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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.
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Int.J.Environ.Res.PublicHealth2021,18,2023.https://doi.org/10.3390/ijerph18042023www.mdpi.com/journal/ijerph
Review
KeyFactorsAssociatedwithAdherencetoPhysicalExercise
inPatientswithChronicDiseasesandOlderAdults:
AnUmbrellaReview
DanielColladoMateo
1
,AnaMyriamLavínPérez
1,2,
*,CeciliaPeñacoba
3
,JuanDelCoso
1
,MartaLeytonRomán
1
,
AntonioLuqueCasado
1
,PabloGasque
4
,MiguelÁngelFernándezdelOlmo
1
andDianaAmadoAlonso
1
1
CentreforSportStudies,ReyJuanCarlosUniversity,Fuenlabrada,28943Madrid,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
GOfitLAB,Ingesport,28003Madrid,Spain
3
DepartmentofPsychology,ReyJuanCarlosUniversity,Alcorcón,28922Madrid,Spain;cecilia.penacoba@urjc.es
4
DepartmentofPhysicalEducation,SportandHumanMotricity,AutónomaUnivesity,CiudadUniversitaria
deCantoblanco,28049Madrid,Spain;pablo.gasque@uam.es
*Correspondence:am.lavin.2018@alumnos.urjc.es
Abstract:Physicalinactivityisamajorconcernandpooradherencetoexerciseprogramsisoften
reported.Theaimofthispaperwastosystematicallyreviewpublishedreviewsonthestudyof
adherencetophysicalexerciseinchronicpatientsandolderadultsandtoidentifythoseadher
encerelatedkeyfactorsmorefrequentlysuggestedbyreviewsforthatpopulation.ThePreferred
ReportingItemsforSystematicReviewsandMetaAnalyses(PRISMA)guidelineswerefollowed.
Resultswereclassifiedconsideringthetargetpopulationandparticipants’characteristicstoiden
tifythemostrepeatedfactorsobtainedforeachcondition.Fiftyfivearticleswerefinallyincluded.
Fourteenkeyfactorswereidentifiedasrelevanttoincreaseadherencetophysicalexercisebyat
leasttenreviews:(a)characteristicsoftheexerciseprogram,(b)involvementofprofessionalsfrom
differentdisciplines,(c)supervision,(d)technology,(e)initialexplorationofparticipant’scharac
teristics,barriers,andfacilitators,(f)participantseducation,adequateexpectationsandknowledge
aboutrisksandbenefits,(g)enjoymentandabsenceofunpleasantexperiences,(h)integrationin
dailyliving,(i)socialsupportandrelatedness,j)communicationandfeedback,(k)availablepro
gressinformationandmonitoring,(l)selfefficacyandcompetence,(m)participant’sactiverole
andn)goalsetting.Therefore,adherencetophysicalexerciseisaffectedbyseveralvariablesthat
canbecontrolledandmodifiedbyresearchersandprofessionals.
Keywords:barriers;facilitators;physicalactivity;lifestyle;cancer;cardiovasculardisease;elderly;
musculoskeletaldisorders;obesity
1.Introduction
Theincreaseinlifeexpectancyandtheremarkableadvancesinmedicinehave
causedthemeanageoftheglobalpopulationtoprogressivelyincrease[1].Linkedtothis,
thenumberofpeoplesufferingfromoneormorechronicdiseaseshasdramaticallyrisen,
whichleadstolargeeconomiccostsforcountriesandagreaterneedforhealthcareser
vices[2].Physicalexercisehasbecomestandardpracticeinclinicalcareduetothefact
thatitleadstonumerousbenefitsinmanydifferentpathologicalandnonpathological
populations[3].Inthisregard,theinclusionofphysicalexerciseprogramsintreatment
plansisnowanessentialtoolformosthealthcareproviders,whiletheuseofevi
dencebasedexerciseprogramssubjectedtotheevaluationofexerciseprofessionalsis
consideredkeyinthepreventionandtreatmentofmanyconditions[3,4].
Citation:ColladoMateo,D.;
LavínPérez,A.M.;Peñacoba,C.;
DelCoso,J.;LeytonRomán,M.;
LuqueCasado,A.;Gasque,P.;
FernándezdelOlmo,M.Á.;
AmadoAlonso,D.KeyFactors
AssociatedwithAdherencetoPhysical
ExerciseinPatientswithChronic
DiseasesandOlderAdults:An
UmbrellaReview.Int.J.Environ.Res.
PublicHealth2021,18,2023.
https://doi.org/10.3390/
ijerph18042023
AcademicEditor:PaulB.Tchounwou
Received:26January2021
Accepted:13February2021
Published:19February2021
Publisher’sNote:MDPIstays
neutralwithregardtojurisdictional
claimsinpublishedmapsand
institutionalaffiliations.
Copyright:©2021bytheauthors.
LicenseeMDPI,Basel,Switzerland.
Thisarticleisanopenaccessarticle
distributedunderthetermsand
conditionsoftheCreativeCommons
Attribution(CCBY)license
(http://creativecommons.org/licenses
/by/4.0/).
Int.J.Environ.Res.PublicHealth2021,18,20232of25
Everyyear,hundredsofrandomizedcontrolledtrialsaimedtoevaluatetheeffects
ofphysicalexerciseonhealthrelatedvariablesarepublished.Thatistheconsequenceof
alargeinvestmentofpublicandprivateinstitutionsandtheworkofmanyresearchers,
whohavedemonstratedthatphysicalexerciseleadstonumerousbenefitsinmanydif
ferentpathologicalandnonpathologicalpopulations[3].Asaresult,physicalexercise
hasbecomeamedicinethateveryoneshouldtakeregularly[5]andmanydifferent
campaigns,advertisements,andpolicieshavebeendevelopedtospreadthatmessage
[6,7].However,althoughmostpeopleknowtherelevanceofhavinganactivelifeasa
partofahealthylifestyle,inactivityisstillamajorconcernandthenumberofsedentary
peoplehasnotbeenproperlyreduced[8,9].
Therefore,thereisakeyquestionthatresearchersworkingonphysicalexerciseand
healthmustask:whypeoplenotexerciseevenknowinghowgooditisfortheirown
health?Theanswertothisquestionmayberelatedtothelackofproperinformationthat
enhancesmotivationandadherencetotheexerciseguidelinesproposed.Forexample,
theWorldHealthOrganization(WHO)hasrecentlypublishednewguidelinesonphys
icalactivityandsedentarybehavior,indicatingthatadultsshoulddoatleast150–300min
ofmoderateintensityaerobicphysicalactivity,oratleast75–150minofvigorousinten
sityaerobicphysicalactivity,oracombinationofmoderate‐ andvigorousintensityac
tivitythroughouttheweek,inordertoobtainsubstantialhealthbenefits[5].However,
theseguidelineslackanyinformationregardingstrategiestoensurethatindividuals
maintaintheselevelsofphysicalexerciseovertimenorstrategiestomotivatesedentary
individualstostartexercising.Hence,itseemsthatneithertheknowledgeofthebenefits
ofexercisenorthesettingofminimumthresholdsofexercisearedrivingforcestoreduce
sedentarismeffectively.
Lowlevelsofadherencetoexercisemaycausesomerandomizedcontrolledtrials
aimedtoassessthebenefitsofexerciseononeorseveralhealthoutcomestonotachieve
significantresults[10,11].However,theadherenceproblemmaybebiggerwhentalking
aboutthegeneralpopulationthatdoesnotparticipateinthosekindsofstudiessince
participantsinrandomizedcontrolledtrialsareusuallyvolunteers,selectedaccordingto
inclusionandexclusioncriteriathatoftenrejectsindividualswithsevereimpairments
thatmayreducetheiradherence(forinstance,itisusualthatpeoplewithseverecogni
tiveimpairmentareexcludedinarticlesinvolvingolderadultsorParkinson’sDisease
patients[12,13]andpeoplewithbonemetastasisareexcludedincancerstudies[14]).
Furthermore,asvolunteers,itcanbeassumedthatparticipantsinstudiesmaybeinher
entlymotivated,oratleasttheyarewillingtobeinvolved.However,thiscannotbeas
sumedforeveryoneinthegeneralpopulationanditcouldhappenthatpatientsengaging
inclinicaltrialsmaynotberepresentativeofthepopulationinquestion,sincetheirpsy
chologicalpredispositiontoexercisemaybedifferentthanthepredispositionoftheoth
ers[15].Inadditiontotheselectionofvolunteersandidealparticipants,randomized
controlledtrialsoftentendtobehighlysupervised,whichmayexplainwhythelevelsof
adherenceareoftenhighercomparedtoobservationalstudies[16].
Manytheoriesandmodelshavebeenproposedfromdifferentdisciplinestoexplain
the“adherencetoexercise”phenomenon[17,18].Somearticleshavesuggestedtheneed
foraparallelpsychologicalintervention,inadditiontotheexerciseprogram,toaidin
behaviorchange[19].Othershaveproposedthebenefitsofincreasingparticipants’mo
tivationtowardsexercisebypayingmoreattentiontothethreebasicpsychological
needs:autonomy,competence,andrelatedness[20].Previousstudieshavealsotriedto
increasetheadherencetophysicalexerciseprogramsbyincludingtechnologicalgadgets
orbyproposingalternativeformsofexercise[21,22].Thereareevensomeauthorswho
havesuggestedtheconvenienceofpayingpeoplefordoingexercise,assomeinsurance
companieshavestartedtodo,knowingthattheirclientswillbehealthieriftheyare
physicallyactiveandtheirincomeswillbeaccordinglyincreased[23].
Despitethelargenumberofstudiesonadherencetoexercise,theveryconceptof
adherenceisnotwellestablishedandvariesfromonestudytoanother,confusingad
Int.J.Environ.Res.PublicHealth2021,18,20233of25
herencewithothertermslikeattendance,i.e.,thenumberorthepercentageofsessions
attended[24].Anothernotfullyappropriatewaytoconceiveadherencetoexerciseisby
countingthenumberofdropoutsduringtheirexerciseintervention.Followingthislast
conception,onecouldinterpretgoodadherencetotheirprogramwhenthepercentageof
theirparticipantswhofinishedtheinterventionishigh.Inthisregard,thePhysiotherapy
EvidenceDatabase(PEDro)Scalesuggeststhatmeasurementsofthekeyvariables
shouldbeobtainedfrommorethan85%oftheinitiallyrandomizedparticipants[25].
Thus,thatcriterionisbasedonthenumberofdropouts,butitdoesnotestablishtheneed
ofcompletingaminimumpercentageofsessions(attendance)northeinvolvementofthe
participantsduringthesessions.Inthisregard,adherencehasbeendescribedastheex
tenttowhichthebehaviorofapersoncorrelateswiththeagreedplanofthesuggested
exerciseintervention,soitwouldberelatedtothedegreetowhichthetargetintensity
andvolumeareachieved[24,26].Therefore,adherencetoexerciseisaconceptwith
deeperrootsintheparticipant’sbehaviorthanamerenumberofdropoutsorpercentage
ofsessionsattended.
Followingthislastdefinitionofadherencethatincludestheassessmentofthein
tensityandvolumeachieved,newadvancesintechnologyhavemadeeasiertheassess
mentofadherencegiventhattheexerciseintensityandvolumecanbemoreeasilymon
itoredorevenselfmonitoredbytheparticipant[27].However,theuseoftechnology
involvesotherproblemsthatshouldbeconsidered,suchaseconomiccosts,theaddi
tionaltimerequiredtosetit,thepotentialunpleasantoruncomfortableexperiences,the
difficultiesexperiencedbytheparticipantstouseitappropriately,andtheshameor
simplythereluctanceofpeoplewhodonotwanttouseit[21,28].
Despitealltheabovementionedinformationandthenumberofarticlespublished
onthistopic,todate,therearemixedandinconclusiveresultsregardingthebestprac
ticesforincreasingexerciseadherence,withlargeheterogeneityintermsofphysicalex
ercisetyperecommended,thepsychologicalapproachused,thetargetpopulation,the
needtotreatachronicdisease,theageofpatientsandthemainaimoftheexercisein
terventions.Therefore,thecurrentstudyaimedtosystematicallyreviewpublishedre
viewsonthestudyofadherencetophysicalexerciseinchronicpatientsandolderadults
andtoidentifythoseadherencerelatedkeyfactorsmorefrequentlysuggestedbyre
viewsforchronicdiseasepatientsandolderadults.
2.MaterialsandMethods
ThecurrentsystematicreviewofreviewshasbeendevelopedfollowingthePre
ferredReportingItemsforSystematicReviewsandMetaAnalyses(PRISMA)guidelines
[29].
2.1.SearchStrategyandSelectionofStudies
ThesearchforpublishedstudieswasconductedinOctober2019inthescientific
databasesPubMed(MEDLINE)andWebofSciences(includingKCIKoreanJournal
Database,MEDLINE,RussianScienceCitationIndex,andSciELOCitationIndex).The
termsusedforthesearchwere“adherence”,“exercise”,and“systematicreviewORme
taanalysis”separatedbytheBooleanoperatorAND.Toselectarticlesfocusedonad
herencetoexerciseandavoidthosethatonlyincludedadherenceasasecondaryor
complementarymeasure,theterm“adherence”hadtobewithinthetitleofthearticle.
Onlyarticlespublishedinthelast10years(2010topresent)wereincludedinthesearch
toshowanupdatedpictureofthetopic.Thesearchforpublishedstudieswasinde
pendentlyperformedbytwoauthors(DCMandAMLP)anddisagreementswerere
solvedthroughdiscussion.
Screeningofsearchedarticlesanditssubsequentlyfulltextreviewwascarriedout
regardingthefollowinginclusioncriteria:(a)systematic/narrativereviewand/orme
taanalysisdesign,(b)studiesfocusedonpatientswithchronicdiseasepatientsorolder
peopleasthetargetpopulation,(c)focusedonanytypeofphysicalexerciseandd)aimed
Int.J.Environ.Res.PublicHealth2021,18,20234of25
toidentifyfactorsassociatedwithadherencetoexercise.Besides,articlesfulfillingthe
followingcriteriawereexcluded:(a)reviewswritteninanylanguagedifferentfrom
EnglishorSpanish,(b)studiesfocusedontheconceptordefinitionofadherence,(c)ar
ticlesaimedtoanalyzetherelationshipbetweenadherenceandintervention’seffects,(d)
reviewsfocusedonthemethodsusedtoassessadherence.
2.2.DataExtraction
Theidentifiedreviewarticlesweredistributedamongalltheauthorsofthisstudy
anddataextractionwasperformedbyduplicate.Foreacharticle,theresearchermanu
allyextractedtheinformationaboutthepopulation,intervention,aim,conclusion,and
studydesign,followingthePICOS(Population/Problem,Intervention,Comparator,
OutcomeandStudyDesign)approach.Keyfactorsreportedinreviewsandme
taanalysiswereextractedbycheckingtheresults,discussion,andconclusionsectionsof
eacharticle.Thesekeyaspectswerefactorsidentifiedinthereviewsthatmayaffectad
herencetoexerciseinthetargetpopulations.Afterthis,theinformationobtainedthrough
dataextractionwascomparedbetweenthetworesearchersassignedtoeacharticle,and
allobserveddifferenceswerescrutinizedandcorrected.Athirdresearcherwassoughtin
thecaseofdiscrepancy.
2.3.DataSynthesis
Afterextractingthedata,anotherauthorcheckedandcombinedtheinformationof
eacharticleandpreparedthetablesthatsummarizethedataofallarticles(Supplemen
tarydataTableS1).Themainkeyfactorsextractedfromthearticlesweregroupedin
topicstoenhancethecomprehensionoftheresultsoutcomes.Thisclassificationoffind
ingswasperformedbasedontheidentifiedfactorsfromthestudiesincludedinthisre
viewandincluded:
1. Characteristicsoftheexerciseprogram,thatwouldcomprisethosefactorsrelatedto
howthephysicalexerciseisplanned,includingtheindividualization,theevi
dencebasedsettings,andothercharacteristicssuchasfrequency,duration,intensi
ty,orvolume.
2. Involvementofprofessionalsfromdifferentdisciplines,thatwouldberelatedtothe
convenienceofincludingexpertsormethodsfromdifferentdisciplines.
3. Supervision,whichwouldincludethesignificanceorirrelevanceofsupervisingthe
exerciseinterventions.
4. Technology,whichwouldbefocusedonthepotentialadditionalbenefitsordisad
vantagesofincludingtechnologicaldevicesandapplicationstoconductthephysical
exerciseintervention.
5. Initialexplorationofparticipant’scharacteristics,barriers,andfacilitators,which
wouldincludetheidentificationofrelevantvariablesofthepatientsbeforetheex
erciseinterventionsthatcouldreduceorincreasetheadherencetoexercise.
6. Participants’education,adequateexpectations,andknowledgeaboutrisksand
benefits,whichwouldberelatedtowhattheparticipantsknoworlearnaboutthe
relevanceofphysicalexercisefortheirownhealthsothattheexpectationsaboutthe
improvementswerenotinaccurate.
7. Enjoymentandabsenceofunpleasantexperiences,whichwouldberelatedtothe
pleasureobtainedwhileexercisingandalsobytheabsenceofpainordiscomfort.
8. Integrationindailyliving,whichincludestheconsiderationoftheparticipant’s
preferencesandbackgroundtoadapttheexercisecharacteristicsandsettings.
9. Socialsupportandrelatedness,whichincludessupportfrompeers,staff,andfami
ly,aswellastheestablishmentofpositivesocialinteractionsandfeelingsofbe
longingtoagroup.
10. Communicationandfeedback,whichisrelatedtotheeffectiveinteractionbetween
thestaffandtheparticipant.
Int.J.Environ.Res.PublicHealth2021,18,20235of25
11. Availableprogressinformationandmonitoring,providingenoughinformationto
thepatientsothattheycanbeawareofthechangesandimprovementsfromobjec
tivedata.
12. Selfefficacyandcompetence,whichisrelatedtotheparticipant’sperceptionof
whattheycandoandwhattheywillbeabletodo.
13. Participant’sactiverole,whichwouldincludeselfmanagement,selfcontrol,
selfmonitoring,autonomy,andempowerment.
14. Goalsetting,whichisrelatedtotheestablishmentofadequateobjectives.
Afterward,thereviewswereclassifiedconsideringthetargetpopulationandpar
ticipants’characteristicsinordertoidentifythemostrepeatedfactorsobtainedforeach
condition:cancer,cardiovasculardisease,olderpeople,participantswithmusculoskele
talpain,obesitypatients,andexercisereferralschemes.
3.Results
3.1.StudySelection
Intheoriginaldatabasesearch,184studieswereinitiallyidentified,85articlesin
PubMedand99inWebofSciences(seeFigure1).Afterremoving102duplicatedarticles,
studieswerescreenedbyanalyzingtheirtitlesandabstracts.Subsequently,34records
wereexcludedduetodifferentreasons:threewereabstractsorletterstotheeditor,seven
werefocusedontheassessmentofadherenceoritsconceptsuniquely,fourwerestudy
protocolsandtwentywerenotfocusedonexercise.Thefulltexttotalof68articleswas
reviewedand13ofthemwereexcludedfordifferentreasons:nothavingchronicpa
tientsorolderadultsastargetpopulation(n=3),notbeingfocusedonexercise(n=6),
focusedontheevaluationofadherence(n=1),aimedtoexploretherelationshipbetween
adherenceandphysicalexerciseimprovements(n=1)ornotbeingareview(n=2).Thus,
55articles,publishedfrom2010to2019,werefinallyincludedinthecurrentumbrella
review.
3.2.StudyCharacteristics
ThemaincharacteristicsoftheselectedreviewsarereportedinTable1.The55re
viewsincluded11metaanalyses.Regardingchronicpatientsandolderadults,sevenar
ticleswerefocusedoncancer[11,14,30–34],sevenoncardiovasculardisease[28,35–40],
eightonelderlypeople[21,41–47],twelveonmusculoskeletaldisorders[48–60],threein
obesityorweightloss[16,61,62],sixonmultiplechronicdiseases[12,27,63–65],twoon
intermittentclaudication[66,67],twoonpopulationwithmildcognitiveimpairmentand
dementia[68,69],andsinglearticlesanalyzedParkinson’sdiseasepatients[13],type2
diabetespatients[70],solidorgantransplantcandidates[15],andparticipantsunder
vestibularrehabilitation[71].

Int.J.Environ.Res.PublicHealth2021,18,20236of25
Figure1.Flowdiagramoftheselectionprocess.
Table1.Summaryofthesamplecharacteristics,typeofexercise,andnumberofreviewsidentified
foreachsampleandexercisetype.
PatientsCharacteristics
Number
of
Studies
TypeofExercise
Interventions
Revised
Cancer
Cancerpatientsorsurvivors 4
Homebased:1review
Any:6reviews
Advancedcancer1
Nonsmallcelllungcancer1
Colorectalcancer1
Cardiovascular
disease
Heartfailure 2Centerbased:1
review
Any:6reviews
Undercardiacrehabilitation
program4
Generalcardiovascularconditions1
Olderadults
Fallsprevention 3Centerbased:2
review
Homebased:1review
Any:5reviews
Healthyelderly 5
Musculoskeletal
disorders
Lowbackpain1Centerbased:1
review
Homebased:1review
Any:10reviews
Arthritis3
Osteoporosis/osteopenia1
General/multiplemusculoskeletal
painorchronicconditions7
Recordsidentifiedthroughdatabase
searching(n=184)
PubMed(n=85)
WebofSciences
(
n=99
)
Screening
Included
Eligibility
Identification
Additionalrecordsidentifiedthrough
othersources
(n=0)
Recordsafterduplicatesremoved
(
n=102
)
Recordsscreened
(
n=102
)
Recordsexcluded(n=34)
Meetingabstractorlettertoeditor(n=3)
Articlefocusedontheevaluationofadherence
ortheconceptofadherence(n=7)
Studyprotocol(n=4)
Notfocusedonexercise(n=20)
Fulltextarticlesassessedfor
eligibility
(n=68)
Fulltextarticlesexcluded,withreasons(n=13):
Nochronicpatientsorolderadults(n=3)
Notfocusedonexercise(n=6)
Aimedtoexploretherelationbetween
adherenceandimprovements(n=1)
Focusedontheevaluationofadherence(n=1)
Noreview(n=2)
Studiesincludedin
qualitativesynthesis
(n=55)
Int.J.Environ.Res.PublicHealth2021,18,20237of25
Obesityorweightloss3Centerbased:3
review
Intermittentclaudication2
Centerbased:1
review
Any:1review
Mildcognitiveimpairmentanddementia2
Centerbased:1
review
Any:1review
Parkinson 1Any:1review
Type2diabetes1Any:1review
Solidorgantransplantcandidates1Any:1review
Undervestibularrehabilitation1Homebased:1review
Differentchronicdiseases6
Centerbased:1
review
Homebased:2
reviews
Any:3reviews
ExerciseReferralschemes 4
Centerbased:2
reviews
Any:2reviews
Centerbased:exerciseprogramsspecificallyconductedinpublicorprivatecenters;Homebased:
exerciseprogramsconductedathome;Any:includingbothcenterbasedofhomebased.
Thirteenoftheincludedrevisionswerebasedonexerciseinterventionsconductedin
publicorprivatecenters,whilefivestudieswerefocusedonadherencetohomebased
exerciseprograms[41,48,58,71,72].Theremaining37reviewsincorporatedexercisepro
gramsmixingcenter‐ andhomebasedinterventionsandinsomecasesalsophysicalac
tivityinterventions,likewalkingorleisuretimeactivities.Althoughallthearticlescom
promisedexerciseinterventions,somealsoincludedphysiotherapy[52,55,58,60],life
stylechanginginterventions[33,61,62,70],exercisereferralschemes[65,73–75],technol
ogyandmultimediaeffects[21,27,38,64],behaviorchangetechniques[47,49,50,56,62],
andbarriersandfacilitatorstoexercise[46,52,59,69,75].Thosestudieswereincluded
sincetheyprovidedvaluableinformationaboutfactorsassociatedwithadherencetoex
ercise.
3.3.OutcomeResults
Theanalysisperformedrevealed14keyfactorsofexerciseprogramsthatmayposi
tivelyinfluencetheiradherencerates.AsTable2shows,thesetopicsreporteddifferent
subkeyaspectsthatrepresentinmoredetailthecharacteristicsofthemostadhered
programs.
First,theresultsoftheglobalanalysisrevealedthatinitialexplorationofpartici
pant’scharacteristics,barriers,andfacilitatorsseemedtobecrucialtoenhanceexercise
adherenceingeneralchronicpatientsandolderadults.Concretely,thirtysixreviews
identifiedtheimportanceofpreparticipationevaluationofparticipants’previouslife
stylehabitsaswellastheirphysicalandmentalhealthstatus.Besides,29reviewsstated
thatpossiblebarriersandfacilitatorstoexercisemayneedtobecontemplatedbeforethe
program’sdelivery.Thenextmostdistinguishedkeyaspect,mentionedbytwentynine
articles,wastostudyparticipantspreferencesandbackgroundstoenhancetheintegra
tionofexerciseintheirlifestyle.Moreover,regardingtheprogramdesigncharacteristics,
twentythreereviewsstatedthatdevelopinganindividualizedexerciseintervention
couldbeakeypointtoenhanceadherencerates.Althoughthepsychologicalvariables
didnotreachsuchhighsupportinthegeneralanalysis,itappearedthatfomentingpar
Int.J.Environ.Res.PublicHealth2021,18,20238of25
ticipants’selfefficacymaybethemostusefulpsychologicalfactorinexerciseadherence
(21articles).
Asfortheindividualanalysisofdifferenthealthconditionsregistered,alsopre
sentedinTable2,consideringpatients’previoushabitsandphysicalandmentalhealth
statuswasthemostvaluableaspectinpatientswithcancer[11,14,30–34],patientswith
cardiovasculardisease[28,35–37,39,40],patientswithmusculoskeletaldisorders
[48,49,52,54,59]andinexerciseprogramsaimedtoreduceobesityorinweightlossexer
ciseinterventions[16,61,62].Inolderadults,fivereviewssupportedtheprovisionofob
jectiveinformationabouttheirprogressandtheconsiderationofparticipants’prefer
encesandbackgroundaseffectivestrategiestoenhanceadherence[21,41,42,46,47].
However,supervisionbyahealthcareorexerciseprofessional,individualizationofthe
exerciseprogram,providinginformationaboutexerciserisksandbenefits,andtheelec
tionofanaccessiblelocationforthedevelopmentoftheexerciseprogramwereeach
supportedbyfouroutofeightreviews.
Outliningbrieflyeachofthechronicdiseases,cancerexerciseprogramsmayalso
needtoanalyzepatients’barriersandfacilitatorstoexercisebeforetheintervention
[14,30,31,33,34]andchoosegoodaccessibilityandanadequateplacetodeliverthein
tervention[11,14,30,34].Exerciseprogramsforpatientswithcardiovasculardisease
shouldanalyzeexercisebarriersandfacilitatorsbeforetheintervention[28,35–37,39,40],
butalso,theyshouldemphasizetheimportanceoffamilyandpeersupport[28,36–39],
togetherwithexercisemonitoring[28,35,37,38]andprovidingeducationalinformation
abouthowtoexerciseintheircondition[35–38].Wheninterventionswerecarriedoutby
participantswithmusculoskeletaldisorders,anassessmentofthebarriersandfacilitators
appearedtobeascrucialasanalyzingtheirpreferencesandbackgroundanddeveloping
multidisciplinaryprograms(fivearticlesineachkeyaspect).Finally,inweightlossin
terventions,orwithobeseparticipants,patients’preferencesandbackgroundstoen
hancetheintegrationoftheprogramintheirlifestyleseemedtobeessential[16,61,62].
Table2.Summaryofkeyfactorsaccordingtodifferentconditions.
KeyFactorsSubKeyFactors
NumberofReviewsIncludingEachKeyFactor
TotalCancerCVD
MusculoS
keletal
Disorders
Older
Adults
Obesity
/
Weight
Loss
Exercise
characteristics
design
Characteristicsoftheexerciseare
individualizedandscientificallycorrect 2333442
Thedurationoftheexerciseintervention
isnottoolong10‐1131
MultidisciplinarityMultidisciplinaryprogram12‐1522
SupervisionSupervision1711441
TechnologyUseofadequatetechnology12‐3131
Initialexplorationof
participant’s
characteristics,
b
arriers,and
facilitators
Previoushabitsandphysicalandmental
healthstatusoftheparticipantsare
known
3676523
Barriersandfacilitatorsareexplored
eforetheexerciseprogramisdelivered
tosearchforalternatives
2956532
Participants
education,adequate
expectations,and
knowledgeabout
risksandbenefits
Participantsareeducatedaboutphysical
exerciseintheircondition1724321
Participantsareadequatelyinformed
abouttherisksandbenefitsofthe
program
15‐3141
Adequateexpectations15‐3331
Int.J.Environ.Res.PublicHealth2021,18,20239of25
Enjoymentand
absenceof
unpleasant
experiences
Enjoyment10‐1321
Absenceofunpleasantexperiences91‐311
Integrationindaily
living
Participant’spreferencesandbackground
areconsideredintheprogramtoenhance
itsintegrationintotheirlifestyle
2932553
Goodaccessibility,adequateplace,and
flexibilityintheschedule2143342
Socialsupportand
relatedness
Socialsupportfrompeersandfamily2215431
Socialsupportfromtheprofessional2223521
Relatedness11‐223‐
Communicationand
feedback
Intrasessionfeedback1122321
Bilateralandfluidcommunicationwith
thestaff16‐2331
Availableprogress
informationand
monitoring
Objectiveinformationforpatientsto
knowtheirprogress1713252
Exerciseismonitored1624‐32
Sel
f
efficacyand
competence
Sel
f
efficacy2123332
Competence7‐3‐1‐
Participant’sactive
role
Selfmanagement,selfcontrol,and
selfmonitoring 161341‐
Autonomyandempowerment8‐112‐
GoalsettingObjectivesareclearandestablishedwith
thepatient12125‐2
Eachnumberrepresentsthenumberofreviewsthatsupporteachfactor,overall,andaccordingtotheconditionforthose
with3ormorereviewsidentified.CVD:cardiovasculardisease.
4.Discussion
Themainaimofthecurrentsystematicreviewofreviewswastoidentifykeyfactors
associatedwithadherencetophysicalexerciseinpatientswithchronicdiseasesandolder
adults.Manydifferentkeyfactorswereidentifiedintheincludedreviewsaspositiveto
promoteadherencetoexerciseandtheywereorganizedandsummarizedinthefollow
inglines.
4.1.DesignoftheExerciseIntervention
Regardingthedesignoftheexerciseprogram,twomainkeyfactorswereidentified:
(a)theindividualizationandthescientificbasisofexercisetypeand(b)thedurationof
theexerciseprograminweeks.Thefirstkeyaspectcanbedividedintwosince21ofthe
includedreviewsfoundthattailoredexerciseisnecessarytoachievehighlevelsofad
herence,andsevenidentifiedtheneedofconductingexerciseinterventionswithascien
tificbackground,withfiveofthosesevenarguingthatbothaspectsarerelevant.The
otherkeyfactoridentifiedby10reviewswasthedurationoftheexercise.Itwasshown
thatlongerexerciseinterventionswererelatedtoloweradherencetotheprogram.This
outcomemaybeassociatedwiththeneedtomaintainahomogeneousexerciseroutine
duringtheentireexerciseprograminrandomizedcontrolledtrials,whichmaycause
someindividualstodroptheprogramduetothelackofvariety.Inthisregard,the
measurementofadherenceinprogramsthatallowthechangeofexerciseactivitiesacross
theprogrammaybenecessarytodetermineiftheconstraintsofrandomizedcontrolled
trialsmaybeovercomebyaffordingpatientsmorelibertytodecidetheexercisetype.
Fromapatientcenteredperspective,theindividualizationoftheexerciseintermsof
type,intensity,duration,frequency,butalsoinneedsandinterests,isnecessaryforef
Int.J.Environ.Res.PublicHealth2021,18,202310of25
fectivepromotionofadherence.Thiswouldelicitasuperiorresponsenotonlyduetoa
betteradjustmenttothephysiologicaldemandsoftheactivitybutalsoduetoenhanced
patientperceptiontowardstheexerciseprogram.Forinstance,amongpatientswithde
mentia,thosewithbettercognitivehealthoftenhaveloweradherencerates[69].This
couldberelatedtoanonadequateadjustmentofdemands,whichmaybeonlytailored
tothosewhohavethepoorestcognitivecapacityinthegroup.Thatcouldalsobetruefor
groupscomprisedofpatientswithdifferentfunctionalcapacity,sinceexercisemaybe
tailoredtothosewiththepoorestphysicalfunction.Therefore,makinghomogeneous
groupsintermsofinterests,needs,andfunctionalitywillincreasetheadjustmentofex
ercisedemands,socialsupport,connectedness,andrelatedness[42]aswellasachievea
superiorphysiologicalandpsychologicalresponse.
Althoughsomeauthorshavepointedthatthecharacteristicsoftheexerciseprogram
mayberelatedtoexerciseadherence,someaspects,likethetypeofexerciseorexercise
intensity,arenotoftenreportedaskeyfactorstopromoteadherence.Inthisregard,we
foundasimilarnumberofreviewsshowingthatvariableslikeintensity,frequency,or
volumearerelevantandreviewsreportingthattheyarenot.Traditionalexerciseinter
ventionssuchaswalkingmayreduceadherencecomparedtoalternativeoptions,suchas
Nordicwalking,resistancetraining,orcircuittraining[67],butwalkingcanalsobecon
sideredasanaccessibleandfeasibleformofexercisethatfacilitatestheattractivenessof
theexerciseprogramforsomeindividuals[46].Regardingtheexercisefrequency,ithas
beenshownthatonesinglesessioneachweekmayleadtoloweradherence,probably
duetoparticipantsdoubtingtheefficacy,thelessfrequentcontactwiththestaffand
peers,andthebiascausedbytheselectionofphysicallyactiveparticipantswhomaybe
unsatisfiedwiththelowexercisefrequency[45].Furthermore,ifparticipantsonlydo
exercisewithintheexerciseprogram,theywouldnotbefollowingtherecommendations
oftheWHO[5].
Findingsrelatedtothedurationoftheexerciseprogramareextremelyalarming.Ten
reviewsshowedthatthelongerthedurationoftheinterventionthelowertheadherence
obtainedintheindividualsthatunderwenttheprogram.Withtheaimofincreasingthe
longtermadherencetophysicalexercise,itseemsthatthereisaneedforalternativesto
escapefromroutineandavoidinterventionsthatcouldboreoroverwhelmthepatients
[45].Thisfindingmayconflictwithscientificaims.Sinceitisknownthatcertainvariables
mayneedacoupleofmonthstobeimprovedbyphysicalexercise,reducingtheduration
oftheinterventionsmaynotbeanadequatealternative.So,whenaspecificintervention
lengthisrequired,researchersandphysicalexerciseprofessionalsmustmakeaneffortto
facilitatetheaccommodationofexerciseswithinthedailylivingofpatients[54].
Insum,individualization,theuseofvariousexercisetypeswithprovenevidenceof
efficacyforthetargetpopulation,afrequencyhigherthanonceperweek,andamoderate
durationoftheprogrammaybekeyfactorstopromoteexerciseadherence.
4.2.MultidisciplinaryTeam
Atotalof12reviewsidentifiedhowthepresenceofdifferentprofessionalswho
conducttheexerciseinterventioncouldimproveadherence.Inadditiontothephysical
exerciseprofessional,whoismainlyresponsibleforthedesignanddevelopmentofthe
exerciseprogram,theadditionofcounselingbyotherprofessionalssuchaspsycholo
gists,physicians,physiotherapists,nutritionists,ornursesishabituallyperceivedas
positivetoreinforceadherence.Inthisregard,somereviews[12,41,47,65]showedthat
theparticipationofphysicianswaskeysincepatientsweremorelikelytoadhereto
physicalexercisewhenitwasprescribedbyahealthcareprofessional.Furthermore,the
laborofpsychologistsmayenhanceadherencetoexercisebyconductingdifferentbe
havioralchangetechniquesorcognitivebehavioralprograms[49,50,55,56,60,65].How
ever,theefficacyoftheseprogramsisstillcontroversial,obtainingmixedresultsand
largeheterogeneity.
Int.J.Environ.Res.PublicHealth2021,18,202311of25
Therefore,thepresenceofamultidisciplinaryteammaycontributetoincreased
adherencetoexerciseamongchronicpatientsandolderadults.Althoughthepresenceof
differentspecialistsmaybeaffordableincontrolledtrialsandotherresearchdesigns,the
costsoftheexerciseprogrammaybelargelyincreasedbythisfactor,whichcouldimpact
thepricethattheusermustaffordtobeinvolvedintheprogramandconsequentlythe
adherenceofexercise,especiallyforthosewithatalowsocioeconomiclevel[69].This
bringsustoanotherrelevantissue:thewillingnesstopayforexercise.Arecentstudy
showedthatonlyhalfoftheolderadultswerewillingtopayforfallpreventionprograms
[76],whilechronicpatientssufferingfromkneeosteoarthritismaybewillingtopaylittle
money,withonly26%willingtopaymorethan65forsixweeksofanevidencebased
programandonly10%willingtopaymorethan100[77].Althoughthebenefitsofex
ercisearewellknown,peoplearestillreluctanttopayforit,evenalowamountof
money.Takingthisintoaccount,itischallengingtoprovideanexerciseprogramin
volvingprofessionalsfromdifferentdisciplinesthatsuitsthelowwillingnesstopayof
olderadultsandchronicpatients.
Insum,theadditionofprofessionalsfromdifferentdisciplinessuchaspsycholo
gists,physicians,ornursesmayincreaseadherencetophysicalexerciseinterventions.
4.3.SupervisionduringtheExerciseSessions
Supervisionwasidentifiedasakeyaspectby17reviews.Supervisionduringthe
exercisesessioninvolvesatleastoneprofessionalcheckinghowtheparticipantisper
formingtheprescribedexercises,whichindeedenhancesthequalityoftheexecution
and,consequently,increasesthepotentialbenefitsandreducesthepossiblerisksofin
adequateexecutions[16,44,66].Furthermore,supervisionalsomakestheevaluationof
adherenceeasierandmoreaccurate,avoidingtheuseofselfreportedexerciseregistries
andproblemsrelatedtotheuseofmonitoringtechnology.Inthisregard,Hughes,
Salmon,Galvin,Casey,andClifford[44]showedthatadherence(assessedthrough
selfreportedregistries)toexercisewashigherinunsupervisedhomeexerciseprograms
whilethebenefitswerelowerthanthoseobservedinclassbasedsupervisedexercise.
Thiscouldbeexplainedbyanoverestimationofadherenceratesduetosocialdesirabil
ityandobsequiousresponsesfromtheparticipants[12].However,theadvantagesof
supervisionaredocumented,allowingparticipantstoaccesstheprofessional’s
knowledge,feedback,andsupport,whichmayincreaseselfefficacyandreducethedis
couragingfeelingandpotentialrisks[16].
Thedebatebetweenfacetofacevs.homebasedexerciseisnotassociatedwithsu
pervision,sincebothtypesofdeliverycanbesupervised,providedthattheprofessional
canbemonitoringwhattheparticipantsaredoingduringsessionsinbothtypesofexer
ciseprograms.Asadisadvantageofsupervisedexercise,thecostsoftheprogramsmay
beincreasedandtheflexibilityintimecanbereducedsincebothparticipantsandpro
fessionalsmustbesimultaneouslyinthesameplaceorconnectedonline,whichcould
reducetheadherenceasaconsequenceofincompatibilityintimetables.
Insum,exerciseprogramssupervisedbyatleastonephysicalexerciseprofessional
mayincreaseadherencetophysicalexercise.However,otherdisadvantageshavebeen
described.
4.4.TheUseofTechnology
Atotalof12reviewshaveanalyzedtheroleoftechnologyinenhancingadherenceto
physicalexercise.Althoughpromisingresultshavebeenachievedintechnologybased
exerciseprogramslikethoseobtainedbyXu,Li,Zhou,Li,Hong,andTong[38],who
observedthatthecompletionwas1.38timeshighercomparedtotraditionalprograms,
theevidenceisstilldebated[27].Someadvantageshavebeenreported,sincethetech
nologymaybeusefultoaccuratelymonitorthephysicalactivityofparticipantsinterms
offrequencydurationandtime,individualizetheexerciseprescription,providerealtime
Int.J.Environ.Res.PublicHealth2021,18,202312of25
feedback,tomakereminders,connectprofessionalsandpatients,sharetheperformed
activitieswithpeers,andprovideinstructions,amongotherbenefits[44,64,71].
However,inchronicpatientsandolderadults,technologymustbeusedwithcau
tion,sincenoteverybodywillhavethesameresponse.Olderadultsmaybelesslikelyto
engageinphysicalexercisetechnologybasedprogramswhileyoungpeoplemayhave
theoppositeperception[28].However,anotherreview[21]foundthatdropoutrates
weresimilarintechnologybasedandtraditionalexerciseprograms,whereasthereasons
weredifferent.Inthisregard,reasonstoabandontraditionalexercisewerelackofmoti
vationandpersonalobligations,whileintechnologybasedprogramsreasonsincluded
lowmotivation,lackofinterest,discomfort,lackoftime,limitedspaceathome,tech
nologyusability,orshame.Furthermore,itmustbenotedthatwhentheexercisepro
gramisbasedontechnology,theinterpretationofadherencemaybedifferent,since
sometimesresearchersareassessingadherencetoadeviceinsteadofadherencetophys
icalexercise[28].
Insum,theuseoftechnologymayberecommendedwhenparticipantsarewillingto
useitandthedevicesandsoftwareareadequateforthem,butitmustbenotedthatsome
peoplemayrefusetechnology.Therefore,itcouldbesuggestedthattheinclusionof
technologymaybevoluntaryandnotmandatoryinexerciseprograms.
4.5.InitialExplorationofParticipant’sCharacteristics,Barriers,andFacilitators
Morethan70%oftheincludedreviewsidentifiedtheneedforcarryingouta
preparticipationcomprehensiveanalysisoftheparticipants’characteristicsandthepo
tentialbarriersandfacilitators.Thirtysixofthe55includedreviewsfoundthatsome
aspectslikethehealthstatus(includingphysicalandmentalhealth)orprevioushabits
(suchasphysicalactivitylevel,smoking,oralcoholintake)arerelevantfactorstopredict
exerciseadherence.Withoutanydoubt,thesefactorsarethemostwidelycitedinthe
scientificliteratureaboutadherencetoexerciseinchronicpatientsandolderadults.
Healthstatusstandsoutasoneofthemajorfactorsforexercising.Thisisacomplex
conceptthatneedstobeunderstoodnotonlyintermsofseverityofsymptoms,butalso
intermsofhealthrelatedphysicalfunctionandothercomponentslikemental,cognitive,
social,orsexualstatus.Dependingonthecondition,differenthealthrelatedaspectswill
belinkedtoloweradherence.Inthisregard,chronicdiseasesthatinvolvepainorfatigue
mayreducetheattendanceandadherenceofpatients[78,79].Furthermore,thosepatients
withdepressionwillalsobemorelikelytoabandontheexerciseprogram[43,72,80].On
theotherhand,nodifferencehasbeenobservedwhencomparingtheadherenceratesof
patientswithconditionslikecancer,cardiovasculardisease,anddiabetes[63].Although
therapistscannotmodifythebaselinehealthstatus,itisrelevanttoproperlyassessand
analyzethestatusbeforetheexerciseprogramisconducted.Furthermore,barriersand
facilitatorsmustbeopenlydiscussedbeforeandatregularintervalsthroughoutinorder
toensureindividualization[61].
Withinthesuggestedinitialexplorationofbarriersandfacilitators,thestageof
changeisastrongpredictorofadherencetoexerciseinchronicpatients[31].Theconcept
ofstageofchangecomesfromthetranstheoreticalmodel,whichdefinesaseriesofbe
haviorchangestages:precontemplation,contemplation,preparation,action,and
maintenance[81].Inthisregard,amismatchbetweenthestageofchangeandtheselected
strategymayleadtoloweradherenceratesandthosepatientswhoarenotphysicallyac
tivearemorelikelytoreportexercisebarriers,butthesedentarybehaviordoesnotnec
essarilyhinderpatientsfrombecomingphysicallyactive[31].
Thediagnosisofachronicdiseasemayinvolveseveralchangesinthedailylivingof
patients,reductioninphysicalactivitylevelsbeingoneofthemajorchanges.Among
others,thediagnosisofInflammatoryBowelDiseasehasbeenrelatedtoareductionin
physicalactivitylevels[82],andeventhosepatientswithhighpreillnessphysicalactiv
itylevelsdrasticallyincreasetheirsedentarybehaviorwhileundergoingcancertreat
ment[83],especiallywhentheyhadprevioussedentaryhabits[32,34].Ontheotherhand,
Int.J.Environ.Res.PublicHealth2021,18,202313of25
somemiddleagedandelderlypeoplemaystarttoexerciseaftertheyarediagnosedwith
achronicdisease[84].Otherchangeshavebeenreportedafterhypertensiondiagnosis,
suchassmokingcessationaccompaniedbyasmallreductionininactivity[85],but
changesinlifestyleareoftennotenough.Althoughtheimplicationsofdiagnosisarestill
controversial,itisclearthatitisatimewherepeoplecanbemorepronetochange,since
itcouldbeinterpretedasa“wakeupcall”toadoptamorehealthylifestyleevenwhen
thatintentionisnottranslatedintorealchanges[86,87].Thisissimilartotheconceptof
“teachablemoments”,whichhasbeendefinedasopportunitiesforchangingunhealthy
habitsafteraspecificcircumstanceorevent[88].Thesemomentsmaybeadiagnosis,a
hospitalization,orotherepisodes,andareinfluencedbyalltheinvolvedhealthcarepro
fessionalsandrequirecommunicationskills[65].
Apartfromthepotentialinternalbarriers,thereareothercontextualandcultural
barriersthatshouldbeconsidered.Forinstance,socioeconomicstatusisacommonbar
rier[35,43,69]andwomeninsomeculturesmayfeeluncomfortablewalkingunaccom
paniedorsimplybeingphysicallyactive[46].Therefore,socialandeconomicfactors,as
wellasbeliefsandgroupnorms,mustbeconsideredwhenanexerciseprogramisde
signed.
Insum,acomprehensivebaselineassessmentmustbecarriedoutbeforetheexercise
programtoidentifypotentialbarriersandfacilitators,includinghealthstatus(physical
andmentalhealth)andpreviouslifestylehabits.
4.6.ParticipantsEducation,AdequateExpectations,andKnowledgeaboutRisksandBenefits
Thisisarelevantissuethatincludedtheeducationinexerciseandhealth(17re
views),adequateinformationaboutbenefitsandpotentialrisks(15reviews),andade
quateexpectationsofchanges(15reviews).Ingeneralterms,itcanbesaidthatthosepa
tientswhoareawareofwhatexercisecandoforthemaremorelikelytoadheretoexer
ciseprograms.Althoughinthelastyearstherehavebeenalotofcampaignstryingto
disclosethebenefitsofbeingphysicallyactive,additionaleffortmustbeexpendedto
educatepeopleonexerciseandhealth.
Peopleoftenshowhigherlevelsofadherencewhentheexerciseisprescribedby
physiciansratherthanbyotherprofessionals.Thatisinlinewiththehealthbeliefmodel,
whichstatesthattheexpectedbenefitsarekeytobeinvolvedinanactivity[89].Thus,
whenparticipantsbelievethattheirhealthstatusisgoingtobeenhanced,theyaremore
likelytobeinvolvedintheexercise.Infact,thisfactorcouldpartiallyexplainwhysome
physicalexerciseprogramsachievedbetteradherencethanothers.Forinstance,infall
preventioninterventions,theadherencetoprogramsaimedtoimprovebalancewas
higherthanadherencetoprogramsaimedtoincreaseflexibility[41,45].Thatcouldbe
explainedbytheparticipants’expectedbenefits,whomaybelievethatflexibilityexercise
isnotgoingtoleadtosubstantialimprovementsthatleadtothepreventionofafallepi
sode.Therefore,patientsmustalwaysbeadequatelyinformedabouttheobjectivesand
theexpectationsofeachexercise.
However,toohighexpectationsmaybeadoubleedgedsword.Oneoftheincluded
reviewsanalyzedtheeffectsofexpectationsonadherencetoaweightlossprogram.They
observedthatthoseindividualswithlowerexpectationshadbetteradherence,while
thosewithunrealisticgoalsweremorelikelytoabandontheprogram[61].Thiswasalso
observedinexercisereferralschemes[73].Therefore,physicalexerciseprofessionals
mustbecautiouswhentheydiscussgoalsandexpectationswiththeparticipantsinorder
toavoidunrealisticoroverlyoptimisticbeliefs.Furthermore,ithasbeensuggestedthat
theseexpectationsshouldbebasedonhealthandqualityoflifevariables,andnotjust
measureslikeweightlossinaspecifictimelength.
Inlinewiththeavoidanceofoverlyoptimisticexpectations,potentialrisksmustbe
ethicallydisclosed,andthepresenceofunpleasantfeelingsshouldbeanticipated[36].
Theymustalsobeadvisedabouttheprogressoftheirdiseaseandwhattheabsenceof
exercisemaycause.Forinstance,ithasbeenshownthatcolorectaladenomapatientsmay
Int.J.Environ.Res.PublicHealth2021,18,202314of25
beunawareoftheincreasedcancerrisktheyhave,[33]andpatientswithheartfailure
hadpoorknowledgeabouttheirdisease[90]andthiscouldreducetheengagementin
healthyactivities.
Insum,participantsinexerciseprogramsshouldbeeducatedinordertobeawareof
thehealthbenefitsofexerciseandtherisksofsedentaryhabits.Theyshouldalsobead
equatelyinformedabouttheusualfeelingsduringthepractice(forexamplethefatigue)
andmustbeprovidedwithenoughinformationtohaverealisticexpectationsofchange,
avoidingoverlyhighorlowexpectations.
4.7.EnjoymentandAbsenceofUnpleasantExperiences
Theexperienceofparticipantswhiledoingexerciseiscrucialtoenhancetheadher
encetophysicalexercise.Enjoymentisanimmediaterewardthatcouldleadtobetter
persistencethandelayedrewards,suchashealthbenefitsinthelongterm[91].Ithas
beenrelatedtoparticipationandefficacyofphysicalexercise[92]andiscloselyassoci
atedwithintrinsicmotivation[93].Inthisregard,participantsaremorelikelytoenjoythe
practicewhenthebasicpsychologicalneedsofcompetence,relatedness,andautonomy
aresatisfied[94].Thoseneedshavealsobeenidentifiedinthissystematicreviewaskey
factorstobeconsidered.Theuseofadequatetechnologymayalsoenhancetheenjoy
mentinchronicpatients[95]andaltertheperceivedeffortofpatientsdoingexercise,
achievingsimilarphysiologicalresponseswithlowerperceivedexertion[96].
Ontheotherhand,thepresenceofunpleasantexperiencesmaylimitparticipation
andadherencetoexercise.Thisisespeciallyrelevantamongthosepatientssufferingfrom
conditionsthatcausepainorfatigueandcanbeincreasedwhentheintensityofexercise
hasrisen[97].Thisisconsistentwiththenotionthatenjoymentisastrongmediatorof
adherencetoexerciseinpatientssufferingfrommusculoskeletalpain[98].
Theaffectiveresponsetoexerciseisbasedontheinterpretationofacomplexnetof
interactionsamongphysiologicaldemands,participant’spsychologicalcharacteristics,
theenvironment,andsituationalappraisals[99].Therefore,theseindividualinterpreta
tionswillbedifferentfromsubjecttosubject,sowhatisenjoyableforsomeonecouldlead
tounpleasantfeelingsinothers.Forinstance,somepeoplecaninterprettheincreased
heartrate,breathing,ortemperatureaspleasantornot[100].Similarly,physicaltiredness
couldbeunpleasantbutalsoleadtoemotionallypleasantfeelings[100].Inthecaseof
pain,cliniciansmustadequatelyinformaboutpainexperienceandbeliefs,reducingthe
associatedfearoranxietyandavoidingtheimmediateabandoningofactivitiesthat
generatealittlediscomfort[52].
Inthecaseofobesity,otherunpleasantfeelingscanemerge,suchastheembar
rassmentwiththeirownappearancewhiledoingexercise,rapidexhaustionrelatedto
poorphysicalconditioningduetophysicalinactivity,orlackofmovementenjoyment
[61,101].
Inthesearchprocess,thissystematicreviewofreviewsalsoidentifiedreviews
aimedtoevaluatetheeffectsofpayingpeopletoexercise.Mitchell,etal.[102]foundthat
financialincentivesincreaseattendanceininterventionsforuptosixmonths.Thisap
proachiscontroversialsince,accordingtotheselfdeterminationtheory,givingexternal
motivatorsinactivitiesthatcouldbeintrinsicallyenjoyablemayreducetheintrinsicmo
tivationoncetheexternalrewardisremoved[103].However,thisharmtointrinsicmo
tivationmaybeloweramongpreviouslyinactivepatientswholackintrinsicmotivation
toexercise[23].Therefore,financialincentivesmaybeonlyadequateinthoseindividuals
thatwouldnotexerciseunderanyotherconditions.
Insum,thepleasantandunpleasantfeelingsduringexercisearegoingtoaffectad
herenceandmotivation.Enjoymentisanimmediaterewardthatmayincreaseadherence
morethanotherdelayedrewardssuchashealthbenefits.Furthermore,unpleasantex
periencesduringtheexercisepracticearealsocommoninpatientswithdifferentcondi
tions,soitisnecessarytogiveenoughinformationsothatthepatientsadequatelyinter
prettheirfeelingsandemotionsandreducetheassociatedfear,anxiety,andavoidance.
Int.J.Environ.Res.PublicHealth2021,18,202315of25
4.8.IntegrationinDailyLiving
Oneofthekeysthatwasreportedbymorethanhalfofthereviewsistheintegration
ofphysicalexerciseindailyliving.Thisisafactorthatmaybeaffectedbytherestofthe
identifiedfactorsandinvolvethetransformationofphysicalexerciseintoalifestylehabit,
whichwouldavoidthecommonbarrierassociatedwiththeperceivedlackoftime
[14,59,61].Manyvariablescanaffectthatprocess,suchastheflexibilityatwork[104]or
theintimidatinggymenvironment[75],butthebackgroundandpreferencesofpatients
arethemostcrucialones.Inthisregard,goodaccessibility(intermsofmoney,distance
fromhome,physicalbarriers,etc.),aswellasrelativeflexibilityinthetimetable(forin
stanceincludingthepossibilityofmakingupthesessionsthatpatientswerenotableto
attendwithintheweek)havebeenidentifiedby21reviews.Onlyexerciseprogramsthat
areinlinewiththepreferencesandcharacteristicsofparticipantscanbecomeanactual
habit.
Inthescientificliterature,manycomparisonsbetweencenterbasedandhomebased
exercisescanbefound.Thefirsttypecouldbemoreeffectivesinceaprofessionalisoften
supervisingandcontrollingtheexecution.Furthermore,thepresen