My Pebble Smartwatch – Experiences so far & potential future applications

photo from http://getpebble.com

For those of you who don’t know, the Pebble Smartwatch has been the first of the ‘next’ crop of smartwatches out of the gate.  Smartwatches already have considerable history, most of which has been rather poor.  Pebble is the first company that has approached getting it right, and its success has already stimulated a whole new crop of smartwatches that can be expected soon from the likes of Apple, Samsung, Google, Sony, amongst many many others.  While it may not be the most aesthetically pleasing piece of tech you’re going to see, and I’ve no doubt the big players I just mentioned will come out with all manner of slicker looking and functioning devices, the fact that Pebble is a start-up company who took a single idea and did it well means they’ve already got me in their corner.  You know, root for the little guy. 

Pebble is also still one of the biggest success stories that grew out of the crowd-funding website Kickstarter despite finishing their funding campaign over a year ago.  Since I was one of the 70,000 Kickstarter backers, I got my Pebble back in March before it was available for retail.  I’m going to offer a short description of how the Pebble has changed the way I interact with my world, and then present a few ideas about how I’d like to see this type of wearable technology integrate with how we provide healthcare.

First, a caveat.  As some readers will be aware, when it comes to the iOS vs. Android, debate, I’m Android all the way.  Not to say I don’t have my share of iOS devices (in fact, at one point I owned 10 iPads for research use), but when it comes to my personal devices, if given the choice I’ll always choose Android.  In this case, that appears to have helped me out.  I won’t pretend to fully understand, but because of the way the two different operating systems handle apps running in the background, the experience of pairing a Pebble with an Android device is apparently much smoother than pairing it with an iOS device.  This may have changed through recent updates (and will almost definitely change when iOS 7 is available), but for now I’m presenting my experiences with the Android side of things. 

The watch itself is probably most analogous to a Kindle e-reader – it has an e-ink display which means it’s easy on the eyes even outdoors, and it has no touchscreen, you navigate through the various menus using hardware buttons, or using the app on your smartphone.  Out of the box, a Pebble smartwatch can be set up without too much trouble and it will give you the first 3 or 4 lines of your text messages, the subject line and first few lines of the body of your emails, and will show you who’s calling on an incoming call.  This is all done through Bluetooth connectivity (another caveat: Android in fact has a deplorable history with Bluetooth support, but the good folks at Pebble made sure that wasn’t a problem for their device.  The new Android 4.3 update has finally allowed pairing with Bluetooth low-energy devices, which will make wearable tech much more useable in the future).  You can set the watch to vibrate a bit any time a notification comes in, or you can turn the vibration off.  There aren’t a whole lot of options in the main application regarding frequency of email push for example, but there are a growing number of apps in the respective app stores that will allow you to tweak things to your liking a bit more.  For example, I use one called Augmented Smartwatch Pro that presents all sorts of tweaking options.

Other fun features of the watch include the ability to install different watchfaces, either from the main Pebble website or from other sites like mypebblefaces.com.  In fact, you can even create your own watchface without too much trouble (and no coding skills required) at http://www.watchface-generator.de/.  Newer advancements are allowing watchfaces that push you weather updates and alerts (the rain alerts I get are freakishly accurate: ‘chance of light rain in 21 minutes, for 46 minutes off/on’, accurate almost to the minute), but this does require additional apps on your smartphone such as Pebble Connect or Pebbler.  Other 3rd party app makers are also coming on board, like RunKeeper, which pushes my time, distance, and pace to my watch while I’m running (assuming you have a phone with a GPS and data plan) so I don’t need a Garmin or other such training watch.  FreeCaddie pushes my distance to the hole to my watch any time I’m out golfing – which has made absolutely no difference to my terrible golf game, but it’s cool all the same.  There will no doubt be additional functions coming down the pipes, so looking forward to what comes next.

As far as how it’s changed the way I interact in my daily life, I will say it’s increased my ability to keep on top of my communications.  Now when I’m in a meeting and I get a text, I can quickly glance at my watch to determine whether it’s something I need to deal with now or can wait until later.  If I’m chatting with someone and I get a phone call, same deal, it’s much less obnoxious to glance at your watch than it is to pull out your phone and see who’s calling.  Although that said, when I first got my Pebble my wife always thought I was in a hurry when I was talking to her since I kept checking my watch.  Probably a happy medium to be had there.  So that’s where we are right now.

But what excites me the most is the potential for this type of technology (whether it be the Pebble or some other piece of tech).  Consider for a moment a future in which, as a clinician, you give your phone or some other device with motion sensing capabilities and Bluetooth connectivity, have the patient perform some kind of standardized and well-defined movement, and then glance at your watch to see if the movement profile of your patient matches some existing database of captured movements.  For example, give your patient with shoulder pain your phone, and ask them to perform one or two movements through full elevation.  The phone does the heavy lifting of comparing that movement pattern to a known database of patterns, and your watch says: this movement pattern is most similar to 300 other people who have known supraspinatus tendonopathy, or superior labrum tears, or adhesive capsulitis (if you can accept that diagnosis), etc…  In fact, most of these wearable tech devices themselves have their own motion sensors built in – I believe the Pebble has a 3-axis accelerometer for example, which may even give them the ability to identify stereotypical aberrant movement patterns themselves without having to give up your phone.  Or consider another application, where your patient calls or emails you to ask if it’s time for them to come back in for progression of their exercise program.  You ask them to open an app on their phone or watch, perform a few standardized movements, and their precise digital range of motion is then sent to you as a text or email.  You as clinician compare their mobility against previous, and decide whether it appears that mobility has increased to a point that it’s time to progress exercises.  Even these are relatively simple ideas, I’m sure people will come up with far more interesting and innovative uses of this new wearable tech as go forward, but I see a real paradigmatic shift on the horizon in how we integrate consumer technologies with rehabilitation.

My week with the FitBit Ultra Tracker

Anyone familiar with my research program will know that I'm always looking for new and innovative ways to capture data in clinic that is normally so resource-intensive it is usually reserved for labs or highly specific and well-funded applications.  Sometimes this is through simplified patient self-report measures, sometimes through simplified clinical tests, or sometimes through less expensive alternatives to high-precisions instruments.  An example of the latter is the new FitBit Wireless Activity tracker available from www.fitbit.com.  This thing is loaded with all sorts of technical goodness, including an accelerometer and an altimeter, which means it can not only count the steps you take in a day (a la a pedometer), but also how fast you were moving, and whether or not you were moving up or down hill (or up or down stairs as it were).  It then corrects your calorie usage through knowledge of these other parameters, making it far superior to a standard pedometer.  It also has a 'sleep tracking' mode, which has you move the little USB-drive-sized device from your pocket (where it normally clips happily and unobtrusively throughout the day) to a specially-designed comfortable wristband for sleeping.  While on your wrist, it basically tracks how restless you were throughout the night by monitoring the amount your arms have flailed about.  It will then send all of this information wirelessly through a USB-connected base station/charger any time you're close to your computer, and you can track your calorie expenditure and sleep habit either online or through handy smartphone apps.  So far pretty cool, right?

Pictures are taken directly from the FitBit.com website.

What drew me to this is that, if we believe the cognitive-behavioural model of chronic pain development, the crux of that model is that catastrophizing and fear of movement lead to disuse and deconditioning, and hence chronic pain and disability.  People have tried in the past to monitor change in activity using a variety of approaches, many of them through use of pedometers, accelerometers, GPS, personal digital assistants, one-shot fitness indices (body fat, strength) or plain old diaries.  So far the results are mixed, with a paper from Dr. Vlaeyen himself suggesting that physical acitivity level doesn't change appreciably over the course of chronic pain development.  Colleagues of mine have tried more advanced approaches (unpublished) through use of a wearable vest that incorporates motion sensors, heart rate sensors, and other such technologies that cost several thousand dollars.  This is the 'resource-intensive' bit I was talking about in the opening sentence.

Enter the FitBit.  While it won't provide heart rate data, it will give total motion data, including speed of movement and change in altitude, and an indicator of 'restfulness' while asleep.  All for $99.  So I had to give it a go to determine whether it would be something I could distribute in a prospective cohort study to evaluate overall movement from say weeks 1 and 2 to weeks 51 and 52 after an acute injury.  Here's my experience:

Like any movement sensor, it's possible to 'game' the device by sitting on your couch and shaking it around, but who are you really cheating there?  Setting it up is not hard, but it does require the download of a driver which some people who are a bit more computer-phobic might not like (I'm thinking about my standard subject here).  As a researcher, I love the fact that I can pull the data from the website any time I want by logging into the FitBit 'Dashboard' and seeing total calories spent and monitoring sleep effectiveness.  This also gives me real-time information about compliance, which is a HUGE bonus.  Here's what a fairly typical, perhaps slightly above-average day looked like for me:

 

Actually, that's probably considerably above average, considering I generally sit in front of a computer most of the day.  The dashboard also gives a sort of summary activity level: 

Which would be difficult to analyze as is but could be tailored I suspect.  And finally, a sleep pattern:

This could come in particularly handy if we believe, as I do, that disturbed sleep is a key indicator of the development of chronic pain.

As far as a clinical/research device, it definitely holds potential.  Some of the possible challenges that would need to be overcome are really just logistic - I occasionally found myself forgetting to put the tracker into the wrist band before bed, then forgetting to take it out and clip it back onto my pajamas when I awoke, and then forgetting to take it off my pajamas and put it onto my pants when I got dressed.  I suspect subjects who aren't as fully engaged as I am would probably forget this even more often.  Similarly, I occasionally forgot to put it into sleep mode before I went to bed, or to take it out of sleep mode when I got up.  This is in no way a criticism of the device, rather when looking at this is as a potential research tool, one needs to consider anything that could bias your results.  That said, it is far superior to either a pedometer or GPS, and is smaller than some other motion sensors I've seen in the past, so definitely has a lot going for it.  The cost is another big plus.  For $5000 I could get 50 of these on a nice prospective cohort and track movement (calories would probably be the key indicator here) over time.  As a clinical tool, these also hold promise for tracking change in activity over time, especially for people with chronic disabilities.  

Now I have to mention one more thing, and this is both a pro and a con.  The device is small and unobtrusive which is great, but as it turns out is also easy to lose.  As I did.  After only 2 weeks.  D'oh!  Now I have to say that the customer service at FitBit are AMAZING.  They have a discounted replacement program, and even offered to replace mine for free (the first time), as long as I promised not to be such a moron again.  Well, they didn't say that exactly, but I read between the lines.  Again, AH-MAZING.  However, this does raise some concern as far as using this as a research or clinical tool - it could become pricey if they keep getting lost.  I will from now on be including a label with my phone number on any ones that I get.  But I would also like to see something like maybe a user-configurable 'alert' system, in which the device can be set to start beeping after some specified period of complete immobility, say 12 hours.

All in all, I love the fact that we are seeing high tech gagets at consumer-accessible prices.  Now, evaluation of patient activity level doesn't have to be confined to the clinic.  I continue to be excited by the next advancement in health technology.  Can't wait to see what else comes down the pipes.