key: cord-012559-tnfkzw84 authors: han, jia; wang, xueqiang; shen, xia; hu, jia; zhang, xin; tang, xin; wang, hong; luo, qinglu; jiang, ying; jiang, zheng; yang, lin; zhang, qi; bai, yiwen; wu, xubo title: on “translating covid-19 evidence to maximize physical therapists’ impact and public health response.” dean e, jones a, yu h.p-m., gosselink r, skinner m. [published online ahead of print june 26, 2020] phys ther. 2020. doi: https://doi.org/10.1093/ptj/pzaa115. implications for advancing therapy education, practice and public health in china date: 2020-07-31 journal: phys ther doi: 10.1093/ptj/pzaa133 sha: doc_id: 12559 cord_uid: tnfkzw84 nan given that china was the initial epicenter for the covid-19 pandemic, we read with particular interest the article by dean and colleagues. 1 there is an urgent need for us to increase the number of physical therapist education programs in order to produce competent practitioners who are especially committed to promoting public health. programs at the baccalaureate level with "physical therapy" in the award title were we support structured bridging courses in which generic rehabilitation therapists can enroll to be upskilled to become qualified physical therapists, so that they meet international standards of practice across clinical settings from the critical care to community care. in chinese, the word for "crisis" has 2 characters, 危机, "danger" and "opportunity." unquestionably, the pandemic is a global crisis; however, we see that there is unlimited opportunity for expediting further development of the physical therapy profession in china. identifying the challenges and solutions is a step in that direction. these include the lack of qualified physical therapists with advanced graduate degrees with academic positions who can conduct research relevant to china as well as teach evidence-informed professional physical therapy courses. to help relieve this demand, the ccptpd has considered sharing teaching resources (staff and teaching and learning materials). in addition, the pandemic has shed light on the paucity of attention that has been allocated to acute care and the cardiorespiratory curriculum. we have advised physical therapist academic programs to revise their curricula to better align with the urgent demand for physical therapy services in china in light of the pandemic. correspondingly, we have actively engaged with clinical placement providers to strengthen the cardiorespiratory component and to enhance students' cardiorespiratory clinical experience, especially in the critical care setting. another initiative is tele-physical therapy, which has been reported to be effective across a range of clinical settings and thus is being encouraged during the covid-19 pandemic. 3 tele-physical therapy is now being considered for inclusion into our regularly revised physical therapy curricula. furthermore, we propose that online lectures and seminars translating covid-19 evidence to maximize physical therapists' impact and public health response coronavirus disease (covid-19): the need to maintain regular physical activity while taking precautions application of a contextual instructional framework in a continuing professional development training program for physiotherapists in rwanda physiotherapists during covid-19: usual business in unusual times key: cord-276591-aft3agxx authors: mittal, vijay a.; firth, joseph; kimhy, david title: combating the dangers of sedentary activity on child and adolescent mental health during the time of covid-19 date: 2020-08-26 journal: j am acad child adolesc psychiatry doi: 10.1016/j.jaac.2020.08.003 sha: doc_id: 276591 cord_uid: aft3agxx nan while the impact of the coronavirus disease 2019 (covid-19) pandemic, subsequent quarantine, and social distancing on physical activity has been covered extensively, there has been limited focus on the resulting sedentary behaviour 1 on existing and emerging psychopathology. this is particularly disconcerting regarding children and adolescents, who rely on the ability to play to meet developmental milestones and require more exercise than adults. youth populations have been significantly disrupted by school closures and home confinement and are in developmental periods that overlap with the emergence of serious mental illness. therefore, it is important to consider the mental health consequences for youth, and also explore ways to combat sedentary activity for this vulnerable population. participation in individual and group exercise has been found to be a robust pro-health activity, both in terms of building social support structures and resiliency factors, as well as in engaging mechanisms driving the onset and persistence of serious mental illness. 2 there is now a large body of literature showing that physical inactivity increases the risk of mental illness. for example, while the relationships between physical activity and mental health have potential for reverse causality, well-powered mendelian randomization studies (which can determine causal relations), using objectively-assessed physical activity, have convincingly demonstrated that high levels of physical inactivity exert a casual effect on increased depression risk. 3 alongside this, longitudinal data supported the protective effect of physical activity on depression and anxiety, 4 which are highly ubiquitous in childhood and adolescence, with benefits more pronounced in youth than adult samples. likewise, sedentary behaviour has been found to correlate with risk markers in adolescents at clinical high-risk for psychosis. 5 the current reality of widespread covid-19 infections in many countries pose a substantial challenge to remediating this state, especially with concerns about a looming j o u r n a l p r e -p r o o f additional waves. however, potential solutions do exist -these can be seen in terms of public space, school, and home-based strategies. public space options are numerous, though some of the more promising strategies would require cooperation from government and adaptive public policy. for example, at the neighbourhood level local leaders might work to allow staggered and monitored playground access with hand sanitizer availability. streets might be closed so that children and teens can play in a social distanced fashion in their community. with close cooperation, these strategies could be easily adapted to meet the constraints and needs of lockdown/stay-at-home orders versus periods of social distancing. where outdoor school infrastructure is available, teacher-or trainer-led group physical activities can be conducted safely, as individual physical distancing can be impact of covid-19 pandemic on children and adolescents' lifestyle behavior larger than expected effects of exercise on anxiety and depression disorders: review of meta-analyses and neurobiological mechanisms an exposure-wide and mendelian randomization approach to identifying modifiable factors for the prevention of depression physical activity and mental health in children and adolescents: a review of reviews physical activity level and medial temporal health in youth at ultra high-risk for psychosis can active video games improve physical activity in adolescents? a review of rct all statements expressed in this column are those of the authors and do not reflect the opinions of the journal of the american academy of child and adolescent psychiatry. see the instructions for authors for information about the preparation and submission of letters to the editor orcid vijay a. mittal, phd: https://orcid.org/0000-0001-9017-5119 joseph firth, phd: https://orcid.org/0000-0002-0618-2752 david kimhy, phd: https://orcid.org/0000-0001-7735-9378all authors contributed to the conceptual planning, drafting, and revision of the manuscript. all authors give final approval on the version to be published and agree to be accountable for all aspects of the work. key: cord-352239-lv2mo7d7 authors: alpalhão, vanessa; alpalhão, miguel title: impact of covid-19 on physical therapist practice in portugal date: 2020-04-17 journal: phys ther doi: 10.1093/ptj/pzaa071 sha: doc_id: 352239 cord_uid: lv2mo7d7 nan the physical therapy profession has been severely affected by the crisis. in portugal, regulatory rules have determined that only -urgent‖ care should be provided for the duration of the pandemic-leaving each physical therapist with the discretionary power to determine which cases could benefit the most from their intervention. although many may recognize the benefit of physical therapy in the face of this infection, 1 many cases may fall into a gray area, resulting in asymmetrical accessibility to care. long-term care and convalescence units are particularly sensitive areas. it is hard to define -urgent‖ interventions in such settings, where the main goal is to reinstitute function and quality of life to patients in the mid to long term. we must also consider that much of the income and social value of these units derive from the rehabilitation care developed and provided by physical therapists. the sudden loss of income may represent a risk for the viability of these institutions. taking this into consideration, physical therapists continue to intervene in all settings, facing an increased risk for covid-19 infection due to the physical proximity involved in our usual practice as well as due to the high number of patients treated each day. furthermore, given that asymptomatic individuals have been shown to spread the infection, 2 the exposed physical therapist might represent a risk to other patients, many of whom may be older and have significant comorbidities. some practices may be adopted to reduce these risks. first, wearing disposable personal protection equipment, which should be changed between patients, can reduce transmission of the infection; second, decreasing the number of patients and therapists in the same physical space may facilitate social distancing; and third, digital physical therapist practice, making use of technology for communicating with and guiding patients, is proposed by some international agencies. 3 these methods, however, have a steep learning curve not suited for an immediate-need context, and many older patients may have limitations using new technologies. involving family and caregivers in the treatment session may reduce this hindrance and promote participation, particularly in patients with neuropsychiatric conditions and in pediatric patients. this strategy would require legal regulation to prevent uncertified individuals from offering health care services, even if in a virtual setting, without the appropriate accreditation and certification of expertise. if the covid-19 crisis lingers for a long time, physical therapists may start shifting their practice toward therapeutic exercise and away from passive techniques that require close proximity. this is far from ideal, as many benefits from an integrative approach could be lost. physical therapist interventions remain fundamental for the health of our communities and should not be avoided as a general rule. all available precautions should be taken to reduce the likelihood of infection for both practitioner and patient, and every patient should have an individual examination for risks and benefits of the planned intervention. therapeutic strategies may be adapted to reduce physical contact to a minimum while providing therapeutic benefit, and new digital strategies may become more widespread, but caution should be taken to ensure the quality of the intervention provided. there is no funding to report. physiotherapy management for covid-19 in the acute hospital setting: clinical practice recommendations transmission of 2019-ncov infection from an asymptomatic contact in germany information and resources about covid-19. world confederation for physical therapy website the authors declare no conflicts of interest. key: cord-286322-wll4hpu5 authors: shahidi, seyed houtan; stewart williams, jennifer; hassani, fahimeh title: physical activity during covid‐19 quarantine date: 2020-06-18 journal: acta paediatr doi: 10.1111/apa.15420 sha: doc_id: 286322 cord_uid: wll4hpu5 the world health organization recommends that children and adolescents aged 5‐17 should engage in at least 60 minutes of moderate to vigorous intensity physical activity a day. physical activity is defined as bodily movement performed by skeletal muscles that demand energy expenditure. the physical benefits of this include musculoskeletal and cardiovascular health, a healthy body weight and neuromuscular awareness, for coordination and controlling movement. the psychological benefits include managing anxiety and building self‐esteem, which are both important for children’s psycho‐social development (1). the world health organization recommends that children and adolescents aged 5-17 should engage in at least 60 minutes of moderate to vigorous intensity physical activity a day. physical activity is defined as bodily movement performed by skeletal muscles that demand energy expenditure. the physical benefits of this include musculoskeletal and cardiovascular health, a healthy body weight and neuromuscular awareness, for coordination and controlling movement. the psychological benefits include managing anxiety and building self-esteem, which are both important for children's psycho-social development (1). however, the covid-19 pandemic has restricted physical activity in people of all ages. in many countries, both indoor and outdoor sports and recreational facilities, such as gyms, public swimming pools and playgrounds, are closed. online communication for work, leisure and shopping is now part of daily family routines and children are using the internet for school work and social interaction. however, it is important that children participate in, and enjoy physical activity, as part of a broader set of life skills during their leisure time. in a parallel field, a new concept known as physical literacy is now renowned in many different countries. although they are related, physical literacy and physical activity are independent of each other. physical literacy is the motivation, confidence, physical competence, knowledge and understanding that people need to value and take responsibility for engaging in physical activity for life (2) . it is a multidimensional concept that encompasses cognitive, emotional and social components that have a mutually beneficial relationship with motor skills and forms of physical activity. importantly, physical literacy does not result from physical activity. it needs to be separately developed as a life skill, preferably before adolescence. therefore, promoting physical activity alone this article is protected by copyright. all rights reserved we need to look forward to how schools can increase physical literacy after covid-19. circus arts are gaining interest in physical education as one way of doing this. the suite of circus training tools includes individual and group activities, such as clowning and acrobatics, manipulation, equilibrium and aerial skills (figure 1) (4) . a canadian school-based study of children aged nine to 12 years focused on 101 children whose physical activity levels were increased when they were given schoolbased circus arts instruction three times a week for approximately 60 minutes. various outcomes were compared with a control group of 110 age-matched children who received standard physical education at schools with the same socioeconomic status. the circus arts group demonstrated statistically significant improvements in motor competence and confidence. boys typically do better than girls when it comes to motor skills, but this gap narrowed in the circus arts group (4). creating and maintaining physical literacy in children with disabilities is particularly important, as they are under-represented in organised sport and are a vulnerable group during this pandemic. another canadian programme that was specifically created for children with autism used equipment such as boxes, bubbles, balloons, foam dice and scarves, to create simple fun games to improve children's physical activity levels, skills and confidence (5) . clearly there are restrictions on what kind or programmes and activities children can get involved in during the pandemic, especially when quarantine and social distancing measures are in place. fun interventions like the circus arts programme and activities for children with disabilities are just some of the ideas that parents and educators may want to consider. there are several worthwhile digital platforms that show how these activities can be introduced into everyday indoor and outdoor routines. the canadian programme "playbuilder" is a cloud-based system which delivers activities that can be conducted at home, to keep children active and mentally engaged during the coronavirus pandemic (https://sportforlife.ca/). "appetite to play" is another canadian initiative designed to promote and encourage healthy eating and physical activity in early childhood. the programme offers self-assessment and planning tools, tips, recipes, games, and other activities for this article is protected by copyright. all rights reserved parents and carers (https://www.appetitetoplay.com/), the "simple movement" programme from the united kingdom, aims to help each child achieve their unique potential in reading and writing as well as in sports and playing. this easy-to-follow animated online programme promotes building developmental skills in a fun and pleasant manner (https://www.simplephysicalliteracy.com/). the pandemic has highlighted structural shifts in society that may lead to less physical activity in the future and this calls for novel approaches. it is very important that parents and educators do not allow children to adopt more sedentary lifestyles and greater screen time. if this happens it will distract them from achieving and sustaining ongoing physical literacy, both now and in the future. world health organization. world health organization global recommendations on physical activity for health physical literacy: throughout the lifecourse: routledge physical literacy and resilience in children and youth the impact of circus arts instruction in physical education on the physical literacy of children in grades 4 and 5 i can develop physical literacy 2104 the authors would like to thank canada for allowing us to include the circus programme image in our paper. no external funding. the authors have no conflicts of interest to declare. circus arts physical literacy programme in children. key: cord-302366-9rohvqp8 authors: lee, alan title: covid-19 and the advancement of digital physical therapist practice and telehealth date: 2020-04-28 journal: phys ther doi: 10.1093/ptj/pzaa079 sha: doc_id: 302366 cord_uid: 9rohvqp8 nan during the covid-19 pandemic, each day challenges us with sobering realities in economy, health care, and politics in our society. 1 the global pandemic has thrust the physical therapy profession and our society into digital physical therapist practice and telehealth. in light of the uncertainty with covid-19, physical therapists are required to socially distance themselves at least 6 feet apart in health care institutions, and patients and clients cannot access necessary physical therapy services in the community due to shelter-in-place and stay-at-home restrictions. furthermore, this unique situation magnifies the challenges and opportunities in digital practice, as practitioners may lack the necessary telehealth competencies identified in the literature. 2, 3 therefore, it is especially important for physical therapy practitioners to consider key recommendations for safe and effective digital practice delivery. the purpose of this point of view is to identify recommendations on digital physical therapist practice and offer future directions in advancing digital practice and telehealth in the physical therapy profession in the wake of covid-19. a joint digital physical therapy practice task force of the world confederation for finally, the task force agreed on service user as the term for actual or potential recipient of physical therapy services and defined in-person care as a situation in which both the provider and service user are in the same location at the same time. the task force described the advantages, limitations, current evidence, regulatory issues, academic implications, and recommendations for future opportunities in digital physical therapist practice prior to covid-19. 4 the advantages of digital practice were differentiated for service user, provider, and society. the common benefit for all stakeholders includes improved access to telehealth physical therapy services by building a strong relationship between service user and provider in order to deliver highquality and safe physical therapist practice via telehealth. covid-19 presents digital practice opportunities for improved access, high quality, and safety in physical therapy services for both service user and provider when deemed medically necessary. in fact, both telehealth and e-visits have been approved by the center for medicare and medicaid services (cms) in the united states during the covid-19 crisis on a temporarily basis. 6 cms noted that telehealth services provided by interactive audio and video telecommunications systems permit real-time communication between end-to-end users, whereas e-visits are non-face-to-face, patient-initiated digital communications requiring a clinical decision that otherwise typically would have been provided in the office. 6 however, specific federal and state payer guidelines, regulatory hurdles, and patient privacy barriers persist, requiring permanent fixes from cms on telehealth and e-visits. 7 for example, health care providers on the front lines of covid-19 have identified that some older adults prefer telephone use to digital telecommunication interactions because of a lack of technology understanding and training. 7 in order to address this immediate crisis and patient preferences, keesara and colleagues 8 recommend expansion of telehealth broadly to include digital tools-beyond interactive audio and video-that offer 256-bit end-to-end encryption, including telephone services. other limitations include inadequate technology training, limited knowledge translation, and regulatory barriers that can stifle innovation and impede progress for service users and providers. 6 dialogue among physical therapy practitioners, telemedicine providers, and payers can result in timely collaborative practice based on current evidence and societal needs in health care. 4 with shelter-in-place and stay-at-home restrictions, digital practice is supported as the way forward, with many countries worldwide formally recognizing the benefits and value of using digital modes of care delivery. the body of evidence in relation to telerehabilitation 5 is limited, however. telerehabilitation tends to require more provider time for consultations, and it is unclear whether telerehabilitation improves access to beneficial services. 9 with paucity of definitive evidence in the wake of covid-19, the joint task force believed it is not possible to recommend conditionspecific digital practice standards. hence, guiding principles should be reviewed by the physical therapy profession until such evidence is available. 4 the task force developed each principle based on current practice, research, and regulatory considerations that may evolve over time (figure) . in summary, the guiding principles require strong provider-patient relationship, valid and reliable evidence, and the conduct of research to show whether telerehabilitation has greater benefit than potential risks for digital physical therapist practice. 4 recently, wcpt identified resources including a tool kit for digital practice implementation, 10 and wcpt recommendations have been translated in spanish 11 for proper guidance in various member countries. in addition, the federation of state boards of physical therapy (fsbpt) provided jurisdiction telehealth laws and guidance for physical therapy providers in the united states. 12 due to covid-19, some of the regulatory issues have been waived at federal and state levels-including licensure, copays, and deductibles and expanded digital services with remote patient monitoring in the united states. 8 because regulatory requirements are dependent upon factors in the legislative framework that exist globally, the best guidance is for providers to be informed of the legal framework that exists in each of their own jurisdictions and to be aware that, in some countries, providers have to take into account the jurisdiction of the service user's country. 4 the task force identified global regulations in the digital landscape for australia, canada, the united kingdom, and the united states prior to covid-19. moving forward, potential regulatory changes must be identified for individual countries in real time. 4 therefore, practitioners should develop guidelines for selecting the ideal technology for the potential service user, risk management strategies, and competency training for digital physical therapist practice in emergent and nonemergent situations. prior to covid-19, the implications of digital physical therapist practice for physical therapist education were investigated. although digital practice competency might prepare future providers for demands in primary care and might improve access to care in high-demand areas, the task force identified a lack of national digital practice answers to these questions must be addressed now in order to advance in digital physical therapist practice and telehealth. overall, the task force recognizes that the role of physical therapists must be advanced by informed practitioners in collaboration with physical therapy professional and international associations, accredited academic and research institutions, and patient advocacy groups. the time is now for the physical therapy profession to learn from the past and define its societal identity at large, 17 because those who cannot remember the past are condemned to repeat it-even in the digital age. 16 covid-19-navigating the uncharted competencies required for nursing telehealth activities: a delphi-study it's not just facetime: core competencies for the medical virtualist world confederation for physical therapy and the international network of physiotherapy regulatory authorities. the report of the wcpt/inptra digital physical therapy american telemedicine association's principles for delivering telerehabilitation services apta covid-19 resources lessons from the front lines-cms covid-19 covid-19 and health care's digital revolution the current state of telehealth evidence: a rapid review telehealth tool kit. how to use telehealth for your patientsduring covid-19 spanish version of the digital practice survey report jurisdiction telehealth laws/guidance for pts and ptas preparing the healthcare workforce to deliver the digital future technology in rehabilitation: ethical and curricular implications for physical therapist education the great influenza: the epic story of the deadliest plague in history the authors thank richard woolf, pt, dpt, and leslie adrian, pt, dpt, mpa.keywords: covid-19, telehealth, telemedicine, telerehabilitation, digital practice, technology accepted: april 20, 2020 submitted: april 10, 2020 key: cord-269872-w2m3cqlx authors: vancini, rodrigo luiz; de lira, claudio andre barbosa; andrade, marília santos; arida, ricardo mário title: covid-19 vs. epilepsy: it is time to move, act and encourage physical exercise’? date: 2020-05-03 journal: epilepsy behav doi: 10.1016/j.yebeh.2020.107154 sha: doc_id: 269872 cord_uid: w2m3cqlx nan j o u r n a l p r e -p r o o f sedentary and have worse levels of physical fitness [10] [11] [12] [13] [14] [15] , which could be worse in this scenario. considering the current perspective and the recommendation from local and global health authorities for social isolation and quarantine, the aim of this article is to present the practice of physical activity as an alternative strategy with which to cope with the pandemic of covid-19 for people with epilepsy and the health professionals who take care of them. the pandemic of covid-19 is frightening the world due to its potential for transmission-dissemination-hospitalization-lethality among more vulnerable populations, such as elderly people [6, [16] [17] [18] [19] . this could include people with epilepsy because the prevalence of epilepsy is higher in elderly people. furthermore, many people with epilepsy have other comorbidities (depression, anxiety, hypertension and obesity) and risk factors (low levels of physical activity) associated or not with the side effects of anti-epileptic drugs [20] . in addition, quarantine and social isolation, associated with the covid-19 pandemic, could impact negatively on the lifestyles (physical activity and diet) and health status (mental health) of health people and those with chronic diseases/morbidities [21] . li et al. [22] recently, an interesting article was published on this topic entitled "a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another?" in this article, hall et al. [21] highlight that the drastic change in people's daily lives (due to the recommendation for social isolation and quarantine) around the world, associated with the pandemic caused by covid-19, could negatively impact physical activity habits and emphasize sedentary behaviors. it is clear that there is a need for a change in the way that health systems are conducted and in strategies for health/education promotion that include changes in lifestyle (encourage the practice of physical exercise) around the world in order to face and cope better with scenarios of this type. in this regard, a physical inactivity pandemic is a real fact and the practice of physical activity by people with epilepsy could improve their physical and mental health [24] [25] [26] [27] [28] . coping with the covid-19 pandemic and the great emotional stress would make society (individually and collectively) stronger. coping is described as behavioral efforts (positive and/or negative) to deal with situations of harm and problem-solving techniques that are utilized to reduce psychological and emotional burden. strategies of coping may include emotional support, meditative techniques, and religiosity/spirituality and physical exercise practice [29] [30] [31] . emotional and psychological stress before, during and after the covid-19 pandemic could include fear, change in sleep patterns, eating, physical inactivity, difficulty in concentration, worsening of chronic health problems and mental health conditions, and increased use of alcohol, tobacco, or other illicit drugs [16, 17] . in such a j o u r n a l p r e -p r o o f "physical exercise is medicine" for many diseases [25] [26] [27] , such as neurological (dementia), metabolic (obesity), cardiovascular (hypertension), pulmonary (asthma), musculoskeletal disorders (osteoporosis), and psychiatric (depression) conditions and also for epilepsy [25] [26] [27] [28] . however, people with epilepsy are known to have low levels of physical activity [32] , which can negatively impact their overall health status, physical fitness and mental health [32] [33] [34] [35] [36] . in this period of necessary social isolation and quarantine it is likely that the already low level of physical activity in people with epilepsy will further deteriorate and sedentary behaviors will increase. therefore, strategies are needed to at least maintain mental health and physical fitness in a safe way, such as practicing light and homebased physical exercises. this practice needs to be adapted to the home environment and directed by skilled health professionals; people with epilepsy should be guided/advised in practicing home-based exercise, which should include aerobic exercises, muscle strength exercises and flexibility exercises [21, 37] . thus, it is necessary to outline effective education and health strategies [37, 38] in the short, medium and long term in order to minimize the negative impact of social isolation and quarantine caused by covid-19 for the general population and people with epilepsy. "physical exercise is medicine and recommended for people with epilepsy" [27, 28] and the general population. there are sufficient evidences that physical exercise produces positive effects on physical fitness, mental health, and lifestyle. the advice of the epilepsy society [2020] is to "try to keep healthy by following a nutritious diet and taking light exercise" during the covid-19 pandemic. the most prudent thing to do is to respect social isolation and quarantine and seek alternative strategies, such as home-j o u r n a l p r e -p r o o f 6 based physical exercise, which may include popular social networks (instagram), video and information search sites (youtube) for health promotion among the general population and people with epilepsy. authors have no competing interests to declare. ilae official report: a practical clinical definition of epilepsy epilepsy society. epilepsy and the coronavirus (covid-19) faqs comorbidities of epilepsy: current concepts and future perspectives atherosclerosis in epilepsy: its causes and implications world health organization (who). (2020a). coronavirus disease (covid mental health and psychosocial considerations during the covid-19 outbreak antiepilepsy drugs and the immune system antiepileptic drugs and the immune system adult epilepsy treatments for the prevention of sudden unexpected death in epilepsy (sudep) physical exercise in women with intractable epilepsy a prospective evaluation of the effects of a 12-week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy coping/managing-stress-anxiety.html evaluation and treatment coronavirus (covid-19). book chapter asian critical care clinical trials group. intensive care management of coronavirus disease 2019 (covid-19): challenges and recommendations neurological comorbidity and epilepsy: implications for treatment a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another? the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users diagnosing and treating depression in epilepsy large-scale physical activity data reveal worldwide activity inequality from depressive symptoms to depression in people with epilepsy: contribution of physical exercise to improve this picture physical activity and epilepsy: proven and predicted benefits exercise as medicine -evidence for prescribing exercise as therapy in 26 different chronic diseases exercise as medicine for people with epilepsy alternative medicine as a coping strategy for people with epilepsy: can exercise of religion and spirituality be part of this context? who uses exercise as a coping strategy for stress? results from a national survey of canadians psychosocial adaptation to epilepsy: the role of coping strategies evaluation of physical exercise habits in brazilian patients with epilepsy could physical activity practice minimize the economic burden of epilepsy? low levels of maximal aerobic power impair the profile of mood state in individuals with temporal lobe epilepsy physical exercise as a coping strategy for people with epilepsy and depression physical exercise: potential candidate as coping strategy for people with epilepsy physical exercise as therapy to fight against the mental and physical consequences of covid-19 quarantine: special focus in older people why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition to all health professionals and scientists who donate their knowledge and key: cord-294863-5qf5dqdg authors: ricci, fabrizio; izzicupo, pascal; moscucci, federica; sciomer, susanna; maffei, silvia; di baldassarre, angela; mattioli, anna vittoria; gallina, sabina title: recommendations for physical inactivity and sedentary behavior during the coronavirus disease (covid-19) pandemic date: 2020-05-12 journal: front public health doi: 10.3389/fpubh.2020.00199 sha: doc_id: 294863 cord_uid: 5qf5dqdg nan since the escalation of coronavirus disease 2019 (covid-19) pandemic, over a billion people across the world have faced restrictions due to varying degrees of confinement, and in the absence of a vaccine against sars-cov-2, massive public health interventions have been implemented to contain the outbreak. the lockdown set up in many countries to combat the covid-19 epidemic entails unprecedented disruption of lives and work, determining specific risks related to mental and physical health in the general population, especially among those who stopped working during the current outbreak (1) . the implementation of confinement policies to contain covid-19 could be a catalyst for concealed mental and physical health conditions, further enhancing the effects of psychosocial risk factors, including stress, social isolation, and negative emotions that may act as barriers against behavioral changes toward an active lifestyle and negatively impact on global health, well-being and quality of life, ultimately resulting in result in a range of chronic health conditions (2, 3). the world health organization (who) classified physical inactivity as the fourth leading risk factor accounting for 6% of global mortality, following hypertension (13%), smoking (9%) and diabetes (6%). the relationship between physical inactivity and obesity trends was quite evident since 1953 when the london busmen study showed that bus drivers who mainly sat during work presented with larger waist circumferences, higher levels of adiposity and increased risk of coronary events than bus conductors, who walked the aisles and climbed the stairs of double-decker buses (4). physical inactivity levels are rising in many countries with significant implications for the prevalence of non-communicable diseases and the general health of the population worldwide. the who recommends that adults accumulate at least 150 min of moderate to vigorous-intensity physical activity (mvpa) or 75 min of vigorous-intensity physical activity (vpa) throughout the week, cumulated in bouts lasting ≥10 min. this volume of physical activity (pa) is associated with a lower risk of cardiovascular (cv) morbidity and mortality and a number of other healthcare benefits (5). unfortunately, attained levels of daily pa are largely insufficient, especially in western countries. recent evidence suggests that sedentary behavior (sb) is independently associated with traditional cv risk factors and increased cv morbidity and global mortality, regardless of pa volume (6). sb is defined as any waking behavior characterized by an energy expenditure ≤1.5 metabolic equivalents, while in a sitting, reclining or lying posture. typical sb includes "screen time" (tv viewing, videogame playing, computer use), car-driving, and reading. importantly, in a dose-response metaanalysis of 34 studies, including 1,331,468 community-dwelling participants, total sitting time volumes >8 h and 6 h/day were associated with increased risk of all-cause death and cv death, respectively, in pa adjusted analyses (7). for tv viewing time, an increased risk for all-cause and cv mortality was strongest above levels of 3-4 h/day, regardless of pa level (7). thus, physical inactivity and sb should be considered as separate entities with their unique determinants and health consequences, but with synergistic harmful effects on cv health (8) . while containing the spreading of the contagion as quickly as possible is the urgent public health priority, there have been few public health guidelines for the public as to what people can or should do in terms of maintaining their daily exercise or pa routines (9, 10) . safeguarding psycho-physical health in a lockdown situation is paramount, and special attention should be paid to elderly and pediatric populations. with advancing age, it becomes more difficult to reverse the effects of deconditioning of the musculoskeletal system. children and adolescents have higher pa needs than adults, and these are more difficult to achieve during the quarantine period, also due to the influence of home environment (11) . both physical and social environmental factors operating within the home space are indeed important influences on sb and pa, especially for the pediatric population (12) . regarding adolescents, another point that warrants careful vigilance concerns the risks associated with increased total screen time, including the total hours spent on computer, tv and video gaming. who just released guidance intended for people in selfquarantine without any symptoms or diagnosis of acute respiratory illness, containing a set of practical advice on how to stay active and reduce sb while at home. who further highlights how standard recommendations of 150 min of mvpa or 75 min of vpa per week, or a combination of both, can still be achieved even at home, with no special equipment and with limited space. there is a robust health rationale for staying active at home in the current precarious environment, for all age groups. the following are general recommendations, unless otherwise specified. you can meet weekly recommendations performing short bouts of pa, including taking the stairs, performing domestic chores, such as cleaning and gardening, or funniest activities such as dancing. walk and stand up take every chance to walk and stand up, like walking during a call, or taking a breath of fresh air, even just at the window. try not to sit continuously for more than 1 h, but rather to take a 1-2 min break every 30 min. alternatively, consider active breaks every 2 h of sb or distribute periods ≥10 min of continuous aerobic activity throughout the day. light-intensity activities like mobilizing the muscular masses and the joints are fine. older people can perform them even in sitting or semi-lying position. follow online exercise classes, play with children, help the elderlies to stay active take the advantage of free, virtual exercise classes on the web, devote more time to playing with children and encourage seniors to stay safe and active choosing suitable exercises for endurance, strength, balance, and flexibility. avoid screen time while playing with children in favor of funny activities and active playing. for children and teens, it is advisable to play with sports or fitness video games with motion sensor controls. performing light-intensity activities while assisting older people protects you from sedentariness. active play rather than screen time helps you and your children to avoid snacking. be regular have regular times for main meals, sleep, and wake-up calls. your sleep should be of sufficient duration and good quality. prioritize continuity and regularity rather than the intensity of the pa and gradually increase frequency, duration, and intensity. activity trackers and smartphone apps can help in monitoring your progress. in case of poor experience and poor physical fitness, be careful. specific recommendations and tips for children, adults, and elderly are further detailed in figure 1 . while recognizing the importance of confinement policies set up to contain covid-19 pandemic, we firmly recommend the relevance of home-based programs for figure 1 | physical activity, sedentary behavior, sleep recommendations, and tips for covid-19 quarantine period. blue, adults; gray, older people; orange, preschooler; yellow, school-aged children and adolescents; bold, international guidelines and recommendations; italic, tips for quarantine period; pa, physical activity; sb, sedentary behavior; lpa, light-intensity physical activity; mpa, moderate-intensity physical activity; vpa, vigorous-intensity physical activity; mvpa, moderate to vigorous-intensity physical activity. in the central portion of the figure we reported recommended hours of sleep by age group. *perform strengthening activities in non-consecutive days. +, ++, + + +: relative importance of pa/exercise type for each age category. dumbbell: muscle and bone strengthening activities; running: aerobic activities; monopodalic standing: balance exercise; bending: flexibility. disruption physical inactivity and sedentary behavior as a critical behavioral strategy for the prevention of global health and consequences of psychosocial stress during the current lockdown. fr and pi drafted the manuscript. all co-authors provided critical revision for important intellectual content. unprecedented disruption of lives and work: health, distress and life satisfaction of working adults in china one month into the covid-19 outbreak sanchis-gomar f. health risks and potential remedies during prolonged lockdowns for coronavirus disease 2019 (covid-19) physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (covid-19) mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis relationship of sedentary behavior and physical activity to incident cardiovascular disease: results from the women's health initiative coronavirus disease (covid-19): the need to maintain regular physical activity while taking precautions a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another? prog cardiovasc dis associations between the home physical environment and children's home-based physical activity and sitting socio-cultural determinants of physical activity across the life course: a 'determinants of diet and physical activity' (dedipac) umbrella systematic literature review the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 ricci, izzicupo, moscucci, sciomer, maffei, di baldassarre, mattioli and gallina. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-262261-tmyeh64y authors: fu, chang-yong; zhang, zhen-zhong; chen, jin; jaiswal, sandip kumar; yan, fu-ling title: unhealthy lifestyle is an important risk factor of idiopathic bppv date: 2020-10-15 journal: front neurol doi: 10.3389/fneur.2020.00950 sha: doc_id: 262261 cord_uid: tmyeh64y background: benign paroxysmal positional vertigo (bppv) is a self-limiting and recurrent disease but the cost is considerable. the number of patients with bppv increased significantly under the quarantine policy in hangzhou. the unhealthy lifestyle risk factors of bppv have not yet been investigated. thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of bppv. methods: one hundred and sixty three patients with idiopathic bppv aged 22–87 years (bppv group), and 89 aged 23–92 years sex-matched control subjects (non-bppv group) were enrolled in this study. all bppv patients received a definitive diagnosis which excluded secondary bppv. non-bppv cases excluded bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent positions, we asked the patient or their family from february 2020 to june 2020, and the rest of the patient's information was acquired by phone or wechat. data analyses: the t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. for each factor, odds ratios were calculated with 95% confidence intervals (cis). moreover, test equality of two or more receiver operating characteristic (roc) analyses were applied to the physical activities, and recumbent position time; area under curve (auc) measures were calculated with 95% cis and compared with each other. results: the bppv group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or vd supplementation in univariate logistic regression analyses (p < 0.05). poor physical activities and prolonged recumbent position time were independently associated with bppv in multiple logistic regression models (or = 18.92, 95% ci: 6.34–56.43, p = 0.00 and or = 1.15, 95% ci: 1.01–1.33, p < 0.04). in the comparison of roc curves of recumbent position time and physical activities in identifying bppv, aucs were 0.68 (0.61–0.74), and 0.68 (0.63–0.73), respectively. conclusion: we conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for bppv patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, and ci, may not be. background: benign paroxysmal positional vertigo (bppv) is a self-limiting and recurrent disease but the cost is considerable. the number of patients with bppv increased significantly under the quarantine policy in hangzhou. the unhealthy lifestyle risk factors of bppv have not yet been investigated. thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of bppv. methods: one hundred and sixty three patients with idiopathic bppv aged 22-87 years (bppv group), and 89 aged 23-92 years sex-matched control subjects (non-bppv group) were enrolled in this study. all bppv patients received a definitive diagnosis which excluded secondary bppv. non-bppv cases excluded bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent positions, we asked the patient or their family from february 2020 to june 2020, and the rest of the patient's information was acquired by phone or wechat. data analyses: the t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. for each factor, odds ratios were calculated with 95% confidence intervals (cis). moreover, test equality of two or more receiver operating characteristic (roc) analyses were applied to the physical activities, and recumbent position time; area under curve (auc) measures were calculated with 95% cis and compared with each other. results: the bppv group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or vd supplementation in univariate logistic regression analyses (p < 0.05). poor physical activities and prolonged recumbent position time were independently associated with bppv in multiple logistic regression models (or = 18.92, 95% ci: 6.34-56.43, p = 0.00 and or = 1.15, 95% ci: 1.01-1.33, p < 0.04). in the comparison of roc curves of recumbent position time and physical activities in identifying bppv, aucs were 0.68 (0.61-0.74), and 0.68 (0.63-0.73), respectively. we conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for bppv patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, and ci, may not be. keywords: bppv-benign paroxysmal positional vertigo, risk factors, physical activity, quarantine policy, recumbent position time background vertigo is one of the most common symptoms in neurological illness and the cost of evaluating dizziness is considerable. benign paroxysmal positional vertigo (bppv) is the most common peripheral vertigo disease (1) . it amounts to 20% of all vertigo patients (2) . bppv has a recurrence rate of about 15% every year (3) . some studies have found that the age, gender, hypertension, hyperuricemia, hyperlipidemia, diabetes, and osteoporosis may be the risk factors of bppv (4, 5) . there are few studies on the unhealthy lifestyle and bppv. after the quarantine policy was performed to prevent covid-19 in hangzhou, it was found that the number of bppv diagnoses increased more rapidly than in the same period in 2019 (figure 1) . therefore, in this study, we aimed to (1) investigate the risk factors of bppv; and (2) explore the association between an unhealthy lifestyle and bppv. we hypothesized that the onset of bppv is associated with people's unhealthy lifestyles. a retrospective observational study was conducted in the department of neurology in tongde hospital of zhejiang province from june 16, 2018 to june 30, 2020. the study included 163 patients with idiopathic bppv aged 22-87 years (bppv group), and 89 aged 23-92 years sex-matched control subjects (non-bppv group). the bppv group patients received a definitive diagnosis and crm treatment, and excluded secondary bppv. the non-bppv group enrolled patients who after an annual physical examination in our hospital excluded diagnoses for bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent position we asked the patients or their family from february 2020 to june 2020, and the rest of the patient's information was acquired by phone or wechat. this references the diagnosis standard of bppv in the 2014 new england journal (6) . all the patients were examined by dix-hallpike and roll-tested. the definition of hyperuricemia is based on the laboratory standard of our hospital that states that serum uric acid in female patients must be higher than 340 µmol/l and in male patients higher than 400 µmol/l. hyperlipidemia is defined when lowdensity lipoprotein is higher than 3.2 mmol/l, total cholesterol is higher than 5.7 mmol/l, or triglyceride is higher than 1.95 mmol/l. lack of physical activity is defined as <5 exercises per week and <20 min at a time. the prolonged recumbent position time is defined as when the daily lying time is longer than or equal to 10 h, including the time of falling asleep and not falling asleep. if the patient had suffered from the following diseases, it will be classified as secondary benign paroxysmal positional vertigo and will be excluded. such as sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis within 1 year, or head trauma within 1 year. the measurement data in accordance with normal distribution are expressed byx ± s, and the comparison between groups is expressed by the t-test; the numeration data were statistically analyzed with the chi-squared test. when p < 0.05, the differences between the two groups were deemed to be statistically significant ( table 1) . multivariable logistic regression was performed to identify the risk factors of bppv in all of the patients ( table 2 ). the comparison of roc curves of recumbent position time and physical activities are shown in (figure 1) . for each factor, odds ratios were calculated with 95% confidence intervals (cis). all statistical analyses were performed using the stata statistical software version 15.1. univariate analysis of bppv related risk factors of the two group's patients were summarized in table 1 . no significant difference was found between the two groups with respect to age, md, sudden deafness migraine, hypertension, hyperlipidemia, chd, ci, and diabetes (p > 0.05). although lifestyles including prolonged recumbent position time (≥10 h) (or = 3.12, 95% ci: 1.75-5.61, p = 0.00), and poor physical activities (or = 24.57, 95% ci: 8.12-98.22, p = 0.00) reached statistical significance in patients with bppv compared with controls. to identify the predictors of bppv, multiple logistic regression analyses were performed. due to the strong correlation, recumbent position time and poor physical activities values were found to be independently associated with bppv in the multiple logistic regression model ( table 2) . multivariable logistic regression revealed that prolonged recumbent position table 2) . receiver operating characteristic analyses were applied to recumbent position time and physical activities variables. aucs were 0.68 (0.61-0.74), and 0.68 (0.63-0.73), respectively (figure 2) . as we all know, age, gender, sex hormones, osteoporosis, hypertension, hyperlipidemia, diabetes, plasma vitamin d level, and hyperuricemia are all considered as risk factors for bppv (4, 5, (7) (8) (9) (10) . according to a previous study, cerebrovascular risk factors influence bppv onset (9, 11) . in addition, some studies have found that age does not increase the recurrence rate of bppv (11) and seasonal vitamin d deficiency in winter is not enough to cause bppv (12) . the risk factor of bppv needs further analysis. in theory, with the increase of age, the function of human organs gradually declines and cardiovascular risk factors increase with age. as a part of the inner ear structure, the metabolism, absorption, and regeneration of otoliths are affected, and can easily fall off and lead to bppv. previous studies have found that the high morbidity of bppv in women may be related to widespread osteoporosis (6) . it may also be related to the abnormal hormone metabolism in post-menopausal women. we found that there was no obvious correlation to the common bppv related risk factors in this study, such as hypertension, hyperuricemia, hyperlipidemia, diabetes, serum bilirubin, chd, and ci. we found that the numbers of idiopathic bppv was significantly higher than the same period a year earlier under the quarantine policy in hangzhou from january 2020 to march 2020. this may correlate with the unhealthy lifestyle of patients during the covid-19 spread. to verify this hypothesis, we expanded the sample size of idiopathic bppv and set up a non-bppv health checker as a control group. as to the lifestyle of the bppv group, the majority of patients had the following characteristics, poor physical activities and prolonged recumbent position time. it can be seen that prolonged recumbent position time and poor physical activities may be important pathogenic factors for bppv. van we confirmed that 11% of the dizziness symptoms in parkinson's patients are likely to be bppv, which is also considered to be related to poor physical activities (13) . it has been suggested that a prolonged recumbent position may promote calcium carbonate deposition and otolith relaxation in the elliptical capsule (4) . the author believes that this view can explain the mechanism of the significant increase of bppv patients in our study. studies have found that poor physical activities is one of the most important risk factors for bppv in women and the morbidity of women who do not exercise is 2.62fold that of women who regularly exercise (14) . regular physical exercise may be a good choice to prevent bppv. some studies found that the decrease in the plasma vitamin d level is directly related to bppv (9, 10) . we believe that prolonged recumbent position time and poor physical activities can lead to sunlight insufficiency, which in turn leads to vitamin d deficiency. through this clinical study, we hypothesized that the broken otolith of the endolymph in healthy people may be continuous, which may be absorbed and dissipated due to regular exercise and suitable recumbent position time. for those who have prolonged recumbent position time or poor regular physical activities, the deposition is affected by gravity, and when they move position such as getting up from a resting position or turning over, it may result in bppv. this finding may explain why bppv occurs several days after trauma, rather than immediately after trauma. the movement of the body and head may promote the circulation of the endolymph in the semicircular canal, and the degenerative otolith also dissolves and dissipates with the circulation. however, prolonged recumbent position time or poor regular physical activities will slow down the circulation. the otolith particles in the membranous labyrinth will also increase due to the unhealthy lifestyle. the three-dimensional movement of the body and head may promote the formation of the normal structure and functional remodeling of otoliths on the utricle. however, an unhealthy lifestyle may lead to otolith structural disorder, which may lead to the otolith falling off easily. this study found that idiopathic bppv had no obvious relationship with hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, or ci. in this study, poor physical activities and prolonged recumbent position time are important predictors for bppv. changing unhealthy lifestyles may be the solution to decrease the morbidity of bppv. the authors speculate that bppv is associated with poor physical activities and prolonged recumbent position time which may be the independent risk factors. the limitations of the study are that it failed to assess the anxiety and depression of all patients. sleep quality was not included in the analysis (15) . bppv styles were not classified. osteoporosis information was obtained only through asking the patient for their medical history, lacking relevant examinations. all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by ethics committee of tongde hospital of zhejiang province. written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. c-yf conceived the study and design, conducted the experiment, and wrote the manuscript. f-ly prepared manuscript, and revised this manuscript. z-zz, jc, and sj conducted the acquisition of subjects and the interpretation of data. all authors contributed to the article and approved the submitted version. characteristics and mechanism of apogeotropic central positional nystagmus epidemiology of benign paroxysmal positional vertigo: a population based study recurrence of benign paroxysmal positional vertigo a geriatric perspective on benign paroxysmal positional vertigo serum uric acid levels correlate with benign paroxysmal positional vertigo concurrent posterior semicircular canal benign paroxysmal positional vertigo in patients with ipsilateral sudden sensorineural hearing loss: is it caused by otolith particles? med hypotheses hyperinsulinemia and hyperglycemia: risk factors for recurrence of benign paroxysmal positional vertigo the impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo vitamin d deficiency and benign paroxysmal positioning vertigo serum levels of 25-hydroxy vitamin d correlate with idiopathic benign paroxysmal positional vertigo clinical characteristics and risk factors for the recurrence of benign paroxysmal positional vertigo a relationship between blood levels of otolin-1 and vitamin d benign paroxysmal positional vertigo in parkinson's disease physical activity in the prevention of benign paroxysmal positional vertigo: probable association assessment of sleep quality in benign paroxysmal positional vertigo recurrence the first author thanks their family for their support and would like to apologize to the babies for sacrificing the time that is supposed to accompany their growth in order to finish the study. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 fu, zhang, chen, jaiswal and yan. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-268040-6i0bmnee authors: dean, elizabeth; jones, alice; yu, homer peng-ming; gosselink, rik; skinner, margot title: translating covid-19 evidence to maximize physical therapists’ impact and public health response date: 2020-06-26 journal: phys ther doi: 10.1093/ptj/pzaa115 sha: doc_id: 268040 cord_uid: 6i0bmnee coronavirus disease 2019 (covid-19) has sounded alarm bells throughout global health systems. late may, 2020, over 100,000 covid-19 related deaths were reported in the united state, the highest number of any country. this article describes covid-19 as the next historical turning point in the physical therapy profession’s growth and development. the profession has had over a 100-year tradition of responding to epidemics including poliomyelitis; two world wars and geographical regions experiencing conflicts and natural disasters; and the epidemic of noncommunicable diseases (ncds). the evidence-based role of non-invasive interventions (non-pharmacologic/non-surgical) that hallmark physical therapist practice has emerged as being highly relevant today in addressing covid-19 in two primary ways. first, despite some unique features, covid-19 presents as acute respiratory distress syndrome (ards) in its severe acute stage. ards is well familiar to physical therapists in intensive care units. body positioning and mobilization, prescribed based on comprehensive assessments/examinations, counter the negative sequelae of recumbency and bedrest; augment gas exchange and reduce airway closure, deconditioning and critical illness complications; and maximize long-term functional outcomes. physical therapists have an indisputable role across the covid-19 care continuum. second, over 90% of individuals who contract and die from covid-19 have co-morbidities, most notably cardiovascular disease, hypertension, chronic lung disease, type 2 diabetes mellitus, and obesity. physical therapists need to redouble their efforts to address ncds by assessing patients for risk factors and manifestations and institute evidence-based health education (smoking cessation, whole-food plant-based nutrition, weight control, physical activity/exercise), and/or support patients’ efforts when these are managed by other professionals. effective health education is a core competency for addressing risk of covid-19 as well as ncds. covid-19 is a wake-up call to the profession, an opportunity to assert its role throughout the covid-19 care continuum and augment public health initiatives by reducing the impact of the current pandemic. for over 100 years in industrialized countries, physical therapists have specialized in human movement and functioning irrespective of disease and its severity (from the community to the icu) and chronic disability. it has become the third largest established health profession in the world, excepting dentists and pharmacists who have distinct practice patterns. 10 physical therapy has been largely hallmarked by its non-invasive approaches, ie, non-pharmacological and non-surgical approaches, and competencies, and has applied this perspective through a history of responding to epidemics including poliomyelitis, two world wars and geographical regions experiencing conflicts, wars and natural disasters, and most recently ncds. 11 the profession has emerged from a tradition of applying passive interventions to maximize movement and function, to a more holistic comprehensive tradition of exploiting means of maximizing overall health and wellbeing to augment movement and function. 5 throughout its history, the physical therapist profession has correspondingly responded in terms of maximizing people's health and function by exploiting non-invasive interventions to the because of this, the icf has been supported by the world confederation for physical therapy (wcpt) 23 and its member organizations. this was another turning point that advanced patient assessment, evaluation and examination to include broad dimensions beyond limitations of structure and function, to activity and participation, and assessment of contextual factors such as the patient's environment and personal factors including lifestyle behaviors. all the while, the research intensity of the profession has been unprecedented and has grown exponential over the past 40 years in terms of securing competitive grant monies and publishing in high-ranking peer-reviewed journals. about 85% of covid-19 cases are mild and may even be undetected. 24 ten percent of those the physical therapy community has responded expediently with the publication of practice guidelines for the acute management of patients with covid-19. [35] [36] [37] these guidelines and recommendations largely build on the position statement for physical therapy for adults with critical illness published in 2008. 38 however, that patients in the icu generally do not do well months, often years, after post-icu discharge has reinforced the notion that the continuum of care including physical therapy needs to extend for months afterwards. [39] [40] [41] with the association of comorbidities, ie, ncds, with increased susceptibility to covid-19 and poorer outcomes including survival, has been well documented. 44, 45 given the prevalence of ncds in the united states and increasingly around the world, most people have one or more risk factors or manifestations, which makes them vulnerable to covid-19 infection. this being the era of ncds, 46 physical therapists have long been urged to exploit lifestyle and behavioral medicine competencies, 47 to reverse ncds and their risk factors, eg, atherosclerosis, smoking, hypertension, type 2 diabetes mellitus and obesity, often within days or weeks, and atherosclerosis within one year or more. 48, 49 in the united states, 94% of those who have succumbed to covid-19 have at least one comorbidity, primarily related to lifestyle-related ncds; in italy this figure is 99%. 50 only 1 in 5 americans engage in 4 or more healthy behaviors, whereas almost half of them participate in fewer than 3 healthy behaviors. 51 increased participation in numerous healthy behaviors can decrease premature mortality, decrease the burden of chronic diseases, improve life quality, and provide substantial economic benefits. 51 thus, reducing such susceptibility is critical. improving lifestyle behaviors has been well documented to prevent, reverse, as well as manage ncds. a public health practice of targeting a constellation of behaviors as opposed to individual behaviors is needed. 52, 53 smoking, sedentary behavior, physical inactivity, and obesity are an independent risk factors for metabolic syndrome, 54-56 as well as cardiovascular disease, and all associated with elevated markers of low grade systematic inflammation. consistent with the recent report of the lancet eat commission, 57 the american college of lifestyle medicine advocates a whole-food plant-based nutrition to maximize health, prevent disease particularly ncds, reverse these conditions, and reduce disability, premature death and socioeconomic burdens associated with them. such a dietary regimen has been well established to reduce risk of heart disease, cancer, high blood pressure, type 2 diabetes, and obesity, and their relative, metabolic syndrome, 48 conditions unequivocally linked to more severe covid infections and poorer outcomes including death. in some instances, such as hypertension and elevated blood glucose, these can be reduced within days or weeks. 58 atherosclerosis can also be reduced or resolved with dietary changes and exercise, however these effects can take many months. 59, 60 overweight can be addressed with a healthy plantbased nutrient-dense diet and exercise. 61 variations in host immune responses might be explained in large part by the healthfulness of the host's lifestyle and behavioral factors including nutritional choices. 41 thus, immune responses to covid-19 and mechanisms of hyperinflammation-driven pathology warrant elucidation to best define therapeutic strategies for covid-19, 62 including nonpharmacologic strategies such as healthy nutrition and exercise. a secondary gain of healthy nutrition could be lower incidence of physical impairment, 63 irrespective of body mass. effective health and lifestyle education are unique physical therapist competencies. 47 as the leading established non-invasive health profession in the world, the profession needs to assume a leadership role with respect to including in their practices and entry-level education curricula, health and risk factor assessment and prescribing health promoting interventions or indications for referral to others. effective health and lifestyle education, ie, lifestyle knowledge translation, warrants being ever more so at the forefront of every physical therapist-patient interaction. 66 at a broad level, the physical therapy profession needs to ensure that health providers and stakeholders continue to be updated about the profession and practitioners' competencies as the professions continues to evolve and serve global societies. this will ensure that stakeholders such as legislators, ministries of health and higher education, hospital managers, university administrators, and other health professions, continue to support the physical 13 therapy profession in its practicing at its highest evidence-informed level, in the interest of health and participation for all. the unprecedented global crisis of covid-19 has become an unprecedented opportunity for the physical therapist profession to continue to advance along its evolving historic trajectory, commensurate with societal and global needs. the profession has an opportunity to respond impactfully. we conclude that the covid-19 pandemic could well augment the profile of the profession of physical therapy within the health professions and within public health, given its potential role in reducing covid-19 susceptibility, and its management from its most severe expression, ards, to maximizing functional return long after hospital or icu stays. prevention and outcome of covid-19 could be substantially impacted with exploitation of non-invasive strategies including health and lifestyle education and exercise, that are subsumed within contemporary physical therapist practice. this is an unparalleled opportunity for the physical therapist profession to step up to the plate, and to further establish itself among the health professions and demonstrate its worth. there is no funding to report. accessed june 15. 2020. and reduce the burden of non-communicable diseases postmortem examination of patients with covid-19 endothelial cell infection and endotheliitis in covid-19 post-discharge cardiac care in the era of coronavirus 2019: how should we prepare? world health organization. covid-19 significantly impacts health services for noncommunicable diseases cardiovascular and pulmonary physical therapy: evidence to practice (5 th ed) long-term complications of critical care rehabilitation quality 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in the nurses' health study american college of lifestyle medicine. competencies for prescribing lifestyle medicine the authors completed the icmje form for disclosure of potential conflicts of interest and reported no conflicts of interest. key: cord-277770-sbieo46s authors: oni, tolu; micklesfield, lisa k.; wadende, pamela; obonyo, charles o.; woodcock, james; mogo, ebele r. i.; odunitan-wayas, feyisayo a.; assah, felix; tatah, lambed; foley, louise; mapa-tassou, clarisse; bhagtani, divya; weimann, amy; mba, camille; unwin, nigel; brugulat-panés, anna; hofman, karen j.; smith, joanne; tulloch-reid, marshall; erzse, agnes; shung-king, maylene; lambert, estelle v.; wareham, nicholas j. title: implications of covid-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries date: 2020-09-01 journal: global health action doi: 10.1080/16549716.2020.1810415 sha: doc_id: 277770 cord_uid: sbieo46s at the time of writing, it is unclear how the covid-19 pandemic will play out in rapidly urbanising regions of the world. in these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the covid-19 pandemic in these contexts. covid-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. however, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. in this current debate piece, focusing on two of the four risk factors that contribute to >80% of the ncd burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. by considering mitigation responses implemented by governments in several lmic cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term. in rapidly urbanising low-and middle-income countries (lmic), the realities of large overcrowded informal settlements, a double burden of infectious and non-communicable diseases (ncds), malnutrition and the precarity of livelihoods [1] have raised added concerns about the potential impact of the covid-19 pandemic. control measures implemented in these settings include closing of national and state/county borders, and schools, restricted movement (including frequency of shopping), working from home, provision of water in informal settlements for hand hygiene, physical distancing and the banning of large gatherings. these measures have been shown to slow down transmission, buying healthcare systems preparation time [2] . however, there has been less of a focus on the indirect impacts of these measures on health behaviours and consequently health risks, particularly in the most vulnerable. these restrictions have the potential to impact ncd risk factors such as dietary intake and physical activity behaviours [3] , by limiting access to healthy foods and to environments conducive to physical activity. while many of the interventions to curb the pandemic are intended to be temporary, they have exposed existing inequities in disease vulnerability and access to care. the amplification of these inequities is resulting in poorer disease outcomes and negative impacts on livelihoods among the poor and marginalised. this debate piece will describe how the implementation of restrictions to limit the spread of the pandemic may impact diet and physical activity behaviours, as well as their determinants. we also reflect on the experiences from mitigation interventions mobilised by several governments to respond to this pandemic, and the potential for these to be leveraged beyond covid-19 in order to retain health as a priority. with the implementation of measures to prevent further spread of covid-19 infections, lmics are experiencing two inter-related pandemics. our public health response to the covid-19 pandemic may be exacerbating behaviours such as unhealthy food consumption, physical inactivity and sedentary behaviour. these aforementioned behaviours are considered the key drivers of obesity epidemic globally, and obesity is a risk factor for adverse outcomes of covid-19 infection [4] . external dimensions of the food environment include the availability, price, vendor and product properties, and promotional information. by comparison, personal dimensions of the food environment are the accessibility, affordability, convenience and desirability of food sources and products. these food environment exposures, which vary considerably between and within high-, middle-and lowincome countries, influence food choices, dietary habits, and food security [5, 6] . the covid-19-related closures of national borders threaten food supply especially in countries already facing food insecurities and those largely dependent on food imports. as a result, maintaining adequate food production, import, storage and transportation can be precarious for both external and personal dimensions of the food environment. the dynamics of purchasing and consumption of healthy food in this context, driven by limited access to fresh foods and refrigeration, has highlighted the growing wealth inequality within countries. for many, the new reality of shelter-in-place measures has resulted in an increase in cooking and eating at home. on one hand, this presents an opportunity for preparing more healthy meals at home. however, a lack of nutritional knowledge and cooking skills, increased snacking behaviour, unavailability and increased costs of healthy foods [7] , and the lack of guidelines to ensure nutritional quality of food parcels to the poor [8] may result in a shift to more unhealthy processed food consumption. this is particularly important for lower-income households without the means, or in some cases, the access to refrigeration, to stock up on fresh food supplies. in addition, school closures result in interrupted access to food for children from households that depend on school-feeding programmes, adding to the financial burden and household food insecurity. these measures are also resulting in a staggering loss of jobs and livelihoods that further impact on people's ability to afford healthy foods. the predominance of the informal economic sector and absence of robust social safety schemes in lmics further compound food affordability. in these circumstances, without social welfare measures, the most vulnerable are left with no choice but to defy social distancing measures to avoid hunger. covid-19 control measures inevitably disrupt routine daily activities and may have positive or negative consequences on physical activity behaviours. stay-at-home orders and curfew measures result in reduced travelling, which in many cases includes walking, potentially reducing the opportunity for physical activity. reduced regular physical activity alone, or compounded by unhealthy eating may result in an increased risk or worsening of chronic conditions such as obesity, diabetes, hypertension and cardiovascular disease [9, 10] , which are increasing in prevalence in lmics [3] . these are the very conditions that have also been associated with an increased risk of hospitalisation and death from covid-19 [11] . some evidence from other emergencies suggests that the deleterious effects of physical inactivity and sedentarism that begin during an outbreak may continue for some time after the end of the outbreak [12] . conversely, this new reality may encourage more physical activity as people seek respite from being stuck at home, particularly if the reduction in traffic makes built environments more conducive to physical activity in public spaces. as such, it would be important to mitigate indirect negative consequences to encourage safe physical activity. while doing this at home would be ideal, it is important to recognise that for the majority of the urban poor, particularly in the context of informal settlements [13] , this will not be practical. furthermore, outdoor physical activity has been associated with greater enjoyment and increased likelihood of achieving the recommended levels of physical activity [14] . this highlights a critical need for guidelines on safe physical activity outdoors at the different alert levels of pandemic response. many governments in lmics have implemented measures to minimise covid-19 risk while working to address underlying social inequities that further increase vulnerability to disease. in so doing, the emergency has highlighted the possibility of previously considered impossible or unfeasible actions [15] . we note the following reflections from these pandemic responses that could be applied to current and future epidemics and pandemics to support equitable access to healthy diets and physical activity: (1) wide-ranging multisectoral action to reduce inequalities is possible at pace when there is social and political will. the response to the covid-19 pandemic has seen unprecedented multisectoral action compared to responses to the ongoing obesity pandemic. of note, governments have led coordination of multisectoral responses, removing bureaucratic processes that could hinder support for vulnerable communities. for example, in kenya, the ministry of agriculture has partnered with county governors to aggregate information on the volumes and prices of staples and nutritious foods in order to ensure affordability [16] . county governors have also prioritized identifying vulnerable families to ameliorate food insecurity [17] . beyond this pandemic, mapping access to nutritious foods and governing their equitable distribution can be utilised to improve dietary behaviours, especially for the urban poor. the implementation of riskcontainment strategies has also required effective partnerships at the community level, with community health volunteers and grassroots organizations constituting the last mile of distribution of health information, rapid testing, healthy food and other supplies. beyond an acute emergency response, continued collaboration with these same partners can ensure that physical activity and healthy diets remain accessible. in another example of government-led strategies to support food security, the state commissioner for agriculture in nigeria established makeshift neighbourhood food markets in schools in lagos which were closed due to the lock down [18] . in a megacity where fresh food markets are often centralised in large markets, like mile 12 market [19] , this intervention brought fresh food supplies closer to neighbourhoods to mitigate the impact of the closure of centralised markets and movement restrictions across the city. in jamaica, with the closure of international borders and the sudden loss of the demand for food from the tourist industry, the government introduced community-based cashless farmers markets and distribution of fixed priced 'vegetable baskets' though community organizations to reduce the waste of perishable agricultural items and help support this sector [20] . larger food manufacturers also increased capacity for fruit preservation though production of purees and manufactured new fruit blends [21] . beyond this pandemic, it would be important to reflect on and evaluate the experience of these endeavours to inform longer term strategies to make fresh foods more locally available within neighbourhoods. (2) covid-19 has revealed significant flaws in our existing urban infrastructure. these flaws include economic systems that reduce resilience to food insecurity, and streets that prioritize motorised traffic, making physical activity for leisure or travel unsafe. understandably, the majority of emergency mitigation responses have focused on food security. however, some settings such as bogota, colombia have created new space for walking and cycling [22] while the jamaican ministry of health and wellness has shifted focus to television and social media-based exercise programmes [23] . given that physical distancing measures are likely to be recommended for some time, contextually relevant research to encourage and support safe accessible physical activity for all should inform recovery plans related to the built environment. (3) there is a need for public health interventions jointly to reinforce democracy, the rights of the individual and the collective good. in the context of acute response to emergencies, varying approaches have been adopted including extensive tracing using big data and deployment of the police to enforce movement restriction measures. if rights are side-lined, these measures potentially compromise data privacy and individual rights if applied in a discriminatory manner. this highlights the importance of a rights-based approach to public health, recognising that the right to health is dependent upon other human rights (such as food, housing, information and participation) and that even well-intended enforcement could bring harms. a rights-based approach could similarly be applied to addressing the obesity pandemic. for example, governance of urban space could ensure that organizations charged with enforcing lockdown measures are thoroughly oriented in equitable governance approaches, and partner with community stakeholders to improve access to neighbourhood resources including safe spaces for physical activity. additionally, it can include collaboration with key actors to facilitate access to space for urban agriculture for the poor. while the impacts of these interventions are yet to be evaluated, these examples hint at the potential for whole-of-society approaches to building stronger systems for health and lower the baseline need for healthcare. in the long term, it is vital that the economic, political, food and built environment sectors mobilised during the pandemic are encouraged (and governed) to retain health as a priority. societies that support and enable healthy eating and active living are vital to reduce vulnerability to covid-19 and other diseases and pandemics in the long term. urban health research in africa: themes and priority research questions how will country-based mitigation measures influence the course of the covid-19 epidemic? fact sheet on noncommunicable diseases. geneva: world health organization world health organization. covid-19 and ncds concepts and critical perspectives for food environment research: a global framework with implications for action in low-and middle-income countries nutrition amid the covid-19 pandemic: a multi-level framework for action pmbejd media statement: food prices and public health messages in a time of covid-19 food aid parcels in south africa could do with a better nutritional balance physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (covid-19) covid-19 related school closings and risk of weight gain among children opensafely: factors associated with covid-19-related hospital death in the linked electronic health records of 17 million adult nhs patients physical activity and sedentary behaviour among children and adolescents living in an area affected by the 2011 great east japan earthquake and tsunami for 3 years slum health: arresting covid-19 and improving well-being in urban informal settlements does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? a systematic review covid-19)-inducedre-imagination: 7 things we knew but could do nothing about until we could and did state seeks to ensure food security in covid-19 war joho sets aside sh200 million to help cushion residents of mombasa from cessation order lagos holds makeshift food markets in schools thursday mile 12 market booming sales at kingston and st andrews farmers markets agriculture and fisheries. agri ministry collaborates with tru-juice to process excess produce bogotá expands bike lanes to curb coronavirus spread jamaica moves encourages home exercise to led the conceptualisation, initial drafting, and the overall drafting process of the manuscript.lkm and pw co-led drafting of significant components of the manuscript and overall drafting process.coo, jw, em, fao, fa, lt were responsible for drafting and editing of subsections of the manuscript.lf, cmt, db, aw, cm, nu, abp, kjh contributed to the editing and finalisation of the manuscript.js, mtr, ae, msk, evl, njw contributed to final edits of the manuscript. no potential conflict of interest was reported by the authors. not applicable. in urban populations with inadequate access to sanitation, food and physical activity, and growing obesity and ncd burden, covid-19 control measures can widen health inequities. addressing the pandemic while mitigating this vulnerability calls for a rights-based approach to governance of urban space. multisectoral government covid-19 responses in these cities to address social inequities highlight the feasibility of economic, political, food and built environment sectors, mobilised during the pandemic, to support healthy eating and active living. key: cord-294180-t5bncpo4 authors: neto, leônidas oliveira; tavares, vagner deuel de oliveira; galvão-coelho, nicole leite; schuch, felipe barreto; lima, kenio costa title: aging and coronavirus: exploring complementary therapies to avoid inflammatory overload date: 2020-06-26 journal: front med (lausanne) doi: 10.3389/fmed.2020.00354 sha: doc_id: 294180 cord_uid: t5bncpo4 nan acute respiratory distress syndrome (ards) is the main cause of death in covid-19 patients (1, 2) . in recent years the relationship between this respiratory syndrome and inflammatory system dysregulation has been discussed (3) . patients with ards could present distinct endophenotypes with respect to immune alterations: hyper-or hypo-inflammatory profiles (4, 5) . the identification of inflammatory endophenotypes of ards is important, as patients respond differently to clinical and hospital management (3) . in patients with a hyper-inflammatory profile, a pro-inflammatory storm is observed in the human body, with elevated rates of biomarkers such as c reactive protein (crp) (2, 6) and cytokines such as interleukins (il)-6 and tumoral necrosis factor (tnf)-α that are able to develop a systemic inflammatory response. the release of il-6 and tnf-α into the systemic circulation directly contributes to the increase in systemic inflammation levels and arteriosclerosis processes (7) . people with chronic clinical comorbidities (1) such as hypertension, diabetes (8) , and kidney disease (9) have a higher risk of becoming critically ill and dying from covid-19. for this reason, the older age population has a higher risk of mortality by covid-19, since they have many of these diseases (10, 11) . it is interesting to highlight that both aging and chronic diseases are linked to an increase in levels of systemic inflammation, which could explain a potential common pathway between these factors and covid-19. therefore, the acute and strong immune system dysregulation induced by the virus may be linked to ards and its complications, such as multiple organ failure, and finally lead to patient death (12) , mainly in those with previous inflammatory allostatic overload (13, 14) . in fact, people with covid-19 present high levels of systemic inflammatory biomarkers (15) , and the detection of these forms part of the preliminary guidelines for the diagnosis and treatment of sars-cov-2 (12) . accordingly, multiple experimental treatments with immune-suppressing or stimulating drugs have been tested, aiming to reduce the pro-inflammatory cascade and, thus, mortality (16) (17) (18) . while the search for effective treatments and vaccines is the top priority, non-pharmacological complementary therapies targeting reductions in baseline inflammatory load, mainly in the oldest population, should receive some attention. during aging, a natural and progressive deterioration in cells and impairment in organ functions occur due to metabolic, immunological, neuroendocrine, or oxidative stress (19) . at a molecular level, imbalance between the oxidant/antioxidant pathways (19) could be explained by malfunction in inflammatory/antiinflammatory homeostatic mechanisms, which result in a chronic low-grade pro-inflammatory state known as inflammaging (20). the inflammatory system is responsible for defending systemic functioning and repairing damages from infections and harmful environmental agents. aging is a process that all living organisms ages and corresponds to a reduction of defenses to the aggressor agents of living beings, and this we call immunosenescence. this process is gradual and differs between genders (21) . at ∼40 years of age, the first major reduction in immune functions occurs and occurs in a similar way between men and women. studies with covid-19 reveal that it is exactly in this age group that lethality doubles, from 0.2 to 0.4%. around the early post-60s, we have a new functional immune decline for men, which only occurs in the late 60s for women, which may partly explain the higher mortality of men worldwide (22) . several studies report that, with aging, both the innate and adaptive immune response suffer changes both in their cellular composition and in their function (23, 24) . in the case of covid-19, the innate immune response in the elderly would be activated, and there would be no satisfactory passage of the innate immune response to adaptive, maintaining a chronic activation of the former and preventing the elimination of sars-cov2 (23, 25) . in addition to maintaining the chronic immune response, which generates a chronic inflammatory state, there is an important decline in the performance of the adaptive system. yet, there is a reduction in the recognition of new antigens by adaptive immunity due to the reduction of naive cells and, moreover, a depletion of aging immune cells, which are already very stimulated and do not retain their functions. there are reports that immune cells of adaptive response also undergo changes in their functions and start to act as cells of the innate response (26) . during the covid-19 pandemic, two of the proinflammatory proteins were elevated in severe patients (27) , yet the inflammatory state may be associated with multiple diseases (25) . in this sense, the consequences are systemic and affect the elderly especially, causing changes in body composition and an imbalance between availability and energy demand that can affect the quality of life and functionality of the elderly (28) . in addition, the inflammation overload makes the elderly more susceptible to several other diseases, such as cardiovascular disease, diabetes, osteoporosis, and ostearthrosis (29) . in this context, lifestyle and nutraceuticals arise as important prophylactic interventions to reduce the burden of baseline inflammation in older adults and consequently improve quality of life, mobility, cognition, mood, and metabolic and immune balances, especially during the pandemic. it is possible that covid-19 will be a long pandemic, with multiple infection waves (30) ; therefore, these strategies are especially important since they can be adopted in the long term and under physical social isolation. the aim of this study is to discuss how diet and nutraceuticals and lifestyle as complementary therapies could help older adults during the covid-19 pandemic, reducing inflammaging. comfort foods are very palatable foods that are rich in saturated fats and carbohydrates, especially sugar, which can decrease stress and anxiety through activation of the dopaminergic pathways of the reward system (31, 32) . in times of lockdown, a rise in the intake of comfort foods is likely, and this behavior tends to strengthen each time the reward system is activated (33) . since comfort foods have a high caloric rate, they can lead to weight gain when the energy expenditure is lower than the caloric intake, resulting in obesity, which is recognized as an inflammatory disease (34) . in order to avoid weight gain, which adds load to inflammaging through an increase in the synthesis of harmful adipocytokines by white adipose tissue (35) , a diet should be prescribed by a specialist. for instance, some diets, such as the mediterranean diet, the low glycemic index diet, moderate carbohydrate intake, and vegetarian diets, should be adapted to the personal demands and preferences of older adults and prescribed in times of lockdown (36) . however, diets with severe restriction should be avoided, as they could lead to impulsive food behaviors (31) . besides adjustment in the diet, some specific nutrient supplementations can assist in health improvement, such as magnesium, zinc, s-adenosyl methionine, omega-3, and vitamin d, which are important for good maintenance of cognitive and physiological mechanisms (37, 38) . magnesium is fundamental for nervous system function and insulin sensitivity, helping in the prevention or management of diabetes mellitus type ii, characterized as a chronic and mild inflammatory disease (34, 39) . zinc also contributes to improving insulin sensitivity (40) and body metabolism (39) . vitamin d, or more specifically, 25hydroxyvitamin d [25 (oh) d], is an anti-inflammatory nutrient (41) , and reduces the activation of the renin-angiotensin system, preventing hypertension (42), besides its importance to bone and muscle, an inverse relationship is also observed between its levels and mortality risk in old adults (43) . omega-3 has an important role in cognition and as an anti-inflammatory agent; thus, it seems effective against age-related mood disorder (44, 45) . recently, 25-hydroxyvitamin d [25(oh)d] has been suggested as a nutraceutical alternative to reduce the risk of covid-19 infection due to improvement in the immune system, whereas vitamin d3 is pointed out as an adjunctive treatment in higher doses (1, 46) . in addition, vitamin c could be an alternative to treat respiratory tract infections. also, one study indicated that administration of ∼ 15 g/day of vitamin c for 4 days may decrease mortality in patients with ards (47). however, the vitamin c supplementation did not significantly improve organ dysfunction scores or alter biomarkers of inflammation and vascular injury. thus, controlled trials and large-population studies should be conducted to prove these hypotheses. moreover, it is important to highlight that the benefits of both diet and nutraceutical interventions are enhanced and the risks reduced when planned for a specific patient, through precisionbased approaches that consider nutritional macro/micronutrient deficiencies, levels of inflammatory cytokines, and genomic and microbiome analysis, among other factors (48) . this individual analysis is mainly relevant to elderly adults who usually show imbalances in many micro-and macronutrient levels as a result of aging or pharmacological treatments. although some of these approaches are low-cost, unhappily, they are not always applied. therefore, their use should be stimulated to has to help reduce the number of deaths around the world, mainly during the pandemic (49) . sedentary behaviors such as longer screen time and lower physical energy expenditure can aggravate physical and mental conditions (50) , especially in this period of social isolation. therefore, reducing the time spent in sedentary behavior at home is of great importance for maintaining health during lockdown (51) . furthermore, increasing the time spent engaging in exercise is essential. lifestyle therapy consists of adopting a health routine that includes a balanced diet, physical exercise, relaxation and meditation techniques, and good sleep (38, 48) . a robust body of evidence has demonstrated the benefits of these modifications of lifestyle for mental health, mainly for mood symptoms (52) (53) (54) (55) , indicating that lifestyle therapy is an effective strategy for preventing and treating some mental disorders (56-59), including in old adults (45) . it is natural that with aging, the frequency and intensity of physical activities will decrease (51) . however, there are further reasons for encouraging an increase in activity levels, such as for improving cardiorespiratory fitness (60) , which in turn reduces mortality risk (61) , and poor health (62) . furthermore, reducing sedentary behavior and engaging in exercise may increasing the production of systemic anti-inflammatory cytokines and help to combat inflammation (63, 64) by increasing innate immune function (65) and decreasing the chronic inflammation related to various diseases (66) . considering the high rate of risk factors being present in older adults as a risk group (67) , it is necessary to build tools directed at this group that aim to reduce sedentary behaviors and to keep them active during the covid-19 pandemic. as well as setting prescribed exercises and encouraging increased levels of daily physical activity, all movements should be stimulated, even simple routine activities such as those related to cleaning the house (68) . with respect to exercises, to reduce sedentary behavior, we recommend the practice of modest exercises that are popularly known as jumping jacks, going up and down stairs, pushups, sit and get up, and balance exercises. these exercises are options that can fit well into the lockdown situation and can be done with home objects such as chairs and benches. however, all exercise should be supervised and prescribed by a trained professional, considering the individual, social, and economic aspects of the subject. however, it is necessary that this orientation occurs using distance-oriented tools, such as internet-based strategies like apps or video calls or mobile telephone messages. group classes can also improve motivation and social support, which in turn reduces psychological stress levels, helping in homeostatic balance (69) . however, as some elderly adults have impaired motor skills, other alternatives have been used to reduce symptoms of mental disorders and reduction inflammation. for this, approaches with an integrative mind-body focus have been gaining ground in order to prevent or treat diseases such as chronic stress, anxiety, and depression (70) , which are known to induce a mildly proinflammatory profile (71) . these approaches use meditative practices as tools aimed at refining attention and promoting better emotional regulation and self-awareness (72) . one of the main components of mindfulness-based activities is the regulation of attention (73) . thus, attentional focus during the exercises proposed in mindfulness programs is directed to the observation of the experience of thoughts, body sensations, and emotions (74, 75) . in addition, the practice of relaxation and meditation also has an effect on reducing inflammation (76) . successful mind-body interventions in older adults have shown improvements in different aspects, such as pain control, sleep quality, attention, global cognition, and working memory (77) . additionally, positive results were recently presented for the reduction of depressive symptoms through internet mindfulness therapy in this population (78) . therefore, applying relaxation and meditation therapies is urgent, as these can improve mental and physical health in older people who are in isolation, following the guidelines of the who. social physical isolation due to covid-19 can bring serious risks to health if older adults continue with, or assume, a nonhealthy lifestyle, which includes a lack of physical activity and a diet low in nutrients and rich in comfort foods. therefore, strategies should be encouraged to promote and raise awareness among the older population about the application of lifestyle and nutraceutical tools. these interventions have great potential for insertion in public policies in different contexts due to their low cost, effectiveness, and simplicity. we are aware that it can be difficult to apply all of these suggestions, mainly in elderly adults, but every step is important and better than none. therefore, a healthy lifestyle should be encouraged as an intervention to prevent frailty among older people, and a multi-professional care system should act in this time of covid-19 to reduce risks and avoid damage related to inflammation overload in older adults. ln: conceptualization, project administration, and writingoriginal draft preparation. vt, ng-c, and fs: reviewing and editing. kl: conceptualization, project administration, and writing-original draft preparation. all authors contributed to the article and approved the submitted version. the authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. ng-c was supported by the capes foundation of the brazilian ministry of education (research fellowship 88887.466701/2019-00) and the national science and technology institute for translational medicine (inct-tm fapesp 2014/50891-1; cnpq 465458/2014-9). a comprehensive literature review on the 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training improve immune function in the aged? reversing age-associated immunosenescence via exercise covid-19 and the consequences of isolating the elderly #traininginhome -training at home during the covid-19 (sars-cov2) pandemic: physical exercise and behavior-based approach resposta ao estresse: ii. resiliência e vulnerabilidade effects of yoga on depressive symptoms in people with mental disorders: a systematic review and meta-analysis is depression an inflammatory disorder? the clinical use of mindfulness meditation for the self-regulation of chronic pain mindfulness: a proposed operational definition full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness how does mindfulness meditation work? proposing mechanisms of action from a conceptual and neural perspective mindfulness meditation and the immune system: a systematic review of randomized controlled trials mindfulness-based stress reduction for chronic insomnia in adults older than 75 years: a randomized, controlled, single-blind clinical trial internet mindfulness meditation intervention (immi) improves depression symptoms in older adults the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 neto, tavares, galvão-coelho, schuch and lima. this is an openaccess article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-308987-p3zh4irp authors: kirkness, carmen s.; fritz, julie m. title: translating research into clinical practice: functional recovery post total hip arthroplasty using outcomes gathered in the usual physical therapy practice setting date: 2011-04-23 journal: health outcomes res med doi: 10.1016/j.ehrm.2011.04.001 sha: doc_id: 308987 cord_uid: p3zh4irp purpose: the purpose of this study is to determine the pattern of functional change after total hip arthroplasty (tha) in patients attending physical therapy (pt) in a usual care setting and to explore the effect of sex and time from surgery to the first physical therapy visit as potential prognostic factors influencing postoperative tha recovery. study design: adults with tha were retrospectively identified in an electronic medical record pt database (october 1, 2004-april 30, 2010). hierarchical linear modeling was used to evaluate growth curves and individual variations in function using the lower extremity function scale (lefs). investigated predictors were: sex, age, start time, and pt visit. results: a total of 147 (81 female, 66 male) postoperative tha patients were included in the study; mean age was 62.7 years (sd 10.6, range 45-91 years). the majority (79%) of patients initiated pt <9 weeks postsurgery; predominately lower-functioning women started at ≥9 weeks. for patients initiating treatment at <9 weeks, the curvilinear slopes of recovery were similar between sexes, although the predicted levels of functional status were lower for females than for males (p = .041). conclusions: this study of usual physical therapy practice supports the findings from controlled studies that post-tha women enter and are discharged from outpatient pt with lower functional status than men. new findings suggest that functional status for early start patients steadily improves over 26 weeks postsurgery. modeling change in clinical practice using outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. r e s u l t s : a total of 147 (81 female, 66 male) postoperative tha patients were included in the study; mean age was 62.7 years (sd 10.6, range 45-91 years). the majority (79%) of patients initiated pt <9 weeks postsurgery; predominately lower-functioning women started at $9 weeks. for patients initiating treatment at <9 weeks, the curvilinear slopes of recovery were similar between sexes, although the predicted levels of functional status were lower for females than for males (p ¼ .041). c o n c l u s i o n s : this study of usual physical therapy practice supports the findings from controlled studies that post-tha women enter and are discharged from outpatient pt with lower functional status than men. new findings suggest that functional status for early start patients steadily improves over 26 weeks postsurgery. modeling change in clinical practice using outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. total hip arthroplasty (tha) is a successful and cost-effective elective surgical procedure frequently used to alleviate pain and dysfunction due to osteoarthritis. 1 the prevalence of tha has rapidly increased in the us 2 and the demand is expected to continue in the future. 3 changes in the perioperative management of tha have resulted in decreased length of hospital stay, shifting the emphasis to postoperative care following hospital discharge. 3 after being discharged from the hospital, patients will often receive postoperative rehabilitation services in inpatient rehabilitation centers, or from home health agencies or outpatient physical therapy clinics. 4 an increasing number of tha procedures will likely lead to an increased use of outpatient physical therapy care. the economic impact resulting from the increased tha procedures will make it even more important to maximize the available rehabilitation resources and to show the effectiveness of rehabilitation options such as outpatient physical therapy. examining the pattern of recovery following tha and the factors associated with recovery is necessary to understand prognosis and to benchmark outcomes after tha. benchmarking provides a means to compare groups and individual patients to the expected outcome. 5 the identification of characteristics that may influence outcome is also important to understanding and predicting the pattern of recovery. controlled studies have found a link between sex and rates of tha recovery. [6] [7] [8] [9] [10] [11] compared with females, males have been shown to have better function immediately after surgery. this trend is maintained through the recovery period as the rate of recovery between males and females is similar. [6] [7] [8] [9] [10] [11] sex differences may be attributable to the patient deciding when surgery is necessary; women appear to be more disabled than men at the time of tha, thereby having lower physical function at the time of surgery. [6] [7] [8] [9] [10] [11] understanding the pattern of recovery after tha surgery can help answer questions patients often ask clinicians related to the recovery process, providing a timeline and reasonable expectations for patients. establishing the pattern of early recovery after tha has been identified as an important marker to provide best practice services in the management of tha rehabilitation. [11] [12] [13] [14] [15] little research has been completed evaluating the pattern of recovery following tha, 11, 13 and existing studies have been completed mainly in controlled research environments rather than in routine care settings, and they may provide estimates not generalizable to usual outpatient physical therapy care. examining recovery from tha in usual outpatient physical therapy care has been difficult due to a lack of outcomes data collection in physical therapy settings 16, 36 and the lack of appropriate methods to allow the contribution of each patient's unique visit (time point) to be taken into account. at present there is no published evidence examining recovery after tha for patients seeking and attending physical therapy in a usual outpatient physical therapy care setting. the purpose of this study is to examine the pattern of change seen in patients attending physical therapy after tha in a usual outpatient physical therapy care setting and to explore the effect of sex and time from surgery to the first physical therapy visit as potential prognostic factors influencing postoperative tha recovery. all data were collected as part of routine clinical practice in 15 outpatient physical therapy clinics of intermountain healthcare, located in the salt lake city, utah region from october 1, 2004 through april 30, 2010. the intermountain physical therapy clinics maintain an electronic database that stores data from all physical therapy visits. the database contains basic demographic information about each patient (age, sex, onset/surgical date, and reason for referral). clinical outcomes, including a pain rating and region-specific disability score, are collected at the beginning of each visit and entered into the electronic database. the lower extremity functional scale (lefs) 17 is used as the region-specific disability questionnaire for all patients with disorders related to the hip at intermountain physical therapy. the lefs is a 20-item selfreport measure designed to assess functional status for patients with a variety of conditions affecting the lower extremity. each item of the lefs is scored from 0-4, with the final score expressed as a sum out of 80 possible e120 physical therapy after total hip arthroplasty points. higher scores are associated with higher functional status. although the lefs was designed for use with a variety of lower-extremity conditions, high reliability estimates have been shown in the tha population (internal consistency 0.93, intraclass correlation coefficient 0.85-0.92, and minimally detectable change of 9 points). 17, 18 the lefs is easy for the patient to use and it is quick to administer and score. 17, 18 a numeric pain rating scale (nprs) is used to assess the patient's current pain level at each visit. the nprs is a 0-10 scale with 0 representing "no pain" and 10 the "worst imaginable pain" (cronbach coefficients 0.86-0.88; test-retest reliability 0.57-0.83). [19] [20] [21] [22] [23] extracted demographic data for this study included age, sex, date of surgery, the number and dates of all visits during the physical therapy episode of care, and the clinical outcome scores (nprs and lefs) recorded for each visit. this study qualified for exempt review from the institutional review board at intermountain healthcare. this study examined patients receiving outpatient physical therapy following a recent tha. specifically, patients were included if they met all of the following criteria: age 45 years or older on the date of the first physical therapy visit, at least one physical therapy visit with an lefs value entered into the database, and the first physical therapy visit was within 26 weeks from date of surgery. patients were identified in 1 of 2 ways. first, we examined the reason for referral in the intermountain physical therapy electronic database. all patients categorized as referred following arthroplasty of the hip were considered for inclusion. to identify patients who may have been categorized otherwise in the electronic database, we examined the intermountain healthcare electronic medical record (emr) from the hospital within intermountain healthcare performing the majority of tha procedures, identifying all patients with an international classification of diseases-9 procedure code indicating a tha procedure (81.51); we then cross-referenced these cases with the physical therapy electronic database. if a patient identified as having a tha was also in the electronic database with an initial visit date that was after the tha surgical date, the patient's physical therapy record was reviewed for inclusion. a total of 166 people receiving physical therapy within a participating clinic following a tha were identified; 150 were identified from the intermountain physical therapy electronic database, and 16 additional patients were identified from the hospital emr, as shown in figure 1 . upon application of the inclusion criteria, 19 patients were excluded as follows: 6 were under age 45 years, 1 had a missing surgery date, and 12 patients had their first visit more than 26 weeks after surgery. we defined the episode of care in physical therapy as the number of days from the initial visit to the final visit. if more than 30 days elapsed between visits, the episode of care was judged to be completed. indicative of usual outpatient physical therapy practice, the patient's initial visit in physical therapy occurred at varying times from the date of surgery. recovery curves constructed from the lefs scores of patients after tha in a controlled research study 13 suggest that at 9 weeks postsurgery, the patient's rate of recovery slows and the patients appear to function moderately well, such that they would have no difficulty with light activity, but would still have a little difficulty with stairs, walking far distances, and with heavy activities. therefore, physical therapists may expect patients who begin physical therapy within 9 weeks after surgery to have diminished physical function due to the natural recovery progression postsurgery; whereas those patients initiating physical therapy 9 weeks or more following surgery may be seeking treatment because their recovery is not progressing as anticipated. we therefore defined an episode of care with the initial visit occurring within 9 weeks (ie, <63 days) of the date of surgery as an "early start" in physical therapy. an episode of care with an initial visit occurring after 9 weeks (ie, $63 days) was defined as a "late start." there is no standardized treatment protocol for postoperative tha used within intermountain physical therapy clinics. typical of usual outpatient physical therapy care, the frequency, number, and content of the physical therapy visits were expected to be variable. the primary reason for this study was to explore physical function between sexes using patient demographics, and treatment characteristics at first visit. the secondary reason was to investigate the relationship between sex and physical therapy start time. first, descriptive statistics (mean, sd, percentage) were calculated for the entire study sample, and for sub-groups of patients based on sex and physical therapy start time. the primary outcome measure was the lefs score. we examined the lefs score as a continuous variable. further analyses exploring sex differences were completed using chi-squared (fishers' exact for late start) and independent t tests for categorical or continuous variables, respectively. variables meeting statistical significance (p <.05) were incorporated into the multilevel model. to evaluate the pattern of recovery from tha, growth curves and individual variations in the pattern of lefs scores across the episode of care were characterized using a randomeffects multilevel modeld hierarchical linear modeling, which allows both the patient's rate of change and initial functional status to vary randomly. the use of a multilevel model allows repeated measures to be gathered over the treatment time by accommodating different time points between scores, allowing different numbers of scores between subjects, and accounting for the correlation that occurs with repeated scores. 35 an unconditional covariance structure was used in the basic model, with lefs scores as the repeated variable (independent variable) and weeks after surgery as the dependent variable. to explain the variation in intercepts and slopes across individual predictors of recovery such as sex, age, and episode of care, early/late start time and number of physical therapy visits were evaluated. following the basic model, a conditional analysis examined predictors of recovery, which were added as level 2 fixed-effect terms into the model. a growth curve will depict the predicted lefs scores over time using the final conditional model. statistical analyses were performed using stata statistical software: release 11 (statacorp lp, college station, tx). physical therapy after total hip arthroplasty the final study population included 147 patients; 81 female patients (55.1%) and 66 male patients (44.9%). their ages ranged from 45 to 91 years (mean 62.7, sd 10.6). there were a total of 845 lefs score measurements, with 80% (n ¼ 117) of the study population having 3 or more measurements per patient (range 2-16). on average, the first clinical visit occurred 6.2 days (sd 4.7) after surgery and patients had an average lefs of 28.2 (sd 14.9), as shown in table 1 . comparing treatment characteristics, the time from tha until the first physical therapy visit was significantly longer (p ¼ .001) for women (7.3 weeks, sd 5.1) than men (4.8, sd 3.7). in addition, women had significantly higher initial nprs scores (p ¼ .02) than men (table 1 ). demographics and treatment characteristics were compared by sex and start time as shown in table 2 . the majority (n ¼ 116, 78.9%) of patients were categorized as having an "early start" in physical therapy. the majority of men (60; 90.9%) were early start, while only 56 (69.1%) of the women were considered early start (p ¼ .001). mean age, time to first visit, total number of visits, and length of treatment were similar between men and women early-start patients. the only significant difference between males and females in the early-start group was that women had more pain on their first visit (p ¼ .01). stratified analysis results by start time and sex indicate that start time differences were significantly associated with sex (p ¼ .001); there were 4 times more women in the late start group (n ¼ 25, 30.1%) compared with men (n ¼ 6; 9.1%). women in the late start group were, on average, 9 years older than the late-start men (p ¼ .002). limited postoperative recovery was found in late-start patients; initial functional status and pain scores for late-start patients were similar to early-start patients. due to the disproportion of males (n ¼ 6) to females (n ¼ 25) and the small sample size, predicted recovery was not completed for latestart patients. growth curves were modeled only for early-start patients due to the low number of patients in the latestart group and the confounding effects of sex in the late-start group. the basic growth model included parameters that estimate the intercept (lefs score) and the patient's rate of change (weeks) with a second-degree polynomial growth term (weeks squared), which provided a reasonable fit for the data over the study interval as the rate of improvement decreased over time. when the potential predictive variables were examined, only establishing the pattern of recovery after tha surgery has been identified as an important benchmarking outcome for both clinicians and patients. 13 in this study, functional ability was measured at varying time points unique to each patient and then used to map recovery after tha for those patients attending usual outpatient physical therapy. the results of this study suggest that in the clinics examined, the majority of patients attend physical therapy within the first 9 weeks after tha surgery, but there was a segment of patients who initiated physical therapy more than 9 weeks after tha surgery. the patients initiating physical therapy later (>9 weeks after tha surgery) had initial pain and function scores similar to the early-start patients, perhaps indicating that recovery was not progressing as anticipated. in addition, those initiating physical therapy later were significantly older than early starters, and the proportion of women that were late starters was 3 times that for men. further research is warranted to explore the determinants characterizing why patients, particularly women, may be initiating physical therapy late in the recovery process and why these patients are well below the predicted level of functional recovery. in addition, investigating whether this trend can be established across different usual outpatient physical therapy practice care settings (ie, national level) would be an important next step for physical therapists. being able to discuss what to expect after tha is important for the patient and clinician. patients want to know what their functional level may be and how long it may take them to recover. to answer the 13 (2006) have been instrumental in providing evidence about the recovery process following tha. in a controlled setting (where patients met specific inclusion criteria, gave consent to participate, and had designated follow-up times), kennedy et al 13 used 4 standardized measures of physical function to evaluate recovery over the first 15 weeks post-tha. using consecutive patients undergoing tha, they found an increased rate of recovery in the first 6-9 weeks, which was followed by a plateau in recovery between weeks 9 and 15. our study builds on the foundation initiated by kennedy et al 13 (2006) by providing insight into the recovery of tha patients that attend usual physical therapy (a noncontrolled setting) and by monitoring 25 weeks of tha recovery. in our early start patient sample, there was an increased rate of recovery in functional ability, with similar levels of functional ability at 15 weeks, similar to the findings of kennedy et al. 13 however, our study found that the recovery plateau occurred 16 weeks after surgery, compared with the plateau at 6-9 weeks reported by kennedy et al. 13 differences between our study and the previous report by kennedy et al 13 may be attributed to multiple factors. first, using outcomes obtained from a usual clinical setting may have removed the selection bias that occurs when patients are part of a controlled study that includes an inclusion criteria and patient's informed consent, factors that may not translate to conditions seen in clinical practice. second, during the study by kennedy et al, 13 a near pandemic of severe acute respiratory syndrome restricted patients' activity due to quarantine procedures and led to loss of follow-up in some cases. although the use of clinically gathered data in our study provides a generalizable sample of patients for those who attend physical therapy, it excludes those who are unable to pay for and attend physical therapy. therefore, those with low socioeconomic status may not be represented in our sample. finally, methodological factors may contribute to the differences due to the lack of preoperative scores available and the longer duration of our study. gathering clinical outcomes data in usual clinical practice is important to advance the understanding of prognosis and the recovery process for a variety of conditions, including tha. clinicians reporting outcome measure use in clinical practice describe "enhanced communication with patients and help to direct the plan of care." 16 the findings of our study illustrate that in day-to-day clinical practice, the use of outcome measures allows recovery to be quantitatively monitored for the individual patient and contributes new information in the recovery process post-tha. barriers in the availability and usability of outcome measures seen in research that examine postoperative tha recovery, such as the womac 24 and short-form health survey, 25 are not in the public domain and readily available to clinicians. advances in the recent literature 10 the present study have shown that clinically available and relevant outcome measures are available and feasible for clinical use. with the advent of emrs and electronic databases into clinical practice, barriers that limit the routine collection of outcome measures may be alleviated, as these tools present the capability of aggregating data to facilitate the routine use of outcome measures in clinical practice. 30 in addition, there are advanced statistical techniques available that can be used to analyze the clinical data. [31] [32] [33] [34] these techniques allow each individual patient to contribute their time point (ie, patient visit) so that a natural process reflective of usual care results. the aggregation of usual physical therapy practice data can serve to move the physical therapy practice forward in providing evidence on the effectiveness of practice. this study demonstrated that in clinical practice, functional gains occur over a longer recovery period, changing the expectation of recovery and the plan of care after tha. the database used in this study originates from actual physical therapy clinical practice; therefore, the data are only as reliable as what is documented in the patient record. thus, there exists the possibility that some lefs scores may not have been documented in the emr, which may have influenced the results of this study. the application of the hierarchical modeling techniques minimize the potential limitation of missing values by allowing each patient to contribute independently to time points. second, the data were limited to 15 clinics within one practice setting. therefore, practice patterns and patient progress may not be reflective of all total post-tha patients. third, the preoperative functional status was unknown due to patients initiating physical therapy after their tha. in controlled studies, preoperative function has been shown to predict postoperative recovery. 11 the lack of preoperative scores in our study may overestimate the rate of recovery. lastly, only patients who attended physical therapy were included in this study. the pattern of recovery is unknown for those post-tha patients who did not seek physical therapy. after tha surgery, women enter and are discharged from outpatient physical therapy with lower function status than men, although the rate of recovery is similar between groups. there are patients who enter physical therapy later in the recovery period and may present a unique problem set that requires further investigation. evaluating change in clinical practice utilizing outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. f i g u r e 2 : predicted recovery curve for early start patients by sex. lefs ¼ lower-extremity functional score. physical therapy after total hip arthroplasty e-mail address: carmen the burden of musculoskeletal diseases in the united states. rosemont, il: american academy of orthopaedic surgeons prevalence of primary and revision total hip and knee arthroplasty in the united states from 1990 through 2002 future clinical and economic impact of revision total hip and knee arthroplasty effectiveness and practice variation of rehabilitation after joint replacement identifying achievable benchmarks of care: concepts and methodology outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery gender differences in functional status and pain in a medicare population undergoing elective total hip arthroplasty gender differences in patient preferences may underlie differential utilization of elective surgery differences between men and women undergoing major orthopedic surgery for degenerative arthritis comparison of gender and group differences in self-report and physical performance measures in total hip and knee arthroplasty candidates preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty effect of baseline functional status and pain on outcomes of total hip arthroplasty modeling early recovery of physical function following hip and knee arthroplasty mapping recovery after total hip replacement surgery: health-related quality of life after three years predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study use of standardized outcome measures in physical therapist practice: perceptions and applications the lower extremity functional scale (lefs): scale development, measurement properties, and clinical application. north american orthopaedic rehabilitation research network validation of the lefs on patients with total joint arthroplasty physical rehabilitation outcome measures pain: a review of three commonly used pain rating scales minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale pain intensity assessment in older adults: use of experimental pain to compare psychometric properties and usability of selected pain scales with younger adults an interdisciplinary expert consensus statement on assessment of pain in older persons validation study of womac: a health status instrument for measuring clinically important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis sf-36 health survey: manual and interpretation guide condition-specific western ontario mcmaster osteoarthritis index was not superior to region-specific lower extremity functional scale at detecting change assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty assessing recovery and establishing prognosis following total knee arthroplasty clinical interpretation of a lower-extremity functional scale-derived computerized adaptive test evidence for electronic health record systems in physical therapy applied longitudinal data analysis: modeling change and event occurrence a growth curve approach to the measurement of change application of hierarchical linear models to assessing change hierarchical linear models: applications and data analysis methods analysis of nonlinear patterns of change with random coefficient models prevalence of outcome measure use by physiotherapists in the management of low back pain key: cord-318528-yc0jw3s1 authors: romero-blanco, cristina; rodríguez-almagro, julián; onieva-zafra, maría dolores; parra-fernández, maría laura; prado-laguna, maría del carmen; hernández-martínez, antonio title: physical activity and sedentary lifestyle in university students: changes during confinement due to the covid-19 pandemic date: 2020-09-09 journal: int j environ res public health doi: 10.3390/ijerph17186567 sha: doc_id: 318528 cord_uid: yc0jw3s1 regular physical activity is related to many factors in a university student’s environment. the coronavirus pandemic and the resulting lockdown have restricted many elements of our environment. the aim of this study was to evaluate students’ physical activity and sedentary behaviour at two points in time: before and during the coronavirus lockdown. as a secondary aim, we also wanted to look at changes resulting from other factors (alcohol, tobacco, diet, stages of change, symptoms of anxiety/depression and sociodemographic characteristics). we conducted an observational, cross-sectional, pre-post study with two cut-off points. two hundred and thirteen students took part in the study. the main dependent variables were physical activity and sitting time, measured using the international physical activity questionnaire—short form (ipaq-sf). parametric and non-parametric tests were used for paired and unpaired data, as well as group-stratified analysis. during lockdown, both weekly physical activity (md: −159.87; ci: −100.44, −219.31) and weekly sitting time increased (md: −106.76; ci: −71.85, −141.67). in the group analysis, differences were observed in relation to gender, year of study, bmi, alcohol consumption, tobacco use, symptoms of anxiety/depression, mediterranean diet, living situation and stage of change. the results showed an increase in both physical activity and sitting time globally and by group. a healthy lifestyle should be promoted among all ages, but the earlier a habit is formed, the more likely it is to become rooted [1] . regular physical activity is one of the most effective ways of preventing premature death [2, 3] . the world health organization (who) recommends at least 150 min of moderate physical activity, 75 min of vigorous activity, or a combination of the two, per week [4] . independently of the physical activity carried out, it is important to assess sedentary behaviour (sb) as this is related to increased morbidity and cardiovascular risk factors [5] . by 2030, the who aims to reduce the prevalence of physical inactivity by 15% worldwide [6] . in spain, the amount of physical activity carried out by university students is low [7] and is in many cases linked to other healthy habits such as eating fruit and not smoking [8] . meanwhile, sedentary behaviour is a health problem in the child and youth population, which is aggravated with age [9] . in university students, sitting time can exceed 9 h a day [10] . it is known that individual factors such as age, sex and health status affect the physical activity that individuals do [11] . other factors associated with physical activity are motivation, lack of time and aspects related to body image or physical appearance [12] ; some of the beneficial effects of physical activity are reduced anxiety and depression [13, 14] . however, there are several factors that come into play throughout an individual's lifetime that can either facilitate or impede a behaviour, with the transition from secondary education to university being a decisive moment [15] . it is at this time that young adults form their behavioural habits, so the role of healthy universities and the healthy habits they acquire at this stage are fundamental in maintaining this behaviour in the years to come [16] . when it comes to making physical activity a regular habit, the elements that may be related have been studied in depth [17] . ecological models are considered one of the most significant theoretical approaches when it comes to analysing habit formation [18] . these models establish that in addition to individual factors, social and environmental factors are determinant in forming and maintaining physical activity habits [19] . the covid-19 pandemic led to the population being confined to their homes [20] . in spain, from march to april 2020, there was a prohibition on going outside to engage in sporting or social activities. during this period, elements of the built environment and other factors related to individuals' environments were restricted due to the state of alarm. this created a valuable opportunity to assess physical activity without taking these factors into account. experts' recommendations to prevent sedentary behaviour during lockdown included taking active breaks, getting up and walking around the house, and doing online workouts [21] . however, during the pandemic, an overall negative effect on physical activity intensity was observed, as well as a rise in the consumption of less healthy food and a 28.6% increase in sedentary behaviour [22] . a reduction in physical activity was also observed in university students [23] , along with increased levels of anxiety among 18-to 34-year-olds [24] . spanish university students had to continue attending classes online, and their social lives were limited due to the prohibition on going outside. during lockdown, physical activity could have been an opportunity to pass the time, or, conversely, sedentary behaviour could have increased. the other characteristics of each individual (gender, motivation, eating habits, mental state etc.) could have either facilitated or interfered with the decision to exercise. the hypothesis put forward was that students' sedentary behaviour would have increased during lockdown since they were confined to their homes, and that their physical activity would have decreased since they could not go outside to exercise. in this study, we aimed to analyse the physical activity university students did before and during lockdown. to broaden our approach, as a secondary aim, we also wanted to look at changes in physical activity and sedentary behaviour resulting from other factors such as alcohol and tobacco consumption, adherence to a mediterranean diet, motivation, symptoms of anxiety/depression and sociodemographic characteristics. we aimed to evaluate whether there were any differences when certain factors affecting individuals' environments were restricted. this was an observational, cross-sectional, pre-post study on health sciences students, with two cut-off points. the first cut-off point was between 15 and 30 january 2020, prior to the state of alarm being put in place, and the second sample point was between 1 and 15 april 2020. this study received the approval of the ethics and clinical research committee of ciudad real, in spain, with protocol number (c-291, 11/2019). this study was carried out within the context of another study that we conducted on healthy habits and lifestyles, with an estimated follow-up period of 9 months. due to the state of alarm and lockdown, recruitment of subjects was temporarily suspended and a decision was made to study the impact of lockdown on the population already participating. there were no exclusion criteria, other than failure to fully complete the questionnaire. to estimate the sample considering a bilateral hypothesis, the following criteria were used: variance in the pre-lockdown control group of 33,929.60, obtained using the total minutes of physical activity [25] , a beta risk of 20% (power = 80%), a confidence level of 95% and a clinically important difference of 60 min with respect to the control group. it was therefore estimated that a minimum of 148 study subjects would be needed. considering a missing values ratio of 20%, the resulting sample size would be 185 subjects. the students invited to take part were first-to fourth-year students who agreed to respond to the questionnaire at both time points. the questionnaires were administered during the second university semester. the first data collection point was two weeks after the end of the exam period, while the second data collection point was four weeks into lockdown. at the second data collection point, students could not leave their homes except for essential purposes such as buying food or going to hospital. outdoor exercise was prohibited across spain; anyone breaching the rules faced a 600 euro fine. during lockdown, university classes continued online with the same schedule as usual. the university provided internet access or technological devices to any students who requested them so that they could continue attending classes. online classes did not contain any recommendations for students to carry out physical activity. an ad hoc self-administered questionnaire was used, collecting sociodemographic information such as sex, age, weight, height, place of residence during the academic year, smoking habits (yes/no and number of cigarettes per day) and alcohol consumption (yes/no and number of drinks per week). for perceived health status and the existence of problems with anxiety/depression, the euroqol 5d (eq-5d) questionnaire was used [26] . to assess adherence to the mediterranean diet, the predimed questionnaire [27] was used, which uses 14 questions to assess the frequency of food consumption and eating habits. each question has a possible score of 0 or 1. the result allows classification into low adherence or high adherence. stages of change (soc) in physical activity were assessed using prochaska and diclemente's transtheoretical model (ttm) [28] . five stages of motivation for change were evaluated: pre-contemplation (i don't exercise and i don't intend to), contemplation (i don't exercise, but i'd like to), preparation (i exercise sometimes), action (i have been regularly exercising for less than 6 months) and maintenance (i have been regularly exercising for more than 6 months). physical activity was measured using the international physical activity questionnaire-short form (ipaq-sf), which contains 7 questions [29] . the questionnaire was used to obtain the total minutes of physical activity per week and sitting time per day. first, descriptive statistical analysis was performed using absolute and relative frequencies for categorical variables and mean with standard deviation (sd) for the quantitative variables. next, bivariate analysis was performed on the whole sample for paired data between weekly minutes of physical activity for the two sample points (pre-lockdown and lockdown). we used the kolmogorov-smirnov test to verify the normality of the quantitative variables. since there were variables that were not normally distributed, we then used the non-parametric wilcoxon signed-rank test. we also used the parametric student-fisher t-test to evaluate whether there were statistical differences in some comparisons and to obtain an approximation of the differences found. finally, the same analyses were performed again, but this time stratified for different sub-groups. mean differences (md) were obtained with a confidence interval of 95% (ci). all calculations were done using the program spss v24.0 (ibm corp, new york, ny, usa). two hundred and thirteen health sciences students participated in this study. the mean age was 20.5 years (sd = 4.56). of the participants, 80.8% (172) were women, 76.5% (163) were normal weight and 9.9% (21) were smokers. the rest of the demographic characteristics and health parameters are shown in table 1 . then, the results of the ipaq questionnaire were analysed: days and minutes of physical activity per week, as well as time spent sitting per week at both time points studied ( table 2) . we observed a significant increase in the number of days on which students engaged in physical activity, both vigorous we then analysed physical activity by group (table 3 ). when we looked at the differences in average minutes of physical activity, all groups analysed spent more time doing physical activity during lockdown (although not all of them significantly). groups that showed significant differences were women; first, second and third year of study; normal or low bmi; and those who did not eat a mediterranean diet. average physical activity time reduced during lockdown for participants in the pre-contemplation (md: 37.50; 95% ci: −115. 33, 190.33) and contemplation (md: 31.08; 95%ci: −15.87, 78.03) stages. in other words, they spent less time on physical activity, although this difference was not significant. conversely, for those in the preparation (md: −75.59; 95%ci: −0.92, −150.25) and action (md: 322.69; 95%ci: −214.84, −430.55) stages, significant differences (p < 0.05) were observed. in the rest of the groups analysed, statistically significant differences were observed between the two time points, except for men, final-year students, those that were overweight or obese and those that ate a mediterranean diet. finally, the analysis by group (table 4 ) showed significant differences (p < 0.05) in sitting time before and during lockdown in all groups except first-year students, those that were overweight or obese, smokers and those in the pre-contemplation stage. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. it also increased in the following groups: second, third and fourth year of study; normal and underweight bmi; non-smokers; those living in a university residence, shared apartment or with family; and those in the contemplation, preparation, action and maintenance stages. this study aimed to evaluate physical activity and sedentary behaviour in health sciences students before and during the lockdown. at the first time point, students were in their normal study environment, while at the second, their social and environmental setting was limited due to lockdown. the results showed changes in physical activity and sedentary behaviour patterns both globally and by group. overall, students spent more time doing physical activity and spent more time sitting when their usual environment was limited. in the analysis by group, minutes of physical activity increased significantly during lockdown among the following groups: women; all years of study except final year; normal or low bmi; those who did not eat a mediterranean diet; and those in the preparation or action stage of change. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. the groups that did not experience differences were: first year of study, overweight or obese, smokers and those in the pre-contemplation stage. these four groups spent the most time sitting at the first data collection point when compared with the rest of their cohort; in other words, sedentary behaviour was already high before lockdown and there were no significant differences at the second data collection point. some researchers believed that lockdown would cause inactivity and an increase in sedentary behaviour and that measures would need to be taken to prevent these effects [30] . in fact, during lockdown, people modified their lifestyles, with an increase in sitting time due to people spending more time at home, and there was also a reduction in the amount of time spent on physical activity [22] . in our study, the initial hypothesis was partially confirmed: there was an increase in sitting time, but unexpectedly, there was also an increase in both the amount of time spent doing physical activity and the number of days on which participants were active. we expected to find an increase in sitting time due to the restrictions on movement; however, we also thought that the increase in screen time would reduce physical activity time, since in previous studies conducted in the spanish university population, more screen time was associated with higher inactivity levels [31] . we do not know the exact reasons why physical activity increased, and we do not know if the effects on physical activity habits would have been maintained if the lockdown had gone on for longer. the environment in which students live affects their sedentary behaviour patterns [32] , and it seems that the characteristics of health sciences students' environments do not facilitate physical activity. rather than being an obstacle, restricted social relations and not having access to the built environment in their community increased the number of days and minutes students spent doing physical activity. in the case of health sciences students, another factor to consider is that their training in promoting healthy habits may have influenced their decision to exercise at home. no changes in physical activity were found in men. perhaps men and women had different motivations and the environment influences one gender more strongly. in previous studies on motives for physical activity by gender [33] , some variables that motivated men but not women were elements related to the environment, such as competition or social recognition, while weight control was the main motivation for women. in our study, women accounted for more than 80% of the sample, so the lack of results may also be due to the fact that there were fewer male participants. the effect of the built environment is yet to be determined for those with a high bmi [34] . the data in this study show that in overweight or obese students, there were no changes in time spent doing physical activity or sitting time. as we have seen, healthy habits that are ingrained in the population are not affected by the lockdown: this is the case of the mediterranean diet [35] . in this study, we observed that students that ate a mediterranean diet spent more time doing physical activity and that their physical activity patterns did not change significantly. this suggests that those that lead a healthy lifestyle pay attention to both diet and exercise and persist with their habits regardless of the environment. conversely, those with unhealthy habits stick to them and experience no changes during lockdown. this is the case for smoking and sedentary behaviour. grouping of healthy and non-healthy factors is habitual in university students [8, 25] : those that are more sedentary are also more likely to smoke or spend a lot of time watching screens, while those that exercise regularly tend to eat more fruit and vegetables and drink less alcohol. contrary to what we expected, smokers did spend more time doing physical activity during lockdown. it would be interesting to investigate the reasons for this. in our sample of the population, the percentage of smokers was very low, and the number of cigarettes smoked per day was also low, so we believe more research is needed in a sample with more smokers. in our results, we also found differences based on year of study. among final-year students, physical activity did not vary significantly. this group also spent the least time doing physical activity at both time points analysed. in their meta-analysis, keating et al. indicate that with regard to year of study, the majority of studies find no differences in physical activity, but that some studies suggest that higher years of study are less active [36] . as for sedentary behaviour, it was observed that first-year students spent more time sitting and that lockdown did not bring about any significant changes. some studies, contrary to the findings of our study, observed that students in higher years of study were more sedentary due to a higher workload [10] . in health sciences students, most of the theoretical workload is in the first year, while in their final year students spend most of their time on placement. another possible factor could be that first-year students might have practiced sport in secondary school and kept up the habit. it would have been interesting to ask students about their sports histories. in this study, we evaluated stages of change, one of the central concepts of the transtheoretical model of change. this model was initially used to treat tobacco and alcohol problems, but it was later adapted to other aspects of health such as physical activity and sedentary behaviour [37] [38] [39] . the analysis of the stages of change and how they affected the participants was very interesting. participants in the first two stages did not experience any changes, and neither did those in the last stage. the behaviour of participants that exercised as part of their routine remained practically the same, as did the behavior of those that did not do any exercise. however, for those that were motivated but had not yet made exercise a regular habit, lockdown was a good opportunity to increase their dedication. in line with these findings, di renzo et al. [35] observed in a recent study that lockdown increased activity among people that did sport occasionally because they had more time at home, but those that did not do any exercise did not use the situation as an opportunity to start. overall, the results show that minutes of physical activity increased, as did minutes of sitting time. although the results during lockdown are positive in terms of physical activity, it is necessary to recognise that this population might suffer from health issues in the future due to an increase in sedentary behaviour. it would be interesting to find out what the reasons were for students having this behaviour. perhaps they realised that their sitting time increased (they were not walking to class, walking to their car, going shopping, standing up, going to their jobs etc.) and compensated for this with some high-intensity exercise. another aspect that could have affected the results is that the students were involved in the health sciences field, so they may have been more prone to exercising during the pandemic than students in other majors such as engineering or literature. this is why we cannot exclusively consider the limitation of the environment during lockdown to be the cause of the changes in physical activity and sedentary behaviour. it would be interesting to continue studying the elements related to university students' physical activity/sedentary behaviour and their surroundings in order to plan strategies that promote an increase in physical activity levels in this group. our study has various limitations that should be considered. firstly, it is an observational study and all study subjects volunteered to participate in the questionnaire, so there may be a selection bias. secondly, we did not measure whether there was any risk of exposure to covid-19 infection, a factor that could have influenced our assessment of physical activity and sedentary behaviour. another limitation is the use of a self-administered questionnaire to evaluate physical activity and sedentary behaviour. it would have been more interesting to perform a real assessment of physical activity using accelerometry and also investigate their sports history. this could be a future line of research. finally, the lack of significance in some of the strata analysed could be due to a lack of statistical power because of the low number of subjects in some groups. furthermore, we do not know if these changes in physical activity would have been maintained if lockdown had gone on longer. as for the strengths, this is the first study to look at physical activity and sedentary behaviour in university students studying health sciences both before and during lockdown. in this study, we observed the behaviour of health sciences students when deprived of their usual social and community environment. participants spent more time doing physical activity and also spent more time sitting. university students' social environment may be a barrier to building an exercise habit, especially among women, and motivation seems to have a significant bearing on whether university students engage in physical activity. more efforts should be made to create strategies that motivate students to lead a healthy lifestyle in all aspects (diet, avoiding harmful substances, mental health etc.), with a particular emphasis on engaging in physical activity and reducing sitting time. programs and policies that promote positive youth development and prevent risky behaviors: an international perspective health benefits of physical activity: the evidence health benefits of physical activity: a systematic review of current systematic reviews world health organization. global recommendations on physical activity for health sedentary behavior and cardiovascular morbidity and mortality: a science advisory from the american heart association world health organization. global action plan on physical activity 2018-2030: more active people for a healthier world levels and patterns of objectively assessed physical activity and compliance with different public health guidelines in university students determinants and patterns of physical activity practice among spanish university students sedentary behavior among spanish children and adolescents: findings from the anibes study how sedentary are university students? a systematic review and meta-analysis correlates of physical activity: why are some people physically active and others not? cultural factors associated with physical activity among u.s. adults: an integrative review physical activity and incident depression: a meta-analysis of prospective cohort studies physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies determinants of health-related lifestyles among university students nouri-aria, k. changes in student physical health behaviour: an opportunity to turn the concept of a healthy university into a reality toward a better understanding of the influences on physical activity: the role of determinants, correlates, causal variables, mediators, moderators, and confounders an ecological perspective on health promotion programs an ecological approach to creating active living communities the resilience of the spanish health system against the covid-19 pandemic recommendations for physical inactivity and sedentary behavior during the coronavirus disease (covid-19) pandemic. front. public health effects of covid-19 home confinement on eating behaviour and physical activity: results of the eclb-covid19 international online survey the impact of isolation measures due to covid-19 on energy intake and physical activity levels in australian university students exploring lifestyle habits, physical activity, anxiety and basic psychological needs in a sample of portuguese adults during covid-19 aguilo-pons, a. clustering of lifestyle factors in spanish university students: the relationship between smoking, alcohol consumption, physical activity and diet quality the spanish version of euroqol: a description and its applications a 14-item mediterranean diet assessment tool and obesity indexes among high-risk subjects: the predimed trial stages and processes of selfchange of smoking:toward an integrative model of change validation of three short physical activity questionnaires with accelerometers among university students in spain how to deal with covid-19 epidemic-related lockdown physical inactivity and sedentary increase in youth? adaptation of anses' benchmarks cluster analysis of health-related lifestyles in university students neighborhood built environment and socioeconomic status are associated with active commuting and sedentary behavior, but not with leisure-time physical activity, in university students college students' motivation for physical activity: differentiating men's and women's motives for sport participation and exercise role of built environments in physical activity, obesity, and cardiovascular disease eating habits and lifestyle changes during covid-19 lockdown: an italian survey a meta-analysis of college students' physical activity behaviors role of counseling to promote adherence in healthy lifestyle medicine: strategies to improve exercise adherence and enhance physical activity application of the transtheoretical model to sedentary behaviors and its association with physical activity status levels of physical activity, motivation and barriers to participation in university students funding: this research received no external funding. the authors declare no conflict of interest. key: cord-339716-1khdh9nf authors: munasinghe, sithum; sperandei, sandro; freebairn, louise; conroy, elizabeth; jani, hir; marjanovic, sandra; page, andrew title: the impact of physical distancing policies during the covid-19 pandemic on health and well-being among australian adolescents date: 2020-10-21 journal: j adolesc health doi: 10.1016/j.jadohealth.2020.08.008 sha: doc_id: 339716 cord_uid: 1khdh9nf purpose: physical distancing policies in the state of new south wales (australia) were implemented on march 23, 2020, because of the covid-19 pandemic. this study investigated changes in physical activity, dietary behaviors, and well-being during the early period of this policy. methods: a cohort of young people aged 13–19 years from sydney (n = 582) were prospectively followed for 22 weeks (november 18, 2019, to april 19, 2020). daily, weekly, and monthly trajectories of diet, physical activity, sedentary behavior, well-being, and psychological distress were collected via smartphone, using a series of ecological momentary assessments and smartphone sensors. differences in health and well-being outcomes were compared preand post-implementation of physical distancing guidelines. results: after the implementation of physical distancing measures in nsw, there were significant decreases in physical activity (odds ratio [or] = .53, 95% confidence interval [ci] = .34–.83), increases in social media and internet use (or = 1.86, 95% ci = 1.15–3.00), and increased screen time based on participants' smartphone screen state. physical distancing measures were also associated with being alone in the previous hour (or = 2.09, 95% ci: 1.33–3.28), decreases in happiness (or = .38, 95% ci = .18–.82), and fast food consumption (or = .46, 95% ci = .29–.73). conclusions: physical distancing and social restrictions had a contemporaneous impact on health and well-being outcomes associated with chronic disease among young people. as the pandemic evolves, it will be important to consider how to mitigate against any longer term health impacts of physical distancing restrictions. aged children, a move to the online delivery of schooling. authorities requested that people remain in their homes wherever possible and limit their travel to obtaining essential goods and services. this public health strategy was absolutely necessary and appears to be yielding the desired result in terms of "flattening the curve" in the australian context [1] . there are potential impacts of physical distancing and social isolation, particularly among younger people, where social connection is a key part of psychosocial development. the necessary policy responses to covid-19 may impact the determinants of poor mental health outcomes, including suicidal behavior [2] . previous studies have shown psychological and physical health impacts of social isolation during quarantine [3] , and more generally, social isolation has been shown to be associated with poor mental and physical health outcomes [4] . in addition, adolescents are likely to have reduced physical activity, particularly incidental physical activity, and increased screen time as a consequence of the physical distancing measures. previous studies have shown the impacts of sedentary behavior on health outcomes in young people [5, 6] and interrelated factors of diet, overweight and obesity, and well-being [5, 7, 8] . the impact of the public health interventions in response to covid-19 to the daily routine of young people in australia on key health and well-being measures known to be associated with chronic disease has not previously been investigated. accordingly, this study investigates whether the physical distancing policies and school closures in the state of new south wales (australia) were associated with changes in physical activity, dietary behaviors, and well-being during the early period of this policy. participants were recruited as part of a broader prospective cohort study of adolescents investigating determinants of health and well-being over time. young people were recruited via social media (instagram and facebook) from the general population aged 13e19 years of a sydney population catchment. promotional and recruitment materials were developed and modified by members of a youth advisory group, and the social media strategy targeted those residing in western sydney; however, participants from areas outside of this catchment were not excluded if they enrolled in the study. the western sydney population catchment is a socioeconomically and ethnically diverse population of approximately one million people. participants were followed prospectively over a period of 22 weeks, from november 8, 2019, to april 19, 2020, after a social media campaign that ran from november 8, 2019, to january 8, 2020. institutional ethics approval for the study was obtained from the western sydney university human research ethics committee (hrec approval number: h13302). the total reach of the social media recruitment campaign was 164,640 adolescents in the western sydney area, of which 61% were female (n ¼ 100,640) and 39% were male (n ¼ 62,944). the total number of impressions (i.e., the number of times advertisements were displayed in news feeds) was 1,389,957, and this was higher among females (n ¼ 955,418, 69%) than males (n ¼ 425,222, 31%). the total number of click-throughs to the study webpage was 11,048, with a higher level of interest among females (n ¼ 8,295, 75%) than males (n ¼ 2,680, 25%). of 11, 048 individuals who clicked through to the study website, a total of 1,298 participants enrolled in the study and completed the baseline questionnaire, from which 582 participants were selected who provided one or more responses to follow-up ecological momentary assessment (ema). participants were predominantly female and aged 16e18 years (table 1) , reflecting the higher engagement in instagram and facebook among females than males more generally [9, 10] . the ethica data smartphone app (https://ethicadata.com/ product) was used to collect data from questionnaires, emas, and smartphone sensors. mobile sensor data were collected automatically through the ethica app only from those participants who provided consent and included geolocation information (via gps, wi-fi, and bluetooth), pedometer, motion-based activity recognition (mbar) data, and screen state (whether the screen of the smartphone is "on" or "off"). a baseline questionnaire and a 16-week schedule of follow-up emas were triggered when participants enrolled in the study, with questions sent directly to each participant's smartphone. there were nine emas relating to psychological distress, well-being, positive emotion, social networks, relationships, diet, physical activity, sleep, and academic behavior. each ema, except psychological distress and well-being, was administered weekly, but on different days. emas relating to psychological distress or well-being were administered monthly. thus, participants received daily emas but received a different ema on each day. emas were sent to participants at random times between 8 a.m. and 10 a.m. or between 3 p.m. and 8 p.m. to avoid notifications during school hours and periods when participants may have been sleeping. the 16week schedule of emas resulted in weekly or monthly measures for each domain spanning the 22-week follow-up period. the primary outcome variables for this study included measures of physical activity, sedentary behavior, dietary behavior, and psychological well-being. self-reported physical activity at baseline was based on responses to the pace þ adolescent physical activity measures [11] , and sedentary behavior was based on the adolescent sedentary activities questions [12] with the tv and computer items modified to also capture information on internet streaming, mobile phone, tablet, or gaming console use. self-reported physical activity and sedentary behavior relating to the previous 24-hour period were also collected each week for the 22week follow-up period via an ema. questions included: (i) "in the past 24 hours, were you physically active for a total of 60 minutes or more? 'physical activity' is any activity that increases your heart rate and makes you get out of breath some of the time"; (ii) "in the past 24 hours, did you spend any time watching tv?"; and (iii) "in the past 24 hours, did you spend any time on the internet, social media (like instagram, youtube, or facebook), or playing computer games?" for participants who answered "yes" to this question, a follow-up question was asked: "if yes, how long did you spend on the internet, social media, or playing computer games?" additional information on physical activity was collected passively via smartphone sensors, including pedometer, screen state (i.e., whether the phone was "on" or "off"), and mbar. the daily number of steps for each participant was collected via the pedometer. screen state was used as a proxy measure of sedentary behavior, with the assumption that during periods where the phone screen was active, participants were less likely to be engaging in physical activity. mbar is a composite indicator of activity provided by the ethica data app, which combines information from the phone sensors, including accelerometer, gyroscope, gravity, and magnetic field [13] . the mbar indicator is a categorical variable that divides each moment into an activity type: "on foot," "walking," "running," "on bicycle," "in vehicle," "unknown," "still" (the device is not moving), and "tilting" (the device angle relative to gravity has changed significantly). each categorization is also ascribed a confidence level score between 0 and 100. in the present study, each participant's mbar category was weighted by this score, such that categories with high confidence level scores were considered a more accurate assessment of the type of activity. self-reported dietary behavior at baseline was measured using questions validated for adolescents by the nsw centre for public health nutrition [14] to allow comparisons with dietary guidelines for children and adolescents in australia [15] . selfreported dietary behaviors relating to the previous 24-hour period were also collected each week for the 22-week followup period via an ema. questions included: (i) "in the past 24 hours, have you eaten any serves of fruit?" if participants responded "yes," a follow-up question was asked: "how many serves of fruit? (a serve ¼ 1 medium piece or 2 small pieces of fruit or 1 cup of diced pieces)"; (ii) "in the past 24 hours, have you eaten any serves of vegetables?" if participants responded "yes," a follow-up question was asked: "how many serves of vegetables? (a serve ¼ 1/2 cup cooked vegetables or 1 cup of salad vegetables)"; and (iii) "in the past 24 hours, have you had any meals or snacks such as burgers, pizza, chicken, or chips from places like mcdonalds, hungry jacks, pizza hut, kfc, red rooster or local takeaway food places?" if participants responded "yes," a follow-up question was asked: "how many meals?" psychological well-being self-reported psychological distress was based on the kessler psychological distress 6-item scale (k6) [16] . response options for each k6 item included "none of the time," "a little of the time," "some of the time," "most of the time," and "all of the time" and were scored in the range of 1e5 respectively. a score 19 was used as indicative of probable mental disorder as recommended [16] ; however, it is important to note that this standard cut point may overlook those with more moderate levels of psychological distress that may still be important [17] . the engagement, perseverance, optimism, connectedness, and happiness (epoch) measure of well-being was also included in the study to capture information on positive psychological characteristics [18] using a 5-point scale from "almost never" to "almost always." the k6 and epoch questionnaires (supplementary materials) were completed by participants at baseline with follow-ups sent to each participant every 4 weeks and short emas relating to selected epoch items sent weekly [19] . in addition, social relationships were measured based on the question: "in the past hour, who were you with?" participants could respond to one or more of the following options: "alone," "mother," "father," "sister(s)," "brother(s)," "other relatives," "classmates, peers," "strangers," "boyfriend or girlfriend," "friends," and "other, please specify." for participants who answered "friends," an additional question was asked: "how many friends?" finally, self-reported sleep duration in the previous 24 hours was also collected at baseline via a weekly ema over the 22-week follow-up period. a range of sociodemographic and other health factors were also collected at baseline. these factors included sex, age, language spoken at home, current year of school and educational achievement, employment status, income, and body mass index (based on self-reported height and weight; table 1 ). the change in measures of physical activity, dietary behavior, and well-being was compared pre-and post-implementation of the nsw guidelines for physical distancing to determine whether this policy resulted in significant changes in these key health behaviors. these guidelines officially came into effect on march 31, 2020 [20] ; however, physical distancing began in the earlier period of march with the closure of pubs, clubs, gyms, cinemas, places of worship on march 23, 2020 [21] and evidence of parents keeping children at home from school. accordingly, the period for when physical distancing began to be implemented was defined as march 23, 2020. analyses were restricted to those participants who completed at least one ema over the follow-up period (n ¼ 582; table 1 ). participants were predominantly female, with a median age of 17 years (interquartile range, 16e18). most participants spoke english at home (86%), were either in their senior year of schooling (23%) or finished school (43%), and almost 60% worked in a job (mainly part time). these participants contributed 4,805 responses to emas over the 22-week follow-up period, including 301 responses in the period after implementation of physical distancing guidelines ( table 2 ). the mean number of emas per week for this group was 9.6 (standard deviation ¼ 5.8), and the median number of emas per week was 10 (interquartile range ¼ 3e16). comparisons of participant characteristics between (1) those who completed baseline and follow-up, (2) those who completed emas pre-and post-implementation of the physical distancing policy, and (3) those who provided or did not provide sensor are provided in supplementary tables 1 and 2 descriptive plots of trajectories of physical activity were examined over the 22-week follow period, based on daily pedometer data, mbar, and weekly self-report emas. trajectories of self-reported fruit, vegetable, and fast food consumption were also examined based on weekly emas, as were trajectories of psychological well-being based on distress, well-being, and sleep duration. multivariate multilevel mixed effect logistic regression models were conducted to investigate associations between the implementation of nsw guidelines (specified as a binary pre-post variable on march 23, 2020) and subsequent changes in physical activity, dietary behavior, and well-being measures. there were significant decreases in physical activity in the period after the implementation of physical distancing measures in nsw. adolescents were significantly less likely to report 60 minutes of physical activity in the previous 24 figure 1a ). declines in physical activity were also evident based on the average number of steps per day and mbar (figure 2a,b) . there was also a significant increase in sedentary activity postimplementation of physical distancing, with higher social media and internet use (or ¼ 1.86, 95% ci ¼ 1.15e3.0; table 3, figure 2a ) and also evidence of increased screen time based on participants' smartphone screen state ( figure 2c ). the implementation of physical distancing measures was associated with lower levels of happiness (or ¼ .38, 95% ci ¼ .18e.82) and positive emotions (or ¼ .23, 95% ci ¼ .14e.39), respondents reporting being alone in the previous hour (or ¼ 2.09, 95% ci ¼ 1.33e3.28), and slightly higher increases in psychological distress (or ¼ 1.48, 95% ci ¼ .74e2.95; table 3 , figure 2b ). there were also declines in fast food consumption following implementation of physical distancing (or ¼ .46, 95% ci ¼ .29e .73) but no substantial changes in fruit and vegetable consumption, tv watching, or sleep duration (table 3 ; figure 1c ). this study investigated the impact of physical distancing guidelines implemented in new south wales, australia, on a range of health and well-being outcomes among a cohort of adolescents aged 13e19 years in sydney. the implementation of physical distancing interventions was associated with decreases in physical activity and well-being, and increases in being alone and social media and internet use in the 4 weeks after the policy was implemented. there was also a decrease in selfreported fast food consumption in the 4 weeks after the policy was implemented, but little change in fruit or vegetable consumption. these findings suggest that the substantial changes to the way in which communities are currently functioning, particularly for young people, has had a contemporaneous impact on health and well-being outcomes associated with chronic disease. an important finding in the present study were the decreases in happiness reported after the implementation of the physical distancing guidelines and a higher likelihood of being alone during this period. social isolation is an important risk factor for poorer psychological well-being among young people and, conversely, peer-, family-and school-connectedness play key roles as protective factors [22] . these protective connections may not have been as accessible to young people during the period of physical distancing resulting in lower levels of psychological well-being. it will be important to ensure that protective connections and other strategies to support the well-being of young people are maintained, to mitigate the potential psychological impact on young people. in australia, covid-19 cases remain low at the time of reporting; however, it is possible that physical distancing restrictions and online education may need to be reinstated if a second or third wave of infections eventuates. the shift to online delivery of education in nsw and the requirement to defer any nonessential travel is reflected in the increase in social media and internet use for the corresponding period in this study. there was also a decrease in physical activity likely related to the suspension of school and community sport and potentially mediated by a lack of access to green space in home environments. recent reviews have suggested both positive and negative impacts of social media, determined by the type of involvement (e.g., passive use, high investment, or support seeking) as well as the amount of time spent on screenbased activity [7, 23, 24] . in addition, some studies have found that screen-based sedentary behavior supplants time spent sleeping or engaged in physical activity [7] . the present study did not directly examine the association between screen-based sedentary behavior and physical activity, but while the pattern of findings is consistent with the idea of displacement, this may only be relevant when time is constrained (such as during school term or nonholiday periods). the finding that sleep hours did not decline contemporaneously with increased screen time perhaps suggests study participants had more time to engage in sedentary behavior without disrupting sleep duration. it remains to be seen whether sedentary behavior observed during the period of physical distancing will revert back to levels observed before physical distancing measures. this will be an important focus for future research, given the evidence that sedentary habits in adulthood are typically established during adolescence [12] . an interesting finding was the decrease in fast food consumption in the context of limited changes to fruit and vegetable consumption. this likely reflects a decrease in opportunistic purchases of fast food during the day and traveling either to school or to work. previous research has found increased consumption of this food type among adolescents and young people where there is a high density of fast food outlets located near schools and transport hubs [25, 26] . since the initial period of physical distancing, many fast food outlets have moved to take away and home delivery; however, the reduced consumption observed may indicate that fast food consumption was opportunistic and more associated with connecting socially with friends [26] . future studies could consider the impact of these changes on food delivery on the consumption of fast food among younger people of different ages and with differing discretionary income and access to private transport. the present study also found that consumption of fruit and vegetables did not increase, suggesting either that similar food types were substituted or there was a decrease in overall caloric intake. consumption of calorie-dense foods can be positively associated with feelings of stress, and given the reduction in fast food consumption occurred in the context of increased social isolation and psychological distress, this might explain the lack of nutritional substitution implied in this finding. despite reduced consumption of these food types via fast food outlets, there may have been an overreliance on processed supermarket food during this periodda limitation to this finding was that more specific questions relating to processed or junk food (i.e., not fast food purchases) were not explicitly measured. australia experienced panic buying of processed foods resulting in supermarkets placing limits on a number of food items because of shortages. however, this was not observed for fresh fruit and vegetables. alternatively, it may be that the development of new healthpromoting behaviors takes time to develop, and the observation period of the present study was not long enough for this to emerge. there are a number of methodological limitations to this study. first, although there was a positive response to the study through instagram and facebook, participants who were more likely to engage were overwhelmingly female and more likely to be older in age (16e18 years). the higher proportion of females may reflect greater engagement in social media among females than males, a phenomenon that has been noted in representative studies of social media use in australia [9, 10] . despite the imbalance by sex, the distribution of responses by key dietary behaviors, physical activity, and wellbeing outcomes was not substantially dissimilar to other representative prevalence studies of adolescents [26, 27] . the higher proportion of older-age adolescents likely reflects that for those aged 13e15 years, parental or guardian consent was required before enrollment in the study. this involved additional steps in making contact with parents or guardians via email and to arrange for links to download the ethica app, which likely discouraged some younger potential participants from enrolling in the study. an additional limitation was the low ema and follow-up survey completion rate. despite the use of an incentive (aud $30 giftpay voucher), only 45% of baseline participants (n ¼ 1,298) completed one or more subsequent ema, and <1% completed all 96 emas over the follow-up period. the weekly schedule of emas may have been too burdensome for participants, and future research may need to consider different schedules or incorporation of personalized feedback to keep young people engaged. there is also the risk of recall bias in this study, given the self-reported nature of the baseline and follow-up questionnaires. however, emas in (near) real time potentially reduce the likelihood or recall bias, in that questions relate to the immediate 24-hour period. patterns of ema responses relating to physical activity and screen time were also consistent with objective measures of physical activity based on available mobile phone sensor data, and the results were also generally comparable with previous adolescent health surveys for some of the measures [26, 27] . smartphone sensor data, collected passively from participants, were also used as proxy measures of physical activity and sedentary behavior. this was an innovative aspect of the study design and allowed comparison with ema responses and investigation of trajectories of spatiotemporal movement among participants. however, a large proportion of participants either did not turn on some smartphone sensors (e.g., geolocation) or there were intermittent trajectories of movement, where sensor data were not collected. this resulted in complete sensor information being available on only 515 participants over the follow-up period, only 40% of baseline participants (n ¼ 1,298) . the reasons for participants choosing not to engage in this aspect of the study are unclear but may relate to concerns about individual privacy, among both participants and caregivers (who were required to give parental consent for young people aged <16 years). there is also likely to be misclassification in smartphone sensor data, where periods between the initiation and cessation of a given state (e.g., "walking" in the mbar sensor) were likely overestimated, as the smartphone did not register the cessation of the state but only the initiation of the subsequent state (e.g., "still" in the mbar sensor). this means that the overall level of activity as measured by the smartphone sensor will be an overestimate; however, relative changes over time are likely to reflect actual declines or increases, and changes in emas appear to be consistent with changes in activities as measured by smartphone sensors. the present study suggests the potential immediate impacts on health behaviors that are intermediary to chronic disease outcomes. however, it is not clear whether there will be longterm psychosocial and health impacts associated with the physical distancing policies. these policies will be slowly wound back over coming weeks, and education and employment experiences will return to a degree of normality. the wider economic impacts associated with physical distancing and other policies relating to the closure of businesses and entertainment precincts on health outcomes are also not known. it is unclear whether the changes in health and well-being documented in the present study will be transient or whether there may be ongoing impacts. additional research needs to establish longer term trends in these outcomes to inform public health policy and intervention responses. this study provided a unique opportunity to measure health behaviors and psychological well-being among australian adolescents during the covid-19 pandemic. data collection occurred pre-and post-implementation of widespread physical distancing regulations in the community. these public health interventions have successfully "flattened the curve" on covid-19 to date; however, there have also been important changes among young people on a range of health and well-being outcomes. further research is needed to monitor the longer term trends in these outcomes. as the pandemic evolves, it will be important to consider how best to support psychological and physical wellbeing for young people to mitigate against potential longer term negative impacts. supplementary data related to this article can be found at https://doi.org/10.1016/j.jadohealth.2020.08.008. australian government department of health. coronavirus (covid-19) current situation and case numbers 2020 suicide risk and prevention during the covid-19 pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence an overview of systematic reviews on the public health consequences of social isolation and loneliness child and adolescent obesity: part of a bigger picture long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review the health indicators associated with screen-based sedentary behavior among adolescent girls: a systematic review longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis office of the esafety commissioner. state of play -youth, kids and digital dangers yellow social media report. melbourne: a sensis company a physical activity screening measure for use with adolescents in primary care the reliability of the adolescent sedentary activity questionnaire (asaq) available at: https://learn.ethicadata. com/documentation/data-sources/motion-sensors recommendations for short questions to assess food consumption in children for the nsw health surveys. sydney: nsw centre for public health nutrition dietary guidelines for children and adolescents in australia. canberra: commonwealth of australia the psychometric properties of the kessler psychological distress scale (k6) in a general population sample of adolescents validity study of the k6 scale as a measure of moderate mental distress based on mental health treatment need and utilization the epoch measure of adolescent well-being a comparison of affect ratings obtained with ecological momentary assessment and the day reconstruction method please cancel travel to regional nsw coronavirus: australia to close pubs, cafes and places of worship 2020 social isolation, psychological health, and protective factors in adolescence social networking sites and associations with depressive and anxiety symptoms in children and adolescentsea systematic review. child adol ment health association between social networks and subjective well-being in adolescents: a systematic review obesogenic neighbourhoods: the impact of neighbourhood restaurants and convenience stores on adolescents' food consumption behaviours overweight/obesity, physical activity and diet among australian secondary students-first national dataset 2009-10. cancer forum. the cancer council australia key: cord-300490-aslvqymx authors: rahman, md. estiar; islam, md. saiful; bishwas, md. sajan; moonajilin, mst. sabrina; gozal, david title: physical inactivity and sedentary behaviors in the bangladeshi population during the covid-19 pandemic: an online cross-sectional survey date: 2020-10-30 journal: heliyon doi: 10.1016/j.heliyon.2020.e05392 sha: doc_id: 300490 cord_uid: aslvqymx this study aimed to determine the prevalence of physical inactivity and sedentary behaviors during the covid-19 pandemic among bangladeshi people. an online survey was conducted among 2,028 people over a period of 10 days on june, 2020 during the covid-19 pandemic at a time that the number of newly diagnosed cases was increasing, lockdown was still in place. survey questions included socio-demographics and an adapted version of the ipaq-sf to assess physical activity and sedentary behaviors. the prevalence rates of physical inactivity (<600 met–minutes/week) and high sedentary behaviors (≥8 h/day) among bangladeshi people were 37.9% and 20.9%, respectively. regression analyses revealed that young age, being a student, from a middle-class family, or upper-class family, living with nuclear family, urban living, and suffering from no chronic diseases were all associated with physical inactivity and high sedentary behaviors. moreover, physical inactivity and high sedentary behavior were strongly interrelated. however, many of the univariate risk factors exhibited interdependency. during the covid-19 pandemic coinciding with lockdown measures a sizeable proportion of bangladeshi people were physically inactive and reported sedentary behaviors ≥8 h/day. public campaigns and media-based interventions encouraging home-based physical activities should be promoted to attenuate the impact of lockdown measures during a pandemic. the outbreak of coronavirus disease 2019 (covid-19) caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has become a global public health threat [1, 2] . the outbreak was first revealed in wuhan city, in the hubei province of china, in late december 2019 [3] . since then, the virus has spread worldwide, with millions of covid-19 cases and related deaths being recorded globally [4] . the first case of covid-19 was confirmed in bangladesh on march 8, 2020 [5, 6, 7] , and more than 317,500 confirmed cases of covid-19 and 4,351 deaths have been recorded by september 03, 2020 [8] . physical activity (pa) is regarded as a critical component of a healthy lifestyle and disease prevention [9] . conversely, physical inactivity increases the risk of many chronic diseases, such as hypertension, coronary heart disease, stroke, diabetes, depression, and risk of falls [10] . regular physical activity helps maintain a healthy weight, reduces the risk of developing obesity, and strengthens the immune system [11, 12] . physical activity also reduces feelings of depression and improves mental health [13] . considering the health benefits of regular physical activity, the who recommends that individuals aged 18-64 years should engage in >150 min of moderate-intensity or >75 min of vigorous-intensity physical activity per week or an equivalent combination of moderateand vigorous-intensity activity [14] . sedentary behavior refers to any waking behavior characterized by an energy expenditure not exceeding 1.5 metabolic equivalents (mets), while in a sitting or reclining position [15, 16] . like the vast majority of the affected countries around the world, bangladesh initiated a lock-down policy to ensure spatial distancing, selfisolation, or quarantine, as part of the efforts to limit the spread of covid-19. the government declared a nationwide lockdown from march 26 to may 30, with a 7 th extension being recently announced [17, 18] . previous studies investigated the impact of covid-19 on physical activity in different age clusters and in different regions [19, 20, 21] . reports have indicated that the covid-19 pandemic-related public health restrictions appear to have led to reductions in physical activity [22, 23, 24, 25] . we hypothesized that the extended periods of lockdown in bangladesh may have adversely impacted physical activity and increased sedentary behaviors in the population. we aimed to determine the prevalence of physical inactivity and sedentary behaviors during the covid-19 pandemic among bangladeshi people. we adopted an online cross-sectional survey approach to assess the levels of physical activity and sedentary behaviors among bangladeshi citizens during the covid-19 pandemic. the survey was carried out between june 20 to june 30, 2020, when the number of newly diagnosed cases increasing, and the government continued to impose lockdown restrictions to limit the spread of covid-19. the target population was the general bangladeshi population. inclusion criteria were being (i) a bangladeshi residence, (ii) aged 18 years or older, and (iii) being able to read bangla. participants were recruited from various social media platforms (e.g., facebook, whatsapp), using convenience sampling. data were collected by means of an anonymous online questionnaire. the questionnaire was translated into bangla (the native language of participants), and then back-translated to english by different experts to assess validity. the most widely used standardized procedure (i.e., beaton et al., 2000) was used to perform the back translation for this questionnaire [26] , which has been previously used in bangladesh [27, 28] . a pilot test was conducted on 50 samples to test the validity of the questionnaire. the data from the pilot survey were not included in the final analysis. the online survey was conducted using a survey link created on google form. a total of 2,083 people completed the online survey. of these, 55 were excluded as they were below 18 years of age. therefore, the final sample consisted of 2,028 participants. socio-demographic variables included in the survey were age (later categorized: young [18-25 years] , and adult [25 þ years]), gender (male vs. female), marital status (unmarried, married, and divorced/widows/ widowers), education levels (secondary/below, higher secondary, and graduation/above), occupation (student, housewife, employed, businessman, and unemployed), monthly family income (later categorized: lower-class [<15,000 bangladeshi taka (bdt)], middle-class [15, 000 bdt] , and upper-class [>30,000 bdt]), family type (nuclear vs. joint), and current place of residence (village, sub-district town, district town, and divisional town). other variables included were self-reported physical health (good, moderate, and poor), chronic diseases (yes vs. no), and cigarette smoking currently (yes vs. no). physical activity level was assessed using the international physical activity questionnaire short form (ipaq-sf) [29] . the ipaq-sf is a valid and reliable tool for physical activity surveillance across a range of populations [30, 31, 32, 33, 34] . validity of the ipaq-sf has been assessed across 12 countries, and showed that acceptable properties for use in many settings and in different languages [35] . the ipaq-sf consists of 6 items providing information on time spent in walking, moderate-and vigorous-intensity activities during a typical week. walking activities are defined as "walking at home and at work, walking to travel from place to place, and any other walking done solely for recreation, sport, exercise, or leisure". moderate-intensity activities are defined as "those that take moderate physical effort and produce a moderate increase in respiration rate", and included examples such as carrying light objects, working in the garden, cycling at a regular pace, or doing prolonged physical work at home. vigorous physical activities are defined as "those that take hard physical effort and produce vigorous increases in respiration rate' such as lifting heavy objects, hoeing the earth, practicing zumba, cycling on an exercise bike, or running on a treadmill at high speed" [29] . for each of walking, moderate-and vigorous-intensity activities, individuals were asked to report the number of days per week that they performed the targeted activity for at least 10 min at a time, and then asked to report how much time they usually spent on one of those days doing the targeted physical activity. according to the ipaq data analysis guideline, all activity data were converted to metabolic equivalent task (met), the standard unit used to express the intensity of physical activities. for all three types of activities (i.e., walking, moderate-and vigorous-intensity activities), met-minutes per week were calculated as follows: walking ¼ (3.3 â walking min â walking days); moderate activity ¼ (4.0 â moderate activity min â moderate activity days); vigorous activity ¼ (8.0 â vigorous activity min â vigorous activity days). physical activity levels for each participant were classified into 3 categories based on the met-minutes/week of the total weekly energy expenditure (i.e., the sum of walking, moderate-and vigorous-intensity physical activities): (i) low (<600 met-minutes/ week); (ii) moderate active (!600 met-minutes/week); (iii) high active (!3000 met-minutes/week) [29] . for ease of regression analysis, physical activity level was later categorized: inactive (low active) and active (moderate/high active). the ipaq-sf has an additional item, namely "during the last week, how long in total did you spend in sedentary activities on a typical day?" to assess sedentary behavior. sedentary activities were defined as "those activities in a sitting, reclining, or lying position (except sleep) requiring very low energy expenditure" and examples included sitting/lying down reading or watching tv, computer use, video games, etc. sedentary behaviors for each participant were categorized as: <8 h/day and !8 h/day (high), as used in previous studies [36, 37] . this categorization is based on a previous cohort study that reported a detrimental association between sb ! 8 h/day and all-cause mortality [38] . statistical analysis was performed using microsoft excel 2019 and statistical package for social science (spss) version 25 (chicago, il). microsoft excel was used for data entry, editing, and sorting. continuous data were presented as mean and standard deviation (sd), and categorical data as frequency and percentage. the chi-square test was applied for categorical variables. logistic regression (both unadjusted and adjusted models) was performed with a 95% confidence interval to determine the significant associations between categorical dependent and independent variables. analyses were univariate, yielding crude odds ratios, followed by multivariable analyses with predictors combined, with the exception of sedentary behavior and physical inactivity in the models of each other, and yielding adjusted odds ratios. the association of variables was considered statistically significant if the two-sided p-value was less than 0.05. the present study was carried out in accordance with the guidelines of the helsinki declaration, 1975. in addition, the formal ethics approval was granted by the ethical review committee, the faculty of biological sciences, jahangirnagar university, savar, dhaka-1342, bangladesh (ref no: bbec, ju/m 2020 (7)1). participants were well informed about the procedure and purpose of the study, and confidentiality of their information. informed consent was ensured by each of participants. furthermore, all data were collected anonymously and analyzed by using the coding system. a total of 2,028 participants were included in the final analysis. of these, 57.2% were male, the mean age was 25.9 years (sd ¼ 8.1) and age ranged 18-65 years. the majority were single (71.1%), had graduation or above level education (64.4%), and were students (60.9%). a sizeable majority were from middle-class families (41.5%), came from nuclear families (69.9%), and were from village areas (32.5%). good physical health reported in 53.4% of responders, with nearly one-fifth of participants indicating chronic diseases (18.3%), and the majority (78.4%) did not smoke currently (table 1) . figure 1 represents the interrelation between physical activity level and sedentary behaviors among bangladeshi people during the covid-19 pandemic. the proportion of physical inactivity was significantly higher among (i) young (18-25 years) young people were 1.9 times more likely to be physically inactive (or pi ¼ 1.9; 95% ci ¼ 1.6-2.4, p < 0.001), and 2.2 times more likely to develop high sedentary behaviors (or sb ¼ 2.2; 95% ci ¼ 1.7-2.8, p < 0.001) compared to adults (table 2 ). other predictors of physical inactivity (pi) and high sedentary behavior (sb) were being students (or pi ¼ 1.6; 95% ci ¼ 1.0-2.5, p ¼ 0.046, and or sb ¼ 2.6; 95% ci ¼ 1.3-5.1, p ¼ 0.005), being from middle class families (or pi ¼ 1.9; 95% ci ¼ 1.4-2.5, p < 0.001, and or sb ¼ 1.4; 95% ci ¼ 1.0-1.9, p ¼ 0.041), being from upper-class families (or pi ¼ 3.0; 95% ci ¼ 2.3-4.0, p < 0.001, and or sb ¼ 1.9; 95% ci ¼ 1.4-2.6, p < 0.001), living with nuclear families (or pi ¼ 1.8; 95% ci ¼ 1.5-2.2, p < 0.001, and or sb ¼ 1.5; 95% ci ¼ 1.2-1.9, p ¼ 0.002), living in urban environment (or pi ¼ 2.2; 95% ci ¼ 1.8-2.8, p < .001, and or sb ¼ 2.9; 95% ci ¼ 2.2-3.7, p < .001), and not suffering from chronic diseases (or pi ¼ 1.7; 95% ci ¼ 1.3-2.1, p < .001, and or sb ¼ 1.4; 95% ci ¼ 1.1-1.9, p ¼ 0.02) ( table 2 ). additional risk factors of physical inactivity were being single (or pi ¼ 3.2; 95% ci ¼ 1.3-7.8, p ¼ 0.012), having higher secondary level education (or pi ¼ 1.9; 95% ci ¼ 1.3-2.7, p ¼ 0.002), having graduation/above level education (or pi ¼ 3.1; 95% ci ¼ 2.2-4.4, p < 0.001), having poor physical health (or pi ¼ 1.8; 95% ci ¼ 1.2-2.5, p ¼ 0.002); in contrast, being housewife was protective (or pi ¼ 0.3; 95% ci ¼ 0.2-0.5, p < 0.001). likewise, additional risk factors of high sedentary behaviors were being female (or sb ¼ 1.5; 95% ci ¼ 1.2-1.9, p < 0.001); conversely, moderate physical condition was a protective factor (or sb ¼ 0.7; 95% ci ¼ 0.5-0.9, p ¼ 0.001) ( table 2) . furthermore, the findings showed a significant association between physical inactivity and high sedentary behaviors (χ 2 ¼ 82.0; df ¼ 1, p < 0.001), as well as physical inactivity (or sb ¼ 2.7; 95% ci ¼ 2.2-3.3, p < 0.001) and sedentary behaviors (or pi ¼ 2.7; 95% ci ¼ 12.2-3.3, p < 0.001) emerged as significant predictors of each other ( table 2) . multivariable logistic regression analyses with each of the factors entered into the model revealed that most of the risk factors were interdependent and lost statistical significance (table 3) . for physical inactivity, significant associations with education level, residence, selfreported physical health, and sedentary behavior emerged. for sedentary behaviors, the only significant associations retained in the model included gender, education level, self-reported physical health, and physical inactivity (table 3) . to our knowledge, this is the first study that investigated physical activity patterns and sedentary behaviors among bangladeshi people during the covid-19 pandemic, and provides a snapshot of such issues. this survey was conducted during a 10-day period, while the number of newly diagnosed cases was increasing in bangladesh, and during which, substantial restrictions that included spatial distancing, home quarantine, social isolation, and travel restriction were in place. in a prior study focused on mental health conducted earlier during the outbreak in bangladesh, we reported that 55.3% participants did not engage in physical exercise while in home quarantine, and 33.9% browsed internet more than 6 h per day [39] . we also reported that those individuals who reported vulnerable mental states (i.e., depression, anxiety, and stress) were significantly more likely not to engage in physical exercise and to browse the internet for longer periods of time. physical inactivity, a major risk factor for global mortality, accounts for 3.2 million deaths each year worldwide [40] . not getting enough physical activity, including among those individuals who have no other associated risk factors, can lead to an increased risk of heart disease. physical inactivity can also increase the likelihood of other risk factors for developing heart disease, such as obesity, high blood pressure, high blood cholesterol levels, and type 2 diabetes [41] . the fear of being infected and the mobility restrictions imposed during the covid-19 pandemic may dissuade people from attaining the recommended levels of physical activity. in the present study, we found that nearly 38% of participants were physically inactive during the covid-19 pandemic. direct comparisons with these findings are quite difficult due to the lack of studies employing a similar instrument in bangladesh. here, we found that the prevalence of physical inactivity was significantly higher among young people (42.5%) compared to those individuals older than 25 years of age (27.7%). young people spend more time on electronic devices than other age groups [42] . while confined at home because of covid-19, young people could spend more time on electronic devices, leading them to increase the time spent as physically inactive. as corroboration of such assumption, single individuals (likely younger) were more likely to be physically inactive. people with higher education levels were more inclined to report physical inactivity. this finding is in conflict with previous research studies that indicated that higher education levels are associated with higher degrees of involvement in physical activity [43, 44] . the discrepancies in this finding may be due to the situation imposed by covid-19. indeed, the prevalence of physical inactivity was significantly higher among students (46%) compared to all other groups, and was anticipated, considering the promotion of online activities during the covid-19 pandemic. since all the educational institutions were closed, students would be more prone to screen exposure in the context of both social media interactions, games or even studies online, and these trends may facilitate the emergence of mental and behavioral stress. people who were living in urban settings reported higher prevalence of physical inactivity. participation in physical activity is largely determined by physical and social environmental factors that influence access, availability, and utilization [45, 46] . in bangladesh, divisional cities are densely populated, and the number of covid-19 cases was comparatively large. accordingly, main factors favoring physical inactivity included being fearful of exposure to covid-19, closed sports facilities, unavailability of friends to exercise with, and a lack of interest in pursuing physical activities during the covid-19 pandemic [47] . the findings of this study also indicate that nearly 21% participants had high sedentary behavior (i.e., time spent on sedentary activities >8hours/day) during the covid-19 pandemic. prolonged sedentary behavior induces adaptations that negatively decondition cardiorespiratory fitness and metabolic profiles, and are therefore intimately related to disease prevention [48, 49] . it is possible that insufficient participation in physical activity over extended periods during the covid-19 emergency may turn into sedentary behaviors. females had higher prevalence of sedentary behaviors compared to males, similar to previous reports, possibly reflecting additional cultural and social norms [50] . additional factors for high sedentary behaviors included being young, being a student, being from an upper-class family, and living in urban settings. since these factors were also associated with physical inactivity, it is not surprising that they also contributed to increased sedentary behaviors. the unique importance of physical activity and of restricting sedentary behaviors cannot be overstated, considering their beneficial effects on health in general, and also on specific elements related to the covid-19 pandemic, such as modulation of the immune system [51] . therefore, the who and many other professional societies recommend the adoption of specific exercise programs and daily strategies including home-based exercise programs to maintain a physically active lifestyle during the pandemic [52, 53] . this study has some limitations that must be considered when interpreting the results. the present research adopted an online selfreport methodology that may be susceptible to potential biases (e.g., social desirability and memory recall). in addition, the study was crosssectional in nature and therefore we cannot infer causality between any of the variables examined. furthermore, due to the online survey and convenience sampling technique, participants were predominantly educated young adults and students, which might affect the generalizability of the findings. physical inactivity is prevalent among the bangladeshi population during the covid-19 pandemic, and appears to be largely impacted by socio-demographic factors. moreover, one-fifth of the cohort reported high sedentary behaviors. the findings suggest that there is a need to promote regular physical exercise in the context of home quarantine measures and increase awareness to induce cogent avoidance of activities related to sedentary behaviors during the covid-19 outbreak. author contribution statement m. rahman: conceived and designed the experiments; performed the experiments; contributed reagents, materials, analysis tools or data; wrote the paper. m. islam: conceived and designed the experiments; performed the experiments; analyzed and interpreted the data; contributed reagents, materials, analysis tools or data; wrote the paper. m. bishwas and david gozal: contributed reagents, materials, analysis tools or data; wrote the paper. m. moonajilin: conceived and designed the experiments; wrote the paper. this research did not receive any specific grant from funding agencies in the public, commercial, or 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is available for this paper. key: cord-034438-9kdmljoq authors: sepúlveda-loyola, w.; rodríguez-sánchez, i.; pérez-rodríguez, p.; ganz, f.; torralba, r.; oliveira, d. v.; rodríguez-mañas, leocadio title: impact of social isolation due to covid-19 on health in older people: mental and physical effects and recommendations date: 2020-09-25 journal: j nutr health aging doi: 10.1007/s12603-020-1500-7 sha: doc_id: 34438 cord_uid: 9kdmljoq objectives: to review the impact of social isolation during covid-19 pandemic on mental and physical health of older people and the recommendations for patients, caregivers and health professionals. design: narrative review. setting: non-institutionalized community-living people. participants: 20.069 individuals from ten descriptive cross-sectional papers. measurements: articles since 2019 to 2020 published on pubmed, scielo and google scholar databases with the following mesh terms (‘covid-19’, ‘coronavirus’, ‘aging’, ‘older people’, ‘elderly’, ‘social isolation’ and ‘quarantine’) in english, spanish or portuguese were included. the studies not including people over 60 were excluded. guidelines, recommendations, and update documents from different international organizations related to mental and physical activity were also analysed. results: 41 documents have been included in this narrative review, involving a total of 20.069 individuals (58% women), from asia, europe and america. 31 articles included recommendations and 10 addressed the impact of social distancing on mental or physical health. the main outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. cognitive strategies and increasing physical activity levels using apps, online videos, telehealth, are the main international recommendations. conclusion: mental and physical health in older people are negatively affected during the social distancing for covid-19. therefore, a multicomponent program with exercise and psychological strategies are highly recommended for this population during the confinement. future investigations are necessary in this field. the covid-19 pandemic due to sars-cov-2 has rapidly spread all over the world since last december. although its prevalence in the community is uncertain due to the asymptomatic cases, all age groups seems to be similarly affected (1) . however, older people are at higher risk of suffering negative outcomes, which can lead to an elevated rate of mortality, being five times higher than the global average for those older than 80 years old (2) . over 95% of fatalities due to covid-19 in europe and around 80% in china have included people older than 60 years-old (3, 4) . in the us, 80% of deaths were among adults 65 and over (5) . hence, health strategies to avoid spread of coronavirus (such as quarantine and social distancing) are important (6, 7) . the world health organization (who) describes a close relationship between physical and mental functions with the level of self-governance and social participation in the community [8] . social participation has been defined as active participation in a religious, sports, cultural, recreational, political, and volunteer community organizations (9) (10) (11) (12) . various studies have reported protective effects of social participation for the health of the elderly, being considered as a stimulus to increase the level of physical activity and cognitive functions (9, 13, 14) . the social participation has been associated with a better quality of life, more muscle mass, balance, cognition and lower comorbidities and disability in older people (9, 13, (15) (16) (17) (18) (19) (20) . participating in social meetings and activities are stimuli that increase the level of physical activity as well as the interaction with other older adults stimulating sensory systems, self-esteem, affectivity, emotional and psychological support (9, 13, 21) . as a preventive measure during the covid-19 pandemic, community organizations have closed. old people are constrained from visits with family members, therefore the social participation have been restricted (7) . thus, the decreasing of social interaction produced by social distancing could have a negative impact on mental and physical health in older people (22) (23) (24) , since it has limited the social participation in community organizations and in family activities (23, 25) . who defines the 'intrinsic capacity' as the 'composite of all the physical, functional, and mental capacities of an individual' (26) (27) (28) , changing the focus from a negative aging (disability) towards a positive one (optimal aging), being related to the onset of autonomy decline, falls and death (27) . physical activity has a positive impact on the health and quality of life, reducing the risk of functional and cognitive impairment, falls and risk of fractures, depression, disability, risk of geriatrics syndromes, hospitalization rates and, consecutively, mortality in older people (29) . not only the physical activity is affected during quarantine, but also mental health. several studies have described mental health consequences in previous quarantines, such as higher risk of depression (30) , emotional disturbance (31) , stress (32), low mood (33), irritability (33) , or insomnia (33) , being also associated with higher rates of suicide in elderly population (34) . however, the effects of covid-19 quarantine on the health of older adults have not yet been broadly studied. hence, the aim of this review is to analyse the potential effects of social isolation caused by covid-19 pandemic on mental and physical health in older adults. additionally, we have analysed the recommendations and proposed activities to avoid mental and functional decline to carry out at home. in this narrative review, the literature search was performed by three authors (wsl, irs and rt). pubmed, scielo and google scholar databases were consulted using the following terms ('covid-19', 'coronavirus', 'aging', 'older people', 'elderly', 'social isolation' and 'quarantine'). articles of any type of methodological design published from 2019 to 2020 (may 20th), in english, spanish or portuguese were included. articles that did not include subjects >60 years old were excluded. additionally, we have searched papers, guidelines, recommendations and update documents from different international organizations related to mental and physical activity. the lists of articles in the databases were downloaded in "bib format" and stored in mendeley for analysis of duplicate articles, title, and abstract reading. the content of the review was divided into two main areas: 1) effect of the reduction of social participation produced by quarantine for covid-19 on mental and physical health in elderly people, and 2) recommendations for mental and physical health of older people during the covid-19 quarantine. a detailed summary of the literature search is provided in figure 1 . six hundred and ninety unique records were identified through database and handsearching, resulting in ten articles involving 20.069 participants included in the final review (women 58%) from asia, europe, and america. of these, 9 adopted a cross-sectional design, and 1 was a qualitative design. all of them are descriptive studies. additionally, 31 articles from experts and authors about recommendations were considered in the full-text review. a summary of the characteristics of the included studies is presented in table 1. selection process of studies our results are based on summary data from eight crosssectional studies (35) (36) (37) (38) (39) (40) (41) (42) . the prevalence of anxiety ranged from 8.3%, 18.7% and 35.1% to 49.7% (36, 38) ; corresponding values from depression were 14.6%, 20.1%, 32.8%, 37.8% and 47.2% (36) (37) (38) . finally, sleep disturbances were observed in 18.2% (38) and 36.4% (37) among the participants. six of them (36, (38) (39) (40) (41) (42) pointed out an increased level of psychological stress defined as higher anxiety (36, (38) (39) (40) (41) , depression (36, (38) (39) (40) (41) and loneliness (42) levels and poorer sleep quality (38) during the lock-down by coronavirus. nevertheless, in one study (35) isolation period by covid-19 turned out in a mild stressful impact. additionally, only one study (37) showed that people during quarantine had lower anxiety levels, but more sleep disturbances. risk factors associated to these results varied across the studies. being female (36, 39, 42) , having a negative selfperception of aging (42) , healthcare workers (38) , family and personal resources (42) , time devoted to covid-19 information (42), having an acquaintance or a family member infected with covid-19 or a previous history of medical problems (39) seem to act as potential risk factors. the impact on physical health of the social distancing was studied for two authors (43, 44) (table 1 ). goethals et al (43) reported that covid-19 pandemic has affected the number of seniors attending group physical activity programs. additionally, castañeda-babarro et al (44) observed that the physical activity was highly decreased during confinement in all population, especially the vigorous activities and walking time. there are several recommendations related to the patient to deal with this social isolation (table 2a) such as strengthen social connections (43, 45-48) (using internet apps, video chat (45, 47) ), telephone support lines or support groups (23, 35, 49) , changes on lifestyle (regular sleep-wake up circle (50), physical activity and nutrition habits (37, 51) ) and cognitive stimulation (using apps or stimulating mental exercises, especially in those people with previous cognitive impairment (50) (51) (52) ). caregivers have an important and crucial role guaranteeing the physical and mental well-being. to reduce anxiety and feeling of usefulness, letting the person participate in adapted daily activities depending on the cognitive status is recommended (51) . the exposure to media must be regulated (53) , avoiding doing it in excess and only from official sources (51, 54) , managing to control the effect of news with traumatic content (51) . explaining clearly (55) or accompanying information with illustrations (53) may help, especially in people with cognitive impairment. to improve older people resilience, a combination of health education and psychological counselling could be useful. reinforcing that being quarantined is helping to keep others safe (23, 35, 46, 49) , adopting inclusive language when talking about the elderly, valuing older people's contributions and avoiding negative emphasis on risk (46) could increase also elderly's resilience. during this covid-19 crisis, healthcare system have had to change completely implementing virtual consultations and telemedicine (video-tools, telephone hotlines or online consultations (49) , guaranteeing rapid access to health care (52, 56) . additionally, the scorare ga, an assessment tool, has been proposed for doing a telematic geriatric assessment (52) . in order to minimize isolation related stress, quarantine should be as short as possible. giving good quality information, using channels that older people use like traditional media is also important for reducing stress (23) . the social distancing has reduced the levels of physical activity, which could have a negative impact on physical health (43, 44) . in this review, we include recommendations about increasing physical activity levels from the following eight global organizations: american college of sports medicine (acsm) (57), american heart association (aha) (58) , american physical therapy association (apta) (59) , international association of physical therapists working with older people (iptop) (60), world health organization (who) (61), world confederation for physical therapy (wcpt) and international network of physiotherapy regulatory authorities (inptra) (62) . they recommended 150-300 minutes per week of moderate-intensity aerobic physical activity and two sessions per week of muscle strength training (57, 61) . additionally, exercise circuit at home with cardio and strength exercises in short bursts of 30 seconds for up to three minutes. finally, coordination, mobility and cognitive exercises are also necessary (63) ( table 2b ). the role of caregivers during the quarantine is to supervise the exercise in those patients with unstable chronic diseases (64) . for health professionals, the principal elements to consider when designing an exercise program for older people confined at home are exercise modality, frequency, volume, and intensity (63) . it is recommended the telehealth using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . iptop has recommended a list of apps[60] such as "otago exercise programme", "clock yourself" and "iprescribe exercise". apta, acsm and aha recommended different online videos and websites (58, 65, 66) (table 2b ). this review suggests a general negative effect on mental health in general population during social isolation for covid-19. this implies higher levels of anxiety and depression as well as poorer sleep quality. the prevalence of anxiety and depression during covid-19 outbreak, varies across the studies, having a wide range from 8.3% (36) to 49.7% (42) for anxiety or 14.6% (36) to 47.2% (42) for depression, in consonance with previous studies of other epidemics. for instance, 39% of prevalence of anxiety was observed in france due to avian influenza (67); 48% of the general population in sierra leone experimented symptoms of anxiety or depression 1 year after ebola outbreak (68); in hong kong due to the sars epidemic, 73% and 57% of individuals presented low mood and irritability (respectively) (33) , as well as depression in 31.2% of 129 quarantined persons for sars epidemic in 2003 (69) . the lower rates of anxiety and depression observed in some studies of our review during activities to improve the mental and physical health at home coronavirus pandemic could be explained for several reasons. the first one is that, based on previous epidemics, strong and quickly measures to keep mental health could have been taken by the governments, avoiding a bigger psychological impact. as time goes by, there was more information about sars-cov-2, which could also lead to a better management of the situation. however, data were collected in a very earlier stage of the pandemic, hence, these results should be taken with caution. some of the risk factors associated to a higher risk of psychological distress have been also described in previous literature. after ebola outbreak, people who knew someone quarantined due to ebola or with any ebola experience were at higher risk of anxiety, depression and post-traumatic stress disorder (68) . additionally, being older than 60 or worried about the recurrence of sars have been also found as risk factors in previous studies (70) . however, we cannot conclude the same in this review, where a more intense effect on older people has not been reported. another parameter that should be taken into account is the duration of isolation, since it is related to the severity of psychological symptoms. a non-significant impact on patients' well-being has been demonstrated during short-term isolation (71) . health providers need to be aware that older adults are at higher risk of having mental health concerns during isolation, and they may have less resources to mitigate them. they should encourage old adults and their families to contact each other daily, as much as they can, to reduce isolation in this population. additionally, maintaining a positive life-style behavior such as regular sleep and meal times, keep a healthy diet, cognitive stimulation and perform physical activity need to be recommended. also, relaxation techniques which may include diaphragmatic respirations or muscular relaxation, practicing a regular routine, alternating with different activities during the day could be useful. it is important for people to be informed by reliable sources and spending a limited time for searching information, maximum once or twice per day. information given to the elderly should be simple, frequent, and displayed in appropriate media. this review has reported that social distancing because of the covid-19 pandemic could lead to negative consequences for the physical health of older adults. this is caused by the decrease of physical activity levels due to the total or partial restriction of social participation in community groups and family activities during the pandemic (42, 43, 44) . social participation has several positive effects on physical health in elderly people (72) . studies have reported that older adults who were enrolled into social activities presented better dynamic balance and muscle strength, healthy lung function and lower disabilities and chronic inflammation compared to those without social participation (14, 72) . for this reason, attending social activities is an important component for successful aging (14, 72) . the relationship between social interaction and physical health may operate through different pathways (14, 72) . a possible explanation for these findings is that participating in meetings or social activities stimulates the musculoskeletal, cardiovascular, respiratory and nervous systems through physical activity and social interaction (73) . physical activity generates benefits for the physical health of older adults, stimulating muscle contraction, energy expenditure, decreasing systemic inflammation and oxidative stress, reducing prevalence of chronic diseases, and geriatric syndromes such as sarcopenia, osteosarcopenia and frailty (74) . as expected decreasing or total restriction of social interaction could generate negative consequences for the health of elderly people, especially in those with chronic diseases, disabilities and geriatric syndromes (14, 63) . evidence has demonstrated a relationship between social isolation and loneliness with disability, chronic diseases, risk of mortality and physical inactivity in elderly population (9, 19, (75) (76) (77) (78) (79) . however, the effect of increased sedentary behavior and decreased physical activity on elderly people during the covid-19 pandemic is unclear. isolated older people have less physical activity and more sedentary behavior than those non-isolated [80] . physical activity is described as any body movement using skeletal muscle that results in energy expenditure > 1.5 metabolic equivalent of task (met), while sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 or less met while in a sitting, reclining or lying posture (81, 82) . increased sedentary behavior has been associated with the prevalence of different comorbidities in elderly people (83) . since a direct association has been reported between sedentary time and time spent at home in elderly people (84) , recommendations have to be made to prevent health consequences in people with social isolation associated to the pandemic covid-19. the global expert organizations included in this review have highlighted the importance of increasing or maintaining the physical activity levels during the pandemic (57-62). although those organization recommended different types of activities or exercises, they are in agreement of using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65). acsm and who recommended 150-300 minutes per week of aerobic physical activity and 2 sessions per week of muscle strength training (57, 61) . however, recommendations for people with social isolation could consider studies that have reported benefits of replacing sedentary time with physical activity. for example, replacing sedentary behavior with 30 minutes of light physical activity and 20 minutes of moderate to vigorous physical activity could have beneficial effects on all cause mortality (85) . in addition, replacing 30 minutes per day of sedentary time with moderate to vigorous physical activity has been associated with a decreased frailty in older people (86) . this information could be used to recommend physical activity as appealing and feasible (87) . additionally, balance, coordination, mobility and cognitive exercises to stimulate neurological system are recommended for older people to reduce the risk of falls and cognitive declining (63) . in those older adults with geriatrics syndromes or unstable chronic diseases, it is recommended the supervision of caregivers to avoid falls, exacerbations and injuries during the exercise (64) . in addition, the health professionals should design the exercise program for older people confined at home with a specific exercise modality, frequency, volume, and intensity (63), using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . finally, the quarantine implied a radical change in the lifestyle of elderly people, reducing the social interaction, participation in exercise group, religious or spiritual group which have negatively affected the mental and physical health in this population (88) . therefore, to maintain an active lifestyle at home is important for the health of older adults, especially those with chronic diseases and geriatrics syndromes. to summarize all the recommendations and articles included in this review, we have proposed different activities to improve the mental and physical health at home in figure 2 . to the best of our knowledge, this is the first review that includes assessing the physical and mental effects of social isolation by covid-19 among older people. however, this study has some limitations, which deserve to be mentioned. studies included in this review were cross-sectional design and not specific in elderly population. as all of them are descriptive studies, no control group was used. additionally, there is also a lack of evidence regarding the most appropriate psychological and physical recommendations and most of the interventions suggested are based on expert opinions and not on high evidence studies. future investigations should consider a longitudinal or cross-sectional design in older individuals, with larger sample size and different outcomes related to mental and physical health. in conclusion, our study suggests that the mental and physical health in older people are negatively affected during the social distancing for covid-19. the main mental and physical outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. experts organizations and who have given different recommendations to keep older people mentally and physically 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exercise, and physical fitness: definitions and distinctions for health-related research sedentary behavior and health outcomes among older adults: a systematic review physical activity in non-frail and frail older adults replacing sedentary time with physical activity: a 15-year follow-up of mortality in a national cohort reallocating accelerometer-assessed sedentary time to light or moderate-to vigorous-intensity physical activity reduces frailty levels in older adults: an isotemporal substitution approach in the tsha study the feasibility and longitudinal effects of a home-based sedentary behavior change intervention after stroke covid-19, mental health and aging: a need for new knowledge to bridge science and service declaration of conflict of interest: none.declaration of sources of funding: co-financed by the european regional development funds (rd120001/0043) and the centro de investigación biomédica en red en fragilidad y envejecimiento saludable-ciberfes (cb16/10/00464).author's contribution: study concept and design: all authors. data collection: wsl, irs, rt. draft of the manuscript: wsl, irs, ppr, fg, rt. full access to all of the data in the study and responsibility for the integrity of the data: wsl, irs. study supervision: lrm. all authors reviewed the manuscript for important intellectual content and approved the final version. key: cord-012623-bc9fj29h authors: pekmezaris, renee; kozikowski, andrzej; pascarelli, briana; handrakis, john p.; chory, ashley; griffin, doug; bloom, ona title: participant-reported priorities and preferences for developing a home-based physical activity telemonitoring program for persons with tetraplegia: a qualitative analysis date: 2019-05-16 journal: spinal cord ser cases doi: 10.1038/s41394-019-0188-6 sha: doc_id: 12623 cord_uid: bc9fj29h study design: focus group. objectives: the purpose of this qualitative study was to explore perceptions and priorities of persons with spinal cord injury (sci) for physical activity and to incorporate their feedback to inform future development of a physical activity program delivered via a telemonitoring platform. setting: new york. methods: qualitative data were collected from a purposive sample of adults with tetraplegia (n = 7). two investigators led an audio-recorded focus group using a moderator’s guide. data were analyzed using a six-phase thematic analysis approach. results: the discussion focused on two major areas, which resulted in multiple derived themes and subthemes. the first theme centered on the daily life of persons with tetraplegia, including changes after sci, gain of function prioritization, and identification of psychosocial support systems that facilitate community reintegration after injury. the second theme centered on participant perceptions and recommendations for a physical activity program delivered via a telemonitoring platform. desired design features included variations in schedule, diverse activities, or exercises included in each class, and optional two-way video to enable social interactions with classmates. conclusions: participants favorably viewed the concept of a physical activity program delivered via a telemonitoring platform and contributed program design ideas. although this was a small sample size, challenges to obtaining physical activity expressed by participants were consistent with those identified previously in larger studies of persons with tetraplegia. therefore, we expect these concepts and their recommendations to be relevant to the greater sci community. approximately 350,000 persons in the us are living with traumatic spinal cord injury (sci) [1, 2] . due to reduced mobility, persons with sci are at increased risk for developing obesity, muscle atrophy, osteoporosis, accelerated atherogenesis, type ii diabetes mellitus, and other medical consequences that increase the risk of stroke and coronary heart disease [1] [2] [3] . this reduced mobility often has deleterious psychosocial effects that impact quality of life, including increased social isolation, reduced social participation, reduced exercise self-efficacy, and depression [4, 5] . thus, there is a critical need for therapeutic strategies that reduce the risk of multiple medical and psychosocial consequences of sci. physical activity is a recommended therapeutic strategy to reduce risks of common medical consequences across diverse clinical populations [6, 7] . physical activity reduces risks of coronary heart disease and diabetes, increases immunity and blood circulation, and decreases inflammation, fat, anxiety, pain, and improves mood and sleep [8] [9] [10] [11] . the american college of sports medicine recommends that able-bodied adults perform 150 min of moderate-intensity aerobic exercise and participate in two or more days of muscle-strengthening exercise weekly [12] . the latest physical activity guidelines for adults with sci recommend, "at least 20 min of moderate to vigorousintensity aerobic exercise two times per week and three sets of strength exercise for each functioning muscle group, at moderate to vigorous intensity, two times per week" [13, 14] . for cardiometabolic health benefits, it is recommended that adults with sci engage in at least 30 min of moderate to vigorous-intensity aerobic exercise three times per week [13, 15] . persons with sci and other disabilities are less likely to engage in regular physical activity, due to many modifiable barriers. these include: lack of knowledge about existing programs/safe exercises, insufficient programming, lack of transportation, cost, and scheduling issues [16] . there are also other barriers, such as feeling too hot or cold outdoors or distance from an adaptive sports facility [17] . in the general population, telemonitoring approaches to delivering physical activity are part of a highly successful commercial fitness industry. consumers are offered the ability to choose a program to engage in at home, with recorded or live classes, that can be delivered to a tv, tablet, phone, or computer via a commercial internet provider. compared to a gym membership, telemonitoring is convenient, scalable, and relatively low cost. regardless of the modality, telemonitoring physical activity programs often require minimal exercise equipment and are delivered at home on a personalized schedule. in addition to the physical health benefits, such as increased muscle strength and improved cardiovascular fitness, many physical activity instructors also engage actively in motivational strategies, to promote adherence and increase exercise self-efficacy [18] . increasingly, telemonitoring enables a participant to experience self-efficacy in the following ways: (1) mastery of experiences, the strongest predictor of self-efficacy, relate to actual performance when successfully meeting a challenging task. participants performing daily health behaviors and seeing progress, experience mastery. (2) vicarious modeling (seeing others facing similar challenges and reaching their goals) will be achieved by viewing other participants of similar abilities attaining activity goals. (3) social persuasion (verbal encouragement) is provided by the instructor. (4) physiological factors, such as anxiety and distress, can be experienced by participants when they fail to meet activity goals; the instructor can interpret this as situational and not associated with overall success [19, 20] . home-based physical activity delivered via telemonitoring may be a particularly useful option for persons with sci as a way to modify common environmental barriers to achieve the benefits of regular physical activity [21] . to address these and other barriers, telehealth approaches are being increasingly studied in the context of sci [21] . sweet and colleagues are starting an rct of an 8-week tele-rehab program for persons with paraplegia to measure changes in psychosocial variables related to exercise participation and quality of life [22] . another study measured the effects of a home-based exercise program in persons with chronic sci, including outcome measures of metabolism, body composition, physical activity, energy intake, measures of health and wellbeing, resting metabolic rate, heart rate, and blood pressure, aerobic capacity, immune function, and adipose gene expression [23] . encouraging results using telemonitoring have been obtained across physical health measures (i.e., wound care), as well as psychological health [21] . there is a need to establish novel methods to facilitate regular physical activity for persons with sci [24] . here, we report the results of a qualitative study of priorities and preferences for developing a home-based physical activity telemonitoring program for persons with tetraplegia. we consider this to be a first step towards optimizing feasibility and acceptability in a physical activity program for persons with sci [13] . this is a qualitative study of adults with chronic (at least 1 year from injury) tetraplegia who were recruited from the ny metropolitan area. the rationale for including only persons with tetraplegia was because, in general, this group has fewer opportunities for achieving physical activity in their daily life, lower reference values of cardiovascular fitness (relative vo2 peak), higher risk factors for cardiovascular disease, and lower life expectancy than persons with paraplegia. a short demonstration video developed by the study team was presented to participants to show the concept of a telemonitoring physical activity program led by a physical therapist for persons with tetraplegia. moderators explained that they envisioned that participants would join the class via a tablet with a split screen that showed themselves, the instructor, and classmates conducting exercises. moderators described that an instructor would monitor vital sign data (heart rate and blood oxygenation) of participants in real time via a pulse oximeter. before engaging in exercise, participants would be trained on proper equipment use. for safety, participants would be asked by the instructor every 5 min during the intervention, to describe any symptoms of discomfort, including pain (musculoskeletal or other), fatigue, shortness of breath, or dizziness. frequency, duration, and type of proposed activities are based on the most recent guidelines on physical activity for persons with sci [24] . the intervention presented was proposed to be delivered three times/week for 45 min, with ≥30 min of activity. the circuit training program proposed was based on evidence of strength and cardiorespiratory benefit in persons with sci [25] . stretching, cardiovascular, and strengthening exercises would be tailored to participants' functional abilities. theraband, with open handgrips (loops), would be used to provide resistance for strength training [26] . moderators explained that the program would consist of three repetitions of: (a) warm-up: a series of active (nonresisted) movements: shoulder lateral raises, flies, shoulder rolls, wide biceps curls, shoulder shrugs, triceps extensions to rear; (b) circuit exercise program: resistance followed by aerobic (arm spinning) exercises with rest periods as needed (~15 s). resisted movements would include: set 1: seated rows, horizontal shoulder abduction, arm spinning/circles (aerobic exercise), set 2: shoulder internal rotation, shoulder external rotation, aerobic exercise, set 3: straight arm pulldowns, chest press, aerobic exercise [26] . a 3-h focus group was conducted in january 2018, led by two moderators previously unknown to participants. moderators used a moderator guide with open-ended questions and probes, related to a range of relevant topics including experiences with and priorities for benefits of physical activity before and after their injuries, technology use, and perceptions of important features that should be incorporated into a telemonitored physical activity program. the discussion was digitally recorded (using two recorders in case of technical failure), stored on an internal password protected server to ensure security, and transcribed professionally. transcripts were checked against the original recordings for accuracy. to optimize credibility, transferability, and dependability of results, we utilized analyst triangulation, peer debriefing, and conducted an audit trail of decisions made during the analysis and rationale. the transcript was analyzed by two researchers (a k and b p), to achieve triangulation to gain a more complex understanding of the data. a six-phase thematic analysis approach was utilized [27, 28] . in the first phase, transcripts were reviewed independently multiple times to become familiar with the data. researchers documented initial theoretical and reflective thoughts, and potential codes and themes. in the second phase, researchers focused on data patterns and generated a comprehensive set of codes through inductive and deductive coding. two researchers documented their reasoning for coding blocks of text from the transcript of the focus group to explain how the data were perceived and examined. the third phase consisted of searching for themes after coding and codes were collated. in the fourth phase, themes were reviewed and refined. criteria for retaining themes were that they needed to be specific enough to be concrete, while broad enough to capture ideas. themes with sparse data were eliminated and those with large amounts of data were further divided into separate themes. in the fifth phase, team members met and discussed the finalization of theme names. in the sixth phase, the report was generated. participants were persons with tetraplegia (n = 7: 5 males and 2 females) who were wheelchair users for community mobility. the discussion explored challenges of living with tetraplegia, gain of function prioritization, social networks, and design recommendations for a telemonitored physical activity program. participants were asked to rank their gain of function prioritization on a seven-point scale, with one being most, and seven being least important, in the following areas: arm/ hand function, upper body/trunk strength and balance, bladder/bowel function, lived experiences of sexual function, elimination of chronic pain, sensation and mobility ("mobility could be anything that gets your body around in space") [29] . most participants ranked either arm/hand function, sensation, or improvement of mobility as the most important. the next gain of function priorities ranked was upper body/trunk strength and balance, elimination of chronic pain, and sexual function. two major discussion themes emerged from a six-phase thematic analysis approach to the transcript. theme one: daily challenges pain several participants described challenges of performing activities of daily living (adls) while experiencing constant pain. the locations of pain symptoms varied by individual, including the back, neck, shoulders, and feet. multiple participants reported that pain symptoms were worse in the morning and did not resolve completely throughout the day. "right now, i feel like someone's kicking me in the back but that's normal for me, so it's just one of those things you kind of deal with…" "…i have chronic back pain that just will not go away. it's probablyif i say on a scale of one to ten, it's probably around a good eight most of the day…" "i'm in pain every day when i get home. i'm in bed by 7:00 because i can't even function." participants also discussed how pain impacted feelings of fatigue and strategies to cope with interruptions in sleep. "and you talk about getting exhausted during the day. i want to sleep every day by 12:00. but i'm at work, so i can go in my office for a little while just to try to rest for a minute." multiple participants reported being athletic and active prior to their sci, had careers in physically enduring professions or participation in active sports including swimming, motocross, running, cycling, and skiing. "yeah, motor cross. yeah. so i used to ride-a lot of cycling, a lot of swimming. i had a home gym that i worked out in all the time. running-i was a terrible runner because my knees weren't that great. so i would run a little bit, but not that much. mostly cycling. i loved cycling. anything with wheels, i was there." "i was very free spirited, i'd say. we'll put it that way. but yeah, i sort of was very spontaneous and enjoyed flying by the seat of my pants and all that. it's like losing a little piece of you." as expected, the intensity and type of physical activity changed for most participants after injury. most focus group participants were not engaged in regular physical activity, outside of the exercises prescribed during physical therapy. for participants who were active, post-injury activities include using a stationary bike, thera-bands for resistance training, and free weights. "when i first came home, i was doing them every day. and then little by little, you're slacking off. but like i said, every day, once i get into bed, that's when i do the most thera-bands or weights or anything because i'll put a wrist [adaptor] on my arm. i'll go on my side and i'll do the left arm. then i get turned the other way, i'll do the right arm." "...everything from thera-bands like you were talking, to cuff weights. i use cuff weights as well that-most people use them on their ankles when they're running or exercising, but they also work great for quads around your arm. it's like a velcro weight. the rickshaw [wheelchair rehab exercise machine]…. it's a great machine for people in wheelchairs. and they have another machine there which is called the upper tone…it's kind of a home gym-type looking machine that's specifically designed for people in wheelchairs and people with limited hand function." variation in physical therapy and interactions with physical therapy personnel were discussed and perceived as impacting the post-injury rehabilitation process. "i've been to great therapists and i've been to not-sogreat therapists, and what they did clinically was not that different from each other. the difference was the therapists' behavior, the interaction." "i mean, it felt like it's a total package there. you get a lot of focused attention. youand theystart on the dime and they give you every second of that hour." participants discussed the critical role of social networks (family and friends) in community reintegration after injury. in addition, participants were motivated and inspired by interacting with peers with sci who demonstrated resilience. "…when you see people getting better, it helps. it makes you believe you can do the same thing too." the importance of self-efficacy to obtaining functional gains was also discussed, including the importance of maintaining both physical and emotional health. the feelings of well-being obtained from exercise were reported to reinforce the desire to continue exercising. "when i'm in a good mood, i feel i can conquer the world. but when i'm in a lousy moodlike today is not a great mood for meis i don't feel good about anything, and i don't want to do anything because i'm miserable. but then tomorrow i'll feel great and say i can pretty much take on the world and do anything i want and just let me do what i got to do." "yeah, inspirational. yeah, it would raise inspiration, want me to build more muscle on my end to want to feel better and know that i'm healthier and to keep going for whatever reason, whether it's for walking or not." "and i can tell you personally that i should probably be further along physically than i am… i think i plateaued and then went the other direction because of my own inability to push those things out of my mind…like if your head's not there, like in anything in life, but especially with sci rehab, it's hard enough knowing that this happened." participants discussed the importance of recognizing that goals and priorities may vary by individual and that each person will begin the program looking for a different outcome. for some, success may be defined as an improvement in mobility, whereas for others success may be defined as increased social interactions, motivation, or health maintenance. "i think everybody's priorities and everybody's goals are different." "so i mean, so i don't want to lose those [functions] any worse than they've been getting over the years because it's like almost limited to what i can kind of do…" "well, i guess it depends on somebody's lifestyle and age has a lot to do with it. so i would say some people are just looking to maintain themselves and stay healthy to be able to continue to do the activities that they currently do." "yeah, and just feeling better as well in daily activities." interaction with other classmates a strong recommendation was made to foster potential interactions among classmates in order to motivate and inspire one another. an additional recommendation was to include a feature to extend class times to allow for social interactions among classmates before or after exercise. some participants suggested that two-way viewing among classmates should be optional, so as to not discourage those who might feel uncomfortable. "i think it would be key to interact with not only the therapist, but with other patients. so i see jack on the one screen and he's struggling, i'm like come on. do one more. do one more. and we're all telling himme, alex-jack, come on. do one more. and he pulls through, so it gives that mental back." "so you said a 45-minute designed program, but maybe its 60 min and we all log on 15 min before. we could all-oh, maria*, how's that going, or chris*, how's that? so the social muscle to it instead of just working on arms and then logging off, like good old talk." "but to have the ability to [see others] should certainly be an option… but they should at least have the option to turn it off if they want i think, right?" participants suggested that it would be helpful for someone to orient a class member, assist with equipment needs and demonstrate specific exercises included in the program prior to session initiation. participants suggested that including a variety of exercises within each class would be desirable, in order to meet personal preferences and to address varying physical abilities. multiple participants suggested that three times per week would be the preferred frequency of classes, held at a variety of days and times to accommodate different schedules (e.g., weekday, weekend, and evening sessions). the goal of this focus group was to discuss experiences with physical activity and gather input from persons with tetraplegia to inform future design of a physical activity program delivered via telemonitoring that would be feasible, acceptable, and consistent with exercise guidelines for those with sci. a minor aspect of the discussion revealed that, in general, priorities for improvement included: arm/hand function, sensation, and improvement of mobility as being most important. in addition, upper body/trunk strength and balance, elimination of chronic pain, and improving lived experiences of sexual function were also ranked as important. data demonstrate that different modalities of exercise and physical activity have indeed been shown to improve aspects of physical capacity, health, and abilities to perform activities of daily living (e.g., functional wheelchair maneuvers and transfers) in persons with sci [30] . participants perceived a home-based physical activity program as needed and important. intensity and type of physical activity performed before and after injury were discussed. participants identified family support, psychological state, and having a peer network (e.g., others with sci) as important factors for their overall recovery. participants regarded their input and feedback as critical for ensuring usability and feasibility, including the ability to make choices regarding whether a participant can be seen by classmates, types of exercises in a class, and timing of class delivery to suit multiple schedules. participants generally expressed enthusiasm for interacting with classmates, a desire for help from a caregiver or professional in initial set up, and comfort with a frequency of three times/week for classes and a duration of 45-60 min per class. participants perceived multiple potential benefits of a physical activity for persons with sci delivered via telemonitoring. participants had several practical suggestions to optimize design and delivery of such a program. clearly, a pilot study in this population testing this kind of intervention is needed. it is important that future studies incorporate feedback from participants on the design and implementation of a physical activity program. data generated during the focus group are not publicly available in order to protect privacy of participants. deidentified data can be made available upon request to the corresponding author. publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons. org/licenses/by/4.0/. annual statistical report for the spinal cord injury model systems public version traumatic spinal injury: global epidemiology and worldwide volume facts and figures at a glance facilitators and barriers to social and community participation following spinal cord injury social and community participation following spinal cord injury: a critical review position statement. part two: maintaining immune health position statement. part one: immune function and exercise reduction in trunk fat predicts cardiovascular exercise training-related reductions in c-reactive protein exercise and respiratory tract viral infections cardiovascular exercise training extends influenza vaccine seroprotection in sedentary older adults: the immune function intervention trial exercise, inflammation, and innate immunity american college of sports medicine position stand. quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline development of scientific exercise guidelines for adults with spinal cord injury the development of evidence-informed physical activity guidelines for adults with spinal cord injury more than just a game: the public health impact of sport and physical activity for people with disabilities (the 2017 delisa lecture) functional and environmental factors are associated with sustained participation in adaptive sports self-efficacy: the exercise of control self-efficacy: the exercise of control self-efficacy mechanism in human agency correlates and determinants of physical activity in persons with spinal cord injury: a review using the international classification of functioning, disability and health as reference framework participation in physical activity in persons with spinal cord injury: a comprehensive perspective and insights into gender differences participation in sport in persons with spinal cord injury in switzerland telehealth for people with spinal cord injury: a narrative review circuit training provides cardiorespiratory and strength benefits in persons with paraplegia a comparison of 2 circuit exercise training techniques for eliciting matched metabolic responses in persons with paraplegia using thematic analysis in psychology causes of death during the first 12 years after spinal cord injury targeting recovery: priorities of the spinal cordinjured population exercise and health-related risks of physical deconditioning after spinal cord injury acknowledgements the authors appreciate the time, effort, and opinions of the focus group participants.funding a grant from the new york state spinal cord injury research board (to ob) and institutional funds supported this work. these funds were used to support sci-related research at our institution and did not influence the specific study in any way.authors' contributions rp, ak, jh, dg, and ob designed the study. rp and ak led development of the moderator guide, to which all authors made contributions. jh and dg developed the proposed physical activity program. rp, ak, jh, dg, and ob created the demo video of the proposed physical activity program. all the authors (rp, ak, jh, dg, ac, bp, and ob) were present for the focus group. rp and ak moderated the focus group. ak and bp analyzed the transcript and wrote the report. all the authors (rp, ak, jh, dg, ac, bp, and ob) contributed to interpreting the data and writing the manuscript. conflict of interest the authors declare that they have no conflict of interest.ethics study activities were deemed not human subject research by the local institutional irb research and therefore did not require irb review. key: cord-344902-bittqpyo authors: scott, jennifer; abaraogu, ukachukwu o.; ellis, graham; giné-garriga, maria; skelton, dawn a. title: a systematic review of the physical activity levels of acutely ill older adults in hospital at home settings: an under-researched field date: 2020-10-15 journal: eur geriatr med doi: 10.1007/s41999-020-00414-y sha: doc_id: 344902 cord_uid: bittqpyo purpose: the purpose of this review was to identify, evaluate and synthesise existing evidence reporting the physical activity levels of acutely ill older patients in a ‘hospital at home’ setting and compare this to patients with similar characteristics treated in a traditional hospital inpatient setting. functional changes and any adverse outcomes due to physical activity (e.g. falls) in both settings where pa was reported or recorded were also evaluated as secondary outcomes. methods: a search strategy was devised for the medline, cinahl, amed, pedro, ot seeker and cochrane databases. search results were title, abstract and full-text reviewed by two independent researchers. data were extracted from included articles using a custom form and assessed for quality and risk of bias using the appraisal tool for cross-sectional studies. results: no studies set in the hospital at home environments were identified. 16 hospital inpatient studies met the criteria for inclusion. older patients managed in inpatient settings that would be eligible for hospital at home services spent 6.6% of their day active and undertook only 881.8 daily steps. functional change was reported in four studies with both improvement and decline during admission reported. conclusion: there is a lack of published research on the physical activity levels of acutely-ill older adults in hospital at home settings. this review has identified a baseline level of activity for older acutely ill patients that would be suitable for hospital at home treatment. this data could be used as a basis of comparison in future hospital at home studies, which should also include functional change outcomes to further explore the relationship between physical inactivity and functional decline. electronic supplementary material: the online version of this article (10.1007/s41999-020-00414-y) contains supplementary material, which is available to authorized users. hospital at home (hah) is a model of healthcare delivery which provides an alternative to hospitalisation by delivering acute-level hospital services in a residential setting [1] . the hah care model has increased in prevalence in recent years, with well-established programmes providing services in western europe, north america, brazil, australia, israel and south east asia [2] . home-hospitalisation has also been advocated during the recent covid-19 pandemic as a means of increasing bed capacity, facilitating quarantine and reducing disease transmission to vulnerable groups [3] . research interest has also been growing, with a more than sixfold increase in hah-related citations between 1999 and 2019 [4] . a recent systematic review found that hah may be a clinically effective alternative to inpatient care for some older, acutely-ill medical patients [5] . furthermore, it suggested hah treatment may pose less risk of physical functional decline to patients than the traditional ward-based inpatient environment [5] . functional decline is a known adverse effect of hospitalisation, affecting between 30 and 56% of older inpatients between admission to hospital and discharge [6] [7] [8] [9] , manifesting as a loss of muscle mass, strength, physical function and/or ability to perform basic activities of daily living such as dressing, eating and maintaining hygiene and continence [10] [11] [12] . physical inactivity while hospitalised, combined with older age, are predictors of functional decline [13] . hospitalised patients are highly inactive, with acute medical and surgical inpatients spending between 93 and 98.8% of their time sitting or lying [14] , and older patients spending as little as 76mins per day in an upright position [15] . recently published draft recommendations on physical activity for inpatients have emphasised the importance of incorporating opportunities for physical activity into the daily care of older adults to improve clinical outcomes, focusing on function, independence and activities of daily living [16] . however, there are many institutional barriers to physical activity in hospital including lack of staff support, tethering to medical devices, lack of assistive devices, and unfamiliar surroundings, as well as a fear of injury [17] . treatment in a less restrictive home environment may overcome such barriers, providing more opportunity for patients to continue to perform regular activities of daily living [5] , thereby lessening the risk of functional decline. this review sought to investigate the hypothesis that older, acutely ill patients treated in a hah setting may be more active than hospital inpatients with similar characteristics. the aim was to identify, evaluate and synthesise primary research studies reporting cumulative physical activity levels in these populations and, where reported, evaluate reports of functional decline or adverse effects resulting from physical activity during admission. as will be reported, no studies conducted in hah treatment settings were identified, and functional change outcomes were largely absent. the review protocol was developed in accordance with preferred reporting items for systematic review and meta-analysis protocols (prisma-p) [18] guidelines and registered with the international prospective register of systematic reviews (prospero, registration number crd42019138822) [19] . the review followed the guidelines set out in the cochrane handbook for systematic reviews of interventions [20] where applicable and complies with the prisma statement [21] for the conduct and reporting of systematic reviews. a comprehensive search strategy was developed in accordance with the cochrane recommendations for health care review [22] and reviewed by a specialist medical librarian. the search was initiated in july 2019 and updated 19 january 2020 to ensure currency. search terms and appropriate synonyms were chosen in alignment with the research objective and combined using boolean operators, subject headings, truncations and wildcards where appropriate. filters limited results to peer reviewed, english language, human studies with available abstracts published since 1980. all study designs were acceptable. the databases medline (ovid interface), central, cumulative index to nursing and allied health literature (cinahl), allied and complementary medicine database (amed), pedro and otseeker were chosen as the most relevant to the subject matter. the full search strategies with database-specific syntaxes for all sources are included in online resource 1. once key papers were identified, reference lists were handsearched and subject experts were approached to identify any further resources. 'grey' literature including conference abstracts, reports, unpublished data and dissertations were not included. multiple publications using the same participant dataset were excluded and the most comprehensive or recent publication used. setting studies set in either an hah or acute medical inpatient environment were included, studies did not have to compare both groups. hah was defined as 'a service that provides acute, hospital-level care by healthcare professionals in a home context for a condition that would otherwise require acute hospital inpatient care' [1] . an acute inpatient setting was defined as 'a hospital (private or public) providing 24-h care for people who are unwell and had an unplanned admission' [23] . as hah is designed to treat acute episodes of transient rather than chronic medical illness [5] , studies set in non-medical or non-acute environments such as palliative care, respite, rehabilitation, mental health, long-term care or residential nursing home facilities were excluded. studies concerned with post-discharge hah services (e.g. 'step-down' hah), were also excluded, as the focus of the research project is hah as an alternative to hospital admission for the preservation of physical function. participants studies involving patients aged 60 and over diagnosed with an acute-onset medical condition that would fall within the scope of a hah service were included. hah services predominantly manage non-surgical, non-critical conditions such as infection, acute exacerbations of cardiac and respiratory conditions, haematological and metabolic disturbances, and acute kidney injury [1] . certain conditions are not appropriate for management in a home setting such as those requiring surgery (e.g. acute coronary syndromes, orthopaedics), critical care or advanced diagnostics and interventions (e.g. stroke). to ensure that intervention and comparison populations were similar, studies containing these large numbers of patients with such conditions were excluded unless these participants could be discounted from the results. a margin of ≤ 10% of patients under 60 and ≤ 10% with excluded conditions was allowed. where numbers exceeded this margin, or other pertinent information was required, study authors were approached via email on up to 2 occasions to request abridged results. where a custom dataset was provided, this was used in analysis over the published dataset. intervention and comparator the intervention of interest was treatment in a hah setting compared to standard inpatient acute care. as this review aimed to establish if there are differences in the cumulative activity levels of patients in each setting, trials of other interventions to increase patient activity such as exercise programmes or physiotherapy sessions over and above usual care were not suitable for inclusion unless the physical activity levels of the control group were available, as the intervention group would not be representative of the general older acute population. outcome the primary outcome measure was the cumulative level of pa performed by patients receiving standard medical care in a hah and/or inpatient setting. it was decided a priori that acceptable measures would include objective methods, such as activity monitor data, or subjective methods, such as direct observation, self-reported instruments or questionnaires. changes in functional independence (e.g. activities of daily living, dependent walking) and physical performance (e.g. handgrip test, timed up and go) from admission to discharge, as well as any adverse effects reported as a consequence of physical activity (e.g. falls) were selected as secondary outcomes. the inclusion and exclusion criteria are summarised in table 1 . literature search results and bibliographic records were exported into refworks to facilitate deduplication and screening of titles and abstracts. articles meeting the inclusion criteria were then subjected to full-text appraisal. all records were reviewed by the lead researcher (js) and independently second-reviewed by another (ds, ua, mg or ge). the decision for inclusion or exclusion was recorded along with reasons for exclusion. where there was disagreement between reviewers on inclusion at any stage, a third reviewer was consulted. sixteen articles were selected for inclusion in the review. this process for identifying these is documented in the prisma flowchart [21] below ( fig. 1 ). the process of data extraction was performed using a custom template which was developed and piloted to extract: (1) data relevant to the research question, and (2) data required to perform a quality appraisal and risk of bias assessment using the appraisal tool for cross-sectional studies (axis) [24] (data extraction table: online resource 2, axis appraisal: online resource 3). the axis tool comprises 20 questions and considers study design and reporting quality in addition to the risk of bias when appraising research studies [25] . the data extracted were spot-checked for accuracy by the review team (ds, ua, mg or ge). where studies reported results for participants that were excluded from this review (e.g. surgical, non-geriatric) these were separated and excluded from the analysis. separate datasets were requested and received from karlsen [26] and valkenet [27] containing only participants that met the inclusion criteria. the physical activity outcomes of the studies were grouped according to their method of measuring physical activity levels and reporting format. in accordance with duvivier [28] , standing and slow walking have both been categorised as physical activity and grouped together into 'active time' for the purposes of analysis. time spent sitting or lying down, including sleep time, has been classified as 'non-active' time. this classification allowed 3 categories to emerge; (1) active time recorded over 24 h, (2) active time recorded over variable timeframes, and (3) physical activity as step count. the percentage of time spent actively was selected as a common scale to enable comparison of data across the studies. studies using step count as a measure of physical activity were reported separately. results reported in minutes were converted into a percentage of 24 h. median and interquartile ranges were converted into mean values using the formula devised by wan [29] to allow results to be summarised as pooled averages. summary independent t-tests were used to examine whether physical activity or step count differed significantly from the pooled averages when grouped by medical condition or studies at lower risk of bias. analyses were performed using spss v26, p < 0.05 was considered significant and 95% confidence intervals are reported. study characteristics no suitable hah studies were identified. all 16 included studies were conducted in single-site [21] acute inpatient hospital environments. the studies were published between 2006 and 2019, and the majority (n = 13) were cross-sectional observational designs aiming to establish the physical activity levels of patients as a primary outcome. this design is consistent with the nature of the research question, which does not aim to evaluate the efficacy of an intervention. of the remaining three studies, two were validation/agreement studies [27, 30] , and one was a randomised controlled trial (rct) [31] . participants most studies concerned general acute medical patients (n = 11, mean sample size 114, range . five studies were exclusively concerned with patients with specific conditions; two each reported physical activity levels of patients with acute exacerbations of chronic obstructive pulmonary disease (mean sample size 13.5, range 10-17) [30, 32] , and heart failure (mean sample size 36, range 27-45) [33, 35] and whilst one reported on patients with mixed medical conditions plus mild-moderate cognitive impairment (sample size 20) [34] . primary outcome all included studies assessed physical activity levels using objective accelerometer-based methods, except belala [34] who used behavioural mapping. valkenet [27] also performed behavioural mapping in addition to accelerometery (dynaport movemonitor). a variety of monitoring devices and algorithms were used, with the activpal (pal technologies, glasgow, uk) being the most commonly used device in studies concerned with posture (5 uses), and the stepwatch activity monitor (modus health, washington, us) used most frequently for step count (4 uses). the validity of the methods used was reported by most studies, except for the mediwalk pedometer (terumo, japan), used by ueda [31] . the range and validity of outcome measures used is available in online resource 4. the included studies were assessed for risk of bias using the axis tool [24] (online resource 3) which was deemed appropriate due to the high proportion of observational studies identified. there is an inherent risk of bias in descriptive, observational study designs, which rank low on evidence hierarchies, however, a well-designed and conducted crosssectional study can be of some evidential value [35] . the axis tool prompts consideration of selection, instrumentation and reporting bias as well as reporting and study design quality. it was also suitable for the evaluation of the methodology used to acquire and report physical activity levels in the rct included in this review [31] . a domain-based risk of bias assessment indicates a low risk of instrumentation and reporting bias, with adequate measurement and reporting of physical activity levels, however, there is a high risk of selection bias within the identified research (fig. 2) . the studies that performed better in the analysis [34, [36] [37] [38] gave greater consideration to reporting information on non-responders (patients that were eligible for inclusion but declined to participate). in terms of quality assessment, overall reporting quality was high, however, study design considerations were less well evidenced, with a broad lack of consideration of sample size, and frequently vague reporting of ethics or consent protocols. active time recorded over 24 h the level of inpatient physical activity reported as a percentage of 24 h could be established in seven studies (table 2) . when averages were pooled, the mean proportion of time spent active was found to be 6.6% ± 6.3 (range 3.8-8.3%). active time recorded over a variable timeframe three studies collected results over shorter, variable timeframes (7-12 h periods), during waking hours, and with different populations and measurement techniques (accelerometery and behavioural mapping), which precludes pooling of results, however, it can be seen that daytime-only levels are higher than the mean for 24 h results, ranging from 8.8 to 13.9% (median 10.7%) ( table 3) . physical activity as step count eight studies used pedometers or accelerometers to record 24 h step count as a measure of physical activity ( functional change between admission and discharge was reported in 4 studies, the results extracted are summarised in table 5 . as will be discussed, the reported outcomes from these studies were highly heterogenous in terms of tools used, data collection protocols and presentation of data, such that no summative conclusions on of the impact of differing physical activity levels on the incidence of functional decline could be drawn from the data. adverse effects occurring during the period of monitoring were poorly reported, with only four studies reporting this outcome; two advised there were no adverse effects [34, 38] and two reported one death (unrelated to physical activity) [31, 32] during the course of their research. sub-group analyses were performed comparing studies at lower risk of bias (according to axis appraisal) and concerning only one medical condition to the overall physical activity and step count results. both sub-group analyses found no significant difference in results comparing these devices to the overall results (table 6) , indicating the general results are an accurate representation of pa levels. the aim of this review was to identify, evaluate and synthesise the evidence on the physical activity levels of acutely ill older patients undergoing treatment in an hah vs inpatient setting. no hah studies of older adults could be identified, representing a significant gap in the literature surrounding this treatment model. despite the lack of hah research in this field, this review has provided useful data on the baseline physical activity levels that could be expected for patients suitable for treatment in a hah model of care: when monitored for 24 h/day, such patients spend on average 6.6% of the time active, and walk as few as 881.8 steps per day. these findings are consistent with other research on hospitalised older adults, despite the strict hah-specific inclusion/exclusion criteria applied. baldwin [14] reviewed 42 studies reporting the activity levels of acutely admitted medical and surgical adult patients, and found patients spent between 93% and 98.8% of their entire stay sitting or lying, and that the majority of studies reported a daily step count of < 1000. similarly, fazio [40] , in a systematic review of standing/ walking activity in medical inpatients, found that patients were active for 70 min per 24 h (4.9% of the time). the baseline pa values provided in this review may be suitable for use as an inpatient comparator value in future hah pa studies. the low levels of activity reflected in our findings can result in functional decline, however, in our results only four of the studies measuring physical activity also measured functional change. this represents a missed opportunity to further explore correlations between physical activity and functional decline that should be addressed in future pa studies in hospitalised and hah patients. where functional changes were reported there was high heterogeneity in results between studies. agmon [41] established that walking less than 900 steps when hospitalised was strongly associated with functional decline in older adults. both ueda [31] and villumsen [39] reported a mean step count below this threshold, and while both reported results using the barthel index, measurements were taken at different points in the studies and the results were presented differently: ueda [31] reported the change in mean score, while villumsen [39] reported the percentage of participants who improved. in all, six different metrics were used in the four studies reporting functional change, with high variability in measurement tools (see online resource 4), data collection protocols and reporting formats, precluding meaningful synthesis of the results. assessing physical function in acutely ill older inpatients who may present with a wide range of medical conditions and functional levels is undoubtedly challenging, and research is ongoing to identify the most feasible tools to use in this patient group [42] . a consensus-driven core outcome set for studies of functional performance in either older or hospitalised populations has yet to be developed and should be a research priority to allow evaluation and meta-analysis of the findings of studies in this field. placing the findings of this review in the wider context of physical activity research is challenging again due to substantial differences in the methods and outcome measures used. the techniques most frequently utilised in the studies in this review (24 h recording, positional accelerometery) rarely feature in population or community-based research. including night-time activity is likely to present a more accurate picture of all activity undertaken, especially in a hospital setting where circadian rhythms may be disrupted [14] , but will result in lower average activity levels than studies of day-time pa or sedentary behaviour only. this is evident in the results for the three studies that conducted monitoring over a shorter, daytime, timeframe (table 3 ) which found physical activity ranged from 8.8 to 13.9% of the monitoring period. as a result of these different outcome measures, recording periods and a lack of objectively established normative values for the 24-h physical activity of healthy free-living older adults, it is challenging to establish how much activity drops when hospitalised. however, as the continuous objective monitoring of research participants becomes easier and cheaper with developments in accelerometery and wearable digital technology, it may be the case that normative values for pa in free-living older adults can be established. this would allow more accurate evaluation of the extent to which normal pa is impeded by acute illness, in both hah and inpatient settings. a strength of this review is that it followed a systematic approach following cochrane guidelines where applicable [20] and was reported in accordance with prisma statement, which reduces the risk of bias. a possible limitation of this review is its high specificity arising from highly refined inclusion and exclusion criteria. this led to some potentially relevant articles being excluded. for instance, two promising rcts were identified during the literature search and selection process which found that adult hah patients may around 2.6 times more active than inpatients [43, 44] , however, these studies were excluded as it was not possible to isolate the results for participants aged over 60 years-only. a further limitation of this review is the high risk of bias present in the studies identified, which may limit the representativeness of the findings. physical and functional decline, caused in part due to inactivity during hospital admission, can have a considerable impact on an older patient's health and ability to remain independent on discharge. hah may offer a treatment environment that preserves and facilitates physical activity in older patients, however, it has been demonstrated in this review that there is a lack of research evidence to confirm this. this review has provided an indication of the baseline activity levels of inpatients suitable for a hospital at home service, however primary objective research is needed in this treatment setting. this review also identified that functional change is infrequently measured along with physical activity, representing a missed opportunity to assess the impact of immobility in hospital on function. where they are reported, functional measures are highly diverse and data collection protocols vary, impeding comparisons between studies. a consensus-driven core outcome set for the investigation of functional decline in hospitalised patients would greatly facilitate the comparison and synthesis of research in this field. sedentary behaviour, defined as 'any waking behaviour characterized by an energy expenditure ≤ 1.5 metabolic equivalents (mets), while in a sitting, reclining or lying posture' [45] , was included in the search strategy as a related field to physical activity. no studies reporting sedentary behaviour as the primary outcome met the inclusion criteria, therefore, this concept is not discussed further in this review. funding the writing of this review was funded through a joint nhs lanarkshire-glasgow caledonian university phd studentship. the funders have had no input in the writing of this review or it's conclusions. hospital at home, guiding principles for service development world hospital at home congress. societies and programs why we should expand hospital-at-home during the covid-19 pandemic citation report for "hospital at home". clarivate analytics admission avoidance hospital at home. cochrane database syst rev no one size fits all-the development of a theory-driven intervention to increase in-hospital mobility: the "walk-for" study the effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis trajectories and predictors of functional decline of hospitalised older patients predictors on admission of functional decline among older patients hospitalised for acute care: a prospective observational study reducing, "iatrogenic disability" in the hospitalized frail elderly the hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients rethinking hospital-associated deconditioning: proposed paradigm shift. phys therapy daytime physical activity and sleep in hospitalized older adults: association with demographic characteristics and disease severity accelerometery shows inpatients with acute medical or surgical conditions spend little time upright and are highly sedentary: systematic review daily and hourly frequency of the sit to stand movement in older adults: a comparison of day hospital, rehabilitation ward and community living groups recommendations for older adults' physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international delphi study attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015: elaboration and explanation cochrane handbook for systematic reviews of interventions preferred reporting items for systematic reviews and meta-analyses: the prisma statement crd's guidance for undertaking reviews in health care targets for older adults' physical activity and sedentary behaviour during hospitalisation: an international delphi study development of a critical appraisal tool to assess the quality of crosssectional studies (axis) methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better improved functional performance in geriatric patients during hospital stay measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer minimal intensity physical activity (standing and walking) of longer duration improves insulin action and plasma lipids more than shorter periods of moderate to vigorous exercise (cycling) in sedentary subjects when energy expenditure is comparable estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range assessing sedentary behavior with the geneactiv: introducing the sedentary sphere impact of oral treatment on physical function in older patients hospitalized for heart failure: a randomized clinical trial gosselink r (2006) physical activity and hospitalization for exacerbation of copd a pilot study examining activity monitor use in older adults with heart failure during and after hospitalization a pilot observational study to analyze (in)activity and reasons for sedentary behavior of cognitively impaired geriatric acute inpatients levels of evidence in medicine walking in hospital is associated with a shorter length of stay in older medical inpatients mobility activity and its value as a prognostic indicator of survival in hospitalized older patients very low levels of physical activity in older patients during hospitalization at an acute geriatric ward: a prospective cohort study 2020) how much do hospitalized adults move? a systematic review and meta-analysis association between 900 steps a day and functional decline in older hospitalized patients feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients hospital-level care at home for acutely ill adults: a pilot randomized controlled trial hospital-level care at home for acutely ill adults: a randomized controlled trial sedentary behavior research network (sbrn): terminology consensus project process and outcome stepping toward discharge: level of ambulation in hospitalized patients acknowledgements thanks to dr alexandra mavroiedi of strathclyde university for advice given during the drafting of the protocol preceding this review and to julie smith, specialist librarian within the school of health and life sciences, glasgow caledonian university for assistance with devising the search strategy. thanks also to professor jon goodwin for advice on data analysis strategy and to dr phillipa dall for assisting with the full text review stage. js was funded to write this review through a joint nhs lanarkshire-glasgow caledonian university phd studentship.author contributions js, ua, ge and ds conceived the review. all authors contributed to the development of the search strategy and participated in the screening, review and selection of the included papers. js drafted the review and all authors reviewed, provided feedback and approved the final manuscript. the authors declare that they have no competing interests.ethical approval not applicable. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. key: cord-329640-10trdf87 authors: jeong, hyun-chul; so, wi-young title: difficulties of online physical education classes in middle and high school and an efficient operation plan to address them date: 2020-10-05 journal: int j environ res public health doi: 10.3390/ijerph17197279 sha: doc_id: 329640 cord_uid: 10trdf87 this study examined the difficulties of running online physical education classes in the context of coronavirus disease 2019 (covid-19) and used the findings to develop an efficient operation plan to address these difficulties. six middle and high school physical education teachers participated; three were experts in online physical education and active in the korea council school physical education promotion, and three were recommended teachers making efforts to improve the online classes offered by the korea ministry of education. a qualitative case study method employing phenomenological procedures to collect and analyze the data was used. the difficulties of operating middle and high school online physical education classes for the first time included (1) the monotony of the classes within their limited environmental conditions and limited educational content that did not adequately convey the value of physical education, (2) trial-and-error methods applied nationwide, resulting from a lack of expertise in operating online physical education classes, and (3) very limited evaluation guidelines proposed by the korea ministry of education, which made systematic evaluation with online methods impossible. to address the identified problems and facilitate the efficient operation of online physical education classes, changes in strategic learning methods are needed to understand online physical education characteristics and thereby better communicate the value of physical education. it is also necessary to cultivate teaching expertise through sharing online physical education classes, where collaboration among physical education teachers is central. in addition, evaluation processes should be less formal to encourage active student participation. the entire world is currently facing a catastrophic situation resulting from the coronavirus disease 2019 (covid19) pandemic, which has affected the daily lives of people worldwide. since the world health organization declared a pandemic on 11 march 2020, avoiding face-to-face activities and engaging in social distancing have become a part of everyday life. the pandemic has also induced changes in many countries' educational environments as they began instituting online classes, including south korea (hereinafter korea), whose schools failed to begin the regular school year in march, for the first time in history. despite this unprecedented situation, korea is actively responding to social changes by offering a diverse school curriculum through online classes and developing new approaches to education. the changes required by the crisis may present an opportunity to adapt to the education needs of the incipient fourth industrial revolution. in many studies preceding covid-19, the possibility of online classes has been examined as a part of future education, in that online classes can provide highly efficient and diverse elective classes to self-directed students [1] [2] [3] [4] [5] [6] . physical education centers on physical activity and is clearly distinct from general knowledge-based subjects. therefore, online physical education classes require special preparation and operation to communicate and practice the values of physical education well. currently, as in-person school attendance and online classes are occurring in tandem around the world, there is a need to examine whether online physical education classes are being held and conveying the values of physical education appropriately. prior studies on the efficiency and potential of online physical education classes, however, are limited [7] [8] [9] . one such study focused on physical education textbooks published by the university of north carolina at greensboro and suggested employing direct and indirect experiential activities in addition to physical activities [8] . it further proposed a teaching and learning strategy for the management of interaction and motivation, learner-centered classes, and the application of a blended learning strategy in middle school physical education classes [9] . however, most existing studies have only examined the efficiency of college classes, within limited areas; to the best of our knowledge, no studies have investigated the difficulties or efficient operation plans of middle and high school online physical education classes. thus, there is a need to identify the existing practices of and best directions for future online physical education classes, both during and after the pandemic. this study identifies the difficulties of middle and high school online physical education classes and suggests ways to efficiently manage future online physical education classes. the results may serve as basic material to help revitalize online physical education classes in the future. the study employed a qualitative case study method using phenomenological procedures to collect and analyze the data [10] . "turning to the nature of lived experience" of research participants' online physical education classes, the study explored the experience of conducting these classes, discussed and reflected on their efficient operation and difficulties experienced therein, and examined the data by "writing and rewriting". to find a generalized representation of middle (14-16 years old) and high (17-19 years old) school online physical education classes in korea, the researcher selected six participants for this study, who were recommended by the korea ministry of education and the council for school physical education promotion, which pursues the revitalization of physical education in korea. three participants were middle and high school physical education teachers who were experts in online physical education; the other three had worked to improve the three types of online classes offered by the korea ministry of education. all participants provided informed consent to participate in the study, which was approved by the korea jeonbuk national university high school. table 1 shows the characteristics of the research participants. as a physical education teacher at "s" middle school in the 7th year of his educational career, he runs a "physical enhancement program", an interactive pe class of about 20 students, utilizing zoom. he is a training instructor for online pe content for physical education teachers nationwide and has a good understanding of the pros and cons of interactive pe classes. "i" high school (9 classes) female a as a physical education teacher for "i" high school in the 20th year of her educational career, she runs a "home training and yoga program" using microsoft teams, for a class of 15. while operating interactive teacher/student physical education classes, she tries to motivate student participation by using various video content and constantly strives for immediate feedback and interaction with students by asking questions via video. content-oriented physical education class "j" middle school (32 classes) female b as a physical education teacher for "j" middle school in the 11th year of her educational career, she runs a content-oriented physical education class using ppt and open broadcaster software (obs studio) programs for a class of 30. she switched to a content-oriented physical education class after initially running an interactive pe class, in which many students found it difficult to participate. "j" high school (24 classes) male b as a physical education teacher at "j" high school in the 15th year of his educational career, he runs a content-oriented physical education class using youtube and videos he has produced for a class of 30. he runs a class that combines theory and practice using physical education textbooks. he also works as a lecturer for the j-region physical education research association. assignment -oriented physical education class "h" middle school (23 classes) male c as a physical education teacher at "h" high school in the 23rd year of his educational career, he runs an assignment-oriented physical education class using basic lecture-type content for a class of over 30. in addition to physical activity assignments, he offers online group learning assignments to students and provides feedback during class. currently, he works as a lecturer in the operation of assignment-oriented physical education classes nationwide. "g" high school (30 classes) female c as a physical education teacher at "g" high school in the 4th year of her educational career, she runs an assignment-oriented physical education class for 30 students. the class is interactive and includes feedback from the teacher and focuses on "national health gymnastics" and "creative gymnastics" developed and practiced by students. the class uses google classroom and is equipped with assignment videos and explanations. pe, physical education. the collected data included material directly produced by the research participants and online videos of their physical education classes. in-depth individual and group interviews were conducted to examine experiences emerging in the participants' journals. we examined the participants' personal diaries and their online physical education class operations. five in-depth individual participant interviews lasting 50-70 min were conducted between march and june 2020. the interviews began with participants describing individual operation plans and were centered on the operation of these cases. five group interviews lasting 60-90 min were also conducted from april to june 2020, focused on difficulties that were encountered and overcome in the online physical education classes. the group interviews were comprised of open discussions among the research participants, which allowed collaborative and interpretive reflection within a seminar format. an inductive category analysis was employed, focusing on open coding, axial coding, and core coding [11] . the researcher worked to understand the overall flow and true meaning of the material through repeated reading. the meanings were classified and grouped by subject and analyzed through technical, reflective, and interpretive writing; then, the relationships between the essential elements of the results were identified to determine the overall structure. finally, an iterative process of reinterpretation, modification, and integration was applied to ensure that the generated categories reflected the purpose of the study. to enhance the validity of the study and test the consistency of the findings, a triangulation technique cross-verified data through an in-depth description from various angles using the collected data and the researcher's notes. the derived results were reviewed by the participants to ensure that their meanings were accurately expressed. the quality of the study was ensured through continuous feedback from two qualitative research experts (professor "s" of "j" university and professor "l" of "s" university), who reviewed the entire study process. difficulties in conveying the value of sports in online physical education classes remained in the modified technical practice. this value included maintaining health through physical activities, cultivating community consciousness through physical activities with friends, and developing sports etiquette through sports participation. students engaged in online physical education classes often cannot secure enough space to effectively take part in physical activity and also have limited access to supplies and equipment needed to follow online physical education classes. thus, the participants running the online physical education classes used supplies that were readily available at home, which necessarily reduced the physical education units that could be taught. this led to a shift in focus from competition, which is a major part of in-school physical education, to health and physical activity challenges in online instruction. teacher "a": in online physical education classes, students had to participate alone and use the supplies at home, so it was inevitable that classes were limited. however, it was easy for me to give feedback because i run a real-time interactive class and students practice it immediately in line with my fitness program. teacher "c": real-time interactive classes can be effectively used in a small class, but it seems inefficient in a class of about 30 students. thus, i used lecture-type content to provide explanations and demonstrations, present assignments, and give feedback. teacher "b": i run a content-oriented class, but i had doubts about whether the values of physical education that we wanted to deliver were being conveyed well, given the limited environment and the fact that students had to practice alone. teacher "c": i agree. i had actually planned a class in the competition area, but i could only do classes in the health area. i was worried that the students would feel too complacent about physical education through such classes. teacher "a": i had no choice but to run really monotonous classes like juggling and "challenging" stay-at-home challenges that could be done in students' own houses. (from the first group interview). in contrast to the general knowledge focus of core subject courses, physical education focuses on physical activity, an emotional domain. all participants had concerns about how to convey physical activities in online physical education classes and how to make the online physical education class a meaningful educational activity. in a study of physical activity limitation, kim et al. [12] reported that various physical educational activities geared toward health should be included in an online class, as most participants, despite various ages and genders, had health problems. it is possible that online physical education classes can be made more efficient if students receive feedback through viewing their own or their classmates' actions. this is in contrast to face-to-face physical education classes, where students can immediately receive feedback on their motor skills or their success completing physical activities. in contrast, students cannot modify their own activities by viewing a video of them, so they receive limited feedback. immediate feedback is needed to motivate students to learn and strengthen their active class attitude. the participants tried to provide feedback across time and space through online media; however, this was difficult, because basic rapport between the teacher and the students and among the students themselves was not able to develop well through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. there was an interaction between teachers and students when the teacher provided feedback by checking students' online assignment performance. this interaction became an advantage of interactive physical education classes and assignment-oriented physical education classes. however, this was difficult because basic rapport was not developed through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. (from the in-depth interview of teacher "a"). like the result of the in-depth interview with teacher "a," the interaction between the teacher and the student becomes an important factor for the realization of the value of physical education. this experience suggests that attempts to convey the value of physical education should be initiated later in the semester, after rapport has been developed between the teacher and their students and after the technical skills for various sports have been reviewed [13] . online physical education classes, instituted nearly worldwide during the 2020 pandemic, were a wholly new experience for both teachers and students. the sudden shift to online classes left teachers unprepared and struggling with unfamiliar teaching methods, forcing them to resort to trial-and-error approaches. inadequate online teaching strategies and low teacher and student readiness for online classes made the transition difficult [14] . i had to think about the content of physical education classes that i could do online with the start of online classes due to covid-19, and about the content of the class that could be evaluated when students came to school later. the content of online physical education classes were selected based on individual sports that can be done while maintaining social distancing after school starts. however, as the use of various evaluations (individual evaluation, group evaluation, etc.) was limited due to restrictions on class activities by group, i was very worried about what to do. (from the in-depth interview of teacher "b"). the filming and production of online class materials by the physical education teacher himself took two to three times longer to prepare (e.g., production and editing) than the existing physical education classes. even if various content (youtube, internet materials, etc.) was used, it took a lot of time and effort to search for videos and materials that matched the teaching content of the physical education teacher's class. (from the in-depth interview of teacher "c"). the participants' principal concerns about running online physical education classes centered on the lack of efficient content and difficulties in using the content. they worried about the students' ability to participate in sufficient physical activities given space restrictions and the online course content they created, and whether the course content was educationally meaningful. the availability of media to capture and edit various physical activity photos and videos was absolutely essential for online course preparation. the participants experienced considerable confusion in their initial attempts at online instruction, although the ministry of education and the municipal and provincial education offices provided guidance and training on operating online classes and copyright issues after the switch to online classes. i feel that it is more important than anything else for physical education teachers to develop their ability to efficiently use content in the areas where various aspects of physical activity are expressed and where the content of explanation, demonstration, and feedback is provided. this is an important point that i realized while lecturing in the content utilization training course due to the fact that physical education is unlike the general subjects. i believe that my experience in online physical education classes will definitely be an opportunity. (from the research journal of teacher "a"). the physical education teachers had to revise their education plans, courses, and evaluations several times in their online physical education classes. it is true that it is very confusing. i am going through a lot of difficulties because it is my first time using the content of online physical education classes and making evaluations. (from the in-depth interview of teacher "b"). physical education teachers who were familiar with online content could easily incorporate it. however, others had difficulties even with simple tasks, such as uploading lectures and linking videos from different sites. those who developed their own lectures experienced difficulties preparing for online physical education classes, because they lacked the necessary equipment (cameras, microphones, laptops, etc.), had no access to software for editing images and coding video files, and/or lacked experience in using such software. to maximize the efficiency of online physical education classes, both teacher effort and collaboration with online experts were essential [7] . the ministry of education presented guidelines for evaluating online classes [15] , which specified that teachers were to refrain from conducting evaluations unless they could be done face-to-face and recommended conducting evaluations after the return to in-class instruction to the extent possible. participants found it difficult to apply evaluations to online physical education classes. it seemed unreasonable to evaluate students on what they had learned in school following a long period of online classes-especially if these were conducted solely through lectures and assignments without the students actually performing and practicing the activities to be evaluated-particularly because the proportion of the evaluation based on physical activity was high, given the nature of the subject of physical education. this differs from general subject evaluations, where written examinations based on online course work can be administered after the return to in-school classes. although students could submit physical education performance evaluations in the form of videos and written assignments, it would be very time-consuming for large schools to determine whether students had submitted the evaluation materials and then to actually evaluate those materials. in order to evaluate a gymnastics movement, i asked the students to take a picture of themselves doing the gymnastics movement and upload it. however, there were limits in uploading the entire gymnastic movement, and so the evaluation was made in partial movements. in addition, there was too much restriction in providing feedback and evaluation for all images. (from the in-depth interview of teacher "c"). it has been a while since online physical education classes started, but i don't believe that the performance evaluation proposed by the ministry of education is a concrete plan yet. evaluations must be done in terms of efficiency and expandability of online physical education classes. (from the in-depth interview of teacher "b"). teacher "c", who had been conducting performance evaluations based on assignments, found it difficult to complete the evaluations, because performance assessment was not conducted in real time. in addition, she felt that the diversity and specificity of the evaluation was very poor because they were limited to evaluating individual activities through videos. each study participant completed evaluations according to the type of online physical education classes they conducted, and all participants described encountering specific difficulties in completing the evaluations. teacher "a": it is very difficult to check the performance of what students practiced in real-time interactive classes. teacher "a": the home training and yoga practice scenes were evaluated in real time, but the evaluation took too long. teacher "b": the performance assignment was checked through simple quizzes and discussions during the content-oriented class, but there were many difficulties in evaluating the actual activities and conducting detailed evaluations. teacher "b": i believe that the evaluation is essential for online physical education classes. for self-directed learning, the evaluation parts associated with the assignment should be presented in various forms. teacher "c": many teachers spend too much time giving feedback and evaluations in assignment-oriented classes. systematic supplementation is needed online. teacher "c": since there is a very limited amount of information that can be recorded in the student record in the existing evaluation, a new evaluation method that can evaluate and record the learning process should be introduced. (summary of the discussion on evaluations in the second and third group interviews). in the second and third group interviews, participants discussed the difficulties of the evaluation and argued that evaluation concepts and practices for online physical education classes should be re-established based on the current evaluation results. they likewise argued that these concepts and practices should include measures that confirm whether students actively participated in the online physical education classes. in addition, physical activity content that can be viewed online needs to be expanded. online physical education classes need to teach the value of physical activity as an important element of health [16] . however, before teaching students the value of physical education, teachers should focus on physical education concepts while preparing students to actively participate in the online class. online physical education classes should teach students to subjectively develop future physical activity plans and self-directed competencies. although the internet delivers classes without time and space constraints that nearly everyone can access, such classes are ineffective and inefficient if students do not actively and responsibly participate. in other words, the students' attitude toward self-directed learning is an important factor in the efficient operation of online physical education classes. therefore, teachers need to develop educational strategies for online classes that help students form a learning attitude. engaging and motivating students to participate in physical activities can help convey the value of physical education [17] . teacher "b": when conducting training for teachers, the issue was raised that no matter how much effort is made by the teacher to conduct a good class, it will be of no use if the students are not willing to listen. in such a case, the plan needs to be re-examined. teacher "c": yes, that is correct. if the online physical education class begins and no assignments are given, it would not be possible to check if the student is listening to the online class. actually, some students do assignments without listening to assignments, which means you can set a group for the class and complete the group work outside of class. thus, i have tried interactive classes among students to complete a set of assignments as a group. teacher "a": that's a good idea. before discussing the value of physical education, it should be preceded by many educational devices and materials so that students can listen to online classes with an attitude toward self-directed learning. teacher "b": yes, i agree. the value of physical education should be naturally achieved in class, and a good class will be meaningless if the students do not have active learning attitudes. teacher "c": yes, i have tried to make changes in the existing physical education class by making students submit reports and videos based on their activities to make them actively participate in class. (from the fourth group interview). in the group interviews, participants discussed the buzz learning method as a way to increase student participation in online classes [18] . changes are essential for developing and applying group assignments that encourage student participation to overcome the disadvantage of online physical education classes [18] . new assignment content needs to be developed in the future that will allow teachers to identify an individual student's learning status, just as the research participants developed different educational strategies to increase the value of the class. physical activity does not necessarily need to be central in the actual class to establish the value of physical education; park et al. [19] reported that the establishment of the value of physical education based on various types of materials is necessary in online physical education classes, as various audiovisual aids and activity equipment are provided to support the positive health behavior of university students. there is a need to develop ways to link the emotional areas while expanding the cognitive and defining areas, which can be an advantage of online physical education classes. teacher "b" made great efforts to motivate and interest students by using physical education textbooks to explain theoretical aspects and presenting images to help students understand the material. indirect experience based on direct experience of physical activity and the value of physical education were delivered through intensive classes in cognitive areas using physical education textbooks. (analyzing the content of teacher "b's" online physical education class). i do not think that it is necessary to teach the value of physical education centered on physical activity. rather, i think that by running this online physical education class, i was able to deliver the value of integrating various topics through theoretical classes in physical education textbooks. i tried to convey the value of physical education by using various video images, arguments, discussions, and reporting that were not well utilized in existing physical education classes. (from the in-depth interview of teacher "b"). online physical education classes are clearly different from traditional physical education classes. participants made changes while running online physical education classes and conveyed the value of physical education in different ways. participants pointed out that one change driven by online physical education classes was the active progress made by physical education teachers through collaboration, which provided training and help to teachers who had difficulty creating content in the early stage of online classes. this collaboration naturally expanded as they produced class videos and shared ideas on assignment methods and structures and class content. this collaboration was driven by the power of collective intelligence within the physical education community and demonstrated a culture of sharing based on the autonomy of the physical education research society and networks among colleagues [20] . considering that this is my first online class this year, the most distinguishing feature is that there is a place where physical education teachers from a variety of schools share the materials, content, and concerns regarding online physical education classes. would you say that we were tightly united in a crisis? it seems to have served as an opportunity for physical education teachers to reduce the trial-and-error and to develop better physical education classes. (from the in-depth interview of teacher "c"). the research participants' videos showed that physical education teachers collaborated on making demonstrations and teaching, thereby producing more professional content by producing a joint video that fit the class subject. (from the researcher's journal) . the importance of the teacher learning community is reported in many studies on the development of teacher expertise [21] [22] [23] . physical education class videos continue to be produced and teachers continue to cultivate their expertise as they develop and produce these class videos. research participants continued to develop their expertise by searching for educational materials, including carefully examining materials from the council school physical education promotion and the physical education research society, while developing online physical education classes. they further developed their expertise by producing and editing their own videos. the results of their efforts provide a good example of how to effectively prepare for future physical education. i was at a loss when i first started preparing for online physical education classes, but i received a lot of help from the teachers at the physical education research society. in addition, it really helped me cultivate my expertise while reflecting on my class. it was also very helpful to be able to view the classes of other physical education teachers, which used to be hard to see before. (from the in-depth interview of teacher "a"). it was great to be able to look at the really valuable materials in the council school physical education promotion and the national physical education teacher group's "katokbang". it was good to see many physical education teachers collaborate and build their expertise in "an opportunity that lies in a crisis". that is why i became confident in my class, too. (from the in-depth interview of teacher "c"). physical education teachers who strive to improve their expertise give students faith in the subject. faith creates interdependence through communication between the teacher and the students and also acts as an "invisible bridge" in physical education classes [24] . faith between the teacher and students can also be indirectly formed by the teacher's demonstrating instructional content and expertise while running an online class. efforts are needed to cultivate professional and practical knowledge suitable for online physical education classes through changes in teaching and learning methods, interaction with students, a broad understanding of the area, and expanded knowledge. online physical education performance is difficult to evaluate. traditional evaluations are extremely limited, including online and offline integrated evaluations, process-oriented evaluations, and physical activity-oriented evaluations. the research participants adapted their evaluation methods to determine whether the student achievement standards were met and whether advancement to the next class was appropriate. teacher "a": teacher evaluation is conducted by looking directly at the student's activities. peer evaluation is conducted by students looking at one another. teacher "a": our evaluation method entails showing various videos that fit the topic of the class and talking about the feelings they elicit in real time. teacher "b": there is no direct evaluation, and the achievement standards are reviewed by looking at the class and simply writing the overall content in the form of a report. teacher "b": a self-assessment is conducted to determine whether the student has participated in class with an attitude toward self-directed learning, and whether the student has completed the assignments, but they are not reflected in the student's score. teacher "c": evaluations cannot be made because it is an assignment-oriented class. images of the student's physical activity are used to deliver feedback through student self-assessment and teacher evaluation. teacher "c": based on the attached content of assignments carried out by the student, the course is recorded in the physical education section of the student's study record. (summary of evaluation discussion in the fourth and fifth group interviews). one characteristic of online education is that students can develop unique thinking through learning activities that meet their needs and cultivate creativity through the process of thinking [25] . evaluation methods need to be improved to capture the process of verbalizing students' thoughts. it is necessary to conduct evaluations in the form of an inspection to understand the educational value of online physical education classes, much like the way in which the research participants expanded the evaluation to assess diagnosis, formation, and achievement in addition to performance. the above student faithfully carried out the assignments regarding national health gymnastics during online physical education classes, understood and analyzed teacher and peer evaluation feedback, and faithfully participated in the assignments. (from the examples of study records by teacher "c"). teacher "a" evaluated interactive lessons in real time, but emphasis was placed on the students who delivered feedback and made corrections according to the feedback. in addition, a peer evaluation method was applied to the class in which feedback was provided by watching videos that in real-time interactive class, meaning other students watch the monitor video between students through informal evaluation. (analyzing the content of teacher "a's" online physical education class). research participants used informal evaluations to record student participation in the study record as a way to induce active participation. this was done while using the performance evaluation content required in physical education classes as a learning strategy. evaluation of the online classes, which was conducted for the first time in 2020, is not yet concrete, and efficient evaluation methods and content should be examined in future studies. this study examined the difficulties teachers experienced in running online physical education classes following the start of online schooling in korea in the context of covid-19 and presented an efficient operation plan for future online physical education classes. the difficulties of operating online middle and high school physical education classes included monotony related to limited environmental conditions and educational content, which ultimately decreased the effectiveness of conveying to students the value of physical education. it is necessary in this light to discuss the value of physical education during online classes. second, physical education teachers across the country lacked expertise in employing online content and had to resort to trial-and-error methods. to address problems like these, we expect that effective content will develop in various directions due to the covid-19 outbreak. third, student evaluations conducted in accordance with the evaluation guidelines proposed by the korea ministry of education were very limited, and a systematic evaluation was not possible because of the online nature of the classes. there is a possibility that a new evaluation method that can be operated effectively in online classes will need to be constructed. in addition, to develop effective online physical education classes, strategic learning methods that incorporate online physical education characteristics are needed to help teachers communicate the value of physical education. in delivering the values of physical education, which is the goal of physical education in korea, addressing the psychodynamic domain and affective domain, which are lacking in online classes, will certainly improve the efficiency of online physical education classes. second, physical education teachers need to prepare for the future methodology of physical education and acquire professional practical knowledge through sharing online physical education content. this collaboration among physical education teachers is central and should incorporate expertise from the korea physical education research society. third, it is necessary for students to make an effort to actively participate in online physical education classes and record the process in their life record books through discussion of evaluation methods and methods suitable for an online physical education class. in this study, the research participants did not have extensive experience in information and communication technology coming into the pandemic and the advent of online education, but they nevertheless actively participated in online physical education classes and played the role of representatives of korea, making the active efforts required by the times. finally, the need is apparent to explore various cases of online physical education, teachers' and students' experiences, and their meaning, to improve the generalizability of the lessons learned. the study findings had several implications. first, it is necessary to study the state of different countries' experiences in online instruction physical education instruction, comparing and analyzing how online physical education classes are conducted worldwide. accordingly, there is a need to review and systematize approaches to online physical education classes that highlight each country's cultural and educational characteristics and to examine the effectiveness of online physical education classes as a whole. second, there is a need to explore the potential of online physical education classes linked to face-to-face physical education classes to examine their respective effectiveness and potential possibilities in light of physical education teachers' increased expertise gained through their operation of online physical education classes. third, future studies should establish a theoretical framework for online physical education classes by examining the educational value of modifying existing pedagogical methods, content, evaluations, and so on to more effectively teach online physical education classes. fourth, future studies should also examine the efficiency and affordances of different online platforms employed by physical education teachers and evaluate their generalizability across actual school sites, especially as novel tools are developed. interaction and presence in the virtual classroom: an analysis of the perceptions of students and teachers in online and blended 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management experience of learner-centered physical education characteristics of online teaching in post-secondary, formal education funding: this research received no external funding. the authors declare no conflict of interest. key: cord-347126-hvrly37e authors: stanton, robert; to, quyen g.; khalesi, saman; williams, susan l.; alley, stephanie j.; thwaite, tanya l.; fenning, andrew s.; vandelanotte, corneel title: depression, anxiety and stress during covid-19: associations with changes in physical activity, sleep, tobacco and alcohol use in australian adults date: 2020-06-07 journal: int j environ res public health doi: 10.3390/ijerph17114065 sha: doc_id: 347126 cord_uid: hvrly37e the novel coronavirus (covid-19) has enforced dramatic changes to daily living including economic and health impacts. evidence for the impact of these changes on our physical and mental health and health behaviors is limited. we examined the associations between psychological distress and changes in selected health behaviors since the onset of covid-19 in australia. an online survey was distributed in april 2020 and included measures of depression, anxiety, stress, physical activity, sleep, alcohol intake and cigarette smoking. the survey was completed by 1491 adults (mean age 50.5 ± 14.9 years, 67% female). negative change was reported for physical activity (48.9%), sleep (40.7%), alcohol (26.6%) and smoking (6.9%) since the onset of the covid-19 pandemic. significantly higher scores in one or more psychological distress states were found for females, and those not in a relationship, in the lowest income category, aged 18–45 years, or with a chronic illness. negative changes in physical activity, sleep, smoking and alcohol intake were associated with higher depression, anxiety and stress symptoms. health-promotion strategies directed at adopting or maintaining positive health-related behaviors should be utilized to address increases in psychological distress during the pandemic. ongoing evaluation of the impact of lifestyle changes associated with the pandemic is needed. first reported in november 2019, the novel coronavirus (covid-19) has resulted in a global health emergency. as of 3 june 2020, the virus has claimed more than 375,000 lives globally and infected more than 6.2 million people. the scale of the pandemic has resulted in worldwide concern, not only for the loss of life but also the social and economic impacts. there is significant concern over how the changes in the ways that people normally engage in everyday activities impact their health and well-being. this is especially relevant for those in self-isolation or quarantine, where feelings of depression, fear, guilt, and anger may manifest [1] . in australia, similar to other countries, social distancing, travel bans, the cancellation of sporting and other mass participation events, and changes to work practices have dramatically affected daily life. the partial lockdown procedures implemented by the australian government to protect citizens and reduce the spread of the virus forced the closure of many businesses in late march 2020 saw unemployment levels rise to 16 .8%, more than three times higher than the pre-covid-19 predicted unemployment rate [2] . the impact of these changes likely comes at significant personal cost, including the onset, or worsening, of mental health issues. to address the psychological distress experienced by australians in the current pandemic, more than aud74 million has been committed to the development and delivery of mental health and well-being support services in australia. multiple calls to ensure the preparedness of psychological services have been presented [3] [4] [5] ; however, the uptake and immediate and long-term impacts of these services are unclear. the covid-19 pandemic may also lead to adverse changes in health behaviors, such as physical activity, smoking, alcohol use and sleep. with the enactment of social isolation and physical distancing restrictions in march 2020, the usual places to be physically active, such as gyms and outdoor recreation facilities, were no longer accessible. although some people may have sufficient autonomous regulation of physical activity to pursue alternate activities (e.g., online fitness classes, other home-based physical activities), others may reduce their physical activity due to the lack of social support available or concerns for contracting the virus in an outdoor environment. on the other hand, those forced to work from home may have spent less time commuting, and may have seized the opportunity to create new physical activity habits. alternatively, since exercise was one of few legitimate reasons for being able to leave the home some people may have developed a walking or cycling habit as a reason to escape being housebound. as many studies have demonstrated strong positive associations between physical activity and lower psychological distress [6, 7] , the commencement or continuation of physical activity during the pandemic will likely aid in reducing psychological distress. however, some concern has been expressed regarding increased risk of respiratory illness in those engaged in high-and very-high intensity exercise due to the potential for reduced immune response [8] . in contrast to health-promoting behavior such as physical activity, some people may manage social isolation and any pandemic-related psychological distress by commencing or increasing adverse health behaviors such as smoking or alcohol use. since covid-19 is an acute respiratory illness, commencement or continuation of tobacco use during the covid-19 pandemic may lead to the worsening of outcomes for those infected with the virus [9] . indeed, early indications suggest the proportion of current and former smokers is higher among those with severe disease and among those admitted to intensive care and requiring ventilation [10, 11] . harmful intake of alcohol leads to neuroadaptations that exacerbate alcohol cravings during times of stress [12] . hence, social isolation, coupled with changes in employment status or uncertainty about the future may trigger an increase in alcohol intake for susceptible individuals [13] . the combined effect of changes in lifestyle behaviors; confinement to the home through government restrictions in travel; and elevated depression, anxiety and stress associated with the current covid-19 pandemic, may have significant negative impacts on sleep [14] . this has been especially evident in healthcare workers, who may be required to work longer shifts in highly stressful environments [15, 16] . poorer sleep quality has been associated with higher levels of depression, stress, and anxiety [17] . maintaining sleep quality is important in strengthening immunity [18] , hence any sleep disturbances subsequent to covid-19-pandemic-induced stress, may increase susceptibility to infection, or compromise recovery in the case of infection [19] . there is currently limited research regarding psychological distress subsequent to the covid-19 pandemic. two recent studies from china reported high levels of psychological distress during the initial stages of the pandemic [20, 21] ; however, the association between psychological distress and health behaviors remains unclear. early evidence during the covid-19 outbreak suggests positive associations between increased physical activity and physical health and inverse associations between sedentary behavior and physical and mental health outcomes [22] . a more detailed exploration of health behaviors during stages of the covid-19 pandemic may help direct future public health messaging to promote positive behaviors and guard against uptake or the worsening of negative behaviors in order to maintain community well-being and mental health. therefore, the present study aims to examine associations between depression, anxiety and stress and changes in health behaviors, including physical activity, sleep, smoking and alcohol use subsequent to the onset of covid-19 and the implementation of social isolation rules in australia. an anonymous online survey was hosted on the survey platform qualtrics and distributed using social media sources (facebook and twitter) and via institutional sources including email and public marketing. eligible participants included all australian adults aged 18 years and over. ethical approval was granted by central queensland university's human research ethics committee (approval number 22332). data collection occurred between 9 and 19 april 2020. at the time of survey distribution, australia was in the midst of significant personal distancing, partial lockdown and travel restrictions. social distancing measures included keeping a minimum 1.5 meters between people, a ban on any public gatherings, a limit of no more than five people at personal gatherings such as weddings and funerals, and no person was allowed to meet with more than one other person outside of their own household. lockdown restrictions also included the closure of restaurants and bars, many retail stores, and restricted access to outdoor parks. most schools were closed, with students advised to study from home while being supported by online learning platforms and materials. university campuses limited or ceased face-to-face teaching and transitioned to online learning, with most clinical placements, residential schools, and simulations postponed. inter-and intra-state travel was banned, and travel within towns and cities was only permitted for essential work/workers, or to access essential services such as medical or health care, or to shop for groceries. existing covid-19 surveys from china, the united kingdom and germany were reviewed to inform development of the present survey. in addition to demographic information, the survey included questions examining chronic health conditions; depression, anxiety and stress; and physical and health behaviors such as physical activity, sleep, smoking and alcohol consumption. the current paper only reports on measures included in the survey associated with the study aim. demographic characteristics included age, gender, marital status, educational attainment, income and chronic disease status. psychological distress was assessed using the well-established 21-item depression, anxiety and stress scale (dass 21) [23] . seven items for each component were scored on a 4-point likert scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time). scores for depression, anxiety and stress items were summed with valid scores ranging from 0-21 for each component. symptom severity was scored according standard cut-points [23] . physical activity was assessed using the active australia survey (aas) which comprises eight items assessing frequency and duration of walking, moderate and vigorous leisure physical activities, and vigorous gardening over the past seven days. total physical activity was calculated according to the aas guidelines, where total minutes of physical activity = minutes of walking + minutes of moderate activity + (minutes of vigorous activity × 2) [24] . a single item asked participants to report their change in physical activity since the onset of covid-19, with six response options ranging from 1 (i am much more physically active than usual) to 6 (i have ceased physical activity altogether). sleep was assessed using two items. first, participants were asked how many hours, on average, they slept per night prior to the onset of the covid-19 pandemic (sleep quantity). second, participants indicated the effect of the covid-19 pandemic on current sleep quality using the question, "since the onset of the covid-19 pandemic, i...". five response options ranged from "am sleeping much better than usual" to "am sleeping much worse than usual". smoking behavior was assessed by asking whether respondents consumed cigarettes or other tobacco products prior to the onset of covid-19. change in smoking behavior was examined using a single item with ten response options ranging from "since the onset of the covid-19 pandemic, i... smoke much more than usual", to "have not smoked (i am a non-smoker)". current alcohol use was examined using the first item of the alcohol use disorder identification test consumption (audit-c) [25] , which asks how often alcohol is consumed. response options were "never", "monthly or less", "2-4 times a month", "2-3 times a week", and "4 or more times a week". changes in alcohol consumption was assessed using a single self-report question: "since the onset of the covid-19 pandemic i . . . ", with the following response options: "drink much more than usual", "drink a little more than usual", "drink about the same as usual", "drink less than usual", "drink much less than usual", "intend to reduce my drinking", "intend to cease drinking", or "have ceased drinking altogether". sas v9.4 (sas institute inc., lane cove, australia) was used for the analysis. the descriptive statistics, including frequencies and percentages, were generated for categorical variables; means and standard deviations (sd) were generated for continuous variables. depression, anxiety and stress scores were compared based on participant's sociodemographic and health status using non-parametric analysis of wilcoxon rank-sum, the kruskal-wallis test and spearman's correlation. the responses for each behavior, i.e., physical activity, sleep, smoking and alcohol use, were recoded into negative change (−1), no change (0), or positive change (+1) for separate analyses of changes in each behavior. a multiple lifestyle behavior index [26] was created by summing the scores of the four behavior change items to reflect a composite health behavior change score, ranged from -4 to +4. the average composite health behavior change scores and sd were presented separately for each level of depression, anxiety and stress. linear regression was used to test associations between composite health behavior change score and depression, anxiety and stress. crude estimates and estimates adjusted for age, years of education, gender, marital status, household income and chronic disease status were reported with 95% confidence intervals (ci). logistic regression was used to test whether negative changes in individual behavior change items were associated with depression, anxiety and stress. crude odds ratios (or) (model 1) and ors adjusted for age, years of education, gender, marital status, household income and chronic disease status (model 2) with 95% ci were reported. all p-values were two-sided and considered significant if less than 0.05. the sociodemographic and health characteristics of the study sample are presented in table 1 . in total, 1491 people (mean age 50.5 ± 14.9 years, 999 female) completed the survey. most (n = 918, 62.8%) were married or in a relationship, and almost half (n = 693, 46.5%) reported having at least one chronic health condition. the average score for depression was 4.6 ± 5.0; anxiety, 2.2 ± 3.4; and stress, 5.2 ± 4.8. the average physical activity of participants was 312.5 minutes/week, but almost half (n = 729, 48.9%) reported a reduction in physical activity since the onset of the covid-19 pandemic. the average sleep duration reported prior to the onset of covid-19 was 7.1 ± 1.3 h per night, with half (n = 756, 50.7%) reporting no change in sleep quality since covid-19. most (n = 1319, 88.5%) were non-smokers, and the majority (n = 1228, 89.7%) reported no change in smoking since the onset of covid-19. almost one-quarter (n = 332, 22.3%) reported consuming alcohol on four or more occasions per week, and just over half (n = 825, 55.3%) reported no change in alcohol consumption. the depression, anxiety and stress scores in relation to different sociodemographic and health characteristics are presented in table 2 . no significant differences were found between males and females for depression and anxiety; however, females had significantly higher stress scores compared to males. younger individuals (18-45 years) had significantly higher depression, anxiety and stress scores compared to their older counterparts. similarly, those who were not in a relationship had significantly higher depression, anxiety and stress scores compared to other categories of relationship status. the spearman's correlation showed a significant negative association between years of education (recorded as a continuous variable) and scores for depression, but not for the anxiety or stress scores. those in the lowest income category had significantly higher depression scores compared to higher income categories; however, no difference was observed between different weekly household incomes and anxiety and stress. respondents who had been diagnosed with a chronic illness reported significantly higher depression, anxiety and stress scores, compared to those without chronic illness. diagnosed with a chronic disease the mean changes in composite health behavior score, stratified by depression, anxiety and stress severity, are presented in table 3 . for depression, anxiety and stress, the number of people in each symptom severity category decreased as the symptom severity increased, except for the categories of extremely severe depression and anxiety. for depression, anxiety and stress, the mean composite health behavior change score decreased as the symptom severity increased, except for the categories of extremely severe anxiety and stress. associations between depression, anxiety and stress severity and negative change in behavior are outlined in table 4 . since adjustment for age, years of education, gender, marital status, household income and chronic disease status did not impact associations, only adjusted or's are presented. participants who reported a negative change in physical activity were more likely to have higher depression (adjusted or = 1.08, 95% ci = 1.06, 1.11), anxiety (adjusted or = 1.09, 95% ci = 1.05, 1.13), and stress (adjusted or = 1.08, 95% ci=1.05, 1.11) symptoms. those who reported a negative change in sleep were more likely to have higher depression (adjusted or = 1.19, 95% ci = 1.15, 1.23), anxiety (adjusted or = 1.25, 95% ci = 1.19, 1.31), and stress (adjusted or = 1.30, 95% ci = 1.26, 1.35) symptoms. for those who reported a negative change in smoking, they were more likely to have higher depression (adjusted or = 1.09, 95% ci = 1.04, 1.13), anxiety (adjusted or = 1.12, 95% ci = 1.06, 1.18), and stress (adjusted or = 1.10, 95% ci = 1.05, 1.15) symptoms. similarly, those who reported a negative change in alcohol intake were more likely to have higher depression (adjusted or = 1.07, 95% ci = 1.04, 1.10), anxiety (adjusted or = 1.08, 95% ci = 1.04, 1.12), and stress (adjusted or = 1.10, 95% ci = 1.07, 1.13) symptoms. the results were consistent for composite change scores. there was a decrease of 0.09 (95% ci = −0.10, −0.07), 0.10 (95% ci = −0.12, −0.07), and 0.10 (95% ci = −0.12, −0.08) points in composite change score for every point increase in depression, anxiety and stress. the present study examined the association between depression, anxiety and stress and the change in health behaviors of physical activity, sleep, smoking and alcohol use subsequent to the onset of covid-19, as individual health behaviors and as a health behavior change index composite score. the main findings were that all aspects of psychological distress (depression, anxiety and stress) were significantly associated with changes in health behavior, both independently and as a composite score. numerous studies have examined the association between a range of health behaviors and psychological distress factors. for example, rebar and colleagues reported significant inverse associations between physical activity participation and depression and anxiety levels in their meta-analysis [27] . previous work has reported significant positive associations between smoking, and depression [28] , but not between smoking cessation and reductions in depression or anxiety [29] . large-scale studies also demonstrate a significant association between alcohol misuse and psychological distress [30] . taken together, the findings of previous work suggest variability in the associations between lifestyle behaviors and depression, anxiety and stress that appear to depend on the nature of the behavior under investigation. the present study also demonstrated that, as the severity of depression increased, the composite health behavior change score worsened. that is, those with normal levels of depression symptoms reported a small negative change (−0.42 points), while for those with extremely severe symptoms, the change in composite health behavior change score was more than three times greater (−1.45). for anxiety and stress, as symptom severity increased from normal to severe, so did negative changes in composite health behavior change score. linear regression showed a significant association between increased depression, anxiety and stress, and negative changes in composite health behavior change scores. logistic regression showed that, compared to no change or positive change, a negative change in all behaviors was associated with a significantly greater likelihood of increased depression, anxiety and stress. a number of reports suggest covid-19 is likely to have significant impacts on psychological distress [21, 31] ; however, the data from the present study suggest that the mean scores for depression, anxiety and stress are mostly within the normal to mild range. moreover, the mean scores for depression and stress were only slightly elevated when compared to normative data for australian adults, and anxiety the scores were marginally lower [32] . viewed another way, more than 60% of all respondents reported psychological distress within the normal range, and less than 13% reported severe to extremely severe scores. the mean scores for depression, anxiety and stress in the present study are all substantially lower than those reported in italy. mazza and colleagues [33] reported mean depression, anxiety and stress scores of 5.34, 2.89, and 7.43, respectively, compared to 4.6, 2.2, and 5.2, respectively, in the present study. these differences may be accounted for in the timing of data collection as data from italy were collected in mid-march, differences in government responses to the pandemic, and differences in the severity of impact on the population. the prevalence of moderate to severe depression in the present study (19.1%) is comparable to that reported in china (16.8%) [21] ; however, the prevalence of moderate to severe anxiety is markedly less in this study (8.3%) compared to that in china (28.8%). in contrast, the prevalence of moderate to severe stress reported in this study (15.1%) is almost double that reported in china (8.1%). the timing of data collection may account for some of these differences since the data from china were collected from residents in 194 cities during late january-early february, one day after the world health organization declared a public health emergency. in contrast, the data for the present study were collected in early to mid-april when significant travel and social distancing restrictions were already in place. it is possible that the low prevalence of depression may also be a result of government investment in mental health support services. the lower anxiety scores in the present study may be attributed to respondents being somewhat accustomed to changes in social contact, whereas the higher stress levels may be attributed to the uncertainly about the future, particularly regarding job losses and economic stress. the total average physical activity was 322.5 ± 36.5 min/week. this is similar to recent australian bureau of statistics data based on the active australia survey, showing that australians aged 15 and over reported 42 min of daily activity, or 294 min per week on average [34] , but substantially less than the peak of 541 min of activity per week reported by alley and colleagues using the same measure [35] . physical activity guidelines for australian adults suggest they should accumulate 150-300 min of moderate intensity physical activity, 75-150 min of vigorous intensity physical activity, or an equivalent combination of both, per week. however, here we report total physical activity, not moderate or moderate-to-vigorous activity. the aas is known to overreport physical activity participation, but actigraphy is not practical in large samples [36] . therefore, our data may be an over-representation of actual physical activity performed. almost half of our respondents (48.9%) reported a negative change (reduction) in physical activity since the onset of the covid-19 pandemic, but about 20% also reported a positive change. this is important to note, since there has been considerable emphasis in the media on the importance of maintaining physical activity for physical and mental health benefits [37, 38] . our data suggests these recommendations may have been ineffective for most people, but not all. these data are hard to interpret as there has been a visible increase in people using walking paths all over the country, as well as a strong increase in registrations to the 10,000 steps australia program [39] . it may be that the extra people who are walking are predominantly those who were already active (e.g., gym and sports club members) prior to the covid-19 onset, but had to undertake different activities at different locations due to the closure of exercise and sporting facilities. the reported overall decline in physical activity is likely a consequence of social distancing, travel restrictions, the closure of usual exercise venues, or unwillingness to change previous exercise habits. nonetheless, given the psychological distress responses to covid-19, [40] and the established benefits of physical activity on psychological distress [41, 42] , additional strategies to promote physical activity are needed. prior to the covid-19 pandemic, mean sleep duration was 7.1 ± 1.3 h, which meets the guidelines of 7-9 h for adults [43] and aligns with a recent national study of australian adults [44] . although half (50.7%) of all respondents reported no change in sleep quality since the onset of the covid-19 pandemic, 40.7% reported a negative change. this is unsurprising given the potential for psychological distress during a global pandemic, change in exercise behaviors, and employment and relationship concerns. a number of recommendations have been made to address poor sleep during covid-19, including maintaining a regular sleep routine, taking time for self-reflection, limiting exposure to covid-19-related news, and getting regular exercise during daylight hours [14] . apart from these covid-19-specific recommendations, most principles mirror those recommended for good sleep hygiene in usual circumstances. only 11% of survey respondents were smokers. this is less than the 15% prevalence of smoking recently reported among australian adults [45] . overwhelmingly, respondents have not changed their smoking behavior, with almost 93% reporting no change or a positive change (reduction) in smoking status since the onset of the covid-19 pandemic. among smokers, 16.3% (n = 28) report a positive change (reduction), 38.4% (n = 59) report no change, while 49.9% (n = 85) report a negative change (increase) in smoking behavior. since covid-19 is a respiratory illness, and smokers are more susceptible to respiratory tract infections, there is significant potential for adverse events in this population. early evidence from china suggests either a significant association, [46] or at least a trend [47] toward smoking being associated with poor prognosis in covid-19 cases. to date, there has been limited attention in the media to smoking cessation programs or adverse risk associated with smoking. although more research is needed, health promotion efforts directed at educating the population regarding the risks for smokers during the covid-19 pandemic are needed. these may include higher exposure to passive smoking during periods of lockdown or relapse-preventions strategies targeting those who have recently ceased smoking. almost three quarters of respondents reported no change or a positive change (reduction) in alcohol use since the onset of covid-19. a reduction in alcohol use might be driven by closures to licensed establishments such as bars and clubs and temporary restrictions on alcohol purchases. in contrast, around one quarter of respondents reported a negative change (increase) in alcohol consumption. this is consistent with research by australia's foundation for alcohol research and education [48] reporting that 20% of australians increased alcohol purchases since the onset of covid-19 and 70% were drinking more than usual. worryingly, this report suggests that almost 30% of adults are drinking more to cope with psychological distress [48] . concerns such as these have prompted the australian government to invest more than aud6 million into drug-and alcohol-related services to combat the risk of substance abuse and related harms, such as domestic violence, due to the pandemic. to the best of our knowledge, this is the first published study to report associations between health behaviors and psychological distress in australian adults during the covid-19 pandemic. one published study from europe reported that reductions in physical activity and increased sedentary behaviors during lockdown were associated with negative changes in physical and mental health [22] . moreover, a number of reports have highlighted the need for rapid and comprehensive responses to increasing mental health needs during covid-19 [3, 5] ; however, it is expected this support will need to be maintained for some years to come given the magnitude of the covid-19 pandemic. there are a number of strengths of the present study, including the inclusion of multiple health behaviors, a large sample size, and the timing of data collection relative to lockdown restrictions in australia. however, there are also some limitations to consider. firstly, all data are self-reported meaning responses are subject to recall bias. secondly, data are cross-sectional and therefore causality cannot be inferred. thirdly, participants in the present study are older compared to other studies examining health behaviors such as sleep [49] , and thus the generalizability to other populations needs to be confirmed. additionally, longitudinal data are needed to observe changes over time to assess the impact of changes in social restrictions. finally, our sample was recruited conveniently and therefore the results may not be generalizable to populations with different characteristics. in conclusion, our data suggests negative changes in health behaviors are associated with increased psychological distress in australian adults during the covid-19 pandemic. effective health promotion strategies directed at adopting or maintain positive health-related behaviors such as targeted social media messaging and balanced media reporting, should be used to reduce the acute and chronic increases in psychological distress during these unprecedented times. ongoing evaluation of the impact of lockdown rules and social distancing (associated with the pandemic) on health behaviors is necessary to inform these targeted health promotion strategies. the psychological impact of quarantine and how 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literature the role of exercise in preventing and treating depression physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies sleep needs across the lifespan; sleep health foundation report to the sleep health foundation: 2016 sleep health survey of australian adults; the adelaide institute for sleep health australian institute of health and welfare alcohol, tobacco & other drugs in australia covid-19 and smoking: a systematic review of the evidence active smoking is not associated with severity of coronavirus disease 2019 (covid-19) foundation for alcohol research and education. alcohol sales and use during covid-19; foundation for the enemy who sealed the world: effects quarantine due to the covid-19 on sleep quality, anxiety, and psychological distress in the italian population this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the research received no external funding. the authors declare no conflict of interest. key: cord-341332-tl3vhd3s authors: levinger, pazit; panisset, maya; dunn, jeremy; haines, terry; dow, briony; batchelor, frances; biddle, stuart; duque, gustavo; hill, keith d. title: exercise intervention outdoor project in the community for older people – results from the enjoy seniors exercise park project translation research in the community date: 2020-11-04 journal: bmc geriatr doi: 10.1186/s12877-020-01824-0 sha: doc_id: 341332 cord_uid: tl3vhd3s background: many research studies evaluate physical activity interventions for older people in the community, however relatively few successfully promote maintenance of physical activity beyond the completion of the intervention. this study aimed to implement and evaluate the effects of sustained engagement in physical activity on mental, social and physical health outcomes through the use of the seniors exercise park physical activity program for older people (the enjoy project). method: people aged ≥60 years underwent a 12-week structured supervised physical activity program using outdoor exercise park equipment followed by 6 months unstructured independent use of the exercise park. participants were assessed at baseline, 3 months and 9 months and completed a test battery evaluating physical activity, physical function and health related quality of life measures. repeated measures anova was used to compare differences between baseline, 3 and 9 months. results: of the 95 participants, 80 (84.2%) completed the 3 months supervised program, and 58 (61%) completed the 9 month assessment (the latter impacted by covid-19 restrictions). a significant increase in physical activity level was demonstrated following the 12 weeks intervention (p < 0.01). significant improvements were also demonstrated in all physical function measures (p < 0.01), self-rated quality of life (p < 0.05), wellbeing (p < 0.01), fear of falls (p < 0.01), falls risk (p < 0.01), depressive symptoms (p = 0.01) and loneliness (p = 0.03) at 3 months. at the 9 months follow up, significant improvements from baseline were demonstrated in the frequency, duration and total of physical activity level (p < 0.05), and all physical function measures (p < 0.05), with no decline in these measures from 3 to 9 months. at 9 months, significant changes were observed in the health related quality of life mobility and self care domains with reductions in both fear of falls and falls risk (p < 0.05). conclusion: the seniors exercise park may be an effective modality for improving and sustaining older people’s physical function and wellbeing and can be an important public health infrastructure investment in promoting physical activity for older people. future work should focus on wider implementation of the program and on scaling up this initiative to achieve public health benefit for the community. trial registration: trial registration number actrn12618001727235, date of registration 19th october 2018, https://www.anzctr.org.au/trial/registration/trialreview.aspx?id=375979 the world's population is ageing rapidly, with the number of older people age 65 and over projected to more than double by 2050 [1] . the number of australians aged 65 and over is expected to increase from around 2.5 million in 2002 to 6.2 million in 2042 [2] . physical activity is one of the key behavioral factors to positively impact health outcomes, including reduction of risk of chronic diseases, cognitive and functional decline, and improvement in mental health [3] . increase in physical activity can also minimise the burden on the health care system [4] . despite the strong evidence around the importance of physical activity, older people do not regularly undertake physical activity [5] , with less than 25% of older australians meeting the recommended physical activity guidelines [6] . there has been considerable research into physical activity interventions for older people in the community, but interventions that successfully promote maintenance of physical activity beyond the completion of the intervention are limited [7, 8] . various methodological challenges exist that often limit translation of physical activity programs into practice, these include: lack of evidence of transferability of trial results to the community setting, insufficient local expertise to roll out community exercise programs, and inadequate infrastructure to integrate evidence based programs into community practice [9] . interventions that are designed to be conducted in a community setting with community engagement have the potential to be sustained beyond the trial period and have shown to be effective in increasing and promoting physical activity [10, 11] . in recent years, outdoor environments and associated infrastructure features (e.g., exercise equipment) have been recognized as an important investment to promote regular physical activity [12, 13] . hence, the design of an age friendly 'active environment' has been recommended as one of the strategies to increase physical activity at a population level [14] . in 2012 we commenced our research work in the area of age friendly active spaces for older people with the utilization of outdoor exercise equipment specifically designed for older people (the seniors exercise park). the seniors exercise park program was designed to actively promote community well-being through the provision of a unique exercise and social support program. in a small 18 week randomized controlled trial (rct), we demonstrated the effectiveness of the seniors exercise park program on improving physical function and social health in older people [15, 16] . these preliminary positive outcomes indicated the need for investigation of its sustained impact on physical and social health outcomes, and its potential wider usage in the community on a larger scale with local governments' (councils') engagement. therefore, the aim of the present study was to implement and evaluate the effects of sustained engagement in physical activity on physical, mental, social and health outcomes through the use of the seniors exercise park physical activity program for older people (the enjoy project). this study was a multi-site prospective study with a pre and post intervention design and 9 month follow up. participants underwent a 12-week structured supervised physical activity program using outdoor exercise park equipment followed by a 6 month unstructured physical activity program, including ongoing unsupervised access to the exercise park. each exercise session was followed by a social gathering with morning/afternoon tea provided by the research team. participants were assessed at baseline, post intervention (3 months) and 9 months follow up time points as detailed in fig. 1 . the study was designed according to the transparent reporting of evaluations with nonrandomized designs (trend) [17] which complements the widely adopted consolidated standards of reporting trials (consort) statement developed for randomized controlled trials [18] . ethical approval was obtained from the melbourne health human research ethics committee, melbourne (application id. hrec/18/mh/286, local number 2018.238). all participants provided informed consent. the full description of the study's methods, design, and procedure can be found in the trial protocol [19] . older people were eligible to participate in the study if they: 1) were aged 60 years and over living in the community (i.e. not living in an institution, such as a nursing home); 2) had one or more falls in the previous 12 months or were concerned about having a fall; 3) were generally independent around the house (able to take care of themselves) and in the community (e.g. able to walk away from home to visit local stores, friends, and other local venues), and able to attend the outdoor exercise park; 4) were able to walk outdoors and use the exercise equipment with no more gait aid support than a single point stick 5) did not have cognitive impairment (abbreviated mental test score (amts) > 7/10) [20] . older adults were excluded from this study if they: 1) had neurological or musculoskeletal conditions limiting walking to less than one block; 2) had a history of stroke, parkinson's disease, or other neurological disorder impacting on mobility; 3) were unable to understand conversational english; 4) were taking part in a structured resistance training and/or an organised balance training program more than once a week; 5) met the australian physical activity recommendations of 150 min of physical activity / week [21] ; 6) had any documented medical condition or physical impairment that was deemed by their medical practitioner to contraindicate their inclusion. older people were recruited from the general community in the suburbs close to the seniors exercise parks location in melbourne, australia. advertisements in local newspapers, council newsletters, posters displayed on notice boards, and flyers distributed to senior groups were used for recruitment. information was also placed online on the councils' and participating partners' websites as well as associated social media platforms (e.g. facebook, twitter). recruitment took place between october 2018 to november 2019. participants who met the inclusion criteria attended an initial (baseline) assessment at a community centre close to their area of residence. demographic characteristics (age, gender), anthropometric measures (height and weight), previous medical history, current medication usage, socioeconomic and cultural background information (e.g. employment, level of education, country of birth, years of residency in australia) and falls history were collected at baseline. assessments were undertaken at baseline, 3 months and 9 months, by an allied health professional (accredited exercise physiologist and/or physiotherapist). physical activity the level of physical activity of the participants was measured using the community healthy activities model program for seniors (cham ps) [22] . the champs provides a self-reported measure of caloric expenditure (and frequency) per week in all exercise-related activities and caloric expenditure (and frequency) per week in moderate exercise -related activities. a comprehensive suite of physical function (strength, balance, functional mobility), psychosocial (quality of life, enjoyment, social isolation, fear of falls, loneliness), and mental health outcomes (mental wellbeing, depression) and falls risk assessment were undertaken as detailed in the protocol paper [19] , and summarized below. physical function measures physical measures of strength, balance and functional mobility were assessed using the following validated tests. (i) functional lower limb muscle strength was assessed using the 30-s sit to stand test [23] ; (ii) exercise tolerance and functional mobility was assessed using the two-minute walk test [24] ; (iii) dynamic balance was assessed using the step test [25] , the sum of the number of steps from each limb was combined and used for the analysis [26] ; and (iv) walking speed was assessed using the 4 m walk test [27] . psychosocial, mental and quality of life health outcomes psychosocial, mental health and quality of life outcomes were assessed using the following questionnaires: (i) health-related quality of life was assessed using the eq-5d-5l [28] . the eq-5d-5l comprises five dimensions (mobility, self-care, usual activities, pain/ discomfort and anxiety/depression) as well as an overall self-rated health status (visual analog scale (vas) 0-100) where higher score represents better health. (ii) mental wellbeing was assessed using the five-item world health organization (who-5) wellbeing questionnaire [29, 30] . the who-5 measures psychological wellbeing and depressive symptoms using 5 simple questions. the raw score was calculated to obtain a percentage score, which ranges from 0 representing the worst imaginable wellbeing and 100 representing the best imaginable well-being. (iii)loneliness was assessed using the ucla 3-item loneliness scale which incorporates three dimensions of loneliness: relational connectedness, social connectedness and self-perceived isolation [31, 32] . the scale gives a possible range of scores from 3 to 9 (higher scores indicate greater feelings of loneliness). (iv) depression was assessed using the short version geriatric depression scale (gds-15) where a score of 0 to 5 is considered normal and a score greater than 5 suggests depressive symptoms [33] . (v) fear of falls was assessed using the short falls efficacy scale international (short fes-i) questionnaire [34] , a 7-item scale ranging from 7 (no concern about falling) to a maximum 28 (severe concern about falling). (vi) self-efficacy barriers to exercise was assessed using the self-efficacy for exercise (see) questionnaire, with scores ranging from 0 to 90 (a higher score indicates higher self-efficacy for exercise) [35] . (vii) enjoyment was assessed using the 8-item version physical activity enjoyment scale (paces), where higher values reflect greater levels of enjoyment (values range 8-56) [36] . (viii)social isolation and social support were assessed using the short version 6-item lubben social network scale (lsns6). the score ranges between 0 and 30 where higher scores indicate more social engagement [37] . falls risk assessment (i) the falls risk for older people in the community (frop-com) risk assessment tool was used to assess fall risk. the frop-com consists of 13 falls risk factor domains, with most risk factors scored to reflect graded risk on a 4-point scale (nil, mild, moderate, or severe) [38] . the seniors exercise park the seniors exercise park equipment (lark industries (australia) and lappset group) consists of outdoor playground equipment specifically designed for older people to improve strength, balance, joint movements and overall mobility and function (fig. 2 ). it comprises multiple equipment stations that target a specific function or movement (upper and lower limb) such as shoulder range of movement, static and dynamic balance (unstable surfaces), and functional movements (walking up/down stairs, sit to stand). the exercise park equipment was installed in two public locations and a third location in a retirement living and aged care community respectively: barry rd. community centre, thomastown, melbourne (under the municipality of whittlesea city council); central park community centre, hoppers crossing, melbourne (under the municipality of wyndham city council); and leith park, st helena, melbourne (old colonists' association of victoria). participants participated in a 12-week supervised exercise intervention program twice a week using the seniors exercise park. the exercise program was delivered by a qualified exercise instructor (accredited exercise physiologist or physiotherapist). participants performed exercises that focused on strength, balance, coordination, mobility and flexibility as detailed in our previous work [39] . each session consisted of 5-7 min of warm-up exercises, followed by 45-75 min at the equipment stations, and concluded with 5 min of cool down exercises (overall duration approximately 80 min). the exercise classes were run as a circuit-based group program with 6-10 participants. each participant was familiarized with the exercises individually and the difficulty level was tailored to the capabilities of the participant. each session was followed by morning/ afternoon tea to encourage socialization. individual and group exercise progression each exercise station included two different exercises which were performed twice by each participant. examples of the stations and the exercises can be found at https://youtu.be/ payucmtnlyk. two participants were allocated to each station such that each participant performed one exercise for the allotted time and then swapped with their partner, repeating each exercise twice before rotating to the next station. rest periods were provided during transition to the next station. the duration of each exercise and rest period were adjusted progressively according to program progression, as detailed in the protocol paper [19] . participation rate (adherence) and exercise monitoring during the 12-week supervised exercise program frequency of exercise session participation was determined using daily attendance logs kept by the exercise instructor. overall adherence to the structured exercise program was defined by the number of sessions attended: where 100% adherence indicated that a participant attended all available 24 sessions. in the event of cancellation (due to weather or public holidays), participants were given alternative make up sessions to achieve the 24 sessions. monitoring exercise uptake following the 12-week exercise program for 6 monthsfob access system at the completion of the structured 12 weeks exercise program participants were given two options to choose from to continue their physical activity. option 1independent unsupervised access and usage of the exercise park in participants' own preferred time. option 2: access to twice a week exercise sessions on the exercise park under supervision but with no formal structured group activity. adherence and exercise uptake for the 6 months post intervention was monitored using a fob access system (citywatch security, melbourne, australia www.citywatchsecurity.com.au/) that included a card reader/scanner and a control panel at each site. participants were assigned an individual identification key (fob) which they used to tap a card reader each time they accessed the seniors exercise park at the site. their access was recorded and monitored (thereby electronically monitoring access). a separate paper will report outcomes and experiences using the fob system. weather elements in extreme weather conditions (e.g. heavy rain, extreme heat (above 30°c)), if deemed by the exercise instructor as unsafe to exercise, sessions were cancelled. in circumstances where sessions were cancelled, or during a holiday period, makeup sessions were organised towards the end of the program (up to two weeks or 4 sessions). any cancellation and the associated reason were recorded in a log book kept by the researchers. adverse events joint pain/discomfort and or muscle soreness instances of joint pain or discomfort (directly related to the exercise program) during the exercise program were recorded. sessions that were missed due to pain or discomfort that had not settled and prevented a participant from attending the exercise sessions were also recorded. any falls during the delivery of the structured supervised exercise programs and during the independent usage phase of the seniors exercise park were recorded. a fall was defined as an event when the participant 'inadvertently comes to rest on the ground, floor or other lower level' (who global report on falls prevention in older age [40] ). any report of difficulty breathing that did not settle quickly with rest, new or unrelenting chest pain, or acute changes in the level of consciousness during the session were documented. a serious adverse event was deemed if symptoms did not settle and medical emergency care was required and organised. a power analysis was undertaken using previously published data using the primary outcome measure champs for measurement of change in physical activity level over a 9 month period [22] . we considered a minimum meaningful change in the physical activity outcome from use of the seniors exercise park intervention to be d = 0.33. using this standardized effect size, 90% power and a twotailed alpha of 0.05, we calculated need for a sample size of 98 participants. previous data indicates a within subject change in daily calorie expenditure for all activities of 1509 and for moderate intensity activities of 1196 when exposed to 6-month physical activity program [22, 41] . this meant we were likely to have 90% power to detect a change of 503 in total daily calorie expenditure, and 399 in daily calorie expenditure in moderate intensity activities. we projected for a 15% drop-out rate, thus we sought a total sample of 113 participants (37-38 per site). for the primary outcome of overall physical activity score (champs) and the physical, mental, and health secondary outcome measures, repeated measures analysis of variance (anova) were used to determine if there were differences between scores collected at baseline assessment and at 9 month follow-up. a separate repeated measures anova (with the equivalent non parametric test for ordinal data) was used to examine the effect of the exercise program on physical activity level, physical, mental and psychosocial and health outcomes between baseline and 3 months; and 3 months vs 9 months. information collected about exercise adherence were reported using descriptive statistics (% of adherence). data were analysed using spss version 26.0 (ibm corp, ny, usa). effect size, partial eta squared, ( η 2 p ) from spss was used to determine effect size as follows: η 2 p values greater than 0.14 were considered a large and significant effect size whereas 0.01 and 0.06 were considered small and medium, respectively [42] . ninety-five older people living in the community who volunteered to participate were eligible to take part in the study, with a mean age of 73.0 ± 7.4, and 82.1% female. the majority of participants (94.7%) suffered from at least one medical condition with the most common conditions reported being arthritis (70.1%), hypertension (62.1%) and hypercholesterolemia (51.6%) ( table 1) . fifteen participants dropped out between baseline and three months follow up (15.7%), leaving 80 participants available for analysis of pre-post intervention (mean age 72.8 ± 7.5 years; 81.3% females). no significant differences existed between those who dropped out and the remaining sample with respect to their medical or demographic characteristics. recruitment and drop out breakdown are provided in fig. 1 . interruption to data collection occurred during the covid-19 pandemic due to the physical distancing and lock down restrictions which prevented access to the seniors exercise park. participants were not able to access the seniors exercise parks for a lengthy period of several months (restrictions of public parks closure and no access to aged care sites as imposed by the australian state government). data of n = 19 was impacted due to covid-19 and were excluded from the analysis (fig. 1) . consequently, a separate analysis was conducted for the comparison of the champs primary and secondary outcomes between baseline and 9 months follow up (n = 58), in addition to the baseline vs 3 months analyses (n = 80). average adherence in the supervised 12-week program was 86%. the most frequently reported reason for absence from classes was due to illness or medical problems (37.6% of the occasions of absences). only 6.9% of sessions were cancelled due to weather (hot or wet). during the 12-week program, 12 people (15%) reported pain or discomfort due to aggravation of pre-existing injury/condition, with 16 events (0.95% of all sessions) reported. five people (6.25%) missed exercise sessions due to aggravation of pre-existing injury/condition with a total of 15 sessions missed (0.89% of all sessions). one fall occurred during the exercise program with no severe injury. no serious adverse events occurred during the program. a significant increase in physical activity level was demonstrated following the intervention (champs caloric expenditure, frequency per week and total time in all exercise and in moderate exercise per week, p < 0.01, moderate to large effect sizes). significant improvements were also demonstrated in all physical function measures (p < 0.01, small to large effect sizes), self rated quality of life (p = 0.04, small effect size), wellbeing (p < 0.01, small effect size), fear of falls (p < 0.01, medium effect size), falls risk (p < 0.01, medium effect size), depressive symptoms (p = 0.01, small effect size) and loneliness (p = 0.03, small effect size). no significant changes were demonstrated in socialisation and self-efficacy for exercise outcomes (p > 0.05) ( table 2) . changes in the eq-5d-5l dimensions are presented in fig. 3 with improvements shown in selfcare (p <0.01) and depression (p = 0.02) domains. for the 9 month follow up (n = 58) significant improvements from baseline were demonstrated in the frequency, duration and caloric expenditure of moderate physical activity and all type of exercises (p < 0.05, moderate to large effects size, table 2 ). significant improvements in all physical function measures were demonstrated between (20) baseline and 9 months follow up (p < 0.05, moderate to large effect size, table 2 ). significant changes were observed only in the health related quality of life mobility and self-care domains (p < 0.05, eq-5d-5l dimensions, fig. 3 ). no changes were observed in the other health related quality of life measures apart from significant reductions in both fear of falls and falls risk (p < 0.01, table 2 ). very few changes were observed between 3 and 9 month follow ups as indicated in table 2 . participation in physical activity is important for the reduction and management of chronic diseases as well as to help older people remain mobile and independent. only a quarter of older people meet the recommended national guidelines for physical activity [43] . participation in the enjoy seniors exercise park program resulted in increases in physical activity level as well as physical and mental health benefits in the short term with sustained physical function benefit in the longer term. although there is strong evidence from randomized controlled trials to support the importance of physical activity, older people have low participation rates in physical activity programs aimed at achieving a variety of positive health outcomes, including falls prevention [44, 45] . those who do commence a physical activity program as part of a research study often return to their inactive lifestyle behaviour once the study is completed, indicating that interventions that are not easy to apply in "real world" situations often do not sustain participation beyond the trial period [9] . hence translating these studies into effective and sustained behaviour change remains a challenge [46] . participation in the enjoy project resulted in significant improvement in physical activity level (all champs outcomes) after the 12 weeks intervention and these improvements were sustained 6 months later (with no decline between 3 and 9 months), suggesting that participants remained physically active over the longer term. importantly, the increase in the moderate exercise type (frequency and duration) indicates that participants exceeded the recommended physical activity participation of 150 min per week of moderate intensity. the sustained engagement in physical activity provides promising results for the potential benefits of scaling up such a program in order to achieve public health benefit for older people in the community. sustained participation in physical activity at a level to maintain or improve health by older people remains challenging to achieve, with fewer than half of older adults being active enough to achieve most of these health benefits [7] . having national and international guidelines or recommendations appear insufficient to achieve this activity [47] . providing widely available and accessible avenues for physical activity options, such as widespread implementation of outdoors seniors exercise parks may assist improving participation levels. state and / or national policies supporting increased physical activity participation by older people may also be beneficial. loneliness and social isolation are greatest among older people and can pose significant physical and mental health risks [48, 49] . loneliness, in addition to other physical and mental problems, gives rise to feelings of depression in older people [50] . physical activity is one possible health promotion strategy that has positive effects on mental health in later life [51] . improvement in depressive symptoms (as reported by the depression domain in the quality of life scale and the geriatric depression scale) and wellbeing were seen after the 3 months intervention. slight improvement in loneliness (relational connectedness, social connectedness and self-perceived isolation) was demonstrated but with no changes in social isolation or social support. caution must be taken, however, in the interpretation of the results as the values reported in both scales (ucla3 and lsns6) did not suggest that the participants experienced severe loneliness or lack of social engagement at baseline. the physical activity program incorporated group setting exercise activity followed by a social morning tea, which facilitated social connection. enjoyment in physical activity was also significantly improved following the intervention. given that fun, enjoyment and social interaction are key motivators for older people to take part in physical activity [52] , these aspects should be an integral part of physical activity programs for older people. consequently, the results highlight the beneficial effect of the seniors exercise park program on general wellbeing. we have previously demonstrated in a small randomized controlled trial the physical and social benefits of utilizing the seniors exercise park program for older people [15, 16] . pre-post studies such as the enjoy trial may be considered to be less rigorous than randomised controlled trials, although in implementation research, especially where one or more previous randomised trials have demonstrated the approach to be effective (as in this study), this is considered acceptable [53] . the enjoy project provides further evidence for the potential effectiveness of the physical and social activity program to improve quality of life and wellbeing on a larger scale beyond the 12 weeks supervised program. the approach utilized in the enjoy project encompasses partnership with local governments to create an innovative enjoyable physical activity for older people with the utilization of specialized outdoor equipment. the availability of the equipment in community settings provides an advantageous set up where participants can have free access beyond the research trial. moreover, the location in outdoor settings also offers additional benefits, as exercising outdoors is known for its' health benefits for mental wellbeing [54] . combining exercise, nature and social components may play a key role in engaging older people in physical activity and health promotion initiatives longer term. older people are at high risk of falls. exercise programs have been shown to be effective in preventing falls in community-dwelling older people [55] . balance and strengthening exercises in particular are important to be incorporated into exercise programs to reduce falls [55] . the seniors exercise park program integrates multimodal exercise stations that target balance (unstable/uneven surfaces), strength and functional movements. this offers an important combination of different physiological aspects to obtain broader health benefits in addition to falls prevention, and is different to what is available in most traditional outdoor exercise equipment, which is usually focused on either cardiorespiratory or strength training [56] . the current sample population included people with high risk of falls (52.5% had previous falls) as well as high fig. 3 proportion of responses by level of severity for eq-5d-5l dimensions: mobility (a), usual activities (b), self-care (c), pain/discomfort (d), anxiety/depression (e) at baseline and at 3 and 9 months follow-ups. *significant between baseline and 3 months. **significant between baseline and 9 months prevalence of complex medical issues. the sustained improvements in the physical function measures as well as the reduction in fear of falls and falls risk at 9 months suggest potential benefits to reduce the risk of falls. this study has several limitations. firstly, the spread of covid-19 in early 2020 and associated restrictions and lockdown prevented older people in the community to be physically active using the seniors exercise park in the latter stages of this project. this has adversely impacted on the enjoy project data collection as participants were unable to access the seniors exercise park sites as well as their ability to maintain their physical activity using this exercise modality. as such the data for the 9 months follow up included a smaller sample which could have potentially impacted on the results, leading to underestimation of the impact of the physical activity program on various health measures. the total dropout rate (n = 18, fig. 1 ) of those who ceased participation in the project was 18.9% which is within the expected rate for exercise related interventional studies among older people [57, 58] . secondly, the level of physical activity was measured using self-reported questionnaires which might not accurately reflect the actual physical activity level of the participants. however it is important to acknowledge that the champs questionnaire has been widely used in research and has been designed for use in evaluating interventions that primarily aim to increase levels of physical activity in older adults [22] . it is a reliable and valid questionnaire that is sensitive to change of the physical activity measures derived from it. the questionnaire was also tested and found suitable to be used with older australians [59] . finally, while our sample is representative of older australians' age, bmi and cultural background, it included a relatively high proportion of females with a small proportion of male participants. although the risk and incidence of falls are greater in females, males are commonly underrepresented in exercise intervention trials [60, 61] . males have been reported to have specific preferences and characteristics of exercise interventions that are most likely to appeal to them [62] . the specific appeal or lack of appeal of this outdoor exercise park approach will need to be explored in future research. the results suggest that the seniors exercise park may be an effective modality for improving older people's physical function and wellbeing beyond an initial supervised program, and can be an important public health infrastructure investment in promoting physical activity for older people. future work should focus on wider implementation of the program and on scaling up this initiative to achieve public health benefit for the community. new york: united nations, department of economic and social affairs, population division the ageing australian population and future health costs: 1996-2051. department of health and aged care occasional papers does physical activity prevent cognitive decline and dementia?: a systematic review and metaanalysis of longitudinal studies the cost of physical inactivity: moving into the 21st century global physical activity levels: surveillance progress, pitfalls, and prospects physical activity in older people: a systematic review exercise-based interventions to enhance long-term sustainability of physical activity in older adults: a systematic review and metaanalysis of randomized clinical trials exercise and fall prevention: narrowing the research-to-practice gap and enhancing integration of clinical and community practice the effectiveness of interventions to increase physical activity. a systematic review community-based efforts to promote physical activity: a systematic review of interventions considering mode of delivery, study quality and population subgroups impact and costeffectiveness of family fitness zones: a natural experiment in urban public parks understanding outdoor gyms in public open spaces: a systematic review and integrative 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12-minute walking tests in respiratory disease a new test of dynamic standing balance for stroke patients: reliability, validity and comparison with health elderly step test scores are related to measures of activity and participation in the first 6 months after stroke gait speed and survival in older adults a single european currency for eq-5d health states. results from a six-country study validity of the five-item who well-being index (who-5) in an elderly population regional office for europe (1998) wellbeing measures in primary health care: the depcare project developing a measure of loneliness ucla loneliness scale (version 3): reliability, validity, and factor structure geriatric depression scale (gds) recent evidence and development of a shorter version the short fes-i: a shortened version of the falls efficacy scale-international to assess fear of falling testing the reliability and validity of the self-efficacy for exercise scale measuring enjoyment of physical activity in older adults: invariance of the physical activity enjoyment scale (paces) across groups and time performance of an abbreviated version of the lubben social network scale among three european community-dwelling older adult populations the reliability and predictive accuracy of the falls risk for older people in the community assessment (frop-com) tool a novel dynamic exercise initiative for older people to improve health and well-being: study protocol for a randomised controlled trial who global report on falls prevention in older age. geneva: world health organisation physical activity outcomes of champs ii: a physical activity promotion program for older adults statistical power analysis for the behavioral sciences physical activity across the life stages older people's participation in and engagement with falls prevention interventions in community settings: an augment to the cochrane systematic review participation levels of physical activity programs for community-dwelling older adults: a systematic review factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies global rocommendations on physical activity for health. geneva: world health organisation loneliness, social isolation, their synergistic interaction, and mortality loneliness and health in older adults: a mini-review and synthesis loneliness, depression and sociability in old age can physical activity improve the mental health of older adults? the acceptability of physical activity interventions to older adults: a systematic review and meta-synthesis effectivenessimplementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact exercise-, nature-and socially interactive-based initiatives improve mood and self-esteem in the clinical population exercise for preventing falls in older people living in the community: an abridged cochrane systematic review guidance about age-friendly outdoor exercise equipment and associated strategies to maximise usability for older people adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review reducing attrition in physical activity programs for older adults measurement properties of the champs physical activity questionnaire in a sample of older australians who participates in physical activity intervention trials? exercise for falls prevention in community-dwelling older adults: trial and participant characteristics, interventions and bias in clinical trials from a systematic review men's preferences for physical activity interventions: an exploratory study using a factorial survey design created with r software publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge whittlesea city council, wyndham city council and old colonists' association of victoria for their collaboration and partnership in this project. moreover, we would like to thank lark industries for the seniors exercise park equipment installation and associated advice and support. this study was funded by gandel philanthropy. this funding source had no role in the design of the study, its execution, analyses, interpretation of the data, and in writing the manuscript for publication. the datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions but are available from the corresponding author on reasonable request.ethics approval and consent to participate ethical approval has been obtained from the melbourne health human research ethics committee, melbourne (application id. hrec/18/mh/286, local number 2018.238). all participants signed a consent form prior to participation. not applicable. the authors declare that they have no competing interests. key: cord-307229-wjx90xki authors: da silveira, matheus pelinski; da silva fagundes, kimberly kamila; bizuti, matheus ribeiro; starck, édina; rossi, renata calciolari; de resende e silva, débora tavares title: physical exercise as a tool to help the immune system against covid-19: an integrative review of the current literature date: 2020-07-29 journal: clin exp med doi: 10.1007/s10238-020-00650-3 sha: doc_id: 307229 cord_uid: wjx90xki acute viral respiratory infections are the main infectious disease in the world. in 2020, a new disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2), coronavirus disease 2019 (covid-19), became a global pandemic. the immune response to the virus depends on factors such as genetics, age and physical state, and its main input receptor is the angiotensin-converting enzyme 2. the practice of physical exercises acts as a modulator of the immune system. during and after physical exercise, proand anti-inflammatory cytokines are released, lymphocyte circulation increases, as well as cell recruitment. such practice has an effect on the lower incidence, intensity of symptoms and mortality in viral infections observed in people who practice physical activity regularly, and its correct execution must be considered to avoid damage. the initial response is given mainly by type i interferons (ifn-i), which drive the action macrophages and lymphocytes, followed by lymphocyte action. a suppression of the ifn-i response has been noted in covid-19. severe conditions have been associated with storms of pro-inflammatory cytokines and lymphopenia, as well as circulatory changes and virus dispersion to other organs. the practice of physical activities strengthens the immune system, suggesting a benefit in the response to viral communicable diseases. thus, regular practice of adequate intensity is suggested as an auxiliary tool in strengthening and preparing the immune system for covid-19. further studies are needed to associate physical exercise with sars-cov-2 infection. acute respiratory infections (aris) are caused by respiratory viruses and bacteria, being the most infectious disease in humans [1, 2] . these can be caused by more than 200 different viruses, with rhinovirus being the most common etiological agent [3] [4] [5] . in december 2019, a new coronavirus outbreak was reported in china, being called the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), spreading rapidly and infecting more than 14 million people, being declared a health emergency international public service on january 30, 2020 [6, 7] . the main mode of transmission is contact with droplets containing viral particles eliminated through the cough or sneeze of an infected person, and the incubation period usually varies from 2 to 14 days. approximately 80% of the cases are asymptomatic or with mild symptoms, and the others can be severe or critical and can lead to death [8] . the development of coronavirus disease 2019 (covid-19) is dependent on the interaction between sars-cov-2 and the host's immune system, the immune response being influenced by genetics (hla genes), age, sex, nutritional status and status physical [9] . the immune response includes two stages, innate immunity and adaptive immunity. the first one comprises physical and chemical barriers and the action of cells such as macrophages, dendritic cells (dcs), natural killer cells (nks), neutrophils and molecules such as cytokines, interleukins (ils), nitric oxide (no) and superoxide anion (o2-). the second one has as mechanism of action the t lymphocytes (tcd4 + and tcd8 +) and b lymphocytes and their products, such as antibodies and cytokines. furthermore, the adaptive immune response can be subdivided into cellular immunity (mediate by cells as macrophages and lymphocytes) and humoral immunity (mediates by cells as macrophages and lymphocytes) and humoral immunity (mediated by antibodies) [10, 11] . the regular practice of physical exercises promotes improvements in quality of life and can act in the immune response, reducing the risk of developing systemic inflammatory processes and stimulating cellular immunity [12] . therefore, the present article aims to perform an integrative review of the literature relating the role of physical exercise on the immune system in the fight against covid-19. for this purpose, the bibliographic study included knowledge about respiratory infections, influences of physical exercise on the immune system and proposed the comprehension of the most recent information about the immunopathogenesis of sars-cov-2 infection, also comprising its relationship with the host's physical and health conditions. physical activity is considered one of the main components of healthy living. in addition to the functions related to the prevention of excess body weight, systemic inflammation and chronic non-communicable diseases, a potential benefit of physical exercise in reducing communicable diseases, including viral pathologies, is suggested [13] . the practice of physical exercise, both in its acute form and in its chronic form, significantly alters the immune system [14, 15] . studies indicate that the modulation of the immune response related to exercise depends on factors such as regularity, intensity, duration and type of effort applied [13, 16] . moderate-intensity physical exercises stimulate cellular immunity, while prolonged or high-intensity practices without appropriate rest can trigger decreased cellular immunity, increasing the propensity for infectious diseases [14, 15] . according to the international society for exercise and immunology (isei), the immunological decrease occurs after the practice of prolonged physical exercise, that is, after 90 min of moderate-to high-intensity physical activity [17] . cellular changes due to physical activity are illustrated in fig. 1 . cytokines are classified as anti-inflammatory and proinflammatory according to their functions. among the antiinflammatory cytokines, we highlight il-10 and transforming growth factor-beta (tgf-β), responsible for inhibiting the production of pro-inflammatory cytokines [18] . among the pro-inflammatory cytokines, we highlight il-1, il-2, il-12, il-18, interferon-gamma (ifn-γ) and tumor necrosis factor-alpha (tnf-α) [19] . cytokine production can be modified due to hormonal or oxidative stress and physical exercise. the muscle contraction has the effect of increasing the release of antinflammatory and pro-inflammatory cytokines at levels that vary according to the volume of contractile mass involved, duration and intensity of exercise [20] . during the practice of physical exercise, the activation of the muscle fiber is responsible for increasing the release of calcium (ca2 +) and, therefore, promoting the synthesis of proinflammatory cytokines, namely tnf-α and il-1β, which act in the regulation of selectins, which, in turn, attract neutrophils to the site [21] . the neutrophilia induced by physical activity is due to the release of neutrophils from the bone marrow due to the influence of cortisol [22] . after aerobic physical exercise (approximately 24 h), there is a significant reduction in neutrophil chemotaxis, however, without compromising bactericidal activity. the reduction in neutrophil chemotaxis is reversed within 48 h after physical activity, during which the opportunistic activity of infectious microorganisms can occur [23] . physical activity is also responsible for increasing the concentration of circulating leukocytes [24] . this is due to shearing of immune cells in blood vessels, especially secondary lymphoid tissues such as liver, spleen and lung [25] . the leukocyte concentration remains high with a peak of 30-120 min after constant physical activity, which may persist for up to 24 h after [24] . the practice of aerobic physical exercise in an exacerbated manner is responsible for decreasing the expression of tolllike receptors (tlrs) in macrophages, considerably reducing the presentation of antigens to t lymphocytes, thus causing the suppression of the inflammatory t helper type 1 (th1) response. thus, the failure to develop an inflammatory activity precludes possible tissue damage resulting from inflammatory mediators and, consequently, the risk of chronic inflammatory processes. however, the susceptibility to infections due to intracellular microorganisms increases [26] . during physical activity, blood flow increases in order to supply the metabolic demands of the human body. the recruitment of nk cells occurs through cellular stress promoted by exercise and a consequent decrease in adhesion molecules induced by catecholamines [27] . however, physical activity lasting more than three hours causes the concentration of nk cells to return to the pre-exercise state or even lower than this. this is because the nk cells migrate to the muscle injury site [28] . during moderate physical exercise, the concentration of lymphocytes increases in the vascular bed and, after strenuous exercise, decreases to levels below the pre-exercise period [29, 30] . the cd4 +:cd8 + ratio decreases as tcd8 + cells increase [14] . tcd4 + cells decrease due to the increase in nk cells [14, 31] . after physical activity, the lymphocyte concentration decreases due to the apoptosis mechanism [32] . thus, the increase in lymphocyte concentrations favors the th1mediated immune response, preventing infections by intracellular microorganisms [24] (fig. 2 ). sars-cov-2 is constituted by single-strand positivesense rna and belongs to the genus betacoronavirus, lineage b and subgenus sarbecovirus. viral genome studies have identified similarity of sars-cov-2 with bat coronaviruses, as well as coronaviruses responsible for two previous pandemics: the severe acute respiratory syndrome-related coronavirus (sars-cov) and the middle eastern respiratory syndrome coronavirus (mers-cov) [33, 34] . similar to sars-cov, the novel coronavirus uses a structural glycoprotein to infect cells: the envelope spike protein (s), using the angiotensin-converting enzyme-2 (ace2) as entry receptor [33, 34] . ace2 consists of a cell membrane protein abundantly expressed in the organism, which is present in cardiac, pulmonary, renal, intestinal and vascular cells, and the binding of sars-cov-2 with this enzyme has a strong affinity, which may explain the high transmissibility of the virus [8, 9, 34] . due to mainly respiratory symptoms, it is believed that the target cells of sars-cov-2 are in lower airways [35] , as is the case of type 2 pneumocytes or alveolar cells, the main site of expression of ace2 receptors [8] . the result of the interaction between the s receptor binding domain (rbd) and ace2 is the fusion of the viral and host membranes, which proceeds for viral replication and dissemination and may reach the other cells with ace2 expression in the organism [8] . with the purpose of containing the infection, the innate and adaptive immune system is activated by mechanisms that are not yet completely elucidated. in spite of this, it is known that effective immunological actions are essential to control viral replication and dissemination, cellular inflammation and tissue injury, and many studies have reported that the immune response of the host influences the severity of covid-19 [9, [36] [37] [38] . to initiate the antiviral response, cells of the innate immune system need to recognize the infection, a process performed through pattern-recognition receptors (prrs) such as tlr, nod-like receptor (nlr), c-type lectinlike receptor (clr), rig-i-like receptor (rlr) and freemolecule receptors in the cytoplasm, which detect pathogen-associated molecular patterns (pamps). once viral nucleic acids are recognized as pamps, prrs activate molecular pathways of inflammatory response, stimulating chemotaxis, maturation of immune cells, phagocytosis and expression of inflammatory factors [39] . viral recognition by tlr3, tlr7 and rig-i receptors leads to activation of the nuclear factor-κb (nf-κb) and irf3 signaling cascade, with nuclear transcription and expression of type i interferons (ifns-i) and pro-inflammatory cytokines, creating the first line of defense against viral infections. the ifns-i (ifn-α and ifn-β) are the most important antiviral cytokines, and they act as immunomodulators influencing the activities of macrophages and lymphocytes, performing actions such as protection of non-infected cells, containment of viral replication and effective activation of the adaptive immune system [8, 9, 39] . a suppression or delay of ifns-i response-due to viral evasion mechanisms-results in impairment of early infection control, hyperinflammatory infiltrate of neutrophils, macrophages and monocytes into the lungs, production of cytokines by these cells and lung tissue damage. this process, described in sars-cov and mers-cov, has been suggested as a possible strategy to trigger or collaborate to the pathology of covid-19 [8, 9] . macrophages and dcs act as apcs for lymphocytes via mhc and produce a microenvironment of signaling cytokines, activating the adaptive immune system. t lymphocytes perform important functions against viral microorganisms, since tcd8 + can cause direct cytotoxicity against infected cells and tcd4 + stimulate b lymphocytes to produce neutralizing antibodies. in turn, t helper lymphocytes (th)-predominantly th1-contribute to the organization of the adaptive response and release cytokines that are able to recruit monocytes and neutrophils and to promote other cascades of pro-inflammatory molecules, amplifying the immune response [8, 39] (fig. 3 ). the complement system can also be activated and has an important role in coronavirus infections, because it helps the innate immune system to identify antigens. however, its activation can contribute to the disease due to its potent capacity to stimulate neutrophils and to recruit inflammatory cells, which can trigger tissue damage [39] . studies suggest that in mild cases, pulmonary tissue macrophages are capable of containing sars-cov-2 and innate and adaptive immune responses are efficiently activated against viral replication. however, severe cases of covid-19 are associated with an imbalance in antiviral immunity, characterized by two main situations: a pro-inflammatory cytokine storm and a lymphopenia state [37, 38] . the degree of lymphopenia and cytokine storm was related to the severity of covid-19 [7] , and similar situations had already been reported in other respiratory viral infections, including influenza, sars-cov and mers-cov. activation of the complement system and abnormalities in coagulation were also observed in severe patients with markers such as c-reactive protein (crp), dimero-d and fibrin degradation products, which are usually elevated in advanced stages of the disease [37, 38] . the mechanism of cytokine storm and lymphopenia associated with circulatory alterations and viral dissemination to several organs was proposed as being responsible for viral sepsis. among the complications of this condition are acute respiratory distress syndrome (ards), septic shock, multiple organ failure (mof) and death [8, 38] . in patients with severe covid-19, increased levels of cytokines were observed, including il-1β, il-2, il-6, il-8, il-10, il-17, interferon-gamma (ifn-γ), tumor necrosis factor alpha (tnf-α), granulocyte-colony stimulating factor (g-csf), gamma-induced protein 10 (ip10), monocyte chemoattractant protein 1 (mcp1), macrophage inflammatory protein 1 alpha (mip1-α) and other molecules, characterizing the cytokine storm [37, 38] . additionally, elevations of il-1β, ifn-γ, ip10 and mcp1 in infections by the novel coronavirus were associated with the th1 response; however, an increase in interleukins of the t helper type 2 (th2) profile, such as il-4, il-5, il10, which suppress the inflammation, was also associated with a greater severity of covid-19, which may demonstrate an imbalance in immune regulation and an attempt to minimize tissue inflammatory damage [35, 40] . the cytokine storm generates an immunological system attack against the organism, which can cause substantial lesions in organs such as the lung, heart, brain, kidneys, spleen, liver and lymph nodes. the increase of neutrophils, macrophages and monocytes in association with a dysfunction of the ifn-i response has been reported as the main cause of lethality in sars-cov and mers-cov pneumonia, and a similar conclusion has been suggested for sars-cov-2 [9, 37, 38] . in the lungs, alveolar macrophages and epithelial cells are the most responsible for the production of cytokines and chemokines. during infection by the novel coronavirus, excessive secretion of these molecules by the immune cells mediates a massive pulmonary infiltrate of neutrophils, monocytes and macrophages, which results in alveolar damage due to wall thickening and formation of hyaline membranes. in addition, the accumulation of neutrophils in the lungs increases the production of reactive oxygen species (ros) and pro-inflammatory molecules, predisposing to injury [41] . therefore, high levels of pro-inflammatory cytokines are associated with respiratory insufficiency, ards and may lead to shock, mof and death in the covid-19 [37, 38] . in comparison, pulmonary disease caused by sars-cov also presents with formation of hyaline membranes, desquamation of alveolar space pneumocytes and interstitial infiltration with lymphocytes and mononuclear cells. in the serum of patients who develop sars, there are high levels of cytokines and pro-inflammatory chemokines [42] . additionally, it has been observed that during viral infections, pro-inflammatory cytokines can stimulate an increase in the levels of ace2 protein, the receptor for sars-cov-2. a larger quantity of this protein may accelerate the entry of the novel coronavirus into the host cells and contribute to its dissemination in the organism, negatively influencing the antiviral response [34] . in critically ill patients, a state of immune suppression is also described, with a significant and sustained decrease in the absolute number of tcd4 + and tcd8 + lymphocytes, possible reduction of b lymphocytes, nk cells, monocytes, eosinophils and basophils [37, 38] . the study conducted by liu et al. [7] did not observe significant changes in the total counts of b lymphocytes, nk cells and monocytes; however, there was a considerable reduction in the lymphocyte count in peripheral blood of patients with severe covid-19 at the beginning of the disease, especially cytotoxic tcd8 + cells [7] . activation markers for tcd4 + and tcd8 + lymphocytes showed excessive stimulation and exhaustion markers for tcd8 + lymphocytes were elevated in the disease, suggesting lymphocyte dysfunction [9, 37] . additionally, an increase in the number of neutrophils and a greater neutrophil-to-cd8 + t cell ratio (n8r) was associated with severe covid-19 and proposed as the most significant predictor of poor prognosis [7, 37] . cell death induced by interaction between fas and fas ligand by activation of the tnf-related apoptosis inducing ligand axis and by direct infection of t lymphocytes by sars-cov-2 may be responsible for the origin of lymphopenia in covid-19 [38] . the cytokine storm can also influence the lymphopenia, since in the study of liu et al. [7] , the peaks in cytokine levels il-2, il-4, il-10, tnf-α and ifn-γ coincided with the lowest t lymphocyte counts, about 4-6 days after the onset of severe covid-19; therefore, the restoration of t cell numbers was associated with reductions in circulating cytokines [7] . the fact that t cells are important regulators of the activation of the immune system during a viral infection may explain how lymphopenia is related to the worsening of inflammatory responses [7] . in consequence of lymphopenia and lymphocyte dysfunction, the adaptive immune response is ineffective and the infection is not adequately controlled, further increasing the stimulation of cytokines and cellular infiltrations [38] . it was observed that patients with sars-cov-2 infection present increased risk of venous thromboembolism (vte) and disseminated intravascular coagulation (dic). coagulopathy associated with covid-19, as it may be named, is characterized by hypercoagulability and thrombosis and is associated with worse prognosis in infection. among the altered coagulation parameters in patients with severe covid-19 are exacerbated coagulation activation, coagulation factor consumption, prolongation of prothrombin time (pt) and activated partial thromboplastin time (appt), moderate to severe thrombocytopenia, increased d-dimer and reduction of fibrinogen [43] . through a retrospective analysis of 183 patients with coronavirus pneumonia, high levels of the d-dimer and fibrin degradation product have been identified, in addition to prolonged pt, as well as appt in patients who had deceased. tang et al. [44] considered the d-dimer as an important coagulopathy marker in cases of sars-cov-2 infection. the same findings were found in the studies by han et al. [45] who see the use of hemostasis tests as tools to be used in early diagnosis and in monitoring disease progression [46] . blood coagulation is the fastest mechanism in the confinement and inactivation of infections, being the first and the last defense line of the innate immune system to take place in tissues and blood circulation. the sore promotes the activation of the endothelial cells and the dysfunction of the endothelium, thus generating a pro-thrombotic state [47] . in cases hyperactivation of the immune system, the coagulation may become intravascular and disseminated, therefore causing multiple organ failure. after all, the amount of vascular endothelial lesions of organs and tissues is, due to their activation intent, inversely proportional to the amount of existing coagulation factors [48] . thereupon, the first clinical studies carried out in patients with pneumonia caused by the coronavirus confirmed the occurrence of organ dysfunction and coagulopathy as possible causes of the negative outcomes of the disease [44] . the activation of the immune system, in response to the infection, leads the production of cytokines and tissue factor expression. the cytokines, in large amounts, harm the gas exchange and lead not only to inflammation but fibrinolysis, thus increasing d-dimer concentration [49] . the tissue factor is related to an increase in thrombin generation and fibrin deposition, leading to hypercoagulability and civd and, thus, a worse prognosis [46, 49] . as a contributor to the coagulation process, there is the presence of polymorphonuclear leukocytes (pmn) that are activated during the inflammatory process, releasing extracellular neutrophil traps (nets) which contain proteases that generate the inactivation of endogenous anticoagulants and the propagation of a procoagulant state. the interaction of activated platelets with pmn can form vaso-occlusive thrombotic complexes [47] . some authors also elucidate the virus's relationship with the eca2 functional receptor, present in the arterial and venous endothelial cells of most human organs and part of both axes of the renin-angiotensin system, the vasoconstrictor eca/ang/at1r and the vasodilator eca2/ang-(1-7)/mas [50, 51] . dalan et al. [52] cite that both aging and metabolic disorders positively regulate the eca/ang/at1r axis, leading to inflammatory, oxidative, vasoconstrictor and fibrotic effects. therefore, the eca2/ ang-(1-7)/mas axis is negatively regulated, resulting in a decrease in the anti-inflammatory and anti-fibrotic effects [52] . the connection of sars-cov-2 to the eca2 receiver affects the balance between eca/ang/at1r and eca2/ang-(1-7)/mas, making the effects of the eca/ ang/at1r axis even more prominent [53] . the different immune responses of the host to the sars-cov-2 infection may explain the reason why men and women, young and old, infected by the virus can suffer a different severity of the disease [54] . therefore, a considerably higher mortality rate was observed in patients with advanced chronological age [55] . immune aging is related to an increase in individuals' susceptibility to infections, due to the decline in immune function, which can occur at any stage of the immune response. such changes can be seen, especially when associated with emotional stress [56] . immune senescence is associated with the suppression of the activation and presentation of antigens by macrophages, which consequently prevent the migration of dendritic cells and the activation made by toll receptors with less effect [56, 57] . ewers et al. [58] mention the decline and proliferation of t cells, in addition to the increased production of pro-inflammatory cytokines il-1, il-6 and tnf-α in the elderly. another point is the imbalance between th1 and th2 cytokines, generating an increase in the susceptibility of these individuals as infections by viruses and extracellular bacteria [58] . in view of this, aging is associated with a constitutive pro-inflammatory environment due to persistent and low-grade immune activation, which can lead to increased tissue damage caused by infections [57] . also, there should be taken into account the positive regulation of the ace-ang-ii-at axis that leads to proinflammatory and pro-fibrotic effects. although not very detailed, it is still suggested the occurrence of a greater number of eca2 receptors associated with aging, which would increase this imbalance. after all, it is through this receptor that sars-cov-2 infects humans and thus contributes to the development of covid-19 in older people [52] . the precarious metabolic health is considered the main risk factor for the development of severe forms of covid-19. this may occur in t2dm, obesity and ms, possibly due to immune dysfunction in synergism with pathophysiological complications of these comorbidities [59] . increased ace2 expression is a protective adaptive mechanism in t2dm; however, it may facilitate the viral entry and spread of sars-cov-2 in the body [59] . adipose tissue also exhibits high expression of ace2, so the population with obesity may present greater vulnerability to covid-19 [43] . it was observed that the expression of ace2 in the adipose tissue of obese patients allows viral entry in adipocytes and makes this tissue a reservoir for the viral dissemination of sars-cov-2, since it is viscerally distributed [43, 51] . in addition, obesity is an important factor for the development of t2dm-especially when associated with low levels of physical activity and poor physical conditioning-and as mentioned, both diseases are related to higher expression of ace2, increasing the risk of advanced infection by sars-cov-2 [43] . metabolic disorders lead to immune activation of tissues such as the adipose, increasing the concentration of lowgrade chronic inflammation plasma markers, called metabolic inflammation or meta-inflammation [61] . in this sense, the release of pro-inflammatory adipokines such as leptin, tnf-α, il-6 and il-1b is observed, with a reduction in antiinflammatory action through the suppression of adiponectins [62, 63] . the presented relationship is directly proportional to the presence of adipose tissue, the same that can be regulated through the practice of physical activity [64] . the pro-inflammatory state found in metabolic syndrome and t2dm may increase the probability of an unbalanced inflammatory response in covid-19, like the cytokine storm described in patients with severe disease [59] . similarly, as obesity is a state of low-grade chronic inflammation, it shows a potential for immune amplification of pathogens, as the regulatory elements of the immune response are absent or dysfunctional and this may contribute to the cytokine storm, which is already in greater concentration in obese individuals and which sustains and activates multiple cytokine pathways for a long time after the viral insult [65, 66] . damage to blood vessels caused by chronic diseases, such as t2dm, associated with hypercoagulability present in covid-19 may intensify the risk of infection complications [59] . obesity can also aggravate endothelial dysfunction present in covid-19 due to inflammation triggered by perivascular and vascular adipose tissue, combined with changes in the synthesis of endogenous vasoactive agents, leading to platelet hyperactivation, leukocyte adhesion and other modifications related to endothelial inflammation, prothrombosis and proatherogenesis [43] . hypercoagulability is directly proportional to the severity of overweight in obese patients. among the pathophysiological mechanisms are the action of adipocytokinins, with leptin and adiponectin, overactivity of coagulation factors, reduction of fibrinolytic function and, once again, increased inflammation (tnf and il-6). other contributors include elevated oxidative stress, lipid and glucose tolerance disorders, ms and venous stasis. thus, it is considered a synergic effect of obesity and ms on the state of hypercoagulability in covid-19, aggravating the risk of vte and dic even more [43] . there is also a greater amount of macrophages in the adipose tissue of obese individuals due to areas of microhypoxia, which lead to the nuclear factor-κb (nf-κb) pathway activation, thus increasing the expression of genes involved in inflammation [61] . this condition is the result of the attraction of monocytes in the circulation made by chemokines; when they infiltrate the adipose tissue, they transform into macrophages, which, in turn, release tnf-α and il-6 which induce the tissue's resistance to insulin [63] . insulin resistance is also related to the host's immune response, as it can inhibit the resolution of t cell-mediated inflammation [61] . the adipose tissue is not the only one affected by the deposition of fats, because of that, bone marrow and thymus also present significant changes to the immune system of obese individuals and those with ms [67] . thus, there is a marked deregulation of immune responses, which leads to a lower presence of circulating t cells, reducing the response to pathogens [60, 61, 65] . despite the lack of accurate data on how physical activity improves the immune response against the new coronavirus, there is evidence of lower rates of ari incidence, duration and intensity of symptoms and risk of mortality from infectious respiratory diseases in individuals who exercise at high levels appropriate. furthermore, different studies suggest that regular physical exercise is directly related to decreased mortality from pneumonia and influenza, improvements in cardiorespiratory function, vaccine response, metabolism of glucose, lipids and insulin [13, 16] . increased immune surveillance against infections has been proposed as a mechanism responsible for improving the immune response related to physical exercise. moderateintensity physical activity is responsible for providing an increase in the anti-pathogenic activity of macrophages, at the same time as elevations in the circulation of immune cells, immunoglobulins and anti-inflammatory cytokines occur, thereby reducing the burden of pathogen on organs such as the lung and the risk of lung damage due to the influx of inflammatory cells [12] . during regular physical exercise practices, inflammatory responses and stress hormones are decreased; in contrast, lymphocytes, nk cells, immature b cells and monocytes are at high levels. thus, there is an improvement in immunovigilance, as well as a reduction in the systemic inflammatory process, factors that corroborate that regular physical activity helps to improve the immune system, while helping to prevent respiratory diseases and thus protect against infections such as covid-19 [68] . dynamic exercises that generate cardiorespiratory overload promote the mobilization and redistribution of effector lymphocytes, mediated by catecholamines. this action primarily stimulates subtypes of lymphocytes capable of migrating from reservoirs-such as blood vessels, spleen and bone marrow-to lymphoid tissues and organs-such as the upper respiratory tract, lungs and intestines, aiming at recognizing and fighting pathogens and, thus, increasing immune surveillance and improving the antiviral response [16] . similarly, regular exercise practices at moderate levels favor the function of the human body's immune surveillance against pathogens, as they stimulate an exchange of white blood cells between the circulatory system and tissues, a fact that reduces morbidity and mortality from acute respiratory disease and infections viral. they are also capable of promoting protection against infections triggered by intracellular microorganisms, as viral agents, given that the predominant immune response is mediated by th1 cells [68] . regular exercise of moderate intensity has already been associated with a reduction in respiratory infections compared to sedentariness. however, exhaustive physical practices before or during an infectious condition, such as influenza or covid-19, can trigger severe illness due to changes in the immune system [40, 68] . this occurs due to the production of th2 anti-inflammatory cytokines in order to reduce muscle tissue damage, but in strenuous activities this effect can reach immunosuppression levels, thus providing the opportunity for infections [12, 40] . therefore, attention should be paid to the importance of developing physical training at appropriate levels of execution. to the detriment of the world demographic change and the habits arising from the technological revolution, the population is aging more, becoming more obese and, consequently, less active when it comes to physical exercise. in this way, the immune system undergoes negative changes; that is, there is a functional impairment of innate immunity and adaptive immunity called immunosenescence, which results in greater susceptibility to infectious diseases and systemic inflammatory processes, decreased response to antibodies and, therefore, compromised immunological surveillance [68] . therefore, for the elderly population, physical activity is even more essential, as these individuals generally have greater comorbidities and, in relation to the new coronavirus, are more vulnerable to contracting the disease [69] . damiot et al. [70] suggested that individuals who have remained active throughout their lives have less pronounced immunosenescence characteristics, which may be a possible protective factor against the development of complications caused by covid-19. in this sense, beneficial effects of regular physical exercise have been reported in the elderly population, including reduction in oxidative stress, improvement in immune competence and reduction in cellular changes related to immunosenescence [13, 16] . elderly individuals who maintain continued physical activity have levels of tcd4 + and tcd8 + lymphocytes similar to younger individuals, in addition to not having harmful defects in the recruitment of lymphocytes during the infectious process [58] . according to the study by ferrer et al. [71] with 116 elderly volunteers, through physical activity there is a decrease in the current levels of il-6, as well as an increase in the expression of il-10 in active individuals [71] . a low presence of circulating pro-inflammatory cytokines is observed in contrast to the increase in anti-inflammatory cytokines. thus, there are positive changes in the immune system of these individuals, including enhancements in host response and vaccine immunoprotection [70] . similarly, while prolonged maintenance or worsening of obesity and ms perpetuates deregulation of immune responses, promoting greater risks of the individual developing diseases and increasing their vulnerability to infection by the novel coronavirus [43, 59, 61 ]. an association between physical activity and reduction of inflammatory markers in obese and overweight patients is suggested [13] . luzi and radaelli [72] add the lack of physical activity as an important factor among obese patients, as it impairs the immune response against microbial agents, from the activation of macrophages to the inhibition of pro-inflammatory cytokines. on the other hand, both metabolic health and immune health benefit from the practice of physical activity, which reduces the risk of infectious complications. thus, regular physical exercise appears as a preventive measure in the defense of the host against viral infection [72] . muscle contraction is responsible for the transient increase in circulating levels of il-6 cytokine, in proportion to the duration of physical activity and the amount of muscle mass recruited. the elevation of this interleukin seems to be followed by increases in antinflammatory cytokines, such as il-10, released by cells of innate immunity and responsible for promoting an antinflammatory environment, inhibiting inflammatory mediators to limit tissue damage. this effect may be beneficial in cases of chronic inflammation, such as obesity, t2dm and ms, and may reduce the risk of a pathogenic inflammatory response such as the cytokine storm present in severe covid-19 [40, 59] . in addition, il-10 is associated with enhanced insulin sensibility and glycemic metabolism [40] . physical practice is able to reduce the excessive concentration of pro-inflammatory adipocin leptin and improve sensitivity to leptin and insulin [72, 73] . in patients with t2dm and new coronavirus infection, good glycemic control has been associated with better prognosis in covid-19 [59] . thus, physical exercise is shown to be an immunomodulatory and non-pharmacological intervention, achieving positive immunomodulation through exercises of light to moderate intensity [72] . through exercise, there is an improvement in the response to infection in obese individuals, due to immune and cellular restoration [74] . although covid-19 is not primarily a metabolic disease, there is a need to maintain metabolic control of glucose, lipid levels and blood pressure in order to prevent metabolic and cardiovascular complications, as well as to reduce the local inflammatory response and block the virus entering the cells [75] . as seen, innate immunity has an important role in the pathogenesis of covid-19 and ards, due to inflammatory cascades, recruitment of neutrophils, macrophages and dc cells and increased production of ross. in turn, by the modulation mechanism of chemokine production, physical training and therapeutic exercises can attenuate alveolar neutrophilia in the face of lung injury [41] . furthermore, the expression of the extracellular superoxide dismutase enzyme (ecsod), an important antioxidant in the body and highly present in the lungs, is enhanced by resistance physical activity and was associated with inhibition of endothelial activation and inflammatory adhesion, with potential benefit to reduce oxidative stress and tissue damage in covid-19 [41] . the amplification of the antioxidant defense generated by routine physical activity also contributes to immunological surveillance [13] . moreover, womack, nagelkirk and coughlin [76] point out that through the intensity of physical exercise, a change in the potential for coagulation, platelet aggregation and fibrinolysis can be seen. as an example, there is long-term training through aerobic exercises where a decrease in the clotting potential is observed in healthy individuals. thus, it is suggested that the practice of physical exercises contributes to reducing the risk of ischemic events depending on their intensity and duration [76] and may contribute to attenuating coagulation disorders associated with sars-cov-2 infection. the anti-inflammatory, antioxidant and endothelial activation inhibitor benefits may also be linked to the reduction in hypercoagulability related to covid-19. this is because, as previously mentioned, the exacerbated activation of the immune system increases the expression of the tissue factor and, consequently, the predisposition to the formation of thrombi; in addition, metabolic disorders, oxidant stress and changes in senescence positively stimulate the vasoconstrictor axis eca/ang/at1r, contributing to endothelial imbalances [46, 47, [49] [50] [51] [52] [53] 69] . therefore, the immunometabolic improvements promoted by physical exercise may help in the control of coagulation disorders in the covid-19 (fig. 4) . finally, in view of the quarantine status adopted in several countries as a measure to prevent and control the spread of sars-cov-2 during the covid-19 pandemic, social isolation and restrictions on the movement of people reduced the practice of physical activity, predisposing the population to adopt sedentary behavior [77] . social distancing is a sine qua non in reducing the speed of contagion of covid-19 and associated deaths. however, due to these measures, sports clubs, gyms and fitness spaces have suspended their activities in order to reduce agglomerations; thus, difficulties regarding physical exercise were imposed [78] . therefore, despite being one of the main strategies against covid-19, social isolation has been related to behavioral and physiological changes, including the increased prevalence of sedentarism and eating disorders (food compulsion, hyperphagia), resulting in negative consequences for metabolic health, such as weight gain, growth of fat tissue, hyperglycemia and insulin resistance and loss of muscle tissue [59] . since this condition can harm the body's defenses and contribute significantly to the reduction in individuals' physical condition, functional and health loss, the adoption of healthy habits and an exercise routine can help in maintaining health [59, 69] . it is significant to consider that contexts like this increase the susceptibility to stressful events and elevations of glucocorticoids (cortisol), with consequent inhibition of the functions of nk cells and tcd8 + lymphocytes in the antiviral response. however, good physical conditioning was associated with lower risks of reactivation of latent viral infections in situations of isolation and confinement, indicating a favored immune system compared to individuals with less physical fitness [16] . physical activity is considered a non-medication practice for the prevention and treatment of diseases of psychological, physical and/or metabolic origin [78] . regular physical exercise should be encouraged during social isolation as a preventive measure for health, given that exercise is essential during the period of fight against the spread of coronavirus [69] . the american college of sports medicine (acsm) recommends that the practice of moderate physical exercise should be maintained during the quarantine period, since it helps in the immune reinforcement against sars-cov-2. the who recommends that asymptomatic and healthy individuals should exercise at least 150 min per week for adults and 300 min per week for children and adolescents. these times can be distributed during the days of the week and according to the person's routine [69] . it is important to emphasize that physical activity should be interrupted and a health professional should be consulted in case symptoms such as fever, dyspnea at rest and dry cough are manifested, because these symptoms can be related to covid-19 [69, 79] . in social isolation, the home environment has become the ideal and necessary place for physical activity. activities that are satisfactory and that allow better exploring the home space should be sought. activities of daily living such as organization of spaces, cleaning and maintenance also help in coping with covid-19. in environments with children, playing and exercising with them is a great way to promote energy expenditure, thus leaving the beginning of sedentary rest. meditation, stretching and relaxation are allies in combating a sedentary lifestyle. it is important to avoid long rest periods, which should be intercalated with active practices [69] . the acsm has published guidelines for moderate-intensity activities that can be practiced during the pandemic period, including aerobic exercises and strength training, indoors, like at home, or outdoors, when permitted by fig. 4 benefits of regular moderate-intensity physical activity on factors that influence the response against to covid-19. source: the authors (2020) government authorities. options for aerobic activities to be performed at home include walk briskly around the house, up-and downstairs, dancing and jumping rope. when possible, walking or running outdoors, cycling, gardening work and family games are interesting alternatives, as long as infection prevention measures are maintained [79] . among the strength activities, acsm indicates downloading a strength workout app that does not require any equipment and suggests exercises such as squat, sit-ups, push-ups, lunges and yoga practice, which can also help in anxious states [79] . oliveira neto et al. [80] suggest resistance exercises based on acsm recommendations to be performed at home, including exercises involving the muscles of the lower body, upper body and limbs, and lower limbs, which can be adapted for beginners in physical practice or experienced people. activities that make use of the individual's own body weight, associated with resistance training as well as the use of elastic bands, provide excellent health results, results similar to those achieved by traditional gyms. thus, objects such as backpacks, books, market bags and water bottles can be used as an auxiliary tool in resistance physical activity. exercises such as squats, jumping jacks and going up and down steps can be effective in physical training [78] . as for the intensity and volume of physical exercise practices, these must be moderate, as they exceed both the volume and the intensity, effects such as momentary immunosuppression are achieved, thus providing greater vulnerability as to the contagion of the novel coronavirus. if individuals want to practice high-intensity exercises, a reduction in exercise volume should be adopted as a preventive measure, in order to avoid strenuous exercises [78] . in addition, technological tools can contribute to the better performance of these activities in the home environment, as video calls with a physical education professional facilitate the orientation of the exercises to be performed, providing support that has, as a consequence, better results and greater safety in the execution of the exercises. regardless of whether or not you are in the risk group for covid-19, regular exercise, according to the acsm, should be regularly performed, given that it aims to improve the immune system, reduce stress perceived and decrease anxiety disorders [78] . there are still gaps in the knowledge regarding the pathogenic mechanisms involved in sars-cov-2 infection. however, there is consensus in the scientific literature about the important involvement of the immune system in the susceptibility, progression and outcome of covid-19. the imbalance in innate and adaptive immune responses, characterized mainly by changes such as cytokine storm and lymphopenia, in addition to the disorders in coagulation-and host-related conditions, including obesity, metabolic syndrome and aging (immunosenescence), is among the factors notoriously associated with a worse prognosis of infection. the benefits of exercise-regular and at appropriate intensity levels-for the immune system in respiratory infections such as covid-19 include increased immunovigilance and improved immune competence, which help in the control of pathogens, a fact that becomes more important considering the immunosenescence and susceptibility of the elderly population to severe infection. other favorable effects in relation to host factors, such as prevention or reduction of overweight, increased physical and cardiopulmonary conditioning, attenuation of the systemic pro-inflammatory and pro-thrombotic states, decrease in oxidative stress, improvements in glycemic, insulinic and lipidic metabolisms, besides the enhancement of the vaccination response, also indicate how adequately physical activity can help the organism's immune response against covid-19. in the covid-19 pandemic situation, adopting mitigation practices is an essential strategy to reduce the risks related to the novel coronavirus infection. these interventions include the use of personal protective equipment (ppe), adherence to hygiene procedures and social isolation measures, as well as actions that lead to a healthier lifestyle, minimize stress factors and strengthen the immune system, such as regular physical activity. however, remaining active at appropriate levels seems to be a challenge in a context of confinement and social isolation, which emphasizes the importance of developing training with recommendations adapted to the new routine of the population. fortunately, there are viable alternatives for performing physical exercises in restricted environments, enabling the population to enjoy the advantages of physical training for health in the context of ovid-19. finally, future studies that deepen the relationship between physical activity and infection by sars-cov-2, including the influences of exercise on metabolic and immunological disorders present in covid-19, will certainly be relevant in view of the probable benefits already mentioned and considering the impacts of infection by the novel coronavirus in the global context. faced with the possibility of new pandemics by previously unknown microorganisms, without totally effective prevention measures, vaccines or specific treatments of proven efficacy, the host organism's capacity against infections becomes the most important line of defense, thus emphasizing the importance of investing in lifestyle habits that promote health and well-being, such as the practice of physical activity. the persistence of acute respiratory 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weight loss impact of obesity on influenza a virus pathogenesis, immune response, and evolution endocrine and metabolic link to coronavirus infection exercise-induced changes in coagulation and fibrinolysis in healthy populations and patients with cardiovascular disease exercise in the time of covid-19 praticar exercícios físicos é fundamental para a saúde física e mental durante a pandemia da covid-19. braz j health rev page_docum ents/eim_rx%20 for %20hea lth_%20sta ying%20act ive%20dur ing%20cor onavi rus%20pan demic traininginhome-home-based training during covid-19 (sars-cov2) pandemic: physical exercise and behavior-based approach authors' contributions dtrs had the idea for the article. es, kksf e mrb performed the literature search, data analysis and translation. mps drafted and revised the work.funding not applicable. conflict of interest the authors declare that they have no conflict of interest.human and animal rights statement and informed consent this article does not contain any studies with human participants or animals performed by any of the authors, and informed consent is not a standard required. key: cord-254758-ubw0chrf authors: newbold, stephen c.; finnoff, david; thunström, linda; ashworth, madison; shogren, jason f. title: effects of physical distancing to control covid-19 on public health, the economy, and the environment date: 2020-08-04 journal: environ resour econ (dordr) doi: 10.1007/s10640-020-00440-1 sha: doc_id: 254758 cord_uid: ubw0chrf physical distancing measures are important tools to control disease spread, especially in the absence of treatments and vaccines. while distancing measures can safeguard public health, they also can profoundly impact the economy and may have important indirect effects on the environment. the extent to which physical distancing measures should be applied therefore depends on the trade-offs between their health benefits and their economic costs. we develop an epidemiological-economic model to examine the optimal duration and intensity of physical distancing measures aimed to control the spread of covid-19. in an application to the united states, our model considers the trade-off between the lives saved by physical distancing—both directly from stemming the spread of the virus and indirectly from reductions in air pollution during the period of physical distancing—and the shortand long-run economic costs that ensue from such measures. we examine the effect of air pollution co-benefits on the optimal physical distancing policy and conduct sensitivity analyses to gauge the influence of several key parameters and uncertain model assumptions. using recent estimates of the association between airborne particulate matter and the virulence of covid-19, we find that accounting for air pollution co-benefits can significantly increase the intensity and duration of the optimal physical distancing policy. to conclude, we broaden our discussion to consider the possibility of durable changes in peoples’ behavior that could alter local markets, the global economy, and our relationship to nature for years to come. in the initial months of the covid-19 pandemic, most nations have attempted to control the spread of infections by reducing the rate of contacts between people who carry the virus and those who have not yet been exposed. the various methods to achieve such reductions in contacts are referred to generically as "physical distancing" measures-also known as "social distancing" or "spatial distancing" (abel and mcqueen 2020) . while physical distancing can reduce the death toll of the pandemic, it also can impose large costs on society as exemplified by the sharp declines in gdp and employment in the months following the initiation of physical distancing measures in the united states (sachs 2020; u.s. department of labor 2020) . this suggests there could be substantial gains from properly calibrating the intensity and the timing of physical distancing restrictions. in this study, we characterize the time path of physical distancing that minimizes total economic damages from controlling the covid-19 epidemic in the united states, accounting for a potentially important category of environmental co-benefits. we develop an integrated epidemiological-economic model that includes a standard model of disease transmission, the monetized value of covid-19 deaths averted and lives saved from exposure to air pollution, and the short-and long-run costs of physical distancing. the model includes the main features of the disease spread process and the economic trade-offs associated with broad-based physical distancing measures that represent the main approach to controlling the spread before a vaccine or effective treatments are available. we expand the model used in on our earlier benefit-cost analysis of physical distancing in several ways (thunström et al. 2020) . first, we explicitly connect the intensity and timing of physical distancing to both lives saved from the infection and the income lost from reduced work hours and lowered productivity. second, we incorporate the co-benefits of reduced mortality risks from declines in air pollution during the period of physical distancing. this extension is motivated by a striking side-effect of physical distancing, as indicated by visibly reduced levels of ambient air pollution in many areas around the world (iea 2020; venter et al. 2020) . globally, outdoor air pollution is responsible for around 4.2 million premature deaths per year (world health organization 2020a), and recent estimates for the u.s. range from around 50,000 to 250,000 premature deaths per year attributable mainly to pm 2.5 (burnett et al. 2018; bowe et al. 2019; goodkind et al. 2019) . adding an air pollution component to our model allows us to account for the lives saved from reductions in pollution emissions as a co-benefit from physical distancing measures whose primary purpose is to control the spread of infections. third, we include a putative link between air pollution and the virulence of covid-19. several recent studies have attempted to identify an interaction effect between air pollution and covid-19 transmissibility or case fatality ratios ogen 2020; persico and johnson 2020) . initial results of these studies suggest that airborne particulate matter could have a significant positive mediating influence on covid-19 fatalities, so we use our model to explore the potential effect of this link on the optimal physical distancing policy. our study draws on a mature literature that integrates economics and epidemiology to examine a wide variety of infectious diseases in humans (e.g. gersovitz and hammer 2004; rowthorn et al. 2009; perrings et al. 2014; fenichel et al. 2011; gersovitz 2011; fenichel 2013; philipson 2016) . we also add to a growing collection of recent studies that apply optimal control theory or computational dynamic optimization techniques to the covid-19 outbreak in particular (e.g. acemoglu et al. 2020; alvarez et al. 2020; eichenbaum et al. 2020; farboodi et al. 2020; gonzalez-eiras and niepelt 2020; kruse and strack 2020; piguillem and shi 2020; toxvaerd 2020) . a comprehensive review of these studies would take us too far afield, so here we briefly describe several closely related studies to highlight points of comparison between our work and that of others in the literature. farboodi et al. (2020) develop a continuous-time optimal control model with a vaccine backstop and endogenous physical distancing by optimizing individuals. they show that without regulation, individuals choose a sub-optimal level of physical distancing, reducing economic activity too late to achieve the socially optimal level of disease suppression. the optimal policy is characterized by an initial rapid ramp-up and a long duration of an intermediate level of physical distancing until a vaccine is developed. the authors apply a calibrated version of the model to the covid-19 epidemic in the united states, which shows that the optimal policy delays the peak of infections to buy time for a vaccine. eichenbaum et al. (2020) examine macroeconomic impacts of pandemics by modeling the behavioral responses of individuals to the evolving tradeoff between consumption and health risks during an infectious disease outbreak. they assume that the risk of infection increases with consumption, which leads to a decline in both market demand and supply during a pandemic, resulting in an economic recession. alvarez et al. (2020) and kruse and strack (2020) also study the optimal timing of physical distancing, accounting for both deaths due to infection and the economic costs of physical distancing, assuming that a vaccine or fully effective treatment will be developed within one year. in both cases, the optimal policy response allows infections to rise until they are close to the medical system capacity, and then physical distancing measures are rapidly implemented to keep the number of infections below the medical system's capacity constraint for a period of time that dampens or eliminates a second wave of infections. acemoglu et al. (2020) include multiple risk groups in a pandemic control model, where the groups are characterized by differing interaction behaviors and by age, which affects their fatality risk if infected. the authors use the model to examine the effects of targeted lockdowns, and find that differentiated lockdown policies will outperform those that are uniformly applied to the whole population. gonzalez-eiras and niepelt (2020) consider the implications of non-optimally timed physical distancing programs, and find that the net benefits of the policy can be drastially reduced if controls are initiated too early or kept in place too long. toxvaerd (2020) characterizes the equilibrium (unregulated) behavior of individuals in a model of infectious disease spread with no risk of death but with reduced flow utility in the infected state and with a linear cost of physical distancing. the equilibrium path of physical distancing has the effect of flattening the curve of infections at a characteristic level of infections determined by a combination of epidemiological and economic parameters. our model differs in the details but shares many of the same basic features as those reviewed above, including a traditional epidemiological model of disease spread and a representation of the influence of physical distancing on deaths from the infection and economic output or income. our main modeling innovation is to incorporate a link between physical distancing and air pollution, as well as the interaction between pollution and the covid-19 fatality rate. to our knowledge, our study is the first to examine this link in an optimal control framework, which allows us to assess a potentially important category of co-benefits from physical distancing. a final note before proceeding to the details of the model. we view our approach, like the studies described above, as closer to the "streamlined" than the "elaborated" end of the spectrum of possible models. we include the main features of the system relevant to our primary research questions, but otherwise we intentionally simplify as much as possible. we agree with pindyck (2020) that calibrated sir models applied to the covid-19 outbreak should be viewed as only rough approximations to reality and taken with a grain of salt. at the same time, even if they cannot provide precise forecasts and definitive policy prescription, we believe that strategically simplified models roughly calibrated to the stylized facts can be useful for developing qualitative insights and for generating preliminary comparisons of alternative control scenarios. to project the number of infections and deaths under various physical distancing policies, we use a discrete-time sir compartment model (kermack and mckendrick 1927; hethcote 1989) . we modify the standard model to represent the influence of physical distancing on the contact rate and the endogeneity of the case fatality ratio as the health care system becomes overwhelmed by a surge of infected individuals seeking medical care. we include a link between physical distancing and mortality from air pollution, as well as an interaction between air pollution concentrations and the covid-19 case fatality ratio. the shortand long-run economic costs of physical distancing depend on the average distancing fraction prior to the arrival of a vaccine and the assumed speed of economic recovery. the equations of motion for susceptible, infected, and recovered individuals are and in eq. (1), is the contact rate without physical distancing, and x t is the fractional reduction in the number of potential transmission encounters that all individuals-both susceptible and infected-have in period t (alvarez et al. 2020) . we refer to x t as the "distancing fraction," which will serve as the control variable in the regulator's optimal control problem. in eq. (2), is the rate of recovery from infection (the reciprocal of the average duration that individuals remain infected and able to spread the virus), and d t is the number of deaths due to infection in period t. denoting the case fatality ratio by t , the number of infected individuals who die in period t is note that t is the probability of dying from the infection before recovering, not the per period probability of death for infected individuals (keeling and rohani 2011, p 34) . we model the case fatality ratio as endogenous to the system, and indirectly responsive to the physical distancing policy through its influence on the evolution of infections. as the number of infected individuals requiring medical care increases, the health care system becomes stressed. this leads to infected individuals receiving a lower standard of care as scarce medical resources are spread ever more thinly. we represent this feedback by a logistic function of infections, (2) where lo is the lower-bound case fatality ratio, which will obtain when i t is much lower than a critical value of infections, ĩ (corresponding to the inflection point of the logistic function), and hi is the upper-bound case fatality ratio, which will obtain when i t is much higher than ĩ . the parameter k controls the steepness of the logistic function, so for high k the relationship approaches a step function with lo for all i t <ĩ and hi for all i t >ĩ , as assumed in thunström et al. (2020) . we assume that recovery from infection yields immunity to the virus, although this has not been firmly established for covid-19. while a number of studies find that people develop antibodies from the infection, the extent of protection from subsequent infections is still uncertain (world health organization 2020b). equations (1)-(5) comprise the modified sir model with physical distancing and endogenous case fatality ratio. we use this model to project the number of infections and deaths under various physical distancing policies represented by the time path of the distancing fractions, x t . the regulator's task is to find and enforce the sequence of x t 's that minimizes the total damage from the outbreak, which includes the value of lives lost due to infection, minus the value of lives saved due to reduced pollution, plus the value of current and future income lost due to the reduced economic activity associated with physical distancing. we account for the value of lives saved from air pollution in the period of physical distancing due to lower emissions from reduced economic activity. to do so, we use a proportional hazard model (cox 1972; harrell 2015) , which implies that the number of deaths averted in a time period due to a reduction in pollution concentration from z 0 to z 1 is where m 0 is the initial deaths from all causes in the time period, z 0 is the initial level of air pollution, z 1 is a lower level of pollution due to reduced economic activity caused by physical distancing, and is the air pollution hazard coefficient. to compress notation in what follows, we define the fractional reduction in the average pollution concentration during the period of physical distancing as z x , so z 0 − z 1 = z x z 0 . air pollution emissions increase with overall economic activity, with an especially strong link to activity in the transportation sector. to represent this linkage, we assume that air pollution emissions on day t are a possibly non-linear function of the physical distancing fraction, x t . specifically, the fractional reduction in the average pollution concentration during the period of physical distancing is where days are indexed by t, and t is the duration of the physical distancing policy in days. the exponent controls the shape of the response of pollution to physical distancing. = 1 is the linear case, for which z x = 1 t ∑ t t=1 x t , while < 1 ( > 1 ) implies a sub-linear (supra-linear) response of emissions to distancing, in which case the fractional reduction in pollution with physical distancing would be less than (greater than) the distancing fraction. to understand how a non-linear response could arise, suppose that the average individual's inter-personal contacts are evenly split between contacts with co-workers at the workplace and contacts with friends and neighbors close to home. also suppose that commuting to and from work accounts for more (less) than half of the average individual's vehicle miles travelled and associated pollution emissions. if early increments of physical distancing mainly involve work-from-home policies, then, under the prior suppositions, the average person's inter-personal contacts would be reduced by half while her pollution emissions would be reduced by more (less) than half, which implies > (<) 1. here we use = 1 , which we view as natural default assumption. several recent studies have examined possible links between air pollution and covid-19 related deaths. long-term exposure to air pollution contributes to many of the underlying health conditions that put people at higher risk for severe consequences from covid-19, particularly respiratory diseases. such respiratory conditions also might be exacerbated by contemporaneous air pollution concentrations, which could compromise the body's ability to mount an effetive immune response to covid-19. focusing on the u.s., find that a 1 g ⋅ m −3 higher long-term average concentration of pm 2.5 (between the years 2000-2016) is associated with an 8% increase in the covid-19 fatality risk. other researchers have examined the possibility that airborne particulate matter (pm) facilitates the transmission of sars-cov-2 through the air (martelletti and martelletti 2020; di toppi et al. 2020; setti et al. 2020) , which could increase force-of-infection for repiratory disease transmission (tang et al. 2018 ). persico and johnson (2020) used the suspension of u.s. environmental protection agency enforcement activities as a natural experiment to estimate the impact of short-run decreases in pollution on covid-19 fatalities at the county level, and find large effects. to examine the potential importance of such a link for the optimal physical distancing policy, we include an interaction between air pollution and the covid-19 case fatality ratio, which appears in eq. (4) above. this allows us to compare the overall deaths from infection and lives saved from air pollution between otherwise equivalent model runs with and without the interaction included. when the interaction is included, the case fatality ratio in each period is adjusted by a factor that depends on the overall reduction in air pollution due to physical distancing, i.e., where is the air pollution-infection interaction coefficient. to value lives saved from infection or air pollution, we use a central estimate of the "value per statistical life" (vsl). this quantity represents the average marginal willingness to pay for reducing the probability of death in a time period, i.e., the marginal rate of substitution between money and mortality risk (viscusi 2018 ). 1 here we use a constant vsl, though some authors use age-adjusted vsl values, typically declining for older individuals (e.g. greenstone and nigam 2020) , and others value the expected loss of life-years rather than expected deaths (e.g. hall et al. 2020 ). pindyck (2020) also suggests that a lower average vsl value should be used when the number of deaths averted is large, due to diminishing marginal willingness to pay for risk reductions. the influence of age on the vsl has been examined in a number of previous studies (e.g. shepard and zeckhauser 1984; kniesner and viscusi 2006; evans and smith 2006; hammitt 2007) , but no clear consensus on a (8) � t = t e − z x z 0 , singular strategy to adjust for age has yet emerged in the literature. in the meantime, we follow u.s. federal agency recommendations and use a fixed central value of the vsl for all ages in our benchmark runs ( the relationship between the extent of physical distancing and lost income in society is typically taken to be linear (e.g. alvarez et al. 2020; toxvaerd 2020; kruse and strack 2020; piguillem and shi 2020; bolzoni et al. 2019; hansen and day 2011; lee et al. 2010 ). yet the possibility exists that the amount of income lost may be lower or higher than the physical distancing fraction. we introduce flexibility into the physical distancing cost function by allowing for non-constant returns to the rate of interpersonal contacts; specifically, we assume that per capita income on day t is a possibly nonlinear function of contacts, i.e., y t ∝ (1 − x t ) , where = 1 is the linear case and < 1 ( > 1 ) implies decreasing (increasing) returns, in which case the fraction of income lost with physical distancing would be less than (greater than) the distancing fraction. if mixing can be reduced initially by some people working remotely, traveling less, minimizing face-to-face meetings, etc., without being furloughed or losing their jobs, then would be less than 1. considering that some fraction of the workforce can reduce mixing with relatively little loss of productivity, we view = 1 as a conservative benchmark assumption. we account for both the short-run and long-run cost of physical distancing. the shortrun cost is the present value of lost income during the period of physical distancing, where y is aggregate income per day with no physical distancing, and r ′ is the daily discount rate. the long-run cost of physical distancing is the present value of lost income after the period of physical distancing, which will depend on the speed of economic recovery after the initial decline in aggregate income. to represent the long-run cost, we assume that income growth will be temporarily elevated as the economy recovers from the shock, and the post-outbreak growth path will asymptotically approach the counterfactual no-outbreak growth path at a constant rate . based on these assumptions, and discounting future income at a constant rate r, the present value of lost income after the period of physical distancing is is the fractional loss of aggregate income during the period of physical distancing, y 0 is aggregate annual income before the outbreak, and r is the annual discount rate. combining the relevant elements specified above, the total damage function is equation (11) combines the value of covid-19 deaths, the value of averted air pollution deaths, and the value of lost income in the short-run and the long-run. note that the control variables, x t , are implicit in eq. (11), through the definitions of z x , y x , v, and v, and through the dependence of the d t 's on the x t 's as determined by eqs. (1)-(5). following thunström et al. (2020) , we use r 0 = 2.4 (liu et al. 2020; ferguson et al. 2020; aronson et al. 2020 ), = 1/6.5 (liu et al. 2020; lauer et al. 2020) , lo = 0.005 , and hi = 0.015 (riou et al. 2020; wilson 2020; yang et al. 2020; dorigatti et al. 2020; unwin et al. 2020 ). 2 in a sensitivity analysis, we use r 0 = 4.8 , which is closer to the more recent estimate reported by sanche et al. (2020) . to specify the inflection point of the case fatality ratio function, ĩ , we assume that if 5 × 10 5 hospital beds are occupied by covid-19 patients-roughly half of the 9.24 × 10 5 staffed beds in u.s. hospitals (american hospital association 2020)-then the case fatality rate would be at the mid-point of its possible range between lo and hi . wu and mcgoogan (2020) reported that 5% of covid-19 cases in china were "critical," so we assume that 5% of covid-19 infections will require the use of a hospital bed. this gives ĩ = 10 6 × 0.5 ÷ 0.05 = 10 7 infected individuals. that is, if on any given day 10 million people are infected by the virus, then a fraction ( lo + hi )∕2 would not be expected to survive. we set the steepness parameter, k, to give a pronounced s-shape but not a severe step function. to calibrate the air pollution hazard coefficient, , we rearrange the proportional hazard function in eq. (6) in our benchmark model we do not include an interaction between air pollution and the covid-19 case fatality ratio, so we set = 0 . a causal link between these variables could have a profound impact on the optimal physical distancing policy, so we examine the implications of such a link in model variations using two preliminary estimates of this association. first, persico and johnson (2020) find that a short-run increase in pm 2.5 of 1 g ⋅ m −3 is associated with a doubling of the covid-19 case fatality ratio, so in a "strong link" model variation we set = ln (2) . second, find that differences in long-run average pm 2.5 concentrations among u.s. counties of 1 g ⋅ m −3 is associated with an 8 percent increase in the covid-19 case fatality ratio, so in a "weak link" model variation we set = ln (1.08). to quantify the benefits of lives saved, we use a benchmark vsl value of $10 million. this is a central estimate from hedonic wage studies of the value per statistical life (viscusi 2018; kniesner and viscusi 2019) , and is consistent with u.s. federal agency benefit-cost guidelines (u.s. environmental protection agency 2014; u.s. department of transportation 2016). in a sensitivity analysis we use a lower value of $4.5 million, which is consistent with the average age-varying vsl used by greenstone and nigam (2020) to monetize the impact of physical distancing in the u.s. to specify , which controls the long-run costs of physical distancing, we make an assumption about the time required for aggregate income to recover to its counterfactual no-outbreak path. specifically, we define the recovery time, t r , as the time required for the gap between the actual gdp path and the no-outbreak path to shrink by 95%, i.e., e − t r = 0.05 , so = −t −1 r ln (0.05) . we assume t r = 10 years, double the average recovery time among all bear markets since 1835 (sachs 2020), which gives = 0.3 yr −1 . finally, to compute the present value of future income losses, we use a u.s. federal agency recommended discount rate of r = 0. to solve the model, we use a numerical policy iteration approach (bertsekas 2015) . first, we initialize the distancing fraction to zero for the entire time horizon, x 0 t = 0 ∀t . then we compute the gradient of the objective function ( where δ is a suitably small step size), and repeat for i = 1, 2, 3, ..., i max iterations. for consistency and reproducibility we use i max = 10 3 , which appears to be sufficient to achieve convergence for all cases examined in this paper. we use the model to characterize the optimal timing and intensity of physical distancing to control the covid-19 outbreak in the u.s., and to examine the influence of air pollution co-benefits on the optimal physical distancing policy. considering the uncertainty surrounding many aspects of the system, our benchmark parameters described above and shown in table 1 are meant to serve mainly as a point of comparison for alternative cases. to maintain continuity with previous work, our benchmark parameters are largely consistent with thunström et al. (2020) , aside from the new model features. three key parameters that drive the model results are the basic reproduction number, r 0 , the value per statistical life, vsl, and the curvature of the physical distancing cost function, . results for our benchmark case and two additional cases involving variations in one or two of these key parameters are presented in figs. 1, 2, 3 and table 2 . the graphs in fig. 1 show results for our benchmark case, which uses our preferred central parameter values and most closely resembles our prior analysis (thunström et al. in all four air pollution variations, the optimal policies shown in panel (a) are initiated with an abrupt increase in the distancing fraction just in time to arrest the early rapid spread of the pathogen and prevent the number of infections from exceeding the critical threshold of the health care system. as i t approaches the threshold, it is optimal to nearly instantaneously increase the physical distancing fraction from 0 to around 0.35, which in our benchmark case is initiated on day 37. ignoring air pollution altogether (solid line), after the immediate rapid increase the physical distancing fraction is then reduced nearly linearly until around day 210. the policy then increases again, modestly and temporarily, before finally decreasing to zero by day 289. at the other extreme, when air pollution co-benefits and a strong link between pollution and covid-19 deaths are included (dotdashed line), the policy begins with nearly identical timing and intensity but is maintained at a higher intensity for a longer duration, decreasing to zero by day 380. qualitatively, the optimal policies in all four air pollution co-benefit variations involve an early rapid increase in the distancing fraction, then a gradual decline over the course of nearly a full year. the influence of air pollution co-benefits on the shape of the optimal policy is negligible if no link between pollution and covid-19 is included, but is prominent if the link is strong. the horizontal line in panel (b) corresponds to ĩ , the inflection point of the case fatality ratio function, and the vertical line corresponds to n(1 − 1∕r 0 ) , the herd immunity threshold for susceptible individuals. the phase diagram in fig. 1 shows that all four controls lead to similar s−i curves, each turning down shortly before the critical threshold is reached and extending to just beyond the herd immunity level, which serves to prevent a second wave of infections after physical distancing restrictions are lifted. the rapid increase in the distancing fraction for all variations shown in panel (a) flattens the curve of infections, as shown in panel (b). the general pattern is similar to those found in other optimal control studies, including alvarez et al. (2020) and kruse and strack (2020) . key outcomes for the benchmark case are provided in the first column of table 2 . using our benchmark parameters, the uncontrolled outbreak results in just over 4 million covid-19 deaths. this is a result of nearly 300 million cases of infection and the elevated case fatality ratio due to the critical threshold of the health care system being exceeded for a large portion of the duration of the uncontrolled outbreak. the controlled scenarios all save nearly 2.5 million lives or more relative to a no-distancing scenario, depending on the influence of air pollution in each variation. when air pollution co-benefits are excluded altogether, 2.47 million covid-19 deaths are averted by physical distancing, which also leads to an initial decline in gdp of nearly 5.95 percent. when air pollution co-benefits are included but with no link between air pollution and covid-19 deaths, the control policy becomes slightly more stringent, as indicated by the slightly larger immediate decline in gdp of 5.98 percent. in addition to the 2.47 million covid-19 deaths averted, 6,540 air pollution deaths due are averted due to the temporarily reduced levels of pm 2.5 during the period of physical distancing. this is roughly 6 percent of the baseline air pollution deaths (107,000), so the lives saved from air pollution are roughly proportional to the immediate decline in gdp. in the third variation, which includes a weak link between air pollution and covid-19 deaths ( = 0.077 , based on , the control policy is now discernably altered from the "no air pollution" variation. with a weak link, 2.55 million covid-19 deaths are averted, which includes an additional 60,000 averted deaths due to the interaction between air pollution and the covid-19 fatality risk. this is nearly ten times larger than the 6,760 deaths averted due to the direct effects of air pollution on mortality. the final variation includes a strong link between air pollution and covid-19 deaths ( = 0.693 , based on persico and johnson 2020). in this case more than 3 million covid-19 deaths are averted, including more than 0.5 million due to the interaction with air pollution, and 8,290 deaths are averted due to the direct effects of air pollution. 4 the stronger interaction between air pollution and covid-19 deaths in this variation leads to a control policy that is sustained at a higher stringency and for a longer duration, which in turn leads to a larger immediate decline in gdp of 7.59 percent. in all four air pollution variations the optimal control policy concludes well before the time horizon of the model, which is 2 years (730 days). this suggests that if a vaccine will not be available before that time, then the vaccine would not affect the optimal physical distancing policy. the vaccine still would be useful in reducing the risk of future infections from imported cases, but it would not be necessary to eliminate the risk of a future outbreak due to community spread because the number of susceptible individuals would have already been decreased below the herd immunity threshold. childhood vaccinations also might be warranted after this time to prevent the number of susceptible individuals from climbing back above the herd immunity threshold over time as immune individuals die and new cohorts enter the population without immunity. and if infection does not confer lifelong immunity, then the role of a vaccine increases further still. results for the second case are shown in fig. 2 and the second column of table 2 . in this case, all parameters are held at their benchmark values except the curvature of the physical distancing cost function, which is here set to = 0.5 . this implies a concave relationship between interpersonal contacts and income, which means that the first increments of physical distancing, which involves a reduction in the rate of interpersonal contacts, are less costly than later increments. in this case the proportional decline in income is less than the physical distancing fraction. the effect of this assumption is to make physical distancing less costly overall, which leads to an optimal policy that is more stringent and of longer duration than our benchmark case, as shown in panel (a) of fig. 2 . here the control policies start around day 31 and conclude between days 437 and 692. with a less costly physical distancing technology, the influence of including air pollution co-benefits is more pronounced. even the variation with no interaction between pollution and covid-19 fatalities is discernible in panel (a), and the variations with a weak and strong link extend the duration of the policy roughly 2 months and 7 months, respectively. the quantitative differences in outcomes can be seen in table 2 . when air pollution co-benefits are excluded entirely, more covid-19 deaths are averted (2.65 million) at a lower immediate decline in gdp (4.49 percent) relative to our benchmark case in column 1. accounting for air pollution co-benefits reveals that an additional 9,410 deaths are averted due to reduced air pollution exposure, but otherwise the outcomes are nearly identical to the no air pollution variation. assuming a weak link between air pollution and covid-19 deaths, the policy adjusts to avert 2.79 million covid-19 deaths, which includes 81,000 deaths averted due to the interaction with air pollution. assuming a strong link with air pollution leads to a dramatic increase in the duration of the policy and the number of deaths averted for about the same cost as in the benchmark case, as reflected in the nearly equivalent immediate gdp decline of 7.6 percent. in addition, given the increased stringency and duration of the program, the relative influence of air pollution co-benefits is magnified. panel (a) in fig. 2 demonstrates the significant difference in optimal physical distancing with and without air pollution cobenefits, and the cumulative numbers of pollution deaths averted increases significantly. while total costs in this case increase, the increased numbers of deaths avoided more than compensates and therefore extends the duration of physical distancing measures. by comparison to our benchmark case, these results suggest that large gains in efficiency could be achieved if the cost heterogeneity of component physical distancing measures is high, and if we are able to deploy the component measures in decreasing order of their cost-effectiveness (newell and stavins 2003) . results for the third and final case we examine in this paper are shown in fig. 3 and the third column of table 2 . in this case we vary two parameters: r 0 is increased to 4.8 [closer to the estimate reported by sanche et al. (2020) ], and vsl is decreased to $4.5 million [to match the average value used by greenstone and nigam (2020) ]. the optimal control policies and associated outcomes are qualitatively different in this case. relative to our first two cases, here the optimal policy rapidly increases to a much higher level of stringencybetween 0.7 and 0.8-but is sustained for a much shorter duration-between about 90 and 180 days. as a result, the curve of infections is not immediately flattened as in cases 1 and 2. in this case, it is optimal to let infections exceed the medical system threshold before initiating physical distancing. infections are allowed to grow past 100 million in the variation with no air pollution co-benefits, and past 60 million in the variation with a strong link between infection fatality risk and air pollution. when physical distancing restrictions are initiated, the high stringency of the measures quickly reduces the number of infections back below the medical system threshold. thereafter, physical distancing measures are gradually released until herd immunity is achieved. when air pollution co-benefits are included and a strong link between pollution and covid-19 deaths is assumed, the peak of infections under the optimal control policy is just over one third of the uncontrolled peak. here again we see that a strong link between pollution and covid-19 deaths has a large influence on the shape of the optimal control policy, but even in this variation the curve of infections is not completely flattened below the critical threshold of the health care system. the optimal policy fails to flatten the curve in this case for two reasons. the obvious reason is that with a lower vsl the demand for saving lives is lowered. assigning a lower value to mortality risks reduces the implied damage to society from the outbreak and results in reduced net benefits of the control policy. the less obvious reason is that with a higher r 0 , physical distancing is less effective at stemming the spread of the virus: reducing r 0 from a very high level to a high level prevents fewer infections than reducing r 0 from a high level to a medium level (thunström et al. 2020 ). these two effects combine to yield an optimal policy that allows a much larger number of deaths than cases 1 and 2. (in other cases not reported here, we found that the infection curve is flattened with r 0 = 4.8 and vsl = $10 million, and is nearly flattened with vsl = $4.5 million and r 0 = 2.4.) physical distancing has so far been the most widely used policy to control the spread of sars-cov-2. while the benefits to physical distancing are large, given the substantial number of lives saved, such measures also impose significant private and social costs. in this study we characterized the intensity and timing of physical distancing that minimizes total economic damages from controlling covid-19, and we examined the co-benefits of lives saved from air pollution and a potential link between air pollution and covid-19 fatalities. our model jointly considers physical distancing that results from policies (mandates or recommendations) and individual decisions to self-protect, independent of policies. benefits from physical distancing are recorded as lives saved, while costs are measured as the loss of income in both the short run (during the period of physical distancing) and the long run (as the economy recovers from the initial shock). on the benefit side, lives saved result both from averted covid-19 deaths and averted air pollution deaths. in our integrated epidemiological-economic model of covid-19 in the u.s., deploying a physical distancing policy with optimal timing and intensity saves millions of lives and generates significant net benefits in comparison to an uncontrolled scenario with no physical distancing. we also find that thousands more deaths are averted due to the reduction of air pollution emissions from physical distancing, and hundreds of thousands more covid-19 deaths are averted if we assume a strong causal link between air pollution concentrations and the covid-19 fatality risk, which is suggested by some preliminary evidence of this association. more than 4 million deaths from infection are predicted in the uncontrolled scenarios, and even in the optimally controlled scenarios more than 1 million deaths are predicted. to provide some context for these results, fig. 4 shows the imputed time path of the effective reproduction number, r e , which is proportional to the contact rate as it changes over the course of the outbreak (aronson et al. 2020) , and the physical distancing fraction, x t , from march 1 through june 23, 2020 in the united states. the graphs are based on u.s. centers for disease control and prevention (cdc) reports of the cumulative number of infections (cdc 2020), assuming that the spread of the virus evolves according to an sir model similar to the one used in our optimal control scenarios (see the "appendix" for details). the the number of infections and deaths relative to a counter-factual scenario with no physical distancing. 5 compared to the number of cases so far reported in the u.s., which provide the basis of the graphs shown in fig. 4 , the optimal control paths shown in figures 1, 2 , and 3 allow a much larger number of infections to accumulate early in the outbreak before the rapid escalation of physical distancing [consistent with other recent studies, e.g. alvarez et al. (2020) and kruse and strack (2020) ]. this strategy provides a head start on achieving herd immunity while still preventing the number of people who are infected at any one time to exceed the critical threshold of the health care system. if aggressive physical distancing measures are implemented before many infections have occurred and are maintained at a sufficiently high intensity to keep the number of infections very low over time, then when physical distancing measures are relaxed a second wave of infections will occur because the number of susceptible individuals would still be very high. at least two categories of control options not considered here could change the character of this result. either the widespread use of cloth masks (eikenberry et al. 2020; howard et al. 2020) , or a program of diagnostic testing and self-quarantine (piguillem and shi 2020; taipale et al. 2020; allen et al. 2020) , or a combination of these, might allow the relaxation of physical distancing and avoid a second wave of infections while awaiting the development of a vaccine or effective treatment. if a vaccine or treatment were to become available before the optimal distancing policies in figs. 1, 2, and 3 are concluded, then a higher intensity and shorter duration physical distancing policy may be optimal. cloth masks and testing and self-isolation measures might also serve as effective substitutes for physical distancing restrictions at all stages of an outbreak, so incorporating these additional control measures into our model would be a useful extension in follow-up work. several other limitations of our model also should be highlighted. first, we value only the reduction in the fatality risks from infection to the exclusion of all other adverse health outcomes short of death. in benefit-cost studies of environmental regulations, fatality risk reductions typically comprise 90 percent or more of the monetized health benefits (e.g. cropper et al. 2011 ), but it is not clear whether this will apply to covid-19 cases. second, the narrow peaks of the infection curves in figs. 1, 2, and 3 are characteristic of a single well mixed population. in reality, the u.s. may be better represented as many connected population centers in a spatially explicit model of disease spread, which could produce a series of overlapping and interacting infection curves more closely matching the observed patterns of cases (unwin et al. 2020) . we also do not distinguish between individuals of different ages or pre-existing health conditions that may make them more vulnerable to covid-19 (acemoglu et al. 2020) , nor do we distinguish between symptomatic and asymptomatic cases (stock 2020) . we also do not model the un-coordinated physical distancing responses of individuals in an unregulated scenario. rather, we compare the optimal physical distancing policy to a completely uncontrolled epidemic, in which individuals engage in no self-protective behaviors. (as might occur if covid-19 were widely but erroneously viewed as no more dangerous than the seasonal flu.) standard economic theory predicts that if the true risks are known then people would choose to distance themselves to a degree that their individual net benefits are maximized (toxvaerd 2020). with high enough infection and fatality risks, we would expect some voluntary physical distancing, but generally less than the economically efficient level. because our net benefit estimates presented in table 2 are calculated with respect to a no-physical distancing counterfactual scenario, they provide an upper bound on the net benefits of externally imposed physical distancing restrictions. we also ignore a number of other potentially important side-effects of physical distancing, which may include increased incidence of domestic abuse as families spend more time at home (van gelder et al. 2020), increased fatality rates from other adverse health conditions as people delay treatment to avoid infection in hospitals (lazzerini et al. 2020) , reductions in crime rates (mohler et al. 2020) , adverse mental health effects of school closures (lee 2020) , and increased rates of suicide due to social isolation (gunnell et al. 2020) . finally, we focus on economic efficiency and do not address the equity implications of the disease risks or the economic effects of physical distancing. like for covid-19 related deaths, the adverse health effects of air pollution are asymmetrical across race and income (e.g. bowe et al. 2019) , and we would expect the economic costs of physical distancing also to be borne disproportionately by marginalized groups and low income households. to conclude, we discuss some potential environmental implications of the pandemic beyond the links between covid-19, physical distancing, and air pollution examined in our optimal control model. our aim in this closing section is two-fold: to acknowledge the narrow focus of our control model, and to highlight opportunities for further research by environmental economists going forward. our brief discussion here is complementary to helm (2020) , iges (2020), and barbier (2020) , who provide broader discussions of the potential long-run environmental impacts from covid-19. a key question highlighted by these articles is whether the necessary fiscal stimulus implemented to accelerate the economic recovery will have the effect of re-entrenching the status quo or helping societies "build back better" by improving economic resilience and environmental quality in tandem. we organize our closing discussion by considering possible long-run changes in how people will work, rest, eat, and play after covid-19. first, among the most important components of physical distancing measures widely adopted during the early months of the pandemic are work-from-home policies, reduced international and domestic travel for in-person meetings, and distance education. to the extent that technical change involves learning by doing, this could lower the cost and thereby increase the long-run prevalence of remote work and online learning. this could in turn reduce polluting emissions from ground and air traffic and make durable a portion of the short-run decline in emissions observed in the early days of the pandemic, thereby slowing the rate of climate change and reducing the incidence of adverse health effects due to pollution. covid-19 also could accelerate the contraction of globalization, reducing the trade of goods and services and the movement of people among nations. this re-animates a large literature on the impacts of globalization on the environment (boyce 2004; gallagher 2009 ). another possibility, likely to vary considerably among nations, is that the cost of economic recovery could crowd-out existing environmental regulations. if there is a de facto constraint on the overall size and scope of government regulations in a country, then an expanded role for government in the provision of public health may lead to a diminished role in the provision of environmental protection. closer to home for readers of scholarly journals like this one, we wonder about the implications of this episode for the conduct of economic research and science communication, including the publication and promotion through popular media of rapid results prior to formal peer review. we see pros and cons of the current emergency response by academics to the pandemic. rapid dissemination of pre-prints may allow for more timely and actionable science to reach the decision-makers who need it, but also might lead to a higher rate of false results (e.g. freedman 2020; joseph 2020; majumder and mandl 2020). striking the right balance between false positives and false negatives in published results during normal times is a complicated (and we think understudied) problem, and it is not clear whether and how the balance should change in times of a public health crisis like covid-19. second, will covid-19 have a lasting influence on where people choose to rest-that is, where they choose to live? if large cities are engines of economic growth-a conventional but not a consensus view (e.g. annez and buckley 2009; parkinson et al. 2015; frick and rodríguez-pose 2018)-but also come be known as engines of infectious disease outbreaks (stier et al. 2020) , what are the implications for the optimal spatial patterns of human settlements? any such influence would have important long-run implications for the environment (newman 2006) . for example, if the covid-19 pandemic helps to slow or reverse the trend of migration from rural areas to urban centers in the u.s. (harris poll 2020), this would in turn change the overall amount and the spatial pattern of pollution and habitat loss. if compact human settlements are better for biodiversity, then a reversal of the trend toward agglomeration in urban centers could have adverse effects on nature and the provision of valuable ecosystem services. this would increase the importance of learning how to design dispersed human settlements that are closely connected to nature with minimal environmental impact, rather than reducing impact by concentrating human settlements into smaller areas. third, will covid-19 have long-run implications for food production and consumption? the pandemic could reduce both the demand and the supply of meat products due to increased concerns about safety on the part of consumers and increased costs of production if stricter safety regulations are imposed on producers. shifting away from animal to plant based proteins has the potential to significantly reduce impacts on the environment, including carbon dioxide emissions (tukker et al. 2011) . preferences for domestically produced food also might increase, as the covid-19 crisis highlights the urgency for securing a sufficient domestic food supply as a means of enhancing the resilience of local economies in the face of heightened risks of pandemics or other large scale disruptions in the future. whether this will positively or negatively affect land conservation or the climate depends on the policy choices made about the changes to food supply. finally, will the pandemic have a lasting influence on how people spend their leisure time? if people become motivated to shift a portion of their time use to outdoor recreation activities-which might pose lower risks of infection than leisure activities indoors or outdoors in large crowds (rice et al. 2020; venter et al. 2020; samuelsson et al. 2020 )-this could increase the instrumental value of a clean environment and untrammeled wilderness areas. it also could expand the health benefits from exercise outdoors (lippi et al. 2020; mattioli and ballerini puviani 2020; gössling et al. 2020 ) and the more general well-being benefits from spending time in nature (bratman et al. 2019; white et al. 2019 ). on the other hand, if people withdraw from travel both abroad and at home and spend more time indoors watching screens, or if yet another case of a pathogen jumping from an animal species to humans (zoonosis) (andersen et al. 2020; berry et al. 2018 ) makes some people more fearful of close contact with nature, the health benefits of outdoor recreation might contract rather than expand. the results from our control model presented in this paper suggest that there may be important environmental side-effects that could alter the optimal intensity and duration of physical distancing policies used to manage the covid-19 epidemic. many interventions designed to affect consumer behaviors have been shown to work in the short run, but people typically revert back to their prior behaviors after the intervention is removed (e.g. nisa et al. 2019) . so the safe bet may be that the salutary environmental side-effects of physical distancing will dissipate as fast as economic activity resumes after the outbreak. on the other hand, some past public health crises have led to lasting and high-impact changes in behaviors. these include long distance migrations in the united states during the 19th century to escape unhealthy living conditions in eastern cities (baur 1959; abrams 2010) , and improved personal and public hygiene practices that today we take for granted such as regular health care visits and hand washing habits (agüero and beleche 2017; foss 2020) . if covid-19 leads to behavioral changes as durable as those spurred by past epidemics, the environmental implications of the outbreak may extend far beyond the short-term air pollution impacts examined here. the covid-19 pandemic calls for spatial distancing and social closeness: not 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disease control and prevention mortality in the united states early estimation of the case fatality rate of covid-19 in mainland china: a data-driven analysis to produce the graphs in fig. 4 of the main text, we assumed that the spread of the virus evolved according to an sir model with an effective contact rate that varies over time with changes in physical distancing . referring back to equations (1)-(4), the effective contact rate on day t is t = (1 − x t ) 2 , and the number of new infections on day t is t s t i t , where is the contact rate with no physical distancing, and x t is the distancing fraction on day t. the u.s. centers for disease control and prevention (cdc) reports the cumulative number of infections since january 22, 2020 (cdc 2020). denoting the cumulative number of infections reported prior to day t as c t , we can write c t+1 − c t = t s t i t . ignoring deaths for simplicity, this leads to the following sequential procedure for imputing t , r e,t , and x t based on the reported values for c t and an assumed value of : key: cord-013203-qvuand0s authors: corbin, charles b. title: conceptual physical education: a course for the future date: 2020-10-14 journal: j sport health sci doi: 10.1016/j.jshs.2020.10.004 sha: doc_id: 13203 cord_uid: qvuand0s the conceptual physical education (cpe) innovation began in the mid-20th century as an alternative approach to college-level, activity-only basic instruction classes. in addition to physical activity sessions, cpe courses (classes) use text material and classroom sessions to teach kinesiology concepts and principles of health-related fitness and health-enhancing physical activity. cpe courses are now offered in nearly all college programs as either required or electives classes. two decades later, the high school cpe innovation began, and kindergarten-8 programs followed. in this commentary, i argue that historian roberta park was correct in her assessment that physical education has the potential to be the renaissance field of the 21st century. scientific contributions of researchers in kinesiology will lead the way, but science-based cpe and companion fitness education (fe) programs that align with physical education content standards and fe benchmarks will play a significant role. cpe courses have been shown to be effective in promoting knowledge, attitudes, and out-of-school physical activity and have the potential to elevate physical education as we chart the course of our future. in 2008 corbin and cardinal 1 cited historian roberta park, 2 who suggested that physical education has the potential to become the renaissance field of the 21st century. her thorough historical account describes the emergence of physical education in the 1800s and traces its development as a science-based profession. park notes that medicine was an emerging field during the 1800s but became the renaissance field of the 20th century largely because of research that provided a scientific basis for medical education and the profession. i believe that park was correct in her suggestion that what was true of medicine in the 20th century can become true for physical education in the 21st century. we can become a renaissance profession, but not without changing our course. the purpose of this article is to articulate the importance of knowledge, especially higher-order knowledge, and conceptual physical education (cpe) as a program central to the delivery of knowledge and other aspects of physical literacy in the future. the dominant focus of 19th-century physical education in the us was formal activities imported from european countries (e.g., gymnastics and regimented exercise) 2 . by mid-19th century, physical education teacher preparation programs were established in the us, and in 1885 the association for the advancement of physical education was formed. the profession of physical education was becoming a force in american education. buoyed by research in psychology (e.g., hall) and education theory (e.g., dewey), leaders put forth theories of play, games, sport, and the -recreative‖ value of physical activity. 2 through the early years of the 20th century the debate about how best to prepare physical educators and the nature of the content of school physical education programs continued. over time the -new physical education‖ of cassidy, nash, williams, wood, and others provided direction for programs of the 1900s. 3 expanded objectives for physical education programs such as leadership, teamwork, and sportspersonship based on uniquely american -democratic values‖ found their way into school programs. physical education became much less regimented, and sports and games became a significant part of the physical education curriculum. the european physical education of the 19th century morphed into the sports-dominated physical education of the 20th century. by the mid-1900s the science movement had begun and prompted park to suggest a new look for the 21st century. she details the new science within physical education (kinesiology) and documents the great strides that have been made in our multiple sub-disciplines. this excerpt characterizes her thoughts: 3 there is a -great need for well-trained and dedicated professional practitioners in areas ranging from the health and fitness industry, to public school physical education, to exercise programs for older populations, to the management of recreational and sporting agencies, and much, much more. the attitude that prizes systematized knowledge, constant questioning, and the ability to forge logical links and see interdependencies, however, must infuse the work of the teacher, coach, and clinician as much as that of the exercise physiologist and biomechanist, sport psychologist, sport sociologist, and sport historian‖ (p. 20) . the new science outlined by park sparked many changes within physical education and kinesiology and was an important factor in the emergence of cpe and fitness education (fe) programs. cpe originally referred to physical education programs (typically a semester-long class or shorter units in a class) that focused on teaching concepts, principles, self-management, and consumer skills to promote healthy lifestyles (e.g., regular physical activity, sound nutrition, making good consumer choices) and the outcomes associated with healthy lifestyle adoption (e.g., fitness, health, wellness). unique features of cpe include classroom sessions and the use of a textbook or text-based materials. 4 knowledge gained in the classroom and from text materials is reinforced in physical activity sessions specifically planned for cpe. although not initially labeled as such, early cpe programs became known as fe programs because they were developed for use with fitness assessment. 5, 6 as health-related fitness testing gained traction, the programs were expanded to help students understand the reasons for testing and to help them learn to effectively plan physical activity programs to build health-related fitness. more than 40 years after the introduction of cpe, fe was formally included in the society of health and physical educators (shape america) fitness education framework 7 as -a subcomponent of the total physical education program, focusing on helping students acquire knowledge and higher-order understanding of health-related physical fitness, the product, as well as habits of physical activity and other healthy lifestyles, the process, that lead to good health-related physical fitness, health and wellness‖ (p. 1). 7 in the years since their inception, cpe and fe programs have evolved significantly. some examples are used to illustrate. fitness for life 8 is an example of a cpe program (e.g., text, classroom and activity sessions) that is also considered to be an fe program because of its extensive fitness-related content. however, over time, it has expanded to include content related to all physical education standards (see later sections). physical best 9 is an fe program that focuses on health-related fitness content. because it does not use a student text or classroom sessions, it is considered to be an fe program, but not a cpe program. science of healthful living 3,10 uses text-based materials but does not use classroom sessions. its authors refer to it as a concepts-based physical education 10 program. for the purposes of this article, concepts-based physical education programs will be included as cpe programs. cpe became widely adopted during an era of change. originally conceived as a physical education offering, college classes are now offered in departments with a variety of names (e.g., kinesiology, exercise science, sport science, health and human performance) and many course titles (e.g., fitness for life, personal fitness, concepts of fitness and wellness). regardless of the academic unit or class name, cpe captures the spirit of park's call for physical education to take its place as an enlightened or renaissance field. at the time of its introduction, cpe was not well received. 11 however, the cpe innovation that began at the college level in the mid-20th century became an offering, either as a required class or an elective, at virtually all institutions of higher learning 1, 12, 13 . cpe -merges the practice and science of the field through a lecturelaboratory approach‖ (p. 467). 1 as cpe grew in popularity, the accompanying science movement provided evidence of the link between physical activity and public health. the epidemiological evidence helped to push performance-based youth fitness testing of the late 1950s toward health-fitness testing by the end of the century. social movements (e.g., civil rights, rights for women, student rights) spurred change as students became active in affecting societal change. they fought for student choice in course and curriculum options. these movements aided the college cpe innovation because cpe provided an alternative to traditional required physical education classes. 1 cpe classes offered a science-based personalized approach as an alternative for all students, especially for those who did not relate to the traditional sports-based physical education offerings. in addition, evidence of the effectiveness of cpe in promoting knowledge, attitudes, and physical activity behaviors provided support for its inclusion. 1 cpe programs, and the evidence supporting them, have saved physical education requirements at many institutions since inception. 1 many of the same factors that led to the college cpe innovation fueled the growth of both cpe and fe programs at the high school level. particularly influential were the growth of the science base within kinesiology and the associated public health approach to physical education. 14-22 knowledge in kinesiology expanded rapidly and provided a platform for advancing the profession of physical education. the shift from performancefitness to health-fitness testing 6 occurred simultaneously with the science boom. practical considerations also contributed to the rationale and need for cpe programs. while kinesiology was accepted in the mainstream of science, physical education was gradually being marginalized in schools. survey data from the youth risk behavior surveillance system 23 indicate that daily physical education attendance decreased from 41.6% in 1991 to 25.4% in 1995. it has remained stable since 1995, but attendance is well below what it was early in the 1900s. 24 facing the challenge of being sidelined or eliminated, many schools adopted cpe as an evidence-and standards-based option that helped protect physical education requirements. 25 furthermore, those who advocated for cpe at the high school level pointed out that not all high school students go to college and that non-collegebound students deserve to participate in effective cpe programs. 26 was the first high school cpe program. a number of others followed, including personal fitness for you, 27 personal fitness: looking good/feeling good, 28 and foundations of personal fitness. 29 fitness for life (6th ed.) is the most widely used model. 8 consistent with park's call for a scientific foundation for physical education, cpe programs are based on sound education theories that provide a foundation for building higher-order learning. promoting confidence, intrinsic motivation, and autonomy (social cognitive theory and self-determination theory); promoting the belief that these factors can help in overcoming barriers (health beliefs model); and providing information about moving through several stages of behavior change (trans-theoretical model) all set the stage for helping students achieve higher-order objectives in cpe. 37 the program stairway to lifetime fitness, health and wellness, as illustrated in figure 1 , provides a visual description that illustrates how theory meets practice in moving students from dependence (in elementary school) to independence and autonomy in middle and high school. 8 central to the -stairway‖ metaphor is the notion that learning (achieving literacy) is vertical, not horizontal. early learning provides a foundation for later learning. accordingly, the stairway emphasizes the importance of addressing higher-order objectives in physical education through teaching for independent thinking and autonomy. as ennis and colleagues 38 have demonstrated, conceptual learning at one grade level provides a foundation for learning in subsequent gradesor to put it another way, it helps students learn how to learn. at steps 1 and 2 (level of dependence) young students are dependent on us, the teachers. they typically lack fitness and physical activity knowledge and benefit from a direct teaching style. they participate as directed and benefit as the directed activities allow. at steps 3 and 4 (level of decision making) students begin to understand and apply concepts and principles and to use self-management skills (e.g., self-assessment, goal setting, self-monitoring, self-planning). they begin to analyze and evaluate their own behaviors. at steps 5 and 6 (level of independence) students become independent and autonomous ( fig. 1) . they become problem-solvers capable of making decisions that can enhance their long-term fitness, health, and wellness. 8 national physical education content standards provide a basis for establishing student objectives and outcomes, including higher-order objectives. the first national physical education content standards were published by the national association for sport and physical education (naspe, now shape america) in 1995. 39 the standards were revised in 2004 40 and again in 2013. 41 the current standards are shown in table 1 . early cpe programs focused on the parts of health-related physical fitness, health-related fitness selfassessments and interpretation, the types of physical activities that promote health and health-related fitness, the fitt (frequency, intensity, time, type) formula for building fitness through physical activity, and steps in program planning. coverage of nutrition and stress management were also included, as were self-management skills (e.g., goal setting, self-monitoring, overcoming barriers). they focused primarily on standards that specifically identify knowledge, concepts, and principles as important student outcomes (standards 2 and 3) and the standard related to health-related fitness (standard 3). cpe continues to provide its original fe function, but as suggested by mohnson, 42 it now covers concepts and principles related to expanded sub-disciplinary content as well as all five physical education content standards. beyond content that focuses on exercise physiology concepts and principles, programs now typically include biomechanical and motor learning principles to help students in their efforts to demonstrate competency in motor skills and movement patterns (standards 1 and 2) and sociological and psychological concepts and principles that underlie the development of self-management skills and social emotional learning (standards 4 and 5). correlation tables have been created to show that programs comprehensively address standards and to indicate which materials and lesson plans address which standards. 43 as noted earlier, in 2012 naspe/shape america developed a framework (with benchmarks) for fe for kindergarten-16 7 . the framework acknowledged the importance of teaching content commonly associated with cpe and fe programs and provided benchmarks for student achievements in these programs. many of the benchmarks (table 1) were derived from longstanding cpe content. for this reason, many cpe programs met all, or most, of the fe framework benchmarks prior to the development of the framework. now, many cpe programs have expanded beyond the fe framework to include content from all physical education content standards. as we move forward, physical education standards and fe benchmarks will need to evolve consistently with the new knowledge that can serve our students in the future. in recent years the term physical literacy has gained traction. 44, 45 the international physical literacy association (ipla) describes a physically literate person as one who has -the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life‖ (p. 1). 46 shape america has adopted this definition but operationalized it to refer to a physically literate person as one who meets national physical education content standards (table 1 ). in a separate paper, 45 i have expressed my concerns about the many different definitions of physical literacy and the use of the term. these concerns will not be revisited here. both the ipla definition and the shape america standards demonstrate that the development of knowledge is an important characteristic of physical literacy. as we move toward the future, i encourage physical educators to expand their view of knowledge development (especially higher-order knowledge) to include concepts central to current definitions of health literacy. health literacy, as defined by the institute of medicine (now the national academy of medicine), -is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions‖ (p. 1). 47 cpe is a program designed to help students to obtain, process, and understand information about physical activity and its health benefits. cpe content centers on providing the knowledge to assist students in making well-informed decisions about physical activity, nutrition, and stress management. as ennis 3 aptly notes, content -transcends the physical, relying on a sound foundation of knowledge to guide and lead physical activity choices and participation across one's lifetime‖(p. 122). she further emphasizes that -knowledge is at the heart of physical literacy‖ and that physical literacy -includes not only knowledge for performance but also the ability to apply knowledge and use knowledge for innovation‖ (p. 119). 3 cpe began at the high school level in the late 1970s with a health-related fitness focus. the content was organized in several major strands as depicted in the first column of table 2 . over time, the cpe content expanded based on user demand and alignment with standards and benchmarks (see the second column of table 2 ). today's middle school cpe content is similar to early high school programs, with representative content indicated by asterisks alongside topics in table 2 . lately, energy balance has also been an area of study in middle school cpe. 48 the original model for high school cpe 43 included an 18-week program (a one-semester class) that met in the classroom two days a week and in activity sessions three days a week. in the us, florida's required personal fitness class was implemented in the 1980s using this model. 49 as was the case when the florida cpe was implemented, the one-semester cpe class is often coupled with a second semester of a -required elective‖ to fulfill a one-year physical education requirement. various states and districts have followed this model, but other alternative schedules are common. for example, some high schools have integrated cpe classroom and activity sessions with traditional activity units, thus extending the class over a full school year. 43 at the middle school level, the three-unit, nine-chapter fitness for life model (taking half a semester) has been widely adopted. 30 in the half-semester plan, two textbook lessons are studied with 2 classroom sessions and 3 activity sessions. however, distributing units over different grade levels is a frequent alternative plan. portfolio sheets are used for recording student data. the science of healthful living curriculum is designed to increase middle school students' knowledge and interest in health-related science. 50 it consists of 120 lessons in 2 units over grades 6, 7, and 8. 3, 10 the curriculum, also referred to as -science in the gym‖ emphasizes a 5e system (engagement, exploration/experiment, explanation, elaboration, and evaluation) to integrate cognitive and physical tasks. students use workbooks and journals as a guide to learning tasks. research on the science for healthful living curriculum indicates that using workbooks is an effective way of promoting knowledge development in physical education. 51,52 fitness tests have been around since the 1950s 53 and were developed primarily to test youth fitness. the early skill-related fitness test batteries gradually gave way to health-related fitness tests beginning with the development of the american alliance for health physical education, recreation, and dance (aahperd, now shape america) health-related fitness test in 1980. after years of debate about various fitness tests, fitnessgram ® created at the cooper institute for aerobics research (cooper institute), morphed from a fitness report into a full health-related test battery with computer-based fitness reports. 6 critics have long suggested that tests by themselves do little to encourage fitness improvement and activity participation and may lead some youths to avoid engaging in physical education altogether. 54 cpe programs were employed to address this concern. although there was no formal collaborative agreement, the fitnessgram ® . 55 the help (h = health, e = everyone, l = lifetime, p = personal) philosophy that originated with fitness for life, by agreement, also became the philosophy of fitnessgram ® . the test items were included in fitness for life as self-assessments providing the basis for building a personal fitness profile in program planning. professional development sessions were conducted at the cooper institute for both fitnessgram ® and fitness for life to help teachers implement the programs and to prepare instructor trainers to conduct workshops to help teachers implement both programs. to fulfill the need for programs for k-8, a variety of fe programs were developed. smart choice, included in the first fitnessgram ® test manual, was an early fe program. 8 it included an award for keeping activity logs and meeting goals. in 1994, it's your move activity booklets were created for elementary school students; and in 1995, you stay active was published jointly by aahperd and the cooper institute. 6 you stay active included teacher materials and student handouts for use in physical education to help students better understand why they were taking fitness tests and how fitness test scores can be used to set goals and aid in program planning. the cooper institute currently offers online instructional materials, called smart coach, for teachers. 55 in 1994 fitnessgram ® became the health-related fitness test battery and fitness reporting system endorsed by shape america. 6 aahperd's physical best health-related fitness test battery was converted to an educational program that supported fitnessgram ® . 6 during the 1990s, aahperd sponsored pre-convention instructor trainer sessions for physical best, fitnessgram ® , and fitness for life. physical best is currently -a program of resources and training for k-12 physical educators … to implement health-related fitness education, including curriculum development and health-related fitness activities‖ (p. 1). 9 physical best activity guides are available for elementary, middle school, and high school teachers. 9 other programs-such as the president's youth fitness program (pyfp), which features fitnessgram ® test items. 56 comprehensive school physical activity programs (cspap), which encourages before-, during-, and after-school physical activity. 57 the active and healthy schools program, which encourages activities throughout the day 58 and fitness for life: elementary school, 59 60 school children 61 have become quite effective in using sound management strategies 60,61 for keeping students active while promoting learning consistent with physical education content standards and fe benchmarks. these programs are often very well conducted by dedicated teachers. i do endorse the inclusion of activities that teach concepts and principles because they can help move students up the stairway to lifetime fitness, health, and wellness ( fig. 1 ) and prepare students for secondary cpe programs. i also endorse whole-school or comprehensive school physical activity programs 57 that create and foster healthy and active school cultures. the remainder of this article will focus on secondary school cpe rather on than elementary school programs. the formal exercise that characterized physical education in the 19th century gave way grudgingly to the -new physical education‖ in the 20th century. however, it was well into the 1900s before the -american‖ model that emphasized sports and games became firmly established. by 1994 the model was dominant. data from the school health policies and practices study (shpps) reveal 23 that team sports were the most frequently offered activities in secondary schools. basketball, volleyball, baseball/softball, football, and soccer were the top 5 activities for both middle schools and high schools. dodgeball and kickball were also frequently included in programs. the team-sport approach of the 1900s is still dominant now, at least in the us. table 3 provides data from the shpps. 62 the results look familiar. four of the team sports that ranked in the top five in 1994 are still in the top 5 for both high schools and middle schools, and sports (mostly team sports) are among the most frequently offered physical education activities. it is important to point out that the data reflect the number of schools offering the activities-not the amount of time spent on the activities. still, the statistics indicate that the same sports activities are repeatedly offered from year to year in secondary school physical education. this can lead to the administrative policy of dumping-mixing lower-grade students in the same classes as upper-grade students, resulting in repeating the same instruction and same activities again for upper-grade students. see mccullick et al. 63 and lounsbery et al. 64 for more information about physical education and physical activity policies and common barriers to successful programming. contrast the activities most frequently taught in schools with the activities in which most adults participate 65 (fig. 2) . team sports that are dominant in school physical education rank well below activities such as individual sports, outdoor activities, and fitness activities. my own observations suggest that fitness activities, most common among adults, are often not available to all students in secondary schools. many high schools, for example, have fitness facilities; but elective resistance training classes using these facilities are open primarily to athletes. physical education classes, required or elective, often cannot use these facilities for classes for nonathletes. additional statistics are revealing. shpps data indicate that 78.8% of middle schools and 95.5% of high schools require students to take physical education as a graduation requirement or for promotion. 61 at first glance, it would appear that most students are required to take secondary physical education. but the same survey data show that the percentage of schools that require physical education in each grade ranges from 34% to 26% for grades 6-8 and from 21% to 9% for grades 9-12. the percentage of students taking physical education 3 days a week is 9.1%. 62 as we plan physical education for the future, we should consider these questions. is it necessary to repeat the same activities over and over again, especially activities that are often not used after the school years? can all youth become proficient in all sports and activities? do they want to? would it be more productive to focus on activities that are more likely to be performed later in life? should students at least have a choice? how does repetition of the same activities contribute to all content standards and benchmarks? is the traditional sports-based model the best model for the future? dintersmithin his book what schools could be, 66 quotes john dewey: -if we teach today's students as we taught yesterday's, we rob them of tomorrow‖(front matter). dintersmith 66  purpose-students attack challenges they know to be important, that make their world better.  essentials-students acquire the skills sets and minds sets needed in an increasingly innovative world.  agency-students own their learning, becoming self-directed, intrinsically motivated adults.  knowledge-what students learn is deep and retained, enabling them to create, to teach others. dintersmith does not address physical education, but his principles can be applied to -what physical education could be". certainly there are many outstanding teachers that currently apply the peak principles in their programs. however, a variety of statistics call into question the universal application of peak principles in secondary physical education. cpe has purpose. in cpe, students are challenged to learn concepts, principles, and self-management skills that can be used throughout life. results of project active teen indicate that students who took cpe as 9th-graders use the information 20 years after high school graduation (see later section). cpe develops essential skills (e.g., self-management, consumer, performance) that are useful in the 21st-century world. cpe programs promote physical literacy that provides a foundation for later innovative learning. cpe builds agency. as shown in fig. 1 , students learn to become intrinsically motivated independent (autonomous) problem solvers and decision makers while in school and in later life. cpe enhances knowledge. as park 2 indicated decades ago, the science base (kinesiology) is significant and growing. cpe focuses on higher-order objectives, enabling students to learn to learn. this enables them to continue their learning throughout life. green 67 labels the -pe effect‖ as physical education's ability to promote lifelong participation in physical activity. he further indicates that despite the belief that physical education produces a -pe effect‖, there remains a dearth of evidence to support this supposition. green 67 states that physical educators often -take-for-granted‖ the positive effects of physical education programs (p. 1) and cites the need for more longitudinal research into the pe effect. the evidence for cpe is described in this section, including the longitudinal research that green recommends. the early research related to cpe was conducted at the college level and provided evidence of the effectiveness of programs in building knowledge, attitudes, and active behaviors. researchers have noted the drop in regular physical activity as teens transition to adulthood 69, 70 . but can physical education stop the drop? is there a pe effect? longitudinal studies suggest that there is. project active teen (pat) began in 1991. 71 high school 9th-graders took a yearlong cpe course using the fitness for life model. students used a textbook and had classroom sessions one day a week. they participated in activity sessions that focused on health-related fitness and the activity sessions were coordinated with classroom content as well as traditional physical education activities. teachers participated in regular professional development sessions that provided training in cpe content and methods, and detailed lesson-plan notebooks were provided. over the 24 years of the study, three different progress reports were published. the first study, pat1, assessed activity patterns of participants as juniors and seniors in high school 71 . results indicated that students who took cpe in the 9th grade had lower levels of inactivity and were more likely to meet physical activity guidelines than both those who took traditional physical education (tpe) and a national sample of age-matched peers. the second study, pat2, found similar results several years after participants graduated from high school cpe. 72 the third study, pat3, was conducted 20 years after the cpe students graduated from high school. as with the first 2 studies, results indicated that the cpe students were more active and less likely to be inactive than national peers and maintained high levels of physical activity 20 years after graduation. 73 questionnaire data 73 showed that -56% of respondents indicated that they remembered content from the class, 50% indicated that they still used the information, 47% indicated that they found the class useful after graduation, and 92% indicated that they currently consider themselves to be well informed about physical fitness and physical activity‖ (p. 3). in the 3 pat studies, 50 tests for statistical differences were conducted. all of the 12 significant differences favored those who took cpe. the authors of pat3 73 suggest that cpe -can be a vital part of a total quality physical education program that promotes lifelong physical activity and complements quality traditional physical education programs‖ (p. 5). ennis, chen, and colleagues 3,10,50 created a middle school cpe program that was used in a multi-year, federally funded intervention study (science of healthy living, shl). students in grade 6-8 in the intervention schools participated in a curriculum based on health, fitness, and nutrition that consisted of 120 lessons in two units and associated physical activity sessions. the results were similar to those for the pat project. two years after the initiation of the study, participants in the shl group had higher out-of-school physical activity levels than the participants taking tpe. they also scored better on knowledge tests. 10 research indicates that secondary school students often lack knowledge and/or hold misconceptions concerning healthy behaviors (e.g., physical activity, physical fitness, nutrition) [74] [75] [76] . other studies document a positive relationship between fitness knowledge and participation in physical activity [77] [78] [79] [80] . there is also evidence that cpe programs can improve physical fitness and physical activity knowledge [81] [82] [83] [84] . furthermore, research has shown that knowledge from lower grade levels enhances learning of knowledge at later grade levels, which is evidence of vertical learning 84 . based on the evidence, wang and chen 85 offer a hypothesis that knowledge is a pathway to motivation for physical activity and ultimately to increased out-of-school physical activity. collectively, the evidence is clear: fitness knowledge-and the resulting knowledge improvement-is an important benefit that results from a well-delivered secondary cpe program. these results support the value of knowledge, especially higher-order knowledge, as a powerful factor that can be the glue that cements together the many benefits of physical education. 86 as we move to the future, a strong case can be made for including cpe as a foundation physical education course in secondary schools. cpe programs are based on a sound philosophy (the help philosophy), a whole-person orientation, and sound learning theory. cpe program objectives align with national physical education content standards (physical literacy) and fe benchmarks. they address higher-order objectives that are consistent with the peak principles. 66 cpe programs also address school reentry considerations that were very important during the corona virus pandemic. 87 in addition, cpe has the support of the national academy of kinesiology 88 and members 89 of the medical community. cpe program content is based on kinesiology's sub-disciplinary sciences that park 2 championed as the basis for moving physical education forward in the 21st century. most importantly, cpe programs work. the evidence is considerable and growing (see previous section). and there is more. in addition to the factors described above, advocates suggest that cpe provides academic connections that benefit students in other subject matter areas (e.g., math, science, english language arts); provides formative and summative assessment tools, including student-centered assessments in the cognitive, affective, and physical domains; and enhances teacher self-esteem and program reputation. 25,37 a quality physical education experience could look like the following for k-12 education. after completing a quality elementary school experience that includes fe, middle school students complete cpe units that provide them with a foundation for entry into a one-semester or one-year high school cpe program. the high school cpe experience, in turn, provides a foundation for practicing lifelong healthy lifestyles (e.g., active living, eating well); for becoming a good fitness, health, and wellness consumer; and for making informed decisions about additional quality physical education and later life experiences. the cpe content is streamlined and coherent from elementary school to high school with a vertical sequence. some of the opportunities for expanding physical education beyond the cpe foundation are listed in fig. 3 , and the sections below illustrate the diverse and adaptive cpe programming for different school settings and situations as demanded for a 21stcentury education. as mccullick et al. 63 have shown in their study of school policies, there is a lack of legislative support for physical education requirements. the lack of support is one reason why most teens are not enrolled in physical education in secondary schools. 90 when physical education is required, it is typically for a limited time (one or two years in high school). enrollment is most prevalent among 9th graders, and by grades 11 and 12, fewer than 10% of students are enrolled. middle school teens are more likely to be enrolled than those in high school, but less than one-third of all students are enrolled in grades 6-8. 62 cpe electives offer students opportunities to continue physical education after the foundation stage to keep learning and maintain in-school physical activity and can be an effective method for increasing enrollment in elective physical education. research has shown that students who have completed cpe have a good knowledge base, as well as self-management, consumer, and decision-making skills. they can use these skills to make their own decisions about elective options. if we teach students to make good decisions, we must allow them to make their own choices. in a school that requires one year of high school physical education, a one-semester cpe course could be followed by a required elective course. students choose the activities that they want to pursue. for this to be a legitimate option, schools must offer what students want to take-not what teachers want to teach. if students want yoga, tai chi, resistance training, self-defense, and dance, we must be prepared to offer these activities and be prepared to teach them. in schools with no requirement, we must offer attractive options that will entice students to take elective physical education. we must also consider ways to reduce barriers to participation. there are obstacles to the introduction of new offerings in secondary schools that are often not easy to overcome. nevertheless, several options are proposed here. the work of teachers in the san francisco unified school district (sfusd) to create an advanced cpe class is one example of how change is possible. it goes without saying that professional development opportunities will be necessary to help physical education teachers implement the proposed options. elective cpe. in schools that do not required physical education, a cpe class can be offered as an elective option. if the option is offered, interested students will take advantage of it. advanced cpe. advanced cpe can also be an elective option. for example, sfusd has a high school cpe requirement for all students 91 . upon completion, students can continue cpe by electing to take an advanced class (fit for life 2). this sfusd class is unique in that it meets university of california admission requirements for electives 91 . the class expands on the content included in the required cpe class. another advanced option is an introduction to kinesiology class. offering an introduction to kinesiology class as a science course is defensible and opens doors for students who want careers in fitness, health, wellness, and allied health occupations. honors cpe. irwin and colleagues 88 recommend that honors classes be offered in physical education. they describe honors classes as courses designed for high-achieving students that include greater depth of coverage 92 . irwin et al. 92 maintain that physical education is a legitimate education domain, and it is appropriate that honors classes be available just as they are in other academic areas. advanced cpe and introduction to kinesiology classes are excellent options for honor classes at the secondary level. advanced placement cpe. advanced placement (ap) classes offer students the opportunity to pursue advanced study in an academic area and allow students to earn college credit in advance of college enrollment. as irwin et al. 92 indicate, -our profession is undergoing a critical dialogue to initiate a much-needed paradigm shift or rebranding of who we are and how society regards us. there is work to be done if we are to increase respect for what we do. we all know that our content can be exceptionally rigorous and just as important to student success as other academic content areas. ap classes can also provide opportunities for students who have a passion for our subject matter to challenge themselves. therefore, we are proposing that it is time to begin the process of creating and launching an ap course focused on our subject matter‖ (p. 8). cpe and introduction to kinesiology courses provide good ap options in physical education. in describing what school could be, dintersmith 66 places great emphasis on project-based learning using peak principles. he describes project-based classes in the schools that he visited and suggests that innovative project-based classes can be part of an effective 21st-century educational system. project-based learning is often structured so that groups of students work together on a specific project (e.g., building a robot in science class). however, students can also work on projects individually. key elements are innovation, student choice and decision-making, the use of 21st-century skills, and, most importantly, a relevant reason or goal that drives the project. cpe classes are, in many ways, project-based. students gain higher-order knowledge and decisionmaking skills driven by the opportunity to create their own lifetime program plan. the outcome can be student portfolios that are exhibits of a healthy-living project based on personal needs and interests. beyond cpe, other project-based physical education opportunities can be offered. sport education classes 93 are, in my view, projectbased classes. elective sport education classes in a variety of activities are consistent with peak principles and allow students (in groups) to play many different roles in sport and physical activity settings. likewise, adventure/outdoor education classes have potential as project-based classes, with students doing the planning and organizing. the health-and-fitness club model 94, 95 can also provide opportunities for project-based learning when students doing the planning, organizing, and administering. this option can be especially rich when students are offered the opportunity to apply their special talents in carrying out a project. for example, student musicians can create music (and background music) for exercise routines, student dancers can choreograph, student artists can create art, and students with computer and other technical skills can create active exergames and apps that encourage active living. schools have been reluctant to offer fully online physical education courses partly because of concerns about how to monitor physical activities and partly because of a lack of digital skills and resources for offering such classes. in 2018, shape america published guidelines for k-12 online physical education 96 . the guidelines offer direction for distance/remote learning of many types (e.g., blended learning, fully online learning, synchronous learning, asynchronous learning). as more and more states and school systems mandate classes in all academic areas, online physical education has become more widespread 86 . cpe classes have been the more frequently offered than tpe because cpe's content is more easily adapted to an online format due to its knowledge-centered approach to physical activity promotion. the corona virus disease 2019 (covid-19) pandemic amplified the value of online learning, especially through cpe. teachers and school districts scrambled to provide remote physical education as schools closed. physical education teachers were tasked with providing alternatives to face-to-face learning for students. more than a few teachers and administrators contacted me to get help with materials and training (e.g., webinars, granting access to resources). those who had already been conducting cpe courses made an easy transition when remote learning became imperative. those who had not made the transition embraced cpe because it was a defensible alternative that administrators could accept. all of the benefits of cpe described in this paper have been used to support it during the pandemic. however, questions remain: if cpe is defensible as the -go to‖ program during the pandemic, why has it not been more universally implemented? will it continue to be implemented post-pandemic? as schools adopt online programs, we must answer the following question: -how do we know that students are active in their remote classes?‖ the answer is: -we don't.‖ face-to-face classes are much better for teaching skills and monitoring physical activity. however, video, activity monitors, and other creative options can help us when remote learning is the only option. in the meantime, student activity logs and reported activities on portfolio sheets can be used. students can design their own activity plans and perform them. no doubt, some may not actually do what they describe in their logs. however, students would learn how to plan and what to include in a program. concepts of personal responsibility can be discussed to help students develop ownership of content. they can learn what to do later in life if they choose to do so. a positive outcome with online cpe is the ability of students to do activities in a non-threatening environment, with none of the baggage of locker room bullying, embarrassing shower room events, and lack of time for personal grooming. for some, online programs can be a good option. on the negative side, we have work to do relating to testing and ensuring that the students enrolled in online classes are actually doing the work. using hybrid options that require students to do some activities face to face, especially assessments, would go a long way in solving this problem. the covid-19 pandemic also helped expose the fact that not all students have equal access to the internet and to the computer tools necessary to take advantage of online classes. for example, 14% of k-12 students have no internet access, 17% have no access to a home computer, and as many as 42% face barriers to connectivity 97 . equality options are necessary to make sure that all students have an opportunity to learn remotely. while there is much more that needs to be done in this regard, when access is available, cpe programs provide digital texts and student resources that can facilitate online learning. print materials can be distributed by mail, delivered, or picked up from the school, thus assuring that all students can have access to at least some of the same experiences. the pandemic also has made obvious the lack of equity in providing resources for teaching in physical education. schools that transitioned to the cpe approach often had large class sizes (sometimes 50 or more) and lacked computers, whiteboards, and other digital tools available to teachers in other subjects. texts, student resources, and teacher resources are also required. while physical education programs often have limited budgets, it should be noted that text materials and student/teacher resources for cpe programs are less expensive than purchasing typical sports equipment. it is my contention that cpe provides us with the ammunition to demand instructional equity (e.g., resources). -how you do it‖ matters when delivering a course of instruction. cpe offers many tools for use by professionals as they facilitate student learning. knowing how to use the tools is as important as selecting the appropriate tool for meeting a specific learning objective. some important factors relating to delivery are listed and briefly described in table 4 . as noted in section 3, cpe is differentiated from other fe programs by its use of classroom sessions and text materials. why classroom sessions? different objectives require the use of different methods. when providing instruction with knowledge as the goal, the classroom offers opportunities for best practices for doing presentations (white boards, computers, vetted text materials, videos) and encouraging student discussions. blocks of time are available for in-depth study of content. because conceptual material is covered in the classroom, students avoid standing and listening during activity. textbooks and text materials provide opportunities to learn in all educational settings: in the classroom (texts), in activity sessions (portfolio sheets or workbooks), out of school (e.g., readings, assignments), and online (digital materials). effective middle school programs have used both textbooks and text-based materials (workbooks, portfolio sheets-print and digital), and effective high school programs have used textbooks (print and digital). one new innovation is interactive web text (iwt), which resides on the web and allows text material to be used on all digital devices (e.g., phones, tablets, computers) and virtually anywhere that an internet connection can be made 97 . this is important in situations where students have a variety of digital devices. however, as noted earlier, for all students to benefit they must have access to digital devices and the internet. when teachers implement cpe, the most common question they ask is: -how can i justify having students sit in a classroom when so many students fail to meet national physical activity guidelines?‖ i offer the following answer, using an excerpt from a previous publication: 37 -an overarching goal of physical education programs is to promote lifelong physical activity. to be sure, taking time from physical activity to be in a classroom reduces physical activity on those days. however, cpe is not meant to be all of physical education, rather it is one part of physical education conducted for a limited time period with a limited number of classroom days. the time spent in cpe yields more physical activity later in high school and later in life, more than compensating for the time lost in physical activity while the student is in the classroom. if, in cpe, we can teach students selfmanagement and consumer skills that will help them to be active for a lifetime, the limited classroom time in cpe seems well worth it. the research supports this idea.‖(p. 46). one of the reasons for the low numbers of students taking physical education in secondary schools is exemptions (allowing alternative school activities to count for physical education credit). proponents of alternatives for fulfilling physical education requirements (e.g., band, jr. rotc, athletics) argue that these alternative programs provide activity and therefore are equal to physical education and are acceptable substitutes. physical educators argue that these alternative programs do not meet the criteria for quality physical education such those outlined in this article. regardless of the amount of activity students get in alternative programs, exempted activities such as band, jr. rotc, and athletics do not meet physical education standards and physical literacy requirements. to fulfill a physical education requirement, an online cpe module can be an option. the online module provides the content for meeting all of the requirements for quality physical education (all standards) while allowing alternative activities to count toward physical activity requirements for the class. physical education teachers conduct the online portion of the class and count students as enrolled. to meet the requirements for the cpe portion of the course, additional activities can be assigned to supplement the alternative programs that often provide relatively low amounts of activity 99 . history has shown that for there are steps that can be taken to provide a pathway to success when implementing a cpe program. three very important steps can be taken to ensure teacher commitment and administrative support, provide teachers with professional development opportunities, and ensure the inclusion of all students. teacher commitment and administrative support. for any program to be effective, teachers must be committed to it. a program such as cpe typically requires teachers to attend professional development sessions and to do extra planning and grading. for some, commitment can be difficult, especially for teachers who are also athletic coaches. research indicates that when roles of coach and teacher conflict in terms of time and resources, priority is often given to the "athletics" portion of the job 25. i readily recognized the many coaches are also quality physical education teachers or teachers of other subjects. however, the primary responsibility of teachers is to fulfilling their duties as teacher, in this case committing to carrying out a quality cpe program. administrative support is also essential. based on my observations, too often the head of the physical education department is also the athletic director or the coach of a major sport. if innovative programs such as cpe are to be effectively implemented, it is my view that the department head should be a physical educator who does not have a coaching or other extracurricular assignment. her/his/their assignment is to administer and direct quality physical education programs. part of the administrative assignment must be holding teachers in the program accountable and making sure that they give a priority commitment to the teaching assignment for which the majority of the person's salary is paid. professional development. for those new to cpe, professional development is essential. teachers need updates on new information, including cpe content, methods, assessments, and technology. my surveys from the 44 state conventions that i have keynoted indicate that few secondary school physical educators attend state conventions, often opting for coaching meetings instead. if cpe (and all of physical education for that matter) is to move forward, it is essential that secondary physical educators attend state conventions and other physical education professional development meetings. for students enrolled in physical education teacher education (pete) programs, a special course designed specifically to help them implement cpe should be offered. recommended content for teacher professional development and pete courses includes cpe instruction methods, content knowledge instruction, methods for overcoming barriers to success (e.g., teacher resistance, teacher workload, coach/teacher role conflict, and student resistance) 25 . commitment to inclusion. the help philosophy emphasizes physical education for everyone and allows students to plan personal programs. to be consistent with this philosophy, programs must offer options for all students. cpe programs, for example, are planned using the universal design for learning framework 100 . the framework helps to -improve and optimize teaching and learning for all people based on scientific insights into how humans learn‖ (p. 1). 100 in addition, programs and program planners can commit to diversity, equity, and inclusion consistent with statements such as the following from the american college of sports medicine (acsm): -we implore every human to go about their responsibilities and every other aspect of their daily lives, making decisions with social justice in their hearts and minds. the future of a pluralistic and just world depends on it!‖ (p. 1). 101 park 2 notes that, as physical education develops in the future, -it may be useful to remember that medicine, an ancient and honored profession that many contend is the most valuable and venerated of the 20th century, was in a general state of disarray at the end of the 19th century‖(p. 20). like medicine, the field of kinesiology was in disarray in the mid-20th century but has made great strides in this century. a robust scientific base has been established, including, but not limited to, evidence that regular physical activity not only enhances fitness and performance but also reduces risk of chronic diseases and conditions (e.g., heart disease, diabetes, some cancers, osteoporosis, obesity). the 2020 covid-19 pandemic accentuated the fact that risk of serious complications and death from the virus are substantially higher among those with hypokinetic conditions. other benefits of physical activity (chronic and acute) include enhanced cognitive function, mental health, and wellness. we also have learned much about the science of human performance (mechanical, physiological, psychological, and sociological) and the science of physical education (sport) pedagogy. those of us who did our undergraduate study in health and physical education in the 1950s did not benefit from the science now available to current and future teachers. texts in many of the subdisciplines did not become available until years later. scientific societies and many important journals were just being founded. earlier generations, however, did lay the groundwork for the dissemination of the new science. the modern profession of physical education, if built on a sound disciplinary foundation, has the opportunity to make strides similar to those made by medicine in the last century. it is interesting that the word doctor is derived from the latin word for teacher, docēre. physical educators do not practice medicine, but they teach. like medical doctors, it is important that they have a strong science background and the ability to pass what they know on to their students. cpe provides an effective platform for them to do so. in my 60 years as an educator and researcher, and especially my years as an advocate for cpe, i have often been criticized and labeled as an opponent of skill learning and other worthy physical education objectives. i have also been accused of wanting to take the -physical‖ out of physical education. to be clear, while i do advocate for cpe as 1 important component of a total quality physical education program, i also support participation in physical activities of all kinds. i support all of the objectives of physical education. i applaud quality skills instruction and instructional methods that foster moderate to vigorous physical activity (mvpa) in physical education. i believe in the importance of social-emotional learning programs that foster diversity and social justice. i endorse programs that help students to find meaning and enjoyment in movement and sport. there is room for them all. cpe is not an opponent of these efforts; it is an important partner. cpe programs that emphasize a knowledge base and that are consistent with peak principles do not distract from other programs-they complement them. students who have -learned to learn‖ are not only more likely to use what they have learned-they can generate their own new knowledge that will guide them in the future. as ennis 102 suggests, engaging -students in a quest for knowledge about the effects of exercise on their bodies requires coordinated efforts by scientists and practitioners to build from kinesiology to society‖ (p. 16) . as outlined in this article, there are many reasons for including cpe as part of a quality physical education program. simply put, if secondary physical education is to thrive in the future, we can and should make knowledge-based cpe programs a central component. if we are to become the renaissance profession of the 21st century, we must be strong in our trust in our science (knowledge) and strong in our conviction to chart a new course for the future based on our science. the advice of robert kennedy 103 can guide us: -some people see things as they are and say why? i dream things that never were and say, why not?‖ table 1 . physical education content standards 41 and fitness education benchmarks. 7 national physical education content standards fitness education instructional framework a standard 1: the physically literate individual demonstrates competency in a variety of motor skills and movement patterns. standard 2: the physically literate individual applies knowledge of concepts, principles, strategies and tactics related to movement and performance. standard 3: the physically literate individual demonstrates the knowledge and skills to achieve and maintain a health-enhancing level of physical activity and fitness. standard 4: the physically literate individual exhibits responsible personal and social behavior that respects self and others. standard 5: the physically literate individual recognizes the value of physical activity for health, enjoyment, challenge, self-expression and/or social interaction. technique: demonstrate competency in techniques needed to perform a variety of moderate to vigorous physical activities. knowledge: demonstrate understanding of fitness concepts, principles, strategies and individual differences. physical activity: participate regularly in fitnessenhancing physical activity. health-related fitness: achieve and maintain a health-enhancing level of health-related fitness. responsible personal and social behaviors: exhibit responsible personal and social behaviors in physical activity settings. values and advocates: values fitness-enhancing physical activity for disease prevention, enjoyment, challenge, self-expression, selfefficacy and/or social interaction. nutrition: strive to maintain healthy diet through knowledge, planning and regular monitoring. consumerism: access and evaluate fitness information, facilities, products, and services. a some fitness education instructional benchmarks were edited for brevity. based on school health policies and programs study (shpps) data 23 . table 4 . factors relating to effective delivery of conceptual physical education (cpe). in a mastery environment, the teacher reinforces efforts toward achieving specific learning goals. consistent with the help philosophy, there is an emphasis on the individual (personal learning). students learn and use selfmanagement skills to make personal decisions related to class content. in cpe, fitness assessments are self-assessments and are used as a basis for personal program planning. criterion-referenced, health-based fitness standards provide the basis for personal rather than comparative assessments. additional established assessment guidelines (e.g., confidentiality, not using fitness scores for grading) are adhered to. portfolios (print or digital) that include fitness and physical activity profiles provide evidence of student accomplishment. instruction focuses on higher-order objects as student's advance. students in cpe use previously learned information as a basis for future learning (vertical learning). some repetition is planned to foster mastery. horizontal learning, such as repeating instruction in the same activities, is contraindicated. when committing to a cpe model and adopting materials to carry out program goals, fidelity is important. staying on task is important for program success. note: the 2020 corona virus pandemic accentuated inequities when many schools used online platforms for remote learning. fig. 1 conceptual physical education: the anatomy of an innovation the second 100 years: or, can physical education become the renaissance field of the 21st century? knowledge, transfer, and innovation in physical literacy curricula exercise for a lifetime: an educational effort recreation and dance. health related physical fitness test manual the history of fitnessgram instructional framework for fitness education in physical education fitness for life society of health and physical educators effects of a concept-based physical education on middle-school students' knowledge, motivation, and out-of-school physical activity ‖ more than 30 editions, and a half-century of effort! -an interview with dr. charles b. (chuck) corbin historical perspective and current status of the physical education graduation requirement at american 4-year colleges and universities the progression and characteristics of conceptually based fitness/wellness courses at american universities and colleges youth fitness, exercise and health: there is much to be done commentary on -children and fitness: a public health perspective health-based physical education the pill not taken: revisiting physical education teacher effectiveness in a public health context impact on schools: implications for curriculum physical education and its role in school health promotion a commentary on children and fitness: a public health perspective physical education's role in public health children and fitness: a public health perspective school physical education: secondary analysis of the school health policies programs study viral hepatitis, std, and tb prevention. trends in the prevalence of physical activity and sedentary behaviors national yrbs: 19912017. available at conceptual physical education: a secondary innovation fitness for life personal fitness and you personal fitness: looking good-feeling good foundations of personal fitness fitness for life: middle school a state level update on secondary physical education policies (abstract) teaching physical lifeskills: practical ideas on health-related fitness aptidao fisica e saude nos programas de educacao fisica: desenvolvimentos recentes e tendencias internacionais fitness for life: physical education concepts fitness for life fitness for life canada: preparing teens for healthy, active lifestyles a dozen reasons for including conceptual physical education in a secondary program educating students for a lifetime of physical activity: enhancing mindfulness, motivation, and meaning moving into the future: national standards for physical education, a guide to content and assessment. reston, va: national association for sport and physical education va: national association for sport and physical education; 2004. 41. society of health and physical educators. national standards and grade level outcomes for k-12 physical education concepts of physical education: what every student needs to know fitness for life: teacher's guide physical literacy, physical activity and health: toward an evidence-informed conceptual model implications of physical literacy for research and practice: a commentary international physical literacy association institute of medicine. health literacy: a prescription to end confusion ninth graders' energy balance knowledge and physical activity aehavior: an expectancyvalue perspective impact of education reforms: the quality of florida's high school physical education programs the science of healthful living learning science-based fitness knowledge in constructivist physical education impact of teacher value orientations on student learning in physical education american association for health, physical education, and recreation. youth fitness test manual american assc for health, physical education and recreation texas youth fitness study: a commentary presidential youth fitness program. presidential youth fitness program comprehensive school physical activity programs active and healthy schools fitness for life elementary school: guide for wellness coordinators the spark programs: a public health model of physical education dynamic physical education for elementary school children human kinetics; 2020 center for disease control and prevention. results from the school health policies and practices study an analysis of state physical education policies in physical education school physical activity policy what schools could be mission impossible? reflecting upon the relationship between physical education, youth sport and lifelong participation college physical education: an unrecognized agent of change in combating inactivity-related diseases gender differences in chronic disease risk behaviors through the transition out of high school tracking pedometer-determined physical activity: a 16-year follow-up study can conceptual physical education promote physically active lifestyles? physical activity participation of high school graduates following exposure to conceptual or traditional physical education effectiveness of secondary school conceptual physical education: a 20-year longitudinal study urban minority ninth-grade students' healthrelated fitness knowledge physical activity and fitness knowledge: how much 1-6 grade students know? physical activity and fitness knowledge in middle school physical education (abstract) fitness knowledge, cardiorespiratory endurance and body composition of high school students to move more and sit less: does physical activity/fitness knowledge matter in youth? determinants of exercise among children: ii. a longitudinal analysis health-related fitness knowledge and physical activity of high school students the effects of conceptually based physical education programs on attitudes and exercise habits of college alumni after 2 to 11 years of follow-up changes in healthy behaviour knowledge of rural pupils effects of florida's personal fitness course on cognitive, attitudinal and physical fitness measures of secondary students: a pilot study does cardiorespiratory fitness knowledge carry over in middle school students? two pathways underlying the effects of physical education on out-of school physical activity society of health and physical educators. school reentry considerations: k-12 physical education, health education, and physical activity american academy of physical education (currently the national academy of kinesiology). conceptual physical education. a position statement shape of the nation: status of physical education in the usa physical education website advanced-placement physical education: an opportunity to act a complete guide to sport education motivating middle school students: a health-club approach society of health and physical educators. guidelines for k-12 online physical education fitness for life: middle school interactive web text more than 9 million children lack internet access at home for online learning jrotc as a substitute for pe: really? the udl guidelines physical education curriculum priorities: evidence for education and skillfulness speech at the university of kansas my thanks to ang chen, pam kulinna, bryan mccullick, and hans van der mars for their reviews of early versions of this manuscript. their time commitment and constructive comments are sincerely appreciated. the author declares that he has no competing interests. key: cord-305743-rnfn6opa authors: anton, stephen d.; cruz-almeida, yenisel; singh, arashdeep; alpert, jordan; bensadon, benjamin; cabrera, melanie; clark, david j.; ebner, natalie; esser, karyn a.; fillingim, roger b.; goicolea, soamy montesino; han, sung min; kallas, henrique; johnson, alisa; leeuwenburgh, christiaan; liu, andrew c.; manini, todd m.; marsiske, michael; moore, frederick; qiu, peihua; mankowski, robert t.; mardini, mamoun; mclaren, christian; ranka, sanjay; rashidi, parisa; saini, sunil; sibille, kimberly t.; someya, shinichi; wohlgemuth, stephanie; tucker, carolyn; xiao, rui; pahor, marco title: innovations in geroscience to enhance mobility in older adults date: 2020-10-22 journal: exp gerontol doi: 10.1016/j.exger.2020.111123 sha: doc_id: 305743 cord_uid: rnfn6opa aging is the primary risk factor for functional decline; thus, understanding and preventing disability among older adults has emerged as an important public health challenge of the 21st century. the science of gerontology – or geroscience has the practical purpose of “adding life to the years.” the overall goal of geroscience is to increase healthspan, which refers to extending the portion of the lifespan in which the individual experiences enjoyment, satisfaction, and wellness. an important facet of this goal is preserving mobility, defined as the ability to move independently. despite this clear purpose, this has proven to be a challenging endeavor as mobility and function in later life are influenced by a complex interaction of factors across multiple domains. moreover, findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. for these reasons, behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. other pharmaceutical interventions, such as oxytocin, and complementary and alternative interventions, such as massage therapy, may enhance physical function both through direct effects on biological mechanisms related to mobility, as well as indirectly through modulation of cognitive and socioemotional processes. thus, the purpose of the present review is to describe evolving interventional approaches to enhance mobility and maintain healthspan in the growing population of older adults in the united states and countries throughout the world. such interventions are likely to be greatly assisted by technological advances and the widespread adoption of virtual communications during and after the covid-19 era. stephen d. anton a (santon@ufl.edu), yenisel cruz-almeida b (cryeni@ufl.edu), arashdeep singh c (a.singh@ufl.edu), jordan alpert d (jordan.alpert@ufl.edu), benjamin bensadon a (bensadon@ufl.edu), melanie cabrera a (melanie.cabrera@ufl.edu), david while prolongation of life remains an important public health goal, of even greater significance is that extended life should involve preservation of the capacity to live independently and to function well [1] . the field of geroscience seeks to understand the genetic, molecular, and cellular mechanisms that make aging a major risk factor and driver of common chronic conditions and diseases of older people. interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [2] [3] [4] [5] [6] . the unprecedented growth of the aging population and increasing prevalence of chronic disease have underscored an urgent need for such interventions. if this the current trend in aging continues, the number of older persons (aged >60 years) will nearly triple in size globally, increasing from 673 million in 2005 to almost 2 billion by 2050 [7] . accordingly, the science of gerontologyor geroscience -has the practical purpose of understanding how aging processes enable diseases and to then apply this knowledge to reduce the emergence and progression of age-related diseases and disabilities. the ultimate goal is to develop feasible, practical, and safe interventions to delay the development of chronic diseases and conditions, while also increasing enjoyment, satisfaction, and quality of life, during the latter stages of an individual's lifespan. [8] interventions that can achieve these objectives may also dramatically lower health care costs. as we have previously described, [9, 10] a hallmark of successful aging is mobility, i.e. the ability to move without assistance, which is necessary for the maintenance of basic independent functioning [11, 12] . additionally, mobility performance (i.e., walking speed) has emerged as a surrogate marker of overall health and functional ability among older adults. [13] improvements in usual gait speed predict better survival and quality of life in older adults [14] . in contrast, mobility limitation is associated with more rapid functional decline, reduced quality of life [15] , as well as hospitalization, nursing home placement, and increased mortality [16] [17] [18] [19] [20] (see figure 1 ). for these reasons, understanding and preventing mobility disability among older adults has emerged as one of the most important public health opportunities of the 21 st century. therefore, identification of promising interventions to preserve mobility that can be widely implemented in older adults is a major clinical and public health priority [21] . since our previous review, [9] several advances in the field of geroscience have been achieved and are highlighted in this paper. for example, discoveries made in the past few years have illuminated the complex interactions between the brain and the body in affecting changes in mobility with aging. more specifically, the important role that the central and neuromuscular systems have in affecting mobility has spawned a host of new treatment options, such as use of neuro-modulatory adjuvants (e.g., transcranial direct stimulation) to enhance the beneficial effects of physical activity. in line with this, a growing body of research indicates that interventions designed to improve cognitive/emotional function (e.g., oxytocin) also have benefits effects on mobility and physical function. thus, it appears virtually impossible to influence an individual's cognitive/emotional function without affecting their physical function, and vice-versa. an increased understanding of biopsychosocial factors that may contribute to functional decline can aid in the development of future interventions designed to improve mobility and function in at-risk older adults. aided by technological developments, the range of interventions now available has greatly increased in the past five years. thus, we have expanded our conceptual model to incorporate technology, neural factors, and environmental factors. although there is a strong consensus on this goal, there are challenges to developing such interventions as an older adult's mobility and functional level are affected by factors across j o u r n a l p r e -p r o o f journal pre-proof multiple domains. moreover, the complex interactions between factors within biological, psychological, and social domains may increase the risk for functional decline and other agerelated chronic disease conditions. as such, promising interventions will need to take into account these multifaceted interactions and also recognize that affecting change in one domain can lead to changes in other domains. with this goal in mind, we first review the role of specific biological contributors to functional decline. next, we describe key behavioral and psychosocial factors that can affect physical function and risk for functional decline in older adults. we then discuss promising interventions from clinical trials that can enhance physical function and mobility, as well as the role of smart and connected technologies in the delivery of these interventions (see figure 2 ). in the final sections, we discuss the importance of preclinical models in guiding intervention selections, statistical considerations in aging research, as well as key strategies to effectively disseminate and implement efficacious interventions in clinical and community settings. the rising prevalence of metabolic syndrome in older adults, a condition diagnosed based on the presence of three or more metabolic risk factors, including abdominal obesity, high triglycerides (tg), low hdl-cholesterol (hdl-c), high blood pressure (bp), and impaired glucose tolerance, correlates with sedentary lifestyles, and poor nutrition habits [22] [23] [24] [25] . approximately one-third of older adults in the usa are obese; however, nearly 55% of those aged 60 years or older are estimated to have metabolic syndrome [26] . given the aging us population, the disproportionately high prevalence of the metabolic syndrome in older adults is a significant public health concern, as it substantially increases the risk for cardiovascular disease j o u r n a l p r e -p r o o f journal pre-proof (cvd) [27] [28] [29] [30] and is associated with increased all-cause mortality, disability, cvd mortality, myocardial infarction, and stroke [31] . additionally, the metabolic syndrome is associated with impairments in basic activities of daily living, social activities, and lower extremity mobility [7, 32] . aging typically promotes a loss of fat-free mass which parallels to the reduction in metabolic rate and energy expenditure, particularly after the age of 50 [32] . this age-related muscle loss (i.e., sarcopenia) can diminish both the metabolic and mechanical functions of the skeletal muscle, [33, 34] a point of concern since skeletal muscle has the greatest contribution to an individual's metabolic rate [35] . in addition to the loss of total muscle mass, the muscle quality also declines with age due to increased fat infiltration within the muscle thus resulting in decreased muscle strength [36] and power [37] . after the age of 50, it is noteworthy that adults lose muscle strength (i.e., dynapenia) at a much faster rate, approximately 3-4% year, than they lose muscle mass, approximately 1-2% per year. therefore, while muscle atrophy and weakness are certainly correlated, the former cannot fully explain lost muscle strength in late-life. moreover, muscle weakness is a major independent contributor to maintaining physical independence in later life. [38] [39] [40] [41] [42] [43] it was originally thought that the loss of skeletal muscle mass largely explained the muscle weakness observed in older adults; however, more recent findings suggest that other anatomical and physiological factors also play an important role in muscle weakness. the mechanisms determining loss of muscle strength or power output are related to both neurological and skeletal muscle properties, as it is well known that the output from these sources control j o u r n a l p r e -p r o o f journal pre-proof muscle force and power production. within the neuromuscular system, there are several potential mechanisms that may contribute to reductions in strength during aging, including reduced excitatory drive to the spinal motor neurons, reductions in motor neuron discharge rates, impairments in neuromuscular transmission, muscle cell death, muscle protein imbalance, reduced repair/regeneration of muscle cells and impairments in the excitation-contraction (e-c) coupling processes. aging in humans has been shown to be accompanied by robust reductions in the population of motor neurons and axon density [44] [45] [46] [47] . between the ages of 60 and 70 there is a ~30% reduction in the number of functional motor units (motor units = motoneuron and innervated muscle fibers) [48] [49] [50] [51] and once the loss of motor units reaches a critical threshold, muscle strength begins to decline [52] . the exact underlying mechanisms of exhausted nmj plasticity and motor neuron cell death remain obscure, but many factors such as deregulated inflammation, autophagy, reduced igf-1 signaling, oxidative stress, and mitochondria dysfunction have been suggested to drive accelerated loss of muscle mass and function in late life [53, 54] . many factors contribute to a loss of automaticity of walking in older adults. one likely factor is impairment of the communication between the nervous system and muscle. motor neurons innervate their axon terminals to the skeletal muscle fibers to form a neuromuscular junction (nmj), which allows the presynaptic motor neurons to transmit chemical signals to the post-synaptic muscle fibers, leading to muscle contraction. during most of the adult life, there is considerable plasticity of the nmj, where surviving motor units expand through collateral axonal sprouting to reinnervate any denervated nmjs [54] [55] [56] . exhaustion of this plasticity (persistent denervation and failed reinnervation) accelerates muscle atrophy during aging and is associated with movement impairment and functional decline [44, 57] . accumulating evidence supports that models of cognitive brain aging may help us understand the decline in walking function in older adults [58] [59] [60] . changes in brain structure and function may also contribute directly to loss of automaticity, as well as reduce the capacity for recruiting additional resources to compensate for the loss of automaticity [60, 61] . additional research is needed to better understand the major modifiable neural factors that influence control of walking with older age, so that targeted interventions can be designed [58] . chronic pain conditions represent three of the five leading causes of disability in the us, including low back pain, which is the leading cause of disability both in the us and worldwide [62, 63] . while pain affects individuals throughout the lifespan, older adults are disproportionately impacted [64] . another important contributor to mobility decline among older adults is movement-evoked pain (mep). mep refers to pain that is generated or exacerbated through physical movement or activity, and some evidence suggests that mep may be driven by different mechanisms than pain at rest [65] . recent findings in middle-aged and older adults with knee pain demonstrated a relationship between mep and physical performance, highlighting the need to directly measure mep when assessing functional performance in older adults [66] . thus, one key mechanism through which pain may contribute to functional decline is through activity limitations among older adults [67] [68] [69] [70] [71] [72] [73] . emerging evidence also suggests that pain may affect aging processes. indeed, several recent studies suggest that pain is associated with cellular aging. specifically, a combination of high psychosocial stress and high levels of knee pain were associated with shorter telomeres among j o u r n a l p r e -p r o o f journal pre-proof middle-aged and older adults [74] , and subsequently these authors showed that more severe knee pain was associated with shorter telomeres [75] . more recently, chronic pain in older adults has been associated with brain aging [76] and a validated epigenetic measure of aging [77] . thus, the relationship between pain and aging appears to be bidirectional and complex, impacting multiple body systems. one area that is gaining recognition for the potential to impact aging processes is circadian rhythms, which are endogenously generated 24h cycles that can be observed in behavior, physiology and metabolic processes. driven by the circadian clock, circadian rhythms are found in virtually every cell in the body [78] . over the last ten years, research has uncovered that the circadian clock functions within cells to support daily tissue homeostasis, and disruption of the clocks leads to lowered resilience [79] . studies in animal models support the decline in function of the circadian system with age, and this age-related decline appears to impact virtually all systems in the body including skeletal muscle and areas of the brain important for learning and memory [80] [81] [82] . in humans, studies have shown that circadian output changes with aging of muscle mass and strength [85] [86] [87] [88] [89] . thus, the available evidence to date strongly implicates mitochondria as having a pivotal role in the pathogenesis of age-related functional decline, and it has been suggested that a substantial decrease in mitochondrial oxidative capacity in aging muscle might contribute to reduced exercise capacity in older adults [90] . why there is a decrease in mitochondrial function with aging remains under debate, but emerging science indicates that there is a clear connection between mitochondrial biogenesis and function with fuel metabolism and circadian rhythms [91] . cardiovascular disease (cvd) is a leading cause of death among older adults in the united states and the prevalence increases proportionally with age. in particular, 70% of older adults between 60-79 years old and 85% of older adults 80 years and older suffer from cvd [92] . during aging, endothelial dysfunction induced by oxidative stress, inflammation and decline in bioavailability of nitric oxide (no) leads to arterial stiffness, which overloads the heart leading to ventricular hypertrophy and myocardial fibrosis [93] . endothelial dysfunction and the overloaded heart reduce arterial-ventricular coupling, reflecting impaired global cardiovascular performance [94] . recent evidence has demonstrated that subclinical declines in cardiovascular function contribute to functional decline by impaired peripheral tissue perfusion [95] . although sepsis can affect all ages, it is recognized to be the "quintessential disease of the elderly" [96] . studies have shown that both the incidence of sepsis and hospital mortality increases exponentially beyond the age of 65 years, with more than 1 million us medicare recipients hospitalized each year with sepsis. numerous age-related factors increase the risk for j o u r n a l p r e -p r o o f developing sepsis including comorbidities (e.g., chronic lung disease and renal insufficiency), malnutrition, increased aspiration risk from altered mental status and decreased gag/cough reflex and immobility. the diagnosis of sepsis is commonly delayed in older patients because of a blunted systemic inflammatory response syndrome (sirs) and the presence of comorbidities that can cause confounding symptoms. as a result, older patients present as septic later in the process. they are more likely to progress into septic shock due to limited cardiac reserve and have worsening of existing organ dysfunctions. the principal cause of sepsis is a dysregulated systemic immune response, which is negatively affected by aging. in contrast to younger adults, older patients have difficulty returning to immunity homeostasis, increasing their risk for sepsis recidivism. pre-existing sarcopenia, frailty and cognitive disabilities all adversely affect recovery. additionally, ongoing sirs induces profound catabolism with tremendous loss of vital lean body mass despite early nutritional support intervention. moreover, care for sepsis in the icu often involves bedrest and mechanical ventilation, exacerbating the ongoing loss of muscle mass and function. once sirs has resolved, older sarcopenic sepsis survivors have anabolic resistance that makes them nonresponsive to nutritional and physical therapy interventions. our senses, hearing, vision, touch, smell, and taste play critical roles in survival throughout the course of life. aging can affect all of these sensory systems, but the auditory system is thought to be especially vulnerable to age-related damages. hearing loss is the third most prevalent chronic health condition affecting older adults and age-related hearing loss (ahl) is the most common form of hearing impairment [97] . the world health organization(who) estimates that one-third of persons over 65 years are affected by hearing j o u r n a l p r e -p r o o f loss [98] . worldwide, approximately 466 million people suffer from hearing impairment and this number is expected to rise to 630 million by 2030 and over 900 million by 2050. ahl is characterized by poor speech understanding (especially in noisy situations), central auditory processing deficits, and social isolation [99] . as humans age, both males and females undergo various changes in hormone levels, leading to numerous long term and significant internal changes. although some of these changes may be more detrimental than others, common and problematic alterations include loss of muscle mass [100] , decreased bone mass [101] , and various cognitive impairments [102] , which all increase risk for mobility loss and loss of independence. in men, aging is often associated with decreased testosterone [100] , which has been linked to bone loss [103] and decreased muscle mass [104] . with the loss of muscle and bone comes an increased risk of sarcopenia, oftentimes resulting in frailty, decreased functional mobility, and growing difficulties with independent living. in females, decreased estrogen levels post-menopause are often postulated to increase one's risk of sarcopenia and frailty [100] . loss of estrogen is accompanied by an increase of pro-inflammatory cytokine il-6, which downregulates insulin-like growth factor-1(igf-1) [100] . high il-6/low igf-1 levels have been shown to significantly limit walking and mobility tasks of daily living [105] , increasing the risk for progressive disability in older females. in addition to sex hormones, a decline in growth hormone (gh) has been observed with aging and is often associated with various changes in body composition, as well as physical and psychological functions [101] . as one approaches the fourth decade of life, there is a progressive decrease of gh secretion by ~15% each decade thereafter [101] . age-related increases in body j o u r n a l p r e -p r o o f mass index (bmi) and diminished functional capacity tend to parallel the decline in gh secretion, although many other factors also likely contribute [101] . in many cases, physical disability is directly caused or aggravated by acute events (stroke and hip fracture) and disease states (heart failure, coronary heart disease, diabetes, arthritis and peripheral artery disease) [106, 107] . however, a large and growing number of older adults experience progressive declines in physical function over several years culminating in agerelated physical disability with no clear connection to a single disease [108, 109] . research over the past decade has highlighted the role of multiple body/biological/health systems in contributing to this decline. moreover, many age-related conditions appear to affect other systems and may induce similar adverse changes at the cellular level. among the behavioral factors, low levels of physical activity combined with excessive and unhealthy calorie intake appear to strongly contribute to functional decline among older adults [110] . in line with this, a recent review of trends in us health by the u.s. burden of disease collaborators found that high body mass index (bmi), smoking, and high fasting plasma glucose are the three most important risk factors for disease and disability in the united states [111] . among these, only the prevalence of smoking is decreasing, while bmi and fasting plasma glucose levels are steadily increasing. skeletal muscle loses the ability to switch between metabolizing lipids and carbohydrates. in addition to the role caloric excess can have in promoting metabolic inflexibility, there is also increasing evidence that the "western-type" diet that is high in sugar, fat, and processed foods seems to be associated with less ideal aging phenotypes [112] . high levels of sedentary behavior (sitting) contributes to lipid accumulation [113] [114] [115] , metabolic impairments [116] , and loss of muscle mass during aging [117] , all of which strongly contribute to functional decline [118] [119] [120] [121] . these findings are of concern as the majority of middle-age americans spend over half their waking day (~8-9 hours) engaged in sedentary pursuits [122, 123] , with older adults spending an even greater proportion (75%) of their waking hours engaged in sedentary behavior (~11 hours per day) [124] . moreover, each additional hour of sedentary behavior was associated with increased risk of the metabolic syndrome, whereas every additional hour of light intensity activity was associated with reduced risk. perhaps the most common complaint older adults have is the lack of quality sleep. sleep affects nearly every tissue and system in the body, from the brain, heart and muscle to metabolic, endocrine, cardiovascular and immune functions, as well as numerous cognitive processes such as learning and memory, emotion and motor control [125] . similar to food and water, sleep is a basic human need, and sleep timing, duration, and quality are all essential to health. despite this, sleep deficiency is prevalent in modern society, including an insufficient amount of sleep, low quality sleep, and sleep at the wrong time of day. according to a recent report from the centers for disease control and prevention (cdc), 30% of u.s. adults report some form of sleep deficiency [126, 127] . sleep deficiency is more prevalent in older adults, exhibiting common nighttime sleep abnormalities, such as early bedtime and rise time, sleep fragmentation (i.e. less consolidated sleep with frequent awakenings), short sleep duration, less total sleep, and deep sleep [128] ; which is correlated with more frequent daytime naps. in fact, 1 in 4 older adults report severe daytime sleepiness that affects daytime mental and physical performance [129] . these agerelated sleep deficiencies have significant consequences for brain and body health, increasing the risk of chronic inflammatory and neuropsychiatric diseases, metabolic and cardiovascular disease, as well as mental health problems and even pain. for example, poor sleep quality and chronic pain are both tied to significant reductions in quality of life in aging [130] . emerging evidence from our group suggests that sleep may negatively impact brain structure and function in older individuals, which may lead to worse self-reported pain [131, 132] . an increased understanding of the behavioral factors that contribute to functional decline in otherwise healthy older adults can assist in both identifying at-risk older adults and designing targeted interventions for individuals in the later stages of life that maintain mobility and slow the rate of functional decline. it is recognized that there are many causes of functional decline and ultimately disability. while we believe behavioral factors, including over and undernutrition, physical inactivity, and sleep, have a central role in maintaining mobility in later life, the pathways leading to physical disability in older adults are likely complex and involve consideration of a larger number of etiologic factors. environment and social relationships can serve as either risk or protective factors for aging adults. environmental factors across the lifespan interact with biology and contribute toward health outcomes [133] . research shows that early life stressors can influence biological functioning, priming the stress system toward a level of heightened sensitivity increasing greater risk for later life health conditions and earlier mortality [134] . as individual age, environmental factors, life experiences, and personal and financial resources can buffer or exacerbate healthrelated conditions. social relationships also influence health and well-being. limitations in social relationships can be experienced as social isolation and loneliness [135] . of concern, approximately one fourth of adults, individuals aged 65 years and older meet social isolation criteria and among individuals aged 60 years and older, greater than 40% endorse loneliness [135] . age-related life changes that increase susceptibility to social isolation and loneliness includes changes in health status limiting functioning and mobility; changes in family structure (divorce, childless); death of friends, family members, and spouse; auditory and visual changes reducing the ability to communicate and interact; and resource reductions including healthcare access and quality of care [135] . there is also research evidence that socially isolated older adults are less physically active independent of any mobility limitations [136] . however, whether or not declines in mobility mediate the well-established relationship between social isolation and all-cause mortality [137, 138] remains unclear. minority older adults are at an even greater risk to the health consequences of environmental and social factors. higher frequency of negative environmental exposures, limited j o u r n a l p r e -p r o o f environmental resources, possible language limitations, and experiences of stigma and discrimination might be further contributing to increased risk of morbidity and mortality [133] . despite this increased risk for poor health outcomes, access to medical care is often limited and the extended wait times to receive care may discourage healthcare utilization, particularly preventive health services among minority populations [139] [140] [141] . thus, environmental and social factors represent an area where research and evidence-based strategies can contribute to improved health outcomes [133, 142, 143] . older adults perceive mobility as essential to feeling whole and identify mobility assistance and adaptation as key to managing age-related changes [144] . in fact, older adults who met just one of five established frailty phenotype criteria were more likely to also be depressed, suggesting frailty has both physical and psychological components [145] . also noteworthy, psychological factors such as balance efficacy and falls efficacy have previously been found to be more important than physical factors (e.g., fall history, medical morbidity, and balance tests) in predicting future falls [146] . theoretically, self-efficacy for specific tasks, mood, and behavior have a reciprocal influence on an older person's decision making and performance. for example, lower baseline self-efficacy for functional tasks predicted decreased walking performance and stair ascent among older women with osteoarthritis [147] . falls efficacy, a measure of falls-specific selfefficacy, can be independently predicted by normal walking pace, anxiety, and depression [148] . dizziness, another common mobility-related complaint of older adults, has been associated with lower falls efficacy and slower walking speed [149] . these trends are consistent with other data j o u r n a l p r e -p r o o f showing fall history and female gender independently predict fear of falling [150] and mobility device use [151] . consistent with the data on the importance of psychosocial factors in mobility, a number of mobility-related clinical interventions are integrating falls-specific self-efficacy [152 2017 ], balance-specific [153] and other psychological concepts into trials targeting frailty in older adults [154] . further, these trials are also targeting motivation for physical activity [155] , adherence to exercise programs [156] , fall prevention [157] , and interventions to reduce the fear of falling and improve balance such as yoga [158] . protocols are emphasizing the need to tailor to older adult's preferences, personal choice, and providing social support [159] . these factors should align with older adults' own attitudes and perceived needs [160] , as well as older adults' perceived enablers and barriers to participation in strength and balance activities (barriers = risk of cardiac events, death, and hyper muscularity; enablers = potential improvement in the ability to complete daily activities, prevent deterioration /disability, and decreased risk and fear of falling) [161] . in a 6month integrated care program that included problem-solving psychotherapy reported improvements in frailty were sustained at one year follow up [162] . although these studies suggest promising results, the integrated biopsychosocial approach to mobility is still underutilized. poor nutrition may be a key factor that promotes metabolic syndrome and can exacerbate a decline in physical function and mobility. given the link between metabolic syndrome or obesity with the musculoskeletal decline among the older population, it is no surprise that dietary interventions that reduce bodyweight also improve health outcomes in older adults. dietary j o u r n a l p r e -p r o o f restriction (or caloric restriction), defined as a mild reduction of energy intake without malnutrition, delays aging in nearly all animal species tested so far [163] . in addition to promoting longevity in various model organisms (e.g., yeast, worm, fly, mouse) [163, 164] , dietary restriction had also been shown to be beneficial for enhancing physical function and mobility in older adults [254] [255] [256] [257] . furthermore, in overweight humans, caloric restriction has been shown to reduce several cardiac risk factors [165] [166] [167] , improving insulin-sensitivity [168] , and enhancing mitochondrial function [169] . current challenges: despite health-promoting biological changes, there are two important concerns related to calorie restriction interventions in older adults. first, weight loss could accelerate aging-associated muscle loss and thereby have adverse effects on physical function [170, 171] . second, most individuals have difficulty engaging in caloric restriction over the long-term and frequently regain weight that was lost [172] . for these reasons, alternative innovative dietary approaches for reducing body weight, specifically body fat, in overweight, older adults at risk for the functional decline are currently being explored. innovations from geroscience: one alternative dietary approach that has been suggested to produce similar biological changes as calorie restriction that has received increasing interest from the scientific community is intermittent fasting or time-restricted eating (tre) [173] . in contrast to traditional calorie restriction paradigms, there is typically no restriction to calorie consumption in tre during designated eating periods (typically 8 -12 hours). in a recent review of the effects of intermittent fasting regimens, specifically tre and alternate-day fasting, we found that tre produced significant reductions in body fat without significant loss of lean tissue, suggesting it may be an effective intervention approach for overweight, older adults [173] . another area of increasing scientific interest is understanding the role of dietary composition in impacting human physiology and physical performance. for example, the mediterranean diet, which consists of healthy fats, fiber, fish, and minimally processed, plantbased foods, has been shown to provide health benefits including improving cardiovascular function, glucose control and decreasing body weight among older adults [174] [175] [176] . also, noteworthy, in some preclinical studies conducted in rodent models, the ketogenic diet has been shown to extend longevity and healthspan, [270[177] improve memory and cognition, [177] [178] [179] and improve endurance athletic performance [274, 275] . based on such findings, the lowcarbohydrate, high-fat ketogenic diet has attracted increasing attention as a potential dietary intervention to promote healthy aging. future directions: to date, the impact of diet interventions on physical function and mobility among seniors with aging-associated morbidities is unknown. although some risk may be associated with lifestyle-based weight loss interventions in older adults, obesity, and sedentary lifestyle are known to predict the development of disability in otherwise healthy older adults [119, 180] . however, randomized controlled studies are needed to demonstrate whether the benefits of these interventions outweigh the risks before implementing these interventions on a broad scale. an important primary focus of these interventions should be enhancing and/or maintaining fat-free mass, as high-quality muscle is the primary driver of metabolism and also directly impacts mobility and physical function [14, 181] . notably, as multimorbidity is often a characteristic feature observed in older individuals with impairments in mobility, a geroscience approach will be instrumental in determining the long-term efficacy of nutrition-based interventions and addressing the potential challenges with aging-associated comorbidities. exercise provides benefits to all major body systems, including the nervous system. aerobic exercise, in particular, can enhance brain health by upregulating neurotrophic factors that improve nerve structure and function [182] . to prevent functional decline, the american college of sports medicine (acsm) guidelines for older adults recommend a regular exercise program that includes a combination of endurance and resistance training [183] . in support of these recommendations, low-intensity aerobic activity such as walking 4-7 days per week [184] or going up and down a 10-stair staircase [185] , have been shown to be protective against loss of mobility and functional decline [184] [185] [186] . current challenges: while structured physical activity is a powerful tool to improve overall health in older adults, involvement in structured physical activity may be overwhelming for frail older adults who are home-bound and have poor physical performance. older adults may not be capable of participating in structured, institution-based physical activity programs with multiple visits to research sites due to poor health status and distant living locations. innovations from geroscience. our group has shown that a structured, moderate-intensity physical activity program compared with a health education program reduced the incidence of major mobility disability over 2.6 years among older adults at risk for disability [187] . other studies have found that resistance training can reduce and delay age-related changes in functional mobility [188] , improves leg strength [189] , and prevents falls by improving transfer of weight and swooping motions in the elderly [190] . reduction of sedentary behavior may be an alternative way to deliver a home-based and remotely supervised intervention to improve the functional status in older adults who cannot engage in center-based physical activity programs. for example, an intervention to reduce sedentary time over 12-weeks improved scores on the short physical performance battery (sppb) and self-reported moderate-to-vigorous physical activity (mvpa) levels in older men and women [192] . such it could be a promising intervention to improve physical function in frail older adults in a home-based setting. strong positive associations between breaks in sedentary time with physical function in older adults have also recently been reported [193] . challenges: remotely delivered interventions are more difficult to achieve long-term adherence to the intervention tasks. additionally, considering heterogenous levels of daily activity and sedentary time among individuals, it is challenging to set daily frequency of sedentary time reduction breaks and design the methods for prompting these breaks as well as an amount of steps to be reached daily. [194] innovations from geroscience: thanks to new developments of well-accepted wearable technology in older adults [195] , such as the fitbit alta device, activity and sedentary-behavior levels can be monitored and registered remotely, and importantly, users can be reminded automatically to transition from sitting to standing position and perform brief light-intensity activity such as leisurely walking [196] . for example, participants using wearable technology aimed to achieve a minimum goal of 25% increase in daily posture breaks, and an additional 1,000 steps a day to baseline, which is considered clinically meaningful in a geriatric rehabilitation population [197] . this novel and practical approach, is less physically strenuous, j o u r n a l p r e -p r o o f does not require frequent visits to research sites, and can be operated and monitored remotely by a research team. future directions: future randomized clinical trials are needed to test wearable technologies in a population of frail older adults with poor physical function, multi-morbidities, and live a far distance from research facilities. given the importance of physical activity and exercise for healthy aging, it is important to consider how these can be optimized to promote neural control of walking. the mode of activity/exercise may be important, and there may be adjuvant interventions that promote neural plasticity. innovations from geroscience. task-specific aerobic exercise that incorporates complex walking tasks and other activities of daily living may be especially helpful for mobility function [198] . an example of these interventions is the use of non-invasive neuromodulation such as transcranial direct current stimulation (tdcs), a mild form of electrical stimulation that is safely delivered via electrode sponges placed on the scalp. tdcs does not directly activate brain neurons, but rather alters the neuronal membrane potential, which is believed to alter the likelihood of eliciting neuron activity (either increased or decreased likelihood, depending on the stimulation parameters) [199] . when paired with task practice, excitatory tdcs might reinforce task-specific neural circuits, enhance learning, retention of new skills, and has been shown to benefit walking tasks in preliminary studies [200] [201] [202] [203] . cognitive interventions refer to a broad set of methods designed to improve or maintain cognitive functioning [204] . because many forms of cognition (e.g., memory, reasoning, speed, executive functioning, attention, working memory) are change with age, and are associated with functional losses in later adulthood [204] [205] [206] , the field of cognitive intervention research has been rather broad. methods of intervention have varied from cognitive training (e.g., providing elders with strategic instruction and practice/feedback in age-vulnerable cognitive domains i ), engagement [207] (having elders engage in complex real-world or leisure activities, including video games) [208] , quilting and digital photography [209] , performing arts [210, 211] interacting with technology [211, 212] , to a wide variety of physical and nutritional strategies (e.g., cardiovascular and strength training, anti-inflammatory diets [213] ). most of this research has sought to investigate whether interventions can improve cognition and/or cognitively demanding activities of daily living. innovations from geroscience. useful field of view training progressively and adaptively trains older individuals to improve the speed with which they make accurate perceptual judgments about targets presented in the center of the field of view, while also correctly noting the location of peripheral objects presented on a display [214] . restrictions in useful field of view have been associated with problems of mobility [215] , balance [216] and increased risk of falling [217] , although direct training benefits have not yet been widely reported. of relevance to the mobility domain, older drivers who received useful field of view training showed a roughly 50% reduction in five-year motor vehicle crash rates [218] , presumably because of the improved ability to rapidly monitor a broad visual display and to divide attention between central and j o u r n a l p r e -p r o o f peripheral targets. the unifying feature of each of these domains of successful cognitive training is the focus on divided attention. in all cases, training included the feature of exposing elders to two tasks at once with one task usually representing a balance/gait or visual-perceptual challenge. generalization of training to mobility tasks seems to be associated with the improved ability to attend to multiple tasks at once, or perhaps to be resistant to distracting tasks by having greater control over attentional prioritization (i.e., reducing the effects of distraction, or improving the ability to exert controlled attentional processing over mobility-relevant tasks). the question of whether cognitive interventions might also improve mobility and physical functioning has received less attention, but a few areas of inquiry have yielded supportive findings. first, dual-task training has been shown to improve standing balance, gait, and to reduce fall risk [213, [219] [220] [221] . the rationale for such studies is that balance and gait are thought to be under central (executive) control, and improving attentional capacity to concurrently conduct cognitive and motor challenges will improve the ability to maintain adequate mobility under distracting conditions, as distractions are thought to put elders at a high risk for falls. there are a number of hormonal interventions that have the potential to impact mobility and improve physical function. we focus on one promising compound, the neuropeptide oxytocin, which serves various adaptive and interrelated physiological, behavioral, and cognitive functions [222] . as a hormone, oxytocin is released into the peripheral circulation and acts directly on multiple organ systems. for example, in humans, low plasma oxytocin levels were associated with increased prevalence of chronic pain, and acute (i.e., one-time) intranasal oxytocin administration decreased experimental pain sensitivity, increased pain inhibition, and j o u r n a l p r e -p r o o f journal pre-proof improved mood and positive affect. in addition, there is increasing evidence of improved wound healing and anti-inflammatory effects associated with oxytocin [223] , promoting physical health. innovations from geroscience: the ability to administer oxytocin centrally via nasal spray [224, 225] , with minimal and inconsistent side effects [226] , has spurred research to explore the neuropeptide's therapeutic potential across functional domains, including physical health and in aging [227] [228] [229] [230] . going beyond its classic role in labor and lactation [231] , oxytocin has been demonstrated to modulate higher-order cognitive processing [232] , improve vasculature in the cardiovascular system, benefits weight control, and insulin sensitivity [222, 233] . oxytocin has also been shown to play a crucial role in endogenous analgesia and has recently been discussed as a promising treatment for pain in older individuals [234] . these analgesic mechanisms may be explained by oxytocin's role as both a neurotransmitter and a paracrine hormone and may be associated with brain-morphological processes. as a neurotransmitter, oxytocin may provide analgesia via widespread effects on the brain and spinal cord. in humans, emerging evidence supports an association between plasma oxytocin levels and brain volumes [235, 236] . preliminary data from a 4-week intranasal oxytocin intervention in older men found increased regional gray matter volume following oxytocin but not placebo treatment, with this oxytocin-induced enlargement in brain volume was associated with improved processing speed [237] . furthermore, animal models that administer repeated oxytocin treatment have documented brain changes driven by cell proliferation, differentiation, and dendritic complexity of new-born neurons in the hippocampus [238] . findings in both models offer promise for future investigations into the potential of intranasal delivery of oxytocin to counteract cognitive decline and positively affect physical health in aging. additionally, data j o u r n a l p r e -p r o o f from an animal model that systematically administered oxytocin found that the administration enhanced muscle regeneration after injury through activation of stem cells and mapk/erk signaling [239] . future directions: only one study to date has specifically examined the effects of intranasal oxytocin administration on physical health among older adults and found that 10-days of oxytocin spray was associated with less self-reported physical decline and reduced selfreported fatigue [240] . the promising findings from these diverse emerging fields call for more systematic research on both acute and chronic oxytocin intervention towards physical function among older adults. examination of exogenous oxytocin's direct and mediated effects, and interaction with the endogenous oxytocin system (e.g., naturally circulating neuropeptide levels, oxytocin receptor gene polymorphisms and methylation levels [228, 241] ), forms an interesting angle for future research on interventions promoting physical function and mobility in aging. in addition, there is growing support in the literature of sex dimorphism in the oxytocin system [226] , including in aging [241] , and evidence of sex-dimorphic effects of intranasally administered oxytocin on both brain [222, 228] and behavior [50, 222, 228] , including among older adults. in an age-heterogenous sample of generally healthy women and men, plasma oxytocin levels were higher in women than men, with young women showing the numerically highest levels and older men showing the numerically lowest plasma oxytocin levels [241] . based on this emerging evidence, future research on the application of oxytocin's effects across different functional domains during aging will benefit from consideratin of sex-by-age variations. pharmacological interventions targeted at underlying mechanisms of mobility decline may also lead to improvements in mobility and physical function in older adults. for example, cell senescence characterized by a loss of cell proliferative capacity, increased metabolic activity, and resistance to apoptosis is a major contributing factor to the development of various agerelated conditions. thus, targeting the removal of senescent cells or suppressing the senescenceassociated secretory phenotype may be helpful in improving physical function [242] . specifically, inhibition of cytoplasmic hsp90 (a chaperone protein needed for proper protein folding) induced by hsp90 inhibitors causes senescent cells to be more susceptible to apoptosis. other pharmacological agents aimed to help proper protein folding or remove misfolded protein aggregates may also delay the onset of age-related diseases and subsequently prevent or ameliorate physical functional decline from these sources. the idea that aging itself may be modified through a pharmaceutical intervention will be tested in the targeting aging with metformin (tame) proposal, the first clinical trial to examine an intervention to slow aging rather than to treat a specific age-related chronic disease in humans pharmacologically [243] . the impetus for this trial is that metformin has been demonstrated to have protective effects against several agerelated diseases in humans. however, there does not appear to be a single biological mechanism targeted. rather metformin appears to have broad systemic effects, which can enhance insulin sensitivity and upregulate stress responses at the cellular level. further, targeting cognition pharmacologically to improve mobility or prevent further decline may be possible, given the brain's neurotransmitter systems shared between cognitive function and the circuits controlling gait. specifically, drugs targeting the cholinergic, j o u r n a l p r e -p r o o f dopaminergic and glutamatergic systems have been reported with various degrees of success in individuals with alzheimer's and parkinson's disease [244] , but may be an additional option to explore in cognitively intact older adults with poor mobility. future directions: to date, there is very limited research focused on pharmacologically targeting aging for improving physical function. given the mosaic of aging processes and potential multi-factorial underlying mechanisms, a geroscience approach will be needed to test interventions with multi-functional properties that target the biopsychosocial contributors to aging processes. natural compounds may also represent an important source of potential new interventions for older individuals. similar to pharmaceutical agents, these compounds would likely be most effectively used as an adjunct treatment with lifestyle interventions, behavioral self-management programs, physical exercise, or cognitive interventions. current challenges: for the vast majority of these compounds, the findings have primarily been shown in preclinical models and have not yet been translated to humans, and/or few clinical trials have shown positive effects on mobility in older adults when biologically based approaches are used alone and not in combination with a behavioral intervention [245] . innovations from geroscience: studies to date suggest some natural compounds may be effective adjuvants to lifestyle interventions. in this section, we will focus on one promising nutraceutical compound, nicotinamide riboside (nr), a form of vitamin b3 that stabilizes the nad metabolome (nad+, nadh, nadp+ and nadph), which in a homeostatic state, mediates transformations from food into energy and repair processes [246, 247] . given the nad metabolome destabilizes with age [248] , supplementation with nr has been shown to stabilize j o u r n a l p r e -p r o o f the nad metabolome in a variety of tissues [249] . clinical studies have demonstrated excellent tolerabilty and safety of nr supplementation in middle-aged and older adults, and improved vascular function [250] and reduced fat tissue [251] following 6 weeks of supplementation. future directions: the effects of nr supplementation alone on physical performance in older humans are unclear, and therefore future studies warrant investigations of longer-duration nr supplementation on physical performance, weight loss and cardiovascular function in humans [252, 253] . much will be learned about the promise of preclinical findings to translate to humans, as well as their compatibility with other interventions, in the coming years. there are many promising complementary and alternative treatment modalities, including biofeedback, hypnosis, meditation, mindful exercise, massage and other types of body-work, acupuncture, and music therapy, that have the potential to improve mobility and physical function in older adults. here we will focus on the potential role of massage therapy (mt), which is a mind-body intervention that has been shown to improve muscle function and quality, preserve of neuromuscular function, improve sleep quality and psychological functioning [229, [254] [255] [256] [257] [258] ; [259] ; [260] . additionally, a growing body of literature supports the use of mt to treat chronic musculoskeletal pain associated with aging [261] [262] [263] [264] . current challenges: while mt shows significant promise for improving factors associated with physical function and quality of life, there are important considerations for older adults, including access, attitudes, and approach. attitudes towards complementary health approaches, specifically mt, are often biased towards a luxury service instead of an actual medical intervention. also declines in mobility and independence may inhibit treatment seeking. innovations from geroscience: specific to biological processes in aging, mt has been shown to modify gene expression, protein synthesis, and inflammatory responses [254] [255] [256] [257] , as well as improve peak isometric torque recovery following intense exercise [265] , and protect against loss of strength and fibrotic nerve and connective tissue changes associated with repetitive motion injuries [266] . massage therapy has also been demonstrated to modulate inflammatory processes that may be protective in aging [267, 268] . of particular relevance, recent preclinical studies using rodent models, demonstrated mt induced immunomodulatory changes (e.g., increased satellite cell number) comparable to those seen in younger animals without damaging muscle tissues. [269] the beneficial effects of massage therapy appear to take place quickly, as a single 10-minute massage therapy session following exercise-induced muscle damage was found to be beneficial for reducing inflammation and promoting mitochondrial biogenesis [270] . additionally, massage therapy is capable of altering proprioceptive feedback to the central nervous system [271, 272] , a critical component for maintaining mobility in aging. adults have yet to be fully elucidated, it is likely that massage therapy can serve a vital role in helping older adults maintain mobility by reducing pain, improving muscle functioning, maintaining proprioceptive abilities, and altering negative inflammatory processes, while improving psychological functioning [259, 260, [273] [274] [275] . although mt may need to be modified to accommodate older adults' needs, it appears to be a safe and effective intervention. given that mt acts upon multiple important pathways for mobility and independence, applying an integrated geroscience approach will improve our understanding of mt in addressing agerelated mobility and functional declines. there is now evidence to support a wide variety of intervention approaches to improve mobility and attenuate functional decline in older adults. both behavioral and biological interventions hold great promise for improving function and mobility and thereby extending healthspan and promoting wellness in functionally limited but healthy older adults. as noted previously, such interventions may enhance physical function directly, as well as indirectly through modulation of cognitive and socioemotional processes. these processes include depression, social stress, and anxiety, which all have high relevance in aging and may contribute to social isolation and reduced well-being among older adults. the utility of such interventions to produce desired outcomes is directly impacted by participant adherence to prescribed treatments, and even the most efficacious intervention can be ineffective if the patient fails to follow treatment recommendations. thus, it is very important to carefully evaluate the sustainability of such interventions, especially in light of research demonstrating that individuals who are not fully adherent to health interventions experience significantly fewer health benefits [276] . a variety of factors can affect long-term adherence to health promotion behaviors, including the complexity of the required changes, the number of decision points needed to carry out such changes on a daily basis, and a number of environmental, socio-cultural, and psychological influences [276] . this suggests the need for two approaches to enhance the effectiveness of behavioral and biologically-based interventions: 1) continued refinement of strategies that can enhance the delivery of and adherence to such interventions, and 2) development of novel intervention approaches (e.g., intermittent fasting and intermittent activity bouts) that have the potential to produce similar health benefits as traditional lifestyle approaches and also may be easier to sustain over the long-term. the role that technological advances may have in increasing the effectiveness of both traditional interventions, as well as more novel intervention approaches, is a topic of great interest. in the section below, we describe some of the key considerations in delivering digital and mobile health (mhealth) based interventions in older adults. personally-held devices, such as smartphones, smartwatches and fitness trackers, provide a ubiquitous infrastructure for researchers and clinicians to passively collect a moment-bymoment quantification of individuals' behavior in their own environment, or recently referred to as digital phenotyping. smartphones are considered the most common electronically held devices. pew research center (prc) conducted a survey about the ownership of smartphones in 2019 showing that 81% of americans and 53% of older adults own smartphones, usage doubling among americans and nearly quadrupling among older adults since 2010 [277, 278] . smartwatches are also growing rapidly. the international data corporation (idc) worldwide quarterly wearable device tracker published that smartwatches accounted for 44.2% of the wearable market in 2018 and is expected to rise to 47.1% by 2023 [279] . prc has published recently a survey showing that onein-five americans (21%) wear a smartwatch or a fitness tracker [280] . a recent study by manini and colleagues [281] about the perception of older adults (65+ years) towards the use of smartwatch technology for assessing pain showed an overall positive view. data collected using smart devices fall under two main categories: active and passive data. the essential difference between these two types is the involvement of participants in reporting data. the active data is described as questions or surveys that a participant has to self-j o u r n a l p r e -p r o o f report at specific times. this data is commonly used for ecological momentary assessment (e.g., pain, mood, or fatigue). in contrast, passive data collection does not require participants to report any data. participants are only required to carry the smart device to be able to continuously collect data through built-in sensors. the type of passively collected data and the quality depend on the availability and modalities of sensors. the most common sensors available are: 1) global positioning sensor (gps) that could be used to measure life-space mobility; which is a measure of the spatial size and frequency of interaction with the surrounding environment; 2) accelerometer that could be used to track physical activity pattern and energy expenditure; 3) microphone that could be used to collect voice samples to be used to extract vocal markers that can serve as a prognostic value for neurological disorders; and 4) call and text logs that can convey information about the size and reciprocity of a person's social network and can also serve as a prognostic value for neurological and psychological disorders. the huge amount of data collected from personally held devices contain hidden, but useful knowledge about the behavior of an individual. fortunately, the advancement of machine learning techniques allowed us to tap into this data and extract patterns. in recent years, sensors embedded into wearable and personal devices such as smartphones have made it possible to develop many mhealth apps, e.g. for tracking physical activity, monitoring blood pressure and heart rate, medication reminders, and many more [282, 283] . some mhealth apps additionally provide just in time (jit) interventions (figure 4) , such as prompting physical activity based on inferred levels of activity or daily steps. a number of recent studies have utilized such mhealth tools in controlled trials to examine mhealth interventions, especially for chronic disease management [284] . several studies have used mhealth intervention tools in cardiovascular and diabetes patients, including the pilot mobile atrial fibrillation (maf) [285] trial (n = 113, cluster randomized design pilot study). as the first mhealth trial of atrial fibrillation patients, maf showed improved drug adherence and anticoagulant satisfaction versus the usual care. in a larger study, the heart failure ii (tim-hf2) trial [286] (n = 1571, randomized parallel-groups), utilized remote monitoring and demonstrated that it could reduce the percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause mortality. in a remote monitoring study, giacomelli et al. [287] showed that remote monitoring after hospitalization for heart failure in older adults had no impact on the primary end-point but it significantly improved patients' quality of life. physical activity promotion also has been examined in several mhealth trials, including the mactive [288] trial which showed that tracking and texting intervention increased physical activity. amorim and colleagues [289] carried out a randomized controlled trial by integrating mhealth, health coaching, and physical activity for patients sufferings from chronic low back pain, demonstrating feasibility and acceptance and a reduction in care-seeking after treatment discharge. other studies have examined mhealth interventions for promoting mental health in clinical trials, including using smartphone cognitive behavioral therapy for refractory depression [290] and smartphone-delivered intervention in patients with a serious and persistent mental health condition, with the improvement shown among patients from racial minority groups [291] . these recent intervention studies and especially controlled trials show promise for the potential scalability and acceptance of mhealth tools. an important but sometimes overlooked j o u r n a l p r e -p r o o f aspect of developing mhealth intervention tools is conducting formative usability evaluation research, besides evaluating efficacy in formal trials. tools must be designed to effectively communicate the proper information by being interactive, interoperable, engaging, and accessible for diverse audiences [292, 293] . therefore, the following attributes should be considered during the development, adoption, and implementation of mhealth tools: 1) ease of use; 2) how the tool fits within the policies, practices, and technical infrastructure of existing health and social systems; and 3) whether intended users can understand and apply the health information provided. performing needs analysis and audience analysis can help guide the design to achieve such objectives [293] . in summary, while mhealth tools may enhance the delivery of some interventions, especially in chronic disease management, evidence regarding their effectiveness for geriatric conditions is still mixed [284, 294] . additionally, most controlled trials have been carried out in high-income countries, and evidence on the effectiveness of such tools in lower-income countries is missing [284] . finally, there is a lack of end-to-end systems for sharing jit intervention results with providers through existing electronic health record (ehr) systems. both humans and animals exhibit an age-dependent progressive decline in mobility [295] [296] [297] [298] . thus, mechanistic studies of age-related mobility impairment in pre-clinical models could advance our understanding of the fundamental mechanisms underlying disability. for example, there is much that can be learned from the study of the simple organism c. elegans. despite its simple anatomy, c. elegans is capable of multifaceted behaviors in response to diverse environmental and intrinsic cues, and exhibits an age-associated decline in locomotion [296, 299] . the multitude of genetic tools available also makes c. elegans an invaluable model system for the study of cellular and molecular mechanisms underlying aging-related locomotor and j o u r n a l p r e -p r o o f movement decline [300] . in c. elegans, the progressive deterioration of muscle occurs with age, which resembles human sarcopenia [301] . importantly, the functional decline of motor neurons at the neural muscular junctions precedes the deterioration of muscle tissues during c. elegans aging [302] , indicating an important role of motor neurons in the age-related mobility impairment. findings from pre-clinical models have led to the identification of important biological mechanisms related to the aging process including mitochondrial function and dynamics [303, 304] , autophagy [305, 306] , oxidative stress [307] , chronic inflammation [308] , muscle composition [309] , hormonal factors [310] , and neurodegeneration [311] . moreover, preclinical studies have led to the transformative discovery that interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [2] [3] [4] [5] [6] . ultimately a strong translational geroscience approach is needed to understand the disease-mediated pathways associated with functional decline and identify promising interventions to maintain mobility and physical function (see figure 4 ). as aging research becomes more information-based, statistics plays a critical role in almost all research topics discussed in the previous sections. for any given aging research project, statistical support is needed at almost all stages starting with the formulation of a scientific hypothesis, study design, data collection, data management and analysis, and conclusion making and ending with manuscript writing. often, the earlier a statistician is involved in an aging research project, the more productive the project will become. let us use a specific example to demonstrate how statistics can significantly help aging research. assume that a research project aims to investigate whether an intervention (e.g., a j o u r n a l p r e -p r o o f nutritional supplement) can improve older adults' mobility. to make the hypothesis more specific, we first need to determine major mobility measurements. according to webber [312] , mobility can be measured in five dimensions (i.e., cognitive, psychosocial, physical, environmental, and financial), and there are many different ways to measure mobility in each dimension. if we are interested in all five dimensions and would like to develop a single mobility index or choose some important ones from all possible mobility measures, then some preliminary studies to collect data on these measures are needed. the data from these preliminary studies can be analyzed by statistical modeling and variable selection approaches, allowing us to come up with either a single mobility index or a relatively small number of mobility measures. these variables can then be used as the response variables of the original study. second, the sample size for the study needs to be properly calculated. to do this, researchers need to specify the smallest meaningful difference between the intervention and control groups for each response variable. the next step is to check whether all model assumptions of the related sample size formula are valid. if not, then a new formula needs to be derived, which could be challenging. for data collection, statisticians are vital in determining which study design is best, such as deciding between a double-blinded randomized study or other types of studies. these steps of study design are extremely important to make the collected data useful in testing the major scientific hypothesis. after data collection, much statistical expertise is required to analyze the data and make solid conclusions. during data analysis, proper statistical methods that clearly describe the observed data need to be chosen, all model assumptions should be verified, and develop new statistical methods when necessary. primary care physicians and geriatricians play an instrumental role in the identification of older adults who have or are at risk for impaired mobility. unfortunately, healthcare providers encounter several barriers to the proper evaluation and treatment of mobility issues in older adults. some of these barriers include insufficient knowledge in latest research findings in the field of geroscience, time constraints in busy clinics, lack of needed resources for treatment interventions, weak patient support systems, and even language barriers in some minority communities. despite these barriers, most patients can be quickly and efficiently screened for cognitive concerns and/or mobility issues with validated assessments, such as the "get up and go" test. when appropriate, providers should deliver succinct but impactful counseling on the importance of adopting a healthy diet, practicing regular physical exercises, and obtaining adequate sleep. the use of educational hand-outs can be very helpful for some patients. clinicians should also use available resources for the enhancement of mobility, such as referrals to physical /occupational therapy, ophthalmology, audiology, and massage therapy. there is a need for more educational programs for healthcare providers covering the latest research findings in the treatment of geriatric conditions including impaired mobility. optimal communication between clinical researchers and clinicians might facilitate the prompt implementation of efficacious new treatments. collaboration among academic investigators and community partners also has the potential to increase the relevance of the research and its potential for addressing public problems such as general health disparities [313] and health problems more specific to seniors, such as limited mobility. such collaborations require (a) culturally sensitive, multidisciplinary academic research teams, (b) empowerment of community members through training them to assume leadership in implementing and disseminating research center-tested j o u r n a l p r e -p r o o f interventions and assisting in getting the institutional review board credentials for being equal research partners, (c) paying trained community member researchers as research professionals, (d) mobilizing community resources and partners (e.g., businesses and local officials) to make policy changes to reduce the social determinants of health (e.g., no/limited public transportation in target low-income black communities) that impede implementation and dissemination efforts. interventions shown to be efficacious in research centers are typically implemented and tested under controlled conditions with non-representative samples of motivated participants [314] . there is a need to implement and disseminate efficacious interventions in communities where uncontrollable social determinants of health (e.g., poverty, race and racism) and associated health disparities negatively influence the length and quality of community members' lives. these communities are where seniors, racial/ethnic minorities, the poor, and/or the medically underserved (i.e., health disparity groups) often live. because of this, ideal implementation and dissemination sites in such communities are churches [315, 316] and primary care centers [317] . it is these sites that commonly serve the aforementioned groups, are stable community structures with physical resources (e.g., meeting spaces), and have human resources (e.g., pastors and physicians) who can influence members of health disparity groups to participate in efforts to implement and disseminate health promotion interventions. the empirically supported community-based participatory research (cbpr) approach [318] is useful in implementing and disseminating efficacious interventions in communities in general and in racial/ethnic minority, poor, and/or medically underserved communities in particular. cbpr creates a paradigm shift from traditional research practices that have characterized academics as experts towards a collaborative research process in which academics are also learners [319] . accordingly, the cbpr approach requires that community members be j o u r n a l p r e -p r o o f actively involved in all aspects of the research process, including the selection of the research topic and methodology, participant recruitment, research implementation, data collection, interpretation of study results, and dissemination of research findings [319, 320] . the patient-centered culturally sensitive healthcare (pc-cshc) model [317] , explains the linkages between provider cultural sensitivity and patients' health outcomes and is useful in guiding implementation and dissemination in community-based healthcare settings. notably, cultural sensitivity extends beyond cultural competence and enables patients to feel comfortable with, trusting of, and respected by providers and researchers, and involves recognizing and overcoming biases and stereotypes that these groups have towards to each other [317] . the provider being culturally sensitive is one key aspect of the pc-cshc model and is a major factor in health promotion. further, patients must be allowed to determine what behaviors, methodologies, etc. enable them to feel comfort, trust and respect. the other key aspect of this model is patient and community empowerment. in accordance with the pc-cshc model, implementation and dissemination of research centertested interventions in community primary care sites that serve health disparity groups requiring that patients and community health workers are active partners with academic researchers. for example, patients should ideally be involved in focus groups and/or interviews to identify culturally sensitive strategies for making these efforts successful. community health workers, physicians, and other providers can then (a) implement these strategies and disseminate the target interventions, and (b) participate with researchers in town hall meetings to disseminate information to the community about the impact of these interventions. culturally diverse, multidisciplinary academic research teams can provide the training needed for physicians/providers and patients to be empowered, equitable partners in implementing and j o u r n a l p r e -p r o o f disseminating target interventions. such empowerment by academic researchers is particularly important for patients such as minority, senior, poor, and medically underserved patients with limited actual and/or perceived power to take charge of their health. patient empowerment is the appropriate response to the increasing national calls for social, health, and healthcare justice. can we really slow the decline in mobility that occurs during aging? and can function improve as we age? the good news is that the answer to both questions appears to be an emphatic yes. effective future interventions, however, will need to take into consideration factors across multiple domains, as well as the complex interaction among these factors. findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, can have a dramatic effect on an older person's mobility and function. additionally, several biological and behavioral factors have been identified as directly related to functional capacity. these are exciting times within the field of gerontology with novel discoveries happening across different fields of study that have direct implications for function and/or functional capacity. for example, the discoveries made within the biology of the aging realm have informed of the types of intervention targets that could truly make a difference in an older adult's functional capacity. furthermore, covid-19 has highlighted the importance of self-care and preventative medicine to promoting wellness and extend healthspan. covid-19 has also highlighted the clear need to protect our older population, particularly minority older adults, as there are clear biological and metabolic factors that increase older adults' susceptibility to this condition. additionally, covid-19 has greatly increased the adoption of virtual communication; j o u r n a l p r e -p r o o f thus, the acceptability of technologically based future interventions is likely to be much greater than prior to covid-19. before translating interventions on a broad scale, however, their suitability and effectiveness across a number of domains are needed to help inform decision making. clearly, there is an important need to evaluate safety outcomes, first and foremost, with the next benchmark related to whether such interventions 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physical health outcomes. sage journals community-based participatory research conceptual model: community partner consultation and face validity the three r's: how community based participatory research strengthens the rigor community-based participatory research from the margin to the mainstream: are researchers prepared? circulation key: cord-336599-r8xgnz87 authors: yaacoub, jean-paul a.; salman, ola; noura, hassan n.; kaaniche, nesrine; chehab, ali; malli, mohamad title: cyber-physical systems security: limitations, issues and future trends date: 2020-07-08 journal: microprocess microsyst doi: 10.1016/j.micpro.2020.103201 sha: doc_id: 336599 cord_uid: r8xgnz87 typically, cyber-physical systems (cps) involve various interconnected systems, which can monitor and manipulate real objects and processes. they are closely related to internet of things (iot) systems, except that cps focuses on the interaction between physical, networking and computation processes. their integration with iot led to a new cps aspect, the internet of cyber-physical things (iocpt). the fast and significant evolution of cps affects various aspects in people’s way of life and enables a wider range of services and applications including e-health, smart homes, e-commerce, etc. however, interconnecting the cyber and physical worlds gives rise to new dangerous security challenges. consequently, cps security has attracted the attention of both researchers and industries. this paper surveys the main aspects of cps and the corresponding applications, technologies, and standards. moreover, cps security vulnerabilities, threats and attacks are reviewed, while the key issues and challenges are identified. additionally, the existing security measures are presented and analyzed while identifying their main limitations. finally, several suggestions and recommendations are proposed benefiting from the lessons learned throughout this comprehensive review. cyber physical systems (cps) are designated as essential components of the industrial internet of things (iiot), and they are supposed to play a key role in industry v4.0. cps enables smart applications and services to operate accurately and in real-time. they are based on the integration of cyber and physical systems, which exchange various types of data and sensitive information in a real-time manner [1] . the development of cps is being carried out by researchers and manufacturers alike [2] . given that cps and industry v4.0 offer a significant economic potential [3] , the german gross value will be boosted by a cumulative of 267 billion euros by 2025 upon the introduction of cps into industry v4.0 [4] . a cps is identified as a network of embedded systems that interact with physical input and output. in other words, cps consists of the combination of various interconnected systems with the ability to monitor and manipulate real iotrelated objects and processes. cps includes three main central components: sensors, aggregators and actuators. moreover, cps systems can sense the surrounding environment, with the ability to adapt and control the physical world [5] . this is mainly attributed to their flexibility and capability to change the run-time of system(s) process(es) through the use of realtime computing [6] . in fact, cps systems are being used in multiple domains (see fig. 1 ), and embedded in different systems such as power transmission systems, communication systems, agricultural/ecological systems, military systems [7] , [8] , and autonomous systems (drones, robotics, autonomous cars, etc.) [9] , [10] . that, in addition to medical care domains to enhance the medical services [11] . moreover, cps can be used in supply chain management to enable echo-friendly, transient, cost efficient, and safe manufacturing process. despite their numerous advantages, cps systems are prone to various cyber and/or physical security threats, attacks and challenges. this is due to their heterogeneous nature, their reliance on private and sensitive data, and their large scale deployment. as such, intentional or accidental exposures of these systems can result into catastrophic effects, which makes it critical to put in place robust security measures. however, this could lead to unacceptable network overhead, especially in terms of latency. also, zero-day vulnerabilities should be minimized with constant software, applications and operating system updates. recently, several research works addressed the different security aspects of cps: the different cps security goals were listed and discussed in [12] , [13] , [14] , [15] ; maintaining cps security was presented in [16] ; cps security challenges and issues were presented in [17] , [18] ; some of the security issues were reviewed, including big data security [19] , [20] , iot storage issues [21] , and operating system vulnerabilities [22] ; several security and privacy solutions using cryptographic algorithms and protocols were discussed in [23] , [24] . however, none of the existing works presented a comprehensive view of cps security in terms of threats, vulnerabilities, and attacks based on the targeted domain (cyber, physical, or hybrid). hence, this paper presents a detailed overview of the existing cyber, physical and hybrid attacks, and their security solutions including cryptographic and non-cryptographic ones. • cyber-physical attacks are presented in relation to the targeted cyber and/or physical system/device, and the corresponding vulnerabilities of each such domain. • risk assessment: a qualitative risk assessment method is presented to evaluate the risk and exposure levels for each cps system, while proposing suitable security countermeasures. • security measures and their limitations are discussed and analyzed, including recent cryptographic and noncryptographic solutions. • forensics solutions are also presented and discussed about securely extracting evidence and thus, to improve forensics investigations. • lessons: various lessons are learnt throughout this survey including how to protect real-time data/information communication among resource-constrained cps devices, and how to achieve protection of cps security goals such as confidentiality, integrity, availability and authentication. • suggestions & recommendations are presented about how to mitigate and overcome various cyber, physical and hybrid threats, vulnerabilities, attacks, challenges and issues for a safe cps environment. aside from the introduction, this paper is divided into six main sections as follows. section ii presents some background about cps including their layers, components, and models. section iii discusses and details the key cps threats, attacks and vulnerabilities in addition to listing and describing several real-case cps attacks, and the main persistent challenges and issues. section v assesses and evaluates the risks associated with cps security attacks, especially in a qualitative risk assessment manner. section v presents and analyzes the main cps security solutions including cryptographic, noncryptographic, and forensics ones. section vi highlights the lessons learnt throughout this study. section vii provides key suggestions and recommendations for a safe and secure cps environment. section viii concludes the presented work. in this section, we present the cps architecture, its main layers and components, as well as the main cps models. the architecture of cps systems consists of different layers and components, which rely on different communication protocols and technologies to communicate among each other across the different layers. 1) cps layers: the cps architecture consists of three main layers, the perception layer, transmission layer, and application layer, which are presented and described in fig. 2 . the analysis of the security issues at the various cps layers is based on the work in [25] . • perception layer: it is also known as either the recognition or the sensing layer [26] . it includes equipment such as sensors, actuators, aggregators, radio-frequency identification (rfid) tags, global positioning systems (gps) along with various other devices. these devices collect real-time data in order to monitor, track and interpret the physical world [27] . examples of such collected data include electrical consumption, heat, location, chemistry, and biology, in addition to sound and light signals [28] , depending on the sensors' type [29] . these sensors generate real-time data within wide and local network domains, before being aggregated and analyzed by the application layer. moreover, securing actuators depends on authorized sources to ensure that both feedback and control commands are error-free and protected [30] . generally, increasing the security level requires an endto-end encryption scheme at each layer [31] . therefore, heavyweight computations and large memory requirements would be introduced [32] . in this context, there is a need for the design of efficient and lightweight security protocols, which take into consideration the devices capabilities and the security requirements. • transmission layer: it is also known as the transport layer or network layer, and it is the second cps layer [29] . this layer interchanges and processes data between the perception and application layers. data transmission and interaction is achieved through the internet for this purpose, various protocols are used to address the increase in the number of internet-connected devices, such as the internet protocol version 6 (ipv6) [33] . this layer also ensures data routing and transmission using cloud computing platforms, routing devices, switching and internet gateways, firewalls and intrusion detection/prevention systems (ids/ips) [34] , [35] . before outsourcing data contents, it is essential to secure their transmission to prevent intrusions and malicious attacks including malware, malicious code injection [36] , denial of service/distributed denial of service (dos/ddos), eavesdropping, and unauthorised access attacks [37] . this introduces a challenge, especially for resource-constrained devices due to the imposed overhead in terms of the required processing and power resources [38] . • application layer: it is the third and most interactive layer. it processes the received information from the data transmission layer and issues commands, which are executed by the physical units including sensors and actuators [39] . this is done by implementing complex decision-making algorithms based on the aggregated data [40] . moreover, this layer receives and processes information from the perception layer before determining the rightly invoked automated actions [29] . in fact, cloud computing, middleware, and data mining algorithms are used to manage the data at this layer [41] . protecting and preserving privacy requires protecting private data from being leaked. the most known protective approaches include anonymization, data masking (camouflage) [42] , [43] , privacy-preserving, and secret sharing [31] . moreover, this layer also requires a strong multi-factor authentication process to prevent unauthorised access and escalation of privilege [44] . due to the increase in the number of internet-connected devices, the size of the generated data has become a significant issue [21] . therefore, securing big data calls for efficient protection techniques to process huge amounts of data in a timely and efficient manner [45] . 2) cps components: cps components are used for sensing information [5] , or for controlling signals (fig. 3) . in this regard, cps components are classified into two main categories: sensing components (sc) that collect and sense information, and controlling components (cc) that monitor and control signals. • sensing components: are primarily located at the perception layer and consist of sensors that collect data/information and forward them to aggregators. then, this data/information is sent to the actuators for further analysis to ensure accurate decision making. in the following, we list the main cps sensing components. -sensors: collect and record real-world data following a correlation process named "calibration", to assess the correctness of the collected data [46] . sensing data is essential since the decisions that will be made are based on the analysis of this data. -aggregators: are primarily located at the transmission layer (i.e routers, switches and gateways) to process the received data/information from sensors, before issuing the corresponding decision(s). in fact, data aggregation is based on the collected information about a specific target, where this information is gathered and summarized following a statistical analysis. online analytical processing (olap) is a prime data aggregation type used as an online reporting mechanism for processing information [46] . -actuators: are located at the application layer to make the information visible to the surrounding environment based on the decisions made by the aggregators. since actuators highly depend on other network nodes, then each action performed by the cps relies on an earlier data aggregation sequence [5] . also in terms of operations, actuators process electrical signals as input and generate physical actions as output [46] . • controlling components: are used to control signals and they play a key role in signal control, monitoring and management to achieve higher levels of accuracy and protection against malicious attacks or accidents, mainly signal jamming, noise and interference. as a result, the reliance on programmable logic controllers (plcs) and distributed control system (dcss) along with their components (i.e programmable automation controller (pac) [47] , operational technology/information tech-nology (ot/it) [48] , control loop/server [49] , and human-machine interface (hmi)/graphical user interface (gui) [50] ) has become highly essential. next, we list the different types of control systems that are used in cps systems: • programmable logic controllers (plc): were initially developed to replace hard-wired relays, and are considered as industrial digital computers that control the manufacturing processes such as robotic devices performance and/or fault diagnosis processing; hence achieving better flexibility and resiliency. • distributed control systems (dcs): are computerized control systems that allow the autonomous controllers' distribution throughout the system using a central operator supervisory control. as a result of the remote monitoring and supervision process, the dcs's reliability is increased, whilst its installation cost is reduced. in some cases, dcs can be similar to supervisory control and data acquisition (scada) systems. • remote terminal units (rtu): or "remote telemetry unit" [51] , are electronic devices controlled by a microprocessor such as the master terminal unit (mtu) [52] . unlike the plc, they do not support any control loop nor control algorithm(s). thus, making them more suitable for wireless communications over wider geographical telemetry areas. rtu's main task is to interface scada to the physical object(s) using a supervisory messaging system that controls these objects through the system's transmission of telemetry data. in fact, both rtus and plcs use a small computerized "artificial brain" (central processing unit (cpu)) to process inputs and outputs from sensing devices and pumping equip-ment [53] ; hence using ieds (intelligent electronic devices) to transmit data flow or trigger an alarm in case of any intrusion. table i presents a comparison of the common points and differences between plcs and rtus. concerning the relation between components and layers, it can be seen that sensing components are mainly deployed at the perception and transmission layers, while the controlling components are deployed at the application layer. cps models can be divided into three main types: • timed actor cps: this model focuses on the functional aspects based on behaviour and correctness, along with the non-functional aspects that are based on performance and timing. a theory was introduced in [54] with a functional and classical refinement that restricts certain behaviour set, improving efficiency while reducing complexity. the main focus is on the refinement based on the "earlier-the-better" principle since it offers the ability to identify deterministic abstractions of non-deterministic systems [55] . in fact, these time-deterministic models are less prone to state explosion problems, with the ability to derive analytical bounds easier [56] . • event-based cps: in such models, an event must be sensed and detected by the proper cps components, before the actuation decisions are made. however, individual component timing constraints vary depending on the non-deterministic system delay, which is caused by the different cps actions including sensing, actuating, communication and computing [57] . in [58] , hu et al. stated that time constraints can be handled through the use of an event-based approach, which uses cps events to ensure the system's communication, computation, and control processes. this allows the cps to be more suitable and more useful for spatio-temporal information. • lattice-based event model in [59] , the cps events are represented according to the event type, along with the internal and external event attributes. if these events are combined, they can be used to define a spatio-temporal property of any given event, while also identifying all the components that were observing the event. • hybrid-based cps model hybrid cps systems are heterogeneous systems that are made up of two distinct interactive system types, continuous state (physical dynamic systems) and discrete-state (discrete computing systems) [60] , [61] . both development and evolution depend on the response of discrete transient events represented by finite state machines, and the the dynamic behaviour represented by differential/difference equation(s) [62] . unlike other cps models, hybrid cps is interconnected via a network, which makes it prone to delays. moreover, hybrid cps systems do not support any hierarchical modeling, and are not suitable for modeling concurrent systems. hence, hybrid systems modeling challenges caused by cps were discussed by benveniste et al. in [63] . in fact, cps system network latency issues were addressed and solved by kumar et al. using a real-time hybrid authentication method [64] , while a configurable real-time hybrid structural testing for cps was presented by tidwell et al. in [65] . finally, an event driven monitoring of cps based on hybrid automata was presented by jianhui in [66] . in a similar manner to most networking systems, security services were not incorporated into cps systems by design, leaving the door open for various vulnerabilities and threats to be leveraged by attackers to launch security attacks. this is also due to the heterogeneous nature of cps devices since they operate in different iot domains and communicate using different technologies and protocols. cps security threats can be classified as cyber or physical threats, as explained below, and if combined, these can result into cyber-physical threats. 1) cyber threats: the main attention on industrial iot security was highly focused on cyber threats rather than physical threats for many reasons, as cited in [18] . this includes the electrical grid evolution into an advanced metering infrastructure (ami), which resulted into the rise of newly unknown cyber threats aside from scada vulnerabilities [67] , [68] , [69] . electronic attacks are now easier to launch from any device, unlike physical attacks that require physical presence and physical tools. moreover, the smart meter interfacing and interconnection with other meters in the near-me area network (nan) and home area network (han) increase its exposure to various remote threats. finally, electronic attacks are difficult to mitigate and overcome in the absence of the right prevention and defensive countermeasures. for further details on cyber threat intelligence, a brief survey of cps security approaches was presented in [14] . for further information about cyber security threats, more details can be found in [70] , [71] . since cyber security is not limited to a single aspect, it can be considered from different perspectives, such as: • centring information: which requires protecting the data flow during the storage phase, transmission phase, and even the processing phase. • oriented function: which requires integrating the cyberphysical components in the overall cps. • oriented threat: which impacts data confidentiality, integrity, availability, and accountability [70] . the above issues make cps systems prone to: • wireless exploitation: it requires knowledge of the system's structure and thus, exploiting its wireless capabilities to gain remote access or control over a system or possibly disrupt the system's operations. this causes collision and/or loss of control [72] . • jamming: in this case, attackers usually aim at changing the device's state and the expected operations to cause sold with plc-like features digital computers designed for output arrangements and multiple inputs electronic device controlled by a microprocessor automates electro-mechanical processes interfaces scada physical objects physical media with process, relays, motion control and networking uses supervisory system messages to control objects does support control loops and algorithms does not support control loops and algorithms immune to electrical noise, resistant to vibration low to null immunity against electrical noise and vibration suitable for local geographical areas suitable for wider geographical telemetry areas mainly iec standards wired/wireless communications damage by launching waves of de-authentication or wireless jamming signals, which would result into denial of device and system services [73] . • reconnaissance: an example of such a threat is where intelligence agencies continuously perform operations targeting a nation's computational intelligence (ci) and industrial control system (ics) mainly through a malware spread [74] . this results in violating data confidentiality due to the limitation of traditional defenses [75] , [76] . • remote access: this is mainly done by trying to gain remote access to the cps infrastructure, for example, causing disturbances, financial losses, blackouts, as well as industrial data theft and industrial espionage [77] . moreover, havex trojans are among the most dangerous malware against icss, as they can be weaponized and used as part of cyber-warfare campaign management against a nation's cps [78] . • disclosure of information: hackers can disclose any private/personal information through the interception of communication traffic using wireless hacking tools [16] , violating both privacy and confidentiality [79] . • unauthorised access: attackers try to gain an unauthorized access through either a logical or physical network breach and to retrieve important data, leading to a privacy breach [80] . • interception: hackers can intercept private conversations through the exploitation of already existing or new vulnerabilities leading to another type of privacy and confidentiality breach [72] . • gps exploitation: hackers can track a device or even a car by exploiting (gps) navigation systems, resulting in a location privacy violation [81] , [72] . • information gathering: software manufacturers covertly gather files and audit logs stored on any given device in order to sell this huge amount of personal information for marketing and commercial purposes in an illegal manner. 2) physical threats: cps systems are recently evolving into the industrial domain by introducing an advanced metering infrastructure (ami), and neighbourhood area networks (nans), along with data meter management systems to maintain the robustness of cps in industrial domains [82] . in fact, physical threats might be classified according to the following three factors: are well protected. this is due to the fact that these stations are well-manned and well-guarded based on the implementation of access controls, authorisation and authentication mechanisms such as usernames and passwords, access cards, biometrics and video surveillance. however, the main concern is related to the less protected power-generating sub-stations since transmission lines are vulnerable to sabotage attacks and disruption. in fact, smart meters are also vulnerable to a number of threats as explained in [83] . to address this problem, smart meters must be tamper-resistant by relying on outage detection or even host-based intrusion detection. however, it is almost impossible to prevent physical tampering or theft by adversaries (such as advanced persistent threats (apts)), except that it is possible to mitigate the risk and reduce its impact. • loss: the most worrying scenario is having more than a single substation failure caused by a malicious attacker. in case of a severe damage in the smart grid, a total blackout of major metropolitan areas may occur for several hours [84] . a real-case scenario includes the cascading blackout that managed to hit the u.s. on august 14th, 2003 [85] , caused by the people liberation army (pla), which is a chinese politically-motivated group [86] . • repair: it can be based on a self-healing process [87] , which is based on the ability to either sense faults or disruptions, whilst isolating the problem and sending alerts to the corresponding control system to automatically reconfigure the back-up resources in order to continuously provide the necessary service. the aim is to ensure a fast recovery in as short of a time as possible. however, critical components do suffer from either a lack or a limited backup capability. therefore, self-healing can respond faster to a severe damage. some of the threats associated with cps systems include: • spoofing: it consists of masquerading the identity of a trusted entity by a malicious unknown source. in this case, attackers are capable of spoofing sensors, for example, by sending misleading and/or false measurements to the control center. • sabotage: sabotage consists of intercepting the legal communication traffic and redirecting it to malicious third party or disrupting the communication process. for example, attackers can sabotage physically exposed cps components across the power grid, to cause a service disruption or even denial of service that leads to either total or partial blackout. • service disruption or denial: attackers are capable of physically tampering with any device to disrupt a service or to change the configuration. this has serious effects, especially in the case of medical applications. • tracking: since devices are physically exposed, an attacker can gain access to a given device, and/or even attach a malicious device or track the legal ones. in the following, we present the main cps vulnerabilities that can be targeted by the above-mentioned threats. a vulnerability is identified as a security gap that can be exploited for industrial espionage purposes (reconnaissance or active attacks). hence, a vulnerability assessment includes the identification and analysis of the available cps weaknesses, while also identifying appropriate corrective and preventive actions to reduce, mitigate or even eliminate any vulnerability [88] . in fact, cps vulnerabilities are divided into three main categories: • network vulnerabilities: include weaknesses of the protective security measures, in addition to compromising open wired/wireless communication and connections, including man-in-the-middle, eavesdropping, replay, sniffing, spoofing and communication-stack (network/transport/application layer) [89] , back-doors [90] , dos/ddos and packet manipulation attacks [91] . • platform vulnerabilities: include hardware, software, configuration, and database vulnerabilities [36] . • management vulnerabilities: include lack of security guidelines, procedures and policies. vulnerabilities occur due to many reasons. however, there are three main causes of vulnerabilities: • assumption and isolation: it is based on the "security by obscurity" trend in most cps designs. therefore, the focus here is to design a reliable and safe system, taking into consideration the implementation of necessary security services, without assuming that systems are isolated from the outside world. • heterogeneity: cps systems include heterogeneous third party components which are integrated to build cps applications. this has resulted in cps becoming a multivendor system, where each product is prone to different security problems [93] . • usb usage: this is a main cause of cps vulnerabilities, such as the case of the stuxnet attack that targeted iranian power plants, since the malware is inside the usb. upon plugging it, the malware spread across several devices through exploitation and replication. • bad practice: is primarily related to a bad coding/weak skills that lead to the code to execute infinite loops, or to become too easy to be modified by a given attacker. • spying: cps systems are also prone to spying/surveillance attacks, mainly by using spyware (malware) types that gain a stealthy access and remain undetected for years with the main task to eavesdrop, steal and gather sensitive/confidential data and information. • homogeneity: similar cyber-physical system types suffer from the same vulnerabilities, which once exploited, can affect all the devices within their vicinity, a prime example is the stuxnet worm attack on iranian nuclear power plants [94] . • suspicious employees: can intentionally or inadvertently damage or harm cps devices, by sabotaging and modifying the coding language, or granting remote access to hackers through the opening of closed ports or plugging in an infected usb/device. thus, cps vulnerabilities can be of three types, including cyber, physical, and when combined, they result into a cyberphysical threat. 1) cyber vulnerabilities: since ics heavily relies on open standard protocols including inter-control center communications protocol (iccp) [95] and transmission control protocol/internet protocol (tcp/ip) [96] , ics applications are prone to security attacks. in fact, iccp suffers from a critical buffer overflow vulnerability [89] and also lacks the basic security measures [97] . in fact, the remote procedure call (rpc) protocol [98] and icss are prone to various vulnerabilities including the stuxnet (1 & 2) [99] , [100] , [101] and duqu malware (1.0, 1.5 & 2.0) attack types [102] , [103] , [104] , gauss malware [105] , [106] , [102] , and red october malware [107] , [108] , as well as shamoon malware (1, 2 & 3) [109] , [110] , [111] , mahdi malware [112] , [113] , [114] , and slammer worm [115] . open/non-secure wired/wireless communications such as ethernet are vulnerable to interception, sniffing, eavesdropping, wiretapping and wardialing and wardriving attacks [116] , [117] , [118] and meet-in-the-middle attacks [119] . short-range wireless communications are also vulnerable, since they can be captured, analysed, damaged, deleted or even manipulated by insiders [120] . moreover, employees' connected devices to ics wireless network, if not secure, are prone to botnet, remote access trojan and rootkit attacks, where their devices will be remotely controlled by an attacker [121] . long-range wireless communications are vulnerable to eavesdropping, replay attacks, and unauthorized access attacks. yet, sql injection remains the most web-related vulnerability since attackers can access any server database without authorization through the injection of a malicious code that keeps on running endlessly once executed without the user's knowledge [122] . since many medical devices heavily rely on wireless communications, they are prone to a large number of wireless attacks including jamming, modification and replay attacks due to the lack of encryption. moreover, gps and the device's microphone are now becoming a tracking tool, allowing the identification of the target's location, or intercepting the in-car conversations through eavesdropping [13] . by default, ics relies on modbus and dnp3 protocols to monitor and send control commands to sensors and actuators. in [16] , humayed et al. stated that the modbus protocol lacks basic security measures such as encryption, authentication and authorization. this has made it prone to eavesdropping, wiretapping, and port-scan [123] , with the risk of the controller being spoofed through false data injection [124] . the dnp3 protocol is also prone to the same vulnerabilities and attacks, with one main difference which is the integration of cyclic redundancy check (crc) as an integrity measure [125] . moreover, windows server services were vulnerable to remote code execution [99] , with more attacks being achieved through the exploitation of buffer overflow vulnerabilities in any running operating system (os). moreover, power system infrastructure of smart grids is prone to the same vulnerabilities as ics, modbus and dnp3, since they are based on the same protocols. as a result, iec 61850 protocol was introduced in substations' communications, which lack security properties and are prone to eavesdropping attacks. therefore, leading to interference attacks [126] , or false information injection attacks [127] . in [128] , santamarta et al. analysed the available documentation of smart meters, and located a "factory login" account used to perform basic configurations. this gives the user full control over a smart meter and leads to power disruption, wrong decision making and targeting neighbouring smart meters within the same network. in addition, many devices are prone to battery exhausting attacks [73] . gollakota et al. [129] and halperin et al. [130] exploited the implantable cardioverter defibrillator (icd) wireless vulnerabilities through injection attacks. the authors also showed that smart cars are vulnerable to various attack types. in [131] , radcliffe, revealed another vulnerability with continuous glucose monitoring (cgm) devices being vulnerable to replay attacks. the cgm device was spoofed with the injection of incorrect values. this is due to the fact that security considerations were not made when the smart cars were designed [132] . in fact, the controller area network (can) protocol suffers from many vulnerabilities, which if exploited could result in attacks against smart cars. this will increase the likelihood of a dos attack [133] . a tire-pressure monitoring system (tpms) is also vulnerable to eavesdropping and spoofing due to the lack of encryption [134] . in addition, adaptive cruise control (acc), which forms a part of the can network can be directly exploited [13] . in fact, a well-equipped attacker is able to interrupt acc sensors' operations by adding noise or spoofing. thus, controlling the car by either reducing, increasing its speed or even causing collisions. 2) physical vulnerabilities: physical tampering may result into misleading data in cyber-physical components. in fact, physical attacks with cyber impact were studied in [135] . the physical exposure of ics components is classified as a vulnerability due to the insufficient physical security provided to these components. thus, making them prone to physical tampering, alteration, modification or even sabotage. cps field devices (i.e smart grids, power grids, supply chains etc.) are prone to the same ics vulnerabilities since a large number of physical components is exposed without physical security, making them prone to physical destruction. therefore, in [136] , mo et al. stressed on detection and prevention solutions. in [16] , humayed et al. stated that medical devices are vulnerable to physical access along with the possibility of installing malware into them, or even modifying the device's configurations, risking the patient's health. moreover, a physical access to any medical device is also a vulnerability since an attacker can retrieve the device's serial number to launch targeted attacks [131] . as listed above, cps systems suffer from various vulnerabilities making them prone to different types of attacks, which are discussed next. in this section, we present the different types of attacks that target the different aspects of cps systems, including cyber and physical ones: 1) physical attacks: physical attacks were more active in past years, especially against industrial cps systems [137] , [138] . many of these attacks were already presented in [139] . nonetheless, this paper presents a broader range of physical attack types: • infected items: this includes infected cds, usbs, devices and drives such as the case of the stuxnet worm [140] , which upon their insertion into a cyberphysical device, a covert malware is installed containing a malicious software. • abuse of privilege: this attack occurs when rogue or unsatisfied employees access the server rooms and installation areas within the cps domain. this allows them to insert a rogue usb for infection through the installation of malicious malware/code or as keystroke, or to capture confidential data. • wire cuts/taps/dialing: since communication lines including telephony and wi-fi of many cyber-physical headquarters (hqs) are still physically visible, attackers can cut the wires or wiretap into them to intercept the communicated data [117] . • fake identity: this attack occurs when attackers masquerade themselves as legitimate employees, with enough experience to fool the others. they mainly act as cleaners to gain an easier access and better interaction with other employees. a prime example of that is australia's maroochy water breach in 2000 [141] . • stalkers: these are usually legal employees who act curious (with malicious intents) by being on the shoulder of cps administrators and engineers to acquire their credentials to blackmail or sell them to other competing cps organisations. • cctv camera interception: this includes intercepting the footage of closed-circuit television cameras that are securing entry and key points within cps areas. this can be done by distorting the signals of cameras, cutting off the communication wires, deleting the footage, gaining access to the remote control and monitoring area, etc., before performing a physical attack in an undetected manner. • key-card hijacking: this includes cloning legitimate cards that are stolen from employees, or creating lookalike genuine copies to gain full/partial access and to compromise the cps domain. • physical breach: this attack requires gaining an illegal physical access to the system, mainly through a physical breach such as the case of the springfield pumping station in 2011 [142] , a backdoor such as the case of us georgia water treatment plant in 2013 [143] , or an exploited security gap such as the case of the canadian telvent company in 2012 [144] . this allows an attacker to damage and shut-down network-connected manufacturing systems and cps devices, resulting into loss of availability and productivity. • malicious third party software provider: the main purpose of this attack is to target the company's cps by compromising the legitimate "industrial control systems" software, such as the case of the georgia nuclear power plant shutdown in 2008 [145] . this includes replacing legitimate files in their repositories with a malware that will be installed to offer remote access functionalities to control or compromise a given system. • abuse of privilege: is mainly led by insiders or "whistleblowers" to perform or help perform a (cyber)-attack from within. such high privilege grants them the ability to conduct these attacks by exposing valuable knowledge on cps systems' vulnerabilities and weaknesses. this abuse of privilege can take many forms. -physical tampering: including gaining unauthorised or masqueraded authorised access to restricted areas to damage cps systems, devices, modify their operational mode, inject malicious data/information or steal confidential documents. -unauthorised activities: are based on performing suspicious tasks, such as opening/closing pumping stations, increasing/decreasing power voltage, opening closed ports, communicating with an external entity, network traffic redirection or information leakage. • social engineering: can take many deceptive forms [91] such as reverse engineering (impersonating a techysavvy), baiting (selling malicious usbs or software), tailgating (following authorised personnel) or quid pro quo (impersonating technical support teams), and is based on the art of manipulating people (either mentally or emotionally) to reveal confidential information by manipulating their emotions to gain their trust to reveal sensitive information related to a cps, plc or ics system. recently, cps systems became the new target of hackers for espionage, sabotage, warfare, terrorism, and service theft [146] , mainly as part of cyber-warfare [147] , cybercrimes [148] , [149] , (cyber)-terrorism [150] , [151] , [152] , (cyber)-sabotage [153] (such as cyber-attacks against estonia in 2007 [154] , and georgia in 2008 [155] ), or (cyber)espionage [156] , [157] . the lack of (cyber)-security revealed a serious issue with possibly drastic effects [12] , especially in countries like lebanon [158] , [159] . 2) cyber attacks: in recent years, there was a rise in the rate of cyber-attacks targeting cps and iocpt with very devastating consequences. according to current studies carried out by [160] , [161] , cps is highly prone to malicious code injection attacks [162] and code-reuse attacks [163] , along with fake data injection attacks [164] , zero-control data attacks [165] , and finally control-flow attestation (c-flat) attacks [160] . such attacks can result into a total blackout targeting cps industrial devices and systems as presented in table ii. • eavesdropping: eavesdropping includes the interception of non-secure cps network traffic to obtain sensitive information (passwords, usernames, or any other cps information). eavesdropping can take two main forms:passive by listening to cps network message transmission, and active by probing, scanning or tampering the message by claiming to be a legitimate source. • cross-site scripting: or xss occurs when third-party web resources are used to run malicious scripts in the targeted victim's web browser (mainly a targeted cps engineer, contractor, workers, etc. ) by injecting malicious coding script into a website's database. xss can achieve session hijacking, and in some cases, can log key strokes along and remotely accesses a victim's machine. • sql injection: or sqli targets cps database-driven websites to read and/or modify sensitive data, along possibly executing administrative operations such as database shutdown, especially when cps systems are still relying on sql for data management [166] . • password cracking: aim to target the authenticity of cps users [167] , [168] (mainly engineers and managers) by trying to crack their passwords using bruteforce [169] , dictionary [170] (mitigated by using key exchange [171] ), rainbow table [172] , birthday (mitigated by hashing) [173] or online/offline password guessing attacks [174] to gain access to the password database, or to the incoming/outgoing network traffic. therefore, it is important to prevent such escalation from taking place [175] , [176] . • phishing: has many types such as e-mail phishing, vishing, spear phishing or whaling that target some or all cps users (such as engineers, specialists, businessmen, chief executive officers (ceos), chief operations officers (coo), or/and chief financial officers (cfo)), through impersonation of business colleagues or service providers. • replay: includes intercepting transmitted/received packets between icss, rtus, and plcs through impersonation to cause delays that affect cps's real-time operations and affect their availability. in some cases, these intercepted packets can be modified, which would seriously hinder normal operations. • dos/ddos: dos attacks target the cyber-physical system resources and are launched from a large number of locally infected devices. ddos attacks are usually exploited by botnets, whereby a large number of infected devices simultaneously launch a ddos attack from different geo-graphical locations. dos attacks can take many forms (i.e blackhole [177] , teardrop [178] ), while ddos can take the following forms (i.e ping-of-death [179] , smurf [180] and black energy series (be-1, be-2 and be-3 [181] , [182] , [183] ), all targeting cps systems. -tcp syn flood: exploits the tcp handshake process by constantly sending requests without responding back to the server, causing the server to constantly allocate space awaiting a reply [184] . this leads to a buffer overflow and causes the cyberphysical system to crash. • malicious third party: includes software that covertly exploit data aggregation network and compromises them, mainly using botnets, trojans or worms to infiltrate information through a cps encrypted channel from an internal system (i.e plc, ics or rtu) through the reliance on trusted third party in disguise, to a botnet commandand-control server. thus, targeting cpss [185] and amis [186] . • watering-hole attack: the attacker scans for any cyberphysical security weakness. once a weakness is identified, the chosen cps website will be manipulated by a "watering hole", where a malware will delivered by exploiting the targeted cps system mainly through backdoor, rootkits or zero-day exploit [187] . • malware: is used to compromise cps devices in order to steal/leak data, harm devices or bypass access control systems. the malware can take many forms, however, the main forms that target cps are briefly listed and presented in the following. -botnets: this includes exploiting cps devices vulnerabilities to turn them into bots or zombies, mainly to conduct hardly-traceable ddos attacks (i.e ramnit (2015) [188] , mirai (2016) [189] , smominru botnet (2017) [188] , mootbot (2020) [190] , wild-pressure and victorygate (2020).) -trojan: is a disguised malware that seems legitimate and tricks users to download it. upon download, the trojan infects the device and offers a remote access to steal data credentials and monitor users activities. this also includes remote access trojans which in turn, can be used to turn a device into a bot (i.e turla (2008) [191] , minipanzer/megapanzer (2009) [192] , gh0st rat (2009) [193] , shylock (2011) [194] , coreflood (2011) [195] , darkcornet (2012) [196] , memz (2016) [197] , tinybanker (2016) [198] and banking.br android botnet (2020)). -virus: it can replicate and spread to other devices through human/non-human intervention. viruses spread by attaching themselves to other executable codes and programs to harm cps devices and steal information. -worms: spread by exploiting operating system vulnerabilities to harm host networks by carrying payloads to steal, modify and delete data, or overload to web-servers (aside stuxnet, flame and duqu, i.e acode red/code red ii (2001) [199] , nimda (2001) [200] , triton (2017 [201] )). -rootkit: is designed to remotely and covertly access or control a computer to execute files, access/steal information or modify system configurations (i.e moonlight maze (1999) [202] , and blackhole exploit kit (2012) [203] ). -polymorphic malware: constantly and frequently changes its identifiable to evade being detected to become unrecognizable against any pattern-matching detection technique. -spyware: is a malicious software covertly installed on a device without the user or authorization knowledge, for spying purposes (e.g surveillance, reconnaissance, or scanning). in fact, they can be used for future cyber-attack purposes (i.e projectsauron (2011) [204] , dark caracal (2012) [205] , red october (2013) [107] , warriorpride (2014) [206] , fin-fisher (2014) [207] , and covid-19 spyware.) -ransomware: is a malicious software that holds and encrypts cps data as a ransom by exploiting cps vulnerabilities, targeting oil refineries, power grids [208] , manufacturing facilities, medical centers and encrypting all data-backups until a ransom has been paid. a prime example of that is the siskey (2016) (2019) and ekans (2020) ransomware [211] , [212] , [213] , [214] . • side-channel: is based on the information gained from the implemented cps system such as timing information, power consumption and electromagnetic leaks that can be exploited. for this reason, some of the most infamous cyber-attacks deserve being mentioned (table ii) . moreover, for further details, you can refer to [139] . in fact, do et al. presented a much more detailed attack description as early as 1980s in [142] . however, this paper aims to classify the occurrence of these attacks as early as 2000 and based on, but not limited to, political, religious, and criminal motives. after reviewing the main cps attacks, it is essential to assess their associated risks to design the convenient countermeasures. in the next section, the risks associated with the different cps security attacks are evaluated. given the different threats, attacks and vulnerabilities that the cps domain suffers from, it is important to highlight the main failures than cps systems suffer from. these failures can either be minor (limited damage) or major (severe damage). in fact, further details can be found in [222] , where avizienis et al. presented a well-defined and detailed explanation in this regards. • content failure: means that the content of the delivered information is inaccurate, which would result into some functional system failure. content failure can be either numerical or non-numerical (i.e alphabets, graphics, sounds or colours). • timing failure: means that the timing of information delivery (transmission/receiving) is delayed or interrupted (received/transmitted too early or too late). this would affect the decision making process and may cause data management issues. • sensors failure: means that the sensors are no longer functioning properly, and would seriously hinder the decision making process due to misinformation, or bringing a cps system to a sudden halt. a similar case occurred in 2005, at taum sauk hydroelectric power station [216] . • silent failure: occurs when there is no message sent or received in a distributed system. • babbling failure: occurs when the information is delivered, causing the system to malfunction and to operate in a babbling manner. • budget failure: occurs when the cost of implementing a cyber-physical system outweighs the budget set, before ever reaching the testing level. this is mainly caused by poor planning. • schedule failure: occurs when the schedule set for planning, testing and evaluating a given cps is not achieved due to further upgrades, additional testing, or inadequacy for users needs. • service failure: occurs when having an error propagates through the service interface and affects its decision making or/and normal performance ability. this failure can either cause a partial or full cps system failure either temporarily or permanently. • consistent/inconsistent failures: a consistent failure occurs when a given service is identically perceived by all cps users. an inconsistent failure takes place when all cps users differently perceive an incorrect service (i.e bohrbugs, mandelbugs, heisenbugs and byzantine failures) [223] . evaluating risks is essential to assess the risk's economic impact of an attack on any cps system, before managing it. such management is based on assessing and analysing the risk before mitigating it, then deploying the right security measures according to the level of severity and risk impact (see fig. 4 ). risk management is implemented in order to identify, analyse, rank, evaluate, plan and monitor any possible risk through risk assessment. • identifying risks: identification is based on uncovering and recognising risks that can negatively affect a project/project outcome and describing it [224] . • analysing risks: risks likelihood and consequence must be determined once they are identified, to understand the nature of a risk. • ranking risks: risks rank is evaluated according to the risk magnitude, based on the combination of both risk likelihood and consequence in case it occurred. • evaluating risks: based on their ranks, risks are either deemed as acceptable or require serious treatment and urgent attention. • planning risks response: highest ranked risks are assessed to treat, modify and mitigate them to once again achieve an acceptable risk level. therefore, risk mitigation strategies are created, along with the deployment of preventive and contingency plans. • monitoring and reviewing risks: risks are constantly monitored, tracked and reviewed. in case of any suspicious activity, these risks are mitigated before any serious threat occurs. risk assessment is implemented to minimize the impact of a given attack [225] . in fact, risks are evaluated based on calculating the average loss in each occurring event [226] . additionally, several risk assessment methods, as well as various techniques to secure cps were revealed in [25] . in fact, since most studies are focused on securing enterprise systems in order to assess risks, security became an emerging issue that imposes a serious risk on cps [227] . as a result in [228] , [229] , lu et al. presented an adequate risk assessment method. the main security focus was based on transferring it from risk assessment, to computer risk assessment (cra), to network risk assessment (nra) with a heavy reliance on the internet [230] . asset identification: is also important, since it is a resource value that can either be tangible, or intangible that impacts daily transactions and services [231] . in fact, cps assets can be divided between cyber assets, physical assets, and cyber-physical assets. finally, since asset quantization is estimated from both direct and indirect economic losses [232] , it is important to determine the asset value (av). risk is assessed based on its possible impact on cps systems. it is divided into three main types: • high impact: in case the risk has occurred, this can result in devastating and damaging effects on cps systems. it is used to evaluate and mitigate persistent advanced threats [233] . • medium impact: in case of its occurrence, the impact is less severe. however, it also imposes a serious threat against cps. it is used to evaluate and mitigate advanced threats [234] . • low impact: in case this risk has occurred, its impact is not severe, nor has damaging effects. as a result, its impact is very limited and can be easily mitigated. it is used to evaluate and mitigate basic threats [235] . risk mitigation requires the adaptation and implementation of a well-built management strategy in addition to cyber and physical security in order to counter-espionage, theft, or/and terrorist attacks. such a mitigation model also requires, data security and protection, as well as anti-counterfeit and supply chain risk management [236] . these models should also be supported by both forensic and recovery plans. this can help in analyzing cyber-attacks whilst coordinating and cooperating with the responsible agencies to identify external cyber-attack vectors [237] . therefore, preventive, detective, repressive and corrective logical security measures can be adopted. as a result, a qualitative risk assessment table is presented (see table iii the cost of security attacks can take many forms, and the main ones are highlighted as follows: • delays: cps systems may be prone to service delays, which may affect their performance and render them inactive (blackout, burnout) until the issue is sorted either through maintenance or back up. • affected performance: system delays due to a malicious (cyber-attack)/non-malicious (accident) event can gradually affect the cps performance and cause it to operate in an abnormal manner which can seriously affect the decision making process. • additional spending: may be required to tackle the advanced persistent threat attempts and zero-day attacks, which require additional spending in terms of security protection in a defense-in-depth manner. • loss of life: can be the result of flooding, radioactivity, fire or electric shock due to hazardous or intentional acts. • disclosure of information: can affect cps businesses and business trades and put the privacy of users at risk of having their personal information being exposed. before proceeding any further, it is important to classify cps components as critical, moderate and non-critical, to identify the risk of an event occurrence (malicious/hazard) along its impact to define the proper security measures (basic, standard or advanced), as seen in fig. 5 . while adopting all possible security measures might be costly in all terms (i.e. complexity, financial cost, delay, etc.), risk management is key for selecting the convenient security solutions. in the next section, the different security solutions proposed to defend the security issues are reviewed. while these security solutions aim at preventing, detecting or correcting system damage, the cps forensics aim at knowing the system issues causes, which help in reducing and preventing future attacks. thus, the main cps forensics solutions are also reviewed. securing cps is not a straightforward task. for this reason, various existing solutions are mentioned and discussed in this section. already existing testing tools are also introduced. all of these schemes are presented to protect cps domains against attacks that target the confidentiality, integrity, availability, authentication and privacy of both data and systems as seen in fig. 6 . according to national institute of standards and technology (nist) guidelines [243] , [244] , ensuring trust between iot and cps, should consist of various multi-factors. this is due to both iot and cps systems relying on safety, security, privacy, consistency, dependability, resiliency, reliability, interaction and coordination, all of which are combined to form a well-designed and trustworthy system. if this condition is satisfied, a perfect cps mechanism is achieved. as a result, several cps testing tools were used to evaluate the security of industrial control devices upon their development (see table iv) . for further details, these tools are explained in [245] . moreover, several security certifications are also discussed, reviewed, analysed and compared according to their different aspects [245] (see table v) . in the following, the main cps security requirements are defined and discussed. • privacy: in cps, a huge data collection process is constantly taking place, and this is what most people are not aware of [256] , [257] . therefore, a person has the right to access his own data, along with being given the right to know what type of data is being collected about them by data collectors, and to whom these data is being given or sold to. however, this also requires preventing the illegal/unauthorised access to the user's personal data and their information disclosure [258] , [259] . • dependability: intelligent physical world (ipw) ensures that the cps adaptive behaviour is achieved to bring a higher dependability and ensure the right quality of service (qos) through the adoption of fault-tolerance mechanisms in a timely manner. dependability includes two other qualities, safety and reliability. safety is often an objective defined in terms of the organisation's [243] . this is due to the negative impact of cybersecurity risks, where vulnerabilities can be compromised and exploited by a hacker, or due to cps failure. hence, safety is of a high concern for iot, cps and (internet of cyber-physical things) iocpt users alike. while reliability is based on the ability to adapt to changing conditions to overcome and recover from any possible disruption either based on cyber or/and physical attacks led by adversaries, in addition to natural disasters [243] . physical systems rely on timing and proper functionality. however, in case of any possible mismatch, unreliability and uncertainty can cause problems and disruptions for cps services. therefore, maintaining a high reliability requires reducing the uncertainty levels. in fact, it is also recommended to implement error-correction algorithms to sort electronic components imperfect reliability [260] . as a result, rajamaki et al. in [260] stated that cps behaviour can be predictable through the implementation and use of artificial intelligence or/and even machine learning (ml) schemes. this allows the prediction of the so called "next-time system state". • resiliency: cps must be resilient to overcome accidents and malicious attacks. therefore, cps logical and physical systems are prone to cyber security vulnerabilities from a security aspect. this included the demonstration of carshark software tools that control a car in [133] , along with the successful design of a virus in 2010 which attacked siemens plant-control systems [261] , along with how hackers broke into the united states federal aviation administration (us faa) air traffic control system in 2009 [262] . resiliency is achieved by each cps component in a base architecture (ba) presented in [263] , where each communication and physical connection path between elements is granted access by the ba's connectors. this requires the ba system to know and identify every possible path, while overcoming any connection disruption. moreover, in case the elements were inconsistent, a multi-view editor will be deployed to make corrections. • interaction and coordination: are essential to maintain an all-time operational cps security. in [58] , hu et al. stated that cps interaction and coordination between cyber and physical system elements are a key aspect. in fact, the main physical world characteristics are based on the constant system change over time. however, the cyber world characteristics are based on sequence series with no temporal semantics. moreover, two basic approaches are presented to study and analyse this problem. these approaches are based on the "cyberizing" the physical (ctp) aspect through the introduction of cyber-properties and interfaces into physical systems, and "physicalizing" the cyber (ptc) where cyber-software components are to be represented in real-time [264] . • operational security (opsec): operational security (opsec) was introduced in 1988 to ensure physical security, information security, and personnel security [265] through careful planning, risk assessment and risk management [266] . its primary task is to ensure operational effectiveness by denying any adversary access to public/private information; hence controlling information and observable actions about a given cyber-physical system, especially in hostile environments/areas [265] . one of its key benefits is providing means to develop cost-effective security measures to overcome a given threat. to achieve this task, opsec involves five main steps: -critical information identification: includes identifying which information, if targeted, can effectively degrade a cps's operational effectiveness or place its potential organizational success at risk, and develop an initial plan to protect it. -threat analysis: includes determining an adversary's potential and capabilities to gather, process, analyze, and use the needed information. -vulnerability analysis: includes studying the weaknesses of a given cyber-physical system and the strengths of an adversary. thus, building a possible view over how a potential adversary might exploit this security gap to perform a security breach. -risk assessment: risks are assessed based on the threat and vulnerability levels combined, depending on how high or how low these levels are. risk assessment levels include evaluating the cost of implementing the right security measures by ensuring a trade-off between the effective cost and benefit balance. -appropriate application countermeasures: once the trade-off is achieved in the earlier phase, the appropriate countermeasures are then developed to offer the best protection of cps against these ongoing threats in terms of feasibility, cost, and effectiveness. • system hardening: system hardening can be used to defend a wider range of threats. therefore, it is highly recommended to isolate critical applications that lack the proper security measures, from any os that is not trusted in order to boost the iocpt and cpt security. in [267] , shepherd et al. analysed different trustcomputing technologies along with their applications in the cps domain. according to [268] , such analysis included a trusted platform module (tpm), trusted execution environments (tee), secure elements (se), and encrypted execution environment (e3), to increase the os's integrity. moreover, the authors' work in [269] has successfully achieved a higher security level in the presence of untrustworthy components. this allowed the improvement of cps by enhancing system's integrity. however, if the graph-based optimization was combined with parameters, it can provide a reasoning basis to ensure an overall system integrity [270] . therefore, it is essential to set the right privileges (task-based, role-based, rulebased, etc..) and strong password complexity policies in order to enhance the security level. moreover, this also includes getting rid of old unused accounts and open yet unused ports to reduce the exposure to remote wireless attacks. as a result, cps nature must be considered before achieving any design. in [136] , mo et al. presented a cyber-physical security by combining systems-theoretic with cyber-physical security controls. the adoption of security measures has many benefits when it comes to protecting cps components, layers and domains. however, despite these advantages, cps systems are impacted by the application of these security measures, which can be summarized as follows: • reduced performance: security measures can partially or fully affect the performance of a given cps, in the absence of careful consideration for a balanced securityperformance trade-off. this can affect normal operations and requires more human interventions to manually assign services and domains. • higher power consumption: is a serious issue, especially for resource-constrained and battery-limited cps end devices. a higher power consumption means a shorter lifespan and a higher cost to maintain their availability. • transmission delays: transmitted/received data is prone to delays due to the additional encryption process that is being added to thwart passive/active eavesdropping and sniffing attacks. despite the protective advantage that is offers, this is unacceptable in a real-time cps systems. • higher cost: higher security levels are associated with higher computational costs, which are not limited to the initial capital spending phase, but also include training, update, and operational phases. • compatibility issues: some cps systems are not compatible with the employed security measures and vice versa. this can be due to the software in-use, firmware, operating system, etc. • operational security delays: upon the deployment of any security service, there is a training phase that precedes the full operational security mode, and during which the service is temporarily ineffective or basic and thus, prone to attacks. maintaining a secure cps environment is not an easy task due to the constant increase of challenges, integration issues and limitation of the existing solutions including the lack of security, privacy and accuracy. nonetheless, this can be mitigated through different means including cryptographic and non-cryptographic solutions as seen in fig. 7 . • safety critical: in such a cps type, an attack can lead to loss of life or to chronic deadly diseases, with significant damage to the environment such as fire, floods, radioactivity (e.g. chernobyl in 1986 and fukushima in 2011) incidents [271] , [272] . • mission critical: for this type of cps, an attack can result into a fatal/non-fatal, total/partial failure of a cps to achieve its objectives [273] . • business critical: in such a cps type, an attack can result into huge financial and economic losses, damaged reputation and loss of cps contractors and clients. • security critical: for this type of cps, an attack can result into a security breach of the cyber-physical system (security gap, exploitable vulnerability, rootkits, backdoors, etc.). cryptographic measures are mainly employed to secure the communication channel from active/passive attacks, along any unauthorized access and interception, especially in scada systems [274] . in fact, traditional cryptography approaches based on utilizing ciphers and hash function are not easily applied to cps including iocpt due to power and size constraints. as a result, the main focus should be limited to data security alone, instead it should maintain and ensure the efficiency of the overall system process along. therefore, various solutions were presented. in [23] kocabas et al. conducted their own survey which was dedicated to conventional and emerging encryption schemes which could be employed to offer secure data storage and sharing. in [24] , lai et al. reviewed and discussed prominent cryptographic authentication and encryption methods [275] to secure distributed energy resources (der) systems, while providing recommendations on applying cryptography to der systems. in [276] , ding et al. presented an overview of recent advances on security control and attack detection of industrial cps, especially against denial-of-service, replay, and deception attacks. in [15] , sklavos et al. presented a tutorial that discusses the implementation efficiency of communications confidentiality, user authentication, data integrity and services availability, along attacks and modern threats with their countermeasures. many solutions were presented to maintain a secure cps environment by fulfilling its main security goals. in [277] , adam et. al. presented a novel framework to understand cyber-attacks and cps risks. their framework offers a novel approach to ensure a comprehensive study of cps attack elements, including the attacker and his objectives, cyber exploitation, control-theoretic and physical system properties. in [232] , stouffer et al. provided a comprehensive ics security guideline that is related to technical controls including intrusion detection systems (ids), access controls (ac), firewalls, and operational controls including training, awareness and personnel security. in [97] , security experts were able to gain the employees' credentials due to their lack of awareness and training, using phishing and social engineering techniques through a simulated attack. in [34] , sommestad et al. conducted a keyword mining comparison, and concluded that the main focus was either on operational controls, or technical controls only. in [278] , sharma et al. presented a novel multi-level network security evaluation scheme (nses) that represent five different levels of security. therefore, providing a holistic view over whether nses is suitable for wireless sensor networks (wsn) security for iot/cps/iocpt applications. nses offers recommendation for network administrators on early design phases to achieve the right security needs. as a result, this paper classifies these solutions in terms of them fulfilling one of the following security goals: • confidentiality: securing cps communication lines is essential. as a result, various cryptographic solutions were presented. in [279] , the authors presented a solution based on the use of compression techniques before being encrypted. their solution reduces the overhead and mitigates the problem. since, lightweight cryptography became the centre of attention with various lightweight block ciphers being presented by different authors, including an ultra-lightweight block cipher by bogdanov et al. [280] and a low-latency block cipher for pervasive computing applications [281] . this was due to their lowcost and low-latency with the ability to provide cryptographic blocks for any resource constrained, normal, industrial, or even medical devices. in [282] , shahzad, et al. suggested the installation of encryption-decryption modules at both ends of non-secure modbus communication to protect its connection from confidentiality attacks. thus, requiring an additional overhead to convert plaintexts into ciphertexts and vice versa. in [283] , the american gas association (aga) presented its aga-12 standard to provide "bump-in-the-wire" encryption services for cps, but at the expense of large latency overheard [284] . in [ [296] . ssu is complementary to the existing siem architectures, and it can transparently intercept its communication control channels along with its physical process input/output lines to constantly assess both security and operational status of plc or rtu. another approach was also presented in [297] , by asem et. al to overcome mitm, replay and command modification attacks by providing an encryption level for the transferred packets, along with the use of hardware cipher models. in [298] , cao et al. presented a layered approach with the aim of protecting sensitive data. their techniques relied on hash chains that provide a layered protection for both high and low security levels zones along with a lightweight key management mechanism. thus, preventing attackers from intercepting data from a higher security level zone. therefore, ics applications vendors should work on releasing compatible versions of their applications to ensure that the ics operators will not resort to older versions of vulnerable os [22] . their presented approach revealed the ineffectiveness of interception, injection and denial of service attacks, along with the ability of their openplc project to overcome man-in-the-middle attacks through data encryption, without interfering with its own real-time characteristics. • authentication: authentication is the first line of defense that should be well-built, designed and maintained [302] , [303] , [259] , [304] . as a result, in [130] , halperin et al. presented a public key-exchange authentication mechanism to prevent unauthorized parties from gaining access. their mechanism relies on external radio frequency rather than batteries as an energy source. in fact, out-ofband authentication were deployed in certain wearable devices, where the authentication mechanism uses additional channels including audio and visual channels [73] . on the other hand, medical cps (mcps) biometrics, including mainly heart rates and blood pressure [305] , can possibly be used to generate a key to encrypt and secure the body sensor network communication [73] . in [ • privacy preserving preserving the privacy of users' big data is not an easy task. as a result, various privacy preserving techniques were presented to solve this issue including differential privacy and homomorphic encryption. -differential privacy: limits the disclosure of private real-time big-data and information during its transmission. in [311] , keshk et al. studied the feature reduction role along privacy protection levels using independent component analysis (ica) as a technique on big power cps data. results revealed that ica is more secure without breaching confidential data and offers a better privacy preservation and data utility. in [312] , j. feng et al. presented a lightweight privacy-preserving high-order bi-lanczos scheme in integrated edge-fog-cloud architectural paradigm for big data processing. user's privacy is achieved using an homomorphic cryptosystem, while computation overheads are offloaded using privacy-preserving tensor protocols. in [313] , ye et al. presented a secure and efficient outsourcing differential privacy (dp) scheme to solve data providers issues related to being vulnerable to privacy attacks. in [314] , zhang et al. presented a practical lightweight identity-based proxy-oriented outsourcing with public auditing scheme in cloudbased mcps, by using elliptic curve cryptography to achieve storage correctness guarantee and proxyoriented privacy-preserving property. -homomorphic encryption: for a better data confidentiality and privacy protection, homomorphic encryption techniques were adopted. in [315] , zhang et al. presented a secure estimation based on kalman filtering (sekf) using a multiplicative homomorphic encryption scheme with a modified decryption algorithm to reduce network overhead and enhance the confidentiality of the communicated data. in [316] , kim et al. a fully homomorphic encryption (fhe) as an advanced cryptographic scheme to directly enable arithmetic operations on the encrypted variables without decryption. moreover, a tree-based computation of sequential matrix multiplication is introduced to slow down the decrease of the lifespan. in [317] , min et al. presented a parallel fully homomorphic encryption algorithm that supports floatingpoint numbers to achieve an efficient ciphertext operation without decryption. results revealed that the ability to limited application problems while meeting the efficient homomorphic encryption requirements in cloud computing environment. many noncryptographic solutions were also presented to mitigate and eliminate any possible cyber-attack or malicious event. this was done by implementing intrusion detection systems (ids), firewalls and honeypots. as a result, various solutions presented by various authors are mentioned and discussed. various ids methodology types are available due to the availability of different network configurations [318] . each ids methodology is characterised by its own advantages and drawbacks when it comes to detection, configuration, cost, and their placement in the network. in [268] , almohri et al. stated that various research activities were implemented to detect attacks against the cps. these attacks are split into two main models. physics-based model, which defines normal cps operations in cps through anomaly detection. cyber-based model which is used in order to recognize potential attacks as listed in [319] , [320] . in fact, existing approaches were mainly designed to detect specific attacks against specific applications, including unmanned aerial vehicles (uav) [321] , industrial control processes [322] , and smart grids [323] . in [324] , zimmer et al. exploited the possibility of a worst case execution time, through obtaining information using a static application analysis in order to detect malicious code injection attacks in cps. in [325] , mitchell et al. analysed a behaviour-rule specification-based technique to employ ids mainly in medical cps. the authors also presented the transformation of behaviour rules in a state machine, which can detect any suspicious deviation initiated from any medical device behaviour specification. -intrusion detection system placement: ids can be placed at the border router of any given iot network, in one or many given hosts, or in every physical object to ensure the required detection of attacks. simultaneously, ids may be able to generate a communication overhead between the lln (low power lossy networks) nodes and the border router due to the ids ability to frequently query the network state. in fact in [326] , zarpel at al. described three main ids placement strategies (see fig. 8 ): fig. 8 : ids structure * distributed ids: d-idss are being employed in every physical lln object, whilst being optimized in each resource-constrained node. therefore, a lightweight distributed ids was presented. in [327] , oh et al. identified a lightweight algorithm matching the attack signatures, and the packet payloads, while suggesting other techniques that require less matching numbers to detect any possible attack. in [328] , lee et al. suggested their own lightweight method that allows them to monitor a node's energy consumption by assigning nodes to monitor their neighbours in the distributed placement. these nodes are defined as "watchdogs". in [329] , cervantes et al., presented a solution called "intrusion detection of sinkhole attacks on ipv6 over low -power wireless personal area networks (6lowpan) for iot" (inti), which combines their concepts of trust and reputation with the watchdogs nodes to mainly detect and mitigate sinkhole attacks. this included the node's role possibly changing every time a network is reconfigured or an attack event has occurred. * centralized ids: c-ids is mainly deployed in centralized components. this allows all data to be gathered and transmitted by the lln to the internet across the border. therefore, centralised ids can analyse all of the exchanged traffic between the lln and the internet. in fact, it is not enough to only detect attacks involving nodes within the lln, since it is difficult to monitor each node during an occurring attack [330] . in [331] , cho et al. presented their solution which is based on analysing all the packets that pass through the border router between physical and network domains. however, the main task is based on how to overcome a botnet attack. in [332] , [333] , kasinathan et al. deployed a centralized placement that allows them to take into consideration the possibility of overcoming dos attacks, where in case of a dos attack, the ids data transmission would not be affected. in [334] , wallgren et al. employed their centralized approach which is placed in the border router to detect the attacks that target the physical domain. * hybrid ids: h-ids utilizes both concepts of centralized and distributed placements, by combining their advantages and overcoming their drawbacks. the initial approach allows the network to be organised into clusters with the main node of each cluster being able to host an ids instance before taking the responsibility for monitoring other neighbouring nodes. therefore, hybrid ids placements can be designed in order to consume more resources than a distributed ids placement. in [335] , le et al. followed the same approach, through the use of a hybrid placement using a relatively small number of "watchdogs" nodes covering the network. this offered them the ability to sniff the communication of its surrounding neighbours in order to indicate whether a node was compromised or not. therefore, reducing the communication overhead. in [336] , le et al. also managed to organize the network into smaller clusters with a cluster head for each, using the same number of nodes. this allowed an ids instance to be placed in each cluster head, with each cluster member reporting its own related information and other neighbours related information to the cluster head. in the second approach, ids modules were placed in, both the border router and other network nodes with the presence of a central component. in [337] , raza et al. presented their own ids named as svelte, where the border router hosts are given the task of processing intensive ids modules that are responsible for detecting any intrusion attempt by analysing the routing protocol low-power and lossy device's (rpl) network data. based on pongle et al.'s work [338] , network nodes were responsible for any detectable changes in their neighbourhood. moreover, network nodes were also responsible for sending information about their surrounding neighbours to their centralized module which is deployed in the border router having the main assigned responsibility of storing and analysing data. thus, making it easier to detect and intrusion while identifying attacks in their early stages. in [339] , thanigaivelan et al. presented an ids, which allocates different responsibilities to the network nodes and also to the router's border. thus, ensuring a cooperative combined work amongst them, with the ids module monitoring neighbouring nodes, detecting any intrusion attempt, and sending notifications to the ids modules. -intrusion detection methods: the four main ids methods are signature-based, anomaly-based, behaviour-based and hybrid based. in fact in [326] , these methods were presented, while testing methods and techniques were classified into five main categories, depending on their detection mechanism . * signature based: such a detection technique is very fast and easy to configure. however, it is only effective for detecting known threats. thus, showing a high weakness against unknown threats mainly polymorphic malwares and crypting services. despite its limited capability, signature based ids is very accurate, and also very effective at detecting known threats, with an easy way to understand mechanism. however, this approach is ineffective against the detection of both new and variants of known attacks, due to their matching signature remaining unknown, and constantly updating its signature patches [340] , [341] . in [327] , oh et al.'s aimed to reduce the computational cost by comparing attack signatures and packet payloads. in [342] , liu et al. presented a signaturebased ids that employs an "artificial immune system" (ais) mechanism with detectors being modelled as immune cells with an ability to classify any datagram as malicious or non-malicious according to the matching signature. such approach can evolve into the adaptation ability new conditions in new environments that are being monitored. in [332] , kasinathan et al. integrated a signature-based ids into the network framework, with the objective of being able to detect dos attacks against 6lowpan-based networks. this ids was implemented through the adaptation of "suricata4" used for 6lowpan networks, with the main objective of reducing the false alarm rate. in [333] , kasinathan et al. presented a signaturebased approach as an extension of their presented approach in [332] . * behaviour based: behaviour based can be classified as a set of rules and thresholds implemented to define the expected behaviour of the network's components including both nodes and protocols. this approach is capable of detecting any intrusion as soon as the network behaviour deviates from its original behaviour. behaviour-based acts in the same way as the anomaly-based detection with a slight difference from specification-based systems where a human expert is needed to manually define each specification rule. thus, providing a lower false-positive rate than the anomaly based detection [343] , [344] . therefore, there will be no need for any training phase, since they are implemented to operate instantly. however, such an approach is not fit for all scenarios, and may become time consuming and error prone. in [345] , misra et al. presented their new approach to protect the iot middleware from ddos attacks, by triggering an alert whenever the request number exceeds the threshold line. in [335] , le et al. presented a different specification-based approach, aimed at detecting rpl attacks [346] , by specifying the rpl behaviour through network monitoring operation and malicious action detection. in [336] , le et al.'s work was extended. their experimentation resulted in a high true-positive rate, where false positive rates were low throughout their experimentation, whilst also causing an energy overhead compared to a typical rpl network as stated in [326] . in [347] , amaral et al. presented a specification-based ids that grants the network administrator the ability to create and maintain rules in order to detect any potential attack. whenever the rule is violated, the ids would right away send an alert to the event management system (ems) that correlates these alerts for different available nodes in a given network. the success of misra et al. [345] and amaral et al. [347] approaches highly relied on the expertise of the network administrator, as well as his experience and skills combined. therefore, in case of any wrong specifications, it will cause an excessively high false-positive rate and/or a high false-negative rate, leading to a possibly serious risk that threatens the network's security. * anomaly based: this type compares system's activities instantly with the ability to generate an alert whenever a deviation from normal behaviour is detected. however, such a detection method suffers from a high false positive rate [343] , [348] , [349] . in [331] , cho et al. presented a botnet detection scheme using the anomaly-based method, by computing an average for each three metrics composing the normal behaviour profile. this was achieved before the system monitors the network's traffic and raises the alert whenever a metric violates the already defined computed averages. in [350] , gupta et al. presented their own architecture for a wireless ids, by applying the necessary computational intelligence algorithms which are used in order to a construct normal profile behaviour. moreover, a distinct normal behaviour profile will be implemented for each different ip address being assigned. in [328] , lee et al. suggested that energy consumption should be classified as parameter in order to be used in analyzing each node's behaviour. thus, defining a regular energy consumption model for each mesh-under routing scheme and route-over routing scheme, where each node will monitor its own energy consumption. in case the node deviates, the ids classifies the node as malicious and removes it. in [351] , summerville et al. successfully managed to develop a deep-packet anomaly detection approach aimed at reducing the run on resource constrained iot devices, by using a bit-pattern matching technique which performs a feature selection. in their experimental evaluation, they used internet enabled devices against four main attack types (including sqli, worms, etc..), and results have shown low false-positive rates. in [339] , thanigaivelan et al. successfully introduced an iot distributed internal anomaly detection system, that monitors the node's data rate and packet size. moreover , in [338] pongle and chavan presented an ids that is designed specifically in order to detect wormhole attacks in iot devices, in addition to presenting three main algorithms to detect network anomalies. as a result, their experiment revealed that the system has achieved a true positive rate of 94% when tested against wormhole detection, whilst scoring an 87% when it came to detecting both, the attack, and the attacker launching it. in [352] , k. demertzis et al. presented an advanced spiking one-class anomaly detection framework (soccadf) based on the evolving spiking neural network algorithm. this algorithm implements a one-class classification methodology in an innovative applicable way, due to it being exclusively trained with data to characterise normal ics operations. moreover, this algorithm can detect any divergence in behaviours and abnormalities that are associated with apt attacks. the authors stated that soccadf is highly suitable for difficult problems, and applications with a huge amount of data. according to their results, the authors stated that soccadf has a better performance at a very fast learning speed, with higher accuracy, reliability, and efficiency, and it outperforms the other approaches. * radio-frequency based: in [353] , stone et al. presented a radio-frequency based anomaly detection method for programmable logic controllers in the critical infrastructure [354] . their experimental results have demonstrated that the use of a single collected waveform response provides sufficient separability to enable the differentiation between anomalous and normal operational conditions. however, in case of using multi-time domain waveform response, their performance significantly degrades. to solve this problem, the authors presented anomaly detection method based on rf fingerprint feature retrieved from the waveform amplitude, phase, and frequency response to ensure a qualitative differentiation between an anomalous and normal operating conditions. in [355] , stone et al. also presented an rf-based methodology to detect anomalous programmable logic controller behaviours with a superior timedomain rf emissions performance. the cincinnati bell any distance (cbad) approach reached a threat agent detection and response (tadr) detection rate higher than 90% benchmark realised at an signal power ratio (snr) higher or equal to 0 db. despite these results, this approach is prone to rf noise, signal degradation and coding loops. in [356] , stephen et al. presented a timing-based side channel analysis technique to help control system operators in detecting any firmware and ladder logic programs modification to the programmable logic controllers. this approach allows a field device to be fingerprinted upon deployment to create an supplicate baseline fingerprint. various fingerprints of the device are taken and compared to the baseline in order to detect and alert operators of both intentional and unintentional modifications in programmable logic controllers. * hybrid based: it is based on using a specification-based techniques of signature-based, and anomaly-based detection in order to maximize their advantage whilst minimizing their drawbacks. in [337] , raza et al. presented a hybrid ids known as svelte which offers the right trade-off between storage cost of signature-based methods, and computational cost of anomalybased methods. in [357] , krimmling et al. tested their anomaly and signature-based ids using the ids evaluation framework that they presented. their results revealed the failure of each approach in detecting certain attacks alone. as a result, the authors combined these approaches to cover and detect a wider attack range. in [329] it is not enough to encrypt, detect and protect against passive and active attacks. in fact, aside from identifying the source of the attack, it is also important to know how the attack was performed despite of the challenges [372] . hence, there an urgent need for the forensics domain to enhance the forensics tools and techniques to retrieve and analyze logs of events that took place before, during and after the incident. in fact, cps forensic analysis is still in its early stages of development, due to the ics specialized nature along with its proprietary and poorly documented protocols [373] . in [374] , awad et al. surveyed the digital forensics applied to scada systems and covered the challenges that surround them. therefore, presenting the current state-of-the-art device and networkspecific tools. in [375] , grispos et al. presented a forensicby-design framework that ensure the integration of forensics principles and concepts in mcps. in [376] , h. al-khateeb et al. shed a light on a new approach where a blockchainbased chain-of-custody may be simultaneously established to the generated preidentified data (data of interest) by an iot device. in [377] , chan et al. described a novel security block method for detecting memory variable changes that may affect the integrity of programmable logic controllers and efficiently and effectively enhancing security and forensics. this is done by by adding monitoring and logging mechanisms to plcs. therefore, ensuring faster anomaly detection with higher accuracy, less overhead and adjustable impact. in [378] , ahmadi et al. presented a federated blockchain (bc) model that achieves forensic-readiness by establishing a digital chain-of-custody (coc) and a cps collaborative environment to qualify as digital witnesses (dw) to support post-incident investigations. in [379] , parry et al. presented a high speed hardware-software network forensics tool that was specifically designed for capturing and replaying data traffic in scada systems. experimental results guaranteed preserving the original packet ordering with improvement in data capture and replay capabilities. in [380] , cebe et al. presented a blockchain infrastructure by integrating a vehicular public key infrastructure (vpki) to achieve membership establishment and privacy along a fragmented ledger related to detailed vehicular data. moreover, identities pseudonyms were used to preserve users' privacy. in [381] , p. taveras presented a high level software application that detects critical situations like abnormal changes of sensor reads and traffic over the communication channel, mainly. therefore, helping by improving critical infrastructure protection and providing appropriate scada forensics tools for incident response and forensics analysis. in [382] , ahmed et. al. presented a testbed of three ipps (industrial physical processes) using real-world industrial equipment including plc. the authors stated that their presented testbed is useful in cyber-security, education (scada systems) and forensics research including plc analysis and programming. moreover, their testbed includes fully functional physical processes which are deemed very essential for both research and pedagogical efforts. in [383] , yau and chow presented a novel methodology which logs relevant memory address values, that are being used by programmable logic controller programs, in addition to their timestamps. this methodology can be extremely valuable in a forensic investigation in case of an ics incident. this is realized by applying machine learning techniques to the logged data in order to identify any anomalous programmable logic controller operation. in [384] saman et. al. combined symbolic execution with model checking to analyse any malicious plc code bound injection. their combined approach can also be used for forensic purposes including the identification of the areas where the code injection took place, along with which part of the code caused its execution. in [385] , mcminn et al. presented a firmware verification tool used for the forensics analysis of trials of the altered firmware codes to gain unauthorised access over ics networks. such verification is achieved either though the analysis of the plc's captured data to check whether the plc's firmware is modified or not. in [386] , kleinmann et al. presented an accurate ids that utilizes a deterministic finite automaton that models the network traffic with a 99.26% accuracy, after analysing and observing the highly periodic network traffic of siemens s7 plc. in [387] , saranyan et al. provided a comprehensive forensic analysis of network traffic generated by the pccc (programmable controller communication commands) protocol, and also presented prototype tool that extracts updates of the programmable logic and crucial configuration information. authors also stated that their proof-of-concept tool, "cutter", which is capable of parsing the content of pccc messages, extracts and presents digital artifacts in a human-readable form such as simple mail transfer protocol (smtp) configuration. moreover, the smtp configuration can be retrieved from the network log and can be parsed, too. in [377] , chan et. al. presented a novel security block method that enhances ics security and forensics by adding monitoring and logging mechanisms to plcs, and ics's key components. their results demonstrated that their approach increased the anomaly detection range, speed and accuracy with a slight performance impact and a reduced network overhead. thus, ensuring a more enhanced, efficient and effective forensic investigation procedure. in [388] , yua et al. described the design and implementation of a novel plc logging system. to overcome the inadequacy of information in forensics investigations, their logging system is used to extract data from siemens s7 communications protocol traffic. this logging system also helps in recording the evidence based on the exchanged data between the plc and other network devices. thus, providing key information about the attack source, actions and timelines. the choice of simatic s7 plc is due to their widespread use [389] and successful exploitation by insidious stuxnet malware. in [390] , chan et al. focused on the logging mechanism of a siemens plc, including the siemens total integrated automation portal v13 program (siemens tia portal, known as siemens step-7). the author's methodology performs an effective and practical forensics analysis of the plc. moreover, it focuses on siemens plc along with an installed computer workstation with the siemens tia portal (previously targeted by stuxnet). during the evaluation and analysis of the existing presented security solutions, several limitations can be deduced, presented and discussed as follows: • asymmetric cryptography: introduces overhead in terms of latency and resources. the asymmetric nature of certain cryptographic work [285] , [292] leaves cps's real-time communication prone to network latency and overhead due to delays in the encryption/decryption process. • weak device/user authentication scheme: many of the presented authentication techniques [130] , [73] , [306] , [308] are not very suitable for a secure appliance, due to the lack of multi-factor authentication schemes to protect cps systems from unauthorised users and access. • cps forensics field: are still prone to many challenges including the lack of tools, skills and responses against any potential anti-forensics activity [372] , [373] . • inefficient honeypot & deception system: despite of the recently proposed techniques in [366] , [368] , [370] , [371] , there are no appropriate honeypot techniques that can be specifically adopted to protect cps systems, especially in the wake of industry v4.0. • lack of firewall protection: firewall solutions including [358] , [359] are not very applicable and suitable for employment into the cps domain, nor they offer an effective protection. the best solution requires dynamic firewalls, as well as application and next generation firewall types. • inefficient intrusion detection systems: despite the availability of various ids types such as anomalybased [352] , behaviour-based [345] and signaturebased [333] , these are generally applied within iot-based domains and not specifically designed to protect cps systems. to secure cps, many lessons were learnt as how to maintain and achieve their required security goals. among such lessons: 1) maintaining security services: new lightweight cryptographic solutions are required to secure cps and iocpt in real-time operations but with minimum computational complexity. these cryptographic solutions can help ensure the following security services: • confidentiality: there is a need for a new class of lightweight block or stream cipher algorithms to secure cps resource-constrained real-time communications. recently, a new approach was presented, and it is based on the dynamic key-dependent cipher structure and it requires two or one iteration with few operations [391] , [392] , [393] , [394] . a set of these solutions can be applied at the physical layer [395] , [393] , [394] . • message/device integrity: this includes the protection of cps data and devices' integrity from any physical/logical alteration(s). this can be done by ensuring that the operating system, applications, and software are securely designed and without any flaws to prevent tampering, with strong cryptographic hash functions (sha256, sha384 and sha512). in this end, a new lightweight hash function was presented in [396] and it requires a single round compared to the existing ones. • device/data availability: requires the need for computational resources along with verified backups, and a self-healing ability of cps in such a way to recover immediately from availability attack types. also, maintaining data availability is as necessary [397] , and this can be done by defining a multi-secure connection [398] [403] . 2) strong device/user authentication: an efficient device/user mutual multi-factor authentication scheme is necessary,along with enhancing verification and identification phases based on attribute access-control privileges (least-privilege) to ensure non-repudiation and stronger accountability. 3) protecting digital evidences: this is highly important since most of the advanced attacks focus on eliminating any source of evidence that traces back to the attack source, such as the case of shamoon, duqu, flame and stuxnet malware types [404] , [109] , [75] . furthermore, modern digital forensics solutions should define new countermeasures to preserve digital forensics logs. 4) enhancing security policy: in many cases, cps attacks occurred by insiders (by accident or on purpose). accordingly, all employees must undergo a screening process before recruitment, and have their privileges suspended outside working hours and monitored their actions in the case of advanced tasks. this means that cps security policy should be contain new rules to limit access and to reduce the potential damage. 5) smart cooperation with non-cryptographic solutions: intrusion detection systems should be hybrid in all terms and should be coordinated in an efficient manner with firewalls and dynamic honeypot systems. 6) enforcing compliance: by respecting users' privacy through ensuring data access regulatory compliance that processes cps's big data via clouds, especially when stored by utility providers (trusted third party (ttp)) to prevent any data leakage and users privacy violations. therefore, maintaining a suitable trade-off between users privacy and systems' security and performance, while also ensuring firmer accountability measures [405] , [406] . 7) achieving trade-off: is essential for maintaining systems' availability, safety and security [407] , [408] . therefore, such a trade-off must be achieved based on the combination of these three key requirements while taking into consideration available budget and cost requirements in terms of risk assessment: • availability & safety: both features are linked together since issues related to the safety of a cps system also affect its operational availability. to ensure this trade-off, verified back-ups of computational devices must always be considered in the planning phase, as a second line of defense to handle any sudden service/system disruption (power cuts, blackouts, pumping stoppage), or maintenance (updates, renovation, installation, etc. different security measures could be adopted and enhanced to enhance the protection against various threats and attacks. these include: • prioritization & classification: of critical cps components and assets before assessing, managing and analysing risks to ensure the proper budget spending on the right choice of security measures (basic, standard or advanced) in accordance to their costs compared to the likelihood of the occurrence of a given incident and its impact. • careful financial planning & management: must be conducted in terms of available budget and needed costs/resources to protect critical/non-critical cps assets and components. • lightweight dynamic key dependent cryptographic algorithms: these solutions can be used to to ensure several security services such as message confidentiality, integrity and authentication, which are mandatory during any secure cps communications. this can be done by using new generation of cryptographic algorithms, which were presented in [392] , [409] , [410] . the advantage of these solutions that it can reach a good balance between security and performance level. the robustness against attacks were proved since a dynamic key is used per message (or a set of messages; depend of application constraints and requirements). moreover, this dynamic key is used to produce a set of cryptographic primitives and update cryptographic primitives. this means different ciphertext can be obtained for the same plaintext since different cryptographic primitives are used. while, the effectiveness is validates since these algorithms require only one round iteration and uses simple operations in addition to avoid diffusion operation. the new generation of these cryptographic algorithms reduce the required latency, resources and computation overhead, which help cps devices to preserve better their main functionalities. • defining privileges: this should be considered as the most suitable access control policy, which assigns permissions and rights depending on the users' roles/tasks/attributes when it comes to accessing cps, and removing these access rights upon completing the task or upon the employee's leave. this also includes the use of the least privilege policy. therefore, the definition of privilege should be done based on attribute based access control (abac), where policies combined with attributes specify access authorizations. note that abac makes access control decisions based on boolean conditions of attribute values. it provides a high level of granularity, which is necessary to make cps control access scheme more secure. • strong entity multi-factor authentication: unfortunately, entity authentication schemes that are based on a single factor of authentication (you have, you know, you do or you are) are not resistant enough against authentication attacks, which are increasingly becoming more dangerous. the first line of defense in any system is the entity authentication scheme since any entity authentication attack can lead to confidentiality, integrity and/or availability attack. recently, the concept of multi-factor authentication was applied by combining two or more factors: 1) "you are" which includes device fingerprint, user fingerprint, hand geometry, iris scan, retina scan, etc., and 2) "you have" which includes cryptographic keys to increase its robustness against authentication attacks such as the ones described in [411] , [412] . this mechanism should be an essential requirement in cps systems, in addition to the use of the geographical location. the advantage of these solutions is their ability to reduce false positives, and to complicate the authentication attacks since several factors should be broken instead of one. consequently, this limits the access only to authorised entities and personnel (devices/users). • strong password & dynamic hashing process: passwords are considered as the "you know" authentication factor. however, several attacks such as rainbow and hash table attacks can be applied. in order to prevent them from occurring, after a periodic interval, passwords must be re-hashed with a new dynamic nonce for each user. moreover, a secure cryptographic hash function should be used such as sha-3 and sha-2 (variant 512). this avoids birthday attacks and reduces rainbow/hash table attacks. • secure and protected audit: can be done by using an audit manager system that collects and stores logs in a distributed system. a possible solution that can be applied in this context was presented recently in [413] . this limits any insider attempt against a cyber-physical system and it preserves the digital evidence of internal and external attacks to trace them back. • enhanced non-cryptographic solutions: require the need for hybrid ids/ips systems or ai-based ids/ips (using machine learning algorithms), along with advanced firewalls (i.e application and next generation firewalls) [414] , and dynamic honeypots [415] to prevent any future security breach based on a vulnerability exploit. this can be done by employing lightweight ids/ips and especially the anomaly-based ones. in fact, one should select the anomaly detection algorithm according to the cps device constraints, which can be statistical for limited ones or based on machine algorithm, such as random forest, for powerful cps devices. on the other hand, signature-based techniques can be applied at the gateway (gw) where all network traffic can be analyzed. • secure & verified backups: this is essential to maintain the cps data availability and to avoid data destruction or alteration by ensuring robustness against dos/ddos and ransowmare attacks, especially that such attacks may result in total blackouts as in the case of the us. this can be done by using lightweight data protection solutions such as the ones presented in [399] . • forensic efforts: are essential to retrieve the traces of any occurring attack. also, new solutions against antiforensic techniques should be introduced to preserve any digital evidence [413] . this is realized by recovering logs and monitoring network and system behaviour, which can successfully limit various reconnaissance attempts. however, the newly introduced forensics tools must be compatible with different cps devices' software/hardware, especially resource constrained devices, and must also be resistant against anti-forensics attempts. • enhanced incident response: includes the ability to identify, alert and respond to a given incident. moreover, incident recovery and incident investigation plans should be put in place to mitigate attacks. this provides protection against non-intentional technical and operational failures (power shortage, blackout) through backup plans, and from intentional failures (cyber-attacks), through cert (computer emergency response) [416] , csirt (computer security incident response) [417] , and ircf (incident response and computer forensics) teams [418] , [419] . as such, cps scientists and engineers must undergo further education and training to ensure an enhanced and efficient cyber, physical and computational environment with secure computing and communications. • real time monitoring: running real-time systems using specialised forensics or non-forensics tools and methods is essential to prevent any cyber-physical system accidental or non-accidental failure. this enables constant checking and monitoring of cps devices' behaviour and hence, the detection of any cyber-attack attempt in its early stages. • security check: and employee screening must be done for each employee before and during the job to eliminate and contain any possible insider/whistle-blower attempt. therefore, signing agreements [420] such as non-disclosure agreement (nda), confidentiality agreement (ca), confidential disclosure agreement (cda), proprietary information agreement (pia) or secrecy agreement (sa) is highly recommended. such security checks are essential especially in critical areas such as nuclear power plants [421] . • periodic employee training: includes periodic awareness training of ics and plc employees on the best cyber-security practices based on their level and knowledge, with the ability to detect any suspicious behaviour or activity. moreover, employees must be trained over various security threats and wrong practices such as avoiding the installation of any software update, how to counter social-engineering and phishing attempts, while also maintaining accountability in case of wrong doings. • periodic pen testing & vulnerability assessment: must be maintained in a periodic manner to enforce system auditing, detecting threats, and mitigating them in a real-time manner before they are discovered and exploited by an attacker under the zero-day exploit conditions. • periodic risk assessment: must also be enforced to study the likelihood and impact of a given risk against a critical/non-critical cyber-physical system based on a qualitative or/and quantitative risk assessment and a cost-benefit analysis (cba), to classify the risk based on acceptable/non-acceptable level and to mitigate it as early as possible. • up-to-date systems: cyber-physical systems must be kept up-to-date in terms of software, firmware and hardware through constant verified patches and updates [422] . moreover, such systems must be secured at different levels of their implementations (layered protection), with the ability to mitigate and tackle a given attack to reduce its impact and prevent further escalation and damage. furthermore, usb ports must be physically and logically removed to prevent any payload injection, and plc systems behaviour and activities must be constantly monitored for any suspicious/abnormal behaviour [422] . • ai security solutions: artificial intelligence is used in ids/ips anomaly detection schemes or in "you are" or "you do" entity authentication schemes. in fact, ai is now being considered as a game-changing solution against a variety of cyber-physical attacks targeting cps systems, devices and communication points. despite the time consuming process of training an ai system, the accuracy of detection and prevention are much higher than any human intervention. recent advancements in machine learning, and especially in deep learning, can make cps systems more secure, robust and resistant against cyber-physical attacks. • defense in-depth: most of the existing solutions offer protection against a single attack aspect or a security requirement. instead, there is need for a multi-purpose security solution that ensures the best protection at each operational layer (perception, transmission and application) of cps. for example, the two most known international standards for functional safety in the automotive industry, the iso 26262 [423] and iec 61508/edition2 [424] , [425] should be respected and applied. this ensures a safe cps implementation based on the functional safety, which includes the safety integrity level (sil) basics [426] which in turn, rely on the probability of failure on demand (pofod) and the risk reduction factor (rrf) to ensure a much more accurate and efficient hazard and risk analysis (hra) [426] , [424] , mainly in the electronic control units (ecu) [427] , [428] ). • cps security & privacy life-cycle: finally, to sum up this work, our paper presents a combined operational and functional safety/security (ofss) life-cycle that ensures a successful and safe cps employment as seen in fig. 9 ). this framework is derived from iso 26262 and iec 61508/edition2 protocols and their approach towards ensuring the cps functional safety/security. the framework consists of six main phases: -phase 1: devising a plan to design a cps system by following a well-defined time-table and schedule in accordance to the needed budget and corresponding costs. this also requires the assistance of humans (businessmen, engineers, workers, etc.) and nonhuman assets (vehicles, machines, etc.). -phase 2: requires a careful risk and hazard analysis, which consists of a proper risk management and asset classification, as well as the mutual connection between the two to ensure an accurate decision-making over the adoption of the right security measures/counter-measures. -phase 3: defines the right functional safety, security and dependability requirements along their key components/mechanisms that are essential to mitigate a risk/hazard and to reduce their likelihood and impact in case of their occurrence. -phase 4: consists of evaluating the performance of cps in terms of the recently introduced functional safety, security and dependability measures in an operational manner where a performance management and analysis will be conducted to ensure a proper/mutual security-performance, safetyperformance and dependability-performance tradeoffs. -phase 5: once the performance is evaluated, the cyber-physical system is tested and validated to detect any remaining software/hardware bug, security gap, or performance issue to apply the required modifications before being commissioned. if the testing is unsuccessful, the process restarts again to find where the issue took place. if successful, the cps will head towards further commissioning before being officially deployed. -phase 6: upon successful testing, the deployed cps system will undergo a trial phase to evaluate its operational status, while monitoring its behaviour and performance before becoming fully operational. cps systems are key components of industry v4.0, and they are already transforming how humans interact with the physical environment by integrating it with the cyber world. the aim of implementing cps systems, either within or outside iot (iocpt), is to enhance the products' quality and systems' availability and reliability. however, cps systems suffer from various security and privacy issues that can degrade their reliability, safety, efficiency, and possibly hindering their wide deployment. in this paper, we first overview all components within cps systems and their interconnections including iot systems, and we focus on the main cps security threats, vulnerabilities and attacks, as related to the components and communication protocols being used. then, we discuss and analyze the recently available cps security solutions, which can be categorized as cryptographic and non-cryptographic solutions. next, we 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computing the safety integrity level (sil) for turbo machinery protection electronic control unit us patent 9,036,026. declare the following financial interests/personal relationships which may be considered as potential competing interests: jean-paul yaacoub is a master student in the department of electrical and lebanon. hassan noura is a research associate in the department of electrical and computer engineering at the american university of beirut (aub), lebanon. nesrine kaaniche is lecturer in cybersecurity and expert in cryptographic solutions at the university of salford, school of computing ali chehab is a professor in the department of electrical and key: cord-011062-ukz4hnmy authors: nan title: poster date: 2020-03-11 journal: j frailty aging doi: 10.14283/jfa.2020.9 sha: doc_id: 11062 cord_uid: ukz4hnmy nan background: frail older adults are at increased risk of postoperative morbidity compared with robust counterparts. simple methods testing frailty such as grip strength have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. objectives: we compared the predictive value of multidimensional frailty score (mfs) with grip strength or conventional risk stratification tool for predicting postoperative complications in older hip fracture patients. methods: from january 2016 to december 2018, 277 older hip fracture patients (age >= 65 years) who underwent surgery and comprehensive geriatric assessment (cga) were retrospectively included for analysis. hip-mfs was calculated based on the cga with component of sex, charlson comorbidity index, serum albumin, koval grade, cognitive function, risk of falling, mini-nutritional assessment and mid-arm circumference. grip strength was also measured before surgery. the primary outcome was a composite of postoperative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). results: among 277 patients (mean age 81.7 ± 6.8 years, 73. accordingly, grip strength could be used for screening tool to identify high-risk patients who need for further comprehensive geriatric assessment among older hip fracture patients. information and data suspected of post-operative infections. the diagnostic criteria of infection dealt with grade ii or more of clavien-dindo classification. diagnosis of infectious disease was made with reference to vital sign, blood test, imaging and bacterial test results. surgical site infection (ssi) was evaluated based on the infectious control team surveillance. results: 47 elderly patients were registered with necessary data. the average age was 77.0 years, 25 males and 22 females were included. in the sarcopenia evaluation, there were 15 cases without sarcopenia and 32 cases with it. 12 cases developed some infectious complications postoperatively. the types of infectious complications (including duplication) were 11 cases of some surgical site infections including suture failures, 5 of pneumonia, 2 of urinary tract infection, 4 of pneumonia and 2 cases of sepsis in 12 patients. infectious complications occurred in 4 cases in the non-sarcopenia group and 8 in the sarcopenia group (p = 0.903). the average postoperative hospitalization was 30.2 days overall, 20.8 in the group with postoperative infectious complications, and 61.9 in the group without sarcopenia. conclusion: in this study, there was no relation in the incidence of postoperative infections and preoperative sarcopenia. however, the postoperative hospitalization in the group with postoperative infectious complications was almost tripled. background: hypertension is one of the major risk factors for cardiovascular disease. lowering blood pressure is effective for preventing stroke, heart failure (hf), myocardial infarction and possibly dementia. in france, the prevalence of elderly people treated for hypertension rising leading to a possible increase of potentially inappropriate antihypertensive prescribing (piap) that may cause adverse drug events. objectives: to identify associated factors with potentially inappropriate antihypertensive prescribing (piap) in elderly people. methods: we conduct a retrospective observational study based on a cohort from geriatric day hospital for assessment of frailty and prevention of disability in toulouse, between january 2016 and april 2018. piap was defined with several explicit criteria: the european list of potentially inappropriate medications, alert and control of iatrogenesis (aci) criteria by the french health authority, the french society of hypertension guidelines, screening tool of older people's potentially inappropriate prescriptions (stopp) version two and summary of product characteristics. the piap has been considered as a binary variable (logistic regression) then as a counting variable by number of nonconformities on antihypertensive drugs (negative binomial regression). results: among the 1115 patients, 30% had piap. frailty, polypharmacy, history of angina and hf are associated with a higher risk of piap. similarly: frailty, polypharmacy and history of angina are associated with an increase in the number of non-conformities antihypertensive drugs. analysis of subgroup of patient hf -piap indicated that 42% had aci criteria whose 82% the aci criteria "4 antihypertensive drugs or more" and 68% the aci criteria "2 diuretics or more". analysis of subgroup of patient history of angina -piap indicated that 65% had stopp criteria, focused on loop diuretics. conclusion: our work suggests that some elderly people characteristics are associated with an increase likelihood of piap. targeting these patients would be beneficial in preventing medicine-related illness. background: social frailty was reported to be associated with age, sex, income, education, marital status, and household status. however, mood status including depression and emotion was relatively less investigated. objectives: the aim of this study is to clarify the association between depression and apathy status and social frailty in community-dwelling japanese elderly. methods: a health promotion project (teng tv project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. we ran a cross-sectional analysis using baseline characteristics of all participants (n=926). demographic data, socio-economic status, comorbidities, and nutrition evaluated by mininutritional assessment-short from (mna-sf) were recorded. functional capacity was assessed by the japan science and technology agency index of competence (jst-ic). mood status including depression, and emotion was measured by geriatric depression scale (gds-15) and apathy evaluation scale (aes). social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. we defined total deficit scores of 2 or more as social frailty, 1 as social pre-frailty, and 0 as robustness. we used a linear regression model to analyze the association between mood status and social frailty after adjusting for age, sex, education, marital status, comorbidities, bmi, mna-sf, jst-ic. results: at baseline, mean age of all participants (46.9% men) was 75±5.9 years. a total of 34.3% and 22% of all participants were categorized as social prefrailty and social frailty, respectively. the mean scores of gds-15 and aes were 3.4±3.3, 14.3±6.7, respectively. in linear regression model after full adjustment, participants with social pre-frailty and social frailty were associated with increased gds-15 scores (social pre-frailty vs. social robustness: b=0.58, 95%ci 0.01-1.15; social frailty vs. social robustness: b=2.49, 95%ci 1.68-3.29) and aes scores (social pre-frailty vs. social robustness: b=0.04, 95%ci -0.67-1.47; social frailty vs. social robustness: b=1.63, 95%ci 0.22-3.03). in addition, jst-ic was also associated with gds-15 and aes scores. conclusion: social pre-frailty and social frailty were associated with greater level of depression and apathy. future studies are warranted to determine the causal relationship among mood status and social participation. inthira roopsawang 1,2 , hilaire thompson 2 , oleg zaslavsky 2 , basia belza 2 ((1) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; (2) biobehavioral nursing and health informatics, school of nursing, university of washington, seatlle, usa) background: frailty is a common geriatric condition with an impact on surgical outcomes. no research has been published on frailty assessment in hospitalized orthopedic patients in thailand. having a valid frailty measure has the potential to improve screening and could enhance quality of care. objectives: to test the ability of the reported edmonton frailty scale-thai version (refs-thai) in predicting hospital outcomes compared with preoperative assessment measures, the american society of anesthesiologists physical status classification (asa) and the elixhauser comorbidity measure (emc) in older thai orthopedic patients. methods: a prospective study was conducted at a university hospital. the hospitalized patients aged 60 years or older scheduled for elective orthopedic surgery were recruited in this study. multiple firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (pod), and discharge disposition, while length of stay (los) was examined by poisson regression. the area under the receiver operating characteristic curve (auc) and mean squared errors (mse) were used to compare predictive ability of the instruments. results: two hundred participants with mean age of 72 (range 60-94 years) were mostly female , 23% were frail, and 58% underwent knee surgery; of which 26.5% had postoperative complications, 12.5 % developed pod, and 11% were unable to be discharged home. average los was 6 days. adjusting for other variables, frailty was significantly associated with postoperative complications (or = 2.38, p = 0.049), pod (or = 3.52, p = 0.034), and prolonged los (relative risk [rr] = 1.42, p = 0.043). applying the refs-thai alone shows good performance in predicting postoperative complications (auc = 0.81, 95% ci = 0.74-0.88) and pod (auc = 0.81, 95% ci = 0.72-0.90). the combination of refs-thai with asa and emc demonstrates improvement in predicting postoperative complications (auc = 0.81, 95% ci = 0.75-0.88 and 0.82 95% ci = 0.75-0.88, respectively) and pod (auc = 0.80, 95% ci = 0.71-0.89 and 0.81 95% ci = 0.72-0.90, respectively). conclusion: frailty assessment using the refs-thai was useful in predicting adverse outcomes in older adults undergoing orthopedic surgery. integrating the refs-thai for preoperative assessment may be useful for enhancing orthopedic care quality. anthony frioux 1 , matthieu faure 2 , margot de battista 2 , benoit roig 1 ((1) université de nîmes, france; (2) université de france) background: the attention of the scientific community to frailty has been drawn over the past several years. frailty is defined as a state of increased vulnerability that may lead to functional disability. if this state is managed soon enough it may be reversible. in parallel, the possibilities of monitoring health status through connected objects such as smartphones are increasing. similarly, it is possible to measure the activity of the inhabitants of a house collecting usage data (water and electricity consumption). our project is in the field of smart home and aging monitoring. objectives: therefore, the objective of our work is to develop an integrative model of frailty based on the contributions of existing scientific tools (fried et al., 2001 ; mitnitski, mogilner, & rockwood, 2001) and current sensors to measure a person's activity. eventually, we are aiming for the detection of the frailty trajectory early on. for example, real-time activity monitoring is used to detect a fall and alert rescue. in our case, these sensors will allow us to identify as soon as possible a dimension that would be abnormal in order to intervene and propose an appropriate intervention. methods: our tool will be able to measure the five fried's frailty criteria which are currently used in clinical practice. we compare the data from the sensors with the results of the evaluation of fried's frailty phenotype. results: we expect to obtain a correlation between our data and phenotype results. conclusion: the main contribution of our tool resides in the possibility to observe deviations from an individual's normal aging trajectory. thus, the evaluation we propose would be more ecological as it will enable us to consider the individual's habits and to have a more detailed assessment of his activity evolution. in conclusion, the holistic aspect of our work will allow the practitioners to base their intervention on a wide range of health data. l. van wagenberg, r.m. wösten-van asperen (department of paediatrics, paediatric intensive care unit. wilhelmina children's hospital, utrecht, the netherlands) background: a frail phenotype is recognized in the elderly population. frailty is associated with a higher mortality for adult intensive care (icu) patients. research in oncology suggests biological age is not the key contributor to frailty, since frailty is also found in the younger population. in paediatrics frailty is an unknown concept and as a consequence, the prevalence and meaning of being frail at young age are unknown. objectives: to assess whether a possible frail phenotype can be found in a critically ill paediatric oncological population. methods: a retrospective cohort study in a paediatric oncological icu population between january 2018 and september 2019. demographic data and need for icu resources (mechanical ventilation, inotropic support and s60 continuous renal replacement therapy (crrt)) were collected. since specific paediatric frailty scores are not available, we addressed patients as having a frail phenotype by textmining their electronic health records on the words "fatigue", "cachexia" and "diminished physical activities" before, during, and after paediatric icu admission. risk factors for a possible frail phenotype (cachexia, use of corticosteroids and lowest serum albumin levels) were collected. primary endpoint was mortality during icu treatment or course of illness. results: 479 admissions were included, of which 74 admissions had a possible frail phenotype. these admissions included 52 unique patients. 52% of patients was male and the median age was 5 years (iqr3-15). patients were predominantly treated for a haemato-oncological malignancy (52%). mortality during icu-admission was 8%, and 23% died subsequently during the course of disease after picu discharge. patients were severely ill, with a mean icu length of stay of 9.9 days (±17), 53% on ventilator support, 34% receiving vasopressor or inotropic support, and 5% on crrt. loss of muscle function or fatigue was present in 54% before icu admission and in 35% acquired atrophy or cachexia was documented during icu treatment. 67% were treated with corticosteroids during picu stay. in 28% a serum albumin ≤2 gram/dl was measured. conclusion: a possible frail phenotype is present in the oncological patient population of a paediatric icu. more research on the contributing factor of frailty on outcome of these patients is needed in the near future. john muscedere 1,2 , amanda lorbergs 1 , jayna holroyd-leduc 3 , anik giguere 4 , leah gramlich 5 , heather keller 6 , ada tang 7 , danielle bouchard 8 , donna fitzpatrick-lewis 7,9 , diana sherifali 7,9 ((1) canadian frailty network, kingston, on, canada; (2) queen's university, kingston, on, canada; (3) university of calgary, calgary, ab, canada; (4) laval university, quebec city, qc, canada; (5) background: despite research evidence related to nutritional and physical activity interventions, there is a gap in provision of evidence-based care focused on preventing and managing frailty among older adults. objectives: to systematically generate evidence-based nutrition and physical activity (pa) clinical practice guidelines to improve health and functioning in older adults with or at risk of frailty. methods: we are using the agree ii guideline development protocol to generate guidelines to improve health and functioning in older adults. for each guideline, systematic review of meta-analyses was conducted by searching three databases for english language citations published since 2001 that included adults aged 65y and older with frailty and/or pre-frailty. nutrition or pa interventions with a comparison group were considered eligible. acceptable study designs included rcts, quasi-experimental trials, and observational cohorts with a comparison group. in a face-to-face meeting with multidisciplinary content experts, healthcare professionals, and end-users we will further appraise the quality and strength of the evidence using the grade approach. this group will use this evidence to form recommendations related to nutrition and pa in this population. results: the nutrition and pa searches resulted in 3158 and 4709 citations, with 119 and 283 eligible for full-text review, respectively. the results will inform guideline recommendations. knowledge translation strategies will be developed to support guideline dissemination and implementation. conclusion: the guidelines will inform health professionals by providing evidence-based nutrition and pa interventions for adults with frailty. ( background: physical and psychosocial factors play important roles in the severity and progression of frailty. frailty screening tools include measures of the more common risk factors, including advanced age, comorbidities, poor diet, weight loss, lower socioeconomic status, and physical inactivity. however, there has been limited standardization in the us on specific frailty screening measures to include in national health surveys or frailty tools/protocols for community health settings. this makes it difficult to monitor frailty incidence/prevalence in the older adult population and to best identify and treat individuals at risk. results: we reviewed the most recent versions of 7 us national health surveys that include older adults, to identify whether frailty screening measures were included in. no national surveys had a battery of measures that would allow for frailty risk screening. most commonly, questions on weight, disability, mental health, physical functioning were included. however, physical functioning measurements such as grip strength or gait speed, measured height and weight, unintentional weight loss, dietary intake or appetite changes were not. further, we used the world health organization criteria for effective community screening programs to review published evidence of the validity, reliability, and feasibility of data-driven screening tools for frailty risk among community-dwelling older adults. of the 10 frailty screening tools reviewed, the frail scale was identified as the most promising, based on test characteristics and cost/ease of use. more community-level s61 research is recommended, particularly on predictive validity of favorable outcomes following physical activity/nutritional interventions. finally, because nutrition plays a significant role in frailty risk, we surveyed registered dietitian nutritionists who work with older adult populations (n=576) to identify their awareness/use of frailty screening protocols/tools and dietitians' potential role in frailty screening. dietitians practicing in the community recognized a potential role, but few dietitians were aware of (<6%) or using (< 4%) specific frailty screening tools. conclusion: future opportunities to better support healthy aging include: addition of frailty screening measures to national health surveys to help prioritize high-risk populations, conduct additional research to validate/recommend a common community-level screening tool, and promote engagement by dietitians and other health professionals who can establish protocols for community-based frailty screening. ming-yueh chou 1,3 , ying-hsin hsu 1 , yu-chun wang 1 , chih-kuang liang 1,3 , li-ning peng 2,4 , liang-kung chen 2,4 , yu-te lin 1 ((1) center for geriatrics and gerontology, kaohsiung veterans general hospital, kaohsiung, taiwan; (2) aging and health research center, national yang ming university, taipei, taiwan; (3) department of geriatric medicine, national yang ming university school of medicine, taipei, taiwan; (4) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, functional decline and mortality, and multi-domain intervention program may prevent those. objectives: the purpose of this study is to evaluate the effectiveness of multi-domain intervention program among those community-dwelling frail older people in southern taiwan. methods: a 12 week multi-domain intervention program were provided for all participants, including physical activity, high protein diet education, medical knowledge education and cognitive simulation activity for 2 hours per week. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds-5), cognitive condition (by mmse) and frailty status according to the definition by the cardiovascular health study (chs) . results: during jan 2018 and may 2019, totally 386 participants were invited for study (75.9% female, mean age 76.0±7.1 years). among them, 31 (9.4%) were clarified as frailty status and 190 (57.4%) as prefrailty status. after the multi-domain intervention program, their mood condition (0.35±0.83 to 0.23±0.71, p<0.001) and cognitive condition (24.40±5.75 to 25.14±5.70, p<0.001) improved significantly. in addition, the walking speed (0.89±0.28 to 0.98±0.49 m/s, p<0.001) and physical activity (13.42±14.51 to 16.31±15.99 mets/week, p<0.001) improved, but not handgrip strength (p=0.850). for the frailty status, those clarified as frailty status decreased from 9.4% to 5.2% and prefrailty status from 57.4% to 41.4% (p<0.001). conclusion: our results showed that through the 12 week multi-domain intervention program, those frail older people could improve their mood condition, cognitive condition, usual gait speed and frailty status. sarah b. lieber 1 , stephen a. paget 1,2 , jessica r. berman 1,2 , medha barbhaiya 1,2 , lisa sammaritano 1,2 , kyriakos a. kirou 1,2 , john a. carrino 3 , dina sheira 1 , mangala rajan 2 , yingtong lyu 2 , lisa a. mandl 1,2 ((1) division of rheumatology, hospital for special surgery, new york, ny, usa; (2) department of medicine, weill cornell medicine, new york, ny, usa; (3) department of radiology and imaging, hospital for special surgery, new york, ny, usa) background: frailty is a clinical phenotype that increases with age, but can occur in younger patients with chronic disease. based on few studies, frailty has been found in up to 27.5% of patients with systemic lupus erythematosus (sle) and is associated with increased mortality. whether frailty is prevalent in other sle cohorts and associated with objective and subjective factors is unknown. objectives: we aimed to determine the prevalence of frailty in a prospective cohort of women with sle and whether inflammatory biomarkers, body composition, and patient-centered domains differed between frail and non-frail women. methods: adult women <70 years old who fulfilled american college of rheumatology sle criteria were recruited from one center. exclusions included pregnancy, dialysis, active malignancy, overlap autoimmune syndromes, and severe sle disease activity. frailty was measured according to fried criteria. patient-reported outcomes (pros) were measured using pro measurement information system (promis) computerized adaptive tests; lupusqol; and disability based on valued life activities. physicianreported sle disease activity and damage indices were collected. inflammatory biomarkers and sarcopenia according to dual-energy x-ray absorptiometry were assessed. differences between frail and non-frail women were evaluated using chisquare tests and kruskal-wallis tests; the association between frailty and disability was determined using logistic regression. results: 71 women enrolled from 8/2018-9/2019. despite age under 70 years old, 21% were frail. frail women had greater disease damage (p=0.01) and were more often smokers (p=0.03). high-sensitivity c-reactive protein (p=0.05) and interleukin-6 (p=0.01) were higher and sarcopenia trended toward greater prevalence (p=0.07) in frail women. significant differences in promis mobility, physical function, pain interference and behavior, and fatigue and lupusqol physical health and pain (all p<0.01) were observed between frail and non-frail women, with frail women reporting consistently worse scores. frail women were 9.5x more likely to be disabled than non-frail women, including after adjustment for age, comorbid conditions, and disease activity/damage. conclusion: the prevalence of frailty was high in this cohort of mid-aged women with sle. frail women had poorer health-related s62 quality of life than non-frail women, including substantially higher disability. if frailty is associated with worse health outcomes, it could be a potential therapeutic target. chariya sumcharoen, supreeda monkong, nuchanad sutti (ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bangkok, thailand) background: bed bound older adults need caring of physical activities, mental, mood, and social from family caregivers. family caregivers usually gets the role strain from caregiving. there are many factors associate with the caregiver role strain but have been rarely reported in bed bound older adults at home. objectives: the study examined age, adequacy of incomes, mutuality, health status, preparedness, and social support influencing caregiver role strain from caregiving activities for bed bound older adults at home. methods: caregiver role strain concept by archbold and colleagues with literature review were used to guide this study. the sample was recruited by purposive sampling consisted of 117 caregivers aged 18 years or older, who have cared for bed bound older adults at home in thailand. data were collected by structured interview using the questionnaires including demographic data, preparedness, health perception, mutuality, social support, and caregiver role strain from the care activities. data was analyzed using descriptive statistics, pearson's product moment coefficients, and multiple regression analysis. results: the most of participants were women (78.33%), age ranging from 26 to 85 years (m= 56.23, sd=11.57) . the result showed that age, adequacy of incomes, mutuality, health status, preparedness, and social support jointly significantly explained 31.9 % of the variation in caregiver role strain from caregiving activities. the regression effects were strongest for health status (beta=-.285, p=.001), followed by preparedness (beta=-.254, p=.002), age (beta=.220, p=.008), and adequacy of incomes (beta=-.214, p=.014) respectively. conclusion: this finding suggests that healthcare providers should find strategies for promoting health status and preparedness of family caregivers for decrease caregiver role strain from caregiving activities. of life, and hospital admissions. objectives: we estimated the prevalence and describe the characteristics of the population with recurrent falls and fear of falling and their association with frailty, physical performance and cognitive fragility. methods: data came from the "salud, bienestar y envejecimiento" (sabe) colombia study, a cross-sectional study conducted in 2015 at the urban and rural research sites (244 municipalities) in colombia. sociodemographic, health, cognitive and anthropometric measures were collected from 23694 community-dwelling adults aged 60 years and older, representative form the total population. frailty was defined using the frailty phenotype proposed by fried. cognitive frailty was defined using the inaa/iagg consensus definition. low performance was evaluated with sppb (short physical performance battery). logistic regression analyses were used to identify factors associated with recurrent falls and fear of falls. results: our study identified 603 elderly who had recurrent falls and 1193 fear of falling (15.6% and 39.5% respectively). young elders (≤ 69 years) had more falls and greater probability for fear of falling compared to older ages. sex had no significant differences. the factor associated with an increased risk of recurrent falls and fear of falling in the elderly were low physical performance, fragility and polypharmacy. chronic illness such as osteoarticular disease, mental disease, diabetes and chronic pulmonary disease were significantly associated with recurrent falls and fear of falling. finally, when adjusted for age, sex, sociodemographic factors and comorbidities in a logistic regression model, frailty was associated with fear of falling and recurrent falls, while cognitive frailty and low physical performance only were associated with fear of falling. conclusion: recurrent falls have a significantly association with frailty. there are cognitive, physical performance and clinical factors associated with fear of falling that could be preventable and treatable. rubbieri gaia 1 , ceccofiglio alice 1 , mazzeo nicla 1 , pupo simone 2 , cartei alessandro 1 , rostagno carlo 1 , mossello enrico 2 ((1) department of perioperative medicine, careggi hospital and university of florence, italy; (2) department of geriatric medicine, careggi hospital and university of florence, italy) background: the prevalence of frailty in patients with hip fracture is high, but little is known about the choice of the best frailty tool in terms of prediction of functional recovery. objectives: the aim of this preliminary study was to determine the most predictive validated frailty tool in older people with hip fracture and to determine whether frailty can predict functional recovery during the hospital acute phase. methods: this study was observational prospective cohort study. participants aged 65+ admitted to hip fracture units in florence, were assessed pre surgery (t0), and post surgery. each participants underwent a comprensive geriatric assessment and frailty was defined using: clinical frailty scale (csf), frail scale (fs), reported edmonton frail scale (refs), postal frailty screening (pfs). the outcome was functional recovery, evaluated by a score of postoperative performance on the cumuleted ambulation score (cas). data recorded included pre-recovery barthel index (bi), charlson comorbidity index (caci), handgrip strenght test (hg), asa score, mini nutritional assessment short-form (mna-sf), delirium. results: sample included 114 patients (mean age 85±8 years, female 75.4 %). cfs was the most predictive frailty tool, with a 88% sensitivity and a 50% specificity (auc = 0.80, cut off >3). dividing the sample according to premorbid bi, while bi itself had the highest predictive value when premorbid level was <80%, cfs was the best predictor of functional outcome in the 80%+ subsample (auc= 0.67). conclusion: frailty defined by cfs can predict short-term functional recovery during acute phase following hip fracture. this appears particularly relevant for subjects with a higher pre-morbid functional independence. s64 52% were women. 385 individuals had data for all five frailty measures. nine percent of participants were non-frail by all instruments, 20 % were frail by all measures and thus 71 % had discordant frailty measurements. 91% were frail by at least one measure method. the prevalence of frailty ranged from 34 % to 75% for the different measures. those classified as frail by cfs and non-frail by bp were more likely to be men, be co-living, have lower cognitive function and a higher dependency in iadl compared to those classified as frail by bp and non-frail by cfs. conclusion: frailty measures cannot be used interchangeably. specifically the cfs might not identify physical frail women, with high cognitive ability who lives alone. factors contributing to the heterogeneity of groups classified as frail by different measures need to be further explored. background: polypharmacy is increasingly common amongst older, multimorbid adults. in these individuals, studies have shown a high prevalence of frailty. identification of frailty can be performed using comprehensive assessments registering accumulation of deficits like in the frailty index, or using single-trait markers of frailty like gait speed and handgrip strength. polypharmacy is recognized as an independent risk factor for the development of frailty, and the subgroup of psychotropic drugs may be particularly important in the development of this syndrome. objectives: our objectives were to study the relationship between the total burden of polypharmacy on frailty status using three different measurements of frailty, and specifically the influence of psychotropic drug use on frailty status. our overall aim was to explore whether either of these could be used as independent predictors of frailty. methods: we used data from a 2-year follow-up study of older people living in the community and receiving home care nursing, i.e. the cascade-study. data collection was completed in june 2018. all 210 participants were aged >65 years (mean 84 years). a 34 item frailty index was calculated based on results from a comprehensive geriatric assessment performed in the patients' own home. a fourmeter gait speed test was performed, as well as measurement of handgrip strength. information on regular medications was collected from the patients if they administered own medications, or from the home care nursing service if they were responsible for administering the patients' medications. psychotropic drugs were selected based on beers 2019 criteria. results: we found a significant association between the use of psychotropic drugs and frailty index, and frailty index increased by 0.03 for each psychotropic drug added (p<0.001). one additional psychotropic drug decreased gait speed by 0,03 m/s (p<0,05). there was no statistically significant association between psychotropic drug use and handgrip strength. conclusion: our study showed that psychotropic drug use was a significant predictor of increased frailty index and reduced gait speed. this was not the case for handgrip strength in our material. laetitia beernaert 1 , frédéric schuind 2 , sandra de breucker 1 ((1)department of geriatrics, hôpital erasme -université libre de bruxelles, belgium; (2) department of orthopedics, hôpital erasme -université libre de bruxelles, belgium) background: anemia is a condition whose prevalence might reach 50% in the geriatric population. anemia and frailty are two prognostic factors for patients admitted for a hip fracture. objectives: we analyzed retrospectively if preoperative frailty and anemia were independently predictive of postoperative complications and mortality in old patients admitted for hip fracture. methods: ninety-seven patients above 65 years old have been admitted for urgent surgery for a hip fracture during 2016 and 2017. we excluded patients with a pathological fracture or fractures due to high energy trauma. preoperative anemia was defined as an hemoglobin level under 12g/dl for women and 13g/dl for men. frailty was assessed with the isar (identification of seniors at risk) score. results: seventy-five percents of patients were considered as frail (isar score>2). the prevalence of preoperative anemia was 37%. we found no statistically significant correlation between anemia and frailty (r = -0.18-p = 0.071). in multiple regression logistic analysis, the only independent parameter associated with anemia was the presence of comorbidities (or 1.12 (1.04-1.20)-p = 0.02), and the only parameter associated with frailty was the presence of malnutrition (or 28.2 (2.8-28.9)-p = 0.005). neither anemia nor frailty was associated with postoperative complications and mortality. conclusion: preoperative anemia and frailty are not interrelated in patients admitted for hip fracture. anemia is associated with comorbidities, but not postoperative mortality. frailty is associated with preoperative malnutrition. the isar score may not be ideal to screen for frailty in old patients admitted for hip fracture, an item being attributed to the current loss of autonomy. settings. m martinez 2 , maria montoya 1,2 , davide angioni 1 , lizeth canchucaja 2 , natalia ronquillo 3 , maria luz gallego 2 , claudia bejar 4 , emmanuel gonzalez 2 , olga vazquez 2 , anna renom 2 ((1) institute de viellisement toulouse, france; (2) hospital del mar, barcelona, spain; (3) hospital de terrasa, barcelona, spain; (4) parc tauli, barcelona, spain) background: frailty is a common critical geriatric syndrome which has been associated with poor health outcomes.a wide variety of frailty indices (fis) have been developed. frail-vig («vig» is the spanish/catalan abbreviation for comprehensive geriatric assessment).it contains 22 simple questions that assess 25 different deficits. it has been inspired by the rapid geriatric assessment. objectives: the aim is to compare the prediction capacity of clinical rockwood index frailty (rif) and frail-vig index (vif) for poor health outcomes (pho) defined as: emergency department visits and/or hospital admission and/or mortalityamong elderly patients. methods: a retrospectiveobservational study was conducted with a followup up to 15 months or pho occurred. patients were admitted in acute geriatric unit care and geriatric day hospital at hospital del mar; barcelona; spain during august 2018 and march 2019. the inclusion criteria were the admission ones. frailty was measured at admission. survival analysis was conducted; cox proportional hazards regression was used to build a pho predictive model based on both indexes. best model according to contrast of hypothesis log-rank ,aic; bic and c harrel was selected.diagnoses of the chosen model was done. results: a total of 49 patients were included, mean age was 78 and 46.9% female. the mean of follow-up was 9.78 , 51% patients presented a pho. 24.4% died, 32% were admitted at emergency department, 26.5% were hospitalized and 22% presented more than one event.survival curves for frail and non-frail according to pho showed statistically significance for vif (x2=6.77 p=0.0093)but not for rif (x2=0.62 p=0.4315). cox proportional hazards regression showed vif hazard ratio 3.44 (p=0.0406) and rif hazard ratio 1.27 (p=0.607). predictive capability resulted in a model for vif containing cognition and sex, with harrel c of 0.735. as for rif the most parsimonious model rif would be absent and harrel c 0.503. the diagnoses of the model showed time covariate variable test with p=0.429, p=0.297, p=0.640 for each predictive variable; squared linear predictor with p=0.39 of and 2 outliners. conclusion: the vig frailty index performed better; compared to rockwood clinical index; in predicting a composite outcome composed by mortality, hospitalization and visits to emergency departments in patients admitted in acute and outpatient settings. after hospital discharge. methods: this study was conducted in the departments of internal medicine and neurology of the university hospital of araba (basque country, spain). participants were >=70 years, scoring >=20 on the mmse test and able to stand and walk independently for at least 4-meter. participants performed twice-weekly moderate intensity group sessions of multicomponent exercise at the hospital during 12-week, followed by a home-based intervention (12week) . both were focused on balance, aerobic capacity and strength. taking together both interventions, participants completed 24-week of physical exercise. at the beginning and the end of the program, frailty was measured though fried´s index1 and sarcopenia with different criteria2: muscle strength (5-chair stand), muscle quality (dxa) and physical performance (sppb). we compared the results before and after the intervention by mcnemar test. results: 55 patients (27 females, 49%) were enrolled, 26 were lost to follow-up at the 24-week time point and 29 people finished the intervention. the intervention decreased significantly the percentage of frail individuals (p<0.001) according to fried´s index, and the percentage of people who met sarcopenia criteria for sitto-stand (p=0.031) and sppb (p=0.031). however, there were no differences in the percentage of people with low appendicular muscle mass. conclusion: our study showed that a multicomponent exercise program is effective for posthospitalization patients because after 24-week intervention there were significant reductions in frailty and improving results in muscle strength and physical performance. we did not find changes related to muscle mass. references: 1. background: alcohol addiction can impact every part of the body, including bones. research shows that chronic heavy alcohol use, especially during adolescence and young adult years, can dramatically affect bone health and increase the risk of osteoporosis and bone fracture later in life. objectives: the purpose of this study is to compare data from international scientific literature with data from the study of patients admitted for alcohol dependence, to assess whether there are significant connections between alcohol dependence and unrecognized fractures. methods: we analyzed 34 meta-analysis's studies from the pubmed search engine to evaluate the association between bone fractures with alcohol use disorders. only humans studies from the last 5 years have been analyzed. subsequently, data related to patients admitted for an alcohol rehabilitation cycle were analyzed. results: scientific literature show that there is a close correlation between alcohol abuse and greater frequency of bone fractures. this is partly due to association between alcohol consumption and both osteoporotic fracture and bone density, and partly to the fact that there is an increased risk of falls in alcohol intoxicated patients compared to the general population. 1145 patients were considered: 71% male and 28.2% female. the average age was 48 years. of these 1145, 5.38%, 61 patients, had unrecognized fractures. conclusion: intoxicated patients admitted in alcoholic rehabilitation with recurrent falls anamnesis often did not perform any diagnostic assessment. this is due to the lack of pain perception in the patients or due to family members or emergency physicians who placed the state of drunkenness before any consequences caused by repeated falls. there is an increased risk of unacknowledged fracture in the patients admitted in alcohol rehabilitation this is partly due to the fact that alcohol intoxicated patients often do not perceive the pain and therefore do not investigate any falls that occurred in a state of drunkenness, in part it is due to the damages that alcohol causes on the bone. our data show that alcohol dependence and unrecognized fractures can often be associated. studies in the literature confirms that there is an increased risk of non-cone fractures in patients with alcohol dependence. zamudio-rodríguez, hélène amieva, luc letenneur, karine pérès (centre de recherche inserm u1219 université de bordeaux -isped, bordeaux, france) background: although conceptually distinct, frailty and disability are very common among older adults. both are multifactorial conditions and share some risk factors and pathophysiological mechanisms, such as inflammation or sympathetic-parasympathetic balance alteration. furthermore, each individual component of the frailty phenotype defined by the cardiovascular health study (chs) has been associated with disability in basic and instrumental activities of daily living. objectives: the present study aimed to determine whether pre-frail and frailty are part of the natural history of the disability process. methods: a sample of 894 people aged 75 of the three cities (3c) study in bordeaux were followed for four years. pre-frailty and frailty were defined according to the original phenotype proposed in the chs. disability was defined using the basic (adl) and instrumental (iadl) activity of daily living scales. seven mutually exclusive hierarchical groups were distinguished at inclusion: 1) robustness (no frailty or disability); 2) pre-frail (without disability); 3) frailty (without disability); 4) iadl (without pre or frailty or adl) 5) pre-frail with iadl (no adl); 6) frailty with iadl (no adl); 7) frailty with iadl and adl. results: 177 deaths (19.8%) occurred during the four years follow-up. compared to the robust group, all other hierarchical subgroups had an increased risk of death, with an increasing gradient: pre-frailty (hr= 1.84; ic 95 %= 1.00 -3.39); frailty (hr= 3.46; ic 95 %= 1, 53) , iadl disability (hr = 3.21; ic 95 %= 1.28 -8,05); pre-frailty with iadl disability (no adl) (hr= 4,08; ic 95%= 2,16 -7.70); frailty with iadl disability (no adl) (hr= 5,42; ic 95%= 2.84 -10.34); frailty with iadl and adl disability (hr= 10,58; ic 95%= 5.39 -20.77) were significant after adjustment by age and sex. conclusion: there is a gradual risk of mortality across the different groups ( i.e., 1) robust; 2) pre-frail; 3) frail; 4) iadl disability without pre or frailty; 5) pre-frail with iadl disability; 6) frail with iadl disability; 7) frail with iadl and adl disability) thus suggesting a hierarchical relationship. this study could have important clinical implications since pre-frailty and frailty are assumed more effectively reversible conditions in order to interrupt the continuum at the early phase of the disability processes. background: joint replacement provides significant improvement in pain, physical function, and quality of life in patients with osteoarthritis. with a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty in joint replacement patients is feasible and improves post-operative outcomes. objectives: to examine the feasibility of a preoperative multi-modal frailty intervention (mmfi) compared to usual care in pre-frail/ frail older adults undergoing elective unilateral hip or knee replacements. methods: in this pilot randomized controlled trial (rct), participants who are 1)>=65 years old; 2) pre-frail (score of 1-2; (fried frailty phenotype (ffp)) or frail (score of 3-5; ffp); 3) having elective unilateral hip or knee replacement with surgery wait times between 3-10 months were recruited from the regional orthopaedic clinic mcmaster university, ontario canada. the mmfi included tailored exercise, protein (20-40 gm/day), vitamin d (1000 iu/day) supplementation, and medication review with recommendations sent to family physicians. frailty and mobility were assessed at baseline and 6-weeks post-operative using ffp, short performance physical battery (sppb) and oxford hip/knee score (ohs/ oks) respectively. results: we recruited and randomized 69 participants between september 2016 and may 2018. of those, 78.3% were referred for total hip replacement and 21.7% for knee replacement. the included participants' mean age (standard deviation (sd)) was 73.9 (7.5) years; 68.1% were women; 30.0% lived alone, body mass index was 31.9 kg/ m2 (7.2) and 44.9% were former smokers. at the baseline assessment, on the ffp, 64% were prefrail, 36% were frail and the sppb was 7.0 (2.2). for participants with hip osteoarthritis, ohs mean (sd) was 19.5 (7.3) and for participants with knee osteoarthritis, oks mean (sd) was 24.5 (7.2). the study recruitment rate was 54.8%, and the retention rate was 87%. eighty three percent of participants of the intervention group completed the intervention. self-reported adherence to the intervention components was as follow: 1) exercise sessions: 68.4%, 2) protein supplement: 87.5%, 3) vitamin d supplement: 85.7% and 4) medication review completion: 100%. conclusion: this is the first study to examine the feasibility of a multi-modal frailty intervention in pre-frail/frail older adults undergoing joint replacement. this study showed that frailty screening, assessment and management is feasible for older adults undergoing joint replacement in orthopaedic surgery clinics. results have informed the current multi-centre rct to determine effectiveness. christine tocchi 1 , sathya amarasekara 2 , michael cary 3 ((1) school of nursing, duke university durham, nc usa; (2) school of nursing, duke university durham, nc usa; (3) school of nursing, duke university durham, nc usa) background: inpatient rehabilitation facilities (irfs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients to the community. determination of eligibility for irf is currently based on preadmission screening. subpopulations of older adults may require special consideration in determination of irf admission due to greater risk for poor functional recovery such as those with pre-existing functional limitations and those who are frail. frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing discharge destination outcomes in irfs. objectives: 1) determine the prevalence of frailty among older adult with hip fracture receiving inpatient rehabilitation; and 2) determine the association between frailty and discharge destination among hip fracture patients receiving inpatient rehabilitation. methods: a retrospective cohort study design using cms 2014 inpatient rehabilitation facility-patient assessment instrument file. multivariate regression models were performed to examine the association between frailty and discharge destination. frailty status was measured using a frailty index of 30 items with the following cut-off points: 0 -0.20 robust/non-frail; 0.20 -0.35 pre-frail; and 0.35 or greater as frail. the final sample included 26,134 hip fracture patients. results: frailty, pre-frailty, and nonfrail were present in 0.33% (n=86), 7.6% (n=1976), and 92% (n=24071) of hip fracture patients, respectively. the majority (65%) of the frail hip fracture patients were discharged home. there were significantly greater proportion of females than males discharged home and those of white race, 65 to 74 years of age, and with higher functional status. regression analysis showed significantly lower functional status at discharge (p < .0001) for patients with these characteristics: males, non-white race, and older age. additional factors that influenced discharge destination included: marital status, living in the community prior hospitalization, and length of stay. conclusion: frailty was the most common frailty status on admission to irf. home is the most common discharge destination for all frailty status groups. frailty status could be used to identify hip fracture patients at high risk for adverse outcomes. future studies should be used to explore the potential of frailty to provide valueadded utility to clinical settings such as irfs. background: front-line care providers are seeking direction on how frailty measures may be integrated into existing or future care pathways to enhance the experience of individuals who live with it. multidimensional frailty measures such as the edmonton frail scale offer the potential for case-finding, estimation of severity, and definition of frailty components. objectives: test the feasibility of the implementation of a multidimensional frailty order set into acute care. methods: in 2016, we conducted a literature search to identify existing frailty guidelines and systematic reviews related to frailty in acute care. an expert panel graded the quality the evidence, then generated recommendations, graded by strength to inform the generation of a clinical knowledge and content management (ckcm) topic for dissemination throughout alberta health services (ahs). ahs is the largest province-wide, fullyintegrated health system in canada. this ckcm would include graded statements and recommendations, clinical decision support, electronic alerts, and a frailty order set. results: four guidelines, 60 systematic reviews, and one scoping review informed the development of the frailty ckcm. from this, we developed eight recommendations, covering topics such as prevention, case-finding, estimation of severity, definition of components, triggers for expert assessment, and linkage to care processes. the recommendations also addressed safeguards to avoid labelling and other unintended consequences. an order set employs the clinical frailty scale, electronic frailty index, and edmonton frail scale to support a clinician to develop a personalized care plan. the order set empowers front-line clinicians to administer these frailty measures, based on cut points that prompt personalized recommendations on diet, activity, fall prevention, bladder management, and infusions. depending on the frailty component of concern, clinicians are also prompted with specific options to address cognitive impairment, functional dependence, falls and immobility, social isolation, nutritional risk, polypharmacy, urinary incontinence, chronic pain, and constipation. in preparation for the conversion to a province-wide electronic medical record (emr) in november 2019, the ckcm was released in may 2018 and the frailty order set was built into the emr by september 2019. conclusion: development and implementation of a multidimensional frailty order set in the setting of acute care is feasible. masayo kojima 1 , toshihisa kojima 2 , yuko nagaya 3 , yasumoto matsui 1 ((1) national center for geriatrics and gerontology, obu, aichi, japan; (2) nagoya university, nagoya, aichi, japan; (3) nagoya city university, nagoya, aichi, japan) background: prevention programs for frailty at community usually target healthy older people. to further prolong healthy life expectancy, we need to approach those who already have got chronic diseases such as rheumatoid arthritis (ra). objectives: the aim of this study is to assess the prevalence and factors associated with frailty in japanese ra patients. methods: ra patients aged 40-79-yearold who visited two university hospitals between march and july 2019 were consecutively invited to join the study. those who agreed to participate the study provided written consent forms. frailty was assessed by the total score of the kihon checklist >=8. self-report questionnaires were used to evaluate patients' demographic characteristics, perceived degree of pain, depression (the beck depression inventory-ii) and physical function (the health assessment questionnaire, haq). rheumatologists' global assessment of disease severity, swelling and/or tender joint counts, years of ra duration, frequency of arthritis surgery and crp level were also measured. results: total of 389 ra patients were included in the study (312 women, average age: 64.5 ± 9.7 years, average disease duration: 15.8 ± 11.8 years), and the prevalence of frailty was 25.6%. the higher the age and the longer the duration of the disease, the higher percentage of ra patients with frailty was observed. 18.4% among ra patients of working age (40-64 years), were frail, whereas 28.0% and 39.3% were frail among those aged 65-74 years and >=75 years, respectively. stepwise logistic regression analysis revealed that age, haq, depression severity and trust in neighbors were independently associated with frailty in ra. no significant gender difference was observed. conclusion: frailty is common even among working age in ra patients. physical function, depression and social capital were suggested to be independently associated with frailty. on-going followup study will disclose the influence of frailty on fracture, dependency, and mortality among ra patients. background: frailty is an important modulator of ageing and might impact on clinical presentation and progression of parkinson's disease. objectives: to evaluate the prevalence of frailty and correlation with motor and non motor symptoms as well as mri atrophy and white matter hyperintensities in parkinson's disease. methods: consecutive parkinson's disease patients underwent a comprehensive motor and non motor evaluation and geriatric assessment using multidimensional prognostic index (mpi). a subset of 60 patients underwent mri with assessment of atrophy and white matter hyoperintensities by visual rating. results: 125 pd outpatients (mean age 69.5 y, mean disease duration 4.6 years) entered the study. pre-frailty assessed by mpi was presented by 20% of patients and correlated with age and disease duration. when adjusting for these ariables, mpi correlated with updrs-iii, non motor symptoms assessed by umsar, prevalence of prevalence of orthostatic hypotension, rbd and depression. the mri assessment showed a correlation between global atrophy and frailty indipendently from mmse and educational levels. no association between frailty and wm hyperintensities was found. conclusion: frailty is a possible important modulator of pathology and brain vulnerability in parkinson's disease and could explain different severity in motor and non motor symptoms. longitudinal studies are warrented to evaluate the impact of frailty in disease progression. background: accidental falls in older adults have been associated with worse health-related outcomes especially in the frailest individuals, such as nursing home (nh) residents. in this special population of older adults, falls have been related to greater morbidity and mortality, but their impact on nutritional status is still unclear. moreover, so far there are no data on the potential role of unmodifiable (e.g. cognitive impairment [ci] ) and modifiable factors (e.g. assistance from informal caregivers) in influencing the impact of falls on nutritional status in older residents. objectives: we aimed to evaluate the changes in body weight during the six months after the occurrence of a fall in nh residents, and the possible influence of severe cognitive impairment, depressive symptoms and of the assistance from informal caregivers on such variations over time. methods: the sample included 148 older residents who experienced at least one fall since nh admission. for each participant, we collected data on sociodemographic information, mean frequency of visits from informal caregivers, medical history, and cognitive and functional status at nh admission. severe ci was defined as the presence of a physician-based diagnosis of ci or a mini-mental state examination <18 points. the frequency of the visits from informal caregivers was categorized as none or 1 (low) vs >1 (high) per week. falls' date and characteristics were obtained from structured forms completed by physicians. monthly body weight in the six months before and after the fall were derived from the nh medical records based on nurses' assessments. linear mixed models were used to evaluate the body weight changes after a fall, as a function of the presence of severe ci and low visits' frequency from informal caregivers, alone or in combination. results: the mean age of our sample was 81.8±8.4 years and 72% were women. more than half (54.7%) of residents involved had severe ci and 51.7% had low visits' frequency from informal caregivers. after adjusting for potential confounders, the presence of severe ci (b=-0.4, se=0.1, p<0.001) and the report of low visits' frequency from informal caregivers (b=-0.2, se=0.1, p=0.03) were associated with steeper decline in body weight during the six months after the fall. when combining these variables, we found an additive effect of severe ci and low visits' frequency from informal caregivers in influencing weight loss (b=-0.44, se=0.13 for residents with severe ci and high visits' frequency, and b=-0.65, se=0.13 for those with severe ci and low visits' frequency; p<0.001 for all). conclusion: our results suggest that cognitive impairment may worsen the impact of falls on nutritional status in nh residents, and that this effect may be exacerbated by scarce assistance from informal caregivers. (2) tokyo women medical university, tokyo, japan, japan; (3) department of geriatic medicine, kyorin university medical hospital, tokyo, japan; (4) tokyo metropolitan institute of gerontology, tokyo, japan) background: in consideration of the future rapid aging of the society, to achieve healthy and active aging is indispensable. because especially the major issue is to prevent "multi-faceted frailty", it is necessary to reconsider regarding nutrition, physical activity and sociality/sociability in the elderly. sarcopenia is associated with adverse health outcomes, such as frailty, limited physical function, falls, disability and loss of independence. objectives: our aim to notice evidencebased new information, leading to frailty prevention, and let the community-based activity by elderly citizen only promote as a voluntary motion in each community. methods: we have already established many new evidences from our on-going japanese large-scale longitudinal study 'kashiwa study'. these evidences include the impact of overlapping of slight oral dysfunction, namely "oral frailty", as well as unbalanced diet and inadequate physical activity in early-stage sarcopenia. furthermore, we found the negative impact of several social disengagements including eating alone, so-called "social frailty", leading to subsequent sarcopenia. we developed a simple screening tool, ''frailty check-up activity'', which elderly citizen supporters only can operate in each small gathering place (e.g. community salon) via support by its local government. results: based on the concept of all-including three pillars, 1) nutrition (i.e. dietary food intake including diversity and adequate protein intake, and treatment/maintenance against oral frailty), 2) physical activity (not only exercises but also social daily activity) and 3) social participation, the newly citizen activity ''frailty check-up'' has developed. after elderly citizen supporters received training fully, they could implement this activity completely and repeatedly in each local municipality. elderly participants could learn how to improve/conquer by themselves with raising their self-awareness for the importance of early frailty/sarcopenia prevention and could change their behavior modification. in addition, using big data combined with preexisting database of new-onset regarding care needs and/or all-cause mortality, we found the new cut-off point in our frailty check-up activity. conclusion: we could confirm that our interdisciplinary "action-research" can raise the citizen's early awareness and affect their behavior modification via elderly citizen supporter system for frailty prevention, consequently leading to extend healthy life expectancy. saguez, carlos márquez, bárbara angel, mario moya, lydia lera (inta, universidad de chile, santiago, chile) background: physical phenotype of frailty has been associated with quality of life deterioration and some studies have calculated cost-effectiveness of interventions on frailty in quality-adjusted life years (qalys), however studies on the direct burden of frailty expressed in qualys lost in community dwelling older adults are scarce. objectives: to forecast qalys lost caused by frailty in older chileans and describe health profiles as determined by euroqol (eq-5d) in community-dwelling older chileans with and without frailty. methods: cross sectional study in 630 (72,4% women, mean age 72y±6.7) community dwelling people >=60years participants in alexandros cohorts. the frailty phenotype was defined as having >=3 from the 5 following criteria: weak handgrip dynamometry, unintentional weight loss, fatigue/ exhaustion, five chair-stands/slow walking speed and low physical activity. qol was evaluated trough euroqol (eq-5d) five dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/depression and self-rated health trough eq5-visual analogue scale (eq-5d-vas). qualys were calculated by the eq5-d time trade-off (tto) method. to estimate life expectancies (le), multistate methods based on the follow-up of alexandros cohorts, were employed. results: frailty was identified in 31,7% of the sample. selfrated health according to eq-5d-vas was lower in frail than non-frail people (63.9±21.2 vs 73.6±18.0, p<0,01). after adjusted multinomial logistic regression, the eq-5d dimensions of anxiety/depression (very depressed rrr= 6.24;95%ci:2. moderate rrr=4.19; 95%ci:2, 23) and pain (much pain rrr=7.89; moderate pain rrr=2.44; had the highest association with frailty. the valorisation of years in qualys was lower in frail than in non-frail people (0.77±0.29 vs. 0.87±0.23 qalys per year, p<0,05) and among those frail, much lower in people >=80y than in the group 60-69y (0.48±0.30 vs. 0.83±0.26, p<0,05). the qualys remaining years were lower in frail people than in non-frail:total le at 60-69y was 22,5y corresponding to 18,8 qalys in frail and 20,5 qalys in the non-frail; in the group >=80y tle was 8,3y corresponding to 3,98 qalys in frail people and 6,72 in the non-frail. conclusion: the high burden of frailty on qalys, mostly related to pain and anxiety/depression makes compulsory its early detection and treatment. its knowledge allows calculating cost-effectiveness of interventions. background: + agil barcelona is a real-life a multicomponent intervention against frailty implemented in a primary care center, which promotes a comprehensive and coordinated approach between primary care, geriatrics teams and community resources, to detect and reverse frailty in the older adults. objectives: we aimed to assess the 3-months impact on physical function of +agil barcelona in community-dwelling frail older adults with cognitive impairment. methods: the study population was driven from the +agil barcelona program population. we included participants with cognitive impairment or dementia past history and those who performed a minicog test < 3 points. after frailty screening by the primary care team, a geriatric team performed the comprehensive geriatric assessment. according to cga results, a tailored and specific multidisciplinary intervention for each person was designed. the intervention could include a) multi-modal physical activity (pa) sessions, b) promotion of adherence to a mediterranean diet c) health education and d) medication review. the physical performance was assessed at baseline and at 3-omths follow-up by the short physical performance battery (sppb) and gait speed. the pre/post intervention analysis was done by a paired sample t-test for repeated samples for continuous variables and chi-square for categorical variables. results: we included 54 participants (mean age= 82.2±5.2, 70.2% woman and 29.8% lived alone). despite being independent in daily life, 36.8% had fallen the past year, 77.2% were vulnerable or frail according to the csf. physical performance was impaired: sppb=7.29±2.5 and gait sped=0.67±0.20m/sec and 46.9% had balance impairments. after 3 months, 73.2% of participants completed >=7.5 physical activity sessions. the mean improvements were +1.15±1.27 points (p<0.001) for sppb, +0.06±0.12 m/ sec (p<0.001) for gait speed, -4.4±8.53 sec (p<0.001) for chair stand test, and 47.6% (p 0.001) improved their balance. additionally, psychoactive treatment was withdrawn in 25.9%. conclusion: according to our results, a multidisciplinary and comprehensive geriatric intervention for frail elderly people with cognitive impairment of the community improves physical function and could reverse fragility at 3 months. clarence mwelwa patrick chikusu, amritha narayanan, joel james (ashford and st peter's nhs foundation trust, chertsey, uk) background: frailty and muscle strength are a critical component of walking ability and presence of these can result in high prevalence of falls. it also results in increased morbidity and mortality among the elderly. despite sarcopenia being very common and a reversible condition in its early stage it is a frequently overlooked and undertreated geriatric syndrome a greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. objectives: this study aimed to assess the current knowledge about the concept of sarcopenia and frailty among the healthcare professionals working in an nhs district general hospital in surrey. methods: this longitudinal study included nhs healthcare professionals (n = 50) who were asked to complete a questionnaire regarding awareness of concept, risk, diagnostic strategy and management of frailty and sarcopenia. results: 63.27% of healthcare professionals stated to know the concept of sarcopenia, 20% indicated to know how to diagnose sarcopenia and 20% had seen patients with suspected sarcopenia in the last one month. only 20 % knew the risk associated with sarcopenia. 83.33% used sarc f questionnaire as diagnostic method for sarcopenia. 100 percent of the cohort experienced bottle necks during the implementation of diagnostic strategy. lack of awareness and time (41.76%) was the main reason for this .97.96 percent heard the term frailty and 76.16% knew that sarcopenia and frailty is not the same .77.55 percent was aware of the scoring methods for the frailty and 76.32 % used clinical frailty score as the method. 65.31% was aware of the frailty pathway but only 53.06% knew whom to contact regarding managing frailty. 57.14% heard the term comprehensive geriatric assessment. only 24.49% was aware of key recommendations of managing frailty in the acute settings. conclusion: although concept of sarcopenia and frailty is familiar to most nhs healthcare professionals, the practical and clinical application is limited due to a lack of awareness regarding the diagnostic methodology, risks as well as time constrains. as such the benefits and potential treatment options may be overlooked and we aim to improve awareness so that these measures can improve outcomes for patients. mahtab alizadeh-khoei 1 , fatemeh sadat mirzadeh 1 , reyhaneh aminalroaya 1 , fati nourhashemi 2 ((1) gerontology & geriatric department, medical school, tehran university of medical sciences, ziaeian hospital, tehran, iran; (2) department of internal medicine and clinical gerontology, toulouse, france) background: frailty is a potentially reversible geriatric syndrome associated with geriatric risk factors. detecting risk factors is a useful purpose to predict frailty levels incidence to plan for institutional or home care services. objectives: the aims were finding frail and prefrailty frequency in iranian geriatric outpatients' and determining demographics related factors and geriatric syndrome predictors on frailty levels, based on frailty fried index. methods: in this cross-sectional study 364 elderly >=60 years old, selected by convenience sampling from geriatric day clinics in the area of tehran university of medical sciences. the effect of risk factors (adl and iadl dependency, obesity, and polypharmacy) and geriatric syndromes (falling, chronic pain, sleep problems, vertigo, vision and hearing impairments, incontinence, dementia, and depression) were evaluated on frailty fried index. predictor factors by logistic regression model were analyzed, according to demographic risk factors and geriatric syndromes. results: the mean age was 67/3±6/2 years old, majority were male (62%). prefrailty was 37.6% in men and 47.1% in women based on fi. the significant risk factors in elderly prefrail women were depression (82.1%), polypharmacy (48.3%), visual impairment (47.2%), and chronic pain (56.6%); although, in prefrail men were vertigo (57.6%), falling (52%), sleep disorder (49.5%), and incontinence (52.1%). in prefrail older adults>=70 years, only sleep disorder was significant. in logistic regression model, six significant predicted factors were included depression, iadl dependency, falling, chronic pain, vertigo, and age. depression increased the risk of prefrailty by 2.8 times, dependency in iadl increased 3.5 times; moreover, chronic pain and vertigo increased prefrailty risk about 2 times. dependency on iadl increased the risk of frailty 5.8 times, and chronic pain and falling increased the risk of frailty about 1.65 times. by logistic regression model, 58% of prefrail outpatients elderly could be diagnosed. conclusion: geriatric syndromes in outpatients' elderly could predict prefrail more than frail elderly. in the iranian community dwellers prevalence of prefrailty was high, so the on-time screening and outpatients' interventions can help to prevent frailty. background: frailty is a key condition to be screened among elderly oncological patients. nevertheless, the use of the frailty index (fi) in onco-geriatrics is still limited. objectives: aim of our work is to measure the functional and prognostic value for 1-year mortality of the frailty index (fi) in a cohort of older women with gynecological cancer. methods: the prognostic value of fi was tested in 200 older women with gynecological cancer (mean age = 73.5 years). fi was retrospectively calculated following the rockwood model[1]. spearman's rho test was used for correlations with other oncological scales: eastern cooperative oncology group performance status (ecog); karnofsky performance status (kps); vulnerable elders scale-13 (ves-13). cox proportional hazard models and roc curve were performed to estimate prognostic role of 1-year mortality. sensitivity and specificity were also calculated. results: fi is normally distributed and descriptive statistics define our population as frail (mean = 0.25±0.11, range 0.08-0.51). 0.7 is confirmed as an upper limit compatible with life. fi doesn't significantly correlates with age, ecog and kps while it positively correlates with ves-13 (r=0.7, p < .01). fi is the strongest predictor for 1-year mortality confirmed after all adjustments for confounders (or 3.40; 95% ci 1.55-7.45, p < .01) and by roc curve analyses (0.66, 95% ci 0.51-0.81, p=.01). conclusion: frailty index is a useful tool to detect vulnerability in onco-geriatrics and it predicts 1-year mortality. it predicts negative health-related outcomes (mortality) better than other traditional scales. its adoption may support a more efficient identification of patients in the need of adapted and personalized care. further studies are needed to confirm and extend these findings. background: frailty has been studied in the old population due to its association with negative outcomes but more information is needed about frailty in very old samples. the fried frailty phenotype (ffp) has been widely used and includes a set of objective indicators: weakness, slowness, unintentional weight loss, exhaustion and low physical activity. objectives: to determine which sociodemographic, functional and health-related variables predict ffp in a sample of community-dwelling individuals aged 80+yrs. methods: data from 142 individuals living in the metropolitan area of porto were considered: sociodemographic information (age, sex, education level, living status), ffp (0-5), functionality (basic and instrumental activities of daily living), health information (nr. medicines, nr diseases, nr. falls, cognitive impairment, and self-perception of health). descriptive and correlational analysis were conducted and followed by a linear regression analysis (stepwise method) of variables significantly associated with ffp. results: participants' mean age was 88.1 years (sd=5.3), they were mainly women (73.9%), with 1-4 years of education (52.8%) and living with a relative (63.4%). high disability levels were found both for basic and instrumental activities of daily living. the mean of medicines intake was 6.8 (sd=3.5) and of diseases 6.4 (sd=2.1); 41.1% of the participants rated their health as poor. the median number of falls in the last year was 1 (iqr=2). participants scored on average 19.4 points (sd=6.4) in mmse. gender or age were not associated with ffp. basic and instrumental activities of daily living, selfperception of health and cognitive performance significantly predicted ffp. in the adjusted model (r2=0.311), the stronger predictor was the higher dependency for basic activities of daily living, followed by worst self-perception of health and lower scores of cognitive performance. the dependency for instrumental activities of daily living lost its significance in the adjusted model. conclusion: our results identify three main predictors of ffp (basic activities of daily living, selfperception of health, and cognitive performance) in participants with advanced age. these results provide relevant information for further understanding of frailty and the ffp among the oldest old. background: unplanned hospital readmissions are associated with poorer prognosis and increased risk of functional decline and dependence in older people. identifying major risk factors and assessing clinical risk scores can help to distinguish patients at risk of worse outcomes and rehospitalization, allowing the proposal of preventive measures. the aim of this study was to compare the accuracy of different instruments and risk factors in predicting readmission, functional decline and death in hospitalized older patients in a brazilian geriatric unit. methods: in a cohort study performed at a geriatric unit, 198 patients, 65 years old or over were included. demographic data, functional status, prisma 7 scale, geriatric depression scale, mini mental state examination, timed get up and go test, gait speed, mini nutritional assessment, palmar prehension strength, charlson comorbities index, frailty score of the cardiovascular health study and the senior index risk for rehospitalization were assessed at study admission. all patients received a follow-up telephone call at 90 days after discharge to assess potential readmissions, deaths and functional status. results: mean age was 79.1 years (sd +-8.63) and the mean barthel adl score was 71.43 (sd +-33.0). altered barthel (5.39; ci95% 2.6-11.4; p<0.001), chs score (11.57; ci95% 1.5-87.4; p<0.001), isar-hp (3.27; ci95% 1.1-9.9; p=0.02), tgug (7.85; ci95% 1.8-34.1; p<0.001), palmar prehension (3.84; ci95% 1.3-11.3; p=0.01) and gait speed (2.94; ci95% 1.6-6.9; p=0.01) were associated with higher mortality 90 days after discharge. the risk of functional decline at 3-month follow up evaluation was higher in patients with altered barthel (4.62; ci95% 1.54-13.9; p<0.001), lawton (5.66; ic95% 1.3-25.2; p=0.01), chs score (4.6; ci95% 1.9-11.0; p<0.001), isar-hp (3.88; ci95% 1.8-8.4; p<0.01), prisma 7 (2.23; ci95% 1.2-4.3; p=0.02), tgug (5.22; ci95% 2.36-11.55; p<0.001), palmar prehension (3.49; ci95% 1.7-7.0; p<0.01) and gait speed (1.98; ci95% 1.13.7; p=0.03). conclusion: altered iadl, frailty chs score, isar, tgug, palmar prehension strength and gait speed are predictive of functional decline and mortality 90 days after hospital discharge. these tools can be useful to pinpoint frailty in older patients, allowing the implementation of preventive interventions to avoid functional decline. more research is needed to evaluate the role of these tools in predicting rehospitalization. to limit the strain on available resources and prevent an unnecessary increase in patient burden. objectives: this study aimed to improve patient selection for multi-disciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. methods: two-centre prospective cohort study in 537 patients aged >=70 years undergoing elective cardiac surgery. before surgery 11 frailty characteristics were investigated. outcome was disability at three months defined as world health organisation disability assessment schedule 2.0 >=25%. multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index were used to identify factors contributing patient selection. results: disability occurred in 91 (17%) patients. ten out of 11 frailty characteristics were associated with disability. a multivariable model including euroscore ii and preoperative haemoglobin yielded a c-statistic of 0.71 (95% ci 0.66 -0.77). after adding prespecified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health related quality of life, and living alone) to this model the c-statistic improved to 0.78 (95% ci 0.73 -0.83). net reclassification index was 0.32 (p<0.001) showing improved discrimination for patients at risk for disability at three months. conclusion: using preoperative frailty characteristics improves discrimination between elderly patients with and without disability at three months after cardiac surgery and can be used to guide patient selection for preoperative multi-disciplinary team care. fabiola valero 1,3 , henry tapia 1,3 , enrique valencia 1,3 , tania tello 1,2,3 ((1) facultad de medicina, universidad peruana cayetano heredia, lima, peru; (2) instituto de gerontología, universidad peruana cayetano heredia, lima, peru; (3) hospital cayetano heredia, lima, peru) background: frailty is increasingly recognized as a risk assessment to detect vulnerability and complexity. currently, there are limited tools to predict adverse perioperative outcomes for the geriatric population with hip fracture. objectives: to determine frailty and functional dependence as predictors of intrahospital adverse events in hospitalized older adults with hip fractures in the orthogeriatric unit of a general hospital in lima, peru. methods: we conducted a prospective cohort involving 218 patients aged 60 years or older who were admitted to the orthogeriatric unit with hip fracture from june 2017 to june 2019. data were obtained at the time of admission to our unit: frailty was assessed with the frail scale, function ability with the barthel scale, cognition with the short portable mental state questionnaire (spmsq) scale of pfeiffer, comorbidities, socio-family assessment and geriatric syndromes. patients were followed up to discharge, and adverse events were evaluated during this period. univariate models were performed, and logistic regression was done subsequently. results: 218 patients with hip fractures were evaluated, the mean age was 80.4 (8.9) years, 73.8% (161) were women and 2.7% (6) came from nursing homes. hypertension was the most frequent comorbidity in 41.2% (90). 56% (122) had a history of functional dependence on basic activities of daily living (abvd), 54% (104) had some degree of cognitive impairment, 13.7% (30) had social problems, polypharmacy in 21.5% (47) and 43.8% (139) history of falls in the last year. according to frail scale, 18.3% (n = 40) were robust, 29.3% (n = 64) were pre-frail and 52.3% were frail (n = 114). 31.8% (69) had an adverse event while hospitalized (pneumonia, uti, delirium, acute renal injury, pet), of whom 15% (6) were robust, 31.2% (20) pre-frail and 38% (43) frail (p = 0.02). 73.9% of patients with functional dependence on abvd presented adverse events. in the multivariate analysis, the factors associated with in-hospital adverse events were functional dependence in abvd, or: 2.72, (ci: 1.3-5.7); frailty with an or: 1.51 ic (0.5-4.5) and social problem, or: 2.72 ic (1.1-6.2). conclusion: older adult patients hospitalized for hip fracture who had frailty, functional dependence, and social problems had significant adverse events at a general hospital in lima, peru. aiko inoue 1 , chi hsien huang 1,2 , chiharu uno 1 , kosuke fujita 1,2 , tomoharu kitada 1,3 , joji onishi 2 , hiroyuki umegaki 2 , masafumi kuzuya 1,2 ((1) institutes of innovation for future society, nagoya university, japan; (2) department of community health and geriatrics, nagoya university graduate school of medicine, nagoya, japan; (3) department of business administration, seijoh university, aichi, japan) background: social frailty was associated with age, sex, income, education, marital status, and household status. however, the risk factors of social frailty relatively less investigated. objectives: the aim of this study is to clarify the risk factors of social frailty in community-dwelling japanese elderly. methods: a health promotion project (nagoya-teng project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. of all participants (n=926), 500 participants with complete baseline information (mean age 75.0±5.9 years, 242 men (46.9%)) were included in our cross-sectional analysis. at baseline, demographic data, socio-economic status, geriatric depression scale (gds-15), japanese version of european health literacy survey questionnaire (j-hls-eu-q47) were obtained. social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. total deficit scores of 2 or more were defined as social frailty,1 as social pre-frailty, and 0 as robustness. results: a total of 234 (46.8%), 172 (34.4%), and 94 (18.8%) of all participants were categorized as social non-frailty, pre-frailty and social frailty, respectively. in multivariable logistic regression model after adjusting for age, sex, bmi, and education level, living without a spouse is a significant risk factor (p<0.001) for social pre-frailty (or 2.95, 95% ci 1.78-4.88) and social frailty (or 4.31, ). low gds-15 scores were associated with high risk of social prefrailty (or 1.16, 95% ci 1.07-1.26) and social frailty (or 1.43, 95% ci 1.30-1.57). in addition, health literacy was inversely associated with social frailty (or 0.92, 95% ci 0.88-0.96). age, sex, and education level were not associated with social frailty. conclusion: regardless of age and sex, living with a spouse and depression which is associated with activity of daily living and quality of life are associated with social frailty. low health literacy is also a risk factor of social frailty. in literature, loneliness and social frailty were associated with functional decline and mortality in the elderly. future approaches incorporating health literacy interventions are warranted to prevent social frailty in the aged society with increasing number of physical frail older adults. background: frailty increases the risk for morbidity and mortality after cardiac surgery. the influence of frailty on postsurgical functional outcomes is largely unknown. objectives: the aim of this research was to study the association of preoperative frailty characteristics on adverse functional outcomes and to investigate the trajectory of functional recovery among frail and non-frail elderly patients up to one year after elective cardiac surgery. methods: a prospective two-centre observational cohort study in 555 elective cardiac surgery patients aged >=70 years. preanaesthesia assessment was supplemented with 11 frailty tests covering the physical, mental, and social domain. functional outcomes were assessed at one year and included change in health related quality of life (hrql) measured by the short form 36 and disability measured by the world health organisation disability assessment schedule 2.0. adverse functional outcome was considered when worse physical or mental hrql or disability was present after surgery. results: frailty characteristics were present in 468 (86%) patients of whom 406 (73%), 214 (39%) and 231 (42%) showed frailty in the physical, mental or social domain respectively. adverse functional outcome at one year after surgery occurred in 257 (46%) patients. patients with an adverse functional outcome were more often frail (92 (36%)) than patients without an adverse functional outcome (47 (16%) p<0.001). worse physical or mental hrql occurred in 134 (24%) and 141 (25%) patients respectively. the most important frailty characteristic associated with worse physical hrql was high preoperative physical hrql (β -0.56 per point (95% ci -0.7 to -0.5). preoperative mental hrql showed the strongest associations for worse mental hrql (β -0.55 per point (95% ci -0.7 to -0.4)). disability was reported by 120 (22%) patients and associated with preoperative polypharmacy, gait speed, health related quality of life, living alone or dependent living. gait speed had the strongest association (β 2.2 per second (95% ci 1.6 to 2.8)). conclusion: preoperative frailty characteristics were common and predictive for adverse functional outcome one year after cardiac surgery. frailty screening can be used to improve risk stratification and decision making in older cardiac surgery patients. background: frailty frailty has many elements and these can be characterised as physical, nutritive (including body composition), cognitive and sensory (including hearing and seeing). the relative prevalence and importance of these elements are not known. objectives: to estimate the prevalence of frailty and relative contribution of physical/ balance, nutritive, cognitive and sensory frailty to important adverse health states (falls, physical activity levels, outdoor mobility, problems in self-care or usual activities, and lack of energy or accomplishment) in an english cohort. methods: analysis of 9803 community-dwelling older people. the sample was drawn from a random selection of all people aged 70 or more registered with 63 general practices across england. data were collected by postal questionnaire. frailty was measured with the strawbridge questionnaire. we used cross sectional, multivariate logistic regression to estimate the association between frailty domains and adverse health outcomes. some models were stratified by sex and age. results: mean age of participants was 78 years (sd 5.7), range 70 to 101 and 47.5% (4653/9803) were men. the prevalence of overall frailty was 20.7% (2005/9671) and there was no difference in prevalence by sex (odds ratio 0.98; 95% confidence interval 0.89 to 1.08). sensory frailty was the most common and this was reported by more men (1823/4586) than women (1469/5056; odds ratio for sensory frailty 0.62, 95% confidence interval 0.57 to 0.68). men were less likely than women to have physical or nutritive frailty. physical frailty had the strongest independent associations with adverse health states. however, sensory frailty was independently associated with falls, less frequent walking, problems in selfcare and usual activities, lack of energy and accomplishment. conclusion: physical frailty was more strongly associated with adverse health states, but sensory frailty was much more common. the health gain from intervention for sensory frailty in england is likely to be substantial, particularly for older men. sensory frailty should be explored further as an important target of intervention to improve health outcomes for older people both at clinical and population level. background: it live independently. our goal is to encourage independent living, wellbeing and to relieve health and care services budget pressure. longevity is one of the biggest achievements of modern societies. by 2020, a quarter of europeans will be over 60 years of age. combined with low birth rates, this will bring about significant changes to the structure of european society, which will impact on our economy, social security and health care systems. the most problematic expression of population ageing is the clinical condition of frailty. frailty develops because of age-related decline in multiple physiological systems. it is estimated that a quarter to a half of people over 85 years are frail , and this is set to reach epidemic proportions over the next few decades. while frailty increases, the average amount of health spending increases as well with the frailty level in a range from 1,500 to 5,000 €/person year, depending upon the frailty status and the setting of care. frailty usually comes along associated with another risk facto; loneliness. then, ageing, frailty and loneliness constitute overlapping conditions submitted to multiple health and care interventions. ecare project aims to deliver disruptive digital solutions for the prevention and comprehensive management of frailty to encourage independent living, wellbeing and to relieve health and care services budget pressure, throughout the implementation of a pre-commercial procurement scheme. pre-commercial procurement is an ideal framework for the delivery of innovative solutions. the ecare network of procurers and the service providers are often on the frontline as new needs emerge. this pcp will allow the procurers to voice out their unmet needs, create a new demand to access sustainable products of higher quality, and develop new applications with lower life cycle costs. the demand and the supply side will work together to co-create and co-design the solutions and validate their functionalities against the specific challenges outlined in the pcp call for tender. this will clearly maximize the engagement of innovation in health and care services. solutions should improve outcomes for frailty in old adults entailing the physical and the psychosocial factors. the target group are the pre-frail/frail old adults with emphasis on those that feel lonely and/or isolated. the project will procure the development, testing and implementation of digital tools/services and communication concepts to facilitate the transition to integrated care models across health and social services and country-specific cross-institutional set-ups, including decentralised procurement environments and collaboration across institutions. objectives: the project objectives are: • newly development easy-to-use and reliable solutions that facilitate early detection of frailty based on the most efficient standards and methods. • improve the understanding of the factors affecting frailty and the feelings of loneliness and isolation, and how they do correlate (e.g.: gender dimension, social context, etc.). • deliver personalised intervention plans taking into account the end-user societal context. • innovative and meaningful means to tackle the feelings of loneliness and isolation. • new approaches to engage patients as active self-managers of their own health. • new technology developments designed and oriented to the target end-user. • and among all, investigate to deliver cost-efficient solutions, affordable to the payers involved. methods: ecare procurers will proactively organize the requirements of the demand for care solutions in a coherent way. the procurers (buyers' group) will assess the solution adequacy to the targets. the preferred partners will contribute with solid knowledge of innovative procurement paths to the innovation procurement tender. the project partners will do this by: • providing a solid and informed base for dialogue between stakeholders by determining a coherent picture of the market state of the art of the sector based on practical experience of customers and suppliers. • enabling a genuine and credible dialogue between the supply-chain and customers to determine the practical policy and procurement actions required to deliver the ecare solutions. • defining the common unmet needs, communicating these to stakeholders and initiating a mobilization plan for a pcp addressing ecare needs. the pcp may be summarized in a series of actions: • convey the relevance of innovation procurement to public procurers: encouraging suppliers to offer novel solutions to address ecare challenges rather than the lowest price solutions. • analyze the state of the art of the market with all potential suppliers, as well as the main problematic and barriers faced in the sector and that need to be overcome a set of actions involving both the supply and demand sides will be carried out: a coordinated first analysis of the state of the art conducted by all project members followed by a coordinated market sounding through all dissemination channels managed by the consortium will be undertaken to spread project results aiming to receive feedback from all key market players. for this, the role of procurers is vital to replicate and stretch the impact of the project. • providing public procurers with procurement know-how to improve public sector procurement efficiency and increase public sector market power by giving support to apply the methodologies of innovation procurement. market sounding will provide an opportunity for engagement and two-way dialogue with innovative companies that can offer solutions and guidance on how to overcome the procurement barriers. • launching an agreed, realistic and validated joint pcp tender. results: the ecare consortium is immerse in a deep process of unmet needs detection. our goal is to be extraordinarily concrete when defining what the end users and the healthcare professionals are willing for. those unmet needs will be critical for the definition of the requirements and uses cases that the it suppliers will have to follow to design the ict solutions. then… what a better way to know their needs that asking them personally? the vision of providing tailored fit solutions and tools to the end users led to the consensus in creating and facilitating focus group sessions across the 4 procurers regions -campania (italy), barcelona (spain), santander (spain) and wroclaw (poland)-. these sessions will be involving end users, health and social care professionals, and it internal departments of the procurers' organisations. -the focus group script for the end users sessions integrates as main topics the specific condition and related symptoms; experiences of services and care provided; experiences of managing condition when progressing rapidly ; needs for symptom management and how these can be met ; integration of it supportive tools in the management of frailty and loneliness. -the professionals are invited to reflect and discuss the topics of common symptoms and actual care model; experiences of monitoring elderly when condition is progressing rapidly; views about the supportive care needs of elderly and caregivers; early integration of the new care in the management of frailty and loneliness; integration of it supportive tools in the management of frailty and loneliness. -the identified and proposed topics for the it staff would be the state of the art of the relation in between it and social/healthcare; state of the art of interventions on frailty and loneliness. all the four procurers were challenged to organize, at least, 3 focus sessions, one with each specific target group. so far, all the procurers already organized and scheduled the sessions that will occur until the end of january. in terms of impact, 119 participants are expected to be involved (56 end users, 42 healthcare professionals and 21 it people). all the representative of the procurers reported so far that the participants have been considering the sessions so interesting and useful. in fact, new topics have been put in the table for discussion in all the different sessions, adding more important information for the definition of the unmet needs. the journey of the project so far has been providing very powerful insights and evidences that people and professionals appreciate to be involved and e(motionally) cared. conclusion: ecare will progress beyond the state of the art by approaching older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. the project key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. for these, a multimodal comprehensive system able to provide the most effective care will need to be provided. background: maintaining autonomy as life progresses has become a challenge for the health systems. this objective can only be achieved by moving the axis of health policies and health care practice from the disease to the preservation of functional capacity. objectives: the aim of this study is to design and pilot a model for the assessment and support of functionality for community dwelling older people. methods: a space in which nurse and social worker jointly assess the functional capacity of older people and identify and provide responses to the detected deficits was proposed. this study was performed in osi donostialdea (gipuzkoa, spain). three main tasks were carried out: 1. definition of the joint assessment procedure of functionality. 2. identification of the existing resources and community assets to give answer to the identified needs. 3. piloting the model in a sample of older people. the identified needs and the availability of resources to respond to them were obtained from the pilot phase. results: in the initial version of this integral assessment were included, functional capacity, physical activity, cognitive capacity, sense organs, nutritional status, social assessment and housing and environmental conditions. a total of 49 individuals (69% women; mean age 82 years, sd=5.8; barthel index, mean 97.0, sd=4.2; 47% living alone; 76% without cognitive impairment) were recruited during the pilot. the following needs were identified: personalized workout routines, fine motor skill exercises, visual and efficient diets adjusted to each patient, make sure resources reach the community, promote the use and design of gadgets to assist the needs of basic and instrumental activities of daily living, improve strategies to prevent cognitive function impairment, ease loneliness and avoid or minimize physical and environmental barriers to access home, to walk the streets and, particularly, to use public transport. there were no resources available for all the identified needs. conclusion: this study will allow the development of a model for the integral assessment of functionality for the aged population, based in a multidisciplinary team, a space and a new way of working in primary care. mónica machón 1-3 , maider mateo-abad 2,3 , mercedes clerencia-sierra 2,4,5 , carolina güell 1,6 , beatriz poblador-pou 2,5 , kalliopi vrotsou 1-3 , antonio gimeno-miguel 2,5 , alexandra prados-torres 2,5 , itziar vergara 1-3 ( (1) background: multimorbidity and frailty are often present in older people and are found to be associated to increased risk of adverse health events. it is necessary to improve the knowledge of the characteristics of such populations to design adequate clinical guidelines seeking to avoid or delay the onset of dependence. objectives: the aim of this study was to identify clusters of chronic diseases in robust and frail individuals and compare sociodemographic and health characteristics between these clusters. methods: this was a cross-sectional study based on data from two longitudinal studies. the sample was composed of functionally independent community-dwelling older people with multimorbidity living in gipuzkoa (basque country, spain). information from electronic health records (diagnose diseases and medication) and a baseline assessment (sociodemographic characteristics, functional status, self-perceived health, cognitive status, sight and hearing impairments, history of falls and nutritional status) was used in the analysis. the timed up and go test of physical performance was included as a measure of frailty. multiple correspondence and cluster analyses were performed to identify groups. results: the study population consisted of 813 individuals (55.1% women; mean age 77.4 years, sd=5.0). frail individuals (n=244) were older, had a lower educational level and a poorer health status than robust individuals (n=569). three clusters were obtained in robust (rc1, n=348; rc2, n=139 and rc3, n=82) and four among the frail individuals (fc1, n=164; fc2, n=23; fc3, n=44 and fc4, n=13). in rc1 and fc1, none of the chronic diseases had a higher prevalence than in rc2-rc3 and fc2-fc3-fc4, respectively. individuals pertaining to rc2 and fc2 presented more frequently diseases related to mobility limitation or limb pain compare to the other clusters. higher rates of cardiovascular diseases and risk factors were seen in rc3 and fc3. in frail individuals a new cluster emerged, fc4, containing individuals with higher rates of cognitive and eye problems and a clearly poorer health status. conclusion: the findings obtained in this exploratory study may provide insight for the designing of more specific health interventions for older patients with multimorbidity, even though the chronic diseases cluster identified were similar in robust and frail individuals. background: older african americans (oaa) are at high risk for becoming frail in later life. interventions can reverse or delay frailty, yet oaa have largely been excluded from frailty intervention research. many interventions are also time and resource intensive, making them inaccessible to socially disadvantaged oaa. objectives: we present results of a feasibility trial of a low dose frailty prevention intervention among 60 community-dwelling, pre-frail oaa aged 55+ recruited from a primary care clinic between june 1st and october 31st 2018. methods: using a 2-arm rct, participants were assigned to the intervention, which was delivered by an occupational therapist (ot) and comprised of four sessions over four months (an ot evaluation, and sessions on healthy dietary practices, increasing physical activity, and maintaining a healthy lifestyle), or enhanced usual care (publicly available information about healthy lifestyle, home safety, and local elder services). feasibility criteria were set a priori at 75% for participant retention (including attrition due to death/ hospitalization), 80% for session engagement, 2 participants/ week for mean participant accrual, and 90% for program satisfaction. results: participants were 65% female with an average age of 76.58 years, 51.67% of which lived alone and 51.67% lived off of less than 15k per year. feasibility metrics were met. the study recruited 2.5 participants per week and retained 75% of participants who attended 95% of scheduled sessions. mean satisfaction scores were 93%. the treatment also resulted in positive trends in the expected direction in the treatment group for the following outcomes (d = effect size): global health (d = .45), mental health (d = .26), qol (d = .18), social functioning (d = .68), depression (d = .24), and pain reduction (d = .43). descriptively, treatment group participants were also less likely to experience a progression (deterioration) in three frailty status indicators at 4-months compared to controls: weight lost, walking speed slowness, and grip strength weakness. conclusion: the intervention was feasible to deliver. qualitative findings from exit interviews suggested changes to the program dose, structure, and content that could improve it for future use. background: it is well known that frail patients are potentially most at risk of functional decline following a hospital admission. objectives: to measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting. methods: this was a parallel single-blinded randomised controlled trial. within two days of admission, older medical inpatients with an anticipated length of stay >=3 days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. until discharge, both groups received twice daily, monday-to-friday half-hour assisted exercises, assisted by a staff physiotherapist. the intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. length of stay was the primary outcome measure. blindly assessed secondary measures included readmissions within three months, and physical performance (short physical performance battery) and quality of life (euroqol-5d-5l) at discharge and at three months. time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation). results: of the 199 patients allocated, 190 patients' (aged 80 ±7.5 years) data were analysed. groups were comparable at baseline. in intention-to-treat analysis, length of stay did not differ between groups (hr 1.09 (95% ci, 0.77-1.56) p=0.6). physical performance was better in the intervention group at discharge (difference 0.88 (95% ci, 0.20-1.57) p=0.01), but lost at follow-up (difference 0.45 (95% ci, -0.43 -1.33) p=0.3). an improvement in quality of life was detected at follow-up in the intervention group (difference 0.28 (95% ci, 0.9 -0.47) p=0.004). overall, fewer negative events occurred in the intervention group (or 0.46 (95% ci 0.23 -0.92) p=0.03). conclusion: improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. its effect on length of stay remains unclear. background: to propose a simple frailty screening tool able to highlight frailty profiles, already since the initial screening phase. methods: a 9-item questionnaire (lorraine frailty profiling screening scale, lofpross), constructed by an experts' working group, was administered by health professionals to participants >70 years old (n=817) and living at home, in 3 different clinical settings: a primary care outpatient clinic (rural population, n=591), a geriatric day clinic (day-clinic population, n=76) and healthy volunteers (urban population, n=147). a multiple correspondence analysis (mca) followed by a hierarchical clustering of the results of the mca performed in each population was conducted to identify participant profiles based on their answers to lofpross. a response pattern algorithm was resultantly identified in the rural (main) population and subsequently applied to the urban and day-clinic populations and, in these populations, the two classification methods were compared. finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. results: the response pattern differed between the 3 subpopulations for all 9 items, revealing significant intergroup differences (1.2±1.4 positive responses for urban vs. 2.1±1.3 for rural vs. 3.1±2.1 for day-clinic, all p<0.05). five clusters were highlighted in the main rural population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. identification of the response pattern algorithm in the rural population yielded a second classification approach, with 83% of tested participants classified in the same cluster using the 2 different approaches. three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the 5 clusters. a similar double classification approach as above was applied to these 3 profiles revealing a very high percentage (95.6%) of similar profile classifications using both methods. conclusion: the present results demonstrate the ability of lofpross to highlight 3 frailty-related profiles, in a consistent manner, among different older populations living at home. such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions. (3) homburg/saar/germany, saarland university medical center, neurology, homburg/germany) background: frailty is the most important short and long term predictor of disability in the elderly. no study to date evaluate the impact of frailty on short and long term independently from neurological outcome measures. objectives: the aim of the study was to evaluate whether diagnosis frailty predicts short and long-term mortality and neurological recovery in old patients who underwent reperfusion acute treatment in stroke unit. methods: consecutive patients were older than 65 years who underwent thrombectomy or thrombolysis in a single stroke unit from 2015 to 2018. predictors of stroke outcomes were assessed including demographics, baseline nihss, time to needle, treatment and medical complications. premorbid frailty was assessed with a comprehensive geriatric assessment (cga) including functional, nutritional, cognitive, social and comorbidities status. at 3 and 12months, all-cause of death and clinical recovery (using mrs) were evaluated. results: 102 patients, of whom 31 underwent mechanical thrombectomy and 71 venous thrombolysis (mean age 77.5, 65-94 years) entered the study. frailty was diagnosed in 32 out of 70 patients and associated with older age (p=0.001) but no differences in baseline nihss score or treatment strategies. at follow-up, frail patients showed higher incidence of death at 3 (25% vs 3%, p=0.008) and 12 (38% vs 7%, p=0.001) months. frailty was associated with worse neurological recovery at 3 month (mrs 3.4 + 1.8 vs 1.9 + 1.9, p=0.005) and one year followup (mrs 3.2 + 1.9 vs 1.9 + 1.9) for free survival patients. conclusion: frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. larger prospective studies are warranted in order to confirm our findings. background: frailty becomes increasingly common as adults age and has known associations with activity limitations and injurious falls among older adults. while it is believed that frailer older adults are less socially connected than their more functional counterparts, less is known about the relationship between frailty and social isolation among community-dwelling older adults. objectives: the purpose of this study was to examine associations of frailty indicators on self-reported social isolation risk among community-dwelling adults age 60 years and older. methods: the upstream social isolation risk screener (u-sirs) was developed to assess social isolation risk among older adults within clinical and community settings. comprised of 13 items (cronbach's alpha=0.80), the u-sirs assesses physical, emotional, and social support aspects of social isolation. using an internet-delivered survey, data were collected from a national sample of 4,082 adults age 60 years and older. participants completed the u-sirs and additional items on sociodemographics and other health risks. theta scores for the u-sirs serve as the dependent variable, which were generated using item response theory. an ordinary least squares regression model was fitted to identify frailty indicators associated with social isolation risk. results: participants' average age was 69.6 (±5.2) years. the majority of participants was female (58.5%) and lived with a partner/spouse (56.9%). twenty eight percent of participants reported difficulty walking or climbing stairs, 4.3% reported difficulty dressing or bathing, and 16.2% reported a fall in the past year. higher u-sirs theta scores were reported among males (b=3.82, p<0.001) and those with more chronic conditions (b=9.34, p<0.001). participants who reported difficulty walking or climbing stairs (b=3.96, p<0.001), difficulty dressing or bathing (b=3.43, p=0.001), or a fall in the past year (b=4.27, p<0.001) also reported higher u-sirs theta scores. further, higher u-sirs theta scores were reported among participants who had not left their home in the past three days (b=10.62, p<0.001). conclusion: findings suggest frailer older adults and those with functional limitations may have greater risk for social isolation. this highlights the critical demand for easy-to-administer and practical assessments for frail older adults that identify their social isolation risk and link them to needed resources and services. background: peak expiratory flow (pef) has been linked to several negative health-related outcomes in older people, but its association with frailty is still unclear. objectives: this study investigates the association between pef and prevalent and incident frailty in older adults. methods: data come from 2559 community-dwelling participants of the swedish national study on aging and care in kundgsholmen (snac-k), aged >=60 years. baseline pef was expressed as standardized residual (sr) percentiles. frailty was assessed at baseline and over six years, according to the fried criteria. associations between pef and frailty were estimated crosssectionally through logistic regressions, and longitudinally by multinomial logistic regression, considering death as alternative outcome. obstructive respiratory diseases and smoking habits were treated as potential effect modifiers. results: our crosssectional results showed that the 10th-49th and <10th pef sr-percentile categories were associated with three-and fivefold higher likelihood of being frail, than the 80th-100th one. similar estimates were confirmed longitudinally, i.e. adjusted or=3.11 (95%ci: 1.61-6.01) for pef sr-percentiles<10th, compared with 80th-100th. associations were enounced in participants without physical deficits, and tended to be stronger among those with baseline obstructive respiratory diseases, and, longitudinally, also among former/current smokers. conclusion: these findings suggest that pef is a marker of general robustness in older adults and its reduction, exceeding that expected by age, is associated with frailty development. background: as consistently reported in the literature, muscle strength (ms) decreases at a higher rate than muscle mass (mm) during aging resulting in a decreased muscle quality (mq). loss of mq has been associated with loss of mobility, falls, frailty and an increased risk of mortality. however, the degree of muscle declines is varying throughout the population leading to 3 states: successful, normal or pathological. it has been proposed that healthy life habits such as be physically active, having a healthy diet etc. could reduce the muscle aging decline. thus, identifying if life habits could counteract or maintain muscle quality during successful aging is important to better characterize aging and to intervene more specifically. objectives: the aim of the present study was to identify whether a physically active lifestyle could attenuate the effects of aging on mq. methods: active young were compared to active older men. to be considered active, young and older men need to practice voluntary physical activity at least 150min/week since 5yrs. body composition (dxa; mri) and maximum knee extension strength were measured. mq was calculated as the ratio of ms to mm. aerobic capacity (vo2max; moxus©) and muscle contractility (emg) were also measured. muscle biopsies were performed to determine fiber typing, size, intermuscular adipose tissue (imat) and intramyocellular lipid content (imcl). results: absolute mm (p<0.001) and ms (p=0.005) was greater in young participants compared to their older counterparts while mq was similar between them. even if total (p=0.04) and type iia (p=0.024) fiber size were greater in ya than in oa, muscle fiber proportion, muscle contractility and lower limb fat mass (imat, imcl) were similar between both groups (p>0.05). conclusion: mq was similar between younger and older physically active men suggesting that being physical activity may have mitigated the loss of mq with aging and delayed some physiological age-related changes (muscle composition, contractility). i r a t x e e g a ñ a , itxaso mugica 1,2 , nagore arizaga 2 , maider ugartemendia 1 , nagore zinkunegi 1 , janire virgala 2 , maider kortajarena 1 ( (1) and sppb test (p<0,01). similar results have been found in other researches. the parameters that have higher influence in cognition are handgrip test (p<0,01) and frailty (p<0,01). in other investigations, they got the same results; better cognition is related to better physical capacity and less fragility. in regards with functionality, the values of tug test (p<0,01) and gait speed (p<0,01) are the ones that show stronger relation. in other investigations, they observed that physical state and functionality were related. conclusion: the quality of life, the functionality and moca test are interconnected and the parameters that have the strongest statistical relationship are fragility and physical state. the greater the physical capacity of the older person is, the greater the functional capacity is too and the fragility decreases. in conclusion, the quality of life is better. kazuki kaji 1 , jun kitagawa 2 , takahiro tachiki 3 , naonobu takahira 2 , masayuki iki 4 , junko tamaki 5 , etsuko kajita 3 , yuho sato 6 , jpos study group 4 ((1) national center for geriatrics and gerontology, obu, aichi, japan; (2) nagoya university, nagoya, aichi, japan; (3) nagoya city university, nagoya, aichi, japan) background: the skeletal muscle mass index (smi), which is the appendicular skeletal muscle mass (asm) adjusted for height squared (kg/m2), is used to assess skeletal muscle mass. we reported at this conference last year that smi was overestimated by height loss due to aging in elderly women. furthermore, age-related changes in smi were inconsistent with changes in physical function such as grip strength and walking speed. objectives: the purpose of this cross-sectional study was to investigate the effects of height loss on agerelated changes in smi and physical function in japanese women aged 50 or older. methods: this study was part of the 15/16-year follow up survey of the japanese population-based osteoporosis (jpos) cohort study conducted in 2011/2012. the jpos study was started in 1996. the subjects of the 15/16year follow-up were 710 women (mean 65.3±10.0 years). we divided the subjects into quartiles based on 15 years of height loss (q1: the lowest, q2, q3 and q4: the highest). asm was measured by dual x-ray absorptiometry (qdr4500a, hologic, usa). grip strength, maximum walking speed, and timed up and go (tug) were also measured. results: the mean change in height during the 15/16-year follow-up was -1.6±1.6 cm. mean changes in height in q1 (n=191), q2 (n=171), q3 (n=172) and q4 (n=176) were -0.2±0.41 cm, -1.0±0.20 cm, -1.8 ±0.26 cm and -3.7±1.84 cm, respectively. the trend test demonstrated significant increases in the mean age and smi from q1 to q4. on the other hand, there was a significant decrease in asm from q1 to q4. the mean grip strength and maximum walking speed significantly decreased from q1 to q4. tug results were similar, suggesting that greater height loss led to longer times. conclusion: in japanese elderly women with height loss, asm and physical function decreased with age, but the smi adjusted for height increased. it may be necessary to establish a muscle mass parameter other than smi to investigate the relationship between muscle mass and physical function. kota tsutsumimoto 1 , takehiko doi 1 , sho nakakubo 1 , satoshi kurita 1 , hideaki ishii 1 , hiroyuki shimada 2 ((1) section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan; (2) center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: sarcopenia was defined as decline in skeletal muscle mass and muscle function, leading to serious health problems including disability. the modifiable risk factors of sarcopenia should be elucidated to contribute to develop intervention from sarcopenia. objectives: to examine the association between anorexia of aging and sarcopenia among community-dwelling elderly japanese individuals. methods: population-based, cross-sectional cohort study in japanese older adults was conducted and participants were identified from the database of the national center for geriatrics and gerontology-study of geriatric syndromes. anorexia of aging was assessed via a simplified nutritional appetite questionnaire. handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. subjects with sarcopenia were defined as those who met the criteria of the asian working group for sarcopenia. the association between anorexia of aging and sarcopenia was then analyzed via multiple regression analysis. results: in total, 9,496 elderly japanese individuals were evaluated. the prevalence of sarcopenia and anorexia of aging was 4.0% and 9.8%, respectively. in multivariable logistic regression model adjusted for the covariates except for nutritional status such as albumin, anorexia of aging was independently associated with sarcopenia (or: 1.45, 95% ci: 1.07 to 1.95; p = 0.015). this significant association remained even after adjusting for all covariates including nutritional status (or: 1.42, 95% ci: 1.06 to 1.92, p = 0.020). conclusion: anorexia of aging is associated with sarcopenia among japanese older adults. further studies are needed to determine whether a causal association exists between anorexia and sarcopenia. background: low grip strength is consistently associated with higher rates of mortality, disability and other age-related health outcomes, and is a key characteristic of sarcopenia. grip strength has thus been proposed as a general biomarker of ageing. life expectancy in russia is substantially lower than in norway but whether this is reflected in differences in grip strength across adulthood, as observed in previous comparisons of older adults from russia, denmark and england, needs to be established and explained. objectives: we aimed to compare grip strength in norwegian and russian populations by age and gender, and investigate whether any observed differences were explained by contrasts in height, weight, smoking or education. methods: we used harmonised cross-sectional data on grip strength for 10,112 men and women aged 40-69 years. this comprised participants from the russian know your heart study (n=4,147) conducted in the cities arkhangelsk and novosibirsk in 2015-18, and from wave 7 of the norwegian tromsø study (n=5,965) conducted in 2015-16. grip strength was assessed using the jamar+ digital dynamometer in both studies, and the maximum of six measurements (three in each hand) was used. the association between grip strength and covariates was assessed using linear regression. results: norwegian males had stronger grip than russian males at all ages, for example they were an average of 3.2kg (95% confidence interval (ci) 2.3, 4.1) stronger at age 40 years and 3.3kg (95% ci 2.6, 4.0) stronger at age 69 years. among women, corresponding numbers were 2.0kg (95% ci 1.2, 2.8) at age 40 and 1.5kg (95% ci 0.9, 2.1) at age 69. adjustment for weight, education and smoking did not affect the results, but height attenuated the between country differences, especially at older ages. among women aged 60+, differences in height between countries fully explained the differences observed in grip strength. conclusion: norwegian 67-year-olds had the grip strength of 60-year-old russians suggesting that russians are ageing more rapidly in terms of muscular strength than their norwegian counterparts. the important role of height in explaining these differences, especially at older ages, suggest contrasts in early life circumstances may be of key importance. eleanor lunt 1,2 , paul greenhaff 2,3 , adam l gordon 2,4,5 , john rf gladman 1,2 ( (1) background: frailty is a state of vulnerability to stressors resulting in adverse clinical outcomes including falls and fragility fractures. identifying biomarkers associated with these outcomes may help target interventions. objectives: to compare parameters of body composition, muscle thickness and muscle strength between patients and healthy older and young volunteers. methods: six young (18-35 years) and 11 older (>= 70 years) healthy female volunteers were recruited by advert from community groups. 15 female patients (>=70 years) with an acute fragility fracture were recruited from hospital wards and measured during first week of admission (median 4th day (iqr 2-6)). frailty was determined by the 5-item frail scale. height, weight, handgrip (jamar dynamometer) and knee extension (lafayette manual muscle tester) were assessed. body composition was estimated using whole body bioelectrical impedance (bodystat quadscan 4000®). midpoint vastus lateralis (vl) muscle thickness and mid-thigh subcutaneous fat thickness were assessed using ultrasound (mylab gold, esaote biomedica, italy) with a 14hz linear-array probe. oneway anova and post hoc tukey's test were used to compare end-point measures between groups. results: frailty was significantly more prevalent in the patient group (53% frail, 40% pre-frail, 7% robust) than the healthy older group (100% robust, p<0.001). the patient group was older (83 ± 7 years vs 78 ± 6 years, p<0.05) and had more co-morbidities (p<0.001). there were no significant differences between the patient and healthy older group in weight, height, bmi, percentage body fat or subcutaneous fat thickness of lateral thigh. vl muscle thickness was lower in the patient group compared to healthy older and young volunteers (1.27±0.43cm, 1.75±0.30cm and 2.09±0.41cm respectively, p<0.01). the patient group also had lower handgrip strength (9.2±5.5kg, 19.9±5.8kg, 41.3±15.6kg respectively, p<0.001) and lower knee extension strength (4.3±1.4kg, 7.8±1.3kg, 9.5±1.3kg respectively, p<0.001). vl muscle thickness associated with muscle strength (knee extension r=0.70, p<0.001 and handgrip r=0.71, p<0.001) and was significantly lower in the frail compared to pre-frail or robust participants (0.98±0.30cm, 1.53±0.27cm, 1.76±0.29cm respectively p<0.001). conclusion: female patients presenting to hospital with a fall and fragility fracture have lower muscle thickness in the thigh compared to non-frail older women, despite no difference in other body composition variables. register, health technology assessment, nhs economic evaluation database) were searched from inception to april 12, 2019. cross-sectional and cohort studies that reported adjusted risk ratios with 95% confidence intervals (ci) for frailty with serum level of total testosterone, free testosterone, sex hormone-binding globulin (shbg) were selected. a metaanalysis was carried out by using fixed effects and random effects models to calculate the or of relationship between low level of testosterone and risk of frailty. results: the crosssectional study concluded 9 articles, there was statistically significant association between lower level of total testosterone and risk of frailty (or=1.59; 95%ci, 1.28-1.98, i2=80%), as well as free testosterone (or=1.59; 95%ci, 1.21-2.08,i2=78% ), the highest level of shbg was no significant associated with the risk of frailty(or=1.05; 95%ci, 0.84, 1.30; i2=62%). the prospective cohort studies obtain 4 articles, no significant were found between frailty and low total testosterone and frailty (pool or=1.12; 95%ci, 0.99-1.32, i2=14%). conclusion: the meta-analysis indicates that low level of serum testosterone is significantly associated with the risk of frailty in the crosssection studies. however, we found no significant relationship between low total testosterone and frailty in the cohort studies. more research is needed to address the underlying mechanisms to explain this relationship and to determine whether testosterone supplementation is effective for preventing frailty syndrome. background: although frailty and abdominal obesity are known risk factors for disability in older persons, few studies have investigated the interaction between both factors on the association with disability. objectives: to investigate the association of frailty and abdominal obesity with disability in older persons. methods: we used data from 13,787 participants (41% men) in the prospective, population-based singapore chinese health study cohort, who were interviewed and examined for frailty, abdominal obesity and disability at mean age of 74 (range 63 to 97) years from 2014-2017. we defined frailty as having three or more features of weak handgrip strength, slow timed-up-and-go test, low energy level, multiple comorbidities, and difficulty carrying out usual activities. we defined abdominal obesity by waist circumference using sexspecific cut-offs, and assessed disability using the lawton instrumental activities of daily living (iadl) scale. we used multivariable logistic regression models to compute the odds ratio (or) and 95% confidence interval (ci) for the association between frailty/abdominal obesity and disability. results: about 7.6% of participants were frail and 58.4% had abdominal obesity. frailty was associated with increased or (95% ci) of 7.78 (6.64-9.12) for disability. conversely, the or (95% ci) for the association between abdominal obesity and frailty was only 1.13 (1.01-1.27). compared to participants who were neither frail nor abdominally obese, the or (95% ci) for disability was 6.19 (4.71-8.14) in those who only had frailty, and 1.10 (0.98-1.24) in those who only had abdominal obesity. however, participants who were both frail and abdominally obese had markedly increased or (95% ci) of 9.57 (7.75-11.81) for disability; p-value for interaction between frailty and abdominal obesity was 0.047. furthermore, while men who were both frail and abdominally obese had increased or (95% ci) of 4.67 (3.27-6.67) for disability compared to their counterparts who were neither frail nor obese, the corresponding or (95% ci) was much higher at 14.92 (11.34-19.65) in women; p value for heterogeneity by sex <0.001. conclusion: frailty and abdominal obesity interacted synergistically to increase the risk of disability in older persons, and the combined effect of both factors on disability was much stronger in women than in men. background: as the world's population ages, the prevalence of cognitive impairment associated with age increases exponentially. objectives: objective of this study was to investigate the longitudinal association of physical activity and cognitive function in two deferentl populations; older adults from mexico representing latin america and south korea representing asia. based on two large population-based longitudinal studies. methods: this is a secondary analysis of two surveys, mhas and klosa, designed to study the aging process of adults living in mexico and south korea. participants>50 were selected from rural and urban areas. here we investigate the longitudinal association of exercise and cognition using the two waves of each study. cross cultural cognitive examination and mini-mental state examinarion were used to analyze the association between physical activity and cognition in mexican and korean older adults. multivariate logistic regression models were used to evaluate the said association. results: in mexico, the prevalence of physical activity was 40.68%, physical active older adults obtained a higher score in ccce (0.099 ± 1.01) p-value < 0.001. they also had more years of education (5.63 ± 4.61 vs. 5.10 ± 4.27) p-value <0.001, had depression (31.55% vs. 35.25%) 0.0090 and consumed less alcohol (89.91 vs. 93.03) p-value <0.001. in korea, the prevalence of physical activity was 35.57%. the physical active group performed better in mmse (-0.123 ± 1.05 vs. 0.046 ± 0.90) p-value <0.001. the no physical active group had a higher proportion of women, less alcohol consumption (50.01 vs. 55.22%) p-value <0.001, fewer years of education p-value < 0.001 and a higher prevalence of depression (5.12% vs 3.64%) p-value 0.0090. in the multivariate analysis an independent association was found in the korean population between physical activity and mmse score even after adjusting for confounders (0.0866 (0.0266 ; 0.1467) p value 0.0047). conclusion: physical activity could have a protective effect on the cognitive decline associated with ageing. background: aging is related to the increase of several chronic diseases, such as, osteoarthritis, osteoporosis, diabetes, hypertension and sarcopenia. sarcopenia (progressive loss of muscle mass and physical performance) is related to difficulties in treating other comorbidities, whether pharmacologically or non-pharmacologically. it's important to understand the relations between muscular strength (w), muscular mass and the phase angle (pa) of bioimpedance, in sarcopenic subjects to prescribe more accurate treatments. objectives: to study the relations of skeletal muscle index (smi) with w, pa and the presents of comorbidities (nc) in elderly subjects. methods: a prospective, observational secondary analysis of data from the "the sarcopenia screening and health related issues in the region of algarve", was performed. community independent living elderly subjects were recruited. body composition was measured by bioimpedance (seca analytics 115), knee flexion and extension isokinetic strength (60º/sec) (humac norm). a screening questionnaire was used to determine the presence of comorbidities. smi levels were assessed using european working group on sarcopenia in older people cut-off points. results: a total of 46 female and 12 males, were included, mean age 73,7 (± 7,64 sd). subject were divided into 3 groups according to smi: normal (n=21), moderated impairment (n=18) and severe impairment (n=19). pearson correlation were calculated within each group for w; pa and comorbidities. normal smi level, were correlated to knee extensors w in both legs (right: r=0,510, p<0,05 and left r=0,506, p<0,05) . no significant correlations were found with pa. moderate smi level: were correlated to knee extensors w in both legs (right: r=0,742, p<0,001 and left r=0,708, p≤0,001), and also with knee flexors w (right: r= 0,677, p< 0,005; left: r= 0,659, p<0,005). a moderate correlation was also found in this group with pa (r= 0,472, p< 0,05). severe smi level: no correlations were found, in this group, with w. a moderate correlation was found with pa (r= 0,565, p< 0,05). comorbidities did not have any correlations with smi levels. conclusion: our results seem to indicate that isokinetic strength (work) may have in the future a role in understanding sarcopenia, once it is related to smi. also, pa may indicate moderate and severe smi impairment. background: body characteristics as low muscle mass and high fat mass (fm) affect the physical function of older people. physical function is a fundamental component for the performance of daily activities and for the maintenance of the independence of older adults. however, the relationship between body composition and physical performance varies in different studies and still demands further research. objectives: this study aimed to investigate the association of fat mass index (fmi) determined by dual-energy x-ray absorptiometry (dxa) with physical performance in brazilian communitydwelling older adults. methods: a cross-sectional study with a sample of 55 participants aged 60 years and older, living in ribeirão preto, brazil, including both men and women, was conducted. fm was measured by dxa and fmi was calculated as fat mass/height2 (kg/m²). the physical performance was assessed by the 6-minute walk test, and walking distance was recorded as the main parameter, considering the distance predicted by sex. the kolmogorov-smirnov test was used to verify the normality of data distribution. the association of physical performance and fmi was analyzed using the pearson's correlation test and statistical significance was set at p ≤ 0.05 (two-sided). results: the participants were aged 70.13±6.3 years, fmi was 9.88±3.1kg/m2 and distance walked was 454.6±83.2m. there was a significant negative association (r = -277, p = 0.040) between fmi and distance walked, showing that higher fat mass index is associated with worse performance in the 6-minute walk test. conclusion: high fat mass index is associated with worse physical performance in brazilian older adults. background: sarcopenia and physical frailty have been shown to be risk factors for mortality and major morbidity in older adults suffering from various forms of cardiovascular disease. ultrasound measurement of quadriceps muscle thickness (qmt) is an emerging biomarker for sarcopenia, which we hypothesized could be conveniently acquired during the routine echocardiographic exam. objectives: to demonstrate the feasibility of measuring qmt at the time of echocardiography, and determine the association between qmt and clinical indictors of frailty. methods: adult inpatients and outpatients undergoing a clinically-indicated echocardiogram for known or suspected cardiovascular disease were recruited for this cross-sectional study at the jewish general hospital. prior to the echocardiogram, trained research assistants measured height, weight, and three clinical indicators of frailty: rockwood's clinical frailty scale, handgrip strength (jamar dynamometer), and bioimpedance phase angle (inbody 770). at the conclusion of the echocardiogram, cardiac sonographers blinded to the preceding assessments acquired a biplane image of the anterior thigh midway between the anterior superior iliac spine and knee, and measured qmt as the combined thickness of the rectus femoris and vastus intermedius muscles. a cardiac ultrasound machine and probe were used (ge vivid e9/e95, 1.5-4.5 mhz probe). results: the cohort consisted of 301 patie