This paper is in the following e-collection/theme issue:

Viewpoints and Perspectives in Rehabilitation and Assist Techn (6) User Needs and Competencies (272) Clinical Communication, Electronic Consultation and Telehealth (548) Cystic Fibrosis (10) Usability of Apps and User Perceptions of mHealth (898) mHealth for Telemedicine and Homecare (363)

Published on in Vol 11 (2024)

This is a member publication of University of Strathclyde (Jisc)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/55718, first published .
Revolutionizing Care: Unleashing the Potential of Digital Health Technology in Physiotherapy Management for People With Cystic Fibrosis

Revolutionizing Care: Unleashing the Potential of Digital Health Technology in Physiotherapy Management for People With Cystic Fibrosis

Revolutionizing Care: Unleashing the Potential of Digital Health Technology in Physiotherapy Management for People With Cystic Fibrosis

Authors of this article:

Lisa Morrison1, 2 Author Orcid Image ;   Zoe Louise Saynor3, 4 Author Orcid Image ;   Alison Kirk5 Author Orcid Image ;   Lisa McCann2 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1West of Scotland Adult Cystic Fibrosis Unit, Queen Elizabeth University Hospital, , Glasgow, , United Kingdom

    2Department of Computer and Information Sciences, University of Strathclyde, , Glasgow, , United Kingdom

    3School of Sport Health and Exercise Science, University of Portsmouth, , Portsmouth, , United Kingdom

    4Cystic Fibrosis Unit, University Hospital Southampton NHS Foundation Trust, , Southampton, , UK

    5Department of Psychological Sciences and Health, University of Strathclyde, , Glasgow, , United Kingdom

    Corresponding Author:

    Lisa Morrison, BSc


    This viewpoint paper explores the dynamic intersection of physiotherapy and digital health technologies (DHTs) in enhancing the care of people with cystic fibrosis (CF), in the context of advancements such as highly effective modulator therapies that are enhancing life expectancy and altering physiotherapy needs. The role of DHTs, including telehealth, surveillance, home monitoring, and activity promotion, has expanded, becoming crucial in overcoming geographical barriers and accelerated by the recent pandemic. Physiotherapy, integral to CF care since 1946, has shifted toward patient-centered approaches, emphasizing exercise training and a physically active lifestyle. The reduction in inpatient admissions due to highly effective modulator therapies has led to increased home care and online or electronic consultations, and DHTs have revolutionized service delivery, offering flexibility, self-management, and personalized care options; however, there is a need to comprehensively understand user experiences from both people with CF and physiotherapists. This paper highlights the essential exploration of user experiences to facilitate clinician adaptation to the digital requirements of modern clinical management, ensuring equitable care in the “future hospitals” arena. Identifying research gaps, this paper emphasizes the need for a thorough evaluation of DHT use in CF physiotherapy education, training, and self-monitoring, as well as the experiences of people with CF with online or electronic consultations, self-monitoring, and remote interventions. Online group exercise platforms address historical challenges relating to infection control but necessitate comprehensive evaluations of user experiences and preferences. Future-proofing DHTs within the physiotherapy management of CF demands a shift toward full integration, considering stakeholder opinions and addressing barriers. While DHTs have the potential to extend physiotherapy beyond the hospital, this paper stresses the importance of understanding user experiences, addressing digital poverty, and working toward more equitable health care access. A flexible approach in the “future hospital” is advocated, emphasizing the need for a nuanced understanding of user preferences and experiences to optimize the integration of DHTs in CF care.

    JMIR Rehabil Assist Technol 2024;11:e55718

    doi:10.2196/55718

    Keywords

    cystic fibrosis; physiotherapy; digital technology; telehealth; cystic fibrosis transmembrane regulator modulators; telemedicine; digital health technology; DHTs; digital health; physical therapy; physical activity; exercise; monitoring; physiotherapists; user; experience; remote; virtual care; consultation; consultations; eConsultations; preferences; digital divide; access; accessible; accessibility; attitude; perception; attitudes; opinion; perceptions; perspectives; eHealth; online health; therapy 


    Cystic fibrosis (CF) is a chronic, autosomal recessive, life-limiting, multisystem disease, historically leading to respiratory failure and premature death [1]. Chest physiotherapy (airway clearance techniques) to enhance secretion clearance has been a cornerstone of CF physiotherapy, with self-management and guided management being the focus of care as people with CF develop and their disease dictates different approaches. Advancements in the clinical management of CF, including the introduction of highly effective modulator therapies (HEMTs), have positively impacted life expectancy [1,2]. Consequently, physiotherapy management of CF and the specialist CF physiotherapist must adapt [3].

    There is a growing body of evidence supporting examples where physiotherapy has benefited from digital health technologies (DHTs), primarily existing in the management of musculoskeletal [4] or neurological issues [5,6]. Here, specific exercise, virtual reality, and gaming have positively influenced rehabilitation; however, this new innovative technology currently does not exist in CF physiotherapy management. DHTs have been used in CF for some time, particularly in areas of geographical diversity, with online or electronic consultation and monitoring therapies becoming increasingly commonplace [7]. DHTs have been used in chipped nebulizers monitoring adherence to therapeutic regimes [8] and home spirometers, alongside other wearables and mobile apps (eg, the Project Breathe patient-driven symptom reporting [9]). There has, however, been limited research into the evaluation of online or electronic physiotherapy interventions in CF, the implementation of DHTs, and their effectiveness within the physiotherapy management for CF.

    Online or electronic physiotherapy in CF could facilitate more than symptom monitoring, extending to simple exercise testing, remote physical activity, and exercise opportunities, as well as implementing measures to influence adherence and the prompt management of symptoms. While online or electronic consultations may be more convenient for some people with CF and reduce the risk of cross infection, not all people with CF will benefit from reducing the frequency of in-person consultations.


    Physiotherapists, originally involved in CF care for chest clearance in 1946, now participate in a global clinical and research network, developing national and international clinical guidance and standards of care [3,10-12]. While global standards of clinical care exist, there will be variations in the implementation of these and DHTs due to socioeconomic factors, availability of infrastructure, and accessibility in health care settings and beyond [13,14]. Irrespective of these challenges, an awareness of data storage, accessibility, and safety of data is essential, and the physiotherapist must be mindful of these factors.

    CF physiotherapy has progressed to a more active, patient-centered approach to clinical care [11,12]. This still includes airway clearance techniques and assessment of respiratory and nonrespiratory manifestations (eg, musculoskeletal and sinuses) and, with a rising prevalence of increase in weight leading to obesity [15] and cardiovascular diseases [16], an ever-increasing involvement in the promotion of exercise testing, training, and physical active promotion. The reduction in inpatient admissions following HEMT has enabled an increase in home care and online or electronic consultations, reducing reliance on hospital services, mitigating cross infection risks, and reducing travel to hospital.

    Online or electronic consultations assess people with CF remotely, with mobile devices monitoring symptoms, assessing pulmonary function, and patient-reported outcomes, as well as promotion of physical activity [17,18]. These have been well received, but with variable compliance due to competing demands impacting overall uptake [17]. Several online or electronic platforms, some led by physiotherapists, offered education and training to people with CF and health care professionals, enabling widespread delivery of information and resources, with the potential for standardized data collection and optimized quality care [17,19-22].

    Self-monitoring, particularly spirometry, has been explored, with physiological data and symptom recognition proposing earlier identification of pulmonary exacerbation [9,23-25]. Self-monitoring, however, may be less accurate, leading to undetected worsening of health status [23,24]. Despite suggestions that self-monitoring is well used [24,26], uploading of digital data is poorly adhered to, and collecting data should be optimized based upon clinical usefulness [23]. Cox et al [27] highlighted in a systematic review that >50% of participants were noncompliant with data entry, with data upload considered burdensome, potentially intrusive, and a barrier to maintainability. Exploration of opportunities for continuous monitoring or passive uploading of data (as occurs with some wearables [9]) may reduce the burden on people with CF and positively influence their use of devices. Improving the accuracy of self-monitoring and symptom monitoring using DHTs may facilitate swifter directed access to relevant professionals providing individually tailored treatments, facilitating personalized discussion and, ultimately, leading to more user-driven outcomes (NCT04798014) [28,29].

    Following the introduction of HEMT, many clinical outcomes observed in people with CF with access have improved, such as fewer pulmonary exacerbations, improved lung function, and exercise tolerance [30]. The physiotherapists’ role in exercise testing, training, and promoting a physically active lifestyle is well researched [31-34] and remains central to the maintenance and optimization of health in people with CF [12]; however, there are no specific CF-related physical activity guidelines [35]. Uptake and adherence to physical activity programs in people with CF is poor [19], and this occurs irrespective of remote delivery [36]. Physical activity is central to the CF physiotherapist’s role; however, segregation requirements historically rendered group activities unachievable. Physical activity platforms have enabled physiotherapists to deliver online group exercise [23], both live and on demand [20], and have been shown in other chronic illnesses to provide solutions to remotely support physical activity and emotional well-being, and improve quality of life [37]. Online group activities allow people with CF to experience peer support [17,20,27], physiotherapy supervision, and education pertinent to their health [20,38]. Despite the anticipated positives of this, significant dropout and discontinuation in some centers have occurred. It is important to evaluate reasons for this and engage with people with CF to identify user opinions for future online physical activity provision.


    The benefits of DHTs in CF care include reducing cross infection [39] and enabling interprofessional team management in areas with diverse geographic distances [7]. People with CF have responded positively to remote consultation, online exercise provision, and monitoring [8,12,13].

    Airway clearance quality has been shown to have a greater impact on respiratory function than quantity and frequency [40,41]. The integration of DHT using pressure sensors embedded in devices may influence physiotherapy assessment and treatment delivery. Using DHTs to guide, counsel, and facilitate goal attainment may enable individualized physiotherapy care for people with CF, offering a flexible approach to modern management, enhancing adherence, and impacting clinical outcomes important to people with CF. For example, the use of wearables and supportive messaging from physiotherapists demonstrated a prolonged and positive change in step count and exercise capacity in adults with CF [42]. Assessment of data derived from online or electronic consultation and self-monitoring can guide assessment of what has worked well and what should perhaps be discontinued. This will include the evaluation of digital literacy skills and acceptance by people with CF in using DHT to access their health care teams effectively and appropriately.

    The role of telehealth for exercise testing has been shown in other diseases to offer a viable alternative to some in-person testing [43] and requires further exploration in CF. To date exercise testing in people with CF has not been researched in a online or electronic capacity but could support centers with limited or no access to in-house exercise testing facilities.


    DHTs are not yet fully integrated into CF management locally or globally [44] and are often considered an “add-on.” Electronic patient records are widely used but have not fully replaced conventional written records for all consultations. Opinions of health care teams and people with CF are essential to strengthen the implementation and maintainability of any future DHTs in routine care [24]. Further research into barriers and facilitators for maintained use of DHTs will support long-term digital plans [45,46]. The optimization of current data uploading applications and platforms to ensure that they are clinically useful for both the user and the stakeholders must occur, including support for training and education when using DHT [44].

    There are numerous frameworks (eg, RE-AIM [Reach, Effectiveness, Adoption, Implementation, and Maintenance] [47] and NASSS [nonadoption, abandonment, scale-up, spread, sustainability] [48]) developed specifically for identifying interacting influences dictating the success or failure of a system [46,49-51]. The recent analysis of the physical activity in people with CF [19] recognized that frameworks offer reasons for nonengagement, with respect to relevance and user satisfaction with interventions and associated technology. Future research should apply these frameworks, exploring how to improve the uptake and use of DHT [52].

    Implications of DHT should be considered, as changing one aspect may influence (positively or negatively) other areas of care [53], and the introduction of DHTs in managing children and adolescents with CF will be significantly different to adults and those with multimorbidities. Some people with CF are digital natives, growing up with an appreciation of DHTs; others have lower levels of digital literacy and trust in digital services and, consequently, the uptake of opportunities to influence their health using this technology may be lower [54,55]. DHTs could negatively impact the “personal” feel of a consultation, leaving people with CF feeling that they are no longer “known” to their clinical care team with respect to their wider societal issues [56].


    DHTs present exciting potential for physiotherapy management in CF. Online or electronic consultations, online physiotherapy (including physical activity and exercise training), and remote monitoring may, however, not be desirable, available, or appropriate for everybody. We urgently need to understand the experience of early implementers, the enablers of success, and the needs of the CF community to better inform equitable use. We must ensure this does not create a digital divide, as digital poverty continues to exist, impacting digital and health literacy, use, and practical application of DHT. We must ensure online or electronic consultations meet the requirements of those accessing them. To ensure “no one is left behind” and optimize care for people with CF, we need to challenge the unsupportable “one-size-fits-all” approach. This involves a flexible infrastructure supporting the future physiotherapy management of people with CF, based on patient experience–related reported outcomes allowing refinement and delivery of an optimal and individualized service.

    Conflicts of Interest

    None declared.

    1. Bell SC, Mall MA, Gutierrez H, et al. The future of cystic fibrosis care: a global perspective. Lancet Respir Med. Jan 2020;8(1):65-124. [CrossRef] [Medline]
    2. Balfour-Lynn IM, King JA. CFTR modulator therapies - effect on life expectancy in people with cystic fibrosis. Paediatr Respir Rev. Jun 2022;42:3-8. [CrossRef] [Medline]
    3. Stanford G, Daniels T, Brown C, et al. The role of the physical therapist in cystic fibrosis care. Phys Ther. Oct 2022;103(1):pzac136. [CrossRef] [Medline]
    4. Merolli M, Gray K, Choo D, Lawford BJ, Hinman RS. Use, and acceptability, of digital health technologies in musculoskeletal physical therapy: a survey of physical therapists and patients. Musculoskeletal Care. Sep 2022;20(3):641-659. [CrossRef] [Medline]
    5. Ammann-Reiffer C, Kläy A, Keller U. Virtual reality as a therapy tool for walking activities in pediatric neurorehabilitation: usability and user experience evaluation. JMIR Serious Games. Jul 14, 2022;10(3):e38509. [CrossRef] [Medline]
    6. Fahr A, Kläy A, Keller JW, van Hedel HJA. An interactive computer game for improving selective voluntary motor control in children with upper motor neuron lesions: development and preliminary feasibility study. JMIR Serious Games. Jul 28, 2021;9(3):e26028. [CrossRef] [Medline]
    7. Shanthikumar S, Ruseckaite R, Corda J, Mulrennan S, Ranganathan S, Douglas T. Telehealth use in Australian cystic fibrosis centers: clinician experiences. Pediatr Pulmonol. Oct 2023;58(10):2906-2915. [CrossRef] [Medline]
    8. Drabble SJ, O’Cathain A, Scott AJ, et al. Mechanisms of action of a web-based intervention with health professional support to increase adherence to nebulizer treatments in adults with cystic fibrosis: qualitative interview study. J Med Internet Res. Oct 6, 2020;22(10):e16782. [CrossRef] [Medline]
    9. Jackson J. Cloud-based health monitor improves care for CF patients during Covid. National Health Executive. May 24, 2021. URL: https://www.nationalhealthexecutive.com/articles/cloud-based-health-monitor-care-cf-patients-covid [Accessed 2024-07-05]
    10. Morrison L, Parrott H. Standards of Care and Good Clinical Practice for the Physiotherapy Management of Cystic Fibrosis. Cystic Fibrosis Trust; 2020.
    11. Southern KW, Castellani C, Lammertyn E, et al. Standards of care for CFTR variant-specific therapy (including modulators) for people with cystic fibrosis. J Cyst Fibros. Jan 2023;22(1):17-30. [CrossRef] [Medline]
    12. Southern KW, Addy C, Bell SC, et al. Standards for the care of people with cystic fibrosis; establishing and maintaining health. J Cyst Fibros. Jan 2024;23(1):12-28. [CrossRef] [Medline]
    13. Rodriguez JA, Shachar C, Bates DW. Digital inclusion as health care - supporting health care equity with digital-infrastructure initiatives. N Engl J Med. Mar 24, 2022;386(12):1101-1103. [CrossRef] [Medline]
    14. World Health Organization. Global Strategy on Digital Health 2020-2025. World Health Organization; 2021. URL: https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf [Accessed 2024-07-08]
    15. Proud D, Duckers J. Weight a minute: exploring the effect on weight and body composition after the initiation of elexacaftor/tezacaftor/ivacaftor in adults with CF. J Cyst Fibros. Sep 2023;22(5):847-850. [CrossRef] [Medline]
    16. Saunders T, Burgner D, Ranganathan S. Identifying and preventing cardiovascular disease in patients with cystic fibrosis. Nat Cardiovasc Res. Mar 2022;1(3):187-188. [CrossRef]
    17. Poulsen M, Holland AE, Button B, Jones AW. Preferences and perspectives regarding telehealth exercise interventions for adults with cystic fibrosis: a qualitative study. Pediatr Pulmonol. May 2024;59(5):1217-1226. [CrossRef] [Medline]
    18. Bass R, Bourke S, Morrison L, et al. Is an online exercise platform, such as Pactster/Beam an acceptable tool to promote exercise participation in adults with cystic fibrosis, with or without online physiotherapy support? Journal of the Association of Chartered Physiotherapists in Respiratory Care. Dec 2022;54(3):47-61. [CrossRef]
    19. Cox NS, Eldridge B, Rawlings S, et al. A web-based intervention to promote physical activity in adolescents and young adults with cystic fibrosis: protocol for a randomized controlled trial. BMC Pulm Med. Dec 19, 2019;19(1):253. [CrossRef] [Medline]
    20. Morrison L, McCrea G, Palmer S. Online activity - a beaming good initiative! delivering alternative exercise opportunities for people with cystic fibrosis. Physiother Theory Pract. Jul 2024;40(7):1609-1615. [CrossRef] [Medline]
    21. Albon D, Thomas L, Hoberg L, et al. Cystic fibrosis learning network telehealth innovation lab during the COVID-19 pandemic: a success QI story for interdisciplinary care and agenda setting. BMJ Open Qual. May 2022;11(2):e001844. [CrossRef] [Medline]
    22. Calthorpe RJ, Smith S, Gathercole K, Smyth AR. Using digital technology for home monitoring, adherence and self-management in cystic fibrosis: a state-of-the-art review. Thorax. Jan 2020;75(1):72-77. [CrossRef] [Medline]
    23. Wong CH, Smith S, Kansra S. Digital technology for early identification of exacerbations in people with cystic fibrosis. Cochrane Database Syst Rev. Apr 14, 2023;4(4):CD014606. [CrossRef] [Medline]
    24. Moor CC. Home monitoring for cystic fibrosis: the future is now. J Cyst Fibros. Jan 2022;21(1):15-17. [CrossRef] [Medline]
    25. Lechtzin N, Mayer-Hamblett N, West NE, et al. Home monitoring of patients with cystic fibrosis to identify and treat acute pulmonary exacerbations. eICE study results. Am J Respir Crit Care Med. Nov 1, 2017;196(9):1144-1151. [CrossRef] [Medline]
    26. Pittman A, Luo NM. Methods for monitoring pulmonary health in cystic fibrosis patients in a remote-first care environment - a survey [Poster]. Pediatr Pulmonol. 2020;55(S2). URL: https:/​/static1.​squarespace.com/​static/​56f97ecfb73abe8dcc3542f6/​t/​6094401748d6c31d64319bf2/​1620328471978/​Folia+NACFC+2020+733+-+Pittman.​pdf [Accessed 2024-06-22]
    27. Cox NS, Alison JA, Rasekaba T, Holland AE. Telehealth in cystic fibrosis: a systematic review. J Telemed Telecare. Mar 2012;18(2):72-78. [CrossRef] [Medline]
    28. Brown C, Sabadosa K, Zhang C, et al. P092 preliminary observations of treatment and symptom reporting in the home-reported outcomes in cystic fibrosis study (HERO-2) [Poster]. J Cyst Fibros. Jun 2023;22:S92. [CrossRef]
    29. Ren C, Psoter K, Sabadosa K, et al. P113 home reported outcomes (HERO-2) in people with cystic fibrosis taking elexacaftor/tezacaftor/ivacaftor: self-reported changes in use of chronic daily therapies at enrollment [Poster]. J Cyst Fibros. Jun 2023;22:S98. [CrossRef]
    30. Gruet M, Saynor ZL, Urquhart DS, Radtke T. Rethinking physical exercise training in the modern era of cystic fibrosis: a step towards optimising short-term efficacy and long-term engagement. J Cyst Fibros. Mar 2022;21(2):e83-e98. [CrossRef] [Medline]
    31. Bannell DJ, France-Ratcliffe M, Buckley BJR, et al. Adherence to unsupervised exercise in sedentary individuals: a randomised feasibility trial of two mobile health interventions. Digit Health. Jun 2023;9:20552076231183552. [CrossRef] [Medline]
    32. Clarkson P, Stephenson A, Grimmett C, et al. Digital tools to support the maintenance of physical activity in people with long-term conditions: a scoping review. Digit Health. Apr 2022;8:20552076221089778. [CrossRef] [Medline]
    33. Cox NS, Alison JA, Button BM, Wilson JW, Holland AE. Feasibility and acceptability of an internet-based program to promote physical activity in adults with cystic fibrosis. Respir Care. Mar 2015;60(3):422-429. [CrossRef] [Medline]
    34. Cox NS, Eldridge B, Rawlings S, et al. Web-based physical activity promotion in young people with CF: a randomised controlled trial. Thorax. Jan 2023;78(1):16-23. [CrossRef] [Medline]
    35. Latour JM, Tomlinson OW. A systematic review to explore how exercise-based physiotherapy via telemedicine can promote health related benefits for people with cystic fibrosis. PLOS Digit Health. Feb 2023;2(2):e0000201. [CrossRef] [Medline]
    36. Reilly C, Sails J, Stavropoulos-Kalinoglou A, et al. Physical activity promotion interventions in chronic airways disease: a systematic review and meta-analysis. Eur Respir Rev. Mar 31, 2023;32(167):220109. [CrossRef] [Medline]
    37. Greenwood SA, Young HML, Briggs J, et al. Evaluating the effect of a digital health intervention to enhance physical activity in people with chronic kidney disease (Kidney BEAM): a multicentre, randomised controlled trial in the UK. Lancet Digit Health. Jan 2024;6(1):e23-e32. [CrossRef] [Medline]
    38. Chen JJ, Cooper DM, Haddad F, Sladkey A, Nussbaum E, Radom-Aizik S. Tele-exercise as a promising tool to promote exercise in children with cystic fibrosis. Front Public Health. Sep 2018;6:269. [CrossRef] [Medline]
    39. Elborn JS. Digital healthcare in cystic fibrosis. Learning from the pandemic to innovate future care (commentary). J Cyst Fibros. Sep 2021;20 Suppl 3:64-66. [CrossRef] [Medline]
    40. Raywood E, Shannon H, Filipow N, et al. Quantity and quality of airway clearance in children and young people with cystic fibrosis. J Cyst Fibros. Mar 2023;22(2):344-351. [CrossRef] [Medline]
    41. Morrison L, Thornton CS. Quality over quantity: the next ACT in airway clearance in cystic fibrosis. Eur Respir J. Sep 2023;62(3):2301354. [CrossRef] [Medline]
    42. Curran M, Tierney AC, Collins L, et al. Steps ahead: optimising physical activity in adults with cystic fibrosis: a pilot randomised trial using wearable technology, goal setting and text message feedback. J Cyst Fibros. May 2023;22(3):570-576. [CrossRef] [Medline]
    43. Holland AE, Malaguti C, Hoffman M, et al. Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: a rapid review. Chron Respir Dis. Jan 2020;17:1479973120952418. [CrossRef] [Medline]
    44. Vagg T, Shanthikumar S, Ibrahim H, et al. Telehealth in cystic fibrosis. A systematic review incorporating a novel scoring system and expert weighting to identify a ‘top 10 manuscripts’ to inform future best practices implementation. J Cyst Fibros. Jul 2023;22(4):598-606. [CrossRef] [Medline]
    45. Digital health and care strategy. Scottish Government. Oct 27, 2021. URL: https://www.gov.scot/publications/scotlands-digital-health-care-strategy/ [Accessed 2024-07-08]
    46. Ruth J, Willwacher S, Korn O. Acceptance of digital sports: a study showing the rising acceptance of digital health activities due to the SARS-CoV-19 pandemic. Int J Environ Res Public Health. Jan 5, 2022;19(1):596. [CrossRef] [Medline]
    47. Holtrop JS, Estabrooks PA, Gaglio B, et al. Understanding and applying the RE-AIM framework: clarifications and resources. J Clin Transl Sci. May 2021;5(1):e126. [CrossRef] [Medline]
    48. Abimbola S, Patel B, Peiris D, et al. The NASSS framework for ex post theorisation of technology-supported change in healthcare: worked example of the TORPEDO programme. BMC Med. Dec 30, 2019;17(1):233. [CrossRef] [Medline]
    49. Carr SB, Ronan P, Lorenc A, Mian A, Madge SL, Robinson N. Children and Adults Tai Chi Study (CF-CATS2): a randomised controlled feasibility study comparing internet-delivered with face-to-face tai chi lessons in cystic fibrosis. ERJ Open Res. Oct 2018;4(4):00042-2018. [CrossRef] [Medline]
    50. Stoumpos AI, Kitsios F, Talias MA. Digital transformation in healthcare: technology acceptance and its applications. Int J Environ Res Public Health. Feb 15, 2023;20(4):3407. [CrossRef] [Medline]
    51. Parker K, Uddin R, Ridgers ND, et al. The use of digital platforms for adults’ and adolescents’ physical activity during the COVID-19 pandemic (Our Life at Home): survey study. J Med Internet Res. Feb 1, 2021;23(2):e23389. [CrossRef] [Medline]
    52. Merolli M, Hinman RS, Lawford BJ, Choo D, Gray K. Digital health interventions in physiotherapy: development of client and health care provider survey instruments. JMIR Res Protoc. Jul 28, 2021;10(7):e25177. [CrossRef] [Medline]
    53. Smith S, Calthorpe R, Herbert S, Smyth AR. Digital technology for monitoring adherence to inhaled therapies in people with cystic fibrosis. Cochrane Database Syst Rev. Feb 3, 2023;2(2):CD013733. [CrossRef] [Medline]
    54. Arias López MDP, Ong BA, Borrat Frigola X, et al. Digital literacy as a new determinant of health: a scoping review. PLOS Digit Health. Oct 2023;2(10):e0000279. [CrossRef] [Medline]
    55. Fitzpatrick PJ. Improving health literacy using the power of digital communications to achieve better health outcomes for patients and practitioners. Front Digit Health. Nov 2023;5:1264780. [CrossRef] [Medline]
    56. Vagg T, Shanthikumar S, Morrissy D, Chapman WW, Plant BJ, Ranganathan S. Telehealth and virtual health monitoring in cystic fibrosis. Curr Opin Pulm Med. Nov 1, 2021;27(6):544-553. [CrossRef] [Medline]

    ‎
    CF: cystic fibrosis
    DHT: digital health technology
    HEMT: highly effective modulator therapy
    NASSS: nonadoption, abandonment, scale-up, spread, sustainability
    RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance

    Edited by Brooke Allemang; submitted 12.01.24; peer-reviewed by Ahmed Hassan, Mark Merolli, Tamara Vagg; final revised version received 29.04.24; accepted 22.05.24; published 15.07.24.

    Copyright

    © Lisa Morrison, Zoe Louise Saynor, Alison Kirk, Lisa McCann. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 15.7.2024.

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