Journal Mobile

Author(s): 

Ranulf Crooke1, Christine Haseler2, Tobias Haseler3, Jack Collins4, Andrew Crockett5

Author Affiliations: 

1General Practitioner, Hilary Cottage Surgery, Fairford, UK; 2General Practitioner, Hucclecote Surgery, Gloucester, UK; 3General Practitioner Specialty Trainee 3, The Bloomsbury Surgery, London, UK; 4General Practitioner, Trafalgar Medical Group Practice, Portsmouth, UK; 5General Practitioner Specialty Trainee 2, Ponteland Medical Group, Newcastle, UK

Correspondence to: 

R Crooke, Hilary Cottage Surgery, Fairford, UK

Email:
ranulf.crooke@nhs.net

Journal Issue: 
Volume 50: Issue 2: 2020
Cite paper as: 
J R Coll Physicians Edinb 2020; 50: 173–80

Format

Abstract

Non-communicable diseases are a leading cause of death and levels are rising. Lifestyle changes, including physical activity, have benefits in all-cause mortality, cardiovascular and metabolic disease, respiratory conditions and cognitive and mental health. In some cancers, particularly colon, prostate and breast, physical activity improves quality of life and outcomes before, during and after treatment. Sedentary time is an independent risk factor with adverse effects in hospitalised patients. Mechanisms include anti-inflammatory effects and augmentation of physiological and neuroendocrine responses to stressors. Engaging patients is affected by barriers: for clinicians, awareness of guidelines and personal physical activity levels are important factors; for patients, barriers are influenced by life events, socioeconomic and cultural factors. Interventions to increase activity levels are effective in the short- and medium-term, including brief interventions. Face-to-face is more effective than remote advice and behavioural interventions are more effective than cognitive. There are no published guidelines for physical activity in hospitalised patients.

HTML Full Text

Benefits and risks of physical activity

Introduction

Non-communicable diseases are rising and account for an estimated 89% of all deaths in the UK.1 Life expectancy in some areas of the UK is projected to fall due to an increase in conditions such as cardiovascular disease, stroke and cancer.2 A significant proportion of non-communicable diseases are thought to be preventable through addressing four main risk factors, one being physical activity, the others: tobacco use, poor diet and excess alcohol.3 Despite evidence of the benefits, physical activity levels remain low, especially in hospitalised patients.4 Engaging patients to change behaviour is challenging.5

In this review article, we wish to provide a broad overview of the background evidence for the benefits of sufficient physical activity, mechanisms through which these are achieved and how barriers to increasing activity might be addressed. Papers were selected from PubMed and Web of Science using the following search terms: physical activity, exercise, inactivity, sedentary, mechanism, benefit, risk, barriers, intervention and motivation. Studies cited in previous relevant reviews and official government publications or guidance and the authors’ collections were also included.

Guidelines and definitions of physical activity and sedentary time

UK guidelines for physical activityrecommend at least 150 minutes of moderate intensity (or 75min vigorous intensity) physical activity every week, strength building at least twice a week, minimising sedentary time and, for older adults, improving balance twice a week. Any amount of movement contributes to the total. Most benefit is gained by switching from minimal to any engagement in physical activity.7

Physical activity is bodily movement produced by skeletal muscles that results in energy expenditure.8 Moderate and vigorous activity can be differentiated by the ‘talk test’: being able to talk but not sing indicates moderate intensity, while having difficulty talking without pausing suggests vigorous activity.6 Moderate intensity is between 3–6 METs (1 MET is the metabolic rate while sitting at rest), light intensity 1.6–3 METs and vigorous intensity over 6 METs.8

Equivalent benefits of meeting the UK guidelines might be achieved at much lower volumes through high intensity interval training (very vigorous physical activities performed in short bursts interspersed with rest or lower intensity activity breaks).6,8

Sedentary time is an independent health risk, irrespective of level of activity, and is defined as any waking-time activity spent in seated or lying posture, expending low levels of energy.9

Major health benefits of physical activity

All-cause mortality

Physical activity is consistently associated with reduced all-cause mortality in a dose-response fashion.10 Increases in physical activity over time, irrespective of baseline activity levels, are associated with reduced all-cause, cardiovascular and cancer mortality.11 This relationship persists after accounting for other associations of increasing physical activity (improved diet, BMI, medical history, blood pressure and lipids). The benefits are comparable with medication in some conditions and surpasses medication in reducing mortality after stroke.12

Cancer

The leading cause of avoidable mortality in the UK is neoplasms.13 Moderate to strong evidence has shown risk reduction in bladder, breast, colon, endometrial, oesophageal, gastric, renal and lung cancers through regular physical activity.8 Sedentary time and increased risk of endometrial, colon and lung cancer also appear to be linked.8 Following a cancer diagnosis, regular physical activity has been shown to reduce all-cause mortality, cancer-specific mortality and risk of recurrence or progression in breast cancer, prostate cancer and colorectal cancer.14,15

Cardiovascular disease

Prevention of cardiovascular disease, the second leading cause of death in the UK,13 shows strong evidence of a dose-response effect of physical activity.8 The effect of physical activity on reducing blood pressure is also significant and may be similar to hypertensive medication.16 Cardiac rehabilitation through physical activity, in established cardiovascular disease, reduces cardiovascular mortality, hospital admissions and improves quality of life, but not myocardial infarction or subsequent cardiac interventions.17

Respiratory disease

Chronic obstructive pulmonary disease is currently in the top three leading causes of death worldwide.18 Whilst brief advice appears to have limited success, pulmonary rehabilitation improves quality of life, breathlessness and exercise capacity.19

Diabetes

Diagnosis of diabetes in the UK has doubled in the last 20 years and represents a significant modifiable disease burden.20 Strong evidence supports an inverse relationship between physical activity and progression of HbA1C, blood pressure, BMI and lipids.8

Brain health

Cognitive health is important not just for lifespan, but for maintaining a greater number of disability-free years.21 Dementia is England’s second leading cause of death.22 Cognitive function is improved by regular physical activity, reducing age-associated decline by up to 33%, the risk of dementia, including Alzheimer’s, by up to 40%, and improving cognition in dementia and stroke patients with established disease.8

Mental health

Low-level physical activity (walking <150min/week) has been associated with reduced risk of depression of up to 63%,23 whilst sedentary time has been associated with an increased risk of depression (relative risk = 1.14; 95% CI: 1.06 to 1.21).24 There is also evidence that the benefits of physical activity, cognitive behavioural therapy and medications may not be significantly different.25

Sleep

Sleep is an important determinant of both physical and mental health.26 Physical activity has been found to improve sleep in a number of ways: total sleep duration, sleep onset latency, rapid-eye-movement sleep, sleep efficiency and sleep quality.27

Obesity

Weight loss or attenuating weight gain is associated with greater amounts of moderate to vigorous physical activity but not with light physical activity.8

Older adults and frailty

With the UK’s ageing population, mitigating the effects of the rise in chronic health conditions is important.28 Light intensity activity in older adults is associated with a reduced risk of obesity, cardiovascular disease, cancer and all-cause mortality,29 as well as reduced unplanned hospital admissions and medication prescriptions.30 Poor physical function has a linear relationship with all-cause mortality, even from mid-life.31 Impaired balance predicts a higher rate of all-cause mortality and cognitive decline.32 Reduced muscle strength is associated with reduced walking speed, increased risk of disability and falls.33

Risks of physical activity

Physical activity is safe and beneficial for almost all people, including those with disabilities.6 A safeguard against doing too much too soon is to start at low durations and intensities, for example 5 to 15 minutes activity 2 to 3 times a week and build up over time as the body adjusts.6,8

High-intensity competitive sport, unlike leisure activity or sport where intensity and duration can be controlled, has defined cautions (such as known or suspected coronary artery disease) where increased haemodynamic load may cause myocardial ischaemia.34 In pregnancy, impact activities causing trauma, prolonged supine lying, high altitude or underwater activities are not advised.35 Activity moderation and psychological support is required for exercise addiction, characterised by obligatory and excessive exercise.36

There is a greater risk of musculoskeletal injury with greater volumes of physical activity and injuries are more common with impact activities.6

Adverse cardiovascular events are rare. Findings from studies of very high leisure-time physical activity levels are contradictory8,37 but analysis suggests benefits against mortality risk continue at ≥10x the recommended guideline level of physical activity.37 The evidence is insufficient to advocate lesser activity levels to avoid possible adverse effects. It is important to note that benefits at high volumes are much the same as guideline recommended lower volumes of physical activity.8

Physical activity

The mechanisms underlying the benefits of regular physical activity are diverse and not fully understood (Figure 1). Some of the possible pathways involve anti-inflammatory effects, augmenting physiological and neuroendocrine responses to biological and psychosocial stressors, creating resilience to stressors and optimising neurogenesis and growth factor production.38 Potential mediators include: increased expression of heat-shock proteins (a group of proteins critically involved in cellular signalling and metabolism),39 short-chain fatty acid production via the gut microbiome,40 improved brain-derived neurotrophic factor, growth factors and tryptophan production, in addition to enhanced neuroplasticity,41 improved anti-oxidative capacity42 and reduced systemic inflammation.43

Figure 1 Mechanisms and benefits of physical activity. See text for references.

Key systems modulated by these changes are the sympathetic nervous system and the hypothalamic–pituitary–adrenal axis, which are activated in a dose-dependent manner by acute physical activity.38 Adaptive response to the short-term, limited physical stress of activity develops increased resilience to physical and psychological stress. This results in protection from the maladaptive regulation of these systems that is observed with chronic exposure to stressors in conditions such as autoimmune, metabolic and cardiovascular diseases, and stress-related health problems, for example, depression.38 The resultant physiological changes comprise reduced visceral adipose tissue inflammation, improved vascular function, glucose and lipid metabolism,38 as well as greater brain volume and cognitive function.44 Lower oxidative stress has been associated with longer telomeres (a biological marker of cellular ageing and senescence) which suggests that regular physical activity conserves telomere length and may mitigate the ageing process.42

Strength and balance training

Muscle and bone mass ordinarily peak before the age of 30, and muscle and bone strengthening activities are required to slow the decline in bone and muscle density to maintain capacity and function (Figure 2).45 Multicomponent physical activity programmes including strength and balance training reduce the risk of fall-related injuries; walking alone does not reduce this risk,46 but any physical activity reduces the risk of hip fracture by 20–40% compared to sedentary individuals.47 A review of strength-training variables demonstrated that duration of training had a greater effect on muscle strength than any other variable such as type of exercise, number of repetitions or degree of resistance.48 Muscles do adapt to training, even into old age.33

Figure 2 Strength and balance ability over the life course and potential ages or events that may change the trajectory of decline with ageing (adapted from Skelton et al 2018).51 The blue line depicts the decline attributed to life events versus the projected green line trajectory without these life events.

Evidence for balance training is less complete,49 but showed some improvement from programmes which ran three times a week for three months, although these were not maintained after cessation. Exercises included gait, balance, 3D exercises, functional exercises and muscle strengthening; multiple exercise types improved indirect measures of balance such as timed get-up-and-go, single-leg stance and walking speed. Physical confidence is improved by training.50

Sedentary time

Adverse effects of sedentary time

Long-term health risks from sedentary behaviour are independent of the amount of time spent undertaking physical activity.6,8 Being active regularly will only partially attenuate risks. Data from over 1.3 million individuals9 showed that over 6–8 hours of daily sedentary time is associated with greater risk of all-cause, cancer and cardiovascular mortality, independently of levels of moderate to vigorous physical activity (Figure 3). Hospital bed rest, (patients may spend 87% of their time lying down)4 is associated with muscle atrophy, insulin resistance, systemic inflammation and microvascular dysfunction amongst other complications.52

Figure 3 Non-linear associations between sedentary behaviour and health outcomes presented with and without physical activity adjustment (Patterson et al 2018).9

Benefits of interrupting sedentary time

One trial observed 19 overweight or obese participants while sedentary or with breaks of 2 minutes every 20 minutes to undertake light or moderate intensity walking on a treadmill. Results showed that glycaemic response to a test drink was 24.1% lower (5.2mmol/l [4.1–6.6], p<0.01) for light-intensity activity and 29.6% lower (4.9mmol/l [3.8–6.1), p<0.001) for moderate-intensity activity compared with uninterrupted sitting (6.9mmol/l [5.5–8.7]) and insulin levels were reduced.53 In 17 overweight postmenopausal women with dysglycaemia, interrupting prolonged sitting with 5 minutes of standing or light intensity walking had similar reductions (34% and 28% respectively) in postprandial glycaemia.54

Barriers and ways to engage patients

Motivators and barriers to physical activity

Table 1 summarises the spectrum of patient and healthcare professionals’ perceived barriers to engaging in physical activity and counselling. Barriers for patients vary according to age demographics,55 ethnicity and culture,56 socioeconomic group,57,58 experience of life events51 and current activity levels.59 Healthcare professionals’ own levels of physical activity are low; 48% of nursing and 38% of medical students do not meet the recommended guidelines.60 Those who are not physically active are less likely to promote physical activity61 and decisions on physical activity promotion tend to be linked to personal activity levels.57 Lack of time, incentive, knowledge, confidence, training and fear of increasing social inequality are reported barriers to counselling patients on increasing physical activity levels.57,62-65

Table 1 Patients’ and healthcare professionals’ barriers to physical activity

Motivators for active people include losing or maintaining weight, avoiding or managing a health condition, improving appearance or improving athletic performance and/or strength. There is a preference towards aerobic activity over resistance exercises.6 Across all types of intervention, sufficient evidence for a consistent and statistically significant maintenance of increased physical activity levels over a long-term period (12 months) was achieved in 2011.67

Brief intervention

‘Brief intervention’ is poorly defined in the literature.68 It is recommended that advice should be tailored to the individual’s circumstances, abilities, goals and health69 using a variety of techniques. There is moderate evidence from 15 studies of an increase in self-reported physical activity levels from those who received brief advice,69 though the evidence is inconclusive as to whether there is a difference in effect between <5 minutes and >5 minutes interventions. There are some studies that show an initial 3–5 minutes consultation with follow-up is enough to bring about a short-term change in physical activity levels.69 Number of contacts, length of contact or type of intervention show no significant difference.70,71 Training physicians in delivering physical activity advice results in increased confidence and increased numbers providing information to patients (from 20% to 74%).72 A practical model, ‘ask-assess-advise’, uses motivational interviewing (Figure 4).73

Figure 4 The Ask-Assess-Advise model (Haseler et al. 2019)73

Face-to-face or remote interventions

Good evidence from several systematic reviews and meta-analyses suggests both face-to-face and remote or web-based interventions have a positive impact on physical activity in targeted populations,74 although the effect is greater face-to-face.70 Communal physical activity, active goal-setting and self-tracking benefit from social interaction and may help sustain improvements in physical activity levels.75

Interventions targeting individuals are more effective than mass-media or targeting entire communities.70 Despite being less effective, remote and web-based interventions have the potential to have an impact at a population level because of the overall efficiency (cost and time).

Information given to patients

How the information is delivered seems to have a significant effect. When education/advice/intervention is delivered as behavioural advice70 (such as goal setting, contracting, self-monitoring, cues, rewards) or cognitive (decision making, health education, providing information), the behavioural advice is significantly more effective. A written exercise-prescription may be beneficial70 but moderate evidence suggests that providing written information does not change the impact of brief advice.69

Hospitalised patients

There are no consensus guidelines for physical activity in hospitalised patients. This is likely due to the heterogeneity of patients and a lack of robust evidence for interventions. Small sample sizes and a lack of standardisation of reporting measures hampers conclusions from current research into why patients spend the majority of their inpatient stay in bed.4

Healthcare professionals supervising 19 minutes of multimodal physical activity sessions daily throughout inpatient stays gave equivocal results.76,77 Additional physical rehabilitation has been shown to improve activity levels and physical function but not length of stay.78 Hospital stay in the previous 12 months is the biggest risk for functional decline in the elderly.51 Changes to ward layout and hospital design are needed to promote ‘recovery’ rather than simply ‘rest’.79 Collective, team-based responsibility to challenge unnecessary sedentary behaviour and encourage activity through campaigns such as ‘End PJ Paralysis’, part of the recently launched ‘Movement Movement’ may also have a role.80,81

Conclusion

Increasing physical activity has definite benefits across a wide range of conditions, non-communicable disease, mental health and inpatient care. Physical activity guidelines emphasise that moving more is safe and indicate optimal levels for health benefits. The important factors in engaging patients are clinician awareness of guidance and personal physical activity levels. Barriers for patients are influenced by life events, socioeconomic and cultural factors. Interventions that help include a brief intervention included in a consultation, face-to-face or web-based interventions or community-based activities. Evidence supports a variety of interventions that achieve immediate post-intervention and long-term increases in physical activity, but this does not yet translate to a population level. More research is needed to facilitate patient engagement in physical activity as an essential dimension of health.

Resources

Moving Medicine provides a range of evidence-based condition-specific information to help professionals advise patients on physical activity: http://movingmedicine.ac.uk/prescribing-movement/

References

1 World Health Organisation. Non-communicable diseases (NCD) country profiles 2014. 2014.

2 Office for National Statistics. Health state life expectancies by national deprivation deciles, England and Wales: 2015 to 2017. London: Office for National Statistics. 2019.

3 World Health Organisation. Global status report on non-communicable diseases 2010. 2011.

4 Orme MW, Harvey-Dunstan TC, Boral I et al. Changes in physical activity during hospital admission for chronic respiratory disease. Respirology 2019; 24: 652–7.

5 Bauman AE, Sallis JF, Dzewaltowski DA et al. Toward a better understanding of the influences on physical activity: the role of determinants, correlates, causal variables, mediators, moderators, and confounders. Am J Prev Med 2002; 23 (2 Suppl): 5–14.

6 UK Department for Health and Social Care. Physical activity guidelines: UK Chief Medical Officer’s report. 2019.

7 Ekelund U, Tarp J, Steene-Johannessen J et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all-cause mortality: systematic review and harmonised meta-analysis. BMJ 2019; 366: l4570.

8 U.S. Department of Health and Human Services, Committee PAGA. 2018 Physical activity guidelines advisory committee scientific report. 2018. https://health.gov/paguidelines/second-edition/report/pdf/PAG_Advisory_Committee_Report.pdf (accessed 05/11/2019).

9 Patterson R, McNamara E, Tainio M et al. Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type-2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol 2018; 33: 811–29.

10 Ross R, Goodpaster BH, Koch LG et al. Precision exercise medicine: understanding exercise response variability. Br J Sports Med 2019; 53: 1141–53.

11 Mok A, Khaw K-T, Luben R et al. Physical activity trajectories and mortality: population based cohort study. BMJ 2019; 365: l2323.

12 Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. Br J Sports Med 2015; 49: 1414–22.

13 Office for National Statistics. Avoidable mortality in the UK: 2017. London: Office for National Statistics. 2019.

14 Oruç Z, Kaplan MA. Effect of exercise on colorectal cancer prevention and treatment. World J Gastrointest Oncol 2019; 11: 348–66.

15 Stevinson C, Campbell A, Nick Cavill N et al. Physical Activity and Cancer. London: Macmillan Cancer Support; 2017.

16 Naci H, Salcher-Konrad M, Dias S et al. How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure. Br J Sports Med 2019; 53: 859–69.

17 Anderson L, Oldridge N, Thompson DR et al. Exercise-based cardiac rehabilitation for coronary heart disease cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016; 67: 1–12.

18 World Health Organization. Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000–2016. 2018.

19 Franklin B, Moy ML, Jackson EA et al. Advances in rehabilitation for chronic diseases: improving health outcomes and function. BMJ 2019; 365: l2191.

20 Diabetes UK. Us, diabetes and a lot of facts and stats. London: Diabetes UK; 2019.

21 Wallin A, Kettunen P, Johansson PM et al. Cognitive medicine – a new approach in health care science. BMC Psychiatry. 2018; 18: 42.

22 Public Health England. Trends in mortality In: Public Health England. Health profile for England: 2018. London: Public Health England; 2018.

23 Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. Am J Prev Med 2013; 45: 649–57.

24 Zhai L, Zhang Y, Zhang D. Sedentary behaviour and the risk of depression: a meta-analysis. Br J Sports Med 2015; 49: 705–9.

25 Lindheimer JB, O’Connor PJ, Dishman RK. Quantifying the placebo effect in psychological outcomes of exercise training: a meta-analysis of randomized trials. Sports Med 2015; 45: 693–711.

26 Walker MP. A societal sleep prescription. Neuron 2019; 103: 559–62.

27 Kredlow MA, Capozzoli MC, Hearon BA et al. The effects of physical activity on sleep: a meta-analytic review. J Behav Med 2015; 38: 427–49.

28 Office for National Statistics. Living Longer: Fitting it in – working, caring and health in later life. London: Office for National Statistics; 2018.

29 LaMonte MJ, Buchner DM, Rillamas-Sun E et al. Accelerometer-measured physical activity and mortality in women aged 63 to 99. J Am Geriatr Soc 2018; 66: 886–94.

30 Simmonds B, Fox K, Davis M, Ku PW et al. Objectively assessed physical activity and subsequent health service use of UK adults aged 70 and over: a four to five year follow up study. PLoS One 2014; 9: e97676.

31 Keevil VL, Luben R, Hayat S et al. Physical capability predicts mortality in late mid-life as well as in old age: findings from a large British cohort study. Arch Gerontol Geriatr 2018; 74: 77–82.

32 Cooper R, Kuh D, Hardy R et al. Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ 2010; 341: c4467.

33 Liu C-J, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database syst rev 2009(3): CD002759-CD.

34 Borjesson M, Dellborg M, Niebauer J et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2019; 40: 13–8.

35 Department of Health. CMO. Physical activity in pregnancy infographic: guidelines. 2017.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/831430/Withdrawn_Physical_activity_pregnancy_infographic_guidance.pdf (accessed 03/05/2019).

36 Hausenblas HA, Schreiber K, Smoliga JM. Addiction to exercise. BMJ 2017; 357: j1745.

37 Zhao M, Veeranki SP, Li S et al. Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 US adults. Br J Sports Med 2019; 53: 1405.

38 Silverman MN, Deuster PA. Biological mechanisms underlying the role of physical fitness in health and resilience. Interface Focus 4 (5): 20140040 doi: 10.1098/rsfs.2014.0040.

39 Archer AE, Von Schulze AT, Geiger PC. Exercise, heat shock proteins and insulin resistance. Philos Trans R Soc Lond B Biol Sci 2018; 373 (1738): 20160529.

40 Okamoto T, Morino K, Ugi S et al. Microbiome potentiates endurance exercise through intestinal acetate production. Am J Physiol Endocrinol Metab 2019; 316: E956-e66.

41 Yuan TF, Paes F, Arias-Carrion O et al. Neural mechanisms of exercise: anti-depression, neurogenesis, and serotonin signaling. CNS Neurol Disord Drug Targets 2015; 14: 1307–11.

42 Gagnon DD, Dorman S, Ritchie S et al. Multi-day prolonged low- to moderate-intensity endurance exercise mimics training improvements in metabolic and oxidative profiles without concurrent chromosomal changes in healthy adults. Front physiol 2019; 10: 1123.

43 Vepsäläinen T, Soinio M, Marniemi J et al. Physical activity, high-sensitivity C-reactive protein, and total and cardiovascular disease mortality in type 2 diabetes. Diabetes care 2011; 34: 1492–6.

44 Li M-y, Huang M-m, Li S-z et al. The effects of aerobic exercise on the structure and function of DMN-related brain regions: a systematic review. Int J Neurosci 2017; 127: 634–49.

45 Public Health England. Muscle and bone strengthening and balance activities for general health benefits in adults and older adults. Summary of a rapid evidence review for the UK Chief Medical Officers’ update of the physical activity guidelines. 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721874/MBSBA_evidence_review.pdf (accessed 21/10/2019).

46 Office of disease prevention and health promotion. 2018 Physical activity guidelines advisory committee scientific report. https://health.gov/paguidelines/second-edition/report/ (accessed: 11/10/2019).

47 Gregg MP, M. Caspersen, C. Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence. J Am Geriatr Soc 2015; 48: 883–93.

48 Silva NL, Oliveira RB, Fleck SJ et al. Influence of strength training variables on strength gains in adults over 55 years-old: a meta-analysis of dose-response relationships. J Sci Med Sport 2014; 17: 337–44.

49 Howe TE, Rochester L, Neil F et al. Exercise for improving balance in older people. Cochrane Database Syst Rev 2011(11): Cd004963.

50 Palmgren A, Ståhle A, Skavberg Roaldsen Ket al. “Stay balanced” – effectiveness of evidence-based balance training for older adults transferred into a physical therapy primary care setting – a pilot study. Disabil Rehabil 2019: 1–6.

51 Skelton D, Mavroeidi, A. How do muscle and bone strengthening and balance activities (MBSBA) vary across the life course, and are there particular ages where MBSBA are most important? J Frailty, Sarcopenia Falls 2018; 3: 74– 84.

52 Brower RG. Consequences of bed rest. Crit Care Med 2009; 37 (10 Suppl): S422–8.

53 Dunstan DW, Kingwell BA, Larsen R et al. Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care 2012; 35: 976–83.

54 Henson J, Davies MJ, Bodicoat DH et al. Breaking up prolonged sitting with standing or walking attenuates the postprandial metabolic response in postmenopausal women: a randomized acute study. Diabetes Care 2016; 39:1 30–8.

55 Justine M, Azizan A, Hassan V et al. Barriers to participation in physical activity and exercise among middle-aged and elderly individuals. Singapore Med J 2013; 54: 581–6.

56 Koshoedo SA, Paul-Ebhohimhen VA, Jepson RG et al. Understanding the complex interplay of barriers to physical activity amongst black and minority ethnic groups in the United Kingdom: a qualitative synthesis using meta-ethnography. BMC public health 2015; 15: 643.

57 Din NU, Moore GF, Murphy S et al. Health professionals’ perspectives on exercise referral and physical activity promotion in primary care: Findings from a process evaluation of the National Exercise Referral Scheme in Wales. Health Educ J 2015; 74: 743–57.

58 O’Brien SP, L. Heffron, M. Wright, P. Physical activity counselling in Ireland: a survey of doctors’ knowledge, attitudes and self-reported practice. BMJ Open Sport Exer Med 2019; 5: e000572.

59 Hoare E, Stavreski B, Jennings GL et al. Exploring motivation and barriers to physical activity among active and inactive Australian adults. Sports (Basel) 2017; 5: 47.

60 Blake H, Stanulewicz N, Mcgill F. Predictors of physical activity and barriers to exercise in nursing and medical students. J Adv Nurs 2017; 73: 917–29.

61 McKenna J, Naylor PJ, McDowell N. Barriers to physical activity promotion by general practitioners and practice nurses. Br J Sports Med 1998; 32: 242–7.

62 Dunlop M, Murray AD. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum. Br J Sports Med 2013; 47: 718.

63 Wheeler PC, Mitchell R, Ghaly M, Buxton K. Primary care knowledge and beliefs about physical activity and health: a survey of primary healthcare team members. BJGP open. 2017; 1(2): bjgpopen17X100809-bjgpopen17X.

64 Chatterjee R, Chapman T, Brannan MG et al. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. Br J Gen Pract 2017; 67: e668-e75.

65 Savill B, Murray A, Weiler R. Is general practice engaged with physical activity promotion? Br J Gen Pract 2015; 65: 484.

66 Guess N. A qualitative investigation of attitudes towards aerobic and resistance exercise amongst overweight and obese individuals. BMC Res Notes 2012; 5: 191.

67 Love R, Adams J, van Sluijs EMF et al. A cumulative meta-analysis of the effects of individual physical activity interventions targeting healthy adults. Obes Rev 2018; 19: 1164–72.

68 Lamming L, Pears S, Mason D et al. What do we know about brief interventions for physical activity that could be delivered in primary care consultations? A systematic review of reviews. Prev Med 2017; 99: 152–63.

69 NICE. Physical activity: brief advice for adults in primary care PH44. National Institute for Health and Care Excellence; 2013.

70 Conn VS, Hafdahl AR, Mehr DR. Interventions to Increase Physical Activity Among Healthy Adults: Meta-Analysis of Outcomes. Am J Public Health 2011; 101: 751–8.

71. Davies CA, Spence JC, Vandelanotte C et al. Meta-analysis of internet-delivered interventions to increase physical activity levels. Int J Behav Nutr Phys Act 2012; 9: 52.

72 Fowles JR, O’Brien MW, Solmundson K et al. Exercise is Medicine Canada physical activity counselling and exercise prescription training improves counselling, prescription, and referral practices among physicians across Canada. Appl Physiol Nutr Metab 2018; 43: 535–9.

73 Haseler C, Crooke R, Haseler T. Promoting physical activity to patients. BMJ 2019; 366: l5230.

74 Richards J, Hillsdon M, Thorogood M et al. Face-to-face interventions for promoting physical activity. Cochrane Database Syst Rev 2013; 9: CD010392.

75 Lidegaard LP, Schwennesen N, Willaing I et al. Barriers to and motivators for physical activity among people with Type 2 diabetes: patients’ perspectives. Diabet Med 2016; 33: 1677–85.

76 Said CM, Morris ME, McGinley JL et al. Additional structured physical activity does not improve walking in older people (>60years) undergoing inpatient rehabilitation: a randomised trial. J Physiother 2018; 64: 237–44.

77 Peiris CL, Taylor NF, Shields N. Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review. Arch Phys Med Rehabil 2011; 92: 1490–500.

78 Scrivener K, Jones T, Schurr K et al. After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review. J Physiother 2015; 61: 61–7.

79 Osadnik CR. Hospitalizations for patients with acute respiratory exacerbations: In pursuit of rest or recovery? Respirology 2019; 24: 618–9.

80 Fitzpatrick D, Doyle K, Finn G et al. Pyjama paralysis: time to make a move! Age and Ageing 2019; 48 (suppl 3): iii1–iii16.

81 Oliver D. David Oliver: Fighting pyjama paralysis in hospital wards. BMJ 2017; 357: j2096.

 

Financial and Competing Interests: 
No conflict of interests declared
PDF