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Physical inactivity is recognised as a major public health problem. In Sweden about 1/3 of the adult population reports being insufficiently active. A central task in public health work is to support the individual, without blaming, in making healthy choices. Initiatives in healthcare, such as counselling on physical activity, have been shown to be both cost-effective and effective for disease prevention and treatment. The use of a physical activity vital sign and brief advice from physicians can make a big difference. In this paper we present how the healthcare system as one of eight evidence-based investments can promote physical activity. The eight investment areas are: whole-of-school programs, active transport, active urban design, health care, public education, sports and recreation, workplaces and community-wide programs. Evidence suggests that the largest population health benefit will be achieved by combining these investments and implementing a systems-based approach.

Recommendations on physical activity and sedentary behaviour for improved health have been prepared by Professional Associations for Physical Activity (YFA) and approved by the Swedish Society of Medicine. All adults should do aerobic physical activity 150-300 minutes at moderate or 75-150 minutes at high intensity, or combined, at a weekly basis. For additional health benefits, muscle-strengthening activity should be performed on at least 2 days a week, and sedentary time should be limited and replaced by physical activity. Older adults should, as part of their weekly physical activity, do multicomponent physical activity that emphasizes balance and strength on at least 2-3 days a week to enhance functional capacity and prevent falls. The benefits of physical activity outweigh the risks. The Swedish National Board of Health and Welfare recommends that healthcare providers offer counselling with exercise on prescription to individuals with physical activity under the recommended dose.

Background For people with prediabetes and type 2 diabetes it is important to be regularly physical active. Increasing and maintaining physical activity (PA) can be challenging. The aim of this study was to evaluate the effects of a pedometer-based intervention on PA, with a compositional data analysis (CoDA) approach, in individuals with prediabetes or type 2 diabetes. Methods Longitudinal data on 188 participants with prediabetes and type 2 diabetes (40% female, mean age = 64.1 years) from a three-armed randomized controlled trail, the Sophia Step Study, was used. The three groups were a multi?component group (self?monitoring of steps with a pedometer, together with group (12 occasions) and individual counselling (10 occasions)), a single?component group (self?monitoring of steps with a pedometer, without counselling) and a standard care group. PA (moderate-to-vigorous PA (MVPA), light-intensity PA (LIPA) and sedentary behaviour (SB)) during the awake time were measured with ActiGraph GT1M accelerometer at baseline, 6, 12, 18 and 24 months. Relative time in MVPA, LIPA and SB for each participant at each measurement point was calculated by using the CoDA approach. Linear mixed models were used to evaluate the intervention effect between the three groups on the relative time in MVPA, LIPA and SB over the two-year period. Results In total, 41% had ≤30 min MVPA at baseline. Significant group by time interactions were found for the multi-component group and the standard care group for the relative time in MVPA, at 6, 18 and 24 months. Differences in predicted group means between the groups were 1.2% at 6 months, 1.3% at 18 months and 0.9% at 24 months. Significant group by time interactions were also found for the single-component group and the standard care group for the relative time in MVPA at 24 months, with a difference in predicted group means of 0.8%. No significant interactions for LIPA or SB were found. Conclusions The multi-component group and the single-component component group maintained their relative time in MVPA, while the standard care group decreased their relative time in MVPA over the two-year period. This indicate that the Sophia Step Study intervention can prevent a decrease in MVPA in people with prediabetes and type 2 diabetes.

BackgroundThe joint associations of total and intensity-specific physical activity with obesity in relation to all-cause mortality risk are unclear.MethodsWe included 34 492 adults (72% women, median age 62.1 years, 2034 deaths during follow-up) in a harmonised meta-analysis of eight population-based prospective cohort studies with mean follow-up ranging from 6.0 to 14.5 years. Standard body mass index categories were cross-classified with sample tertiles of device-measured total, light-to-vigorous and moderate-to-vigorous physical activity and sedentary time. In five cohorts with waist circumference available, high and low waist circumference was combined with tertiles of moderate-to-vigorous physical activity.ResultsThere was an inverse dose–response relationship between higher levels of total and intensity-specific physical activity and mortality risk in those who were normal weight and overweight. In individuals with obesity, the inverse dose–response relationship was only observed for total physical activity. Similarly, lower levels of sedentary time were associated with lower mortality risk in normal weight and overweight individuals but there was no association between sedentary time and risk of mortality in those who were obese. Compared with the obese-low total physical activity reference, the HRs were 0.59 (95% CI 0.44 to 0.79) for normal weight-high total activity and 0.67 (95% CI 0.48 to 0.94) for obese-high total activity. In contrast, normal weight-low total physical activity was associated with a higher risk of mortality compared with the obese-low total physical activity reference (1.28; 95% CI 0.99 to 1.67).ConclusionsHigher levels of physical activity were associated with lower risk of mortality irrespective of weight status. Compared with obesity-low physical activity, there was no survival benefit of being normal weight if physical activity levels were low.

ObjectiveTo examine the joint associations of daily time spent in different intensities of physical activity, sedentary behaviour and sleep with all-cause mortality.MethodsFederated pooled analysis of six prospective cohorts with device-measured time spent in different intensities of physical activity, sedentary behaviour and sleep following a standardised compositional Cox regression analysis.Participants130 239 people from general population samples of adults (average age 54 years) from the UK, USA and Sweden.Main outcomeAll-cause mortality (follow-up 4.3–14.5 years).ResultsStudies using wrist and hip accelerometer provided statistically different results (I2=92.2%, Q-test pConclusionThis federated analysis shows a joint dose–response association between the daily balance of time spent in physical activity of different intensities and sedentary behaviour with all-cause mortality, while sleep duration does not appear to be significant. The strongest association is with time spent in moderate to vigorous physical activity, but it is modified by the balance of time spent in light physical activity relative to sedentary behaviour.

BACKGROUND The trend of an exponential increase in pre- and type 2 diabetes (T2D) is projected to continue rising worldwide. Physical activity could help prevent type 2 diabetes and the progression and complications of the disease. Therefore, we need to create opportunities for individuals to acquire the necessary knowledge and skills to self-management their chronic condition through physical activity. Electronic health (e-health) is a potential resource that could facilitate self-management and thus improve population health. However, there is limited research on users’ perception of e-health in supporting self-management of physical activity in primary care settings. OBJECTIVE The study aims to explore the perspectives of health care professionals and individuals with pre- or type 2 diabetes on e-health as a support system for self-management of physical activity. METHODS A qualitative approach was applied using focus group discussions in individuals with pre- or type 2 diabetes (14 participants in four groups) and health care professionals (10 participants in two groups). The discussions were audio-recorded and transcribed verbatim. Qualitative content analysis was used inductively to code the data. RESULTS Three main categories emerged: utility, adoption process and accountability. The utility of e-health was described as a motivational, entertaining, and stimulating tool. Registration of daily medical measurements and lifestyle parameters in a cohesive digital platform was recognized as a potential resource for strengthening self-management skills. The adoption process includes e-health to increase accessibility of care and personalize the support for self-management of physical activity. However, participants stated that digital technology might not suit everyone and could increase health care providers' administrative burden. Accountability requires the necessary knowledge and skills to optimize e-health and ensure data integrity and security. CONCLUSIONS Applying e-health technology to improve self-management of physical activity in primary care settings seems feasible. People with pre- and type 2 diabetes and health care professionals proposed that a cohesive platform for personal metrics, goal setting and social support could improve self-management of physical activity. A supportive environment including technical expertise and continuous education is needed to upgrade the skills and to adopt e-health in daily clinical practice.

Background: Sedentary behavior (SB) is associated with several chronic diseases and office workers especially are at increased risk. SB is defined by a sitting or reclined body posture with an energy expenditure of ≤1.5 metabolic equivalents. However, current objective methods to measure SB are not consistent with its definition. There is no consensus on which sensor placement and type should be used. Aim: To compare the accuracy of newly developed artificial intelligence models for 15 sensor placements in combination with four signal types (accelerometer only/plus gyroscope and/or magnetometer) to detect posture and physical in-/activity during desk-based activities. Method: Signal features for the model development were extracted from sensor raw data of 30 office workers performing 10 desk-based tasks, each lasting 5 min. Direct observation (posture) and indirect calorimetry (in-/activity) served as the reference criteria. The best classification model for each sensor was identified and compared among the sensor placements, both using Friedman and post hoc Wilcoxon tests (p ≤ .05). Results: Posture was most accurately measured with a lower body sensor, while in-/activity was most accurately measured with an upper body or waist sensor. The inclusion of additional signal types improved the posture classification for some placements, while the acceleration signal already contained the relevant signal information for the in-/activity classification. Overall, the thigh accelerometer most accurately classified desk-based SB. Conclusion: This study favors, in line with previous work, the measurement of SB with a thigh-worn accelerometer and adds the information that this sensor is also accurate in measuring physical in-/activity while sitting and standing.

Funder: National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands, Funder: National Institute on Aging, Funder: Stockholms Läns Landsting; FundRef: http://dx.doi.org/10.13039/501100004348, Funder: Norwegian Directorate for Public Health, Funder: Centrum for Idrottsforskning; FundRef: http://dx.doi.org/10.13039/501100005350, Funder: The Coca-Cola Company, Objectives: To examine the joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality. Methods: We conducted a harmonised meta-analysis including nine prospective cohort studies from four countries. 44 370 men and women were followed for 4.0 to 14.5 years during which 3451 participants died (7.8% mortality rate). Associations between different combinations of moderate-to-vigorous intensity physical activity (MVPA) and sedentary time were analysed at study level using Cox proportional hazards regression analysis and summarised using random effects meta-analysis. Results: Across cohorts, the average time spent sedentary ranged from 8.5 hours/day to 10.5 hours/day and 8 min/day to 35 min/day for MVPA. Compared with the referent group (highest physical activity/lowest sedentary time), the risk of death increased with lower levels of MVPA and greater amounts of sedentary time. Among those in the highest third of MVPA, the risk of death was not statistically different from the referent for those in the middle (16%; 95% CI 0.87% to 1.54%) and highest (40%; 95% CI 0.87% to 2.26%) thirds of sedentary time. Those in the lowest third of MVPA had a greater risk of death in all combinations with sedentary time; 65% (95% CI 1.25% to 2.19%), 65% (95% CI 1.24% to 2.21%) and 263% (95% CI 1.93% to 3.57%), respectively. Conclusion: Higher sedentary time is associated with higher mortality in less active individuals when measured by accelerometry. About 30–40 min of MVPA per day attenuate the association between sedentary time and risk of death, which is lower than previous estimates from self-reported data.

Background. Recent studies indicate that exercise can induce neuroplastic changes in people with Parkinson’s disease (PwPD). Reports of feasibility outcomes from existing pilot trials however are, of date, insufficient to enable replication by others in larger definitive trials. Objective. To evaluate trial design for a definitive trial by exploring process and scientific feasibility. Methods. The trial design was a parallel-group RCT pilot with a 1 : 1 allocation ratio to either HiBalance or an active control group (HiCommunication). Both groups received one-hour sessions twice weekly, plus home exercises weekly, for 10 weeks. Participants with mild-to-moderate Parkinson’s disease (PD) were recruited via advertisement. Assessment included physical performance, structural and functional MRI, blood sampling, neuropsychological assessment, and speech/voice assessment. Process and scientific feasibility were monitored throughout the study. Process feasibility involved recruitment, participant acceptability of assessments and interventions, assessment procedures (focus on imaging, blood sampling, and dual-task gait analysis), and blinding procedures. Scientific feasibility involved trends in outcome response and safety during group training and home exercises. Data are presented in median, minimum, and maximum values. Changes from pre- to postintervention are reported descriptively. Results. Thirteen participants were included (4 women, mean age 69.7 years), with a recruitment rate of 31%. Attendance rates and follow-up questionnaires indicated that both groups were acceptable to participate. Image quality was acceptable; however, diplopia and/or sleepiness were observed in several participants during MRI. With regard to dual-task gait performance, there appeared to be a ceiling effect of the cognitive tasks with seven participants scoring all correct answers at pretest. Blinding of group allocation was successful for one assessor but was broken for half of participants for the other. Conclusions. The overall trial design proved feasible to perform, but further strengthening ahead of the definitive RCT is recommended, specifically with respect to MRI setup, cognitive dual-tasks during gait, and blinding procedures. This trial is registered with NCT03213873.

Most patients treated in a hospital setting are fully or partially immobilised. The Activity Board (Träningstavlan® Phystec) is a useful tool to enhance mobilisation after major abdominal cancer surgery. Knowledge of patient experiences of the mobilisation tool is crucial in implementing the Activity Board in health care. This study aimed to describe patient experiences of using the Activity Board after surgery for abdominal cancer. Semi-structured face-to-face interviews were conducted in 15 patients who underwent abdominal surgery due to colorectal, ovarian or urinary bladder cancer. All 15 patients (mean age 67.7 years, range 40–86) used the Activity Board postoperatively. The interviews were transcribed verbatim and analysed according to inductive content analysis. The overarching theme that emerged from the interviews was that “enabling participation facilitates empowerment over rehabilitation”. Three categories supported the theme: prerequisites for using the Activity Board, the value of using supportive behavioural techniques, and the possibility to influence the patients’ care. These findings suggest that the Activity Board could be a viable tool that activates the person-centred postoperative rehabilitation process by cooperating with the medical team at the hospital ward.Implications for rehabilitationPatients who are in hospital due to cancer surgery are often immobilised, which increases the risk of complications.The Activity Board can stimulate the patients to participate in the rehabilitation process in a more active way.The Activity Board can be used to improve and clarify the person-centred approach in hospital settings. Patients who are in hospital due to cancer surgery are often immobilised, which increases the risk of complications. The Activity Board can stimulate the patients to participate in the rehabilitation process in a more active way. The Activity Board can be used to improve and clarify the person-centred approach in hospital settings.

IntroductionLiving with chronic pain often involves negative consequences. Interdisciplinary Pain Rehabilitation Programmes (IPRP) is considered superior to single-treatment measures in patients with chronic pain. Despite this, effects emerge suboptimal and more than 20% of patients deteriorate in patient-reported physical health outcomes after IPRP. A novel e-Health intervention, eVISualisation (eVIS) of physical activity and pain, was systematically developed to facilitate individualisation of physical activity levels. By adding elements of data collection, visualisation and communication of objectively measured physical activity and patient-reported outcomes (pain intensity, interference of pain, pharmaceutical consumption) to existing treatment modalities in IPRP, the IPRP team acquires prerequisites to adapt advice and physical activity prescriptions and to evaluate set activity goals. The overall aim is twofold. First, the aim is to evaluate the feasibility of the subsequent registry-based randomised controlled clinical trial (R-RCT). Second, the aim is to prospectively evaluate the effectiveness of the eVIS-intervention as a supplement to IPRP on our defined primary (physical health) and secondary outcomes.Methods and analysisIn the R-RCT, recruitment of 400 patients with chronic pain will be performed at 15 IPRP units. A random allocation to either IPRP + eVIS or to control group that will receive IPRP only will be performed. Data from the initial 30 participants completing the study period (6 months) will be included in a pilot study, where key feasibility outcomes (recruitment, randomisation, implementation, treatment integrity, data collection procedure, preliminary outcome measures) will be evaluated. Outcome variables will be extracted from the web application Pain And TRaining ON-line (PATRON) and from six national registries. Multivariate statistics and repeated measure analyses will be performed. Quality-adjusted life years and incremental cost-effectiveness ratio will be calculated for cost-effectiveness evaluation.Ethics/disseminationThe Swedish Ethics Review Board granted approval (Dnr 2021/02109). Results will be disseminated through peer-reviewed journals.Trial registration numberNCT05009459. Protocol V.1.

BACKGROUND Physical activity and a diet that follows general recommendations can help to prevent noncommunicable diseases. However, most adults do not meet current recommended guidelines, and support for behavior change needs to be strengthened. There is growing evidence that shows the benefits of eHealth and mobile health (mHealth) services in promoting healthy habits; however, their long-term effectiveness is uncertain because of nonadherence. OBJECTIVE We aimed to explore users’ perceptions of acceptability, engagement, and usability of eHealth and mHealth services that promote physical activity, healthy diets, or both in the primary or secondary prevention of noncommunicable diseases. METHODS We conducted a systematic review with a narrative synthesis. We performed the literature search in PubMed, PsycINFO, and CINAHL electronic databases in February 2021 and July 2021. The search was limited to papers published in English between 2016 and 2021. Papers on qualitative and mixed method studies that encompassed eHealth and mHealth services for adults with a focus on physical activity, healthy diet, or both in the primary or secondary prevention of noncommunicable diseases were included. Three authors screened the studies independently, and 2 of the authors separately performed thematic analysis of qualitative data. RESULTS With an initial finding of 6308 articles and the removal of 427 duplicates, 23 articles were deemed eligible for inclusion in the review. Based on users’ preferences, an overarching theme—eHealth and mHealth services provide value but need to be tailored to individual needs—and 5 subthemes—interactive and integrated; varying and multifunctional; easy, pedagogic, and attractive; individualized and customizable; and reliable—emerged. CONCLUSIONS New evidence on the optimization of digital services that promote physical activity and healthy diets has been synthesized. The findings represent users’ perceptions of acceptability, engagement, and usability of eHealth and mHealth services and show that services should be personalized, dynamic, easily manageable, and reliable. These findings can help improve adherence to digital health-promoting services.

BACKGROUND: People with Parkinson disease (PD) are known to be at risk of physical inactivity and may therefore be especially vulnerable to negative health outcomes during the COVID-19 pandemic due to social distancing recommendations. PURPOSE: To investigate sensor-derived physical activity and perceived health of people with PD during the first wave of the COVID-19 pandemic, as well as the factors associated with these outcomes. METHODS: Physical activity was measured over 7 days using the Actigraph GT3x accelerometer. Data were collected regarding perceived health status and physical activity habits, as well as rehabilitation attendance during the pandemic. Multiple linear and logistic regression analyses were used to identify factors associated with physical activity and perceived changes in health. RESULTS: Of 89 participants, a majority (67%) reported a pandemic-related reduction in exercise habits. Women more commonly reported a reduction in scheduled exercise and cancelled rehabilitation than men. Study participants took on average 5876 ± 3180 steps per day. In the multivariate analysis, female gender, being 70 years of age and older, and greater reported mobility problems were associated with being less physically active. A pandemic-induced deterioration in health was reported by 42% and women were 5 times more likely than men to do so (odds ratio: 5.12, 95% confidence interval, 1.87-15.03; P = 0.002). DISCUSSION AND CONCLUSIONS: Despite a pandemic-related reduction in reported exercise habits and rehabilitation, the participants in this Swedish sample were relatively physically active. However, women were less active at moderate-vigorous levels and were at greater risk of deterioration in perceived health during this time.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A359).

The association between the composition of movement behaviors and mortality risk, acknowledging the composition nature of daily time data, is limited explored. The aim was to investigate how the composition of time spent in sedentary behaviors (SB), light intensity physical activity (LIPA), and moderate-to-vigorous physical activity (MVPA) is associated with all-cause mortality, in a cohort with 15 years follow-up time, using compositional data analysis. Eight hundred fifty-one participants (56% women, mean age 53 years) provided objectively assessed physical activity data using an ActiGraph accelerometer and were followed for 15 years. Association of daily time composition of movement behaviors with risk of mortality was explored using compositional data analysis and hazard ratios (HR) of mortality were estimated based on a cox regression model. A significant (P < .001) positive association between time spent in SB relative to time in other behaviors and a significant (P = .018) negative association between time spent in LIPA relative to time in other behaviors, with all-cause mortality, were found. Substituting time spent in LIPA or MVPA with time in SB increased the hazard for all-cause mortality, with greater effect found for MVPA (20 minutes replacement; HR 1.26, 95% CI 1.04-1.52) than for LIPA (20 minutes replacement; HR 1.06, 95% CI 0.65-1.73). In a public health perspective, it is recommended to substitute SB with either LIPA or MVPA, but for individuals with little time spent in MVPA, the most important message may be to try to maintain that behavior.

Background and purpose Accelerometer threshold values to detect physical activity intensity in the oldest old persons with coronary artery disease (CAD) are lacking as well as knowledge about their free-living physical activity behavior. The purpose of this study was 2-fold. (1) To assess the sensitivity and specificity of 3 existing intensity threshold values for ActiGraph accelerometers for the oldest old persons with CAD. (2) To assess free-living physical activity, applying the threshold values with the highest sensitivity and specificity for assessing at least moderate intensity, among these persons. Methods In a cross-sectional design, a total of 24 persons with CAD, mean age 87.5 (3.7) years, participated in the study at a university hospital in Sweden. To assess the sensitivity and specificity of the existing threshold values, the participants walked at different speeds wearing the accelerometer at a pace corresponding to individualized perceived exertion at light, moderate, and high intensity according to the Borg Rating of Perceived Exertion Scale. For the free-living physical activity assessment, the persons wore the accelerometer for 7 consecutive days. The percentage agreement for light-, moderate-, and high-intensity threshold values, as well as receiver operating characteristic curves, was used to identify the sensitivity and specificity of the existing threshold values for moderate intensity. Results and discussion The threshold values for at least moderate intensity at 1041 counts per minute according to Copeland had the highest sensitivity (0.739) and specificity (0.609) to identify at least moderate intensity for the ActiGraph GT3X+ accelerometer. In a free-living setting, the oldest old persons with CAD spent 11 of 13.5 (81%) waking hours in a sedentary position and, of the 2.5 hours of being active, 19 minutes (2%) were at least at moderate intensity. Nine of 24 persons (38%) reached 20 minutes of moderate- to vigorous-intensity physical activity 3 days a week, according to guidelines for exercise-based cardiac rehabilitation. Conclusions The existing threshold values according to Copeland had the highest sensitivity and specificity to identify at least moderate intensity and are valid for use in the oldest old persons with CAD. Using accelerometry as an objective measurement for physical activity can help further improve our understanding of free-living physical activity behavior and to assess relationships between free-living physical activity and health outcomes among the oldest old persons with CAD.

Although increasing evidence supports the benefit- of exercise among people with Parkinson disease (PwPD), it is unclear whether a given exercise modality suits all PwPD, given the heterogeneity of the disease. The purpose of this study was to explore factors associated with responsiveness to a highly challenging training intervention that incorporated dual-task exercises.Forty-seven PwPD (mean age: 73 years; 19 females, Hoehn and Yahr stages 2-3) who had participated in 10 weeks of highly challenging gait and balance training were included. Baseline demographics, disease-related factors, physical and cognitive ability, and perceived health were used for the prediction of percent change in balance performance (the Mini-BESTest) and comfortable gait speed between the pre- and postassessments, using multiple linear regression analyses.Thirty-five percent of the variance of change in balance performance was explained by General Health Perceptions (β = -0.36), the Timed Up and Go test (β = -0.33), and the single-task performance of a cognitive task (β = -0.24). Forty-nine percent of change in gait speed was explained by gait speed while performing a dual task (β = -0.46), dual-task interference while walking (β = 0.43), time to complete the Timed Up and Go test (β = -0.29), and percent error on a cognitive task (β = -0.25).The results may suggest that the PwPD with overall lower perceived health, functional mobility, and cognitive functions are the ones most likely to benefit from highly challenging and attention-demanding gait and balance training.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A240).

Background Describing implementation features of an intervention is required to compare interventions and to inform policy and best practice. The aim of this study was to conduct a process evaluation of the first 12 months of the Sophia Step Study: a primary care based RCT evaluating a multicomponent (self-monitoring of daily steps plus counseling) and a single component (self-monitoring of steps only) physical activity intervention to standard care on cardiometabolic health. Methods The evaluation was guided by the Medical Research Council Guidance for complex interventions. To describe the implementation communication with the health professionals implementing the interventions, attendance records and tracking of days with self-monitored pedometer-determined steps were used. Change in physical activity behaviour was measured at baseline, 6 and 12 months as daily steps by accelerometry. Results During April 2013 to January 2018 188 participants were randomized and intervened directly after inclusion. Response rate was 49% and drop out was 10%. A majority, 78%, had type 2 diabetes and 22% were diagnosed with prediabetes. Mean [Standard deviation (SD)] body mass index was 30.4 (4.4) kg/m2 and steps per day was 6566 (3086). The interventions were delivered as intended with minor deviation from the protocol and dose received was satisfying for both the multicomponent and single component group. The mean [95% Confidence Interval (CI)] change in daily steps from baseline to 6 months was 941(227, 1655) steps/day for the multicomponent intervention group, 990 (145, 1836) step/day for the single component group and − 506 (− 1118, 107) for the control group. The mean (95% CI) change in daily steps from baseline to 12 months was 31(− 507, 570) steps/day for the multicomponent intervention group, 144 (− 566, 853) step/day for the single component group and − 890 (− 1485, − 294) for the control group. There was a large individual variation in daily steps at baseline as well as in step change in all three groups. Conclusions Applying self-monitoring of steps is a feasible method to implement as support for physical activity in the primary care setting both with and without counseling support. Trial registration ClinicalTrials.gov, NCT02374788. Registered 2 March 2015.

Background This aimed to evaluate the effects of self-monitoring of daily steps with or without counselling support on HbA1c, other cardiometabolic risk factors and objectively measured physical activity (PA) during a 2-year intervention in a population with prediabetes or type 2 diabetes. Methods The Sophia Step Study was a three-armed parallel randomised controlled trial. Participants with prediabetes or type 2 diabetes were recruited in a primary care setting. Allocation (1:1:1) was made to a multi-component intervention (self-monitoring of steps with counselling support), a single-component intervention (self-monitoring of steps without counselling support) or standard care. Data were collected for primary outcome HbA1c at baseline and month 6, 12, 18 and 24. Physical activity was assessed as an intermediate outcome by accelerometer (ActiGraph GT1M) for 1 week at baseline and the 6-, 12-, 18- and 24-month follow-up visits. The intervention effects were evaluated by a robust linear mixed model. Results In total, 188 subjects (64, 59, 65 in each group) were included. The mean (SD) age was 64 (7.7) years, BMI was 30.0 (4.4) kg/m2 and HbA1c was 50 (11) mmol/mol, 21% had prediabetes and 40% were female. The dropout rate was 11% at 24 months. Effect size (CI) for the primary outcome (HbA1c) ranged from -1.3 (-4.8 to 2.2) to 1.1 (-2.4 to 4.6) mmol/mol for the multi-component vs control group and from 0.3 (-3.3 to 3.9) to 3.1 (-0.5 to 6.7) mmol/mol for the single-component vs control group. Effect size (CI) for moderate-to-vigorous physical activity ranged from 8.0 (0.4 to 15.7) to 11.1 (3.3 to 19.0) min/day for the multi-component vs control group and from 7.6 (-0.4 to 15.6) to 9.4 (1.4 to 17.4) min/day for the single-component group vs control group. Conclusion This 2-year intervention, including self-monitoring of steps with or without counselling, prevented a decrease in PA but did not provide evidence for improved metabolic control and cardiometabolic risk factors in a population with prediabetes or type 2 diabetes. Trial registration ClinicalTrials.gov, NCT02374788. Registered 2 March 2015—Retrospectively registered.

Background Identifying physical activity (PA) profiles of people with Parkinson’s Disease (PD) could provide clinically meaningful knowledge concerning how to tailor PA interventions. Our objectives were therefore to i) identify distinct PA profiles in people with PD based on accelerometer data, ii) explore differences between the profiles regarding personal characteristics and physical function. Methods Accelerometer data from 301 participants (43% women, mean age: 71 years) was analysed using latent profile analyses of 15 derived PA variables. Physical function measurements included balance performance, comfortable gait speed and single and dual-task functional mobility. Results Three distinct profiles were identified; “Sedentary” (N = 68), “Light Movers” (N = 115), “Steady Movers” (N = 118). “Sedentary” included people with PD with high absolute and relative time spent in Sedentary behaviour (SB), little time light intensity physical activity (LIPA) and negligible moderate-to-vigorous physical activity (MVPA). “Light Movers” were people with PD with values close to the mean for all activity variables. “Steady Movers” spent less time in SB during midday, and more time in LIPA and MVPA throughout the day, compared to the other profiles. “Sedentary” people had poorer balance (P = 0.006), poorer functional mobility (P = 0.027) and were more likely to have fallen previously (P = 0.027), compared to “Light Movers. The Timed Up and Go test, an easily performed clinical test of functional mobility, was the only test that could distinguish between all three profiles. Conclusion Distinct PA profiles, with clear differences in how the time awake is spent exist among people with mild-moderate PD.

BACKGROUND Physical activity is evidently a crucial part of the rehabilitation process for patients with chronic pain. Modern wrist-worn activity tracking devices seemingly have a great potential to provide objective feedback and assist in the adoption of healthy physical activity behavior by supplying data of energy expenditure expressed as metabolic equivalent of task units (MET). However, no studies of any wrist-worn activity tracking devices’ have examined criterion validity in estimating energy expenditure, heart rate, or step count in patients with chronic pain. OBJECTIVE The aim was to determine the criterion validity of wrist-worn activity tracking devices for estimations of energy expenditure, heart rate, and step count in a controlled laboratory setting and free-living settings for patients with chronic pain. METHODS In this combined laboratory and field validation study, energy expenditure, heart rate, and step count were simultaneously estimated by a wrist-worn activity tracker (Fitbit Versa), indirect calorimetry (Jaeger Oxycon Pro), and a research-grade hip-worn accelerometer (ActiGraph GT3X) during treadmill walking at 3 speeds (3.0 km/h, 4.5 km/h, and 6.0 km/h) in the laboratory setting. Energy expenditure and step count were also estimated by the wrist-worn activity tracker in free-living settings for 72 hours. The criterion validity of each measure was determined using intraclass and Spearman correlation, Bland-Altman plots, and mean absolute percentage error. An analysis of variance was used to determine whether there were any significant systematic differences between estimations. RESULTS A total of 42 patients (age: 25-66 years; male: 10/42, 24%; female: 32/42, 76%), living with chronic pain (duration, in years: mean 9, SD 6.72) were included. At baseline, their mean pain intensity was 3.5 (SD 1.1) out of 6 (Multidimensional Pain Inventory, Swedish version). Results showed that the wrist-worn activity tracking device (Fitbit Versa) systematically overestimated energy expenditure when compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X). Poor agreement and poor correlation were shown between Fitbit Versa and both Jaeger Oxycon Pro and ActiGraph GT3X for estimated energy expenditure at all treadmill speeds. Estimations of heart rate demonstrated poor to fair agreement during laboratory-based treadmill walks. For step count, the wrist-worn devices showed fair agreement and fair correlation at most treadmill speeds. In free-living settings; however, the agreement for step count between the wrist-worn device and waist-worn accelerometer was good, and the correlation was excellent. CONCLUSIONS The wrist-worn device systematically overestimated energy expenditure and showed poor agreement and correlation compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X), which needs to be considered when used clinically. Step count measured with a wrist-worn device, however, seemed to be a valid estimation, suggesting that future guidelines could include such variables in this group with chronic pain.

Background Physical activity is evidently a crucial part of the rehabilitation process for patients with chronic pain. Modern wrist-worn activity tracking devices seemingly have a great potential to provide objective feedback and assist in the adoption of healthy physical activity behavior by supplying data of energy expenditure expressed as metabolic equivalent of task units (MET). However, no studies of any wrist-worn activity tracking devices’ have examined criterion validity in estimating energy expenditure, heart rate, or step count in patients with chronic pain. Objective The aim was to determine the criterion validity of wrist-worn activity tracking devices for estimations of energy expenditure, heart rate, and step count in a controlled laboratory setting and free-living settings for patients with chronic pain. Methods In this combined laboratory and field validation study, energy expenditure, heart rate, and step count were simultaneously estimated by a wrist-worn activity tracker (Fitbit Versa), indirect calorimetry (Jaeger Oxycon Pro), and a research-grade hip-worn accelerometer (ActiGraph GT3X) during treadmill walking at 3 speeds (3.0 km/h, 4.5 km/h, and 6.0 km/h) in the laboratory setting. Energy expenditure and step count were also estimated by the wrist-worn activity tracker in free-living settings for 72 hours. The criterion validity of each measure was determined using intraclass and Spearman correlation, Bland-Altman plots, and mean absolute percentage error. An analysis of variance was used to determine whether there were any significant systematic differences between estimations. Results A total of 42 patients (age: 25-66 years; male: 10/42, 24%; female: 32/42, 76%), living with chronic pain (duration, in years: mean 9, SD 6.72) were included. At baseline, their mean pain intensity was 3.5 (SD 1.1) out of 6 (Multidimensional Pain Inventory, Swedish version). Results showed that the wrist-worn activity tracking device (Fitbit Versa) systematically overestimated energy expenditure when compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X). Poor agreement and poor correlation were shown between Fitbit Versa and both Jaeger Oxycon Pro and ActiGraph GT3X for estimated energy expenditure at all treadmill speeds. Estimations of heart rate demonstrated poor to fair agreement during laboratory-based treadmill walks. For step count, the wrist-worn devices showed fair agreement and fair correlation at most treadmill speeds. In free-living settings; however, the agreement for step count between the wrist-worn device and waist-worn accelerometer was good, and the correlation was excellent. Conclusions The wrist-worn device systematically overestimated energy expenditure and showed poor agreement and correlation compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X), which needs to be considered when used clinically. Step count measured with a wrist-worn device, however, seemed to be a valid estimation, suggesting that future guidelines could include such variables in this group with chronic pain.

Background Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer. Methods In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme. Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used. Discussion This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients. Trial registration ClinicalTrials.gov. Clinical trial registration number NCT03998579. First posted June 26, 2019.

By exploring multiple characteristics of physical activity and sedentary behavior (SB), different physical activity profiles could be obtained, which may be beneficial for health and targeted physical activity interventions. The aim of this study was to identify distinct physical activity profiles based on accelerometer-derived activity characteristics and to determine whether these profiles are associated with all-cause mortality. Eight hundred fifty-one participants (56% women, mean age: 53 years) provided objectively assessed physical activity data using an ActiGraph accelerometer and were followed for 15 years. Physical activity profiles were determined using latent profile analyses of 14 derived activity variables, resulting in that three profiles were identified: "Low Active" (n = 147), "Average Active" (n = 397), and "High Active" (n = 307). "Low Active" was characterized by participants with low absolute, relative, and limited variation of time spent in physical activity, and high time spent in SB. "Average Active" had the most balanced movement behavior with values close to the mean for all activity variables. "High Active" was characterized by participants with high absolute, relative, and great variation of time spent in physical activity. Overall, a potentially non-linear pattern between multiple activity variables and all-cause mortality was found as "Low Active" was significantly (P < .05) positively associated with all-cause mortality, and no difference in mortality risk was found between "High Active" and "Average Active." Our data suggest that day-to-day variation in SB is not associated with all-cause mortality. The important message is to keep the overall time spent in SB low and replace this behavior with physical activity.

OBJECTIVES: To compare sleep in young children at different obesity risks, which were based on parental weight, as well as to explore the longitudinal associations of sleep characteristics with adiposity. METHODS: In total, 107 children from an obesity prevention project were included, of which 43 had normal-weight parents (low obesity risk) and 64 had overweight and/or obese parents (high obesity risk). Sleep was measured yearly from ages 2 to 6 years by using actigraphy. Five sleep characteristics, that of late sleep, long sleep latency, short sleep duration, low sleep efficiency, and irregular sleep onset, were defined and scored across ages, with a higher score indicating more frequent exposure. The outcome variables, also measured yearly, were BMI z score and waist circumference. RESULTS: There was no difference in sleep patterns among children at different risks. Higher short sleep duration score was associated with a greater increase in BMI z score (0.12; 95% confidence interval [CI] 0.01 to 0.25) across ages. Independently of sleep duration, higher late sleep score was associated with greater increases in BMI z score (0.16; 95% CI 0.05 to 0.27) and waist circumference (0.60 cm; 95% CI 0.23 to 0.98). Moreover, compared with children at low risk and without habitual late sleep, children at high risk and with habitual late sleep had greater increases in BMI z score (0.93; 95% CI 0.40 to 1.45) and waist circumference (3.45 cm; 95% CI 1.78 to 5.12). CONCLUSIONS: More frequent exposures to late sleep were associated with greater increases in adiposity measures from ages 2 to 6 years, particularly in children with obese parents.

Background To increase the knowledge about physical activity (PA) patterns and correlates among children under the age of 4, there is a need for study’s using objective measurements. The aim of this study was therefore to investigate if objectively measured PA among 3-year-old children differed between day of week and time of day and whether it correlated to child weight status and sex as well as parental weight status and education. Methods Totally 61 children (51% girls) aged 3, participating in Early Stockholm Obesity Prevention Project were included. PA was measured with a tri-axial accelerometer (ActiGraph GT3X+) worn on the non-dominant wrist for one week. The main outcome was average PA expressed as counts per minute from the vector magnitude. PA and demographics/family-related factors were collected at baseline and at age 3. To analyze the results simple linear regression, ANOVA and paired t-tests were performed. Results The mean number of valid days was 6.7 per child. The children were more active on weekdays than weekends (p p = 0.0001). Children to parents with low education were more active (p = 0.01) than those with highly educated parents. No differences in PA by child weight status, sex nor parental weight status were found. Conclusions PA in 3-year-old children was lower during weekends than weekdays and varied over the day. Boys and girls had similar PA patterns, these patterns were independent of child or parental weight status. Children to parents with low education were more active than their counterparts. The fact that PA differed between weekdays and weekends indicates that PA might be affectable in 3-year-old children.

Background Measuring physical activity and sedentary behavior accurately remains a challenge. When describing the uncertainty of mean values or when making group comparisons, minimising Standard Error of the Mean (SEM) is important. The sample size and the number of repeated observations within each subject influence the size of the SEM. In this study we have investigated how different combinations of sample sizes and repeated observations influence the magnitude of the SEM. Methods A convenience sample were asked to wear an accelerometer for 28 consecutive days. Based on the within and between subject variances the SEM for the different combinations of sample sizes and number of monitored days was calculated. Results Fifty subjects (67% women, mean ± SD age 41 ± 19 years) were included. The analyses showed, independent of which intensity level of physical activity or how measurement protocol was designed, that the largest reductions in SEM was seen as the sample size were increased. The same magnitude in reductions to SEM was not seen for increasing the number of repeated measurement days within each subject. Conclusion The most effective way of reducing the SEM is to have a large sample size rather than a long observation period within each individual. Even though the importance of reducing the SEM to increase the power of detecting differences between groups is well-known it is seldom considered when developing appropriate protocols for accelerometer based research. Therefore the results presented herein serves to highlight this fact and have the potential to stimulate debate and challenge current best practice recommendations of accelerometer based physical activity research.

Background: This study aimed to identify distinct profiles of physical activity (PA) patterns among individuals with prediabetes or type 2 diabetes participating in a two-year PA trial and to investigate predictors of the profiles. Methods: Data (n = 168, collected 2013–2020) from the cohort of a randomized trial aimed at increasing PA in individuals with prediabetes and type 2 diabetes were used. PA and sedentary behaviours were assessed by waist-worn ActiGraph GT1M accelerometers at baseline and at 6, 12, 18 and 24 months. Fifteen PA and sedentary variables were entered into a latent class mixed model for multivariate longitudinal outcomes. Multinominal regression analysis modelled profile membership based on baseline activity level, age, gender, BMI, disease status and group randomisation. Results: Two profiles of PA patterns were identified: “Increased activity” (n = 37, 22%) included participants increasing time in PA and decreasing sedentary time. “No change in activity” (n = 131, 78%) included participants with no or minor changes. “Increased activity” were younger (p = 0.003) and more active at baseline (p = 0.011), compared to “No change in activity”. No other predictor was associated with profile membership. Conclusions: A majority of participants maintained PA and sedentary patterns over two years despite being part of a PA intervention. Individuals improving PA patterns were younger and more active at baseline.

It was hypothesized that supplementation of omega-3 fatty acids could increase physical activity (PA) levels, where traditional interventions often fail. The aim of this double-blind, randomized, placebo-controlled trail was to evaluate the effects of 15-week administration of omega-3 fatty acids on objectively measured PA and relative body weight in 8–9 year-old children. The children were randomly assigned to supplementation of omega-3 fatty acids or placebo. Primary outcome was change in PA counts per minute (cpm), and secondly change in body mass index standard deviation score (BMI SDS). Covariance models were applied adjusting for age, gender, weight status, PA and intervention season. Compliance was controlled for by analyzing fatty acid composition in plasma. The intention to treat population consisted of 362 children (omega-3 n = 177, placebo n = 185). No significant effects of omega-3 fatty acids on PA or relative body weight were observed. In covariance models no effects were observed by gender, weight status or change in PA (all p > 0.05), but inactive children increased their PA more than children classified as active at baseline (p

Objective To investigate the feasibility of using accelerometers to monitor physical activity in persons with stroke admitted to inpatient rehabilitation. Design Longitudinal observational study. Participants Persons with stroke admitted to a specialized rehabilitation centre for sub-acute rehabilitation were recruited between August and December 2016. Methods Volume and intensity of physical activity were assessed with accelerometers throughout the rehabilitation period. Indicators of feasibility included processes (recruitment, protocol adherence and participants' experiences) and scientific feasibility, which assessed the accelerometers' ability to detect change in physical activity among stroke survivors who ambulate independently and those who are dependent on a mobility device. Results Twenty-seven out of 31 eligible individuals took part in this study, with 23 (85%) completing it. In total, 432 days of rehabilitation were monitored and valid physical activity data were obtained for 408 days (94%). There were no indications that the measurement interfered with participants' ability to participate in rehabilitation. Despite the subjects' ambulation status, the number of steps and time spent in moderate-to-vigorous physical activity increased significantly across the first 18 days of rehabilitation, whereas sedentary time was unchanged. Conclusion This study supports the feasibility of using accelerometers to capture physical activity behaviour in survivors of stroke during inpatient rehabilitation.

The measurement of physical activity (PA) is fundamental to health-related research, practice and policy. For decades, self-report measures have provided unique insights into the role of PA for human health and society. In fact, studies, in which participants reported their behaviours—or the behaviours of others—using diaries, logs, questionnaires and recalls, have historically provided the evidence that underpins global PA guidelines.1 Self-reports have been used extensively in various settings, including population surveillance, observational and intervention studies and routine assessment as part of healthcare. The field of PA measurement is rapidly evolving. We have a wealth of measurement instruments and achieved remarkable advancements in the use of device-based information such as raw accelerometry, novel algorithms for pattern recognition and worldwide initiatives for data harmonisation.2 3 The technological evolution has changed the practice of PA self-reports as well, and led to electronic surveys and ecological momentary assessments (EMAs) for the measurement of PA in natural environments and in ‘real time’. Despite significant improvements, an established standard for the measurement of PA does not exist due to the complexity of the behaviour.4 PA is multifaceted and encompasses different domains (eg, leisure, occupation, transport, household), dimensions (eg, frequency, duration, intensity, …

Introduction: Support for physical activity (PA) is central in diabetes care. The Sophia Step Study is a three-armed randomised controlled trial aiming to evaluate different levels of support for i ...

To investigate objectively measured physical activity in stroke survivors living in low-income areas of Cape Town, South Africa, specifically to: (a) describe the volume of daily physical activity and time spent in different intensity levels and (b) investigate the association of factors covering the International Classification of Functioning, Disability and Health with sedentary behavior.A cross-sectional design was used, where forty-five ambulatory community-dwelling stroke survivors participated. Volume and intensity of physical activity were assessed with accelerometers for three to five consecutive days. Personal and environmental factors, along with body function and activity, were captured. Multiple linear regression was used to investigate factors associated with the percentage of days spent sedentary.The median number of steps per day was 2393, and of the average 703 minutes of wear time, 80% were spent in sedentary, 15% in light, and 5% in moderate-to-vigorous intensity physical activity. Age, stroke severity, and failing to receive outpatient rehabilitation were independently associated with sedentary, which, taken together, explained 52% of the variance.Low volumes of physical activity and high amount of sedentary time emphasize the need to develop strategies that will increase physical activity. Providing outpatient rehabilitation in a systematic manner post-stroke is a potential target of health care programs in order to reduce sedentary behavior. Implications for rehabilitation Objectively measured physical activity among community-dwelling survivors of stroke in Cape Town, South Africa was low in volume, and the majority did not meet the recommendations of 150 minutes of at least moderate intensity physical activity. The majority of stroke survivors in South Africa spent most of their time sedentary, which could further increase the risk of cardiovascular impairments. Outpatient rehabilitation should be provided to all patients after stroke since it appears to reduce sedentary time.

Background: The aims of physical therapy are to develop, maintain, and restore optimal movement and functional ability throughout the lifespan for individuals and populations. Physical activity is ...

On behalf of the HELENA Study Group., The aim was to investigate whether there was an association between amino acid (AA) intake and physical fitness and if so, to assess whether this association was independent of carbohydrates intake. European adolescents (n = 1481, 12.5–17.5 years) were measured. Intake was assessed via two non-consecutive 24-h dietary recalls. Lower and upper limbs muscular fitness was assessed by standing long jump and handgrip strength tests, respectively. Cardiorespiratory fitness was assessed by the 20-m shuttle run test. Physical activity was objectively measured. Socioeconomic status was obtained via questionnaires. Lower limbs muscular fitness seems to be positively associated with tryptophan, histidine and methionine intake in boys, regardless of centre, age, socioeconomic status, physical activity and total energy intake (model 1). However, these associations disappeared once carbohydrates intake was controlled for (model 2). In girls, only proline intake seems to be positively associated with lower limbs muscular fitness (model 2) while cardiorespiratory fitness seems to be positively associated with leucine (model 1) and proline intake (models 1 and 2). None of the observed significant associations remained significant once multiple testing was controlled for. In conclusion, we failed to detect any associations between any of the evaluated AAs and physical fitness after taking into account the effect of multiple testing., The HELENA study took place with the financial support of the European Community Sixth RTD Framework Programme (Contract FOOD-CT: 2005-007034).

BACKGROUND AND PURPOSE: We have developed a 12-week balance training program for older adults shown to improve fall-related concerns, gait speed, balance performance, and physical function. We hypothesized that this balance training would also contribute to higher habitual physical activity (PA) levels and improved health-related quality of life (HRQoL). The primary aim was to evaluate short- and long-term effects of the balance training program on objectively measured habitual PA in older adults with osteoporosis. Secondary aims were to assess the effects of the balance training on HRQoL, and to study whether any effects on PA were associated with changes in HRQoL, gait speed, balance performance, fall-related concerns, and physical function. METHODS: A randomized controlled trial with follow-up at 3, 9, and 15 months, including 91 participants with osteoporosis (75.6 ± 5.4 years), compared a balance training group (n = 61) with a control group (n = 30). The primary outcome was effect on habitual PA measured as steps/day, dichotomized into less than 5000 or 5000 or more steps/day. Physical activity was assessed with pedometers (Yamax) and accelerometers (Actigraph), HRQoL with the Short Form-36 (SF-36), gait with a GAITRite walkway, balance performance with Modified-Figure-Eight test and one-leg stance, fall-related concerns with Falls Efficacy Scale International, and physical function with the advanced lower extremity subscale of the questionnaire Late Life Function and Disability Instrument. Statistical methods used were multivariate logistic regression and logistic generalized estimating equation. RESULTS: Sixty-eight participants completed the short-term follow-up at 3 months, and 53 participants completed the long-term follow-up at 15 months. Per-protocol analysis (n = 68) showed that the odds ratio for having a daily step count of 5000 or more at 3 months was 6.17 (95% confidence interval, 1.23-30.91), P =.027, for the intervention group compared with the control group. The longitudinal analysis (n = 91) showed that the odds ratio for having a daily step count of 5000 or more at 15 months was 2.02 (95% confidence interval, 0.88-4.64), P =.096, for the intervention group compared with the control group. The mental component sum of the SF-36 improved significantly from baseline to 3 months in the intervention group, and the physical component sum improved in both groups, but no statistically significant differences were found between groups. No associations were found between PA and changes in covariates. DISCUSSION AND CONCLUSIONS: The short-term evaluation showed that balance training increased habitual PA in community-dwelling older adults with osteoporosis. A significantly higher proportion of participants in the intervention group reached a level of 5000 or more steps/day, which is important for overall health. This effect was not associated with improvements in HRQoL, gait speed, balance performance, or fall-related concerns, and did not persist through the long-term follow-up. To accomplish a sustained PA change, a prolonged intervention or more support regarding habitual PA may be required, such as reinforcement with personalized behavior change counseling or PA on prescription.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Language: en

BACKGROUND AND PURPOSE: In order for people with Parkinson disease (PwPD) to benefit from neurorehabilitation research, interventions tested in research settings require assessment in real-world clinical practice. There is little evidence for whether efficacious exercise interventions for PwPD remain effective when transferred to standard clinical settings. The aim of this study was to assess the clinical effectiveness of the adapted HiBalance program on balance control and gait among PwPD. METHODS: Participants (n = 117) with mild-moderate Parkinson disease were consecutively included into either the 10-week HiBalance group training (n = 61) or the control (n = 56) group. The main outcome was balance performance (Mini-BESTest). Secondary outcomes were comfortable gait speed (10-m Walk Test); functional mobility (Timed Up and Go [TUG] test) and dual-task interference (cognitive TUG test); physical activity level (steps per day); perceived balance confidence (Activities-specific Balance Confidence scale) and perceived walking difficulty (Walk-12G) and self-rated health (EQ-5D visual analog scale). RESULTS: In total, 98 people completed the trial. Compared with controls, the training group showed significant improvement in balance performance (P < 0.001), gait speed (P = 0.001), and dual-task interference (P = 0.04) following the intervention. No group differences were observed for physical activity level or any patient-reported measures. DISCUSSION AND CONCLUSIONS: Highly challenging balance training is effective at improving balance, gait, and dual-task performance when delivered at a clinically feasible dose, in a range of rehabilitation settings, without direct involvement of the research group.Video Abstract available for more insights from the authors (see the Video, Supplementary Digital Content 1, available at: http://links.lww.com/JNPT/A299).

Background Parkinson’s disease (PD) affects many physiological systems essential for balance control. Recent studies suggest that intensive and cognitively demanding physical exercise programs are capable of inducing plastic brain changes in PD. We have developed a highly challenging balance training (the HiBalance) program that emphasizes critical aspects of balance control through progressively introducing more challenging exercises which incorporates dual-tasking. Earlier studies have shown it to be effective in improving balance, gait and dual-tasking. The study design has thereafter been adjusted to link intervention-induced behavioral changes to brain morphology and function. Specifically, in this randomized controlled trial, we will determine the effects of the HiBalance program on balance, gait and cognition and relate this to task-evoked functional MRI (fMRI), as well as brain-derived neurotrophic factor (BDNF) in participants with mild-moderate PD. Methods One hundred participants with idiopathic PD, Hoehn & Yahr stage 2 or 3, ≥ 60 years of age, ≥ 21 on Montreal Cognitive Assessment will be recruited in successive waves and randomized into either the HiBalance program or to an active control group (the HiCommunication program, targeting speech and communication). Both interventions will be performed in small groups, twice a week with 1 h sessions for 10 weeks. In addition, a 1 h, once a week, home exercise program will also be performed. A double-blinded design will be used. At the pre- and post-assessments, participants will be assessed on balance (main outcome), gait, cognitive functions, physical activity, voice/speech function, BDNF in serum and fMRI (3 T Philips) during performance of motor-cognitive tasks. Discussion Since there is currently no cure for PD, findings of neuroplastic brain changes in response to exercise would revolutionize the way we treat PD, and, in turn, provide new hope to patients for a life with better health, greater independence and improved quality of life. Trial registration ClincalTrials.gov: NCT03213873, first posted July 11, 2017.

To investigate the associations between objectively measured sedentary behavior (SB), light-intensity physical activity (LIPA) and moderate-to-vigorous physical activity (MVPA) and cardiometabolic ...

The development of accelerometers has revolutionized measurement of physical activity, and they are used to a large extent in research and have started to be implemented into clinical settings. However, achievement of reliable outcomes requires good methodological knowledge and skills by the user. Otherwise, significant measurement errors may occur, interfering with assessment of the physical activity level in the population, group differences, associations with health parameters or effect of treatments. This paper by the Swedish Network for Objective Measurement of Movement (NORM) provides an overview of physical activity measurement including sections of data collection, processing of raw data into useful metrics and statistical analysis. It targets users of accelerometer in research, health care and national surveys.

Objectives To assess the stability and determinants of total and context specific sitting in a follow-up of adults. Design Longitudinal study. Methods Participants in the DILGOM cohort (n = 3735, men 45%), reported daily sitting in five contexts (work-related, in vehicle, at home by the TV, at home at the computer, and elsewhere) in 2007 and 2014. Sociodemographic background, lifestyle and health were assessed in 2007. Total sitting comprised the sum of context specific sitting. Changes in, and determinants of context specific sitting, stratified by baseline age into young middle-aged ( 68 years) were estimated by generalized linear mixed models. Results In 2007, total daily sitting was 7 h 26 min, 6 h 16 min, and 6 h 3 min in young middle-aged, late middle-aged and older-aged groups, respectively. Over 7 years, total sitting decreased on average by 26 min. Sitting at the computer increased by 7–17 min. The late middle-aged group also increased sitting by the TV, and decreased total, work-related, vehicle and elsewhere sitting. Occupational status determined context specific sitting, but somewhat differently in young and late middle-aged groups. Poor self-rated health determined less work-related and more sitting by the TV in the young, whereas good health determined less work-related sitting in the late middle-aged group. Conclusions Self-reported sitting is a fairly stable behavior, with the exception for the late middle-aged group, where all context specific and total sitting changed significantly. Occupational status and health determined changes in sitting; however, somewhat differently by age group.

Background: This study investigates the association between self-rated health and the time spent in sedentary behavior (SB), low light-intensity physical activity (LLPA), high light-intensity physical activity (HLPA), and moderate to vigorous physical activity (MVPA), by controlling for demographics, socioeconomic status, and chronic diseases. Methods: A total of 1665 participants (55% women) completed a questionnaire about demographics, chronic diseases, and anthropometric characteristics and provided objective physical activity data on time in SB, LLPA, HLPA, and MVPA, using an ActiGraph 7164 accelerometer. Association between self-rated health and activity data was explored in a compositional data analysis. Results: The multinomial logistic regression analysis showed a significantly lower time spent in MVPA in proportion to time in other movement behaviors (SB, LLPA, and HLPA) for participants who rated their health as alright or poor compared with excellent (P Conclusions: Promoting MVPA, as opposed to time in other movement behaviors, is suggested to be beneficial for excellent self-rated health.

Aim To study the sleep development and sleep characteristics in children at different obesity risks, based on parental weight, and also to explore their weekday–weekend sleep variations and associated family factors. Methods A total of 145 children participating in a longitudinal obesity prevention project were included, of which 37 had normal‐weight parents (low obesity risk), and 108 had overweight/obese parents (high obesity risk). Sleep diaries at ages 1 and 2 years were used to study sleep development in children at different obesity risks. Objectively assessed sleep using an accelerometer at 2 years of age was used to analyse weekday–weekend sleep variations. Results There was no difference in sleep development from age 1 to age 2 among children at different obesity risks, but more children in the high‐risk group had prolonged sleep onset latency and low sleep efficiency. At 2 years of age, children in the high‐risk group had more weekday–weekend variation in sleep offset (mean difference 18 min, 95% confidence interval (CI) 4–33 min), midpoint of sleep (mean difference 14 min, 95% CI 3–25 min) and nap onset (mean difference 42 min, 95% CI 10–74 min) than children in the low‐risk group, after adjusting for other family factors. However, no difference could be detected between groups in weekday–weekend variation in sleep duration. Conclusions Unfavourable sleep characteristics, as well as more variation in sleep schedules, have been observed in children at high obesity risk. While the differences were relatively small, they may reflect the unfavourable sleep hygiene in families at high obesity risk.

The HiBalance program is a progressive and highly challenging balance training intervention incorporating Parkinson’s disease (PD) specific balance components. The program improves balance and gait and increases the amount of ambulation in short-term, in older adults with PD. Yet, potential short- and long-term effects on habitual physical activity and sedentary behavior are currently unidentified. The aim of this study was to conduct preplanned secondary analyses of short- and long-term effects of the HiBalance program on objectively measured amount and bouts of brisk walking, sedentary behavior, and total physical activity in older adults with PD. Further, our aim was to investigate demographic, intervention-related, disease-related, and function-related factors potentially related to a difference in activity after intervention. A total of 100 older adults with mild-moderate PD were recruited. The intervention group participated in the HiBalance program, and the control received care as usual and was offered the HiBalance program after study termination. Physical activity data were collected using accelerometers at baseline, after intervention and after 6 and 12 months. A multilevel model was utilized to investigate the postintervention and long-term (6 and 12 months) effects on total physical activity, amount and bouts of brisk walking (i.e., moderate intensity physical activity), and sedentary behavior. Between-group difference for the main outcome brisk walking was at postintervention: Δ −10, CI −23.78 to 3.69 min/day (p<0.05); 6 months: Δ −10, CI −23.89 to 3.89 min/day (p<0.05); and 12 months: Δ −4, CI −16.81 to 8.81 min/day (p=0.43). Being part of the intervention group as well as finishing training during spring/summer showed an independent association to increased brisk walking after the intervention period. In conclusion, the HiBalance program increases the physical activity on moderate intensity after intervention and at 6 months but not at 12 months, independently of improved balance. Season seems to influence the effect on the physical activity.

The aim of the study was to examine the relationship between employment status and job activity level with physical activity (PA) and sedentary time, stratified by gender and country.Cross-sectional study design.Data from working age adults (18-65 years) from two cross-sectional studies, the Swedish 2001-2002 and 2007-2008 Attitude Behavior and Change Study (ABC; n=1165) and the 2003-2006 US National Health and Nutrition Examination Survey (NHANES; n=4201), were stratified by employment status (employed and not employed) and job activity level (active, sedentary and mixed). PA in counts×min(-1) and time spent in sedentary, low and moderate or higher intensity were measured with accelerometers. Analyses were conducted in 2012-2013.In NHANES, the employed had significantly higher counts×min(-1) and spent more time in moderate or higher intensity PA than those not employed. In ABC, no significant differences were observed between employed and unemployed. Adults with active versus sedentary occupations had higher counts×min(-1) and less sedentary time in both the USA and Sweden and in both men and women. For example, counts×min(-1) were 20-40% greater in active versus sedentary jobs.Employment status is related to PA and sedentary time among men and women in the USA but not in Sweden. Among the employed, occupational PA is associated with total PA and sedentary time for both genders and in both countries. Comparisons of PA levels based on objective measurements can refine understanding of country differences in activity.

Aim:To describe objectively-measured physical activity levels and patterns among community-dwelling older adults with osteoporosis, impaired balance, and fear of falling, and to explore the associations with gait, balance performance, falls self-efficacy, and health-related quality of life (HRQoL).Methods:Ninety-four individuals (75.6 ± 5.4 years) were included. Physical activity was assessed with pedometers and accelerometers. Mean steps/day, dichotomized into < 5,000 or = 5,000 steps/day, and time spent in different physical activity intensities were analyzed. Gait was assessed with a GAITRite walkway, balance performance was assessed with the modified figure-eight test and oneleg stance, falls self-efficacy was assessed with the Falls Efficacy Scale International, and HRQoL was assessed with Short Form-36.Results:Mean steps/day were 6,201 (991–17,156) and 40% reported < 5,000 steps/day. Participants with < 5,000 steps/day spent more time sedentary, had slower gait speed, poorer balance performance, and lower HRQoL than participants with ≥ 5,000 steps/day. No participants with < 5,000 met the recommended level of physical activity.

Objective: To determine the cost-effectiveness of the HiBalance training program for managing Parkinson’s disease (PD)-related balance and gait disorders. Design: Cost comparison design following the randomized controlled trial comparing a novel balance training intervention with care as usual. Subjects: A total of 100 participants with mild–moderate PD were randomized to either the intervention ( n = 51) or the control group ( n = 49). Intervention: A 10-week (three times per week), group-based, progressive balance training program, led by two physical therapists. Main outcomes: All program costs were collected for both groups. Cost-utility was evaluated using quality-adjusted life years (QALYs) and cost-effectiveness measures were the Mini Balance Evaluation Systems Test (Mini-BESTest; assessing balance performance) and gait velocity. Incremental cost-effectiveness ratios were calculated and a probabilistic sensitivity analysis was conducted. Results: The between-group difference in QALYs was 0.043 (95% confidence interval (CI): 0.011–0.075), favoring the intervention group. Between-group differences in balance performance and gait velocity were 2.16 points (95% CI: 1.19–3.13) and 8.2 cm/second (95% CI: 2.9–13.6), respectively, favoring the intervention group. The mean cost per participant in the intervention group was 16,222 SEK (€1649) compared to 2696 SEK (€274) for controls. The estimated incremental cost-effectiveness ratios were 314,558 SEK (€31,969) for an additional QALY, 6262 SEK (€631) for one point improvement in balance performance, and 1650 SEK (€166) for 1 cm/second increase in gait velocity. Sensitivity analyses indicated a high probability (85%) of program success. Conclusion: In terms of QALYs, the HiBalance program demonstrated a high probability of cost-effectiveness in the short-term perspective when considering the willingness-to-pay thresholds used in Europe.

Ing-Mari Dohrn,1 Lydia Kwak,2 Pekka Oja,3 Michael Sjöström,4 Maria Hagströmer1,5 1Department of Neurobiology, Care Sciences and Society (NVS), 2Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden; 3UKK Institute, Tampere, Finland; 4Department of Biosciences and Nutrition (BioNut), Karolinska Institutet, 5Functional Area Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden Background: Sedentary behavior is associated with health risks in adults. The potential benefits of reducing sedentary time may be dependent not only on decrease per se, but also on the type of activity it replaces. Few longitudinal studies have investigated the effects on mortality when replacing objectively assessed sedentary time with another physical activity (PA) behavior. Objective: To investigate the effects of replacing objectively assessed sedentary time with time in light-intensity PA or moderate-vigorous PA (MVPA) on all-cause mortality, cardiovascular disease (CVD) mortality or cancer mortality in a cohort with 15 years follow-up time.Methods: In total, 851 women and men from the population-based Sweden Attitude Behaviour and Change study were included. Time spent sedentary, in light-intensity PA and in MVPA were assessed using an Actigraph 7164 accelerometer. Mortality data were obtained from Swedish registers. Cox proportional hazards models estimated hazard ratios (HR) of mortality with 95% confidence intervals (CI) and isotemporal substitution models were used to estimate the effect of replacing sedentary behavior with PA for the same amount of time.Results: Over a follow-up of 14.2 years (SD 1.9) with 12,117 person-years at risk, 79 deaths occurred, 24 deaths from CVD, 27 from cancer, and 28 from other causes. Replacing 30 minutes/day of sedentary time with light-intensity PA was associated with significant reduction in all-cause mortality risk (HR: 0.89, 95% CI: 0.81-0.98) and CVD mortality risk (HR: 0.76, 95% CI: 0.63-0.92). Replacing 10 minutes of sedentary time with MVPA was associated with reduction in CVD mortality risk (HR: 0.62, 95% CI: 0.42-0.91). No statistically significant reductions were found for cancer mortality.Conclusion: This statistical modelling study suggests that replacing sedentary time with light-intensity PA could have beneficial effect on both all-cause mortality and CVD mortality. Replacing sedentary time with MVPA could reduce CVD mortality. Keywords: accelerometry, isotemporal substitution, light intensity, moderate-to-vigorous intensity, prospective, sedentary behavior

Today’s health and social care systems are facing a challenge in how to effectively address caregiving for ageing populations facing cognitive disorders and frailty. Scholars and policy makers are now identifying a rise of “hidden form of care”, e.g. informal caregiving, as a phenomenon in support for ageing populations. Across Europe for instance, the rise in the older old adult population has led to a rapid expansion of the number of carers, both professional (formal) and informal. The latter, representing mostly family members caring for their loved ones, truly represents a “hidden form of care”. This can be a problem if formal and informal caregivers are not fully integrated into the healthcare continuum or are not given a systematic support to carry out caregiving in a relevant and safe way. There is currently no comprehensive European-wide legal framework and support mechanisms, in terms of training and education for this group. CARE Campus, an EIT Health programme within the Educational Campus Pillar, is a new model of collaboration between academic institutions, the private sector, and the public sector whose main aim is to support the development of a comprehensive training for formal and informal caregivers in Europe. The initial phase of the development encompasses nine (09) online training modules with a quality control process to ensure that the curriculum is evidence-based, compliant with the national and local regulations, and addresses the needs of caregivers across Europe. The objective is to support formal, informal, and family caregivers and reduce the burden on health care systems, whilst improving the quality of care for older adults.

Summary Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation. Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the fi rst of a series of annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the fi rst level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular fi ltration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation.