Digital and Mixed Interventions Support Physical Activity After Exercise Therapy

Sustaining Physical Activity in Chronic Disease Management

Physical activity is a cornerstone of managing chronic conditions like cardiovascular disease, chronic respiratory disease, and musculoskeletal pain, with clear benefits for prognosis and quality of life [1, 2, 3]. However, clinicians know that adherence to exercise regimens often declines after a structured therapy program ends [4, 5, 6]. This drop-off can erode the gains from initial interventions, contributing to poorer long-term health outcomes and presenting a persistent challenge in clinical practice [7, 8, 9, 10]. A recent, large-scale review of existing evidence offers new clarity on which maintenance strategies are most effective for helping these patients stay active over the long term.

Reviewing the Evidence on Maintenance Strategies

To synthesize the current evidence, researchers conducted an umbrella review, a study design that systematically gathers and evaluates multiple existing systematic reviews. This high-level approach provides a broad overview of the evidence from randomized controlled trials (RCTs) on interventions designed to maintain physical activity after initial exercise therapy. The search, which spanned Medline, Embase, and CINAHL from their inception to August 20, 2024, yielded 10,931 initial results. The final analysis included 19 systematic reviews, which together represented 136 unique RCTs. The certainty of the evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) framework, a system for rating confidence in research findings.

The included trials covered a range of chronic conditions, with 64 RCTs focusing on chronic respiratory disease, 54 on cardiovascular disease, 14 on knee or hip osteoarthritis, and 4 on chronic low back pain. However, a crucial limitation emerged from the analysis: the methodological quality of the underlying evidence was often questionable. The authors found that 10 of the 19 included systematic reviews had an unclear risk of bias, a finding that tempers the confidence in the review's overall conclusions. The PROSPERO registration number for this umbrella review is CRD42024579734.

Delivery Mode Matters: Digital, In-Person, and Hybrid Approaches

The analysis categorized maintenance strategies into three groups by delivery mode: primarily digital, primarily in-person, and a mixed category that could include digital-only, in-person-only, or hybrid approaches. The findings reveal significant differences in effectiveness based on how interventions were delivered. Digital health interventions were associated with beneficial effects on subjective, or self-reported, physical activity (standardized mean difference [SMD] 0.37, 95% CI 0.05 to 0.69). The SMD is a statistical measure that allows for comparison of outcomes across different studies; an SMD of 0.37 represents a small to moderate effect. However, the certainty of this evidence was rated as low. In stark contrast, traditional in-person booster sessions showed no beneficial effects, with the certainty of this negative finding ranging from very low to low.

More encouragingly, interventions in the mixed category demonstrated a broader range of benefits. These strategies were linked to improved health-related quality of life, a finding supported by moderate certainty evidence across multiple measures (mean difference [MD] 0.28 points, 95% CI 0.05 to 0.52; SMD 0.22, 95% CI 0.03 to 0.41; and MD -2.69 points, 95% CI -4.49 to -0.9). Mixed interventions also produced a large, though low-certainty, beneficial effect on objective, or device-measured, physical activity (SMD 2.14, 95% CI 0.9 to 3.38). Furthermore, they were associated with a small to moderate improvement in objective physical function (SMD 0.48, 95% CI 0.19 to 0.77), also with low certainty. These results suggest that a flexible approach combining different delivery methods may be more effective than relying on a single mode of contact.

Inconsistent Findings for Other Outcomes and Future Directions

While maintenance interventions showed some success in promoting activity and quality of life, their impact on other important clinical endpoints was less clear. The review found no effect or inconsistent effects for fitness levels, adverse events, hospitalization rates, and return-to-work outcomes. The certainty of evidence for these null findings was low to moderate, indicating that current maintenance strategies may not influence these broader health and functional measures. This is a critical point for clinicians managing patient expectations about the benefits of long-term adherence programs.

The authors conclude that while maintenance interventions may help patients with chronic conditions sustain physical activity and function, this conclusion is largely based on low-certainty evidence. For many outcomes, the effects were inconsistent or absent. The data suggest that digital tools may be a viable component of a maintenance strategy, particularly for improving self-reported activity, but they are not a complete solution. To build a stronger evidence base for clinical practice, the researchers emphasize the need for higher-quality studies with more rigorous methodologies across a wider range of chronic conditions. Without such studies, clinicians will continue to operate with a low degree of certainty when recommending long-term exercise maintenance programs.

References

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