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Now you've started to understand their views, it may be appropriate to introduce and explore further benefits:

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“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.

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2-3 benefits of physical activity for people with

Reduces pain

Reduces pain

Evidence summary

A large body of good quality randomised controlled trial data shows consistent reduction in pain due to osteoarthritis, with benefits reported in strengthening, weight-bearing and aerobic exercise [1–7]. This benefit is comparable with other treatment modalities, including many oral and topical analgesics [6]. Effect size diminishes with time from structured physical activity intervention with no sustained benefit seen >6 months after a 3 month intervention in 5222 participants reported in a good quality meta-analysis of 54 RCTs suggesting physical activity needs to be sustained to maintain effect [2]. Strengthening exercises alone have been shown to have the greatest effect on pain, although a combination of strengthening, aerobic and flexibility exercises is advised due to this combination still adequately improving pain and having a greater effect on function and general health [7]. A systematic review looking at the safety of physical activity interventions in those with knee osteoarthritis found that no studies reported an increase in pain in the physical activity group versus controls [8].

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Physical activity can be recommended for the treatment of pain to most people with osteoarthritis in most circumstances and should be undertaken unless there are compelling reasons to do otherwise.

References

1         Tanaka R, Ozawa J, Kito N, et al.Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil2013;27:1059–71. doi:10.1177/0269215513488898

2         Fransen M, McConnell S, Harmer AR, et al.Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med2015;49:1554–7. doi:10.1136/bjsports-2015-095424

3         Hall J, Swinkels A, Briddon J, et al.Does Aquatic Exercise Relieve Pain in Adults With Neurologic or Musculoskeletal Disease? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Arch Phys Med Rehabil2008;89:873–83. doi:10.1016/j.apmr.2007.09.054

4         O’Keeffe M, Hayes A, McCreesh K, et al.Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis. Br J Sports Med2017;51:126–32. doi:10.1136/bjsports-2015-095410

5         Anwer S, Alghadir A, Brismée J-M. Effect of Home Exercise Program in Patients With Knee Osteoarthritis. J Geriatr Phys Ther2016;39:38–48. doi:10.1519/JPT.0000000000000045

6         Babatunde OO, Jordan JL, Van Der Windt DA, et al.Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One2017;12:1–30. doi:10.1371/journal.pone.0178621

7         Uthman OA, van der Windt DA, Jordan JL, et al.Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Bmj2013;347:f5555–f5555. doi:10.1136/bmj.f5555

8         Quicke JG, Foster NE, Thomas MJ, et al.Is long-term physical activity safe for older adults with knee pain?: A systematic review. Osteoarthr Cartil2015;23:1445–56. doi:10.1016/j.joca.2015.05.002

Reduces stiffness

Reduces stiffness

Evidence summary

A systematic review of 17 RCTs identified 7 studies that had examined the association between resistance exercises in those with osteoarthritis of the knee. A meta-analysis of their results demonstrated a small effect size in favour of improved stiffness (SMD -0.31), identifying that they are beneficial within 12 weeks. The authors advise that exercises including seated leg press, leg extension and leg curls, as well as hip abduction and adduction exercises, can be used to obtain these benefits [1].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Conclusion

Physical activity prescriptions for those with knee osteoarthritis should incorporate resistance exercises, as they can be effective for alleviating stiffness.

References

1         Li Y, Su Y, Chen S, et al.The effects of resistance exercise in patients with knee osteoarthritis: A systematic review and meta-analysis. Clin Rehabil2016;30:947–59. doi:10.1177/0269215515610039

Improves physical function

Improves physical function

Evidence summary

A large volume of evidence from systematic reviews of high-quality RCTs shows consistent improvements in physical function following physical activity interventions in those with hip and knee osteoarthritis [1–9]. Interventions included aerobic exercises, strengthening exercises and a combination of both. These benefits are sustained versus controls beyond 6 months [1,6,10,11]. The NNT to improve physical function using the ESCAPE-pain (Enabling Self-management and Coping with Arthritis Pain using Exercise) programme in those with knee osteoarthritis has been shown to be 3.7 immediately after the programme, and 6.7 at 30 months [11]. A combination of strengthening, aerobic and flexibility exercises has been shown to have the greatest effect on physical function [8]. A systematic review looking at the safety of physical activity interventions in those with knee osteoarthritis found that no studies reported lower physical function in the physical activity group versus controls [12].

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity can help improve physical function in those with osteoarthritis of the hip or knee.

References

1         Fransen M, McConnell S, Harmer AR, et al.Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med2015;49:1554–7. doi:10.1136/bjsports-2015-095424

2         Fransen M, McConnell S, Hernandez-Molina G, et al.Exercise for osteoarthritis of the hip. Cochrane Database Syst RevPublished Online First: 22 April 2014. doi:10.1002/14651858.CD007912.pub2

3         Anwer S, Alghadir A, Brismée J-M. Effect of Home Exercise Program in Patients With Knee Osteoarthritis. J Geriatr Phys Ther2016;39:38–48. doi:10.1519/JPT.0000000000000045

4         Li Y, Su Y, Chen S, et al.The effects of resistance exercise in patients with knee osteoarthritis: A systematic review and meta-analysis. Clin Rehabil2016;30:947–59. doi:10.1177/0269215515610039

5         Tanaka R, Ozawa J, Kito N, et al.Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Clin Rehabil2013;27:1059–71. doi:10.1177/0269215513488898

6         Fernandopulle S, Perry M, Manlapaz D, et al.Effect of Land-Based Generic Physical Activity Interventions on Pain, Physical Function, and Physical Performance in Hip and Knee Osteoarthritis. Am J Phys Med Rehabil2017;0:1. doi:10.1097/PHM.0000000000000736

7         Sampath KK, Mani R, Miyamori T, et al.The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Clin Rehabil2015;30:1141–55. doi:10.1177/0269215515622670

8         Uthman OA, van der Windt DA, Jordan JL, et al.Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Bmj2013;347:f5555–f5555. doi:10.1136/bmj.f5555

9         Babatunde OO, Jordan JL, Van Der Windt DA, et al.Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One2017;12:1–30. doi:10.1371/journal.pone.0178621

10       Hurley M V., Walsh NE, Mitchell HL, et al.Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: A cluster randomized trial. Arthritis Care Res2007;57:1211–9. doi:10.1002/art.22995

11       Hurley M V., Walsh NE, Mitchell H, et al.Long-Term outcomes and costs of an integrated rehabilitation program for chronic knee pain: A pragmatic, cluster randomized, controlled trial. Arthritis Care Res2012;64:238–47. doi:10.1002/acr.20642

12       Quicke JG, Foster NE, Thomas MJ, et al.Is long-term physical activity safe for older adults with knee pain?: A systematic review. Osteoarthr Cartil2015;23:1445–56. doi:10.1016/j.joca.2015.05.002

 

Improves quality of life

Improves quality of life

Evidence summary

The evidence base regarding physical activity and its impact on quality of life in those with osteoarthritis is conflicting. Whilst some have demonstrated that it can have a positive effect in OA knee [1,2], other have failed to find a correlation [3,4]. There are no reports that physical activity impacts negatively on quality of life.

Quality of evidence

Moderate quality – while good quality trials have been undertaken in this area there is a current inconsistency of findings.

Strength of recommendation

Weak recommendation – on the basis of the existing evidence and expert clinical opinion some people can be expected to report improved quality of life.

Conclusion

Whilst a definite positive impact on quality of life has not been demonstrated throughout the literature, there is no evidence to suggest a negative impact. Some people with OA can be expected to report an improved quality of life due to the recognised positive impact of physical activity on pain, function and stiffness.

References

1         Fransen M, McConnell S, Harmer AR, et al.Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med2015;49:1554–7. doi:10.1136/bjsports-2015-095424

2         Tanaka R, Ozawa J, Kito N, et al.Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials. J Phys Ther Sci2015;27:3309–14. doi:10.1589/jpts.27.3309

3         Fransen M, McConnell S, Hernandez-Molina G, et al.Exercise for osteoarthritis of the hip. Cochrane Database Syst RevPublished Online First: 22 April 2014. doi:10.1002/14651858.CD007912.pub2

4         Sampath KK, Mani R, Miyamori T, et al.The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Clin Rehabil2015;30:1141–55. doi:10.1177/0269215515622670

Improves general health

Improves general health

Evidence summary

One review article with meta-analysis specifically looked into the association between physical activity and health related quality of life in those with OA [1]. This identified a positive trend towards significance in the general health component of the SF-36 questionnaire, although the result did not reach statistical significance. There is no evidence to suggest a negative effect of physical activity on general health in people with OA.

Quality of evidence

High quality

Strength of recommendation

Weak recommendation – on the basis of the existing evidence and expert clinical opinion some patients can be expected to report improved general health.

Conclusion

Whilst there is no statistically significant evidence to support an improvement in general health in those with OA undertaking regular physical activity, there is certainly no evidence of harm. Moreover, many with OA may report improved general health due to the recognised improvements in pain, function and stiffness when undertaking regular physical activity.

References

1         Tanaka R, Ozawa J, Kito N, et al.Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials. J Phys Ther Sci2015;27:3309–14. doi:10.1589/jpts.27.3309

Improves mental health

Improves mental health

Evidence Summary

One review article with meta-analysis specifically looked into the association between physical activity and health related quality of life in those with OA [1]. This identified a trend towards significance in the mental health component of the SF-36 questionnaire, although the result did not reach statistical significance. There is no evidence to suggest a negative effect of physical activity on mental health in people with OA.

Quality of evidence

Moderate quality

Strength of recommendation

Weak recommendation – on the basis of the existing evidence and expert clinical opinion some people may be expected to report improvements in their mental health.

Conclusion

Whilst there is no statistically significant evidence to support an improvement in mental health in those with OA undertaking regular physical activity, there is no evidence of harm. Moreover, there is good quality evidence from those in the general population that regular physical activity can have a positive impact on mental health [2].

References

1         Tanaka R, Ozawa J, Kito N, et al.Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials. J Phys Ther Sci2015;27:3309–14. doi:10.1589/jpts.27.3309

2         DOH. Start Active , Stay Active: a report on physical activity from the four home countries’ Chief Medical Officers. London: 2011.

Some benefits will be generic (feel better, have more energy, improve sleep, improve fitness levels, improve mood, etc.) and others will be condition specific (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).

 

Cancer (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

 

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).

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).

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

Reduces morbidity and mortality

Evidence summary

Those with osteoarthritis are known to have an increased cardiovascular risk, with an increased prevalence of hypertension, obesity, metabolic syndrome and cardiovascular events [1,2]. There is also an increased risk of all-cause mortality, with walking disability and reduced physical function shown to independently increase this [3]. Physical activity levels in this population are known to be low, with only 44% or older adults with knee pain meeting current physical activity recommendations in a survey of older adults registered with one UK GP surgery [4]. Regular physical activity is known to positively affect these risk factors so should be discussed and encouraged in all with osteoarthritis.

Individuals with chronic widespread musculoskeletal pain are reported to have an increased risk of premature death, although the exact mechanism for this is uncertain [5]. Some have suggested that higher rates of cancer explain the association [6], whereas others also found higher rates of death from cardiovascular disease [7]. Recent research has identified that mortality rates in those with chronic widespread pain are no higher than the general population when results are adjusted for confounding factors [8]. It is felt that adverse lifestyle factors, including low levels of physical activity, are responsible for the excess mortality [5,9]. The impact that pain has on daily life, rather than pain itself, is associated with an increased risk of mortality, as it is more likely to lead to reduced physical activity levels, which is known to be associated with a number of medical conditions [9]. A recent Spanish study identified that women with fibromyalgia who undertook inadequate levels of physical activity had an increased risk of cardiovascular disease [10]. Addressing adverse lifestyle factors, therefore, including physical inactivity is vital in these patients.

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity should be recommended to most people with musculoskeletal pain in most circumstances to reduce their increased risk of cardiovascular morbidity and premature mortality.

References

1         Calvet J, Orellana C, Larrosa M, et al.High prevalence of cardiovascular co-morbidities in patients with symptomatic knee or hand osteoarthritis. Scand J Rheumatol2016;45:41–4. doi:10.3109/03009742.2015.1054875

2         Nüesch E, Dieppe P, Reichenbach S,et al.All cause and disease specific mortality in patients with knee or hip osteoarthritis: Population based cohort study. Bmj2011;342:638. doi:10.1136/bmj.d1165

3         Hawker GA, Croxford R, Bierman AS,et al.All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: A population based cohort study. PLoS One2014;9:1–12. doi:10.1371/journal.pone.0091286

4         Holden MA, Nicholls EE, Young J, et al.Exercise and physical activity in older adults with knee pain: a mixed methods study. Rheumatology2015;54:413–23. doi:10.1093/rheumatology/keu333

5         Macfarlane GJ, Barnish MS, Jones GT. Persons with chronic widespread pain experience excess mortality: Longitudinal results from UK Biobank and meta-Analysis. Ann Rheum Dis2017;76:1815–22. doi:10.1136/annrheumdis-2017-211476

6         Macfarlane GJ, McBeth J, Silman AJ. Widespread body pain and mortality: Prospective population based study. BMJ2001;323:662–5. doi:10.1136/bmj.323.7314.662

7         McBeth J, Symmons DP, Silman AJ, et al.Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology2008;48:74–7. doi:10.1093/rheumatology/ken424

8         Åsberg AN, Heuch I, Hagen K. The Mortality Associated With Chronic Widespread Musculoskeletal Complaints: A Systematic Review of the Literature. Musculoskeletal Care2016;15:104–13. doi:doi: 10.1002/msc.1156.

9         Smith D, Wilkie R, Croft P, et al.Pain and Mortality in Older Adults: The Influence of Pain Phenotype. Arthritis Care Res2018;70:236–43. doi:10.1002/acr.23268

10       Acosta-Manzano P, Segura-Jiménez V, Estévez-López F, et al.Do women with fibromyalgia present higher cardiovascular disease risk profile than healthy women? The al-Andalus project.Clin Exp Rheumatol2017;35:61–7.

 

 

Reduces pain

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).

Reduces frequency of painful episodes

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).

Improves physical function

Improves physical function

Evidence summary

There is strong evidence that physical activity reduces functional limitations in those with chronic lower back pain (>12 weeks duration) and that these changes are sustained long-term, although the effect size is small [1,2]. Adopting a multidisciplinary biopsychosocial approach is more effective than physical treatments alone at reducing disability [3]. It is uncertain whether back schools are effective in improving physical function for acute or chronic low back pain due to the low quality evidence available [4,5].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Conclusion

Regular physical activity can result in small, but significant, improvements in physical function and should be encouraged in those with chronic lower back pain.

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         Geneen L, Smith B, Clarke C, et al.Physical activity and exercise for chronic pain in adults: an overview of Cochrane reviews. Cochrane LibrPublished Online First: 2017. doi:10.1002/14651858.CD011279.pub3.www.cochranelibrary.com

3         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

4         Parreira P, Mw H, Mw VT, et al.Back Schools for chronic non-specific low back pain ( Review ). Published Online First: 2017. doi:10.1002/14651858.CD011674.pub2.www.cochranelibrary.com

5         Poquet N, Cwc L, Mw H, et al.Back schools for acute and subacute non-specific low-back pain ( Review ) SUMMARY OF FINDINGS FOR THE MAIN COMPARISON. Cochrane Database Syst RevPublished Online First: 2016. doi:10.1002/14651858.CD008325.pub2.www.cochranelibrary.com

Reduces work absence

Reduced work absence

Evidence summary

A Cochrane review concluded that physical conditioning interventions have a small positive effect on reducing sick leave in those with chronic low back pain at 12 months follow up [1]. There was no effect in those with acute low back pain. In those with non-specific low back pain, there is good evidence of a moderate reduction in work disability with exercise interventions versus usual care, with long-term work disability reduced by 34% [2]. However, the authors were unable to determine which of the different exercise interventions were most effective, and there was no significant effect observed in the short or medium term.

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Conclusion

Long-term work absence in those with chronic low back pain is not uncommon, and physical activity interventions, ideally with biopsychosocial components, are likely to benefit many.

References

1         Schaafsma FG, Whelan K, Beek AJ Van Der,et al.Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain ( Review ) Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Published Online First: 2013. doi:10.1002/14651858.CD001822.pub3.Copyright

2         Oesch P, Kool J, Hagen KB, et al.Effectiveness of exercise on work disability in patients with non-acute non-specific low back pain: Systematic review and meta-analysis of randomized controlled trials. J Rehabil Med2010;42:193–205. doi:10.2340/16501977-0524

Some benefits will be generic (feel better, have more energy, improve sleep, improve fitness levels, improve mood, etc.) and others will be condition specific (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).

 

Cancer (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

 

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).

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

Reduces morbidity and mortality

Evidence summary

Those with osteoarthritis are known to have an increased cardiovascular risk, with an increased prevalence of hypertension, obesity, metabolic syndrome and cardiovascular events [1,2]. There is also an increased risk of all-cause mortality, with walking disability and reduced physical function shown to independently increase this [3]. Regular physical activity is known to positively affect these risk factors so should be discussed and encouraged in all with osteoarthritis.

Individuals with chronic widespread musculoskeletal pain are reported to have an increased risk of premature death, although the exact mechanism for this is uncertain [4]. Some have suggested that higher rates of cancer explain the association [5], whereas others also found higher rates of death from cardiovascular disease [6]. Recent research has identified that mortality rates in those with chronic widespread pain are no higher than the general population when results are adjusted for confounding factors [7]. It is felt that adverse lifestyle factors, including low levels of physical activity, are responsible for the excess mortality [4,8]. The impact that pain has on daily life, rather than pain itself, is associated with an increased risk of mortality, as it is more likely to lead to reduced physical activity levels, which is known to be associated with a number of medical conditions [8]. A recent Spanish study identified that women with fibromyalgia who undertook inadequate levels of physical activity had an increased risk of cardiovascular disease [9]. Addressing adverse lifestyle factors, therefore, including physical inactivity is vital in these people.

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity should be recommended to most people with musculoskeletal pain in most circumstances to reduce their increased risk of cardiovascular morbidity and premature mortality.

References

1         Calvet J, Orellana C, Larrosa M, et al.High prevalence of cardiovascular co-morbidities in patients with symptomatic knee or hand osteoarthritis. Scand J Rheumatol2016;45:41–4. doi:10.3109/03009742.2015.1054875

2         Nüesch E, Dieppe P, Reichenbach S, et al.All cause and disease specific mortality in patients with knee or hip osteoarthritis: Population based cohort study. Bmj2011;342:638. doi:10.1136/bmj.d1165

3         Hawker GA, Croxford R, Bierman AS, et al.All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: A population based cohort study. PLoS One2014;9:1–12. doi:10.1371/journal.pone.0091286

4         Macfarlane GJ, Barnish MS, Jones GT. Persons with chronic widespread pain experience excess mortality: Longitudinal results from UK Biobank and meta-Analysis. Ann Rheum Dis2017;76:1815–22. doi:10.1136/annrheumdis-2017-211476

5         Macfarlane GJ, McBeth J, Silman AJ. Widespread body pain and mortality: Prospective population based study. BMJ2001;323:662–5. doi:10.1136/bmj.323.7314.662

6         McBeth J, Symmons DP, Silman AJ, et al.Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology2008;48:74–7. doi:10.1093/rheumatology/ken424

7         Åsberg AN, Heuch I, Hagen K. The Mortality Associated With Chronic Widespread Musculoskeletal Complaints: A Systematic Review of the Literature. Musculoskeletal Care2016;15:104–13. doi:doi: 10.1002/msc.1156.

8         Smith D, Wilkie R, Croft P, et al.Pain and Mortality in Older Adults: The Influence of Pain Phenotype. Arthritis Care Res2018;70:236–43. doi:10.1002/acr.23268

9         Acosta-Manzano P, Segura-Jiménez V, Estévez-López F, et al.Do women with fibromyalgia present higher cardiovascular disease risk profile than healthy women? The al-Andalus project. Clin Exp Rheumatol2017;35:61–7.

Reduces pain

Improves pain

Evidence summary

There is moderate quality evidence that strengthening the scapulothoracic and upper extremity muscles improves pain immediately post-treatment and in the short-term. Using a standardised exercise programme which includes cervical strengthening, rotations and flexibility has been shown to improve pain, with a Number Needed to Treat (NNT) of four. Moderate pain relief can be achieved with a combination of stretching and strengthening exercises of the cervical and scapulothoracic muscles immediately post-treatment, at intermediate follow up and at long-term follow up. Exercise interventions have been shown to be more effective at reducing pain than other interventions, including acupuncture, spinal manipulation and TENS [1].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Conclusion

Physical activity should be encouraged in those with neck pain, but it is important to include specific stretching and strengthening exercises of the musculature throughout the neck and shoulder.

References

1         Gross AR, Paquin JP, Dupont G, et al.Exercises for mechanical neck disorders: A Cochrane review update. Man Ther2016;24:25–45. doi:10.1016/j.math.2016.04.005

Improves physical function

Improves physical function

Evidence summary

There is moderate quality evidence that strengthening the scapulothoracic and upper extremity muscles improves function in the short-term. Using a standardised exercise programme which includes cervical strengthening, rotations and flexibility has been shown to improve physical function, with a NNT of five. A moderate degree of improved function can be achieved with a combination of stretching and strengthening exercises of the cervical and scapulothoracic muscles immediately post-treatment, at intermediate follow up and at long-term follow up [1].

Quality of evidence

Moderate quality

Strength of recommendation

Strong

Conclusion

Physical activity should be encouraged in those with neck pain, but it is important to include specific stretching and strengthening exercises of the musculature throughout the neck and shoulder.

References

1         Gross AR, Paquin JP, Dupont G, et al.Exercises for mechanical neck disorders: A Cochrane review update. Man Ther2016;24:25–45. doi:10.1016/j.math.2016.04.005

Some benefits will be generic (feel better, have more energy, improve sleep, improve fitness levels, improve mood, etc.) and others will be condition specific (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).

 

Cancer (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

 

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).

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

Reduces morbidity and mortality

Evidence summary

Those with osteoarthritis are known to have an increased cardiovascular risk, with an increased prevalence of hypertension, obesity, metabolic syndrome and cardiovascular events [1,2]. There is also an increased risk of all-cause mortality, with walking disability and reduced physical function shown to independently increase this [3]. Regular physical activity is known to positively affect these risk factors so should be discussed and encouraged in all with osteoarthritis.

Individuals with chronic widespread musculoskeletal pain are reported to have an increased risk of premature death, although the exact mechanism for this is uncertain [4]. Some have suggested that higher rates of cancer explain the association [5], whereas others also found higher rates of death from cardiovascular disease [6]. Recent research has identified that mortality rates in those with chronic widespread pain are no higher than the general population when results are adjusted for confounding factors [7]. It is felt that adverse lifestyle factors, including low levels of physical activity, are responsible for the excess mortality [4,8]. The impact that pain has on daily life, rather than pain itself, is associated with an increased risk of mortality, as it is more likely to lead to reduced physical activity levels, which is known to be associated with a number of medical conditions [8]. A recent Spanish study identified that women with fibromyalgia who undertook inadequate levels of physical activity had an increased risk of cardiovascular disease [9]. Addressing adverse lifestyle factors, therefore, including physical inactivity is vital in these people.

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity should be recommended to most people with musculoskeletal pain in most circumstances to reduce their increased risk of cardiovascular morbidity and premature mortality.

References

1         Calvet J, Orellana C, Larrosa M, et al.High prevalence of cardiovascular co-morbidities in patients with symptomatic knee or hand osteoarthritis. Scand J Rheumatol2016;45:41–4. doi:10.3109/03009742.2015.1054875

2         Nüesch E, Dieppe P, Reichenbach S, et al.All cause and disease specific mortality in patients with knee or hip osteoarthritis: Population based cohort study. Bmj2011;342:638. doi:10.1136/bmj.d1165

3         Hawker GA, Croxford R, Bierman AS, et al.All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: A population based cohort study. PLoS One2014;9:1–12. doi:10.1371/journal.pone.0091286

4         Macfarlane GJ, Barnish MS, Jones GT. Persons with chronic widespread pain experience excess mortality: Longitudinal results from UK Biobank and meta-Analysis. Ann Rheum Dis2017;76:1815–22. doi:10.1136/annrheumdis-2017-211476

5         Macfarlane GJ, McBeth J, Silman AJ. Widespread body pain and mortality: Prospective population based study. BMJ2001;323:662–5. doi:10.1136/bmj.323.7314.662

6         McBeth J, Symmons DP, Silman AJ, et al.Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology2008;48:74–7. doi:10.1093/rheumatology/ken424

7         Åsberg AN, Heuch I, Hagen K. The Mortality Associated With Chronic Widespread Musculoskeletal Complaints: A Systematic Review of the Literature. Musculoskeletal Care2016;15:104–13. doi:doi: 10.1002/msc.1156.

8         Smith D, Wilkie R, Croft P, et al.Pain and Mortality in Older Adults: The Influence of Pain Phenotype. Arthritis Care Res2018;70:236–43. doi:10.1002/acr.23268

9         Acosta-Manzano P, Segura-Jiménez V, Estévez-López F, et al.Do women with fibromyalgia present higher cardiovascular disease risk profile than healthy women? The al-Andalus project. Clin Exp Rheumatol2017;35:61–7.

Reduces pain

Reduces pain

Evidence summary

A review of self-management interventions for those with chronic musculoskeletal pain that included 46 trials identified that courses run in groups, courses led by healthcare professionals and courses that included a psychological component had beneficial effects on pain, especially in the short-term [1]. Walking interventions have been shown to significantly reduce pain in the short and medium term compared with controls [2]. In those with fibromyalgia, resistance exercises help to reduce pain and tenderness [3]. Whilst a Cochrane review found only a non-statistically significant improvement in pain in those with fibromyalgia undertaking aerobic exercise interventions, there was a statistically significant improvement in tender trigger points [4]. Exercise is the only therapy based intervention given a ‘strong for’ recommendation in the latest EULAR fibromyalgia guidelines [5].

Quality of evidence

High quality

Strength of recommendation

Strong recommendation

Conclusion

Regular physical activity, including walking, can significantly improve pain in those with chronic musculoskeletal pain and should be advised. Consider referring those presenting with a significant psychosocial contribution to exercise intervention programmes with a psychological component, ideally group programmes that are led by an experienced healthcare professional.

References

1         Carnes D, Homer KE, Miles CL, et al.Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review. Clin J Pain2012;28:344–54. doi:10.1097/AJP.0b013e31822ed2f3

2         O’Connor SR, Tully MA, Ryan B, et al.Walking exercise for chronic musculoskeletal pain: Systematic review and meta-analysis. Arch Phys Med Rehabil2015;96:724–734.E3. doi:10.1016/j.apmr.2014.12.003

3         Busch AJ, Webber SC, Richards RS, et al.Resistance exercise training for fibromyalgia. Cochrane Database Syst RevPublished Online First: 2013. doi:10.1002/14651858.CD010884

4         Busch AJ, Barber KAR, Overend TJ, et al.Exercise for treating fibromyalgia syndrome (Review). Cochrane Database Syst RevPublished Online First: 2007. doi:10.1002/14651858.CD003786.pub2.Copyright

5         Macfarlane GJ, Kronisch C, Dean LE, et al.EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis2017;76:318–28. doi:10.1136/annrheumdis-2016-209724

Improves fatigue

Improves fatigue

Evidence summary

A Cochrane review identified a significant improvement in fatigue in those with fibromyalgia undertaking resistance exercise interventions [1]. Their meta-analysis of two RCTs demonstrated a large improvement in the intervention group, with the Mean Difference -14.66 on a 0-100 scale (-20.55 to -8.77).

Quality of evidence

Moderate quality

Strength of recommendation

Strong recommendation

Conclusion

Regular physical activity that includes a degree of resistance exercise is likely to improve fatigue in those with chronic musculoskeletal pain. There is no evidence to suggest that regular physical activity has a negative impact on fatigue in this population.

References

1         Busch AJ, Barber KAR, Overend TJ, et al.Exercise for treating fibromyalgia syndrome (Review). Cochrane Database Syst RevPublished Online First: 2007. doi:10.1002/14651858.CD003786.pub2.Copyright

 

Improves physical function

Improves physical function

Evidence summary

There is good evidence that physical activity interventions improve physical function in those with chronic pain. Aerobic exercise, such as walking interventions, have been shown to significantly improve physical function to a moderate degree in the short, medium and long-term [1]. A moderate effect in favour of improvement has also been demonstrated with resistance exercises [2]. Interventions that include group-based activities with a psychological component have been shown to be most beneficial [3].

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity, including aerobic and resistance exercises, can significantly improve physical function in those with chronic musculoskeletal pain and should be advised. Consider referring those presenting with a significant psychosocial contribution to group-based exercise intervention programmes with a psychological component.

References

1         O’Connor SR, Tully MA, Ryan B, et al.Walking exercise for chronic musculoskeletal pain: Systematic review and meta-analysis. Arch Phys Med Rehabil2015;96:724–734.E3. doi:10.1016/j.apmr.2014.12.003

2         Busch AJ, Webber SC, Richards RS, et al.Resistance exercise training for fibromyalgia. Cochrane Database Syst RevPublished Online First: 2013. doi:10.1002/14651858.CD010884

3         Carnes D, Homer KE, Miles CL, et al.Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review. Clin J Pain2012;28:344–54. doi:10.1097/AJP.0b013e31822ed2f3

Improves self-efficacy

Improves self-efficacy

Evidence summary

One systematic review with meta-analysis looked at the effect of the physical activity components of self-management programmes on self-efficacy in those with chronic musculoskeletal pain. A small-moderate benefit was observed in the short, medium and long-term [1].

Quality of evidence

Moderate quality

Strength of recommendation

Weak

Conclusion

Regular physical activity may improve self-efficacy in those with chronic musculoskeletal pain. Many may report improvements due to the recognised benefit on their pain and function. Consider referring those presenting with a significant psychosocial contribution to group-based exercise intervention programmes with a psychological component.

References

1         Carnes D, Homer KE, Miles CL, et al.Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review. Clin J Pain2012;28:344–54. doi:10.1097/AJP.0b013e31822ed2f3

Improves general wellbeing

Improves general wellbeing

Evidence summary

One systematic review with meta-analysis looked at the effect of the physical activity components of self-management programmes on global wellbeing in those with chronic musculoskeletal pain. A moderate benefit was observed in the short and medium-term [1]. One RCT of 21 patients included within a Cochrane review demonstrated an improvement of 40 on a self-reported 0-100 scale [2].

Quality of evidence

Moderate quality

Strength of recommendation

Weak

Conclusion

Regular physical activity may improve general wellbeing in those with chronic musculoskeletal pain. Many may report improvements due to the recognised benefit on their pain and function. Consider referring those presenting with a significant psychosocial contribution to group-based exercise intervention programmes with a psychological component.

References

1         Carnes D, Homer KE, Miles CL, et al.Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review. Clin J Pain2012;28:344–54. doi:10.1097/AJP.0b013e31822ed2f3

2         Busch AJ, Webber SC, Richards RS, et al.Resistance exercise training for fibromyalgia. Cochrane Database Syst RevPublished Online First: 2013. doi:10.1002/14651858.CD010884

Improves fitness

Improves fitness

Evidence summary

A Cochrane review identified a significant improvement in cardiovascular fitness in those with fibromyalgia undertaking aerobic physical activity interventions [1]. Their meta-analysis of 3 RCTs demonstrated a large improvement in the intervention group, with the Standardised Mean Difference 0.79 (0.37-1.21).

Quality of evidence

Moderate quality

Strength of recommendation

Weak

Conclusion

Regular physical activity can be expected to improve cardiovascular fitness in those people with chronic musculoskeletal pain who were previously inactive.

References

1         Busch AJ, Barber KAR, Overend TJ, et al.Exercise for treating fibromyalgia syndrome (Review). Cochrane Database Syst RevPublished Online First: 2007. doi:10.1002/14651858.CD003786.pub2.Copyright

Improves mental health

Improves mental health

Evidence summary

Whilst physical activity interventions have been shown to improve a number of patient outcomes, there is conflicting evidence regarding depression and psychological function. One RCT included within a Cochrane review demonstrated a large effect in favour of resistance exercises on depression in those with fibromyalgia, but the same review demonstrated no effect on overall mental health [1]. An earlier Cochrane review concluded that psychological function cannot be expected to improve with aerobic exercises in those with fibromyalgia [2].

Quality of evidence

Low quality

Strength of recommendation

Strong – while the evidence supporting an improvement in mental health outcomes is poor, expert clinical consensus is that people should be informed of the positive effect of physical activity on their mental health.

Conclusion

Regular physical activity is known to be an effective intervention in those with depression, but the quality of evidence in the chronic pain population is poor. Expert consensus is that the reduced pain and improved function that can be expected from regular physical activity is likely to improve an individual’s mental wellbeing.  Consider referring those presenting with a significant psychosocial contribution to exercise intervention programmes with a psychological component, ideally group programmes.

References

1         Busch AJ, Webber SC, Richards RS, et al.Resistance exercise training for fibromyalgia. Cochrane Database Syst RevPublished Online First: 2013. doi:10.1002/14651858.CD010884

2         Busch AJ, Barber KAR, Overend TJ, et al.Exercise for treating fibromyalgia syndrome (Review). Cochrane Database Syst RevPublished Online First: 2007. doi:10.1002/14651858.CD003786.pub2.Copyright

Some benefits will be generic (feel better, have more energy, improve sleep, improve fitness levels, improve mood, etc.) and others will be condition specific (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).

 

Cancer (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

 

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).

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

Reduces morbidity and mortality

Evidence summary

Those with osteoarthritis are known to have an increased cardiovascular risk, with an increased prevalence of hypertension, obesity, metabolic syndrome and cardiovascular events [1,2]. There is also an increased risk of all-cause mortality, with walking disability and reduced physical function shown to independently increase this [3]. Regular physical activity is known to positively affect these risk factors so should be discussed and encouraged in all with osteoarthritis.

Individuals with chronic widespread musculoskeletal pain are reported to have an increased risk of premature death, although the exact mechanism for this is uncertain [4]. Some have suggested that higher rates of cancer explain the association [5], whereas others also found higher rates of death from cardiovascular disease [6]. Recent research has identified that mortality rates in those with chronic widespread pain are no higher than the general population when results are adjusted for confounding factors [7]. It is felt that adverse lifestyle factors, including low levels of physical activity, are responsible for the excess mortality [4,8]. The impact that pain has on daily life, rather than pain itself, is associated with an increased risk of mortality, as it is more likely to lead to reduced physical activity levels, which is known to be associated with a number of medical conditions [8]. A recent Spanish study identified that women with fibromyalgia who undertook inadequate levels of physical activity had an increased risk of cardiovascular disease [9]. Addressing adverse lifestyle factors, therefore, including physical inactivity is vital in these people.

Quality of evidence

High quality

Strength of recommendation

Strong

Conclusion

Regular physical activity should be recommended to most people with musculoskeletal pain in most circumstances to reduce their increased risk of cardiovascular morbidity and premature mortality.

References

1 Calvet J, Orellana C, Larrosa M, et al.High prevalence of cardiovascular co-morbidities in patients with symptomatic knee or hand osteoarthritis. Scand J Rheumatol2016;45:41–4. doi:10.3109/03009742.2015.1054875

2 Nüesch E, Dieppe P, Reichenbach S, et al.All cause and disease specific mortality in patients with knee or hip osteoarthritis: Population based cohort study. Bmj2011;342:638. doi:10.1136/bmj.d1165

3 Hawker GA, Croxford R, Bierman AS, et al.All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: A population based cohort study. PLoS One2014;9:1–12. doi:10.1371/journal.pone.0091286

4 Macfarlane GJ, Barnish MS, Jones GT. Persons with chronic widespread pain experience excess mortality: Longitudinal results from UK Biobank and meta-Analysis. Ann Rheum Dis2017;76:1815–22. doi:10.1136/annrheumdis-2017-211476

5 Macfarlane GJ, McBeth J, Silman AJ. Widespread body pain and mortality: Prospective population based study. BMJ2001;323:662–5. doi:10.1136/bmj.323.7314.662

6 McBeth J, Symmons DP, Silman AJ, et al.Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology2008;48:74–7. doi:10.1093/rheumatology/ken424

7 Åsberg AN, Heuch I, Hagen K. The Mortality Associated With Chronic Widespread Musculoskeletal Complaints: A Systematic Review of the Literature. Musculoskeletal Care2016;15:104–13. doi:doi: 10.1002/msc.1156.

8 Smith D, Wilkie R, Croft P, et al.Pain and Mortality in Older Adults: The Influence of Pain Phenotype. Arthritis Care Res2018;70:236–43. doi:10.1002/acr.23268

9 Acosta-Manzano P, Segura-Jiménez V, Estévez-López F, et al.Do women with fibromyalgia present higher cardiovascular disease risk profile than healthy women? The al-Andalus project. Clin Exp Rheumatol2017;35:61–7.

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?