Potential application of continuous pulse oximetry in cardiac rehabilitation programs: scientific review

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Abstract

Real-time monitoring of patients' vital signs and feedback in virtual rehabilitation can be achieved through the use of remote technologies. Wearable sensors during training allow monitoring of heart rate, electrocardiography, and blood pressure. Oxygen saturation indicators are measured less frequently, although they may have greater diagnostic value. The search was conducted in PubMed, Scopus, Web of Science, PEDro, and Google Scholar databases. As of January, 62 sources, including Cochrane and systematic reviews, had been selected.

Blood oxygen saturation can only be measured using a pulse oximeter, which operates on the Bouguer-Lambert-Beer law and emits two wavelengths; the measurement can be carried out by transmission and reflective methods. In medically certified devices, the data are transmitted to the technological system and evaluated by trained medical personnel. Bracelets and rings have shown the greatest convenience and reliability for fixing pulse oximeter. Continuous monitoring of oxygen saturation during stress tests and physical training ensures their safety and allows the load adjustment. When connected to a telemedicine platform, the system should ensure direct interaction between the doctor and the patient with monitoring of vital parameters.

When conducting cardiac rehabilitation, a reliable certified medical device able to provide a continuous monitoring is required. Monitoring of vital parameters is carried out using a device with the necessary sensors, a patient feedback system and a telemedicine platform accessible to medical personnel for storing and analyzing the obtained data.

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Introduction

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide [1]. Cardiac rehabilitation (CR) is recommended as a key multicomponent intervention to reduce these rates, decrease the number of repeated hospitalizations, and improve quality of life [2; 3]. The CR program includes physical exercise, psychological counseling, and education on modifying CVD risk factors. However, despite its proven benefits, patient adherence to CR programs remains low, most often due to limited access to rehabilitation centers, transportation costs, reluctance to participate in group programs, lack of time, and career commitments.

An alternative solution could be CR using telemedicine technologies [4], which allows patients to participate in programs remotely, ensuring monitoring of physiological parameters, interaction with the attending physician, and training in physical activity intensity assessment skills [5; 6]. Widespread availability of communication and significant growth in the use of remote technologies are contributing to the introduction of complex personalized telemedicine programs for patients with CVD. Recently published results of the Cochrane review [7] and systematic reviews of clinical studies [8–10] have demonstrated the high effectiveness and feasibility of digital CR in improving physical activity (PA) and quality of life in patients. In addition, a systematic review conducted by V. Antoniou et al. [11] showed that the use of remote CR leads to a reduction in the frequency of adverse cardiovascular events and readmission rates.

The use of remote technologies and wearable sensors in CR has made it possible to monitor patient indicators in real time, ensuring constant observation and necessary feedback [12; 13]. Various sensors are used to assess the characteristics of PA (duration and intensity of training, distance covered), heart rate (HR), blood pressure (BP), electrocardiography (ECG) indicators, and blood oxygenation (SpO2). Monitoring physiological parameters allows the rehabilitation program to be tailored to the individual capabilities of the patient and realistic goals to be set, while dynamic measurement helps to assess how effectively rehabilitation measures are helping to improve the functioning of the body [14; 15].

Wearable sensors used in remote CR can be used in continuous 24-hour monitoring mode, during training or at various stages of training, and can operate automatically or require user involvement. In most studies on telemedicine CR, cardiovascular system indicators were assessed during training: HR monitoring [16; 17], ECG indicators [18; 19], and BP was measured before and after physical exercise [20–22]. Blood oxygenation was also assessed before and after physical activity [23], although a decrease in SpO2 during exercise may have greater diagnostic value.

The aim of the study is to investigate the need for continuous SpO2 monitoring during cardio training and to develop recommendations for its practical application based on an analysis of systematic reviews and meta-analyses of randomized controlled trials (RCTs).

Materials and Methods

The search was conducted in the PubMed, Scopus, Web of Science, PEDro, and Google Scholar databases using the keywords: “dynamic pulse oximetry”, “physical exercise”, and “continuous oxygenation monitoring.” A total of 62 sources were selected as of January 2025, of which 22 (35.5 %) were systematic reviews, 2 (3.2 %) were Cochrane reviews, and 38 (61.3 %) were randomized clinical trials. The time period of publication of the articles was the last 15 years, the intervention under evaluation consisted of an exercise program with oxygen saturation monitoring; the sample included patients who had suffered an acute myocardial infarction and/or had chronic heart failure; the outcome of the intervention was assessed based on the presence of complaints and clinical manifestations, parameters for assessing heart function and/or structure, cardiorespiratory endurance, and peak oxygen consumption (VO2peak). The last search was conducted on February 1, 2025.

Methods for Measuring Blood Oxygenation Using Wearable Sensors

Blood oxygenation in CR is most often measured using a pulse oximeter—a small device that attaches to a finger or earlobe and determines the level of oxygen saturation in the blood using a non-invasive method.

The principle of operation of a pulse oximeter is based on the Beer–Lambert–Bouguer law, which allows the concentration of a substance to be estimated based on the intensity of absorbed light. Depending on its oxygenation, hemoglobin is capable of absorbing light of a certain wavelength to varying degrees as it passes through a section of tissue. The sensor is attached to the patient's body and contains two diodes that emit monochromatic light with wavelengths of 660 and 940 nm, respectively. These parameters are chosen because oxygenated (HbO2) and deoxygenated hemoglobin (Hb) absorb light differently under these conditions, and SpO2 is determined by calculating their ratio. Light passes through human tissue and is detected by a photodetector (transmission measurement). The saturation value is shown on the pulse oximeter display [23].

There are also devices that operate on the principle of reflection: the light source and photodetector are located on the same side (reflective measurement). For long-term monitoring in cardiac rehabilitation, T. Leppänen et al. [24] recommend reflective technology due to its versatility and fewer artifacts during movement. However, when calculating SpO₂, it is necessary to take into account that with any measurement method, light scattering occurs in tissues, which is associated with differences in the refractive index between cell organelles and cell fluid, as well as between intracellular, extracellular fluids, and blood. Therefore, the relationship between the physiological and measurable SpO2 parameters cannot be obtained directly from calculations based on the Boucher–Lambert–Berger law of light absorption in HbO2 and Hb, but is determined experimentally for each type of pulse oximeter sensor by calibration: SpO2 is measured in healthy volunteers simultaneously with the oxygen content in arterial blood using a gas analyzer [25].

Currently, there are many studies proposing the use of photoplethysmography (PPG) to measure blood oxygenation [26; 27]. The PPG method is based on measuring blood volume in tissues through optical light absorption. In the most common PPG technique (transmission mode), the tissue is irradiated with a light-emitting diode, and the light intensity is measured by a photosensor on the other side of the tissue. The stroke volume of blood increases the optical density and path length through illuminated tissue (due to an intravascular increase in the number of red blood cells and the light-absorbing hemoglobin they carry), which reduces the intensity of light on the photodetector. The amplitude of the PPG signal is related to the maximum change in blood volume during systole [25; 28].

When performing PPG, a single wavelength of radiation is typically used (most often green light or infrared waves). However, two wavelengths (red and infrared light) must be used to measure saturation, as only with their help can HbO2 and Hb be distinguished. One wavelength in PPG allows to measure only heart rate, heart rate variability, pulse wave characteristics, but not blood oxygen level [29].

Characteristics of Different Types of Wearable Sensors

Currently, many wearable sensors have been developed and manufactured to obtain data on physiological parameters. Among them, two types can be distinguished::

  1. Commercial devices: smartwatches, or “fitness bracelets” that measure SpO2 using reflection. Such devices often come with ECG, heart rate, and physical activity monitoring functions. They record and monitor parameters instantly or over a short period (1–2 minutes), but cannot perform continuous recording around the clock. Commercial devices cannot reflect recorded vital indications in a single report to provide doctors with a complete set of data and a detailed assessment of the patient's health.
  2. Medically certified devices that record vital signs transmit data to an integrated technological system consisting of several components: a wearable device, processing and filtering algorithms (ensuring the accuracy and high quality of the data obtained, as well as the elimination of artifacts), and a medical report that complies with international standards. The duration of SpO2 measurement varies depending on the purpose of use:
  3. Instantaneous: standard application, performed by placing the fingertip on the sensor while the patient's hand is at rest. The device display shows pulse and oximetry values [30].
  4. During long periods of time when monitoring SpO2 in chronic patients in stable conditions. A conventional pulse oximeter with a finger sensor or a special wearable sensor on the patient's wrist (chest, earlobe) is used, operating on the principle of transmission. The recorded data is then transferred to a personal computer for processing and analysis [31].
  5. Remote real-time monitoring to check on the patient's health while they're doing their cardio or strength training program of CR. This can be done using a wearable device with several sensors (blood pressure, heart rate, SpO2, movement, etc.), which is usually placed on the patient's wrist or chest to avoid discomfort and restrict movement. The measurements are transmitted to a special platform and are available in a mobile app and/or on a website, where they are evaluated by trained medical personnel [32; 33].

This review will examine clinical studies that used only medically certified devices.

Various methods of attaching a wearable SpO2 sensor to the human body when measuring physiological parameters over a long period of time are also of interest. Placing a pulse oximeter on a finger is standard practice in clinical measurements due to its ease of use and high-quality signal. However, this method is inconvenient for long-term monitoring during physical activity or when blood perfusion in peripheral tissues is reduced [30].

Smart watches worn on the wrist, have been in development and refinement for several years. One of the first devices of this type was AMON, with a wireless data transmission module, first introduced in 2002 and providing monitoring of heart rate, SpO2, and skin temperature [34]. Then a new generation of smartwatches with wireless and mobile connectivity appeared. They are convenient and comfortable to wear, and are also capable of providing long-term monitoring of vital functions. However, the accuracy of the sensors when worn on the wrist depends on how tightly the device fits against the skin, as well as on changes in the position of the hand during physical activity, when there is a high probability of artifacts appearing [35].

Ring sensors have been proposed for measuring blood oxygen saturation using the transmission method. Most of them are still in development, but the devices already available have proven to be comfortable to wear and quick to adapt to in clinical settings [36]. J.J. Mastrototaro et al. [37] conducted a prospective clinical study in which volunteers were connected to devices for administering an oxygen-depleted breathing mixture. Parallel SpO2 measurements were performed by inserting a specialized cannula into the brachial artery to analyze blood gas composition and using test sensors, one of which was placed on the fingertip and the other in the form of a ring. According to the results of the study, both test medical devices showed high accuracy in measuring blood oxygen saturation.

Placing the sensor on the earlobe also allows for reliable SpO2 measurement, as the high density of blood vessels in this area ensures high accuracy and suitability for patients with peripheral circulatory disorders. However, long-term placement of the sensor in this location is uncomfortable and may cause it to shift during physical activity. Some authors suggest using an in-ear sensor for this purpose [38]. However, the use of devices that attach to the ear canal is complicated by the presence of numerous artifacts caused by jaw movements during chewing, talking, or physical exercise [39]. When the sensor is attached to the chest using a chest strap or adhesive tape, the results obtained may depend on respiratory movements, and during physical activity, fewer artifacts are observed. A good and stable signal can be obtained with correct placement. Researchers note that with this device placement, discomfort may arise if the sensor is moved frequently [40].

For the convenience of recording vital signs during training, multisensor T-shirts have been developed, which can use both reflective and transmissive methods of signal detection. LED and photodiode strips with copper wires are integrated into the fabric of the T-shirt to conduct the signal in the textile fiber. Sometimes the light source and detectors are optical fibers sewn into the fabric [35]. However, the “smart clothing” developed and marketed uses the PPG method, which, as mentioned earlier, can be used to record heart rate, heart rate variability, and pulse wave characteristics, but is not used to determine SpO2. In addition, clothing for attaching wearable devices is not yet very comfortable, so developers are focusing on integrating non-invasive and flexible sensors and reducing the size of the electronics used [41].

Advantages of Continuous Oxygen Saturation Monitoring

In the early stages of telemedicine-based CR, physiological parameters were measured before and after physical exercise. In a study by R. Hwang et al. [23], a telerehabilitation program was implemented using a synchronous videoconferencing platform via the Internet at home. Patients were provided with an automatic sphygmomanometer and pulse oximeter for self-monitoring and verbal reporting of blood pressure, heart rate, and SpO2 levels at the beginning and end of each exercise session. Group training sessions were conducted under the supervision of a therapist, with two-way audiovisual communication ensuring interaction between the parties. The use of this technology ensured that patients performed the exercises correctly in real time, and changes could be made to the rehabilitation program based on the data obtained. However, to ensure patient safety during cardio training and timely detection of deterioration in their condition, continuous SpO2 monitoring is necessary [42; 43].

A review published by P. Agarwala et al. [44] showed that the use of continuous SpO2 monitoring during the six-minute walk test (6MWT) increases the safety of the test for patients by allowing additional parameters to be assessed. The 6MWT was recommended for assessing cardiac and respiratory function in the official ATS statement: guidelines for the six-minute walk test [45]. Unlike cardiopulmonary exercise stress testing, it does not require complex equipment or technical knowledge to perform [46]. The patient is asked to walk as far as possible along a 30-meter corridor at maximum speed for 6 minutes, with the primary outcome measure being the distance covered in 6 minutes, measured in meters. Initially, continuous pulse oximetry was not planned to be used during 6MWT [47]. However, after it became possible to monitor heart rate and SpO2 during the test [40], it was proven that oxygen desaturation affects the distance covered. It was also proven that the product of the minimum oxygen saturation level and the distance covered predicts morbidity and mortality in chronic respiratory diseases [48; 49]. In a study by Y. Matsuoka et al. [50], indices were used that take into account desaturation caused by physical exertion during the 6MWT in patients with CVD. The authors evaluated the DDR (desaturation distance ratio) index, which is the product of the distance covered and the lowest oxygen saturation value during the 6MWT [51; 52], and the DSP (distance-saturation product) index – the ratio of the desaturation area (the difference between the maximum possible SpO2 (100 %) and the patient's SpO2 every 2 seconds) to the distance covered [53; 54]. It has been shown that oxygen desaturation during the test affects the distance covered in patients with CVD even without pulmonary complications, and DDR is more suitable than DSP as an assessment of physical activity. All of the above emphasizes the important role of continuous SpO2 monitoring during the 6MWT.

The study by M. Hermann et al. [55] examined cardiac rehabilitation in patients after COVID-19 infection. The aerobic program consisted of controlled walking indoors or outdoors, during which pulse oximetry was performed. The initial exercise intensity was determined using the 6MWT, and the criteria for stopping or reducing the intensity were a decrease in SpO2 to less than 88 %, a perceived exertion score of more than 16 on the Borg scale (scale “6–20”) and/or reaching submaximal HR. The authors emphasize that continuous SpO2 monitoring ensured the safety of physical exercises. For this same group of patients, F. Yang et al. [56] demonstrated the effectiveness of cardiopulmonary rehabilitation at home. Physical exercises were performed under the control of physiological parameters (ECG, HR, SpO2), the results of which were reported by telephone and allowed the attending physician to adjust the prescribed program. M. Chan et al. [57] proposed using a special chest biosensor capable of recording ECG and PPG signals with high accuracy and transmitting data to a remote platform for evaluation by medical personnel to ensure continuous SpO2 monitoring.

Use of Continuous SpO2 Monitoring in Telemedicine Systems Providing Support for Remote CR

Various artificial intelligence tools play a fundamental role in ensuring complex and in-depth analysis of bioelectrical and biometric signals obtained from wearable sensors. These tools include signal preprocessing, feature extraction, classification or clustering, and statistical analysis [58]. Recently published works have described telemedicine systems that use wearable sensors to record and monitor vital signs. For example, S. Marathe et al. [59] presented the use of a patient monitoring system with four sensors: ECG, blood pressure, temperature, and SpO2. The data collected from the sensors is sent to the Wi-Fi module and uploaded to cloud storage. The attending physician can view it at a convenient time, and feedback is provided via telephone calls. I. Joseph et al. [60] propose in their study the use of a telemedicine system that records the same parameters: ECG, blood pressure, temperature, and SpO2, with sensors connected to the Internet. The data obtained is accessible via a mobile app or a dedicated website, allowing doctors to monitor the patient's condition in real time and adjust the exercise program. The authors suggest using this system to monitor CR in remote areas where there is a shortage of medical personnel. C. Nwibor et al. [61] propose using a specially designed sensor for remote CR, which receives and measures the PPG signal and then stores it on a remote ThinkSpeak platform. After computer processing of the signal, the patient's blood pressure, heart rate, and SpO2 are assessed and made available to the physician in real time.

Requirements for a Wearable Device for SpO2 Recording

In a recently published review, S. Nardini et al. [62] described the necessary requirements for a wearable device for continuous SpO2 monitoring during remote rehabilitation. It should be a fully certified medical device that could automatically, without any intervention from the patient, record pulse, blood pressure, SpO2, movement, coughing, and sneezing accurately and consistently, with a high sampling rate (less than 5 s). Access to data received from the device is provided in real time, but continuous recording of physiological parameters is also possible to monitor the patient's condition. It should be simple and convenient for the patient, reliable, durable, and stable in operation. In addition, the device must connect to a telemedicine platform where an expert can analyze data, provide diagnostics, and, if necessary, adjust the prescribed rehabilitation program. The system should also enable direct interaction between the physician and the patient. All components of the system should be classified as medical devices so that they can be used in clinical settings. The device should probably be equipped with a display for the patient, informing them of changes in their readings, which could serve as an educational component in the rehabilitation program.

Conclusions

Measuring blood oxygen saturation plays a critical role in cardiac rehabilitation. Only medically certified devices that record vital signs and generate a medical report allowing the physician to assess the patient's health and, if necessary, adjust the exercise program may be used for monitoring. Various devices can be used to secure the sensor for long periods of time: a ring, bracelet, chest strap, or adhesive patch with built-in equipment. SpO2 monitoring allows the rehabilitation program to be tailored to the individual capabilities of the patient and realistic goals to be set, while dynamic SpO2 measurement helps to assess how effectively rehabilitation measures are helping to improve heart and lung function. During the 6MWT, a decrease in blood oxygen saturation affects the distance covered in patients with CVD even without pulmonary complications. Continuous SpO2 monitoring allows for the assessment of an additional index: the product of the distance covered and the lowest oxygen saturation value during the 6MWT more accurately assesses the level of physical activity. The use of telemedicine systems allows this parameter to be used for remote CR in remote areas. To ensure continuous monitoring during CR, a reliable, certified medical device is required, including a device with sensors for vital signs, a telemedicine platform for storing and analyzing the data obtained, which is accessible to medical personnel, and a feedback system with the patient.

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About the authors

I. E. Mishina

Ivanovo State Medical University; Saint Petersburg State University

Author for correspondence.
Email: xenny7@yandex.ru
ORCID iD: 0000-0002-7659-8008

DSc (Medicine), Professor, Professor of the Department of Hospital Therapy, Cardiology and General Medical Practice, Professor of the Department of Postgraduate Medical Education, First Deputy Director of the Medical Institute

Russian Federation, Ivanovo; Saint Petersburg

K. A. Blinova

Ivanovo State Medical University

Email: xenny7@yandex.ru
ORCID iD: 0000-0002-2896-8764

PhD (Medicine), Associate Professor of the Department of Oncology and Radiation Therapy

Russian Federation, Ivanovo

A. S. Parfenov

Ivanovo State Medical University

Email: xenny7@yandex.ru
ORCID iD: 0000-0002-5729-4121

PhD (Technical Sciences), Associate Professor of the Department of Physics, Chemistry and Mathematics

Russian Federation, Ivanovo

E. V. Berezina

Ivanovo State Medical University

Email: xenny7@yandex.ru
ORCID iD: 0000-0002-6958-0619

Doctor of Technical Sciences, Associate Professor, Head of the Department of Physics, Chemistry and Mathematics

Russian Federation, Ivanovo

O. V. Khoroshilova

Cardiology Center, Ivanovo

Email: xenny7@yandex.ru
ORCID iD: 0000-0003-0487-7697

Cardiologist

Russian Federation, Ivanovo

M. V. Zhaburina

Ivanovo State Medical University

Email: xenny7@yandex.ru
ORCID iD: 0000-0003-4028-0708

PhD (Medicine), Associate Professor of the Department of Otorhinolaryngology and Ophthalmology

Russian Federation, Ivanovo

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