Developing a decision support system for exercise engagement among individuals with conditions causing mobility impairment: Perspectives of fitness facility fitness exercisers and adapted fitness center trainer

Abstract

BACKGROUND:

Persons with conditions causing mobility impairment such as multiple sclerosis (MS), Parkinson’s disease (PD) and stroke (CVA) do not have accessible resources or programs that promote and sustain exercise engagement.

OBJECTIVE:

This study explored perceptions of fitness facility exercisers with MS, PD and CVA, and adapted fitness center trainers, regarding a decision support system (DSS), and its design and components, for promoting, guiding, and sustaining exercise engagement.

METHODS:

Fitness facility exercisers ( $n=$ 15) and adapted fitness center trainers ( $n=$ 5) partook in semi-structured qualitative interviews. The interviews were audio-recorded and transcribed verbatim. We applied thematic analysis and identified themes and sub-themes regarding perceptions, design features, and components of a DSS for promoting, guiding, and sustaining exercise engagement.

RESULTS:

All fitness facility exercisers and adapted fitness center trainers believed that a DSS would be a beneficial tool for exercise prescription and progression. There were concerns about individualization and safety, and participants felt that a DSS should include evidenced-based, disease-specific, and individualized exercise prescriptions as well as prescreening for contraindications and fall risk. The participants further reported that behavioral change strategies were desirable for promoting and sustaining exercise participation.

CONCLUSION:

The study results identified perceptions and desired features of a DSS for promoting, guiding, and sustaining exercise engagement among individuals with conditions causing mobility impairment. This information will guide development of a prototype for subsequent usability and feasibility testing.

Keywords

Decision support system exercise mobility impairment exercise prescription

1. Introduction/background

There are guidelines for clinical exercise prescription and promotion in conditions that result in mobility disability such as multiple sclerosis (MS), Parkinson’s disease (PD), and cerebrovascular accident (CVA) or stroke [1], yet persons with those conditions are not receiving appropriate evaluation, prescription, and promotion of exercise behavior change in the context of the patient-provider interaction [2]. This evidence-to-care gap underscores the importance of better knowledge translation strategies for the inclusion of exercise in clinical and everyday care and health promotion among persons with MS, PD, and CVA. The development of a decision support system (DSS) may be optimal for the promotion of exercise in diseases that result in mobility disability [2, 3], as it facilitates knowledge translation by providing high-quality evidence during the point of care [3, 4, 5, 6]. This may be particularly important for providers with limited knowledge about mobility impairment [4, 5] and environments that might not have experienced adapted fitness center trainers [7]. The development of a DSS further promotes disease management through patient-specific assessments of safety and readiness for change [4, 5], and generation of recommendations for clinicians/practitioners through the input of data into a computer combined with the assistance of a software algorithm that can match information from a knowledge database [4, 5].

Researchers have developed and applied DSSs for health behavior change in healthy individuals and those with a variety of health conditions, including prediabetes, diabetes and cardiovascular disease [8, 9, 10, 11]. The results of these studies have been positive and support the application of DSSs for a variety of health behaviors, including medication adherence, healthy eating, self-management of diabetes, and engagement in exercise [3, 4, 5, 6]. One recent systematic review further reported that 100% of randomized controlled trials ( $n=$ 7) applying a DSS for weight loss and management of prediabetes/diabetes resulted in increased physical activity [11]. Further notable takeaways were that the majority of these trials included behavioral interventions and were developed based upon theoretical models [11]. We note that none of the studies in that review included persons with mobility disability caused by MS, PD, or CVA, and this is pertinent as these individuals have reduced exercise participation and use of a DSS may additionally facilitate exercise participation for these populations.

The development of a DSS might capitalize on recent qualitative work focusing on the patient-provider interaction for exercise promotion in MS and other diseases resulting in mobility disability. The qualitative work with MS patients indicated a need for (a) information on the benefits of exercise and exercise prescription, (b) materials to facilitate home and community exercise, and (c) tools for initiating and maintaining exercise behavior [12]. The qualitative work with providers indicated a need for (a) opportunities to promote exercise through the health care system, (b) education on exercise for those with MS, and (c) tools and strategies to help promote exercise for persons with MS [12]. We combined this qualitative research into a conceptual model that provides a framework for the facilitation of exercise promotion in comprehensive MS care centers through the patient-provider interaction [13]. Such research may be important for informing the development of a DSS for guiding exercise promotion through the patient-provider interaction in diseases of mobility disability.

The current study adopted a qualitative research design and explored the perceptions of potential users of a DSS for exercise promotion in persons with conditions resulting in mobility impairment, including fitness facility members with a history of MS, PD, and CVA and trainers within an adaptive fitness center. This research design is appropriate and necessary for informing the design of a DSS that can be translated into a functional prototype for subsequent usability and feasibility testing. The specific research question was what are the perceptions of fitness facility exercisers (diagnosed with a condition causing mobility impairment) and adapted fitness trainers regarding a DSS and its preferred design and content features for exercise prescription and progression. We define fitness facility exerciser as a person with MS, CVA or PD who currently exercises, and adapted fitness trainer as a person who works with individuals with disabilities that prescribe, develop and progress exercise programs.

Table 1
Interview scripts

Exerciser script
Ice breaker questions:
Tell me about your current exercise routine. (site, equipment used, frequency, duration, progressive or static)
What would you change about your exercise routine?
How did you learn about this exercise routine?
Was this exercise routine personalized for you? How? By whom?
Tell us about the person(s) who support your exercise routine.
How do you progress your exercise routine?
Decision Support System defined, followed by:
Tell me your thoughts about a Decision Support System
Would a DSS help your exercise routine? Why or why not?
What type of information should a DSS collect about you?
What is the best way for you to receive information from a DSS?
What format would you find most useful? (text worksheet, personalized manual, etc.)
When using a DSS, how would you envision interacting with your trainer?
How would use the DSS information in your exercise routine?
Trainer script
Tell me about your approach to prescribing exercise for individuals with MS.
Tell me your thoughts about a Decision Support System (DSS).
How would DSS align with your current practice?
Based on your practice, what should be in a DSS?
Would a DSS change your practice? If yes, describe. If no, why?
What information would you envision collecting from a person to enter into a DSS?
What is the best method for entering information into a DSS?
What type of information should your client receive from a DSS?
In what form would you like to receive information from a DSS?
What are your perceptions of our proposed DSS?
Would our proposed DSS be helpful to your practice? Why or Why not?
What would you change about our proposed DSS?

2. Research data and methods

2.1 Recruitment

This study included stratified purposeful sampling. We sought a sample of participants who were fitness center users with mobility disability and staff of an adapted fitness center for securing opinions from target users who would interface with a DSS and inform its design features. The participants who were fitness center users with mobility disability included those with MS, PD, and CVA. Importantly, MS and PD are both progressive neurodegenerative conditions with the majority of individuals experiencing impairment and gradual loss in mobility resulting in reduced participation in activities of daily living (ADLs) over time [1]. By comparison, CVA is a neurological event resulting in deficits that are not progressive, but as with MS and PD, can result in loss of mobility and reduced participatition in ADLs [1]. MS, CVA and PD have different causes and outcomes but result in similar and significant deficits such as reduced mobility, cognition and sensory loss, and are among the most common conditions resulting in mobility disability among adults. Symptoms such as weakness, fatigue, pain, depression can further result in reduced quality of life [1]. The adapted fitness facility staff included fitness and aquatics directors and a recreation specialist. Other inclusion criteria included English speaking and cognitively intact, as those criteria were important for participating in data collection procedures. We did not seek medical diagnosis of cognitive status, but rather this was verified by adaptive fitness center personnel who had worked with participants at the facility and had access to admission applications documenting medical diagnoses. We recruited all participants from a community fitness facility dedicated to serving those with primarily physical disabilities. The facility, the Lakeshore Foundation, is located in a suburban area in the southeast United States. The facility offers exercise, athletic, and recreation opportunities among persons across the lifespan with a disability and serves as an Olympic and paralympic training center. This was an ideal recruitment location as our study purpose involved learning about the perspectives of potential DSS users with the end goal of designing a prototype. We recruited for equal numbers of each group until saturation was achieved.

2.2 Data collection

This study applied qualitative inquiry for discerning the perspectives of potential users of a DSS. Qualitative methodology was an appropriate approach for this stage of research, as we were interested in gaining perspectives on the interest in a DSS as well as program elements and features for DSS prototype development. We applied an inductive approach for gaining detailed perspectives of potential DSS users. The interviews were conducted with open-ended questions, as this allowed for developing a database on elements and features for the DSS prototype that is ideally suited for fitness facility exercisers with health conditions and adapted fitness center trainers.

Table 2
Participant characteristics

Role	Disease	Gender	Age	Exercise frequency	Membership duration (years)
Exerciser	MS	Male	63	1–4X/month	3
Exerciser	MS	Female	51	2X/week	17
Exerciser	MS	Female	66	5X/week	7
Exerciser	MS	Female	49	4X/week	7
Exerciser	MS	Female	60	5X/week	1
Exerciser	PD	Male	78	2X/week	2
Exerciser	PD	Male	77	0X/week	2
Exerciser	PD	Male	75	2X/week	1
Exerciser	PD	Male	70	3X/week	3
Exerciser	PD	Male	62	3X/week	6
Exerciser	CVA	Female	33	3X/week	1
Exerciser	CVA	Female	48	3X/week	4
Exerciser	CVA	Male	55	3X/week	5
Exerciser	CVA	Male	48	2X/week	3
Exerciser	CVA	Male	59	5X/week	1
Role	Area	Gender	Age	n/a	Employment duration (years)
Trainer	Aquatics ${}^{*}$	Female	32	–	9
Trainer	R/A ${}^{*}$	Female	28	–	5
Trainer	R/A ${}^{*}$	Male	33	–	10
Trainer	F/HP ${}^{*}$	Female	59	–	9
Trainer	F/HP	Female	46	–	19

Note: MS $=$ multiple sclerosis; PD $=$ Parkinson’s disease; CVA $=$ cerebral vascular accident; R/A $=$ Recreation and Athletics; F/HP $=$ Fitness and Health Promotion; ${}^{*}$ $=$ Director.

Our sample included 15 fitness facility exercisers and 5 adapted fitness center trainers. The users were selected based on the diagnosis of MS ( $n=$ 5), PD ( $n=$ 5), or CVA ( $n=$ 5). We screened 23 fitness facility exercisers, and eight declined or were unable to be scheduled thereby resulting in the final sample of 15. All five adapted fitness facility center trainers who were screened participated in the study. The participants partook in one-on-one semi-structured interviews that focused on perceptions of a DSS and the desired characteristics of this device for prescribing, progressing, and supporting exercise change over time. Table 1 provides the interview scripts of fitness facility exerciser and adaptive fitness facility trainer. One investigator completed all of the interviews within the adapted fitness facility, and the interviews lasted between 60 and 90 minutes. All interviews were audio-recorded and transcribed verbatim via an online service. We reviewed all transcripts for accuracy. The university institutional review board approved the study and all participants provided written consent.

2.3 Data analysis

We examined the data using thematic analysis. This facilitated the discovery of patterns and meanings within the data and enabled a better understanding of the perceptions of a DSS [14]. To ensure rigor, we applied Braun and Clarke’s stages of thematic analysis [14]. Using this process, we first organized question responses, immersing ourselves in the data by reading each transcript multiple times. We then generated preliminary codes by chunking together meaningful data and ascertaining the key concepts that would later be formed into themes. We next arranged, combined and split our preliminary key concepts and developed overarching themes. To reduce bias, we applied the use of a critical friend; one researcher independently coded the data, followed by a discussion with a second investigator who was a content expert not involved with data collection or analysis [15]. This allowed collegial dialogue that assisted the analyzing researcher with understanding and clarifying the meanings and interpretations within the data.

3. Results

The sample ( $n=$ 20) included fitness facility exercisers ( $n=$ 15) and adapted fitness center trainers ( $n=$ 5). The mean age of facility adapted fitness center trainers was 39.6 years. The CVA group was the youngest of the condition groups with a mean age of 48.6 years, followed by MS (57.8 years) and PD (72.4 years). Table 2 provides additional details about the study sample characteristics.

Figure 1.

Decision support system perceptions theme, sub-themes and categories.

We achieved agreement between the investigator and the critical friend on all coding and themes. Three themes emerged for both adapted fitness center trainers and fitness facility exercisers, namely (1) DSS perceptions, (2) DSS access, and (3) DSS content. The following describes the results, comparing and contrasting data for adapted fitness center trainers and fitness facility exercisers.

3.1 Decision support system perceptions

We defined this theme, DSS perceptions, as beliefs that adapted fitness center trainers and fitness facility exercisers possess about the use of this system for exercise prescription and progression. Two sub-themes emerged, namely (a) benefits and (b) concerns. Figure 1 illustrates the themes, sub-themes and categories for DSS perceptions. All adapted fitness center trainers and fitness facility exercisers reported a belief that a DSS would be beneficial for facilitating exercise participation, including both prescribing and progressing an exercise program. Adapted fitness center trainers expressed that a DSS could be used as a tool during orientation and that it would improve work efficiency by providing a variety of exercise routines. One trainer stated, “I think it could make it more efficient, especially like I said, if it spits out something that is at least a baseline, that is helpful”. Another stated, “So much time would be saved”. Fitness facility exercisers in all groups shared the belief that a DSS should not take the place of a trainer, but instead be used in conjunction with a trainer. The majority felt that the DSS would facilitate connecting with a trainer and that this would diminish fear of starting a program. One fitness facility exerciser diagnosed with MS who discussed connection with a trainer stated, “If it gave you something in writing that you could take to a trainer, the trainer could make it fun and help develop a plan”.

The DSS might be particularly beneficial for exercise progression, as the majority of the fitness facility exercisers in all condition groups reported difficulty progressing in current exercise programs and routines. One participant who had sustained a CVA reported that his exercise program, “pretty much stays the same”. Another with a diagnosis of PD stated, “I need to do more. I can see it”. Those who did progress personal exercise programs did so randomly. All fitness facility exercisers reported low levels of satisfaction with current exercise programs and routines and desired progression and envisioned a DSS aiding in this process. Adapted fitness center trainers focusing on improving aerobic capacity and strength reported feeling confident with program progression while adapted fitness center trainers focusing on recreation did not. One recreation trainer noted when talking about progression, “I just guess and keep my own little notes and go based on what I know to be true instead of having anything concrete. If there’s something already set to say, once you get to this, we’re going here, than I think that would be helpful”.

Fitness facility exercisers reported a desire for evidenced-based exercise programs and felt a DSS would provide this information. One participant with PD expressed this by stating, “I would like to know what I am supposed to do according to the research and if a DSS can do that, it would be wonderful”. Adapted fitness center trainers agreed that evidence-based programming is important. The adapted fitness center trainers in this study reported an existing and general knowledge of evidence-based programming for those with disabilities but thought a DSS would be particularly helpful for fitness professionals who do not possess this expertise and for delivering a population or disease/condition-specific recommendation.

Fitness facility exercisers and adapted fitness center trainers expressed overlapping concerns about using a DSS. All participants expressed concerns that a DSS exercise program might lack individualization. For example, one trainer stated, “…you may have two individuals with CVA right-sided weakness that present very different. So I think just the barrier of not everyone looks the same or can tolerate the same”. Both adapted fitness center trainers and fitness facility exercisers felt that this barrier could be diminished by a collaborative orientation between a trainer and fitness facility exerciser using a DSS as an informative guide.

Another concern expressed by all participants was safety. Adapted fitness center trainers expressed concerns about fitness facility exercisers using new and/or unfamiliar equipment, and reported the importance of adaptation and instruction for those with disabilities. One adapted fitness center trainer expressed this stating, “you may have to do modifications and I’m not sure how that would go…”. Adapted fitness center trainers recommended that the DSS include a disclaimer of injury responsibility prior to distributing a program. Fitness facility exercisers expressed similar concerns with equipment safety and expressed needing instruction on the correct use and positioning that could be provided during an initial collaborative meeting with a trainer.

3.2 Decision support systems access

We defined DSS access as the design of the device and how it is operated. Two sub-themes emerged, namely (a) design and (b) input/output. Figure 2 depicts the themes, sub-themes and categories for DSS access. All participants agreed that the system design should be electronic in the form of a kiosk, app or website with a paper option for output. “Access through multiple sources” was important for both adapted fitness center trainers and fitness facility exercisers. Whereas the adapted fitness center trainers only commented that the DSS should accommodate a variety of access abilities, the fitness facility exerciser group provided specific recommendations. All reported that electronic input of information was appropriate and felt competent in independently entering information such as diagnoses, secondary conditions, exercise preferences, current activity level, and other demographic information – as long as the point of entry was accessible. The trainer group recommended “red-flagging” specific medical information such as a history of seizures or falls for safe participation. “Flexibility” and “simplicity” were key phrases reported amongst all fitness facility exercisers. The CVA group all preferred access through Smartphone use. All groups highlighted the importance of accessibility features such as a touchscreen for one-handed access, audio input/output options, icons or pictures versus text and large print, and high contrast design for those with vision deficits. All groups reported that DSS output should be available both electronically and through paper format. The PD fitness facility exercisers were the only group that preferred paper only output. Preferences in input and output between fitness facility exercise groups could be partially attributed to age.

Figure 2.

Decision support system access theme, sub-themes and categories.

Figure 3.

Decision support system content theme, sub-themes and categories.

3.3 Decision support system content

The final theme, DSS content, describes features of the system that facilitate exercise engagement and progression. Two sub-themes emerged from the data, namely (a) exercise prescription and (b) behavior change interventions. Figure 3 illustrates the themes, sub-themes and categories for DSS content.

Adapted fitness center trainers suggested that the DSS should provide an exercise prescription that is based on guidelines, and that includes both individual and group activities and outlines exercise frequency and intensity. The exercise groups had similar ideas, and further thought the prescription should include variety, safety recommendations, caregiver tips, graded guidelines for progression and functional home activities. One exercise participant stated that the DSS should provide, “Regular everyday stuff, because nobody really wants to sit in the gym 24 hours a day, 7 days a week to try to strengthen and get range right and all that stuff, but just everyday activities that you can do that are considered therapeutic”. Another stated, “I would like to know what I can do at home or outside”. Both the fitness facility exercise group and adapted fitness center trainers expressed a desire for a resource page, but for different purposes. The adapted fitness center trainers articulated the need for a trainer resource page that directs professionals toward “disability exercise organizations”, “places to get adapted equipment” or information about healthy nutrition and diet. The fitness facility exercisers felt an exercisers resource page could provide information on exercise events and activities.

All adapted fitness center trainers and fitness facility exercisers discussed the importance of the DSS, including approaches for supporting behavior change. The approaches included self-monitoring, social interaction and engagement, goal setting, notifications, incentives and knowledge building. All adapted fitness center trainers and exercises acknowledged the importance of goal setting and self-monitoring. Several fitness facility exercisers expressed interest in a visual “trend line” or feedback that displays progress towards goals within the DSS. One fitness facility exerciser with PD stated, “if you’re accomplishing something or gaining on things, it’s really easy to be motivated to keep gaining, success means a lot to somebody especially somebody that’s in a handicap situation”. Adapted fitness center trainers felt that if the DSS could send them tracking results, such information could support and reinforce behavior change through messaging. One adapted fitness center trainers stated, “… I can message back something like, ‘Way to crush your goals’ or something like that. If there’s a way to just increase motivation that way, I don’t know if there would be a way to share with people what you are doing”. Both groups of participants believed that the DSS could provide positive affirmations for log-ins and other routines. Additionally, email or text reminders, such as “get to the gym”, may support exercise behavior change.

All participants felt the DSS should provide a platform for social interaction. This could involve the connection between adapted fitness center trainers and fitness facility exercisers, and connecting fitness facility exercisers with one another. There was interest in building a sense of community for accountability and potential connections among exercise group members or partners. One fitness facility exerciser with PD stated, “well, you’ll put forth effort to do more things if you get somebody that’s pulling for you or if you have a common goal”. Another stated, “I am more likely to go exercise if my buddy comes with me. If I’m not with someone, I’m much more likely to say, I’m tired, I don’t want to go”. The adapted fitness center trainers discussed success with past competitions for small prizes such as drink coupons or t-shirts. All fitness facility exercisers reported that group or individual competitions with incentives was motivating. Several mentioned how the accumulation of “points” or “badges” for exercise competitions, individual or group, could be “cashed in” for prizes or deductions off membership dues.

All participants discussed the importance of knowledge building. This specifically focused on enhancing knowledge regarding the benefits of exercise and exercise precautions and safety. The methods for enhancing knowledge may include instructional videos or handouts, games, webinars and podcasts. Adapted fitness center trainers expressed that knowledge building activities could apply to providers with little experience training those with disabilities. The DSS could provide training about how to adapt and safely prescribe exercise for individuals with health conditions that limit par ticipation.

4. Discussion

There is strong evidence for the benefits of exercise in persons with conditions causing mobility disability [2], but the rate of participation is exceedingly low in these conditions [16]. There has been a recent focus on changing exercise behavior in MS through the patient-provider interaction, and this would likely work for those with PD or CVA. Such a focus on the patient-provider interaction likely occurs within the context of healthcare provider services and centers, and this supports the importance of DSS for promoting and sustaining exercise engagement. To that end, we undertook a qualitative study of the value and perceptions of a DSS for promoting exercise in persons with conditions causing mobility disability, and this was accomplished through semi-structured qualitative interventions with exercise and staff/adapted fitness center trainers from an adapted exercise training facility. We learned much regarding the perceptions, design, and features of a DSS for persons living with mobility disabling consequences of MS, PD, and CVA. Our results offer important perceptions of a DSS by fitness facility exercisers with conditions causing mobility impairment and adapted fitness center trainers. All participants, including fitness facility exercisers and adapted fitness center trainers, expressed the opinion that a DSS would be beneficial for exercise prescription and progression, and this is consistent with the literature demonstrating that clients and patients who are prediabetic, diabetic, overweight or have cardiovascular disease and use a DSS are more likely to adhere to exercise programs [8, 9, 10, 11]. DSS design varies and may include internet-linked, mobile, sensing devices and telehealth models [11]. Our participants too preferred electronic design with the fitness facility exerciser groups being highly focused on accessibility of input and output. We did not find literature describing DSSs designed with a focus on universal design features. This appears an important consideration for these groups. The study participants discussed collaborative use of the DSS between trainer and fitness facility exerciser. This appears in common practice when designing and using a DSS [11]. An essential element of a DSS is the proper prescription of an exercise program guided by the input of pertinent user health information and providing “coaching” or instruction at the onset of the exercise program [11].

The development of a DSS should be informed by conceptual models such as the aforementioned model focusing on patient-provider interaction for persons with MS and consist of three components/systems (a) risk/needs profile assessment system; (b) exercise prescription system; and (c) behavior change support system. The profile assessment system includes (i) risk assessment based on SPPB (physical function); (ii) disease classification; (iii) preferences for exercise training modality; and (iv) motivational profiling for supporting behavior change. The data from the risk/needs assessment system are then processed using a decision algorithm programmed using a rules-based approach into a tablet with exercise prescription and behavior change support systems. The exercise prescription system is based on disease classification as well as preferences for exercise modality and risk stratification, and provides a detailed, manualized, and precise prescription for a 16-week period of exercise training in a supervised setting with trainer support. The motivational profile and support system are based on components of Social Cognitive Theory (SCT) and its stepwise implementation [17]. The support system is delivered via a customized handbook with newsletters and other materials for supporting change over time and can be discussed with the support of a trainer. These are delivered in a scheduled manner that aligns with keys points in the 16-week exercise prescription (e.g., knowledge when starting the program; self-monitoring and goal setting immediately after initiating the program; and self-efficacy, outcome expectancies, and facilitators/barriers as the program progresses).

We propose to develop a Minimum Viable Product (MVP) of the DSS [18] using the results above. MVPs are used in the Lean Startup Methodology [19], wherein the MVP contains enough features to attract early-adopters to validate a product idea early in the product development cycle. This lean approach helps the team receive user feedback as quickly as possible, enabling multiple iterations to improve the product. This MVP contains essential features to test the early usability, acceptability and feasibility of the DSS. Upon development of the MVP, an IRB approved usability and feasibility study is proposed. Feedback from the usability and feasibility study will be used to revise the system, and a randomized controlled trial will be conducted. Based on the results above, our MVP will primarily consist of three systems (a) risk/needs profile assessment system; (b) exercise prescription and progression system; and (c) behavior change support system. An overview of these systems is presented below.

The risk/needs profile assessment system (PAS) includes (i) risk assessment based on SPPB (physical function); (ii) disease classification; (iii) preferences for exercise training modality; and (iv) motivational profiling for supporting behavior change. The data from the risk/needs assessment system will then be processed using a rules-based expert system [20] to deduce a safe and individualized exercise prescription for the fitness facility exercisers to start with. With safety as a high priority, the risk assessment system shall identify fitness facility exercisers who need medical clearance and/or extra safety precautions.

The exercise prescription and progression system (EPPS) uses the data from the PAS and provides a disease-specific individualized prescription for a 16-week period of exercise training in a supervised and collaborative setting with trainer support. The EPPS collects feedback from the adapted fitness center trainers to understand the progression made by the participants and uses this information to tweak the progression process. The EPPS collects information from the fitness facility exercisers at the end of each session to monitor prescription compliance, satisfaction and other related items.

The motivational profile and support system (MPPS) is based on components of the Social Cognitive Theory (SCT) and its stepwise implementation. The support system will deliver customized behavior support material (e.g., knowledge when starting the program; self-monitoring and goal setting immediately after initiating the program; and self-efficacy, outcome expectancies, and facilitators/barriers as the program progresses) all through the 16 week training period on a schedule. The system also includes various self-monitoring features and text/email notifications.

Scientific evidence supports the benefits of engagement in physical activity [2]. Despite these documented benefits, statistics demonstrate that the majority of those with conditions causing mobility impairment either do not exercise or do not exercise enough to garner these benefits [2, 16]. Behavior change interventions have been shown to be effective strategies to enhance exercise behavior [11]. All of our participants, adapted fitness center trainers and fitness facility exercisers, described in detail the desire to have behavior change interventions included in the design of a DSS. Effective DSSs described in the literature have included behavior change interventions such as goal setting, tracking, reminders and feedback [11]. The most frequently cited included personalized goal setting and motivational feedback [8, 9, 10, 11].

4.1 Limitations

Participants in this study were fitness facility exercisers and adapted fitness center trainers from one facility whose direct mission involves serving those with disabilities, and this environment might be quite unique compared with other settings [21]. Nevertheless, this is the first step in the design of a DSS and the eventual DSS prototype will be tested for usability and feasibility within this site and then elsewhere for designing a robust system for exercise promotion. Of note, the opinions and perceptions of those outside of this facility were not elicited, and this might represent a limitation. Particularly, adapted fitness center trainers who do not possess the knowledge and skills for working effectively with individuals who have health conditions and disability may uncover very different perceptions of DSS usefulness and content.

The sample size of adapted fitness center trainers ( $n=$ 5) and fitness facility exercisers ( $n=$ 15) was relatively small but fully appropriate for this type of study design. It should be noted however that we will use the results of this study to develop a DSS prototype; our intent is not the generalization of study results. We lastly recognize that our approach for ensuring intake cognitive status of the participants was not ideal, and future work may consider using healthcare provider verification, administration of a cognitive screener, or neuropsychological testing.

4.2 Future research

Future research will center on the development of a DSS prototype and subsequent usability and feasibility studies. Successful development will lead to intervention trial studies. Additional qualitative research should be completed to solicit the perceptions of fitness facility exercisers and adapted fitness center trainers from various facilities with varying degrees of knowledge and healthcare providers who are trained in adaptive fitness such as physical and occupational therapists. Expanding the data by interviewing those with and without adaptive fitness training could inform decisions about DSS use with varying professionals, fitness facility exercisers and settings and potential design modifications for these groups.

Footnotes

Conflict of interest

None to report.

References

Kim

Lai

Mehta

Thirumalai

Padalabalanarayanan

Rimmer

, et al. Exercise training guidelines for multiple sclerosis, stroke and parkinson disease: rapid review and synthesis. Am J Phys Med Rehabil. 2019 Jul 1; 98(7): 613-21.

Motl

Sandroff

Kwakkel

Dalgas

Feinstein

Heesen

, et al. Exercise in patients with multiple sclerosis. Lancet Neurol. 2017 Oct 1; 16(10): 848-56.

Hansen

, et al. The european association of preventative cardiology exercise prescription in everyday practice and rehabilitative training (EXPERT) tool: a digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definition and construction methodology. Soc of Card. 2017; 24(10): 1017-1031.

Kastner

Lottridge

Marquez

Newton

Straus

. Usability evaluation of a clinical decision support tool for osteoporosis management. Qual Life Res. 2010; 5(96): 1-12.

Kastner

Lottridge

Marquez

Newton

Straus

. Development of a prototype clinical decision support tool for osteoporosis disease management: a qualitative study of focus groups. BMC Med Info Dec Making. 2010; 10(40): 1-15.

Motl

Barstow

Blaylock

Richardson

Learmonth

Fifolt

. Promotion of exercise in multiple sclerosis through healthcare providers. Ex Sports Sci Rev. 2018; 46(2): 105-111.

Richardson

Motl

. Promoting inclusion in a fitness center through non-impaired staff: creating a multi-narrative environment. Qual Res Sport, Ex and Health. 2019. doi: 10.1080/2159676X.2019.1637926.

Triantafyllidis

Filos

Buys

Claes

Cornelissen

Kouidi

, et al. Computerized decision support for beneficial home-based exercise rehabilitation in patients with cardiovascular disease. Comput Methods Programs Biomed. 2018 Aug; 162: 1-10.

Kaissi

Parchman

. Organizational factors associated with self-management behaviors in diabetes primary care clinics. Diabetes Educ. 2009 Sep; 35(5): 843-50.

10.

Bright

Wong

Dhurjati

Bristow

Bastian

Coeytaux

, et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012; 157(1): 29-43.

11.

Triantafyllidis

Filos

Claes

Buys

Corneilssen

Kouidi

, et al. Computerized decision support in physical activity interventions: a systematic literature review. Int J Med Inform. 2018 Mar 1; 111: 7-16.

12.

Learmonth

Adamson

Balto

Chiu

Molina-Guzman

Finlayson

, et al. Investigating the needs and wants of healthcare providers for promoting exercise in persons with multiple sclerosis: a qualitative study. Disabil Rehabil. 2018 Aug 28; 40(18): 2172-80.

13.

Richardson

Blaylock

Barstow

Fifolt

Motl

. Evaluation of a conceptual model to guide health care providers in promoting exercise among persons with multiple sclerosis. Adapt Phys Activ Q. 2019 Jan 1; 36: 109-31.

14.

Braun

Clarke

Weate

. Using thematic analysis in sport and exercise research. In: Smith

Sparkes

. (eds.) Routledge Handbook of Qualitative Research in Sport and Exercise. London: Routledge, 2016, pp. 191-205.

15.

Fougler

. External conversations: an unexpected discovery about the critical friend in action research inquiries. Act Res. 2010 Jun; 8(2): 135-52.

16.

Klaren

Motl

Dlugonski

Sandroff

Pilutti

. Objectively quantified physical activity in persons with multiple sclerosis. Arch Phys Med Rehab. 2013 Dec 1; 94(12): 2342-8.

17.

Fifolt

Richarson

Barstow

Motl

. Exercise behaviors of persons with multiple sclerosis through the stepwise implementation lens of social cognitive theory. Disabil Rehabil. 2018 Dec 4; 1-9. doi: 10.1080/09638288.2018.1514077.

18.

Moogk

. Minimum viable product and the importance of experimentation in technology startups. Tech Innova Manage Rev. 2012; 2(3): 23-6.

19.

Blank

. Why the lean start-up changes everything. Harvard Business Review. https://hbr.org/2013/05/why-the-lean-start-up-changes-everything (2013, accessed 13 January, 2020).

20.

Shortliffe

. Medical expert systems – knowledge tools for physicians. West J Med. 1986 Dec; 145(6): 830-9.

21.

Richardson

Motl

. A narrative exploration of an adapted physical activity space and its impact on persons with physical impairments. Disabil Soc. 2019 May; 1-22. doi: 10.1080/09687599.2019.1617111.

Developing a decision support system for exercise engagement among individuals with conditions causing mobility impairment: Perspectives of fitness facility fitness exercisers and adapted fitness center trainer

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction/background

Table 1 Interview scripts

2.1 Recruitment

2.2 Data collection

Table 2 Participant characteristics

3. Results

3.2 Decision support systems access

4. Discussion

4.1 Limitations

4.2 Future research

Footnotes

Conflict of interest

References

Table 1
Interview scripts

Table 2
Participant characteristics