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PEDro systematic review update This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (www.pedro.org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
Physical activity promotion in primary care has a sustained influence on activity levels of sedentary adults ▸ Orrow G, Kinmonth A, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389
BACKGROUND Despite the well-established benefits of physical activity (PA) a large proportion of people in developed countries still lead sedentary lifestyles.1 Community-based interventions can improve PA levels of sedentary individuals, but improvements are inconsistently sustained.2–4 Primary care may play an important role in facilitating sustained regular PA through direct intervention or via referral to other programmes as many people routinely access primary care.
AIM This systematic review aimed to determine whether the promotion of PA in primary care had a sustained effect on PA or fitness levels in sedentary adults; and whether referral interventions were more effective than other interventions.
SEARCHES AND INCLUSION CRITERIA Studies were identified through searches of seven electronic databases, reference lists of relevant articles and previous systematic reviews, and contact with an independent expert. Eligible studies were randomised controlled trials recruiting adult patients (16 years and above) through primary care for any PA promotion intervention with a goal to increase activity or fitness level (or both) in patients. The minimum follow-up was 12 months after randomisation. Studies of multifactorial interventions were excluded.
INTERVENTIONS Any primary care intervention that aimed to increase PA or fitness was eligible. Most intervention designs were based on theories of motivational interviewing or the transtheoretical
model of behaviour change. In the majority of studies, interventions included the provision of written materials, two to five face-to-face sessions of advice or counselling on PA and telephone support (up to 12 calls or automated messages). Interventions were provided by general practitioners, trained practice nurses, physiotherapists or trained facilitators from a range of health professions. Often assistance from an exercise or PA specialist was available. Exercise referral studies involved the referral of patients to group-based programmes. Control interventions included ‘no intervention’ or a ‘comparator intervention’ involving mailed information or advice (one to one or group based).
MAIN OUTCOME MEASURES Outcome measures were mostly self-report questionnaires of PA captured retrospectively. One study captured a prospectively recorded activity logbook. Studies using dichotomous outcome data measured whether the patient had achieved a specified target level of PA recommended in accepted guidelines, or whether the patient had increased on their baseline level of activity. Studies reporting continuous outcomes measured minutes of activity/week, energy expenditure or frequency of activity/week. Fitness outcomes were VO2 max or aerobic capacity.
STATISTICAL METHODS The primary analysis considered all types of PA promotion and involved three separate meta-analyses (dichotomous, continuous and fitness data). Two secondary meta-analyses focused on exercise referral interventions. Meta-analyses were conducted using random effects models. Intervention effects were calculated for each study for PA and/or fitness outcomes. ORs for dichotomous outcomes, and standardised mean differences (SMDs) with 95% CIs for continuous outcomes were calculated. Heterogeneity was assessed by calculating I2; values between 30% and 60% indicated moderate heterogeneity and larger values indicated high heterogeneity.
RESULTS Fifteen studies were included in the review, collectively enrolling 8745 participants aged between 17 and 92 years. Participants were from general primary care populations and selected based on sedentary behaviour, or for adverse vascular risk or cardiovascular disease. Studies with dichotomous outcomes indicated a small to moderate effect of the interventions on self-reported activity at 12 months with moderate heterogeneity (pooled OR 1.42; 95% CI 1.17 to 1.73; I2=43%, 13 studies; table 1). Studies with continuous outcomes indicated a small effect of PA promotion on self-reported activity with high heterogeneity (SMD 0.25, 95% CI 0.11 to 0.38; I2=70%, 11 studies). Effects
Table 1 Pooled intervention effects for PA and fitness outcomes Impact on self-reported PA Intervention
N
OR (95% CI)
PA promotion vs no intervention PA promotion vs comparator control Combined PA promotion Exercise referral
6 7 11 3
1.74 1.18 1.42 1.38
(1.39 (0.95 (1.17 (0.98
to to to to
2.18)* 1.48) 1.73) 1.95)
Heterogeneity (I2)
N
SMD (95% CI)
Heterogeneity (I2)
Low (21%) Low (9%) Moderate (43%) Low (0%)
6 7 9 2
0.36 0.03 0.25 0.20
Low (0%) Low (0%) High (70%) High (76%)
(0.28 to 0.43)** (−0.17 to 0.11) (0.11 to 0.38) (−0.21 to 0.61)
*p
PEDro systematic review update This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (www.pedro.org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
Physical activity promotion in primary care has a sustained influence on activity levels of sedentary adults ▸ Orrow G, Kinmonth A, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389
BACKGROUND Despite the well-established benefits of physical activity (PA) a large proportion of people in developed countries still lead sedentary lifestyles.1 Community-based interventions can improve PA levels of sedentary individuals, but improvements are inconsistently sustained.2–4 Primary care may play an important role in facilitating sustained regular PA through direct intervention or via referral to other programmes as many people routinely access primary care.
AIM This systematic review aimed to determine whether the promotion of PA in primary care had a sustained effect on PA or fitness levels in sedentary adults; and whether referral interventions were more effective than other interventions.
SEARCHES AND INCLUSION CRITERIA Studies were identified through searches of seven electronic databases, reference lists of relevant articles and previous systematic reviews, and contact with an independent expert. Eligible studies were randomised controlled trials recruiting adult patients (16 years and above) through primary care for any PA promotion intervention with a goal to increase activity or fitness level (or both) in patients. The minimum follow-up was 12 months after randomisation. Studies of multifactorial interventions were excluded.
INTERVENTIONS Any primary care intervention that aimed to increase PA or fitness was eligible. Most intervention designs were based on theories of motivational interviewing or the transtheoretical
model of behaviour change. In the majority of studies, interventions included the provision of written materials, two to five face-to-face sessions of advice or counselling on PA and telephone support (up to 12 calls or automated messages). Interventions were provided by general practitioners, trained practice nurses, physiotherapists or trained facilitators from a range of health professions. Often assistance from an exercise or PA specialist was available. Exercise referral studies involved the referral of patients to group-based programmes. Control interventions included ‘no intervention’ or a ‘comparator intervention’ involving mailed information or advice (one to one or group based).
MAIN OUTCOME MEASURES Outcome measures were mostly self-report questionnaires of PA captured retrospectively. One study captured a prospectively recorded activity logbook. Studies using dichotomous outcome data measured whether the patient had achieved a specified target level of PA recommended in accepted guidelines, or whether the patient had increased on their baseline level of activity. Studies reporting continuous outcomes measured minutes of activity/week, energy expenditure or frequency of activity/week. Fitness outcomes were VO2 max or aerobic capacity.
STATISTICAL METHODS The primary analysis considered all types of PA promotion and involved three separate meta-analyses (dichotomous, continuous and fitness data). Two secondary meta-analyses focused on exercise referral interventions. Meta-analyses were conducted using random effects models. Intervention effects were calculated for each study for PA and/or fitness outcomes. ORs for dichotomous outcomes, and standardised mean differences (SMDs) with 95% CIs for continuous outcomes were calculated. Heterogeneity was assessed by calculating I2; values between 30% and 60% indicated moderate heterogeneity and larger values indicated high heterogeneity.
RESULTS Fifteen studies were included in the review, collectively enrolling 8745 participants aged between 17 and 92 years. Participants were from general primary care populations and selected based on sedentary behaviour, or for adverse vascular risk or cardiovascular disease. Studies with dichotomous outcomes indicated a small to moderate effect of the interventions on self-reported activity at 12 months with moderate heterogeneity (pooled OR 1.42; 95% CI 1.17 to 1.73; I2=43%, 13 studies; table 1). Studies with continuous outcomes indicated a small effect of PA promotion on self-reported activity with high heterogeneity (SMD 0.25, 95% CI 0.11 to 0.38; I2=70%, 11 studies). Effects
Table 1 Pooled intervention effects for PA and fitness outcomes Impact on self-reported PA Intervention
N
OR (95% CI)
PA promotion vs no intervention PA promotion vs comparator control Combined PA promotion Exercise referral
6 7 11 3
1.74 1.18 1.42 1.38
(1.39 (0.95 (1.17 (0.98
to to to to
2.18)* 1.48) 1.73) 1.95)
Heterogeneity (I2)
N
SMD (95% CI)
Heterogeneity (I2)
Low (21%) Low (9%) Moderate (43%) Low (0%)
6 7 9 2
0.36 0.03 0.25 0.20
Low (0%) Low (0%) High (70%) High (76%)
(0.28 to 0.43)** (−0.17 to 0.11) (0.11 to 0.38) (−0.21 to 0.61)
*p
