General Health, Attitudes, and Activity in Self-directed Exercise in Patients With Cystic Fibrosis (GAINS-CF)

Adults with CF aged 18 and above, who have access to either Google Play (Google LLC) or Apple (Apple Inc.) smart device, and are patients of the University of Virginia Adult CF clinic will be enrolled in this study. Subjects will be invited by the PI during routine pre-visit planning for quarterly appointments. Subjects who are unable to provide consent, pregnant or trying to become pregnant, or have a known physical condition that precludes exercise will be excluded. Enrolled subjects will serve as their own controls, and there will be an additional four healthy non-CF controls. We will recruit subjects from each lung function subgroup FEV1 < 40%, FEV1 40-79%, and FEV1 >80%.

Enrolled subjects will be screened using the Physical Activity Readiness Questionnaire (PAR-Q) prior to exercise. Respondents who are not eligible for exercise based on PAR-Q results will be excluded. Subjects will participate in the Exercise Benefits/Barriers Scale (EB/BS) to identify perceived benefits and barriers to exercise via online secured Qualtrics Research Suite link. They will participate in a one-on-one conversation with the PI answering open-ended questions about how their life experience with CF may impact exercise behavior, as well as their attitudes toward use of personal technology in exercise. Input will be qualitatively analyzed for themes that may aid in developing more personalized plans for exercise engagement.

Subjects will complete the Short General Health Questionnaire (GHQ 12) to establish self-reported baseline levels of general physical and mental health. They will be fitted with a wrist actigrapher (FitBit Inspire 2; Google, LLC). They will receive training on FitBit usage and how to safely export data via HIPAA-secured electronic communication. For four weeks, physical activity will be logged, including steps per day, time spent in aerobic activity, respiratory rate, and heart rate. This will establish baseline levels of activity.

Subjects will then begin the "Team \& Technology" exercise intervention. Team: Participants will receive weekly phone calls from members of the CF care team encouraging exercise and offering motivational interviewing personalized from earlier interviews. Technology: Participants will take part in a live demonstration of three subscription-based exercise apps compatible with Apple and Google Play personal devices, and will receive unlimited access to all apps. They will also receive access to a mobile-friendly exercise community website designed by UVA patient partner for adults with CF (www.activate65.org, Elize Hewitt, 2021). The apps were selected based of their ability to provide a variety of workouts from home using only body weight, without specialized equipment. Apps included in this study are BodBot (BodBot, LLC), an AI-learning exercise app that customizes exercise plans to the user and incorporates body weight and aerobic exercise; SHRED (Shred Labs, LLC), an AI-learning exercise app that incorporates both muscle-building and aerobic exercise; Seven (Perigee AB), and J\&J Official 7 Minute Workouts (Johnson \& Johnson Health and Wellness Solutions, Inc) two apps that generate high-intensity interval training (HIIT) workouts in 7-minute intervals based on self-selected skill level. Subjects will be encouraged to exercise using any method they wish, including using any combination of the technology options, or their own methods. Multiple apps with different methods and styles have been selected so that any one specific app does not become the intervention per se, but rather provides exercise options. Physical activity will be logged, along with app and website usage. After four weeks, EB/BS and GHQ 12 surveys will be repeated.

After the intervention period, motivational phone calls will end. Subjects will still have unlimited access to the technology, and will continue to wear actigraphers. Technology usage and physical activity will be logged at the end of an additional four weeks to assess for sustainability of exercise habits. Finally, EB/BS and GHQ 12 surveys will be repeated during a debrief phase.

This pilot study will identify perceived benefits and barriers to exercise, based on the unique lived experiences of adults with CF. We will determine whether attitudes toward exercise correlate with elements of emotional and physical wellbeing, and we will assess whether perceived benefits and barriers toward exercise can be positively shaped by motivational interviewing and encouragement from the individual's care team. We will further determine whether the use of widely available personal smart devices can be leveraged to form sustainable exercise habits in adults with CF.

Exercise is a critical component to physical and mental health, and is of particular importance as we inch closer to a cure for CF. We believe that the qualitative input on attitudes toward exercise behavior will be a valuable aspect to creating sustainable exercise plans that address the specific challenged faced by people with CF. We hypothesize that having access to wrist actigraphy alone will increase physical activity by creating immediate positive feedback and personal accountability. We further anticipate that having access to a variety of home workout options, along with personal support and motivational interviewing from the CF care team, will increase overall exercise habits and positively impact attitudes toward exercise. We hypothesize that physical activity will decrease in the sustainability period, but overall activity and attitudes toward perceived barriers will improve compared to baseline.

If exercise sustainability is observed as we anticipate, we plan to embark on a large, randomized controlled using pilot data to inform power analysis. This trial will investigate the role of sustained home exercise in CF on lung function, exacerbation rates, mental health, BMI, lean muscle composition, and other important clinical outcomes. These questions are of particular interest in the era of highly-efficacious CFTR modulator therapies that are extending length and quality of life.