The exercise prescription: a tool to improve physical activity

Exploring physical activity preferences and motivation in long-term cardiac prevention: An Austrian cross-sectional survey

Cardiac rehabilitation (CR) patients often do not sustain physical activity (PA) behaviour in the long run, once they progress into a self-management stage of secondary prevention. This study aimed to explore former CR patients' PA preferences, determinants (i.e., influencing factors) and motivation for sustained PA engagement. We conducted a cross-sectional multi-centre survey using an original questionnaire based on prior qualitative interviews with cardiac patients. Five CR centres in Austria posted 500 questionnaires to former CR patients who had completed CR approximately three years prior, and 117 patients (23%) responded. Descriptive analysis was used to analyse closed-ended questions, and self-determination theory (SDT) was applied as a qualitative framework to analyse open-ended questions concerning motivation for PA engagement. Patients were generally physically active, but the majority (75.3%) did not fulfil the World Health Organisation's recommendations for aerobic PA and muscle strengthening. Most patients preferred being physically active outdoors (70%), engaging in aerobic-related (95%), individual and non-competitive exercises, with cycling (52%), walking (32%) and hiking (25%) among the most popular activities. Main determinants of PA were health, pain and motivation for 80%, 68%, 67% of patients, respectively. A subset of patients (77%) expanded on their motivations behind PA. According to SDT, most reasons (90%) were regulated by autonomous motivation (either extrinsically autonomously-regulated or intrinsic motivation) and stemmed mostly from health-related goals (e.g., fitness, general health, weight control), future quality-of-life aspirations (e.g., self-sufficiency in old age, presence for loved ones, preserving mobility) and enjoyment of PA. Patients' responses underscore the importance of promoting not only general PA, but also muscle strengthening training in CR interventions to maximise optimal health benefits. Our data further suggest that interventions which are aligned to patients' health goals and foster autonomous motivation may be particularly beneficial in increasing adherence to PA in the long-term.

Using ChatGPT to promote college students' participation in physical activities and its effect on mental health

As one of the most famous large language models, ChatGPT has great potential for application in physical education. It can provide personalized exercise plans, a variety of exercise options, and interactive support. The integration of ChatGPT into the teaching process can promote college students' participation in physical activities and improve their mental health while expanding the traditional teaching environment and promoting the reform of traditional teaching methods. However, the application of ChatGPT faces challenges and obstacles in physical education. To make full use of ChatGPT in physical education, it can be combined with wearable devices and sports equipment to enhance the efficiency of interactions with users. Relevant policies are urgently needed to avoid the improper use of users' data.

Use of a Home-Based, Commercial Exercise Platform to Remotely Monitor Aerobic Exercise Adherence and Intensity in People With Parkinson Disease

OBJECTIVE

Physical therapists are well-positioned to prescribe exercise outside of a clinical setting to promote positive health behaviors in people with Parkinson disease (PD). Traditionally, a barrier to precise exercise prescription has been reliance on participant self-reported exercise adherence and intensity. Home-based, commercially available exercise platforms offer an opportunity to remotely monitor exercise behavior and facilitate adherence based on objective performance metrics. The primary aim of this project was to characterize the feasibility and processes of remote aerobic exercise data monitoring from a home-based, commercially available platform in individuals participating in the 12-month Cyclical Lower Extremity Exercise for PD II (CYCLE-II) randomized clinical trial. Secondary aims focused on using exercise behavior to classify the cohort into exercise archetypes and describing a shared decision-making process to facilitate exercise adherence.

METHODS

Data from each exercise session were extracted, visualized, and filtered to ensure ride integrity. Weekly exercise frequency was used to determine exercise archetypes: Adherent (2-4 exercise sessions per week), Over-adherent (>4 exercise sessions per week), and Under-adherent (<2 exercise sessions per week).

RESULTS

A total of 123 people with PD completed 22,000+ exercise sessions. Analysis of exercise frequency indicated that 79% of participants were adherent; 8% were over-adherent; and 13% were under-adherent. Three case reports illustrate how shared decision-making with the use of exercise performance data points guided exercise prescription.

CONCLUSIONS

The number of exercise sessions and completeness of the data indicate that people with PD were able to utilize a commercial, home-based exercise platform to successfully engage in long-term aerobic exercise. Physical therapists can use objective data as a part of a shared decision-making process to facilitate exercise adherence.

IMPACT

Commercially available exercise platforms offer a unique approach for physical therapists to monitor exercise behavior outside of a clinical setting. The methods used in this project can serve as a roadmap to utilizing data from consumer-based platforms.

Analysis of the effects of physical activity on chronic diseases based on multidimensional data analysis

In recent years, the incidence of chronic diseases in the middle-aged and elderly population has been increasing, with high morbidity, disability, and mortality rates, and is one of the most dangerous factors leading to death in middle-aged and elderly people. Although drugs are the most common means of treating chronic diseases, long-term medication can bring serious side effects and cause chronic damage to multiple organs. Evidence-based medical evidence shows that sports prescription interventions have better intervention effects on chronic diseases without side effects, and they have become a common means to promote recovery and improve the quality of life of patients with chronic diseases. In this paper, we will analyze the effects of different sports on the indicators of chronic diseases from a multidimensional perspective and develop a scientific sports prescription to help patients with chronic diseases recover. The experimental results show that high-intensity intermittent exercise and resistance exercise also have good intervention effects on patients with chronic diseases; in addition, different exercise prescription factors such as exercise intensity, exercise time, and exercise items directly affect the intervention effects of exercise, and unscientific exercise prescriptions not only fail to promote patients’ recovery but also bring adverse effects on patients’ physical functions and even aggravate the development of the disease. The recovery of the physical function of the patients in the experimental group is sufficient to show the feasibility of exercise intervention. Therefore, the development of scientific exercise intervention prescriptions is of great significance to the rehabilitation of patients with chronic diseases.

The role of self-regulation strategies in physical activity behavior change: results from an exercise prescription program at a Federally Qualified Health Center

Physical activity (PA) improves quality of life and prevents chronic disease, yet many adults are inactive. Planning with health care providers in the form of exercise "prescriptions" may increase PA, but the role of individual psychosocial factors within exercise prescription programs is not well understood. Therefore, the purpose of this study is to describe the role of self-regulation strategies (e.g., goal setting, self-monitoring, reinforcements) in PA behavior change within the context of an exercise prescription program. Patients at a large, Federally Qualified Health Center with an on-site exercise facility (ie, "Wellness Center") referral were eligible to exercise with a personal fitness advisor. Self-reported PA and use of 15 self-regulation strategies were measured via survey at two time points and merged with electronic health records and attendance data. Patients (n = 151) were, on average, 50.3 ± 13.3 years and mostly female (76.8%). Almost one-third (30.5%) were Hispanic/Latino, 48.3% were non-Hispanic Black, and 20.5% were non-Hispanic white. Participants completed 10.7 ± 12.0 in-person exercise sessions with a fitness advisor. Between baseline and follow-up, the self-regulation strategies that had the largest change in frequency over time were keeping track of PA (p < 0.001), thinking about surroundings (p < 0.001), rewarding yourself for PA (p < 0.001), making PA more enjoyable (p < 0.001), setting goals (p < 0.001), and trying different kinds of PA (p < 0.001). Among exercise prescription program participants, the total self-regulation strategies score was significantly associated with physical activity at follow-up (p = 0.04). Leveraging self-regulatory skill-building activities within the context of exercise prescription programs in clinical settings may provide a personalized and multicomponent approach to PA promotion. Self-regulation strategy training for fitness advisors and/or health care providers has great potential for supporting long-term health behaviors like PA for managing chronic disease among underserved patients.

Effect of a Multimodal Supervised Therapeutic Exercise Program on Quality of Life, Pain, and Lumbopelvic Impairments in Women With Endometriosis Unresponsive to Conventional Therapy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of "Physio-EndEA", a multimodal nine-week supervised exercise intervention, on quality of life, pain, and lumbopelvic impairments in women with endometriosis unresponsive to conventional therapy.

DESIGN

Parallel-group randomized controlled trial. Outcomes were measured at baseline, post-intervention, and at 1 year.

SETTING

Two Public University Hospitals.

PARTICIPANTS

This trial included 31 women with endometriosis (N=31) randomly allocated to "Physio-EndEA" group (n=16) or control group (n=15). Four participants dropped out of the study for causes unrelated to the intervention.

INTERVENTIONS

The "Physio-EndEA" program consisted of a 1-week lumbopelvic stabilization learning phase followed by an 8-week phase of stretching, aerobic, and resistance exercises focused on the lumbopelvic area. It was sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. Control group received the usual treatment stipulated by their gynecologist.

MAIN OUTCOME MEASURES

The primary outcome was quality of life. Secondary outcomes were pain intensity, pressure pain thresholds, pain-related catastrophic thoughts, abdominal and back strength, lumbopelvic stability, and muscle architecture.

RESULTS

Adherence rate was 90.6% and mean (±standard deviation) satisfaction was 9.44±0.73 out of 10. No remarkable health problems were reported during the trial. In comparison with controls, the quality of life was improved post-intervention and at 1 year in the Physio-EndEA group with large effect sizes (d>0.80). This group also evidenced: a reduced intensity of dyspareunia, catastrophic thoughts; an increase in pelvic, lumbar, and distal pressure pain thresholds; increases in abdominal and back strength and lumbopelvic stability; and increased thickness of transversus abdominis (right side) and width of lumbar multifidus (left side).

CONCLUSION

A 9-week program of multimodal supervised therapeutic exercise is a feasible and effective intervention to improve QoL in women with endometriosis. This program also offers benefits in terms of pain/sensitization and lumbopelvic impairments.

Polymorphisms in Cytokine Receptor and Regulator Genes are Associated with Levels of Exercise in Women Prior to Breast Cancer Surgery

Background: Little is known about the genetic characteristics associated with exercise in women undergoing breast cancer surgery. Purpose: In a sample of women who were evaluated prior to breast cancer surgery (n = 310), we evaluated for differences in demographic and clinical characteristics between patients who did and did not exercise on a regular basis and evaluated for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators. Methods: Patients completed an investigator-developed exercise questionnaire. Based on the recommended level of exercise (≥150 minutes/week), survivors were classified into no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) groups. Candidate gene analyses were done to identify relationships between polymorphisms and exercise group membership (i.e., NoEx vs. RecEx). Only 23.5% of the total sample met the recommendations for regular exercise. Results: Compared to the RecEx group (n = 78), patients in the NoEx group (n = 120) had less education; were less likely to report being White or Asia/Pacific Islander; more likely to report a lower household income; had a higher body mass index (BMI), had a poorer functional status; had a higher comorbidity burden; were more likely to self-report high blood pressure; and were more likely to have received neoadjuvant chemotherapy. Polymorphisms in IFNGR1 and NFKB1 were associated with membership in the NoEx group. Conclusions: While they warrant replication, our findings suggest that variations in cytokine-related genes may play a role in exercise behavior, and that clinicians need to assess for barriers to regular exercise and educate patients on its benefits.

COVID-19 and Cardiometabolic Health: Lessons Gleaned from the Pandemic and Insights for the Next Wave

PURPOSE OF REVIEW

To review the current evidence regarding the impact of the coronavirus disease 2019 (COVID-19) pandemic on cardiometabolic health, with a focus on strategies to help mitigate adverse effects on population health.

RECENT FINDINGS

Individuals with cardiometabolic disease are particularly vulnerable to worse outcomes with COVID-19 infection. In addition, the pandemic itself has had significant deleterious impact on the cardiometabolic health of the population, including declines in physical activity, increases in smoking and alcohol use, worsening blood pressure and glycemic control, and detrimental effects on mental health. Targeted interventions at the patient and community level will be needed to mitigate the long-term consequences of the COVID-19 pandemic on population cardiometabolic health. The COVID-19 pandemic has worsened cardiometabolic health, but there are several opportunities and enhanced tools available to counteract these changes.

Primary Care and Physical Literacy: A Non-Randomized Controlled Pilot Study to Combat the High Prevalence of Physically Inactive Adults in Austria

The multidimensional concept of physical literacy is fundamental for lifelong physical activity engagement. However, physical literacy-based interventions are in their infancy, especially among adults. Therefore, the purpose of this pilot study was to assess the association of a physical literacy-based intervention with changes in self-reported physical literacy among inactive adults. A non-randomized controlled study (2 × 2 design) was conducted, comparing pre- vs. postintervention. Twenty-eight inactive healthy participants in the intervention group (89% female, 53 ± 10 years) entered a physical literacy-based intervention once weekly for 14 weeks. The non-treated control group consisted of 22 inactive adults (96% female, 50 ± 11 years). Physical literacy was evaluated with a questionnaire encompassing five domains: physical activity behavior, attitude/understanding, motivation, knowledge, and self-efficacy/confidence. ANOVA models were applied to evaluate changes by time and condition. Following the intervention, significant improvements were seen for overall physical literacy and in four out of five physical literacy domains, including physical activity behavior, attitude/understanding, knowledge, and self-efficacy/confidence (all p < 0.01, Cohen's d = 0.38-0.83). No changes by time x condition were found for motivation. The physical literacy-based intervention applied in this study may be a promising approach to help inactive adults to adopt an active lifestyle.

ABC of prescribing exercise as medicine: a narrative review of the experiences of general practitioners and patients

BACKGROUND

Exercise prescribing can help patients to overcome physical inactivity, but its use in general practice is limited. The purpose of this narrative review was to investigate contemporaneous experiences of general practitioners and patients with exercise prescribing.

METHOD

PubMed, Scopus, Science Direct and Cochrane reviews were reviewed using the terms 'exercise prescription', 'exercise prescribing', 'family practice', 'general practice', 'adults' and 'physical activity prescribing'.

RESULTS

After screening by title, abstract and full paper, 23 studies were selected for inclusion. Qualitative, quantitative and mixed-methods studies revealed key experiences of general practitioners and patients. Barriers identified included: physician characteristics, patients' physical and psychosocial factors, systems and cultural failures, as well as ambiguity around exercise prescribing. We present a synthesis of the key strategies to overcome these using an ABC approach: A: assessment of physical activity: involves asking about physical activity, barriers and risks to undertaking an exercise prescription; B: brief intervention: advice, written prescription detailing frequency, intensity, timing and type of exercise; and C: continued support: providing ongoing monitoring, accountability and progression of the prescription. Multiple supports were identified: user-friendly resources, workshops for doctors, guidelines for specific illnesses and multimorbidity, electronic devices, health system support and collaboration with other healthcare and exercise professionals.

DISCUSSION

This review has identified levers for facilitating exercise prescribing and adherence to it. The findings have been presented in an ABC format as a guide and support for general practitioners to prescribe exercise.

Enabling exercise prescription for survivors of cancer

Although exercise is widely recommended for survivors of cancer, readily implementable approaches for evaluating exercise tolerance enabling exercise prescriptions at appropriate levels of cardiovascular exertion are not always available. We evaluated the utility of modified Harvard Step tests within the context of a standard physical examination for fitness evaluation and exercise prescription for survivors of cancer across a range of age, BMI and exercise history. While 52% of presenting individuals with a past cancer diagnosis were able to complete a 3-min test at pace with a reduced 9-in. step, adoption of self-determined pacing, test duration and completion on a flat surface enabled relative fitness rating and appropriate exercise prescription for the remaining survivors. Younger age and more vigorous exercise histories correlated with completion of the standard 3-min test at pace, but all 9-in. formats led to exercise prescriptions more vigorous than current activity. The physical examination setting expedited inclusion of core and specific muscle group strength testing. The approach is adaptable to a range of health care settings, providers, and patients, providing a shared opportunity for providers and patients to evaluate exercise tolerance. It can be used to further expand incorporation of exercise testing and prescription into routine care.

Effect of exercise intervention dosage on reducing visceral adipose tissue: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Visceral adipose tissue (VAT) are deleterious fat deposits in the human body and can be effectively reduced by exercise intervention. Despite well-established exercise prescriptions are available, the effective dosage of exercise for reducing VAT requires verification.

OBJECTIVES

The aims of this systematic review and meta-analysis were to determine the most effective exercise dosage (modality, intensity, duration, and amount) for decreasing VAT.

METHODS

Nine databases (EMBASE, Medline, Cochrane Central Register of Controlled Trial, PubMed, CINAHL, Scopus, Web of Science, Airiti Library, and PerioPath) were systematically searched for randomized controlled trials that objectively assessed VAT. The arms of included studies covered with different exercise modalities and dosage. Relevant databases were searched through February 2020.

RESULTS

Of the 34 studies (n = 1962) included in systematic review, 32 (n = 1900) were pooled for pairwise or network meta-analysis. The results indicated that high-intensity interval training (SMD -0.39, 95% CI -0.60 to -0.18) and aerobic exercise (SMD -0.26, 95% CI -0.38 to -0.13) of at least moderate intensity were beneficial for reducing VAT. By contrast, resistance exercise, aerobic exercise combined with resistance exercise, and sprint interval training had no significant effects. No difference in VAT reduction was observed between exercising more or less than 150 min per week. Meta-regression revealed that the effect of VAT reduction was not significantly influenced by an increase in the duration of or amount of exercise in an exercise program. The effective dosage of exercise for reducing VAT was three times per week for 12 to 16 weeks, while duration per session for aerobic exercise was 30-60 min, and either less than 30 min or 30-60 min of high-intensity interval training accomplished sufficient energy expenditure to impact VAT.

CONCLUSIONS

These results can inform exercise prescriptions given to the general population for improving health by reducing VAT.

The Value of Rehabilitation Interventions --Integrating Evidence, Clinical Expertise, Critical Assessment, and , Patient Needs: A Conference Report

In order to understand issues related to value, outcomes, and cost-effectiveness of rehabilitation interventions, and to explore how scientific evidence, clinical expertise, and patient needs can be integrated, the Rehabilitation Research and Training Center on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function held a State of the Science (SOS) Symposium on "The Value of Rehabilitation Interventions" at Shirley Ryan AbilityLab in Chicago in 2017. In this conference, the perspectives of 35 invited experts, including people with disabilities, professionals, and consumers, explored the topic of "value" of rehabilitation interventions and discussed their perspectives on the means to integrate best scientific evidence with clinical expertise and patient preferences. This Symposium also resulted in the production of several multifaceted manuscripts providing perspectives on the topic of value and how to use evidence to best determine and demonstrate it. These papers comprise this Supplement. The present paper introduces the key concepts of value, evidence, and knowledge translation, in an effort to provide a context for the papers of the Supplement.

Cardiac Rehabilitation in Heart Failure

Heart failure (HF) is a complex clinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in reduced organ perfusion. The goals of treatment in patients with HF are to improve functional capacity and quality of life, and to reduce mortality. Cardiac rehabilitation (CR) including exercise training is one of the treatment options, and current guidelines recommend CR as safe and effective for patients with HF. CR has been known to improve exercise capacity and quality of life, minimize HF progression, and lower mortality in patients with HF. Improvement of vascular endothelial function, activation of the neurohormonal system, increase of mitochondrial oxygen utilization in peripheral muscles, and increase of chronotropic responses are possible mechanisms of the beneficial effects of exercise-based CR in HF. Although CR has been shown to decrease morbidity and mortality, it is underutilized in clinical practice. Despite the existence of concrete evidence of clinical benefits, the CR participation rates of patients with HF range from only 14% to 43% worldwide, with high dropout rates after enrollment. These low participation rates have been attributed to several barriers, including patient factors, professional factors, and service factors. The motivation for participating in CR and for overcoming the patients' barriers for CR before discharge should be provided to each patient. Current guidelines strongly recommend applying a CR program to all eligible patients with HF.

The effectiveness of two different multimodal training modes on physical performance in elderly

The study compared the effect of 12-week multimodal training programme performed twice a week at the regular exercise facility (REF) with the 12-week multimodal training programme performed three times per week as a part of the research programme (EX). Additionally, the study analysed how the experimental training programme affect the physical performance of cognitive healthy and mild cognitive impaired elderly (MCI). The REF training group included 19 elderly (65.00±3.62 years). The experimental training programme combined cognitively healthy (EXH: n=16; 66.3±6.42 years) and age-matched individuals with MCI (EXMCI: n=14; 66.00±4.79 years). 10m maximal walking speed (10mMWS), Five Times Sit-to-Stand Test (FTSS), maximal and relative voluntary contraction (MVC & rel. MVC) were analysed. The REF group improved in 10mMWS (t=2.431, p=.026), the MVC (t=-3.528, p=.002) and relative MVC (t=3.553, p=.002). The EXH group improved in FTSS (t=5.210, P=.000), MVC (t=2.771, p=.018) and relative MVC (t=-3.793, p=.004). EXMCI improved in FTSS (t=2.936, p=.012) and MVC (t=-2.276, p=.040). According to results, both training programmes sufficiently improved walking speed and muscle strength in cognitively healthy elderly. Moreover, the experimental training programme improved muscle strength in MCI elderly.

Therapeutic Exercise

Physicians often overlook exercise as a treatment or prophylactic measure for many common diseases and ailments. It can be used to treat comorbidities including obesity, cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, osteoporosis, osteoarthritis, cancer, and low back pain. Education on the general physical activity guidelines as well as easy exercise prescription methods can improve the ability of physicians to prescribe exercise as a therapeutic option. In addition, identifying barriers to compliance with exercise and ways to overcome these barriers is also necessary in order to use therapeutic exercise effectively.

Promoting Participation in Physical Activity and Exercise Among People Living with Chronic Pain: A Qualitative Study of Strategies Used by People with Pain and Their Recommendations for Health Care Providers

OBJECTIVE

To explore strategies used by people living with chronic pain when participating in physical activity and exercise and their recommendations for health care providers when promoting participation in physical activity and exercise.

DESIGN

Interpretive description qualitative study.

SETTING

Participants were recruited from primary care sites and a hospital-based chronic pain clinic in Kingston, Ontario, Canada.

SUBJECTS

Adults (>18 years of age) who self-identified as experiencing chronic pain (three months' duration) were interviewed.

METHODS

In-depth semistructured interviews were conducted with participants. Interviews were audio-recorded, transcribed verbatim, and reviewed for accuracy by the interviewer. Transcripts were analyzed using thematic analysis. Peer debriefing, reflexivity, and multiple in-person meetings were used to establish trustworthiness.

RESULTS

Sixteen adults (five men, 11 women) with a median age of 53 years were interviewed. Strategies used by people living with chronic pain to participate in physical activity and exercise included 1) finding the motivation, 2) setting up for success, 3) leveraging social support, and 4) managing pain and discomfort during activity. Recommendations for health care providers when promoting participation in physical activity and exercise for people living with chronic pain included 1) the importance of listening, 2) providing tailored advice, 3) being supportive, and 4) making physical activity and exercise programming accessible.

CONCLUSIONS

People living with chronic pain reported using multiple strategies to participate in physical activity and exercise. Recommendations for health care providers centered on the importance of listening and taking a supportive approach when promoting engagement in physical activity and exercise for this population.

Could Ankle Muscle Activation be Used as a Simple Measure of Balance Exercise Intensity?

Few, if any, studies have reported the effects of intensity of balance exercise for balance training and rehabilitation. The aim of the present study was to find a relative measure of intensity of balance exercise. On this basis, we analysed ankle muscle activation in the sagittal plane with increasing difficulty for a one leg stance on a T-board. Ten adults (7 men, 24.1 ± 3.5 years; 3 women, 30.6 ± 5.8 years) performed 3 trials on a T-board within 6 randomly assigned stability levels. T-board swaying velocities in the sagittal plane were manipulated to attain different stability levels (conditions). Concurrently, angular distance of the T-board and active balance time (i.e., percentage of a total time balancing) under each condition were measured. Surface electromyography from the tibialis anterior, gastrocnemius and soleus were monitored during one leg stance. The surface electromyography amplitude in the time domain was quantified using the root-mean-square values. Significant effect of stability levels on angular distance (F_5,45 = 3.4; p = 0.01) and velocity of the T-board (F_5,45 = 4.6; p = 0.002) were obtained. Active balance time decreased by ∼15% (p = 0.001) from the maximal to the minimal stability conditions. The graded level of balance board stability conditions did not generate significantly higher root-mean-square values in any muscles and hence could not be used as a relative measure of intensity of balance exercise. These findings imply that there could be a plateau in difficulty of balance exercise for enhancement of ankle muscle activity.

Models of anatomically based oropharyngeal rehabilitation with a multilevel approach for patients with obstructive sleep apnea: a meta-synthesis and meta-analysis

OBJECTIVES

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

RESULTS

A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40 kg/m², mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] - 9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9 cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1 kg/m² (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR.

CONCLUSIONS

Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.

Swim exercise in Caenorhabditis elegans extends neuromuscular and gut healthspan, enhances learning ability, and protects against neurodegeneration

Exercise is a powerful antiaging intervention that protects against cardiovascular disease, dementia, diabetes, sarcopenia, and cancer. How exercise promotes health benefits to multiple tissues in the body, however, remains poorly understood. We establish a young adult swim exercise regimen for the short-lived nematode Caenorhabditis elegans that induces health benefits at the neuromuscular, intestinal, and cognitive levels and protects against neurodegeneration in models of tauopathy, Alzheimer’s disease, and Huntington’s disease. Importantly, we found that swim exercise performed exclusively in early adulthood promotes long-lasting systemic benefits that are still detectable in midlife. The advantages of C. elegans as a short-lived genetic model will allow for dissection of the molecular circuitry involved in system-wide exercise benefits.

Regular physical exercise is the most efficient and accessible intervention known to promote healthy aging in humans. The molecular and cellular mechanisms that mediate system-wide exercise benefits, however, remain poorly understood, especially as applies to tissues that do not participate directly in training activity. The establishment of exercise protocols for short-lived genetic models will be critical for deciphering fundamental mechanisms of transtissue exercise benefits to healthy aging. Here we document optimization of a long-term swim exercise protocol for Caenorhabditis elegans and we demonstrate its benefits to diverse aging tissues, even if exercise occurs only during a restricted phase of adulthood. We found that multiple daily swim sessions are essential for exercise adaptation, leading to body wall muscle improvements in structural gene expression, locomotory performance, and mitochondrial morphology. Swim exercise training enhances whole-animal health parameters, such as mitochondrial respiration and midlife survival, increases functional healthspan of the pharynx and intestine, and enhances nervous system health by increasing learning ability and protecting against neurodegeneration in models of tauopathy, Alzheimer’s disease, and Huntington’s disease. Remarkably, swim training only during early adulthood induces long-lasting systemic benefits that in several cases are still detectable well into midlife. Our data reveal the broad impact of swim exercise in promoting extended healthspan of multiple C. elegans tissues, underscore the potency of early exercise experience to influence long-term health, and establish the foundation for exploiting the powerful advantages of this genetic model for the dissection of the exercise-dependent molecular circuitry that confers system-wide health benefits to aging adults.

Developing a training programme in physical activity counselling for undergraduate medical curricula: a nationwide Delphi study

OBJECTIVES

To identify the essential content and approaches for developing a training programme in physical activity (PA) counselling for undergraduate medical curricula.

DESIGN

A three-round Delphi survey was conducted to investigate four key topics: (1) contents of PA counselling in medical education; (2) teaching and learning methods; (3) medical school collaboration and (4) educational policy implementation. Round 1 collected opinions from the participants. Round 2 focused on scoring the opinions. Round 3 summarised the expert opinions. A mean score of 4 or above identified as an important item.

SETTING

All 23 medical schools in Thailand.

PARTICIPANTS

Academic staff who were experts or in charge of medical schools in the fields of PA, health promotion or medical education.

RESULTS

A total of 20 representatives from 18 of the 23 Thai medical schools participated in the study (for a response rate of 78.2%). The top three most important indicators of knowledge were (1) the definition and types of PA (4.75±0.55), (2) the FITT principle (frequency, intensity, time and type) (4.75±0.55) and (3) the benefits of PA (4.65±0.67). The most important component of the training involved general communication skills (4.55±0.60). An extracurricular module (4.05±0.76) was preferable to an intracurricular module (3.95±0.94). Collaborations with medical education centres and teaching hospitals (4.45±0.78) and supporting policies to increase medical students' PA (4.40±0.73) were considered to be important.

CONCLUSION

Knowledge and counselling skills are important for PA counselling. Building collaborations between medical education and health institutions, as well as implementing effective educational policies, are key approaches to the integration of PA counselling into medical education. Future research should focus on investigating the effects of training in PA counselling on the learning outcomes of medical students and the clinical outcomes of patients.

Physical activity counselling among GPs: a qualitative study from Thailand

BACKGROUND

Physical activity (PA) counselling is an intervention to promote PA among patients in primary care, yet it remains limited in this clinical setting. This study aimed to explore PA counselling practices among general practitioners (GPs), as well as barriers to and recommendations for improving PA counselling.

METHODS

This qualitative study employed a descriptive approach. Data were collected by in-depth interviews and analysed by thematic analysis. The study was conducted in district hospitals in Nakhon Si Thammarat, Thailand, from February 2017 to February 2018. The study participants were GPs who worked at district hospitals.

RESULTS

Seventeen GPs (6 males and 11 females, mean age 29.8 ± 3.4 years) from 6 district hospitals were interviewed. Their clinical experience ranged from 2 to 12 years (mean 4.7 ± 2.9). The GPs saw 30-80 outpatients/day (mean 56.2 ± 14.1) and spent 1-8 min (mean 3.8 ± 1.8) with each patient. They emphasised PA in patients with poorly controlled non-communicable diseases (NCDs) using the word 'exercise' in the Thai language as well as discussing time and frequency of exercise. PA was considered a non-pharmacological treatment in the management of NCDs, which improved patient health and quality of life. Barriers to PA counselling among GPs included time constraints, insufficient knowledge, and lack of opportunities to follow-up previously counselled patients. GPs suggested that training in PA counselling was required.

CONCLUSIONS

GPs concurred that PA counselling is essential in the treatment of NCDs. Physicians' recommendations to improve the quality of PA counselling in primary care include 3 Ts: training in PA counselling, tools for prescribing PA, and teams of healthcare professionals. Implementing use of written PA prescriptions may encourage patients to increase PA. Multidisciplinary teams should be developed to support PA counselling in the clinical setting. Further studies should focus on appropriate techniques to implement PA counselling and overcome existing barriers.

Bridging the gap between clinicians and fitness professionals: a challenge to implementing exercise as medicine

Objective

Health clubs (HC) and personal trainers (PT) are traditional outlets for the promotion of physical activity (PA) and exercise programming. As physicians are increasingly being called on to write exercise prescriptions for their patients, this study sought to investigate the level of integration between the healthcare and fitness systems.

Design

An internet study was designed with five domains to understand physicians’: (1) overall perception of HC, (2) appropriateness and recommendation of HC and PT to their patients, (3) attitude regarding specific aspects of HC, (4) support of patient participation in HC sponsored exercise and (5) elements of HC that physicians would like to know for referral.

Methods

An electronic survey was sent to members of two mailing lists of primary care and sports medicine specialty physicians during 2011–2012.

Results

On a Likert scale of 1–10 412 physicians reported being familiar with HC (8.9±2.1), indicated a favourable view of HC (7.9±2.2), and believe HC to be an appropriate venue for their patients (7.5±2.3). However, physicians only recommend HC to 41%±28% of their patients and PT for only 21%±21.6% of patients. Physicians ranked expense and convenience as the most problematic elements of HC (8.1±2.1 and 6.3±2.5, respectively). 72% of physicians indicated cost as most concerning when recommending a specific HC.

Conclusion

HC and PT are a significant implementation system for the promotion of physical activity, yet physicians are concerned with several elements of HC and are not adequately relying on this partnership to promote physical activity to their patients.

Physical activity counseling in primary care and family medicine residency training: a systematic review

BACKGROUND

Physical inactivity is a global public health challenge. Physical activity (PA) promotion in healthcare delivery systems is effective to reduce physical inactivity. A primary care setting provides an appropriate environment for PA counseling since it is a primary contact with primary care or family physicians encounter the majority of the population. Lack of knowledge and inadequate training in PA counseling is one of the most important barriers to PA promotion. The purpose of this systematic review was to evaluate PA counseling training in primary care residency programs.

METHODS

The authors systematically searched PubMed, Web of Science, Scopus and The Cochrane Library for articles published in English from 2000 to 2017. Articles regarding PA counseling in primary care residency training were extracted and outcomes assessed for this systematic review.

RESULTS

Based on the initial review, 378 articles were excluded (362 articles excluded based on titles and abstracts and 16 articles excluded based on full texts). Four articles were included in this review, addressed PA counseling curricula in primary care residency training. All studies included PA counseling training as part of obesity and healthy lifestyle training. The training improved knowledge among primary care residents, but may not necessarily result in better attitudes or self-efficacy, which could be improved by elective rotations that focus on improved attitudes, self-efficacy, and professional norms for PA counseling. Brief training in counseling did not improve quality nor increase the rate of counseling.

CONCLUSIONS

This systematic review demonstrates a lack of evidence due to a small number of included studies. The heterogeneous outcomes from the minimal programs are needed to carefully interpret. However, this review sheds light on the importance of training in PA counseling in primary care residency programs. The development of training in PA counseling should focus on an approach that improves attitudes and the self-efficacy of primary care residents. Elective rotations, where residents voluntarily choose their subject, may provide the appropriate training period for PA counseling. Policymakers and academics should play an active role in the implementation of PA counseling as an essential competency for primary care physicians.

Physician Practice Patterns and Barriers to Counselling on Physical Activity in Solid Organ Transplant Recipients

Background

Many solid organ transplant (SOT) recipients fail to meet the recommended physical activity (PA) levels. “Physician recommendation” has previously been reported by SOT recipients as a key facilitator to being more physically active. The purpose of this study was to determine the proportion of Canadian SOT physicians providing PA counselling and identify barriers to including such counselling as part of the SOT recipients’ routine care.

Material/Methods

We conducted a cross-sectional web-based survey study to evaluate physicians’ PA counselling practices, including the prevalence and barriers to such practice. A survey link was sent to a convenience sample of transplant physicians who are members of the Canadian Society of Transplantation.

Results

Thirty-four physicians (13.6%) participated in the survey. While 97% (n=33) of the participants reported providing PA counselling to their transplant patients, only 18% (n=6) responded they were very confident in PA counselling. Lack of time (n=19; 56%) and a lack of exercise guidelines (n=18; 53%) were identified as the main barriers to PA counselling.

Conclusions

Incorporating sufficient PA knowledge into physicians’ educational curricula system, developing specific PA guidelines as well as establishing an easier referral system to exercise specialists might improve the frequency and quality of PA counselling post-transplant.

Programme frequency, type, time and duration do not explain the effects of balance exercise in older adults: a systematic review with a meta-regression analysis

OBJECTIVE

The objective of this systematic review was to examine the effects of different balance exercise interventions compared with non-balance exercise controls on balance task performance in older adults.

DESIGN

Systematic review.

DATA SOURCES

Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus and Cochrane Database of Systematic Reviews were searched until July 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews and meta-analyses of randomised trials of balance exercise interventions for older adults were identified for extraction of eligible randomised trials. Eligibility criteria for inclusion of randomised trials in meta-analyses were comparison of a balance exercise intervention with a control group that did not perform balance exercises, report of at least one end-intervention balance outcome measurement that was consistent with the five subgroups of balance exercise identified, and full-text article available in English.

RESULTS

Ninety-five trials were included in meta-analyses and 80 in meta-regressions. For four balance exercise types (control centre of mass, multidimensional, mobility and reaching), significant effects for balance exercise interventions were found in meta-analyses (standardised mean difference (SMD) 0.31-0.50), however with considerable heterogeneity in observed effects (I²: 50.4%-80.6%). Risk of bias assessments (Physiotherapy Evidence Database score and funnel plots) did not explain heterogeneity. One significant relationship identified in the meta-regressions of SMD and balance exercise frequency, time and duration explained 2.1% of variance for the control centre of mass subgroup.

CONCLUSION

Limitations to this study included the variability in design of balance interventions, incomplete reporting of data and statistical heterogeneity. The design of balance exercise programmes provides inadequate explanation of the observed benefits of these interventions.

Clinical Markers of the Intensity of Balance Challenge: Observational Study of Older Adult Responses to Balance Tasks

BACKGROUND

Effective balance rehabilitation is critically important to the aging population. Optimal exercise prescription for balance rehabilitation has not been described, as there is no measure of balance exercise intensity. To rate the intensity of balance exercise, an item set is required.

OBJECTIVES

The aim of this study was to explore verbal and nonverbal markers that differentiated tasks of high, medium, and low balance intensity to inform the development of an instrument to measure the intensity of balance challenge.

DESIGN

This was an observational study utilizing an interpretive description approach.

METHODS

Twenty older adults were observed performing 3 balance tasks that challenged balance at low to high intensity. Verbal and nonverbal responses were recorded. After each task, participants were asked to describe the test experience. Data were analyzed to identify potential markers of balance challenge intensity.

RESULTS

Markers of the intensity of balance challenge were grouped by time periods defined as pretask, in-task, and posttask. A key pretask finding was an increased delay to task commencement with increased task difficulty. Commencement delay was accompanied by talk in 19 of 21 instances. Physical markers of the intensity of balance challenge were grouped into 3 categories-bracing, postural reactions, and sway-and were increasingly observed as intensity of balance challenge increased. Participants described tasks as pushing them toward the limits of their balancing capacity as the intensity of balance challenge increased.

CONCLUSIONS

Verbal and nonverbal markers of the intensity of balance challenge in older adults performing balance tasks that differentiated high-intensity tasks from medium- to low-intensity tasks were identified. The pretask phase of balance exercise performance is an important diagnostic space, rich in verbal and nonverbal markers.

Linking community resources in diabetes care: a role for technology?

Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as "assets"). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care.

Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels

BACKGROUND

Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk.

OBJECTIVE

To examine the clinical impact of a newly implemented program ("Exercise as a Vital Sign" [EVS]) designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit.

DESIGN AND PARTICIPANTS

The EVS program was implemented in four of 11 medical centers between April 2010 and October 2011 within a single health delivery system (Kaiser Permanente Northern California). We used a quasi-experimental analysis approach to compare visit-level and patient-level outcomes among practices with and without the EVS program. Our longitudinal observational cohort included over 1.5 million visits by 696,267 adults to 1,196 primary care providers.

MAIN MEASURES

Exercise documentation in physician progress notes; lifestyle-related referrals (e.g. exercise programs, nutrition and weight loss consultation); patient report of physician exercise counseling; weight change among overweight/obese patients; and HbA1c changes among patients with diabetes.

KEY RESULTS

EVS implementation was associated with greater exercise-related progress note documentation (26.2 % vs 23.7 % of visits, aOR 1.12 [95 % CI: 1.11-1.13], p < 0.001) and referrals (2.1 % vs 1.7 %; aOR 1.14 [1.11-1.18], p < 0.001) compared to visits without EVS. Surveyed patients (n = 6,880) were more likely to report physician exercise counseling (88 % vs. 76 %, p < 0.001). Overweight patients (BMI 25-29 kg/m(2), n = 230,326) had greater relative weight loss (0.20 [0.12 - 0.28] lbs, p < 0.001) and patients with diabetes and baseline HbA1c > 7.0 % (n = 30,487) had greater relative HbA1c decline (0.1 % [0.07 %-0.13 %], p < 0.001) in EVS practices compared to non-EVS practices.

CONCLUSIONS

Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.

Lifestyle Approach for Increasing Physical Activity in Youth

Although physical activity (PA) provides children with various health benefits, many children do not engage in regular PA. Health care professionals can effectively encourage children and their families to participate in more PA through lifestyle changes. The strategies that clinicians can employ to promote PA are discussed in this article.