The goal of this research is to increase physical activity among individuals with a spinal cord injury (SCI) through a customized, interactive smartphone-based health app and e-coaching using three phases: (1) leading focus groups of potential app users and clinicians to gain information regarding health apps preferences for optimal consumer use, (2) conducting a usability study of the customized app to determine the quality and implement further changes for optimization, and (3) conducting a sequential multiple assignment randomized trial (SMART) to determine the most effective adaptive intervention to improve exercise adherence. A SMART trial will be used to determine when and how to adapt dosage, timing, and delivery to increase adherence and address low-response behaviors. In Stage-I, the investigators will compare outcomes among participants using a generic, non-interactive exercise app (Group 1) to a customized, interactive app that can gain information through frequent Ecological Momentary Assessments (EMA) that will be used to modify each participant's exercise programs (Group 2). After 12 weeks, participants who are not meeting the exercise guidelines at least 50% of the time will also be asked to participate in motivational interviewing-based e-coaching either two or four times per month in addition to their originally assigned intervention (Stage-II). By completing these three phases, this project addresses deficiencies in exercise levels and compliance by implementing an individualized exercise prescription, an adaptive intervention for low responders, a way to address barriers to exercise, and a free smartphone app for broad implementation.
Individual with diagnosis of SCI, formal or informal caregiver of an individual with an SCI, or clinician that regularly sees individuals with SCI
18-80 years of age
English-speaking
Willing to download the study apps
Severe visual or cognitive problems that would affect the ability to complete the study
Does not own, or is unable to use a smartphone
Individual with diagnosis of SCI, complete (only paraplegia) or incomplete, cervical C3- C4 and below
18-80 years of age
Sequential
Stage-I, Group 1: Self monitoring using Non-interactive App
BehavioralParticipants in Group 1 will have minimal features that affect compliance (notifications, rewards, EMA, etc.) and no modifications to their exercise program after initial prescription.
Stage-I, Group 2: Self monitoring using Interactive App
BehavioralParticipants in Group 2 will use the version of the exercise app that has been modified based on the findings from Phases 1 and 2 of this study. Group 2 will be able to use the full features of the interactive app including notifications, ability to submit videos, and non-synchronous messaging/communicating with the researcher. Additionally, participants in Group 2 will be asked to complete 2-5 EMA-based surveys daily to gain information about the participant's barriers and facilitators to exercise. The information from the EMA questionnaires will be used to progress and modify the exercise program at regular intervals for each participant in Group 2.
Stage-II, Groups 1a/2a: E-Coaching 1x per month
BehavioralIn addition to the Stage-I assigned app, participants will be asked to complete at least daily EMA questionnaires and e-coaching sessions two times a month throughout Stage-II (weeks 13-24). Participants will only receive the augmented e-coaching intervention if they were not adherent to the exercise guidelines for at least 50% of the weeks during Stage-I (weeks 1-12).
Stage-II, Groups 1b/2b: E-Coaching 2x per month
BehavioralIn addition to the Stage-I assigned app, participants will be asked to complete at least daily EMA questionnaires and e-coaching sessions four times a month throughout Stage-II (weeks 13-24). Participants will only receive the augmented e-coaching intervention if they were not adherent to the exercise guidelines for at least 50% of the weeks during Stage-I (weeks 1-12).
Rate of Adherence to SCI exercise guidelines
Using app-based data and self-report, the investigators will determine if each participant met the SCI aerobic exercise guidelines (moderate to vigorous aerobic exercise for at least 20 minutes twice per week) for each week of the study. The investigators will total the number of weeks in which the participants achieved adherence and calculate the percentage of adherence over each 12-week stage. An overall adherence rate of 50% will be regarded as meeting exercise guidelines for the stage.
Rate of Adherence to SCI exercise guidelines
Using app-based data and self-report, the investigators will determine if each participant met the SCI aerobic exercise guidelines (moderate to vigorous aerobic exercise for at least 20 minutes twice per week) for each week of the study. The investigators will total the number of weeks in which the participants achieved adherence and calculate the percentage of adherence over each 12-week stage. An overall adherence rate of 50% will be regarded as meeting exercise guidelines for the stage.
Change in Six-Minute Walk/Push Test from Baseline to 12 weeks
The Six-minute Walk (6MWT) and Six-minute Push (6MPT) Tests measure the distance a subject can cover while indoors on a flat, hard surface in a period of 6 minutes. The investigators will determine which test is most appropriate to administer based on the participant's primary mode of mobility (ambulation= 6MWT, manual wheelchair=6MPT). These tests will be used to determine each participant's change in endurance capacity with a greater increase in distance at the later time indicating greater improvements in endurance.
Change in Six-Minute Walk/Push Test from 12 to 24 weeks
The Six-minute Walk (6MWT) and Six-minute Push (6MPT) Tests measure the distance a subject can cover while indoors on a flat, hard surface in a period of 6 minutes. The investigators will determine which test is most appropriate to administer based on the participant's primary mode of mobility (ambulation= 6MWT, manual wheelchair=6MPT). These tests will be used to determine each participant's change in endurance capacity with a greater increase in distance at the later time indicating greater improvements in endurance.
Change in Six-Minute Walk/Push Test from Baseline to 24 weeks
The Six-minute Walk (6MWT) and Six-minute Push (6MPT) Tests measure the distance a subject can cover while indoors on a flat, hard surface in a period of 6 minutes. The investigators will determine which test is most appropriate to administer based on the participant's primary mode of mobility (ambulation= 6MWT, manual wheelchair=6MPT). These tests will be used to determine each participant's change in endurance capacity with a greater increase in distance at the later time indicating greater improvements in endurance.
Change in Exercise Self-Efficacy from Baseline to 12 weeks
The Exercise Self-Efficacy Scale assesses an individual's beliefs in their ability to continue exercising on a three time per week basis at moderate intensities for 40+ minutes per session in the future. Participants will indicate their confidence for each domain on a 100-point percentage scale comprised of 10-point increments, ranging from 0% (not at all confident) to 100% (highly confident). Exercise Self-Efficacy scale will be modified to match the SCI exercise guidelines of exercising on a two time per week basis at moderate intensities of aerobic exercise for 20+ minutes per session and/or prescribed strength training. A greater increase in score at the later time point is indicative of greater improvements in self-efficacy (better outcome).
Change in 10 Meter Walk or Wheelchair Propulsion Test from Baseline to 12 Weeks
The 10-Meter Walk Test (10-MWT) assesses subject walking speed in meters per second for 10 meters. Subjects may repeat each measure up to 3 times at their normal self-selected walking speed and 3 times at a fast speed while still able to maintain safety. If the participant primarily uses a manual wheelchair, the Wheelchair Propulsion Test (WPT) will instead be administered. The WPT assesses subject push speed, push frequency, and push effectiveness for 10 meters. Subjects will propel using their usual method and may complete up to 3 trials. For either assessment, a higher change in speed would indicate faster ambulation/wheelchair propulsion (better outcome) at the later time point than the earlier time point.
Change in 10 Meter Walk or Wheelchair Propulsion Test from 12 to 24 Weeks
The 10-Meter Walk Test (10-MWT) assesses subject walking speed in meters per second for 10 meters. Subjects may repeat each measure up to 3 times at their normal self-selected walking speed and 3 times at a fast speed while still able to maintain safety. If the participant primarily uses a manual wheelchair, the Wheelchair Propulsion Test (WPT) will instead be administered. The WPT assesses subject push speed, push frequency, and push effectiveness for 10 meters. Subjects will propel using their usual method and may complete up to 3 trials. For either assessment, a higher change in speed would indicate faster ambulation/wheelchair propulsion (better outcome) at the later time point than the earlier time point.
Change in 10 Meter Walk or Wheelchair Propulsion Test from Baseline to 24 Weeks
The 10-Meter Walk Test (10-MWT) assesses subject walking speed in meters per second for 10 meters. Subjects may repeat each measure up to 3 times at their normal self-selected walking speed and 3 times at a fast speed while still able to maintain safety. If the participant primarily uses a manual wheelchair, the Wheelchair Propulsion Test (WPT) will instead be administered. The WPT assesses subject push speed, push frequency, and push effectiveness for 10 meters. Subjects will propel using their usual method and may complete up to 3 trials. For either assessment, a higher change in speed would indicate faster ambulation/wheelchair propulsion (better outcome) at the later time point than the earlier time point.
Change in Barriers to Physical Activity Questionnaire for People with Mobility Impairments from Baseline to 12 Weeks
The Barriers to Physical Activity Questionnaire for People with Mobility Impairments (BPAQ-MI) is a self-reported 43-item questionnaire to identify the perceived barriers and the extent of barriers to physical activity experienced by people with mobility impairments. Items are weighted, so minimum and maximum values for each domain vary. A higher score is always indicative of more problematic barriers and a decrease in BPAQ-MI scores at the later time point (compared to the earlier time point) would be indicative of less problematic barriers and a better outcome.
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