Physical Activity as a Vital Sign: A Systematic Review

Physical activity should be the primary intervention for individuals living with chronic pain A position paper from the European Pain Federation (EFIC) 'On the Move' Task Force

BACKGROUND

There is clear evidence demonstrating the benefits of physical activity (PA) on pain and overall health, however, PA is challenging for many individuals living with chronic pain. Even non-exercise specialists can (cost) effectively promote PA, but many health professionals report a number of barriers in providing guidance on PA, suggesting that it is not consistently promoted. This expert position paper summarizes the evidence and provides five recommendations for health professionals to assess, advise and support individuals living with any chronic pain condition with a long life expectancy in adopting and sustaining physically active lifestyles.

METHODS

This position paper was prepared by the 'On The Move' Task Force of the European Pain Federation EFIC. Final recommendations were endorsed by the European Pain Forum, Pain Alliance Europe and the Executive Board of EFIC.

RESULTS

We recommend that all health professionals (1) Take a history of the persons' PA levels, and put PA on the agenda, (2) Advise that PA is important and safe for individuals living with chronic pain, (3) Deliver a brief PA intervention and support individuals living with chronic pain in becoming physically active, (4) Discuss acceptable levels of PA-related soreness and pain and (5) Provide ongoing support in staying physically active.

SIGNIFICANCE

Physical activity is safe and offers several advantages, including general health benefits, low risk of side effects, low cost and not requiring access to healthcare. Adoption of these recommendations can improve the quality of care and life of individuals living with chronic pain and reduce their overall health risks.

The association between blood biological age at rehabilitation admission and physical activity during rehabilitation in geriatric inpatients: RESORT

Geriatric rehabilitation inpatients have high levels of sedentary behaviour (SB) and low levels of physical activity (PA). Biological age predicted by blood biomarkers is indicative of adverse outcomes. The objective was to determine the association between blood biological age at rehabilitation admission and levels of SB and PA during rehabilitation in geriatric inpatients. Inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital (Melbourne, Australia) from October 22, 2019, to March 29, 2020, in the REStORing health of acute unwell adulTs (RESORT) observational cohort were included. Blood biological age was predicted using SenoClock-BloodAge, a hematological ageing clock. Patients wore an inertial sensor to measure SB and PA. Logistic regression analyses were conducted. A total of 111 patients (57.7% female) with mean age 83.3 ± 7.5 years were included in the analysis. The mean blood biological age was 82.7 ± 8.4 years. Patients with 1-year higher blood biological age had higher odds of having high SB measured as non-upright time greater than 23 h/day (odds ratio (OR): 1.050, 95% confidence interval (CI): 1.000-1.102). Individuals having 1-year higher age deviation trended towards lower odds of having high levels of PA measured as stepping time greater than 7.4 min/day (OR: 0.916, CI: 0.836-1.005) and as greater than 19.5 sit-to-stand transitions/day (OR: 0.915, CI: 0.836-1.002). In conclusion, higher biological age was associated with higher levels of SB and trended towards lower PA. Incorporating blood biological age could facilitate resource allocation and the development of more tailored rehabilitation plans.

Physical Activity with Sports Scientist (PASS) programme to promote physical activity among patients with non-communicable diseases: a pragmatic randomised controlled trial protocol

Physical activity (PA) effectively prevents and treats non-communicable diseases in clinical settings. PA promotion needs to be more consistent, especially in busy primary care. Sports scientists have the potential to support PA promotion in primary care. The Physical Activity with Sports Scientist (PASS) programme is created to personalise PA promotion led by a sports scientist in a primary care clinic. A pragmatic randomised controlled trial with two parallel groups will be conducted at a family medicine clinic. Physically inactive participants aged 35-70 years who have type 2 diabetes mellitus, hypertension or dyslipidaemia will be invited. The control group (n=60) will receive usual care. The intervention group (n=60) will receive the PASS programme and usual care. The PASS programme will consist of a tailored PA prescription after the physician's consultation at the first visit and monthly phone follow-ups. The primary outcome is the proportion of participants who have achieved the PA goal defined as aerobic activity (≥150 min/week of moderate to vigorous-intensity PA), muscle-strengthening activity (≥2 days/week of moderate or greater intensity) and multicomponent PA (≥2 days/week of moderate or greater intensity). Secondary outcomes are body composition and physical fitness. The primary and secondary outcomes will be measured and compared between the control and intervention groups at visit 1 (month 0: baseline measurements), visit 2 (months 3-4: follow-up measurements), visit 3 (months 6-8: end-point measurements) and visit 4 (months 9-12: continuing measurements). The study protocol was registered with the Thai Clinical Trials Registry. Trial registration number: TCTR20240314001.

Cloud-Based Machine Learning Platform to Predict Clinical Outcomes at Home for Patients With Cardiovascular Conditions Discharged From Hospital: Clinical Trial

BACKGROUND

Hospitalizations account for almost one-third of the US $4.1 trillion health care cost in the United States. A substantial portion of these hospitalizations are attributed to readmissions, which led to the establishment of the Hospital Readmissions Reduction Program (HRRP) in 2012. The HRRP reduces payments to hospitals with excess readmissions. In 2018, >US $700 million was withheld; this is expected to exceed US $1 billion by 2022. More importantly, there is nothing more physically and emotionally taxing for readmitted patients and demoralizing for hospital physicians, nurses, and administrators. Given this high uncertainty of proper home recovery, intelligent monitoring is needed to predict the outcome of discharged patients to reduce readmissions. Physical activity (PA) is one of the major determinants for overall clinical outcomes in diabetes, hypertension, hyperlipidemia, heart failure, cancer, and mental health issues. These are the exact comorbidities that increase readmission rates, underlining the importance of PA in assessing the recovery of patients by quantitative measurement beyond the questionnaire and survey methods.

OBJECTIVE

This study aims to develop a remote, low-cost, and cloud-based machine learning (ML) platform to enable the precision health monitoring of PA, which may fundamentally alter the delivery of home health care. To validate this technology, we conducted a clinical trial to test the ability of our platform to predict clinical outcomes in discharged patients.

METHODS

Our platform consists of a wearable device, which includes an accelerometer and a Bluetooth sensor, and an iPhone connected to our cloud-based ML interface to analyze PA remotely and predict clinical outcomes. This system was deployed at a skilled nursing facility where we collected >17,000 person-day data points over 2 years, generating a solid training database. We used these data to train our extreme gradient boosting (XGBoost)-based ML environment to conduct a clinical trial, Activity Assessment of Patients Discharged from Hospital-I, to test the hypothesis that a comprehensive profile of PA would predict clinical outcome. We developed an advanced data-driven analytic platform that predicts the clinical outcome based on accurate measurements of PA. Artificial intelligence or an ML algorithm was used to analyze the data to predict short-term health outcome.

RESULTS

We enrolled 52 patients discharged from Stanford Hospital. Our data demonstrated a robust predictive system to forecast health outcome in the enrolled patients based on their PA data. We achieved precise prediction of the patients' clinical outcomes with a sensitivity of 87%, a specificity of 79%, and an accuracy of 85%.

CONCLUSIONS

To date, there are no reliable clinical data, using a wearable device, regarding monitoring discharged patients to predict their recovery. We conducted a clinical trial to assess outcome data rigorously to be used reliably for remote home care by patients, health care professionals, and caretakers.

Physically active primary care physicians consult more on physical activity and exercise for patients: A public teaching-hospital study

Physical activity and exercise (PAE) improve quality of life and reduce the effects of chronic diseases. Primary care physicians (PCPs) play an important role to encourage PAE in patients. We aim to assess PCPs' current PAE consultation practices and their enablers/barriers in daily clinical practice. We had 64 PCPs (age [35.3 ​± ​4.7] y, 47 women) that completed self-administered questionnaires on PAE consultation practices, training, and confidence levels. PCPs (n ​= ​42) also completed the International Physical Activity Questionnaire-Short Form to assess their physical activity (PA) levels. We conducted correlation, one-way analysis of variance and a linear regression to assess the associations between enablers, barriers and PA levels to PAE consultation practices. On average, PCPs consulted on PAE in 49.7% of their daily clinical appointments. Majority of PCPs (70%) strongly agreed that more PAE knowledge were needed to increase consultation practices. Top three barriers related (p ​< ​0.001) to practices were lack of PAE education (r ​= ​0.47), patients' preference of pharmaceutical interventions (r ​= ​0.45) and lack of continuing education in PAE for PCPs (r ​= ​0.37). Physically active PCPs (health-enhancing PA levels, n ​= ​6) gave significantly more daily consultations in PAE, 73.2% ​± ​21.9%, compared to inactive PCPs (n ​= ​13), 37.4% ​± ​22.8% (p ​= ​0.013). In our regression output, PCPs who had higher PA levels consulted more on PAE daily (R2 ​= ​0.38, p ​< ​0.001) while controlling for age. Conclusion, PCPs require more knowledge on PAE and need be physically active themselves to increase PAE consultation for patients in their daily practice. Medical education should consider including more PA and exercise topics that may benefit both physicians and their patients.

Exercise Prescription Practices Among Mental Health Professionals on College Campuses: Testing the Information-Motivation-Behavioral Skills Model

BACKGROUND

The co-occurrence of physical inactivity and poor mental health in the college student population can lead to chronic health issues that have negative short-term effects (e.g., academic success). Poor mental health is associated with long-term conditions (e.g., obesity, serious mental illness) that are linked to premature mortality. The purpose of this study was to examine the information-motivation-behavioral (IMB) skills model and evaluate its ability to explain the variance in the use of exercise prescription in mental health treatment.

METHOD

Mental health professionals (MHPs) (n = 255) were recruited from college counseling centers in the USA. Structural equation modeling was used to examine the relationship between the predictor variables of information (exercise knowledge and benefits of exercise), motivation (personal beliefs, perceived barriers, and organizational support), and behavioral skills (self-efficacy), and the outcome variable of exercise prescription (i.e., brief counseling and referral for exercise).

RESULTS

The predictors accounted for 23% of the variance in exercise prescription (p = .001). Organizational support had a significant direct effect on exercise prescription (β = 0.27, p = .05). Personal beliefs (β = 0.96, p = .05) and organizational support (β = 0.31, p = .04) had significant direct effects on self-efficacy for prescribing exercise. MHP personal exercise behavior was associated with exercise prescription.

CONCLUSION

MHPs may be willing to support physical activity promotion and exercise prescription, but organizational structures are critical to enhance and sustain the delivery of this adjunctive therapy. The personal exercise history of MHPs may be an important consideration for behavior change interventions. The development and validation of scales are important considerations for future intervention study design.

A strategy to implement the American College of Sports Medicine's Exercise is Medicine® (EIM) initiative in a community oncology clinic

PURPOSE

Despite proven benefits, few cancer patients exercise during chemotherapy. The American College of Sports Medicine's Exercise is Medicine® (EIM) initiative describes a model to integrate exercise into oncology care, based upon assessing patients' ability to exercise safely, advising on exercise benefits, and referring patients to exercise. We developed and tested a strategy to implement EIM in a community-based oncology clinic, to assess-advise-refer 20 patients undergoing chemotherapy to a 3-month online exercise class, and measured implementation outcomes.

METHODS

Using a community-based provider participation in research (CBPPR) model, researchers and staff co-designed and tested a 4-level implementation strategy, with a goal of assessing-advising-referring 20 cancer patients to exercise. Surveys and interviews were conducted with 12 (100%) staff at baseline and post-implementation on acceptability/appropriateness/feasibility, perceptions of individual implementation roles, and organizational strengths/conditions. Data were analyzed using correlations, t-tests, and content analysis.

RESULTS

The proposed strategy was revised in collaboration with staff who requested assistance for recruitment and data collection. EIM was successfully implemented with 41 (92%) patients assessed, 37 (90%) advised, and 22 (60%) referred to exercise classes. Barriers to implementation were staff shortages and time constraints; facilitators included research team supports. Staff's perceived organizational strengths were positively correlated with exercise promotion acceptability, appropriateness, and feasibility. There were no statistically significant changes in implementation outcomes (acceptability/appropriateness/feasibility) post-implementation.

CONCLUSIONS

Using a collaborative model, EIM was successfully implemented in a community oncology clinic; however, the clinic required significant support from the research team. Adaptations to the EIM process may be required to improve implementation outcomes.

Risk profiles of adults with heavy alcohol use: Drinking patterns, behavioral and metabolic factors, health problems, and racial and ethnic disparities

BACKGROUND

Heavy alcohol use is a growing risk factor for chronic disease, yet little is known about its co-occurrence with other risk factors and health problems. This study aimed to identify risk profiles of adults with heavy alcohol use and examined potential disparities by race and ethnicity.

METHODS

This cross-sectional study included 211,333 adults with heavy alcohol use (in excess of daily or weekly limits recommended by National Institute on Alcohol Abuse and Alcoholism) between June 1, 2013 and December 31, 2014 in Kaiser Permanente Northern California. Latent class analysis was used to examine how heavy drinking patterns clustered with other behavioral and metabolic risk factors and health problems to form risk profiles. Multinomial logistic regression models were fit to examine associations between race, ethnicity, and risk profiles.

RESULTS

A 5-class model was selected as best fitting the data and representing clinically meaningful risk profiles: (1) "heavy daily drinking and lower health risks" (DAILY, 44.3%); (2) "substance use disorder and mental health disorder" (SUD/MH, 2.3%); (3) "heavy weekly drinking and lower health risks" (WEEKLY, 19.6%); (4) "heavy daily drinking and more health risks" (DAILY-R, 18.5%); (5) "heavy weekly drinking and more health risks" (WEEKLY-R, 15.3%). American Indian or Alaska Native (AIAN) and Black patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles than the DAILY profile. AIAN, Black, and Latino/Hispanic patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles rather than the WEEKLY profile.

CONCLUSIONS

AIAN, Black, and Latino/Hispanic patients with self-reported heavy drinking were more likely to be in risk profiles with greater alcohol consumption, more health risks, and higher morbidity. Targeted, culturally appropriate interventions for heavy alcohol use that may address other modifiable risk factors are needed to work towards health equity.

Incorporating Physical Activity Assessments and Behavior Change Techniques Into Geriatrics

Ninety-one percent of adults 65 years and older do not perform the recommended levels of physical activity (PA), resulting in increased risk of disability, morbidity, and mortality. Despite knowing the benefits of PA and acknowledging the importance of assessing and addressing inadequate PA levels, 50%-75% of health care providers do not incorporate behavior change techniques into clinical practice. This clinical gap can be explained by a lack of knowledge or confidence in (1) assessing PA levels; (2) addressing inadequate PA levels; and (3) justifying the time needed to use these techniques in clinical practice. In this special communication, we address this gap by providing a 3-step theoretical-based clinical decision pathway that guides health care providers on how to identify older adults with inadequate PA levels, determine readiness to increase PA, and empower patents to develop an action plan that will increase their PA levels. We also provide a conceptual model that supports the use of techniques that assess and address inadequate PA by tying PA to the Age-Friendly Health System's 4Ms (ie, What Matters to the older adult, Mentation, Mobility, and Medications).

Tools to guide clinical discussions on physical activity, sedentary behaviour, and/or sleep for health promotion between primary care providers and adults accessing care: a scoping review

BACKGROUND

Health care providers have reported low knowledge, skill, and confidence for discussing movement behaviours (i.e., physical activity, sedentary behaviour, and sleep), which may be improved with the use of tools to guide movement behaviour discussions in their practice. Past reviews have examined the psychometric properties, scoring, and behavioural outcomes of physical activity discussion tools. However, the features, perceptions, and effectiveness of discussion tools for physical activity, sedentary behaviour, and/or sleep have not yet been synthesized. The aim of this review was to report and appraise tools for movement behaviour discussions between health care providers and adults 18 + years in a primary care context within Canada or analogous countries.

METHODS

An integrated knowledge translation approach guided this review, whereby a working group of experts in medicine, knowledge translation, communications, kinesiology, and health promotion was engaged from research question formation to interpretation of findings. Three search approaches were used (i.e., peer-reviewed, grey literature, and forward searches) to identify studies reporting on perceptions and/or effectiveness of tools for physical activity, sedentary behaviour, and/or sleep. The quality of included studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

In total, 135 studies reporting on 61 tools (i.e., 51 on physical activity, one on sleep, and nine combining two movement behaviours) met inclusion criteria. Included tools served the purposes of assessment (n = 57), counselling (n = 50), prescription (n = 18), and/or referral (n = 12) of one or more movement behaviour. Most tools were used or intended for use by physicians, followed by nurses/nurse practitioners (n = 11), and adults accessing care (n = 10). Most tools were also used or intended to be used with adults without chronic conditions aged 18-64 years (n = 34), followed by adults with chronic conditions (n = 18). The quality of the 116 studies that evaluated tool effectiveness varied.

CONCLUSIONS

Many tools were positively perceived and were deemed effective at enhancing knowledge of, confidence for, ability in, and frequency of movement behaviour discussions. Future tools should guide discussions of all movement behaviours in an integrated manner in line with the 24-Hour Movement Guidelines. Practically, this review offers seven evidence-based recommendations that may guide future tool development and implementation.

Adaption of tele-behavioral activation to increase physical activity in depression: Protocol for iterative development and evaluation

Background

Poor treatment outcomes, disease recurrence, and medical co-morbidities contribute to the significant burden caused by depressive disorders. Increasing physical activity in persons with depression has the potential to improve both depression treatment outcomes and physical health. However, evidence for physical activity interventions that can be delivered as part of depression treatment remains limited. This study will examine a Behavioral Activation teletherapy intervention adapted to include a specific focus on increasing physical activity.

Methods

The two-phase study will include a preliminary pilot study (n = 15) to evaluate and refine the manualized intervention using a mixed-methods approach followed by a single-arm study to evaluate feasibility and preliminary efficacy of the adapted BA teletherapy. Participants will be adults, age 18-64, with moderate to severe depressive symptoms (defined as a PHQ-9 score ≥10) and who currently engage in 90 min or less of moderate-to-vigorous physical activity. Individuals will be excluded if they have a current or past manic or hypomanic episode, psychosis, schizophrenia or schizophreniform disorder, or active suicidal ideation, or if not medically-cleared to exercise. The BA intervention will consist of 8 weekly sessions, followed by 2 bi-weekly booster sessions. Feasibility outcomes will include metrics of screening, enrollment, intervention adherence and fidelity, and participant retention. Intervention preliminary efficacy will be evaluated through assessment of changes in depressive symptoms and moderate-to-vigorous physical activity.

Conclusion

Data from this trial will be used to support the conduct of a randomized controlled trial to evaluate the efficacy of the adapted BA intervention.

Obesity-related hypertension: Implications for advanced nursing practice

ABSTRACT

Obesity increases the risk of hypertension and other cardiometabolic comorbidities. Lifestyle modifications are usually recommended, though lasting effects on weight and BP reduction are limited. Weight-loss medications, especially incretin mimetics, are effective for short- and long-term treatment. Metabolic surgery provides cure of obesity-related hypertension in some patients. NPs are well positioned to manage obesity-related hypertension to improve clinical outcomes of affected individuals.

Effectiveness of a targeted primary preventive intervention in a high-risk group identified using an efficiency score from data envelopment analysis: a randomised controlled trial of local residents in Japan

OBJECTIVE

To determine whether a minimal intervention based on the data envelopment analysis (DEA)-identified efficiency score effectively prevents hypertension.

DESIGN

Randomised controlled trial.

SETTING

Takahata town (Yamagata, Japan).

PARTICIPANTS

Residents aged 40-74 years belonged to the information provision group for specific health guidance. Participants with a blood pressure ≥140/90 mm Hg, those taking antihypertensive medication, or those with a history of cardiac diseases were excluded. Participants were consecutively assigned based on their health check-up visit at a single centre from September 2019 to November 2020 and were followed up at the check-up in the following year, until 3 December 2021.

INTERVENTION

A targeted approach using minimal intervention. Target was identified using DEA and 50% of participants with higher risk were targeted. The intervention was notifying the results of their risk of hypertension according to the efficiency score obtained by the DEA.

PRIMARY OUTCOME MEASURES

A reduction in the proportion of participants who developed hypertension (≥140/90 mm Hg or taking antihypertensive medication).

RESULTS

A total of 495 eligible participants were randomised, and follow-up data were available for 218 and 227 participants in the intervention and control groups, respectively. The risk difference for the primary outcome was 0.2% (95% CI -7.3 to 6.9) with 38/218 (17.4%) and 40/227 (17.6%) events in the intervention and control group, respectively (Pearson's χ² test, p=0.880). The adjusted OR of the effect of the intervention was 0.95 (95% CI 0.56 to 1.61, p=0.843), and that of the efficiency score (10-rank increase) was 0.81 (95% CI 0.74 to 0.89, p<0.0001).

CONCLUSIONS

Minimal intervention to a high-risk population stratified by DEA was not effective in reducing the onset of hypertension in 1 year. The efficiency score could predict the risk of hypertension.

TRIAL REGISTRATION NUMBER

UMIN000037883.

Protocol for a bandit-based response adaptive trial to evaluate the effectiveness of brief self-guided digital interventions for reducing psychological distress in university students: the Vibe Up study

INTRODUCTION

Meta-analytical evidence confirms a range of interventions, including mindfulness, physical activity and sleep hygiene, can reduce psychological distress in university students. However, it is unclear which intervention is most effective. Artificial intelligence (AI)-driven adaptive trials may be an efficient method to determine what works best and for whom. The primary purpose of the study is to rank the effectiveness of mindfulness, physical activity, sleep hygiene and an active control on reducing distress, using a multiarm contextual bandit-based AI-adaptive trial method. Furthermore, the study will explore which interventions have the largest effect for students with different levels of baseline distress severity.

METHODS AND ANALYSIS

The Vibe Up study is a pragmatically oriented, decentralised AI-adaptive group sequential randomised controlled trial comparing the effectiveness of one of three brief, 2-week digital self-guided interventions (mindfulness, physical activity or sleep hygiene) or active control (ecological momentary assessment) in reducing self-reported psychological distress in Australian university students. The adaptive trial methodology involves up to 12 sequential mini-trials that allow for the optimisation of allocation ratios. The primary outcome is change in psychological distress (Depression, Anxiety and Stress Scale, 21-item version, DASS-21 total score) from preintervention to postintervention. Secondary outcomes include change in physical activity, sleep quality and mindfulness from preintervention to postintervention. Planned contrasts will compare the four groups (ie, the three intervention and control) using self-reported psychological distress at prespecified time points for interim analyses. The study aims to determine the best performing intervention, as well as ranking of other interventions.

ETHICS AND DISSEMINATION

Ethical approval was sought and obtained from the UNSW Sydney Human Research Ethics Committee (HREC A, HC200466). A trial protocol adhering to the requirements of the Guideline for Good Clinical Practice was prepared for and approved by the Sponsor, UNSW Sydney (Protocol number: HC200466_CTP).

TRIAL REGISTRATION NUMBER

ACTRN12621001223820.

Virtual Programming for Physical Activity Interventions: Integration of Behavioral Components

The SARS-Cov-2 pandemic changed many contemporary experiences, including how healthcare and exercise programming are delivered. As a result of the pandemic, there was an increase in virtual services and programming and there continues to be a demand for virtual options. The results from Desir et al support the use of virtual visits to successfully change lifestyle factors, specifically nutrition and physical activity. The use of individualized dietary and exercise goals were important to the success of the intervention, and should not be disregarded. As virtual healthcare and exercise continues to evolve, to maximize behavior change, we should also consider how to include the social and community aspects of exercise. Regardless, it is encouraging to see that significant advances are being made in virtual programming and that the needed engagement can occur in a virtual setting.

Tracking changes in physical activity during inpatient treatment in a psychiatric clinic in Germany by asking two simple questions

Increasing physical activity is essential to improve psychiatric patients' physical and mental health. This study aimed to characterise the physical activity levels of inpatients in a general psychiatric clinic and to determine the feasibility of using a simple tool in everyday practice to assess physical activity levels in standard patient documentation. We assessed the level of physical activity undertaken by patients treated on an inpatient basis in a psychiatric hospital over 20 months. A total of 328 patients were included in the analysis. Physical activity was measured using a slightly altered version of the Exercise as a vital sign (EVS) questionnaire. All information was extracted from letters of discharge. During inpatient treatment, moderate to vigorous activity levels increased, and more patients engaged in physical activity. Patients with mood or anxiety disorders displayed the most considerable increase in physical activity. Patients with other diagnoses, such as schizophrenia, benefitted less or not at all. Factors associated with physical activity included-among others-history of substance use, education and month of admission. Investigating the feasibility of standardised documentation of physical activity showed fluctuation in documentation rates throughout the study. The level of physical activity performed by psychiatric patients can be increased during inpatient treatment. Implementing physical activity level as part of standard patient documentation is a first step in gathering data to assess the need for interventions to achieve an optimal physical activity in psychiatric patients throughout inpatient treatment.

Associations between alcohol brief intervention in primary care and drinking and health outcomes in adults with hypertension and type 2 diabetes: a population-based observational study

OBJECTIVES

To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D).

DESIGN

A population-based observational study using electronic health records data.

SETTING

An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care.

PARTICIPANTS

Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017.

MAIN OUTCOME MEASURES

We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and 'controlled HbA1c' (HbA1c<8%) at 18-month follow-up.

RESULTS

For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined.

CONCLUSIONS

Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact.

Associations Between Physical Activity Vital Sign in Patients and Health Care Utilization in a Health Care System, 2018-2020

BACKGROUND

Physical inactivity is a risk factor for many chronic conditions. This retrospective cohort study examined associations between physical activity (PA) with health care utilization (HU).

METHODS

A PA vital sign was recorded in clinics from January 2018 to December 2020. Patients were categorized as inactive, insufficiently active, or sufficiently active by US PA aerobic guidelines. Associations between PA vital sign and visits (inpatient admissions, emergency department, urgent care, and primary care) were estimated using population average regression by visit type.

RESULTS

23,721 patients had at least one PA vital sign recorded, with a mean age of 47.3 years and mean body mass index (BMI) of 28; 52% were female and 63% were White. Sufficiently active patients were younger, male, White, and had lower BMI than insufficiently active patients. Achieving 150 minutes per week of moderate to vigorous PA per 1000 patient years was associated with 34 fewer emergency department visits (P < .001), 19 fewer inpatient admissions (P < .001), and 38 fewer primary care visits (P < .001) compared with inactive patients. Stronger associations between lower PA and higher HU were present among those who were older or had a higher comorbidity. BMI, sex, ethnicity, and race did not modify the association between PA and HU.

CONCLUSIONS

Meeting aerobic guidelines was associated with reduced HU for inpatient, primary care, and emergency department visits.

Physical activity promotion in chiropractic: a systematic review of clinician-based surveys

BACKGROUND

Physical inactivity is a global health pandemic. Allied healthcare providers, including chiropractors, are well placed to integrate individual physical activity (PA) promotion into routine care. A previous systematic review identified that approximately 90% of chiropractors held a positive opinion towards healthier patient lifestyles; however, the extent to which chiropractors promote PA to their patients within routine care is unclear. This systematic review aimed to describe chiropractors' attitudes towards and current practice in advising, counselling, discussing, supporting, or recommending PA to patients.

METHODS

Five databases were searched from inception to December 2021 for cross-sectional surveys that explored PA promotion by chiropractors in practice. We assessed the risk of bias of the included studies with the 'Risk of Bias in Cross-Sectional Surveys of Attitudes and Practices' tool. Descriptive data were extracted, grouping similar survey questions and responses into emerging categories. Chiropractors' views regarding the perceived importance and/or their preparedness to counsel and provide PA or exercise information are reported.

RESULTS

From 661 studies, 15 met the selection criteria. Surveys included 7999 chiropractors primarily from the USA, UK, Australia, and Sweden. All studies were rated as moderate-to-high risk of bias, with methodological weaknesses characterised by inconsistent reporting of missing data, non-representative samples, low response rates (i.e., less than 60%), and unknown validity of survey instruments. Chiropractors frequently recognised the importance of PA promotion, as demonstrated by the proportion of respondents reporting that they: (1) support the importance of providing PA or exercise information and counselling (64% to 100%); (2) are prepared to provide PA or exercise information and/or counselling to patients (91% to 92%,); (3) frequently obtain PA or exercise information from patients (87% to 97%,); 4) frequently discuss PA or exercise and/or provide PA or exercise information to patients (68% to 99%); and 5) frequently provide PA counselling to patients (50% to 81%.).

CONCLUSION

A large majority of practising chiropractors actively engage with PA promotion. However, the results should be interpreted with caution owing to the moderate-to-high risk of bias of the included studies. Forthcoming research initiatives should explore unbiased surveys, further PA education and training as well as capitalising on chiropractors' own PA participation.

Cardiorespiratory fitness and self-reported physical activity levels of referring mental healthcare professionals, and their attitudes and referral practices related to exercise and physical health

BACKGROUND

Physical activity (PA) interventions can improve mental and physical health of people with mental illness, especially when delivered by qualified exercise professionals. Also, the behaviour, engagement and support of referring mental healthcare professionals (HCP) seem essential, but research is scarce. We aimed to study HCP physical fitness and PA, and associations with their attitudes and referral practices related to physical health and PA interventions.

METHODS

HCP at the Dutch Association for Psychiatry congress (2019) were invited to an online questionnaire (demographic/work characteristics, stress, PA levels, knowledge/attitudes regarding PA, referral practices) and cycle ergometer test. Strongest associations were analysed using linear and logistic regression.

RESULTS

Of the 115 HCP who completed the questionnaire (40 also completed the ergometer test), 43% (n = 50) met PA guidelines (i.e., ≥150min moderate-to-vigorous PA and ≥2x bone/muscle-strengthening exercises/week). Women, HCP interns/residents and HCP experiencing more stress were less active and less likely to meet PA guidelines. Conversely, there were positive associations with personal experience with an exercise professional. Knowledge/attitudes on physical health and PA were positive. HCP were more likely to refer patients to PA interventions if they met PA guidelines (OR = 2.56, 95%BI = 0.85-7.13) or had higher beliefs that exercise professionals can increase adherence to PA interventions (OR = 3.72, 95%BI = 1.52-9.14).

LIMITATIONS

Mainly psychiatrists, affecting generalizability.

CONCLUSIONS

HCP report the importance and relevance of PA in mental healthcare. Despite strong evidence and guidance for PA interventions in prevention and treatment, referral to such interventions partly depends on the PA behaviour and attitude of patient's physician/clinician.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study

Background

Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania.

Methods

The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence.

Results

A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3–0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4–0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3–0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3–0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4–0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4–0.8, p<0.001) to be independent associated factors for poor adherence.

Conclusion

A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.

Prevalence and Associated Factors of Physical Activity among Medical Students from the Western Balkans

The student population includes young adults who need nutrition and regular physical activity (PA) for mental, cognitive, and physical development. It is estimated that, globally, only 25–40% of the university student population is involved in regular PA. To date, no research has been conducted in the Western Balkans to address the PA of medical students. The aim of this study was to investigate the prevalence and factors influencing PA among medical students from the Western Balkans. A cross-sectional study included 2452 students from 14 medical faculties in five countries (Slovenia, Croatia, Bosnia and Herzegovina, North Macedonia and Serbia). There were significantly more students who engaged than those who did not engage in some type of regular (daily) PA. Gender, overweight or obesity, and household income are significantly associated with students’ PA. Students who are more often involved in regular daily PA and have higher daily PA levels are more likely to be males whose household income is above average. In order to improve the health of the student population, the public health authorities need to continuously investigate the PA of students and introduce appropriate activities to increase their level of PA.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Alcohol brief intervention, specialty treatment and drinking outcomes at 12 months: Results from a systematic alcohol screening and brief intervention initiative in adult primary care

BACKGROUND

Alcohol screening, brief intervention and referral to treatment (SBIRT) in adult primary care is an evidence-based, public health strategy to address unhealthy alcohol use, but evidence of effectiveness of alcohol brief intervention (ABI) in real-world implementation is lacking.

METHODS

We fit marginal structural models with inverse probability weighting to estimate the causal effects of ABI on 12-month drinking outcomes using longitudinal electronic health records data for 312,056 adults with a positive screening result for unhealthy drinking between 2014 and 2017 in a large healthcare system that implemented systematic primary care-based SBIRT. We examined effects of ABI with and without adjusting for receipt of specialty alcohol use disorder (AUD) treatment, and whether effects varied by patient demographic characteristics and alcohol use patterns.

RESULTS

Receiving ABI resulted in significantly greater reductions in heavy drinking days (mean difference [95% CI] = -0.26 [-0.45, -0.08]), drinking days per week (-0.04 [-0.07, -0.01]), drinks per drinking day (-0.05 [-0.08, -0.02]) and drinks per week (-0.16 [-0.27, -0.04]). Effects of ABI on 12-month drinking outcomes varied by baseline consumption level, age group and whether patients already had an AUD, with better improvement in those who were drinking at levels exceeding only daily limits, younger, and without an AUD.

CONCLUSIONS

Systematic ABI in adult primary care has the potential to reduce drinking among people with unhealthy drinking considerably on both an individual and population level. More research is needed to help optimize ABI, in particular tailoring it to diverse sub-populations, and studying its long-term public health impact.

To Be Active or to Stop? A Cross-Sectional Retrospective Study Exploring Provider Advice and Patient Fears Surrounding Physical Activity in Pregnancies Complicated by Fetal Growth Restriction

Exercise guidance for women with pregnancies complicated by fetal growth restriction (FGR) is vague, despite the fact that physical activity during pregnancy improves placental development, placental blood flow, and encourages healthy fetal growth. The goal of this study is to test the hypothesis that women with pregnancies complicated by FGR are fearful of physical activity and are being given unclear or limited advice from healthcare providers. Participants (N = 78) (women who delivered an infant diagnosed with FGR within the past 5 years) took an electronic survey including demographic information, pregnancy information, provider advice recall, and other health-related information relevant to growth-restricted pregnancies. Quantitative and qualitative (post-positivism paradigm) methods were employed to analyze the data. When asked specifically about how the FGR diagnosis impacted their activity levels, nearly 50% of participants said the diagnosis led them to decrease their activity levels. Participants reported that healthcare providers who do discuss activity with pregnant patients with FGR suggest low-intensity activities or ceasing activity, although the majority of providers did not discuss activity at all. More fears surrounding physical activity were reported post-FGR diagnosis, including worrying about fetal growth and development and causing fetal harm when engaging in physical activity.

What can we learn from physical capacity about biological age? A systematic review

OBJECTIVE

To systematically investigate the relationship between objective measures of physical capacity (e.g., cardio-respiratory fitness or daily step count) and biological age, measured in different ways.

DATA SOURCE

PubMed; SCOPUS - Elsevier API; and Web of Science - ISI 1984-present, as well as contextual search engines used to identify additional relevant publications.

STUDY SELECTION

Cross-sectional and longitudinal studies that assessed the association between objectively measured physical capacity and biological aging in adult individuals (age>18).

RESULTS

Analysis of 28 studies demonstrated that physical capacity is positively associated with biological aging; the most dominant measures of physical capacity are muscular strength or gait speed. The majority of the studies estimated biological aging by a single methodology - either Leukocyte Telomere Length or DNA methylation levels.

CONCLUSIONS

This systematic review of the objective physical capacity measures used to estimate aging finds that the current literature is limited insofar as it overlooks the potential contribution of many feasible markers. We recommend measuring physical capacity in the context of aging using a wide range of modifiable behavioral markers, beyond simple muscle strength or simple gait speed. Forming a feasible and diversified method for estimating physical capacity through which it will also be possible to estimate biological aging in wide population studies is essential for the development of interventions that may alleviate the burden of age-related disease.

Factors associated with recording the exercise vital sign (EVS) in the electronic health records of patients in chiropractic teaching clinics

OBJECTIVE

We set out to identify factors associated with recording of exercise minutes per week in electronic patient files at chiropractic teaching clinics to better understand whether this important health determinant - exercise vital sign (EVS) - is captured or not.

METHODS

Patient files (4018) from 23 clinicians eligible for inclusion underwent multilevel logistic regression modeling to explore the association between a recorded EVS and the following: patients' age, sex, comorbidities and interns nested within clinicians.

RESULTS

EVS discussion was documented in 81.2% of patient files, whereas 44.9% had exercise minutes recorded numerically. Clinicians and interns explained 1.7% and 25.5% of the variance in the EVS outcome.

CONCLUSION

To enhance EVS recording, clinic directors and clinicians should better educate the interns on the importance of exercise is medicine and appropriate record keeping, as they explained the largest portion of variability in recording exercise in minutes per week.

Study protocol for the Innovative Support for Patients with SARS-COV-2 Infections Registry (INSPIRE): A longitudinal study of the medium and long-term sequelae of SARS-CoV-2 infection

Background

Reports on medium and long-term sequelae of SARS-CoV-2 infections largely lack quantification of incidence and relative risk. We describe the rationale and methods of the Innovative Support for Patients with SARS-CoV-2 Registry (INSPIRE) that combines patient-reported outcomes with data from digital health records to understand predictors and impacts of SARS-CoV-2 infection.

Methods

INSPIRE is a prospective, multicenter, longitudinal study of individuals with symptoms of SARS-CoV-2 infection in eight regions across the US. Adults are eligible for enrollment if they are fluent in English or Spanish, reported symptoms suggestive of acute SARS-CoV-2 infection, and if they are within 42 days of having a SARS-CoV-2 viral test (i.e., nucleic acid amplification test or antigen test), regardless of test results. Recruitment occurs in-person, by phone or email, and through online advertisement. A secure online platform is used to facilitate the collation of consent-related materials, digital health records, and responses to self-administered surveys. Participants are followed for up to 18 months, with patient-reported outcomes collected every three months via survey and linked to concurrent digital health data; follow-up includes no in-person involvement. Our planned enrollment is 4,800 participants, including 2,400 SARS-CoV-2 positive and 2,400 SARS-CoV-2 negative participants (as a concurrent comparison group). These data will allow assessment of longitudinal outcomes from SARS-CoV-2 infection and comparison of the relative risk of outcomes in individuals with and without infection. Patient-reported outcomes include self-reported health function and status, as well as clinical outcomes including health system encounters and new diagnoses.

Results

Participating sites obtained institutional review board approval. Enrollment and follow-up are ongoing.

Conclusions

This study will characterize medium and long-term sequelae of SARS-CoV-2 infection among a diverse population, predictors of sequelae, and their relative risk compared to persons with similar symptomatology but without SARS-CoV-2 infection. These data may inform clinical interventions for individuals with sequelae of SARS-CoV-2 infection.

The Role of Physical Activity and Exercise in Preventive Cardiology

The cardiovascular epidemiologist, Jeremy Morris, called physical activity "the best bargain in public health," but few clinicians use exercise and physical activity in their practice. Clinicians should routinely inquire about physical activity and recommend that patients achieve the minimal levels recommended by the 2018 Physical Activity Guidelines for Americans. Clinician should avoid unnecessary testing that discourages patients from an active lifestyle. Patients after myocardial infarction, cardiac surgery, or the diagnosis of heart failure or claudication should be referred to an exercise-based cardiac rehab program. Physical activity and exercise training may be a clinical bargain, but as all medicines must be used to be effective.

Physical Activity Assessment and Promotion in Clinical Settings in the United States: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to systematically examine interventions that focused on physical activity assessment and promotion in clinical settings in the United States.

DATA SOURCES

A literature search was performed in 6 major databases to extract published peer-reviewed studies from 2008 to 2019.

INCLUSION AND EXCLUSION CRITERIA

Interventions with practicing health professionals in the United States who performed physical activity assessment and promotion with adult patients 18 years of age and older. Studies were excluded if they were published in non-English, observational or case study designs, or gray literature.

DATA EXTRACTION

Studies were screened and coded based on the population, intervention, comparison, outcomes and study setting for scoping reviews (PRISMA-ScR) framework. Of 654 studies that were identified and screened for eligibility, 78 met eligibility criteria and were independently coded by two coders.

DATA SYNTHESIS

Data were synthesized using qualitative and descriptive methods.

RESULTS

Forty-three of the included studies were randomized controlled trials with a majority being delivered by physicians and nurses in primary care settings. Fifty-six studies reported statistically significant findings in outcome measures such as anthropometrics and chronic disease risk factors, with 17 demonstrating improvements in physical activity levels as a result of the interventions.

CONCLUSION

The assessment and promotion of physical activity in clinical settings appears to be effective but warrants continued research.

Self-Reported Physical Activity and Asthma Risk in Children

BACKGROUND

Increased physical activity (PA) may protect against asthma but PA can trigger asthma symptoms.

OBJECTIVE

To investigate relationships between moderate-to-vigorous PA (MVPA) assessed during routine care visits and incident asthma.

METHODS

For this retrospective cohort, 542,486 children between 2 and 17 years from 2010 to 2017 were included who had an MVPA assessment (exercise vital sign) during routine care visits. The association of MVPA and asthma was analyzed using Cox proportional hazards regression models as a function of age, with MVPA and body mass index (BMI) being time-varying factors, adjusted for race and ethnicity, socioeconomic status, and air pollution.

RESULTS

The mean MVPA was 5.4 (standard deviation: 4.4) hours/week. Crude asthma incidence density rate (IDR) was highest in children with <1 hour/week of MVPA (IDR: 9.07, 95% confidence interval [CI]: 8.79, 9.36) and lowest in children engaging in 4 to 7 hours/week of MVPA (IDR: 6.55, 95% CI: 6.33, 6.77). In adjusted models, an increase in MVPA was associated with lower asthma risk in children reporting 0 hour/week of MVPA (hazard ratio: 0.981, 95% CI: 0.973, 0.990). In children with ≥8 hours/week of MVPA, an increase in MVPA was associated with higher asthma risk (1.005, 95% CI: 1.002, 1.009). There was no significant BMI by MVPA interaction.

CONCLUSION

Increasing MVPA in children with low activity levels is associated with lower asthma risk; children reporting high levels of activity may experience greater asthma risk as their activity levels increase further. Understanding the role of PA in the development of asthma and assessing MVPA during routine care visits in children may help to develop targeted interventions and guide asthma management.

Innovation in the pediatric electronic health record to realize a more effective platform

Commercial electronic health records (EHRs) were first developed to automate business processes. As EHRs developed, design principles focused on transferring existing paper-based documentation to comparable electronic forms. In addition, a strong industry focus on adult healthcare settings and quality measures has limited attention and resources for high priority EHR functionality needed for the unique health care of children. The objective of this paper is to provide a review of innovation in the EHR, that includes a variety of established and emerging technologies that may help realize a more effective EHR in child health settings. A more effective EHR would serve as an electronic hub. Existing EHR infrastructure could provide the foundation upon which new technologies and approaches branch and extend, enabling more rapid and customizable innovation to better meet shifting stakeholder and end-user needs. Among many areas for improvement, key goals of innovation could include technology that relieves ambulatory primary care clinician documentation burden, identifies needs, and supports improved care coordination and outcomes, focused on the following key areas: identification of child and family care needs, decision support, documentation, care coordination, and family communication.

Group-Based Exercise in CKD Stage 3b to 4: A Randomized Clinical Trial

Rationale & Objective

We aimed to test interventions to improve physical activity in persons with advanced chronic kidney disease not yet receiving dialysis.

Study Design

Randomized controlled trial with parallel-group design.

Setting & Participants

We embedded a pragmatic referral to exercise programming in high-volume kidney clinics servicing diverse populations in San Jose, CA, and Atlanta, GA. We recruited 56 participants with estimated glomerular filtration rates < 45 mL/min/1.73 m².

Interventions

We randomly assigned participants to a mobile health (mHealth) group—wearable activity trackers and fitness professional counseling, or an Exercise is Medicine intervention framework (EIM) group—mHealth components plus twice-weekly small-group directed exercise sessions customized to persons with kidney disease. We performed assessments at baseline, 8 weeks at the end of active intervention, and 16 weeks after passive follow-up and used multilevel mixed models to assess between-group differences.

Outcomes

Activity tracker total daily step count.

Results

Of 56 participants, 86% belonged to a racial/ethnic minority group; randomly assigned groups were well balanced on baseline step count. In intention-to-treat analyses, the EIM and mHealth groups both experienced declines in daily step counts, but there was an attenuated reduction in light intensity physical activity (standard error 0.2 [5.8] vs −8.5 [5.4] min/d; P = 0.08) in the EIM compared with the mHealth group at 8 weeks. In as-treated analyses, total daily step count, distance covered, and light and moderate-vigorous activity minutes per day improved in the EIM group and declined in the mHealth group at 8 weeks (standard error +335 [506] vs −884 [340] steps per day; P = 0.05; P < 0.05 for secondary measures), but group differences faded at 16 weeks. There were no differences in quality-of-life and mental health measures during the study.

Limitations

Small sample size, limited duration of study, assessment of intermediate outcomes (steps per day).

Conclusions

A clinic-integrated referral to small-group exercise sessions is feasible, safe, and moderately effective in improving physical activity in an underserved population with high comorbid conditions.

Funding

Normon S Coplon Applied Pragmatic Clinical Research program.

Trial Registration

NCT03311763

Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study

BACKGROUND

The evolution of cognitive impairment of vascular origin is increasingly becoming a prominent health threat particularly in this era where hypertension is the leading contributor of global disease burden and overall health loss. Hypertension is associated with the alteration of the cerebral microcirculation coupled by unfavorable vascular remodeling with consequential slowing of mental processing speed, reduced abstract reasoning, loss of linguistic abilities, and attention and memory deficits. Owing to the rapidly rising burden of hypertension in Tanzania, we sought to assess the prevalence and correlates of cognitive impairment among hypertensive patients attending a tertiary cardiovascular hospital in Tanzania.

METHODOLOGY

A hospital-based cross-sectional study was conducted at Jakaya Kikwete Cardiac Institute, a tertiary care public teaching hospital in Dar es Salaam, Tanzania between March 2020 and February 2021. A consecutive sampling method was utilized to recruit consented hypertensive outpatients during their scheduled clinic visit. General Practitioner Assessment of Cognition (GPCOG) Score was utilized in the assessment of cognitive functions. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with cognitive impairment. Odd ratios with 95% confidence intervals and p-values are reported. All tests were 2-sided and p < 0.05 was used to denote a statistical significance.

RESULTS

A total of 1201 hypertensive patients were enrolled in this study. The mean age was 58.1 years and females constituted nearly two-thirds of the study population. About three quarters had excess body weight, 16.6% had diabetes, 7.7% had history of stroke, 5.7% had heart failure, 16.7% had renal dysfunction, 53.7% had anemia, 27.7% had hypertriglyceridemia, 38.5% had elevated LDL, and 2.4% were HIV-infected. Nearly two-thirds of participants had uncontrolled blood pressure and 8.7% had orthostatic hypotension. Overall, 524 (43.6%) of participants had cognitive impairment. During bivariate analysis in a logistic regression model of 16 characteristics, 14 parameters showed association with cognitive functions. However, after controlling for confounders, multivariate analysis revealed ≤primary education (OR 3.5, 95%CI 2.4-5.2, p < 0.001), unemployed state (OR 1.7, 95%CI 1.2-2.6, p < 0.01), rural habitation (OR 1.8, 95%CI 1.1-2.9, p = 0.01) and renal dysfunction (OR 1.7, 95%CI 1.0-2.7, p = 0.04) to have independent association with cognitive impairment.

CONCLUSION

This present study underscore that cognitive decline is considerably prevalent among individuals with systemic hypertension. In view of this, it is pivotal to incorporate cognitive assessment in routine evaluation of hypertensive patients.

The use of accelerometer-based wearable activity monitors in clinical settings: current practice, barriers, enablers, and future opportunities

Background

Wearable activity monitors (WAMs, e.g. Fitbits and research accelerometers) show promise for helping health care professionals (HCPs) measure and intervene on patients’ activity patterns. This study aimed to describe the clinical use of WAMs within South Australia, barriers and enablers, and future opportunities for large-scale clinical use.

Methods

A descriptive qualitative study was undertaken using semi-structured interviews. Participants were HCPs with experience using WAMs in South Australian clinical settings. Commencing with participants identified through the research team’s professional networks, snowball recruitment continued until all identified eligible HCPs had been invited. Semi-structured interviews were used to explore the research aims, with quantitative data analysed descriptively, and qualitative data analysed thematically.

Results

18 participants (physiotherapists n = 8, exercise physiologists n = 6, medical consultants n = 2, and research personnel recommended by medical consultants n = 2), represented 12 discrete “hubs” of WAM use in clinical practice, spanning rehabilitation, orthopaedics, geriatrics, intensive care, and various inpatient-, outpatient-, community-based hospital and private-practice settings. Across the 12 hubs, five primarily used Fitbits® (various models), four used research-grade accelerometers (e.g. GENEActiv, ActivPAL and StepWatch accelerometers), one used Whoop Bands® and another used smartphone-based step counters. In three hubs, WAMs were used to observe natural activity levels without intervention, while in nine they were used to increase (i.e. intervene on) activity. Device selection was typically based on ease of availability (e.g. devices borrowed from another department) and cost-economy (e.g. Fitbits® are relatively affordable compared with research-grade devices). Enablers included device characteristics (e.g. accuracy, long battery life, simple metrics such as step count) and patient characteristics (e.g. motivation, rehabilitation population, tech-savvy), whilst barriers included the HCPs’ time to download and interpret the data, multidisciplinary team attitudes and lack of protocols for managing the devices.

Conclusions

At present, the use of WAMs in clinical practice appears to be fragmented and ad hoc, though holds promise for understanding patient outcomes and enhancing therapy. Future work may focus on developing protocols for optimal use, system-level approaches, and generating cost-benefit data to underpin continued health service funding for ongoing/wide-spread WAM use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07096-7.

Physical activity, post-traumatic stress disorder, and exposure to torture among asylum seekers in Sweden: a cross-sectional study

BACKGROUND

Forced migrant populations have high rates of trauma-related ill health, including post-traumatic stress disorder (PTSD). Physical activity (PA) is well-established as an effective stress reliever, while insufficient PA is associated with adverse effects on both mental and physical health. The aim of this study was to examine the prevalence of different levels of PA and its association with PTSD symptom severity, controlled for exposure to torture, among asylum seekers in Sweden.

METHODS

A cross-sectional survey study, with data from 455 asylum seekers, originating from Afghanistan, Eritrea, Iraq, Somalia, and Syria, residing at large housing facilities across Sweden. Level of PA was assessed by the Exercise Vital Sign and categorized as; Inactive, Insufficient PA, and Sufficient PA. Prevalence estimates for proportions of different levels of PA were calculated. Analysis of variance were conducted to determine the association between levels of PA and PTSD symptom severity, measured by the Harvard Trauma Questionnaire. Multivariable logistic regression analysis was performed to determine the contribution of PA on PTSD beyond sex, age, and exposure to torture.

RESULTS

About half of the participants (53.3, 95% CI: 48.6-58.1) met the recommendations for Sufficient PA. One third of the participants (33.3, 95% CI: 28.7-37.8) were insufficiently engaged in PA, and 13.4% (95% CI: 10.1-16.7) were inactive. There was a significant difference in PTSD symptom severity between groups of asylum seekers with different levels of PA (F(2, 316) = 23.15, p < .001). When controlling for sex, age, and exposure to torture, Sufficient PA was found to be associated with less PTSD symptom severity compared to both Insufficient PA (B = 0.297, SE = 0.086, p < .001) and Inactive (B = 0.789, SE = 0.104, p < .001).

CONCLUSIONS

Insufficient PA was common among the asylum seekers and our findings suggest that more PA is highly associated with lower PTSD symptom severity. An increased focus on assessment and promotion of PA is justified and discussed as particularly pertinent considering the much extended time of asylum-seeking processes. The results support previous evidence of PA as a potentially important factor in the context of PTSD and forced migrants' health.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Patient and provider factors associated with receipt and delivery of brief interventions for unhealthy alcohol use in primary care

BACKGROUND

Unhealthy alcohol use is a serious and costly public health problem. Alcohol screening and brief interventions are effective in reducing unhealthy alcohol consumption. However, rates of receipt and delivery of brief interventions vary significantly across healthcare settings, and relatively little is known about the associated patient and provider factors.

METHODS

This study examines patient and provider factors associated with the receipt of brief interventions for unhealthy alcohol use in an integrated healthcare system, based on documented brief interventions in the electronic health record. Using multilevel logistic regression models, we retrospectively analyzed 287,551 adult primary care patients (and their 2952 providers) who screened positive for unhealthy drinking between 2014 and 2017.

RESULTS

We found lower odds of receiving a brief intervention among patients exceeding daily or weekly drinking limits (vs. exceeding both limits), females, older age groups, those with higher medical complexity, and those already diagnosed with alcohol use disorders. Patients with other unhealthy lifestyle activities (e.g., smoking, no/insufficient exercise) were more likely to receive a brief intervention. We also found that female providers and those with longer tenure in the health system were more likely to deliver brief interventions.

CONCLUSIONS

These findings point to characteristics that can be targeted to improve universal receipt of brief intervention.

Implementing the physical activity vital sign in an academic preventive cardiology clinic

The aims were to implement physical activity (PA) screening as part of the electronic kiosk check-in process in an adult preventive cardiology clinic and assess factors related to patients' self-reported PA. The 3-question physical activity vital sign (PAVS) was embedded in the Epic electronic medical record and included how many days, minutes and intensity (light, moderate, vigorous) of PA patients conducted on average. This is a data analysis of PAVS data over a 60-day period. We conducted multivariable logistic regression to identify factors associated with not meeting current PA recommendations. Over 60 days, a total of 1322 patients checked into the clinic using the kiosk and 72% (n = 951) completed the PAVS at the kiosk. The majority of those patients were male (58%) and White (71%) with a mean age of 64 ± 15 years. Of the 951 patients completing the PAVS, 10% reported no PA, 55% reported some PA, and 35% reported achieving at least 150 min moderate or 75 min vigorous PA/week. In the logistic model, females (AOR = 1.4, 95%CI: 1.002-1.8, p = .049) vs. males, being Black (AOR = 2.0, 95%CI: 1.04-3.7, p = .038) or 'Other' race (AOR = 1.5, 95%CI: 1.02-2.3, p = .035) vs. White, unknown or other types of relationships (AOR = 0.0.26, 95%CI: 0.10-0.68, p = .006) vs. being married/partnered, and those who were retired (AOR = 1.9, 95% CI: 1.4-2.8, p < .001) or unemployed (AOR = 2.2, 95%CI: 1.3-3.7, p = .002) vs. full-time workers were associated with not achieving recommended levels of PA. The PAVS is a feasible electronic tool for quickly assessing PA and may prompt providers to counsel on this CVD risk factor.

Physical activity decline is disproportionate to decline in pulmonary physiology in IPF

BACKGROUND AND OBJECTIVE

Patients with idiopathic pulmonary fibrosis (IPF) have reduced levels of daily physical activity (DPA); however, little is known about how DPA changes as disease progresses. We aimed to (i) describe change in DPA over 12 months, (ii) analyse its association with conventional markers of disease severity and quality of life and (iii) assess DPA as a prognostic tool.

METHODS

A total of 54 patients with IPF had DPA monitored at baseline and at 6 and 12 months with a SenseWear armband for 7 consecutive days. Participants completed the Hospital Anxiety and Depression scale, St George's Respiratory Questionnaire and Leicester Cough Questionnaire at each time point and provided clinical data including forced vital capacity (FVC), diffusion capacity of carbon monoxide and 6-min walk distance (6MWD).

RESULTS

Baseline and 12-month daily step count (DSC) were 3887 (395) and 3326 (419), respectively. A significant reduction in DSC (mean = 645 [260], p = 0.02) and total energy expenditure (mean = 486 kJ [188], p = 0.01) was demonstrated at 12 months. The decline in DSC over 12 months was proportionally larger than decline in lung function. Annual change in DPA had weak to moderate correlation with annual change in FVC % predicted and 6MWD (range r = 0.34-0.45). Change in physical activity was not associated with long-term survival.

CONCLUSION

In IPF, decline in DPA over 12 months is significant and disproportionate to decline in pulmonary physiology and may be a useful tool for assessment of disease progression.

Effects of multicomponent exercise program with progressive phases on functional capacity, fitness, quality of life, dual-task and physiological variables in older adults: Randomized controlled trial protocol

INTRODUCTION

The multicomponent exercise program must be carried out in phases, due to the low tolerance of the old adults to prolonged efforts, since their functional reserve is reduced. The aim of study is investigate the effects of Multicomponent on Progressive Phases Program on functional capacity, fitness, quality of life, dual-task and physiological variables in the elderly.

METHODS

This is a randomized controlled trial protocol with blind examiners. The protocol was registered at clinictrials.gov (protocol number: NCT04118478). The experimental group will participate in a progressive multi-component program of 27 weeks divided into 3 phases of 9 weeks each of them. Primary outcomes will be determined by evaluating functional capacity using the Short Physical Performance Battery (SPPB), gait speed, and Time up and Go test. Fitness will be determined by the handgrip, 2-min step test, chair sit and reach test, and back scratch test. Quality of life will appear with the SF-36 questionnaire and dual-task with the walking-while-talking test. The physiological variables evaluated will be heart rate and blood pressure at rest, autonomic balance and forced spirometry. Secondary outcomes are determined by measuring the level of physical activity, motivation for exercise, and anthropometric variables.

DISCUSSION

The results derived from this research will increase the knowledge about the effects of a program of this type. The possible discoveries could serve as a guide to encourage future researchers to develop similar protocols. The purpose of the program is to serve as a practical and viable tool for the benefit of older people. Clinical trial registry protocol: NCT04118478.

Identifying meaningful dietary intake and physical activity questions for individual and population health

We aimed to identify valid screening questions for adults regarding physical activity and dietary behaviours that (a) were correlated with BMI, (b) were deemed by patients and providers to be relevant to clinical care, and (c) have utility for longitudinal understanding of health behaviours in populations. The goal was to identify screening questions that could be implemented at annual health care visits. First, we identified dietary behaviour questions and solicited patient input. Next, we tested both physical activity and dietary behaviour questions in a large sample to test their potential utility. Finally, we used cognitive interviews with patients and physicians to narrow our assessment for clinical settings. We present a parsimonious and reliable six-question scale of physical activity and dietary behaviours for research settings, as well as a three-question scale for clinical settings. We demonstrate a robust relationship between these measures and obesity. Additionally, we present evidence that these measures may serve as a useful red flag for patients before they develop obesity. We provide a concise and useful tool for assessing patients' physical activity and dietary behaviours in a variety of research settings. We also highlight the importance of incorporating this tool into the clinical intake flow for inclusion in patients' Electronic Health Record.

Validity of the Exercise Vital Sign Tool to Assess Physical Activity

INTRODUCTION

Assessment and counseling by healthcare providers can successfully increase physical activity; however, a valid instrument to effectively measure physical activity is needed. This study examines the validity of the Exercise Vital Sign tool by comparing Exercise Vital Sign data collected at Kaiser Permanente Northwest with accelerometry data.

METHODS

Participants (n=521) completed accelerometer monitoring and had ≥1 Exercise Vital Sign measurement in their electronic medical record. Using accelerometry as the gold standard, the association between moderate-to-vigorous physical activity minutes per week estimated through Exercise Vital Sign and that estimated through accelerometry was examined using the Spearman correlation coefficient. Comparability of moderate-to-vigorous physical activity categories (inactive, lowly active, moderately active, sufficiently active) was assessed using simple and weighted κ statistics. Sensitivity, specificity, and positive and negative predictive values were calculated. The study was conducted in 2012-2015, with analysis in 2019-2020.

RESULTS

Average accelerometry-based moderate-to-vigorous physical activity was 212 minutes per week, and 57% of the participants were considered sufficiently active. Exercise Vital Sign‒based moderate-to-vigorous physical activity averaged 170 minutes per week, and 53% of the participants were active. There was a positive correlation between the moderate-to-vigorous physical activity minutes per week reported through Exercise Vital Sign and that reported through accelerometry (r =0.38, p<0.0001). A fair agreement was observed between Exercise Vital Sign‒ and accelerometry-based moderate-to-vigorous physical activity categories (weighted κ=0.29), with the highest agreement occurring for those with physical activity level ≥150 minutes per week. The positive correlation increased when moderate-to-vigorous physical activity was examined dichotomously (<150 or ≥150 minutes per week, κ=0.34). The sensitivity, specificity, positive predictive value, and negative predictive value for Exercise Vital Sign (when compared with those of accelerometry) were 67%, 68%, 61%, and 73%, respectively.

CONCLUSIONS

The Exercise Vital Sign is a useful physical activity assessment tool that correctly identifies the majority of adults who do and do not meet physical activity guidelines.

Closing Gaps in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease

The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.

The Future(s) of Pediatric Primary Care

Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the "new morbidity" of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in "learning health systems" will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.

Habitual Physical Activity and Diabetes Control in Young and Older Adults with Type II Diabetes: A Longitudinal Correlational Study

This study aimed to determine whether daily physical activity in young and older adults with T2DM is associated with diabetes control. A prospective correlational study involving 206 young (≤65 years) and older (>65 years) adults was conducted. The International Physical Activity Questionnaire was used to assess their daily physical activity levels. Patients’ mean HbA1c level was 7.8% (±1.4), and 95.9% of patients had unsatisfactory diabetes control. Performing more minutes per week of moderate-intensity daily physical activity was associated with a lower risk of glycemia in both young and older adults. Furthermore, moderate daily physical activity significantly lowered the risk of glycemia. Health personnel must encourage patients to engage in moderate daily physical activities to improve diabetes control.