CA20104 – Ne wo k on e idence-based
physical ac i i y in old age (PhysAgeNe )
Deli e able D2.2
D2.2 Scien i ic li e a u e s a us, equi emen s and oadmap o
he de elopmen o s anda ds and u ilisa ion o bioma ke s,
beha iou al ma ke s and en i onmen al ac o s wi h open da a
RCO 1 Compile he li e a u e on biological and beha iou al
ma ke s, and en i onmen al ac o s
Con ibu o s
Wo king G oup 2
E ja Po egijs (WG2 leade ), Ca l-Philipp Jansen (WG2 co-leade ), O on Le in
(WG2 co e g oup), Ma yam Ziaei (WG2 subg oup leade ), I an Bau mans (WG2
subg oup leade ), Wou e Vin s (WG2 e iew leade ), Vee le Knoop (WG2
e iew leade ), Da id Beckwée (WG2 e iew leade )
Pa icipan s in he expe discussions and e iew g oups ha e all con ibu ed
o hese esul s
This publica ion is based upon wo k
om COST Ac ion PhysAgeNe ,
CA20104, suppo ed by COST
(Eu opean Coope a ion in Science
and Technology).
COST (Eu opean Coope a ion in Science and
Technology) is a unding agency o esea ch
and inno a ion ne wo ks. Ou Ac ions help
connec esea ch ini ia i es ac oss Eu ope and
enables scien is s o g ow hei ideas by
sha ing hem wi h hei pee s. This boos s
hei esea ch, ca ee and inno a ion.
1
Table o Con en
1. In oduc ion ........................................................................................................................................ 2
2. Resul s ................................................................................................................................................. 3
2.1. INTRINSIC CAPACITY ................................................................................................................ 3
2.1.1. LOCOMOTOR AND VITALITY CAPACITY AND FUNCTION ............................................. 3
2.1.2. COGNITIVE CAPACITY AND FUNCTION ............................................................................ 6
2.1.3. PSYCHOLOGICAL FACTORS ................................................................................................ 7
2.2. EXTERNAL FACTORS ...................................................................................................................... 9
2.2.1. ENVIRONMENTAL FACTORS .................................................................................................. 9
3. Roadmap o compile and condense ............................................................................................ 10
4. Re e ences ........................................................................................................................................ 11
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1. INTRODUCTION
Au ho : E ja Po egijs
Heal hy Ageing is highligh ed by he Uni es Na ions’ “Decade o Heal hy Ageing” and
emphasizes he g owing impo ance o add essing he challenges associa ed wi h ageing
popula ions. Physical ac i i y in old age is impo an o main enance o heal h and unc ion,
and he p e en ion o ch onic condi ions. In addi ion, heal h bene i s o physical ac i i y
in e en ions a e widely epo ed using a wide a ie y o measu es. Howe e , he e is no
consensus on speci ic concep s and measu es o be used o assessing in e en ion ou comes.
The success o in e en ions, howe e , also depends on i s implemen a ion and up ake by he
a ge g oup. Resea ch is ypically conduc ed in well-con olled se ings and wi h a bias
owa ds pa icipan s wi h be e unc ion and highe ac i i y. When implemen ing physical
ac i i y in e en ions in eal-li e se ings, a ious ac o s a ec he up ake o he in e en ion,
adhe ence o he p o ocol, and sus ained pa icipa ion. Thus, esea ch on physical ac i i y
in e en ions should assess no only ou comes, bu also o he ac o s unc ioning as
mode a o s o media o s o he in e en ions. This equi es a holis ic ocus, encompassing no
only mo e adi ional physical o biological bioma ke s, bu also beha io al and en i onmen al
ma ke s.
Technology and digi al ools a e inc easingly used o suppo physical ac i i y in e en ions.
Compa ed wi h adi ional ehabili a ion, echnologies such as se ious games can use i id
ideo and pic u es and may become mo e a ac i e, accep able, and mo e e ec i e as a
highe di e si y o asks can be ained. Fu he mo e, hese echnologies can p o ide imely
eedback, con inuous moni o ing, and ou come assessmen , as such in o ming he ins uc o
o pe sonalized adap a ions. Howe e , such echnology-assis ed in e en ions may equi e
addi ional skills and unde s anding om olde pa icipan s (Kim & Xie 2017), posing addi ional
ba ie s and selec ion bias.
To ad ance he measu emen and moni o ing o ( echnology-assis ed) physical ac i i y
in e en ion ou comes as well as ac o s ela ed o hei up ake and main enance in old age,
he PhysAgeNe COST ac ion ne wo k b ough oge he esea che s om di e en Eu opean
uni e si ies. Technology-assis ed in e en ions p o ide a imely con ex . Howe e , hey a e no
always sui able when s udying no el and less esea ched measu emen and moni o ing
pa ame e s. The e o e, on a cases by case basis, li e a u e e iews a e based on physical ac i i y
in e en ions, o echnology-assis ed physical ac i i y in e en ions. Expe s discuss and cla i y
biological and beha io al bioma ke s and en i onmen al ac o s comp ehensi ely and
decided upon he mos ele an con ex . Join ly he esul s o WG2 will es ablish equi emen s
and a oadmap o u u e moni o ing o in e en ions.
Regula expe discussions we e conduc ed in 2022 and a e s ill ongoing. I was decided o
depa om he p e-exis ing e minology o biological and beha io al bioma ke s and
en i onmen al ac o s and o cap u e and ie oge he hese and o he ele an concep s
holis ically in a heo e ical amewo k. Expe s oge he decided o use he Heal hy Ageing
amewo k de eloped by he WHO (2015). The concep o "heal hy ageing" ocuses on
main aining unc ional abili y and o e all well-being in olde age, a he han solely ocusing
on disease managemen . The amewo k is ypically applied in he con ex o mapping he
aging p ocess. Howe e , he PhysAgeNe WG2 in ends o use i in he con ex o physical
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ac i i y in e en ion. The amewo k iden i ies in insic and ex insic ac o s and linked
unc ional domains ( igu e 1). Fu he mo e, subdomains a e lis ed and speci ied.
Conside ing he b oad ange o pa ame e s o be conside ed o a holis ic amewo k, i was
decided o spli in o h ee expe g oups, wi h u he subdi isions when ele an , discussing
he ollowing opics:
• Vi ali y and locomo o abili y and unc ion
• Cogni i e abili y and unc ion
• Psychological ac o s
• En i onmen al ac o s
The ollowing sec ion 2 desc ibes he wo k and p og ess in each g oup and sec ion 3 desc ibes
how his con ibu es o he de elopmen o he se o equi emen s and oadmap o assessing
( echnology-assis ed) physical ac i i y in e en ions.
2. RESULTS
2.1. INTRINSIC CAPACITY
2.1.1. LOCOMOTOR AND VITALITY CAPACITY AND FUNCTION
Au ho : Vee le Knoop (I an Bau mans)
Locomo o and i ali y capaci y a e wo domains o in insic capaci y and ha e ecen ly been
ede ined by an expe ask o ce ini ia ed by he WHO. A new WHO wo king de ini ion o
i ali y capaci y (VC) has been p oposed by 20 in e na ional expe s in an expe mee ing,
de ining VC as "a physiological s a e (due o no mal accele a ed biological ageing p ocesses)
esul ing om he in e ac ion be ween mul iple physiological sys ems, e lec ed in ( he le el
o ) ene gy and me abolism, neu omuscula unc ion, and immune and s ess esponse
unc ions o he body" (Bau mans e al., 2022). Locomo o capaci y on he o he hand is de ined
by he WHO ask o ce as “a s a e (s a ic o dynamic o e ime) o he musculoskele al sys em
ha encompasses endu ance, balance, muscle s eng h, muscle unc ion, muscle powe and
a join unc ion o he body” (Ve onese e al., 2022). Ea ly iden i ica ion and moni o ing o
changes in in insic capaci y is key o be e p e en ion and heal h managemen . Howe e , no
cu en consensus exis s on he me ics o sys ema ic quan i ica ion o moni o ing o
locomo o and i ali y capaci y in he con ex o in insic capaci y.
Me hodology o iden i y domains and bioma ke s o i ali y and locomo o capaci y
Since May 2022 mon hly ( i ual) mee ings ha e been o ganized o iden i y bioma ke s o
in insic capaci y ( i ali y & locomo o ) and unc ional abili y a ec ing he up ake o
main enance o he in e en ion o ac o s indica ing mechanisms o change. As a i s s ep
di e en domains o i ali y and locomo o capaci y we e p oposed by he expe s, hey we e
di ided in o ou comes, mode a o s and mechanisms. As a nex s ep, di e en bioma ke s o
each domain we e iden i ied. These nex bioma ke s and domains we e used subsequen ly o
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conduc a sys ema ic e iew on measu es ha can be ecommended o ou ine moni o ing
o i ali y and locomo o capaci y.
A la ge se o bioma ke s we e e alua ed and g ouped by he expe s in ol ed (see able 1, s ep
1). All he bioma ke s we e coded acco ding o he expe s in o ou comes, mode a o s and
mechanisms. As a nex s ep, bioma ke s appoin ed as ou comes will be e alua ed acco ding
o he ollowing c i e ia: easible o quan i y bioma ke s o p oxy bioma ke s; use ul and
in o ma i e o moni o ing (su icien sensi i i y o change wi h in e en ion) and
implemen able (e.g., in dedica ed popula ion su eys on ageing o mul ipu pose su eys).
Table 1. S eps o iden i y bioma ke s o i ali y & locomo o capaci y
S epwise iden i ica ion o bioma ke s o i ali y and locomo o capaci y
Vi ali y
Domain
Bioma ke s
Ene gy & me abolism
Sel -pe cei ed a igue (mode a o )
Muscle a igabili y (ou come)
Malnu i ion (mode a o )
Body composi ion (mode a o )
Fib e yping (mode a o )
Ci cula ing bioma ke s o me abolism
(mechanism)
Neu omuscula s eng h
Knee ex enso s eng h (ou come)
Knee lexo s eng h (ou come)
Handg ip s eng h (mode a o )
Respi a o y Muscle s eng h (ou come)
Volun a y muscle ac i a ion (mode a o )
Muscle con ac ibili y (mechanism)
Muscle s i ness (mechanism)
Muscle powe (mechanism)
Immune & s ess esponse
In lamma o y bioma ke s (mechanism)
Immune symp oms (mode a o )
O2 Sa u a ion (ou come)
Au onomic unc ion (ou come)
Ho monal le els (mechanism)
Locomo o
Muscle powe
S ai climbing es (ou come)
Chai s and es (ou come)
Cycling es (ou come)
Ve ical jump (ou come)
Join unc ion
Flexibili y (ou come)
Range o Mo ion (ou come)
Si and each es (ou come)
Uppe back s e ch (ou come)
Hip lexion (ou come)
Hip ex e nal o a ion (ou come)
Spinal mobili y (ou come)
Func ional each (ou come)
Muscle s eng h
1 RM es (ou come)
Isokine ic de ice(ou come)
Elec ical s imula ion (ou come)
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Ra e o To que de elopmen (ou come)
Balance
Be g Balance scale (ou come)
Func ional each es (ou come)
Cen e o p essu e signals (ou come)
Endu ance
Gai speed (ou come)
2min walk es (ou come)
PA le els (ou come)
Func ional abili y
No mal gai speed (ou come)
2-minu es walk es (ou come)
Physical ac i i y ques ionnai es (ou come)
Ac i i y o Daily li ing ques ionnai es
(ou come)
To ensu e su icien manpowe o ca y ou he e iew wo k i was decided o i s ly ocus on
wo opics and o conduc umb ella e iews speci ied below:
• Re iew 1: “Measu emen p ope ies o ins umen s o measu e lowe limb unc ional
abili y and balance a e echnology-assis ed physical ac i i y in e en ions in
communi y-dwelling olde adul s: an umb ella e iew o sys ema ic e iews and me a-
analysis o andomized clinical ials” (Re iew # 1, leade s I an Bau mans and Vee le
Knoop). Since a la ge o e lap be ween unc ional abili y and balance we decided o
combine bo h domains and pe o m an umb ella e iew o iden i y a ailable
ins umen s sui able o measu ing lowe -limb unc ional abili y in communi y-
dwelling olde adul s and b) o c i ically e iew he measu emen p ope ies o he
iden i ied ins umen s. Many di e en physical echnology-assis ed in e en ions ha e
been p oposed o imp o e unc ional abili y and balance in olde adul s. Howe e , i is
no clea ye which ins umen s o unc ional abili y and balance a e key o measu e
e ec s o echnology assis ed physical in e en ions. In his umb ella e iew, we will
compile he exis ing li e a u e on lowe limb unc ional abili y and balance
measu emen s used a e echnology assis ed in e en ions. Fo his he ins umen s
a e needed o ha e good psychome ic p ope ies and should be a dis inc a ibu e o
measu ing lowe limb unc ional abili y and balance. We will indica e any missing
pieces in he cu en s a e o esea ch, which will help esea che s o p io i ize
unc ional abili y and balance ac o s ha a e ele an o be e unde s and and
in e p e in e en ion e ec s. The PROSPERO p o ocol has been submi ed and he
selec ion p ocess has been s a ed. We expec o condense he lis o a iables o
measu ing unc ional abili y and balance and p opose a iables ha can be used in he
Cos ac ion amewo k.
• Re iew 2: “The e ec o physical in e en ions on in lamma o y ma ke s (Il-6, IL10, CRP,
TNF-alpha), an umb ella e iew o sys ema ic e iews and me a-analyses” (Re iew # 2,
leade I an Bau mans). Based on a ecen published sys ema ic e iew we ound ha
he in lamma o y ma ke s CRP, IL-6, TNF-a and IL-10 (an i) in lamma o y ma ke we e
mos esponsi e o exe cise (Bau mans e al., 2021). Howe e , we would like o con i m
his in an umb ella e iew and o look only a e idence o CRP, IL-6, TNF-a and IL-10
based on al eady published sys ema ic e iews and me a-analysis. Aging- ela ed
al e a ions o he immune sys em in ol e a ch onic low-g ade in lamma ion called
“in lammageing”, cha ac e ized by inc eases in he le els o p o-in lamma o y
molecules, which impai he main enance o immunological homeos asis. Di e en
modali ies o exe cise in e en ions ha e been p oposed o educe in lammageing in
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olde adul s. This umb ella e iew will ocus on ga he ing e idence on he possible
modi ica ion o ci cula ing le els o in lamma o y molecules, pa icula ly C- eac i e
p o ein (CRP), umou nec osis ac o alpha (TNF-α), in e leukin 6 (IL6), and in e leukin-
10 (IL10), by exe cise in e en ions in communi y-dwelling popula ions o olde adul s.
The e o e, he e iew ques ion o be add essed is: A e ci cula ing concen a ions o
CRP, TNF- α, IL6 o IL10 (O) in olde adul s (aged 60 and o e ) (P) in luenced by exe cise
in e en ions (I)? The PROSPERO p o ocol has been submi ed and he selec ion
p ocess has been s a ed. We expec o condense he lis o a iables o measu ing
unc ional abili y and balance and p opose a iables ha can be used in he Cos ac ion
amewo k.
2.1.2. COGNITIVE CAPACITY AND FUNCTION
Au ho s: Ma yam Ziaei, O on Le in (Wou e Vin s)
Towa ds iden i ying bioma ke s o b ain and cogni i e heal h. Ou subg oup aims o iden i y
bioma ke s om cogni i e and neu al domains o be e unde s and how and why exe cise
impac s cogni i e unc ions and which a eas show he mos signi ican e ec s. Tho ough
li e a u e e iew is ca ied ou o delinea e he ac o s ha con ibu e o his ela ionship and
epo ed in se e al pape s. The e iew pape s will p o ide aluable insigh s in o he ac o s ha
con ibu e o b ain and cogni i e heal h. These ac o s will se e as he basis o de eloping
a ge ed s a egies and guidelines o imp o e cogni i e and b ain heal h. Ou goal is o deli e
angible ou comes ha will ha e a signi ican impac on cogni i e and b ain heal h.
Me hodology o iden i y bioma ke s o cogni i e capaci y and unc ion
We conduc h ee li e a u e sea ches o publica ions epo ing he e ec s o physical ac i i y
(PA) on di e en se s i o biological ma ke s ela ed o cogni i e unc ion (1 and 2) and on
unc ional ma ke s o b ain and cogni i e unc ion (3).
• Ci cula ing ac o s eleased in o he blood s eam om muscle issue ha a e ei he
expec ed o known o (in)di ec ly a ec he cen al ne ous sys em h ough exe cise
(Re iew # 1, leade Wou e Vin s). This e iew is planned o be a li ing sys ema ic e iew.
A lis o ele an muscle-de i ed biological ma ke s (i.e. myokines) wi h ele ance o
exe cise-induced cogni i e changes will be ex ac ed om his e iew pape , which will
be upda ed on a egula basis o a pe iod o i e yea s a e publica ion o he i s
e sion o he e iew. The speci ic e iew ques ions a e: (1) which speci ic cogni i e
componen s a e associa ed wi h exe cise-induced myokine le el changes; (2) which o
he s udied myokines in exe cise-cogni ion s udies in olde adul s signi ican ly
inc eases o dec eases wi h exe cise; (3) o wha ex en does he pooled e ec size o
he exe cise e ec on myokine le els in exe cise-cogni ion s udies depend on exe cise
cha ac e is ics (i.e., ype o exe cise, in ensi y o exe cise in e en ion du a ion,
equency o exe cise, session leng h); (4) which o he s udied myokines can be
conside ed a media o o cogni ion; and (5) whe he speci ic myokines a ec speci ic
cogni i e componen s. A Coch ane p oposal o he li ing sys ema ic e iew has been
submi ed and a p o ocol pape is in p og ess.
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• B ain and muscle me aboli es ha can be quan i ied in- i o wi h magne ic esonance
spec oscopy (MRS) and ha a e known o be ma ke s o neu odegene a ion,
neu ogenesis, b ain/muscle issue composi ion, age- ela ed co-mo bidi ies, o
muscle/b ain me abolic s a us (Re iew # 2, leade O on Le in). This e iew is planned
as scoping e iew wi h an o e a ching aim o highligh he ole o MRS as a easible
me hod o assessing he e ec s o physical exe cise on muscle and b ain me abolism.
The speci ic e iew ques ions a e: (1) wha MRS me hods a e used in esea ch o clinical
se ings o quan i ica ion o b ain and muscle me aboli es and which bioma ke s can
be quan i ied eliably wi h hose me hods; (2) wha MRS neu ome aboli es and
biochemical p ope ies could be signi ican and possibly use ul bioma ke s o
quan i ica ion o exe cise-induced ou comes in b ain and muscle issue; (3) wha MRS
measu emen s a e conside ed mos alid bioma ke s o exe cise-induced changes in
b ain and muscle heal h in he gene al aging popula ion; (4)wha MRS bioma ke s can
be used as p edic o s o bene icial o de imen al exe cise on cogni ion, mobili y,
men al heal h o quali y o li e in he aging popula ion; (5) is he e a su icien body o
expe imen al da a coming om MRS s udies o guide e idence-based
ecommenda ions on exe cise du a ion and in ensi y o p ese ing/imp o ing b ain
and muscle heal h in aging. Based on he indings a se o MRS bioma ke s ha can be
se e as ma ke s o exe cise-induced bene icial/de imen al e ec s on b ain and
muscle heal h will be ex ac ed. Since use o MRS o explo ing exe cise-induced e ec s
on b ain heal h in aging is ela i ely new, he e iew will also discuss me hodological
limi a ions, esea ch gaps and p opose di ec ions o u he esea ch. The scoping
e iew p o ocol has been egis e ed and a p o ocol pape is in p og ess.
• Cogni i e unc ions a e execu i e unc ion and mul i- asking o speed o p ocessing. A
li e a u e e iew epo ing he e ec s o physical ac i i y (PA) on unc ional pa ame e s
o cogni i e unc ion will be conduc ed wi h a ocus on b ain s uc u e and unc ional
bioma ke s (Re iew # 3, leade Ma yam Ziaei). A scoping e iew p o ocol o p e-
egis a ion is in p og ess and will be submi ed by he end o Ap il.
2.1.3. PSYCHOLOGICAL FACTORS
Au ho : Da id Beckwée
No single in e en ion s a egy, o package o s a egies was ound o be e ec i e ac oss all
pe sons, condi ions, and se ings. E ec s o physical ac i i y (PA) in e en ions o imp o e olde
adul s’ heal h o example depend on in e en ion du a ion and adhe ence. Adhe ence o
in e en ion p o ocols is de ined by he Wo ld Heal h O ganisa ion (WHO, 2003) as he ‘ex en
o which a pe son’s beha iou co esponds wi h ag eed ecommenda ions om a heal hca e
p o ide ’, ha is, adhe ence ansla es as he deg ee o which he a ge in ensi y and olume
o a physical exe cises a e achie ed and sus ained o e ime (Hawley-Hague e al. 2016).
Pa ien s o en encoun e mul iple ba ie s ha impede hei abili y o adhe e o in e en ion
plans op imally, which a e a leas pa ly oo ed in he pa icipan ’s psychological de e minan s
and beha io (Collado-Ma eo e al. 2021). The issue o how o mo i a e pa ien s o con inue
exe cising ollowing supe ised PA in e en ions holds signi ican ele ance in clinical p ac ice.
Technologies may inc ease exe cise up ake and long- e m adhe ence as hey can o e come
many pe cei ed ba ie s o exe cise. Howe e , when using echnology, use s’ adhe ence o he
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echnology (in addi ion o he in e en ion) is a dis inc cons uc ha needs o be conside ed
(Payne e al. 2021). Technological in e en ions a e o en plagued by apidly declining e en ion
a es (Chen e al. 2015). In addi ion, exis ing comme cially a ailable heal h echnologies a e
limi edly g ounded in beha io al heo y and es ed o hei e icacy (Payne e al. 2021), he
apid pace o new echnology de elopmen makes i inc easingly di icul o esea che s o
de elop, pilo - es , and e alua e in e en ions be o e such echnologies become ou da ed o
obsole e (Bake e al. 2014, Pago a e al. 2015).
Me hodology o iden i y psychological concep s and a iables
The aim o his subg oup is o conduc a scoping e iew o iden i y psychological and
mo i a ional ac o s ha con ibu e o olde people’s adhe ence when hey use echnology o
suppo he physical ac i i y in e en ion. “Psychological and mo i a ional ac o s o olde
people’s adhe ence o echnology-suppo ed physical ac i i y in e en ions. A Scoping
Re iew.” (Re iew # 1, leade s Da id Beckwée and E ja Po egijs). The me hods used o iden i y
a icles abou physical ac i i y in olde adul s will be e iewed o e idence o he in e ac ion
be ween adhe ence and (psychological o mo i a ional) measu es. Based on mul iple expe
discussions, he ollowing s uc u e and de ini ions we e de eloped o guide he wo k:
• S anda dized measu es o a pa icula psychological a iable o he olde pa icipan
Psychological capabili y is de ined as he capaci y o engage in he necessa y hough
p ocesses such as comp ehension and easoning. Mo i a ional de e minan s a e
de ined as e lec i e p ocesses (in ol ing e alua ions and plans) and au oma ic
p ocesses (in ol ing emo ions and impulses ha a ise om associa i e lea ning and/o
inna e disposi ions).
o Examples o psychological capabili ies: Thinking Skills, C i ical Thinking, Men al
P ocesses/Compe encies, Re lec ion, Analysis, Reasoning
o Examples o mo i a ional de e minan s: Implemen a ion Plans, A i udes,
Emo ions, Goals, In en ion
• Ou comes ela ed o adhe ence o he olde pa icipan . A leas one ou come should
ela e o use ’s adhe ence o he physical in e en ion and/o adhe ence o he
echnology. Adhe ence o he physical in e en ion e lec s he dose- esponse
ela ionship o physical in e en ions and can be exp essed wi hin he FITT dimensions
(F equency, In ensi y, Time and Type o exe cises). Adhe ence o he echnology e lec s
he ac ha he echnology i sel can be a de e mining ac o in in e en ion e ec s.
• Examples o adhe ence o he physical in e en ion: The a io o he numbe o
sessions ha we e ca ied ou e sus he numbe o planned sessions, and he a io
o he [ o al ‘ aining load’ x du a ion] e sus [p esc ibed o al aining load x
du a ion] (Compliance)
• Examples o adhe ence o he echnology: numbe o logins, numbe o days o
echnology use, ime spen on he pla o m, numbe o lessons o modules
accessed o inished, numbe o elemen s accessed o used
• Desc ip ion o he physical in e en ions. Exe cise and PA ha e many dimensions and
a y in equency, in ensi y, ype, du a ion, ma e ials, p o ide , deli e y, loca ion,
dosage, ailo ing, and compliance. The e o e, ele an in o ma ion on he physical
in e en ions, as ecommended by he ‘Consensus on Exe cise Repo ing Templa e
(CERT)’ (Slade e al. 2016), will also be ex ac ed.
• Func ional measu es. Whene e PA/exe cise p ac ice is linked o he use o echnology,
i is no su icien o p omo e he e ec s o he echnologies wi hou an accompanying
