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Objectives: The Benchmarking Exercise Programme for Older People (BEPOP) service improvement project seeks to determine and promote the exercise training characteristics associated with positive outcomes for resistance exercise for older people living with, or at risk of, sarcopenia or physical frailty. Methods: Mixed-methods service improvement project. Ten UK National Health Service physiotherapist-led therapy services delivering exercise interventions for older people submitted anonymized data for up to 20 consecutive patients. A multidisciplinary expert panel generated a report and recommendations with site-specific benchmarking data and feedback. In parallel, participating physiotherapy team members were interviewed to elicit feedback on BEPOP rationale, processes and perceived value. Results: Data from 188 patients were included, mean age 80 years (range 60-101). 115 (61%) received objective assessment of strength-based physical performance. Bodyweight exercises (173 [92%]) and resistance bands (49 [26%]) were the commonest exercise modalities. Exercises progressed predominantly through increased repetitions (163 [87%]) rather than increased load. 50 (30%) had no reassessment of outcomes; only 68 (41%) were signposted to follow-on exercise services. Staff interviews identified themes around knowledge, diagnosis, data collection and practice reflection. Conclusion: BEPOP was feasible to deliver and generated actionable insights for service improvement via improved diagnosis, measurement and progression of resistance exercise.

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AIMS: The study aimed to synthesize evidence of daily physical activity (PA) following Behavior-change technique (BCT)-based interventions compared to any control in individuals with peripheral arterial disease/intermittent claudication (PAD/IC); and examine the relationship between BCTs and daily PA. METHODS: Systematic search of 11 databases from inception to 30/11/2022 was conducted, plus weekly email alerts of new literature until 31/8/2023. Studies comparing BCT-based interventions with any control were included. Primary analysis involved a pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane-RoB-2 and ROBINS-I tools. Certainty of evidence was evaluated with the GRADE system. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed. Outcome measures were short-term (<6 months) change in daily PA, and maintenance of the daily PA (6 months or longer) reported as standardized mean differences (SMDs) with 95% confidence intervals (95%CIs). RESULTS: Forty-one studies (4,339 patients; 26 RCTs/3,357 patients; 15 non-RCTs/982 patients; study mean age 60.3 to 73.8, 29.5% female) were included. Eleven RCTs (15 comparisons, 952 participants) suggested that BCT-based interventions increased daily PA in the short term compared to non-SET [increase of 0.20 SMD (95%CI: 0.07 to 0.33), ∼473 steps/day] with high certainty. Evidence of maintenance of daily PA (≥6 months) is unclear [increase of 0.12 SMD (95%CI: -0.04 to 0.29); ∼288 steps/day; 6RCTs, 8 comparisons, 899 participants], with moderate certainty. For daily PA, compared to SET it was inconclusive both for < 6months change [-0.13 SMD, 95%CI: -0.43 to 0.16); 3RCTs, 269 participants; low certainty] and ≥6months [-0.04 SMD, 95%CI: -0.55 to 0.47); 1 RCT, 89 participants; very low certainty]. It was unclear whether the number of BCTs or any BCT domain were independently related to an increase in PA. CONCLUSION: BCT-based interventions improve short-term daily PA in people with PAD/IC compared to non-SET controls. Evidence for maintenance of the improved PA at 6 months or longer and comparison with SET is uncertain. BCT-based interventions are effective choices for enhancing daily PA in PAD/IC.

This study evaluated the effect of behavior-change interventions on daily physical activity (PA) in people with intermittent claudication. In individuals with intermittent claudication, behavior-change interventions improve short -term physical activity compared to controls, but additional research is needed to ascertain their sustained benefits at 6-months or longer, as well as their benefit compared to SET.Behavior-change technique (BCT) based interventions may support patients to engage in daily physical activity.

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PURPOSE: The aim of this study is to explore the feasibility of using machine learning approaches to objectively differentiate the mobilization patterns, measured via accelerometer sensors, of patients pre- and post-intervention. METHODS: The intervention tested the implementation of a Frailty Care Bundle to improve mobilization, nutrition and cognition in older orthopedic patients. The study recruited 120 participants, a sub-group analysis was undertaken on 113 patients with accelerometer data (57 pre-intervention and 56 post-intervention), the median age was 78 years and the majority were female. Physical activity data from an ankle-worn accelerometer (StepWatch 4) was collected for each patient during their hospital stay. These data contained daily aggregated gait variables. Data preprocessing included the standardization of step counts and feature computation. Subsequently, a binary classification model was trained. A systematic hyperparameter optimization approach was applied, and feature selection was performed. Two classifier models, logistic regression and Random Forest, were investigated and Shapley values were used to explain model predictions. RESULTS: The Random Forest classifier demonstrated an average balanced accuracy of 82.3% (± 1.7%) during training and 74.7% (± 8.2%) for the test set. In comparison, the logistic regression classifier achieved a training accuracy of 79.7% (± 1.9%) and a test accuracy of 77.6% (± 5.5%). The logistic regression model demonstrated less overfitting compared to the Random Forest model and better performance on the hold-out test set. Stride length was consistently chosen as a key feature in all iterations for both models, along with features related to stride velocity, gait speed, and Lyapunov exponent, indicating their significance in the classification. CONCLUSION: The best performing classifier was able to distinguish between patients pre- and post-intervention with greater than 75% accuracy. The intervention showed a correlation with higher gait speed and reduced stride length. However, the question of whether these alterations are part of an adaptive process that leads to improved outcomes over time remains.

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BACKGROUND AND PURPOSE: The COVID-19 pandemic has raised concerns about nursing home (NH) residents' well-being, with recent studies indicating a significant increase in functional decline rate during this critical period. However, a comprehensive exploration of functional capacity trajectories in NH residents during the pandemic remains unexplored. This study aims to address this research gap by conducting an in-depth analysis of the impact of the COVID-19 pandemic on NH residents' functional capacity. METHODS: A 24-month multicenter prospective study involving 123 NH residents from Spain, with data collected at 6-month intervals over 5 waves, starting just before the pandemic's onset. Functional capacity was assessed using the Modified Barthel Index, and data were analyzed employing the actuarial method, log-rank test, and Cox's regression. RESULTS AND DISCUSSION: The likelihood of maintaining functional capacity was unfavorable, with only a 19.3% chance of preservation for a 1-point decline (FD-1) in Barthel scores and a 50.5% probability for a 10-point decline (FD-10). Personal hygiene, eating, and toilet use were identified as the most affected activities of daily living. Urinary continence decline emerged as a risk factor for FD-1, while fecal continence decline was associated with FD-10. The probability of maintaining functional capacity in the initial 6 months of a pandemic was comparable to a 2-year non-pandemic follow-up. Pandemic-induced isolation strategies significantly impacted toileting and personal hygiene. Urinary decline was associated with minor functional decline (FD-1), while fecal decline correlated with major functional decline (FD-10). Notably, the number of days spent in room confinement did not significantly contribute to the observed decline. CONCLUSIONS: A substantial increase in the risk of FD among NH residents during the COVID-19 pandemic compared to the pre-pandemic period was found. It is crucial to implement urgent, targeted interventions that prioritize promoting physical activity and the implementation of mobility and toileting programs. These measures are pivotal for mitigating functional decline and enhancing the overall health and well-being of NH residents in a pandemic context.

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BACKGROUND: Falls among older adults represent a major health hazard across the world. In 2022, the World Falls Guidelines was published, summarising research evidence and expert recommendations on how to prevent falls, but we need more knowledge on how the evidence can be successfully implemented into routine practice. In this study we used an implementation strategy co-created by healthcare providers, older adults who had fallen and researchers, to facilitate uptake of fall prevention recommendations. This current study aimed to evaluate the feasibility of this co-created implementation strategy in homecare services and provide information on the intervention and measurements for a full-scale cluster-randomized trial. METHODS: This study was a single-armed feasibility study with an embedded mixed-method approach completed in two city districts of Oslo, Norway, over a period of ten weeks. The co-created implementation strategy consists of a package for implementing national recommendations for preventing falls, empowering leaders to facilitate implementation, establish implementation teams, competence improvement and implementation support. City districts established implementation teams who were responsible for the implementation. Feasibility was assessed both qualitatively and quantitatively, using focus group interviews with implementation team members and individual interviews with leaders and staff members and the Feasibility of Intervention Measure (FIM). Qualitative data were analysed using thematic analysis and the Normalisation Process Theory. RESULTS: Qualitative data were collected from 19 participants: 12 implementation team members, 2 leaders and 5 staff members. 8 of the implementation team members responded to FIM. The analysis revealed four themes: 1) Fostering consensus through tailored implementation and discussions on fall prevention, 2) The importance of multi-level and interdisciplinary collaboration in fall prevention implementation, 3) Minimizing perceived time usage through utilization of existing areas for implementation activities, and 4) Reflective monitoring demonstrates the importance of facilitation and structure in the implementation strategy. For FIM, there were a high level of agreement related to how implementable, possible, doable, and easy to use the implementation strategy was. CONCLUSIONS: Overall, we found the implementation strategy to be feasible to enhance uptake of fall prevention recommendations in the Norwegian homecare services. To succeed with the implementation, a dedicated implementation team should receive support through the implementation process, they should choose small implementation activities to enhance fall prevention competence and managers should possess implementation knowledge. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/2JFHV Registered: January 11, 2023.

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In 2021, a 'call to action' was published to highlight the need for professional regulation of clinical exercise physiologists to be established within UK healthcare systems to ensure patient safety and align training and regulation with other health professions. This manuscript provides a progress report on the actions that Clinical Exercise Physiology UK (CEP-UK) has undertaken over the past 4 years, during which time clinical exercise physiologists have implemented regulation and gained formal recognition as healthcare professionals in the UK. An overview of the consultation process involved in creating a regulated health profession, notably the development of policies and procedures for both individual registration and institutional master's degree (MSc) accreditation is outlined. Additionally, the process for developing an industry-recognised scope of practice, a university MSc-level curriculum framework, the Academy for Healthcare Science Practitioner standards of proficiency and Continuing Professional Development opportunities is included. We outline the significant activities and milestones undertaken by CEP-UK and provide insight and clarity for other health professionals to understand the training and registration process for a clinical exercise physiologist in the UK. Finally, we include short, medium and long-term objectives for the future advocacy development of this workforce in the UK.

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Objectives: 1) Map FaME delivery across the UK, 2) explore and understand delivery of the FaME programme in practice. Methods: Sequential exploratory mixed methods. 1) survey of n=247 Postural Stability Instructor (PSIs) across the UK, 2) purposively sampled n=23 PSIs to take part in interviews. Quantitative data was described descriptively due to low sample size, and qualitative data coded using thematic analysis. Results: Instructors pre-dominantly delivered classes in a community-setting, were mostly White British females with a range of experience. Most respondents were exercise instructors, physiotherapists, or therapist assistants. Only 136 (55.1%) respondents currently delivered the programme. The essential components of the FaME programme that instructors did not implement routinely were backward chaining, floorwork and Tai Chi. Five main themes emerged from qualitative data: individual, delivery and set-up, evidence-based delivery, motivational strategies, and instructor-based factors. Most instructors reported fidelity to most components of FaME and shared barriers and facilitators to delivering classes. Conclusion: This study gives a UK overview of the implementation of FaME. PSIs present a complex picture of the ways set-up and delivery of evidence-based programmes in practice can influence older adults' attendance, adherence and experience of the programme, and barriers and facilitators to delivery of the programme with fidelity.

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BACKGROUND: Age, multimorbidity, immunodeficiency and frailty of older people living in nursing homes make them vulnerable to COVID-19 and overall mortality. OBJECTIVE: To estimate overall and COVID-19 mortality parameters and analyse their predictive factors in older people living in nursing homes over a 2-year period. METHOD: Design: A 2-year prospective longitudinal multicentre study was conducted between 2020 and 2022. SETTING: This study involved five nursing homes in Central Catalonia (Spain). PARTICIPANTS: Residents aged 65 years or older who lived in the nursing homes on a permanent basis. MEASUREMENTS: Date and causes of deaths were recorded. In addition, sociodemographic and health data were collected. For the effect on mortality, survival curves were performed using the Kaplan-Meier method and multivariate analysis using Cox regression. RESULTS: The total sample of 125 subjects had a mean age of 85.10 years (standard deviation = 7.3 years). There were 59 (47.2%) deaths at 24 months (95% confidence interval, CI, 38.6-55.9) and 25 (20.0%) were due to COVID-19, mostly in the first 3 months. In multivariate analysis, functional impairment (hazard ratio, HR 2.40; 95% CI 1.33-4.32) was a significant risk factor for mortality independent of age (HR 1.17; 95% CI 0.69-2.00) and risk of sarcopenia (HR 1.40; 95% CI 0.63-3.12). CONCLUSION: Almost half of this sample of nursing home residents died in the 2­year period, and one fifth were attributed to COVID-19. Functional impairment was a risk factor for overall mortality and COVID-19 mortality, independent of age and risk of sarcopenia.

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Objective: To implement and evaluate a Frailty Care Bundle (FCB) targeting mobilisation, nutrition, and cognition in older trauma patients to reduce hospital associated decline. Methods: We used a two group, pretest-posttest design. The FCB intervention was delivered on two orthopaedic wards and two rehabilitation wards, guided by behaviour change theory (COM-B) to implement changes in ward routines (patient mobility goals, nurse assisted mobilisation, mealtimes, communication). Primary outcomes were patient participants' return to pre-trauma functional capability (modified Barthel Index - mBI) at 6-8 weeks post-hospital discharge and average hospital daily step-count. Statistical analysis compared pre versus post FCB group differences using ordinal regression and log-linear models. Results: We recruited 120 patients (pre n=60 and post n=60), and 74 (pre n=43, post n=36) were retained at follow-up. Median age was 78 years and 83% were female. There was a non-significant trend for higher mBI scores (improved function) in the post compared to pre FCB group (OR 2.29, 95% CI 0.98-5.36), associated with an average 11% increase in step-count. Conclusion: It was feasible, during the Covid-19 pandemic, for multidisciplinary teams to implement elements of the FCB. Clinical facilitation supported teams to prioritise fundamental care above competing demands, but sustainability requires ongoing attention. ISRCTN registry: ISRCTN15145850 (https://doi.org/10.1186/ISRCTN15145850).

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BACKGROUND: Urinary incontinence (UI) is a common geriatric syndrome with high health and socio-economic impacts in nursing home (NH) residents. OBJECTIVES: To estimate the prevalence and types of UI and its associated factors in older people living in NHs in Central Catalonia (Spain). We also determined the proportion of residents who were receiving behavioural strategies to prevent/manage UI. DESIGN AND SETTING: Cross-sectional study in 5 NHs conducted from January to March 2020. METHODS: We included consenting residents aged 65 + permanently living in the NHs. Residents who were hospitalized, in a coma or palliative care were excluded. UI was assessed using Section H of the Minimum Data Set. Sociodemographic and health-related variables were examined. Descriptive, bivariate, and multivariate (logistic regression) analyses were performed. RESULTS: We included 132 subjects (82.6% women), mean age of 85.2 (SD = 7.4) years. The prevalence of UI was 76.5% (95% CI: 68.60-82.93). The most common type was functional UI (45.5%), followed by urgency UI (11.4%). Only 46.2% of residents received at least one behavioural strategy to manage UI. Most sedentary behaviour (SB) variables presented a p-value lower than 0.001 in the bivariate analyses, but none remained in the final model. Moderate-severe cognitive impairment (OR = 4.44, p =.003), anticholinergic activity (OR = 3.50, p =.004) and risk of sarcopenia using SARC-F (OR = 2.75, p =.041) were associated with UI. CONCLUSIONS: The prevalence of UI was high in this sample of NH residents compared to the literature, yet less than half received prompted voiding as a strategy to prevent/reduce UI.UI was associated with cognitive impairment, anticholinergic activity, and risk of sarcopenia.

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BACKGROUND: Despite substantial research evidence indicating the effectiveness of a range of interventions to prevent falls, uptake into routine clinical practice has been limited by several implementation challenges. The complexity of fall prevention in municipality health care underlines the importance of flexible implementation strategies tailored both to general determinants of fall prevention and to local contexts. This cluster-randomised trial (RCT) investigates the effectiveness of a tailored intervention to implement national recommendations on fall prevention among older home-dwelling adults compared to usual practice on adherence to the recommendations in health professionals. METHODS: Twenty-five municipalities from four regions in Norway will be randomised to intervention or control arms. Each municipality cluster will recruit up to 30 health professionals to participate in the study as responders. The tailored implementation intervention comprises four components: (1) identifying local structures for implementation, (2) establishing a resource team from different professions and levels, (3) promoting knowledge on implementation and fall prevention and (4) supporting the implementation process. Each of these components includes several implementation activities. The Consolidated Framework for Implementation Research (CFIR) will be used to categorise determinants of the implementation process and the Expert Recommendations for Implementing Change (ERIC) will guide the matching of barriers to implementation strategies. The primary outcome measure for the study will be health professionals' adherence to the national recommendations on fall prevention measured by a questionnaire. Secondary outcomes include injurious falls, the feasibility of the intervention, the experiences of the implementation process and intervention costs. Measurements will be carried out at baseline in August 2023, post-intervention in May 2024 and at a follow-up in November 2024. DISCUSSION: This study will provide evidence on the effectiveness, intervention costs and underlying processes of change of tailored implementation of evidence-based fall prevention recommendations. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/JQ9T5 . Registered: March 03, 2023.

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OBJECTIVE: To determine the effects of high velocity resistance training (HVRT) on bone mineral density (BMD) in older adults. METHODS: A systematic review was conducted using five databases. Records were screened by two independent reviewers. INCLUSION CRITERIA: adults ≥50 years old, HVRT defined as rapid concentric and slow eccentric phase against an external load, control group and/or other intervention group, BMD measured using dual X-ray absorptiometry, and ≥6 months. RESULTS: 25 studies met the inclusion criteria. 12 were original intervention studies (8 RCTs) with n = 1203 people. 13 papers were follow up studies of these original interventions. Heterogeneity of studies meant no meta-analysis was performed. Moderate evidence suggests a small statistically significant effect of HVRT on BMD in older adults at the lumbar spine, total hip, and femoral neck ranging from 0.9 % to 5.4 %. BMD measurements significantly decreased post-intervention in follow-up studies where the interventions had ceased. Dose-response of HVRT was shown to positively impact BMD when ≥2 sessions per week are completed. CONCLUSIONS: HVRT plays a role in increasing BMD of the lumbar spine, femoral neck, and total hip. Doses of higher intensity exercise performed ≥2 sessions per week will yield the most skeletal benefits, and if exercise is stopped for >6 months, benefits achieved may be lost.

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BACKGROUND: NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual. METHODS: In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283. FINDINGS: This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI -0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (-1·237, -2·127 to -0·348) and frailty (-0·124, -0·232 to -0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending. INTERPRETATION: This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population. FUNDING: National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

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BACKGROUND: Limited mobility in older adults consistently predicts both morbidity and mortality. As individuals age, the rates of mobility disability increase from 1.0% in people aged 15-24 to 20.6% in adults over 65 years of age. Physical activity can effectively improve mobility in older adults, yet many older adults do not engage in sufficient physical activity. Evidence shows that increasing physical activity by 50 min of moderate intensity physical activity in sedentary older adults with mobility limitations can improve mobility and reduce the incidence of mobility disability. To maximize the healthy life span of older adults, it is necessary to find effective and efficient interventions that can be delivered widely to prevent mobility limitations, increase physical activity participation, and improve quality of life in older adults. We propose a randomized controlled trial to assess the effect of a physical activity health coaching intervention on mobility in older adults with mobility limitations. METHODS: This randomized controlled trial among 290 (145 per group) community-dwelling older adults with mobility limitations, aged 70-89 years old, will compare the effect of a physical activity health coaching intervention versus a general healthy aging education program on mobility, as assessed with the Short Physical Performance Battery. The physical activity health coaching intervention will be delivered by exercise individuals who are trained in Brief Action Planning. The coaches will use evidence-based behavior change techniques including goal-setting, action planning, self-monitoring, and feedback to improve participation in physical activity by a known dose of 50 min per week. There will be a total of 9 health coaching or education sessions delivered over 26 weeks with a subsequent 26-week follow-up period, wherein both groups will receive the same duration and frequency of study visits and activities. DISCUSSION: The consequences of limited mobility pose a significant burden on the quality of life of older adults. Our trial is novel in that it investigates implementing a dose of physical activity that is known to improve mobility in older adults utilizing a health coaching intervention. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration System: NCT05978336; registered on 28 July 2023.

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INTRODUCTION: Scarce evidence is available about the minimum number of valid days wearing the activPAL3 to obtain a precise estimate of sedentary behaviour (SB) and awake-time movement behaviours (ATMB) in nursing home (NH) residents. The study aimed to determine the minimum number of valid days required for accurately estimate SB and ATMB using the activPAL3 device in NH residents. It also investigated how the starting point of a day (the 24-h period) impacted reliability. METHODS: Participants wore an activPAL3 for 7 consecutive days. The data was classified in two-time blocks (00:00 Ante Meridiem (AM)-00:00 AM midnight vs 12:00 Post Meridiam (PM) -12:00 PM midday) and the sample was stratified into two groups according to their capacity to stand and walk, to examine if timing of sampling or physical functioning affected minimum wear time. SB, ATMB, sociodemographic, and health-related variables were collected. Sensitivity of the time-blocks were tested through the dispersion frequencies and differences between blocks through Kolmogorov-Smirnov test for normality; parametric variables through two-related means T-test and Wilcoxon test for non-parametric data. Reliability was assessed with the Cronbach's Alpha and the intra-class correlation coefficient (ICC), using a one-factor model estimating the reliability for each measurement day loading in the same latent factor. RESULTS: Ninety-five NH residents (81.1% women; age = 85.8 ± 7.2 years) were included. The midnight block had higher reliability, sensitivity and no statistically significant differences between days were found. At least three consecutive days of monitoring were necessary to achieve a reliability of ICC ≥ 0.8 for those NH residents able to stand and walk and six days for those unable. CONCLUSIONS: NH residents who are able to stand and walk require a minimum of three consecutive days wearing the device, while those who are unable require at least six days due to their highly homogenous daily routines and sensitivity to PA events. Regardless of the activPAL3 recording start time, data processing should reference the midnight time block.

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Kyphosis can lead to back pain, poor posture, and increased falls risk. This systematic review aimed to synthesize research on stretching alone, or in combination with strengthening, as a management for hyperkyphosis in the adult population (≥18 years old). An electronic database search was conducted from February to March 2022. The author and an independent reviewer screened titles and abstracts for inclusion criteria - those whose intervention involved stretching alone or with strengthening exercises. The author appraised and extracted data from included articles and performed a meta-analysis where appropriate. The database and citation search yielded 327 articles, 18 of which met inclusion criteria. One study included performed stretching as a standalone intervention; the remainder used a combination of stretching and strengthening. The meta-analysis (n=3, with 5 exercise groups) found a statistically significant difference (MD = -6.97 (95% CI -9.84, -4.10), p<0.00001) in post-intervention measures of hyperkyphosis favouring the exercise group. The narrative review of studies agrees with this finding, demonstrating statistically significant improvement in hyperkyphosis following various exercise programs. This review suggests that stretching and strengthening exercises improve hyperkyphosis in the short and long term. Low-quality evidence supports stretching as a standalone intervention. Further, more robust research is required to recommend procedures and determine if stretching alone is effective for treating hyperkyphosis in adults.