Implementation of accelerometersand self-measurement tests of legstrength in primary health care –a feasibility study

Örebro University School of Medicine Degree project, 30 ECTS January 14th, 2018

Implementation of accelerometers

and self-measurement tests of leg

strength in primary health care –

a feasibility study

Version 2

Author: Elin Björk, Bachelor of Medicine

Supervisor: Lillemor A Nyberg, MD, PhD, GP

Abstract

Introduction: Primary health care is in need of better ways to implement physical activity into clinical practice. Monitoring physical activity with accelerometers and self-measurement tests of leg strength are two possible methods enabling this. Aim: The aims were to 1) examine whether using accelerometer and self-measurement tests are feasible in primary health care and to 2) investigate the physical activity levels and sedentary time and compare them with national recommendations.

Material and Methods: This was a feasibility study on nine primary health care patients (mean age 43 years) participating in or being on the waiting list for

multimodal rehabilitation programme. ActiGraph GT3X BT accelerometer was worn for seven days. Four self-measurement tests of leg strength were introduced.

Participants answered two questionnaires, one about physical function and physical activity and one feasibility questionnaire about participation.

Results: Valid accelerometer wear time was achieved by 66.7 % of participants. The majority scored highly on participating in the study (56 %) and performing the self-measurement tests (78 %), 44 % scored highly on wearing the accelerometer. A third of the participants met the national recommendations for physical activity and 57.1 % of the day was spent sedentary.

Conclusion: This study suggests that accelerometers can be used to monitor physical activity and sedentary time in primary health care. The self-measurement tests were well accepted by participants and can be recommended to health care workers when assessing their patients´ leg strength. The findings from this study could be attributed to other studies in the future.

Table of Contents

1. Introduction

Being physically active has major health benefits, including decreasing the risk of non-communicable diseases, such as cardiovascular diseases and diabetes, and improving overall health [1]. Evidence suggests that the Swedish population are less physically active than recommended, spending a lot of time sedentary [2–4]. The last decade the consequences of sedentary behaviour have been declared in several studies; sedentary time increases mortality and non-communicable diseases independently of physical activity (PA) [5–7].

The national Swedish recommendation for PA is consistent with the WHO global recommendations, 150 minutes of moderate intensity PA, or 75 minutes of vigorous intensity PA a week that occurs in consecutive periods (bouts) of at least 10 minutes [8,9].

A sedentary lifestyle has not only a negative impact on the individual health but also on a society level. The consequences of a sedentary lifestyle, which is strongly associated with non-communicable diseases and more disability-adjusted life years (DALYs), lead to huge national economic costs – both directly as in health care and indirectly as in loss of production [10,11].

Multiple studies have shown a negative dose-response association between PA and sick leave [12–14]; the less physically active you are, the higher are the risks of sick leave. Stress-related disorders and musculoskeletal disorders are two of the main causes of sick-leave in Sweden [15]. Since PA has been proven to reduce the risk of both of these two types of disorders, many of the cases of sick leave could be prevented with increased PA [8,16].

Being on sick leave is also a risk for developing physical inactivity and thus reduced leg strength [17], creating a vicious circle. A way to assess patient leg strength and function is the standardised maximal step-up test (MST), a validated test that

measures the maximal step-up height at pre-set intervals and correlates positively with muscle strength [18,19]. This test is one of four tests included in “Self-performed tests of leg strength”, a manual of tests developed in cooperation between Sports medicine

Örebro County, Örebro County Sports Federation and Region Örebro County

Community Healthcare West [20]. The tests are 30-second chair-stand test (30s-CST), heel-raising test (HR), squat and MST. These tests were chosen because of their material and implemental simplicity, with the aim to investigate the patient’s acceptance and attitude towards them. The tests have previously been studied in patients with chronic diseases as well as adolescents [21,22]. They were also tested for repeatability and validity by the Swedish School of Sport and Health Sciences (GIH) in Stockholm during spring 2017, but the results from this study are still

unpublished. The tests could be used both as a tool to assess leg strength and function, but also as exercises to increase leg strength.

Self-reported questionnaires have for a long time been the main method for

examining the level of PA within a population [1,23,24]. Even though the benefits of such a method is prominent, amongst other things easily managed and cost-beneficial, this method is susceptible to different types of biases [24]. The difficulties to validate different types of PA levels and the issue to remember all times you have been physically active in the past are two of the main biases [25]. Accelerometers enables monitoring of physical and sedentary activity in a more objective way than self-reported methods [26,27]. The accelerometer measures activity in accelerations. The researcher can examine the frequency of planned PA as well as the amount of time spent in different intensities of PA and sedentary time using the accelerometer [28].

The Swedish National Board of Health and Welfare suggests that the health care system should offer instructions on PA, PA on prescription and/or an objective method to measure and improve individual PA levels, e.g. pedometer or

accelerometer to people with insufficient PA [9]. To the author’s knowledge, there is no study on using accelerometers in primary health care. Using accelerometers could enable clinicians to measure if a patient is sufficiently physically active and allow monitoring of a change in behaviour.

To summarize, the benefits of PA are many. Despite this, PA levels in Sweden are low and are not used in health care as much as it should be [29]. Health care is thus in need of better ways to measure and individualize PA, both in prevention and

health care practitioners to increase PA and leg strength, respectively, in clinical practice.

1.1 Aims

The primary aim of this study is to examine whether using accelerometer and self-measurement tests are feasible in primary care patients participating in a multimodal rehabilitation programme. The secondary aim is to investigate the PA levels and sedentary time and compare them with national recommendations for PA.

2. Material and Methods

This was a feasibility study taking place in a primary care centre in Örebro Region County. Twenty patients participating in or being on the waiting list for a multimodal rehabilitation (MMR1) programme were asked to join the study. The

MMR1-programme constitutes of a group with complex problems, often resulting in sick leave, and that often requires great support from the health care system (more described below). This group were chosen because they could possibly be a patient group benefiting from using accelerometers and self-measurement tests in the future. The MMR1-participants were recruited by verbal invitation during one of their MMR1 meetings. They received written information about the study that they could read at home before making their decision. Eight patients from the waiting list were randomly chosen to participate. These patients were recruited by an invitational letter containing information about the study and a written consent form.

2.2 Measurements and self-measurement tests

Registration of the following descriptive variables was made: sex

(female/male/other), age (years), length (cm), weight (kg) and BMI (Body Mass Index, kg/cm2). Height was measured without shoes using a scale fixed to the wall. Body weight was measured without shoes using electronic scales (Seca Delta model 707).

The four self-measurement tests of leg strength were performed with help from the author. In the 30s-CST, the number of repetitions that the patient can rise from a chair

standing against a wall without hand support in 30 seconds is measured. The HR test is performed with and without hand support, evaluating if the patient can stand high on the toes in a controlled movement. The test is then repeated with each leg

separately, discriminating if any difference between the legs exists. The squat test evaluates the ability to do a deep squat, with and without hand support. The HR and squat tests are presented as the percentage of patients who could accomplish

performing the tests. In the MST, the theoretical maximal step-up height (MSH) is calculated by measuring the distance to the ground when the patient has the knee- and hip joint in a 90° angle. The patient steps up onto the step-up box, invented for this test. The height of the box can be modified with three cm-intervals by adding or removing several boards, depending on the patient’s MSH. The percentage of the theoretical MSH is calculated, enabling comparison with others studies. Any difference between the legs is registered.

2.3 Multimodal Rehabilitation level 1 (MMR1)

Multimodal rehabilitation level 1 is a programme aimed for patients with complex rehabilitation needs in primary care. A team with multiple professions cooperate to cover different areas of health, including medicine, psychology and physiotherapy. The purpose of MMR1 is to break the patterns that cause the patient’s illnesses and to increase the patient’s quality of life, enabling return to work if being on sick leave [30]. The criteria for MMR1 is the following: chronic pain ≥ 3 months and/or a psychiatric disorder (mild-moderate anxiety or depression), medically investigated (no medical cause of chronic pain), motivation for a change in behaviour, no abuse or other disease that can influence the procedure and the patient understands Swedish [30].

2.4 Accelerometer setups and procedure

ActiGraph GT3X BT, a physical activity-monitoring device was the accelerometer used in the study. It registers acceleration in the vertical-, horizontal- and sagittal plane [28], and measures PA intensity, frequency and duration. The accelerometer measures accelerations in the unit counts per minutes (cpm), which is collected into a user determined length interval, epoch. In this study, one minute epoch was used, as it’s one of the most regularly used epoch in accelerometer studies and validated for adults [31].

The definitions of wear time and nonwear time in this study were gathered from Troiano et al [26]. Wear time was defined by subtracting nonwear time from 24 hours. Nonwear time was defined as an interval ≥ 60 consecutive minutes of zero counts, allowing 1-2 minutes to be in non-zero counts between 0-100 counts. In order to define the data collection as valid, at least four days with a minimum of 10 hours of daily wear time was required [26].

Distribution of accelerometers took place during individual 45-minute long meetings with the author. This type of face to face distribution has been associated with higher levels of compliance [31]. During the same meeting, the patients performed the self-measurement tests, answered the questionnaires about physical function and PA levels and collection of biometric data was done. The author held a short presentation during the meetings about the study, the benefits of PA and the negative outcomes associated with sedentary behaviour.

The participants were instructed to wear the accelerometer for seven consecutive days during all the time they were awake, except for activities in water. The accelerometer was attached to an elasticized belt and worn around the waist in line with the hip, one of the placements recommended by Trost et al [31]. Participants were asked to fill out an activity log where they noted wear time, non-wear time and the reason for that. The purpose of the log was to function as a reminder, one of the strategies known to increase compliance [31]. The log also functions as help for the author to value data collected by the accelerometers when doing the analysis. Collection of accelerometers took place either during another of their MMR1 meeting or was returned to the

primary health care centre. At the same time the feasibility questionnaire were

distributed. Data from the accelerometer was downloaded to the Software programme ActiLife version 6.13.3. If the patient wished, the results including daily steps and time spent in different activity levels were emailed to them. The national

recommendations of physical activity were also included in the email, making it easier to interpret their results.

Accelerometer wear time was expressed as the percentage of participants meeting the valid wear time criterion and mean daily wear time in minutes. The PA and sedentary

levels were measured as time spent in different intensities of PA (cut-off values for low-, moderate and vigorous PA) and time spent sedentary, defined as <100 cpm [32]. Low intensity PA (e.g. easy walking [33]) was defined as counts between 100-2019. Moderate intensity PA (e.g. brisk walking [34]) was defined as counts between 2020-5998, vigorous PA (e.g. running [34]) as counts >5999 [26] and the combination of them both (MVPA) as >2020. Adherence to national recommendations for PA was determined by the percentage of participants spending ≥ 150 minutes of MVPA occurring in ≥ 10-minute bouts. Missing accelerometer data (non-valid data) were excluded from the analysis, except for the wear time analysis.

2.5 Self-reported physical function and physical activity

Patients’ self-reported physical function was collected from questions previously used in a study on a similar population [18]. These questions are based on the Swedish version of the Short Form Health Survey (SF-36), a questionnaire regarding patient health [35]. The questions concerned limitations in exhausting activities such as running, moderately exhausting activities such as vacuuming, climbing several flights of stairs, bending/kneeling and walking more than two kilometres. Every question had three answering alternatives: 1) Yes, very limited, 2) Yes, somewhat limited and 3) No, not limited. Data on physical activity level and sedentary time were collected with questions from The National Board of Health and Welfare, recently validated on a similar population [36].

2.6 Feasibility questionnaire

A feasibility questionnaire with five set alternatives (very good, good, neither bad or good, bad or very bad) was developed. This questionnaire revealed the participants’ thoughts about participating in the study, wearing the accelerometers, performing the self-measurement tests and answering the questionnaires.

2.7 Statistics

The statistical analyses were made with the statistical programme SPSS (Statistical package of social science, version 22). All the descriptive data is presented with means and standard deviation and percentage.

2.8 Ethical considerations

Written consent form was signed before

participation. After data collection was done, all patient data were de-identified. Only the authors had access to the original patient data.

3. Results

In total, 9 patients out of 20 accepted participation in the study (figure 1). All of the participants were women. Patient characteristics, self-reported limitations in physical function and results from self-measurement tests are presented in Table 1.

3.1 Accelerometer data

In this study, 66.7 % (n=6) met the recommended valid wear time (table 1). Two participants wore the accelerometer for one or two days respectively, and one wore the accelerometer for seven days but did not achieve enough daily wear time. The percentage spent in different activity levels per day is shown in figure 3. One out of three participants met the national recommendations for PA.

3.2 Self-measurement tests

All the patients performed the four self-measurement tests. The results are shown in table 1. All the patients could

successfully perform the HR test when both legs were tested simultaneously, and 66.7 % (n=6) had a side difference when

Table 1. Patient characteristics, accelerometer data, self-reported limitations in physical function and self-measurement tests results.

n=9 Age mean (SD) 43 (6.5) Weight mean (SD) 78.6 (13.5) Height mean (SD) 167.3 (3.3) BMI mean (SD) 28.0 (4.3) MMR1-participants/Waiting list % 66.7/33.3 Accelerometer

Valid wear time1 4 days/10 h % 66.7 Valid days with accelerometer (SD) 5.8 (2.4) Wear time/day in minutes, mean (SD) 736.8 (228.3)

Self-reported limitations2 _%

Exhausting activities 100

Moderately exhausting activities 88.9 Climbing several flights of steps 66.7

Bending/kneeling 77.8

Walking >2 km 44.4

Self-measurement tests

30s-CST3, mean (SD) 14.7 (5.8) Heel-raising test/side difference % 100/66.7 Squat, without/with hand support % 88.9/88.9 Maximal step-up test

MSH right/left mean cm 20.3/22.0 MSH right and left leg mean cm 21.2 % of theoretical MSH right/left mean 58.7/63.6 Side difference mean cm (SD) 3.7 (3.9)

Figure 1. Study population 1 Multimodal rehabilitation level 1 2 Due to migraine

3 Defined as 4 days/week, 10 hours/day

1 Defined as 4 days/week, 10 hours/day 2 Questionnaire results showing the percentage of participants reporting limitations in physical function 3 30 second chair stand-test, presented as number of repetitions managed during 30 seconds Heel-raising and squat tests are presented as the percentage of patients who could accomplish performing the tests

each leg was tested separately. One patient could not perform the squat test with the right technique, neither with nor without hand support. All the patients could

successfully perform the MST. The MSH is presented as mean MSH of both legs in all patients as well as the percentage of their theoretical MSH for the right and left legs (table 1).

3.3 Questionnaire results

3.1.1 Physical function and physical activity

The majority reported having physical function limitations in four out of five

questions (table 1). Two thirds (n=6) reported being physically active for less than 30 minutes in a regular week during the latest month.

3.1.2 Feasibility questionnaire

Out of nine participants, eight answered the feasibility questionnaire.

The results from the questionnaire revealed that the majority (62.5 %, n=5) rated participation as good or very good. A high frequency responded positively about wearing the accelerometer, performing the self-measurement tests and filling in the questionnaires (figure 2). Two participants reported irritation on the skin and an annoying feeling from wearing the elastic belt around the waist.

Figure 2. Results from the feasibility questionnaire. Figure 3. Mean percentage of daily physical activity levels and sedentary time.

PA Phyiscal Activity 57,1 38,6 3,7 _0,6 Sedentary Light PA Moderate PA Vigorous PA 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Feasibility questionnaire Answer missing Very bad/ bad Neither bad or good

4. Discussion

The major findings in this study were that there was high acceptance of wearing the accelerometer (66.7 %) and performing the self-measurement tests (100 %). The percentage of valid wear time is consistent with that of other accelerometer studies [2,26]. These results indicate that the primary aims of this study are feasible, i.e. wearing the accelerometer and performing self-measurement tests in primary health care patients. However, since the major fall-out number was from not accepting participation (n=11/20), the recruitment strategy should be considered in the future in order to achieve a higher acceptance. A higher frequency MMR1-participants (50 %) accepted participation than patients from the waiting list (37.5 %). A limitation with the recruitment strategy in the waiting list-group could be that they only had about one week after getting the invitational letter to decide whether they should participate or not. Giving the patients a call a few days before their meeting could perhaps increase acceptance, giving more information about the study and answering eventual questions. The fall-out number could also be considered to depend on the study sample, with diseases such as chronic pain and psychiatric disorders that perhaps interfere with their interest in joining a study.

The MMR1-programme had a predominance of women, which could be one of the reasons why only women accepted participation.

The high acceptance of the self-measurement tests was shown in the feasibility questionnaire, where the majority scored very good/good. With these results, health care workers could be recommended these simple tests, making leg strength more available in clinical practice.

The study revealed that the majority of the awake time was spent sedentary and only one of three met the national recommendations for PA. The mean number of

repetitions in the 30s-CST were 14.7, which is below the ≥20 repetitions cut-off value considered a high leg strength for individuals below the age of 50 years old [20]. The mean MSH for both legs were 21.2 cm, which has been correlated to limitations in physical functions such as climbing several flights of steps, kneeling and walking more than two kilometers in another study [18]. This combined with a high

percentage of reported limitations in very exhausting and exhausting activities could further strengthen the need to have better ways to measure and individualize PA in health care.

PA has been proven to reduce chronic pain by several mechanisms. The gate control theory; inhibition of pain modulating neurons in the spinal cord by activation of tactile nerve fibres, is one way that increased muscle work can reduce the experience of pain [37,38]. Activation of mechanoreceptors in contracting skeletal muscle leading to increased activation of central opioid systems is another [39]. New evidence suggests that PA is also effective in prevention [40] and treatment of depression [41]. Increasing PA in this study population could therefore be highly beneficial in an individual and society point of view, perhaps decreasing the risk of sick leave.

Participants were given thoroughly written and verbal information about wearing the accelerometers; still a third did not have enough valid data. To avoid this, one possibility could be to make reminder calls/send reminder text messages, which has been proven to increase compliance [31]. Another alternative is to investigate whether a shorter wear time could be considered as valid, which has been done in another feasibility study on accelerometers [42].

4.1 Limitations

This study has several limitations that need to be considered. The greatest limitation is the small study sample, consisting of only nine participants. This demands the results to be interpreted with caution. With more study subjects, it could be possible to investigate differences within and between groups. It would also be possible to measure differences in PA and sedentary levels as well as differences in the self-measurement tests results before and after e.g. a training intervention. Another limitation is that the results are not representative for the general population, though the study sample consists of women with complex problems. Despite this, the design of this study could probably be attributed to other study populations in the future. A third limitation is the different recruitment strategies to the MMR1-participants and

the waiting list-participants, which possibly could be one of the reasons for the different participation acceptance.

Some accelerometer limitations should be considered. No definitive consensus about how to use the accelerometer in practice exists, so when doing an accelerometer study, the settings before and after the data collection are many. This could therefore be a possible source of error when dealing with the results [31]. Amongst other things, many definitions of the cut-points for the different PA-levels and sedentary time exist. When comparing the results with other studies and with, for example, the national recommendations for PA, the cut-points are what decide how the results are interpreted. Thorough preparatory work is therefore a prerequisite and could be considered a disadvantage with using accelerometers.

Another possible problem with using accelerometers is the Hawthorne effect: patients achieve more than they would normally do, because they are being monitored [43]. A similar type of problem is also reported by Pedišić et al, suggesting the possibility of patients interfering with accelerometer data by choosing when to wear it, shaking it or changing their PA behaviour [44]. Giving the participants thorough instructions about how to wear the accelerometer and informing them that they should live under as normal conditions as they can, could possibly overcome a part of this problem.

4.2 Strengths and future implications

The results from this feasibility study indicate that use of accelerometers and self-measurement tests of leg strength can be feasible in primary health care patients. These two methods for measuring PA and leg-strength enables self-monitoring, which improves motivation for continuous adherence to a behavioural change [45]. This enables PA to become a part of clinical practice in a simple way, contributing to the change in lifestyle needed in order to improve overall health [46].

In future studies, the amount of time for each individual meeting could be reduced from 45 minutes to about 30 minutes. This is considered to be enough time to give brief information about PA and the study, introduce the tests, measure the patient’s weight and height and distribute the accelerometer. In the future, it would also be

beneficial to have access to the accelerometers for a longer period of time. The

accelerometer data could then be complemented if not enough valid data was gathered from the beginning.

Being a feasibility study, the findings regarding study methods and design could probably be attributed to other studies when planning and executing larger studies in the future, despite the small study sample. In studies with more subjects, it would be possible to examine and increase levels of PA and leg strength and compare results within and between groups.

5. Conclusion

This study suggests that accelerometers can be used to measure physical activity and sedentary time in order to increase physical activity in primary health care. The self-measurement tests were well accepted by the patients and were easy to conduct. The tests can be recommended to health care workers when assessing their patients´ leg strength. A third of the participants met the national recommendations for physical activity and the majority of time was spent sedentary. Changes to further improve participant acceptance and compliance needs to be done in future studies.

6. Acknowledgments

I would like to dedicate a special thanks to my supervisor, Lillemor Nyberg, for her persistent engagement, support and tolerance during this study. She is a true source of inspiration that motivated me to do this study from the very beginning. It has been a pleasure to be working together. I would also like to thank Karin Lobenius-Palmér, for her invaluable help with the accelerometers; the preparatory work as well as the analysis. I am very grateful for all the time you spent helping me. Thanks also to the University Health Care Research Center in Örebro for lending us the accelerometers. Lots of thanks to Charlotta Helgesen and to the MMR1-group leaders Tove Reis and Ulla Wase-Cavallie, for their help with the patient information and support during the test days. I am very thankful to the patients participating for their time and dedication in the study. Finally, I would also like to thank my seminar group and my seminar leader, Johan Jendle, for all the help and ideas you gave me along the way.

6.

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7. Cover letter

Corresponding author: Elin Björk, University of Örebro. January 4th, 2018

Dear Editor,

I am sending you a manuscript to consider for publication called ”Implementation of accelerometers and self-measurement tests of leg strength in primary health care – a feasibility study”.

Primary health care is in need of better ways to improve physical activity levels, since evidence suggests that the Swedish population is less physically active than

recommended. Implementing accelerometers and self-measurement tests of leg strength are two ways that could improve the use of physical activity.

A main result from our study suggests that it is feasible to use accelerometers in order to measure physical activity and sedentary time. It was also seen in the study that the self-measurement tests of leg strength were well accepted by the patients and were easy to conduct. The tests could be used to assess patients’ leg strength.

We believe that publication of this study could enable other researchers to take our results in consideration when doing larger clinical studies in the future. It could also help general practitioners to implement physical activity in an easy way in their patients. To our knowledge, there is no similar study on a primary care population. Considering physical activity is getting more attention in new research, we believe this study is up-to-date.

This study has not been published before, neither is it under consideration for publication elsewhere. We have no conflicts of interest to disclose.

Thank you for your consideration! Best regards,

8. Sammanfattning på svenska

Användning av accelerometrar för mätning av fysisk aktivitet samt

självtester av benstyrka i primärvården

Fysisk aktivitet förbättrar livskvalitet och minskar risken för att utveckla sjukdomar som t.ex. hjärt- kärlsjukdomar och cancer. Trots hälsovinsterna av fysisk aktivitet rör sig den svenska befolkningen mindre än rekommenderat. Hälso- och sjukvården behöver enklare metoder för använda fysisk aktivitet i vården för att öka den fysiska aktivitetsnivån. Denna studie syftade därför till att undersöka genomförbarheten av användning av accelerometrar och självtester av benstyrka i primärvården för att möjliggöra detta.

Accelerometern är en avancerad utrustning som mäter hur mycket man rör sig i olika intensitetszoner, från hur mycket man sitter stilla till väldigt ansträngande fysisk aktivitet. Det ger ett bättre värde på den fysiska aktiviteten jämfört med

självrapporterade enkäter, då det ofta är svårt att komma ihåg exakt hur man rört sig den senaste tiden.

De fyra självtesterna för benstyrka är enkla tester som kräver lite utrustning och som enkelt kan läras ut till patienter. Med hjälp av den redan befintliga manualen

”Självtest Benstyrka” kan patienterna följa sin utveckling vid kontinuerligt utförande och sjukvårdspersonal kan få ett mått på sina patienters benstyrka.

Resultat från den här studien tyder på att det är möjligt att använda accelerometrar i primärvården för att enklare kunna använda fysisk aktivitet som både förebyggande och behandling av sjukdomar och tillstånd. Studien har också visat att fyra enkla självtester för benstyrka kan användas. Dessa två metoder skulle kunna göra det lättare att få patienter att bli mer fysiskt aktiva.

9. Ethical considerations

This study investigated the use of accelerometers and self-measurement tests of leg strength in primary health care patients participating in multimodal rehabilitation in a primary health care centre in Region Örebro County. Wearing the accelerometer has no known risk for the patients. However, since it’s an advanced technical device, a lot of setups need to be done before and after the accelerometer is worn and requires a lot of research before the initial setup. If this is not properly done, the accelerometer data may not be valid and used to its full potential, which interferes with the reasons patients accept to participate in the study. The patients then might have spent their time and effort in vain.

Performing the self-measurement tests of leg strength does not put the participants at any risk, considperformering the only loads used in the tests are the patient’s own body weight. If any discomfort or pain appeared when doing the tests, the participant could immediately discontinue the test.

All the participants had to sign written consent form before entering the study. Patient data were de-identified and only handled by the author.

This study is important though it enables PA to become a way of clinical practice and the everyday life of the patients, which could improve the overall health. This study can act as a guidance when doing future studies; with more study subjects and an ethical approval that is required for publication this could help spreading the knowledge further.