Perspectives on the Evolution of Mobile (mHealth) Technologies and Application to Rehabilitation

doi: 10.2522/ptj.20130534 Published online June 12, 2014PHYS THER.

Pramana, Derek Coughenour and Alan A. PetrazziFairman, Theresa M. Crytzer, Daihua X. Yu, Gede Brad E. Dicianno, Bambang Parmanto, Andrea D.Technologies and Application to RehabilitationPerspectives on the Evolution of Mobile (mHealth)

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Running head: mHealth Technologies and Application to Rehabilitation

Innovative Technologies Special Issue

Perspectives on the Evolution of Mobile (mHealth) Technologies and Application to Rehabilitation

Brad E. Dicianno, Bambang Parmanto, Andrea D. Fairman, Theresa M. Crytzer, Daihua X. Yu, Gede

Pramana, Derek Coughenour, Alan A. Petrazzi

B.E. Dicianno, MD, Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare

System, Pittsburgh, Pennsylvania; and Department of Physical Medicine and Rehabilitation, School of

Medicine, and Department of Health Information Management, School of Health and Rehabilitation

Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania. Mailing address: Human Engineering

Research Laboratories, University of Pittsburgh, 6425 Penn Ave, Suite 400, Pittsburgh, PA 15206 (USA).

Address all correspondence to Dr Dicianno at: [email protected].

B. Parmanto, PhD, Department of Health Information Management, School of Health and Rehabilitation

Sciences, University of Pittsburgh.

A.D. Fairman, PhD, MOT, OTR/L, CPRP, Department of Rehabilitation Science and Technology, School

of Health and Rehabilitation Sciences, University of Pittsburgh, and Department of Occupational

Therapy, Duquesne University, Pittsburgh, Pennsylvania.

T. Crytzer, PT, DPT, ATP, Department of Rehabilitation Science and Technology, School of Health and

Rehabilitation Sciences, University of Pittsburgh.

by guest on October 27, 2014http://ptjournal.apta.org/Downloaded from


2

D.X. Yu, Department of Health Information Management, School of Health and Rehabilitation Sciences,

University of Pittsburgh.

G. Pramana, MS, Department of Health Information Management, School of Health and Rehabilitation

Sciences, University of Pittsburgh.

D. Coughenour, PT, DPT, MPM, CLD, Clinical Support Service Line, Rehabilitation Department,

Veterans Affairs Pittsburgh Healthcare System.

A.A. Petrazzi, PT, MPT, MPM, VHA-CM, Primary Care Service Line, Veterans Affairs Pittsburgh

Healthcare System.

[Dicianno BE, Parmanto B, Fairman AD, et al. Perspectives on the evolution of mobile (mHealth)

technologies and application to rehabilitation. Phys Ther. 2014;94:xxx–xxx.]

© 2014 American Physical Therapy Association Published Ahead of Print: xxxx Accepted: June 1, 2014 Submitted: November 7, 2013



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Abstract

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often

require complex habilitative and rehabilitative services to prevent and treat these complications. This

paper reviews the evolution of mHealth technologies and presents insights as to how this evolution

informed our development of a novile mHealth system, iMHere, and other technologies, including those

used by the Veterans Administration. We will explain the novel applications of mHealth for rehabilitation

and specifically physical therapy. Perspectives on the roles of Rehabilitation professionals in the delivery

of healthcare using mHealth systems are included. We will discuss challenges to mHealth including

regulatory and funding issues. This article also describes how mHealth can be used to improve patient

satisfaction and delivery of care and to promote health and wellness.



4

Introduction

The term “mHealth” refers to the concept of using mobile devices, such as mobile phones tablets, and

smartphones, in medicine and public health. mHealth can be considered a subcategory of “eHealth,”

which is a broader term for the use of all electronic technologies such as computers in medicine and

public health. Over 80% of Americans have mobile phones, and over 40% own smartphones; with the

latter percentage projected to grow to over 80% within 10 years.1 Nearly half of American adults also

have at least one chronic medical condition, and this number is also growing.2 Chronic conditions result

in poor medical outcomes as well as increased cost and utilization of healthcare services not only for

older adults, but for all age groups.3 Because of the ubiquitous nature of mobile devices, and the fact that

many Americans cannot leave home without them, their potential role in medicine and rehabilitation

continues to become more evident. Recent statistics show that 83% of smartphones are always turnd on

and always with the user.4

Perhaps the “simplest” forms of mHealth are voice communication and text messaging. An advantage of

these methods is that they can occur via low-cost mobile phones. Voice communication, either via person

to person or using interactive voice response, is a simple example of mHealth.5 Text and video based

messages have been used in cardiac rehab programs6,7 and to support consumer and clinician

communication in disease management.8,9 One meta-analysis reviewed several trials and reported overall

modest evidence that text messaging has a positive impact on self-management and outcomes in

conditions like diabetes, asthma and hypertension.10 A pilot study using text messages demonstrated

increased healthy behaviors and improved diabetes self-efficacy and medication adherence in a

population of low income and bilingual individuals with diabetes.11 However, meta-analyses10,12 reveal

that small sample size, dearth of studies that compare various modalities with each other (text messaging,

calls, etc) or study long term interventions, and bias of publication of studies showing only positive

results are barriers to evaluating efficacy of these basic technologies.



5

An exponential growth in the use of smartphones, however, has saturated the market with applications

(“apps”) and web-based systems specifically geared for health and wellness purposes. As of 2010, there

were 5,820 apps within health and wellness categories for smartphones.13 As of 2013, analysts estimate

that over 17,000 mobile medical apps exist, with the vast majority being free to the consumer.14 Thirty-

one percent of cellular phone owners and 52% of smartphone owners have used their phone to look up

health or medical information, and 19% of smartphone owners have downloaded an app specifically to

track or manage health.15 The Food and Drug Administration (FDA) predicts that over the next two years,

over 500 million smartphone users will use mobile medical applications.14

The range of functionality of health and wellness apps and systems vary widely, and can be categorized

generally into 6 groups.

Lifestyle-oriented Apps are those that aim to help individuals lead a healthier lifestyle by tracking their

progress in such activities as diet, weight loss, or exercise programs.16 Examples include “Nexercise,”17

“Weight Watchers Mobile,”18 and “Lose It.”19 Individuals use these “stand-alone” apps on their own

smartphones, usually without oversight by a clinician. Individuals both with and without chronic

conditions may use these apps.

Patient-oriented Apps aid individuals with medical problems in managing chronic medical conditions

through early self-identification of symptoms as well as management and adherence to treatment. For

example, “iTriage”20 allows users to “self-diagnose” conditions and find appropriate medical providers.

These apps do not have the capability of interacting directly with a clinician and therefore must be used

with caution in the absence of advice of a professional.

Clinician-oriented Apps aid the clinician in managing patients by providing 1) reference or educational

information or 2) medical decision making or measurement tools or calculators. These apps are geared for

clinicians to use on their own or to examine patients, but not for “patient-only” use. Examples of

reference or educational information include rehabilitation exercise guides,21,22 medical encyclopedias,

and drug reference books.23 Examples of tools include mobile accelerometers, inclinometers or



6

goniometers.24,25 The accuracy of some of these systems in gathering data is constantly improving. In one

study, it was possible to quantify gait parameters with an iPhone with a degree of accuracy and reliability

comparable to that of the tri-axial accelerometer.26 However, native apps on the iPhone, the clinometer

and compass, may not be as reliable when used to measure range of motion.27

Disease Management Systems are portals (often web-based) that help clinicians monitor patients with

chronic conditions. These systems may be integrated into electronic medical records, practice

management systems, and pharmacies and may include decision support tools. These systems utilize

traditional computers but do not offer applications for monitoring of patients with external, remote

devices as part of their core features. The drawback of these systems are that they require an active

internet connection.28

Traditional Telehealth Systems use electronic communications to provide and deliver information and

services over any distance.29 Typically they have interfaces for both the consumer and clinician and

include a dedicated external device, such as a home-based blood pressure or heart rate monitor, and

support communication via a desktop or laptop computer, but not a mobile device such as a smartphone.

Similar to disease management systems, they require clinician supervision and some require an active

internet connection.

mHealth Systems operate similarly to traditional telehealth applications, but include a mobile phone or

tablet application rather than a computer. For example, teledermatology applications have been described

in which patients can report the condition and photos of a surgical wound or other skin problems to a

dermatology specialist through a smartphone.30 Individuals can use these systems in their natural

environments and even when cellular or wireless connectivity may be unreliable since, in some systems,

data can be stored and forwarded once connectivity resumes. Such mHealth applications are therefore

useful in situations in which sustained adherence to schedules and interventions are the aims. Research

has demonstrated improved health outcomes using mHealth applications in such conditions as

hypertension.28 Applications for diabetes management have also begun to utilize two-way mobile



7

communications but this functionality is scarce in applications used in rehabilitation,31 and therefore

literature in this area is still sparse for rehabilitation.

Why smartphones?

Smartphones are becoming integral to mHealth for several reasons. First, as mobile phones and

smartphones become more prevalent, individuals are becoming accustomed to carrying their devices

unremittingly and using them for many different purposes. Thus, devices such as Personal Digital

Assistants (PDAs) are now scarce, despite the fact that they have shown promise in some prior studies.

For example, PDAs were found to have a modest beneficial effect on weight loss.32

Second, as people carry smartphones all throughout the day, the phones can collect Ecological

Momentary Assessment (EMA) data, which are data obtained in real time when a person is in his or her

natural environment. Such data are less subject to recall bias and can be used to maximize ecological

validity in studies.33 Often, EMAs are used to dispense Ecological Momentary Interventions (EMIs),

timely, point of care treatments delivered when a symptom or need is identified.

Third, smartphones can directly connect to external devices either directly or wirelessly. These external

devices can be placed on or within the body to sense, sample, process or transmit physiological signals.

Examples of signals include temperature, heart rate, blood pressure, oxygen saturation,

electrocardiography, electromyography, energy expenditure, glucose level, or environmental conditions.34

35 Various forms of wireless sensors such as accelerometers, gyroscopes, and force sensors can be used to

record physical activity, movement or gait patterns. This information can allow a clinician to monitor the

quality of or compliance with exercise programs, and information can be fed back to the user for

motivation. This may be useful clinically to reduce cost and time associated with travel and also from a

research perspective since it provides objective data on compliance.36



8

Finally, smartphones also contain numerous internal sensors (e.g. GPS, gyroscope, oscillometers, etc) that

can be used with external devices to allow us to monitor a variety of contextual factors about a patient’s

activities. These sensor data can be combined with EMA data using machine learning systems to enable

context-appropriate responses (delivering timely feedback, providing guidance during therapy, etc.)

without relying on the patient to initiate such therapeutic interactions.37

Unique features of mHealth technologies

As mHealth technologies evolve, it is our expectation that they will provide an over-arching infrastructure

to support self-management, health monitoring, self-directed learning, and interactive patient-clinician

communications. Recent advances in mHealth provide unprecedented opportunities for developing

innovative health services and interventions that take advantage of the novel characteristics of mobile

technologies.

Interventions delivered through mHealth can have several properties that give them the potential to be

more effective.38 Interactivity, the ability of the technology to exhibit a bi-directional mode of

communication, can provide a “personal coach” type environment to delivering care. Personalization, the

ability of the technology to provide an intervention that is customized to an individual’s own unique

needs, may open new opportunities for learning and skill development. Timeliness, the ability of the

technology to assess and deliver an intervention at the right time focusing on relevant, targeted and timely

information, may allow the intervention to occur when it is most likely to have the most beneficial effect.

Context sensitivity is the ability of the technology to shape the intervention based on a unique

circumstance or the individual’s environment.39 Ubiquity and Accessibility refer to the availability and

familiarity of the technology to all segments of populations and geographic areas, including underserved

populations. Mobile phones are now available and popular even in some of the most remote and

resource-poor environments.40 They are also the most commonly carried devices for people with



9

disabilities.41 These features allow “anytime and anywhere” assessments and interventions in those who

may have the most limited access to care.42-44

Roles of rehabilitation professionals and patients in using mHealth

It is first important to note that mHealth is not meant to take the place of in-person care, but to enhance

the service delivery process.45 The enhanced services, however, may benefit the patient in several ways.

First, the patient may be able to use the system to track and record data of interest, such as calories eaten

and burned, vital signs, or time spent exercising. They may access educational materials such as exercise

videos, diagrams, or instructions. In most outpatient clinical settings, patients with an active therapy plan

of care may receive a very limited amount of therapy per week. mHealth may extend the clinical

interface time by enabling two-way communication at a time and place of convenience for the patient.

This mobile on-demand access creates new opportunities for patients to strengthen their relationship with

their therapist, reinforce their understanding of the plan of care, confirm home exercise techniques,

receive education and proactively address relevant concerns. Such higher patient-clinician information

engagement can in some medical scenarios significantly improve the ability of the patient to adhere to

preventative medical plans.46 Health systems offering the continuum of therapy care could use mHealth

applications across a range of settings to improve the patient’s experience during transition of care, while

maintaining patient engagement.

For Rehabilitation professionals, mHealth technology provides tools to monitor the effects of home

exercise programs, collect reliable outcome measures or vital signs, provide feedback on posture and

body mechanics, supply educational material, and prompt patients with motivating messages. The

improved access to clinical knowledge databases may provide therapists with supplementary ways to

deliver evidenced-based interventions.



10

Because of the unique features of mHealth, Rehabilitation professionals can utilize EMAs to provide

EMIs to their patients in the environments in which they live and function.47 For instance, a therapist

could receive data on pain collected when a patient is actually experiencing the pain, combined with data

on whether he or she is adhering to exercise regimens, rather than collecting this information through

standard paper measurements after the event occurred, subjecting the data to more recall bias. Therapists

could also choose to address these issues immediately when the patient is experiencing the pain, using an

EMI, versus waiting until the next visit. “In vivo” care produces better health outcomes, and users of

technology find it easier to apply learned skills when done so in natural environments.48

The concept of gamification in mHealth

Gamification49 is a process by which the desirable features of games are used in non-game contexts to

leverage a person’s interest in competition to achieve results in another realm. Gamification is important

to recognize as a trend in mHealth for two reasons.49 First, mobile consumers continuously seek newer

and better smartphone devices, and this provides game designers more opportunities to create interactive

health interventions. Second, developers are generally eager to take what they learn about players’

behaviors and incorporate them back into the software they develop.

Compliance with treatment recommendations can be enhanced through gamification strategies. For

example, one study provided adolescents with diabetes an app that allows them to “team up” and monitor

their blood glucoses together. When rewards through iTunes music and apps were given, consistency of

glucose monitoring and satisfaction with the program improved.50 There are several additional examples

provided in a paper by Lin and Zhu.51

Apps can provide supportive messaging or virtual rewards, such as coupons for products or restaurants.52

A social component is available through many of these apps that may incentivize individuals to exercise

or lose weight through peer support and a bit of healthy competition amongst friends and family as



11

everyone reports their progress. A recent newspaper article53 pointed out the latest apps that are geared to

creating fun-filled unique challenges and reward systems for exercise.

The role of mHealth in patient-centered rehabilitation

mHealth technologies can be used as a patient-centered approach to healthcare to impact important patient

outcomes.54 High satisfaction with care has resulted from mHealth systems that improved diabetes self-

efficacy and adherence.55 The use of mHealth has improved the quality of healthcare by collecting blood

pressure readings from patients through mobile phones, and allowing doctors to make more informed

choices and provide feedback to patients from the web services.56 mHealth systems have also been found

to have great potential for behavior modification in drug abuse treatment, in HIV therapies,57 health

behaviors, and physical and psychological symptoms.58

Our experiences in using mHeath within a community setting

Because of the potential to use mHealth to improve outcomes in the face of complex and chronic

conditions, we developed our own system59 and piloted it in individuals with spina bifida (SB) to assist

them in managing skin integrity, neurogenic bowel and bladder, and general health issues such as

medication management and mental health. We based our system our own Wellness Pilot Program in

which wellness coordinators (WCs) managed the care of individuals with SB and which resulted in

improved outcomes in terms of reducing the number of medical complications and reducing healthcare

costs.60 Our mHealth System, iMHere (interactive Mobile Health and Rehabilitation),59 is a web-based

portal used by a WC that is linked to a suite of smartphone apps used by patients. iMHere delivers

reminders to patients to perform self-care activities like catheterization, taking medications, or checking

the skin for pressure ulcers that might have occurred from using orthoses or inadequate weight shifting

within a wheelchair. If a problem is encountered, the patient can report the problem and provide

information such as a photo of the wound or information about symptoms. The WC can provide

instructions or educational materials to the patient, and she can use the dashboard on the portal to triage



12

and manage a cohort of patients with the goal of identifying problems early and delivering EMIs. The

system was evaluated by a focus group of individuals with SB, clinicians, and caregivers who were

overall receptive to adopting a system for personal and professional use.45

The usability studies revealed several key issues of interest to Rehabilitation professionals when using

mHealth. Concerns of respondents about the time efficiency of using the system and frequency of alarms

resulted in significant design changes to make the system more user-friendly. Some clinicians, individuals

with SB, and caregivers were more receptive to “new technology” than others. Thus, it is crucial with any

mHealth system to carefully consider who the optimal users will be. Clinicians were most enthusiastic

about having the ability to deliver EMIs in a new way. We have recently concluded a full randomized,

clinical trial evaluating the impact of the system on health and psychosocial outcomes as well as health

care utilization and results are still being analyzed.

A second type of mHealth system developed at the Human Engineering Research Laboratories (HERL) is

a virtual coaching system. Virtual coaching is a form of persuasive technology that provides encouraging

messages to elicit voluntary behavior change.52 The Virtual Seating Coach is a programmable intelligent

reminder system that was assimilated onto power wheelchairs to monitor the utilization patterns of power

seat functions (e.g. tilt, recline and elevating leg rests) and provide reminders and cues for seat function

use in accordance with clinical practice guidelines.61,62 The Virtual Coach can support in-person clinician

training on seat function use with auditory and visual feedback and reminders through text appearing on a

touch screen display. For example, the Virtual Coach reminds, guides and provides positive

reinforcement to a user who has skin breakdown or lower extremity edema for adjusting the tilt to a

degree (within a range established by the therapist) that has been found to relieve pressure or reduce

edema. A new mobile phone application of the Virtual Coach is being tested that provides feedback on

seat function use plus affords users access to all the features of their phones. The app is likely to eliminate



13

the need for permanent changes to the chair and is expected to improve the availability of this technology

to clinicians.63

Initiatives of the Veterans Administration

mHealth Policy has still not caught up to the technology, and more evidence from research is needed to

influence policy regarding the efficacy of mHealth. However, the Veterans Administration (VA) has

embraced all forms of telehealth and is currently providing clinical services, and VA clinicians are billing

for it. The VA has aggressively deployed mHealth and telemedicine also, in part, to support its aims to

provide patient-centered care.64,65 Early studies evaluated in-home telehealth messaging systems that were

linked to landline phones. Veterans indicated that this mode of communication was acceptable, easy to

use, and helpful in the setting of drug and alcohol abuse.64 The authors concluded that, because of the

Veterans’ perceived benefits, these types of services could be especially beneficial for those who may

otherwise lack access to traditional treatment services.64 Another study evaluating the efficacy of a home

exercise program for inactive older Veterans revealed that those who received text message reminders had

higher adherence to home exercise programs.65

The VA’s newer mobile health initiatives have targeted 3 groups: Veterans, caregivers, and VA clinical

teams.66 Pilot projects have included a smartphone and tablet system that allows clinicians to access

critical information from a patient’s electronic health record; a tablet program with multiple apps

connecting Veterans, caregivers, and clinicians and which provide coaching, access to medical records,

and medication refills among other functionality; and a system to make appointment requests through

mobile browsers. The VA has already released several apps geared to supporting psychological health,

treating symptoms of Post-Traumatic Stress Disorder, improving sleep, and assisting with smoking

cessation.66 The VA will also be releasing its own VA App Library once the Pilot programs are complete.

Regulatory issues and funding challenges



14

While mHealth is not yet a reimbursable service for rehabilitation providers in all states, the overarching

method of service delivery termed “telehealth” is being reimbursed within an increasing number of states

in the US.

The American Physical Therapy Association (APTA) endorses the development and use of telehealth for

the purpose of overcoming problems with access to in-person physical therapy services.29,67 Delivery of

telehealth, however, must follow the standards of practice, position statements, policies and ethics of the

APTA,68 including the Guide to Physical Therapist Practice69 as well as state and federal laws for

maintaining patient security and privacy,29,67 Standards of PT Practice, and Code of Ethics.70 In addition,

Rehabilitation professionals licensed in the state where the telehealth services are provided must be

accountable, follow standard documentation procedures, and have the experience and proficiency to

provide top-quality telehealth services in a safe manner. The APTA stresses the importance of employing

reliable electronic systems to deliver telehealth that deliver concise messages and receive accurate input

from users and are able to be improved as technology progresses.29

The American Occupational Therapy Association (AOTA) has also been a strong advocate for the

integration of telehealth services into clinical practice. A 2010 and a recently revised 2013 position paper

by AOTA on telehealth provides an overview of the various technologies, terminology, policies and

ethical guidelines as well as several case studies which exemplify use of telehealth practices in delivering

occupational therapy services.71,72

In September 2013, the FDA released a statement on the guidance of regulation for mHealth apps.73 They

concluded that the majority of medical apps do not pose a significant health risk to consumers, and do not

require oversight. However, systems that use either a smartphone or tablet connected to a peripheral

device such as a heart monitor or blood pressure cuff, for example, should be regulated on a federal level.



15

At the time of the released guidance document, FDA officials had approved 75 mobile medical

applications.14,73

A global perspective

Worldwide, two international organizations that are actively promoting mHealth are the World Health

Organization (WHO) and the International Telecommunications Union (ITU). The ITU develops

standards for interconnection of technologies and networks, and aims to improve access to information

and communication technologies all over the world. In addition, the International Society for

Telemedicine and eHealth (ISFTEH) has official relationships with WHO and ITU, acts as a federation of

telehealth organizations, and assists with starting new technology initiatives in developing countries.

Worldwide, mHealth is seen as an enabler of change because of its high reach and low cost solutions,

especially in the areas of chronic and communicable diseases.10,74 Mobile phone penetration in

developing countries is 89% while computer penetration is only 5%.75 While mHealth is becoming useful

in resource-constrained environments, particularly in developing countries where access to care may be

limited, there are a few barriers that may limit its efficacy. A review article76 by Chib states that while

most literature on global use of mHealth describes technology development for developing countries,

there is a gap in the literature on health outcomes and adoption of mHealth in global populations. Since

mHealth is intended to augment but not completely replace medical care, outcomes from its use may not

be as favorable in some populations if few individuals ultimately access in-person medical services, even

if they are provided and use the technology. Moreover, socioeconomic and cultural differences as well as

extreme poverty and illiteracy can influence the adoption of mHealth. In countries where gender and

social-cultural hierarchies exist, some women must rely on men to access information or technologies.

Looking ahead to the future

A significant barrier for using smartphones in rehabilitation is cost. In a previous study using a diabetes

self-management program in which patients were given rebates to purchase phones and service, drop-out



16

rate was high because patients still could not afford them.77 While there are widely varying estimates

about what smartphones will cost in the coming years, what is agreed upon is that costs will inevitably

decrease. According to a report released by the International Data Corporation, average retail prices of

smartphones are expected to drop as low as $304 by 2017.78 A study by Informa Telecoms & Media

predicts that 50% of smartphones sold in 2017 will cost $150 or less.79

The lower cost of smartphones is certainly a factor that will allow them to continue to become more

ubiquitously used. However, mHealth systems will eventually need to be able to share data with the

electronic health record or personal health record.28 Today, there are only a few systems that achieve such

integration, and in those cases, provide exchange of a very limited number of data points. Some diabetes

applications, for example, synchronize with a personal health record or server, relaying information in

diabetes management to the clinician based, but few provide detailed or personalized patient education.31

The ability to exchange vast amounts of information on a patient’s multiple, chronic conditions with

health records is crucial to harness the full potential of mHealth systems. Furthermore, rehabilitation

professionals will need to lend expertise to teams developing mHealth systems for these technologies to

evolve to standards that meet the needs of the rehabilitation profession.

Conclusions

The evolution of mHealth technologies has changed the way we deliver and think about delivering care to

patients with chronic conditions and how individuals in the community manage their own health and

wellness. In general, these systems have shown promise from improving the quality of health care

delivery, patient satisfaction, adherence to self-care regimens, and behavior modification. However, there

are significant information gaps regarding the long-term effects, acceptability, costs, and risks of such

interventions, which warrant more research. While the role of mHealth within the field of Rehabilitation

grows, the emergence of studies on novel applications like iMHere will begin to elucidate the impact they

can have on important functional and patient-centered outcomes.



17

Acknowledgments

Dr Dicianno, Dr Parmanto, and Dr Fairman provided concept/idea/project design. Dr Dicianno, Dr

Parmanto, Dr Fairman, Dr Crytzer, Ms Yu, Mr Pramana, and Mr Petrazzi provided writing. Dr Dicianno

provided project management. Dr Crytzer, Dr Coughenour, and Mr Petrazzi provided consultation

(including review of the manuscript before submission).

Dr Dicianno, Dr Parmanto, Dr Fairman, Mr Pramana, and Ms Yu are inventors of the iMHere technology.

This research was supported, in part, by grants from the National Institute on Disability and

Rehabilitation Research (NIDRR) grant H133E090002, the Rehabilitation Engineering Research

Center on Telerehabilitation (RERC-TR), and the Verizon Foundation.

The contents of this article do not represent the views of the Department of Veterans Affairs or

the US Government.

DOI: 10.2522/ptj.20130534



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doi: 10.2522/ptj.20130534 Published online June 12, 2014PHYS THER.

Pramana, Derek Coughenour and Alan A. PetrazziFairman, Theresa M. Crytzer, Daihua X. Yu, Gede Brad E. Dicianno, Bambang Parmanto, Andrea D.Technologies and Application to RehabilitationPerspectives on the Evolution of Mobile (mHealth)

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