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1
Ask

‘Can I share with you what we now know?’  or  ‘Can I tell you some more information to see what you make of it?’

Sharing evidence on physical activity in the context of their disease can be important in helping people to consider change. Ask them how they think this new information might be relevant to them and help them to think this through.

2
Share

2-3 benefits of physical activity for people with Inflammatory Rheumatic Disease (General)?

Manage fatigue

Manage fatigue

Evidence summary

Fatigue is a common in people with inflammatory rheumatic disease. There is an evidence base to show that regular physical activity can improve fatigue ratings [1,2].  Sveeas et al meta-analysis found nine RCTs that included data on fatigue and the results showed moderate quality evidence for a small beneficial effect of exercises [1]. Physical activity can be recommended to help manage this challenging symptom.  It is important to emphasize that being active can be just as important as taking medication and works effectively alongside them. Recommending people start gradually with paced activity is a helpful way for them to begin to regain control and help address this symptom

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Reference

  1. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.
  2. Katz P, Margaretten M, Gregorich S, Trupin L. Physical Activity to Reduce Fatigue in Rheumatoid Arthritis: A Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2018;70(1):1-10.

Reduce pain

Reduce pain

Evidence summary

In their meta-analysis of those with inflammatory rheumatic disease, Sveaas et al.  found twelve RCTs that provided data on pain scores. The results showed moderate quality evidence for a small beneficial effect of exercise [1].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Reference

  1. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.

Reduce stiffness

Reduce stiffness

Evidence summary

Joint stiffness is hallmark of many of the inflammatory rheumatic diseases. Sveass et  al in concluded in their meta-analysis from  7 RCTs that included joint stiffness as an outcome score that there was moderate quality evidence for medium beneficial effect of exercise interventions [1].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Reference

  1. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.

Reduce disease activity

Reduce disease activity

Evidence summary

There is a strong evidence base to show that regular physical activity can improve disease activity scores [1].  Sveass et al in a meta-analysis, which included a number inflammatory rheumatic diseases, found 12 RCTs which reviewed the effect of exercise on disease activity scores. It concluded that there was high quality evidence for a small beneficial effect of exercise [1].

Quality of evidence

High quality

Strength of recommendation

Strong

Reference

  1. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.

Improve self-esteem

Improve self-esteem

Evidence summary

Low mood and depression is common in people with inflammatory rheumatic disease. There is evidence in some disease groups that physical activity/ exercise interventions reduce depressive symptoms, improve mood and mental wellbeing [1]. Drawing from evidence from the general population, being active improves self-esteem and mood [2].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

References

  1. Kelley GA, Kelley KS, Hootman JM. Effects of exercise on depression in adults with arthritis: a systematic review with meta-analysis of randomized controlled trials. Arthritis Res Ther. 2015;17:21
  2. Department of Health. Start Active, Stay Active. In: Strategy; 2011.

 

Promote a better night’s sleep

Promote a better night’s sleep

Evidence summary

Sleep disturbance and fatigue are common symptoms. Exercise interventions have shown improvements in sleep quality [1]. Similarly, in the general population, there is moderate level evidence that physically activity  improves sleep [2,3] Motivating patients to be more physically active can help with this challenging symptom.

Quality of evidence

Moderate quality

Strength of recommendation

Grade 1 – Strong Recommendation

References

  1. Durcan L, Wilson F, Cunnane G. The effect of exercise on sleep and fatigue in rheumatoid arthritis: a randomized controlled study. J Rheumatol. 2014;41(10):1966-1973.
  2. Department of Health. Start Active, Stay Active. In: Strategy; 2011.
  3. Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015;38(3):427-449.

Keeps bones strong

Keeps bones strong

Evidence summary

Many people with inflammatory rheumatic disease are at increased risk of having a lower bone mineral density and developing osteporosis [1,2].  There is evidence from the general population of an inverse association between physical activity and risk of hip fracture and vertebral fracture. The magnitude of the effect of physical activity on bone mineral density is 1% to 2%. Increases in exercise and training can increase spine and hip bone marrow density and can also minimise age related reduction in spine and hip bone mineral density [3].

Quality of evidence

Low quality

Strength of recommendation

Weak

Conclusion

Those with inflammatory rheumatic disease are at risk of osteoporosis. Evidence from the general population suggests keeping active is positive for bone health.

References

  1. Hauser B, Riches PL, Wilson JF, Horne AE, Ralston SH. Prevalence and clinical prediction of osteoporosis in a contemporary cohort of patients with rheumatoid arthritis. Rheumatology (Oxford). 2014;53(10):1759-1766
  2. Haugeberg G, Uhlig T, Falch JA, Halse JI, Kvien TK. Bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis: results from 394 patients in the Oslo County Rheumatoid Arthritis register. Arthritis Rheum. 2000;43(3):522-530
  3. Department of Health. Start Active, Stay Active. In: Strategy; 2011

Improves quality of life

Improves quality of life

Evidence summary

There is a strong evidence that physical activity/exercise interventions improve quality of life in patients with Rheumatoid arthritis, especially aerobic exercise. There is also strong evidence that physical activity/exercise interventions improve disease scores. Drawing from evidence from the general population active individuals may enjoy an improved quality of life [1].

Quality of evidence

High quality

Strength of recommendation

Strong

Reference

  1. Baillet A, Zeboulon N, Gossec L, et al. Efficacy of cardiorespiratory aerobic exercise in rheumatoid arthritis: meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken). 2010;62(7):984-992.
  2. Baillet A, Vaillant M, Guinot M, Juvin R, Gaudin P. Efficacy of resistance exercises in rheumatoid arthritis: meta-analysis of randomized controlled trials. Rheumatology (Oxford). 2012;51(3):519-527
  3. Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072
  4. Department of Health. Start Active, Stay Active. In: Strategy; 2011.

 

 

 

 

 

Improves fitness

Improves fitness

Evidence summary

Physical activity interventions have been shown to improve cardiovascular fitness [1-3]. A recent meta-analysis found a moderate beneficial effect on cardiovascular fitness in people with inflammatory arthritis [3].

Quality of evidence

High quality

Strength of recommendation

Strong

References

  1. Saracoglu I, Kurt G, Okur EO, et al. The effectiveness of specific exercise types on cardiopulmonary functions in patients with ankylosing spondylitis: a systematic review. Rheumatol Int. 2017;37(3):409-421.
  2. Niedermann K, Sidelnikov E, Muggli C, et al. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res (Hoboken). 2013;65(11):1844-1852.
  3. Rausch Osthoff AK, Niedermann K, Braun J, Adams J, Brodin N, Dagfinrud H, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018.

 

 

Some benefits will be generic (feel better, have more energy, improve sleep, improve fitness levels, improve mood, etc.) and others will be condition specific (experience less pain, reduce risk of serious complications in the future, etc.) Based on your discussion so far, choose to share the benefits you judge will be most relevant and important to them.

Type 2 Diabetes
-50%

Type 2 Diabetes

Current national guidance denotes a clear Inverse relationship with physical activity and the development of type 2 diabetes (1). A risk reduction of 30%-40% in moderately active people compared to sedentary has been quoted (1) with strong evidence suggesting up to a 50% risk reduction (2).

In examining the dose needed to achieve such risk reduction it can be noted that low intensity physical activity led to similar risk reductions in comparison to high intensity physical activity (3,4).

 

However, a systematic review of large scale prospective cohorts identified a curvilinear dose–response relationship between physical activity and the incidence of type 2 diabetes.

There was no evidence that there was a minimum threshold for health benefits and in continuity with previously mentioned data the greatest relative benefits were observed at the lowest levels of activity (5).

Nevertheless, additional benefits are seen at physical activity levels far greater than current international recommendations (5).

 

In contradiction to these studies a systematic reviews of several randomised controlled trials suggested there is no firm evidence that physical activity alone can modify the risk of developing type 2 diabetes in high risk individuals but rather physical activity in combination with a change in diet drastically reduces or delays the development of type 2 diabetes (6,7).

Credence must also be given to the evidence illustrated in a high quality randomised clinical trial of exercise resulting in significant reduction in the frequency of gestational diabetes mellitus in overweight/obese pregnant women (8).

 

Quality of evidence

Grade A/B- Moderate to High Quality

 

 

References:

  1. Start active, stay active: report on physical activity in the UK.

[online] Available at: https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers GOV.UK. (2018).

 

  1. Exercise the Miracle Cure.

(2015). [ebook] Available at: http://www.aomrc.org.uk/…/2016/05/Exercise_the_Miracle_Cure_0215.pdf [Accessed 9 Jun. 2018].

 

  1. Health benefits of physical activity: a systematic review of current systematic reviews. Warburton DER, Bredin SSD. Curr Opin Cardiol. 2017 Sep;32(5):541-556. doi: 10.1097/HCO.0000000000000437. Review.

 

  1. Physical activity and the risk of type 2diabetes: a systematic review and dose-response meta-analysis.

Eur J Epi-demiol 2015; 30:529–542 Aune D, Norat T, Leitzmann M,et al.

 

  1. Physical activity and incident type2 diabetes mellitus: a systematic review and dose-response meta-analysis of prospective cohort studies.

Diabetologia 2016; 59:2527–2545 Smith AD, Crippa A, Woodcock J, Brage S.

 

  1. Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews.

Hemmingsen, B., Gimenez-Perez, G., Mauricio, D., Roqué i Figuls, M., Metzendorf, M. and Richter, B. (2017).

 

  1. Effects of exercise training alone vs a combined exercise and nutritional lifestyle intervention on glucose homeostasis in prediabetic individuals: a randomised controlled trial.

Diabetologia, 59(10), pp.2088-2098. Slentz, C., Bateman, L., Willis, L., Granville, E., Piner, L., Samsa, G., Setji, T., Muehlbauer, M., Huffman, K., Bales, C. and Kraus, W. (2016).

 

  1. A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women.

American Journal of Obstetrics and Gynecology, 216(4), pp.340-351. Wang, C., Wei, Y., Zhang, X., Zhang, Y., Xu, Q., Sun, Y., Su, S., Zhang, L., Liu, C., Feng, Y., Shou, C., Guelfi, K., Newnham, J. and Yang, H. (2017).

Hypertension
-50%

Hypertension

A systematic review of several high-quality studies demonstrated a dose–response relationship between physical activity and incidence of hypertension (2). The risk for hypertension was reduced overall by 33%. Other high quality reviews have shown risk reduction of up to 52% (1) Indeed there is a large body of literature demonstrating the protective effects of physical activity and exercise (3). Recent data from large prospective studies among U.S. populations including the Nurses’ Health Study II, the Aerobics Center Longitudinal Study (ACLS), and the Coronary Artery Risk Development in Young Adults (CARDIA) study have shown that physical activity is inversely associated with the development of hypertension (4,5,6). Considering the dose response relationship of physical activity in hypertension some reviews have noted that the evidence is unclear on the benefits of increased exercise. However a large study in 2013 concluded that a dose-response relationship for total volume of physical activity and incident hypertension was present, but that the inclusion of vigorous physical activity did not provide supplementary benefits in the prevention of hypertension beyond that from moderately intense activity (7).

 

Quality of evidence

Grade A/B- Moderate to High Quality

 

 

References:

  1. Exercise the Miracle Cure.

(2015). [ebook] Available at: http://www.aomrc.org.uk/…/2016/05/Exercise_the_Miracle_Cure_0215.pdf [Accessed 9 Jun. 2018].

 

  1. Dose-response association between physical activity and incident hypertension: a systematic review and meta-analysis of cohort studies. Hypertension 2017; 69:813–820. Liu X, Zhang D, Liu Y,et al.

 

  1. Physical Activity and the Prevention of Hypertension.

Current Hypertension Reports. 2013;15(6):659-668. Diaz K, Shimbo D.

 

  1. Joint associations of physical activity and aerobic fitness on the development of incident hypertension: coronary artery risk development in young adults. Hypertension. 2010;56:49–55. Carnethon MR, Evans NS, Church TS, Lewis CE, Schreiner PJ, Jacobs DR, Jr, et al.

 

  1. The association of cardiorespiratory fitness and physical activity with incidence of hypertension in men. Am J Hypertens. 2009; 22:417–24. Chase NL, Sui X, Lee DC, Blair SN.

 

  1. Diet and lifestyle risk factors associated with incident hypertension in women. 2009;302:401–11. Forman JP, Stampfer MJ, Curhan GC.

 

  1. Does Vigorous Physical Activity Provide Additional Benefits Beyond Those of Moderate? Med Sci Sports Exerc. 2013 Pavey TG, Peeters G, Bauman AE, Brown WJ.

 

Coronary Heart Disease
-40%

Coronary Artery Disease

Current national guidance suggests the risk reduction afforded by physical activity in stroke is evidenced to be around 30%, and in coronary heart disease 40% (1).

A high quality meta-analysis on physical activity and cardiovascular disease found that high levels of physical activity reduce the overall risk of incident coronary heart disease and stroke among men and women by 20 to 30 percent and 10 to 20 percent, respectively. (2)

 

Quality of evidence

Grade B- Moderate Quality

 

References:

  1. Exercise the Miracle Cure. (2015). [ebook] Available at: http://www.aomrc.org.uk/…/2016/05/Exercise_the_Miracle_Cure_0215.pdf [Accessed 9 Jun. 2018].

 

  1. Physical Activity and Risk of Cardiovascular Disease—A Meta-Analysis of Prospective Cohort Studies.

International Journal of Environmental Research and Public Health, 9(2), pp.391

  1. Li, J. and Siegrist, J. (2012).
Stroke
-30%

Stroke

It has been shown in a meta-analysis of cohort studies that not only do high levels of physical activity reduce the incidence of stroke (24-17% ) but leisure time and occupational physical activity are also associated with a reduction in stroke risk (3,4).

Despite these large-scale epidemiologic studies and many interventional trials providing strong evidence of the effects physical activity in the primary prevention of cardiovascular disease, the effect of this exercise on the burden of stroke is not well understood and appreciated (5).

 

 

Quality of evidence

Grade B- Moderate Quality

 

References:

  1. Exercise the Miracle Cure. (2015). [ebook] Available at: http://www.aomrc.org.uk/…/2016/05/Exercise_the_Miracle_Cure_0215.pdf [Accessed 9 Jun. 2018].

 

  1. Physical Activity and Risk of Cardiovascular Disease—A Meta-Analysis of Prospective Cohort Studies.

International Journal of Environmental Research and Public Health, 9(2), pp.391

  1. Li, J. and Siegrist, J. (2012).

 

  1. Physical activity and stroke. A meta-analysis of observational data.

Int J Epidemiol. 2004;33:787-798. doi: 10.1093/ije/dyh168 Wendel-Vos GC, Schuit AJ, Feskens EJ, Boshuizen HC, VerschurenWM, Saris WH, et al.

 

  1. Physical activity in primary stroke prevention: just do it!

Stroke. 2015 Jun;46(6):1735-9. Howard VJ, McDonnell MN.

 

  1. The role of physical activity in the prevention of stroke.

Cent Eur J Public Health. 2005 Sep;13(3):132-6 Chrysohoou Ch, Pitsavos Ch, Kokkinos P, Panagiotakos DB, Singh SN, Stefanadis Ch.

Depression
-30%

Depression

A large review of 49 prospective cohort studies (1,837,794 patient-year follow-up) evaluating the incidence of depression compared to levels of physical activity has demonstrated that those with high levels of physical activity had a lower chance of developing depression when compared to those with low levels of physical activity (adjusted odds ration 0.83; 95% CI 0.79,0.88). This effect was observed regardless of age and geographical location (1). A cross-sectional study of 4402 US medical students demonstrated overall higher quality of life scores, and lower features of burnout, in those who followed the recommended Centres for Disease Control & Prevention (CDC) exercise guidelines for both aerobic (51.3% vs 60.8%; p<0.0001) and strength-training exercise (51.8% vs 58.6%; p<0.0001), compared to those who did not meet the activity guidelines, independent of age, sex, relationship status, children & year of study (2). Another prospective cohort study showed that regular moderate exercise for >15 minutes/session, 3x/week is significantly associated with a lower risk of depressive symptoms in older adults (3). A cross-sectional survey-based study of individuals with a history of stroke demonstrated that physical activity reduced the risk of post-stroke depression by between 36.1-42.4%, however this did not take into account all factors, including severity of the stroke, pre-depression status and if there was a previous history of treatment for depression (4).

 

Quality of evidence

Grade A- High Quality

 

 

References:

  1. Physical Activityand Incident Depression: A Meta-Analysis of Prospective Cohort Studies.

Am J Psychiatry. 2018 Apr 25

 

  1. Healthy Exercise Habits Are Associated With Lower Risk of Burnout and Higher Quality of Life Among U.S. Medical Students.

Acad Med. 2017 Jul;92(7):1006-1011.

 

  1. Effects of different amounts of exercise on preventing depressive symptoms in community-dwelling older adults: a prospective cohort study in Taiwan.

BMJ Open. 2017 May 2;7(4): e014256

 

  1. Physical Activity and the Risk of Depression in Community-Dwelling Korean Adults With a History of Stroke.

Phys Ther. 2017 Jan 1;97(1):105-113

Cardiovascular disease
-25%

Cardiovascular Disease

A large body of epidemiological data demonstrated a reduction in the development of cardiovascular disease of 20-25%, with a clear inverse relationship (1). Although there was a dose-response relationship associated with cardiovascular disease; the greatest relative health gains were observed with small amounts of physical activity (in those previously inactive) (2). Many studies focus on the reduction of risk factors leading towards cardiovascular disease in an effort at primary prevention. One such study demonstrated aerobic exercise alone or combined with resistance training improves glycaemic control, Systolic Blood Pressure, triglycerides, and waist circumference in those with type 2 diabetes (3). However, no clinical trial of exercise in type 2 diabetes patients has demonstrated a reduction in major CVD endpoints or mortality.

More recently a large multi-centred, randomised controlled community intervention had significantly positive results with a 10% reduction in adverse cardiovascular events over 2 years with adherence to regular physical activity. In fact within 9 months the intervention group had marked improvements in systolic blood pressure and cholesterol (4).

Low cardiorespiratory fitness is strong predictor of CVD and all-cause mortality, even after adjusting for established risk factors (5).

 

Quality of evidence

Grade A – High Quality

 

 

References:

  1. Start active, stay active: report on physical activity in the UK.

[online] Available at: https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers GOV.UK. (2018).

 

  1. Quantifying the association between physical activity and cardiovascular disease and diabetes: a systematic review and meta-analysis.

J Am Heart Assoc 2016; 5 Wahid A, Manek N, Nichols M,et al.

 

  1. Effects of Exercise on Cardiovascular Risk Factors in Type 2 Diabetes: A meta-analysis. Diabetes Care, 34(5), pp.1228-1237. Chudyk, A. and Petrella, R. (2011).

 

  1. Effectiveness of a physical activity program on cardiovascular disease risk in adult primary health-care users: the “Pas-a-Pas” community intervention trial.

 

BMC Public Health, 17(1). Arija, V., Villalobos, F., Pedret, R., Vinuesa, A., Timón, M., Basora, T., Aguas, D. and Basora, J. (2017).

 

  1. Prediction of Cardiovascular Mortality by Estimated Cardiorespiratory Fitness Independent of Traditional Risk Factors: The HUNT Study.

Mayo Clinic Proceedings, 92(2), pp.218-227. Nauman, J., Nes, B., Lavie, C., Jackson, A., Sui, X., Coombes, J., Blair, S. and Wisløff, U. (2017).

 

Joint and Back pain
-25%

Reduces pain and frequency of painful exacerbations

Evidence summary

There is a large volume of high quality evidence demonstrating that exercise therapy significantly improves pain in those with chronic low back pain. A Cochrane review identified the mean improvement as 10.2 points on a 0-100 VAS scale when compared with no intervention [1]. In addition, trial evidence also suggests that regular exercise is effective at reducing the incidence of back problems in working age populations [2,3]. Lesser quality evidence suggests that exercise therapy is more effective when undertaken alongside an educational programme [4]. Adopting a multidisciplinary biopsychosocial approach is more effective than physical treatments alone at improving pain [5]. A variety of interventions, including walking therapy [6], core stability exercises [7], resistance training [8]and motor control exercises [9], have been shown to be effective.

There is no convincing evidence that exercise interventions are helpful in the management of acute back pain [1]. However, continuing activities during episodes of acute back pain is important in reducing long-term morbidity and should be encouraged [10].

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Exercise interventions should be offered to those with chronic lower back pain, with or without educational and psychological interventions depending on the psychosocial contribution to their symptoms. Those with acute low back pain should be encouraged to keep active.

References

1         Hayden J, van Tulder MW, Malmivaara A, et al.Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst RevPublished Online First: 2005. doi:10.1002/14651858.CD000335.pub2.www.cochranelibrary.com

2         Bigos SJ, Holland J, Holland C, et al.High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J2009;9:147–68. doi:10.1016/j.spinee.2008.11.001

3         Shiri R, Falah-Hassani K. Does leisure time physical activity protect against low back pain? Systematic review and meta-analysis of 36 prospective cohort studies. Br J Sports Med2017;51:1410–8. doi:10.1136/bjsports-2016-097352

4         Steffens D, Maher CG, Pereira LSM, et al.Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med2016;176:199–208. doi:10.1001/jamainternmed.2015.7431

5         Kamper SJ, Apeldoorn AT, Chiarotto A, et al.Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj2015;350:h444–h444. doi:10.1136/bmj.h444

6         Lawford BJ, Walters J, Ferrar K. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Clin Rehabil2016;30:523–36. doi:10.1177/0269215515590487

7         Wang XQ, Zheng JJ, Yu ZW, et al.A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain. PLoS One2012;7:1–7. doi:10.1371/journal.pone.0052082

8         Kristensen J, Franklyn-Miller A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med2012;46:719–26. doi:10.1136/bjsm.2010.079376

9         Macedo LG, Maher CG, Latimer J, et al.Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther2009;89:9–25. doi:10.2522/ptj.20080103

10       NICE. Low back pain and sciatica in over 16s: assessment and management | Guidance and guidelines | NICE. https://www.nice.org.uk/guidance/ng59/chapter/Recommendations (accessed 14 Jun 2018).

Cancers (Breast, Colon, others)
-25%

Breast Cancer

A large body of good quality randomised control trial data shows consistent reduction in breast cancer risk (20-30%) with vigorous physical activity whilst being physically active reduces the risk of postmenopausal breast cancer. Physical activity reduces the risk of breast cancer more strongly in post-menopausal women than premenopausal women. Exercise performed in adolescence and adulthood helps reduce the risk of developing breast cancer but there is no conclusive evidence on precise age range where physical activity reduces this risk.

Quality of evidence

Grade A- High Quality

 

References:

  1. Moderate/vigorousrecreational physical activity and breast cancer risk, stratified by  menopause  status:a systematic review and meta-analysis.

Neilson HK1Farris MSStone CRVaska MMBrenner DRFriedenreich CM.Menopause. 2017 Mar;24(3):322-344. doi: 10.1097/GME.0000000000000745.

 

  1. Physical activity and the risk of breast cancer in BRCA1/2 mutation carriers.

Pijpe A, Manders P, Brohet RM, Collée JM, Verhoef S, Vasen HF, Hoogerbrugge N, van Asperen CJ, Dommering C, Ausems MG, Aalfs CM, Gomez-Garcia EB; HEBON, Van’t Veer LJ, van Leeuwen FE, Rookus MA.

Breast Cancer Res Treat. 2010 Feb;120(1):235-44. doi: 10.1007/s10549-009-0476-0. Epub 2009 Aug 13. PMID: 19680614

 

  1. Primary and secondary prevention of breast cancer.

Kolak A, Kamińska M, Sygit K, Budny A, Surdyka D, Kukiełka-Budny B, Burdan F.

Ann Agric Environ Med. 2017 Dec 23;24(4):549-553. doi: 10.26444/aaem/75943. Epub 2017 Jul 18. Review.PMID: 29284222

 

  1. Monitoring modifiable risk factors for breast cancer: an obligation for health professionals.

Guerrero VG1Baez AF1Cofré González CG1Miño González CG1.Rev Panam Salud Publica. 2017 Jun 8;41:e80.

 

 

Colon Cancer

Good quality evidence via a review of 25 epidemiological studies which demonstrated that physical activity which meets the recommended targets reduces the risk of colorectal cancer by 18-21%.

 

Quality of evidence

Grade A- High Quality

 

References:

  1. Recent Evidence for Colorectal Cancer Prevention Through Healthy Food, Nutrition, and Physical Activity: Implications for Recommendations.

Perera PS, Thompson RL & Wiseman MJ. Curr Nutr Rep. 2012 DOI 10.1007/s13668-011-0006-7

 

  1. The fractions of cancer attributable to modifiable factors: A global review.

Whiteman DC1Wilson LF2. Cancer Epidemiol. 2016 Oct;44:203-221. doi: 10.1016/j.canep.2016.06.013. Epub 2016 Jul 25.

 

 

Bladder Cancer

A meta-analysis of 15 studies showed a decreased bladder cancer risk with higher physical activity levels, with risk equal between men and women. The higher the intensity of physical activity, the lower the risk of cancer, (20% risk reduction for vigorous, 15% for moderate and 10% for occupational physical activity).

 

Quality of Evidence

Grade A- High quality

 

References:

  1. The association between physical activity and bladder cancer: systematic review and meta-analysis.Keimling M1Behrens G1Schmid D1Jochem C1Leitzmann MF1.

Br J Cancer. 2014 Apr 2;110(7):1862-70. doi: 10.1038/bjc.2014.77. Epub 2014 Mar 4.

 

  1. Modifiable risk factors for the prevention of bladder cancer: a systematic review of meta-analyses.

Al-Zalabani AH1Stewart KF2Wesselius A3Schols AM4Zeegers MP3. Eur J Epidemiol. 2016 Sep;31(9):811-51. doi: 10.1007/s10654-016-0138-6. Epub 2016 Mar 21.

 

 

Skin and Prostate cancer

A follow up cohort study of 5000 subjects showed there was no significant association between physical activity and skin or prostate cancer (p value =0.126, p value =0.189 respectively).

 

Quality of evidence

Grade B- limited to only data regarding men, so further studies needed for skin cancer.

 

  1. Cardiorespiratory fitness and cancer incidence in men.

Vainshelboim B, Müller J, Lima RM, Nead KT, Chester C, Chan K, Kokkinos P, Myers J.

Ann Epidemiol. 2017 Jul;27(7):442-447. doi: 10.1016/j.annepidem.2017.06.003. Epub 2017 Jun 29.PMID: 28789775

 

Falls and Frailty
-21%

Falls & Frailty

There is strong evidence to suggest that exercise interventions in at-risk individuals are associated with reduced falls, fall-related injuries and frailty. A systematic review & meta-analysis of exercise as a single intervention (88 trials; 19 478 particpants) in older people demonstrated a 21% reduction in falls in older people living in the community (pooled rate ratio 0.79; 95% CI 0.73-0.85; p<0.001). Greatest effect was conveyed by interventions that included both balance training and greater than 3h of physical activity per week (1). Another meta-analysis of RCTs demonstrated that exercise interventions reduced both fall-related fractures (relative risk 0.604; 95% CI 0.453-0.840; p=0.003) and rate of falls (rate ratio 0.856; 95% CI 0.778-0.941; p=0.001) in older people (2). This was confirmed again by a single group study of individuals in community seniors centres, which demonstrated a 49% reduction in number of falls after implementation of an evidence-based exercise & education falls prevention programme (3).

 

Evidence from an RCT comparing group- and home-based exercise interventions against standard care demonstrated a significant reduction in falls-related injuries (IRR 0.55; p=0.04). This effect lasted for 12 months after the end of the intervention and there was a significant reduction in total fall rate during this 12 month period (IRR 0.74; p=0.04). A significant reduction in falls incidence persisted in participants of the group-based exercise intervention who maintained levels of 150 minutes of moderate-vigorous physical activity/week at 24 months after the intervention (4). A recent Systematic review & meta-analysis reported that, compared to controls, practice of Tai Chi was associated with a significant reduction in chance of falling more than once, and rate of falls (5). No significant difference was demonstrated between eccentric vs. traditional resistance exercises for those >65y with ≥1 fall in the preceeding 12 months (6).

 

Physical inactivity has been linked to frailty in both mid and later life. A prospective longitudinal cohort (n=6233) study reports that moderate or no physical activity at age 50y is a predictor for frailty (7). This was confirmed by another birth cohort study which demonstrated that poor performance in physical tests (grip strength, chair rise & standing balance) at age 53y was associated with mobility or personal care disability at age 69y (8). A positive association has been demonstrated between physical activity in mid-life and both ‘successful ageing’ (no major chronic diseases, no cognitive impairment, physical impairment or mental health limitations) and reduced disability/frailty (9). 5 out of studies in this systematic review reported a positive association between physical activity in mid-life and physical mobility/physical functioning/reduced disability in later life (1 study observed no significant association). An RCT (n=172; mean participant age 78.3y) demonstrated that implementation of a combined physical activity and nutritional assessment programme in older adults led to a trend towards reduced frailty – 4.9% of the intervention group had progressed to frailty, compared to 15.3% of the control group (odds ratio 0.19; 95% CI 0.08-1.08; p=0.052) (10).

 

Quality of evidence

Grade A- High Quality

 

 

 

References:

  1. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis.

Br J Sports Med. 2017 Dec;51(24):1750-1758. Epub 2016 Oct 4.

 

  1. Exercise interventions and prevention of fall-related fractures in older people: a meta-analysis of randomized controlled trials.

Int J Epidemiol. 2017 Feb 1;46(1):149-161.

 

  1. Implementing an Evidence-Based Fall Prevention Intervention in Community Senior Centers.

Am J Public Health. 2016 Nov;106(11):2026-2031. Epub 2016 Sep 15.

 

  1. Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial.

Arch Gerontol Geriatr. 2016 Nov-Dec;67:46-54. Epub 2016 Jun 29.

 

  1. Systematic review and meta-analysis: Tai Chi for preventing falls in older adults.

BMJ Open. 2017 Feb 6;7(2):e013661.

 

  1. Eccentric versus traditional resistance exercise for older adult fallers in the community: a randomized trial within a multi-component fall reduction program.

BMC Geriatr. 2017 Jul 17;17(1):149.

 

  1. Midlifecontributors to socioeconomic differences in frailty during later life: a prospective cohort study.

Lancet Public Health. 2018 Jun 13. pii: S2468-2667(18)30079-3.[Epub ahead of print]

 

  1. Can measures ofphysicalperformance in mid-life improve the clinical prediction of disability in early old age? Findings from a British birth cohort study.

Exp Gerontol. 2018 Jun 7;110:118-124. [Epub ahead of print]

 

  1. Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review.

PLoS One. 2016 Feb 4;11(2):e0144405. eCollection 2016.

 

  1. Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial.

Age Ageing. 2017 May 1;46(3):401-407.

 

 

Dementia
-21%

Dementia

A recent meta-analysis of prospective studies has reported a protective effect for physical activity in all-cause dementia – incidence of dementia was reduced by 21% in those who undertook high levels of physical activity, and by 24% with moderate levels. Greater benefit was seen in Alzheimer’s Disease (37% risk reduction with high levels of activity, 29% with moderate levels), but no protective effect was observed in vascular dementia (although this finding may have been limited by a smaller sample size) (1). Another systematic review reported that physical activity conveys a mild positive effect on cognition but was not able to observe a dose-response relationship (2). This finding has not always been observed in the oldest age groups – a population-based cohort study of over-75s demonstrated no significant effect of physical inactivity and risk of severe cognitive impairment or dementia (3). Physical activity in mid-life has been associated with positive ageing outcomes, including the absence of cognitive impairment or mental health limitations (4).

A retrospective study of individuals with a family history of Alzheimer’s Disease (≥1 affected relative), showed greater cognitive function in those who met recommended physical activity guidelines, compared to those who were inactive (5). There is increasing evidence that higher levels of physical activity may be associated with reduced risk of cognitive decline, but such conclusions are limited by a large variability in study design, differences in assessment of cognition/definitions of dementia and use of self-reported levels of physical activity.

 

Quality of evidence

Grade B- Moderate Quality

 

 

References:

  1. Impact of Physical Activity on Cognitive Decline, Dementia, and Its Subtypes: Meta-Analysis of Prospective Studies.

Biomed Res Int. 2017;2017:9016924. Epub 2017 Feb 7.

 

  1. Physical Activity in Community Dwelling Older People: A Systematic Review of Reviews of Interventions and Context.

PLoS One. 2016 Dec 20;11(12):e0168614.

 

  1. Lack of associations between modifiable risk factors and dementia in the very old: findings from the Cambridge City over-75s cohort study.

Aging Ment Health. 2017 Feb 2:1-7. [Epub ahead of print]

 

  1. Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review.

PLoS One. 2016 Feb 4;11(2):e0144405. eCollection 2016.

 

  1. Physical activity is associated with higher cognitive function among adults at risk for Alzheimer’s disease.

Complement Ther Med. 2018 Feb;36:46-49. Epub 2017 Nov 24.

Obesity
-10%

Obesity

There is strong evidence from a number of trials that there is favourable and consistent effect of aerobic physical activity on achieving weight maintenance with  less than 3% change (1). Similar data however notes there is no effect in achieving 5% weight loss (Physical activity alone)  – unless from large volumes or with iso-calorific diets (such weight loss may not be considered as primary prevention)(1).

The general consensus is of a moderate effect of physical activity on the risk of obesity with up to a 10% risk reduction. However, this is achieved primarily through weight maintenance from aerobic activity (2).

A longitudinal study on the association between sedentary behaviour and childhood obesity concluded that targeting sedentary behaviour may be effective for preventing obesity in the periods where children normally have large increases in sedentary time (ages 9-12)(4)

Note must be made however of studies showing that obese men who were moderately/highly fit had less than half the risk of dying than the normal-weight men who were unfit (3).

Although, regular physical activity helps with weight management, the activity is very important to the patient’s health, with positive health outcomes whether or not they lose weight (3).

The aetiology of obesity in youth and adults is likely the result of a complex interplay of multi-causal influences (5). The evidence is not strong that physical activity alone is an adequate method of prevention, however in combination with other strategies taking into account the complex relationships and mechanisms of suspected behaviours affecting obesity, there is likely to be a large positive effect on obesity prevention (5).

Indeed a systematic review of the evidence regarding efficacy of obesity prevention interventions among adults proved that physical activity alone had worse outcomes than both diet alone and worse outcomes than physical activity and diet intervention combined, with the latter showing the most promising results (6).

 

Quality of evidence

Grade A/B- Moderate to High Quality

 

 

References:

  1. Start active, stay active: report on physical activity in the UK.

[online] Available at: https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers GOV.UK. (2018).

 

  1. Exercise the Miracle Cure.

(2015). [ebook] Available at: http://www.aomrc.org.uk/…/2016/05/Exercise_the_Miracle_Cure_0215.pdf [Accessed 9 Jun. 2018].

 

  1. Physical inactivity: the biggest public health problem of the 21st century.

Br J Sports Med. 2009 Jan;43(1):1-2. Blair SN1.

 

  1. Longitudinal study of the associations between change in sedentary behavior and change in adiposity during childhood and adolescence: Gateshead Millennium Study. International Journal of Obesity, 41(7), pp.1042-1047. Mann, K., Howe, L., Basterfield, L., Parkinson, K., Pearce, M., Reilly, J., Adamson, A., Reilly, J. and Janssen, X. (2017).

 

  1. Prevention of overweight and obesity in children and adolescents : Critical appraisal of the evidence base

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. Nov; 59(11):1423-1431 Pigeot I, Baranowski T, Lytle L, Ahrens W. (2016)

 

  1. A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults.

Obesity Reviews, 9(5), pp.446-455. Lemmens, V., Oenema, A., Klepp, K., Henriksen, H. and Brug, J. (2008).

Living an active life reduces your risk of illness and disease

Co-morbidities are common – reduce this risk:

Evidence summary

Many patients with inflammatory rheumatic diseases are at higher risk of co-morbidities [1]. There is strong evidence in the general population that being physically activity can reduce the risk of type 2 diabetes; cardiovascular disease; falls, depression and dementia; and cancer of colon and breast [2].

References

  1. Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73(1):62-68.
  2. Department of Health. Start Active, Stay Active. In: Health Do, ed: Strategy; 2011.

All – Cause Mortality

A large body of evidence has consistently demonstrated a clear inverse relationship between levels of physical activity and all-cause mortality (1,2). Up to a 30% risk reduction has been noted for all-cause mortality in physical activity (1,2). A large cohort study attributed low cardiorespiratory fitness as causal to 16% of deaths (3). In addition, a recent systematic review of systematic reviews noted there is irrefutable evidence that routine physical activity reduces the risk for premature mortality and is an effective primary and secondary preventive strategy for at least 25 chronic medical conditions (4).

Interestingly the review also noted that clinically relevant health benefits can be accrued at volumes of physical activity that are well below current international recommendations. In fact, there is a suggestion that clinicians should avoid threshold based physical activity messaging (4). Another review of 16 high quality cohorts with over 1 million participants further proved a dose dependant relationship between physical activity and risk of all-cause mortality (5)

When considering the maximal effect of physical activity in primary prevention of all-cause mortality a recent  systematic review of 9 cohort studies with a mean follow-up of 9.8 years (6) and 2 recent prospective studies on large population cohorts followed for 14 and 8 years, respectively) demonstrated clear dose–response effects of physical activity to overall mortality (7,8); each 10 minutes of physical activity accumulated per day led to an approximately 10% relative risk reduction in mortality, up to 32% to 44% relative risk reduction at 150 minutes of moderate to vigorous physical activity per week, depending on the amount of vigorous activity as part of the physical activity. The dose–response effect seems to plateau at a 50% to 60% reduction at 3 to 5 times the stated Guidelines (ie, 750 min/wk).

 

Quality of evidence

Grade A- High Quality

 

References:

  1. Start active, stay active: report on physical activity in the UK

[Internet]. GOV.UK. 2018 [cited 28 June 2018]. Available from: https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers

 

  1. Physical inactivity: the biggest public health problem of the 21st century.

Br J Sports Med. 2009 Jan;43(1):1-2.Blair S

 

  1. Health benefits of physical activity: a systematic review of current systematic reviews. Warburton DER, Bredin SSD. Curr Opin Cardiol. 2017 Sep;32(5):541-556. doi: 10.1097/HCO.0000000000000437. Review.

 

  1. Does physical activity attenuate, or even eliminate,the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet 2016;388:1302–1310 Ekelund U, Steene-Johannessen J, Brown WJ,etal.,Lancet SedentaryBehaviour Working Group.

 

  1. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship.

 

JAMA Intern Med. 2015;175:959–967. Arem H, Moore SC, Patel A, et al.

 

  1. Effect of moderate to vigorous physical activity on all-cause mortality in middle-aged and older Australians.

JAMA Intern Med. 2015;175:970–977. SFX Bibliographic Links [Context Link] Gebel K, Ding D, Chey T, et al.

 

  1. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study.

Lancet. 2011;378:1244–1253. Wen CP, Wai JP, Tsai MK, et al.

 

3
Reflect

‘What do you make of what I have just said?’

Allow some space for people to talk and explore the information rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

Listen and reflect their concerns: ‘you’re worried about X’. Help them to address these issues by sharing the experience of other people:  ‘other people I’ve worked with have had those concerns, but what typically happens when they get started is…’  or  ‘whilst there is a small risk of X when you get started, this is outweighed by the risk reduction you experience once you have started moving more’. Ask what they think about what you have said.

 

4
Ask

“What would be the top 2-3 reasons for you personally becoming more active, if you decided to?”

Help them to generate and articulate their own reasons, which may or may not be health-related. Saying ‘if you decided to’ reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

Did you know?

"I can’t imagine just being on the biologics and not doing exercise, but equally I can’t imagine just doing exercise and not taking biologics!"

Reference:

O’Dwyer T, McGowan E, O’Shea F, Wilson F. Physical Activity and Exercise: Perspectives of Adults With Ankylosing Spondylitis. J Phys Act Health. 2016;13(5):504-513.

"It’s (physical activity) just best all-around for mental health and you just feel more alive."

Reference:

Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1065-1072.