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When it comes to an app-based home exercise intervention for people with spinal cord injury (SCI), potential users and their care partners say it should be user-friendly, provide clear instruction and guidelines for each exercise, and include a way to communicate with clinicians. The findings, based on a survey and focus groups, are reported in Disability and Health Journal.
Researchers at Shirley Ryan AbilityLab led by Alex Wong, PhD, Assistant Director of the Center for Rehabilitation Outcomes Research and Arun Jayaraman, PT, PhD, Executive Director of the Technology & Innovation Hub, are developing an app to deliver tailored exercise programs to people with SCI.
People with SCI can become rapidly deconditioned after their injury, and about one in four don’t meet the physical fitness required for daily activities, which can lead to secondary conditions including cardiovascular disease and diabetes. Commitment to a regular exercise plan can help prevent the loss of muscle, reduce complications associated with SCI and improve overall functionality and independence, but most people with SCI still don’t engage in enough physical activity.
The app-based exercise program will be customized to the user’s individual needs. Participants who need additional “nudges” to engage with the app will be supported by an “e-coach.” There are also in-app videos to guide users on how to complete each exercise.
The app will use what is known as ecological momentary assessment to monitor users’ conditions, like pain and other barriers that impede their exercise participation by sending messages asking about current feelings and experience. Therapists will review responses to these messages in real time to update and tailor exercises for each user.
“There are many barriers to maintaining a consistent exercise regimen, but for people with SCI, those barriers can be somewhat magnified,” Wong says. Cost, accessibility of gyms, transportation and personal challenges like depression, anxiety and low motivation can all get in the way. Home-based exercise programs get around some of these barriers, but adherence can still be a problem, explains Wong. While most people have smartphones, a mobile-based app designed to improve exercise adherence in people with SCI has yet to be developed.
“Having a customized exercise program in the palm of your hand that is accessible and engaging can help people with SCI stay motivated to exercise regularly, but we need to know which features are most important to user and other stakeholders,” Wong explained.
Wong and colleagues surveyed 26 experts including physicians, physical therapists, occupational therapists and registered nurses about what features they thought were most important for the app to have. They also conducted several focus groups. Focus group participants included 23 people with SCI, six caregivers of people with SCI and six SCI clinicians. In the focus groups, participants reviewed an early version of the app and suggested improvements, discussed preferences for exercise instructions and how they would integrate the app-based program into their daily routines. They were also asked about how many daily prompts from the app to engage in the program were acceptable. Participants were also asked to describe their “dream” app, what features it would have and how it would help them stay motivated to exercise regularly.
The survey and focus group revealed unique requirements and priorities for each type of participant: people with SCI, SCI rehabilitation clinicians and caregivers of people with SCI.
Individuals with SCI and caregivers stressed the importance of making the app easy to use and user-friendly to encourage consistent engagement. They also suggested that “gamification’ of the app through features like achievement badges, and leaderboards would help sustain motivation and engagement. Clinicians emphasized the importance of accurate selection of exercises tailored to each user and highlighted the importance of features supporting program customization. They also mentioned the need for people with SCI to be included in videos that demonstrate the exercises. Clinicians and caregivers talked about the need for quick and efficient clinician response to user inquiries through the app. All stakeholders stressed that tracking progress through the app was important so that users can see tangible results over time.
“The results of the survey provided several insights that will improve app design and functionality,” Wong said. “Stakeholders’ opinions resonate with the needs for inclusivity and user-centered design in tailoring health and fitness apps for persons with SCI and other disabling conditions.”
Wong and colleagues have modified the app based on recommendations from the expert survey and focus groups and are wrapping up usability testing to ensure the app meets participants’ needs and preferences. Wong expects that an updated version of the app will be piloted this September via a clinical trial.
Sara Nataletti, PhD, Anusha Banerjee, Rebecca Macaluso, and Sara Prokup, PT, DPT of Shirley Ryan AbilityLab, are co-authors on the paper.
This research is funded by the National Institute on Disability, Independent Living and Rehabilitation Research (grant 90SIM0015).
