Physical inactivity is the fourth biggest contributor to global mortality, accelerating the progression of noncommunicable diseases (NCDs).1 Physical inactivity is responsible for 6% to 10% of the burden of disease from conditions such as type 2 diabetes, coronary heart disease, and cancer.2 In 2008, 9% of global premature deaths were attributed to complications of physical inactivity.2 As physical inactivity is a substantial mortality risk factor,1,2 the aim of healthcare providers should be to increase patient's physical activity (PA) levels to decrease the number of inactive adults and contribute toward preventing long-term health conditions.
To be physically active, adults must achieve 150 to 300 minutes of moderate intensity PA or 75 to 150 minutes of vigorous intensity PA, or an equivalent combination of both each week, as well as muscle-strengthening activities on at least 2 days each week.3 Worldwide, 31.1% of adults self-report that they are physically inactive (not meeting PA guidelines), with the Americas having the highest inactivity prevalence (43.3%).4 When PA data are obtained through objective methods (eg, accelerometry), less than 5% of American adults are shown to meet PA recommendations.5 Australian self-report data in 2014 to 15 indicate 55.5% of Australians aged 18 to 64 years were physically active in the past week, 29.7% were insufficiently active, and 14.8% were inactive.6
Promotion of healthy behaviors such as PA, healthy diet, not smoking, and limiting alcohol intake is possible in the physiotherapy setting. Physiotherapists are considered well placed to provide PA guidance and support to a variety of clinical populations7,8 and are encouraged to promote PA at every opportunity.9,10 The American Physical Therapy Association has designed resources to facilitate this process.11
Physiotherapists have the skills7,8 and feel professionally responsible to promote and implement PA interventions.12–15 Their education and experience enable physiotherapists to recognize and address patient's perceived barriers to PA.16 However, limited resources, tools, knowledge and training in health promotion practices, and time pressures in a busy clinical environment might reduce the likelihood of physiotherapists promoting PA if it distracts from the patient's immediate concern.8,17 Hence, promoting PA in the physiotherapy primary care setting can prove difficult.
Several systematic reviews show that primary care interventions to promote PA are efficacious at increasing PA levels in the short to medium term in different populations18–24 yet are ineffective for patients with chronic musculoskeletal conditions.25 A variety of healthcare professionals delivered these reviewed interventions, so the effectiveness of interventions delivered specifically by physiotherapists is unknown.
This systematic review reviewed the efficacy of one-on-one, physiotherapist-led physical activity (PLPA) interventions at increasing PA levels among adults in clinic-based private practice, primary care, and outpatient settings.
Protocol and Registration
The protocol for this review was registered in PROSPERO (CRD42015024275). The review methods were informed by the Cochrane Handbook for Systematic Reviews of Interventions26 and the PRISMA statement.27
Published studies meeting the National Health and Medical Research Council criteria for level II to IV studies were eligible for inclusion [randomized controlled trials (RCTs), pseudorandomized controlled trials, cohort studies, case–control studies, cross-sectional, and case series].28 Studies examining the efficacy of clinic-based, PLPA interventions used to increase PA levels in adults attending private practice, primary care, and outpatient physiotherapy clinics were identified.
Included articles studied adults (≥18 years) with a musculoskeletal injury, had risk factors for NCD (eg, hypertension, hyperglycaemia, overweight, or physically inactive), or who were suffering from one of the main NCDs (eg, cardiovascular disease, diabetes, and cancer) as outlined in the World Health Organisation's Global Recommendations on Physical Activity for Health.1 Studies focusing on patients recovering from surgery, not receiving any clinic-based care (ie, only telephone based) or with conditions that prevented unsupervised PA (eg, participation in a walking program between scheduled appointments) were excluded.
The interventions included in this review were PLPA interventions, defined as an intervention delivered by a physiotherapist with the aim to increase patient PA levels. The intervention had to be delivered one-on-one, face-to-face, and be clinic based. Group, multidisciplinary, interdisciplinary, and home-based interventions were excluded to ensure that included studies reflected the common one-on-one patient treatment environment seen in private practice and clinic-based outpatient settings. Interventions could include supplementary delivery methods, such as telephone contact, in addition to a clinic-based intervention. No restrictions were placed on the type of comparison or control intervention.
Measures must have subjectively (eg, questionnaire) or objectively (eg, accelerometry) quantified change in PA.
Twelve electronic databases were searched (see Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JSM/A131). Forward and backward citation tracking and database alerts were used to ensure that all relevant studies were identified. Authors of relevant conference abstracts were contacted to determine whether published full reports existed.
Search strategies were developed by 2 authors (B.E.K. and J.E.G.) and conducted by B.E.K. The development of the search strategy met the criteria of Sampson et al29 with the exception of the limitation to English-language publications. A full electronic search was conducted using database-appropriate subject headings, keywords, wildcards, and truncations. Search yields were limited to English and adults (≥18 years) and was conducted in August 2015. Database alerts ceased in December 2016. No publication date restriction was imposed. The search strategy used keywords specific to physiotherapy and PA (see Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JSM/A132).
Screening by title and abstract was completed using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia, www.covidence.org) by 2 independent, blinded reviewers (B.E.K. and N.F.) using a priori screening criteria. Disagreements were resolved by consensus and, if required, a third reviewer (J.E.G.). Full texts were reviewed once consensus was reached. Authors of included studies were asked to split reported data if studies grouped participants who met review inclusion criteria with participants who met exclusion criteria. Author names, institutions, and journal titles were not blinded from reviewers. The study selection process is outlined in the PRISMA flow diagram (Figure 1).
The interrater agreement for including or excluding articles was measured using a prevalence-adjusted bias adjusted kappa (PABAK)30 at the abstract and full-text stage; PABAK was calculated using the epiR package within the R software environment. Level of agreement was rated as poor (<0.00), slight (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), or almost perfect (0.81-1.00) as suggested by Landis and Koch.31
Data Collection Process and Data Items
Two authors independently extracted data from the included articles and assessed risk of bias (B.E.K. and N.F.). Data extracted from the selected studies included participant characteristics, study design, intervention content, statistical analysis, and results for participant PA levels. Where data were not reported in sufficient detail, authors were contacted by email up to 3 times over 2 months.
Additional information from authors, study protocols, supporting studies, and supplementary appendices was used to extract additional intervention data. All information was used to complete the Template for Intervention Description and Replication (TIDieR) Checklist for all experimental and control interventions, which facilitates analysis of the aims, processes, delivery methods and procedures, intervention providers, location, training procedures, delivery frequency, tailoring, and intervention fidelity used by included studies.32
Risk of Bias in Individual Studies
Studies were assessed for bias by 2 reviewers (B.E.K. and N.F.). The Cochrane Risk of Bias tool (see Appendix 3, Supplemental Digital Content 3, http://links.lww.com/JSM/A133) was used for nonrandomized, quasi-experimental, randomized, and cluster-randomized controlled trials.33 The Quality Assessment Tool for Before–After (Pre–Post) Studies With No Control Group34 (see Appendix 4, Supplemental Digital Content 4, http://links.lww.com/JSM/A134) was used for one pre–post study.35 Risk of bias for each study was categorized as low, moderate, or high.
Meta-analysis was conducted for studies that had a control group. Continuous and dichotomous data for PA outcomes were extracted into categories specific to follow-up time, achievement of minimum recommended PA levels, and intervention length. Data were entered into RevMan (version 5.3) and standardized mean differences (SMDs) and odds ratios (ORs), with associated 95% confidence intervals (95% CI), were calculated using a fixed-effects analysis. An SMD of ≥0.8 was interpreted as a large effect, ≥0.5 a moderate effect, and ≤0.2 a small effect.36 Medians were assumed as means for the purposes of meta-analysis37 for one study.38 SDs were calculated from 95% CI [using SD = SE × SQRT(n), where SE = 95% CI/(the t-critical value for the 95% CI and participant number reported)] and interquartile range (IQR) (using SD = IQR/1.35). Initial participant numbers were used for one study that did not report final follow-up participant numbers or an intention-to-treat approach.39 PlotDigitizer (Free Software Foundation, version 2.1) was used to estimate values for one study where bar graphs were provided without data points.35
Meta-analyses were performed using 6 studies.38–43 Analyses examining the efficacy of PLPA interventions in the short to medium term (7 weeks-1 year) used results collected at follow-up points less than 1 year. Results collected at or after 1 year were used to examine long-term intervention efficacy. If outcome measures were taken more than once within one period (eg, at 3 and 6 months in a short to medium term follow-up period), then the measure taken at the later time point was chosen for analysis. Final follow-up results were used to identify (1) the efficacy of PLPA interventions at achieving minimum recommended PA levels; and (2) the efficacy of PLPA interventions of different lengths [short (less than 1 year) or long (over 1 year)].
Results that could not be included in meta-analysis were reported individually in a nonstatistical analysis and checked for accuracy by 2 reviewers. Results included in this analysis represent the efficacy of PLPA interventions on increasing PA performed at different intensities (low, moderate, and vigorous).
Electronic and manual searches yielded 4140 studies for review (Figure 1). Four studies identified through nondatabase sources did not meet the inclusion criteria. Additional information was requested from authors of 8 abstracts, with 4 authors replying and their studies included. Two studies were included despite nonresponse due to inclusion criteria still being met; the other 2 were excluded as inclusion criteria could not be accurately applied to the study.
The absolute rate of reviewer agreement for the title and abstract screening process was 98%, and the PABAK was 0.96 (95% CI: 0.95-0.97), indicating an excellent rate of agreement.31 Full text screening was conducted on 42 studies. Thirty-four studies were excluded from analysis with reasons and 8 studies were included in the final review (Figure 1). The absolute rate of agreement for the full text screening stage was 69%, and the PABAK was 0.38 (95% CI: 0.05-0.64), representing a fair rate of agreement.31
Risk of Bias Within Studies
Three studies had high risk of bias,39,42,44 one had moderate risk,35 3 had low risk,38,40,43 and one41 had an unclear risk of bias (see Appendices 4 and 5, Supplemental Digital Content 4 and 5, http://links.lww.com/JSM/A133, http://links.lww.com/JSM/A134).
Risk of Bias Across Studies
Five studies blinded assessors38,40–43 and 238,43 blinded participants; however, it was unclear how many studies blinded personnel delivering the intervention, as this was often not reported. Accelerometry was not used to measure PA in any study, despite it being considered a more direct PA measure.45 One study used accelerometry to measure energy expenditure.38 These data were not converted to PA volume, as this conversion might underestimate PA46 and were not included in this review.
Physiotherapist contact frequency varied between studies, with one study using only one contact39 and several using twice weekly contacts.35,40,44 Intervention duration ranged from 5 minutes39 to 2 years.38,42 Participant number ranged from 4044 to 586.38 Most included studies were RCTs,38,40–43 and 5 studies used a usual care control.38,39,41–43 Intervention fidelity was measured in 2 studies.40,43 All studies measured PA using self-report measures and reported values using different units. In one study, the unit of measurement was unclear44 (Table 1).
Meeting Minimum Recommended Physical Activity Levels
The meta-analysis showed that PLPA interventions were efficacious at assisting adults achieve the minimum recommended PA levels (Figure 2). The meta-analysis of dichotomous outcomes included 2 studies39,41 and showed PLPA interventions increased the odds of achieving minimum recommended PA levels at final follow-up (OR = 2.15, 95% CI, 1.35-3.43, P = 0.001) (Figure 2). These results confirm those reported in a pre–post study included in this review,35 where the number of participants meeting recommended PA levels increased after a 12-week PLPA intervention (Table 1).
Physiotherapist-led physical activity interventions had a small effect on total PA levels in the short to medium term. Results from 5 studies reporting short- and medium-term follow-up data38,40–43 demonstrated a significant, small effect (SMD = 0.15, 95% CI, 0.03-0.27, P = 0.02) (Figure 3). Three studies included a long-term follow-up38,41,42 and demonstrated a similar effect to the short- to medium-term analysis for PA levels; however, the result was not significant (SMD = 0.14, 95% CI, −0.00 to 0.28, P = 0.05) (see Forest plot, Supplemental Digital Content 1S, http://links.lww.com/JSM/A135, which presents the meta-analysis at long-term follow-up).
Efficacy of PLPA interventions did not differ based on their length. Three experimental studies used a short intervention (<1 year).39,40,43 Final follow-up results demonstrated a nonsignificant, small effect (SMD = 0.13, 95% CI, −0.11 to 0.37, P = 0.29) for total PA.
Three experimental studies used a long intervention (≥1 year)38,41,42 and collectively demonstrated a nonsignificant, small effect (SMD = 0.14, 95% CI, −0.00 to 0.28, P = 0.05) for total PA.
Additional meta-analyses were conducted using the first follow-up results for short- and long-term intervention studies to further explore the effect of intervention length on efficacy. No effect for the intervention was seen for short (SMD = 0.22, 95% CI, −0.02 to 0.46, P = 0.08) or long (SMD = 0.05, 95% CI, −0.09 to 0.18, P = 0.51) interventions at first follow-up.
Different PA Intensities
The efficacy of PLPA interventions to increase vigorous intensity PA was examined in one study.35 A significant improvement of 340 metabolic equivalent task (MET)-minute/week (IQR 0-1440, P = 0.007) was seen after a 12-week individually tailored intervention in adults with chronic musculoskeletal conditions.
Statistically significant improvements for moderate intensity PA were reported by 2 studies. A significant improvement of 440 MET-minute/week (IQR 160-1140, P = 0.033) was seen in one study,35 and another study demonstrated a significant 17.9 min/d (95% CI, 4.0-34.9, P = 0.012) increase at 6 months in 116 older adults with mobility problems.43 A nonsignificant improvement of 9.9 min/d (95% CI, −3.9 to 23.7, P = 0.160) occurred at an earlier 3-month follow-up in this study.43
Statistically significant improvements were also identified for low-intensity PA (ie, walking) in 2 studies. Adults with osteoarthritis of the hip/knee walked at least 30 minutes daily on 0.7 days (95% CI, 0.01-1.5) per week more than the control group after receiving a behavioral graded activity intervention.41 Significant improvements in walking of 495 MET-minute/week (IQR 206-1179, P = 0.047) were seen in participants with chronic musculoskeletal conditions.35
Physiotherapist-led physical activity interventions were efficacious at (1) doubling the odds of adults achieving the minimum recommended PA levels; (2) increasing total PA levels in the short to medium term (up to 1 year after intervention); and (3) increasing the amount of low, moderate, and vigorous intensity PA adults perform. These improvements were not seen beyond 1 year and were not enhanced by using longer interventions.
Physiotherapist-led physical activity interventions resulted in only small PA improvements that lasted for less than 1 year. This result was expected as PA interventions, delivered by other healthcare professionals, have also been shown to improve PA levels in the short to medium term.18 This result might be due to the approach healthcare professionals, specifically physiotherapists, take when promoting PA. A cross-sectional study examining the types of PA known to physiotherapists found sport to be the most recognized type; 95.1% of physiotherapists identified sport as a type of PA, compared with only 24.9% who reported recognizing less-intense leisure activities.13 This suggests physiotherapists are more likely to promote sport as a suitable option for PA compared with other activities. However, adopting sport, or vigorous intensity activity, as a method to become physically active might be difficult for sedentary and unfit patients,13 potentially negatively impacting intervention efficacy and patient outcomes. Therefore, PLPA interventions might benefit from promoting less vigorous forms of PA.
Intervention and treatment fidelity (completeness and quality of intervention delivery) might influence outcomes of PLPA interventions.47 A meta-analysis examining the efficacy of motivational interviewing interventions to increase PA for people with chronic conditions demonstrated trials measuring treatment fidelity had larger effects.48 Inconsistencies around the true definition of fidelity and the ways monitoring is reported make examining fidelity difficult.49 In this review, 2 studies reported treatment fidelity40,43 by using recordings of treatment sessions or reviewing patient files. However, it is unclear how well this was completed. Physiotherapists have high PLPA intervention fidelity47; however, unless the tools used are well defined, it is unclear if implementation fidelity was high in the included studies. High intervention fidelity is likely to improve the efficacy of interventions intended to change behavior,50 such as PLPA interventions.
This review demonstrates longer PLPA interventions are not more efficacious than shorter interventions. Longer interventions are considered “high intensity” because they involve a larger number of contact hours. A review of PA promotion in primary care reviews found no clear associations between intervention intensity and efficacy.20 Intervention length can be negatively associated with theory-based PA intervention efficacy, meaning shorter interventions could result in larger increases in PA.51 In addition, shorter interventions tailored to the individual have been suggested as more effective than longer interventions.52 Thus, studies that report delivering 5-minute interventions rather than 2-year interventions might not be more or less efficacious just based on intervention intensity alone. Focusing on more than just length or intensity might be important when designing PLPA interventions.
The impact that intervention content has on efficacy must also be considered. It is important that PA promotion and adoption is treated as changing a behavior.53,54 Therefore, experimental studies should use content to support behavior change, such as behavior change techniques (BCTs), and incorporate behavioral and cognitive theories when designing interventions, instead of only focusing on intervention duration. Interventions using a theoretical base are reported to be more efficacious than those that do not.55,56 Six of the included studies reported using theory to design their interventions.38–43 However, our review demonstrates only one of these studies41 had consistent improvements in PA at all follow-up points, including long-term follow-up. Therefore, simply using theory might not be sufficient for efficacious outcomes and more attention might need to be paid to the way theory is used and implemented (ie, treatment fidelity) within intervention design.
Theory-based PA interventions significantly improve PA levels.57 A recent systematic review showed that exercise interventions using at least one BCT were more efficacious at increasing walking after stroke compared with interventions without BCTs.58 The Medical Research Council (United Kingdom) guidelines encourage incorporating theory into complex intervention design, such as designing behavior change interventions (eg, an intervention to assist a physically inactive patient become physically active).59 Designing PA interventions using theory-based strategies that are replicable and teachable to the physiotherapist in charge of delivering it is important. However, the design of these behavior change focused interventions can be time and resource consuming.60
Adequate training of healthcare professionals before and during intervention delivery is required for effective PA interventions.61 Four of 8 studies included in this review either did not report providing physiotherapists with intervention training or training lasted less than 1 day (Table 1). Having appropriate knowledge and skill to deliver PA interventions is likely to enhance delivery.62 Training for physiotherapists delivering interventions involving PA behavior change is especially important. Although physiotherapists seem to have the knowledge and skill to deliver PA interventions,7 they might not be trained to use psychology-based techniques required for behavior change interventions.63–65 This places large importance on providing appropriate training before intervention delivery.
Poor maintenance of PA can result in the loss of improvements seen after a PLPA intervention. Lack of attention toward maintenance of PA might contribute toward poor long-term effects.66 Interventions using techniques designed to support maintenance, such as self-monitoring and relapse prevention,67 might see PA improvements last longer. Only one study within this review showed a significant between-group difference favoring the intervention at increasing PA at long-term follow-up.41 The intervention included 5 of 7 techniques that can facilitate maintenance67 and provided booster sessions after the main intervention period. These maintenance-focused inclusions might be important to achieve long-term improvements and should be considered when designing efficacious PLPA interventions.
To be physically active, one must perform both aerobic and strengthening activities.3 Performing both of these activities is more efficacious than aerobic training alone for reducing cardiovascular risk factors and the odds of suffering multimorbidity.68,69 Therefore, it is important to address both activities when designing PLPA interventions. Only 338,40,43 of the 8 included studies reported using PA outcome measures that examined strength and aerobic activities. Therefore, the effect of PLPA interventions on recommended levels of both aerobic and strengthening activities together is unclear.
Few studies have examined the efficacy of one-on-one PLPA interventions to increase adult PA levels in clinic-based private practice, primary care, and outpatient settings. Future research should focus on intervention content design, utilizing behavior change theory and techniques, to support adoption and maintenance of physically active behaviors. Once designed, the efficacy of these interventions should be evaluated in high quality effectiveness and implementation trials with a focus on enhancing intervention fidelity and clinical (“real world”) integration of the intervention.70
The ability to replicate the intervention should be of prime importance when reporting the results of future interventions. The TIDieR checklist should be used to outline all intervention characteristics32 to enhance clarity and transparency regarding intervention design, delivery, and fidelity assessment to ensure sufficient information is provided to clinicians attempting to accurately replicate interventions clinically.
This review excluded studies with interventions conducted outside the clinic (eg, home based, telephone, and Internet) to ensure that conclusions were specific to clinic-based, face-to-face interventions. In addition, this review did not include studies conducted in inpatient settings, thus the findings of this review cannot be applied to these settings. Only 8 studies were identified for this review, with only 2 studies reporting dichotomous outcomes to calculate ORs. However, the broad search criteria and the use of citation tracking increased the chance that all relevant research was found.
Data extraction for key parameters was conducted by 2 investigators; however, it was not feasible to have 100% duplication and this might have influenced the interpretation of intervention content. The extraction of study results and bias risk was duplicated in full, meaning the results analysis is as accurate as possible. The risk of bias tool used for the pre–post study was the most appropriate and accessible tool to address bias risk in studies using this design; however, the validity of this tool is currently unclear. The statistical conversion of median and interquartile range to mean and standard deviation for 2 studies35,38 was not ideal but has, in simulations, been shown to be accurate.37
This systematic review and meta-analysis demonstrated that one-on-one PLPA interventions delivered in clinic-based private practice, primary care, or outpatient settings were efficacious at increasing adult PA levels. The odds of meeting minimum recommended PA levels were doubled, and low, moderate, and vigorous intensity PA levels were increased as a result of these interventions. However, improvements only remained in the short term and were not enhanced by increasing the length of the intervention. Future PLPA interventions should focus on intervention content, rather than length, in the design phase to enhance their efficacy. Finally, the importance of including strategies to enhance maintenance of PA improvements cannot be understated.
The authors thank statistician Marijke Welvaert for her help calculating PABAK in the R computer language.
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