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PM&R : The Journal of Injury, Function and Rehabilitation

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PM&R  is the official scientific journal of AAPM&R. The Academy launched this peer-reviewed journal in 2009 specifically for the physical medicine and rehabilitation physician.  PM&R  was selected for MEDLINE indexing later that year.

The goal of the publication is to advance education and impact the specialty through the timely delivery of clinically relevant and evidence-based research and review information. Topics include: acute and chronic musculoskeletal disorders and pain, neurologic conditions involving the central and peripheral nervous systems, rehabilitation of impairments associated with disabilities in adults and children, and neurophysiology and electrodiagnosis.

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PM&R  is looking to expand its pool of peer reviewers. Responsibilities include: providing timely, honest and constructive review of manuscripts assessing importance, quality and credibility. Interested in volunteering? AAPM&R members  can apply here.  Questions? Email  [email protected] .

2023 Award-Winning Articles from PM&R

PM&R congratulates the recipients of the following three Best Paper Awards:

Foundation for PM&R/ PM&R Best Original Research Award

Sanguino, RA, Sood V, Santiago KA, Cheng J, et al. Prevalence of rapidly progressive osteoarthritis of the hip following intra-articular steroid injections . PM&R 2023; 15(3): 259-264.

PM&R Best Young Investigator Original Research Paper

Hentschel CB, Abramoff BA, Dillingham TR, Pezzin LE.  Race, ethnicity, and utilization of outpatient rehabilitation for treatment of post COVID-19 condition . PM&R 2022; 14(11): 1315-1324. 

PM&R Best Paper Original Research-International

Ho ES, Parsons JA, Davidge K. et al. Developing a decision aid for youth with brachial plexus birth injuries facing treatment decisions for an elbow flexion contracture . PM&R  2022; 14(8): 971-986. 

View more at  www.pmrjournal.org .

All original research articles published (in print) in PM&R between July 2022 and June 2023 were eligible for this year's awards. Selection criteria included the following:

• The importance of the contribution of the manuscript to the clinical or basic science related to physical medicine and rehabilitation.
• Relevance to clinical practice.
• The quality of the research methodology and interpretation of the findings.
• Quality of the writing.

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Advance articles

Maternal health disparities in acute care rehabilitation.

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Comparing Physical Activity and Exercise Experiences, Values, and Beliefs of Latino, Latina, and/or Latine People and Non-Latino, Non-Latina, and/or Non-Latine People with Parkinson Disease: A Qualitative Study

On “is it time to reframe how health care professionals label musculoskeletal conditions” zadro jr, o’keeffe m, ferreira ge. phys ther . 2024;104:pzae018. https://doi.org/10.1093/ptj/pzae018, facial swelling and neuritis after internal carotid endarterectomy in an 81-year-old woman with type 2 diabetes mellitus: a case report..

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Associations of Co-Occurring Chronic Conditions With Use of Rehabilitation Services in Older Adults With Back Pain: A Population-Based Cohort Study

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Factors Associated With Physical Activity and Sedentary Behavior in People With Parkinson Disease: A Systematic Review and Meta-Analysis

Computerized adaptive testing for the berg balance scale improves measurement efficiency without compromising precision in people with stroke, a falls prevention program for people after stroke in guyana: an international collaboration, geographic inequity in physical medicine and rehabilitation services: an administrative case report of successful advocacy for change, identifying deficits in hip and knee muscle strength on the surgical and nonsurgical sides in women up to 12 months after total hip arthroplasty, becoming jedi warriors in physical therapy research: a multifaceted approach, working in the margins: the untapped potential of disability inclusion, author response to hébert and perron, on “concerns on the science and practice of a movement system.” joyce ct, beneciuk jm, george sz. phys ther. 2023;103:pzad087. https://doi.org/10.1093/ptj/pzad087, how integrating the 5 pillars of community practice can transform physical therapist education and reduce health disparities, the influence of active, passive, and manual therapy interventions on escalation of health care events after physical therapist care in veterans with low back pain, a culture shift for excellence in physical therapy: promoting equity through the structural determinants of health, burnout, exhaustion, experiences of discrimination, and stress among underrepresented and first-generation college students in graduate health profession education, culturally responsive pedagogy in physical therapist professional education, implementing the effective coach2move approach for community-dwelling older adults with mobility limitations in physical therapist practice: a multi-methods process evaluation, holistic care for people living with chronic musculoskeletal pain: the relevance and importance of sexual function, prestroke physical activity matters for functional limitations: a longitudinal case-control study of 12,860 participants, optimizing total knee arthroplasty rehabilitation with telehealth physical activity behavior change intervention: a randomized clinical trial, training an anti-ableist physical therapist workforce: critical perspectives of health care education that contribute to health inequities for people with disabilities, activity and participation are associated with future falls, hospitalizations, and emergency visits in community-dwelling older adults, cultural responsiveness in academic physical therapy: an administrative case report, disparities in physical therapy outcomes based on race and ethnicity: a scoping review, a community development approach in physical therapist education, transgender, gender-diverse, and nonbinary experiences in physical therapy: a descriptive qualitative study, vestibular rehabilitation: improving symptomatic and functional outcomes of persons with vestibular schwannoma: a systematic review, equitable grading practices in physical therapist education: a case report, development of movement and postural patterns in full-term infants who are at low risk in belgium, india, norway, and the united states, upper limb function in people with upper and lower limb loss 8 years postinjury: the armed services trauma outcome study (advance) cohort study, effect of a 4-week telerehabilitation program for people with post-covid syndrome on physical function and symptoms: protocol for a randomized controlled trial, beyond discharge disposition: a scoping review on sociodemographic disparities in rehabilitation use after hip and knee arthroplasty, widespread pressure pain hyperalgesia is not associated with morphological changes of the wrist extensor tendon in unilateral lateral epicondylalgia: a case–control study, effectiveness of photobiomodulation in reducing pain and disability in patients with knee osteoarthritis: a systematic review with meta-analysis, diversity, equity, inclusion, and antiracism research in physical therapy over the last 25 years: a scoping review, instructing to impact: exploration of doctor of physical therapy education instruction of social determinants of health and health equity for people with disabilities, prognostic factors and treatment effect modifiers for physical health, opioid prescription, and health care utilization in patients with musculoskeletal disorders in primary care: exploratory secondary analysis of the stems randomized trial of direct access to physical therapist–led care, lgbtqia+ cultural competence in physical therapist education and practice: a qualitative study from the patients’ perspective, national benchmarks to understand how doctor of physical therapy learners from minoritized race and ethnicity groups perceive their physical therapist education program, functional recovery of adults following acute covid-19: a systematic review and meta-analysis, differences in pain experience among different racial and ethnic groups, community mobility among older adults who are socioeconomically disadvantaged: addressing the poverty penalty, queering the physical therapy curriculum: competency standards to eliminate lgbtqia+ health disparities, email alerts.

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• Physical Therapy

Explore the latest in physical therapy, including management of sports injuries, postoperative rehabilitation, strength conditioning in the elderly, and more.

Publication

Article type.

This randomized clinical trial investigates the efficacy of combination physiotherapy and cognitive behavioral therapy for individuals with functional movement disorders.

This study examines the content, including mention of benefits and harms of testing and treatment, and funding of disease awareness campaign websites recognized by major noncommercial institutions.

This randomized clinical trial of children with cerebral palsy compares overground robot-assisted gait training using an untethered, torque-assisted, wearable exoskeletal robot with standard physical therapy.

This nonrandomized clinical trial examines 6 escalated exercise therapy dose levels ranging from 90 to 450 minutes per week for men with treatment-naive localized prostate cancer.

This systematic review maps the certainty and quality of evidence reported by systematic reviews in 2018 to 2023 of massage therapy for pain in adults.

This randomized clinical trial investigates which strategy is more effective in patients with atrial fibrillation and obesity: dual or single direct-current cardioversion.

• Meta-Analysis: Touch Tied to Improved Mental, Physical Health JAMA News May 3, 2024 Dermatology Complementary and Alternative Medicine Pain Medicine Psychiatry and Behavioral Health Depressive Disorders Full Text | pdf link PDF

This report describes 2 cases of benign paroxysmal positional vertigo symptoms in middle-aged patients who experienced onset after using a handheld massage gun.

This randomized clinical trial evaluates the effectiveness of self-administered acupressure on reducing knee osteoarthritis (OA) pain among middle-aged and older adults.

This cross-sectional study examines the extent to which states have introduced or enacted mandates for coverage of nonpharmacological pain treatments and characterizes the variation in such mandates.

• Extracorporeal Shockwave for Claudication—Potential Efficacy JAMA Surgery Opinion April 10, 2024 Cardiology Lifestyle Behaviors Physical Activity Ischemic Heart Disease Full Text | pdf link PDF

This randomized clinical trial evaluates quality-of-life outcomes in patients with claudication following extracorporeal corporeal shockwave therapy.

This cross-sectional study evaluates the association of preoperative circulating tumor HPV DNA levels with disease burden or adverse pathologic features among patients with HPV-associated oropharyngeal squamous cell carcinoma who have undergone primary transoral robotic surgery.

• Exercise Therapy for Post–COVID-19 Condition—Does No Harm JAMA Network Open Opinion April 4, 2024 Physical Medicine and Rehabilitation Nutrition, Obesity, Exercise Coronavirus (COVID-19) Lifestyle Behaviors Physical Activity Full Text | pdf link PDF open access

This cohort study evaluates the association of a virtual synchronized prehabilitation program with perioperative outcomes among patients undergoing thoracic cancer surgery.

This cohort study aims to establish whether anterior vs posterior tumor extension may represent a prognostic factor in oral tongue and floor squamous cell carcinoma.

This study attempts to verify if Hand-Arm Bimanual Intensive Therapy Including Lower Extremities would improve manual abilities in young children with unilateral cerebral palsy more than usual motor activity.

This review summarizes current evidence regarding the diagnosis and treatment of knee osteoarthritis, patellofemoral pain, and meniscal tears.

This cohort study examines the association between the receipt of physical therapy to treat dizziness and the risk of falls requiring medical care in the subsequent year.

This cohort study assesses receipt of physical therapy and chiropractic care for chronic low back pain among Medicare beneficiaries with opioid use disorder (OUD) from different racial and ethnic groups.

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• Published: 28 August 2024

Exercise induced hypoalgesia after a high intensity functional training: a randomized controlled crossover study

• Fabian Tomschi   ORCID: orcid.org/0000-0003-1738-4891 1 ,
• Pia Ransmann   ORCID: orcid.org/0000-0002-8466-5389 1 ,
• Alexander Schmidt   ORCID: orcid.org/0009-0001-5577-7306 1 &
• Thomas Hilberg   ORCID: orcid.org/0000-0002-0935-2526 1  

BMC Sports Science, Medicine and Rehabilitation volume  16 , Article number:  182 ( 2024 ) Cite this article

Metrics details

Acute physical activity often induces an acute reduction in pain sensitivity known as exercise induced hypoalgesia (EIH). The aim of this study was to investigate the effects of a high intensity functional training (HIFT) on EIH compared to a control session.

50 (age: 26.0 ± 2.7; 23 female) participants successfully conducted this study consisting of a pre-experimental test as well as a 12-minute HIFT (body-weight exercises) and a 12-minute control (supervised breathing) session in a randomized crossover design. Pre and post, pressure pain thresholds (PPT) were measured at the ankles, knees, elbows, and forehead.

The HIFT resulted in a relative maximum and average heart rate of 96.2% (± 3.6%) and 91.1% (± 4.2%), respectively, and maximum and average RPE values of 19.1 (± 1.2) and 16.2 (± 1.4), respectively. Results reveal a significant ‘Intervention’ × ‘Time point’ interaction ( p  < 0.001) for PPT (pooled for one average value) with hypoalgesia observed following the HIFT ( p  < 0.001; pre: 56.0 ± 16.8, post: 61.6 ± 19.0 [Newton]) and no change following the control ( p  = 0.067; pre: 56.6 ± 18.4, post: 55.3 ± 18.9 [Newton]). Further, a significant ‘Time’ × ‘Intervention’ × ‘Landmark’ interaction effect ( p  = 0.024) is observed and all landmarks showed significant hypoalgesia following HIFT ( p  < 0.01), except for the right elbow and forehead. Following control, no hypoalgesia was observed at any landmark. Analysing male and female participants separately, it was observed that EIH occured only in men.

A HIFT using bodyweight exercises reduces pain sensitivity. Hence, combining strength and aerobically demanding exercises in a short but high intensity manner, as done in HIFT, can be seen as a usable tool to induce hypoalgesia. Yet, these results were observed only in male participants, necessitating future sex-specific research.

Trial registration

DRKS00034391, retrospectively registered on the 4th of June 2024.

Peer Review reports

Introduction

Major components of health-related fitness (e.g., aerobic and strength capacity, body composition as well as cardiovascular, metabolic and mental health, etc.) can be improved by regular physical activity [ 1 , 2 ]. Physical exercise further contributes to a reduction of overall bodily pain in the long term [ 3 ] as well as to a reduced pain sensitivity after exercise. This acute reduction in pain sensitivity is known as “exercise induced hypoalgesia” (EIH) [ 4 , 5 ]. Pain sensitivity can be measured using different experimental stimuli (thermal, mechanical, chemical) while the use of mechanical pressure pain thresholds (PPT) is recommended and usually used in the context of EIH studies [ 6 ]. EIH studies in the healthy population have used a variety of exercise protocols in terms of exercise type, time, and intensity and it was demonstrated that aerobic exercise and resistance exercise can result in hypoalgesic effects [ 6 ]. However, these different exercise types seem to induce EIH in a different magnitude. A recent meta-analysis revealed that aerobic exercise results in largest EIH effects while dynamic resistance exercise only induces small EIH effects and isometric exercise does not induce any effects [ 7 ]. There is further evidence that higher intensity aerobic exercise protocols seem to induce higher EIH compared to more moderate and metabolically less demanding aerobic exercises [ 8 ]. Besides, available literature indicates that there might be variations in pain perception and EIH between male and female participants. Yet, these results are equivocal with studies indicating that exercise results in EIH in women but not in men [ 9 , 10 ], while also no sex-dependent differences in EIH were reported [ 11 ]. Investigating these differences is essential to determine whether specific exercise regiments are equally effective for both males and females.

Recently, a new method to improve health-related fitness has emerged, namely the high intensity functional training (HIFT) [ 12 ]. HIFT can be characterized by possessing the intensity of high intensity interval training (HIIT) programs (along with the usually rather short duration), while incorporating functional strength and aerobically demanding movements. Usually, HIFT can be conducted with no or little equipment and can further be performed at home [ 13 ]. HIFT integrates a wider variety of exercises compared to the more conventional HIIT. HIIT usually consists of unimodal endurance-focused modalities (i.e., running, cycling, rowing, etc.). Contrastingly, HIFT aims at using multimodal and “functional” multi-joint strength training exercises involving mostly whole body, multiple planes movements. This can be performed using only ones own bodyweight e.g., squats, lunges, vertical jumps, and push-ups or with additional free weights, e.g., barbells, kettlebells, dumbbells, or medicine balls [ 14 , 15 ]. Recent literature presents that HIIT and HIFT regiments both improve aerobic capacity and anaerobic power [ 16 ]. However, HIFT further induces improvements in muscle strength, power, and muscular endurance [ 17 ] as it provides more complex stimuli compared to the unimodal HIIT.

Due to the fact that HIFT incorporates both aerobically demanding exercises as well as strength exercises it presents a highly interesting novel training modality to explore pain physiological effects of this exercise model on EIH. To the best of our knowledge, available EIH-literature mostly explored unimodal exercise designs and its effects on EIH, while no study explored an exercise model that induced both strength and aerobic physiological stimuli of high intensity. Therefore, the aim of this study was to evaluate the potential hypoalgesic effects of a 12-minute HIFT program compared to a control session. Based on these considerations the following hypotheses were formulated: (1) One bout of HIFT results in an acute reduced pain sensitivity compared to a control session. (2) This hypoalgesia occurs primarily at the body landmarks close to majorly working musculature. (3) There is no difference in the hypoalgesic response between male and female participants.

General study design

The study was designed as a randomized controlled crossover trial and consisted of three sessions. All examinations were performed in the same laboratory of the Department of Sports Medicine (University of Wuppertal, Germany) from March 2022 to February 2024. First, a pre-experimental session was conducted, in which eligibility of the participants in terms of in- and exclusion criteria was determined, anthropometric data were obtained, and an incremental bicycle ergometer test up to exhaustion was performed. In the two subsequent sessions two interventions were carried out in a randomized order. Randomization was performed by a researcher outside of the measurements. These sessions were scheduled with a minimum wash-out period of 72 h in between to avoid any carry-over effects as literature states that EIH effects last from about 30 min up to a maximum of 24 h [ 18 , 19 ]. Sessions consisted on the one hand of a control intervention (Control) using a 12-minute breathing exercise and on the other hand a 12-minute HIFT exercise. PPT measurements were conducted after participants had rested for 5 min (pre) and one minute after finishing the respective session (post). Participants were asked not to perform any highly intensive training 24 h prior to any intervention and not to have sore muscles, to refrain from caffeine 4 h, and not to eat 2 h before the respective sessions. When participants took any pain medication 24 h before any of the sessions or were suffering from spontaneous pain (e.g., headache) the respective intervention was rescheduled. Reporting of this study is performed according to the CONSORT checklist for randomized controlled crossover trials [ 20 ] and no changes to methods after inclusion of the first participant were done.

This study was conducted in accordance with the principles of good clinical and ethical practice and was approved by the local ethic committee of the University of Wuppertal (MS/AE 220203). Along with the Declaration of Helsinki, all participants gave written informed consent after being informed about the study´s protocol. This study was retrospectively registered at the German Clinical Trials Register (DRKS00034391; registration date: 4th of June 2024).

Participants

The sample size was calculated via an a priori power analysis using G*power (Version 3.1.9.4) for a repeated measures, within-between interaction. As aerobic exercise was shown to have a large effect and dynamic resistance exercise a small effect [ 7 ], we chose to use a standardized medium effect size f  = 0.25 along with a power of (1 −  β ) = 0.90 and an α-error probability of 0.05 resulting in a sample size of N  = 46. Considering a dropout rate of approximately 20%, N  = 56 participants were to be included in this study. The following inclusion criteria were considered for recruitment: Age between 18 and 35 and minimum weekly physical training amount of four hours. Participants were excluded when fulfilling one of the following criteria: Acute or chronic pain conditions, regular pain medication, joint diseases (e.g., osteoarthritis), psychological disorders, cardiovascular (e.g., hypertension), or metabolic condition (e.g., diabetes mellitus). For female participants, measurements were not performed during menstruation [ 21 ]. Participants were recruited via flyers and advertisements at the university. Participants’ characteristics are presented in Table  1 .

Pre-experimental session

Anthropometric measurements, baseline- and stress electrocardiogram (ECG), resting and exercise blood pressure, health-related questionnaires (Physical Activity Readiness Questionnaire [ 22 ], German Pain Questionnaire [ 23 ]), as well as medical anamnesis were conducted in this pre-experimental session. PPT measurements were performed to familiarize participants with the assessment tools to avoid any confounding results due to the novelty of the measurement. Besides, a graded bicycle ergometer (Excalibur Sport 925900, Lode, Groningen, Netherlands) test up to exhaustion was conducted starting at 30 watts (W), with an increase of 40 W every three minutes. Participants were asked to remain a velocity of 80 ± 10 revolutions per minute. Heart rate (HR) was recorded using an ECG (SEMA CS-200, SCHILLER Medizintechnik Gmb, Feldkirchen, Germany). Lactate samples (20 µl) were taken from the earlobe at rest, at the end of every stage, at the time point when the exercise session was ceased, as well as one minute post exercise and subsequently analysed (Biosen S.linelab, EKF Diagnostics, Penarth, United Kingdom). Rate of perceived exertion (RPE) using the Borg Scale [ 24 ] was recorded at the end of every stage and when the exercise session was stopped.

Exercise session

The exercise session consisted of a standardized warm-up and a HIFT program. Both were recorded beforehand, and the same video was shown to the participants. Participants were asked to imitate the exercises conducted in a high intensity manner. The warm-up routine consisted of whole-body-low-intensity and mobilization exercises, respectively, and lasted for a total of five minutes. The HIFT was designed with 40 s per exercises and 20 s rest for six different exercises, which were conducted twice, resulting in a total of 12 exercises and a total HIFT duration of 12 min (see Table  2 ). HR (Polar m400; Polar Electro OY, Kempele, Finland) and RPE (BORG scale) were recorded at baseline, post warm-up, in every 20 s break, and at the end of the HIFT. Before the exercise session started, participants were instructed to perform the workout in a high-intensity manner and participants were verbally motivated during the HIFT to achieve maximum effort [ 25 ].

Control session

Supervised deep breathing was used as a control condition as done before by van Weerdenburg et al. [ 26 ]. This active control condition was used because participants need to focus on their breathing. Hence, negative thinking and resulting psychological effects during the 12-minute control period, such as for instance ruminating, that might affect pain perception are avoided [ 27 ]. In short, participants were asked to position themselves in a relaxing and comfortable supine position. Instructions for the deep breathing session were recorded beforehand and the same recording was used for every participant by using headphones to assure a standardized procedure. Participants inhaled for four seconds and exhaled for six seconds. This was done for one minute. This produces breathing at a frequency of 0.1 Hz, corresponding to six breaths per minute. After this minute, there was a one-minute period with normal breathing. This procedure was repeated six times resulting in a total of 12 min [ 26 ]. HR was recorded and the rate of perceived relaxation (RPR) was documented on a 0–10 numeric rating scale (0 = not all relaxed, 10 = very relaxed).

Pressure pain threshold measurements

PPT were measured using a handheld digital algometer (FPX 25 Compact Digital Algometer, Wagner Instruments, Greenwich, CT, USA) by applying pressure with a one cm 2 rubber tip to different landmarks of the body, i.e., bilaterally to the ankle -, knee-, and elbow -joints, and the forehead as done before [ 28 , 29 ]. These landmarks included the forehead (1 cm above the midpoint of the right eyebrow), and bilaterally at the joints of the elbow (lateral space below the lateral humeral epicondyle), knee (medial space at the midpoint below the medial femoral epicondyle), and ankle (lateral space between the lateral malleolus and the talus bone) [ 28 , 29 ]. During these measurements, participants were positioned sitting on an examination couch with their feet suspended off the ground and their arms placed comfortably on their thighs. The use of bony landmarks offers stable and consistent reference points for measurements, thereby reducing anatomical variability and ensuring repeatability across participants and temporal points. This approach also mitigates the potential impact of muscle-related variables such as fatigue or soreness, which are known to influence PPT readings [ 30 , 31 , 32 ]. To avoid systematic errors, the order of these measurements was randomized in each session and this unique sequence was consistently maintained for both pre- and post-assessment within the same session. PPT measurements were performed by the same investigator. Blinding of the rater was not possible due to the participants’ exertion (e.g., heavy breathing, sweating). A cut-off value of 140 N was determined beforehand to prevent any tissue damage [ 33 , 34 ]. The average value of three consecutive measurements (10 s of pause) was used for analysis. If participants did not report any pain until 140 N, a PPT value of 140 N was recorded. PPT values of each landmark are presented individually and as one mean value (PPT total ).

Performance related data are presented descriptively and compared between male and female participants using an unpaired t-test. Relative mean and relative maximum HR of the HIFT/Control session were calculated by dividing the max. HR of the HIFT/Control session by the maximum HR of the pre-experimental test. This value was then multiplied by 100.

Statistical analyses were conducted on all PPT measurements taken at the seven landmarks (left ankle, right ankle, left knee, right knee, left elbow, right elbow, and forehead) individually and on the combined mean value (PPT total ) for the different time points (pre, post) and the two interventions (HIFT, Control). All PPT data were normally distributed (tested via the Kolmogorov-Smirnov test and visual inspection of histograms and Q-Q plots) with no need for further transformation.

To evaluate potential carry-over or repeated bout effects, pre values (PPT total and PPT of individual landmarks) of both interventions were compared using dependent t-tests.

The main analysis was conducted to test the 1st hypothesis. A two-way repeated-measures ANOVA was used for PPT total , with the factors ‘Time’ (pre, post) and ‘Intervention’ (HIFT, Control). For the individual landmarks, a three-way ANOVA was used, with the factors ‘Time’ (pre, post), ‘Intervention’ (HIFT, Control), and ‘Landmark’ (left ankle, right ankle, left knee, right knee, left elbow, right elbow, and forehead). For all ANOVA calculations, sphericity was checked (using the Mauchly test) and the Greenhouse-Geisser adjustment was used if necessary. This analysis was also used to test the 2nd hypotheses. Additionally, a one-way repeated measures ANOVA was conducted with ΔPPT of the individual landmarks (calculated by subtracting the pre value from the post value) using the factor ‘Landmark’ (left ankle, right ankle, left knee, right knee, left elbow, right elbow, and forehead).

A further analysis was performed for the stated 3rd hypothesis to detect potential differences between men and women. Here, a three-way mixed model ANOVA was calculated using PPT total as the depended variable and ‘Intervention’ (HIFT, Control) and ‘Time’ (pre, post) as the within-factors. The factor ‘Sex’ (male, female) was determined as the between-factor. In addition, a two-way mixed model ANOVA was calculated using ΔPPT total as the depended variable and ‘Intervention’ (HIFT, Control) as the within-factor and ‘Sex’ (male or female) as the between-factor. For these latter two analyses, homogeneity for the factor ‘Sex’ was confirmed by the Levene test. Besides, the covariate “BMI” was added to these two analyses to account for the potential influence of different BMI values observed between male and female participants.

In the case of a significant interaction effect, subsequent LSD post-hoc tests were calculated. Effect sizes are presented as partial eta-squared ( η² partial ) with values of 0.01 representing a small, 0.06 a medium, and ≥ 0.14 a large effect, respectively, and Cohen’s d and d z for post-hoc testing with < 0.5 indicating a small effect, 0.5 to 0.8 a medium effect, and > 0.8 a large effect [ 35 ]. Statistical analyses of the data were performed using the statistics software package SPSS 27 (IBM©, Armonk, NY, United States). Data are presented as means ± standard deviation, unless otherwise marked. Differences were considered significant with p  < 0.05.

56 participants were recruited to take part in this study. 6 participants dropped out due to personal reasons and these data were not considered in any analyses. Anthropometric and performance data of the pre-experimental test are presented in Table  1 . No harms or other adverse events (e.g., falls, accidents, injuries, or fainting) occurred in this study. Performance related outcomes of the respective sessions are presented in Table  3 . No carry-over effects were observed regarding PPT total ( p  = 0.684) and PPT of the individual landmarks ( p  = 0.131–0.691).

Regarding the main 1st hypothesis, the two-way ANOVA revealed a significant ‘Intervention’ × ‘Time point’ interaction ( p  < 0.001; η² partial = 0.371) for PPT total . The respective post-hoc test revealed hypoalgesia for PPT total after the HIFT ( p  < 0.001) and no differences, but a trend toward hyperalgesia, resulting from the Control session ( p  = 0.067). Results of the three-way ANOVA reveal a significant ‘Time’ × ‘Intervention’ × ‘Landmark’ interaction effect ( p  = 0.024, η²partial  = 0.052). The respective post-hoc test results are to be found in Fig.  1 . Raw values are presented in Supplement 1 and further observed main and interaction effects and effect sizes of the three-way ANOVA are presented in Supplement 2.

Pressure pain thresholds (PPT) in response to the HIFT and Control presented as one mean value (PPT total ) and individual landmarks. Data are expressed as means ± standard deviation including individual data points (grey circles). Significant differences are indicated with * ( p  ≤ 0.05), ** ( p  ≤ 0.01), and *** ( p  ≤ 0.001). HIFT = High intensity functional training , PPT = Pressure pain threshold

Regarding the 2nd hypothesis, the one-way ANOVA performed for the HIFT session revealed significant differences between the landmarks ( p  = 0.034; η² partial = 0.050) with higher values observed for ΔPPT of the lower extremity landmarks compared to the forehead (see Fig.  2 ). No differences between landmarks were observed in the Control session ( p  = 0.080; η² partial = 0.040).

Delta (post value – pre value) pressure pain thresholds (ΔPPT) in response to the HIFT and Control of individual landmarks and represented as one mean value (PPT total ). Data are expressed as means ± standard deviation including individual data points (grey circles). Significant differences to the forehead are indicated with * ( p  ≤ 0.05) and *** ( p  ≤ 0.001). HIFT = High intensity functional training , PPT = Pressure pain threshold

Regarding the 3rd hypothesis, the three-way mixed model ANOVA to detect potential differences between men ( n  = 27) and women ( n  = 23) revealed a significant ‘Intervention’ × ‘Time’ × ‘Sex’ interaction effect ( p  < 0.001, η²partial  = 0.257). Subsequently calculated post-hoc tests revealed that male participants showed higher PPT total (hypoalgesia) values following the HIFT session ( p  < 0.001), while no differences were observed in female participants ( p  = 0.363). The Control session revealed a trend towards hyperalgesia in males ( p  = 0.055), but no difference in females ( p  = 0.531; see Fig.  3 ). Further observed main and interaction effects and effect sizes of the three-way ANOVA are presented in Supplement 3. The covariate “BMI” did not significantly adjust the results observed ( p  = 0.369). A significant ‘Intervention’ × ‘Time’ × ‘Sex’ interaction effect is still observed for the three-way mixed model ANCOVA ( p  = 0.002, η²partial  = 0.195).

Besides, the two-way mixed model ANOVA revealed a significant ‘Intervention’ × ‘Sex’ effect ( p  < 0.001, η²partial  = 0.252) and a significant ‘Intervention’ ( p  < 0.001, η²partial  = 0.411) and ‘Sex’ ( p  = 0.010, η²partial  = 0.131) effect for ΔPPT total . Subsequently calculated post-hoc test showed that male (9.21 ± 7.79 N) participants exerted a larger degree of hypoalgesia compared to female participants (1.33 ± 5.28 N; p  < 0.001) following the HIFT session (data not shown). The covariate “BMI” did not significantly adjust the results observed ( p  = 0.952). A significant ‘Intervention’ × ‘Sex’ interaction effect is still observed for the two-way mixed model ANCOVA ( p  = 0.002, η²partial  = 0.194).

Pressure pain thresholds (PPT) in response to the HIFT and Control presented as one mean value (PPT total ) separately presented for male and female participants. Data are expressed as means ± standard deviation including individual data points (grey circles). Significant differences are indicated with *** ( p  ≤ 0.001). HIFT = High intensity functional training , PPT = Pressure pain threshold

This study evaluated effects of a single HIFT session on EIH compared to a control session. Results confirm the 1st hypothesis as the HIFT session resulted in global hypoalgesia indicated by higher PPT total values observed after the training, while no such effects were observed after the control session. Further, and in the light of the 2nd hypothesis, the HIFT resulted in hypoalgesia observed at all landmarks except for the right elbow and the forehead. Regarding ΔPPT values, ΔPPT of the lower extremity landmarks were higher compared to the forehead. Interesting findings were observed regarding the 3rd hypothesis. Here, hypoalgesia was observed in male participants following the HIFT, while female participants did not reveal such hypoalgesia.

The HIFT was designed to be highly intensive and to consist of different multimodal and functional exercises. Participants reached an average HR and maximum HR throughout the HIFT that was above 90% and 95%, respectively, of their individual maximum HR determined in the pre-experimental test. Further, participants perceived this HIFT as very hard as observed in maximum RPE values of above 19, equalling a description between “very hard” and “very, very hard” [ 24 ].

Regarding hypoalgesic effects and in the light of the 1st hypothesis, current literature mainly focuses on unimodal and constant load aerobic exercises, such as cycling and running, and its hypoalgesic effects [ 7 ]. Within this aerobic modality it is believed that hypoalgesia occurs more robustly the higher the intensity is [ 5 , 28 , 36 , 37 , 38 ]. For instance, Naugle et al. showed that 20 min of vigorous cycling exercise at 70% of HR reserve increased PPT whereas PPT was unaltered after moderate exercise at 50% of HR reserve [ 37 ]. Another study by Vaegter et al. also revealed that a high intensity bicycle exercise at a calculated intensity of 75% VO 2 max led to a larger EIH response compared to a low intensity exercise conducted at 50% VO 2 max [ 36 ]. Most likely, the present HIFT involved a substantial aerobic component, but as the exercises were performed for 40 s and with very high intensity followed by a 20-second recovery period, there was also a large anaerobic component involved in the HIFT. Previous research dealing with anaerobic exercises show that these exercise types (e.g., 90-second all-out isokinetic cycling [ 29 ], a ‘Wingate Anaerobic Test’ for 30 s [ 39 ], or 60-second all-out rowing [ 28 ]) result in hypoalgesia. Therefore and also in the light of the results of the present study, high intensity exercises along with a high anaerobic demand are most likely to induce EIH.

Yet, hypoalgesic effects resulting from dynamic resistance exercise are less explored and the current literature indicates that dynamic resistance exercise only has small effects on hypoalgesia as indicated by a recent meta-analysis [ 7 ]. One major difference between conventional dynamic resistance training and HIFT is that the cardiovascular strain is much higher during HIFT when considering the HR profile. For instance, one study conducted a conventional strength training consisting of lifting three sets of 10 repetitions at 75% of an individual’s one repetition maximum. This training led to HR of around 100 beats/min [ 40 ]. Another study conducted a 40-minute dynamic circuit resistance training at 60% of the individuals’ one repetition maximum to evaluate differences in pain sensitivity. This training led to HR of around 150 beats/min and lactate concentrations of around 10 mmol/l. PPT were measured at the dorsal side of the non-dominant hand at the base of the skin web between the thumb and index finger. Results reveal no difference in PPT from pre to post exercise [ 41 ]. Contrastingly, the results presented herein show that a HIFT session, which consisted of dynamic multimodal exercises using the own body weight and no equipment, induces hypoalgesia. The exercises can be characterized as incorporating dynamic resistance exercises, which at the same time are highly demanding for the cardiovascular system, as observed in the very high HR and RPE values. Hence, the combination of muscular and cardiovascular strain during the HIFT might be responsible for inducing hypoalgesia. In the present study, no blood pressure responses were measured. Yet, is known that heavy resistance exercise can result in intraarterial systolic and diastolic blood pressures of up to 320/250 mmHg, especially when a Valsalva manoeuvre is performed [ 42 ]. However, blood pressure increases are more moderate during and following HIFT with blood pressure increases to 154/77 and 140/71 in male and female participants, respectively, following a 15-minute HIFT session [ 43 ]. Reduced pain sensitivity is most likely induced by the release of analgetic endogenous opioid-related substances expressed centrally in the nervous system. Moreover, these substances are released more locally close to the contractile musculature attenuating nociceptive signalling [ 44 , 45 ]. It is therefore proposed that hypoalgesia is highest at body landmarks close to the working musculature and less pronounced at remote landmarks [ 19 ].

This assumption was tested as part of the 2nd hypothesis. Results presented herein reveal that hypoalgesia occurred primarily at the ankle and knee joints. The used exercises in the HIFT focussed mainly on the lower extremity musculature (i.e., lunges, high knees, burpees, squad jumps, and skaters). Contrastingly, no hypoalgesia was observed at the forehead and right elbow. However, hypoalgesia also occurred at the left elbow. The reasons explaining these side differences at the elbows remain elusive and cannot be sufficiently explained. Yet, hypoalgesic effects may be less pronounced and may occur less consistently depending on the distance to the primary exercising body parts and musculature [ 36 , 46 ]. Besides, it might be possible that participants conducted some exercises (i.e., push-up, commandos) with a more pronounced activity of the dominant arm, which resulted in divergent hypoalgesic effects at the elbows. Yet, no information on the handedness of the participants were recorded, which might have had provided some explanations for this observation. The phenomenon that no effects were present at the forehead was also observed in another study, in which participants conducted differently intensive bicycle ergometer sessions for 30 min. In this study, hypoalgesia was also observed at the elbows, but not at the forehead [ 5 ]. Yet, a maximal “all-out” rowing exercise of about 60 s as well as “all-out” isokinetic bicycle exercises of 15 and 90 s, respectively, resulted in global hypoalgesia also observed at the forehead [ 28 , 29 ].

Interestingly and in the light of the 3rd hypothesis, only male participants revealed hypoalgesia. Reasons explaining these findings remain elusive. Male and female participants exerted similar performance levels (i.e., Watt/kg) excluding differences in pain processing or perception due to fitness levels [ 47 ]. BMI values were different between male (24.1 ± 2.2) and female (22.2 ± 1.8) participants, even though both being in the normal weight range, which might influence EIH responses due to different fitness levels regrading muscle and/or fat mass. Yet, this differentiation in body composition was not considered in this study. The covariate analyses reveal that the participants’ BMI did not adjust the results. Both relative average and maximum HR observed during the HIFT did not differ between men and women. Yet, maximum RPE values (but not average RPE) are slightly but significantly higher in men (19.5 ± 0.7 vs. 18.7 ± 1.5; d  = 0.738). Therefore, the observed divergent results regarding EIH might in part be explained by different subjectively perceived effort but not by objectively measured exertion. While direct comparisons between men and women regarding EIH are limited in the literature, the available research suggests that men and women experience EIH as observed in studies including men and women [ 21 , 48 , 49 ] as well as in studies including only women [ 50 ]. However, some studies reveal specific differences in EIH between men and women. In two studies, isometric exercises were shown to result in EIH in women but not in men [ 9 , 10 ], while research also shows that no sex-dependent differences in EIH occur after isometric exercise [ 11 ]. Yet, further research directly comparing sex-specific differences in EIH across various conditions is necessary for a definitive understanding.

In contrast to the HIFT, the control session did not result in hypoalgesia. The control session was perceived as relaxing with the degree of relaxion being at about 8 out of 10. Previous research demonstrated that slow, deep breathing procedures can result to lower ratings of heat pain intensity ratings [ 51 ], increased thermal pain thresholds [ 52 ] and hypoalgesic suprathreshold electrical stimulations [ 53 ]. In the present study, no such effects were observed for mechanical PPT.

Strengths and limitations

The main strengths of this study are that a 12-minute body weight HIFT protocol was developed that led to average HR of over 90% and maximum HR of over 95% of the participants’ individual HR, respectively. Consequently, this program can be used as a home-based HIFT (e.g., during public lockdowns), which does not need any additional equipment, to induce hypoalgesia. Yet, there are some limitations to this research study. It should be noted that our study was conducted only with young and healthy adults who were physically active. Hence, results are not transferable to any clinical populations. Due to the intentionally set very high intensity, this HIFT program and the used exercises as well as the results observed might also not be transferable to very untrained people, as the experienced high exertion resulting from this training might result in a loss of motivation and pleasure [ 54 , 55 ]. Besides, it is not suitable for chronic pain patients in clinical settings suffering from severe pain due to psychological factors associated, such as kinesiophobia [ 56 ] or catastrophising [ 57 ]. Further, PPT were measured solely at bony landmarks, limiting their comparability with studies that use muscular landmarks for PPT assessment. Future studies should also aim to evaluate the difference response to exercise when using bony and muscular landmarks for PPT measurements. Important information regarding, for instance the use of contraceptives or menstrual cycle phase, were not documented. Further, due to the high intensity of the HIFT and the nature of the control session, blinding of the rater for pain measurement was not possible.

Future directions

Future research should aim to compare further pain physiological effects resulting from trending and/or innovative training methods. HIFT should be compared to traditional training modalities such as conventional isometric or dynamic resistance training or aerobic training modalities in terms of its pain reducing potentials. Besides, the time span of hypoalgesic effects after exercise should be investigated in future studies, as this investigation (and most other publications) only tested immediate effects. Moreover, future research should focus on sex-specific research questions in the context of EIH, since these results, as well as other previously published studies, might hint to the fact that differences in pain processing between men and women can exist. Here, the use of contraceptives should be controlled and the menstrual cycle phase, when interventions (i.e., exercise and controls sessions) are performed, should be carefully considered [ 58 ]. Future research should also explore the clinical possibilities of high or higher intensity exercise regimens (such as HIFT) as a therapeutic tool to manage specific pain conditions. This kind of exercise may be suitable for people experiencing mild and/or intermittent forms of nonspecific pain, such as for instance nonspecific chronic low back pain, which was shown to increase in prevalence and intensity during public lockdowns [ 59 , 60 ]. It is important to note that this was not assessed in the study presented herein and warrants further investigation in future research.

This study for the first time presents that a short 12-minute HIFT session in which participants achieve a mean HR of > 90% of their individual maximum HR leads to EIH. On a physiological level, the study shows that the combination of strength and aerobically demanding exercises going along with a high cardiovascular and muscular demand induces hypoalgesia. This reduced pain sensitivity occurs predominantly at lower extremity body parts while no changes were observed at the forehead and right elbow. An interesting finding is that hypoalgesia was only present in male and not in female participants suggesting sex-related differences in the context of EIH. The HIFT training method can be easily conducted at home as no additional material (e.g., dumbbells, free weights, etc.) are needed. Especially during times when public sport facilities are closed or no group training is possible (e.g., during public lockdowns), the proposed HIFT session can be easily used to modulate pain sensitivity.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

High-Intensity Functional Training

Pressure Pain Threshold

High-Intensity Interval Training

Consolidated Standards of Reporting Trials

Electrocardiogram

Rating of Perceived Exertion

Rate of Perceived Relaxation

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Acknowledgements

The authors would like to thank Ms. Dshamilja Böing-Messing and Ms. Nina Simonis for their support in this study.

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Fabian Tomschi, Pia Ransmann, Alexander Schmidt & Thomas Hilberg

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FT had the original idea for the study. FT, PR, AS, and TH contributed to the conception or design of the study. FT performed the analysis of data. FT, PR, AS, and TH interpreted the data of the present study. FT wrote the first draft of the manuscript. PR, AS, and TH contributed intellectually to the final version of the manuscript. TH supervised the study.

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Tomschi, F., Ransmann, P., Schmidt, A. et al. Exercise induced hypoalgesia after a high intensity functional training: a randomized controlled crossover study. BMC Sports Sci Med Rehabil 16 , 182 (2024). https://doi.org/10.1186/s13102-024-00969-4

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• Volume 10, Issue 3
• Comparative effects of time-restricted feeding versus normal diet on physical performance and body composition in healthy adults with regular exercise habits: a systematic review and meta-analysis
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• http://orcid.org/0009-0008-4377-3165 Ke-wen Wan 1 , 2 ,
• Zi-han Dai 1 ,
• http://orcid.org/0000-0003-2722-4234 Robin Sze-tak Ho 1 ,
• Huang Wendy Yajun 2 ,
• http://orcid.org/0000-0002-6821-4545 Stephen Heung-Sang Wong 1
• 1 Department of Sports Science and Physical Education , The Chinese University of Hong Kong , Hong Kong , People's Republic of China
• 2 Dr. Stephen Hui Research Centre for Physical Recreation and Wellness , Hong Kong Baptist University , Hong Kong , People's Republic of China
• Correspondence to Dr Huang Wendy Yajun; wendyhuang{at}hkbu.edu.hk

Background Time-restricted feeding (TRF), a form of intermittent fasting, limits daily caloric intake to a 6–12 hour window and has been shown to effectively promote weight loss and improve overall health. This systematic review and meta-analysis aimed to compare the effects of TRF versus normal diet (ND) on physical performance and body composition in healthy adults with regular exercise habits.

Methods MEDLINE, PubMed, Embase, SPORTDiscus, Web of Science, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases were searched for relevant records. Subgroup analyses were conducted based on the duration of intervention and type of exercise. Physical performance was analysed using standardised mean differences (SMDs) and 95% CIs, whereas body composition parameters were analysed using mean differences (MDs) and 95% CIs. The quality of the included studies was examined using the Cochrane risk-of-bias tool version 2.

Results 15 randomised controlled trials with 361 participants were included in the systematic review. In comparison with the ND group, TRF significantly decreased body weight (MD=−1.76 kg, 95% CI –3.40 to −0.13, p=0.03, I 2 =11.0%) and fat mass (MD=−1.24 kg, 95% CI −1.87 to −0.61, p<0.001, I 2 =0.0%). No between-group differences in physical performance-related variables and fat-free mass were found. According to the result of the risk-of-bias assessment, one study showed a low risk of bias, 13 showed some concerns, and one showed a high risk of bias.

Conclusion TRF may be a valuable nutritional strategy to optimise body composition and maintain physical performance in healthy adults engaged in regular exercise.

PROSPERO registration number CRD42022310140.

• Sports and nutrition
• Performance
• Weight loss

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All data relevant to the study are included in the article or uploaded as supplementary information. To facilitate data transparency and reproducibility in scientific research, we have made the tabulated data available on the Open Science Framework (OSF) data repository. You can access the tabulated data for our study at the following link: https://osf.io/jc8ek/ .

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https://doi.org/10.1136/bmjsem-2023-001831

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WHAT IS ALREADY KNOWN

Time-restricted feeding (TRF) is effective for weight loss, overall health improvement and optimal nutrient utilisation. It is a favourable approach for individuals with exercise habits to achieve desired body composition goals.

Previous randomised controlled trials evaluating the impact of TRF versus a normal diet (ND) in individuals with regular exercise habits have yielded inconsistent findings.

The effects of combining TRF with different exercise modalities show mixed results on physical fitness.

WHAT ARE THE NEW FINDINGS

TRF leads to significant weight and fat mass reduction without significant impact on fat-free mass compared with ND in healthy adults with regular exercise habits.

TRF with exercise does not lead to a significant impact on physical performance compared with an ND with the same exercise programme.

TRF combined with endurance or resistance training resulted in significant reductions in fat mass compared with ND combined with the same exercise modalities.

Practitioners should consider combining TRF with exercise as a viable fat loss strategy without negatively impacting physical performance.

Introduction

Intermittent fasting (IF) is a dietary approach that involves alternating periods of caloric consumption and caloric restriction. 1 Various versions of IF have been proposed, including the popular 16/8 method, alternate-day fasting and the 5:2 diet. 2 One specific version of IF, known as time-restricted feeding (TRF), involves dividing the day into a period of depletion and restriction. 3 TRF is a behavioural intervention that involves limiting daily caloric intake to a consistent 6–12 hour window and fasting for the remaining hours of the day, without the need for individuals to count calories or monitor food intake during the eating window. 4 5 It has demonstrated efficacy in promoting weight loss, enhancing overall health and optimising nutrient utilisation without explicitly restricting energy intake. 6 7 Study reports in both animals and humans have consistently demonstrated TRF’s effectiveness in reducing obesity, inflammation and insulin resistance. 8 9

People with exercise habits and related practitioners often explore novel strategies regarding athletic training, nutritional supplementation and post-exercise recovery to improve physical performance. 10 Restricting energy intake can help them achieve a certain body mass category, aesthetic reasons or a better force-to-mass ratio. 11 Thus, many practitioners consider it an effective means of enhancing their physical performance. 12 TRF, identified as a highly adaptable form of IF, has been demonstrated in a systematic review to hold promise as a dietary approach for losing fat, improving metabolic health and maintaining physical fitness and muscular function, thereby warranting its inclusion as a component of a periodised nutrition plan for people with exercise habits. 13

Additionally, recent randomised controlled trials (RCTs) have shown that TRF combined with exercise can significantly optimise the balance between fat mass (FM) and fat-free mass (FFM) by comparing with a normal diet (ND) combined with an equivalent amount of exercise. 14 15 Therefore, in recent years, more and more athletes and people with exercise habits tend to employ a combination of TRF and exercise training routines during the fat loss period to achieve better fat reduction results.

Existing RCTs examining the effects of TRF compared with ND on physical performance in healthy individuals with regular exercise habits present varying and inconsistent results. Specifically, different types of exercise training routines showed different effects on outcomes related to physical performance. Certain RCTs have shown that TRF compared with ND can enhance fat reduction effects in adults with resistance training habits. 8 16 17 Thus, the impact of TRF on physical fitness has exhibited substantial variability and inconsistency. Notably, M. Correia et al reported a significant increase in lower body jump performance and dynamic strength index in the TRF group compared with the ND group, 18 while other studies found no significant difference between the two groups on physical performance. 19 Regarding the synergistic effects of TRF with other types of exercise, a randomised crossover trial revealed that a 4 week TRF plus endurance training programme did not significantly improve submaximal or peak exercise capacity in well-trained males compared with an ND plus endurance training group. 20 Besides, after 8 weeks of high-intensity interval training (HIIT), the TRF group showed a significant increase in jumping performance compared with the ND group. 21 These discrepancies highlight the need for a systematic review to comprehensively evaluate the available evidence and provide a clearer understanding of the effects of TRF combined with various exercise modalities on physical fitness.

To the best of our knowledge, no systematic reviews have compared the effects of TRF and an ND on physical performance and body composition in healthy adults with regular exercise habits. Only one systematic review has examined the effects of IF on exercise performance outcomes. 1 However, that study analysed TRF as a subgroup, with limited included studies and mixed populations, showing that TRF might be effective in improving physical performance (aerobic capacity). The studies included in the systematic review mentioned used many types of IF strategies, and neither of them provided a systematic and detailed description of the strategy of combining TRF with exercise. Therefore, we conducted a systematic review with meta-analysis to examine the comparative effects of TRF versus ND on physical performance and body composition in healthy adults with regular exercise habits.

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 22 23 recommendations and was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (identification code: CRD42022310140; available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=310140 ).

Eligibility criteria

Studies that meet the following criteria were included in our systematic review: (i) included adults aged 18–64 years with regular exercise habits, (ii) the fasting protocol entailed a reduced eating window of time recurring daily (the usual length of fasting is 12–21 hours per day), 13 (iii) the studies performed comparisons with ND in participants’ daily life, (iv) the outcomes included physical performance indicators (eg, one repetition maximums, maximal oxygen uptake (VO 2 max), peak power output, jump height) and body composition indicators (eg, FM, FFM), (v) the study adopted a randomised controlled design and randomised crossover design and (vi) studies were peer-reviewed and written in English. Studies were excluded if they (i) were comments, editorials or reviews and (ii) included another type of fasting strategy (eg, Ramadan).

Information sources and search strategy

Seven electronic databases (MEDLINE, PubMed, Embase, SPORTDiscus, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL)) were searched for relevant studies on 30 October 2023. The search strategy is shown in online supplemental table S2 . Endnote (Clarivate Analytics) was used to import all search results, and any duplicates were removed. Two researchers (KW, ZD) independently performed title, abstract screening and full-text screening of each article, and no automated or semi-automated approaches, including machine learning-based methods, were used for record screening. According to the PRISMA guidelines, duplicates were removed using the EndNote software. A third independent reviewer (RH) was consulted to settle any discrepancies in the results. Furthermore, we manually searched the reference lists of articles included in the final analysis.

Supplemental material

Selection and data collection process.

The data extraction was completed independently by two reviewers (KW, ZD). The characteristics of the included studies are summarised in online supplemental table S1 . The following information was extracted: (i) first author name and year of publication, (ii) characteristics of participants (health status, number of participants, age, sex, body mass index), (iii) study design, (iv) characteristics of TRF (fasting duration, TRF strategy), (v) training protocol, (vi) physical performance test and (vii) sports-related results and findings of each study.

Physical performance and body composition indicators in the TRF and control groups are described as means and SD, which were screened and extracted by two reviewers (KW, ZD). A third independent reviewer (RH) was consulted to settle any discrepancies during the data extraction process. To convert SE to SD, we used the formula SD=SE * sqrt(n). If the missing data are still not available, the graph data were extracted using WebPlotDigitizer. 24

Study risk-of-bias assessment

Two reviewers used the revised Cochrane risk-of-bias tool for randomised trials (RoB 2) and the RoB 2 additional considerations for crossover trials 25 26 to evaluate the risk of bias in each included study. The assessment encompassed six domains, including randomisation, deviation from the intended intervention, missing outcome data, measurement, selection of reported results, as well as period and carryover effects, which specifically applied to the RoB 2 additional considerations for crossover trials. The two reviewers judged each included study as ‘high risk’, ‘some concerns’ or ‘low risk’ by the signalling questions in each domain. 25 Any disputes between the two reviewers (KW, ZD) were resolved by a third researcher (RH).

Synthesis methods

Meta-analysis was performed with the aid of the metan package of the Software Stata v 15.0 (StataCorp, College Station, TX, USA) when data were available from two or more trials. In the meta-analysis, means and SD were extracted from the included studies where the outcome was continuous. Physical performance was analysed using standardised mean differences (SMDs) and 95% CIs, whereas body composition parameters were analysed using weighted mean differences (MDs) and 95% CIs. The results of the meta-analysis were based on the post-intervention data extracted from the included studies. If a trial was included more than once in the meta-analysis for comparison with other trials, the sample size for that trial was split by the number of times it was used. 27 For data synthesis, random effect models (DerSimonian and Laird) were used. Statistical significance was indicated by a p value less than 0.05.

Funnel plots visually explained publication bias if at least ten studies were included in the meta-analysis. Egger’s linear regression test for funnel plot asymmetry was used to investigate publication bias. Egger’s weighted regression tests for publication bias were also performed using the metan package of the Software Stata v 15.0 (StataCorp, College Station, TX, USA).

A series of sensitivity analyses were performed to examine the impact of each study, including those with a high risk of bias, on the overall conclusions to improve the robustness of the findings. We conducted sensitivity analyses using a leave-one-out approach. I 2 values were used to represent statistical heterogeneity, and I 2 values were classified as low (0% to 25%), moderate (26% to 50%), substantial (50% to 75%) and high (more than 75%). 27

To further explore the effects of TRF intervention on body composition outcomes, we conducted a subgroup analysis based on the duration of the intervention (less than 8 weeks and 8 weeks or more) and the type of exercise employed (endurance training, resistance training, concurrent training and HIIT). 28 29 The subgroup analysis for the physical performance was only based on the duration of the intervention.

Certainty assessment

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was employed to assess the certainty of evidence. The certainty of evidence was categorised as high, moderate, low or very low, reflecting the level of confidence in the estimated effect. To determine the potential downgrading of certainty and strength of recommendations, criteria such as risk of bias, consistency, directness, precision and publication bias were considered. 30

Study selection

In the initial phase, 2893 records were identified through database searching in seven electronic databases. After removing 990 duplicate records, 1851 records remained. 1799 records that did not meet the inclusion criteria and were excluded by title and abstract screening. Full-text article assessment was performed for the remaining 52 records for eligibility and 38 records were excluded for the following reasons: (i) subjects did not meet the inclusion criteria (n=8), (ii) studies employed other types of fasting programmes (n=6), (iii) abstract only available (n=14), (iv) studies did not meet outcome criteria (n=5), (v) review paper (n=3) and (vi) the control group did not meet the inclusion criteria (n=2). The details are reported in the flow diagram (refer to PRISMA) based on the results of the literature search ( figure 1 ).

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Flowchart of publications included in systematic review and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Study characteristics

The systematic review included a total of 15 RCTs involving 361 participants, all of whom were healthy adults. Among these studies, four specifically focused on athletes, such as professional runners and elite cyclists. Two studies included distance-trained individuals, three recruited in-school physical education students, four included physically active individuals and two studies enrolled a general population of healthy adults. Furthermore, two studies exclusively included women, while eleven studies included only men.

Eight studies included in our review were RCTs, and seven studies were randomised crossover studies. All the studies included an intervention group that followed a TRF diet and a control group that ate whenever they wanted. For the duration of the intervention, the studies ranged in length from 11 days to 4 weeks, 8 weeks and 12 months. The key characteristics (participants, study design, intervention and outcome information) of these eligible studies are summarised below (see online supplemental table S1 ).

In the studies included in this meta-analysis, the duration of fasting during TRF varied among the different interventions. A total of 12 studies 8 10 14 16 17 20 31–36 implemented a fasting period of 8 hours, where participants consumed their meals within an 8 hour window and abstained from caloric intake for the remaining 16 hours of the day. One study 21 employed a fasting duration of 10 hours, with participants adhering to a 10-hour eating window and a 14-hour fasting period. Another study 37 explored a more restricted fasting duration of 2 hours, allowing participants to consume their meals within a 2 hour window and maintaining a fasting period of 22 hours. Lastly, one study 38 used a fasting duration of 4 hours, where participants consumed their meals within a 4 hour window and abstained from caloric intake for the remaining 20 hours of the day. Additionally, seven studies 10 14 17 31 32 36 38 implemented ad libitum TRF, wherein participants were allowed to consume food freely within the designated feeding window. Seven studies 8 16 20 21 33 34 37 used the isocaloric TRF modality, participants adhered to a TRF schedule while maintaining an equal caloric intake throughout the day. One study 35 in our analysis employed the calorie restriction TRF modality.

Results of data synthesis

Physical performance, strength performance.

Strength performance included one-repetition maximum (1RM) performance in the bench press or leg press, handgrip strength and other strength-related metrics. Seven RCTs 8 16 21 31 35 36 38 were included. There was no significant difference in strength performance between the TRF group and the ND group (SMD=0.09, 95% CI −0.13 to 0.30, p=0.43, I 2 =31.9%). Furthermore, no significant difference was found in strength-related performance in the subgroup analysis based on intervention duration ( figure 2A ).

Meta-analysis of the effects of time-restricted feeding combined with exercise versus controls on (A) strength performance, (B) power performance, (C) muscular endurance performance, (D) aerobic capacity performance and (E) jump performance. SMD (standard mean difference) indicates the mean difference in the post-test value of the time-restricted feeding versus the control groups. Effects for the subgroups are based on the duration of the intervention (less than 8 weeks vs 8 weeks or more). The plotted points are the SMDs and the horizontal error bars represent the 95% CIs.

Power performance

Power performance encompasses various metrics, such as peak power output assessed through evaluations like the Wingate test and graded exercise test. Four RCTs 14 21 33 37 were included in the analysis, with three RCTs using the Wingate test to assess peak power and one RCT employing the graded exercise test for peak power assessment. No significant difference was observed in peak power performance between the TRF group and the ND group (SMD=−0.04, 95% CI −0.45 to 0.38, p=0.85, I 2 =0.0%). No significant difference was observed between groups when conducting subgroup analysis based on the duration of the intervention and the type of exercise employed ( figure 2B ).

Muscular endurance performance

Muscular endurance performance included measures of endurance in specific exercises or activities, such as bench press endurance or any other endurance-based tests. Muscular endurance was assessed in two RCTs 35 38 by performing repetitions to failure at 65% of the 1-RM, while one RCT 36 employed repetitions to failure at 70% of the 1-RM. Overall, pooled data from three RCTs showed no significant difference in muscular endurance performance between the TRF group and the ND group (SMD=−0.13, 95% CI −0.45 to 0.19, p=0.42, I 2 =23.2%). For subgroup analysis, no significant difference was observed, as shown in figure 2C .

Aerobic capacity performance

Aerobic capacity performance encompassed assessments such as VO 2max , which serves as an indicator of aerobic capacity or cardiovascular fitness. To assess VO 2max , all five RCTs used the incremental exercise test, with three RCTs 10 17 20 employing treadmill tests and two RCTs 33 37 employing ergometer bike tests. There was no significant difference observed between the TRF group and the ND group (SMD=−0.10, 95%CI −0.27 to 0.47, p=0.59, I 2 =0.0%) ( figure 2D ).

Jump performance

Jump performance included metrics such as jump height and vertical jump performance, which evaluate explosive power and lower-body strength. Five RCTs were included in the analysis, with three RCTs 21 31 37 using the countermovement squat jump to assess jump performance, two RCTs 35 36 using the vertical jump and one RCT 31 employing the squat jump for assessment. The TRF group would not result in a significant difference by comparing with the ND group (SMD=−0.02, 95%confidence interval −0.53 to 0.49, p=0.93, I 2 =64.1%). In addition, no significant difference was observed in the subgroup analysis ( figure 2E ).

Body composition

FM, as an indicator, was the most frequently used measure, with 13 RCTs 12 14 15 24–28 30 31 included in the analysis. In long-term intervention studies lasting 8 weeks or more, a significant difference was observed between the TRF group and the ND group (MD=−1.24 kg, 95% CI −1.87 to −0.61, p<0.001, I 2 =0.0%). For short-term intervention (less than 8 weeks), the TRF group demonstrated a significant reduction compared with the ND group (MD=−1.24 kg, 95% CI −1.87 to −0.61, p<0.001, I 2 =0.0%) ( figure 3A ). Furthermore, TRF plus endurance training (MD=−1.47 kg, 95% CI −2.48 to −0.46, p<0.001, I 2 =7.5%) or resistance training (MD=−1.24 kg, 95% CI −2.37 to −0.11, p=0.03, I 2 =0.0%) demonstrated significant effects in reducing FM when compared with ND plus endurance training or resistance training ( figure 4A ).

Meta-analysis of the effects of time-restricted feeding combined with exercise versus controls on (A) fat mass, (B) fat-free mass, (C) body fat and (D) body weight. MD (mean difference) indicates the mean difference in the post-test value of the time-restricted feeding versus the control groups. Effects for the subgroups are based on the duration of the intervention (less than 8 weeks vs 8 weeks or more). The plotted points are the weighted MDs and the horizontal error bars represent the 95% CIs.

Meta-analysis of the effects of time-restricted feeding combined with exercise versus controls on (A) fat mass, (B) fat-free mass, (C) body fat and (D) body weight. MD (mean difference) indicates the mean difference in the post-test value of the time-restricted feeding versus the control groups. Effects for the subgroups are based on different types of exercise (endurance training, resistance training, concurrent training and high-intensity interval training). The plotted points are the weighted MDs, and the horizontal error bars represent the 95% CIs.

Fat-free mass

The analysis included a total of 11 RCTs, 8 10 14 16 17 20 21 31 33 34 36 and the meta-analysis results revealed that there is no significant effect on FFM based on the pooled data between the TRF and ND group (MD=−0.47 kg, 95% CI −1.38 to 0.44, p=0.31, I 2 =0.0%). For subgroup analysis, no significant difference was observed, as shown in figure 3B and figure 4B .

A total of seven RCTs 14 20 21 34–36 38 have been included in the meta-analysis. Regarding the effects of TRF regimens on body fat (BF), no significant effect was observed (MD=−0.46%, 95% CI −1.65 to −0.73, p=0.45, I 2 =0.0%). For the subgroup analysis, no significant difference was observed, as shown in figure 3C and figure 4C .

Body weight

Body weight (BW) data were available in 12 RCTs, 10 14 16 17 20 21 31–36 38 there was a significant overall difference in the TRF groups when compared with the ND group (MD=−1.76 kg, 95% CI −3.40 to −0.13, p=0.03, I 2 =11.0%). Among the subgroups based on exercise types, only TRF plus resistance training demonstrated a significant reduction in BW when compared with ND plus resistance training (MD=−2.60 kg, 95% CI −5.14 to −0.07, p=0.04, I 2 =14%) as depicted in figure 4D .

Risk of bias in studies

The ROB 2 was employed to assess the risk of bias for each publication. A summary of the overall assessments for all five domains of bias is presented in table 1 . One study 37 was deemed to have a high risk of bias, while one study 36 was considered to have a low risk of bias. It is worth noting that all the studies included in our analysis were randomised trials; however, only three studies 10 16 36 provided thorough details on the randomisation process. Similarly, only the three studies explicitly stated that participants remained blinded until they arrived at the laboratory to complete the trials. One study was identified as having a high risk of bias, primarily due to concerns related to baseline differences between the intervention groups at the beginning of the first period. The studies were rated as having some concerns due to a lack of detailed information on the randomisation process, and deviations from the intended intervention may have occurred due to contextual factors within the trials.

• View inline

Risk-of-bias assessment in the observational studies included in the systematic review

Overall certainty of evidence

The overall certainty of evidence was assessed using the GRADE tool and is presented in online supplemental table S13 . We downgraded the certainty of evidence to low, for the following outcomes: fat mass, fat-free mass, body fat, power performance, aerobic capacity performance and jump performance. Body weight, strength performance and muscular endurance performance were downgraded with the certainty of evidence to moderate, indicating that we believe the true effect is probably close to the estimated effect.

Sensitivity analyses and publication bias

The results of sensitivity analyses, where studies with a high risk of bias were excluded, showed no significant impact on the overall findings. Eighty percent of studies showed some concerns in the field of the randomisation process. A series of sensitivity analyses were performed by removing each of the studies. The result indicated that excluding one study by Tinsley et al 36 reduces heterogeneity when a meta-analysis of strength performance and muscular endurance performance is conducted, but this did not substantially change the results.

The publication biases of three outcomes, namely, FM, FFM and BW, are shown in figure 5 . Funnel plots showed no indication of publication bias in FFM (p=0.08) and BW (p=0.64). However, it showed publication bias on FM (p=0.00).

Funnel plot for publication bias detection on (A) fat mass, (B) fat-free mass and (C) body weight. The funnel plot shows the observed mean differences (on the x-axis) against standard errors (on the y-axis).

To the best of our knowledge, no prior systematic review with meta-analysis has been conducted to specifically compare the effects of TRF versus ND on physical performance and body composition in healthy adults with regular exercise habits. In total, 15 studies were identified, and all were available for meta-analysis. In the meta-analysis, we specifically investigated whether TRF could serve as a more efficacious nutritional approach compared with an ND when individuals in both groups undergo an identical exercise training regimen. Our findings suggest that the combination of TRF with regular exercise training does not result in significant changes or improvements in physical performance outcomes when compared with ND with the same exercise training programme. However, it successfully achieves a significant fat loss outcome.

In this meta-analysis, it is important to note that the indicator of aerobic capacity performance in all the included studies was assessed using the indicator of VO 2max , which is considered a critical indicator for the assessment of aerobic performance. 39–41 Our findings revealed that the combination of TRF with regular exercise training did not lead to a significant change in aerobic capacity performance compared with the ND group. This contrasts with the conclusions of a previous systematic review conducted by Correia et al , which reported a positive impact of TRF on VO 2max . 1 Additionally, our meta-analysis indicated that the combination of TRF and regular exercise training did not have a significant influence on power performance, a critical factor closely linked to athletic performance and essential for incremental tests. 14 18 42 Subgroup analysis further showed that the combination of TRF with regular exercise training exhibited no significant influence on either aerobic capacity or power performance, regardless of the intervention duration (less than 8 weeks and 8 weeks or more). These findings emphasise that key performance indicators such as oxygen utilisation and power output are not reduced or physiologically affected following the implementation of such interventions. Discrepancies between our review and a previous systematic review 24 can be attributed to differences in study characteristics. Our meta-analysis specifically focused on the 16/8 TRF strategy, consisting of a consistent 16-hour fasting period followed by an 8 hour eating window, maintained for 4 to 8 weeks. In contrast, the previous systematic review 24 encompassed a broader range of IF strategies with varying durations and fasting periods, which may have led to diverse physiological adaptations among participants. 10 Robust and comprehensive conclusions regarding the effectiveness of combining TRF with exercise on aerobic capacity and power performance in future clinical research necessitate well-designed large-scale studies.

Despite the existence of a narrative review 43 and a systematic review 1 on the topic, there is a lack of a meta-analysis in the literature examining the effects of the TRF programme in combination with daily exercise training on indicators related to muscle performance. Correia et al ’s previous meta-analysis on IF and muscle strength reported non-significant effects. However, it is important to acknowledge the limitations of that study, including a limited number of included studies and the incorporation of diverse IF regimens (eg, Ramadan IF, TRF), which may not have fully taken into account the potential differences between the two fasting approaches. 24 In our meta-analysis, we found no significant comparative effects of TRF versus non-TRF on muscle performance-related indicators, including strength performance, muscular endurance performance and jump performance in healthy adults with regular exercise habits. These findings indicate that the incorporation of TRF as a nutritional intervention alongside daily exercise training regimens may not have a significant impact on certain aspects of muscle performance when compared with the ND group. However, the existing RCTs on this topic have yielded mixed findings. For instance, the RCT conducted by Moro et al demonstrated that TRF plus resistance training resulted in no change in muscle cross-sectional area of the arm and thigh as well as maximal strength after an 8 week intervention by comparing to the ND with the same amount of exercise, 8 while another study found a greater increase in lower body strength with TRF combined with resistance training. 38 Furthermore, our subgroup analysis, which stratified the studies based on intervention duration, revealed a slight improvement in strength performance when TRF was combined with exercise. However, this increase was not statistically significant, suggesting that the effects of TRF on physical performance may diminish over time, potentially due to adaptive changes and the development of tolerance to TRF. 43

In athletics, the optimisation of body composition and the adjustment of physical condition play vital roles. The meticulous management and equilibrium between lean muscle mass and fat are critical factors that substantially influence sports-related performance, particularly in sports such as boxing, weightlifting and others that rely heavily on strength and power. 44 Our findings indicate that including TRF with regular exercise training is effective in achieving significant reductions in weight and FM with no significant difference in FFM compared with ND with regular exercise training. The potential benefits of TRF on body composition can be attributed to two main reasons. First, TRF may promote a reduction in daily calorie intake. When individuals are faced with time constraints, restricting food consumption becomes a practical strategy for reducing calorie intake, particularly when compared with the time-consuming tasks of meal preparation, cooking and calorie counting. 3 In contrast, traditional dieting’s continuous calorie counting often leads to participant attrition. However, TRF offers an alternative approach by emphasising time rather than calorie monitoring. Previous studies have shown that differences in weight loss were not statistically significantly different between the TRF and daily calorie restriction. 5 45 Moreover, TRF has been found to reduce overall calorie intake by approximately 25–38%, 3 although individual responses to fasting may vary. 1 Those characteristics of TRF enhance long-term adherence and enable sustainable weight control. 9 45 46 Second, another reason may relate to metabolic benefits observed in the context of TRF, which can be attributed to the improved synchronisation of eating patterns with the individual’s biological circadian clock. 47 Aligning eating patterns with the circadian clock has been associated with reduced fasting glucose concentration, improved insulin resistance and positive changes in lipid profiles. 48 49 The slight improvements in glucose and lipid metabolism indicators observed with TRF could be partly attributed to the associated slight weight loss. 47

While there is substantial evidence supporting the effectiveness of TRF with daily exercise training for fat loss, there are still divergent findings in the literature. For instance, the RCT conducted by Correia et al demonstrated that TRF in conjunction with regular training led to improvements in Wingate test performance but did not result in notable changes in body composition. 14 The variability in fat loss across studies may be explained by the type of exercise performed in the intervention, duration of the experiment, total energy intake and participant characteristics. Specifically, in the subgroup analysis based on exercise type within our meta-analysis, encompassing four different types of exercise, the findings indicated that only the combination of TRF with endurance training and resistance training exhibited a statistically significant reduction in FM compared with the ND groups. Furthermore, intriguingly, shorter-term interventions demonstrated greater effects on FM reduction when comparing the TRF group with the ND group, potentially attributed to physiological adaptations.

Strengths and limitations

The current systematic review used a rigorous and comprehensive search strategy encompassing physical performance and body composition indicators. Distinguishing from previous studies, our review with meta-analysis adopted a more focused approach, specifically incorporating studies that only employed TRF as the intervention. However, this study still has several limitations that need to be addressed. First, although the form of TRF used in the included studies was predominantly the 16/8 method, there were variations in the daily fasting periods employed. These differences in fasting periods have the potential to influence biological rhythms and may impact the observed results. Therefore, future studies incorporating diverse fasting periods within TRF protocols would be valuable in further elucidating the effects of TRF on the outcomes of interest. Second, for some physical performance indicators (eg, endurance and power performance), the meta-analysis included a small number of studies, reducing statistical power. Additionally, our review did not specifically discuss blood test biomarkers and their implications for overall health and well-being. Further research in this area is needed to enhance our understanding of the physiological mechanisms involved and their potential impact on overall health and well-being. Finally, for the outcome of fat mass, our study is limited by potential publication and small study bias, which may affect the validity of the findings specifically for this outcome. Our methods to assess publication bias may not capture all forms of bias accurately. Additionally, we cannot differentiate between small study bias and publication bias for fat mass, introducing uncertainty in interpreting the overall effect size for this outcome.

This meta-analysis contributes to a more comprehensive understanding of the comparative effects of TRF versus ND on physical performance and body composition in healthy adults with regular exercise habits. The study findings highlight that including TRF with daily exercise training yields significant benefits in terms of fat reduction while maintaining physical performance, compared with ND with the same exercise training programme. Moreover, the results highlight the need for further intervention studies investigating the impact of TRF and exercise on physical performance. Such research endeavours hold promise in offering valuable insights and practical applications for people with regular exercise habits and practitioners seeking optimal nutrition strategies to optimise performance outcomes and body composition.

Patient and public involvement

At what stage in the research process were patients/the public first involved in the research and how.

This study did not involve direct patient or public involvement at any stage of the research process.

How were the research question(s) and outcome measures developed and informed by their priorities, experience and preferences?

The research questions and outcome measures were developed based on a review of existing literature and expert consensus, without direct input from patients or the public.

How were patients/the public involved in the design of this study?

Patients and the public were not involved in the design of this study.

How were they involved in the recruitment to and conduct of the study?

There was no recruitment or direct conduct involving patients or the public, as this study synthesised existing research data.

Were they asked to assess the burden of the intervention and time required to participate in the research?

This was not applicable, as there was no primary data collection involving interventions or direct participation.

How were (or will) they be involved in your plans to disseminate the study results to participants and relevant wider patient communities (eg, by choosing what information/results to share, when and in what format)?

Dissemination plans primarily involve academic channels, including publication in peer-reviewed journals and presentations at conferences. There was no direct involvement from patients or the public in determining dissemination plans.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

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X @doctorojunior

Contributors KW assumed the lead role in this study, overseeing data access, systematic search for eligible studies, data extraction, result interpretation, manuscript drafting and serving as the guarantor. ZD, RH, WH and SW actively participated in the study’s conception, design, systematic search for eligible studies, data extraction and manuscript composition. RH played a key role in drafting the manuscript and providing critical revisions. All authors thoroughly reviewed and granted approval for the final manuscript submission.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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A Qualitative Study of Strategies to Improve Occupational Well-being in Physical Medicine and Rehabilitation Physicians

Amano, Alexis MS; Makowski, Maryam S. PhD; Trockel, Mickey T. MD, PhD; Menon, Nikitha K. BA; Wang, Hanhan MPS, MPS; Sliwa, James DO; Weinstein, Stuart MD; Kinney, Carolyn MD; Paganoni, Sabrina MD; Verduzco–Gutierrez, Monica MD; Kennedy, David J. MD; Knowlton, Tiffany JD, MBA; Stautzenbach, Thomas MA, MBA; Shanafelt, Tait D. MD

From the Stanford University, Stanford, California (AA, MSM, MTT, NKM, HW, TDS); Los Angeles Fielding School of Public, Health, University of California, Los Angeles, California (AA); American Board of Physical Medicine and Rehabilitation, Rochester, Minnesota (JS, CK); Northwestern University Feinberg School of Medicine, Chicago, Illinois (JS); Shirley Ryan Ability Lab, Chicago, Illinois (JS); University of Washington, Seattle, Washington (SW); American Academy of Physical Medicine and Rehabilitation, Rosemont, Illinois (SW, DJK, TS); Mayo Clinic, Phoenix, Arizona (CK); Spaulding Rehabilitation Hospital, Boston, Massachusetts (SP); Association of Academic Physiatrists, Baltimore, Maryland (SP, MV-G, TK); University of Texas Health Science Center at San Antonio, San Antonio, Texas (MV-G); and Vanderbilt University, Nashville, Tennessee (DJK).

All correspondence should be addressed to: Tait D. Shanafelt, MD, Department of Internal, Medicine, 300 Pasteur Drive, Stanford, CA, USA.

Funding information, Stanford WellMD Center; American Board of Physical Medicine and Rehabilitation; Association of Academic Physiatrists; American Academy of Physical Medicine and Rehabilitation.

This article has been simultaneously co-published with PM&R . The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article.

© American Academy of Physical Medicine and Rehabilitation and Wolters Kluwer Health, Inc.

FUNDING INFORMATION: Funding for this study was provided by the American Academy of Physical Medicine and Rehabilitation, the American Board of Physical Medicine and Rehabilitation, the Association of Academic Physiatrists, and the Stanford WellMD Center.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.ajpmr.com ).

Background 

Physiatry is a specialty with high rates of burnout. Although organizational strategies to combat burnout are key, it is also important to understand strategies that individual physiatrists can use to address burnout.

Objective 

The aim of the study is to identify changes that resulted in improvement of occupational well-being of physiatrists over a 6- to 9-mo period.

Design 

We employed two quantitative surveys spaced 6-9 mos apart to identify physiatrists who experienced meaningful improvement in occupational burnout and/or professional fulfillment between the two survey time points. These physiatrists were subsequently recruited to participate in a qualitative study using semistructured interviews to identify changes that respondents felt contributed to improvements in burnout and professional fulfillment.

Setting 

Online surveys and interviews.

Participants 

Physiatrists in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Membership Masterfile.

Main Outcome Measure 

Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index.

Results 

One hundred twelve physiatrists responded to the baseline and follow-up surveys. Of these, 35 were eligible for interviews based on improvements in the Stanford Professional Fulfillment Index, and 23 (64%) agreed to participate. Themes from the qualitative interviews highlighted the importance of personal lifestyle choices, approaches to improve professional satisfaction, and strategies to foster work-life harmony. Personal lifestyle strategies included investing in wellness and mental health. Efforts to improve professional satisfaction included decreasing work intensity, prioritizing meaningful aspects of work, and building relationships with colleagues. Fostering work-life harmony also included making trade-offs in both domains, setting boundaries at work, setting expectations at home, and overcoming personal challenges.

Conclusions 

Our findings illustrate that in addition to organizational strategies demonstrated to be effective, there are actions that individual physiatrists can take to recover from burnout and foster professional fulfillment.

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Physical Activity and Health Through Physical Education

• First Online: 25 August 2024

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• Adrià Muntaner-Mas 2 , 3  

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Physical education (PE) is an academic subject that provides the opportunity for students to learn the knowledge and skills needed to establish and maintain physically active lifestyles throughout their lifetime. Unequivocally, PE play a crucial role in augmenting physical activity (PA) daily levels, which are linked to a myriad of health benefits. One of the aims of this chapter is to provide an overview of findings from systematic reviews and meta-analyses that have explored PE’s influence on youth health, highlighting its impact on physical fitness, academic performance, cognition, and obesity-related factors within the educational framework. Despite the necessity of additional research, PE via PA programs has revealed improvements in cardiorespiratory fitness, muscular strength, and academic outcomes and has shown a positive effect on obesity-related factors. The chapter emphasizes that PE offer unique opportunities for enhancing health in the school environment, which are not offered by other academic subjects. The chapter concludes by highlighting the necessity for ongoing research to better understand and advocate for PE’s importance in both public health and educational contexts.

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Muntaner-Mas, A. (2024). Physical Activity and Health Through Physical Education. In: García-Hermoso, A. (eds) Promotion of Physical Activity and Health in the School Setting. Springer, Cham. https://doi.org/10.1007/978-3-031-65595-1_7

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Managing Conflict with Humor

Finding joy during difficult times, improving emotional intelligence (eq).

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The benefits of laughter

What are the physical, mental, and social benefits of laughter, laughter helps you stay mentally healthy, laughter brings people together and strengthens relationships, how to bring more laughter into your life, tips for developing your sense of humor, using humor to overcome challenges and enhance your life, laughter is the best medicine.

It’s fun to share a good laugh, but did you know it can actually improve your health? Learn how to harness the powerful benefits of laughter and humor.

It’s true: laughter is strong medicine. It draws people together in ways that trigger healthy physical and emotional changes in the body. Laughter strengthens your immune system, boosts mood, diminishes pain, and protects you from the damaging effects of stress. Nothing works faster or more dependably to bring your mind and body back into balance than a good laugh. Humor lightens your burdens, inspires hope, connects you to others, and keeps you grounded, focused, and alert. It also helps you release anger and forgive sooner.

With so much power to heal and renew, the ability to laugh easily and frequently is a tremendous resource for surmounting problems, enhancing your relationships, and supporting both physical and emotional health. Best of all, this priceless medicine is fun, free, and easy to use.

As children, we used to laugh hundreds of times a day, but as adults, life tends to be more serious and laughter more infrequent. But by seeking out more opportunities for humor and laughter, you can improve your emotional health, strengthen your relationships, find greater happiness—and even add years to your life.

Laughter is good for your health

Laughter relaxes the whole body. A good, hearty laugh relieves physical tension and stress, leaving your muscles relaxed for up to 45 minutes after.

Laughter boosts the immune system. Laughter decreases stress hormones and increases immune cells and infection-fighting antibodies, thus improving your resistance to disease.

Laughter triggers the release of endorphins, the body’s natural feel-good chemicals. Endorphins promote an overall sense of well-being and can even temporarily relieve pain.

Laughter protects the heart. Laughter improves the function of blood vessels and increases blood flow, which can help protect you against a heart attack and other cardiovascular problems.

Laughter burns calories. Okay, so it’s no replacement for going to the gym, but one study found that laughing for 10 to 15 minutes a day can burn approximately 40 calories—which could be enough to lose three or four pounds over the course of a year.

Laughter lightens anger’s heavy load . Nothing diffuses anger and conflict faster than a shared laugh. Looking at the funny side can put problems into perspective and enable you to move on from confrontations without holding onto bitterness or resentment.

Laughter may even help you to live longer. A study in Norway found that people with a strong sense of humor outlived those who don’t laugh as much. The difference was particularly notable for those battling cancer.

Physical health benefits

• Boosts immunity
• Lowers stress hormones
• Decreases pain
• Relaxes your muscles
• Prevents heart disease

Mental health benefits

• Adds joy and zest to life
• Eases anxiety and tension
• Relieves stress
• Improves mood
• Strengthens resilience

Social benefits

• Strengthens relationships
• Attracts others to us
• Enhances teamwork
• Helps defuse conflict
• Promotes group bonding

Laughter makes you feel good. And this positive feeling remains with you even after the laughter subsides. Humor helps you keep a positive, optimistic outlook through difficult situations, disappointments, and loss.

[Read: Cultivating Happiness]

More than just a respite from sadness and pain, laughter gives you the courage and strength to find new sources of meaning and hope. Even in the most difficult of times, a laugh–or even simply a smile–can go a long way toward making you feel better. And laughter really is contagious—just hearing laughter primes your brain and readies you to smile and join in the fun.

The link between laughter and mental health

Laughter stops distressing emotions. You can’t feel anxious, angry, or sad when you’re laughing.

Laughter helps you relax and recharge. It reduces stress and increases energy, enabling you to stay focused and accomplish more.

Laughter shifts perspective , allowing you to see situations in a more realistic, less threatening light. A humorous perspective creates psychological distance, which can help you avoid feeling overwhelmed and diffuse conflict.

Laughter draws you closer to others, which can have a profound effect on all aspects of your mental and emotional health.

Speak to a Licensed Therapist

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There’s a good reason why TV sitcoms use laugh tracks: laughter is contagious. You’re many times more likely to laugh around other people than when you’re alone. And the more laughter you bring into your own life, the happier you and those around you will feel.

Sharing humor is half the fun—in fact, most laughter doesn’t come from hearing jokes, but rather simply from spending time with friends and family. And it’s this social aspect that plays such an important role in the health benefits of laughter. You can’t enjoy a laugh with other people unless you take the time to really engage with them. When you care about someone enough to switch off your phone and really connect face to face, you’re engaging in a process that rebalances the nervous system and puts the brakes on defensive stress responses like “fight or flight.” And if you share a laugh as well, you’ll both feel happier, more positive, and more relaxed—even if you’re unable to alter a stressful situation.

How laughing together can strengthen relationships

Shared laughter is one of the most effective tools for keeping relationships fresh and exciting. All emotional sharing builds strong and lasting relationship bonds, but sharing laughter also adds joy, vitality, and resilience. And humor is a powerful and effective way to heal resentments, disagreements, and hurts. Laughter unites people during difficult times.

Humor and playful communication strengthen our relationships by triggering positive feelings and fostering emotional connection. When we laugh with one another, a positive bond is created. This bond acts as a strong buffer against stress, disagreements, and disappointment. Humor and laughter in relationships allows you to:

Be more spontaneous. Humor gets you out of your head and away from your troubles.

Let go of defensiveness. Laughter helps you forget resentments, judgments, criticisms, and doubts.

Release inhibitions. Your fear of holding back is pushed aside.

Express your true feelings. Deeply felt emotions are allowed to rise to the surface.

Use humor to resolve disagreements and tension in your relationship

Laughter is an especially powerful tool for managing conflict and reducing tension when emotions are running high. Whether with romantic partners, friends and family, or co-workers, you can learn to use humor to smooth over disagreements , lower everyone’s stress level, and communicate in a way that builds up your relationships rather than breaking them down.

Laughter is your birthright, a natural part of life that is innate and inborn. Infants begin smiling during the first weeks of life and laugh out loud within months of being born. Even if you did not grow up in a household where laughter was a common sound, you can learn to laugh at any stage of life.

Begin by setting aside special times to seek out humor and laughter, as you might with exercising, and build from there. Eventually, you’ll want to incorporate humor and laughter into the fabric of your life, finding it naturally in everything.

Here are some ways to start:

Smile. Smiling is the beginning of laughter, and like laughter, it’s contagious. When you look at someone or see something even mildly pleasing, practice smiling. Instead of looking down at your phone, look up and smile at people you pass in the street, the person serving you a morning coffee, or the co-workers you share an elevator with. Notice the effect on others.

Count your blessings. Literally make a list. The simple act of considering the positive aspects of your life will distance you from negative thoughts that block humor and laughter. When you’re in a state of sadness, you have further to travel to reach humor and laughter.

[Listen: Gratitude in Difficult Times]

When you hear laughter, move toward it. Sometimes humor and laughter are private, a shared joke among a small group, but usually not. More often, people are very happy to share something funny because it gives them an opportunity to laugh again and feed off the humor you find in it. When you hear laughter, seek it out and ask, “What’s funny?”

Spend time with fun, playful people. These are people who laugh easily–both at themselves and at life’s absurdities–and who routinely find the humor in everyday events. Their playful point of view and laughter are contagious. Even if you don’t consider yourself a lighthearted, humorous person, you can still seek out people who like to laugh and make others laugh. Every comedian appreciates an audience.

Bring humor into conversations. Ask people, “What’s the funniest thing that happened to you today? This week? In your life?”

Simulated laughter

So, what if you really can’t “find the funny?” Believe it or not, it’s possible to laugh without experiencing a funny event—and simulated laughter can be just as beneficial as the real thing. It can even make exercise more fun and productive. A Georgia State University study found that incorporating bouts of simulated laughter into an exercise program helped improve older adults’ mental health as well as their aerobic endurance. Plus, hearing others laugh, even for no apparent reason, can often trigger genuine laughter.

To add simulated laughter into your own life, search for laugh yoga or laugh therapy groups. Or you can start simply by laughing at other people’s jokes, even if you don’t find them funny. Both you and the other person will feel good, it will draw you closer together, and who knows, it may even lead to some spontaneous laughter.

Creating opportunities to laugh

• Watch a funny movie, TV show, or YouTube video.
• Invite friends or co-workers out to a comedy club.
• Read the funny pages.
• Seek out funny people.
• Share a good joke or a funny story.
• Check out your bookstore’s humor section.
• Host game night with friends.
• Play with a pet.
• Go to a “laughter yoga” class.
• Goof around with children.
• Do something silly.
• Make time for fun activities (e.g. bowling, miniature golfing, karaoke).

An essential ingredient for developing your sense of humor is to learn not to take yourself too seriously and laugh at your own mistakes and foibles. As much as we’d like to believe otherwise, we all do foolish things from time to time. Instead of feeling embarrassed or defensive, embrace your imperfections. While some events in life are clearly sad and not opportunities for laughter, most don’t carry an overwhelming sense of either sadness or delight. They fall into the gray zone of ordinary life—giving you the choice to laugh or not. So, choose to laugh whenever you can.

How to develop your sense of humor

Laugh at yourself. Share your embarrassing moments. The best way to take yourself less seriously is to talk about times when you took yourself too seriously.

Attempt to laugh at situations rather than bemoan them. Look for the humor in a bad situation, and uncover the irony and absurdity of life. When something negative happens, try to make it a humorous anecdote that will make others laugh.

Surround yourself with reminders to lighten up. Keep a toy on your desk or in your car. Put up a funny poster in your office. Choose a computer screensaver that makes you laugh. Frame photos of you and your family or friends having fun.

Remember funny things that happen. If something amusing happens or you hear a joke or funny story you really like, write it down or tell it to someone to help you remember it.

Don’t dwell on the negative. Try to avoid negative people and don’t dwell on news stories, entertainment, or conversations that make you sad or unhappy. Many things in life are beyond your control—particularly the behavior of other people. While you might view carrying the weight of the world on your shoulders as admirable, in the long run it’s unrealistic and unhealthy.

Find your inner child. Pay attention to children and try to emulate them—after all, they are the experts on playing, taking life lightly, and laughing at ordinary things.

Deal with stress. Stress can be a major impediment to humor and laughter, so it’s important to keep your stress levels in check. One great technique to relieve stress in the moment is to draw upon a favorite memory that always makes you smile—something your kids did, for example, or something funny a friend told you.

Don’t go a day without laughing. Think of it like exercise or breakfast and make a conscious effort to find something each day that makes you laugh. Set aside 10 to 15 minutes and do something that amuses you. The more you get used to laughing each day, the less effort you’ll have to make.

The ability to laugh, play, and have fun not only makes life more enjoyable but also helps you solve problems, connect with others, and think more creatively. People who incorporate humor and play into their daily lives find that it renews them and all of their relationships.

Life brings challenges that can either get the best of you or become playthings for your imagination. When you “become the problem” and take yourself too seriously, it can be hard to think outside the box and find new solutions. But when you play with the problem, you can often transform it into an opportunity for creative learning.

[Read: Managing Conflict with Humor]

Playing with problems seems to come naturally to children. When they are confused or afraid, they make their problems into a game, giving them a sense of control and an opportunity to experiment with new solutions. Interacting with others in playful ways helps you retain this creative ability.

Here are two examples of people who took everyday problems and turned them around through laughter and play:

• Roy , a semi-retired businessman, was excited to finally have time to devote to golf, his favorite sport. But the more he played, the less he enjoyed himself. Although his game had improved dramatically, he got angry with himself over every mistake. Roy wisely realized that his golfing buddies affected his attitude, so he stopped playing with people who took the game too seriously. When he played with friends who focused more on having fun than on their scores, he was less critical of himself. Now golfing was as enjoyable as Roy had envisioned. He scored better without working harder. And the brighter outlook he was gaining from his companions and the game spread to other parts of his life.
• Jane worked at home designing greeting cards, a job she used to love but now felt had become routine. Two little girls who loved to draw and paint lived next door. Eventually, Jane invited the girls over to play with all of her art supplies. At first, she just watched, but in time she joined in. Laughing, coloring, and playing pretend with the little girls transformed Jane’s life. Not only did it end her loneliness and boredom, but it sparked her imagination and helped her artwork flourish. Best of all, it rekindled the playfulness in Jane’s relationship with her husband.

As laughter, humor, and play become integrated into your life, your creativity will flourish and new opportunities for laughing with friends, coworkers, acquaintances, and loved ones will occur to you daily. Laughter takes you to a higher place where you can view the world from a more relaxed, positive, and joyful perspective.

More Information

• Buchowski, M. S., Majchrzak, K. M., Blomquist, K., Chen, K. Y., Byrne, D. W., & Bachorowski, J.-A. (2007). Energy expenditure of genuine laughter. International Journal of Obesity , 31(1), 131–137. Link
• Laugh and be thankful—It’s good for the heart—Harvard Health . (n.d.). Retrieved May 25, 2022, from Link
• Manninen, S., Tuominen, L., Dunbar, R. I., Karjalainen, T., Hirvonen, J., Arponen, E., Hari, R., Jääskeläinen, I. P., Sams, M., & Nummenmaa, L. (2017). Social Laughter Triggers Endogenous Opioid Release in Humans. The Journal of Neuroscience , 37(25), 6125–6131. Link
• Miller, M., & Fry, W. F. (2009). The effect of mirthful laughter on the human cardiovascular system. Medical Hypotheses , 73(5), 636–639. /p> Link
• Romundstad, S., Svebak, S., Holen, A., & Holmen, J. (2016). A 15-Year Follow-Up Study of Sense of Humor and Causes of Mortality: The Nord-Trøndelag Health Study. Psychosomatic Medicine , 78(3), 345–353. Link
• Speer, M. E., & Delgado, M. R. (2017). Reminiscing about positive memories buffers acute stress responses. Nature Human Behaviour , 1(5), 0093. Link
• Yim, J. (2016). Therapeutic Benefits of Laughter in Mental Health: A Theoretical Review. The Tohoku Journal of Experimental Medicine , 239(3), 243–249. Link

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Physical Activity for Health and Fitness: Past, Present and Future

Gaurav kapoor.

1 Department of Physiotherapy, Jayoti Vidyapeeth Women’s University, Rajasthan, India

Priya Chauhan

2 Department of Physiotherapy, UIAHS, Chandigarh University, Punjab, India

Gurjant Singh

Nitesh malhotra.

3 Department of Physiotherapy, Manav Rachna International University, Faridabad, India

Aksh Chahal

4 Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India

It’s a saying “The early we start, the early we attain good health”. Health is a state of complete physical, mental and social well-being and not merely absence of disease Fitness is an ability to execute daily functional activities with optimal performance, endurance, and strength to manage minimalist of disease, fatigue, stress and reduced sedentary behavior. In the modern era with advancement in technology, erosion of physical activity has drastically led to retardation in health and fitness. Hoods of luxurious and competition among students for scores/grades and professionals for promotions/incentives/benefits have deviated people from concentrating towards their health and putting it secondary. In 2016, across the globe, prevalence of physical inactivity was estimated at 27.5%, among adult population. To support further, in June 2018, WHO reported, 1 in five adults, and 4 of five adolescents to pose reduced physical activity. In the current ongoing pandemic era this scenario has been further negatively impacting the society to suffer from psychosocial, financial and economic loss, contributing to lack of physical activity. Health benefits of physical activity are not limited only to improved cardiorespiratory and muscular fitness, bone and cardiometabolic health, and positive effects on weight status, but it also boosts mental health and social health. Acknowledging the significance and urgency of decreasing insufficient physical activity globally, WHO endorsed a Global Action Plan on Physical Activity (GAPPA) at the World Health Assembly in 2018, wherein the member countries agreed to reach a new target of 15% relative reduction in insufficient physical activity among adolescents by 2030.

INTRODUCTION

It’s a saying “The early we start, the early we attain good health”. Health is a state of complete physical, mental and social well-being and not merely absence of disease [ 1 ]. Fitness is an ability to execute daily functional activities with optimal performance, endurance, and strength to manage minimalist of disease, fatigue, stress and reduced sedentary behavior [ 2 ]. In the modern era with advancement in technology, erosion of physical activity has drastically led to retardation in health and fitness. Hoods of luxurious and competition among students for scores/grades and professionals for promotions/incentives/benefits have deviated people from concentrating towards their health and putting it secondary [ 3 ]. Since the last few decades, studies have documented inactive and sedentary life style to make individuals prone towards chronic diseases [ 2 , 4 ]. Despite our increased understanding of importance of being active, data from the World Health Organization (WHO) instigates, inactivity prevalent today in the society, contributing to the 6-10% burden of chronic disease and premature mortality [ 2 ]. A review document from 2012 expressed prevalence of physical inactivity to exist in wide regions of the world; 27.5% in Africa, 43.3% in America, 34.8% in Europe, 17% in South East Asia and 33.7% in the Western Pacific [ 5 , 6 ]. To support further, in June 2018, WHO reported, 1 in five adults, and 4 of five adolescents to pose reduced physical activity [ 7 ]. Girls, women, geriatric population, under privileged population, individuals with disabilities and chronic diseases, marginalized groups, and indigenous people to have further fewer opportunities to keep themselves active [ 8 ]. It is not surprising that the prevalence of inactivity is more evident in urban community when compared to rural [ 2 , 9 ]. As it’s a general trend physical activity slows with aging and is reduced in retired, unemployed and less educated people, in the current ongoing pandemic era this scenario has been further negatively impacting the society to suffer from psychosocial, financial and economic loss, contributing to lack of physical activity [ 10 ]. Policies encouraged by WHO, such as Global Action Plan for Physical Activity 2018-2030 [ 11 , 12 ] and The European Physical Activity Strategy 2016-2025 [ 13 ] promised to encourage and makes the society aware on benefits of being physically active.

Benefits of physical activity have been documented since early 20 th century [ 14 ]. Study show rate of coronary heart disease lower among physically active London bus conductors than bus drivers and government clerks [ 15 ]. Health benefits of physical activity are not limited only to improved cardiorespiratory and muscular fitness, bone and cardiometabolic health, and positive effects on weight status, but it also boosts mental health and social health [ 2 ]. Sibold and colleagues showed remarkable decline in suicidal thoughts and attempts by 23% in bullied adolescents engaged in physical activity than physically inactive people [ 16 ]. Acknowledging the significance and urgency of decreasing insufficient physical activity globally, WHO endorsed a Global Action Plan on Physical Activity (GAPPA) at the World Health Assembly in 2018, wherein the member countries agreed to reach a new target of 15% relative reduction in insufficient physical activity among adolescents by 2030 [ 8 ].

In many researches males are found to be more active when compared to their female counterpart [ 17 - 20 ]. On the flipside, sitting time throughout day is higher in males than females [ 2 , 21 ]. Researches also document students to be poorly active than adults [ 22 - 25 ].

FITNESS RECOMMENDATIONS FOR VARIABLE AGE GROUPS

1. general considerations.

Physical activities can be implemented and regularized through two modes; self and under supervision. Physical activities pose negligible negative effects in comparison to medication [ 26 ]. WHO proposes individuals to indulge in any kind of a moderate intensity exercise for at least 150-300 minutes per week [ 27 ]. Looking at the minutes, it sounds fairly high, however if we divide the same into days, it is only 30 to 60 minutes per day for 5 days per week. This recommendation is stated for nearly all age group people with special variability to be kept in mind (if required). Further, it is important to mention that, it does not mean spending 30-40 minutes on physical activity to follow with no activity throughout the remaining day. Bodily active movement after every 1 to 2 hours is vital for maintaining normal tone and elasticity of blood vessels [ 28 , 29 ] and soft tissues (capsule, ligament, muscle, tendon etc.) [ 30 ]. In fact, it is a sedentary lifestyle, becoming more common in the modern era. This physical inactivity is lethal for human body as the heart needs to be active throughout the day. It’s worth noting that benefits include enhanced thinking or cognition in youngsters aged 6 to 13, as well as reduced short-term anxiety in adults. Physical activity helps to accelerate and thinking, learning, and cognitive skills [ 31 ]. Physical activity further helps to have better sleep quality and lessen self risk of depression and anxiety [ 32 ]. As children are more physically active, WHO recommends children to remain active throughout the day with rest period as appropriate as per their age and physical limits to be increased in a slow and regular manner.

A study documented, individuals watching television for more than 4 hours per day, live in an inactive state and have 80% higher risk of mortality from cardiovascular disease [ 33 ].

2. Daily modifications and upgradations

Furthermore, achieving increased levels of physical activity necessitates the implementation of comprehensive and integrated initiatives. Physical activity benefits are dependent on one’s personal efforts to enhance exercise in self, families, friends, subjects patients, and coworkers, etc., at school, workplace/office. Physical activities appropriate for present fitness level and health goals should be chosen at the outset, based on the advice of an exercise physiologist or physical therapist, because certain activities are safer than others. To reach criteria for health goals, there needs to be progressively increase in physical activity with passage of time. Inactive people should “start small and build up” by beginning with lower-intensity activities and progressively increase frequency and duration of their activities.

In order to combat with physical inactivity, modification in environment focusing varied social levels with planning of offices, road and transport system should be constructed with the aim to promote active lifestyle. At work place, employees should be encouraged to get up and walk to catch up a cup of tea and speaking on mobile while walking at work place. In return, these movements promote blood circulation and muscle relaxation by contracting and relaxation of the muscles of upper and lower limbs, thorax and spine. Meetings should be made recreational, instead of standard ideal sitting criterion. In addition to the above use of stairs should be encouraged inspite elevators/escalators. Parking lot should be at distance, encouraging walking.

3. Exercises/Movements

As per the Physical Activity Guidelines by the American College of Sports Medicine (ACSM), it is encouraging to develop person specific exercise interventions for a positive health and overall wellbeing [ 34 ]. Studies recommend; balance, endurance training, flexibility, and strengthening exercises for generation and management of physical health and fitness [ 35 , 36 ]. Physical activities can be combination of two or more components. It helps to encourage the performer to remain active throughout life by creating enthusiasm and eliminate boredom by taking the physical act to higher and extended time along with advancement of age. Exercises like Lunges, Pushups, Squats, Running, Planks, Swimming, and Dumbbell rows should be practiced right from adolescent and carried till later years of life (medical consultation to be consider, if required).

It is important to create personal objectives for healthy physical life. When setting goals, one should explore a variety of activities and try both indoor and outdoor activities. Simple and ambitious goals are both possible. For example, going for a 45-minute brisk walk in the nearby vicinity with friends/family three times a week and walking to lunch twice a week, or using active transportation—walking, biking, or wheelchair walking—to get to school, work, or the shop may be the best option for someone.

Despite the numerous health benefits of physical activity, injuries like sprain/strain/contusion or in worst case a fracture can occur [ 37 ]. The musculoskeletal system is the most common domain to get injured with physical activities/exercises [ 38 ]. This is attributed to overheating and dehydration [ 39 ]. Rarely people experience heart attacks while exercising. Practically, physical activity is safe for everyone.

People with and/or at risk of acquiring chronic diseases and symptoms, such as pregnant women and the elderly, should take advice from a health care professionals like Exercise Physiologist/physical therapist for the type and level of activity to begin with.

4. Fitness trackers

An activity tracker, often known as a fitness tracker, is a gadget or applications that monitors and tracks fitness-related metrics like distance walked or run, calorie consumption, and, in some circumstances, heart rate [ 40 ]. It’s a form of computer that one wears on his/her body part. Smart watches are commonly used in as they are connected via wireless, to a computer or smartphone for long-term data tracking [ 41 ]. Independent smartphone and software applications are also available. In recent years, wearable devices namely, Fitness Trackers, Smart Watches, Heart Rate Monitors, and Global Positioning System (GPS) tracking devices have boomed with its use extending from children to elderly. These devices are designed and marketed with the aim to push inactive individuals to think critically towards their health by creating mental concern for heart rate, number of steps/cadence, duration of current and projection of future workout, calorie loss, running distance, activity recording, sleep patterns and blood pressure thereby, enabling them to become physically active. According to a systematic review, activity trackers increased people’s physical activity by 1850 steps a day [ 42 ].

Designing, promoting and encouraging physical activity is a vital from childhood to elderly. These goals can be achieved by sharing information using community-wide and mass media campaigns, social support enhancing physical activity at community level and work places, physical education, classroom physical activities, after-school sports and active transport to school for school going children are few steps to improve the health of the society. The present article proposes benefits of physical activity in imparting health and fitness, and measures to improve the same, to reduce the present and future multiple negative impacts on individuals and nations economy.