General program: Co-I
Mental health program: PI
National Heart, Lung, & Blood Institute (NHLBI)
Pennsylvannia Department of Health
Penn State University
THE BIG PICTURE:
Exercise is a proven method for preventing or modifying several chronic diseases, but few people get enough of it to truly benefit.
It's all about fun. Our team identified a lack of enjoyment or fun as a fundamental reason for people not starting exercise or sticking with it over time.
We developed and fine-tuned a novel exercise program (PlayFit) to make exercise more enjoyable and promote long-term use.
PlayFit is being studied in different groups of users to better understand its short- and long-term benefits.
Overview & Theoretical Framework
Roughly 80% of U.S. adults fail to meet physical activity guidelines (see figure below), dramatically increasing their risk for chronic disease, and costing ~$117 billion in annual health care costs. Our research team at Penn State developed and tested a novel program called “PlayFit” to promote sustained physical activity among sedentary adults. The simple, yet powerful, idea behind this program was that people generally do not get enough enjoyment out of the typical exercise experience to sustain it long-term.
Enjoyment can influence behavior through the experience and expectation of pleasure (or displeasure). In the scientific literature, enjoyment of physical activity appears to indeed be a key predictor of exercise initiation and adherence over time.
Initial Pilot Work
Inspired by the popularity of Pickleball—a version of tennis modified to reduce effort, with a smaller court and plastic ball—we settled on a design for a positive, enjoyable, supportive PA program consisting of several modified sports. Each sport could be rotated to provide variety and minimize overuse injuries. We first recruited 14 adults for pilot studies in which we modified 10 commonly-played sports to reduce effort (e.g., smaller court; lightweight volleyball for soccer) and to maximize positive playful social interactions (e.g., choosing sides randomly each session; scheduling opportunities for socializing and frequent encouragement by staff; switching players if scores became lop-sided; minimizing physical contact).
The Second Pilot
In our second pilot of the PlayFit program, 22 adults participated for a period of 3 months. Five sports (e.g., kickball) were removed due to inadequate energy expenditure, leaving 5 (soccer, ultimate Frisbee, ultimate football, team handball and netball) that have a similar set of rules and, based on accelerometry, at least 88% of time is in the moderate-to-vigorous range and 24% in the vigorous range. Satisfaction, measured after each session using the Net Promoter Score, was high (7.7-8.4 out of 10). The comments were VERY positive, highlighting how the program was able to promote positive affect (“fun” was most frequent descriptor) while still being physically rigorous. A sample of participant comments about PlayFit are pictured below.
You can read more about the study in our published paper in the Journal of Physical Activity and Health.
The Randomized Controlled Trial
Starting in 2018, our team was awarded major research funding from the NIH's National Heart, Lung, & Blood Institute (NHLBI) to definitively study PlayFit on a larger scale (280 adults) in a randomized controlled trial. This trial is currently active and is rigorously testing whether PlayFit leads to greater fitness gains versus a conventional group fitness comparison group over 12 months. Importantly, the results of this study have potential to help patients, providers and fitness center directors make better recommendations concerning what types of exercise programs should be offered to sedentary adults to promote long-term adherence and fitness.
In you are interested in the nitty gritty details of the trial, we have published the protocol paper (2021) (PDF download) in Contemporary Clinical Trials Communications.
Adapting PlayFit for the COVID-19 Pandemic
The problem. The COVID-19 pandemic has caused major disruptions to how people around the world live their day-to-day life. Physical activity has been noted to be decreased since the pandemic started in some large-scale studies. The reasons for this are many and complex, but factors such as mandatory stay-at-home orders, quarantines, and fears related to disease contraction and transmission feature prominently.
The study. Our team enrolled 17 healthy (though sedentary) participants to investigate the feasibility, acceptability, and short-term adherence to the PlayFit program following its modification to incorporate COVID-19 risk mitigation strategies.
Major results. The PlayFit program modified for safety (e.g., social distancing, universal masking) had an outstanding overall session adherence rate of 91%. Critically, no participants reported new or existing COVID-19 symptoms or diagnoses during the study period. We learned that despite enforcing numerous safety measures, participants still reported enjoying the program and feeling socially connected. As an added bonus, the new safety procedures also contributed to an enhanced feeling of safety among participants.
Adapting PlayFit for People Experiencing Psychological Distress (PlayFit-D)
Exercise as Medicine. As it turns out, exercise is a really powerful form of medicine for mental health, with strong empirical support for its power to reduce troubling symptoms associated with several mental health problems. Yet, as with most lifestyle behaviors that are good for you, the research literature also shows that exercise must be maintained long-term to sustain the mental health benefits.
Special Barriers to Exercise in Mental Health. Unfortunately, barriers to exercise are even more amplified and numerous for those with one or more forms of psychological distress (e.g., reduced capacity to experience reward, low motivation). Because of this special challenge, we need better ways to engage this group and keep them active.
PlayFit as a Possible Solution? Enter PlayFit. While our previous work with the PlayFit program led to the creation of an exercise experience that was more appealing to the general population, when focusing on those with distress, it would need to be tailored to the unique needs of that group. Our team was awarded pilot grant funding from the Pennsylvania Department of Health to adapt PlayFit for physically inactive people in Central PA living with distress.
The Pilot Study. Following recruitment, we enrolled 11 adults aged 26-70 with a sedentary lifestyle and active symptoms of distress (e.g., self-reported symptoms of depression via structured clinical interview), while also meeting other eligibility criteria. We first conducted focus groups (led by yours truly) to understand basic barriers to exercise as well as gain early feedback on the PlayFit program concept, tentative protocol, and materials. Focus group feedback was recorded, transcribed and analyzed by our team to make appropriate adjustments to the program and the broader study procedures prior to testing the adapted PlayFit-D prototype.
Next, our study participants engaged in 8-weeks of outdoor PlayFit sessions from August-October 2021, at a rate of 3-days per week. Because we offered the program during the COVID-19 pandemic, we also implemented several safety precautions suggested by amateur and professional sport agencies and University mandates (e.g., pre-participation health screenings, temperature checks). Beyond formal assessments of mental health and other variables of interest at baseline and post-intervention, we also collected data during active sessions each week (e.g., post-session surveys, behavioral observation) in order to gauge acceptability, usability, and intervention fidelity, as well as actively problem-solve. I personally attended most sessions (I sometimes enjoy field work) and this form of feedback was powerful.
Preliminary Results. With the major caveat that the study sample size was small, enjoyment of PlayFit in this group appeared to be significantly greater than enjoyment of other past physical activity experiences...Hooray for PlayFit! More importantly, participants really enjoyed the experience according to our qualitative assessments (see quotes below), subjective observations during sessions, and on self-reported quantitative measures (e.g., Net Promoter Score). There was also qualitative and quantitative evidence to suggest that the adapted PlayFit program provided some relief from distress-based symptoms. Overall, the pilot study was very fruitful and early results are promising. A table of selected quotes and self-reported satisfaction scores are included in the table below.
Next Steps. Our team is currently working on a manuscript to report our findings. Based on our gathered insights, PlayFit-D will need to be further adapted and tested in a larger sample to better estimate its impact among those dealing with common mental health struggles.