sessions. Exercise adherence will be used as a covariate in analysis of change in clinical rating and injury rate.

Conclusion

This randomised controlled trial will examine the effectiveness of an exercise program designed to improve LPS compared to a control exercise program in recreational athletes. It is expected that the stability program will be more effective in improving LPS, changing movement patterns and reducing injury than the stretching program.

The trial is dependent on the use of mobile technology, both internet and smartphone, to deliver the exercise program instructions and technique, to provide feedback on exercise technique and to monitor exercise adherence and injury. Exercise trials that rely on teaching exercise programs face to face or that require participants to attend exercise groups are expensive and time consuming to conduct for both researchers and participants. The use of text messages simplifies the process of monitoring adherence and injury rather than the use of exercise/injury diaries. The ability to deliver the randomised controlled trial in a time and cost effective manner has implications for first, the specific outcome of this trial on lumbopelvic stability and second, for exercise trials for other health conditions. If the LPS exercise program is successful in changing LPS and also in reducing injury this provides an effective method to make the exercise program available for the general sporting community. It would also be possible for individuals to perform the important movement tests that enable them to be classified as having good, poor or neither good nor poor LPS at home and send them via the Coach’s Eye app to be assessed. If they do not have good LPS they could be provided with the stability exercise program via the internet and receive feedback with the app. This enables athletes who are geographically remote from skilled physiotherapists to access proven exercise techniques for their LPS. In addition to the direct outcome of this trial, other researchers or health professionals can use the methods in this protocol to establish exercise programs for other health conditions by videoing correct performance of exercise technique to deliver the exercise programs and provide feedback using mobile technology.

The trial will be reported in accordance with the CONSORT group statement.

Trial status

At the time of manuscript submission recruitment of participants had not commenced.

General Disclosure Statement

Ms Perrott and Dr. Pizzari have nothing to disclose. Prof. Cook reports a relevant financial activity outside the submitted work as a director of company that has interests in tendon imaging and management.

Video Links

http://youtu.be/d_6xRbu83r8

http://youtu.be/LcMyL4tkPgc

http://youtu.be/i6Slpw67vK0

http://youtu.be/LQnDWRmtjek

http://youtu.be/sMLIifMuOw0

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Read More

‘The role of smartphones in the recording and dissemination of medical images’

Michael Kirk, MBBS¹, Sarah R Hunter-Smith, BBiomed, MD², Katrina Smith, BAppSci (Biol), Grad Dip Health Admin¹, David J Hunter-Smith, MBBS, MPH, FRACS, FACS^1,3

¹Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, 2 Hastings Road, Frankston 3199, Victoria, Australia; ²University of Melbourne Medical School, Parkville, Victoria, Australia; ³Monash University Plastic and Reconstructive Surgery Group, Clayton, Victoria, Australia

Correspondence Author: dhuntersmith@mac.com

Journal MTM 3:2:40–45, 2014

doi:10.7309/jmtm.3.2.7

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Introduction

Clinicians’ smartphone photography practices are an important issue, and research in this nascent area is emerging in the literature^1–5. Technological advances have resulted in the ubiquitous presence of digital cameras in hospitals worldwide, as part of a mobile phone or in the form of a personal digital camera. Such readily available devices may lead to casual capture and accumulation of patient images, and may detract from the concept of images as elements of a patient’s medical record.

Photography assists clinicians to objectively evaluate and document medical conditions for analytical purposes, while at the same time facilitating important “before and after” comparisons. The ultimate aim of capturing, storing and sharing clinical photographs should be to improve the outcome for the individual patient. Photography is a useful adjunctive means of accomplishing this goal.

As well as being integral to medical practice, clinical photography is also essential to our role as mentors and teachers. Whether teaching young colleagues at the bedside or via peer reviewed journal publications and clinical presentations, photography plays an important role in illustrating particularly interesting and rare cases to the wider medical community.

Technology advances at an ever-increasing rate within the health sector, bringing with it a range of ethical and legal dilemmas⁶. The ownership of medical images taken in this environment is one such dilemma and is different to those of other documents because of the sensitive nature and duty of confidentiality assumed by the patient when the image is taken. Taking an image does not necessarily mean ownership of the image, for instance in the public sector these photographs may become both the property and responsibility of the hospital⁸.

When clinical photographs are taken, patients are often vulnerable and undignified; our performance as clinicians must be transparent, honest, legal and auditable at all times^{6, 7}. Doctors have always had an obligation to maintain confidentiality in relation to patient information. A breach of privacy or confidentiality can lead to a complaint of professional misconduct, and potential disciplinary proceedings before medical boards and authorities⁸. In addition, clinical decision-making is influenced by the information contained within the image, making the image an important part of the patient clinical record. The image should be stored in the medical record, be archived and available to the patient through ‘freedom of information’ legislation.

A medical practitioner can only use or disclose health information for the purpose for which it was collected, unless the individual’s consent has been obtained – and not doing so may have serious consequences⁹. Patients also have the right to withdraw their consent at anytime in the future.

The loss or misplacement of a portable device containing unsecured medical images present privacy risks to individuals and organisations. Recent healthcare legislative changes to the Australian privacy act took effect in March 2014. Under these changes to federal law, health professionals with unsecured patient images on their smart devices will face fines up to $340,000 and institutions up to $1,700,000 for a breach of patient privacy⁹. Australian regulations stipulate that sensitive data, such as information that constitutes part of the medical record, cannot be transferred across Australian borders. This issue of trans-border security and data flow has not, until recent times, been addressed by suitable large-scale data storage facilities within Australia (for example, Amazon web services¹⁰ offer storage that can only be accessible within particular countries). Whether commercial operations will satisfy Australian privacy standards is yet to be tested.

The core policies and principles of using smartphones are no different to using a film camera or stand-alone digital camera. Most health care organisations (including ours) have policies that address the safe collection of such images. However these policies now need to address electronic issues such as evidence of signed informed consent, delineation of specific intended use(s), strong encryption of transmitted data with authenticated access, and secure storage thereof¹¹.

Smartphones have evolved to the point that they now routinely integrate a digital camera of an acceptable clinical quality capable of capturing medical images. Multimedia messaging (MMS), email services, and social networking provides a quick and simple method of media distribution. This rapid evolution of technology creates the potential to enhance the clinical care of patients within a hospital environment, but also brings with it issues of confidentiality, privacy and policy control^{2, 4–6, 12}. Their uptake by physicians in a clinical setting has evolved at a rapid rate over the past decade¹³ to the point that most clinicians now carry a camera embedded device in their pocket when undertaking clinical work. However, the prevalence of one of the simplest operations available on these devices, namely the photographic function, has been poorly described or quantified.

The aim of this study is to quantify the use, storage and dissemination of medical images taken on smartphones in a clinical environment, and to assess perceptions regarding policies, practice and patient care.

Methods

All clinicians and medical students employed or undergoing rotation at an outer metropolitan hospital in Melbourne, Australia during March 2012 (n= 409) were sent an email inviting them to participate in a de-identified 34 item online survey administered by SurveyMonkey(™)¹⁴. The survey (Figure 2) was piloted on a number of medical staff whose results were not included in the final analysis. The survey questioned respondent’s demographics and medical speciality as well as issues surrounding the recording and dissemination of medical images using smartphones. Two email reminders were sent over a one-month period. The HREC committee of Peninsula Health reviewed the research methodology. Because of the sensitivity of the nature of this study, full committee ethical approval was required and approval granted for this study (Peninsula Health HREC/12/PH/26).

Results

Demographics (Table 1)

134 responses (32%) were received. The majority of the respondents were from the surgical discipline (45%), followed by medicine (22%), emergency medicine (20%), critical care (7%) and paediatrics (6%). Consultants were the highest respondents (35%), followed by registrars (27%). No responses were received from women’s health, mental health or radiology.

Table 1: Participant characteristics

Smartphone ownership (Figure 1)

All but one respondent (99%) owned a mobile phone equipped with a camera, with 89% of smartphone owners having Internet connectivity. Less than half of smartphones were password protected with PIN control.

Figure 1: Key points: Smartphone ownership and characteristics

Image-capture, distribution & consent (Figure 1)

Almost two-thirds (65%) of respondents acknowledged taking medically sensitive images on a personal device, yet in nearly a quarter of cases (24%) no consent at all was gathered. For those that did obtain consent, only 7% gained written consent, whilst 78% failed to document the procedure in the patient record. Images were kept by 63% of clinicians, either on the device itself (64%), on another storage device (12%) or on both the device and another storage device (21%). Four per cent of clinicians stored their images both locally and on Internet “cloud” based storage.

Figure 2: SMARTPHONE QUESTIONNAIRE Questions asked of participants (all response options not shown):

The most common method used to share an image was physically on the device itself, with non-secure delivery techniques including multimedia-messaging service (MMS), email, and instant messaging prevalent. One respondent admitted to uploading these medical images to a social networking site (Facebook or Twitter).

Perceptions, policies & protocols

Only 43% of respondents were aware that an institutional policy existed regarding medical image photography, and of those respondents, only 28% recalled reading such a policy. Perceptions regarding ownership of captured medical images varied, however less than half of the respondents accurately understood that the employer owned the image i.e. the hospital. Most thought (incorrectly) that the patient was the owner of the image.

Respondents often stated multiple reasons for image capture which included ‘input from another clinician’, ‘education or training purposes’, ‘usage in presentations’, to ‘show someone outside the hospital’ or simply due to the fact they found something interesting or unusual about the case. The vast majority (90%) of clinicians felt the use of clinical photography using smartphone technology had a positive effect on patient care.

Discussion

Medical photography is widely accepted as an important part of contemporary medical practice with benefits that are well recognised¹⁵. Technology now has evolved to a point where personal devices have the ability to not only capture these images, but also easily store and distribute them. Ultimately their primary function in a professional environment is to deliver quality clinical care to patients in a timely and resource friendly manner. Our collective aim should be to bridge the divide between legislation, local policy and best practice.

This report highlights the growing use of personal devices within the clinical environment to assist with the delivery of quality patient care in an increasingly globalised healthcare system. This study supports the notion that although clinical photography is commonly used in clinical practice^16–18, there is a general lack of understanding regarding policy, image ownership, professional obligation and risks associated with the use of smartphone technology.

The results of this study seem compelling (Figure 1), however, because of the small sample size and single institutional basis it is important not to generalize these findings to the wider health care community. Further multicentre studies will help to establish whether these obvious and important findings are consistent across a larger sample size.

There has been much debate regarding the ethics and legality of taking clinical photographs using personal cameras, whether these be part of a mobile telephone or the user’s own digital camera^4–6, ^18–21. In practice, it appears that these considerations impact little on clinicians, who most commonly use a personal digital camera⁵.

A clinical photograph may be, and is likely to be considered part of a patient’s medical record, even when stored electronically. Doctors should be aware of the applicable health records legislation within the state in which they practice, as they may be obligated to hold patient records — in most cases, for seven years⁶. In addition, patients may be able to access their own clinical photographs in the context of freedom of information legislation.

This paper highlights privacy issues, poor recognition of hospital policy, lack of consent or documentation, and an overall ignorance to legislative and hospital guidelines. Although this study did not explore patient perceptions, there is evidence to confirm most patients are happy for images to be taken by treating clinicians but unhappy for clinicians involved directly in their care to store their clinical images stored on personal devices²².

Conclusion

We now find ourselves on the brink of new Australian legislative requirements²³ that will force healthcare professionals to change what are already entrenched practices. Medical practitioners and their employers should appreciate that this area of law is a dynamic one and aim to stay abreast of changes in legislation when drafting their own policies and practices⁶.

Users of smartphone cameras for clinical purposes require education into their responsibility regarding patient privacy and photography. The core policies and principles are no different to using a film camera or stand-alone digital camera and in many organisations almost certainly already exist. The major difference using a smartphone camera is the ease of making a clinical photograph publicly available, which presents more of an education issue than a policy issue.

The issues that need to be addressed include;

• The poor understanding of hospital policy,
• The apparent lack of knowledge about legislative requirements (consent, medical record statutes, freedom of information laws, trans-border data flow and image ownership), and
• Creation of hospital workflows that allow the use of new technology such as smartphones in a safe and compliant manner.

Our organisation has begun processes to develop new procedural policy and education that will ensure the safe capturing of medical images a standard practice.

Acknowledgements

None.

Funding/Support

Nil

Ethical approval

The Research and Ethics committee of the Peninsula Health care network Australia approved this study.

Disclosures

David Hunter-Smith holds shares in the smartphone application company Picsafe Medi Pty Ltd.

References

1. Lewis N. Healthcare mobile devices forcast to gain 7%. Information Week [Internet]. 2010, Feb 7. Available from: http://www.informationweek.com/mobile/healthcare-mobile-devices-forecast-to-gain-7-/d/d-id/1090464?

2. Fernando J. Clinical software on personal mobile devices needs regulation. Med J Aust. 2012;196(7):437.

3. Dolan PL. Physician smartphone popularity shifts health IT focus to mobile use. American Medical News [Internet]. 2010 Aug 23. Available from: http://www.amednews.com/article/20100823/business/308239976/1/

4. Burns K, Belton S. “Click first, care second” photography. Med J Aust. 2012;197(5):265.

5. Berle I. Clinical photography and patients rights: the need for orthopraxy. J Med Ethics. 2008;34(2):89–92.

6. Mahar PD, Foley PA, Sheed-Finck A, Baker CS. Legal considerations of consent and privacy in the context of clinical photography in Australian medical practice. Med J Aust. 2013;198(1):48–9.

7. Australian Medical Council. Good medical practice: A code conduct for doctors in Australia. Canberra: Australian Medical Council, July 2009.

8. Gorton M, Tobin I. Making complaints against health practitioners – are you protected? Russell Kennedy Client Bulletin. 2012.

9. Privacy Amendment (Enhancing Privacy Protection) Act 2012, S1 – Australian Privacy Principles.

10. What’s new: Amazon CloudFront adds GeoRestriction feature: Amazon Web Services, Inc.; 2014. Available from: http://aws.amazon.com/about-aws/whats-new/2013/12/18/amazon-cloudfront-adds-geo-restriction-feature/.

11. McDonald K. Cloud-based solution for mobile clinical photography. Pulse IT. 2012:42–3.

12. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302(12):1309–15.

13. Franko OI, Tirrell TF. Smartphone app use among medical providers in ACGME training programs. J Med Syst. 2012;36(5):3135–9.

14. SurveyMonkey. Palo Alto, California, USA. Available from: http://www.surveymonkey.com.

15. Cleland H, Ross R, Kirk M, Hunter-Smith DJ. Clinical photography: Surgeons need to get smart. ANZ J of Surg. 2013;83:600–1.

16. Farshidi D, Craft N, Ochoa MT. Mobile teledermatology: as doctors and patients are increasingly mobile, technology keeps us connected. Skinmed. 2011;9(4):231–8.

17. Piek J, Hebecker R, Schuteze M, Sola S, Mann S, Buchholz K. Image transfer by mobile phones in neurosurgery. Zentralbl Neurochir. 2006;67(4):193–6.

18. Burns K, Belton S. Clinicians and their cameras: policy, ethics and practice in an Australian tertiary hospital. Aust Health Rev. 2013;37(4):437–41.

19. Harty-Golder B. Photos and “photo cell phones” prompt new policies. MLO Med Lab Obs. 2004;36(3):40.

20. Seigmund CJ, Niamat J, Avery CM. Photographic documentation with a mobile phone camera. Br J Oral Maxillofac Surg. 2008;46(2):109.

21. Derbyshire SW, Burgess A. Use of mobile phones in hospitals. BMJ. 2006;333(7572):767–8.

22. Qureshi A, JC K. Patient knowledge and attitidue towards information technology and teledermatology: some tentative findings. Telemed J E Health. 2003;9(3):259–64.

23. Earles M. New reform to Australia’s privacy laws. Vicdoc. Feb 2013:14–5.

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mHealth intervention development to support patients with active tuberculosis

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Sarah J. Iribarren, PhD^1,2, Susan L. Beck, PhD, APRN, FAAN, AOCN², Patricia F. Pearce, MPH, PhD, APRN, FAANP, FANP³, Cristina Chirico, MPH, MD⁴, Mirta Etchevarria⁴, Fernando Rubinstein, MPH, MD⁵

¹Columbia University School of Nursing, New York, NY, USA; ²University of Utah, College of Nursing, Salt Lake City, UT, USA;

³School of Nursing, Loyola University, New Orleans, LA, USA; ⁴Region V TB Program, Province of Buenos Aires, Argentina;

⁵Institute for Clinical Effectiveness and Healthcare Policy, Buenos Aires, Argentina

Corresponding author: si2277@cumc.columbia.edu

Journal MTM 3:2:16–27, 2014

doi:10.7309/jmtm.3.2.4

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Use of smartphones among medical students in the clinical years at a medical school in Sub-Sahara Africa: A pilot study

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Nasiru A Ibrahim, MBBS, FWACS¹, Mohammad Salisu, MBBS, FWACPaed², Abiodun A Popoola, MBBS, FWACS³, Taofeeq I Ibrahim, MBBS⁴

¹Department of Surgery, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ²Department of Paediatrics, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ³Department of Radiology, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria; ⁴Federal Medical Centre, Ebute Metta, Lagos State, Nigeria

Corresponding author: Nasiru A Ibrahim, Department of Surgery, Lagos State University College of Medicine, 1–4 Oba Akinjobi Street, Ikeja, Lagos State, Nigeria. Tel: +2348023044971, E-mail: ibrahimakanmu@yahoo.com

Journal MTM 3:2:28–34, 2014

doi:10.7309/jmtm.3.2.5

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Simple, Low-Cost Smartphone Adapter for Rapid, High Quality Ocular Anterior Segment Imaging: A Photo Diary

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David Myung, MD PhD¹, Alexandre Jais, MS¹, Lingmin He, MD MS¹, Robert T. Chang, MD¹

¹Byers Eye Institute at Stanford, Stanford University School of Medicine, Stanford, California

Corresponding Author: viroptic@gmail.com

Journal MTM 3:1:2–8, 2014

doi:10.7309/jmtm.3.1.2

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DIY – Smartphone Slit-Lamp adaptor

Jan Bond Chan, (MBBS)^1,2, Hao Chi Ho, (MBBS)^1,2, Nor Fariza Ngah, (MBBS, MS Ophthal)¹, Elias Hussein, (MBBS, MS Ophthal)¹

¹Department of Ophthalmology, Hospital Selayang, Malaysia; ²Department of Ophthalmology, Hospital Universiti Sains Malaysia

Corresponding Author: janbond@hotmail.com

Journal MTM 3:1:16–22, 2014

doi:10.7309/jmtm.3.1.4

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Online Appendix

http://www.youtube.com/watch?v=jwq7nDwgxa0&feature=youtu.be

Video 1: Video of manufacturing and assembly of the device with example of usage.

Link to get raw material

http://www.daisojapan.com/p-20209-eva-cushion-d315-in-4-pcs-12pks.aspx

Introduction

In the Ophthalmology setting, taking pictures of the anterior segment is of crucial use for ophthalmologists in their daily practise. Ophthalmologists relies heavily of anterior segment camera for recording of progression of disease, documentation for case presentation and discussion, referrals to colleagues or subspecialty clinic and education for junior doctors and patients.

A conventional slit lamp camera is usually used for taking good quality pictures of the eye. The problem with slit lamp camera is that it is expensive and usually immobile.

The use of the smartphone in ophthalmology is more common than ever before^1–5. Although most ophthalmology clinics are equipped with slit lamp but not all clinics are fortunate enough to be equipped with a high quality anterior segment slit lamp camera. Smartphones are usually incorporated with high resolution cameras which are commonly used by ophthalmologist capture pictures of the anterior segment of the eye ^1–5. There are several commercially available smartphone adaptors to a slitlamp but they are expensive and is specific for certain slit lamp brands only⁶. We are writing to introduce an easy method to produce and use your own smartphone as a slitlamp anterior segment camera – Do it yourself (DIY).

Advantages of smartphone slit lamp camera

Cost saving and maintenance

Conventional slit lamp camera is expensive costing at about USD 15,000.00. The commercially available smartphone slit lamp camera adaptor (eg. EyePhotoDoc, Zarf iPhone Adaptor, Magnifi iPhone adaptor, Steady iPix Telescope Photo adaptor for iPhone, Keeler portable slit lamp, iExaminer, Tiger Lens and Skylight) ranges from USD 75.00 to USD 520.00. The estimated cost for a DIY smartphone slit-lamp adaptor is USD 15.00 (Refer Table 1) which reduces the cost significantly. A conventional slit lamp camera needs to be serviced and maintenance needs to be done which incurs additional cost to the ophthalmologist. By using the smartphone slit lamp camera, there is virtually zero maintenance.

Table 1: Things needed to built a smartphone slit lamp camera adaptor

Portability

In comparison to the conventional slit lamp camera, the smartphone slit lamp camera is easily portable. It fits into a pocket and when it is needed, it can be easily mounted to an already existing slit lamp during routine examination.

Ease of use

Conventional slit lamp camera is usually placed in a special room and not easily accessible but with the smartphone slit lamp adaptor, it can easily be used in any slit lamp at anytime.

Patient will be explained of the anterior segment photography and consent will be taken.

Ease of Referrals

By using the smartphone slit lamp camera, pictures taken can be shared easily and securely to another colleague for further management or opinion. It can also be used by general practitioner who has a clinic equipped with a slit lamp.

How to DIY (do it yourself) a smartphone slit lamp camera

Determine the focal point of your smartphone by placing the camera aperture directly opposite the eye piece of the slit lamp making sure that placement is centred. The distance between your smartphone and the eye piece of slit lamp will be the focal length of your smartphone. This determines the thickness of the sponge you will be using for sponge Section B (Refer to Figure 1). The focal length for iPhone 4,4s,5, and 5c and 5s is 1.0cm and the focal length Samsung Galaxy Note I, II and III is 0.75cm. Figure 2 shows a completed DIY Smartphone Slit Lamp Adaptor.

Figure 1: Blueprint of smartphone slitlamp camera

Figure 2: Smartphone Slit Lamp Camera

Prepare materials of sponges, super glue and surgical knife (Refer Figure 3, Picture 1). To make Section A sponge (Mounting of slit lamp), 1cm thick hard sponge is first measured by removing the eye piece from the slit lamp (Refer Figure 3, Picture No. 2). Use hard sponges or polystyrene that are 20mm wider than the eye piece so that the rim of the sponge is 10mm wide (Refer Figure 1, Sponge Section A). The author suggest to use Ethylene Vinyl Acetate (EVA) material as it is firm yet does not damage the slit lamp eye piece. Using the eye piece as a guide, a line is drawn using a pen for Section A – use the slit lamp eye piece (Refer Figure 3, Picture No. 2).

Figure 3: Steps of preparation of smartphone slitlamp adaptor

To make Section B sponge(the focal length of your smartphone), another 1cm thick hard sponge is used and measured with a small coin large enough for the smartphone camera hole (Figure 3, Picture No. 3). Caution needs to be taken during the measuring of the sponge making sure that the eye piece is in the centre.

All the sponges measured are then cut-to-fit the slit lamp eye piece and the viewing hole of smartphone camera (Refer Figure 3, Picture No. 4).

The sponges are then glued together using super glue using two to three pieces of sponge to form Section A and one piece of sponge to form Section B (Refer Figure 3, Picture No. 5–7). Attach the glued sponge to slit lamp after it is dry (Refer Figure 3, Picture No. 8).

The combined sponges are then glued to the smartphone cover by first marking the sponge (Refer Figure 3, Picture No.9). The smartphone is then inserted into the smartphone casing and then aligned with the slit lamp eye piece. Minimal amount of super glue is to be applied on the sponge to avoid spillage (Refer Figure 3, Picture No.10). Care is to be taken to ensure that the viewing hole is centred otherwise the end product will not be well aligned. All smartphones are generally suitable for mounting to the slit lamp (Refer Figure 4).

Figure 4: The finished products with different types of smartphones

The smartphone camera adaptor is then mounted to slit lamp and ready to be used. With the help of a VGA or HDMI cable of the smartphone (available commercially), we may also display the photo taken through a LCD projector, monitor or even an LED/LCD TV. Not only it can show live pictures but also the possibility of capturing videos and replay it and can be shown to the patient (Refer Figure 5).

Figure 5: An innovative way to display anterior segment pictures through LCD projector, monitor or LED/LCD TV

How to use the smartphone slit lamp camera

After mounting the adaptor to the slit lamp camera, one may use the built-in camera app in your smartphone and just snap pictures or video as desired. The camera flash should be disabled.

Zooming in/out: It is recommended to use the slit lamp magnification for zooming in and out instead of the camera app as the quality of picture may reduce (Refer Figure 6).

Figure 6: Different lighting and zooming of anterior segment pictures

Background lighting: It is recommended to switch on the room lights during picture taking. The quality of pictures improve with some additional background lighting (Refer Figure 6).

Diffuser: Some slit lamps comes with a diffuser which can be used to diffuse light if the ophthalmologist wishes to take pictures of the entire eye without slitting the light source. This gives a diffuse lighting to the eye. Refer to Figure 6 for detail.

AE/AF Lock: The picture quality may be increased by controlling lighting of the smartphone camera manually. AE (Auto Exposure) and AF (Auto Focus) lock enable the ophthalmologist to lock the exposure and focus to only on specific locations and lighting needs.

Quality of the pictures are comparable to the commercially available anterior segment camera (Refer Figure 7 & 8).

Figure 7: Sample pictures showing head to head comparison between Smartphone Camera (Top pictures) and conventional anterior segment camera (bottom) in a 20 year old patient with corneal foreign body. Picture A shows initial presentation. Picture B shows post-removal of corneal foreign body with retained rust ring. Picture C shows post removal of rust ring with corneal scar

Figure 8: Samples of pitures taken with DIY – Smartphone Slit Lamp Camera

Conclusion

In the era today, most doctors are equipped with a smartphone which can help us not only in our daily lives but also in our work. Smartphone photography is something simple and yet very useful in the world of ophthalmology.

Though there might be concern regarding patient’s confidentiality when pictures taken are stored in the doctor’s personal smartphone, these problems may be solved by archiving the picture in a separate system like Picture Archiving and Communication System (PACS)⁷.

The use of smartphone photography in medical practice is not an uncommon practice. With this DIY guide, smartphone slit lamp anterior segment camera should no longer be seen as something unattainable to ophthalmologist. Instead it should be viewed as an indispensable accessory to slit lamp examination.

Acknowledgements

We greatly appreciate Dr Siti Zaleha Mohd Salleh, Dr Haireen Kamaruddin, Dr Azura Ramlee, Dr Nik Nazihah Binti Nik Azis, Mr Zawawi Zakaria, Ms Maziatul Nor Akmar for their contribution in the creation of iPhone slit lamp cameras.

References

1. Chhablani J, Kaja S, Shah VA. Smartphones in ophthalmology. Indian J Ophthalmol. Mar-Apr 2012;60(2):127–31.

2. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. Jun 2010;117(6):1274–1274 e1273.

3. Stanzel BV, Meyer CH. [Smartphones in ophthalmology: Relief or toys for physicians?]. Ophthalmologe. Jan 2012;109(1):8–20.

4. Tahiri Joutei Hassani R, El Sanharawi M, Dupont- Monod S, Baudouin C. [Smartphones in ophthalmology]. J Fr Ophtalmol. Jun 2013;36(6):499–525.

5. Bastawrous A, Cheeseman RC, Kumar A. iPhones for eye surgeons. Eye (Lond). Mar 2012;26(3):343–54.

6. Hester CC. Smart Phoneography – How to take slit lamp photographs with an iPhone. http://eyewiki.aao.org/Smart_Phoneography_-_How_to_take_slit_lamp_ photographs_with_an_iPhone. Accessed 21 September 2013.

7. Picture archiving and communication system (PACS). http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system. Accessed 22 September 2013.

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