Introduction Intermittent claudication is a peripheral artery disease caused by arteriosclerosis. People with intermittent claudication experience leg cramping during walking, with relief of symptoms during rest. Evidence shows that by participating in supervised exercise therapy and smoking cessation programs, people with intermittent claudication can reduce those symptoms and improve health-related quality of life and maximal walking distance while minimizing the need for an operation. However, implementation of such health-promoting initiatives in clinical practice in Denmark and other countries is limited. This is a protocol presenting the implementation process of supervised exercise therapy and smoking cessation in a region of Denmark. Methods and analysis The implementation process is a collaboration between the municipalities in the Region of Zealand and the Department of Vascular Surgery at University Hospital Zealand. The study uses a convergent mixed-methods prospective clinical cohort design, and the theoretical frame of this implementation process follows the framework for Adapting an existing intervention to a new context (ADAPT). The process involves stakeholder engagement, ongoing evaluation through key performance indicators and relevant outcomes that will inform the implementation process across and within each municipality. Dissemination Dissemination will happen throughout the process through continued meetings with stakeholders and dissemination of performance indicators and outcome results obtained through a database. All information about the study and material will be freely available. The project is registred on Clinicalgov (NCT06299956).

The OUTPAC cohort study evaluates the setup and implementation of a nationwide Danish initiative focused on the impact of structured outdoor physical activity (PA) on individuals with rheumatic diseases. This prospective cohort study includes more than 1600 participants, predominantly women (92%), with an average age of 65 years (range: 28–93). The cohort primarily consists of individuals with osteoarthritis (72%), rheumatoid arthritis (18%) and nonspecific lower back pain (13%). Volunteer instructors conducted interventions in outdoor settings, targeting strength, balance, physical capacity, mental health, and interaction with nature. Data collection involved questionnaires and physical tests in four primary outcome domains: quality of life, pain, physical function and activity, and mental health. Despite moderate pain (VAS mean: 48.3), high medication use (71%), and serious fatigue (54%), participants indicated having a good quality of life (EQ-5D-5L mean: 0.81) and average mental health (WHO-5 mean: 62.9). Baseline scores from physical tests showed results comparable to the general population aged 60–69 years. The OUTPAC project offers clinical insight into the implications of outdoor PA interventions on individuals with rheumatic disease while shedding light on the development and implementation of a large-scale nationwide outdoor PA intervention. Future analyses will examine short- and long-term changes and potential determinants.

OBJECTIVE:To examine the benefits and harms of structured outdoor physical activity (PA) for people living with one or more somatic or mental diseases. METHODS:We identified articles from inception until Marts 2023 in MEDLINE, EMBASE, CINAHL and CENTRAL and citation tracking in Web of Science. We included randomized controlled trials (RCTs) and observational studies examining structured outdoor PA reporting physical function, health-related quality of life (HRQOL), pain or mental outcomes. We used random-effect meta-analyses and investigated heterogeneity in subgroups, sensitivity and meta-regression analyses. Observational studies and studies with insufficient data were summarized narratively. Certainty of evidence was assessed with GRADE. RESULTS:From 4098 hits, 20 studies (19 RCTs and 1 cohort) were included (n: 1759 participants). Studies varied in type of disease and intervention. End of intervention results suggested a small effect on HRQOL (k = 10, SMD = 0.45, 95%CI: 0.19 to 0.71) and physical function (k = 14, SMD = 0.39, 95%CI: 0.13 to 0.64), while effects were moderate on mental outcomes (k = 13, SMD = -0.52, 95%CI: -0.82 to -0.23) favoring the outdoor intervention over comparators (no intervention, usual care, indoor PA or outdoor intervention without exercise). We were not able to conclude on outdoor interventions' effect on pain. Four studies reported adverse events including non-serious (pain, falls, fatigue) and serious (hospitalization, pneumonia). Certainty of evidence was overall very low. CONCLUSION:Structured outdoor PA may improve HRQOL and physical function, as well as mental health outcomes. The very low certainty of evidence calls for high quality RCTs to determine benefits and harms of structured outdoor PA.

Aim To provide detailed descriptions of the amount of daily physical activity (PA) performed by people with multimorbidity and investigate the association between the number of conditions, multimorbidity profiles, and PA. Methods All adults (≥18 years) from The Lolland-Falster Health Study, conducted from 2016 to 2020, who had PA measured with accelerometers and reported medical conditions were included (n=2,158). Sedentary behavior and daily PA at light, moderate, vigorous, and moderate to vigorous intensity and number of steps were measured with two accelerometers. Associations were investigated using multivariable and quantile regression analyses. Results Adults with multimorbidity spent nearly half their day sedentary, and the majority did not adhere to the World Health Organization’s (WHO) PA recommendations (two conditions: 63%, three conditions: 74%, ≥four conditions: 81%). Number of conditions was inversely associated with both PA for all intensity levels except sedentary time and daily number of steps. Participants with multimorbidity and presence of mental disorders (somatic/mental multimorbidity) had significantly lower levels of PA at all intensity levels, except sedentary time, and number of daily steps, compared to participants with multimorbidity combinations of exclusively somatic conditions. Conclusion Levels of sedentary behavior and non-adherence to PA recommendations in adults with multimorbidity were high. Inverse associations between PA and the number of conditions and mental multimorbidity profiles suggest that physical inactivity increases as multimorbidity becomes more complex.

BACKGROUND:Research in Denmark indicates that approximately 30% of people with confirmed COVID-19 infection experience at least one physical symptom 6-12 months after the acute infection. The lived experiences of undergoing prolonged recovery processes and how these processes unfold need further attention.AIM:To contribute in-depth knowledge about recovery, as experienced over time by people living with the post COVID-19 condition.METHODS:Within a qualitative research design, nine women and six men were interviewed. Ten of them gave a follow-up interview. Prompt cards and participant-generated photographs were included. A phenomenological-hermeneutic approach inspired by Ricoeur's theory of interpretation guided the data analysis.FINDINGS:Living with long-term health problems associated with the post COVID-19 condition involved recovery processes where participants struggled with reduced capacity, new unpredictability and uncertainty in everyday life. Participants continuously searched for improvement and aimed for regaining former health and well-being. Lack of knowledge, acknowledgement and support made it difficult to find clear directions for improvement. Participants created a protective shield and struggled, often jointly with family and friends, to cope with bodily, cognitive, emotional, existential and social challenges. Over time, some participants realised that they might not be able to fully return to their earlier habitus. However, some of them gained a new foothold and sense of hope for the future.CONCLUSION:This study provides in-depth insight into the experience of changing and open-ended recovery processes while living with the post COVID-19 condition. Over time, some participants learned to rebuild their lives, adapting to their reduced capacities. Future care and rehabilitation models for these patients must address the complex and challenging nature of recovery processes associated with living with post-COVID-19 condition.

Introduction: Existing estimates of PD prevalence in Denmark are lower than those in the rest of Europe and are based on identification via single registries. Hence, are aim was to use a combined registry/self-report survey approach to identify people with PD and also investigate whether using different registry methods led to differences in the accuracy, completeness and characteristics of the identified cohorts. Methods: This study had a cross-sectional design using routinely collected health registry data to identify adults, >= 18 years of age and resident in Denmark, with PD from either the Danish National Patient (DNP) registry or Danish Prescription Medicines (DPM) registry. Those identified were asked to confirm their PD diagnosis using a national self -report survey. Results: 13,433 people were identified potentially as having PD via the DNP or DPM registry and sent a survey. Of these, 9094 responded (68 %) of which 85 % confirmed they had PD (n = 7763; 194/100,000; 95%CI:7650-7876). When adjusting for non -respondents, assuming an equal rate of confirmation in respondents and non -respondents, estimated Danish PD population was 11,467 (198.4/100,000; 95 % CI:197.2-199.6). Identification of people using those found in both registries led to 98 % confirming they had PD versus using one registry: DNP 93 % and DPM 88 %. No clear differences in sociodemographic characteristics were found between different registry identification methods. Conclusions: Estimated PD population in Denmark was significantly higher than previous Danish estimates and close to existing estimates in other European countries. The most accurate PD population was identified when including those found in both the DNP and DPM registries.

BACKGROUND:Little is known about delivering telehealth from a healthcare provider's perspective. PURPOSE:To investigate physiotherapists' (PTs) experiences in delivering live online exercise and education for people with knee osteoarthritis (OA). METHODS:This was a qualitative individual interview study with a thematic analysis approach. The interviewees were six PTs delivering 8 weeks of supervised online exercise and education for people with knee OA in secondary public care in Denmark. RESULTS:The three main themes were (1) From hands to words-on the transition from on-site to on-line physiotherapy, (2) Online selection-on the perceived barriers to managing a telehealth service and (3) Therapeutic relation under pressure-on the contextual difficulties in building relationships and alliances in online classes. CONCLUSION:The PTs in this study seemed to gradually come to terms with delivering first-line OA care online, appreciating advantages and new possibilities. PTs' initial apprehension towards this new form of physiotherapy service may be rooted in the traditional conception of physiotherapy as a predominantly manual profession but also in a lack of formal training in physiotherapy telehealth services. This study underlines the growing need for better and more formalised training in physiotherapy telehealth services to meet growing demands.

Arthritis significantly reduces health-related quality of life, causing pain, fatigue, and decreased physical activity. To address this, exercise is highly recommended. However, men are less likely to participate in rehabilitation compared to women. We detected the same tendency in a nationwide nature-based exercise program in Denmark, with only 8% male participants. Therefore, this qualitative study investigated what engaged and restrained men with arthritis from participating in a nature-based exercise program. We employed interviews as the primary method for data collection. Data were analyzed using Braun and Clarke’s thematic analysis, revealing key patterns in participants’ experiences. This study finds that the fourteen participants’ experiences revealed two themes: (1) meeting with the nature-based exercise program was confusing, motivating, and disappointing, and (2) the social aspect is less important. To better engage men, future programs should include a clear description of the concept of the exercise, high-intensity exercise, a reduced emphasis on social activities, and consistency in the instructors’ roles and guidance. Incorporating these findings can better address the needs and preferences of men, helping them feel more like individuals than patients.

Arthritis affects many individuals and can cause pain and limit physical functioning. Exercise is an important treatment option for individuals with arthritis; however, adherence to exercise programs can be challenging. A new initiative in Denmark has introduced nature-based exercises for patients with arthritis. This qualitative study aimed to explore the experiences of the individuals who participated in those exercises. The study used a hermeneutic-phenomenological approach and conducted along-side interviews with 12 women and three men who participated in nature-based exercise programs for arthritis. Analysis of the data revealed two main themes. The first theme highlighted the positive effects of being in nature, such as increased vitality, reduced pain, and a sense of well-being. The second theme emphasized the social benefits of participating in these exercises, including a sense of connection and community with others. Overall, this study suggests that incorporating nature-based exercises in treatment programs for arthritis could have significant benefits for individuals with this condition.

Objective To evaluate the feasibility of a mobile health-supported intervention in patients with cardiovascular diseases after completion of a cardiac rehabilitation programme. Methods The feasibility study was performed in two hospitals and one municipality in Region Zealand, Denmark. Eligible participants were ≥18 years old, participated in a supervised cardiac rehabilitation programme, had access to a mobile phone, and could walk 3 m independently. Participants received a 12-week intervention utilizing behaviour change techniques, consisting of action planning, text messages, and phone support. Feasibility was assessed using pre-defined progression criteria, which included recruitment (≥75%), retention (≥80%), accelerometer data completeness (≥80%), coordinator (phone support) time (≤30 min), the response rate on patient-reported outcomes (≥90%), adherence (≥75% respond to ≥75% of messages), and acceptability (≥75%). The secondary outcome of objective physical activity was assessed with accelerometers. Results Ten women and 30 men with cardiovascular diseases aged 63.5 (±9.8 SD) participated. The progression criteria for retention (90%), accelerometer data completeness (83%), coordinator time (9.9 min), adherence (83%), and acceptability (82%) were at acceptable levels, exceptions were progression criteria for recruitment (35%) being below acceptable levels for recruitment, and response rate on patient-reported outcomes (75%). High satisfaction (92.6%) with the intervention was found. All objectively measured physical activity levels remained unchanged from baseline to follow-up. No serious adverse events related to the intervention were reported. Conclusion Mobile health-supported maintenance of physical activity after cardiac rehabilitation completion was feasible, safe, and acceptable. Yet, changes to improve recruitment and response rate are needed before conducting a large-scale effect evaluation.

Objective To summarise the effectiveness of digital health maintenance interventions for subjectively and objectively measured physical activity level (PA) and physical function, fitness and health-related quality of life (HRQoL) after completion of phase II cardiac rehabilitation (CR). Methods We conducted a search for studies in MEDLINE, Embase, CENTRAL, and CINAHL (inception to May 2024). Independent reviewers selected and included randomised controlled trials (RCTs) using digital health interventions to maintain PA in patients with cardiovascular disease after phase II CR. Independent reviewers conducted data extraction, assessed the risk of bias using the Cochrane Risk of Bias 2 tool and rated the certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation – registered at PROSPERO: CRD42023396629. Results From 17,455 hits, 20 RCTs with 1801 participants were included. Risk of bias for most studies reporting on PA outcomes was rated as ‘some concerns’. Comparing digital health intervention with minimal intervention/usual care showed no effect of objective PA (standardised mean difference (SMD) 0.85, 95% CI: −0.07 to 1.77) and a small effect of subjective PA (SMD 0.37, 95% CI: 0.05 to 0.69) at the end of intervention both graded as very low certainty of evidence. We found very low certainty of evidence for moderate effects on physical function (SMD 0.63, 95% CI: 0.03 to 1.24), and low certainty of evidence for no effect on physical fitness (SMD 0.19, 95% CI: 0.05 to 0.34) and HRQoL (SMD 0.13, 95% CI: −0.02 to 0.28), I2= 0.00%) at the end of intervention. Conclusion Digital health interventions showed a small effect on subjectively measured PA, and no effect on objective PA, physical fitness and HRQoL, but may increase physical function after CR completion. Yet, the certainty of evidence is low and higher quality studies with longer follow-up duration are needed to guide this area further.

Aims: This study aimed to investigate the cross-sectional associations of stress and well-being with the total amount of sedentary activity and sedentary bouts in adults with diabetes and prediabetes. A secondary aim was to explore the sedentary activity pattern during a day in adults with diabetes and prediabetes. Methods: This cross-sectional study from the Danish Lolland-Falster Health Study categorized participants into diabetes (including both type 1 and type 2 diabetes) and prediabetes based on their HbA1c level and selfreported use of diabetes medication. Exposures were Perceived Stress Scale (scores >= 18 = moderate to high stress) and WHO-5 Well-Being Index (scores <= 50 = low well-being). Outcomes were total daily sedentary activity and sedentary bouts assessed with thigh-worn and back-worn accelerometers. Results: Among the 562 included adult participants, 15 % had low well-being and 65 % had moderate to high stress. Higher well-being was associated with lower total sedentary activity in participants with diabetes (-1.1 min/day, 95 % CI -2.0; -0.2, for every 1-point increase in WHO-score) and participants with prediabetes (-0.6 min/day, 95 % CI -1.1; -0.05, for every 1-point increase in WHO-score). No association was found between stress and sedentary activity. During a day, participants with diabetes were more sedentary with a mean difference of -0.7 h/day (95 % CI -1.1; -0.4) when compared with participants with prediabetes. Conclusions: This study found that higher well-being is associated with lower total daily sedentary activity in individuals with diabetes and prediabetes, while no association between stress and sedentary activity was found. These findings imply that individuals with diabetes and prediabetes and low well-being may need additional support to reduce time spent on daily sedentary activity.

BACKGROUND:Cardiac rehabilitation (CR) is recommended following acute coronary syndrome (ACS). Diabetes is a common long-term condition associated with ACS, and the inclusion of these patients in CR has been less studied. This study examines the referral, uptake, and completion rates in the CR pathway for ACS patients with and without diabetes to identify potential barriers in the CR pathway. METHODS:The study included patients aged 18 or above who were discharged after a diagnosis of ACS in the Central Denmark Region between 1 September 2017 and 31 August 2018. Diabetes information was obtained from three sources. Logistic regression models were used to examine the associations between having diabetes and the three outcomes: non-referral, non-uptake and non-completion. Results were reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS:A total of 2447 patients were eligible for the study, of which 457 (18.7%) had diabetes. Only non-uptake was found to be significantly associated with diabetes after adjustment for prespecified variables (OR = 1.38, 95% CI 1.01-1.90). Associations for non-referral (OR = 1.11, 95% CI 0.87-1.41) and non-completion (OR = 1.06, 95 %CI 0.73-1.53) were not found to be statistically significant between ACS patients with diabetes and those without diabetes. CONCLUSION:This study highlights a significant disparity in the uptake of CR between patients with and without diabetes following ACS, demonstrating that patients with diabetes require early promotion and increased assistance to enrol in CR.

AbstractBackground and AimsRehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well‐documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure.MethodsThis prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15−20 min face‐to‐face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi‐structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate.ResultsPhysiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety‐one percent data completeness was achieved. The intervention was well‐accepted by patients and health care professionals. The enrollment rate reached 79%.ConclusionThe novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full‐scale trial. The novel referral strategy was well‐accepted, and enrollment rate approached an acceptable level.

Background Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear. Objective This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions. Methods We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation. Results Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up. Conclusions Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention. Trial Registration PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028

Osteoarthritis (OA) is a leading global contributor to years lived with disability and accounts for the largest global increase in years lived with disability during the past 30 years among musculoskeletal conditions (Cieza et al., 2020). International guidelines recommend exercise therapy alongside patient education and weight management (if needed) as first-line treatment for all individuals with knee OA (KOA) (Bannuru et al., 2019). However, clinical care pathways for KOA do not seem to reflect these recommendations and community-based OA care is generally of suboptimal quality (Hagen et al., 2016). This is mirrored in a Danish health care setting, where only about 1/3 of patients who were referred to an orthopaedic assessment in secondary care (the hospital) had received exercise therapy and patient education during the preceding year in the period March 2018 to February 2019 (Ingelsrud et al., 2020). These numbers give reasons to believe that a substantial part of the current KOA waiting lists for orthopaedic assessment in secondary health care is comprised of inappropriate referrals (Mikkelsen et al., 2019), that is, artificially inflating waiting lists and wasting both the patient's and the orthopaedic surgeon's time in an inefficient use of the scarce resources in secondary health care. These scarce resources in secondary health care were evident during the extraordinary events of the COVID-19 pandemic, which created a big backlog of KOA patients waitlisted for orthopaedic assessment in secondary health care around Europe (Hampton et al., 2021; Uimonen et al., 2021). In Denmark, this led to a COVID-19 enforced initiative at one public hospital, introducing orthopaedic assessments by specially trained physiotherapists to reduce waiting lists and provide quicker referrals to appropriate KOA care. Using data from this clinical initiative, this report aims to describe patient and clinical characteristics along with patients' treatment preferences and expectations of treatment outcomes among wait-listed KOA patients to better understand referral patterns and health care seeking behaviour in current clinical KOA practice in Denmark. This was an observational cohort study conforming to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for reporting of observational studies. This study complied with the principles of the declaration of Helsinki and was waived from applying for approval with the Scientific Ethics committee of Region Zealand, Denmark (J.nr. 20-000013). The study was approved by the Danish Data Protection Agency (REG-149-2021). All patients received written and oral information about the study and use of patient data for analytic purposes and signed an informed consent. The study is based on cohort data collected as part of a COVID-19 enforced clinical initiative to reduce waiting lists for people with symptoms of KOA referred to the Orthopaedic Department at Næstved Hospital, Region Zealand, Denmark. Individuals with symptoms of KOA referred from primary care practice to secondary care for an orthopaedic assessment were distributed between orthopaedic surgeons and physiotherapists (PT), specially trained in knee assessments. For most initial referrals from primary care, it was not possible to derive information on prior treatment received. Thus, most referrals were distributed at random between orthopaedic surgeons and PTs. The data reported in this study is based on those KOA patients that were distributed to an orthopaedic assessment performed by the PT. The PT first performed an extensive objective assessment of the knee as well as collecting self-reported outcomes. Based on the assessment, the patient and the PT then decided whether he or she should start with an exercise therapy programme (either tele-based or in-person in the municipalities) or should be referred to the orthopaedic surgeon. Outcomes were collected and stored in two ways: (a) Through data entries in the national registry of Good Life with Osteoarthritis in Denmark (GLA:D®), which is a non-profit initiative, providing exercise and education for patients with knee and hip OA symptoms hosted at the University of Southern Denmark (Skou and Roos, 2017). (b) Through data entries in the electronic journal system of Region Zealand (“Sundhedsplatformen”). Additionally, as a standard part of their visit at the hospital, antero-posterior radiographs of the patient's index knee were obtained and subsequently evaluated. We included variables collected by the PT during the initial knee assessment, covering pain, function, prior treatment, the patient's treatment preferences and expectations of treatment outcomes along with structural OA (radiographs). We also included an overview of any re-referrals to the Orthopaedic Department at Næstved Hospital within a 6-month window from the initial knee assessment. Age, sex, and body mass index (BMI [kg/m2]). Pain (numeric rating scale (NRS) 0–10) during the past week, at rest, during the initiation of movement, during stair climbing and level walking. Subscale function from the short-form version of the Knee injury and Osteoarthritis Outcome Score (KOOS-12) (Roos et al., 2007). Structural OA severity (Kellgren & Lawrence grade, ranging from 0 (none) to 4 (severe)) (Kellgren and Lawrence, 1957), clinical OA diagnosis, using the European League Against Rheumatism (EULAR) scoring criteria (Zhang et al., 2010). Quality and appropriateness of prior treatment using the osteoarthritis quality indicator (OA-QI) (Østerås et al., 2013), and patient preferences for treatment (single-item answers) and expectations (5-point Likert scale; very small to very strong). Data were analysed using descriptive statistics presented as means (with standard deviations (SD)), Confidence Intervals (95% CI) or frequencies (with proportions, n (%)). During the period from May 2020 (start of clinical initiative) to May 2021 (end of clinical initiative), 2224 individuals with KOA symptoms were referred to an orthopaedic assessment at Næstved Hospital. Of these, 282 individuals (13%) were assessed by one of two specially trained PTs. The skewed distribution of referrals is due to the fact that Næstved Hospital has a high-volume orthopaedic department with ≥10 orthopaedic consultants. The 282 individuals were split into two groups depending on whether they required a referral to the orthopaedic surgeon (n = 25) or not (n = 257) (Figure 1, flowchart). Reasons for referring to the orthopaedic surgeon were multifactorial, based on the clinical assessment along with patients' treatment preferences and other conditions/symptoms requiring a second opinion by the orthopaedic surgeon. The group of patients, not referred to the orthopaedic surgeon were referred to exercise therapy online or onsite (Holm et al., 2023). For these patients, we searched for re-referrals to the orthopaedic surgeon in the electronic journal system up to November 2021 (final possible 6-month re-referral). A total of 74 patients (29%) were referred to the orthopaedic surgeon during this period, constituting planned (n = 17, 7%) and not planned (n = 57, 22%) re-referrals at initial PT-led orthopaedic assessment (Figure 1, flowchart). Flowchart of patients assessed by physiotherapists after referral to orthopaedic assessment. Overall, the mean age (SD) was 67.5 years (9.7), mean BMI (SD) was 29.8 kg/m2 (4.8) and 150 (53%) were female. Most patients had a radiographic KL grade of 3 (n = 125, 44%), followed by 2 (n = 77, 27%) and 4 (n = 69, 25%). 158 (56%) patients were identified as having a EULAR clinical diagnosis of KOA. With few exceptions, the two groups (referral to orthopaedic surgeon or not) had similar individual and clinical characteristics (Table 1). Overall, 214 patients (75%) chose exercise therapy with a PT as their preferred treatment. 181 patients (85%) who preferred exercise therapy with a PT as treatment had a moderate or strong expectation that this would reduce their pain and 190 (89%) had a moderate or strong expectation that it would improve their function. 214 patients (76%) had not received information about KOA in the last year and 199 (70%) had not consulted a PT within the last year. There were no noteworthy differences in prior treatment, treatment preferences and expectations among the two groups (referral to orthopaedic surgeon or not) (Table 2). The mean pass rate for OA-QI was 30% (proportion of ‘yes’ answers out of all ‘yes’/‘no’ answers throughout the 15 OA-QI questions) (Table 3). Considering that 9 out of 10 patients (91%) assessed by a PT in our study did not require a referral to the orthopaedic surgeon, our findings indicate that most of the assessed referrals from primary care to secondary hospital care were inappropriate. This is supported by the fact that 3 out of 4 patients had not received the recommended first line OA care (exercise and education) within the preceding year. These numbers clearly demonstrate an alarming underutilisation of recommended first-line OA care for patients with symptoms of KOA. Based on the OA-QI questionnaire, our included sample of patients had a mean pass rate of 30%, indicating that roughly two-thirds of OA care quality indicators are not achieved prior to orthopaedic referral. This number is similar to previous numbers reported for Denmark (median 23%–29%) (Ingelsrud et al., 2020; Østerås et al., 2015) but somewhat lower than for Norway (median 50%), Portugal (median 48%) and the UK (median 55%) (Østerås et al., 2015). Although numbers differ by country (at least partly due to different health systems), there is still overall room for improvement in care quality across these countries (Østerås et al., 2015). One driving factor of inappropriate referrals and inferior quality of care for KOA patients may be the attitudes and beliefs of the referrer, as highlighted in the scoping review by Nissen, Holm and colleagues (Nissen et al., 2021). Especially, general practitioners seem to have a prevailing outdated narrative of KOA as a wear and tear disease with knee replacement surgery as an inevitable end-stage treatment (Nissen et al., 2021). Coupled with a lingering less-than-positive attitude towards exercise as a treatment option (Nissen et al., 2021), this severely restricts referrals to exercise and education as first-line KOA treatment, despite existing clinical guidelines. Notably, our findings of roughly 3 out of 4 patients preferring PT-led exercise therapy as treatmente is somewhat in contrast to the findings by Ingelsrud and colleagues, who found that two-thirds of patients expected to be waitlisted for surgery (Ingelsrud et al., 2020). Although somewhat speculatively, our findings seem to question the weight of patient preferences in current treatment pathways, seemingly pointing to other reasons for inconsistent referral patterns. Patients also seemed to generally have a strong belief that exercise therapy could improve their symptoms—reflected by approximately 9 in 10 patients (85%–89%) having moderate to very strong expectations that exercise therapy would reduce their knee pain and improve function. 183 patients or 7 out of 10 patients who were referred to exercise therapy did not have a re-referral in the public system within 6 months (see Figure 1). Although we have no data on exercise therapy adherence rates or other referrals (e.g., private care referrals), this may imply that exercise therapy has been an appropriate first-line treatment for most of the assessed patients. Interestingly, individual characteristics, clinical characteristics, or treatment preferences did not seem to differ between those patients who did or did not require further referral to the orthopaedic surgeon upon the initial PT-led orthopaedic assessment. Since initial referrals were distributed predominantly at random between assessment with orthopaedic surgeons or PTs, we believe that the current sample of KOA patients referred to secondary public hospital care provides a representative outlook of current referral patterns. The included sample of patients with KOA symptoms were all initially assessed by a PT, who also performed the screening of all self-reported outcomes, including treatment preferences and expectations. Even though PTs were instructed not to initially advise in favour of any treatment, this setting may have introduced some desirability bias, where patients were inclined to favour exercise therapy with a PT over other treatments due to the screening context. This may be one underlying factor for the high number of patients preferring this treatment and needs to be taken into consideration. These numbers are based on a selected sample of patients (n = 282), representing 13% of a 1-year caseload to one Danish public hospital in one of five Danish Regions (Region Zealand); thus, we cannot necessarily generalise these findings to the entire Danish public health care sector or internationally. Based on our data of 282 patients, 9 out of 10 with symptoms of KOA are inappropriately referred to an orthopaedic assessment in secondary health care before receiving recommended first-line treatment. Coupled with the fact that 3/4 patients prefer a PT-led exercise therapy programme over surgery and other treatments, our report reinforces the urgent call for optimising current KOA care pathways to ensure that treatment is based on both evidence-informed recommendations and patient values and preferences. Study conception and design: Hinz, Bruhn, Tang, Skou, Holm. Recruitment of patients: Nyberg, Holm. Acquisition of data: Hinz, Nyberg, Holm. Analysis and interpretation of data: Hinz, Bruhn, Holm. Draughting the article or revising it critically for important intellectual content: Hinz, Bruhn, Tang, Nyberg, Skou, Holm. Final approval of the article: Hinz, Bruhn, Tang, Nyberg, Skou, Holm. All authors had full access to all the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. We would like to thank physiotherapists, doctors, nurses, secretaries and other staff at the Department of Physiotherapy and Occupational Therapy and the Orthopedic Department at Næstved, Slagelse and Ringsted (NSR) Hospitals involved in collecting data for this study. We would also like to thank Dorte T. Grønne, database manager of GLA:D®, for preparing and providing data from the GLA:D® registry. Finally, we would like to thank all the individuals with knee osteoarthritis who provided data for this study. This study was funded by a program grant from Region Zealand (Exercise First). Tang is funded by The Danish Health Confederation through the Development and Research Fund for financial support (project no. 2703) and Næstved-Slagelse-Ringsted Hospitals research fund, Denmark (project no. A1277). Holm is funded by a program grant from Region Zealand (Exercise First). Skou is currently funded by two grants from the European Union's Horizon 2020 research and innovation program, one from the European Research Council (MOBILIZE, grant agreement No 801790) and the other under grant agreement No 945377 (ESCAPE). These institutions had no role in the study design, collection, analysis and interpretation of data, in the writing of the manuscript, or in the decision to submit the manuscript for publication. Skou is co-founder of GLA:D®, associate editor of the JOSPT and has received grants from the Lundbeck Foundation and personal fees from Munksgaard, TrustMe-Ed and Nestlé Health Science, outside the submitted work. Data is available for sharing upon reasonable request. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

INTRODUCTION:Exercise is an effective component in rehabilitation of a range of chronic conditions. There is a growing interest in the use of exercise-based nature interacted rehabilitation (EBNIR), but an overview of current evidence is missing. The objective of this scoping review was to map existing exercise-based rehabilitation interventions conducted with incidental or intentional nature interaction focusing on its populations, types of outcomes, and theoretical rationale for people with physical and mental disabilities. METHODS:This scoping review identified peer-reviewed publications, registered upcoming trials and grey literature. To map all available knowledge, a comprehensive search of selected databases (MEDLINE; EMBASE; CINAHL; Cochrane; Web of Science; Pedro) from inception to October 2022. Data were synthesized in a thematic presentation guided by TIDieR, supplemented by a checklist developed for this study accounting nature incidental or intentional interaction. RESULTS:Twelve studies including 856 participants met the inclusion criteria. Eleven were completed trials and one was registered in clinicaltrials.gov to be run in 2023. A total of 856 patients were enrolled in the 12 studies (range 18-262, median 50). The included studies had great variation. The incidental or intentional interacted exercise-based interventions consisted of outdoor walks, neck exercises and surfing interventions in patients with physical or mental health conditions. CONCLUSIONS:This scoping review presents an overview of limited and diverse evidence within the field of EBNIR, in patients with physical or mental health conditions. Our review provides an overview that will be helpful in the design of future EBNIR trials.

Aim Evidence suggests low-grade inflammation (LGI) to be associated with multimorbidity. Furthermore, there are links between inflammation markers, physical activity (PA), and labour market participation. The aims of this study were to examine the association between PA and LGI in people with multimorbidity and if this association was moderated by self-reported labour market attachment. Methods Cross-sectional data were collected in the Lolland-Falster Health Study (LOFUS) from 2016–2020. We included 1,106 participants with multimorbidity and valid accelerometer data. PA was measured as the average counts per minute (CPM) per day during wake time and split in time spent in moderate to vigorous intensity (MVPA) and light intensity (LPA). Degree of inflammation was determined by high sensitive C-reactive protein (hsCRP) level. Associations were investigated using multiple logistic regression analyses, stratified by labour market attachment. Results The odds of having LGI was higher with lower amount of daily LPA. The highest odds of LGI was observed for CPM < 200 per day (odds ratio (OR) 2.55; 95% confidence interval (CI) 1.46–4.43), MVPA < 15 minutes per day (OR 2.97; 95 % CI 1.56–5.62), and LPA < 90 (OR 2.89; 95 % CI 1.43–5.81) with the reference groups being CPM ≥ 400 per day, MVPA ≥ 30, and LPA ≥ 180 min per day, respectively. We could not preclude an interaction between LPA and labour market attachment ( p = 0.109). Conclusion PA recommendations should be developed with attention to people with chronic diseases, who may experience barriers to reach PA at high intensities. People with no labour market attachment may benefit from primary and secondary prevention of multimorbidity.

Physical activity and exercise therapy appear safe and beneficial for people with multimorbidity and should therefore be considered in the prevention and management of multimorbidity, as argued in this review. General practitioners and specialists should refer people with multimorbidity to supervised exercise therapy (2-3 times/week for 8-12 weeks, strengthening or aerobic exercise or a combination), while encouraging and educating patients to improve physical activity to improve overall health by e.g., integrating physical activity in everyday-life practices such as gardening, transportation, and house chores.