mHealth system (ATOPE+) to support exercise prescription in breast cancer survivors: a reliability and validity, cross-sectional observational study (ATOPE

A cross-sectional observational examine was performed to check the reliability and validity of ATOPE+ with 22 BCS.


Potential contributors have been recognized from the referrals obtained from the Surgical Unit of the Hospital Universitario Clínico San Cecilio in Granada, Spain, between February and August 2021. BCS have been eligible if they’d been identified with breast most cancers (levels I-III), needed to have primary cell phone capabilities, and had at the very least one yr because the finish of oncological remedy (hormonal remedy was not an exclusion criterion). In distinction, potential contributors have been excluded if they’d not completed chemotherapy or radiotherapy at the very least one yr earlier than the examine begin date, had psychiatric or cognitive issues that prevented from following the directions of the protocol given, or didn’t have entry to a smartphone.

Eligible girls have been requested to return to the CUIDATE group’s services. A member of the analysis group defined the evaluation protocol and put in ATOPE+ on their cellphones. They have been requested to make use of ATOPE+ within the presence of a researcher to make sure appropriate evaluation efficiency. They have been additionally given the supplies wanted for distant evaluation (i.e., ECG gadget, chest strap, questionnaires and assessments directions).

Pattern dimension

A pattern dimension of 20 contributors was estimated to be essential to establish an intraclass correlation coefficient (ICC) of 0.8 between the imply sq. root variations of the usual deviation (LnRMSSD) assessed with the Polar H10 chest band and the ECG (Gold Commonplace), 90% energy, and an alpha error of 0.527. Contemplating a possible 10% dropout fee, 22 BCS have been recruited for the examine.

Description of ATOPE+ and knowledge assortment

To finish the examine, sufferers needed to take measurements with ATOPE+ and their comparability devices (Desk 1): Holter monitor22, Perceived Restoration Standing Scale23, Sleep Diary24, Emotional Misery Thermometer25, and Borg CR-10 Scale26, throughout 4 consecutive mornings, together with one weekend day so as to be as exact to regular routine as doable. Sufferers have been informed to comply with a standard sleep routine through the examine. As soon as they completed the appliance protocol, they continued filling out the comparability questionnaires given in paper format and the sleep diary. An summary of the ATOPE+ mHealth system is proven in Fig. 1.

Desk 1 ATOPE+ and criterion devices particulars.
Determine 1
figure 1

ATOPE+ mHealth system overview. Created with

ATOPE+ was developed by the Biomedical (BIO-277) ‘CUIDATE’ analysis group and the Division of Pc Structure and Expertise, CITIC-UGR Analysis Centre, each from the College of Granada, Spain. The event of ATOPE+ is a part of the ATOPE venture28, registration quantity NCT03787966, December 2019.

The ATOPE+ mHealth system consists of a cross-platform software (Android/iOS) and a centralized safe server. The applying offers sufferers with an interface to report their HRV and to report their wellness via questionnaires. The centralized safe server permits knowledge storage and processing, in addition to the era of tailor-made train prescription in keeping with skilled guidelines. The structure and value of ATOPE+ have beforehand been described16. The license plate of the system is 1710092555522.

As soon as the analysis group has put in the appliance on the participant’s telephones and created their private profiles, sufferers have been prepared to start out utilizing the appliance. In the primary view, sufferers have been capable of learn a fast tutorial of easy methods to carry out the evaluation or begin it. The measurement began as soon as they pushed the “Begin” button, in order that they needed to be ready earlier than pushing the button. The evaluation of the HRV was first. A notification with sound and vibration alerted the participant that this primary step was accomplished, and the remainder of the protocol continued.

Perceived restoration, sleep satisfaction and fatigue have been assessed with horizontal steady Likert scales from 0 to 10 with labels within the values on the extremes and a steady slider included in ATOPE+. For emotional misery, the scale was positioned vertically. The ultimate a part of the evaluation consisted of performing 10 repetitions of the “Sit To Stand Check” (STS) and assessing the fatigue perceived after the trouble with a score of perceived exertion scale from 0 to 10. After that, the analysis was accomplished. The solutions have been despatched to the server, and the participant obtained an computerized customized message about their readiness for both a high-intensity session, a moderate-intensity session, or energetic restoration. Extra details about the intervention was printed on a earlier protocol28.

Comparability devices

Autonomic steadiness

Autonomic steadiness was assessed with ATOPE+ and a Polar H10 chest strap (Polar H10, Polar Electro Oy, Kempele, Finland) related via Bluetooth and was in contrast with an ECG (Norav Holter DL800, Braemar Inc, Eagan, EEUU) monitor, which is thought-about the gold commonplace. From a 7-min recording, the primary and final minutes have been minimize off to realize clear and exact interpretations of vagal tone with a 5-min sign, as really helpful by the Activity Pressure of the European Society of Cardiology and the North American Society for Pacing and Electrophysiology29. The time area parameter rMSSD (the sq. root of the imply squared variations) was analysed.

For ATOPE+ , knowledge have been exported to a pc for evaluation. As really helpful by the Taskforce, all artifacts (ectopic beats, arrhythmic occasions, and noise results) within the RR time sequence have been corrected or eliminated to cut back the possibilities of substantial deformities that may happen in HRV evaluation30. Within the case of Holter monitor knowledge, NH300 software program (Norav, model 3.0, 2009, Norav Medical Ltd) was used to carry out the spectral evaluation through the use of Quick Fourier remodel algorithms to take away noise from recordings. The sampling fee was 128 samples/second. The frequency filter was set from 0.05 to 60 Hz. Because of low sampling fee, the software program itself utilized an interpolation algorithm to enhance R peak detection31.

After waking up and emptying their bladder, contributors have been instructed to moisten and place the chest band and the ECG monitor. Then, mendacity on their beds dealing with the ceiling, knowledge recording was carried out below the identical phrases of period for each gadgets.

Notion of restoration

The Notion of Restoration Scale was used as a comparability to evaluate the notion of restoration. It’s a subjective self-administered Likert-type scale with scores from 1 to 10 (Desk 1) and with a sensitivity and specificity of 0.82 and 0.81, respectively23.

Sleep satisfaction

As a comparability instrument, the subsection of high quality of sleep from the consensus sleep diary, a dependable software for prospectively measuring high quality of sleep24, was used. It’s a self-reported technique that features quantitative and qualitative features associated to every evening of relaxation (Desk 1). This technique, in comparison with polysomnography, has a kappa coefficient of 0.8732.

Emotional misery

The Emotional Misery thermometer in keeping with “The NCCN Scientific Apply Tips in Oncology” was used as a comparability to measure emotional misery. This software consists of a Likert-type scale with values from 0 to 10, the place 0 is “no emotional misery” and 10 constitutes “excessive emotional misery” (Desk 1). Within the Spanish oncology inhabitants, this thermometer has a sensitivity of 0.9 and a specificity of 0.6433.

Peripheral fatigue

The Borg-CR 10 scale was used as comparability for the analysis of the perceived degree of fatigue after bodily exertion. After performing 10 repetitions at a rhythm of 40 beats per minute (marked by a metronome included in ATOPE+) of the STS, a check continuously used as a protocol to induce fatigue within the decrease extremities, contributors accomplished this questionnaire, which consists of scores from 0 to 10 (“By no means” to “Very, very laborious”, respectively) (Desk 1). This scale has a reliability of 0.66 in keeping with the kappa coefficient within the scientific inhabitants of girls26.

Statistical evaluation

A descriptive evaluation was carried out to summarize sociodemographic and scientific traits of contributors. Steady variables are expressed because the imply ± commonplace deviation, and categorical variables are expressed as numbers and percentages. The conventional distribution of the variables was checked via the Shapiro-Wilks check. Knowledge that did not comply with a standard distribution have been remodeled into Ln(x) or Ln(x + 1) to allow parametric evaluation. All analyses have been carried out by a blinded researcher.

IBM SPSS model 24 was used for all analyses (IBM Statistical Program for Social Sciences SPSS Statistic, Corp., Armonk, New York). Bland–Altman analyses have been carried out so as to correctly set up  settlement34 between ATOPE+ strategies and Gold Commonplace strategies through the use of Excel worksheets (Microsoft Excel model 16.55, Microsoft, Washington, EEUU). A 95% Confidence Interval (CI) was established, and significance was set at p < 0.05.


For every final result measure, concordance between comparability devices and people included in ATOPE+ was calculated. Taking into account that Pearson correlation coefficients, paired t check, and Bland–Altman plots are strategies for analysing settlement however not very best by way of reliability35, interdevice ICC have been calculated to mirror relative reliability (Desk 2). ICC scores have been categorized as poor (< 0.5), average (0.5–0.75), good (0.75–0.90) and glorious (> 0.90)36. Weighted kappa was used for categorical variables. The advised interpretation for settlement is as follows: ≤ 0 poor, 0.01–0.20 slight, 0.21–0.40 truthful, 0.41–0.60 average, 0.61–0.80 substantial, and 0.81–1 virtually excellent37. Moreover, the usual error of measurement was calculated. These calculations recognized inside topic variation for every technique, indicating the magnitude to which repeated measures modified for contributors.

Desk 2 Indices of reliability of ATOPE+mHealth system for imply HRV parameter, restoration, sleep, emotional misery and fatigue of breast most cancers survivors (N = 21).


To find out the validity of ATOPE+, paired samples t assessments have been performed evaluating ATOPE+ measurements versus dependable measurements. Steady variables have been analyzed by Scholar’s t-test within the case of regular parametric variables, and nonparametric variables have been analyzed with Wilcoxon check. Contemplating that they solely mirror proportional relationships and may trigger misguided interpretation of measurements, to determine the settlement between the comparability devices and ATOPE+ strategies, Bland–Altman analyses have been additionally carried out, which allowed us to see the distinction between two scientific measurement gadgets towards every technique’s imply. To acquire additional data, sleep satisfaction was handled as a steady variable for this objective. To determine interdevice settlement, Cohen’s d for impact dimension was used, with impact sizes categorised as follows: 0 to 0.19, trivial; 0.2 to 0.59, small; 0.6 to 1.19, average; 1.2 to 1.99, giant; and > 2.0, very giant38. The Wilcoxon rank check and impact dimension have been calculated for ordinal variables.

Ethics approval and consent to take part

This examine was accredited by the ‘Ethics Committee of Biomedical Analysis of Granada’ (Granada, Spain) (0507-N-18, July 27, 2018). All contributors obtained written and verbal data. Knowledgeable consent was obtained from all contributors by signing a selected doc for this objective. All strategies have been carried out in accordance with the Declaration of Helsinki.

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