Key Factors Associated with Adherence to Physical Exercise in Patients with Chronic Diseases and Older Adults: An Umbrella Review

Abstract

Physical inactivity is a major concern and poor adherence to exercise programs is often reported. The aim of this paper was to systematically review published reviews on the study of adherence to physical exercise in chronic patients and older adults and to identify those adherence-related key factors more frequently suggested by reviews for that population. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results were classified considering the target population and participants’ characteristics to identify the most repeated factors obtained for each condition. Fifty-five articles were finally included. Fourteen key factors were identified as relevant to increase adherence to physical exercise by at least ten reviews: (a) characteristics of the exercise program, (b) involvement of professionals from different disciplines, (c) supervision, (d) technology, (e) initial exploration of participant’s characteristics, barriers, and facilitators, (f) participants education, adequate expectations and knowledge about risks and benefits, (g) enjoyment and absence of unpleasant experiences, (h) integration in daily living, (i) social support and relatedness, j) communication and feedback, (k) available progress information and monitoring, (l) self-efficacy and competence, (m) participant’s active role and n) goal setting. Therefore, adherence to physical exercise is affected by several variables that can be controlled and modified by researchers and professionals.

Full text

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Int.J.Environ.Res.PublicHealth2021,18,2023.https://doi.org/10.3390/ijerph18042023www.mdpi.com/journal/ijerph
Review
KeyFactorsAssociatedwithAdherencetoPhysicalExercise
inPatientswithChronicDiseasesandOlderAdults:
AnUmbrellaReview
DanielCollado‐Mateo
1
,AnaMyriamLavín‐Pérez
1,2,
*,CeciliaPeñacoba
3
,JuanDelCoso
1
,MartaLeyton‐Román
1
,
AntonioLuque‐Casado
1
,PabloGasque
4
,MiguelÁngelFernández‐del‐Olmo
1
andDianaAmado‐Alonso
1
1
CentreforSportStudies,ReyJuanCarlosUniversity,Fuenlabrada,28943Madrid,Spain;
daniel.collado@urjc.es(D.C.‐M.);juan.delcoso@urjc.es(J.D.C.);marta.leyton@urjc.es(M.L.‐R.);
antonio.luque@urjc.es(A.L.‐C.);miguel.delolmo@urjc.es(M.Á.F.‐d.‐O.);diana.amado@urjc.es(D.A.‐A.)
2
GOfitLAB,Ingesport,28003Madrid,Spain
3
DepartmentofPsychology,ReyJuanCarlosUniversity,Alcorcón,28922Madrid,Spain;cecilia.penacoba@urjc.es
4
DepartmentofPhysicalEducation,SportandHumanMotricity,AutónomaUnivesity,CiudadUniversitaria
deCantoblanco,28049Madrid,Spain;pablo.gasque@uam.es
*Correspondence:am.lavin.2018@alumnos.urjc.es
Abstract:Physicalinactivityisamajorconcernandpooradherencetoexerciseprogramsisoften
reported.Theaimofthispaperwastosystematicallyreviewpublishedreviewsonthestudyof
adherencetophysicalexerciseinchronicpatientsandolderadultsandtoidentifythoseadher‐
ence‐relatedkeyfactorsmorefrequentlysuggestedbyreviewsforthatpopulation.ThePreferred
ReportingItemsforSystematicReviewsandMeta‐Analyses(PRISMA)guidelineswerefollowed.
Resultswereclassifiedconsideringthetargetpopulationandparticipants’characteristicstoiden‐
tifythemostrepeatedfactorsobtainedforeachcondition.Fifty‐fivearticleswerefinallyincluded.
Fourteenkeyfactorswereidentifiedasrelevanttoincreaseadherencetophysicalexercisebyat
leasttenreviews:(a)characteristicsoftheexerciseprogram,(b)involvementofprofessionalsfrom
differentdisciplines,(c)supervision,(d)technology,(e)initialexplorationofparticipant’scharac‐
teristics,barriers,andfacilitators,(f)participantseducation,adequateexpectationsandknowledge
aboutrisksandbenefits,(g)enjoymentandabsenceofunpleasantexperiences,(h)integrationin
dailyliving,(i)socialsupportandrelatedness,j)communicationandfeedback,(k)availablepro‐
gressinformationandmonitoring,(l)self‐efficacyandcompetence,(m)participant’sactiverole
andn)goalsetting.Therefore,adherencetophysicalexerciseisaffectedbyseveralvariablesthat
canbecontrolledandmodifiedbyresearchersandprofessionals.
Keywords:barriers;facilitators;physicalactivity;lifestyle;cancer;cardiovasculardisease;elderly;
musculoskeletaldisorders;obesity

1.Introduction
Theincreaseinlifeexpectancyandtheremarkableadvancesinmedicinehave
causedthemeanageoftheglobalpopulationtoprogressivelyincrease[1].Linkedtothis,
thenumberofpeoplesufferingfromoneormorechronicdiseaseshasdramaticallyrisen,
whichleadstolargeeconomiccostsforcountriesandagreaterneedforhealthcareser‐
vices[2].Physicalexercisehasbecomestandardpracticeinclinicalcareduetothefact
thatitleadstonumerousbenefitsinmanydifferentpathologicalandnon‐pathological
populations[3].Inthisregard,theinclusionofphysicalexerciseprogramsintreatment
plansisnowanessentialtoolformosthealthcareproviders,whiletheuseofevi‐
dence‐basedexerciseprogramssubjectedtotheevaluationofexerciseprofessionalsis
consideredkeyinthepreventionandtreatmentofmanyconditions[3,4].
Citation:Collado‐Mateo,D.;
Lavín‐Pérez,A.M.;Peñacoba,C.;
DelCoso,J.;Leyton‐Román,M.;
Luque‐Casado,A.;Gasque,P.;
Fernández‐del‐Olmo,M.Á.;
Amado‐Alonso,D.KeyFactors
AssociatedwithAdherencetoPhysical
ExerciseinPatientswithChronic
DiseasesandOlderAdults:An
UmbrellaReview.Int.J.Environ.Res.
PublicHealth2021,18,2023.
https://doi.org/10.3390/
ijerph18042023
AcademicEditor:PaulB.Tchounwou
Received:26January2021
Accepted:13February2021
Published:19February2021
Publisher’sNote:MDPIstays
neutralwithregardtojurisdictional
claimsinpublishedmapsand
institutionalaffiliations.

Copyright:©2021bytheauthors.
LicenseeMDPI,Basel,Switzerland.
Thisarticleisanopenaccessarticle
distributedunderthetermsand
conditionsoftheCreativeCommons
Attribution(CCBY)license
(http://creativecommons.org/licenses
/by/4.0/).

Int.J.Environ.Res.PublicHealth2021,18,20232of25
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Everyyear,hundredsofrandomizedcontrolledtrialsaimedtoevaluatetheeffects
ofphysicalexerciseonhealth‐relatedvariablesarepublished.Thatistheconsequenceof
alargeinvestmentofpublicandprivateinstitutionsandtheworkofmanyresearchers,
whohavedemonstratedthatphysicalexerciseleadstonumerousbenefitsinmanydif‐
ferentpathologicalandnon‐pathologicalpopulations[3].Asaresult,physicalexercise
hasbecomeamedicinethateveryoneshouldtakeregularly[5]andmanydifferent
campaigns,advertisements,andpolicieshavebeendevelopedtospreadthatmessage
[6,7].However,althoughmostpeopleknowtherelevanceofhavinganactivelifeasa
partofahealthylifestyle,inactivityisstillamajorconcernandthenumberofsedentary
peoplehasnotbeenproperlyreduced[8,9].
Therefore,thereisakeyquestionthatresearchersworkingonphysicalexerciseand
healthmustask:whypeoplenotexerciseevenknowinghowgooditisfortheirown
health?Theanswertothisquestionmayberelatedtothelackofproperinformationthat
enhancesmotivationandadherencetotheexerciseguidelinesproposed.Forexample,
theWorldHealthOrganization(WHO)hasrecentlypublishednewguidelinesonphys‐
icalactivityandsedentarybehavior,indicatingthatadultsshoulddoatleast150–300min
ofmoderate‐intensityaerobicphysicalactivity,oratleast75–150minofvigorousinten‐
sityaerobicphysicalactivity,oracombinationofmoderate‐ andvigorous‐intensityac‐
tivitythroughouttheweek,inordertoobtainsubstantialhealthbenefits[5].However,
theseguidelineslackanyinformationregardingstrategiestoensurethatindividuals
maintaintheselevelsofphysicalexerciseovertimenorstrategiestomotivatesedentary
individualstostartexercising.Hence,itseemsthatneithertheknowledgeofthebenefits
ofexercisenorthesettingofminimumthresholdsofexercisearedrivingforcestoreduce
sedentarismeffectively.
Lowlevelsofadherencetoexercisemaycausesomerandomizedcontrolledtrials
aimedtoassessthebenefitsofexerciseononeorseveralhealthoutcomestonotachieve
significantresults[10,11].However,theadherenceproblemmaybebiggerwhentalking
aboutthegeneralpopulationthatdoesnotparticipateinthosekindsofstudiessince
participantsinrandomizedcontrolledtrialsareusuallyvolunteers,selectedaccordingto
inclusionandexclusioncriteriathatoftenrejectsindividualswithsevereimpairments
thatmayreducetheiradherence(forinstance,itisusualthatpeoplewithseverecogni‐
tiveimpairmentareexcludedinarticlesinvolvingolderadultsorParkinson’sDisease
patients[12,13]andpeoplewithbonemetastasisareexcludedincancerstudies[14]).
Furthermore,asvolunteers,itcanbeassumedthatparticipantsinstudiesmaybeinher‐
entlymotivated,oratleasttheyarewillingtobeinvolved.However,thiscannotbeas‐
sumedforeveryoneinthegeneralpopulationanditcouldhappenthatpatientsengaging
inclinicaltrialsmaynotberepresentativeofthepopulationinquestion,sincetheirpsy‐
chologicalpredispositiontoexercisemaybedifferentthanthepredispositionoftheoth‐
ers[15].Inadditiontotheselectionofvolunteersandidealparticipants,randomized
controlledtrialsoftentendtobehighlysupervised,whichmayexplainwhythelevelsof
adherenceareoftenhighercomparedtoobservationalstudies[16].
Manytheoriesandmodelshavebeenproposedfromdifferentdisciplinestoexplain
the“adherencetoexercise”phenomenon[17,18].Somearticleshavesuggestedtheneed
foraparallelpsychologicalintervention,inadditiontotheexerciseprogram,toaidin
behaviorchange[19].Othershaveproposedthebenefitsofincreasingparticipants’mo‐
tivationtowardsexercisebypayingmoreattentiontothethreebasicpsychological
needs:autonomy,competence,andrelatedness[20].Previousstudieshavealsotriedto
increasetheadherencetophysicalexerciseprogramsbyincludingtechnologicalgadgets
orbyproposingalternativeformsofexercise[21,22].Thereareevensomeauthorswho
havesuggestedtheconvenienceofpayingpeoplefordoingexercise,assomeinsurance
companieshavestartedtodo,knowingthattheirclientswillbehealthieriftheyare
physicallyactiveandtheirincomeswillbeaccordinglyincreased[23].
Despitethelargenumberofstudiesonadherencetoexercise,theveryconceptof
adherenceisnotwellestablishedandvariesfromonestudytoanother,confusingad‐

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herencewithothertermslikeattendance,i.e.,thenumberorthepercentageofsessions
attended[24].Anothernotfullyappropriatewaytoconceiveadherencetoexerciseisby
countingthenumberofdropoutsduringtheirexerciseintervention.Followingthislast
conception,onecouldinterpretgoodadherencetotheirprogramwhenthepercentageof
theirparticipantswhofinishedtheinterventionishigh.Inthisregard,thePhysiotherapy
EvidenceDatabase(PEDro)Scalesuggeststhatmeasurementsofthekeyvariables
shouldbeobtainedfrommorethan85%oftheinitiallyrandomizedparticipants[25].
Thus,thatcriterionisbasedonthenumberofdropouts,butitdoesnotestablishtheneed
ofcompletingaminimumpercentageofsessions(attendance)northeinvolvementofthe
participantsduringthesessions.Inthisregard,adherencehasbeendescribedastheex‐
tenttowhichthebehaviorofapersoncorrelateswiththeagreedplanofthesuggested
exerciseintervention,soitwouldberelatedtothedegreetowhichthetargetintensity
andvolumeareachieved[24,26].Therefore,adherencetoexerciseisaconceptwith
deeperrootsintheparticipant’sbehaviorthanamerenumberofdropoutsorpercentage
ofsessionsattended.
Followingthislastdefinitionofadherencethatincludestheassessmentofthein‐
tensityandvolumeachieved,newadvancesintechnologyhavemadeeasiertheassess‐
mentofadherencegiventhattheexerciseintensityandvolumecanbemoreeasilymon‐
itoredorevenself‐monitoredbytheparticipant[27].However,theuseoftechnology
involvesotherproblemsthatshouldbeconsidered,suchaseconomiccosts,theaddi‐
tionaltimerequiredtosetit,thepotentialunpleasantoruncomfortableexperiences,the
difficultiesexperiencedbytheparticipantstouseitappropriately,andtheshameor
simplythereluctanceofpeoplewhodonotwanttouseit[21,28].
Despitealltheabove‐mentionedinformationandthenumberofarticlespublished
onthistopic,todate,therearemixedandinconclusiveresultsregardingthebestprac‐
ticesforincreasingexerciseadherence,withlargeheterogeneityintermsofphysicalex‐
ercisetyperecommended,thepsychologicalapproachused,thetargetpopulation,the
needtotreatachronicdisease,theageofpatientsandthemainaimoftheexercisein‐
terventions.Therefore,thecurrentstudyaimedtosystematicallyreviewpublishedre‐
viewsonthestudyofadherencetophysicalexerciseinchronicpatientsandolderadults
andtoidentifythoseadherence‐relatedkeyfactorsmorefrequentlysuggestedbyre‐
viewsforchronicdiseasepatientsandolderadults.
2.MaterialsandMethods
ThecurrentsystematicreviewofreviewshasbeendevelopedfollowingthePre‐
ferredReportingItemsforSystematicReviewsandMeta‐Analyses(PRISMA)guidelines
[29].
2.1.SearchStrategyandSelectionofStudies
ThesearchforpublishedstudieswasconductedinOctober2019inthescientific
databasesPubMed(MEDLINE)andWebofSciences(includingKCI‐KoreanJournal
Database,MEDLINE,RussianScienceCitationIndex,andSciELOCitationIndex).The
termsusedforthesearchwere“adherence”,“exercise”,and“systematicreviewORme‐
ta‐analysis”separatedbytheBooleanoperatorAND.Toselectarticlesfocusedonad‐
herencetoexerciseandavoidthosethatonlyincludedadherenceasasecondaryor
complementarymeasure,theterm“adherence”hadtobewithinthetitleofthearticle.
Onlyarticlespublishedinthelast10years(2010topresent)wereincludedinthesearch
toshowanupdatedpictureofthetopic.Thesearchforpublishedstudieswasinde‐
pendentlyperformedbytwoauthors(DC‐MandAML‐P)anddisagreementswerere‐
solvedthroughdiscussion.
Screeningofsearchedarticlesanditssubsequentlyfull‐textreviewwascarriedout
regardingthefollowinginclusioncriteria:(a)systematic/narrativereviewand/orme‐
ta‐analysisdesign,(b)studiesfocusedonpatientswithchronicdiseasepatientsorolder
peopleasthetargetpopulation,(c)focusedonanytypeofphysicalexerciseandd)aimed

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
toidentifyfactorsassociatedwithadherencetoexercise.Besides,articlesfulfillingthe
followingcriteriawereexcluded:(a)reviewswritteninanylanguagedifferentfrom
EnglishorSpanish,(b)studiesfocusedontheconceptordefinitionofadherence,(c)ar‐
ticlesaimedtoanalyzetherelationshipbetweenadherenceandintervention’seffects,(d)
reviewsfocusedonthemethodsusedtoassessadherence.
2.2.DataExtraction
Theidentifiedreviewarticlesweredistributedamongalltheauthorsofthisstudy
anddataextractionwasperformedbyduplicate.Foreacharticle,theresearchermanu‐
allyextractedtheinformationaboutthepopulation,intervention,aim,conclusion,and
studydesign,followingthePICOS(Population/Problem,Intervention,Comparator,
OutcomeandStudyDesign)approach.Keyfactorsreportedinreviewsandme‐
ta‐analysiswereextractedbycheckingtheresults,discussion,andconclusionsectionsof
eacharticle.Thesekeyaspectswerefactorsidentifiedinthereviewsthatmayaffectad‐
herencetoexerciseinthetargetpopulations.Afterthis,theinformationobtainedthrough
dataextractionwascomparedbetweenthetworesearchersassignedtoeacharticle,and
allobserveddifferenceswerescrutinizedandcorrected.Athirdresearcherwassoughtin
thecaseofdiscrepancy.
2.3.DataSynthesis
Afterextractingthedata,anotherauthorcheckedandcombinedtheinformationof
eacharticleandpreparedthetablesthatsummarizethedataofallarticles(Supplemen‐
tarydataTableS1).Themainkeyfactorsextractedfromthearticlesweregroupedin
topicstoenhancethecomprehensionoftheresultsoutcomes.Thisclassificationoffind‐
ingswasperformedbasedontheidentifiedfactorsfromthestudiesincludedinthisre‐
viewandincluded:
1. Characteristicsoftheexerciseprogram,thatwouldcomprisethosefactorsrelatedto
howthephysicalexerciseisplanned,includingtheindividualization,theevi‐
dence‐basedsettings,andothercharacteristicssuchasfrequency,duration,intensi‐
ty,orvolume.
2. Involvementofprofessionalsfromdifferentdisciplines,thatwouldberelatedtothe
convenienceofincludingexpertsormethodsfromdifferentdisciplines.
3. Supervision,whichwouldincludethesignificanceorirrelevanceofsupervisingthe
exerciseinterventions.
4. Technology,whichwouldbefocusedonthepotentialadditionalbenefitsordisad‐
vantagesofincludingtechnologicaldevicesandapplicationstoconductthephysical
exerciseintervention.
5. Initialexplorationofparticipant’scharacteristics,barriers,andfacilitators,which
wouldincludetheidentificationofrelevantvariablesofthepatientsbeforetheex‐
erciseinterventionsthatcouldreduceorincreasetheadherencetoexercise.
6. Participants’education,adequateexpectations,andknowledgeaboutrisksand
benefits,whichwouldberelatedtowhattheparticipantsknoworlearnaboutthe
relevanceofphysicalexercisefortheirownhealthsothattheexpectationsaboutthe
improvementswerenotinaccurate.
7. Enjoymentandabsenceofunpleasantexperiences,whichwouldberelatedtothe
pleasureobtainedwhileexercisingandalsobytheabsenceofpainordiscomfort.
8. Integrationindailyliving,whichincludestheconsiderationoftheparticipant’s
preferencesandbackgroundtoadapttheexercisecharacteristicsandsettings.
9. Socialsupportandrelatedness,whichincludessupportfrompeers,staff,andfami‐
ly,aswellastheestablishmentofpositivesocialinteractionsandfeelingsofbe‐
longingtoagroup.
10. Communicationandfeedback,whichisrelatedtotheeffectiveinteractionbetween
thestaffandtheparticipant.

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11. Availableprogressinformationandmonitoring,providingenoughinformationto
thepatientsothattheycanbeawareofthechangesandimprovementsfromobjec‐
tivedata.
12. Self‐efficacyandcompetence,whichisrelatedtotheparticipant’sperceptionof
whattheycandoandwhattheywillbeabletodo.
13. Participant’sactiverole,whichwouldincludeself‐management,self‐control,
self‐monitoring,autonomy,andempowerment.
14. Goalsetting,whichisrelatedtotheestablishmentofadequateobjectives.
Afterward,thereviewswereclassifiedconsideringthetargetpopulationandpar‐
ticipants’characteristicsinordertoidentifythemostrepeatedfactorsobtainedforeach
condition:cancer,cardiovasculardisease,olderpeople,participantswithmusculoskele‐
talpain,obesitypatients,andexercisereferralschemes.
3.Results
3.1.StudySelection
Intheoriginaldatabasesearch,184studieswereinitiallyidentified,85articlesin
PubMedand99inWebofSciences(seeFigure1).Afterremoving102duplicatedarticles,
studieswerescreenedbyanalyzingtheirtitlesandabstracts.Subsequently,34records
wereexcludedduetodifferentreasons:threewereabstractsorletterstotheeditor,seven
werefocusedontheassessmentofadherenceoritsconceptsuniquely,fourwerestudy
protocolsandtwentywerenotfocusedonexercise.Thefull‐texttotalof68articleswas
re‐viewedand13ofthemwereexcludedfordifferentreasons:nothavingchronicpa‐
tientsorolderadultsastargetpopulation(n=3),notbeingfocusedonexercise(n=6),
focusedontheevaluationofadherence(n=1),aimedtoexploretherelationshipbetween
adherenceandphysicalexerciseimprovements(n=1)ornotbeingareview(n=2).Thus,
55articles,publishedfrom2010to2019,werefinallyincludedinthecurrentumbrella
review.
3.2.StudyCharacteristics
ThemaincharacteristicsoftheselectedreviewsarereportedinTable1.The55re‐
viewsincluded11meta‐analyses.Regardingchronicpatientsandolderadults,sevenar‐
ticleswerefocusedoncancer[11,14,30–34],sevenoncardiovasculardisease[28,35–40],
eightonelderlypeople[21,41–47],twelveonmusculoskeletaldisorders[48–60],threein
obesityorweightloss[16,61,62],sixonmultiplechronicdiseases[12,27,63–65],twoon
intermittentclaudication[66,67],twoonpopulationwithmildcognitiveimpairmentand
dementia[68,69],andsinglearticlesanalyzedParkinson’sdiseasepatients[13],type‐2
diabetespatients[70],solid‐organtransplantcandidates[15],andparticipantsunder
vestibularrehabilitation[71].


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Figure1.Flowdiagramoftheselectionprocess.
Table1.Summaryofthesamplecharacteristics,typeofexercise,andnumberofreviewsidentified
foreachsampleandexercisetype.
PatientsCharacteristics
Number
of
Studies
TypeofExercise
Interventions
Revised
Cancer
Cancerpatientsorsurvivors 4
Home‐based:1review
Any:6reviews
Advancedcancer1
Non‐smallcelllungcancer1
Colorectalcancer1
Cardiovascular
disease
Heartfailure 2Center‐based:1
review
Any:6reviews
Undercardiacrehabilitation
program4
Generalcardiovascularconditions1
Olderadults
Fallsprevention 3Center‐based:2
review
Home‐based:1review
Any:5reviews
Healthyelderly 5
Musculoskeletal
disorders
Lowbackpain1Center‐based:1
review
Home‐based:1review
Any:10reviews
Arthritis3
Osteoporosis/osteopenia1
General/multiplemusculoskeletal
painorchronicconditions7
Recordsidentifiedthroughdatabase
searching(n=184)
PubMed(n=85)
WebofSciences
(
n=99
)

Screening
Included
Eligibility
Identification

Additionalrecordsidentifiedthrough
othersources
(n=0)
Recordsafterduplicatesremoved
(
n=102
)

Recordsscreened
(
n=102
)

Recordsexcluded(n=34)
Meetingabstractorlettertoeditor(n=3)
Articlefocusedontheevaluationofadherence
ortheconceptofadherence(n=7)
Studyprotocol(n=4)
Notfocusedonexercise(n=20)
Full‐textarticlesassessedfor
eligibility
(n=68)
Full‐textarticlesexcluded,withreasons(n=13):
Nochronicpatientsorolderadults(n=3)
Notfocusedonexercise(n=6)
Aimedtoexploretherelationbetween
adherenceandimprovements(n=1)
Focusedontheevaluationofadherence(n=1)
Noreview(n=2)
Studiesincludedin
qualitativesynthesis
(n=55)

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Obesityorweightloss3Center‐based:3
review
Intermittentclaudication2
Center‐based:1
review
Any:1review
Mildcognitiveimpairmentanddementia2
Center‐based:1
review
Any:1review
Parkinson 1Any:1review
Type2diabetes1Any:1review
Solid‐organtransplantcandidates1Any:1review
Undervestibularrehabilitation1Home‐based:1review
Differentchronicdiseases6
Center‐based:1
review
Home‐based:2
reviews
Any:3reviews
ExerciseReferralschemes 4
Center‐based:2
reviews
Any:2reviews
Center‐based:exerciseprogramsspecificallyconductedinpublicorprivatecenters;Home‐based:
exerciseprogramsconductedathome;Any:includingbothcenter‐basedofhome‐based.
Thirteenoftheincludedrevisionswerebasedonexerciseinterventionsconductedin
publicorprivatecenters,whilefivestudieswerefocusedonadherencetohome‐based
exerciseprograms[41,48,58,71,72].Theremaining37reviewsincorporatedexercisepro‐
gramsmixingcenter‐ andhome‐basedinterventionsandinsomecasesalsophysicalac‐
tivityinterventions,likewalkingorleisuretimeactivities.Althoughallthearticlescom‐
promisedexerciseinterventions,somealsoincludedphysiotherapy[52,55,58,60],life‐
style‐changinginterventions[33,61,62,70],exercisereferralschemes[65,73–75],technol‐
ogyandmultimediaeffects[21,27,38,64],behaviorchangetechniques[47,49,50,56,62],
andbarriersandfacilitatorstoexercise[46,52,59,69,75].Thosestudieswereincluded
sincetheyprovidedvaluableinformationaboutfactorsassociatedwithadherencetoex‐
ercise.
3.3.OutcomeResults
Theanalysisperformedrevealed14keyfactorsofexerciseprogramsthatmayposi‐
tivelyinfluencetheiradherencerates.AsTable2shows,thesetopicsreporteddifferent
sub‐keyaspectsthatrepresentinmoredetailthecharacteristicsofthemostadhered
programs.
First,theresultsoftheglobalanalysisrevealedthatinitialexplorationofpartici‐
pant’scharacteristics,barriers,andfacilitatorsseemedtobecrucialtoenhanceexercise
adherenceingeneralchronicpatientsandolderadults.Concretely,thirty‐sixreviews
identifiedtheimportanceofpre‐participationevaluationofparticipants’previouslife‐
stylehabitsaswellastheirphysicalandmentalhealthstatus.Besides,29reviewsstated
thatpossiblebarriersandfacilitatorstoexercisemayneedtobecontemplatedbeforethe
program’sdelivery.Thenextmostdistinguishedkeyaspect,mentionedbytwenty‐nine
articles,wastostudyparticipants’preferencesandbackgroundstoenhancetheintegra‐
tionofexerciseintheirlifestyle.Moreover,regardingtheprogramdesigncharacteristics,
twenty‐threereviewsstatedthatdevelopinganindividualizedexerciseintervention
couldbeakeypointtoenhanceadherencerates.Althoughthepsychologicalvariables
didnotreachsuchhighsupportinthegeneralanalysis,itappearedthatfomentingpar‐

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
ticipants’self‐efficacymaybethemostusefulpsychologicalfactorinexerciseadherence
(21articles).
Asfortheindividualanalysisofdifferenthealthconditionsregistered,alsopre‐
sentedinTable2,consideringpatients’previoushabitsandphysicalandmentalhealth
statuswasthemostvaluableaspectinpatientswithcancer[11,14,30–34],patientswith
cardiovasculardisease[28,35–37,39,40],patientswithmusculoskeletaldisorders
[48,49,52,54,59]andinexerciseprogramsaimedtoreduceobesityorinweightlossexer‐
ciseinterventions[16,61,62].Inolderadults,fivereviewssupportedtheprovisionofob‐
jectiveinformationabouttheirprogressandtheconsiderationofparticipants’prefer‐
encesandbackgroundaseffectivestrategiestoenhanceadherence[21,41,42,46,47].
However,supervisionbyahealthcareorexerciseprofessional,individualizationofthe
exerciseprogram,providinginformationaboutexerciserisksandbenefits,andtheelec‐
tionofanaccessiblelocationforthedevelopmentoftheexerciseprogramwereeach
supportedbyfouroutofeightreviews.
Outliningbrieflyeachofthechronicdiseases,cancerexerciseprogramsmayalso
needtoanalyzepatients’barriersandfacilitatorstoexercisebeforetheintervention
[14,30,31,33,34]andchoosegoodaccessibilityandanadequateplacetodeliverthein‐
tervention[11,14,30,34].Exerciseprogramsforpatientswithcardiovasculardisease
shouldanalyzeexercisebarriersandfacilitatorsbeforetheintervention[28,35–37,39,40],
butalso,theyshouldemphasizetheimportanceoffamilyandpeersupport[28,36–39],
togetherwithexercisemonitoring[28,35,37,38]andprovidingeducationalinformation
abouthowtoexerciseintheircondition[35–38].Wheninterventionswerecarriedoutby
participantswithmusculoskeletaldisorders,anassessmentofthebarriersandfacilitators
appearedtobeascrucialasanalyzingtheirpreferencesandbackgroundanddeveloping
multidisciplinaryprograms(fivearticlesineachkeyaspect).Finally,inweightlossin‐
terventions,orwithobeseparticipants,patients’preferencesandbackgroundstoen‐
hancetheintegrationoftheprogramintheirlifestyleseemedtobeessential[16,61,62].
Table2.Summaryofkeyfactorsaccordingtodifferentconditions.
KeyFactorsSub‐KeyFactors
NumberofReviewsIncludingEachKeyFactor
TotalCancerCVD
Musculo‐S
keletal
Disorders
Older
Adults
Obesity
/
Weight
Loss
Exercise
characteristics
design
Characteristicsoftheexerciseare
individualizedandscientificallycorrect 2333442
Thedurationoftheexerciseintervention
isnottoolong10‐ 1131
MultidisciplinarityMultidisciplinaryprogram12‐ 1522
SupervisionSupervision1711441
TechnologyUseofadequatetechnology12‐ 3131
Initialexplorationof
participant’s
characteristics,
b
arriers,and
facilitators
Previoushabitsandphysicalandmental
healthstatusoftheparticipantsare
known
3676523
Barriersandfacilitatorsareexplored
b
eforetheexerciseprogramisdelivered
tosearchforalternatives
2956532
Participants
education,adequate
expectations,and
knowledgeabout
risksandbenefits
Participantsareeducatedaboutphysical
exerciseintheircondition1724321
Participantsareadequatelyinformed
abouttherisksandbenefitsofthe
program
15‐ 3141
Adequateexpectations15‐ 3331

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

Enjoymentand
absenceof
unpleasant
experiences
Enjoyment10‐ 1321
Absenceofunpleasantexperiences91‐ 311
Integrationindaily
living
Participant’spreferencesandbackground
areconsideredintheprogramtoenhance
itsintegrationintotheirlifestyle
2932553
Goodaccessibility,adequateplace,and
flexibilityintheschedule2143342
Socialsupportand
relatedness
Socialsupportfrompeersandfamily2215431
Socialsupportfromtheprofessional2223521
Relatedness11‐ 223‐
Communicationand
feedback
Intra‐sessionfeedback1122321
Bilateralandfluidcommunicationwith
thestaff16‐ 2331
Availableprogress
informationand
monitoring
Objectiveinformationforpatientsto
knowtheirprogress1713252
Exerciseismonitored1624‐ 32
Sel
f
‐efficacyand
competence
Sel
f
‐efficacy2123332
Competence7‐3‐ 1‐
Participant’sactive
role
Self‐management,self‐control,and
self‐monitoring 161341‐
Autonomyandempowerment8‐112‐
GoalsettingObjectivesareclearandestablishedwith
thepatient12125‐2
Eachnumberrepresentsthenumberofreviewsthatsupporteachfactor,overall,andaccordingtotheconditionforthose
with3ormorereviewsidentified.CVD:cardiovasculardisease.
4.Discussion
Themainaimofthecurrentsystematicreviewofreviewswastoidentifykeyfactors
associatedwithadherencetophysicalexerciseinpatientswithchronicdiseasesandolder
adults.Manydifferentkeyfactorswereidentifiedintheincludedreviewsaspositiveto
promoteadherencetoexerciseandtheywereorganizedandsummarizedinthefollow‐
inglines.
4.1.DesignoftheExerciseIntervention
Regardingthedesignoftheexerciseprogram,twomainkeyfactorswereidentified:
(a)theindividualizationandthescientificbasisofexercisetypeand(b)thedurationof
theexerciseprograminweeks.Thefirstkeyaspectcanbedividedintwosince21ofthe
includedreviewsfoundthattailoredexerciseisnecessarytoachievehighlevelsofad‐
herence,andsevenidentifiedtheneedofconductingexerciseinterventionswithascien‐
tificbackground,withfiveofthosesevenarguingthatbothaspectsarerelevant.The
otherkeyfactoridentifiedby10reviewswasthedurationoftheexercise.Itwasshown
thatlongerexerciseinterventionswererelatedtoloweradherencetotheprogram.This
outcomemaybeassociatedwiththeneedtomaintainahomogeneousexerciseroutine
duringtheentireexerciseprograminrandomizedcontrolledtrials,whichmaycause
someindividualstodroptheprogramduetothelackofvariety.Inthisregard,the
measurementofadherenceinprogramsthatallowthechangeofexerciseactivitiesacross
theprogrammaybenecessarytodetermineiftheconstraintsofrandomizedcontrolled
trialsmaybeovercomebyaffordingpatientsmorelibertytodecidetheexercisetype.
Fromapatient‐centeredperspective,theindividualizationoftheexerciseintermsof
type,intensity,duration,frequency,butalsoinneedsandinterests,isnecessaryforef‐

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
fectivepromotionofadherence.Thiswouldelicitasuperiorresponsenotonlyduetoa
betteradjustmenttothephysiologicaldemandsoftheactivitybutalsoduetoenhanced
patientperceptiontowardstheexerciseprogram.Forinstance,amongpatientswithde‐
mentia,thosewithbettercognitivehealthoftenhaveloweradherencerates[69].This
couldberelatedtoanon‐adequateadjustmentofdemands,whichmaybeonlytailored
tothosewhohavethepoorestcognitivecapacityinthegroup.Thatcouldalsobetruefor
groupscomprisedofpatientswithdifferentfunctionalcapacity,sinceexercisemaybe
tailoredtothosewiththepoorestphysicalfunction.Therefore,makinghomogeneous
groupsintermsofinterests,needs,andfunctionalitywillincreasetheadjustmentofex‐
ercisedemands,socialsupport,connectedness,andrelatedness[42]aswellasachievea
superiorphysiologicalandpsychologicalresponse.
Althoughsomeauthorshavepointedthatthecharacteristicsoftheexerciseprogram
mayberelatedtoexerciseadherence,someaspects,likethetypeofexerciseorexercise
intensity,arenotoftenreportedaskeyfactorstopromoteadherence.Inthisregard,we
foundasimilarnumberofreviewsshowingthatvariableslikeintensity,frequency,or
volumearerelevantandreviewsreportingthattheyarenot.Traditionalexerciseinter‐
ventionssuchaswalkingmayreduceadherencecomparedtoalternativeoptions,suchas
Nordicwalking,resistancetraining,orcircuittraining[67],butwalkingcanalsobecon‐
sideredasanaccessibleandfeasibleformofexercisethatfacilitatestheattractivenessof
theexerciseprogramforsomeindividuals[46].Regardingtheexercisefrequency,ithas
beenshownthatonesinglesessioneachweekmayleadtoloweradherence,probably
duetoparticipantsdoubtingtheefficacy,thelessfrequentcontactwiththestaffand
peers,andthebiascausedbytheselectionofphysicallyactiveparticipantswhomaybe
unsatisfiedwiththelowexercisefrequency[45].Furthermore,ifparticipantsonlydo
exercisewithintheexerciseprogram,theywouldnotbefollowingtherecommendations
oftheWHO[5].
Findingsrelatedtothedurationoftheexerciseprogramareextremelyalarming.Ten
reviewsshowedthatthelongerthedurationoftheinterventionthelowertheadherence
obtainedintheindividualsthatunderwenttheprogram.Withtheaimofincreasingthe
long‐termadherencetophysicalexercise,itseemsthatthereisaneedforalternativesto
escapefromroutineandavoidinterventionsthatcouldboreoroverwhelmthepatients
[45].Thisfindingmayconflictwithscientificaims.Sinceitisknownthatcertainvariables
mayneedacoupleofmonthstobeimprovedbyphysicalexercise,reducingtheduration
oftheinterventionsmaynotbeanadequatealternative.So,whenaspecificintervention
lengthisrequired,researchersandphysicalexerciseprofessionalsmustmakeaneffortto
facilitatetheaccommodationofexerciseswithinthedailylivingofpatients[54].
Insum,individualization,theuseofvariousexercisetypeswithprovenevidenceof
efficacyforthetargetpopulation,afrequencyhigherthanonceperweek,andamoderate
durationoftheprogrammaybekeyfactorstopromoteexerciseadherence.
4.2.MultidisciplinaryTeam
Atotalof12reviewsidentifiedhowthepresenceofdifferentprofessionalswho
conducttheexerciseinterventioncouldimproveadherence.Inadditiontothephysical
exerciseprofessional,whoismainlyresponsibleforthedesignanddevelopmentofthe
exerciseprogram,theadditionofcounselingbyotherprofessionalssuchaspsycholo‐
gists,physicians,physiotherapists,nutritionists,ornursesishabituallyperceivedas
positivetoreinforceadherence.Inthisregard,somereviews[12,41,47,65]showedthat
theparticipationofphysicianswaskeysincepatientsweremorelikelytoadhereto
physicalexercisewhenitwasprescribedbyahealthcareprofessional.Furthermore,the
laborofpsychologistsmayenhanceadherencetoexercisebyconductingdifferentbe‐
havioralchangetechniquesorcognitive‐behavioralprograms[49,50,55,56,60,65].How‐
ever,theefficacyoftheseprogramsisstillcontroversial,obtainingmixedresultsand
largeheterogeneity.

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Therefore,thepresenceofamultidisciplinaryteammaycontributetoincreased
adherencetoexerciseamongchronicpatientsandolderadults.Althoughthepresenceof
differentspecialistsmaybeaffordableincontrolledtrialsandotherresearchdesigns,the
costsoftheexerciseprogrammaybelargelyincreasedbythisfactor,whichcouldimpact
thepricethattheusermustaffordtobeinvolvedintheprogramandconsequentlythe
adherenceofexercise,especiallyforthosewithatalowsocioeconomiclevel[69].This
bringsustoanotherrelevantissue:thewillingnesstopayforexercise.Arecentstudy
showedthatonlyhalfoftheolderadultswerewillingtopayforfallpreventionprograms
[76],whilechronicpatientssufferingfromkneeosteoarthritismaybewillingtopaylittle
money,withonly26%willingtopaymorethan65€forsixweeksofanevidence‐based
programandonly10%willingtopaymorethan100€[77].Althoughthebenefitsofex‐
ercisearewell‐known,peoplearestillreluctanttopayforit,evenalowamountof
money.Takingthisintoaccount,itischallengingtoprovideanexerciseprogramin‐
volvingprofessionalsfromdifferentdisciplinesthatsuitsthelowwillingnesstopayof
olderadultsandchronicpatients.
Insum,theadditionofprofessionalsfromdifferentdisciplinessuchaspsycholo‐
gists,physicians,ornursesmayincreaseadherencetophysicalexerciseinterventions.
4.3.SupervisionduringtheExerciseSessions
Supervisionwasidentifiedasakeyaspectby17reviews.Supervisionduringthe
exercisesessioninvolvesatleastoneprofessionalcheckinghowtheparticipantisper‐
formingtheprescribedexercises,whichindeedenhancesthequalityoftheexecution
and,consequently,increasesthepotentialbenefitsandreducesthepossiblerisksofin‐
adequateexecutions[16,44,66].Furthermore,supervisionalsomakestheevaluationof
adherenceeasierandmoreaccurate,avoidingtheuseofself‐reportedexerciseregistries
andproblemsrelatedtotheuseofmonitoringtechnology.Inthisregard,Hughes,
Salmon,Galvin,Casey,andClifford[44]showedthatadherence(assessedthrough
self‐reportedregistries)toexercisewashigherinunsupervisedhomeexerciseprograms
whilethebenefitswerelowerthanthoseobservedinclass‐basedsupervisedexercise.
Thiscouldbeexplainedbyanover‐estimationofadherenceratesduetosocialdesirabil‐
ityandobsequiousresponsesfromtheparticipants[12].However,theadvantagesof
supervisionaredocumented,allowingparticipantstoaccesstheprofessional’s
knowledge,feedback,andsupport,whichmayincreaseself‐efficacyandreducethedis‐
couragingfeelingandpotentialrisks[16].
Thedebatebetweenface‐to‐facevs.home‐basedexerciseisnotassociatedwithsu‐
pervision,sincebothtypesofdeliverycanbesupervised,providedthattheprofessional
canbemonitoringwhattheparticipantsaredoingduringsessionsinbothtypesofexer‐
ciseprograms.Asadisadvantageofsupervisedexercise,thecostsoftheprogramsmay
beincreasedandtheflexibilityintimecanbereducedsincebothparticipantsandpro‐
fessionalsmustbesimultaneouslyinthesameplaceorconnectedonline,whichcould
reducetheadherenceasaconsequenceofincompatibilityintimetables.
Insum,exerciseprogramssupervisedbyatleastonephysicalexerciseprofessional
mayincreaseadherencetophysicalexercise.However,otherdisadvantageshavebeen
described.
4.4.TheUseofTechnology
Atotalof12reviewshaveanalyzedtheroleoftechnologyinenhancingadherenceto
physicalexercise.Althoughpromisingresultshavebeenachievedintechnology‐based
exerciseprogramslikethoseobtainedbyXu,Li,Zhou,Li,Hong,andTong[38],who
observedthatthecompletionwas1.38timeshighercomparedtotraditionalprograms,
theevidenceisstilldebated[27].Someadvantageshavebeenreported,sincethetech‐
nologymaybeusefultoaccuratelymonitorthephysicalactivityofparticipantsinterms
offrequencydurationandtime,individualizetheexerciseprescription,providereal‐time

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feedback,tomakereminders,connectprofessionalsandpatients,sharetheperformed
activitieswithpeers,andprovideinstructions,amongotherbenefits[44,64,71].
However,inchronicpatientsandolderadults,technologymustbeusedwithcau‐
tion,sincenoteverybodywillhavethesameresponse.Olderadultsmaybelesslikelyto
engageinphysicalexercisetechnology‐basedprogramswhileyoungpeoplemayhave
theoppositeperception[28].However,anotherreview[21]foundthatdropoutrates
weresimilarintechnology‐basedandtraditionalexerciseprograms,whereasthereasons
weredifferent.Inthisregard,reasonstoabandontraditionalexercisewerelackofmoti‐
vationandpersonalobligations,whileintechnology‐basedprogramsreasonsincluded
lowmotivation,lackofinterest,discomfort,lackoftime,limitedspaceathome,tech‐
nologyusability,orshame.Furthermore,itmustbenotedthatwhentheexercisepro‐
gramisbasedontechnology,theinterpretationofadherencemaybedifferent,since
sometimesresearchersareassessingadherencetoadeviceinsteadofadherencetophys‐
icalexercise[28].
Insum,theuseoftechnologymayberecommendedwhenparticipantsarewillingto
useitandthedevicesandsoftwareareadequateforthem,butitmustbenotedthatsome
peoplemayrefusetechnology.Therefore,itcouldbesuggestedthattheinclusionof
technologymaybevoluntaryandnotmandatoryinexerciseprograms.
4.5.InitialExplorationofParticipant’sCharacteristics,Barriers,andFacilitators
Morethan70%oftheincludedreviewsidentifiedtheneedforcarryingouta
pre‐participationcomprehensiveanalysisoftheparticipants’characteristicsandthepo‐
tentialbarriersandfacilitators.Thirty‐sixofthe55includedreviewsfoundthatsome
aspectslikethehealthstatus(includingphysicalandmentalhealth)orprevioushabits
(suchasphysicalactivitylevel,smoking,oralcoholintake)arerelevantfactorstopredict
exerciseadherence.Withoutanydoubt,thesefactorsarethemostwidelycitedinthe
scientificliteratureaboutadherencetoexerciseinchronicpatientsandolderadults.
Healthstatusstandsoutasoneofthemajorfactorsforexercising.Thisisacomplex
conceptthatneedstobeunderstoodnotonlyintermsofseverityofsymptoms,butalso
intermsofhealth‐relatedphysicalfunctionandothercomponentslikemental,cognitive,
social,orsexualstatus.Dependingonthecondition,differenthealth‐relatedaspectswill
belinkedtoloweradherence.Inthisregard,chronicdiseasesthatinvolvepainorfatigue
mayreducetheattendanceandadherenceofpatients[78,79].Furthermore,thosepatients
withdepressionwillalsobemorelikelytoabandontheexerciseprogram[43,72,80].On
theotherhand,nodifferencehasbeenobservedwhencomparingtheadherenceratesof
patientswithconditionslikecancer,cardiovasculardisease,anddiabetes[63].Although
therapistscannotmodifythebaselinehealthstatus,itisrelevanttoproperlyassessand
analyzethestatusbeforetheexerciseprogramisconducted.Furthermore,barriersand
facilitatorsmustbeopenlydiscussedbeforeandatregularintervalsthroughoutinorder
toensureindividualization[61].
Withinthesuggestedinitialexplorationofbarriersandfacilitators,thestageof
changeisastrongpredictorofadherencetoexerciseinchronicpatients[31].Theconcept
ofstageofchangecomesfromthetranstheoreticalmodel,whichdefinesaseriesofbe‐
haviorchangestages:pre‐contemplation,contemplation,preparation,action,and
maintenance[81].Inthisregard,amismatchbetweenthestageofchangeandtheselected
strategymayleadtoloweradherenceratesandthosepatientswhoarenotphysicallyac‐
tivearemorelikelytoreportexercisebarriers,butthesedentarybehaviordoesnotnec‐
essarilyhinderpatientsfrombecomingphysicallyactive[31].
Thediagnosisofachronicdiseasemayinvolveseveralchangesinthedailylivingof
patients,reductioninphysicalactivitylevelsbeingoneofthemajorchanges.Among
others,thediagnosisofInflammatoryBowelDiseasehasbeenrelatedtoareductionin
physicalactivitylevels[82],andeventhosepatientswithhighpre‐illnessphysicalactiv‐
itylevelsdrasticallyincreasetheirsedentarybehaviorwhileundergoingcancertreat‐
ment[83],especiallywhentheyhadprevioussedentaryhabits[32,34].Ontheotherhand,

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somemiddle‐agedandelderlypeoplemaystarttoexerciseaftertheyarediagnosedwith
achronicdisease[84].Otherchangeshavebeenreportedafterhypertensiondiagnosis,
suchassmokingcessationaccompaniedbyasmallreductionininactivity[85],but
changesinlifestyleareoftennotenough.Althoughtheimplicationsofdiagnosisarestill
controversial,itisclearthatitisatimewherepeoplecanbemorepronetochange,since
itcouldbeinterpretedasa“wake‐upcall”toadoptamorehealthylifestyleevenwhen
thatintentionisnottranslatedintorealchanges[86,87].Thisissimilartotheconceptof
“teachablemoments”,whichhasbeendefinedasopportunitiesforchangingunhealthy
habitsafteraspecificcircumstanceorevent[88].Thesemomentsmaybeadiagnosis,a
hospitalization,orotherepisodes,andareinfluencedbyalltheinvolvedhealthcarepro‐
fessionalsandrequirecommunicationskills[65].
Apartfromthepotentialinternalbarriers,thereareothercontextualandcultural
barriersthatshouldbeconsidered.Forinstance,socioeconomicstatusisacommonbar‐
rier[35,43,69]andwomeninsomeculturesmayfeeluncomfortablewalkingunaccom‐
paniedorsimplybeingphysicallyactive[46].Therefore,socialandeconomicfactors,as
wellasbeliefsandgroupnorms,mustbeconsideredwhenanexerciseprogramisde‐
signed.
Insum,acomprehensivebaselineassessmentmustbecarriedoutbeforetheexercise
programtoidentifypotentialbarriersandfacilitators,includinghealthstatus(physical
andmentalhealth)andpreviouslifestylehabits.
4.6.ParticipantsEducation,AdequateExpectations,andKnowledgeaboutRisksandBenefits
Thisisarelevantissuethatincludedtheeducationinexerciseandhealth(17re‐
views),adequateinformationaboutbenefitsandpotentialrisks(15reviews),andade‐
quateexpectationsofchanges(15reviews).Ingeneralterms,itcanbesaidthatthosepa‐
tientswhoareawareofwhatexercisecandoforthemaremorelikelytoadheretoexer‐
ciseprograms.Althoughinthelastyearstherehavebeenalotofcampaignstryingto
disclosethebenefitsofbeingphysicallyactive,additionaleffortmustbeexpendedto
educatepeopleonexerciseandhealth.
Peopleoftenshowhigherlevelsofadherencewhentheexerciseisprescribedby
physiciansratherthanbyotherprofessionals.Thatisinlinewiththehealthbeliefmodel,
whichstatesthattheexpectedbenefitsarekeytobeinvolvedinanactivity[89].Thus,
whenparticipantsbelievethattheirhealthstatusisgoingtobeenhanced,theyaremore
likelytobeinvolvedintheexercise.Infact,thisfactorcouldpartiallyexplainwhysome
physicalexerciseprogramsachievedbetteradherencethanothers.Forinstance,infall
preventioninterventions,theadherencetoprogramsaimedtoimprovebalancewas
higherthanadherencetoprogramsaimedtoincreaseflexibility[41,45].Thatcouldbe
explainedbytheparticipants’expectedbenefits,whomaybelievethatflexibilityexercise
isnotgoingtoleadtosubstantialimprovementsthatleadtothepreventionofafallepi‐
sode.Therefore,patientsmustalwaysbeadequatelyinformedabouttheobjectivesand
theexpectationsofeachexercise.
However,toohighexpectationsmaybeadouble‐edgedsword.Oneoftheincluded
reviewsanalyzedtheeffectsofexpectationsonadherencetoaweightlossprogram.They
observedthatthoseindividualswithlowerexpectationshadbetteradherence,while
thosewithunrealisticgoalsweremorelikelytoabandontheprogram[61].Thiswasalso
observedinexercisereferralschemes[73].Therefore,physicalexerciseprofessionals
mustbecautiouswhentheydiscussgoalsandexpectationswiththeparticipantsinorder
toavoidunrealisticoroverlyoptimisticbeliefs.Furthermore,ithasbeensuggestedthat
theseexpectationsshouldbebasedonhealthandqualityoflifevariables,andnotjust
measureslikeweightlossinaspecifictimelength.
Inlinewiththeavoidanceofoverlyoptimisticexpectations,potentialrisksmustbe
ethicallydisclosed,andthepresenceofunpleasantfeelingsshouldbeanticipated[36].
Theymustalsobeadvisedabouttheprogressoftheirdiseaseandwhattheabsenceof
exercisemaycause.Forinstance,ithasbeenshownthatcolorectaladenomapatientsmay

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beunawareoftheincreasedcancerrisktheyhave,[33]andpatientswithheartfailure
hadpoorknowledgeabouttheirdisease[90]andthiscouldreducetheengagementin
healthyactivities.
Insum,participantsinexerciseprogramsshouldbeeducatedinordertobeawareof
thehealthbenefitsofexerciseandtherisksofsedentaryhabits.Theyshouldalsobead‐
equatelyinformedabouttheusualfeelingsduringthepractice(forexamplethefatigue)
andmustbeprovidedwithenoughinformationtohaverealisticexpectationsofchange,
avoidingoverlyhighorlowexpectations.
4.7.EnjoymentandAbsenceofUnpleasantExperiences
Theexperienceofparticipantswhiledoingexerciseiscrucialtoenhancetheadher‐
encetophysicalexercise.Enjoymentisanimmediaterewardthatcouldleadtobetter
persistencethandelayedrewards,suchashealthbenefitsinthelong‐term[91].Ithas
beenrelatedtoparticipationandefficacyofphysicalexercise[92]andiscloselyassoci‐
atedwithintrinsicmotivation[93].Inthisregard,participantsaremorelikelytoenjoythe
practicewhenthebasicpsychologicalneedsofcompetence,relatedness,andautonomy
aresatisfied[94].Thoseneedshavealsobeenidentifiedinthissystematicreviewaskey
factorstobeconsidered.Theuseofadequatetechnologymayalsoenhancetheenjoy‐
mentinchronicpatients[95]andaltertheperceivedeffortofpatientsdoingexercise,
achievingsimilarphysiologicalresponseswithlowerperceivedexertion[96].
Ontheotherhand,thepresenceofunpleasantexperiencesmaylimitparticipation
andadherencetoexercise.Thisisespeciallyrelevantamongthosepatientssufferingfrom
conditionsthatcausepainorfatigueandcanbeincreasedwhentheintensityofexercise
hasrisen[97].Thisisconsistentwiththenotionthatenjoymentisastrongmediatorof
adherencetoexerciseinpatientssufferingfrommusculoskeletalpain[98].
Theaffectiveresponsetoexerciseisbasedontheinterpretationofacomplexnetof
interactionsamongphysiologicaldemands,participant’spsychologicalcharacteristics,
theenvironment,andsituationalappraisals[99].Therefore,theseindividualinterpreta‐
tionswillbedifferentfromsubjecttosubject,sowhatisenjoyableforsomeonecouldlead
tounpleasantfeelingsinothers.Forinstance,somepeoplecaninterprettheincreased
heartrate,breathing,ortemperatureaspleasantornot[100].Similarly,physicaltiredness
couldbeunpleasantbutalsoleadtoemotionallypleasantfeelings[100].Inthecaseof
pain,cliniciansmustadequatelyinformaboutpainexperienceandbeliefs,reducingthe
associatedfearoranxietyandavoidingtheimmediateabandoningofactivitiesthat
generatealittlediscomfort[52].
Inthecaseofobesity,otherunpleasantfeelingscanemerge,suchastheembar‐
rassmentwiththeirownappearancewhiledoingexercise,rapidexhaustionrelatedto
poorphysicalconditioningduetophysicalinactivity,orlackofmovementenjoyment
[61,101].
Inthesearchprocess,thissystematicreviewofreviewsalsoidentifiedreviews
aimedtoevaluatetheeffectsofpayingpeopletoexercise.Mitchell,etal.[102]foundthat
financialincentivesincreaseattendanceininterventionsforuptosixmonths.Thisap‐
proachiscontroversialsince,accordingtotheself‐determinationtheory,givingexternal
motivatorsinactivitiesthatcouldbeintrinsicallyenjoyablemayreducetheintrinsicmo‐
tivationoncetheexternalrewardisremoved[103].However,thisharmtointrinsicmo‐
tivationmaybeloweramongpreviouslyinactivepatientswholackintrinsicmotivation
toexercise[23].Therefore,financialincentivesmaybeonlyadequateinthoseindividuals
thatwouldnotexerciseunderanyotherconditions.
Insum,thepleasantandunpleasantfeelingsduringexercisearegoingtoaffectad‐
herenceandmotivation.Enjoymentisanimmediaterewardthatmayincreaseadherence
morethanotherdelayedrewardssuchashealthbenefits.Furthermore,unpleasantex‐
periencesduringtheexercisepracticearealsocommoninpatientswithdifferentcondi‐
tions,soitisnecessarytogiveenoughinformationsothatthepatientsadequatelyinter‐
prettheirfeelingsandemotionsandreducetheassociatedfear,anxiety,andavoidance.

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4.8.IntegrationinDailyLiving
Oneofthekeysthatwasreportedbymorethanhalfofthereviewsistheintegration
ofphysicalexerciseindailyliving.Thisisafactorthatmaybeaffectedbytherestofthe
identifiedfactorsandinvolvethetransformationofphysicalexerciseintoalifestylehabit,
whichwouldavoidthecommonbarrier