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Eden KB, Orleans T, Mulrow CD, et al. Clinician Counseling to Promote Physical Activity [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2002 Aug. (Systematic Evidence Reviews, No. 9.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Clinician Counseling to Promote Physical Activity [Internet].

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Analytic Framework and Key Questions

The ideal evidence to support counseling would link counseling directly to improved health outcomes in a controlled trial. In the absence of such evidence, the clinical logic behind counseling is based on a chain of critical assumptions represented in Figure 1 (see Appendix C). For counseling to be effective, the clinician must be able to assess whether a patient is sedentary or physically active (Arrow 3), and counseling must increase physical activity in the sedentary group (Arrow 1). Also, the benefits of this increase in physical activity must be greater than the adverse effects of assessment and counseling (Arrow 2).

Using the analytic framework, we arrived at a number of key questions that guided our literature search and that we address in the "Results" section of this report. Of these, the primary question we addressed is: "Does counseling children, adolescents, adults and seniors in primary care settings to incorporate physical activity into their daily routines improve sedentary or maintain physical activity levels?" (Arrow 1). We will be focusing on "improve," since we found no information on primary care counseling interventions to "maintain" a physical activity behavior. We did not critically examine evidence linking improved levels of physical activity to improved health outcomes, because the Task Force agreed that the evidence for this link is well established.

Search Strategy and Selection of Studies

We searched the Cochrane Database of Systematic Reviews and Registry of Controlled Trials in April 2000 and again in February 2001 using the term "physical activity," and found abstracts for 27 reviews and 787 controlled trials. We searched the MEDLINE and HealthStar databases from 1994 to June 2001, using the MeSH terms "exercise," "physical fitness," "counseling," "patient education," and "health education," and found 649 additional abstracts. A search of the Best Evidence database, using the terms "counsel," "patient education," "physical activity," and "exercise," returned no additional abstracts. The full search string can be found in Appendix A.

We identified studies published before 1994 from the Guide to Clinical Preventive Services, 2nd edition (27) and from the Surgeon General's Physical Activity and Health report (17). We used reference lists of pertinent articles to locate 124 additional articles, most of which provided background material. Experts provided an additional 21 references.

We included randomized and nonrandomized controlled trials, case-control studies, observational studies, and systematic reviews published 1994 and later if they reported behavioral outcomes of an intervention to increase physical activity in the general primary care population, and if some components of the intervention (assessment, advising, counseling, referral, etc.) were performed by the patient's primary care clinician (nurse practitioner, nurse, physician, or physician assistant). We excluded studies that received a rating of "poor" according to criteria developed by the USPSTF (28).

Data Abstraction and Synthesis

A single reviewer abstracted the information about setting, patient participants, providers, interventions, compliance, and outcomes. At least two reviewers summarized the quality of each included study using criteria developed by the USPSTF (28). To examine specific counseling components, we used an abstraction tool developed by the Behavioral Counseling Work Group of the current USPSTF (29). The tool is based on a practical "5-A" framework (Assess, Advise, Agree, Assist, and Arrange/Adjust) developed to describe the elements of brief provider tobacco-cessation interventions (30). In evidence tables, we summarized the design of each included trial, along with ratings of methodological quality, and major study results, focusing on the magnitude of change and duration in physical activity levels.

This review was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF. AHRQ staff and USPSTF members participated in the initial design of the review and reviewed interim summaries as well as the final manuscript. Since our report was prepared for the USPSTF, it was distributed for review to 13 outside experts and representatives of professional societies and federal agencies.


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