The Association of Stair Climbing Behaviors With Hazard of All-Cause Mortality in Adults With or At Risk of Knee Osteoarthritis.

OBJECTIVE: To investigate the association of stair climbing difficulty and stair climbing frequency with the risk of all-cause mortality over 13 years in adults with or at high risk for knee OA. METHODS: We used data from the Osteoarthritis Initiative (OAI), a prospective cohort study of community-dwelling adults with or at high risk for symptomatic knee OA. The exposures were stair climbing difficulty and frequency, assessed at baseline using self-report questionnaires. The outcome was all-cause mortality, assessed from baseline through 13 years of follow-up. Kaplan-Meier survival curves and Cox proportional hazards regression were used to investigate the association between stair climbing exposures and all-cause mortality. RESULTS: Three hundred seven (6.81%) and 310 (6.84%) participants in the difficulty and frequency samples, respectively, died during 13 years of follow-up. Those who were limited in any capacity in terms of their stair climbing ability had 54% to 84% greater hazard of all-cause mortality, and those who climbed at least 7 flights of stairs per week had 38% lower hazard of all-cause mortality. CONCLUSION: Adults with or at high risk for knee OA who report difficulty with climbing stairs or who infrequently use stairs are at greater hazard of all-cause mortality. Stair climbing difficulty and frequency are simple to collect and changes may occur early in OA progression, allowing for early intervention. Brief questions about stair climbing behaviors can serve as a functional vital sign within the clinician's toolbox.

Daily Walking and the Risk of Knee Replacement Over 5 Years Among Adults With Advanced Knee Osteoarthritis in the United States.

OBJECTIVE: To examine the association of the volume and intensity of daily walking at baseline with the risk of knee replacement (KR) over 5 years in adults with advanced structural knee osteoarthritis. DESIGN: Prospective, longitudinal, and multicenter observational study. SETTING: Osteoarthritis Initiative study with follow-up from 2008-2015. PARTICIPANTS: Community-dwelling adults with or at risk of knee osteoarthritis were recruited from 4 sites in the United States (N=516; mean age, 67.7±8.6y; body mass index, 29.3±4.7 kg/m2; 52% female). We included participants with advanced structural disease, without KR and had valid daily walking data (quantified using Actigraph GT1M), at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOMES: KR. Walking volume was measured as steps/day and intensity as minutes/day spent not walking (0 steps/min) and walking at very light (1-49 steps/min), light (50-100 steps/min), or moderate (>100 steps/min) intensities. To examine the relationship of walking volume and intensity with the risk of KR, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for covariates. RESULTS: Of 516 adults with advanced structural disease, 88 received a KR over 5 years (17%). Walking an additional 1000 steps/d was not associated with the risk of KR (adjusted HR=0.95; 95% CI, 0.84-1.04). Statistically, replacing 10 min/d of very light and light walking with 10 min/d of moderate walking reduced the risk of KR incidence by 35% and 37%, respectively (adjusted HR=0.65, 95% CI, 0.45-0.94, for very light and adjusted HR=0.63; 95% CI, 0.40-1.00, for light). CONCLUSIONS: Daily walking volume and intensity did not increase KR risk over 5 years and may be protective in some cases in adults with advanced structural knee osteoarthritis.

Improving stamina and mobility with preop walking in surgical patients with frailty traits -OASIS IV: randomized clinical trial study protocol.

BACKGROUND: Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits. METHODS: We will be conducting a randomized clinical trial with a total of 120 patients permitting up to a 33% rate of attrition, to reach a final sample size of 80 (with 40 patients for each study arm). We will include patients who are age 60 or higher, score 4 or greater on the Edmonton Frailty Scale assessment, and will be undergoing a surgical operation that requires a 2 or more night hospital stay to be eligible for our trial. Using block randomization stratified on baseline 6MWD, we will assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) will provide a daily step count goal reflecting a 10-20% increase from baseline. Subsequently, the AT will call weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls will receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We will also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps. CONCLUSION: If changes in a 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints. TRIAL REGISTRATION: The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019.

Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery.

BACKGROUND: The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery. METHODS: Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months. RESULTS: After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively. CONCLUSION: Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.

Physical Function After Total Knee Replacement: An Observational Study Describing Outcomes in a Small Group of Women From China and the United States.

OBJECTIVE: To describe physical function before and six months after Total Knee Replacement (TKR) in a small sample of women from China and the United States. DESIGN: Observational. SETTING: Community environment. OUTCOMES: Both groups adhered to the Osteoarthritis Research Society International (OARSI) protocols for the 6-minute walk and 30-second chair stand. We compared physical function prior to TKR and 6 months after using linear regression adjusted for covariates. PARTICIPANTS: Women (N=60) after TKR. INTERVENTIONS: Not applicable. RESULTS: Age and body mass index in the China group (n=30; 66y and 27.0kg/m2) were similar to those in the U.S. group (n=30; 65y and 29.6kg/m2). Before surgery, the China group walked 263 (95% confidence interval [CI], -309 to -219) less meters and had 10.2 (95% CI, -11.8 to -8.5) fewer chair stands than the U.S. group. At 6 months when compared with the U.S. group, the China group walked 38 more meters, but this difference did not reach statistical significance (95% CI, -1.6 to 77.4), and had 3.1 (95% CI, -4.4 to -1.7) fewer chair stands. The China group had greater improvement in the 6-minute walk test than did the U.S. group (P<.001). CONCLUSIONS: Despite having worse physical function before TKR, the China group had greater gains in walking endurance and similar gains in repeated chair stands than did the U.S. group after surgery.

Trajectories of functional decline in knee osteoarthritis: the Osteoarthritis Initiative.

OBJECTIVE: To describe trajectories of functional decline over 84 months and study associated risk factors among adults initially without limitation who had or were at risk of knee OA. METHODS: We used annual measures of WOMAC physical function over 84 months from the OA Initiative. We included knees with no functional limitation (i.e. WOMAC = 0) at baseline. Knee-based trajectories of functional decline from WOMAC were identified from a group-based trajectory model (PROC TRAJ). RESULTS: We identified five trajectories from 2110 knees (1055 participants, age 61.0 ± 9.3, BMI 27.1 ± 4.4, 52% women). Half of the knees (54%) remained free of limitation over 84 months, 26% slowly declined to a WOMAC of 1.5, 9% were limitation free for the first 36 months and declined to a WOMAC of 11.3, 6% rapidly declined over the first 12 months and gradually recovered to a WOMAC of 3.3 and 5% steadily declined to a WOMAC of 13.2. Baseline radiographic disease, knee pain, obesity and depressive symptoms at baseline were associated with trajectories of worse functional decline. CONCLUSION: Five per cent of our sample initially without limitation was on a trajectory of progressive functional decline over 84 months later. We found worse disease and health status at baseline to be associated with faster decline over time.

It Is Time to Invite Patients to the Physical Activity Party .

Physical activity is associated with a myriad of health benefits relevant to adults who commonly receive rehabilitation. Unfortunately, the prescription for exercise and overall activity still continues to be overlooked, which is a missed opportunity because those receiving rehabilitation are most likely to benefit from the effects of physical activity. The purpose of this supplement is to fill this knowledge gap by featuring articles that examine the efficacy of physical activity, and describe mechanisms underlying changes in physical activity and how physical activity in rehabilitation populations fits within broader medical and public health frameworks.

Association of Psychosocial Factors With Physical Activity and Function After Total Knee Replacement: An Exploratory Study.

OBJECTIVES: To examine the association between self-efficacy, social support, and fear of movement with physical activity and function at baseline and after 12 weeks of physical therapy. DESIGN: Nonrandomized cohort study, repeated-measures design. SETTING: Outpatient rehabilitation clinic within the general community. PARTICIPANTS: Adults (N=49) undergoing outpatient physical therapy for total knee replacement (TKR). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-efficacy for exercise (SEE), fear of movement, leisure-time physical activity (LTPA), 6-minute walk test (6MWT), and Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) were assessed at baseline and 12 weeks. RESULTS: Mean functional change scores significantly increased at 12 weeks for the 6MWT (95% confidence interval [CI], 42.3-106.2), KOS-ADLS (95% CI, 12.7-23.3), and LTPA (95% CI, 6.5-26.1). Self-efficacy and fear of movement were not significantly associated with function at baseline or 12 weeks. Participants with lower SEE had 6 fewer metabolic equivalents per week of improvement in LTPA than those with high self-efficacy (95% CI, -27.9 to 14.8), and those with high fear of movement had 26.1m less improvement in the 6MWT than those with low fear of movement (95% CI, -42.2 to 94.5). Most participants reported having no family or peer support for exercise. CONCLUSIONS: Physical therapy for TKR improves physical function and self-reported physical activity. High fear of movement and low SEE may be associated with less improvement in physical activity and function over time.

Do radiographic disease and pain account for why people with or at high risk of knee osteoarthritis do not meet physical activity guidelines?

OBJECTIVE: Knee osteoarthritis (OA) and pain are assumed to be barriers to meeting physical activity guidelines, but this has not been formally evaluated. The purpose of this study was to determine the proportions of people with and those without knee OA and knee pain who meet recommended physical activity levels through walking. METHODS: We performed a cross-sectional analysis of community-dwelling adults from the Multicenter Osteoarthritis Study who had or who were at high risk of knee OA. Participants wore a StepWatch activity monitor to record steps per day for 7 days. The proportion of participants who met the recommended physical activity levels was defined as those accumulating≥150 minutes per week at ≥100 steps per minute in bouts lasting ≥10 minutes. These proportions were also determined for those with and those without knee OA, as classified by radiography and by severity of knee pain. RESULTS: Of the 1,788 study participants (mean±SD age 67.2±7.7 years, mean±SD body mass index 30.7±6.0 kg/m2, 60% women), lower overall percentages of participants with radiographic knee OA and knee pain met recommended physical activity levels. However, these differences were not statistically significant between those with and those without knee OA; 7.3% and 10.1% of men (P=0.34) and 6.3% and 7.8% of women (P=0.51), respectively, met recommended physical activity levels. Similarly, for those with moderate/severe knee pain and those with no knee pain, 12.9% and 10.9% of men (P=0.74) and 6.7% and 11.0% of women (P=0.40), respectively, met recommended physical activity levels. CONCLUSION: Disease and pain have little impact on achieving recommended physical activity levels among people with or at high risk of knee OA.

The effects of exercise and intra-articular injections versus exercise alone for the treatment of knee osteoarthritis: A scoping review of the evidence.

Objective: Current treatment for knee Osteoarthritis (OA) includes exercise and intra-articular injections with corticosteroid (CS), hyaluronic acid (HA), etc., which address OA-related pain and functional limitation. While these interventions can be given together, little is known about the efficacy of a multi-modal approach. The purpose of this scoping review is to examine studies that compare combining exercise and intra-articular knee injections to exercise alone for the management of knee OA. Methods: A search was performed using PubMed, CINAHL, and Clinicaltrials.gov with MeSH terms "knee osteoarthritis" AND "exercise" AND "injections". Abstracts were screened to meet inclusion criteria of both intervention groups including exercise and one group receiving an injection for treatment of knee OA. Full text articles were screened to meet inclusion criteria and rated using the Pedro Scale. Results: 11 studies that met inclusion criteria. The included studies utilized CS, hyaluronic acid (HA), and Bone Marrow Concentrate (BMC), botulinum toxin A, or a combination of dextrose and lidocaine injections. Most studies included supervised exercise interventions with all studies including strengthening of the quadriceps. CS and exercise compared to exercise alone showed similar improvements in pain. The HA injection studies yielded mixed results with two studies finding HA and exercise was not superior than exercise alone while two other studies found that HA and exercise were superior. Conclusion: There was a paucity of literature investigating multimodal approaches. Most of the included studies did not find superior effects of adding a knee injection to exercise compared to exercise alone for knee OA.

Concurrent Validity and Reliability of Video-Based Approach to Assess Physical Function in Adults With Knee Osteoarthritis.

OBJECTIVES: The aim of this study was to determine the concurrent validity and reliability of the Osteoarthritis Research Society International recommended performance-based tests delivered by video-based in adults with knee osteoarthritis. METHODS: Thirty-two participants (aged 40-70 years; 15 men) undertook assessments of 4 performance-based tests via both video-based (real-time and recorded) and face-to-face approaches, on the same day. Outcome measures were performance-based test and the number of technical issues encountered. The performance-based tests included the 40-Meter Fast-Paced Walk Test (velocity, m/s), the 30-Second Chair Stand Test (number of repetitions), the Stair Climb Test (time, seconds), and the Timed "Up & Go" Test (time, seconds). The Bland-Altman limit of agreement measures, standard error of measurement (SEM), coefficient of variation (CV), minimal detectable changes, and bias (mean difference) were employed to analyze the concurrent validity between video-based and face-to-face approaches of the performance-based tests. Reliability was measured using intraclass correlation coefficients, CV, and SEM. RESULTS: A high degree of concurrent validity for the Timed "Up & Go" Test (bias = -0.22), the 30-Second Chair Stand Test (bias = -0.22), the Stair Climb Test (bias = -0.31), and the 40-Meter Fast-Paced Walk Test (bias = -0.06) was found. SEM and CV values were within the acceptable level for concurrent validity. There was a high degree of reliability demonstrated for all tests analyzed. Intraclass correlation coefficient measures ranged from 0.95 to 1.00 for intrarater reliability, and from 0.95 to 0.99 for interrater reliability. CONCLUSIONS: Video-based assessment of physical performance tests is a valid and reliable tool for measuring physical function among adults with knee osteoarthritis via Microsoft Teams (Microsoft Corp, Redmond, WA, USA). IMPACT: Video-based assessment is a promising public health tool to measure physical function in adults with knee osteoarthritis.

Does Physical Activity Confound Race Differences in Osteoarthritis-Related Functional Limitation?

OBJECTIVE: This study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)-related functional limitation. METHODS: OA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self-reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68. RESULTS: African American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to vigorous physical activity, the association between AA race and inability to walk a community walking speed slightly decreased (from relative risk [RR] 2.15, 95% confidence interval [95% CI] 1.64-2.81, to RR 1.99, 95% CI 1.51-2.61). Association between AA race and other measures of functional limitation mildly decreased (slow walking speed: from RR 2.06, 95% CI 1.40-3.01, to RR 1.82, 95% CI 1.25-2.63; low physical functioning: from RR 3.44, 95% CI 1.96-6.03, to RR 3.10, 95% CI 1.79-5.39). When further adjusted for demographic and other clinical variables, only the association between race and low physical functioning (WOMAC) significantly decreased and no longer met statistical significance. CONCLUSION: Greater physical activity is unlikely to completely make up for race differences in OA-related functional limitation, and other barriers to health equity need to be addressed.

Walking to meet physical activity guidelines in knee osteoarthritis: is 10,000 steps enough?

OBJECTIVE: To study if step goals (eg, walking 10,000 steps a day) approximate meeting the 2008 Physical Activity Guidelines for Americans. DESIGN: Cross-sectional observational cohort. SETTING: Community. PARTICIPANTS: People with or at high risk of knee OA (N=1788). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Objective physical activity data were collected over 7 consecutive days from people with or at high risk of knee OA participating in the Multicenter Osteoarthritis Study. Using activity monitor data, we determined the proportion that (1) walked ≥10,000 steps per day, (2) met the 2008 Physical Activity Guidelines, and (3) achieved both recommendations. RESULTS: Of the subjects studied (mean age ± SD, 67±8y; mean body mass index ± SD, 31±6kg/m(2); 60% women), 16.7% of men and 12.6% of women walked ≥10,000 steps per day, while 6% of men and 5% of women met the 2008 Physical Activity Guidelines for Americans. Of those walking ≥10,000 steps per day, 16.7% and 26.7% of men and women, respectively, also met the 2008 Physical Activity Guidelines. CONCLUSIONS: Among this sample of older adults with or at high risk of knee OA, walking ≥10,000 steps a day did not translate into meeting public health guidelines. These findings highlight the disparity between the number of steps believed to be needed per day and the recommended time-intensity guidelines to achieve positive health benefits.

Factors Associated with Trajectories of Physical Activity Over 8 Years in Knee Osteoarthritis.

OBJECTIVE: The aim of the study was to investigate (1) trajectories of physical activity (PA) over 96 months and (2) study to what extent knee pain, muscle strength, physical function, and radiographic disease were associated with PA trajectories in adults with or at risk of knee osteoarthritis (KOA). METHODS: Using the Osteoarthritis Initiative (OAI) database, we described PA trajectories with the Physical Activity Scale for the Elderly (PASE) over 96 months. Knee pain was categorized into three groups: "no pain" [visual numeric pain rating scale (VAS=0)], "little to some pain" (VAS=1-3), or "moderate to severe pain" (VAS ≥ 4). Knee extensor strength was classified into high [>16.21 (men) and >10.82 (women) N/kg/m2 ] and low [12 seconds) and fast (<12 seconds) groups. Radiographic disease was classified as present [Kellgren-Lawrence (KL) ≥2] or absent (KL grade <2) of KOA. RESULTS: Among 3755 participants (age 61.0 ± 9.0 years, body mass index 28.5±4.8 kg/m2 , 58% female), we identified three trajectories: sedentary PA with slow decline (44.3%), low PA with slow decline (41.3%), and high PA with slow decline (14.4%). Poorer gait speed (OR: 2.32; 95% CI: 1.71-3.16), chair stand time (OR: 1.45; 95% CI: 1.07-1.96), and knee extensor strength (OR: 1.35; 95% CI: 1.03-1.76), but not pain or radiographic disease, were associated with PA trajectory of sedentary PA with slow decline. CONCLUSION: Physical function and strength, but not pain and radiographic disease, were associated with a trajectory of decline in PA among adults with or at risk of KOA.

Stepping Forward: A Scoping Review of Physical Activity in Osteoarthritis.

Physical activity (PA) is recommended to mitigate the symptoms of osteoarthritis (OA); however, this modality remains an unfamiliar construct for many patients and clinicians. Moreover, there can be confusion over the nuanced differences in terminology, such as exercise, sedentary behavior, and moderate intensity. The purpose of this scoping review is to provide a basic overview of PA including terminology, summarize the importance of PA for adults with OA, and discuss current gaps in the literature. Broadly, PA is defined as any energy expenditure from skeletal muscle above a resting level, and exercise is considered a type of PA that is planned, structured, and repetitive. Robust literature shows that PA has a modest protective effect on pain, functional limitation, and disability for OA, in addition to positive effects on a broad range of outcomes from mood and affect to mortality and morbidity in the general population. We provide recommendations for which measurement instruments can be used to record PA, both from a clinical and research perspective, as well as which metrics to employ for summarizing daily activity.

The COVID-19 Pandemic and Daily Steps in the General Population: Meta-analysis of Observational Studies.

BACKGROUND: The COVID-19 pandemic has the potential to accelerate another pandemic: physical inactivity. Daily steps, a proxy of physical activity, are closely related to health. Recent studies indicate that over 7000 steps per day is the critical physical activity standard for minimizing the risk of all-cause mortality. Moreover, the risk of cardiovascular events has been found to increase by 8% for every 2000 steps per day decrement. OBJECTIVE: To quantify the impact of the COVID-19 pandemic on daily steps in the general adult population. METHODS: This study follows the guidelines of the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) checklist. PubMed, EMBASE, and Web of Science were searched from inception to February 11, 2023. Eligible studies were observational studies reporting monitor-assessed daily steps before and during the confinement period of the COVID-19 pandemic in the general adult population. Two reviewers performed study selection and data extraction independently. The modified Newcastle-Ottawa Scale was used to assess the study quality. A random effects meta-analysis was conducted. The primary outcome of interest was the number of daily steps before (ie, January 2019 to February 2020) and during (ie, after January 2020) the confinement period of COVID-19. Publication bias was assessed with a funnel plot and further evaluated with the Egger test. Sensitivity analyses were performed by excluding studies with low methodological quality or small sample sizes to test the robustness of the findings. Other outcomes included subgroup analyses by geographic location and gender. RESULTS: A total of 20 studies (19,253 participants) were included. The proportion of studies with subjects with optimal daily steps (ie, ≥7000 steps/day) declined from 70% before the pandemic to 25% during the confinement period. The change in daily steps between the 2 periods ranged from -5771 to -683 across studies, and the pooled mean difference was -2012 (95% CI -2805 to -1218). The asymmetry in the funnel plot and Egger test results did not indicate any significant publication bias. Results remained stable in sensitivity analyses, suggesting that the observed differences were robust. Subgroup analyses revealed that the decline in daily steps clearly varied by region worldwide but that there was no apparent difference between men and women. CONCLUSIONS: Our findings indicate that daily steps declined substantially during the confinement period of the COVID-19 pandemic. The pandemic further exacerbated the ever-increasing prevalence of low levels of physical activity, emphasizing the necessity of adopting appropriate measures to reverse this trend. Further research is required to monitor the consequence of long-term physical inactivity. TRIAL REGISTRATION: PROSPERO CRD42021291684; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=291684.