text:
The charge to the Physical Activity Guidelines Advisory Committee
(PAGAC) was to review existing scientific literature to identify where
sufficient evidence exists to develop comprehensive public health physical
activity recommendations for all Americans and to target them as necessary for
specific segments of the population. The higher levels of chronic disease risk
and burden in racial/ethnic and/or lower socioeconomic status (SES)
communities, and the growing cultural diversity of the United States, make
these population segments a priority in considering such targeting. The primary
focus of the PAGAC scientific review was research on primary prevention and
health/fitness promotion, not research on the delivery of exercise as a therapy
or treatment for specific disease conditions (e.g., physical therapy for
musculoskeletal disease or injury, cardiac rehabilitation). However, the PAGAC
recognized that many of the health benefits of physical activity for the
general population also pertained to many people who have some health condition
that typically excludes them from physical activity and health research.
Included in these populations are people with various disabilities, women
during pregnancy and the postpartum period, and races and ethnicities other
than non-Hispanic whites. Therefore, the PAGAC decided to conduct a separate
review of the scientific literature focusing on these three populations.
The first part of this chapter reviews the science published since
1995 evaluating the general health and fitness benefits of increased activity
in persons with selected physical and cognitive disabilities. The second part
provides a brief review of the science regarding physical activity performed by
women during pregnancy and the postpartum period. The last section provides an
overview of the science addressing the question, "Is there evidence that the
physical activity dose for improving health and fitness should differ for
people depending upon race or ethnicity?" Each PAGAC subcommittee was asked to
consider this question in its review of the literature, but committee members
agreed that it would help in better understanding this issue if the available
evidence was summarized in this section of the report.
The lack of participation in beneficial physical activity is a serious
public health concern for all Americans, but it is even more acute for people
with disabilities, who are demonstrably at much greater risk of developing the
types of serious health problems associated with a sedentary lifestyle.
Healthy People 2010 outlines current levels of physical activity and
exercise for various subpopulations in the United States based on
cross-sectional surveys, as well as goals for the year 2010 (1). As shown in Table G11.1,
individuals with disabilities are currently much less active than their
non-disabled counterparts and participate in less regular and less vigorous
physical activity. They also report substantially more secondary conditions
that are directly or indirectly associated with their disability but are
considered preventable (e.g., fatigue, weight gain, deconditioning, pain) (2).
Patterns of low physical activity reported
among people with disabilities raise serious concern about their health and
well being, particularly as they enter their later years, when the effects of
the natural aging process are compounded by years of sedentary living and
severe deconditioning (3). Although substantial public
health initiatives strive to prevent disease, injury, and disability,
a growing recognition among public policy experts is the need to address people
with disabilities as a target population who can benefit from health promotion
activities, including increased participation in physical activity (4;5). Recognizing that people with
disabilities are less physically active than the general population (6;7), have poorer health status (8), and in particular, are more likely to experience chronic
and secondary conditions such as obesity, pain, fatigue, and depression (2), an examination of the existing evidence associated with
the effects of physical activity in people with disabilities is urgently needed
(9). A first step in this process is to (a) determine
whether people with disabilities receive similar cardiovascular,
musculoskeletal , metabolic, mental and functional health benefits as people
without disabilities, and (b) understand if these benefits outweigh the risks
of physical activity in these populations.
Eight categories of physical disability, 3 categories of cognitive
disability, and 1 group of combined disabilities are the focus of this review
(Table G11.2). These groups were selected because
of the higher volume of research identified on these populations compared to
other groups, such as spina bifida and polio, where very few research studies
were identified.
For these categories, the following questions were asked:
Following these discussions, the chapter addresses the safety concerns
and complications associated with physical activity in people with physical and
cognitive disabilities.
The Physical Activity Guidelines for Americans Scientific
Database (see Part F: Scientific
Literature Database Methodology for a detailed description of
the Database and its development) included only a few manuscripts that
evaluated the effects in populations with disabilities. Thus, a comprehensive
literature review was conducted using the MEDLINE and CINAHL databases. Two
abstractors combined several keywords associated with disability and physical
activity or exercise. Reference lists in each individual article were also
reviewed for additional articles, including meta-analytic articles and
systematic review articles. The articles were included if they met the
following inclusion criteria:
Studies were excluded if they: (1) involved therapeutic exercise
modalities available primarily at a medical facility, such as body weight
supported treadmill training or functional electrical stimulation, as the main
exposure variable; (2) used single bouts of exercise; or (3) were conducted
using qualitative methods or case study.
Each of the identified studies was classified into 3 types of study
design: Randomized controlled trial (RCT), non-randomized trial with control
group, and pre/post-test with no control group. RCT is listed as the highest
level of evidence; non-randomized trials with a control group as middle level
of evidence; and pre/post designs with no control group as the lowest level of
evidence (10). No cross-sectional, retrospective
observational, or prospective observational studies were included in the
A total of 139 articles published between 1995 and 2007 and that met
all inclusion criteria were identified and reviewed for this report. Data were
independently extracted by 2 reviewers who have backgrounds in disability and
rehabilitation using the following categories:
Figure G11.1 illustrates the number and
design type of reviewed trials by disability group. Trials investigating the
effects of exercise on people with Stroke had the most number of
intervention-related exercise articles (n=23), while lower limb loss had the
lowest number of identified articles (n=2).
The type of available evidence used in this report to determine the
effects of exercise on health outcomes in people with physical or cognitive
disabilities was based on a modification of the criteria used by the US Agency
for Healthcare Research and Quality (AHRQ, formerly known as the US Agency for
Health Care Policy and Research) (11). We did not review
the quality of each study (i.e., power, intent-to-treat , different testers on
pre/post outcomes, etc.) as recommended by AHRQ and we also changed the
categories of evidence to parallel the work of the Committee. Non-randomized
trials were collapsed under the category of Pre/Post Studies with no Control
Group (i.e., Non-RCT).
Type 1: Two or more RCTs with positive results and no
studies reported significant negative effects.
Type 2a: One RCT with positive results and no studies
reported significant negative effects.
Type 2b: At least one Non-RCT with positive results
and no studies with significant negative effects.
Type 3a: Well designed prospective cohort studies and
case-control studies.
Type 3b: Other observational studies – weak
prospective cohort studies or case-control studies; cross-sectional studies or
case series.
Type 4: Non-significant findings or no studies
investigating the effects of exercise on people with disabilities.
Type 1 evidence indicates that cardiorespiratory fitness can be
improved in people with Lower Limb Loss, Multiple Sclerosis, Spinal Cord
Injury, Stroke, and Mental Illness. Type 2a evidence provides the same findings
for people with Traumatic Brain Injury and Intellectual Disability, type 2b
evidence provides these findings in persons with Cerebral Palsy, Muscular
Dystrophy, and Alzheimer's Disease, and type 4 is indicative of no data or
non-significant findings on Parkinson's Disease. Overall, the evidence is
highly supportive of the use of physical activity in improving
cardiorespiratory fitness among people with physical and cognitive
Twenty-one RCTs targeted improvements in cardiorespiratory fitness in
persons with physical and cognitive disabilities (Table G11.3). Of these 21 RCTs, 18 (86%) reported
significant favorable cardiorespiratory fitness outcomes. Of 25 non-RCTs, 21
(84%) reported significant favorable cardiorespiratory fitness outcomes.
a S, Significant findings; b NS,
Non-significant findings; c Major depression disorder
The evidence on the use of physical activity for cardiovascular risk
reduction is less clear than it is for cardiorespiratory fitness. Two RCTs and
2 non-RCTs reported significant reductions in total cholesterol and
triglycerides, and two non-RCTs found no differences in cholesterol reduction
after the exercise intervention.
Health outcomes targeted in these studies included triglycerides and
total cholesterol. Among persons with physical disabilities, 3 (75%) of 4
studies showed reduction in cholesterol (spinal cord injury) and triglycerides
(multiple sclerosis) (Table G11.4). Among persons
with cognitive disability, 1 (50%) of 2 studies reported reduction in
triglycerides (mental illness). In 3 of the 4 studies, subjects had high
cholesterol and triglycerides at baseline.
a S, Significant findings; b NS,
Non-significant findings; c Triglycerides; d Total cholesterol
Type 1 evidence indicates that resistance exercise, aerobic exercise,
or a combination of resistance and aerobic exercise all increase muscle
strength in various subgroups with physical and cognitive disabilities.
Although less evidence exists on flexibility interventions for the 11
population subgroups, in the 4 RCTs conducted on individuals with Parkinson's
disease (n=1), Stroke (n=2) and Traumatic Brain Injury (n=1), findings were
significant for each disability group. Of the 4 non-RCTs on flexibility
training, 2 studies, which involved subjects with Spinal Cord Injury and
Combined Disabilities (i.e., physical and intellectual disabilities), were
found to be significant. The other two non-RCTs were not significant in persons
with Multiple Sclerosis and Intellectual Disability. Type 1 evidence finds that
flexibility can be improved in persons with Stroke, and type 2a evidence finds
that it can be improved in persons with Parkinson's disease and Traumatic Brain
Type 2a evidence exists on the use of exercise in improving bone
mineral density (BMD) in people with physical and cognitive disabilities. Only
2 studies were identified that used an exercise exposure to improve BMD, one in
youth with Cerebral Palsy and the other study on adults with unilateral Stroke.
Both studies supported the use of exercise in improving BMD in these
populations, but more evidence is needed to determine whether these findings
will be supported by further studies.
Table G11.5 summarizes the 37 exercise
interventions addressing improvements in muscle strength. Of the 17 RCTs, 14
(82%) studies reported significant positive effects. Of the 20 non-RCTs, 19
(95%) trials reported significant improvements in muscle strength.
Table G11.6 summarizes the intervention
research on flexibility. Four RCTs targeted improvements in flexibility in
persons with physical disabilities. All 4 (100%) studies reported significant
positive findings. Of the 4 non-RCTs, 2 (50%) reported significant improvements
in flexibility.
Two studies found in the literature used exercise to improve BMD in
people with disabilities. In the first study (RCT), children with cerebral
palsy were exposed to a program of various types of upper and lower extremity
exercises. The program consisted of 1 hour-long session per week for 8 weeks,
which was increased to 3 sessions per week for the next 24 weeks. The program
showed significant improvement in BMD compared to controls (61). In the second RCT, researchers concluded that exercise
can slow the decline in bone loss in the affected femoral neck of people with
unilateral Stroke (41).
aS, Significant findings; bNS,
Non-significant findings; cNS in Myotonic Dystrophy group, S in
Charcot-Marie-Tooth group; reference was counted only one time.
a S, Significant findings; b NS,
Non-significant findings
Functional health has a broad association with several performance
measures associated with basic and instrumental activities of daily living (ADL
and IADL). This includes walking speed, walking distance, quality of life,
functional independence, and balance. Evidence from a variety of studies
supports the use of exercise to improve walking speed and distance and other
measures of functional health across a range of disabilities.
A total of 74 interventions targeted one or more measures of
functional health under the categories of walking speed, walking distance,
quality of life/well-being, functional independence, and balance. These studies
provided type 1 evidence (Table G11.7) for the use
of exercise in improving walking speed in persons with Multiple Sclerosis,
Stroke, and Intellectual Disability, type 2a evidence for the use of exercise
in persons with Parkinson's disease and Alzheimer's disease, and type 2b
evidence for the use of exercise in persons with Cerebral Palsy and Spinal Cord
Injury (where the propulsion speed of pushing a wheelchair is used as an
equivalent to walking speed). The studies provided type 1 evidence that walking
distance can be improved in persons with Multiple Sclerosis, Stroke, and
Intellectual Disability (Table G11.8) and type 2a
evidence that walking speed can be improved in people with Parkinson's disease.
On Quality of Life (Table G11.9), the studies
provided type 1 evidence to support exercise for people with Multiple
Sclerosis, Spinal Cord Injury, and Stroke and type 2a evidence to support
exercise in people with Muscular Dystrophy, Alzheimer's disease, Intellectual
Disability, and Mental Illness. For Functional Independence (Table G11.10), the studies provided type 1 evidence
supporting the use of exercise in people with Stroke and type 2a evidence
supporting exercise in people with Multiple Sclerosis, Parkinson's disease,
Traumatic Brain Injury, and Alzheimer's disease. For Balance (Table G11.11), the studies provided type 1 evidence
supporting the use of exercise in improving balance only in people with
Parkinson's disease and Stroke. The studies had type 2b or 4 evidence for the
other disability subgroups.
Table G11.7 summarizes the 35
intervention studies that used walking speed as a health outcome. Of the 19
RCTs, 13 (68%) reported significant increases in walking speed. Of the 16
Non-RCTs, 10 (63%) reported significant increases in walking speed.
a S, Significant findings; b NS,
Non-significant findings; c Specific to propulsion speed pushing a
Table G11.8 summarizes the 18
interventions that used walking distance as an outcome. Of the 13 RCTs, 10
(77%) reported significant increases in walking distance. Of the five Non-RCTs,
four (80%) reported significant increases in walking distance.
a S, Significant findings; b NS,
Non-significant findings; c Down syndrome; d
Table G11.9 summarizes the 27
interventions on quality of life/well-being. Of the 19 RCTs, 13 studies (68%)
reported significant positive findings. Seven (88%) of the eight non-RCTs (n=8)
demonstrated significant improvements in quality of life or well-being.
a S, Significant findings; b NS,
Non-significant findings; cOne RCT(18) showed a
significant finding in well-being (measured by the emotional well-being
subscore in the Multiple Sclerosis Quality of Life-54 scale) but a
non-significant finding in quality of life (measured by the overall score in
the Multiple Sclerosis Quality of Life-54); dOne RCT(89) reported a significant finding in well-being measured by
the Profile of Mood States instrument) but a non-significant finding in quality
of life (measured by the Stroke Specific Quality of Life Scale).
Table G11.10 summarizes the 35
interventions on functional independence, which was primarily measured by an
assessment of ADL, and IADL or motor function (i.e., motor control, function of
upper/lower extremity, motor skills). A total of 17 RCTs targeted improvements
in functional independence primarily in people with physical disabilities
(14 of the 17 RCTs). Out of these 17 RCTs, 9 (53%) reported significant
outcomes. In addition, 18 non-RCTs targeted people with physical disabilities,
and 14 (82%) of these studies reported significant findings on functional
a S, Significant findings, b NS
, Non-significant findings, c one Non-RCT (129) showed a significant finding in motor function but a
non-significant finding in functional independence; d two RCTs (77;101) reported a significant finding
in motor function in the lower extremity but a non-significant finding on
functional independence.
Table G11.11 summarizes the 21exercise
interventions on balance. Of the 13 RCTs, 6 (46%) reported significant
findings. Of the 8 non-RCTs, 6 (75%) reported significant positive findings.
The majority of studies were conducted on Parkinson's disease and Stroke.
a S, Significant findings; b NS,
Non-significant findings; c One RCT (118)
under Parkinson's disease indicated a lower prevalence of falls among the
exercise group compared to the control group but also reported a
non-significant finding on the Berg Balance Score.
Individuals with disabilities are likely to be at increased risk for a
number of preventable health problems referred to as secondary
conditions. According to Chapter 6 of the Healthy People 2010
report (1), secondary conditions are defined as
"...physical, medical, cognitive, emotional, or psychosocial consequences to
which persons with disabilities are more susceptible by virtue of an underlying
impairment, including adverse outcomes in health, wellness, participation and
quality of life (p. 163)." Several secondary conditions are prominent among
people with disabilities, and pain and fatigue are reported to be two of the
most common secondary conditions observed in people with physical and cognitive
disabilities (9).
Type 1 evidence exists for the use of exercise in reducing fatigue in
people with Multiple Sclerosis, type 2a evidence supports exercise in persons
with Muscular Dystrophy, and type 4 evidence supports exercise in the remaining
subgroups. In addition, type 1 evidence indicates that pain can be reduced in
people with Spinal Cord Injury, type 2a evidence based on one study has similar
findings for people with Down syndrome, and type 4 evidence exists that
exercise can reduce pain on the other subgroups.
Table G11.12 summarizes the 10
interventions on fatigue. Of the 8 RCTs, 4 (50%) reported significant positive
health outcomes. Of the 2 non-RCTs, both (100%) showed significant positive
reductions in fatigue. The major target subgroup was persons with Multiple
Table G11.13 summarizes the evidence on 5
exercise interventions targeting musculoskeletal pain. Two RCTs and 2 non-RCTs
indicated significant reductions in pain in people with Spinal Cord Injury.
Three studies targeted reduction in shoulder pain in persons with Spinal Cord
Injury, and the other study evaluated general pain. Only one RCT involving
individuals with cognitive disabilities was identified, and this study reported
significant reductions in pain associated with intermittent claudication in
persons with Down syndrome.
a S, Significant findings; b NS,
Non-significant findings; People with Down syndrome who suffered from
intermittent claudication
Type 2a evidence indicates that exercise can improve body composition
in persons with Stroke, Intellectual Disability, Mental Illness, Traumatic
Brain Injury, and a combined group of individuals with different types of
physical disabilities. Type 4 evidence suggests the same finding for the
remaining disability subgroups. On metabolic factors, type 2a evidence exists
for improvements in fasting glucose and insulin sensitivity in two disability
subgroups (Stroke and Mental Illness) and type 4 evidence shows the same result
for the remaining subgroups.
Table G11.14 summarizes the 19
interventions on body composition including those focused on body weight, body
fat, body mass index (BMI), and waist circumference. Of the 10 RCTs, 5
studies (50%) reported significant positive effects in decreasing body weight.
Of the 9 non-RCTs, 2 (22%) reported significant positive findings on body
a S, Significant findings; b NS,
Non-significant findings; Down syndrome; Schizophrenia
Three RCTs also targeted improvements in metabolic factors (fasting
glucose, insulin sensitivity, fasting insulin, and insulin-like growth
factor-binding protein-3). Two (67%) of these 3 studies reported significant
positive findings in people with Stroke (40) and
Schizophrenia (60) while one study (33%) reported
non-significant findings in people with Spinal Cord Injury (27).
Type 1 evidence indicates that exercise can reduce depression in
people with Alzheimer's disease and Mental Illness. Type 2a evidence shows the
same result in persons with Multiple Sclerosis, Spinal Cord Injury, Stroke, and
Intellectual Disability, as does type 4 evidence in the remaining subgroups.
The highest level of evidence was reported in people with Mental Illness (6
RCTs reporting significant outcomes). Physical activity also appears to have
beneficial effects on several other mental health outcomes including
self-esteem, quality of sleep, interpersonal relationships, disruptive
behavior, negative symptoms, and anxiety. No type 1 studies were identified for
any of these outcomes. However, type 2a evidence was reported for beneficial
effects of self-esteem (Muscular Dystrophy, Traumatic Brain Injury, and
Intellectual Disability), quality of sleep (Spinal Cord Injury and Alzheimer's
disease), interpersonal relationships (Stroke and Mental Illness), and negative
symptoms (Mental Illness).
Table G11.15 summarizes the 20
interventions targeting reduction in depression. Out of the 17 RCTs, 12 studies
(71%) reported significant reductions in depression. Three non-RCTs (100%) also
reported significant reductions in depression.
Table G11.16 summarizes the evidence on
12 exercise interventions targeting other mental health outcomes in persons
with disabilities, including self-esteem, quality of sleep, interpersonal
relationships, negative psychiatric symptoms, anxiety, and disruptive behavior.
In people with Muscular Dystrophy, Traumatic Brain Injury, and Intellectual
Disability, the improved health outcome was self-esteem. In people with Spinal
Cord Injury and Alzheimer's disease, quality of sleep improved; people with
Mental Illness had reduced negative psychiatric symptoms and increased
interpersonal relationships; and people with Stroke reported improvements in
interpersonal relationships.
a S, Significant findings; b NS,
Non-significant findings; c self-esteem; d quality of
sleep; e interpersonal relationships; f disruptive
behavior; g negative symptoms; h anxiety
The majority of studies reviewed in this report included doses of
exercise that are typically used in studies targeting the general population.
Intensity of cardiorespiratory exercise was set at 50% or higher of target
heart rate reserve or VO2peak. Frequency of exercise ranged from 3
to 5 days a week and duration lasted from 30 to 60 minutes per session. The
precise quantitative characteristics of the dose-response relationship between
improvements in various health outcomes, however, still requires additional
research before certain conclusions can be made regarding what doses effect
what outcomes in targeted disability groups.
Among some health care professionals, an underlying perception exists
that exercise may present an increased risk of injury for certain
individuals with disabilities. This section provides an overview of the
available literature describing issues associated with safety of exercise in
people with physical and cognitive disabilities from the 139 articles that the
Understudied Populations subcommittee reviewed for this chapter. The 139
exercise trials included 2,961 subjects exposed to an exercise intervention and
1,832 control subjects. The duration of the trials ranged from 1 week to 52
Two abstractors carefully reviewed the Methods, Results, and
Discussion sections of each article to identify reported side effects or
adverse events. In particular, the abstractors focused on the reasons, when
available, that the subject withdrew from the study, to determine whether it
was related to the exercise exposure. The data are reported in frequencies and
percentages and separated by exercise and control groups. The information
contained in this section includes the most commonly reported complications or
adverse events reported for each disability subgroup.
To determine whether a reported event was considered a complication
(not serious) or adverse event (serious), we considered the following criteria
from the Office for Human Research Protections (OHRP, 2007) (149): event was (1) undesirable in nature; (2) related or
possibly related to the intervention; and (3) harmful to the participant either
physically or psychologically. For the purpose of this review, the subcommittee
modified these criteria to classify health complications associated with the
intervention as not serious adverse events and serious adverse
events. Serious adverse events frequently caused participants to drop out
of the study.
Adverse events were reported for 53 exercise subjects and 11 control
subjects (Table G11.17). The percentage of
exercise subjects (1.8%) and control subjects (0.6%) with any reported adverse
event was not substantially different. Similarly, the percentage of exercise
subjects (1.1%) and control subjects (0.6%) reported to have an adverse event
serious enough to cause them to drop out of the study also were not
substantially different.
a Serious adverse events involved those in
which the subject dropped out of the study.
This review of evidence identified very few reported adverse events
associated with exercise in people with physical and cognitive disabilities.
Disability-related risks and activity-related risks are two common issues
related to exercise training interventions in people with disabilities (150).
We reviewed all the reported serious and non-serious adverse events and
arranged them into 4 categories: (a) progression or recurrence of disease
(i.e., disability-dependent risks) including recurrent Stroke or Multiple
Sclerosis exacerbation, and/or worsening of conditions associated with the
disability such as elevated spasticity, bladder spasms, mild seizure,
recurrence of inguinal hernia, and increased depression; (b) cardiovascular
problems including angina symptoms, dizziness, drop in blood pressure, acute
myocardial infarction, and abnormal electrocardiogram; (c) falls; and (d)
exercise-related musculoskeletal problems, including muscle soreness, pain, and
increased fatigue.
Among the total number of adverse events [serious + non-serious]
reported in the exercise group (n=53) (Table
G11.18), musculoskeletal problems were the most commonly reported adverse
event (n=24, 45%). Falls, cardiovascular problems, and increased fatigue were
the other adverse events reported but occurred at a much lower rate.
Table G11.18 also illustrates that recurrent
Stroke, exacerbation in persons with Multiple Sclerosis, and cardiovascular
problems were the major reported adverse events in the control group. A
detailed overview of complications for each specific disability group can be
found in Table
aIncludes only subjects in studies of
persons with a history of stroke; bIncludes only subjects in studies
of persons with multiple sclerosis; cIncludes only subjects in
studies of persons with mental illness; dIncludes only subjects in
studies of persons with spinal cord injury.
People with Stroke can exercise safely without serious adverse events
by performing a careful prescreening exam and being supervised during exercise.
No data indicate that exercise will increase the rate of recurrent Stroke if
the appropriate monitoring and precautions are taken.
Among the 23 reviewed trials in which 538 Stroke survivors
participated in some type of exercise intervention, 6 participants (1.1%)
experienced a recurrent Stroke (39;103). In controls (n=335), recurrent Stroke occurred in 2
participants (0.6%) (102). The incidence of recurrent
Stroke in the exercise group was lower than the incidence rate (2.9% to 6.0%)
reported among individuals 3 to 6 months after their Stroke who are not
involved in an exercise intervention (101).
Angina symptoms, dizziness, mild seizure, and drop in blood pressure
during exercise or VO2peak testing were reported in 2 studies (43;78). All reported side effects
improved and all participants, with the exception of one individual who had a
drop in post-exercise blood pressure and was removed from the study, received
medical clearance to complete the exercise trial. Complications occurred in 2
Stroke participants who reported excess fatigue and dropped out of the study
(41;131). Three other participants
experienced back or knee pain but were able to complete the intervention (82).
Although it is important to closely monitor any changes in disease
symptoms for people with Multiple Sclerosis during and after the exercise
training sessions, the concern of potential worsening symptoms related to the
exercise exposure does not appear to be justified based on this literature
review. This finding is in agreement with a recent report by Ginis and Hicks
(7), who were charged with the development of a physical
activity guide for Canadians with physical disabilities. In particular, there
is no scientific evidence to support the notion that individuals with certain
forms of Multiple Sclerosis may have worsening symptoms related to increased
core temperature during/after exercise (7).
A total of 16 exercise trials involving persons with Multiple
Sclerosis were reviewed. Among the participants in the exercise groups (n=363),
4 experienced musculoskeletal problems (1.1%), 2 reported elevated spasticity
(0.6%), and 4 had an exacerbation (1.1%). In terms of the total number of
subjects in the control groups (n=266), 1 subject experienced knee pain (0.4%)
and 5 subjects had an exacerbation (1.9%). More specifically, 3 RCTs indicated
no difference in relapse symptoms between the exercise and control groups (15;18;19). One
trial reported that 2 participants in the exercise group experienced
exacerbations while none did in the control group (115).
However, 2 other trials reported that only participants in the control group
(n=3) had an exacerbation of symptoms compared to no relapse in the exercise
groups (16;68). Two studies indicated
adverse events related to the exercise exposure. Two subjects in the
intervention group experienced elevated spasticity of the lower extremity after
completing the exercise test (16), and a few participants
reported temporary low back muscle soreness (n=1) and leg muscle soreness (n=3)
during the initial training period (69). Based on this
literature review, there is currently no evidence to support the notion that
exercise imposes a higher risk of exacerbation or harm in people with Multiple
Sclerosis. This finding is consistent with a recent report published in Canada
(7) that concluded that exercise has no effect on disease
progression and should be an important component of disease management.
Back pain, muscle soreness, and feelings of fatigue were the most
commonly reported adverse events associated with exercise in subjects with
Muscular Dystrophy. Among 230 subjects in the exercise groups of 12 examined
studies, 7 participants reported musculoskeletal problems (3.0%), compared to
no reported adverse events in the control groups (n=155). Specifically, 2
subjects withdrew from the exercise intervention due to training-related back
pain (73;151). Some subjects
complained of transient muscle strength reduction (n=3) at the beginning of the
exercise program (25;71;151) or expressed worsening fatigue (n=2) (22;23), but all subjects were able to
complete the intervention.
Muscle pain was the most commonly reported adverse event in people
with Spinal Cord Injury who participated in an exercise intervention. Among 208
subjects, 4 (1.9%) experienced muscle pain during the aerobic training sessions
(77) or after isokinetic testing (31). None of these complications affected their ability to
complete the exercise program. One study (77) noted that
exercise did not worsen the skin health of people with Spinal Cord Injury, and
in 2 of 4 subjects who had pressure sores not associated with the exercise
intervention, they healed by the completion of the study. One RCT reported that
exercise using an arm ergometer in the supine position caused one participant
(0.5%) to have bladder spasms (28).
In the 11 reviewed studies involving 123 subjects in the exercise
group and 69 subjects in the control group, no studies reported any
complications in individuals with Cerebral Palsy, and only one study reported
that a 6-week strengthening exercise intervention had negatively affected
self-concept in children with Cerebral Palsy, but the reasons behind the
unexpected reduction were unclear (152).
The major concern regarding exercise interventions for older persons
with Alzheimer's disease is risk of falls. Among 229 individuals with
Alzheimer's disease in 6 different exercise trials in which the primary
exercise mode was walking, one study reported that there was no difference in
the incidence of falls over a one year period between the exercise and control
group referred to as the routine medical care group (139
versus 136) (106).
In the 14 exercise interventions reviewed consisting of 287 subjects
in the exercise condition and 183 subjects in the control condition, no adverse
events related to the exercise exposure in people with Parkinson's disease
occurred. In one study that was conducted to determine whether high-force
eccentric resistance exercise caused subjects with Parkinson's disease muscle
damage to their lower extremity, the researchers noted that the exercise
exposure did not have a negative impact on muscle damage or function (75).
In the 15 studies that addressed the effects of exercise in
participants with major depression disorder (n=335), only 2 RCTs reported
adverse events related to the exercise exposure. These included musculoskeletal
injuries (n=8, 2.4%), chest pain (n=1, 0.3%), and increased severity of
depressive symptoms (n=1, 0.3%) (54;144). One study concluded that compared to medication use,
subjects in a treadmill exercise program experienced a lower incidence of
diarrhea or loose stools (21% for those exercising at home and 10% in
supervised exercise group) compared to those in the antidepressant group (31%)
(53). Further, no adverse events related to exercise
training were reported in 135 participants who were diagnosed with
schizophrenia and bipolar disorder (n=11). Among all control group participants
(n=210), no reported adverse events occurred.
In the 12 exercise trials involving persons with Intellectual
Disability including Down syndrome, none of the studies reported any physical
complications. Only one trial reported that swimming in an integrated
environment caused negative effects on perceived athletic competence for youth
with intellectual disability compared to a segregated swimming class, although
the swimming performance of subjects in the integrated setting increased (153).
This report systematically evaluated published evidence regarding the
effects of physical activity on people with physical and cognitive
disabilities. Table G11.19 presents the findings
in aggregate form, collapsing all physical disabilities into one group and
cognitive disabilities into another group. Aggregating these data allows for a
summary of the changes associated with exercise by health outcome and
disability group (physical versus cognitive).
To determine the strength of evidence, each health outcome across the
6 categories evaluated in this report was identified and categorized by level
of evidence according to the following criteria: Strong: 75% or more of
reviewed trials had significant findings; Moderate: 50% to 74% of reviewed
trials had significant findings; Limited: less than 49% of reviewed trials had
significant findings. Two or more studies with significant findings on the
identified health outcome were required for classification into strong or
moderate level of evidence. Based on this classification scheme, for people
with physical disabilities there was strong evidence that exercise can increase
cardiorespiratory, musculoskeletal and mental health outcomes; moderate
evidence to improve a variety of functional health outcomes and reduce the
effects of certain types of secondary conditions (i.e., pain and fatigue
associated with the primary disability); and limited evidence in improving
healthy weight and metabolic health. For people with cognitive disabilities,
there was strong evidence that exercise can improve musculoskeletal health,
select functional health and mental health outcomes; moderate evidence for
improving cardiorespiratory, musculoskeletal, and healthy weight and metabolic
health; and limited evidence for reducing secondary conditions.
Physical Disability:
Cardiorespiratory Health
In summary, since the publication of the Surgeon General's Report
on Physical Activity and Healthin 1996 (154), a
growing volume of research, including a number of RCTs, supports the use of
physical activity to improve health and function among people with
disabilities. With appropriate screening procedures, physical activity is
considered to be a relatively safe, effective, and very important health
recommendation for people with physical and cognitive disabilities. Data on
select disability groups show improvements in various health outcomes including
cardiorespiratory, musculoskeletal , functional, metabolic, and mental health,
in addition to reducing certain secondary conditions associated with the
primary disability such as pain and fatigue. An important caveat in
interpreting these findings is that each study had its own prescreening
evaluation for entrance into the study, which may have limited the sample to a
select group of individuals within a certain range of health and function.
Within this limitation, however, the consistency of the findings suggest that
exercise training is an effective intervention for promoting health at a low
risk of complications/adverse events in individuals with physical and cognitive
This report also provides a framework for continuing to build an
evidence base that can identify specific doses of physical activity in relation
to key health outcomes in people with a variety of physical and cognitive
disabilities. New studies and other disability groups can be added to the
database as more research is published. In the future, in areas where data are
lacking, researchers will be able to review the evidence and develop
interventions that target key health outcomes in underserved groups of
individuals with disabilities.
The development of appropriate inclusion/exclusion criteria is an
important approach to ensuring that exercise is safe for a specific subgroup of
people with disabilities. In all of the studies reviewed, screening and
specific inclusion/exclusion criteria were important in terms of distinguishing
individuals who were or were not appropriate for the intervention, usually
based on level of current health or functional limitations. With younger, less
disabled groups, risks associated with exercise appear to be typical of the
general population. Given the high rate of physical inactivity reported among
people with disabilities, it is critical for policymakers to promote physical
activity guidelines among professional groups and associations that have
regular contact with people who have disabilities (e.g., rehabilitation
providers, fitness professionals, health care professionals, public health
programs, service providers), and to support efforts to increase access to
physical activity venues including indoor and outdoor sports, recreation and
fitness facilities.
This review also provides strong evidences that the benefits of
physical activity for people with physical and cognitive disabilities far
outweigh the risks. Very few reported serious adverse events (n=34, 1.15%).
Although most of the studies were done in a controlled setting and may have
excluded severely disabled subjects, the existing evidence supports the use of
physical activity as a recommended health promoting activity among people with
disabilities, including those with progressive disorders (i.e., multiple
sclerosis) or more severe conditions (i.e., muscular dystrophy).
This report does not account for differences in methodological
quality. In the future, it would be helpful to qualify the RCTs based on
selection criteria such as adequate sample size, equal groups (control and
experimental) at baseline, blinding of study staff (i.e., different assessors
for pre- and post-testing), recording of participant completion and dropout,
and intention to treat. Studies were evaluated by their level of significance
and not according to their effect sizes. We focused on 11 key disability groups
only and did not include other disabled populations, such as those with
rheumatoid arthritis, and populations in which disabilities occur at low
incidences, such as those with spina bifida and polio, where not enough studies
were available to include in this review.
All of the studies reviewed in this report had several outcomes (e.g.,
physical and emotional well being, reduced fatigue, increased fitness, etc.),
and used a variety of interventions and doses of exercise (length of training,
frequency, duration, intensity, modality). Several studies included individuals
with a wide range of function and age, which may have attenuated the potential
effects of the training regimen on certain subgroups within the larger sample
(e.g., younger versus older subjects). Although heterogeneous populations make
it easier to recruit subjects (e.g., using individuals with para- and
tetraplegia in the same study) and obtain higher levels of statistical power,
generalizability to the entire population (i.e., Spinal Cord Injury or
Multiple Sclerosis) may be limited because of variations in health and function
among the different subjects.
Another limitation was that the studies did not necessarily represent
individuals with severe forms of the disability (i.e., tetraplegia vs.
paraplegia, severe cerebral palsy versus mild cerebral palsy; advanced types of
multiple sclerosis). Therefore, it is not possible to generalize the findings
to various subgroups within each disability who may have had an advanced
condition. Data on certain subgroups (i.e., lower limb loss, cerebral palsy)
also were limited, which reduced their generalizability.
Although we identified all the complications/adverse events reported
in the 139 studies that were reviewed, it is possible that some of the studies
did not report certain complications or adverse events.
It is important to identify optimal doses of exercise based on
evidenced-based outcomes that delineate the safety of the activity and the
specific health outcomes achieved by various exercise regimens for various
disabled populations. The lack of data pertaining to the frequency, intensity,
duration, and modality components of an exercise prescription for persons with
disabilities has made it difficult to recommend specific training regimens to
improve certain health outcomes or reduce the severity of certain secondary
conditions associated with the disability (e.g., pain, fatigue).
The questions posed for this review suggest several lines of research
to understand the dose-response effects of exercise in the treatment and
management of targeted health outcomes. In order to establish a focused
research agenda, studies should have an acceptable level of homogeneity (i.e.,
age, health status, functional level), and a consistent methodology, training
dose and targeted outcome(s).
The very low exercise participation rate observed among people with
disabilities may be associated with the gap between an individual's needs,
interests and functional level, and the barriers that are often present in the
environment. Environmental factors also can have a significant role in a
person's ability to exercise, including access to exercise equipment or
programs/classes, available transportation to and from the facility, and cost
of the program. Collectively, these factors can make it extremely difficult for
someone with a disability to participate in regular exercise. Health
professionals must increase their awareness of the personal and environmental
barriers that can have a substantial negative effect on participation in people
with different types and severities of disabilities.
Early studies on physical activity and pregnancy were concerned more
with harm to the mother and fetus than with potential benefits. Most studies
used animal models, though some human studies examined cardiorespiratory
responses and thermoregulation in the mother, fetal heart rate, and pregnancy
outcomes such as birth weight, gestational length, and adverse events.
The American College of Obstetricians and Gynecologists (ACOG)
developed the first exercise guidelines for pregnant women in 1985 (156). Those guidelines were based on limited data and were
conservative. They included upper limits of 140 beats per minute for maternal
heart rate and recommended that sessions of strenuous activity be limited to 15
minutes. The guidelines also noted the potential need to individualize physical
activity recommendations.
Between 1985 and 1994, nearly 600 relevant studies were published,
most of which focused on doing no harm. Many studies were laboratory
investigations with small sample sizes, and most involved acute maternal
responses to exercise. The data suggested no detrimental effects of the
targeted exercise to mother or fetus, possible reduced length of labor,
possible improvement in gestational diabetes, and relatively little loss of
fitness by chronic exercisers. The use of a target heart rate was found to be
quite problematic. ACOG updated its guidance for exercise during pregnancy in
1994 (157) and again 8 years later (158). Currently, ACOG recommends that pregnant women
participate in 30 minutes of moderate-intensity physical activity on most days
of the week in the absence of medical/obstetrical complications (158). Although this recommendation does not endorse
participation in vigorous activities for all (for which information is scarce),
it does not recommend against women being strenuously active during
This part of the Understudied Populations section
addresses 3 questions:
The evidence presented here was based on references included in the
review of the literature for the 2006 Institute of Medicine report on physical
activity and health (159) and an updated search of the
Cochrane Library and MEDLINE for published RCTs, meta-analyses, and review
articles. Search terms included exercise, physical activity, pregnancy,
postpartum, the names of experts in the field and/or a combination of these
terms. Search limits included human studies in women published in the English
language from 1996 onward. Relevant articles were reviewed and the
subcommittee's conclusions were summarized and presented here.
Moderate-intensity leisure-time physical activity is not associated
with an increased risk of low birth weight, preterm delivery, or early
pregnancy loss (160;161). A recent
review concluded that moderate-intensity leisure-time physical activity during
pregnancy normally does not affect birth weight. However, participation in
vigorous activities has been associated with small reductions (about 200 to 400
grams) in birth weight compared to birth weights of babies born to less active
women (160). Similar results were reported in a
meta-analysis published in 2003 (162).
Information on strenuous activity during pregnancy is very limited. A
prospective study in the United States found that participation in vigorous (6
or more METs) activities in the first and second trimesters was associated with
non-significant risk reductions for preterm delivery (163). Similarly, a prospective Australian study found no
significant effects of vigorous physical activity during pregnancy on
gestational age at birth or birth weight (164). Results
from these studies must be applied cautiously as only a select subset of
pre-trained women chose to continue vigorous activity during pregnancy.
In 2005, an expert panel was assembled to examine the impact of
physical activity during pregnancy and the postpartum period on maternal
chronic disease risk (165). The panel also addressed the
association of physical activity with the risk of preeclampsia and gestational
diabetes mellitus (GDM). Regular physical activity in early pregnancy has been
found to be associated with a reduced risk of preeclampsia in 2 case-control
studies (166;167) and one cohort
study (168). The evidence is not strong, but is
consistent. A more recent Cochrane Review of RCTs found a non-significant
reduction in risk of preeclampsia associated with moderate physical activity
during pregnancy; although only two trials with a combined sample size of 45
women met review criteria (169). A Cochrane Review for
GDM also showed no significant effect of physical activity (170). However, reviews of observational studies consistently
show a reduced risk of GDM associated with moderate physical activity
participation before and/or during early pregnancy (160;171). Although conclusions from
these reviews along with data from a large population-based prospective study
(172) confirm that leisure-time physical activity reduces
risk and helps to treat GDM, data are insufficient to develop specific optimal
physical activity guidelines for GDM prevention.
Investigators also have evaluated maternal physical activity in
relation to health-related fitness, psychological health, and the course of
labor and delivery. The evidence clearly supports that maternal physical
activity of any kind helps to maintain fitness levels, which normally decrease
during pregnancy (161;173). Fewer
studies have considered maternal mood during pregnancy, yet available evidence
suggests that maternal physical activity improves mood and is associated with
increased self-esteem (161;174).
Conflicting results exist relating maternal physical activity to the course of
labor and delivery. Some studies report easier and shorter deliveries, others
find no effect, and some show that induction of labor is used more often among
women who exercise (161). Variances in methodology and
activity definitions make these studies difficult to summarize and compare. A
recent study (175) showed that women who exercised during
pregnancy were less likely to have preterm delivery compared to their sedentary
counterparts. However, the authors were not able to clearly separate the role
of moderate versus vigorous activity on this effect.
Available evidence has shown maternal physical activity during the
postpartum period is associated with enhanced mood (165;176;177),
increased cardiovascular fitness (177;178), and obesity prevention (179).
Larson-Meyer (177) reviewed approximately 60
cross-sectional studies and RCTs on postpartum weight reduction, specifically,
looking at postpartum exercise. When compared to no physical activity, moderate
physical activity did not appear to increase postpartum weight reduction unless
caloric restriction was included. Studies also have showed that moderate
intensity aerobic exercise did not adversely affect milk volume, composition,
or infant growth (165;177;180). Some longitudinal data on future disease risk come
from Rooney and colleagues (179) who examined nearly 800
women immediately postpartum and again 15 years later. Disease and risk factor
development (diabetes, heart disease, dyslipidemia, and hypertension) were
directly related to weight gain over 15 years. Women who continued to perform
aerobic exercise postpartum were less likely to become obese than those who did
not. In summary, in the absence of medical complications, physical activity
during the postpartum period is beneficial to the overall health of the mother
(both in the short- and long-term) while not adversely affecting her newborn's
Although the benefits of maternal physical activity have clearly been
demonstrated, prospective, randomized intervention studies in diverse
populations are greatly needed. Based on current evidence, unless there are
medical reasons to the contrary, a pregnant woman can begin or continue a
regular physical activity program throughout gestation, adjusting the
frequency, intensity, and time as her condition warrants. Very little evidence
exists for the dose of activity that confers the greatest health benefits to
women during pregnancy and the postpartum period. In the absence of data, it is
reasonable for women during pregnancy and the postpartum period to follow the
moderate-intensity physical activity recommendations set for adults unless
specific medical concerns warrant a reduction in activity. Habitual exercisers
with high fitness levels undergoing a healthy pregnancy need not drastically
reduce their activity levels, provided that they remain asymptomatic and
maintain open communication with their health care providers so that
adjustments can be made if necessary. This same communication should be
continued into the postpartum period, where the time needed before a woman
returns to performing regular physical activity should be governed by medical
safety concerns, rather than a set time period.
The charge to the PAGAC by the Secretary of Health and Human Services
was to review the science pertaining to physical activity and public health,
including the literature that would help ensure that new federal physical
activity guidelines and policy statements would apply to all Americans and, as
best possible, also meet the needs of specific subgroups of the population.
Chronic disease risk and disease burden in the United States are
higher in racial/ethnic minority communities than in non-Hispanic whites. Thus,
special attention to the particular physical activity needs and requirements of
these groups is warranted. To summarize the science addressing racial/ethnic
specific health-related responses to various doses of physical activity, each
subcommittee identified and reported data for specific racial/ethnic groups.
The objective was to determine whether such responses significantly differed
from those observed for non-Hispanic white men and women.
Compared to the large number of studies published since 1995
investigating the role of physical activity in disease prevention and health
promotion, quite limited data exist on race-ethnic specific responses (181-185). Many studies have included only non-Hispanic white
participants, or have included small sub-samples of other racial and ethnic
groups, precluding meaningful sub-group analyses by race/ethnicity. Also
limiting a comprehensive review of this issue is the failure of some authors to
include (and editors to require) precise information on the racial/ethnic
characteristics of the study populations (186). A few,
mostly observational, studies have included data on several racial/ethnic
populations or on one population other than non-Hispanic whites. Most of the
latter have been studies conducted in countries other than the United States.
The contexts for the physical activity-disease association in other countries
may differ for similar populations living in the United States. However,
studies in other countries provide a broader and more diverse perspective than
may be obtained from US data alone.
The public health burden imposed by physical inactivity may be
disproportionately high in ethnic minority and lower SES communities (187-192). African Americans, American Indians/Alaska
Natives, Asian Americans, Pacific Islanders, and Latinos have significantly
lower levels of regular physical activity, and significantly higher levels of
inactivity than do whites (6;193).
Though Asian Americans and Pacific Islanders have traditionally been merged
together in most data sets, disaggregation of these groups is critical because
they tend to be at the opposite ends of the spectrum of body weight, which
influences and is influenced by physical activity (Asian Americans have less,
and Pacific Islanders, more obesity, compared to other population groups).
Growing but smaller ethnic minority populations who are not always separately
identified (e.g., South Asian and Middle Eastern), also likely experience
challenges in achieving adequate physical activity participation (194). These differences are magnified by the recent data
documenting the extremely low levels of objectively measured
moderate-to-vigorous physical activity, and high levels of sedentariness,
across the entire United States population, but especially among ethnic
minorities (195;196).
Disparities exist in most physical activity-related chronic diseases
and conditions. For example, overweight and obesity rates vary substantively by
ethnicity, even taking into account SES (e.g., (197); (198), (199)). Despite the public
health consensus that physical inactivity is an important determinant in a host
of health disparities across population segments, racial/ethnic differences in
the contribution of physical activity to various health outcomes have rarely
been systematically investigated. Several reasons for possible differences have
been postulated. There may be modest differences in the energy cost of physical
activity, for example, as a result of racial anthropomorphic variations (see
Part G. Section 4: Energy Balance
for additional discussion). Alternatively, the dose response of
physical activity on health outcomes may be similar across racial/ethnic
populations, while cultural and contextual factors may lead to differences in
the achieved effective dose of a particular intervention (implementation) or in
the accuracy of a particular measure in capturing the dose delivered
The marked skewing of racial-ethnic minority populations toward lower
SES compared with whites complicates interpretation of these observations of
racial/ethnic differences in public health surveillance (200). SES explains some, but usually not all, racial/ethnic
differences. In some studies, ethnicity was no longer significant when other
sociodemographic variables reflecting SES were included in multivariate
analyses of physical activity (185;201). In others, the magnitude of physical activity
variation by ethnicity was statistically significant but much less substantive
than variations related to other socio-demographic and health status
characteristics (193;202).
This skewing makes it difficult, if not impossible, to examine the
influence of SES independent of race/ethnicity on physical activity-related
outcomes. In fact, because the data are so scant, heterogeneity between and
within racial/ethnic groups generally limits extrapolation between studies.
Inter-ethnic, and even intra-ethnic comparisons are further complicated because
of the substantial confounding of race/ethnicity and SES. Lower SES
non-Hispanic whites comprise a relatively low proportion of the white
population overall, and are underrepresented in public health research. In
contrast, substantial numbers and in some cases a majority of African American,
Latino, Pacific Islander and American Indian study participants are of lower
SES. As a result, inadequate sub-samples of lower income non-Hispanic whites or
higher income ethnic minority participants hinder analytical disaggregation by
race/ethnicity and SES. Therefore, we will focus on racial/ethnic differences,
recognizing that race/ethnicity is, in part, a proxy measure for SES.
This portion of the Understudied Populations
section addresses one major question:
A search of the Physical Activity Guidelines for
Americans Scientific Database identified research articles on the
effect of physical activity on racially/ethnically diverse groups. These
articles were not readily identifiable within the database, as many articles
retrieved using racial- or ethnic-specific keywords had very small minority
samples and mention of racial/ethnic variations in outcomes were rare. Because
so few relevant studies were available in the Database, pertinent reviews
available through a MEDLINE search were considered, as were recently published
and "in press" journal articles identified through reference lists of articles
cited and through expert consultation.
Data addressing race- and ethnicity-specific responses to physical
activity are still extremely limited. Very few subgroup analyses were reported
that permitted direct comparisons between racial/ethnic groups. No clinically
significant differences were identified in the review of studies comparing
responses to physical activity between different racial or ethnic groups or in
analyses adjusting for race and ethnicity. Data on various health outcomes in
prospective observational studies involving populations other than non-Hispanic
white men and women do not suggest any race- or ethnicity-specific responses to
physical activity. However, too little evidence is available to draw firm
conclusions. While additional data are being generated, the available evidence
suggests that the major health benefits of physical activity are not race- or
Provided below is a brief summary of published research addressing the
issue of race- and ethnicity-specific health-related responses to physical
activity. For additional information about the health outcomes described here
and for information about race/ethnicity data for other outcomes, the reader is
referred to the remaining chapters in Part G: The Science Base. In general
for these outcomes, data are insufficient to draw any conclusions regarding
race- or ethnicity-specific effects or dose response.
Three studies included nationally representative samples of
participants (203-205) and another comprised 48.3% blacks
(206). In addition, 2 studies specifically enrolled
Hispanics (207) and Japanese-American men (208). Five studies were conducted in Asia enrolling Chinese
and Japanese subjects (209-213). No inter-ethnic/racial
differences in the effect of physical activity on all-cause mortality were
Few studies conducted in the US have had an adequate sample size and
clinical outcomes to evaluate the association between physical activity and
cardiovascular disease (CVD) clinical events in race-ethnic groups other than
non-Hispanic whites. An analysis of this issue in data from the Women's Health
Initiative Observational Study (214) included 61,574
white women and 5,661 black women with a mean follow-up of 3.2 years. The
relation between physical activity level (quintiles of MET-hours per week) and
CVD clinical events was significant for both groups of women with relative risk
(RR) for the highest versus lowest quintile of activity for white women being
0.56 (P for trend <0.001) and for black women 0.48 (P for
trend = 0.02). In contrast to these results, a report on the Atherosclerosis
Risk in Communities (ARIC) study population indicated that although there was a
significant inverse relation between activity level and CVD clinical events in
white men and women, no such relation was found for either black men or women
(215). The authors suggest that this lack of association
in blacks may be due to the limited number of blacks reporting vigorous
physical activity (5% in black men versus 15% in white men). The different
geographic locations of the black (primarily Mississippi) and white (Washington
State, Minnesota, and North Carolina but not Mississippi) cohorts in ARIC may
be relevant here. However, outside the United States where the relation between
physical activity level and CVD clinical events has been evaluated in
racial/ethnic populations other than whites, no indication exists that the
favorable association frequently reported for non-Hispanic white men and women
is absent. For example, physically active Japanese men and women living in
Japan (216) and older Japanese men living in Hawaii (208) had lower CVD mortality rates than their least active
counterparts. Similar results have been reported for Chinese women living in
Shanghai (212) and Chinese men and women living in Hong
Kong (210). In a case-control study that included men and
women, conducted in New Delhi and Bangalore India, the RR for myocardial
infarction of 145 or more MET-minutes per day of LTPA versus no activity was
0.44 (95% CI 0.27-0.41) and time spent in non-work sedentary activity also was
directly associated with risk of myocardial infarction (RR for at least 215
minutes per day versus less than 70 minutes per day = 1.58 [95% CI:
1.05-2.36]). In an aerobic exercise training study lasting 20 weeks that
included African-American and non-Hispanic white men and women, no
racial-ethnic differences were observed in the percent increase in
VO2max (217).
Within the United States, associations between increased physical
activity and decreased breast cancer incidence have been observed in
multiethnic populations (218-220) as well as in
investigations in specific racial/ethnic minorities: black (219;221), Hispanic (220;222), and Asian American women (223). No differences in the magnitude or quality of this
association were apparent.
Twenty-four articles that included data on various racial-ethnic
groups were identified during the systematic literature review. Half reported
on studies conducted outside of the United States, including 9 in Asia/Pacific
Islands, 2 in Africa, and 1 in Central America. Fourteen were cross-sectional
studies (185;202;224-235), 3 were longitudinal cohort studies (201;231;236),
and 7 were interventions (192;237-242). Only one of the intervention studies included a
direct comparison between two racial-ethnic groups, whites and blacks (239). The actual body weight lost during the 20 weeks of
exercise was the same for both groups – 0.2 kilogram – and
this loss was statistically significant in whites but not blacks, most likely
because of a lower statistical power for the blacks due to their much smaller
sample size. It should also be noted that this was designed as an exercise
training study and not a weight loss study. Also, adjustments for subtle
racial/ethnic anthropomorphic variations that might explain any racial/ethnic
differences (e.g., shorter trunk length in blacks), identified in experimental
exercise physiology studies (243) were not reported (239).
The majority of studies with large sample sizes was either conducted
in Europe or was composed of whites of American or European descent. Though
some of the better studies were conducted in populations composed of both
African Americans and non-Hispanic whites, no studies examined the physical
activity-metabolic syndrome association in an African-American or Hispanic
population only (244-246). Thus, limited data are
available on the relation between physical activity or fitness and preventing
metabolic syndrome in populations other than non-Hispanic whites. It should be
noted that studies that used populations composed of both whites and African
Americans, such as NHANES (cross‑sectional) and CARDIA (prospective),
showed a strong dose response between activity (or fitness) and prevention of
metabolic syndrome (245;246).
In observational studies that included women only, 3 large US cohort
studies (247-250) all found that greater physical
activity was associated with a lower incidence of diabetes. However, in one
study, this relation was present only in white women and not in women of
African-American, Hispanic or Asian descent (250). These
findings await confirmation because the study may not have been powered to
detect differences across all racial/ethnic groups. Results were based on
self-report of diabetes diagnosis in the total population but were confirmed in
a subset using blood samples and physician reports. Data from RCTs as well as
observational studies suggest clearly that, overall, women and men benefit from
increased levels of physical activity in terms of preventing type 2 diabetes.
In the Diabetes Prevention Program (251), treatment
effects did not differ significantly according to either sex or racial/ethnic
group. Although participant numbers became too small for clear results when
grouped by ethnicity, it appears that risk reduction compared with placebo was
greater for the lifestyle group (both diet and physical activity were parts of
this intervention) than for the group taking the common diabetes drug,
Metformin in whites (50% versus 12%, respectively) and Hispanics (57% versus
2%, respectively) (252). In African Americans (42% versus
29%) and Native Americans (43% versus 42%), the lifestyle and Metformin groups
showed more similar efficacy. For Asian Americans, Metformin showed a
non-significantly greater reduction than intensive lifestyle intervention (62%
versus 30%).
Given the paucity of outcome-specific studies providing useful
information about racial/ethnic minority populations, evidence of physical
activity influences across content areas was assessed
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text:
Creamy Gluten-Free Chocolate Frosting
The coconut oil in this creamy gluten-free chocolate frosting gives the frosting a satiny texture. Add more cocoa powder if you like a deeper chocolate taste. Coconut oil is solid at room temperature; in fact, it's so solid that it's difficult to combine with the butter unless both are melted together.
Preparation time: 20 minutes
Cooking time: 3–5 minutes
Yield: 8 servings
2 tablespoons coconut oil
1/2 cup butter
1 cup semisweet chocolate chips
6 tablespoons cocoa powder
Pinch salt
1/4 cup heavy cream
1/3 cup sour cream
2 teaspoons vanilla
3-1/2 cups sifted powdered sugar
In a large saucepan, combine the coconut oil, butter, and chocolate chips. Melt over low heat until smooth, stirring frequently, about 3 to 5 minutes.
Remove from the heat and beat in the cocoa powder and salt.
Transfer the mixture to a large bowl.
In a small bowl, combine the heavy cream, sour cream, and vanilla; whisk to combine.
Alternately add the powdered sugar and cream mixture to the melted chocolate mixture, beating well after each addition.
You may need to add more heavy cream or more powdered sugar for desired spreading consistency. This recipe fills and frosts one 9-inch layer cake.
Per 1 tablespoon serving: Calories 82 (From Fat 40); Fat 4g (Saturated 3g); Cholesterol 8mg; Sodium 5mg; Carbohydrate 11g; Dietary Fiber 0g; Protein 0g.

subset: commoncrawl


text:
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text:
In minutes, the South by Southwest keynote speech by Twitter CEO Evan Williams went from jam-packed to nearly empty. The difference was so startling that the number of people who bailed lightened the load on AT&T's much-derided network -- those left behind were getting better service on their iPhones.
Instead of a line to get into the much-anticipated discussion with Williams, there was a line to leave the panel room.
One person on Twitter, @burtherman, even joked "seems there's even a @foursquare checkin location now for people leaving the @ev keynote."
Many blamed the interviewer, Havas Media Lab director Umair Haque, and the pace of the discussion – too slow, boring, slow pace, etc.
However CNET believes it's because Williams announced the news everyone was waiting to hear -- the @anywhere platform – right at the outset of the talk.
Local blogger Jennifer Van Grove, who is in Austin covering SXSW for NBCSanDiego, felt even @anywhere was presented in a dry way. The news, which Van Grove said felt glossed over, was rushed by Williams. She said he seemed a little too nonchalant about the announcement.
Listening in on the conversation while someone behind her snored, Van Grove said there was a general sense in the audience of "why am I here?"


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By DAVID GREEN
Fayette school superintendent Russ Griggs figures he's saving taxpayers a little more than a mill worth of taxes by serving on a part-time basis.
He wants to bump the savings up to 1.8 mills in the next school year by working even fewer days.
"Contrary to the current business model used by major corporations," Griggs said, "my reductions start at the top of the organization."
Griggs was hired in 2007 to replace David Hankins who was retiring. Griggs, himself, was a retired school administrator with more than 25 years of experience. When Griggs was interviewed for the job, he spoke with board of education members about working less than full time.
When his contract was renewed for the 2008-09 school year, the new pact called for a reduction of 30 working days. For the current school year, another 20 days was cut out of the contract.
The standard contract for a superintendent in Ohio calls for 260 days on the job, Griggs said. He's down to 210 days this year and proposes dropping to 150 days for the next school year.
"Due to the size of the school district and having two building administrators already in the district made discussing the concept possible," Griggs wrote in a letter to the board. "Past experience at Stryker Local Schools showed the concept was effective in a transition period. Stryker Schools passed a bond issue and an operating levy while reducing growth in operational spending with a part-time superintendent."
Shrinking revenue and growing costs require boards to be creative, Griggs said. Since he is already officially retired, the board doesn't pay for his health insurance or vacation time.
Griggs said his current reduced schedule saved the district more than $43,000. His proposal for fewer days next year would result in a savings of $68,955 for 2009-10.
Griggs said his status allows flexibility with a mix of half-day and full-day sessions. Communication via e-mail and cellular phone allows contact when he's out of the office. The majority of daily issues can be addressed by the principals and support staff, he said.
On the negative side, Griggs acknowledged that he isn't always available for immediate consultation by students, staff or community members. With the frequency of meetings and off-campus obligations, Griggs said he's often unavailable with the current contract.
Griggs pointed out to the board that it has protection should he not get the job done or go into "a coasting mode."
"The contract with the superintendent has a clause that allows the majority of the board to terminate the contract at any time, with notice, without cause or repercussions to the district," he wrote.
Griggs wrote that he wouldn't want to continue working in the district without the support of board members.
When he leaves, Griggs said, the board should keep in mind that it would face much higher administrative costs if returning to the traditional full-time superintendent.
If his proposal for a further reduction in days is accepted, Griggs said that his savings to the district, from when he started in Dec. 2007 through the end of July 2010, would total $123,984.
Budget cuts due to shrinking revenue are expected to be announced at the next board of education meeting March 16.
A response from board of education president Paula Schaffner arrived too late for publication:
I have two ways of looking at Russ's schedule. One is that sometimes it is inconvenient not to be able to call or stop in to talk to him at any time as one might do with a "full-time" superintendent. However, I found that, as Russ mentions in his article, many times a superintendent is out of the office attending to things in the building, or at meetings which are important that he attend. I do know that we are able to contact him immediately by phone or email if necessary. Would I like a superintendent that is here full-time? The answer is, "Yes."
The other way is that over that last few years we have been trying to find ways to save money. One way to save money was to hire Russ. He came to us with many years of experience and some of these years as a "less-than-full-time" superintendent. He was aware of what could and couldn't be done in a situation like ours. He has come into our district, finished overseeing the building project, spend countless hours working out the "blips" that come with a building project as big as ours with as many different contractors that we had. He is working to help us find ways to save money in the future. We are not waiting to see what we MAY or MAY NOT get from the state or the federal government. Right now he is saving us quite a bit of money by being part-time.
We DO NOT want to have to come back the community for more money. We know that if and when we do, there will be those who will say, "Yeah, they built that new school and now they need more money to run it." Well, to them I would say that if we hadn't built the new school, we would probably have been to you much sooner to keep the old buildings running. The Franklin Building needed a new sewage system and a new water system. The EPA gave us a pass because we were going to move out of the Franklin Building. The Fayette Building need many, many repairs that would have been very costly. Without the money we received from the OSFC, we would have come to the public for funds to make those and continued costly repairs to keep the two older buildings safe and up-to-code.


text: Product Search Search Effective Health Care website Submit search Search Tip: Use double quotes around phrases to rank exact matches higher in the result list. 295 results Sort search results by Sorted by relevance Sort by date Registry of Patient Registries (RoPR) Policies and Procedures Research Report May 31, 2012 Behavioral Programs To Help Manage Type 1 Diabetes Consumer Summary Archive November 29, 2016 An Ethical Framework for N-of-1 Trials: Clinical Care, Quality Improvement, or Human Subjects Research? (Chapter 2) Research Report February 12, 2014 Development of Harmonized Outcome Measures for Use in Patient Registries and Clinical Practice: Methods and Lessons Learned White Paper February 11, 2019 Evaluation of the AHRQ Healthcare Horizon Scanning System Research Report May 26, 2016 Information Technology Infrastructure for N-of-1 Trials (Chapter 5) Research Report February 12, 2014 Data Points #10: Proton beam radiotherapy in the U.S. Medicare population: growth in use between 2006 and 2009 Research Report May 7, 2012 EPC Pilot Project: A Dual Approach To Facilitate Health Systems Uptake of Evidence Synthesis Reports. Anxiety in Children Research Report October 1, 2018 Barriers to Patient Engagement (Session II) White Paper September 30, 2015 Data Points #17: Trends in bariatric surgery in Medicare beneficiaries Research Report Archive November 30, 2012 Radiation Therapy for Head and Neck Cancer Consumer Summary Archive September 2, 2015 Prompt Reduction in Use of Medications for Comorbid Conditions After Bariatric Surgery Research Report July 30, 2010 Financing and Economics of Conducting N-of-1 Trials (Chapter 3) Research Report February 12, 2014 Horizon Scanning Protocol and Operations Manual Research Report October 1, 2015 Patient Engagement: Roles of Activation, Evidence, and Context (Session I) White Paper September 30, 2015 The Incident User Design in Comparative Effectiveness Research Research Report May 15, 2012 Supplemental Project To Assess the Transparency of Reporting for Strategies To Improve Mental Health Care for Children and Adolescents Research Report January 6, 2017 Chronic Venous Leg Ulcer Treatment: Future Research Needs Research Report Archive January 10, 2014 Potential High Impact Reports Potential High Impact Report January 7, 2016 Data Points #20: Echocardiography Trends Research Report May 13, 2014 A Systematic Review of Methods for Health Care Technology Horizon Scanning Research Report August 26, 2013 Linking Evidence Reviews to Organizational Guideline Planning: A Pilot Test of an Interactive, Web-Based Presentation and Discussion of Evidence Research Report October 18, 2018 Data Points #18: Use of and access to health care by Medicare beneficiaries with diabetes: impact of diabetes type and insulin use, 2007-2011 Research Report January 29, 2014 Development and Usability Testing of EPC Evidence Review Dissemination Summaries for Health Systems Decisionmakers Research Report November 9, 2018 Data Points #19: Medication Use in Medicare Research Report April 23, 2014 Registries for Evaluating Patient Outcomes: A User's Guide: 2nd Edition Research Report September 27, 2010 Observed Association Between Antidepressant Use and Pneumonia Risk Was Confounded by Comorbidity Measures Research Report May 22, 2008 Eliciting Patients' Values and Preferences in Decision Making (Session II) White Paper September 30, 2011 Case Study Comparing Bayesian and Frequentist Approaches for Multiple Treatment Comparisons Research Report March 28, 2013 Web-based Cancer Communication and Decision-Making Systems: Connecting Patients, Caregivers and Clinicians for Improved Health Outcomes (Session IV) White Paper September 30, 2009 PreviousPage 1 of 10Next


text:
Another day, another Hollywood power couple boards the bus to Splitsville.
Actress Rachel Weisz, 40, and her director husband, Darren Aronofsky, 41, are separating after nine years together, a rep for Aronofsky told E! News. The pair, who have a four-year-old son, Henry, have been together since 2001 and engaged since 2005.
Weisz, who starred in "The Mummy," "The Constant Garrdner and "The Fountain," once acknowledged her hesitation to get hitched to Aronofsky, who directed "The Wrestler." But she sounded like she was ready for a longterm commitment last January, in an appearance on ABC's "The View."
"Funnily enough, just recently I suddenly felt like I really would like to get married," Weisz told the chatter klatch. "It's just a feeling. I know it's a funny thing."
E! noted there have been rumors about Weisz and Daniel Craig. She and the 007 star allegedly did some serious Bond-ing while working on the film "Dream House" earlier this year, though neither has confirmed any romance.
The couple plan to share custody of Henry and continue to raise him in New York.


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Dir: Christopher Menaul. UK. 2013. 93mins
There is something engagingly watchable about the impressively mounted Summer In February, a lush and elegantly staged melodrama that – despite its painting-by-numbers storyline – is a gently familiar tale of unrequited love, all set against the rugged beauty of the Cornish coast just before World War I.
The film is at its best when the majestic countryside and the blossoming romance combine perfectly.
The strong cast helps give the film a stronger edge, and while overly familiar to a well-made BBC period drama at times, this beautifully shot film has the qualities to break out theatrically on a modest level, with strong lead roles from Dominic Cooper, Emily Browning and Downton Abbey star Dan Stevens guaranteeing sales as well as a strong home entertainment life.
Emily Browning stars as Florence Carter-Wood, a fresh-faced, well-to-do, young woman who joins her brother with the bohemian Lamorna Group on the wild Cornish coast. The group of painters are dominated by the charismatic Alfred Munnings (Cooper), a talented artist – especially of horses – who is also something of a local lothario and naturally enough takes a shine to the lovely Emily, promising to help her with her art.
Also attracted to her is the mild-mannered Gilbert Evans (Stevens), the land agent in charge of the Lamorna estate, who also happens to be Munnings best friend. He is driven by a great sense of propriety and when Florence is won over by Munnings' bombastic charm he steps back and lets their relationship develop, despite the fact that it is clear to everyone that Munnings is something of a cad.
For some reason Florence (and many of the other women in the group) are entranced by Munnings and his - rather cringe-worthy - drunken poetry recitals at the local pub, and while for a time it looks as if the charmingly gentle Gilbert might win her over the sheer melodrama of the story dictates that Munnings should be the man she decides to marry.
Things get interesting for a while as she comes to realise she has made a terrible mistake, and when their marriage becomes a loveless and sexless union she begins a tentative affair with the stoically tweedy Gilbert. Naturally enough, things don't end well.
The film is at its best when the majestic countryside and the blossoming romance combine perfectly. Elegantly shot, beautifully costumed and with a suitably romantic score, Summer In February certainly looks the part, though at times Jonathan Smith's script (based on his own novel) stutters rather than fully engages and the characters feel a little too simplistic with the sudden changes of emotional direction less than convincing.
But the truth is that this romance is based on reality, and Gilbert's real-life diaries revealed the intensity of the relationship. Florence Carter-Wood was complex woman keen to escape her upper middle-class life, while A.J. Munnings went on to be hailed as one of the greatest painters of horses and later become president of the Royal Academy.
Emily Browning is impressively restrained as Florence, tinged with a fresh sense of her burgeoning sexuality, while Dan Stevens trades nicely on his Downton Abbey persona to convince as honourable man in love but wanting to do the right thing. Dominic Cooper has a fine old time as the larger-than-life Munnings, though often overpowers the film with his sheer force of personality.
Production companies: CrossDay Productions, Apart Films, Marwood Pictures
Producers: Jeremy Cowdrey, Janette Day, Pippa Cross, Dan Stevens
Executive producers: Bruno Wu, Stephen Henderson
Screenplay: Jonathan Smith, based on his novel
Cinematography: Andrew Dunn
Editors: Chris Gill, St John O'Rourke
Production designer: Sophie Becher
Music: Benjamin Wallfisch
Website: www.summerinfebruary.com
Main cast: Dominic Cooper, Emily Browning, Dan Stevens, Hattie Morahan, Shaun Dingwall, Mia Austen, Max Deacon, Michael Maloney, Nicholas Farrell