Towards a healthier lifestyle in wheelchair users: the potential of mHealth and wearables

Can wheelchair users improve their lifestyle and health using a combination of standard wearable sensors and a customised mHealth platform? By gaining insight in the lifestyle of wheelchair users, provide an evidence-based mHealth application, combined with wearable technology, and evaluate lifestyle changes during a 12- week intervention in wheelchair users with a chronic lower-limb disability, we strived to answer the main research question. Results in chapter 2 emphasize the necessity of health promotion for people with spinal cord injury (SCI). Results showed that it is difficult to combine both aerobic and strength exercises on a weekly basis for people with SCI. An older age, being female, having a tetraplegia and a low educational level were negatively associated with exercise behavior. On a positive side, relatively low exercise levels were associated with improved respiratory function. Increased aerobic exercise levels were associated with improved physical fitness (VO2peak), exercise capacity (POpeak) and body composition. With no associations found between exercise levels and lipid profile or blood pressure, only limited results on health were found. The evidence-based exercise guidelines for people with SCI seem to partly achieve what they are designed for and should, therefore, be used as a guide towards healthier physical activity behavior and health promotion. Wearable technology could play a role in healthy lifestyle promotion. This also applies to wheelchair users, provided that this technology can accurately measure their physical activity behavior. Chapter 3 shows that the heart rate recording accuracy of wearables, measured with the photoplethysmography (PPG) technique, could be less precise in people with SCI. Results showed that the heart rate recording accuracy is in general lower in people with an SCI than in able-bodied individuals, and fell just outside the acceptable mean absolute percentage error (MAPE) of ± 10%. Accuracy severely dropped in people with lesion levels above Thoracic 1 during wheelchair activities (MAPE=20.43%) and strength exercise (MAPE= 22.29%). Therefore, PPG-based heart rate measurements should be taken with caution in people with high lesion SCI, especially when the importance of accurate data is high. In chapter 4, the developmental process and experienced usability and feasibility of the WHEELS mHealth application is presented. The development process describes how intervention goals were determined with the corresponding behavior change techniques and implemented in the WHEELS app. The results of the pilot study showed a reasonable usability score with suggestions for improvement. The application seemed feasible to deploy on a larger scale and the first results on lifestyle change were promising. In chapter 5, integration of a wearable was included in the WHEELS app and was evaluated on a larger scale. During a 12-week intervention study, lifestyle-related outcomes on physical activity, diet and sleep were collected together with self-reported body composition measurements and health-related quality of life. Significant positive changes were found on diet, body composition, experienced body satisfaction, fatigue, mental health and vitality. No enduring changes were found on physical activity and sleep behavior. Based on these results, the app seems like an easy and feasible tool for wheelchair users with a chronic disability to support a healthy lifestyle in a home setting, particularly for dietary behavior. With this, the main research question has also been answered. Based on the results we can conclude that a combination of a standard wearable sensor combined with a customized mHealth platform can improve the lifestyle of wheelchair users. However, room for improvement remains with no enduring improvements observed in physical activity and sleep quality. Aspects of wearables and mHealth that could contribute to a better intervention effect are further discussed below and further development and future research is suggested.