Bewegungsförderung bei Menschen mit nichtübertragbaren Erkrankungen

Physical inactivity is one of the biggest public health problems of the 21st century. The global prevalence of physical inactivity was 27.5% in 2016, with 1.4 billion people inactive. Globally, physical inactivity accounts for 5-10% of the high burden of disease associated with noncommunicable diseases, causes 5.3 million premature deaths annually, and has an economic cost of $53.8 billion. Against this backdrop, promoting physical activity is both a key challenge and a strategy for health promotion. Reducing physical inactivity by 10% is one of the global targets of the World Health Organisation for preventing and controlling noncommunicable diseases. Efforts to promote physical activity are essential for people with noncommunicable diseases such as cardiovascular disease, cancer, diabetes, chronic obstructive pulmonary disease (COPD) or mental illness. Despite the proven comprehensive health effects of regular exercise, a physically inactive lifestyle is widespread among people with pre-existing conditions. At the same time, people with noncommunicable diseases form a large group in Germany, constituting around 40% of the adult population, which will continue to grow in the future. This postdoctoral thesis aims to contribute to the promotion of a physically active lifestyle in people with noncommunicable diseases. Twenty-two publications on the three overarching topics of physical activity recommendations, physical activity behaviour and exercise therapy are included, which address a broad spectrum of content and use a variety of scientific approaches and methods. The results of this habilitation thesis include the following: 1.) The conceptual development of national recommendations for physical activity and physical activity promotion for adults with noncommunicable diseases; dissemination of these recommendations using a participatory approach; and complementary analysis of the development, dissemination, and implementation of the recommendations. 2.) An epidemiological analysis of the physical activity behaviour of adults with noncommunicable diseases in Germany. 3.) The elaboration of non-linear dose-response relationships of physical activity and mortality for people with noncommunicable diseases based on a systematic review with meta-analysis. 4.) A randomised controlled efficacy analysis of the long-term physical activity-promoting effects of a pedometer-based behavioural intervention in pulmonary rehabilitation for patients with chronic obstructive pulmonary disease, as well as prediction of their physical activity trajectories six weeks and six months after the rehabilitation measure based on the integrative model of physical activity-related health competency. 5.) The development of a national inventory of exercise therapy in medical rehabilitation with a view on both the facility and actor level, in each case focusing on promoting physical activity. The results of this work (a) confirm the health-promoting benefits of physical activity, (b) increase our knowledge on the actual level of physical activity and make it possible to define particularly inactive target groups, (c) improve our understanding of the person-related determinants of physical activity behaviour of adults with noncommunicable diseases, (d) lay the foundation for the further systematic development and optimisation of exercise therapy, (e) help inform people with noncommunicable diseases about the health-promoting benefits of physical activity, (f) provide action orientation for health professionals in the field of promoting physical activity, (g) support the development of physical activity-promoting policies, and (h) facilitate networking for promoting physical activity. This work strengthens the evidence for the successful promotion of physical activity for people with noncommunicable diseases. This work has implications for adults with noncommunicable diseases, exercise therapists, physical therapists, physicians and other health professionals involved in physical activity promotion and exercise therapy, responsible persons in the health system, and policy makers. Overall, this postdoctoral thesis provides multiple impulses for promoting physical activity at the individual, organisational, and political levels and contributes to the success of future efforts promoting physical activity for people with noncommunicable diseases.Die hohe Prävalenz körperlicher Inaktivität stellt ein globales Problem dar, das zu steigender Morbidität beiträgt und jährlich 5,3 Millionen frühzeitige Todesfälle sowie ökonomische Kosten von 53,8 Milliarden US-Dollar verursacht. Die Entwicklung von Strategien der Bewegungsförderung ist vor diesem Hintergrund eine zentrale Herausforderung. Bewegungsförderung ist eine zentrale Strategie der Gesundheitsförderung; die Reduktion körperlicher Inaktivität um 10 % ist eines der Kernziele der Weltgesundheitsorganisation (WHO) zur Prävention und Kontrolle nichtübertragbarer Erkrankungen. Bemühungen zur Bewegungsförderung sind bei Menschen mit nichtübertragbaren Erkrankungen wie Herzkreislauferkrankungen, Krebserkrankungen, Diabetes, chronisch obstruktiver Lungenerkrankung (COPD) oder psychischen Erkrankungen von besonderer Bedeutung. Trotz der nachgewiesenen umfassenden Gesundheitswirkungen regelmäßiger Bewegung ist ein körperlich inaktiver Lebensstil bei Menschen mit Vorerkrankungen weit verbreitet. Gleichzeitig bilden Menschen mit nichtübertragbaren Erkrankungen in Deutschland mit rund 40 % der erwachsenen Bevölkerung eine große Personengruppe, die in Zukunft aller Voraussicht nach weiter anwachsen wird. Die vorliegende kumulative Habilitationsschrift widmet sich dem Thema Bewegungsförderung bei Menschen mit nichtübertragbaren Erkrankungen. Die Arbeit möchte einen Beitrag dazu leisten, körperlich aktive Lebensstile bei Menschen mit nichtübertragbaren Erkrankungen erfolgreich zu fördern. Hierfür werden 22 Einzelbeiträge zu den drei übergeordneten Themenbereichen Bewegungsempfehlungen, Bewegungsverhalten und Bewegungstherapie eingebracht, die ein breites inhaltliches Spektrum adressieren und vielfältige wissenschaftliche Ansätze und Methoden nutzen. Die zentralen Arbeitsergebnisse der Habilitationsschrift beinhalten: 1.) Die konzeptionelle Entwicklung von Nationalen Empfehlungen für Bewegung und Bewegungsförderung für Erwachsene mit nichtübertragbaren Erkrankungen, die Dissemination dieser Empfehlungen mittels eines Beteiligungsansatzes sowie die ergänzende analytische Betrachtung der Entwicklung, Dissemination und Implementierung der Empfehlungen. 2.) Eine epidemiologische Analyse zum Bewegungsverhalten von Erwachsenen mit nichtübertragbaren Erkrankungen in Deutschland. 3.) Die Herausarbeitung nichtlinearer Dosis-Wirkungs-Beziehungen zwischen körperlicher Aktivität und Mortalität für Menschen mit nichtübertragbaren Erkrankungen auf Basis einer systematischen Übersichtsarbeit. 4.) Eine randomisierte kontrollierte Wirksamkeitsanalyse zu den langfristigen bewegungsförderlichen Effekten einer Schrittzähler-basierten Verhaltensintervention im Rahmen der pneumologischen Rehabilitation für Rehabilitandinnen und Rehabilitanden mit COPD sowie die Prädiktion deren körperlicher Aktivitätsverläufe sechs Wochen und sechs Monate nach der Rehabilitationsmaßnahme, basierend auf dem integrativen Modell der Bewegungsbezogenen Gesundheitskompetenz. 5.) Die Erarbeitung einer nationalen Bestandsaufnahme der Bewegungstherapie in der medizinischen Rehabilitation mit Blick sowohl auf die Einrichtungs- als auch auf die Akteursebene, jeweils mit besonderem Fokus auf das Ziel der Bewegungsförderung Die Ergebnisse dieser Arbeit a) bestätigen den hohen gesundheitsförderlichen Nutzen körperlicher Aktivität, b) erweitern das Wissen über das tatsächliche Ausmaß an körperlicher Aktivität bei Menschen mit nichtübertragbaren Erkrankungen und ermöglichen es, besonders inaktive Subgruppen zu definieren, c) verbessern das Verständnis zu den personbezogenen Determinanten des Bewegungsverhaltens von Menschen mit Vorerkrankungen, d) legen die Grundlage für die systematische Weiterentwicklung und Optimierung einer bewegungsförderlichen Bewegungstherapie, e) geben Handlungsorientierung für Gesundheitsfachberufe im Bereich der Bewegungsförderung, f) unterstützen die Entwicklung bewegungsförderlicher Politik und g) begünstigen die Netzwerkbildung für Bewegungsförderung. In der Summe stärkt diese Arbeit die Evidenzbasis für erfolgreiche Bewegungsförderung bei Menschen mit nichtübertragbaren Erkrankungen. Diese Arbeit bietet relevante Erkenntnisse für Erwachsene mit nichtübertragbaren Erkrankungen, Bewegungstherapeutinnen und -therapeuten, Ärztinnen und Ärzte sowie andere Gesundheitsfachkräfte, die sich mit Bewegungsförderung und Bewegungstherapie befassen, wie auch für Entscheidungsträgerinnen und träger im Gesundheitswesen und in der Politik. In ihrer Gesamtheit setzt diese Habilitationsschrift vielfältige Impulse für Bewegungsförderung auf individueller, organisationaler sowie politischer Ebene und kann dazu beitragen, zukünftige Bemühungen der Bewegungsförderung bei Menschen mit nichtübertragbaren Erkrankungen erfolgreich zu gestalten

Aufbau eines körperlich aktiven Lebensstils in der Rehabilitation chronischer Erkrankungen: Verhaltensbezogene Bewegungstherapie und die Bedeutung der affektiven Einstellungskomponente gegenüber Sporttreiben

Promoting regular physical activity in rehabilitation is a key for the long term success of rehabilitation interventions. The beneficial effects of exercise have led to a general adoption of exercise therapy in the rehabilitation of chronic conditions. Nevertheless, adherence to exercise programmes and long-term physical activity behaviour changes are often low. The doctoral thesis “Promoting regular physical activity in rehabilitation” addresses 1. the conceptual development of an ICF-based behavioural exercise therapy (BET) and 2. the integration of exercise-related affective associations into the Health Action Process Approach (HAPA) to better predict long-term physical activity behaviour changes amongst individuals with obesity and type 2 diabetes subsequent to an exercise-based rehabilitation. In summary, this doctoral thesis advances the understanding of physical activity behaviour changes, offers explicit methods and contents for physical therapists to promote physical activity behaviour, and introduces the ICF-based conceptual idea of a behavioural exercise therapy. Some parts of this doctoral thesis are available as a pre-release in English: “Geidl, W., Semrau, J. & Pfeifer, K. (2014). Health behaviour change models and theories: contributions to an ICF-based behavioural exercise therapy for individuals with chronic diseases (BET). In: Disability and Rehabilitation, 36(24), 2091-2100.“Der Schlüssel zur Erreichung der Rehabilitationsziele und einer nachhaltigen Gesundheitsförderung bei Menschen mit chronischen Krankheiten ist die Förderung eines angemessenen Gesundheitsverhaltens. Den Ausgangspunkt dieser Arbeit bildet die als verbesserungswürdig charakterisierte Wirksamkeit bewegungsbezogener Rehabilitationsmaßnahmen bezüglich überdauernder Änderungen des Bewegungsverhaltens. Im Rahmen der Dissertation „Aufbau eines körperlich aktiven Lebensstil in der Rehabilitation chronischer Erkrankungen“ werden zwei übergeordnete Problemstellungen bearbeitet: 1. Konzeptionelle Entwicklung einer verhaltensbezogenen Bewegungstherapie (VBT) und deren Einbettung in ein ICF-basiertes Rahmenkonzept sowie 2. Integration der affektiven Einstellungskomponente gegenüber Sporttreiben innerhalb des sozial-kognitiven Prozessmodells des Gesundheitsverhaltens bei Menschen mit Typ 2 Diabetes und/oder Adipositas im Setting der Rehabilitation. Zusammenfassend leistet diese Arbeit einen Beitrag dazu, das Bewegungsverhalten von Menschen mit chronischen Erkrankungen besser zu verstehen und die Wirksamkeit bewegungsbezogener Rehabilitationsmaßnahmen bzgl. überdauernder Bewegungsverhaltensänderungen zu erhöhen

Physical activity promotion in daily exercise therapy: the perspectives of exercise therapists in German rehabilitation settings

Background This study aims to explore exercise therapists’ perspectives on the topic of physical activity promotion (PAP) with a focus on identifying (i) the intervention content and methodological approaches used for promoting physical activity (PA) in daily practice and (ii) the barriers and facilitators that affect PAP. Methods This qualitative study comprised the heads of exercise therapy departments (n = 58; 41% women; mean age = 45 years) from different rehabilitation clinics in Germany. Each participant took part in a semi-structured focus-group discussion on PAP in exercise therapy. The findings of the focus groups were processed and interpreted using a conventional qualitative content analysis. Results The exercise therapists demonstrated detailed didactic–methodological strategies and action orientations for PAP. The identified core topics of the content and methods of PAP were (1) conceptualization, (2) exercise and PA for enjoyment and pleasure, (3) education with practice–theory combinations, (4) media and materials for self-directed training, and (5) strategies to enhance personal responsibility and independence. The core topics for the associated barriers and facilitators were (1) structural conditions, (2) the role of exercise therapists, (3) the interdisciplinary rehabilitation team, (4) rehabilitant experiences and expectations, and (5) aftercare services. Conclusion The topic of PAP is addressed with a high level of variability; exercise therapists involved in this study identify various methods and content for the promotion of PA within their individual practices. However, they display a limited awareness of existing evidence- and theory-based concepts for the promotion of PA as well as underlying theories of behavioural change. This variability may be due to the lack of a defined common framework for promoting PA, insufficient emphasis being placed on PA promotion in the current curricula and training, or extensive conceptual differences within German exercise therapy departments (e.g. different weighting of PAP)

Dose–response relationship between physical activity and mortality in people with non-communicable diseases: a study protocol for the systematic review and meta-analysis of cohort studies

Introduction This study protocol outlines our planned systematic review and dose-response meta-analysis of postdiagnosis physical activity and mortality in people with non-communicable diseases (NCDs). Methods and analysis This study is based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Protocols. A systematic literature search will be conducted in various databases—namely, PubMed, Scopus and Web of Science—by two researchers in order to identify prospective observational studies that investigate postdiagnosis physical activity or activity-related energy expenditure and mortality in individuals with NCDs. The target population is adults (≥18 years of age) with one of the following nine NCDs: low back pain, type 2 diabetes mellitus, osteoarthritis, depressive disorder, chronic obstructive pulmonary disease, breast cancer, lung cancer, stroke or ischaemic heart disease. We will focus on all-cause mortality as the primary outcome and investigate indication-specific mortality as the secondary outcome. For each study identified as a result of the literature search, we will conduct graphical dose-response analyses of mortality as a function of activity-related energy consumption. If more than two studies are available for one disease, we will perform linear and non-linear dose-response meta-analyses for said disease using random-effects models. We will investigate the heterogeneity of the studies and publication bias. To assess the risk of bias and the quality of the included studies, we will use the Risk Of Bias In Non-randomised Studies - of Interventions tool, which is a Cochrane tool

Exercise Therapy Teamwork in German Rehabilitation Settings: Results of a National Survey Using Mixed Methods Design

A key prerequisite for implementing biopsychosocial exercise therapy concepts as parts of multimodal rehabilitation programs is interprofessional teamwork. Based on a nationwide survey of exercise therapy using a mixed methods design, it is of interest to determine to what extent there are links between team-related processes (e.g., interprofessional exchange) and structural features of the exercise therapy departments (e.g., department size) and the individual rating of interprofessional teamwork. The first part of the study involved a questionnaire-based survey, where exercise therapy heads of 1146 rehabilitation facilities were contacted. In the second part of the study, 58 exercise therapy heads held discussions in six focus groups. The results from both parts showed that interprofessional teamwork was rated positively overall. Team meetings were seen as the central platform for exchange. However, particularly in larger facilities, the hierarchical position of medical management and lacking resources were negatively associated with interprofessional exchange. The results affirm empirically that a more binding provision of adequate structural and organizational conditions, such as sufficient time slots for liaising on content, are essential for effective teamwork. This would facilitate and improve the promotion of physical activity in multimodal rehabilitation programs

Effects of behavioural exercise therapy on the effectiveness of a multidisciplinary rehabilitation for chronic non-specific low back pain: Study protocol for a randomised controlled trial

Background In Germany, a multidisciplinary rehabilitation named “behavioural medical rehabilitation” (BMR) is available for treatment of chronic low back pain (clbp). A central component of BMR is standard exercise therapy (SET), which is directed mainly to improve physical fitness. There is a need to address psychosocial factors within SET and therefore to improve behavior change with a focus on the development of self-management skills in dealing with clbp. Furthermore, short-term effectiveness of BMR with a SET has been proven, but the impact of a behavioural exercise therapy (BET) for improvement of the long-term effectiveness of BMR is unclear. Methods/design To compare the effectiveness of two exercise programs with different approaches within BMR on the effects of BMR a prospective randomized controlled trial (RCT) in two rehabilitation centres will be performed. 214 patients aged 18–65 with clbp will be, based on an urn randomisation-algorithm, randomly assigned to a BMR with SET (function-oriented, n=107) and BMR with BET (behaviour-oriented, n=107). Both exercise programs have a mean duration of 26 hours in three weeks and are delivered by a limited number of not-blinded study therapists in closed groups with six to twelve patients who will be masked regarding study group. The main differences of BET lie in its detailed manualised program with a theory-based, goal-orientated combination of exercise, education and behavioural elements, active participation of patients and consideration of their individual preferences and previous experiences with exercise. The primary outcome is functional ability assessed with the Hannover Functional Ability Questionnaire directly before and after the rehabilitation program, as well as a six and twelve-month follow-up. Discussion This RCT is designed to explore the effects of BET on the effectiveness of a BMR compared to a BMR with SET in the management of patients with clbp. Methodological challenges arise from conducting a RCT within routine health care as well as from ensuring high treatment integrity. Findings of this study might contribute to a better understanding of the mechanism of action of BMR and the special effects of BET and may be used to improve the quality of these interventions in routine care, therefore reducing the burden to patients with disabling clbp

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs). Methods The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs. Results The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs. Conclusion The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations

Physical Activity and Sedentary Behaviour Patterns in 326 Persons with COPD before Starting a Pulmonary Rehabilitation: A Cluster Analysis

This study applies a cluster analysis to identify typical physical activity (PA) and sedentary behaviour (SB) patterns in people with chronic obstructive pulmonary disease (COPD) before starting pulmonary rehabilitation (PR). We implemented an observational design which assessed baseline data of objectively measured PA and SB from the STAR (Stay Active after Rehabilitation) study. A total of 355 persons wore an accelerometer (Actigraph wGT3X) for seven days before the start of their PR. Sociodemographic and disease-related parameters were assessed at the start of PR. We applied cluster analysis and compared clusters applying univariate variance analyses. Data was available for 326 persons (31.6% women; age ø = 58 years). Cluster analysis revealed four movement clusters with distinct PA and SB patterns: Sedentary non-movers (28.5%), sedentary occasional movers (41.7%), sedentary movers (19.6%), and sedentary exercisers (10.1%). The four clusters displayed varying levels of moderate PA before rehabilitation (Ø daily min: 9; 28; 38; 70). Notably, all four clusters displayed considerably long average sedentary time per day (Ø daily minutes: 644; 561; 490; 446). The clusters differed significantly in disease-related parameters of GOLD severity, FEV1, CAT, and 6-Min-Walk-Test. In addition to PA promotion, PR programs should consider the reduction of sedentary behaviour as a valuable goal

Impact of Disease-Specific Fears on Pulmonary Rehabilitation Trajectories in Patients with COPD

Disease-specific fears predict health status in chronic obstructive pulmonary disease (COPD), but their role in pulmonary rehabilitation (PR) remains poorly understood and especially longer-term evaluations are lacking. We therefore investigated changes in disease-specific fears over the course of PR and six months after PR, and investigated associations with PR outcomes (COPD assessment test (CAT) and St. Georges respiratory questionnaire (SGRQ)) in a subset of patients with COPD (n = 146) undergoing a 3-week inpatient PR program as part of the STAR study (Clinicaltrials.gov, ID: NCT02966561). Disease-specific fears as measured with the COPD anxiety questionnaire improved after PR. For fear of dyspnea, fear of physical activity and fear of disease progression, improvements remained significant at six-month follow-up. Patients with higher disease-specific fears at baseline showed elevated symptom burden (CAT and SGRQ Symptom scores), which persisted after PR and at follow-up. Elevated disease-specific fears also resulted in reduced improvements in Quality of Life (SGRQ activity and impact scales) after PR and at follow-up. Finally, improvement in disease-specific fears was associated with improvement in symptom burden and quality of life. Adjustment for potential confounding variables (sex, smoking status, age, lung function, and depressive symptoms) resulted in comparable effects. These findings show the role of disease-specific fears in patients with COPD during PR and highlight the need to target disease-specific fears to further improve the effects of PR

A life span perspective on competencies for a healthy, physically active lifestyle: Findings of a data pooling initiative with over 7000 individuals.

Individuals are recommended to lead active lifestyles throughout the life course. The model of physical activity-related health competence (PAHCO) adopts a competence approach by integrating physical, cognitive, and motivational determinants for health-enhancing PA (movement competence, control competence, self-regulation competence). Drawing on a comprehensive dataset pooling, the goal of the present study was to model the idiosyncratic courses of 10 PAHCO indicators over the life span. We identified studies that empirically operationalized PAHCO, combining data of 7134 individuals (age range: 15-97 years; 61% female) from 18 different populations (prevention and rehabilitation sectors). We applied a stepwise multilevel analysis approach with disjunct sub-samples (n = 48) to examine linear and quadratic associations between age and PAHCO. Indicators of movement competence (i.e., manageability of endurance, strength, and balance demands; task-specific self-efficacy) congruently showed negative associations with age (0.054 ≤   ≤ 0.211). However, parameters of control competence remained stable across the life span (-0.066 ≤ β ≤ 0.028). The three indicators of self-regulation competence revealed an inconsistent relationship with age, though uncovering positive associations for self-control (β = 0.106) and emotional attitude toward PA (β = 0.088). The associations of some indicators varied significantly across sub-samples. The results suggest differential analyses for associations between PAHCO and age. While the physically determined PAHCO indicators (movement competence) probably decline across the life span, the ability to ensure regularity of PA (self-regulation competence) or align PAs with an individual's health (control competence) appear to remain constant or improve with increasing age. The findings reinforce a de-stigmatizing approach for PA promotion practices with considerable space for aligning activities with health also in the elderly