Photoplethysmography (PPG) is a low-cost, noninvasive optical technique that uses change in light transmission with changes in blood volume within tissue to provide information for cardiovascular health and fitness. As remote health and wearable medical devices become more prevalent, PPG devices are being developed as part of wearable systems to monitor parameters such as heart rate (HR) that do not require complex analysis of the PPG waveform. However, complex analyses of the PPG waveform yield valuable clinical information, such as: blood pressure, respiratory information, sympathetic nervous system activity, and heart rate variability. Systems aiming to derive such complex parameters do not always account for realistic sources of noise, as testing is performed within controlled parameter spaces. A wearable monitoring tool to be used beyond fitness and heart rate must account for noise sources originating from individual patient variations (e.g., skin tone, obesity, age, and gender), physiology (e.g., respiration, venous pulsation, body site of measurement, and body temperature), and external perturbations of the device itself (e.g., motion artifact, ambient light, and applied pressure to the skin). Here, we present a comprehensive review of the literature that aims to summarize these noise sources for future PPG device development for use in health monitoring.

Blood pressure is a critical risk factor for cardiovascular diseases (CVDs), yet most adults do not monitor it frequently enough to prevent serious complications. This is in part because the traditional cuff-based method is inconvenient, uncomfortable, and does not allow for continuous monitoring. To address these constraints, we developed a unique multi-modal wearable device and used a random forest regression (RFR) algorithm that resulted in a model capable of accurate cuffless blood pressure prediction. This multi-modal device features two photoplethysmography (PPG) sensors and two bioimpedance (BioZ) sensors to measure pulse wave propagation along the radial artery on the wrist. The redundancy in the design enhances prediction accuracy. To validate the device, a novel human subject study protocol was also developed that allows an individual's blood pressure to rise safely and repeatably by more than 40 mmHg (systolic pressure) from baseline measurements. In this study, using multiple pulsatile waveforms from the PPG and BioZ sensors as inputs into the machine learning prediction algorithm, showed that the model had higher accuracy than models using a single sensor. Specifically, the training, validation, and leaving one subject out of data sets all showed mean absolute errors of less than 3.3 mmHg for both systolic and diastolic blood pressures (BPs). While results from this test were promising, a subject-wise evaluation showed variability depending on how well an individual's BP distribution matched the training set. These findings demonstrate the potential for a universal model for cuffless BP estimation, with further validation needed in more diverse populations. Thus, the accompaniment of the RFR model with the multi-modal wearable device offers the potential for robust and continuous blood pressure monitoring, providing a unique and practical solution for long-term cardiovascular health management.

Cardiovascular disease (CVD) is the leading cause of global mortality, with hypertension affecting over one billion people. Current noninvasive blood pressure (BP) systems, like cuffs, suffer from discomfort and placement errors and lack continuous monitoring. Wearable solutions promise improvements, but technologies like photoplethysmography (PPG) and bioimpedance (BIOZ) face usability and clinical accuracy limitations. PPG is sensitive to skin tone and body mass index (BMI) variability, while BIOZ struggles with electrode contact and reusability. We present a novel, strain gauge-based wearable BP device that directly quantifies pressure via a dual transducer system, compensating for tissue deformation and external forces to enable continuous, accurate BP measurement. The reusable, energy-efficient, and compact design suits long-term daily use. A novel leg press protocol across 10 subjects (systolic: 71.04–241.42 mmHg, diastolic: 53.46–123.84 mmHg) validated its performance under dynamic conditions, achieving mean absolute errors of 2.45 ± 3.99 mmHg (systolic) and 1.59 ± 2.08 mmHg (diastolic). The device showed enhanced robustness compared to the Finapres, with less motion-induced noise. This technology significantly advances current methods by delivering continuous, real-time BP monitoring without reliance on electrodes, independent of skin tone, while maintaining a high accuracy and user comfort.

Many commercial wearable sensor systems typically rely on a single continuous cardiorespiratory sensing modality, photoplethysmography (PPG), which suffers from inherent biases (i.e., differences in skin tone) and noise (e.g., motion and pressure artifacts). In this research, we present a wearable device that provides robust estimates of cardiorespiratory variables by combining three physiological signals from the upper arm: multiwavelength PPG, single-sided electrocardiography (SS-ECG), and bioimpedance plethysmography (BioZ), along with an inertial measurement unit (IMU) providing 3-axis accelerometry and gyroscope information. We evaluated the multimodal device on 16 subjects by its ability to estimate heart rate (HR) and breathing rate (BR) in the presence of various static and dynamic noise sources (e.g., skin tone and motion). We proposed a hierarchical approach that considers the subject’s skin tone and signal quality to select the optimal sensing modality for estimating HR and BR. Our results indicate that, when estimating HR, there is a trade-off between accuracy and robustness, with SS-ECG providing the highest accuracy (low mean absolute error; MAE) but low reliability (higher rates of sensor failure), and PPG/BioZ having lower accuracy but higher reliability. When estimating BR, we find that fusing estimates from multiple modalities via ensemble bagged tree regression outperforms single-modality estimates. These results indicate that multimodal approaches to cardiorespiratory monitoring can overcome the accuracy–robustness trade-off that occurs when using single-modality approaches.

We review the published work on the optical properties of the epidermis. Considering three primary skin tone groups, we summarize the existing data on epidermal absorption and scattering coefficient across the 300- to 1000-nm range. We include both experimentally derived values and ones extrapolated through models of bulk skin. We note a paucity of experimental data across all skin tones, which highlights the need for further research on epidermal melanin and skin tone to improve the reliability of optical devices interfacing with the skin.