Population and Community-Based Promotion of Physical Activity: A Priority for Physical Therapy

Effects of Exercise-Based Interventions on Physical Activity Levels in Persons With Parkinson's Disease: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Parkinson's disease (PD) is the most common neurodegenerative movement disorder. Symptom severity leads to devastating consequences such as falls, immobility, impaired quality of life, and reduced general activity. Adopting a sedentary lifestyle creates a vicious circle, as physical inactivity can negatively affect the clinical domains of PD. Despite the recognition of the disease-modifying potential of physical activity (PA), achieving adequate exercise levels can be challenging for individuals with PD. This study aimed to investigate the repercussions of exercise-based interventions to improve PA levels in persons with PD through a systematic review with meta-analysis.

METHODS

A search was conducted from database inception to February 2021 across 3 databases: PubMed, Web of Science, and Scopus. Randomized controlled trials were included if they involved persons with PD, outcome measures associated with PA levels, and an exercise-based intervention. Two reviewers performed independent data extraction and methodologic quality assessment of the studies using the Downs and Black quality checklist.

RESULTS

A total of 6 studies were included in the study (1251 persons with PD). Four intervention types were identified: balance, strength, aerobic, and multimodal exercise (combination of several types of exercise programs). The meta-analysis showed that exercise interventions have a positive effect on PA (standard mean difference = 0.50, 95% CI =-0.02, 1.00; P = .06). The risk of bias was generally low.

CONCLUSIONS

The findings support the use of exercise-based interventions (aerobic exercise, balance exercise, strength exercise, and/or multimodal exercise) to improve PA levels. However, the limited number of studies and the heterogeneity of the interventions do not allow us to draw a definitive conclusion.

Adding Physical Activity Coaching and an Activity Monitor Was No More Effective Than Adding an Attention Control Intervention to Group Exercise for Patients With Chronic Nonspecific Low Back Pain (PAyBACK Trial): A Randomized Trial

OBJECTIVE

To investigate whether adding physical activity coaching and an activity monitor enhanced the effects of a group exercise program on pain intensity and disability for people with chronic nonspecific low back pain.

DESIGN

Randomized controlled trial with concealed allocation, intention-to-treat analysis, and blinding of participants and assessors.

METHODS

One hundred sixty participants with chronic nonspecific low back pain who were aged between 18 and 60 years and seeking care at an outpatient physiotherapy clinic participated. Both groups received supervised group exercise therapy. The intervention group also received physical activity coaching sessions aimed at improving physical activity, and physical activity electronic feedback delivered by an activity monitor. The attention control group received modified approaches of coaching sessions and an activity monitor. Disability was measured using the Roland Morris Disability Questionnaire (0-24), and pain intensity was measured using the 11-point Numerical Rating Scale (0-10). Linear mixed models were performed to test for differences between groups.

RESULTS

There were no differences between groups for reductions in disability (mean difference [MD] = -0.5 out of 24 points; 95% confidence interval [CI]: -2.2, 1.1) and pain intensity (MD = -0.4 out of 10 points; 95% CI: -1.3, 0.5) at 3-month follow-up. There were no between-groups differences at 6- and 12-month follow-up assessments.

CONCLUSION

Adding targeted physical activity coaching and an activity monitor did not reduce pain intensity or disability more than an attention control approach in participants with chronic low back pain who were undertaking a group exercise program. J Orthop Sports Phys Ther 2022;52(5):287-299. doi:10.2519/jospt.2022.10874.

Embedding Population Health in Physical Therapist Professional Education

The future of health care professional education is moving from a focus on the individual to embrace the health of the larger society. The COVID-19 pandemic has further highlighted the connection between social determinants and the health of populations. There are frameworks and competencies to support the delivery of population health content in the entry-level Doctor of Physical Therapy (DPT) curriculum. Three options for integrating population health content into the DPT curriculum are presented: (1) threading the content throughout the curriculum, (2) concentrating the content in 1 or 2 identified courses, and (3) offering elective courses. Each of these strategies has benefits and challenges, but threading the content throughout the curriculum provides the best opportunity to reinforce population health competencies across populations and practice settings. Experiential learning using authentic scenarios provides an ideal opportunity for students to understand population health concepts in a real-world context. Activities that incorporate interaction with other health professions broaden students' perspectives of the role of different professions for achieving population health goals. Examples of learning activities are included in 3 competency areas, Foundations of Population Health, Prevention and Health Promotion, and Health Policy. Current societal issues provide an opportunity to enhance population health education from a meaningful perspective for students. The topic of health equity presents an opportunity to tie social and political factors of population health to social justice and health outcomes. Similarly, the COVID-19 pandemic puts issues of mental health, health disparities, and health systems front and center in our understanding of population health.

IMPACT

Health care practitioners are looking at health through the lens of health equity and acknowledging the impact of social and political determinants on health to address health disparities, decrease health care expenditures, and respond to changes necessitated by pandemics such as COVID-19. As health care systems and practices are rethought and reconstructed, the intentional integration of population health principles woven into the fabric of professional education is a critical component of preparing future providers. This article describes how population health concepts can be meaningfully embedded into the DPT curriculum along with providing realistic examples and activities.

Adopting Population Health Frameworks in Physical Therapist Practice, Research, and Education: The Urgency of Now

Chronic, noncommunicable diseases have replaced acute, infectious diseases as the leading causes of global mortality and morbidity. Efforts among physical therapists to address noncommunicable diseases have primarily focused on the promotion of healthy behaviors among individual clients. However, the strongest predictors of chronic disease are tied to where we live, work, learn, and play, our families, and our communities. Population health frameworks can help us better understand the complex interrelations between individuals' health condition and their social and physical environment over time and also inform the development of effective programs and policies that improve the health of individuals and communities. The objectives of this article are to: (1) define population health, prevention, and health promotion; (2) provide a current perspective on the utility of population health frameworks in physical therapy; and (3) identify opportunities for the expanded use of population health frameworks in physical therapist practice, research, and education.

Experiences of people with stroke and multiple sclerosis and caregivers of a community exercise programme involving a healthcare-recreation partnership

Purpose: To explore perceptions of people with neurological conditions and their caregivers of the health benefits of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership.Materials and methods: Descriptive qualitative study. Individuals with balance and mobility deficits from a neurological condition, and their caregivers, were interviewed on completion of a group, task-oriented community-based exercise programme incorporating a healthcare-recreation partnership. A thematic analysis was performed.Results: Nine people post-stroke, and four people with multiple sclerosis (MS) (n = 13; 54% male) and 12 caregivers (83% spouses) participated. Two themes emerged. One theme indicated that the programme fosters diverse, interrelated health benefits. Participants described experiences of improved balance, strength, and confidence that translated to improved everyday functioning and social participation. Benefits were reinforced through repeated programme registration. A second theme indicated that caregivers experience challenges and diverse benefits related to the programme. Transportation and programme cost were primary challenges. Caregivers described emotional health benefits from assisting participants during classes and observing participants improvement over time.Conclusions: Group, task-oriented community-based exercise programmes incorporating a healthcare-recreation partnership may yield health benefits for exercise participants and caregivers. Results can guide programme evaluation, the nature and timing of education about such programmes, and efforts to address cost and transportation issues.Implications of rehabilitationStroke and multiple sclerosis commonly cause balance and mobility limitations that can result in physical inactivity and further deterioration in health.Group, task-oriented community-based exercise programmes in which rehabilitation professionals train and support fitness instructors to deliver the exercise programme in community centres may increase access to exercise participation for this group.Study results suggest by improving balance and mobility, these programmes help increase independence in activities of daily living and social and leisure participation, while improving caregiver mental health and decreasing the need for caregiver assistance.Rehabilitation professionals can use findings to inform patient education, and support programme implementation and referral.

Beyond the individual: population health and physical therapy

Improving the health of populations is critical to meeting global health targets. The purpose of this article is to define population health and differentiate it from related concepts and introduce a framework that can be used to inform the population-based practice of physical therapists. The Population-Based Practice (PBP) Framework is modified from the Public Health Nursing Intervention Wheel and can be used to understand levels (i.e., systems, community, and individual) and types (i.e., screening and outreach, referral and follow-up, health teaching and coaching, consultation and collaboration, advocacy and policy development, and social marketing) of population-based practice. Several physical therapy examples illustrate selected cells within the model. The PBP Framework provides practitioners, educators, and scholars with a new way to envision population-based practice for physical therapists. Such a shift in both thinking and practice is needed if physical therapists are to use their unique skills to move beyond the individual, embracing population-based practice to improve health outcomes and reduce health disparities while controlling costs.

Physical activity and disability measures in chronic non-specific low back pain: a study of responsiveness

Objectives:

To compare the responsiveness of disability measures with physical activity measures in patients with chronic low back pain (CLBP) undergoing a course of physical therapy treatment.

Design:

This is a prospective cohort study with two-month follow-up.

Subjects:

A total of 106 patients presenting with non-specific CLBP of more than three months duration were recruited.

Main measures:

Disability measures investigated were Quebec Back Pain Disability Scale and Roland Morris Disability Questionnaire. Physical activity measures analyzed include the Baecke Habitual Physical Activity Questionnaire and objective measures derived from an accelerometer (i.e. total time spent in moderate-to-vigorous and light physical activity, number of steps and counts per minute). Disability and physical activity measures were collected at the baseline and after eight weeks of treatment. For the responsiveness analyses, effect size (ES) and standardized response mean (SRM) were calculated. Correlations between the change in disability and physical activity measures were calculated.

Results:

Responsiveness for disability measures was considered to be large with ESs ranging from −1.03 to −1.45 and SRMs ranging from −0.99 to −1.34, whereas all physical activity measures showed values lower than 0.20. Changes in disability measures did not correlate with changes in physical activity measures (correlation coefficients ranged from −0.10 to 0.09).

Conclusion:

Disability measures were responsive after a course of physical therapy treatment in patients with CLBP. The lack of responsiveness in the physical activity measures might be due to the inability of these measures to detect change over time or the use of an intervention not designed to increase physical activity levels.

The efficacy of a multimodal physical activity intervention with supervised exercises, health coaching and an activity monitor on physical activity levels of patients with chronic, nonspecific low back pain (Physical Activity for Back Pain (PAyBACK) trial): study protocol for a randomised controlled trial

Background

Physical activity plays an important role in the management of chronic low back pain (LBP). Engaging in an active lifestyle is associated with a better prognosis. Nevertheless, there is evidence to suggest that patients with chronic LBP are less likely to meet recommended physical activity levels. Furthermore, while exercise therapy has been endorsed by recent clinical practice guidelines, evidence from systematic reviews suggests that its effect on pain and disability are at best moderate and not sustained over time. A limitation of current exercises programmes for chronic LBP is that these programmes are not designed to change patients’ behaviour toward an active lifestyle. Therefore, we will investigate the short- and long-term efficacy of a multimodal intervention, consisting of supervised exercises, health coaching and use of an activity monitor (i.e. Fitbit Flex) compared to supervised exercises plus sham coaching and a sham activity monitor on physical activity levels, pain intensity and disability, in patients with chronic, nonspecific LBP.

Methods

This study will be a two-group, single-blind, randomised controlled trial. One hundred and sixty adults with chronic, nonspecific LBP will be recruited. Participants allocated to both groups will receive a group exercise programme. In addition, the intervention group will receive health coaching sessions (i.e. assisting the participants to achieve their physical activity goals) and an activity monitor (i.e. Fitbit Flex). The participants allocated to the control group will receive sham health coaching (i.e. encouraged to talk about their LBP or other problems, but without any therapeutic advice from the physiotherapist) and a sham activity monitor. Outcome measures will be assessed at baseline and at 3, 6 and 12 months post randomisation. The primary outcomes will be physical activity, measured objectively with an accelerometer, as well as pain intensity and disability at 3 months post randomisation. Secondary outcomes will be physical activity, pain intensity and disability at 6 and 12 months post randomisation as well as other self-report measures of physical activity and sedentary behaviour, depression, quality of life, pain self-efficacy and weight-related outcomes at 3, 6, and 12 months post randomisation.

Discussion

This study is significant as it will be the first study to investigate whether a multimodal intervention designed to increase physical activity levels reduces pain and disability, and increases physical activity levels compared to a control intervention in patients with chronic LBP.

Trial registration

ClinicalTrials.gov, ID: NCT03200509. Registered on 28 June 2017.

Electronic supplementary material

The online version of this article 10.1186/s13063-017-2436-z) contains supplementary material, which is available to authorized users.