The association of diet quality and physical activity with cardiovascular disease and mortality in 85,545 older Australians: A longitudinal study.

BACKGROUND: A quality diet and an active lifestyle are both important cornerstones of cardiovascular disease (CVD) prevention. However, despite their interlinked effects on metabolic health, the 2 behaviors are rarely considered jointly, particularly within the context of CVD prevention. We examined the independent, interactive, and joint associations of diet and physical activity with CVD hospitalization, CVD mortality, and all-cause mortality. METHODS: CVD-free Australian participants aged 45-74 years (n = 85,545) reported physical activity, diet, and sociodemographic and lifestyle characteristics at baseline (2006-2009) and follow-up (2012-2015), and data were linked to hospitalization and death registries (03/31/2019 for CVD hospitalization and all-cause mortality and 12/08/2017 for CVD mortality). Diet quality was categorized as low, medium, and high based on meeting dietary recommendations. Physical activity was operationalized as (a) total moderate-to-vigorous physical activity (MVPA) as per guidelines, and (b) the composition of MVPA as the ratio of vigorous-intensity physical activity (VPA) to total MVPA. We used a left-truncated cause-specific Cox proportional hazards model using time-varying covariates. RESULTS: During a median of 10.7 years of follow-up, 6576 participants were admitted to the hospital for CVD and 6581 died from all causes (876 from CVD during 9.3 years). A high-quality diet was associated with a 17% lower risk of all-cause mortality than a low-quality diet, and the highest MVPA category (compared with the lowest) was associated with a 44% and 48% lower risk of CVD and all-cause mortality, respectively. Multiplicative interactions between diet and physical activity were non-significant. For all outcomes, the lowest risk combinations involved a high-quality diet and the highest MVPA categories. Accounting for total MVPA, some VPA was associated with further risk reduction of CVD hospitalization and all-cause mortality. CONCLUSION: For CVD prevention and longevity, one should adhere to both a healthy diet and an active lifestyle and incorporate some VPA when possible.

Validity of the Active Australia Survey in an Australian cardiac rehabilitation population.

OBJECTIVES: To examine the long-term validity of the Active Australia Survey in a cardiac rehabilitation population using accelerometry as the reference measure. DESIGN: Cohort validation study. METHODS: Cardiac rehabilitation participants with coronary heart disease were recruited to a prospective cohort study. Over 7-days, 61 participants wore an ActiGraph ActiSleep accelerometer (1-second epoch, 10-minute bout) and completed the self-administered Active Australia Survey at baseline, 6-weeks, 6 and 12-months. Total daily moderate-to-vigorous physical activity from both methods was compared using Bland-Altman plots and Spearman rank-order correlations. RESULTS: Participants tended to over-report moderate-to-vigorous physical activity, with more active participants more likely to over-report moderate-to-vigorous physical activity. There was a good level of agreement between the accelerometer 1-second epochs and Active Australia Survey at all time points (mean bias (ratio) 1.04, 1.16, 1.14, and 1.06, respectively), with weak-moderate correlations (ρ = 0.3-0.48). Conversely, there was a poor level of agreement between the accelerometer 10-minute bouts and Active Australia Survey at all time points (mean bias (ratio) 6.78, 9.09, 6.35, and 5.68, respectively), with weak-moderate correlations (ρ = 0.3-0.52). Agreement between the two measures did not improve over time for both 1-second and 10-minute bout accelerometry data. CONCLUSIONS: The Active Australia Survey may be an acceptable self-report measure of moderate-to-vigorous physical activity in cardiac rehabilitation attendees when capturing any time spent in moderate-to-vigorous physical activity. The Active Australia Survey may be useful to routinely monitor physical activity levels over-time in Australian cardiac rehabilitation programs at both individual and group levels. TRIAL REGISTRATION: Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx.

Activity counseling early postelective percutaneous coronary intervention (ACE-PCI): Mixed-methods pilot randomized controlled trial.

Background: Physical activity (PA) levels of people with coronary heart disease are low in the first 30 days after percutaneous coronary intervention (PCI), increasing the risk of recurrent cardiac events. Following PCI, PA counseling delivered by a physiotherapist before discharge may increase the PA levels of patients. Preliminary work is required to determine the effects of the counseling session compared to usual care. Objectives: To investigate the feasibility and potential efficacy of a brief physiotherapist-led PA counseling session immediately after an elective PCI compared to usual care for improved PA early post-PCI. Methods: Using concealed allocation and blinded assessments, eligible participants (n = 30) were randomized to a physiotherapist-led PA counseling session (30 min) or usual care (nurse-led PA advice < 5 min). The primary outcome was daily minutes of moderate-to-vigorous PA (accelerometry; 3 weeks). Secondary outcomes included cardiac rehabilitation intention, anxiety and depression levels (Hospital Anxiety and Depression Scale), and quality-of-life (MacNew questionnaire). Recruitment, retention, and attrition were assessed for feasibility. Semistructured interviews were conducted with 13 participants to determine intervention acceptability, and barriers and enablers to PA. Results: Between and within-group comparisons were not significant in intention-to-treat analyses. All feasibility criteria were met except for retention and attrition of participants. At 3 weeks, only 25% of participants were planning to attend cardiac rehabilitation, with no between-group differences. Increased PA at 3 weeks was associated with participants that were younger, without other chronic disease,s and more active immediately following discharge. Interviews revealed personal, environmental, and program-based themes for barriers and enablers to PA. Conclusions: A physiotherapist-led PA counseling session may not improve PA levels early post-elective PCI compared to very brief PA advice delivered by nurses. A larger multicentre randomized controlled trial is feasible with minor modifications to participant follow-up. Further research is required.

Very brief intervention for physical activity behaviour change in cardiac rehabilitation: protocol for the 'Measure It!' effectiveness-implementation hybrid trial.

INTRODUCTION: Physical inactivity is a risk factor for repeat cardiac events and all-cause mortality in coronary heart disease (CHD). Cardiac rehabilitation, a secondary prevention programme, aims to increase physical activity levels in this population from a reported low baseline. This trial will investigate the effectiveness and implementation of a very brief physical activity intervention, comparing different frequencies of physical activity measurement by cardiac rehabilitation clinicians. The Measure It! intervention (<5 min) includes a self-report and objective measure of physical activity (steps) plus very brief physical activity advice. METHODS AND ANALYSIS: This type 1 hybrid effectiveness-implementation study will use a two-arm multicentre assessor-blind randomised trial design. Insufficiently active (<150 min of moderate-to-vigorous physical activity per week) cardiac rehabilitation attendees with CHD (18+ years) will be recruited from five phase II cardiac rehabilitation centres (n=190). Patients will be randomised (1:1) to five physical activity measurements or two physical activity measurements in total over 24 weeks. The primary effectiveness outcome is accelerometer daily minutes of moderate-to-vigorous intensity physical activity at 24 weeks. Secondary effectiveness outcomes include body mass index, waist circumference and quality-of-life. An understanding of multilevel contextual factors that influence implementation, and antecedent outcomes to implementation of the intervention (eg, feasibility and acceptability), will be obtained using semistructured interviews and other data sources. Linear mixed-effects models will be used to analyse effectiveness outcomes. Qualitative data will be thematically analysed inductively and deductively using framework analysis, with the framework guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. ETHICS AND DISSEMINATION: The study has ethical approval (University of Canberra (ID 11836), Calvary Bruce Public Hospital (ID 14-2022) and the Greater Western Area (ID 2022/ETH01381) Human Research Ethics Committees). Results will be disseminated in multiple formats for consumer, public and clinical audiences. TRIAL REGISTRATION NUMBER: ACTRN12622001187730p.

Testing the Effect of a Smartphone App on Hospital Admissions and Sedentary Behavior in Cardiac Rehabilitation Participants: ToDo-CR Randomized Controlled Trial.

BACKGROUND: People with coronary heart disease are at an increased risk of morbidity and mortality even if they attend cardiac rehabilitation. High sedentary behavior levels potentially contribute to this morbidity. Smartphone apps may be feasible to facilitate sedentary behavior reductions and lead to reduced health care use. OBJECTIVE: We aimed to test the effect of a sedentary behavior change smartphone app (Vire app and ToDo-CR program) as an adjunct to cardiac rehabilitation on hospital admissions and emergency department (ED) presentations over 12 months. METHODS: A multicenter, randomized controlled trial was conducted with 120 participants recruited from 3 cardiac rehabilitation programs. Participants were randomized 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and ToDo-CR program (intervention) or usual care (control). The primary outcome was nonelective hospital admissions and ED presentations over 12 months. Secondary outcomes including accelerometer-measured sedentary behavior, BMI, waist circumference, and quality of life were recorded at baseline and 6 and 12 months. Logistic regression models were used to analyze the primary outcome, and linear mixed-effects models were used to analyze secondary outcomes. Data on intervention and hospital admission costs were collected, and the incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS: Participants were, on average, aged 62 (SD 10) years, and the majority were male (93/120, 77.5%). The intervention group were more likely to experience all-cause (odds ratio [OR] 1.54, 95% CI 0.58-4.10; P=.39) and cardiac-related (OR 3.26, 95% CI 0.84-12.55; P=.09) hospital admissions and ED presentations (OR 2.07, 95% CI 0.89-4.77; P=.09) than the control group. Despite this, cardiac-related hospital admission costs were lower in the intervention group over 12 months (Aus $252.40 vs Aus $859.38; P=.24; a currency exchange rate of Aus $1=US $0.69 is applicable). There were no significant between-group differences in sedentary behavior minutes per day over 12 months, although the intervention group completed 22 minutes less than the control group (95% CI -22.80 to 66.69; P=.33; Cohen d=0.21). The intervention group had a lower BMI (ß=1.62; P=.05), waist circumference (ß=5.81; P=.01), waist-to-hip ratio (ß=.03, P=.03), and quality of life (ß=3.30; P=.05) than the control group. The intervention was more effective but more costly in reducing sedentary behavior (ICER Aus $351.77) and anxiety (ICER Aus $10,987.71) at 12 months. The intervention was also more effective yet costly in increasing quality of life (ICER Aus $93,395.50) at 12 months. CONCLUSIONS: The Vire app and ToDo-CR program was not an outcome-effective or cost-effective solution to reduce all-cause hospital admissions or ED presentations in cardiac rehabilitation compared with usual care. Smartphone apps that target sedentary behavior alone may not be an effective solution for cardiac rehabilitation participants to reduce hospital admissions and sedentary behavior. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001223123; https://australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619001223123. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-040479.

If you measure it, it matters!: a survey of factors influencing implementation of physical activity promotion in cardiac and pulmonary rehabilitation in Australia.

OBJECTIVE: To identify factors related to the frequency of physical activity (PA) promotion by health professionals working in cardiac and/or pulmonary rehabilitation. METHODS: A cross-sectional online survey of health professionals working in cardiac and/or pulmonary rehabilitation in Australia was conducted between July and November 2022. RESULTS: A total of 71 health professionals from four disciplines (physiotherapy, nursing, exercise physiology, occupational therapy) completed the survey. The majority agreed that PA promotion was part of their role. Despite this, only half of the participants encouraged ≥ 10 patients per month to be more physically active. In logistic regression modelling, health professionals that measured patients' PA levels (odds ratio 8.04, 95% confidence level 1.45-44.19) and prioritised PA promotion regardless of other patient problems (odds ratio 3.3, 95% confidence level 0.74-14.82) were much more likely to frequently promote PA to patients. CONCLUSION: Measurement of patients' PA levels within cardiac and pulmonary rehabilitation and making PA promotion a priority may impact the implementation of PA promotion within these programs. PRACTICAL IMPLICATIONS: Physical activity measurement as a key performance indicator in cardiac and pulmonary rehabilitation is indicated. This may be an important strategy to increase physical activity promotion by cardiac and pulmonary rehabilitation health professionals.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement.

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Physical Activity Levels in People with Cancer Undergoing Chemotherapy: A Systematic Review.

OBJECTIVES: Physical activity (PA) has been shown to improve chemotherapy side effects, survival rates and treatment adherence in people with cancer. This review aimed to identify whether people undergoing chemotherapy in different exercise interventions meet PA guidelines during chemotherapy. DATA SOURCES: Databases searched were CINAHL complete, PubMed, Cochrane Library, EMBASE, AMED, Joanna Briggs Institute, OVID MEDLINE, and Google Scholar. Eligibility and risk-of-bias were reviewed by two authors. PROSPERO registration: CRD42018093839. CONCLUSION: Thirty-three studies were eligible (14 randomized controlled trials, six pre-post, and 13 cross-sectional studies), which included 2,722 people with cancer undergoing chemotherapy. Studies (n = 11/13) found PA interventions successfully increased or maintained PA participation levels, whereas PA declined without intervention. This review has identified that due to limited evidence it is not possible to determine the most appropriate intervention to improve PA for people undergoing chemotherapy. Despite the well-documented benefits of PA, most people undergoing chemotherapy do not achieve the PA guidelines. Clinicians should be aware that during treatment, participants may not meet PA guidelines even if they participate in an intervention. However, interventions may prevent PA levels from declining. Further research is required to determine the most effective approaches to increase PA levels while undergoing chemotherapy. IMPLICATIONS FOR NURSING PRACTICE: Nurses are well placed to have conversations with patients undergoing chemotherapy regarding PA levels. PA should be considered as part of a treatment regimen. Tailored advice must be provided aiming to improve health outcomes. Referral to an exercise professional is best practice to improve the uptake of PA.

Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol.

BACKGROUND: Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months. METHODS: This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research. DISCUSSION: Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.

Association of device-measured physical activity and sedentary behaviour with cardiovascular risk factors, health-related quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees with coronary heart disease.

BACKGROUND: Few studies have considered the relationship between risk factors, physical activity and sedentary behaviour in people with heart disease. Here we examine the independent relationship of device-measured physical activity and sedentary behaviour on risk factors, quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees. METHODS: Hospital-based phase II cardiac rehabilitation participants with coronary heart disease were assessed at the start and end of cardiac rehabilitation (6-weeks), 6 and 12-months. Physical activity (moderate-to-vigorous (MVPA), light-intensity (LIPA); min/day) and sedentary behaviour (min/day, bouts, breaks) were measured using an ActiGraph accelerometer. Risk factors included waist circumference, body mass index, systolic blood pressure (SBP), fasting blood lipid and glucose levels, anxiety and depression. Quality-of-life and exercise capacity were also collected. Associations were assessed with Generalized Estimating Equation modeling. RESULTS: Sixty-seven participants were included (mean age = 64 (SD 9) years; 81% male). An association was found between higher MVPA and lower high density lipoprotein (p ≤ 0.001). No significant (p ≤ 0.001) associations were found between sedentary behaviour variables and other outcomes. At p < 0.05 several associations were significant. Increased MVPA and LIPA were associated with decreased total cholesterol. Higher MVPA was associated with decreased SBP, whereas higher LIPA was associated with decreased waist circumference and body mass index. Higher sedentary behaviour bouts and breaks were associated with increased total cholesterol, anxiety and depression, and decreased SBP over time. CONCLUSIONS: Any intensity of physical activity was associated with decreased total cholesterol. Increased LIPA was associated with improved measures of adiposity, while breaking up sedentary behaviour and increasing MVPA may decrease SBP over time. Further investigation of MVPA, LIPA and the distribution of sedentary behaviour is indicated in cardiac rehabilitation attendees to explore their relationship with risk factors. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx . Registered 22 September 2015.

Australian University Nursing and Allied Health Students' and Staff Physical Activity Promotion Preparedness and Knowledge: A Pre-Post Study Using an Educational Intervention.

The promotion of physical activity (PA) by health professionals is a key strategy to increase PA levels in the population. In this study, we investigated PA promotion, preparedness, and knowledge among university nursing and allied health students and staff, as well as PA resource usage within curricula, before and after an educational intervention. Students and staff from 13 health disciplines at one Australian university were invited to complete an online survey, and a curriculum audits were conducted before and after PA teaching resources were promoted by academic PA champions (n = 14). A total of 299 students and 43 staff responded to the survey pre-intervention, and 363 and 32 responded to the post-intervention, respectively. PA promotion role perception (≥93%) and confidence to provide general PA advice (≥70%) were high throughout the study. Knowledge of PA guidelines was poor (3−10%). Students of physiotherapy, sport and exercise science, as well as more active students, were more likely to be aware of the PA guidelines (p < 0.05). Over 12 months, PA promotion preparedness and knowledge did not change significantly, nor was there a change in the amount of PA content delivered, despite a significant increase in the use of the teaching resources across a number of disciplines (p = 0.007). Future research should be carried out to investigate the implementation of the resources over time and to develop additional strategies for PA promotion and education scaffolded across curricula.

Behaviour change techniques in cardiovascular disease smartphone apps to improve physical activity and sedentary behaviour: Systematic review and meta-regression.

BACKGROUND: Smartphone apps are increasingly used to deliver physical activity and sedentary behaviour interventions for people with cardiovascular disease. However, the active components of these interventions which aim to change behaviours are unclear. AIMS: To identify behaviour change techniques used in smartphone app interventions for improving physical activity and sedentary behaviour in people with cardiovascular disease. Secondly, to investigate the association of the identified techniques on improving these behaviours. METHODS: Six databases (Medline, CINAHL Plus, Cochrane Library, SCOPUS, Sports Discus, EMBASE) were searched from 2007 to October 2020. Eligible studies used a smartphone app intervention for people with cardiovascular disease and reported a physical activity and/or sedentary behaviour outcome. The behaviour change techniques used within the apps for physical activity and/or sedentary behaviour were coded using the Behaviour Change Technique Taxonomy (v1). The association of behaviour change techniques on physical activity outcomes were explored through meta-regression. RESULTS: Forty behaviour change techniques were identified across the 19 included app-based interventions. Only two studies reported the behaviour change techniques used to target sedentary behaviour change. The most frequently used techniques for sedentary behaviour and physical activity were habit reversal and self-monitoring of behaviour respectively. In univariable analyses, action planning (ß =0.42, 90%CrI 0.07-0.78) and graded tasks (ß =0.33, 90%CrI -0.04-0.67) each had medium positive associations with increasing physical activity. Participants in interventions that used either self-monitoring outcome(s) of behaviour (i.e. outcomes other than physical activity) (ß = - 0.47, 90%CrI -0.79--0.16), biofeedback (ß = - 0.47, 90%CrI -0.81--0.15) and information about health consequences (ß = - 0.42, 90%CrI -0.74--0.07) as behaviour change techniques, appeared to do less physical activity. In the multivariable model, these predictors were not clearly removed from zero. CONCLUSION: The behaviour change techniques action planning and graded tasks are good candidates for causal testing in future experimental smartphone app designs.

Testing the validation and reliability of the Caregiver-Patient Activation Measure (CG-PAM).

Objective: The objective of this study was to test the reliability and validity of the Caregiver-Patient Activation Measure (CG-PAM). Methods: Based on the psychometric testing of the original Patient Activation Measure (PAM), three assessments of reliability and validity were completed on the CG-PAM. Test-retest reliability was assessed across two weeks (n = 23). Criterion validity was assessed by interviewing participants from the test-retest cohort (n = 10), with transcripts assessed by subject matter experts (n = 3) to classify activation levels of the interviewee. Construct validity was assessed through a survey (n = 179) consisting of demographic questions, the CG-PAM and concepts hypothesised to be related to caregiver activation. Results: There was strong test-retest reliability (r = 0.893), but poor criterion validity. Assessment o;f construct validity demonstrated significant relationships found between caregiver activation and weekly hours of care provided (p < 0.001), relationship satisfaction (p < 0.001), and dyad typology (p < 0.001), but not with perceived levels of stress or social support. Conclusion: The CG-PAM was found to have strong reliability, but there were inconsistent results across the validation tests conducted. Innovation: Future research must consider the dynamic nature of caring and the importance of the relationship between the caregiver/recipient when defining activation levels within the CG-PAM.

Nursing perspectives on reducing sedentary behaviour in sub-acute hospital settings: A mixed methods study.

AIM AND OBJECTIVES: To determine the factors influencing nurses' decisions and capacity to reduce sedentary behaviour in hospital inpatients in sub-acute hospital settings. BACKGROUND: Sedentary behaviour in hospital inpatients is a complex issue that can be resistant to resolution. There is little research investigating factors influencing nurses' promotion of reduced levels of sedentary behaviour in sub-acute hospital settings. DESIGN: An explanatory sequential design was employed, comprising quantitative and qualitative phases. METHODS: An online survey was conducted with a convenience sample of 138 nurses from five Australian states. Logistic regression modelling identified demographic and behavioural characteristics of nurses who often encouraged patients to reduce their sedentary behaviour. In-depth interviews were conducted with 11 ward nurses and nurse managers, with the content subjected to thematic analysis. STROBE and GRAMMS checklists were employed. RESULTS: Nurses recognised their role in promoting reduced sedentary behaviour but faced a range of personal and organisational barriers in achieving this outcome for patients. Few nurses were aware of national physical activity and sedentary behaviour guidelines. Five themes emerged from interviews (nursing role, care challenges, expectations of advocates, teamwork and improving the experience). Overall, many nurses experienced a lack of agency in promoting reduced sedentary behaviour and cognitive dissonance in feeling unable to undertake this role. CONCLUSIONS: The results of this study are significant in confirming that reducing sedentary behaviour in hospital inpatients is influenced by a range of complex and multi-level factors. There is a fundamental need for organisational and clinical leadership in building a culture and climate in which staff feel empowered to promote reduced sedentary behaviour in their patients. RELEVANCE TO CLINICAL PRACTICE: The results of this study highlight the importance of taking action to reduce sedentary behaviour in sub-acute hospital settings. A co-design approach to developing interventions in local health services is warranted.

Inspiratory muscle training in intensive care unit patients: An international cross-sectional survey of physiotherapist practice.

BACKGROUND: Inspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated. OBJECTIVES: The objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education. METHOD: Online cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU. RESULTS: Of 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules. CONCLUSION: In this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice.

Smartphone applications for physical activity and sedentary behaviour change in people with cardiovascular disease: A systematic review and meta-analysis.

BACKGROUND: Smartphone applications provide new opportunities for secondary prevention healthcare. This systematic review and meta-analysis aimed to determine if smartphone applications are effective at changing physical activity and sedentary behaviour in people with cardiovascular disease. METHODS: Six electronic databases (Medline, CINAHL Plus, Cochrane Library, SCOPUS, Sports Discus and EMBASE) were searched from 2007 to October 2020. Cardiovascular disease secondary prevention physical activity or sedentary behaviour interventions were included where the primary element was a smartphone or tablet computer application (excluding SMS-only text-messaging). Study quality was assessed using validated tools appropriate for each study design. Random effects model was used and the pooled mean difference between post scores were calculated. Subgroup analyses were conducted to examine differences based on diagnosis, sample size, age, intervention duration, activity tracker use, target behaviour, and self-report versus device-measured outcome. RESULTS: Nineteen studies with a total of 1,543 participants were included (coronary heart disease, n = 10; hypertension, n = 4; stroke, n = 3; heart failure, n = 1; peripheral artery disease, n = 1). Risk of bias was rated as high. Thirteen studies were included in the meta-analysis. Only two controlled studies reported on sedentary behaviour. Smartphone applications produced a significant increase of 40.35 minutes of moderate-to-vigorous intensity physical activity per week (7 studies; p = 0.04; 95% CI 1.03 to 79.67) and 2,390 steps per day (3 studies; p = 0.0007; 95% CI 1,006.9 to 3,791.2). Subgroup analyses found no difference when comparing diagnoses, sample size, activity tracker use, target behaviour and self-report versus device-measured outcome. Larger improvements in physical activity were noted in intervention durations of ≤3-months and participants ≥60yrs (95.35 mins.week-1; p = 0.05). CONCLUSIONS: Smartphone applications were effective in increasing physical activity in people with cardiovascular disease. Caution is warranted for the low-quality evidence, small sample and larger coronary heart disease representation. More rigorous research is needed to investigate the effect of smartphone applications across diagnoses and in sedentary behaviour.