Paediatric Respiratory Reviews 15 (2014) 237–239
Contents lists available at ScienceDirect
Paediatric Respiratory Reviews
Interventions to promote physical activity in people with cystic ﬁbrosis N.S. Cox 1,*, J.A. Alison 2, A.E. Holland 1,3 1 2 3
School of Physiotherapy, La Trobe University, Melbourne, Australia Clinical and Rehabilitation Sciences, Faculty of Health Sciences, University of Sydney, Sydney, Australia Department of Physiotherapy, Alfred Health, Melbourne, Australia
WHY DO WE NEED THIS REVIEW? Participation in regular physical activity can confer numerous health beneﬁts for the general population, including reducing the risk of cardiovascular disease, and improving mental health and quality of life . For most people with cystic ﬁbrosis (CF) physical activity and exercise participation are routinely recommended as these can afford health beneﬁts including enhanced clearance of pulmonary secretions, and improved blood glucose control and bone mineral accretion . Despite this, participation in prescribed physical activity programs is often poor . The best way to encourage people with CF to participate in more physical activity is unclear. The aim of the review was to evaluate the effect of interventions to increase physical activity participation in people with CF . WHAT COMPARISIONS DID WE MAKE IN THE REVIEW? Interventions to promote physical activity in both the inpatient and outpatient setting were included. In studies where the intervention commenced in the inpatient setting, follow up in the discharge period was deemed necessary to evaluate the effects of the intervention on activity levels in daily life. Potential interventions included (but were not limited to) one-to-one physical activity counseling or advice; supervised or unsupervised exercise programs; or telerehabilitation. We identiﬁed 17 potentially eligible studies of strategies to promote increased physical activity participation in daily life in children or adults with CF. Four randomized controlled trials (RCTs) were included in the review [4–7]. A further two studies (published as abstracts) will be assessed for inclusion in future
* Corresponding author. http://dx.doi.org/10.1016/j.prrv.2014.05.001 1526-0542/ß 2014 Elsevier Ltd. All rights reserved.
reviews if they are published in full. The four included studies had a total of 191 participants with a mean (SD) participant age ranging from 13.2  years to 19.5  years, and a mean FEV1% predicted ranging from 57% predicted  to 89% predicted . Two authors independently assessed studies for inclusion. Authors of included studies were contacted for additional information. It was intended to undertake subgroup analyses for activity promotion strategies targeting children versus those for adults, and for supervised interventions versus unsupervised interventions; however, the small number of included trials prevented such analyses. Data are reported by type of intervention (supervised versus unsupervised) and categorised according to the timepoint at which follow-up data were reported. These time categories were: Less than or equal to one month (short term) From one to six months; and Greater than six months.
WHAT DID WE FIND? The studies were predominantly conducted in children with CF, with only one study having a combined cohort of adult and paediatric participants. One study was conducted in an inpatient setting with follow up in the outpatient setting , while the remaining three studies were conducted in individuals with stable respiratory disease in the outpatient setting [4,5,7]. All included studies used exercise training to promote participation in physical activity, with the duration of the intervention period ranging from 18 days to three years. None of the included studies were primarily designed to increase participation in physical activity, but rather assessed the effect of the exercise training intervention on a range
N.S. Cox et al. / Paediatric Respiratory Reviews 15 (2014) 237–239
Figure 1. Comparison 1 Supervised exercise training compared to no intervention, Outcome 1 Participation in physical activity (MJ/day).
Figure 2. Comparison 1: Supervised exercise training compared to no intervention; Outcome 4 Change in FEV1 (% predicted).
N.S. Cox et al. / Paediatric Respiratory Reviews 15 (2014) 237–239
of outcomes which included participation in physical activity. Judgments of risk of bias were largely classiﬁed as ‘‘unclear’’ as the description of the study methods was inadequate to assess the risk of bias, particularly with regard to blinding of assessors and selective reporting. The primary outcomes of interest for the review were objective or subjective assessment of participation in physical activity (expressed as change from baseline where possible) and participant reported health related quality of life. No improvement in physical activity participation was reported with any intervention period less than or equal to six months (Figure 1). Improvements in physical activity participation were only seen with activity counseling and exercise advice to undertake a home exercise program where follow up occurred beyond 12 months. There was no signiﬁcant impact on quality of life from any of the intervention strategies. The secondary outcomes included measures of exercise capacity, pulmonary function, body composition and bone mineral density, adherence to the intervention and compliance with other CF treatments during the intervention, adverse outcomes and cost analysis. There was some limited evidence of an effect of exercise training on pulmonary function. In-hospital resistance training resulted in signiﬁcant improvements in FEV1 at hospital discharge and one-month following discharge when compared to participants in a no-intervention control group  (Figure 2), while there was a trend for greater annual decline in FEV1 in the nointervention control group compared to participants undertaking a 3-year home exercise program . IMPLICATIONS FOR PRACTICE? This review provides very limited evidence that activity counselling and exercise advice, undertaken over at least six months, may result in improved physical activity participation in people with CF. All included studies in this review assessed exercise training interventions only and were conducted in
relatively young people with CF. The outcomes reported were variable and we were unable to calculate any pooled effects. Thus from this review it is difﬁcult to draw any strong conclusions regarding the most effective strategies to promote the uptake and the continued participation in physical activity for this population. Since participation in physical activity is generally regarded as beneﬁcial for people with CF, further research is needed to determine the effect of strategies such as health coaching or telemedicine applications in promoting the uptake and adherence to regular participation in physical activity. In addition, future research may focus on identifying whether activity promotion strategies work equally well for different groups, such as males compared to females, children compared to adults, and severe CFlung disease compared to mild or moderate disease. In collaboration with the Cochrane CF and Genetic Disorders Group’ http://cfgd.cochrane.org/. References  WHO. Global recommendations for physical activity and health. Geneva: WHO Library Cataloguing-in-Publication Data; 2010.  Bradley J, Moran F. Physical training for Cystic ﬁbrosis. Cochrane Database of Systematic Reviews. 2008; 2008(1). Art. No.: CD002768.  Cox N, Alison JA, Holland AE. Interventions for promoting physical activity in people with cystic ﬁbrosis. Cochrane Database of Systematic Reviews 2013 (Issue 12). Epub 13 December 2013. Art. No.: CD009448.  Schneiderman-Walker J, Pollock SL, Corey M, Wilkes DD, Canny GJ, Pedder L, et al. A randomized controlled trial of a 3-year home exercise program in cystic ﬁbrosis. Journal of Pediatrics 2000 Mar;136(3):304–10. PubMed PMID: 10700685.  Hebestreit H, Kieser S, Junge S, Ballmann M, Hebestreit A, Schindler C, et al. Long-term effects of a partially supervised conditioning programme in cystic ﬁbrosis. European Respiratory Journal 2010;35(3):578–83.  Selvadurai HC, Blimkie CJ, Meyers N, Mellis CM, Cooper PJ, Van Asperen PP. Randomized controlled study of in-hospital exercise training programs in children with cystic ﬁbrosis. Pediatr Pulmonol 2002 Mar;33(3):194–200. PubMed PMID:11836799. Epub 2002/02/12.eng.  Klijn PHC, Oudshoorn A, van der Ent CK, van der Net J, Kimpen JL, Helders PJM. Effects of Anaerobic Training in Children With Cystic Fibrosis*. Chest 2004;125(4):1299–305.
In collaboration with the Cochrane CF and Genetic Disorders Group’ http://cfgd.cochrane.org/.