What makes community-based, multilevel physical activity promotion last? A systematic review with narrative synthesis on factors for sustainable implementation

AIM

To follow the need for more research and strategies to enhance the knowledge of sustainable implementation, we examined cases of community-based, multilevel physical activity-related health promotion after initial funding has ceased and aimed to identify factors that influence their sustainable implementation.

METHODS

Five scientific databases (PubMed; Scopus; Ebsco Host with CINAHL, PsychInfo, and Sportdiscus; ProQuest and Web of Science) were systematically searched for relevant literature in December 2021. Three reviewers performed a title/abstract screening and independently screened the full texts of the remaining papers, followed by a quality assessment. A narrative synthesis method, including qualitative text analysis, was used to synthesise retrieved articles. As starting point, the framework of Schell et al. containing nine domains for sustainability capacity was used and new emerging themes were inductively added.

RESULTS

The search revealed 270 potentially eligible articles out of 27,652 hits. After the systematic review process, 14 studies were included. In the synthesis, 14 factors influencing the sustainablity of community-based, multilevel physical activity-related health promotion were identified of which six are new factors compared to Schell et al. In particular, our findings bring forth a novel understanding of the importance of the factors 'Participation and Partnerships', 'Empowerment and Capacity Building' and 'Community Support'. A dynamic interplay and high connectedness between factors were visible.

CONCLUSION

The identified factors can help establish a better understanding of sustainability processes within whole-system approaches intervening on multiple levels in the community with the aim of systems change. They are relevant for practitioners, researchers and policy makers alike. Future research should more closely examine based on further theoretical elaboration how an interplay between the factors can promote sustainability and which interdependencies are of particular importance in facilitating sustainable and equitable change.

The "can do, do do" concept in individuals with chronic obstructive pulmonary disease: an exploration of psychological mechanisms

Background

The “can do, do do” concept aims at identifying subgroups among persons with chronic obstructive pulmonary disease (COPD). Following a two-dimensional categorization, individuals are binarily classified with respect to their levels of physical capacity (“can’t do” or “can do”) and physical activity (“don’t do” or “do do”), resulting in four disjunct quadrants. The approach has been debated recently and the latest articles have concluded that the quadrants should be specifically examined in terms of psychological aspects of physical activity. Therefore, the goal of the present study was to explore the role of psychological variables in physical activity in the context of the “can do, do do” quadrant concept.

Methods

Within the scope of secondary data analyses of the “Stay Active After Rehabilitation” (STAR) randomized controlled trial, a total of 298 COPD rehabilitants of an inpatient pulmonary rehabilitation program were grouped into the suggested quadrants. We set fixed cut-offs at 70% of relative 6-min walking test performances for healthy individuals (physical capacity dimension) and 5.000 steps per day (physical activity dimension). Univariate and multivariate logistic regression analyses served to analyze whether depression scores, fear avoidance behaviors, disease-specific anxiety, self-concordance for physical activity, and five indicators of physical activity-related health competence (PAHCO) effectively discriminated between the “don’t do” and “do do” groups.

Results

Among persons with lower relative physical capacity, depression scores, fear avoidance behaviors, and disease-specific anxiety (univariate case) significantly differentiated between the more and the less active. Among persons with higher relative physical capacity, fear avoidance behaviors, disease-specific anxiety, as well as three PAHCO indicators (physical activity-specific self-efficacy, self-control, and affect regulation) significantly separated the more and the less active. In multivariate analyses, only fear avoidance behaviors and affect regulation discriminated among individuals with better relative physical capacity.

Conclusion

The findings identified important psychological and competence-oriented variables that explain discrepancies in the quadrant concept. Based on this, we discuss implications for physical activity promotion in individuals with COPD. Respiratory research can benefit from future studies complementing the quadrant concept through further behavioral analyses.

Trial registration Clinicaltrials.gov, ID: NCT02966561. Registered 17 November, 2016, https://clinicaltrials.gov/ct2/show/NCT02966561.

A randomized study to evaluate the effect of exercise on fatigue in people with relapsing-remitting multiple sclerosis treated with fingolimod

Background

Fatigue is a major symptom of multiple sclerosis (MS) in patients, and it has been shown to improve with physical exercise. Although fingolimod might lessen fatigue, it is unclear how patients treated with fingolimod react to physical activity regarding fatigue.

Objective

This study evaluated the effect of an exercise intervention on fatigue in relapsing–remitting MS patients receiving fingolimod.

Methods

People with MS (PwMS) were randomized to either a structured internet-based exercise program (e-training) or no e-training intervention. The primary endpoint was the change in the Modified Fatigue Impact Scale (mFIS) after six months.

Results

The primary analysis showed no statistically significant difference between groups in the mFIS change. Subgroup analyses revealed a beneficial effect of physical exercise for PwMS with low aerobic capacity and with low aerobic capacity plus more severe fatigue. The incidence of adverse events was similar in both groups. No cardiovascular events were reported. The majority of PwMS were relapse free.

Conclusion

Physical exercise benefits on fatigue may depend on the physical capacity of the patient and requires individualized training. Consistent with previous studies, these results suggest that physical exercise generally does not impose a risk and that this holds true also for patients receiving fingolimod.

Trial registration: ClinicalTrials.gov, NCT01490840.

Analysis of a RECQL splicing mutation, c.1667_1667+3delAGTA, in breast cancer patients and controls from Central Europe

RECQL is a DNA helicase required for genomic stability. Two studies have recently identified RECQL as a novel breast cancer susceptibility gene. The most common RECQL mutation, the 4 bp-deletion c.1667_1667+3delAGTA, was five-fold enriched in Polish breast cancer patients, but the exact magnitude of the risk is uncertain. We investigated two hospital-based breast cancer case-control series from Belarus and Germany, respectively, comprising a total of 2596 breast cancer patients and 2132 healthy females. The mutation was found in 9 cases and 6 controls, with an adjusted Odds Ratio 1.23 (95% CI 0.44-3.47; p = 0.69) in the combined analysis. Among the cases, heterozygosity for c.1667_1667+3delAGTA was linked with estrogen-receptor positive breast cancer. There was no significant difference in age at diagnosis between carriers and non-carriers, and only one of the carriers reported a first-degree family history. Meta-analysis with the initial study from Poland suggests an about two-fold increase in risk for this mutation (OR 2.51; 95% CI 1.13-5.57, p = 0.02). Altogether, the data indicate that RECQL* c.1667_1667+3delAGTA is not a high-risk mutation for breast cancer though it could represent a moderate-risk breast cancer susceptibility allele. Further studies will be required to determine the clinical significance of testing for this RECQL mutation.

Inhibition of Formation of Rev-RRE Complex by Pyronin Y

The interaction of pyronin Y, an RNA intercalating drug, with the binding of Rev protein from human immunodeficiency virus type 1 (HIV-1) to Rev-responsive element (RRE)-containing env RNA was studied. In gel retardation assays, recombinant Rev protein tightly bound to in vitro transcribed RRE RNA. Nitrocellulose-filter-binding studies revealed a dissociation constant of ≈(1–2) = 10−10M (Pfeifer et al., 1991). Pyronin Y efficiently suppressed formation of the Rev-RRE complex. At a concentration of 1 μg ml−1, complex formation was almost completely inhibited. Electron microscopy showed that Rev oligomerizes in the presence of RRE-containing RNA with the formation of short rod-like structures or long filaments, depending on the length of the transcript. Assembly of Rev protein along RRE-containing RNAs was abolished after addition of pyronin Y. Thus pyronin Y represents the first compound described to inhibit Rev-RRE complex formation.

Prevalence of Nutrition and Health-Related Claims on Pre-Packaged Foods: A Five-Country Study in Europe

This study is part of the research undertaken in the EU funded project CLYMBOL ("Role of health-related CLaims and sYMBOLs in consumer behaviour"). The first phase of this project consisted of mapping the prevalence of symbolic and non-symbolic nutrition and health-related claims (NHC) on foods and non-alcoholic beverages in five European countries. Pre-packaged foods and drinks were sampled based on a standardized sampling protocol, using store lists or a store floor plan. Data collection took place across five countries, in three types of stores. A total of 2034 foods and drinks were sampled and packaging information was analyzed. At least one claim was identified for 26% (95% CI (24.0%-27.9%)) of all foods and drinks sampled. Six percent of these claims were symbolic. The majority of the claims were nutrition claims (64%), followed by health claims (29%) and health-related ingredient claims (6%). The most common health claims were nutrient and other function claims (47% of all claims), followed by disease risk reduction claims (5%). Eight percent of the health claims were children's development and health claims but these were only observed on less than 1% (0.4%-1.1%) of the foods. The category of foods for specific dietary use had the highest proportion of NHC (70% of foods carried a claim). The prevalence of symbolic and non-symbolic NHC varies across European countries and between different food categories. This study provides baseline data for policy makers and the food industry to monitor and evaluate the use of claims on food packaging.

[Sensorimotor Deficits in Functional Ankle Instability]

Lateral ankle sprains are among the most common sports injuries, with a prevalence of 25 to 30 % of all injuries. At least one-third of individuals develop long-term complaints and chronic instabilities at the ankle, which in many cases cannot be attributed to mechanical insufficiencies of the joint. This condition is referred to as functional ankle instability (FAI). Impairments of the sensorimotor control system, such as disturbed proprioception and postural control, as well as reduced muscle strength and reflex activity, have been suggested to contribute to the aetiology of FAI. This review summarises the current body of literature regarding sensorimotor control in individuals with FAI. We discuss the results in the context of current neurophysiological models of the development of functional joint instabilities.

[Acceptance of the Implementation of Standardised Patient Education Programmes by the Multidisciplinary Rehabilitation Team Using the Example of a Back School - A Qualitative Study]

AIM

The transfer of standardised patient education programmes into practice is a complex process with a multitude of influencing factors. Determinants relate among others to the organisation and individuals (e. g., practitioner, patient). Knowledge about individual factors regarding the trainers of patient education programmes in the German rehabilitation system is scarce. The aim of this study is to explore the acceptance of trainers concerning the implementation of a standardised back school and to derive facilitators and barriers to the implementation of patient education programmes.

METHODS

Semi-structured guideline-based interviews were conducted in 10 rehabilitation clinics. The sample consisted of 46 trainers (25 women): 11 physicians, 11 psychologists, 21 physio-/exercise therapists and 3 occupational therapists with a mean age of 41. The opinions of the trainers regarding the central components of back schools in general, their opinions about the new curriculum, their expectations on its implementation, anticipated difficulties with implementation and requests to the project team were explored as indicators for acceptance. The data were analysed with a multi-step qualitative content analysis.

RESULTS

6 main categories comprising 136 subcategories were created and 729 quotations coded. Regarding the central components that should be covered by back schools, back-friendly behaviour was addressed most often. Opinions regarding the new curriculum were mostly positive. Trainers' approval of content and methods was highlighted and the similarity with existing offers in the clinics as well as the structure of the programme were rated positively. The trainers expected an increased patient orientation and personal development as well as a common, coherent language and interdisciplinarity. Difficulties were anticipated regarding time and personnel as well as therapy and appointment planning and also regarding the motivation/acceptance of patients. A wish for communication, education of trainers and feedback was directed at the project team.

CONCLUSION

The study demonstrates high acceptance of programme implementation and central components of modern patient education programmes among trainers. The basis of individual facilitators and barriers has been investigated and might contribute to further development of implementation interventions. Communication and education considering those factors play a central role.

Functional ankle instability as a risk factor for osteoarthritis: using T2-mapping to analyze early cartilage degeneration in the ankle joint of young athletes

OBJECTIVE

The aim of this study was to investigate, using T2-mapping, the impact of functional instability in the ankle joint on the development of early cartilage damage.

METHODS

Ethical approval for this study was provided. Thirty-six volunteers from the university sports program were divided into three groups according to their ankle status: functional ankle instability (FAI, initial ankle sprain with residual instability); ankle sprain Copers (initial sprain, without residual instability); and controls (without a history of ankle injuries). Quantitative T2-mapping magnetic resonance imaging (MRI) was performed at the beginning ('early-unloading') and at the end ('late-unloading') of the MR-examination, with a mean time span of 27 min. Zonal region-of-interest T2-mapping was performed on the talar and tibial cartilage in the deep and superficial layers. The inter-group comparisons of T2-values were analyzed using paired and unpaired t-tests. Statistical analysis of variance was performed.

RESULTS

T2-values showed significant to highly significant differences in 11 of 12 regions throughout the groups. In early-unloading, the FAI-group showed a significant increase in quantitative T2-values in the medial, talar regions (P = 0.008, P = 0.027), whereas the Coper-group showed this enhancement in the central-lateral regions (P = 0.05). Especially the comparison of early-loading to late-unloading values revealed significantly decreasing T2-values over time laterally and significantly increasing T2-values medially in the FAI-group, which were not present in the Coper- or control-group.

CONCLUSION

Functional instability causes unbalanced loading in the ankle joint, resulting in cartilage alterations as assessed by quantitative T2-mapping. This approach can visualize and localize early cartilage abnormalities, possibly enabling specific treatment options to prevent osteoarthritis in young athletes.

[Physical activity and exercise recommendations for cancer patients during rehabilitation]

AIM OF THE WORK

Cancer and its commonly required continuous and intensive medical treatment have a profound and lasting effect on patients' physical, functional, emotional and social wellbeing. In this context the positive comprehensive effects of physical exercise interventions increasingly prove to be promising. The aim of this review is to derive physical exercise recommendations for patients with cancer, especially concerning aerobic and resistance training during rehabilitation, based on the current literature. In a second step the 3 main cancer types breast cancer, prostate cancer and colon cancer and their distinctive features will be addressed briefly.

METHODS

A hierarchic literature research was conducted using the medical information portal Medpilot. The evaluation system of the "European Society of Cardiology" was applied in order to evaluate the evidence and compile evidence-based exercise recommendations for patients with cancer.

RESULTS

When summing up the current data, physical exercise proves to be efficient, safe and feasible for patients with cancer. Both aerobic and resistance training have a positive influence on a patient's physical, psychological and social level and should therefore be included in every exercise program.

CONCLUSION

While the evidence for breast cancer and increasingly also for prostate cancer is strong, research in colon cancer, for example, is still sparse. In order to create precise recommendations regarding the ideal exercise type and dose for the different cancer types during various treatment phases further high quality studies are necessary.

Risk-reducing Surgery in Women at Risk for Familial Breast or Ovarian Cancer

An estimated 5 % of breast cancers and 10 % of ovarian cancers may be due to inherited autosomal dominant breast and ovarian cancer alleles BRCA1 und BRCA2. According to population-based studies 1 or 2 women per 1000 carry such a risk allele. The cumulative cancer risk for healthy women with a BRCA-mutation is between 60 and 85 % for breast cancer and between 20 and 60 % for ovarian cancer. Recent studies have reported an increased risk for contralateral breast cancer in women after unilateral breast cancer. Since 1997 the German Cancer Aid has supported an interdisciplinary approach for high-risk women consisting of genetic testing, counselling and prevention in 12 specialised centres. Since 2005 this concept has received additional support from health insurance companies, and results have been assessed with regard to outcomes (e.g. reduced mortality due to more intensive early diagnosis). The number of centres has increased to 15 at various university hospitals. These interdisciplinary centres offer women the opportunity to participate in a structured screening programme for the early diagnosis of breast cancer and provide non-directive counselling on the options for risk-reducing surgery, e.g., prophylactic bilateral salpingo-oophorectomy, prophylactic bilateral mastectomy or contralateral prophylactic mastectomy after unilateral breast cancer. Such surgical interventions can significantly reduce the risk of disease, the respective disease-specific mortality and - particularly prophylactic bilateral salpingo-oophorectomy - total mortality in BRCA-mutation carriers.

[Resource management: ICF-oriented exercise programs for patients with diabetes mellitus type 2. Chronic illnesses and biopsychosocial status]

Common health problems are increasing due to the combination of decreased physical activity demands in everyday life and demographic changes; thus, the importance of exercise therapy is increasing. The incidence and prevalence of today's predominant chronic diseases are directly related to physical activity. However, daily clinical routine does not stay abreast with these changes. The education of physicians, and thus their scope of action, is dominated by biomedical therapy concepts, predominantly drug therapy concepts. Differential and consolidated findings of modern exercise and sport science are astonishingly rare in the counselling and treatment portfolio of medical care. The present disease management program for persons with diabetes mellitus type 2 is a good example. Referring to this background, the authors address the new approach of "ICF-oriented exercise programs and biopsychosocial status." They present resource-related interventional strategies and health care concepts for chronic health disorders like the metabolic syndrome or diabetes mellitus type 2. The relevance and use of active health promotion and care - due to lifestyle- and age-related health problems of the population - will increase in importance and be more commonly recommended.

[Behaviour-orientated exercise therapy--initiating and maintaining a physically active lifestyle]

BACKGROUND

The promotion of a physically active lifestyle has become an important issue in exercise therapy. Exercise-only interventions are frequently used for the rehabilitation of individuals with chronic diseases. These do indeed improve functional and physical performance, but they are not alone sufficient to initiate long lasting changes in physical-activity behaviour. Behaviour-related aspects are rarely integrated into exercise-therapy interventions.

OBJECTIVE

Based on theories of health behaviour change, effective techniques for changing physical-activity behaviour in the context of exercise therapy will be identified.

METHODOLOGY

The starting point is a theory-driven definition of individual behavioural determinants of physical activity and the identification of techniques for influencing the determinants. Subsequently, the potential of the techniques for enhancing physical activity is evaluated. The available evidence was reviewed on the basis of international reviews and control-group studies from the German rehabilitation setting. Finally, recommendations are offered for designing exercise-based interventions to promote participation in and adherence to physical activity.

RESULTS

A total of 28 techniques for the promotion of physical activity behaviour were identified. An approach that proved particularly effective was self-monitoring of physical activity behaviour in a variety of combinations with other techniques, such as contracting, feedback, rewards, generating one's own varied exercise experience, action planning and barrier management.

DISCUSSION

The integration of behaviour-related techniques in the context of exercise therapy interventions shows great promise as a means of initiating and promoting a physically active lifestyle.

Multiple sclerosis relapses are not associated with exercise

Since multiple sclerosis (MS) often affects physically active young individuals, it is important to know if exercise can result in increased disease activity. Therefore we used a self-report questionnaire to examine the relationship of different levels of sports activity and relapses in 632 patients with MS. In order to analyse whether subjective recall might have biased the results, we performed, in a subgroup of our sample, an objective assessment of clinical data and physical fitness parameters. We were unable to find any association between sports activity and clinical relapses in either of the two analyses. The group with highest activity even shows the lowermost mean values, standard deviations and range concerning the number of relapses. Our data suggest that physical activity has no significant influence on clinical disease activity.

[DGRW-update: exercise therapy in medical rehabilitation--effects, quality, perspectives]

Exercise therapy constitutes the better part of rehabilitative treatment. However, in rehabilitation research the scientific analysis of exercise therapy only plays a minor role. Taking the theoretical model of rehabilitation and the International Classification of Functioning, Disability and Health (ICF) into account, we propose a heuristic model of aims and effects of exercise therapy and define a system of methodological target setting. This system offers a background for an expanded scientific discussion about biopsychosocial determinants and effects of exercise therapy as well as quality development and the evaluation of exercise treatment concepts within and across indications in the context of multimodal medical rehabilitation.

The Fried frailty criteria as inclusion criteria for a randomized controlled trial: personal experience and literature review

BACKGROUND

among current operational definitions of frailty, the criteria proposed by Fried and colleagues have attracted great scientific interest. However, these criteria have usually been applied in epidemiological and only rarely in interventional studies.

OBJECTIVE

the present paper aims at testing the applicability of the Fried frailty criteria in the context of the recruitment process of a randomized controlled trial in prefrail older persons, and it discusses the respective scientific literature.

METHODS

recruitment was promoted by newspaper articles as well as by targeted mail to customers of a local health insurance company and to recently treated patients of a geriatric day clinic. Furthermore, presentations were given in assisted living facilities. Potential candidates were screened for prefrailty, i.e. to see whether they met 1 or 2 of the Fried criteria (weight loss, handgrip strength, gait speed, exhaustion, physical activity).

RESULTS

a total of 298 people were screened. Among them 181 were not frail, 116 were prefrail and 1 was diagnosed as frail. The most prevalent criterion was exhaustion (24% of those screened). The second most prevalent criterion was low handgrip strength (20%). Low gait speed (8%), low physical activity (2%) and weight loss (2%) had a lower prevalence. According to the Geriatric Depression Scale, 14% of those who met the criterion 'exhaustion' were depressed. With regard to the Minnesota Leisure Time Physical Activity Questionnaire, used for the evaluation of 'physical activity', only 3 activities among the 18 selected by Fried were applicable to our cohort.

CONCLUSIONS

under the study conditions, good applicability of the Fried criteria was observed. Nevertheless, further refinement may be expedient in several criteria, especially exhaustion and physical activity, to enhance clinical usefulness. It may be helpful to adapt the cutoffs when applying the criteria to a European population.

[Multiple sclerosis and exercise : effects of physical activity on the immune system]

Multiple sclerosis is a chronic inflammatory CNS disease which accounts for functional impairment and lasting disability in young adults. Current studies demonstrate that physical activity in patients with MS counteracts depression and fatigue and may improve quality of life. Interventional studies have described a reduction of the functional impairment in MS patients. This report presents information on the effects of physical activity on the immune system and the release of neurotrophic factors, and highlights current data on a potential immunomodulatory effect of exercise in multiple sclerosis.

Reliability and performance-dependent variations of muscle function variables during isometric knee extension

Despite the common use of standardised methods analysing neuromuscular function during knee extension, there is a lack of test-retest reliability studies. Furthermore, for most of the investigated variables it is unknown which changes of values indicate an enhancement of performance. The aim of the present study was to investigate performance-dependent variations of muscle functions during isometric contraction of knee extensors and to examine test-retest reliability of their measurement methods. For test-retest reliability sports students completed three test sessions. Highly skilled athletes, sports students and untrained subjects were investigated to determine the performance-dependent variations. The following variables were analysed: maximal voluntary contraction (MVC), voluntary activation (VA), absolute muscle reaction time (AR), muscle endurance (ME), and EMG frequency analysis (MF) of m. vastus lateralis (VL), m. vastus medialis (VM) and m. rectus femoris (RF). RESULTS TEST-RETEST-RELIABILITY: A high reliability between session 1 vs. 2 and session 2 vs. 3 was shown for MVC (ICC=0.92 and .97), VA (0.92/0.95) and ME (0.87/0.95). ICC in AR (0.23) was low between the first and second session and moderate between the second and third session (0.74). MF of VL, VM and RF showed low ICC between sessions. PERFORMANCE DEPENDENT VARIATIONS: Significant differences in nearly all variables (except VA) were found between trained (athletes and sports students) and untrained subjects.