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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 amputation can be important in helping people to consider change. Ask them how they think this new information might be relevant to them and help them to think this through.

2
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2-3 benefits of physical activity for people with issues relating to lower limb amputations?

Reduces morbidity and mortality

Reduces morbidity and mortality

Evidence summary

An increased risk of mortality following a major lower limb amputation is consistently reported in prospective and retrospective studies from the UK and the rest of the world, with mortality rates ranging from 30-50% at 1 year [1-3] and 60-77% at 5 years [1, 3, 4]. A prospective review of referrals to a regional rehabilitation centre in the UK identified that 57.1% underwent amputation for peripheral vascular disease, 31.4% due to diabetes mellitus, 7.6% due to trauma and 3.8% due to tumours [5]. They found an increased risk of mortality in people with diabetes, with 52% mortality at 3 years in those with diabetes compared with 33% overall. The reported rates of mortality are higher in those studies excluding amputations due to trauma and tumours, as these patients tend to be younger and have fewer co-morbidities. In addition, the rates of mortality are lower in those that are fitted with a prosthesis, a decision often based upon the presence of medical co-morbidities and frailty.

Those undergoing a lower limb amputation are known to have a high number of co-morbidities. A retrospective study at a regional UK vascular centre looked at those undergoing an above knee amputation and found that 58% of their cohort had diabetes mellitus, 39% had chronic kidney disease, 35% had heart failure and 13% had COPD [6]. Similar rates of diabetes and chronic kidney disease were reported in a retrospective study from the USA looking specifically at those undergoing amputation for peripheral vascular disease, with 83% also having hypertension and 51% having hyperlipidaemia [2]. 63 of their 391 patients had a subsequent contralateral amputation during their follow up period. Physical activity should be encouraged in lower limb amputees, as regular physical activity is known to positively influence many of these co-morbidities. In people with type 2 diabetes mellitus who have undergone a lower limb amputation, the risk of major cardiac events is increased if they do not meet physical activity recommendations, in addition to smoking cessation, anti-platelet therapy and dietary change [7].

Amputees spend more time in low-intensity activities than the general population and have high levels of physical inactivity [8,9]. The presence of sarcopenia on abdominal MRI within 1 year of a lower limb amputation for diabetes mellitus predicts an increased risk of mortality, with a mortality rate of 60.7% in those with sarcopenia and 36.4% without [4]. The risk of sarcopenia, a loss of skeletal muscle mass and strength, is known to be reduced by regular physical activity, including cardiovascular and strengthening exercises.

Quality of evidence

High

Strength of recommendation

Strong

Conclusion

Regular physical activity should be recommended to most people following a major lower limb amputation to help reduce their increased risk of mortality and the high number of co-morbidities.

References

  1. Jones WS, Patel MR, Dai D, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. American Heart Journal 2013;165(5):809-+. doi: 10.1016/j.ahj.2012.12.002
  2. Shah SK, Bena JF, Allemang MT, et al. Lower Extremity Amputations: Factors Associated With Mortality or Contralateral Amputation. Vascular and Endovascular Surgery 2013;47(8):608-13. doi: 10.1177/1538574413503715
  3. Fortington LV, Geertzen JHB, van Netten JJ, et al. Short and Long Term Mortality Rates after a Lower Limb Amputation. European Journal of Vascular and Endovascular Surgery 2013;46(1):124-31. doi: 10.1016/j.ejvs.2013.03.024
  4. Kim YK, Lee HS, Ryu JJ, et al. Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot. Journal of Foot and Ankle Research 2018;11 doi: 10.1186/s13047-018-0274-1
  5. Singh RK, Prasad G. Long-term mortality after lower-limb amputation. Prosthetics and Orthotics International 2016;40(5):545-51. doi: 10.1177/0309364615596067
  6. Kennedy G, McGarry K, Bradley G, et al. All-Cause Mortality Amongst Patients Undergoing Above and Below Knee Amputation in a Regional Vascular Centre within 2014-2015. The Ulster medical journal 2019;88(1):30-35.
  7. Shalaeva EV, Saner H, Janabaev BB, et al. Tenfold risk increase of major cardiovascular events after high limb amputation with non-compliance for secondary prevention measures. European Journal of Preventive Cardiology 2017;24(7):708-16. doi: 10.1177/2047487316687103
  8. Desveaux L, Goldstein RS, Mathur S, et al. Physical Activity in Adults with Diabetes Following Prosthetic Rehabilitation. Canadian Journal of Diabetes 2016;40(4):336-41. doi: 10.1016/j.jcjd.2016.02.003
  9. Pepin ME, Akers KG, Galen SS. Physical activity in individuals with lower extremity amputations: a narrative review. Physical Therapy Reviews 2018;23(2):77-87. doi: 10.1080/10833196.2017.1412788

 

Improves quality of life

Improves quality of life

Evidence summary

A review of 47 papers identified 6 studies that reviewed the relationship between participation in regular physical activity or sport and quality of life [1]. They found that participation in physical activity reduced following an amputation, but that amputees engaging in regular sport or physical activity reported a better quality of life. A number of factors may contribute to an improved quality of life, including an increased number of social contacts, acceptance of their disability, improved motor skills and a greater knowledge of about what they can do to participate in sport and physical activity. A greater proportion of participants in these studies had undergone a traumatic amputation than would be expected in the general population. A further systematic review identified that in military veterans who had undergone a lower limb amputation for trauma, higher levels of physical activity were positively associated with better physical and mental health related quality of life measures [2].  Social interactions and relationships are known to be a key determinant of quality of life in lower limb amputees, and physical activity interventions, whilst important, should not compromise these [3].

Quality of evidence

Moderate

Strength of recommendation

Strong

Conclusion

Most lower limb amputees should be encouraged to undertake regular physical activity. However, it is important that this is not at the expense of social interaction, and regular physical activity should be encouraged within a supportive social environment.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. Bragaru M, Dekker R, Geertzen JHB, et al. Amputees and Sports A Systematic Review. Sports Medicine 2011;41(9):721-40. doi: 10.2165/11590420-000000000-00000
  2. Christensen J, Ipsen T, Doherty P, et al. Physical and social factors determining quality of life for veterans with lower-limb amputation(s): a systematic review. Disability and Rehabilitation 2016;38(24-26):2345-53. doi: 10.3109/09638288.2015.1129446
  3. Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: A study of a lower-limb amputee population. Prosthetics and Orthotics International 2008;32(2):186-200. doi: 10.1080/03093640802016514

 

Improves cardiopulmonary function

Improves cardiopulmonary function

Evidence summary

A review of 47 papers identified 12 studies that reviewed the relationship between regular physical activity and cardiopulmonary function, concluding that there were beneficial effects [1]. In addition, rehabilitation time was found to be shorter in those that incorporate physical training into their rehabilitation programmes. Other studies have identified that greater cardiovascular fitness is associated with more successful prosthetic rehabilitation [2,3]. Physical activity interventions also reduce the metabolic cost of exercise [4,5].

Quality of evidence

Moderate

Strength of recommendation

Strong

Conclusion

Regular physical activity should be encouraged in people with lower limb amputations as this can be expected to improve their cardiopulmonary function. Amputees learning to use a prosthesis are more likely to be successful with their rehabilitation if they have greater cardiopulmonary function, and this can be addressed with regular physical activity.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. Bragaru M, Dekker R, Geertzen JHB, et al. Amputees and Sports A Systematic Review. Sports Medicine 2011;41(9):721-40. doi: 10.2165/11590420-000000000-00000
  2. Chin T, Sawamura S, Shiba R. Effect of physical fitness on prosthetic ambulation in elderly amputees. American Journal of Physical Medicine & Rehabilitation 2006;85(12):992-96. doi: 10.1097/01.phm.0000247653.11780.0b
  3. Hamamura S, Chin T, Kuroda R, et al. Factors Affecting Prosthetic Rehabilitation Outcomes in Amputees of Age 60 Years and Over. Journal of International Medical Research 2009;37(6):1921-27. doi: 10.1177/147323000903700630
  4. Ward KH, Meyers MC. Exercise Performance of Lower-Extremity Amputees. Sports Medicine 1995;20(4):207-14. doi: 10.2165/00007256-199520040-00001
  5. Darter BJ, Nielsen DH, Yack HJ, et al. Home-Based Treadmill Training to Improve Gait Performance in Persons With a Chronic Transfemoral Amputation. Archives of Physical Medicine and Rehabilitation 2013;94(12):2440-47. doi: 10.1016/j.apmr.2013.08.001

Improves physical function

Improves physical function

Evidence summary

A range of targeted physical activity interventions have demonstrated clear improvements in numerous parameters that improve overall function, particularly in those walking with a prosthesis. A systematic review of 8 studies supported the use of exercise programmes that incorporate balance exercises, muscle strengthening, supervised walking, gait training and functional exercises as they have all been shown to improve gait performance [1]. Programmes incorporating these, as well as flexibility exercises, have shown clinically meaningful improvements in walking ability, walking speed, degree of weight bearing through the prosthetic limb and less activity limitation [2-5].

In addition to programmes that incorporate a range of exercises, gait training interventions have also been shown to improve gait performance in those using a prosthetic limb. A systematic review of 13 studies, incorporating individuals that had undergone a lower limb amputation due to dysvascular disease, trauma or malignancy found that supervised gait training improves gait, is safe and improves the bioenergetic efficiency of gait [6]. These benefits have been found with both walking and using a treadmill [6,7]. Balance training may improve physical function [8] as can strengthening the hip abductor muscles [9].

Quality of evidence

Moderate

Strength of recommendation

Strong

Conclusion

The physical function of lower limb amputees and the walking performance of prosthetic users improves with physical activity interventions. However, the evidence presented relates to targeted interventions and programmes rather than increasing physical activity levels. Exercise programmes available to amputees during their rehabilitation which incorporate exercises to improve muscle strengthening, balance, physical function, flexibility (and, if applicable, walking) should be of benefit.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so. Signposting them to appropriate resources may help to empower and assist them in becoming more active.

References

  1. Wong CK, Ehrlich JE, Ersing JC, et al. Exercise programs to improve gait performance in people with lower limb amputation: A systematic review. Prosthetics and Orthotics International 2016;40(1):8-17. doi: 10.1177/0309364614546926
  2. Rau B, Bonvin F, De Bie R. Short-term effect of physiotherapy rehabilitation on functional performance of lower limb amputees. Prosthetics and Orthotics International 2007;31(3):258-70. doi: 10.1080/03093640600994615
  3. Godlwana LL, Stewart A, Musenge E. Mobility during the intermediate stage of rehabilitation after lower limb amputation from an under resourced community: a randomized controlled trial. Physiotherapy 2015;101:e458. doi: 10.1016/j.physio.2015.03.3243
  4. Miller CA, Williams JE, Durham KL, et al. The effect of a supervised community-based exercise program on balance, balance confidence, and gait in individuals with lower limb amputation. Prosthetics and Orthotics International 2017;41(5):446-54. doi: 10.1177/0309364616683818
  5. Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait & Posture 2018;63:282-89. doi: 10.1016/j.gaitpost.2018.04.030
  6. Highsmith MJ, Andrews CR, Millman C, et al. Gait Training Interventions for Lower Extremity Amputees: A Systematic Literature Review. Technology and Innovation 2016;18(2-3):99-113. doi: 10.21300/18.2-3.2016.99
  7. Darter BJ, Nielsen DH, Yack HJ, et al. Home-Based Treadmill Training to Improve Gait Performance in Persons With a Chronic Transfemoral Amputation. Archives of Physical Medicine and Rehabilitation 2013;94(12):2440-47. doi: 10.1016/j.apmr.2013.08.001
  8. Matjacic Z, Burger H. Dynamic balance training during standing in people with trans-tibial amputation: a pilot study. Prosthetics and Orthotics International 2003;27(3):214-20. doi: 10.1080/03093640308726684
  9. Pauley T, Devlin M, Madan-Sharma P. A Single-Blind, Cross-Over Trial of Hip Abductor Strength Training to Improve Timed Up & Go Performance in Patients With Unilateral, Transfemoral Amputation. Journal of Rehabilitation Medicine 2014;46(3):264-70. doi: 10.2340/16501977-1270

Improves self-esteem

Improves self-esteem 

Evidence summary

A systematic review identified 6 studies that reviewed the relationship between participation in regular physical activity or sport and self-esteem [1]. Self-esteem was found to be higher amongst those engaging in regular sport or physical activity. This may be due to a number of factors, such as an increased number of social contacts, an acceptance of their disability, improved motor function and an increased knowledge and understanding of how they can maintain regular activity. A greater proportion of participants in these studies had undergone a traumatic amputation that would be expected in the general population.

Quality of evidence

Moderate

Strength of recommendation

Strong

Conclusion:

Regular physical activity is likely to improve self-esteem in lower limb amputees.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to  prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. Bragaru M, Dekker R, Geertzen JHB, et al. Amputees and Sports A Systematic Review. Sports Medicine 2011;41(9):721-40. doi: 10.2165/11590420-000000000-00000

Reduces risk of falls

Reduces risk of falls 

Evidence summary

Balance is known to deteriorate following an amputation [1], and fear of falling is a common barrier to physical activity in amputees [2,3]. RCTs have demonstrated that exercise programmes incorporating balance activities result in a reduced risk of falls in in the short-term [4] and a reduced incidence of falls in the longer-term [5]. Balance and balance confidence, clearly linked to a risk of falling, have also been shown to improve when dedicated balance exercises are incorporated into these programmes [6].

Quality of evidence

Moderate

Strength of recommendation

Strong

Conclusion

Targeted balance exercises can reduce the risk of falls in lower limb amputees and, whilst the evidence provided relates to exercise programme interventions, lower limb amputees should be encouraged to incorporate balance exercises into their activity routine.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. van Velzen JM, van Bennekom CAM, Polomski W, et al. Physical capacity and walking ability after lower limb amputation: a systematic review. Clinical Rehabilitation 2006;20(11):999-1016. doi: 10.1177/0269215506070700
  2. Littman AJ, Boyko EJ, Thompson ML, et al. Physical activity barriers and enablers in older Veterans with lower-limb amputation. Journal of Rehabilitation Research and Development 2014;51(6):895-906. doi: 10.1682/jrrd.2013.06.0152
  3. Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disability and Health Journal 2017;10(4):600-06. doi: 10.1016/j.dhjo.2017.03.004
  4. Godlwana LL, Stewart A, Musenge E. Mobility during the intermediate stage of rehabilitation after lower limb amputation from an under resourced community: a randomized controlled trial. Physiotherapy 2015;101:e458. doi: 10.1016/j.physio.2015.03.3243
  5. Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait & Posture 2018;63:282-89. doi: 10.1016/j.gaitpost.2018.04.030
  6. Miller CA, Williams JE, Durham KL, et al. The effect of a supervised community-based exercise program on balance, balance confidence, and gait in individuals with lower limb amputation. Prosthetics and Orthotics International 2017;41(5):446-54. doi: 10.1177/0309364616683818

Improves balance and balance confidence

Improves balance and balance confidence 

Evidence summary

Balance is known to deteriorate following an amputation [1], and fear of falling is a common barrier to physical activity in amputees [2,3]. One study demonstrated a clinically meaningful improvements in balance and balance confidence following a 6-week supervised exercise programme that incorporated balance exercises, as well as exercises to address flexibility, gait, core strength and lower limb strength [4]. Hip abductor strengthening programmes have been shown to improve balance confidence in those with transfemoral amputations [5]. Poor balance may result in falls, and exercise programmes incorporating balance activities have been shown to reduce the risk of falls in in the short-term [6] and reduce the incidence of falls in the longer-term [7].

Quality of evidence

Low

Strength of recommendation

Strong

Conclusion

While there is a paucity of high-quality evidence, lower limb amputees should be encouraged to incorporate balance exercises into their activity routine to improve their balance and balance confidence and reduce their risk of falls.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. van Velzen JM, van Bennekom CAM, Polomski W, et al. Physical capacity and walking ability after lower limb amputation: a systematic review. Clinical Rehabilitation 2006;20(11):999-1016. doi: 10.1177/0269215506070700
  2. Littman AJ, Boyko EJ, Thompson ML, et al. Physical activity barriers and enablers in older Veterans with lower-limb amputation. Journal of Rehabilitation Research and Development 2014;51(6):895-906. doi: 10.1682/jrrd.2013.06.0152
  3. Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disability and Health Journal 2017;10(4):600-06. doi: 10.1016/j.dhjo.2017.03.004
  4. Miller CA, Williams JE, Durham KL, et al. The effect of a supervised community-based exercise program on balance, balance confidence, and gait in individuals with lower limb amputation. Prosthetics and Orthotics International 2017;41(5):446-54. doi: 10.1177/0309364616683818
  5. Pauley T, Devlin M, Madan-Sharma P. A Single-Blind, Cross-Over Trial of Hip Abductor Strength Training to Improve Timed Up & Go Performance in Patients With Unilateral, Transfemoral Amputation. Journal of Rehabilitation Medicine 2014;46(3):264-70. doi: 10.2340/16501977-1270
  6. Godlwana LL, Stewart A, Musenge E. Mobility during the intermediate stage of rehabilitation after lower limb amputation from an under resourced community: a randomized controlled trial. Physiotherapy 2015;101:e458. doi: 10.1016/j.physio.2015.03.3243
  7. Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait & Posture 2018;63:282-89. doi: 10.1016/j.gaitpost.2018.04.030

Improves lower limb strength

Improves lower limb strength

Evidence summary

Lower limb muscle atrophy and reduced strength is common following a lower limb amputation [1,2]. An RCT demonstrated that an exercise programme incorporating lower limb and core muscle strengthening activities, as well as flexibility, balance and cardiovascular fitness exercises, can significantly increase power generation and absorption in both the intact and remnant limbs [3]. A hip strengthening programme in active, mostly traumatic lower limb amputees that were experienced prosthetic users demonstrated an improved hip strength, enabling a number of participants to run following the intervention [4].

Quality of evidence

Low

Strength of recommendation

Strong

Conclusion

While there is a paucity of high-quality evidence, reduced lower limb muscle strength following an amputation is common. Lower limb strengthening exercises should be advised to lower limb amputees to address this.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. Isakov E, Burger H, Gregoric M, et al. Isokinetic and isometric strength of the thigh muscles in below-knee amputees. Clinical Biomechanics 1996;11(4):233-35. doi: 10.1016/0268-0033(95)00078-x
  2. Nolan L. Lower limb strength in sports-active transtibial amputees. Prosthetics and Orthotics International 2009;33(3):230-41. doi: 10.1080/03093640903082118
  3. Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait & Posture 2018;63:282-89. doi: 10.1016/j.gaitpost.2018.04.030
  4. Nolan L. A Training Programme to Improve Hip Strength in Persons With Lower Limb Amputation. Journal of Rehabilitation Medicine 2012;44(3):241-48. doi: 10.2340/16501977-0921

Reduces back pain

Reduces back pain 

Evidence summary

Chronic low back pain is known to be prevalent in lower limb prosthetic users, with surveys suggesting up to 64% are affected [1,2]. One study identified that up to 40% of lower limb prosthetic users report restricted ability to undertake regular physical activity due to low back pain [1]. A prospective study of 19 lower-limb prosthetic users with chronic lower back pain identified that an 8-week lumbar strengthening programme significantly reduced their pain [3]. Back school interventions and home exercise programmes that include lower limb strengthening, core strengthening, lower limb stretching, spinal stabilisation and dynamic stump exercises have also been shown to significantly improve lower back pain in this cohort [4].

Quality of evidence

Low

Strength of recommendation

Strong

Conclusion

While there is a paucity of high-quality evidence for physical activity interventions in lower limb prosthetic users with low back pain, it is a common problem in this population and limited evidence shows a benefit. In addition, it is known that similar interventions in the general population are effective. Lower limb prosthetic users with lower back pain should be offered targeted programmes to address this, and regular physical activity should be advised.

Lower limb amputations are performed for a number of clinical indications. Although most evidence around physical activity relates to prosthetic users and for dysvascular amputees, the benefits of physical activity are not exclusive to these groups and should be shared with all lower limb amputees. Lower limb amputees wishing to increase their physical activity levels should be encouraged to do so.

References

  1. Devan H, Tumilty S, Smith C. Physical activity and lower-back pain in persons with traumatic transfemoral amputation: A national cross-sectional survey. Journal of Rehabilitation Research and Development 2012;49(10):1457-66. doi: 10.1682/yrrd.2011.09.0155
  2. Devan H, Hendrick P, Hale L, et al. Exploring Factors Influencing Low Back Pain in People With Nondysvascular Lower Limb Amputation: A National Survey. Pm&R 2017;9(10):949-59. doi: 10.1016/j.pmrj.2017.02.004
  3. Shin MK, Yang HS, Yang H-E, et al. Effects of Lumbar Strengthening Exercise in Lower-Limb Amputees With Chronic Low Back Pain. Annals of Rehabilitation Medicine-Arm 2018;42(1):59-66. doi: 10.5535/arm.2018.42.1.59
  4. Anaforoglu B, Erbahceci F, Aksekili MAE. The effectiveness of a back school program in lower limb amputees: a randomized controlled study. Turkish Journal of Medical Sciences 2016;46(4):1122-29. doi: 10.3906/sag-1503-131

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

Type 2 Diabetes
-50%

Type 2 Diabetes

Current national guidance denotes a clear inverse relationship with physical activity and the development of type 2 diabetes (1). A risk reduction of 30%-40% in moderately active people compared to sedentary has been shown (1) with strong evidence suggesting up to a 50% risk reduction (2). 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 the greatest relative benefits were observed at the lowest levels of activity (5). Additional benefits are seen at physical activity levels far greater than current international recommendations (5).

A systematic reviews of several randomised controlled trials has 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 reduces or delays the development of type 2 diabetes (6,7).

A randomised clinical trial of exercise resulted in significant reduction in the frequency of gestational diabetes mellitus in overweight/obese pregnant women (8).

Quality of evidence

Moderate to High

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 reviews have shown risk reduction of up to 52% (1). 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). Some reviews have noted that the evidence is unclear, 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

Moderate to High

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 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

Moderate

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.

Stroke
-30%

Stroke

In a meta-analysis of cohort studies 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 large-scale epidemiological studies and interventional trials providing strong evidence of the effects of physical activity in the primary prevention of cardiovascular disease, the effect of exercise on the burden of stroke is not well understood (5).

Quality of evidence

Moderate

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 review of 49 prospective cohort studies (1,837,794 patient-year follow-up) evaluating the incidence of depression and levels of physical activity 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%, although 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

High

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 is a class of diseases that involve the heart or blood vessels. Cardiovascular disease includes coronary artery diseases such as angina and myocardial infarction (commonly known as a heart attack).

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 cardiovascular disease 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. Within 9 months, the intervention group had marked improvements in systolic blood pressure and cholesterol (4).

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

Quality of evidence

High

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 and 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 while 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 a precise age range where physical activity reduces this risk.

Quality of evidence

High

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

High

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

High

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

Limited to only data regarding men, so further studies needed for skin cancer.

References

  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

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 shown with 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 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

High

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 a dose-response relationship was not shown (2). This finding has not always been found 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

Moderate

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 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)

Studies show 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, activity is 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 positive effect on obesity prevention (5).

A systematic review of 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

Moderate to High

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

All–cause mortality

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

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

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

Quality of evidence

High

References

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

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

 

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

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

 

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

 

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

 

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

 

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

 

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

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

 

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

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

3
Reflect

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

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

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

4
Ask

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

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

Did you know?

<40% of lower limb amputees are sufficiently active and 33% are considered sedentary

Langford J, Dillon MP, Granger CL, et al. Physical activity participation amongst individuals with lower limb amputation. Disability and Rehabilitation 2019;41(9):1063-70. doi: 10.1080/09638288.2017.1422031

The least active individuals stand to gain the most from a small increase in physical activity.

Large health gains are seen in individuals increasing their activity levels from very low amounts. For instance, increasing from 10 to 20 minutes of moderate intensity activity per week has a significant effect on life expectancy even though individuals are below the recommended 150 minutes of moderate intensity. So, it’s worth supporting very inactive individuals to change their behaviour, particularly as many of the least active members of the population are often seen in healthcare settings.

Reference

Department of Health. Start Active, Stay Active: A report on physical activity from the four home countries’ Chief Medical Officers. London: 2011.

NICE. Physical activity: brief advice for adults in primary care. Natl Inst Heal care Excell Public Heal Guidel 44 2013;PH44.nice.org.uk/guidance/ph44

With modern prostheses and advanced rehabilitation, the metabolic cost of walking for unilateral transtibial amputees is similar to able bodied individuals

Jarvis HL, Bennett AN, Twiste M, et al. Temporal Spatial and Metabolic Measures of Walking in Highly Functional Individuals With Lower Limb Amputations. Archives of Physical Medicine and Rehabilitation 2017;98(7):1389-99. doi: 10.1016/j.apmr.2016.09.134

Evidence has demonstrated that unsupervised physical activity at an appropriate intensity is safe for disabled adults

Smith B, Kirby N, Skinner B, et al. Physical activity for general health benefits in disabled adults: summary of a rapid evidence review for the UK Chief Medical Officers’ update of the physical activity guidelines. London: Public Health England, 2018