# data[].attributes.headline
Canadian 24-Hour Movement Guidelines:An Integration of Physical Activity, Sedentary Behaviour, and Sleep

# data[].attributes.subject
Canadian 24-Hour Movement Guidelines:An Integration of Physical Activity, Sedentary Behaviour, and Sleep

# data[].attributes.attachment_link.title
24-Hour Movement Guidelines – Canadian 24-Hour Movement Guidelines

# data[].attributes.headline
Effects of reduced sedentary time on cardiometabolic health in adults with metabolic syndrome: A three-month randomized controlled trial

# data[].attributes.subject
Effects of reduced sedentary time on cardiometabolic health in adults with metabolic syndrome: A three-month randomized controlled trial

# data[].attributes.attachment_link.readable_text
Abstract

Objectives

To investigate if reducing sedentary behavior improves cardiometabolic biomarkers in adults with metabolic syndrome.

Design

Randomized controlled trial.

Methods

Sixty-four sedentary middle-aged adults with metabolic syndrome were randomized into intervention (INT; n = 33) and control (CON; n = 31) groups. INT was guided to limit sedentary behavior by 1 h/day through increased standing and light-intensity physical activity. CON was instructed to maintain usual habits. Sedentary behavior, breaks in sedentary behavior, standing, and physical activity were measured with hip-worn accelerometers for three months. Fasting blood sampling and measurements of anthropometrics, body composition, and blood pressure were performed at baseline and at three months. Linear mixed models were used for statistical analyses.

Results

INT reduced sedentary behavior by 50 (95% CI: 24, 73) min/day by increasing light-intensity and moderate-to-vigorous physical activity (19 [8, 30] and 24 [14, 34] min/day, respectively). Standing increased also, but non-significantly (6 [−11, 23] min/day). CON maintained baseline activity levels. Significant intervention effects favoring INT occurred in fasting insulin (INT: 83.4 [68.7, 101.2] vs. CON: 102.0 [83.3, 125.0] pmol/l at three months), insulin resistance (HOMA-IR; 3.2 [2.6, 3.9] vs. 4.0 [3.2, 4.9]), HbA 1c (37 [36, 38] vs. 38 [37, 39] mmol/mol), and liver enzyme alanine aminotransferase (28 [24, 33] vs. 33 [28, 38] U/l).

Conclusions

Reducing sedentary behavior by 50 min/day and increasing light-intensity and moderate-to-vigorous activity showed benefits in several cardiometabolic biomarkers in adults with metabolic syndrome. Replacing some of the daily sedentary behavior with light-intensity and moderate-to-vigorous physical activity may help in cardiometabolic disease prevention in risk populations.

# data[].attributes.attachment_link.title
Effects of reduced sedentary time on cardiometabolic health in adults with metabolic syndrome: A three-month randomized controlled trial

# data[].attributes.attachment_link.description
To investigate if reducing sedentary behavior improves cardiometabolic biomarkers in adults with metabolic syndrome. Randomized controlled trial. Sixty-four sedentary middle-aged adults with metabolic syndrome were randomized into intervention (INT; n = 33) and control (CON; n = 31) groups. INT was guided to limit sedentary behavior by 1 h/day through increased standing and light-intensity physical activity.

# data[].attributes.headline
Sedentary Activity Associated With Metabolic Syndrome Independent of Physical Activity

# data[].attributes.subject
Sedentary Activity Associated With Metabolic Syndrome Independent of Physical Activity

# data[].attributes.attachment_link.title
Sedentary Activity Associated With Metabolic Syndrome Independent of Physical Activity

# data[].attributes.attachment_link.description
OBJECTIVE. This study examined the association between objectively measured sedentary activity and metabolic syndrome among older adults.RESEARCH DESIGN AND MET

# data[].attributes.attachment_link.readable_text
What is metabolic syndrome?

Metabolic syndrome is a group of five risk factors, that when left untreated, increase the likelihood of developing heart disease, diabetes, and stroke. It may also be called syndrome X or insulin resistance syndrome.

The five risk factors are:

high blood pressure, including taking medicine to lower your blood pressure

high blood sugar levels (insulin resistance), or taking medication to lower your blood sugar

excess fat around the waist

high triglyceride levels, or taking medicine to lower your levels

low levels of good cholesterol or HDL, or taking medicine to manage low HDL

Having one of these risk factors does not mean that you have metabolic syndrome. However, having one will increase your chances of developing cardiovascular disease. Having three or more of these factors will result in a diagnosis of metabolic syndrome and will increase your risk of health complications including type 2 diabetes.

Metabolic syndrome is common. In the United States, over 40 percent of people over the age of 50 have this condition.

What are the risk factors for metabolic syndrome?

The risk factors for metabolic syndrome are related to obesity. The two most important risk factors are defined by the National Heart, Lung, and Blood Institute as:

central obesity, or excess fat around the middle and upper parts of the body

insulin resistance, which makes it difficult for the body to use sugar

There are other factors that can increase your risk for metabolic syndrome. These include:

age

family history of metabolic syndrome

not getting enough exercise

having obstructive sleep apnea, chronic kidney disease, or nonalcoholic fatty liver disease

being diagnosed with polycystic ovary syndrome

What are the signs and symptoms of metabolic syndrome?

If you have metabolic syndrome, you may not have any specific symptoms.

One sign that may be observable is a larger waistline or an apple-shaped body.

If you have high blood sugar, you may notice symptoms of diabetes, including increased thirst, blurred vision, headaches, and fatigue.

If you have one of the five risk factors of metabolic syndrome, talk with a doctor to determine whether you should be tested for the others.

How is metabolic syndrome diagnosed?

To diagnose metabolic syndrome, a doctor will need to perform several different tests. The results of these tests will be used to look for three or more signs of the disorder.

According to 2021 best practices, the tests and at-risk levels include:

Waist circumference. Doctors will measure your waist. A measurement of 40 inches for men or 35 inches for women is considered a risk factor.

Fasting blood triglycerides. To check fasting triglycerides, a lipid panel is performed after fasting. A level equal to or greater than 150 milligrams per deciliter (mg/dL) of blood indicates a risk factor.

Cholesterol levels. The lipid panel will also show doctors the levels of high density lipoprotein (HDL) and low density lipoprotein (LDL) in your blood. An HDL level of 40 mg/dL in men or 50 mg/dL in women is considered at risk.

Blood pressure. Systolic blood pressure in the range of 130 mmHg or higher or diastolic blood pressure at 85 mmHg or higher indicates you may be at risk.

Fasting glucose level. This blood glucose test is also performed after fasting. A reading of l00 mg/dL or greater is considered a risk factor.

You may have metabolic syndrome if three or more of these tests come back with a reading within the above ranges.

What are the causes of metabolic syndrome?

Having excess weight in your abdominal region can lead to fat accumulating in the liver and muscle cells.

Insulin resistance can develop. This is when your cells stop responding to insulin in the bloodstream. It can lead to higher insulin levels and blood sugar levels. If your blood sugar levels become too high, you can develop type 2 diabetes.

What are the complications of metabolic syndrome?

The complications that may result from metabolic syndrome are frequently serious and long-term (chronic). They include:

hardening of the arteries (atherosclerosis)

diabetes

heart attack

kidney disease

stroke

nonalcoholic fatty liver disease

peripheral artery disease

cardiovascular disease

If diabetes develops, you may be at risk for additional health complications, including:

eye damage (retinopathy)

nerve damage (neuropathy)

kidney disease

amputation of limbs

How is metabolic syndrome treated?

If you are diagnosed with metabolic syndrome, the goal of treatment will be to reduce your risk of developing further health complications.

A doctor may suggest:

a healthy diet

regular exercise, including aerobic exercise or resistance training

weight loss

medication

reducing other cardiovascular risks, such as by quitting smoking

Your doctor may recommend losing around 7 percent of your current weight and getting at least 30 minutes of moderate to intense exercise 5 to 7 days a week. This may help reverse the syndrome.

Medications for metabolic syndrome may include

What is the outlook for people with metabolic syndrome?

If symptoms are managed, people with metabolic syndrome can reduce their risks of developing serious health problems such as heart attack or stroke. The condition may be able to be reversed with weight loss or managed with a combination of diet, exercise, and medication.

Although symptom management will reduce health complications, most people with this condition have a long-term risk of cardiovascular disease. If you develop this condition, you may need to be monitored by your doctor to help prevent serious health problems such as heart attack and stroke.

How can metabolic syndrome be prevented?

Maintaining a healthy waist circumference and blood pressure and cholesterol levels reduce your risk for metabolic syndrome. Exercise and weight loss can aid in these efforts and decrease insulin resistance.

You can reduce your risk of developing metabolic syndrome with the following lifestyle changes:

Diet. Eat a healthy diet that includes fruits, vegetables, and whole grains. Avoid processed foods and those containing sugar and refined carbs.

Drink water. Avoid sugary beverages and substitute them for zero-calorie options like water and tea.

Exercise. Regular physical activity will reduce your blood pressure, blood sugar, and cholesterol levels.

Talk to a doctor before beginning an exercise program or radically changing your diet. They can help you find an option that is safe for you.

Regular physical exams may also help prevent metabolic syndrome. A doctor can measure your blood pressure and complete blood work. This may help detect the condition in the early stages, and prompt treatment can help reduce health complications over the long term.

Takeaway

Metabolic syndrome refers to a group of five risk factors that together can raise the risk for cardiovascular disease, insulin resistance, diabetes type 2, and stroke.

If you have metabolic syndrome, weight loss, regular exercise, a healthy diet, and medications may help reduce your risk for serious health complications.

# data[].attributes.attachment_link.title
Metabolic Syndrome: Risk Factors, Diagnosis, and More

# data[].attributes.attachment_link.description
Metabolic syndrome is a group of five risk factors, that when left untreated, increase the likelihood of developing heart disease, diabetes, and stroke. It may also be called syndrome X or insulin resistance syndrome.

# data[].attributes.headline
Use of COM-B to increase physical activity in older adults with chronic disease

# data[].attributes.subject
Use of COM-B to increase physical activity in older adults with chronic disease

# data[].attributes.headline
COM-B and Behaviour change wheel - original paper

# data[].attributes.subject
COM-B and Behaviour change wheel - original paper

# data[].attributes.attachment_link.readable_text
Implementation Science 6, Article number: 42 (2011) Cite this article

802k Accesses

5359 Citations

1148 Altmetric

Metrics

Abstract

Background

Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations.

Methods

A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity.

Results

Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity.

Conclusions

Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.

Peer Review reports

Background

Improving the implementation of evidence-based practice and public health depends on behaviour change. Thus, behaviour change interventions are fundamental to the effective practice of clinical medicine and public health, as indeed they are to many pressing issues facing society. 'Behaviour change interventions' can be defined as coordinated sets of activities designed to change specified behaviour patterns. In general, these behaviour patterns are measured in terms of the prevalence or incidence of particular behaviours in specified populations ( e.g., delivery of smoking cessation advice by general practitioners). Interventions are used to promote uptake and optimal use of effective clinical services, and to promote healthy lifestyles. Evidence of intervention effectiveness serves to guide health providers to implement what is considered to be best practice (for example, Cochrane reviews, NICE guidance). While there are many examples of successful interventions, there are also countless examples of ones that it was hoped would be effective but were not [[ 1], e.g. [ 2, 3]]. To improve this situation, and to improve the translation of research into practice, we need to develop the science and technology of behaviour change and make this useful to those designing interventions and planning policy.

The process of designing behaviour change interventions usually involves first of all determining the broad approach that will be adopted and then working on the specifics of the intervention design. For example, when attempting to reduce excessive antibiotic prescribing one may decide that an educational intervention is the appropriate approach. Alternatively, one may seek to incentivise appropriate prescribing or in some way penalise inappropriate prescribing. Once one has done this, one would decide on the specific intervention components. This paper examines this first part of this process. We and others are also working on how one identifies specific component 'behaviour change techniques' [ 4, 5].

In order to identify the type or types of intervention that are likely to be effective, it is important to canvass the full range of options available and use a rational system for selecting from among them. This requires a system for characterising interventions that covers all possible intervention types together with a system for matching these features to the behavioural target, the target population, and the context in which the intervention will be delivered. This should be underpinned by a model of behaviour and the factors that influence it.

Interventions are commonly designed without evidence of having gone through this kind of process, with no formal analysis of either the target behaviour or the theoretically predicted mechanisms of action. They are based on implicit commonsense models of behaviour [ 6]. Even when one or more models or theories are chosen to guide the intervention, they do not cover the full range of possible influences so exclude potentially important variables. For example, the often used Theory of Planned Behaviour and Health Belief Model do not address the important roles of impulsivity, habit, self-control, associative learning, and emotional processing [ 7].

In addition, often no analysis is undertaken to guide the choice of theories [ 8]. Useful guidance from the UK Medical Research Council for developing and evaluating complex interventions advocates drawing on theory in intervention design but does not specify how to select and apply theory [ 9]. It should also be noted that even when interventions are said to be guided by theory, in practice they are often not or are only minimally [ 10].

Thus, in order to improve intervention design, we need a systematic method that incorporates an understanding of the nature of the behaviour to be changed, and an appropriate system for characterising interventions and their components that can make use of this understanding. These constitute a starting point for assessing in what circumstances different types of intervention are likely to be effective which can then form the basis for intervention design.

There exists a plethora of frameworks for classifying behaviour change interventions but an informal analysis suggests that none are comprehensive and conceptually coherent. For example, 'MINDSPACE' an influential report from the UK's Institute of Government, is intended as a checklist for policymakers of the most important influences on behaviour [ 11]. These influences provide initial letters for the acronym MINDSPACE: messenger, incentives, norms, defaults, salience, priming, affect, commitment, and ego. The framework does not appear to encompass all the important intervention types. Moreover, the list is a mixture of modes of delivery ( e.g., messenger), stimulus attributes ( e.g., salience), characteristics of the recipient ( e.g., ego), policy strategies ( e.g., defaults), mechanisms of action ( e.g., priming), and related psychological constructs ( e.g., affect). In that sense it lacks coherence. The report recognises two systems by which human behaviour can be influenced -- the reflective and the automatic -- but it focuses on the latter and does not attempt to link influences on behaviour with these two systems.

A second example comes from the Cochrane Effective Practice and Organisation of Care Review Group (EPOC)'s 2010 taxonomy [ 12]. This categorises interventions to change health professional behaviour into professional, financial, organisational, or regulatory, covering many of the key intervention types. However, the categories are very broad and within each is a mixture of different types of interventions at different conceptual levels. For example, 'professional' includes individual behaviour (distributing educational materials) and organisational interventions (local consensus processes); 'financial' includes individual and organisational incentives and environmental restructuring (changing the available products); 'organisational' includes input (changing skill mix), processes (communication) and effects (satisfaction of providers); and 'regulatory' includes legal (changes in patient liability) and social influence (peer review). Professional, financial, and organisational interventions are found across all categories.

Aside from specific frameworks, there are some broad distinctions that have been widely adopted. One such distinction is between population-level and individual-level interventions [ 13]. While superficially appealing, there are many interventions that this distinction cannot readily classify and it has not been possible to arrive at a satisfactory definition of the distinction that does not contain inconsistencies. For example, if wide reach is a feature of population level interventions, routine general practitioner (GP) smoking assessment and advice (given to all patients) should fall into that category; yet it is delivered specifically to individuals and can be tailored to those individuals. Indeed, the NHS Stop Smoking Services might be considered a typical case of individual-level interventions, but they reach more than 600,000 smokers each year [ 14]. We do not consider these broad distinctions further in this paper.

It appears that most intervention designers do not use existing frameworks as a basis for developing new interventions or for analysing why some interventions have failed while others have succeeded. One reason for this may be that these frameworks do not meet their needs. In order to choose the interventions likely to be most effective, it makes sense to start with a model of behaviour. This model should capture the range of mechanisms that may be involved in change, including those that are internal (psychological and physical) and those that involve changes to the external environment. In general, insufficient attention appears to be given to analysing the nature of behaviour as the starting point of behaviour change interventions [ 15], a notable exception being intervention mapping [ 16]. 'Nature of the behaviour' was identified as one of 12 theoretical domains of influence on implementation-relevant behaviours [ 9]. Whilst this framework of 12 theoretical domains has proved useful in assessing and intervening with implementation problems [ 9], the domain of behaviour has remained under-theorised and therefore underused in its application.

There are a number of possible objections to attempting to construct the kind of behavioural model described and link this to intervention types. The most obvious criticism is that the area is too complex and that the constructs too ill-defined to be able to establish a useful, scientifically-based framework. Another is that no framework can address the level of detail required to determine what will or will not be an effective intervention. The response to this is twofold: these are empirical questions and there is already evidence that characterising interventions by behaviour change techniques (BCTs) can be helpful in understanding which interventions are more or less effective [ 6, 17]; and not to embark on this enterprise is to give up on achieving a science of behaviour change before the first hurdle and condemn this field to opinion and fashion.

To achieve its goal, a framework for characterising interventions should be comprehensive: it should apply to every intervention that has been or could be developed. Failure to do this limits the scope of the system to offer options for intervention designers that may be effective.

Second, the framework needs to be coherent in that its categories are all exemplars of the same type of entity and have a broadly similar level of specificity. Thus, categories should be from a super-ordinate entity ( e.g., function of the intervention), and the framework should not include some categories that are very broad and others very specific. A beautiful example of an incoherent classification system is the Ancient Chinese Classification of Animals: 'those that belong to the Emperor, embalmed ones, those that are trained, suckling pigs, mermaids, fabulous ones, stray dogs, those that are included in this classification, those that tremble as if they were mad, innumerable ones, those drawn with a very fine camel's hair brush, others, those that have just broken a flower vase, and those that resemble flies from a distance' (Luis Borges 'Other Inquisitions: 1937-1952').

In addition, the categories should be able to be linked to specific behaviour change mechanisms that in turn can be linked to the model of behaviour. These requirements constitute three criteria of usefulness that can be used to evaluate the framework: comprehensiveness, coherence, and links to an overarching model of behaviour. We limited the criteria to those we considered to form a basis for judging adequacy. There are others, e.g., parsimony, that are desirable features but do not lend themselves to thresholds. Other criteria can be used to evaluate its applicability, e.g., reliability, ease of use, ease of communication, ability to explain outcomes, usefulness for generating new interventions, and ability to predict effectiveness of interventions

In light of the above, this paper aims to:

1. 1.
Review existing frameworks of behavioural interventions to establish how far each meets the criteria of usefulness, and to identify a comprehensive list of intervention descriptors at a level of generality that is usable by intervention designers and policy makers.

2. 2.
Use this list to construct a framework of behaviour change interventions that meets the usefulness criteria listed above.

3. 3.
Establish the reliability with which the new framework can be used to characterise interventions in two public health domains.

Methods

Prior to reviewing the literature on intervention frameworks, we needed to establish a set of criteria for evaluating their usefulness. Following this, our method involved three steps: a systematic literature review and evaluation of existing behaviour change intervention frameworks, development of a new framework, and a test of the reliability of the new framework.

Establishing criteria of usefulness

From the analysis set out in the Introduction, we established three criteria of usefulness:

1. 1.
Comprehensive coverage -- the framework should apply to every intervention that has been or could be developed: failure to do this limits the scope of the system to offer options for intervention designers that may be effective.

2. 2.
Coherence, i.e., categories are all exemplars of the same type and specificity of entity.

3. 3.
Links to an overarching model of behaviour.

We use the term 'model' here in the sense defined in the Oxford English Dictionary: 'a hypothetical description of a complex entity or process.' For the overarching model of behaviour, we started with motivation, defined as: brain processes that energize and direct behaviour) [ 18]. This is a much broader conceptualisation than appears in many discourses, covering as it does basic drives and 'automatic' processes as well as choice and intention.

Our next step was to consider the minimum number of additional factors needed to account for whether change in the behavioural target would occur, given sufficient motivation. We drew on two sources representing very different traditions: a US consensus meeting of behavioural theorists in 1991 [ 19], and a principle of US criminal law dating back many centuries. The former identified three factors that were necessary and sufficient prerequisites for the performance of a specified volitional behaviour: the skills necessary to perform the behaviour, a strong intention to perform the behaviour, and no environmental constraints that make it impossible to perform the behaviour. Under US criminal law, in order to prove that someone is guilty of a crime one has to show three things: means or capability, opportunity, and motive. This suggested a potentially elegant way of representing the necessary conditions for a volitional behaviour to occur. The common conclusion from these two separate strands of thought lends confidence to this model of behaviour. We have built on this to add non-volitional mechanisms involved in motivation ( e.g., habits) and to conceptualise causal associations between the components in an interacting system.

In this 'behaviour system,' capability, opportunity, and motivation interact to generate behaviour that in turn influences these components as shown in Figure 1 (the 'COM-B' system). Capability is defined as the individual's psychological and physical capacity to engage in the activity concerned. It includes having the necessary knowledge and skills. Motivation is defined as all those brain processes that energize and direct behaviour, not just goals and conscious decision-making. It includes habitual processes, emotional responding, as well as analytical decision-making. Opportunity is defined as all the factors that lie outside the individual that make the behaviour possible or prompt it. The single-headed and double-headed arrows in Figure 1 represent potential influence between components in the system. For example, opportunity can influence motivation as can capability; enacting a behaviour can alter capability, motivation, and opportunity.

The COM-B system - a framework for understanding behaviour.

A given intervention might change one or more components in the behaviour system. The causal links within the system can work to reduce or amplify the effect of particular interventions by leading to changes elsewhere. While this is a model of behaviour, it also provides a basis for designing interventions aimed at behaviour change. Applying this to intervention design, the task would be to consider what the behavioural target would be, and what components of the behaviour system would need to be changed to achieve that.

This system places no priority on an individual, group, or environmental perspective -- intra-psychic and external factors all have equal status in controlling behaviour. However, for a given behaviour in a given context it provides a way of identifying how far changing particular components or combinations of components could effect the required transformation. For example, with one behavioural target the only barrier might be capability, while for another it may be enough to provide or restrict opportunities, while for yet another changes to capability, motivation, and opportunity may be required.

Within the three components that generate behaviour, it is possible to develop further subdivisions that capture important distinctions noted in the research literature. Thus, with regard to capability, we distinguished between physical and psychological capability (psychological capability being the capacity to engage in the necessary thought processes - comprehension, reasoning et al.). With opportunity, we distinguished between physical opportunity afforded by the environment and social opportunity afforded by the cultural milieu that dictates the way that we think about things ( e.g., the words and concepts that make up our language). With regard to motivation, we distinguished between reflective processes (involving evaluations and plans) and automatic processes (involving emotions and impulses that arise from associative learning and/or innate dispositions) [ 7, 18, 20]. Thus, we identified six components within the behavioural system (Figure 1). All, apart from reflective motivation, are necessary for a given behaviour but it is possible to generate a profile of which should be targeted to achieve the behavioural target.

Systematic literature review of current frameworks

We used the following search terms to identify scholarly articles containing frameworks of behaviour change interventions: Topic = (taxonomy or framework or classification) AND Topic = ('behaviour change' or 'behavior change') AND Topic = (prevention OR intervention OR promotion OR treatment OR program OR programme OR policy OR law OR politics OR regulation OR government OR institute OR legislation).

Searches of Web of Science (Science and Social Science databases), Pubmed. and PsycInfo were supplemented by consulting with eight international experts in behaviour change, drawn from the disciplines of psychology, health promotion, epidemiology, public health, and anthropology. Given that there may be frameworks described in books and non peer-reviewed articles, we acknowledged that it was unlikely that we would arrive at a complete set, but we sought to canvass enough to be able to undertake an analysis of how well as a whole they matched the criteria described earlier and to achieve sufficient coverage of the key concepts and labels.

Documents were included if: they described a framework of behaviour change interventions (not specific behaviour change techniques); the framework was specified in enough detail to allow their key features to be discerned; and they were written in English. They were originally selected on the basis of titles and abstracts. A subset was then selected using the inclusion criteria for full review. The nature of the topic meant that this review could not be undertaken using the PRISMA guidelines [ 21].

Once the frameworks were identified, their categories and category definitions were extracted and tabulated. This was done independently by MS and a researcher who was not part of the study team or familiar with this work. The frameworks were coded according to the criteria for usefulness by RW and SM.

Develop a new framework

The new framework was developed by tabulating the full set of intervention categories that had been identified and establishing links between intervention characteristics and components of the COM-B system that may need to be changed. The definitions and conceptualisation of the intervention categories were refined through discussion and by consulting the American Psychological Association's Dictionary of Psychology and the Oxford English Dictionary. The resulting framework was then compared with the existing ones in terms of the criteria of usefulness ( i.e., met or not met).

Finally, a structure for the framework, in terms of organisation of components and links between them was arrived at through an iterative process of discussion and testing against specific examples and counter-examples. Linking interventions to components of the behaviour system was achieved with the help of a broad theory of motivation that encapsulated both reflective and automatic aspects, and focused on the moment to moment control of behaviour by the internal and external environment which in turn is influenced by that behaviour and the processes leading up to it [ 7]. Thus, for example, interventions that involved coercion could influence reflective motivation by changing conscious evaluations of the options or by establishing automatic associations between anticipation of the behaviour and negative feelings in the presence of particular cues. There is not the space to go into details of this analysis here. These can be found in [ 7].

Test the reliability of the framework

The framework was used independently by RW and SM to classify the 24 components of the 2010 English government tobacco control strategy [ 22] and the 21 components of the 2006 NICE obesity guidance [ 23]. The level of inter-rater agreement was computed and any differences resolved through discussion. The areas of tobacco control and obesity reduction were chosen because these are among the most important in public health and ones where health professional behaviour has consistently been found to fall short of that recommended by evidence-based guidelines [ 24- 26]. In addition, these documents cover a wide spectrum of behaviour change approaches. Following reliability testing and discussion of any disagreements, a 'gold standard' was established.

Next, reliability of use by practitioners was assessed by asking two policy experts (the Department of Health Policy Lead for implementation of the 2010 English government tobacco control strategy and a tobacco researcher) to independently classify the 24 components of the strategy (see Additional file 1 for coding materials). Their coding data were compared with the 'gold standard.'

Results

Systematic literature review of existing frameworks

From the systematic literature search, 1,267 articles were identified from the electronic databases, eight of which met our inclusion criteria. The expert consultations produced a further 17 articles, 11 of which met the inclusion criteria resulting in a total of 19 articles describing 19 frameworks. (See Additional file 2 for more detail of flow of studies through the review process, and Additional file 3 for reasons for exclusion). Additional file 4 shows the frameworks and gives a brief description of each [ 11, 12, 16, 27- 42].

Several things became apparent when reviewing the frameworks. First of all, it was clear it would be necessary to define terms describing categories of intervention more precisely than is done in everyday language in order to achieve coherence. For example, in everyday language 'education' can include 'training,' but for our purposes it was necessary to distinguish between 'education' and 'training' with the former focusing on imparting knowledge and developing understanding and the latter focusing on development of skills. Similarly we had to differentiate 'training' from 'modelling.' In common parlance, modelling could be a method used in training, but we use the term more specifically to refer to using our propensity to imitate as a motivational device. A third example is the use of the term 'enablement.' In everyday use, this could include most of the other intervention categories, but here refers to forms of enablement that are either more encompassing (as in, for example, 'behavioural support' for smoking cessation) or work through other mechanisms (as in, for example, pharmacological interventions to aid smoking cessation or surgery to enable control of calorie intake). There is not a term in the English language to describe that we intend, so rather than invent a new term we have stayed with 'enablement.'

Second, it became apparent that a distinction needed to be made between interventions (activities aimed at changing behaviour) and policies (actions on the part of responsible authorities that enable or support interventions). For example, an intervention that involved incentivising primary care organisations to prioritise public health interventions could be implemented through different policies such as producing guidelines and/or legislation. A second example is that raising the financial cost of a behaviour whose incidence one wishes to reduce (an example of coercion) could be enabled and supported by different policies, from fiscal measures (taxation) to legislation (fines). We therefore had to divide the categories that emerged into 'interventions' and 'policies.'

Third, any given intervention could in principle perform more than one behaviour change function. Thus the intervention categories identified from the 19 existing frameworks were better conceived of as non-overlapping functions: a given intervention may involve more than one of these. For example, a specific instance of brief physician advice to reduce alcohol consumption may involve the three different functions of education, persuasion, and enablement, whereas another may involve only one or two of these. With regard to the policies, it was possible to treat them as non-overlapping categories.

With this in mind, scrutiny of the frameworks yielded a set of nine intervention functions and seven policy categories that were included in at least one framework. Table 1 lists these and their definitions (their sources are detailed in Additional file 5). Additional file 6 shows whether or not the intervention functions and policy categories were covered by each of the reviewed frameworks. The inter-rater reliability for coding the frameworks by intervention functions and policy categories was 88%.

Table 1 Definitions of interventions and policies

Additional file 7 shows how existing frameworks met the criteria of usefulness. It is apparent that no framework covered all the functions and categories and thus did not meet the criterion of comprehensiveness. Only three frameworks met the criterion of coherence. Seven were explicitly linked to an overarching model of behaviour.

Development of a new framework

Given that policies can only influence behaviour through the interventions that they enable or support, it seemed appropriate to place interventions between these and behaviour. The most parsimonious way of doing this seemed to be to represent the whole classification system in terms of a 'behaviour change wheel' (BCW) with three layers as shown in Figure 2. This is not a linear model in that components within the behaviour system interact with each other as do the functions within the intervention layer and the categories within the policy layer.

The Behaviour Change Wheel.

Having established the structure of the new framework, the next step was to link the components of the behaviour system to the intervention functions and to link these to policy categories using the approach described in the Methods section. This led to a framework that met the third criterion of linkage with an overarching model of behaviour change (Tables 2 and 3).

Table 2 Links between the components of the 'COM-B' model of behaviour and the intervention functions

Table 3 Links between policy categories and intervention functions

Testing the reliability of the new framework

The initial coding of the intervention functions and policy categories of the 2010 English Tobacco Control Strategy was achieved with an inter-rater agreement of 88%. The inter-rater agreement for the NICE Obesity Guidance was 79%. Differences were readily resolved through discussion (see Additional file 8 for details of the analysis). The percentage agreement between the identified components and the 'gold standard' was 85% for the implementation lead for the 2010 English government tobacco control strategy in the Department of Health and 75% for the tobacco researcher.

Discussion

Within 19 frameworks for classifying behaviour change interventions, nine intervention functions and seven policy categories could be discerned. None of the frameworks covered all of these. Only a minority of the frameworks could be regarded as coherent or linked to an overarching model of behaviour. However, it was possible to construct a new BCW framework that did meet these criteria from the existing ones. This framework could be reliably applied to classify interventions within two important areas of public health.

We believe that this is the first attempt to undertake a systematic analysis of behaviour intervention frameworks and apply usefulness criteria to them. This is also the first time that a new framework has been constructed from existing frameworks explicitly to overcome their limitations. Moreover, we are not aware of other attempts to assess the reliability with which a framework can be applied in practice.

It must be recognised that there are a near infinite number of ways of classifying interventions and intervention functions. The one arrived at here will no doubt be superseded. But for the present, it has the benefits of having been derived from classifications already available and therefore covering concepts that have previously been considered to be important, and using an overarching model of behaviour to link interventions to potential behavioural targets. The most important test of this framework will be whether it provides a more efficient method of choosing the kinds of intervention that are likely to be appropriate for a given behavioural target in a given context and a given population.

Just by identifying all the potential intervention functions and policy categories this framework could prevent policy makers and intervention designers from neglecting important options. For example, it has been used in UK parliamentary circles to demonstrate to Members of Parliament that the current UK Government is ignoring important evidence-based interventions to change behaviour in relation to public health [ 43, 44]. By focusing on environmental restructuring, some incentivisation and forms of subtle persuasion to influence behaviour, as advocated by the popular book 'Nudge' [ 45], the UK Government eschews the use of coercion, persuasion, or the other BCW intervention functions that one might use.

Although awareness of the full range of interventions and policies is important for intervention design, the BCW goes beyond providing this. It forms the basis for a systematic analysis of how to make the selection of interventions and policies (as in Tables 2 and 3). Having selected the intervention function or functions most likely to be effective in changing a particular target behaviour, these can then be linked to more fine-grained specific behaviour change techniques (BCTs). Any one intervention function is likely to comprise many individual BCTs, and the same BCT may serve different intervention functions. An examination of BCTs used in self-management approaches to increasing physical activity and healthy eating [ 46], and in behavioural support for smoking cessation [ 47, 48], shows that these BCTs serve five of the intervention functions: education, persuasion, incentivisation, training, and enablement. The other four intervention functions (coercion, restriction, environmental restructuring, and modelling) place more emphasis on external influences and less on personal agency. Reliable taxonomies for BCTs within these intervention functions have yet to be developed.

One of the strengths of this framework is that it incorporates context very naturally. There is a general recognition that context is key to the effective design and implementation of interventions, but it remains under-theorised and under-investigated. The 'opportunity' component of the behavioural model is the context, so that behaviour can only be understood in relation to context. Behaviour in context is thus the starting point of intervention design. The behaviour system also has automatic processing at its heart, broadening the understanding of behaviour beyond the more reflective, systematic cognitive processes that have been the focus of much behavioural research in implementation science and health psychology (for example, social cognition models such as the Theory of Planned Behaviour).

An existing framework that has made an important contribution to making intervention design more systematic is 'intervention mapping' [ 16]. A key difference between this and the BCW approach is that intervention mapping aims to map behaviour on to its 'theoretical determinants' in order to identify potential levers for change, whereas the BCW approach recognises that the target behaviour can in principle arise from combinations of any of the components of the behaviour system. It may appear that some components are more important than others because of a lack of variance in (including absence or universal presence of) the variables concerned in the population under study. This can be illustrated by a study of GP advice to smokers, which found that a single variable -- degree of concern that it would harm the doctor-patient relationship -- accounted for significant variance in the rate of advice-giving [ 49]. 'Intervention mapping' would suggest that concern be the target for an intervention (as long as a judgement were made that this could be modified using interventions that were realistically applicable). The BCW would analyse the target behaviour in context and note that, regardless of what covariation might currently exist, the target behaviour consists of an activity in which capability is not at issue, and the reflective motivation is broadly positive. The problem arises because automatic motivational factors are currently working against the behaviour ( e.g., lack of emotional reward for giving advice or punishment for not giving it and lack of cues to action). Moreover, the physical opportunity is limited (lack of time) and the social opportunities are also somewhat limited. It would then consider the full range of ways in which the frequency of advice-giving could be increased. Because the target behaviour is part of a 'system,' a single intervention may have consequences for other parts of the system - these might work against sustainable change or in favour of it.

Thus, the BCW approach is based on a comprehensive causal analysis of behaviour and starts with the question: 'What conditions internal to individuals and in their social and physical environment need to be in place for a specified behavioural target to be achieved?' The 'intervention mapping' approach is based on an epidemiological analysis of co-variation within the behavioural domain and starts with the question: 'What factors in the present population at the present time underlie variation in the behavioural parameter?' When it comes to theoretical underpinnings, the BCW approach draws from a single unifying theory of motivation in context that predicts what aspects of the motivational system will need to be influenced in what ways to achieve a behavioural target, whereas the 'intervention mapping' approach draws on a range of theoretical approaches each of which independently addresses different aspects of the behaviour in question.

The BCW is being developed into a theory- and evidence-based tool allowing a range of users to design and select interventions and policies according to an analysis of the nature of the behaviour, the mechanisms that need to be changed in order to bring about behaviour change, and the interventions and policies required to change those mechanisms. An ongoing programme of research is developing an 'intervention design tool' based on the BCW. It starts with a theoretical understanding of behaviour to determine what needs to change in order for the behavioural target to be achieved, and what intervention functions are likely to be effective to bring about that change. It is being field tested by a range of staff involved in policy and intervention work applying the framework to develop prototype strategies for specific implementation targets. Data are being collected about ease of use and the potential of the BCW to generate new insights.

There are a number of limitations to the research described in this paper. First, it is possible that the systematic review missed important frameworks and/or intervention functions. Second, judgement is inevitably involved in conceptualising intervention functions and policy categories. There are many different ways of doing this, and no guarantees that the one arrived at here is optimal. Indeed, different frameworks may be more or less useful in different circumstances. Third, even though the proposed framework appears to be comprehensive and can be used reliably to characterise interventions, it is possible that it may prove difficult to use. However, the systematic way in which development of the BCW has been approached should enable it to provide a more robust starting point for development of improved frameworks than has hitherto been possible.

References

Download references

Acknowledgements

Marie Johnston, University of Aberdeen and Jamie Brown, University College London, provided astute and helpful comments on an earlier draft of the paper. Also thanks to Marie Johnston, Queen of acronyms, for COM-B. We thank Dorien Pieters, Maastricht University, for her work in coding frameworks into categories to provide a reliability check for data extraction. Cancer Research UK provided financial support for RW. Matthew West (of Vasco Graphics) created the artwork.

Author information

Authors and Affiliations

1. Research Dept of Clinical, Educational, and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK

Susan Michie

2. VU University Medical Center, EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands

Maartje M van Stralen

3. Health Behaviour Research Centre, University College London Epidemiology and Public Health, London, UK

Robert West

Corresponding author

Correspondence to Susan Michie.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

SM and RW conceived the study, designed the measures, supervised the systematic review, supervised the analyses and drafted the write-up. MMvS undertook the systematic review, performed the coding and commented on the write-up. All authors read and approved the final manuscript.

Electronic supplementary material

Authors' original submitted files for images

Below are the links to the authors' original submitted files for images.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Reprints and Permissions

About this article

Cite this article

Michie, S., van Stralen, M.M. & West, R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Sci 6, 42 (2011). https://doi.org/10.1186/1748-5908-6-42
Download citation
Keywords

# data[].attributes.attachment_link.title
The behaviour change wheel: A new method for characterising and designing behaviour change interventions - Implementation Science

# data[].attributes.attachment_link.description
Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose.

# data[].attributes.attachment_link.readable_text
Robert West Susan Michie ¹ ¹,

Author(s) details

Changing human behaviour is crucial to meeting the challenges facing society, including the climate emergency, pandemics, violence, and addictive behaviours such as tobacco use. A model of behaviour has been developed that aims to assist developers of behaviour change interventions to identify appropriate targets for those interventions: the COM-B model. Linked to this model is a broad model of motivation that aims to describe how reflective thought processes and emotional and habitual factors interact in each moment to drive motivation to act in particular ways. This paper provides a brief summary of the COM-B and PRIME models. Fuller details can be found in ​​.

The COM-B Model of behaviour

The COM-B model represents the observation that at any given moment, a particular behaviour will occur only when the person concerned has the capability and opportunity to engage in the behaviour and is more motivated to enact that behaviour than any other behaviours ​. Figure 1 illustrates the model including definitions of the entities involved and specification of the relationships between them.

Figure 1: The COM-B model of behaviour

Several features should be noted. First, capability and opportunity are shown as influencing the relationship between motivation and behaviour, rather than the behaviour itself. This represents the idea that, at an individual and moment-to-moment basis, they act like 'logic gates' in that both of the 'gates' (capability and opportunity) need to be open for motivation generate the behaviour. Aggregated over time and people, we can think of capability and opportunity more quantitatively: the greater the capability and opportunity the more likely a behaviour is to occur because the more often the 'gates' will be open when the motivation is present.

Secondly, both capability and opportunity will often influence a person's motivation to enact a behaviour. In general, the more capable we are, or believe we are, in enacting a behaviour and the more conducive the environment is to enacting it, the more we tend to want to do it. Conversely, when a behaviour is difficult, or we believe it to be so, we are less motivated to do it (unless the difficulty is itself part of the attraction).

Thirdly, behaviour feeds back to all three of its precursors sometimes creating positive feedback cycles and sometimes creating negative ones. For example, when engaging in a behaviour such as learning to drive that requires skill, practising the behaviour will improve capability that will increase motivation to engage in the behaviour. By contrast, when engaging in behaviours that meet homeostatic drives, such as eating, engaging in the behaviour will reduce the drive to engage in the behaviour.

Fourthly, motivation can be thought of as a quantity attaching to any behaviours that capability and opportunity would permit in a given situation. In theory there could be millions of these but in practice in any given situation there are only a small number that the brain will be in some sense considering, either though habit or desire. These behaviours may or may not enter conscious awareness and indeed most of the time our actions seem to us simply to flow from stimuli in our environment and our thoughts. But motivation always involves a competition between alternative behaviours which means that sometimes getting someone to enact a behaviour can involve decreasing motivation to enact a competing behaviour as much as increasing motivation to enact the behaviour itself.

The PRIME Theory of motivation

The PRIME Theory of motivation was developed to bring into a single framework, the large number of models and theories of motivation currently being used, including ones that focus on reflective choice processes, ones that focus on emotions and drives, and ones that focus on habit and instinct ​. It is not a replacement for these more specific theories, but a model that links them to help address the diversity of factors that influence motivation and therefore behaviour.

At the heart of the theory is a representation of how the 'human motivational system' is structured. Figure 2 shows this in schematic form.

Figure 2: The structure of human motivation according to PRIME Theory

Behaviours consist of responses that are generated by brain processes that create and compare potentially competing or reinforcing impulses and inhibitions.

Impulses are patterns of brain activity that coordinate and impel responses, while inhibitions are patterns of brain activity that work directly oppose these.

Impulses and inhibitions are generated, either directly from input from sensory or perceptual processes though learned (habit) or innate (instinct) associations, or they are generated by motives.

Motives are feelings of 'want' or 'need'. Wants are feeling of attraction arising from anticipated pleasure or satisfaction; needs are feelings of attraction generated by anticipated relief from mental or physical discomfort. Thus wants and needs lie at the heart of all goal directed human behaviour. As such PRIME theory recognises a fundamental principle of human behaviour which that at every moment we act in pursuit of what we most want or need at that moment'. When attempting to change behaviour by changing motivation, a key target is the momentary wants and needs that will be experienced at the moment when the behaviour becomes appropriate.

Wants and needs are generated by processes involving associations with positive and negative emotions and by drive states such as hunger and thirst. They are also driven to some extent by evaluations.

Evaluations are beliefs that involve some form of judgement about 'goodness' or 'badness'. Thus they include beliefs about what is right and wrong, good or bad, beneficial or harmful. It is important to distinguish between beliefs as processes that are active at a given moment and 'belief dispositions' that involve a propensity to generate such beliefs under certain conditions. This is because unless a belief is active at a given moment it will not directly influence motives and therefore not directly influence behaviour.

Evaluations are generated by sensory processes and perception, memory, and by inference of some form (not necessarily logical). They are also influenced by wants and needs - we tend to believe what we want or need to believe. Important evaluations are beliefs about what we 'should' and 'should not' do: what may be termed 'imperatives'. These are beliefs about behaviours that are judged to be good or bad. However, these only influence behaviour if they lead to corresponding motives - feelings of wanting or needing to do the behaviour at a particular moment.

There are certain kinds of evaluation that apply to a wide range of situations and we term these 'values'. Values can relate to classes of behaviour (e.g. lying is bad), objects (e.g. human life is important), or abstract concepts (e.g. justice is good). These play an important role in behaviour, but only if they translate into specific evaluations and imperatives relevant to the situation at the relevant moment. If they conflict with another evaluation or a motive they can either be overridden or an 'exception' will be created which allows the desired action to occur despite the value (e.g. lying is bad but in this case it would be a kindness to praise a child for a drawing that has no artistic value to avoid the child being upset and the parent being angry).

Aside from imperatives being generated by emotional and thought processes described above, they are also generated by remembering 'plans'. Plans are self-conscious intentions to enact behaviours under certain conditions, e.g. at a given point in time or in response to a given set of circumstances. Plans are generated when an imperative is formed but the appropriate conditions for the behaviour are not present at the current moment in time. The imperative is stored in memory, or some memory aid, with the aim of being activated at the appropriate moment.

Plans form the overarching structure of human behaviour and are represented in diaries and physical or mental to-do lists. There are some kinds of plans that relate to circumstances or events that repeat over time. These can be termed 'personal rules'. Personal rules represent the practical and moral precepts governing our behaviour and as such are extremely important influences on it. These include such diverse behaviours as always brushing one's teeth for 2 minutes on getting up in the morning and before going to bed, and not eating red meat.

Like beliefs, it is important to distinguish plans as active processes at a given moment and plan dispositions, that are in a sense stored plans, ready to be activated at the appropriate time. Thus plans, and their subclass personal rules, can only influence behaviour if they are activated at the relevant moment. They also have to generate imperatives (a belief that the action should be undertaken) at that moment, which then has to generate a want or need to enact the behaviour and ultimate the impulse to engage in it. Therefore, plan dispositions (that can be thought of as stored plans) can only influence behaviour if they are remembered when required, people still think the behaviour is worth doing and still wants of need to do it. At each point in this process it could be coming into competition with other plans, imperatives and wants and needs. This is an important reason why so many of our intentions fail to be enacted.

The paragraphs above describe the structure of the human motivational system. PRIME Theory recognises a number of important principles of its operation, and the kinds of things that generate wants and needs. Two of these are considered to be particularly worthy of note. One is identity and the other is modelling or imitation.

Identity consists of all thoughts and images we have pertaining to ourselves are we were, are or could be, together with feelings attaching to these. It is particularly important as a source of wants or needs. This is because a sense of self is essential for the generation of plans, but also because we are highly salient and usually highly valued objects in our world. What happens to us and who we consider ourselves to be creates strong positive and negative affect.

Modelling and imitation are important because humans are highly imitative and evidence indicates that we mimic others, even without conscious awareness. This modelling or imitation appears to operate at all levels of behaviour and thought, from mannerisms and accents to values and personal rules.

Conclusions

The COM-B model of behaviour and the PRIME Theory of motivation provide a basis for developing behaviour change interventions that recognise the importance of all the relevant factors influencing behaviour. They are general models and provide guidance on broad strategies. COM-B and PRIME need to be used in conjunction with more specific models relevant to the specific behaviours in question.

# data[].attributes.attachment_link.title
A brief introduction to the COM-B Model of behaviour and the PRIME Theory of motivation

# data[].attributes.attachment_link.description
The COM-B model of behaviour is widely used to identify what needs to change in order for a behaviour change intervention to be effective. It identifies three factors that need to be present for any behaviour to occur: capability, opportunity and mot...

# data[].attributes.body
Physical rehabilitation after Stroke

# data[].attributes.attachment_link.readable_text
In this blog for stroke survivors, their families and clinical staff, Mark Smith, Consultant Physiotherapist in Stroke Rehabilitation, looks at Cochrane evidence on physical rehabilitation approaches for the recovery of function and mobility following stroke and explores the importance of the findings with respect to service delivery in an ever changing landscape of health and social care.
Stroke is often termed a "recovering neurological condition", but how much recovery can we expect in response to what sorts of intervention and in what doses? Strokes happen as a result of a disturbance of the blood supply to the brain, mostly in older people and mostly due to the blocking of arteries supplying oxygenated blood to the brain. But less commonly, strokes can affect younger people (and children) and may also be the result of a burst blood vessel causing a haematoma (collection of blood) within the brain mass.

Acting FAST

The stroke "pathway" extends from the initial hyper-acute episode, usually the first minutes and hours post onset of symptoms in the community setting, emphasising that "time is brain" through the "FAST" (Face, Arm, Speech, Time to call 999) campaign supported by the main UK stroke charities, Stroke Association and Chest, Heart & Stroke Scotland. The aim is to deliver patients with a suspected stroke to appropriately specialist hospital/stroke unit care as soon as possible in order to receive life saving and disability reducing hyper-acute interventions such as thrombolysis (using clot-busting drugs) and more recently thrombectomy (breaking and removing the clot with tools) in patients who meet the necessary criteria.

This hyper-acute stage of the pathway is highly evidence-based, medicalised and thoroughly audited across the UK by the two main stroke audits - Sentinel Stroke National Audit Programme (SNNAP) in England and Wales, and the Scottish Stroke Care Audit (SSCA) in Scotland, with a view to time critical delivery to all eligible patients. However, the subsequent audit around rehabilitation interventions can be less thorough despite a growing body of evidence to support physical interventions.

Ongoing physical rehabilitation: what should we do?

Most patients with stroke will need some kind of ongoing physical rehabilitation to assist them in achieving best outcomes possible (with respect to the severity of the stroke but also with respect to the resource available) and we are increasingly becoming aware that there are some critical elements in achieving that. But can we, and do we, deliver what patients should receive in our publicly funded UK health and social care system and is the evidence sufficiently persuasive to argue strongly for this? How do we ensure that a health condition such as stroke which spans a pathway from the community through hyper-acute medical hospital care, possibly downstream in-patient rehabilitation and back to the community via health and social care is fit for purpose? And how do we remove the diagnostic stroke "badge" and simply allow an individual to function again in society with the support they need to manage their long term condition?

Perhaps there is a persuasive argument for delivering evidence-based stroke rehabilitation with appropriate levels of quality and intensity as it is considered a human right in many societies?

The evidence for physical rehabilitation after stroke

Evidence for physical interventions relating to walking and physical rehabilitation after stroke is becoming increasingly available in the form of high quality systematic reviews that can inform clinical guidelines as well as high level government strategy with respect to stroke. We tend to find it mostly relating to physical therapy and exercise/fitness interventions.

Updating Cochrane evidence: a novel approach

Pollock et al (2014a) revisited an older Cochrane Review (Pollock et al 2009). Previous versions of the review had focussed on physiotherapy interventions for the lower limb and walking after stroke but they decided to use a novel approach in the reappraisal of the literature and update of the evidence. The review was subsequently re-titled Physical Rehabilitation Approaches for the Recovery of Function, Balance and Walking following Stroke. The academic elements of reviewing papers followed the usual Cochrane protocol.

Seeking "real world" views on the evidence

In order to gauge the relevance of the evidence for clinical practice, but also critically for stroke survivors and carers, in parallel with revisiting the evidence through systematic review,co Pollock and colleagues also convened a multi key stakeholder short life working group comprised of stroke survivors, carers and clinical staff. This group was charged with sense-checking and "validating" the evidence as being clinically relevant as it emerged, using formal group consensus methods based on nominal group techniques. This involved a system of voting which focussed the group in reaching consensus. The academic researchers involved in the systematic review attended the working group meetings and presented the various options in directing the review, but did not vote themselves so as to minimise bias. This arm of the project culminated in a presentation at the 2014 Cochrane UK and Ireland Symposium, held in Manchester, in which key stakeholders in the review led a workshop on user-involvement in writing Cochrane Reviews. The dual aims of this work were to determine if physical treatment approaches are effective in the recovery of function and mobility in patients with stroke and to see whether any one physical treatment approach is more effective than any other approach.

The presentation of the updated evidence as a result

Ninety six studies, involving 10,401 stroke were included in the review (Pollock et al 2014a). Results of 27 studies (3243 stroke survivors) could be combined comparing physical rehabilitation with no treatment at all. Twenty five of these studies were carried out in China and were unusual in that they compared an active treatment/intervention group to a control group with no clinical intervention. Additional physical rehabilitation versus usual care was described in 12 of these studies demonstrating improved motor function (887 stroke survivors), standing balance (five studies, 246 stroke survivors) and walking speed (14 studies, 1126 stroke survivors). There was also limited evidence of dose intensity for the first time, with treatment durations given between 30 and 60 minutes per day apparently carrying the most significant benefits, but future research needs to verify this.

Key messages:

Physiotherapy, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. Treatment sessions of 30-60 minutes, 5-7 days a week may provide a significant beneficial effect.

No one approach to physical treatment is any more (or less) effective in promoting recovery of function and mobility after stroke.

Physiotherapists should use their expert clinical reasoning to select individualised, patient-centred, evidence-based physical treatment, with consideration of all available treatment components, and should not limit their practice to a single "named" approach.

Fitness training after stroke

This work is supported by another recently updated Cochrane Review around Fitness Training for Stroke Survivors ( Saunders et al 2016) which included 58 trials involving 2797 participants with stroke. These studies were grouped according to the type of fitness training intervention - cardiorespiratory (28 trials, 1408 participants) resistance (13 trials, 432 participants) and mixed training (17 trials, 4342 participants).

Key messages:

Cardiovascular fitness training, particularly involving walking, can improve exercise ability and walking after stroke.

Mixed training improves walking ability and improves balance.

Unable to draw reliable conclusions regarding effects on quality of life, mood or cognitive function.

No evidence of injury or other health problems and exercise appears to be a safe intervention.

Circuit Class Therapy

English et al (2017) included 17 trials involving 1297 stroke survivors (most of whom could walk 10 metres) in another recent Cochrane Rcoeview to examine the effectiveness and safety of Circuit Class Therapy (CCT) on mobility in adults with stroke. Ten studies (835 participants) measured walking capacity, demonstrating that CCT was superior to the comparison intervention, eight measured gait speed again finding that CCT was of significant benefit. Their conclusion was that there was moderate evidence to suggest that CCT is effective in improving mobility for people after stroke. These effects may be greater later after the stroke and stroke survivors may be able to walk further, faster, with more independence and confidence in their balance, but further high quality research is required.

Other relevant reviews

There have also been Cochrane Reviews providing low to moderate quality evidence of the rehabilitation benefits of electro mechanically or robotic assisted gait training devices ( Mehrholz et al 2017a), treadmill training for stroke patients who could already walk ( Mehrholz et al 2017b) and repetitive task training ( French et al 2016). A Cochrane overview (a review of systematic reviews) presenting moderate quality evidence for upper limb rehabilitation after stroke, suggested beneficial effects of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice ( Pollock et a. 2014b). Again, information was insufficient to reveal the relative effectiveness of different interventions.

So what...

Well, the research evidence, albeit largely of moderate quality, points to the efficacy of a broad range of interventions in the physical rehabilitation of people with stroke, with little detail about which specific interventions are of most value in which settings, and indeed the best delivery mechanisms to make them most easily and effectively implemented. More research is needed to generate higher quality evidence and implementation guidance. Recommendations in stroke guidelines ( RCP 2016) and stroke strategies ( Scottish Government 2014) have been made on the basis of these findings, particularly with respect to adequate dose. However, given that studies are disparate, have been derived from around the world and as a result conducted within a great variety of different healthcare (and social care/leisure) settings, it is challenging for clinicians to know exactly how to implement the reported findings.

The work of Pollock et al (2014) in engaging multi key stakeholders in making more "real" the findings of their systematic review made an effort to think about how we might implement the evidence, particularly in relation to the views of stroke survivors, carers and therapists. Perhaps we need to be less defensive of historical professional and service silo boundaries and use this evidence in the best interests of the stroke survivors we aim to serve, though imaginative use of commissioning mechanisms, third sector organisations, the leisure industry, healthcare staff resources and the capacity we have to deliver stroke rehabilitation interventions?

The World Health Organisation (WHO) has recently argued that the benefits of rehabilitation are realised beyond the health sector and that delivered appropriately can reduce care costs and enable participation in education and gainful employment ( WHO 2017). With respect to the stroke pathway, if we are serious about saving lives at the "front door", let's also make them worth living at the "back door" and beyond.
Join in the conversation on Twitter with @CochraneUK #LifeAfterStroke or leave a comment on the blog.
References may be found here.
Mark Smith is a Trustee of the Stroke Association.

# data[].attributes.attachment_link.title
Physical rehabilitation after stroke - Evidently Cochrane

# data[].attributes.attachment_link.description
In this blog for stroke survivors, their families and clinical staff, Mark Smith, Consultant Physiotherapist in Stroke Rehabilitation, looks at Cochrane evidence on physical rehabilitation approaches for the recovery of function and mobility following stroke and explores the importance of the findings with respect to service delivery in an ever changing landscape of health and social care.

# data[].attributes.headline
Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update 

# data[].attributes.subject
Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update 

# data[].attributes.attachment_link.description
We are sorry, but we are experiencing unusual traffic at this time. Please help us confirm that you are not a robot and we will take you to your content.

# data[].attributes.headline
Aerobic exercise after stroke: clinician's guide

# data[].attributes.subject
Aerobic exercise after stroke: clinician's guide

# data[].attributes.headline
Aerobic Exercise Recommendations to Optimize Best Practices in Care AfterStroke: AEROBICS 2019 Update

# data[].attributes.subject
Aerobic Exercise Recommendations to Optimize Best Practices in Care AfterStroke: AEROBICS 2019 Update

# data[].attributes.headline
Aerobic exercise after stroke: patient's guide

# data[].attributes.subject
Aerobic exercise after stroke: patient's guide

# data[].attributes.headline
High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity

# data[].attributes.subject
High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity

# data[].attributes.attachment_link.readable_text
Abstract

Introduction. Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke. Objectives. To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research. Results. Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown. Conclusion. Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.

References

10.

Billinger, SA, Boyne, P, Coughenour, E, Dunning, K, Mattlage, A. Does aerobic exercise and the FITT principle fit into stroke recovery? Curr Neurol Neurosci Rep. 2014;15:519. doi:10.1007/s11910-014-0519-8.
Google Scholar

31.

Carl, DL, Boyne, P, Meyrose, C. Feasibility and intensity of recumbent stepper in high intensity interval training (HIT) in chronic stroke. Med Sci Sport Exerc. 2016;48(5 suppl 1):256.
Google Scholar

32.

Boyne, P, Dunning, K, Carl, D, Gerson, M, Khoury, J, Kissela, B. Within-session responses to high-intensity interval training in chronic stroke. Med Sci Sport Exerc. 2014;47:476-484. doi:10.1249/MSS.0000000000000427.
Google Scholar

41.

Thomas, R, Line, J, Geertsen, SS, Christiansen, L, Roig, M, Lundbye-Jensen, J. Acute exercise and motor memory consolidation: the role of exercise timing. Neural Plast. 2016;2016:6205452. |
Google Scholar Medline

52.

Garrett, KL, Huth, C. The impact of graphic contextual information and instruction on the conversational behaviours of a person with severe aphasia. Aphasiology. 2002;16:523-536. doi:10.1080/02687030244000149.
Google Scholar

59.

Daussin, FN, Ponsot, E, Dufour, SP. Improvement of Vo | ₂max by cardiac output and oxygen extraction adaptation during intermittent versus continuous endurance training. Eur J Appl Physiol. 2007;101:377-383. doi:10.1007/s00421-007-0499-3.
Google Scholar Medline | ISI

71.

Burley, CV, Bailey, DM, Marley, CJ, Lucas, SJE. Brain train to combat brain drain; focus on exercise strategies that optimize neuroprotection. Exp Physiol. 2016;101:1178-1184. doi:10.1113/EP085672.
Google Scholar

# data[].attributes.attachment_link.title
High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity

# data[].attributes.attachment_link.description
Abstract Introduction. Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise.

# data[].attributes.headline
High-intensity interval training (HIIT) after stroke: a big hit?

# data[].attributes.subject
High-intensity interval training (HIIT) after stroke: a big hit?

# data[].attributes.attachment_link.provider_name
BJSM blog - social media's leading SEM voice

# data[].attributes.attachment_link.readable_text
Stroke and ischemic heart disease accounted for 15 million out of 57 million deaths in 2016; these cardiovascular diseases have been the leading causes of death for the last 15 years [1]. Stroke incidence is proportionally related to age - the average population is aging - so stroke prevention and treatment is increasingly important. Classic neurorehabilitation programmes for stroke survivors provide a 'limited opportunity for cardiovascular exercise' and 'the use of moderate-intensity continuous exercise (MICE) to improve cardiorespiratory fitness. Niether of these two types or exercise is routinely implemented in clinical practice. When used, their intensity may be insufficient to elicit a training effect [2]. Post stroke guidelines recommend MICE to improve aerobic capacity, mobility and walking speed. However, effects on functional recovery, aerobic fitness and quality of life remain unclear [3]. Most stroke rehabilitation programs - which generally last only a few months - lack aerobic exercise training [4]. This might be due to lack of knowledge regarding exercise testing and prescription for people after stroke. Classic stroke rehabilitation certainly does not include aerobic- or resistance-type high-intensity interval training (HIIT). One assumption is that high-exertion activity would increase spasticity [3]. HIIT is a training that consists of repeated (very) short bursts of high-intensity exercises (at 85%-95% of peak heart rate) followed by low-intensity recovery activity. HIIT improves fitness, ie, aerobic capacity in healthy as well as persons with cardiovascular diseases [4]. Does HIIT constitute a safe and effective method to improve the lives of stroke survivors? What does science tell us?
What type of (research) knowledge exists regarding HIIT in stroke survivors?
HIIT for stroke survivors undoubtedly found its way into neurorehabilitation after many benefits were shown over the years 'High-intensity interval training (HIIT) emerged as a powerful time-efficient alternative to MICE for individuals without known disability, as well as clinical populations' [2]. Furthermore, HIIT might be superior to MICE in persons with heart disease [7]. To improve function, mobility and prevent further disease in stroke survivors there is emerging information from randomized controlled trials (RCTs) that HIIT may be safe and effective.[8] Billinger and colleagues write that "compared to lower intensity, higher intensity training elicits greater improvement in aerobic fitness among healthy adults, persons with heart disease, and persons with stroke". While we acknowledge that repetitive taks training (RTT) does not mimic high intensity training, we alert the read to the Cochrane Review which found low- to moderate-quality evidence for the effectiveness of repetitive task training (RTT) on upper and lower limb function in patients after stroke [9]. Additionally,Veerbeek et al conclude that RTT intervention should be executed in high-intensity [10].
What are possible benefits of HIIT for stroke survivors?
One study found similar increases in VO2max in four weeks of HIIT compared to 6 months of moderate intensity continuous exercise (MICE) as well as improvements in (persistent hemiparetic) gait, walking economy, walking speed and walking distance in chronic stroke survivors [6]. Another trial compared HIIT with conventional care physiotherapy following moderate stroke demonstrating that HIIT leads to better results in cardiovascular fitness, reflected in improved self-rated functional mobility, i.e. improved independence in performing basic activities of daily living, improved maximum gait speed, balance and quality of life [11].
What is the level of effectiveness and safety in HIIT in stroke survivors? Is it accepted among stroke survivors?
Some reports suggest that HIIT is feasible and safe in moderate stroke patients [6]. Billinger and colleagues note that "low-intensity exercise can be prescribed for most, if not all, persons with stroke, higher intensities should be prescribed whenever safe and well tolerated because they are generally more effective". In addition to this, results from a safety analysis show the potential for HIIT in stroke survivors as an adjunct to established (pharmacological) therapy [12].A feasibility study demonstrated its clinical applicability when necessary precautions for high-risk populations were taken into account with the American College of Sports Medicine guidelines [13]. Also, Boyne and colleagues report that HIIT appears to be safe with no serious adverse events being reported. HIIT generally has good acceptance in chronic stroke patients [14].
Could HIIT be a big `HIT` for stroke rehabilitation?
Research in HIIT in stroke survivors is limited to feasibility studies and safety analyses (indicating the effectiveness of HIIT in stroke patients). Some small clinical trials exist, primarily small sample-sized efficacy studies, which limit the generalizability of effects. There is a need for high quality randomized controlled studies to address the questions in this blog.

HIIT for stroke survivors is safe and effective and is well accepted by many patients. HIIT can rapidly show benefits such as improved quality of life in stroke patients. Future research is needed to prove if HIIT has the chance to become the next big `HIT` in neurorehabilitation for stroke survivors.

***

Michiel R.M. Twiss @Physiotwiss is a physiotherapist and has a private practice in Buchs SG (Switzerland). He is currently enrolled in a master's degree in physiotherapy at the University of Applied Sciences in Bern (Switzerland). Email: mrmtwiss@gmail.com
If you would like to contribute to the "Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercice Medicine" Blog Series please email justin.carrard@gmail.comfor further information.
None declared

1. WHO | The top 10 causes of death. (n.d.). Retrieved October 26, 2017, from http://www.who.int/mediacentre/factsheets/fs310/en/

2. Rognmo, Ø., Hetland, E., Helgerud, J., Hoff, J., & Slørdahl, S. A. (2004). High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity in patients with coronary artery disease. European Journal of Cardiovascular Prevention and Rehabilitation: Official Journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 11(3), 216-222.

3. Veerbeek JM, van Wegen E, van Peppen R, van der Wees PJ, Hendriks E, Rietberg M, et al. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one. 2014;9(2):e87987

(Visited 1,901 times, 3 visits today)

# data[].attributes.attachment_link.title
High-intensity interval training (HIIT) after stroke: a big hit? | BJSM blog - social media's leading SEM voice

# data[].attributes.attachment_link.description
Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series By Michiel R.M. Twiss @physiotwiss Stroke and ischemic heart disease accounted for 15 million out of 57 million deaths in 2016; these cardiovascular diseases have been the leading causes of death for the last 15 years [1].

# data[].attributes.headline
Physical Activity after Stroke: A Systematic Review and Meta-Analysis

# data[].attributes.subject
Physical Activity after Stroke: A Systematic Review and Meta-Analysis

# data[].attributes.attachment_link.title
Physical Activity after Stroke: A Systematic Review and Meta-Analysis

# data[].attributes.attachment_link.description
Background and Purpose. Physical activity is beneficial after stroke, but it is unclear how active stroke survivors are. This systematic review and meta-analysis sought to determine levels of activity and factors predicting activity. Summary of Review: Methods. MEDLINE (1946 to present) and EMBASE (1980 to present) were systematically searched until July 2012.

# data[].attributes.headline
Physical Activity in Hospitalised Stroke Patients

# data[].attributes.subject
Physical Activity in Hospitalised Stroke Patients

# data[].attributes.headline
Integrating Individuals With Stroke Into Cardiac Rehabilitation Following Traditional Stroke Rehabilitation: Promoting a Continuum of Care

# data[].attributes.subject
Integrating Individuals With Stroke Into Cardiac Rehabilitation Following Traditional Stroke Rehabilitation: Promoting a Continuum of Care

# data[].attributes.attachment_link.title
Manchester Neurotherapy Centre - Body Weight Support Treadmill Training