A user-centred approach to developing bWell, a mobile app for arm and shoulder exercises after breast cancer treatment

Helena Harder, Patrick Holroyd & Lynn Burkinshaw, Phil Watten, Charles Zammit, Peter R. Harris& Anna Good & Val Jenkins. J Cancer Surviv (2017) 11:732–742

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A user-centred approach to developing bWell, a mobile app for arm and shoulder exercises after breast cancer treatment

Helena Harder, Patrick Holroyd & Lynn Burkinshaw, Phil Watten,  Charles Zammit, Peter R. Harris& Anna Good & Val Jenkins. J Cancer Surviv (2017) 11:732–742.

Purpose

The study aim was to develop a mobile application (app) supported by user preferences to optimise self management of arm and shoulder exercises for upper-limb dysfunction (ULD) after breast cancer treatment.

Methods

Focus groups with breast cancer patients were held to identify user needs and requirements. Behaviour change techniques were explored by researchers and discussed during the focus groups. Concepts for content were identified by thematic analysis. A rapid review was conducted to inform the exercise programme. Preliminary testing was carried out to obtain user feedback from breast cancer patients who used the app for 8 weeks post surgery.

Results

Breast cancer patients’ experiences with ULD and exercise advice and routines varied widely. They identified and prioritised several app features: tailored information, video demonstrations of the exercises, push notifications, and tracking and progress features. An evidence-based programme was developed with a physiotherapist with progressive exercises for passive and active mobilisation, stretching and strengthening. The exercise demonstration videos were filmed with a breast cancer patient. Early user testing demonstrated ease of use, and clear and motivating app content.

Conclusions

bWell, a novel app for arm and shoulder exercises, was developed by breast cancer patients, health care professionals and academics. Further research is warranted to confirm its clinical effectiveness.

Implications for cancer survivors

Mobile health has great potential to provide patients with information specific to their needs. bWell is a promising way to support breast cancer patients with exercise routines after treatment and may improve future self-management of clinical care.

Main findings

  • Participants were asked to use the app for 8 weeks and were sent a study-specific questionnaire at the end of the study.
  • Small sample size with nine women participating.
  • Participants also referred to a need for tailored information
  • Participants also referred to a need for tailored information on ULD and the arm and shoulder exercises, and thought that this would promote recovery. There was a strong preference for video demonstrations (i.e. instruction videos of each individual exercises, and a longer video for each stage with the exercises performed in a sequence) including verbal instructions to help patients understand and safely perform the exercises at home.
  • They stated that the timing and frequency of the reminders needed to be well designed so that they could be customised by the users. The majority of participants expressed concerns about using goal setting features. Some remarked that if predetermined outcome goals were not achieved, this could have a negative impact.
  • Based on a rapid evidence assessment, an exercise programme for bWell was developed which incorporated three key stages of exercise progression with the aim to maintain/increase ROM, facilitate lymphatic transport and increase strength and stability of the affected arm and shoulder:
    • Stage 1: early post-operative exercises for passive mobilisation (six active assisted exercises below shoulder level) starting the first day after surgery.
    • Stage 2: intermediate post-operative exercises for active mobilisation and stretching (four exercises above shoulder level) starting after 1 week after surgery or when the drains are removed.
    • Stage 3: late post-operative exercises for muscle strengthening and sustained stretching (five exercises) starting 4– 6 weeks after surgery depending on wound healing and recovery
  • The exercises were chosen for their ability to be performed independently without special equipment.
  • Three sets of five repetitions (stages 1and2) or two sets of 10 repetitions (stage3) were recommended prior to moving onto the following exercise. Each exercise stage would take approximately 15 min to complete. In line with other programmes, the bWell exercises were not suitable for patients who had immediate breast reconstruction.
  • All women reported that the app kept them motivated and engaged, and would definitely recommend bWell to other breast cancer patients.
  • Results from the focus group showed that patients were aware of the importance of arm and shoulder exercises, but advice from HCPs was often inconsistent or sometimes lacking.
  • The top desired features among focus group participants were reminders and detailed video demonstrations of the exercises. Tailored information about ULD and tracking exercise and progress were also perceived to be helpful behavioural change features for bWell. Goal setting features were seen as a barrier in the uptake.