Obstructive Sleep Apnea Syndrome, Objectively Measured Physical Activity and Exercise Training Interventions: A Systematic Review and Meta-Analysis

Monique Mendelson, Sébastien Bailly, Mathieu Marillier, Patrice Flore, Jean Christian Borel, Isabelle Vivodtzev, Stéphane Doutreleau, Samuel Verges, Renaud Tamisier, Jean-Louis Pépin, Monique Mendelson, Sébastien Bailly, Mathieu Marillier, Patrice Flore, Jean Christian Borel, Isabelle Vivodtzev, Stéphane Doutreleau, Samuel Verges, Renaud Tamisier, Jean-Louis Pépin

Abstract

A systematic review of English and French articles using Pubmed/Medline and Embase included studies assessing objective physical activity levels of obstructive sleep apnea (OSA) patients and exploring the effects of exercise training on OSA severity, body mass index (BMI), sleepiness, and cardiorespiratory fitness [peak oxygen consumption (VO2peak)]. Two independent reviewers analyzed the studies, extracted the data, and assessed the quality of evidence. For objective physical activity levels, eight studies were included. The mean number of steps per day across studies was 5,388 (95% CI: 3,831-6,945; p < 0.001), which was by far lower than the recommended threshold of 10,000 steps per day. For exercise training, six randomized trials were included. There was a significant decrease in apnea-hypopnea-index following exercise training (mean decrease of 8.9 events/h; 95% CI: -13.4 to -4.3; p < 0.01), which was accompanied by a reduction in subjective sleepiness, an increase in VO2peak and no change in BMI. OSA patients present low levels of physical activity and exercise training is associated with improved outcomes. Future interventions (including exercise training) focusing on increasing physical activity levels may have important clinical impacts on both OSA severity and the burden of associated co-morbidities. Objective measurement of physical activity in routine OSA management and well-designed clinical trials are recommended. Registration # CRD42017057319 (Prospero).

Keywords: exercise training; meta-analysis; obstructive sleep apnea; physical activity; randomized controlled trials; systematic review.

Figures

Figure 1
Figure 1
Prisma flow chart of articles identified and evaluated during the study selection process for (A) physical activity and (B) exercise training.
Figure 1
Figure 1
Prisma flow chart of articles identified and evaluated during the study selection process for (A) physical activity and (B) exercise training.
Figure 2
Figure 2
Forest plot for mean physical activity levels in obstructive sleep apnea patients. Ref (, –22).
Figure 3
Figure 3
Forest plot presenting steps per day before and after interventions [continuous positive airway pressure (CPAP) and exercise]. Ref (–, –22).
Figure 4
Figure 4
Forest plot for the mean change in apnea–hypopnea index (AHI) (events/h) following exercise training. The diamond reflects the 95% confidence interval of the pooled estimate of mean difference. Ref (, , –33).
Figure 5
Figure 5
Forest plot for the mean change in Epworth sleepiness scale following exercise training. The diamond reflects the 95% confidence interval of the pooled estimate of mean difference. Ref (16, 22, 30, 33).
Figure 6
Figure 6
Forest plot for the mean change in peak oxygen consumption (VO2peak) following exercise training. The diamond reflects the 95% confidence interval of the pooled estimate of mean difference. VO2peak measured in milliliter per kilogram per minute. Ref (16, 22, 30, 31, 33).
Figure 7
Figure 7
Forest plot for the mean change in body mass index (BMI) (kilogram per square meter) following exercise training. The diamond reflects the 95% confidence interval of the pooled estimate of mean difference. Ref (22, 30, 33).
Figure 8
Figure 8
Hypothetical relationship between exercise training/physical activity and obstructive sleep apnea (OSA). The rostral fluid shift contributes to the pathogenesis of OSA and its attenuation via physical activity (47) and exercise training has been shown to alleviate OSA. The strength and fatigability of the upper airway dilators have been shown to be altered in patients with OSA. Specific exercise training modalities may improve upper airway function in OSA patients and thus contribute to decrease OSA severity. An elevated body mass index (BMI) is a key risk factor for the development of OSA while sleep disturbances can influence body composition. Exercise training has been shown to favorably modify body composition (increase lean mass, decrease fat mass) and can reduce BMI, therefore potentially alleviating the severity OSA. OSA is often accompanied by cardiovascular and metabolic co-morbidities, which can impair exercise tolerance. Exercise training has been shown to be beneficial for the improvement of a number of these co-morbidities (hypertension, dyslipidemia, type 2 diabetes, etc.).

References

    1. Tamisier R, Pépin JL, Rémy J, Baguet JP, Taylor JA, Weiss JW, et al. 14 nights of intermittent hypoxia elevate daytime blood pressure and sympathetic activity in healthy humans. Eur Respir J (2011) 37(1):119–28.10.1183/09031936.00204209
    1. Lévy P, Kohler M, McNicholas WT, Barbé F, McEvoy RD, Somers VK, et al. Obstructive sleep apnoea syndrome. Nat Rev Dis Primers (2015) 1:15015.10.1038/nrdp.2015.15
    1. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep (1985) 100(2):126–31.
    1. Kraus WE, Bittner V, Appel L, Blair SN, Church T, Despres JP, et al. The national physical activity plan: a call to action from the American Heart Association: a science advisory from the American Heart Association. Circulation (2015) 131(21):1932–40.10.1161/CIR.0000000000000203
    1. Kline CE. The bidirectional relationship between exercise and sleep: implications for exercise adherence and sleep improvement. Am J Lifestyle Med (2014) 8(6):375–9.10.1177/1559827614544437
    1. Sherrill DL, Kotchou K, Quan SF. Association of physical activity and human sleep disorders. Arch Intern Med (1998) 158(17):1894–8.10.1001/archinte.158.17.1894
    1. Chasens ER, Sereika SM, Houze MP, Strollo PJ. Subjective and objective appraisal of activity in adults with obstructive sleep apnea. J Aging Res (2011) 2011:751819.10.4061/2011/751819
    1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol (2013) 177(9):1006–14.10.1093/aje/kws342
    1. Hong S, Dimsdale JE. Physical activity and perception of energy and fatigue in obstructive sleep apnea. Med Sci Sports Exerc (2003) 35(7):1088–92.10.1249/01.MSS.0000074566.94791.24
    1. Rosenzweig I, Glasser M, Polsek D, Leschziner GD, Williams SC, Morrell MJ. Sleep apnoea and the brain: a complex relationship. Lancet Respir Med (2015) 3(5):404–14.10.1016/S2213-2600(15)00090-9
    1. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK, et al. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc (2009) 41(2):459–71.10.1249/MSS.0b013e3181949333
    1. Cornelissen VA, Fagard RH. Effect of resistance training on resting blood pressure: a meta-analysis of randomized controlled trials. J Hypertens (2005) 23(2):251–9.10.1097/00004872-200502000-00003
    1. Schuler G, Adams V, Goto Y. Role of exercise in the prevention of cardiovascular disease: results, mechanisms, and new perspectives. Eur Heart J (2013) 34(24):1790–9.10.1093/eurheartj/eht111
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ (2009) 339:b2700.10.1136/bmj.b2700
    1. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “how many steps are enough?”. Med Sci Sports Exerc (2008) 40(7 Suppl):S537–43.10.1249/MSS.0b013e31817c7133
    1. Kline CE, et al. The effect of exercise training on obstructive sleep apnea and sleep quality: a randomized controlled trial. Sleep (2011) 34(12):1631–40.10.5665/sleep.1422
    1. Diamanti C, Manali E, Ginieri-Coccossis M, Vougas K, Cholidou K, Markozannes E, et al. Depression, physical activity, energy consumption, and quality of life in OSA patients before and after CPAP treatment. Sleep Breath (2013) 17(4):1159–68.10.1007/s11325-013-0815-6
    1. Igelström H, Emtner M, Lindberg E, Asenlöf P. Physical activity and sedentary time in persons with obstructive sleep apnea and overweight enrolled in a randomized controlled trial for enhanced physical activity and healthy eating. Sleep Breath (2013) 17(4):1257–66.10.1007/s11325-013-0831-6
    1. Verwimp J, Ameye L, Bruyneel M. Correlation between sleep parameters, physical activity and quality of life in somnolent moderate to severe obstructive sleep apnea adult patients. Sleep Breath (2013) 17(3):1039–46.10.1007/s11325-012-0796-x
    1. Mendelson M, Vivodtzev I, Tamisier R, Laplaud D, Dias-Domingos S, Baguet JP, et al. CPAP treatment supported by telemedicine does not improve blood pressure in high cardiovascular risk OSA patients: a randomized, controlled trial. Sleep (2014) 37(11):1863–70.10.5665/sleep.4186
    1. Bamberga M, Rizzi M, Gadaleta F, Grechi A, Baiardini R, Fanfulla F. Relationship between energy expenditure, physical activity and weight loss during CPAP treatment in obese OSA subjects. Respir Med (2015) 109(4):540–5.10.1016/j.rmed.2015.02.010
    1. Mendelson M, Lyons OD, Yadollahi A, Inami T, Oh P, Bradley TD. Effects of exercise training on sleep apnoea in patients with coronary artery disease: a randomised trial. Eur Respir J (2016) 48(1):142–50.10.1183/13993003.01897-2015
    1. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Available from: (accessed October 2017).
    1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials (1996) 17(1):1–12.10.1016/0197-2456(95)00134-4
    1. Jüni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA (1999) 282:1054–60.10.1001/jama.282.11.1054
    1. Morris SB. Estimating effect sizes from pretest-posttest-control group designs. Organ Res Methods (2008) 11(2):364–86.10.1177/1094428106291059
    1. DerSimonian R, Kacker R. Random-effects model for meta-analysis of clinical trials: an update. Contemp Clin Trials (2007) 28(2):105–14.10.1016/j.cct.2006.04.004
    1. Higgins JP, et al. Measuring inconsistency in meta-analyses. BMJ (2003) 327(7414):557–60.10.1136/bmj.327.7414.557
    1. Viechtbauer W. Conducting meta-analyses in R with the meta for package. J Stat Softw (2010) 36(3):1–48.10.18637/jss.v036.i03
    1. Sengul YS, Ozalevli S, Oztura I, Itil O, Baklan B. The effect of exercise on obstructive sleep apnea: a randomized and controlled trial. Sleep Breath (2011) 15(1):49–56.10.1007/s11325-009-0311-1
    1. Servantes DM, Pelcerman A, Salvetti XM, Salles AF, de Albuquerque PF, de Salles FC, et al. Effects of home-based exercise training for patients with chronic heart failure and sleep apnoea: a randomized comparison of two different programmes. Clin Rehabil (2012) 26(1):45–57.10.1177/0269215511403941
    1. Ackel-D’Elia C, da Silva AC, Silva RS, Truksinas E, Sousa BS, Tufik S, et al. Effects of exercise training associated with continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Sleep Breath (2012) 16(3):723–35.10.1007/s11325-011-0567-0
    1. Desplan M, Mercier J, Sabaté M, Ninot G, Prefaut C, Dauvilliers Y. A comprehensive rehabilitation program improves disease severity in patients with obstructive sleep apnea syndrome: a pilot randomized controlled study. Sleep Med (2014) 15(8):906–12.10.1016/j.sleep.2013.09.023
    1. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation (2007) 116(9):1081–93.10.1161/CIRCULATIONAHA.107.185649
    1. DeLany JP, Kelley DE, Hames KC, Jakicic JM, Goodpaster BH. High energy expenditure masks low physical activity in obesity. Int J Obes (Lond) (2013) 37(7):1006–11.10.1038/ijo.2012.172
    1. Quan SF, O’Connor GT, Quan JS, Redline S, Resnick HE, Shahar E, et al. Association of physical activity with sleep-disordered breathing. Sleep Breath (2007) 11(3):149–57.10.1007/s11325-006-0095-5
    1. Demeyer H, Louvaris Z, Frei A, Rabinovich RA, de Jong C, Gimeno-Santos E, et al. Physical activity is increased by a 12-week semiautomated telecoaching programme in patients with COPD: a multicentre randomised controlled trial. Thorax (2017) 72(5):415–23.10.1136/thoraxjnl-2016-209026
    1. Thorup C, Hansen J, Grønkjær M, Andreasen JJ, Nielsen G, Sørensen EE, et al. Cardiac patients’ walking activity determined by a step counter in cardiac telerehabilitation: data from the intervention arm of a randomized controlled trial. J Med Internet Res (2016) 18(4):e69.10.2196/jmir.5191
    1. Mendelson M, Tamisier R, Laplaud D, Dias-Domingos S, Baguet JP, Moreau L, et al. Low physical activity is a determinant for elevated blood pressure in high cardiovascular risk obstructive sleep apnea. Respir Care (2014) 59(8):1218–27.10.4187/respcare.02948
    1. Alonso-Fernández A, García-Río F, Arias MA, Mediano O, Pino JM, Martínez I, et al. Obstructive sleep apnoea-hypoapnoea syndrome reversibly depresses cardiac response to exercise. Eur Heart J (2006) 27(2):207–15.10.1093/eurheartj/ehi621
    1. Beitler JR, Awad KM, Bakker JP, Edwards BA, DeYoung P, Djonlagic I, et al. Obstructive sleep apnea is associated with impaired exercise capacity: a cross-sectional study. J Clin Sleep Med (2014) 10(11):1199–204.10.5664/jcsm.4200
    1. Hargens TA, Guill SG, Zedalis D, Gregg JM, Nickols-Richardson SM, Herbert WG. Attenuated heart rate recovery following exercise testing in overweight young men with untreated obstructive sleep apnea. Sleep (2008) 31(1):104–10.10.1093/sleep/31.1.104
    1. Rizzi CF, Cintra F, Mello-Fujita L, Rios LF, Mendonca ET, Feres MC, et al. Does obstructive sleep apnea impair the cardiopulmonary response to exercise? Sleep (2013) 36(4):547–53.10.5665/sleep.2542
    1. Lin CC, Hsieh WY, Chou CS, Liaw SF. Cardiopulmonary exercise testing in obstructive sleep apnea syndrome. Respir Physiol Neurobiol (2006) 150(1):27–34.10.1016/j.resp.2005.01.008
    1. Ucok K, Aycicek A, Sezer M, Genc A, Akkaya M, Caglar V, et al. Aerobic and anaerobic exercise capacities in obstructive sleep apnea and associations with subcutaneous fat distributions. Lung (2009) 187(1):29–36.10.1007/s00408-008-9128-0
    1. Vanhecke TE, Franklin BA, Zalesin KC, Sangal RB, deJong AT, Agrawal V, et al. Cardiorespiratory fitness and obstructive sleep apnea syndrome in morbidly obese patients. Chest (2008) 134(3):539–45.10.1378/chest.08-0567
    1. Kasai T, Floras JS, Bradley TD. Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation (2012) 126(12):1495–510.10.1161/CIRCULATIONAHA.111.070813
    1. West SD, Kohler M, Nicoll DJ, Stradling JR. The effect of continuous positive airway pressure treatment on physical activity in patients with obstructive sleep apnoea: a randomised controlled trial. Sleep Med (2009) 10(9):1056–8.10.1016/j.sleep.2008.11.007
    1. Drager LF, Brunoni AR, Jenner R, Lorenzi-Filho G, Benseñor IM, Lotufo PA. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax (2015) 70(3):258–64.10.1136/thoraxjnl-2014-205361
    1. Drager LF, Li J, Reinke C, Bevans-Fonti S, Jun JC, Polotsky VY. Intermittent hypoxia exacerbates metabolic effects of diet-induced obesity. Obesity (Silver Spring) (2011) 19(11):2167–74.10.1038/oby.2011.240
    1. Igelström H, Emtner M, Lindberg E, Åsenlöf P. Tailored behavioral medicine intervention for enhanced physical activity and healthy eating in patients with obstructive sleep apnea syndrome and overweight. Sleep Breath (2014) 18(3):655–68.10.1007/s11325-013-0929-x
    1. Mantoani LC, Rubio N, McKinstry B, MacNee W, Rabinovich RA. Interventions to modify physical activity in patients with COPD: a systematic review. Eur Respir J (2016) 48(1):69–81.10.1183/13993003.01744-2015
    1. Bock BC, Carmona-Barros RE, Esler JL, Tilkemeier PL. Program participation and physical activity maintenance after cardiac rehabilitation. Behav Modif (2003) 27(1):37–53.10.1177/0145445502238692
    1. Warren JM, Ekelund U, Besson H, Mezzani A, Geladas N, Vanhees L, et al. Assessment of physical activity—a review of methodologies with reference to epidemiological research: a report of the exercise physiology section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil (2010) 17(2):127–39.10.1097/HJR.0b013e32832ed875
    1. Chen KY, Bassett DR, Jr. The technology of accelerometry-based activity monitors: current and future. Med Sci Sports Exerc (2005) 37(11 Suppl):S490–500.10.1249/01.mss.0000185571.49104.82
    1. Plasqui G, Bonomi AG, Westerterp KR. Daily physical activity assessment with accelerometers: new insights and validation studies. Obes Rev (2013) 14(6):451–62.10.1111/obr.12021
    1. Hart TL, Swartz AM, Cashin SE, Strath SJ. How many days of monitoring predict physical activity and sedentary behaviour in older adults? Int J Behav Nutr Phys Act (2011) 8:62.10.1186/1479-5868-8-62
    1. Brage S, Ekelund U, Brage N, Hennings MA, Froberg K, Franks PW, et al. Hierarchy of individual calibration levels for heart rate and accelerometry to measure physical activity. J Appl Physiol (1985) (2007) 103(2):682–92.10.1152/japplphysiol.00092.2006
    1. Aiello KD, Caughey WG, Nelluri B, Sharma A, Mookadam F, Mookadam M. Effect of exercise training on sleep apnea: a systematic review and meta-analysis. Respir Med (2016) 116:85–92.10.1016/j.rmed.2016.05.015
    1. Iftikhar IH, Kline CE, Youngstedt SD. Effects of exercise training on sleep apnea: a meta-analysis. Lung (2014) 192(1):175–84.10.1007/s00408-013-9511-3
    1. Anandam A, Akinnusi M, Kufel T, Porhomayon J, El-Solh AA. Effects of dietary weight loss on obstructive sleep apnea: a meta-analysis. Sleep Breath (2013) 17(1):227–34.10.1007/s11325-012-0677-3
    1. Greenburg DL, Lettieri CJ, Eliasson AH. Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis. Am J Med (2009) 122(6):535–42.10.1016/j.amjmed.2008.10.037
    1. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep (2015) 38(5):669–75.10.5665/sleep.4652
    1. Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, et al. Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Med Rev (2016) 27:108–24.10.1016/j.smrv.2015.08.001
    1. Bailly S, Destors M, Grillet Y, Richard P, Stach B, Vivodtzev I, et al. Obstructive sleep apnea: a cluster analysis at time of diagnosis. PLoS One (2016) 11(6):e0157318.10.1371/journal.pone.0157318
    1. Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA (2009) 301(19):2024–35.10.1001/jama.2009.681
    1. American College of Sports Medicine. ACSM’s Metabolic Calculations Handbook. Philadelphia, PA: Lippincott Williams & Wilkins; (2006).
    1. McEvoy RD, Antic NA, Heeley E, Luo Y, Ou Q, Zhang X, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med (2016) 375(10):919–31.10.1056/NEJMoa1606599
    1. Jullian-Desayes I, Joyeux-Faure M, Tamisier R, Launois S, Borel AL, Levy P, et al. Impact of obstructive sleep apnea treatment by continuous positive airway pressure on cardiometabolic biomarkers: a systematic review from sham CPAP randomized controlled trials. Sleep Med Rev (2015) 21:23–38.10.1016/j.smrv.2014.07.004
    1. Committee PAGA. Physical Activity Guidelines Advisory Committee Report. Washington, DC: U.S. Department of Health and Human Services; (2008).
    1. Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation (2014) 129(25 Suppl 2):S76–99.10.1161/01.cir.0000437740.48606.d1
    1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jr, et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension (2003) 42(6):1206–52.10.1161/01.HYP.0000107251.49515.c2
    1. Stamler J, Rose G, Stamler R, Elliott P, Dyer A, Marmot M. INTERSALT study findings. Public health and medical care implications. Hypertension (1989) 14(5):570–7.10.1161/01.HYP.14.5.570
    1. Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA (2001) 286(10):1218–27.10.1001/jama.286.10.1218
    1. Way KL, Hackett DA, Baker MK, Johnson NA. The effect of regular exercise on insulin sensitivity in type 2 diabetes mellitus: a systematic review and meta-analysis. Diabetes Metab J (2016) 40(4):253–71.10.4093/dmj.2016.40.4.253
    1. Pamidi S, Tasali E. Obstructive sleep apnea and type 2 diabetes: is there a link? Front Neurol (2012) 3:126.10.3389/fneur.2012.00126
    1. Gordon B, Chen S, Durstine JL. The effects of exercise training on the traditional lipid profile and beyond. Curr Sports Med Rep (2014) 13(4):253–9.10.1249/JSR.0000000000000073
    1. Coughlin SS, Stewart J. Use of consumer wearable devices to promote physical activity: a review of health intervention studies. J Environ Health Sci (2016) 2(6).10.15436/2378-6841.16.1123
    1. Allet L, Knols RH, Shirato K, de Bruin ED. Wearable systems for monitoring mobility-related activities in chronic disease: a systematic review. Sensors (Basel) (2010) 10(10):9026–52.10.3390/s101009026
    1. Benzo R. Activity monitoring in chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev (2009) 29(6):341–7.10.1097/HCR.0b013e3181be7a3c
    1. Chiauzzi E, Rodarte C, DasMahapatra P. Patient-centered activity monitoring in the self-management of chronic health conditions. BMC Med (2015) 13:77.10.1186/s12916-015-0319-2
    1. Cook DJ, Thompson JE, Prinsen SK, Dearani JA, Deschamps C. Functional recovery in the elderly after major surgery: assessment of mobility recovery using wireless technology. Ann Thorac Surg (2013) 96(3):1057–61.10.1016/j.athoracsur.2013.05.092
    1. Fanning J, Mullen SP, McAuley E. Increasing physical activity with mobile devices: a meta-analysis. J Med Internet Res (2012) 14(6):e161.10.2196/jmir.2171
    1. Mendoza L, Horta P, Espinoza J, Aguilera M, Balmaceda N, Castro A, et al. Pedometers to enhance physical activity in COPD: a randomised controlled trial. Eur Respir J (2015) 45(2):347–54.10.1183/09031936.00084514
    1. Richardson CR, Newton TL, Abraham JJ, Sen A, Jimbo M, Swartz AM. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med (2008) 6(1):69–77.10.1370/afm.761

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