Abstract
Behavioral interventions targeting moderate- to vigorous-intensity physical activity (MVPA) to ensure health benefits can be strengthened by a simple metric that helps adults understand if they are exercising at the target intensity. Laboratory studies have established that a cadence of 100 steps/min is equivalent to MVPA, but intervention application is largely unexplored. The aim of this narrative review was to describe how cadence has been implemented in behavioral interventions. PubMed, PsychInfo, and SCOPUS were searched with a standardized search string. Studies were included if peer-reviewed interventions reporting on targeting MVPA increases for adults through cadence or if non-intervention programs directly targeting cadence. Of 232 unique studies identified, 6 were included in the final sample. Cadence was monitored using subjective cues (n = 3), time-oriented goals (n = 2), step-counting (n = 2), auditory cues (n = 2), and visual cues (n = 2), and measured by pedometers (n = 5) or mp3 player (n = 1). No studies reported detailed participant instructions to teach cadence. Results suggest that use of cadence in behavioral interventions is feasible but nascent. Reviewed studies provided insufficient detail to replicate methods and there was no consensus on best practices for implementing cadence. Results point to the potential utility of cadence and offer approaches for future refinement and standardization.
“Consensus on the best way to define cadence may lead to broader adoption of cadence as an intervention target in lifestyle physical activity interventions.”
Introduction
Regular physical activity (PA) is associated with numerous positive health outcomes such as a reduced risk of chronic disease, and is inversely related to all-cause mortality.1-3 Public health guidelines recommend that adults should complete at least 150 minutes of moderate-intensity aerobic PA, 75 minutes of vigorous-intensity aerobic PA, or an equivalent combination of the two each week. 3 Despite the benefits of regular moderate-to vigorous-intensity physical activity (MVPA), less than half of adults in the United States meet the public health guidelines for MVPA. 3 Insufficient PA burdens society through direct health care costs and lost productivity. 4 Approximately $117 billion in annual aggregate health care expenditures in the United States are associated with insufficient PA.3,5
One potential strategy for promoting MVPA is through the use of walking interventions. Targeting walking in interventions has proven effective in increasing participants’ PA levels. 6 Walking is a natural, continuous aerobic activity that is easily accessible for most people in the general population without major mobility limitations. 7 It does not require special equipment, has a low risk of injury, and can be performed in a variety of settings.6-8 Pedometer-based step goals or step count monitoring and accelerometry are largely utilized in PA interventions focused on increasing walking. Prescription of walking in PA interventions using these methods include feasible and attainable goals for participants to reach such as achieving a daily step goal, completing walking sessions, or recording the number of steps taken after a certain period of walking.9,10 However, people typically engage in walking at light and moderate intensities, and thus it may not be a good representation of the full spectrum of physical activity (i.e., vigorous).11-13 While walking interventions may increase the time participants spend engaging in PA and have benefits associated with mitigating physical inactivity, these interventions often do not include advice for achieving at least MVPA or provide direction on how to monitor intensity. Therefore, an easy-to-implement tool is needed to support participants to reach and maintain activity at the targeted MVPA level.
Using cadence (steps/min), is a potential strategy for targeting MVPA within walking interventions. Cadence is an individual’s walking speed characterized by the number of steps taken per minute. 14 Promising evidence from large epidemiologic studies has shown that higher step intensity, measured as cadence, is related to lower mortality and disease risk reductions,15-17 including 2 studies that found that this risk reduction to be independent of total daily steps.16,17 In controlled laboratory settings, a heuristic cadence of 100 steps per minute has been consistently established as a cut point for walking at a moderate-intensity for adults between the ages of 20 to 85.14,18-24 Furthermore, 100 steps per minute has been shown to be a feasible cadence for adults to achieve while exercising25-27 and requires inexpensive equipment such as metronomes and pedometers.14,18,28 Thus, cadence may be a feasible and potentially cost-effective strategy to promote MVPA in a variety of populations. 23
Despite the promise of targeting cadence, past research demonstrates that adults do not tend to walk naturally (i.e., unprompted) at a moderate-intensity cadence or higher and that this may be particularly difficult for insufficiently active adults.14,29 For example, one study found that when looking at the self-selected cadences of adults, walking at a self-selected moderate-intensity cadence rarely occurs, with just an average time of 7 minutes a day at a moderate-intensity cadence. 25 Prior evidence has shown that adults tend to spend the majority of their time walking at cadences of less than 100 steps per minute. In one study, the average cadence of adults was found to be 76 ± 6 steps per minute and continuous walking accounted for only 12% of total daily walking time. 26 Without sufficient guidance, insufficiently active adults may not reach or maintain the appropriate cadence to experience the positive health outcomes associated with regular MVPA.
The utility of cadence in behavioral interventions and best practices for its implementation have not been well characterized to date. The purpose of this narrative review is to describe how cadence has been implemented in behavioral interventions with adults, including how it is explained to participants, what devices have been used to measure cadence, how participants are taught to self-monitor cadence, and what the impact of these interventions has been on PA.
Methods
Given the early stages of research in the area of cadence in behavioral interventions, a narrative review format was selected, to provide the first steps of evidence synthesis in this area. A standardized search string was implemented to identify candidate studies through the PubMed, PsychInfo, and Scopus databases in December 2021 and refreshed in March 2023 and October 2023 to ensure studies published in the interim period were accounted for.
The search string was constructed with equivalent parameters across the three databases (PubMed, PsycINFO, and SCOPUS); additional snowball searches of citations from retrieved articles and relevant review papers were manually conducted to identify additional studies. For example, the following was used in PubMed: (((“Physical activity” [Title/abstract] OR steps [Title/abstract] OR jog [Title/abstract] OR jogg* [Title/abstract] OR jogs [Title/abstract] OR walk* OR running [Title/abstract] OR run [Title/abstract] OR runs [Title/abstract] OR “moderate-intensity” [Title/abstract] OR “moderate intensity” [Title/abstract])) AND ((cadence [Title/abstract] OR “real-time cadence” [Title/abstract]) OR (“step-count*” [Title] OR “step count*” [Title]OR tempo [Title] OR “Steps per minute” [Title] OR “counts per minute” [Title]; OR “step frequency” [Title] OR “step rate” [Title] OR “stride frequency” [Title] OR “stride rate” [Title] OR walking tempo [Title]))) AND ((monitor* [Title/Abstract] OR track* OR pedomet* [Title/Abstract] OR acceleromet* [Title/Abstract]) AND (“intervention”) AND English [Filter]).
Given the formative nature of the use of cadence in behavioral interventions, broad inclusion criteria and minimal exclusion criteria were used to screen studies. Studies were included if they (1) targeted cadence as a tool to promote MVPA, and (2) if an intervention, aimed to increase the MVPA of participants. Exclusion criteria included non-human studies, non-intervention studies (i.e., surveillance studies) that did not directly target cadence, non-English studies, protocol papers, review papers, dissertations, conference proceedings, or studies that did not use cadence to assist participants in exercise at MVPA or did not aim to increase the MVPA of participants. Records from the databases were retrieved and imported into Zotero, where duplicates were totaled and removed. The remaining records were screened to determine eligibility with a title and abstract review, followed by a full article review. A standardized form for data extraction was then completed using Microsoft Excel. Records were evaluated based on several open-ended items that explored: (1) general characteristics of the sample and study design, (2) establishment and use of cadence cut points, (3) communication with participants regarding cadence, (4) strategies for self-guiding cadence during the intervention, (5) instruments used to assist participants in guiding their cadence, and (6) changes in PA from pre- to post-intervention. The second author (TIW) read all eligible studies and extracted relevant data.
Results
Overview
A total of 248 studies were initially identified; the flow of search results is shown in Figure 1. Fifty were then excluded as they were duplicates (n = 47) or not peer-reviewed (n = 3) leaving a total of 198 for title review. After a review of the titles, studies were excluded (n = 131) if they did not use step-cadence to assist participants in exercise at MVPA (n = 111), or did not aim to increase the MVPA of participants (n = 17). Following an initial screening, 67 records were left for an abstract review, where 230 were excluded as they did not use cadence to assist participants in exercise at MVPA (n = 23), or did not aim to increase the MVPA of participants (n = 7). The full text of 37 studies were evaluated and an additional 31 studies were excluded, as they did not use cadence to assist participants in exercise at MVPA (n = 27), or did not aim to increase the MVPA of participants (n = 4) resulting in an analytic sample of 6 studies. Screening and selection procedures for identifying articles to be included in the review and the number of articles meeting different criteria at each phase.
General Study Characteristics
Description of Studies (n = 6) Included in Narrative Review.
Participant Instruction About Cadence
Several methods were used to instruct participants on reaching a cadence in MVPA (Table 1). In 2 studies, instructions were provided for reaching a target cadence to accumulate at least 3000 steps per day at a moderate-intensity cadence of 100 steps per minute and to increase their total number of steps per day.31,34 In 3 other studies, instructions were provided for reaching a target cadence focused on accumulating at least 150 minutes/week of MVPA in bouts lasting at least 10 minutes in duration.32,33,35 In the last study, minimal instructions for reaching a target cadence were provided; instead, participants were instructed to select pre-determined music playlists and walk to the beat of the music for the duration of the playlist. 30
Cadence for MVPA
Two strategies were used to establish cadence cut points for MVPA (Table 1). Cadence cut points were in four interventions through previous literature.23,25,28,35 Three of the four interventions used a heuristic cadence of 100 steps per minute. In the other intervention, stride-rate calculations from previous literature were used to individualize cadence cut points of participants. 30 Aerobic fitness testing were used in the remaining two interventions to establish individualized cadence cut points for participant.32,33 Before the start of each intervention, aerobic fitness testing was completed and participants’ cadence was calculated based on 40% of VO2 reserve.32,33
Strategies Used for Self-Guiding Step-Cadence
Five strategies were used to assist participants in self-guiding their cadence; 4 studies used a single strategy,26,27,30,35 and 2 studies used multiple strategies.31,34 Strategies used included step-counting techniques, time-oriented goals, auditory cues, visual cues, and subjective cues (Table 1).
Step-Counting Techniques and Time-Oriented Goals
Two studies used step-counting techniques, in combination with time-oriented goals, to assist participants with self-guiding their cadence.31,34 One study provided information to participants on how to monitor their steps while walking for a set amount of time, aiming for 30 minutes with at least 3000 to 4000 steps accumulated (i.e., ≥100 steps per minute). 31 In the other study, participants were taught to count the number of steps necessary to complete regularly walked routes within a pre-determined time. 34 Time-oriented goals were calculated by dividing the total number of steps required to reach a destination by the desired cadence.
Auditory Cues
Two studies used auditory cues derived from music to assist participants with self-guiding their cadence.30,34 In one study, participants were instructed to walk to music measured at 100-105 beats per minute. 34 Information regarding music selection was not provided in this intervention. In the other study, individualized workouts were designed for each participant based on the American
College of Sports Medicine’s guidelines for sedentary adults, with playlists developed to match the workouts. 30 The music preferences of participants were considered, and selected songs were manipulated to match the participant’s target cadence via a music editing program. 30 Music manipulation involved adjusting the tempo of the music by ± 5 beats per minute, as further manipulation of beats per minute was reported to noticeably distort sound quality. 30 Playlists were then manually assessed by tapping to the beat to ensure beats per minute matched the appropriate cadences of participants. 30 Neither study provided information regarding how participants were taught to walk in stride to the beat.30,34
Visual Cues
Two studies used visual cues to assist participants with self-guiding their cadence.32,33 Both studies used the StepsCount Pedometer from Piezo Rx to display visual icons and targeted cadences of participants were pre-programmed into the devices. Visual cues were presented on the interface of pedometers when participants reached and maintained the targeted cadence for 10 minutes.32,33 The visual icon of a star was used in both studies. In one of the studies, the accumulation of 15 stars was used as an outcome goal. The accumulation of 15 stars indicated that participants had accumulated 150 minutes of MVPA over the course of the week. 33
Subjective Cues
Three studies used subjective cues.31,34,35 Two studies used them in combination with other strategies, to assist participants with self-guiding their cadence. Here, subjective cues based on previous experiences walking at a known moderate-intensity cadence. Subjective cues involved participants assessing their efforts and reflecting on how their heart rate and breathing rate compared to previous experiences.31,34 These studies did not provide information regarding participants’ previous exposure to the targeted cadence before the intervention. The third study used a training session in the baseline assessment, where participants learned about perceived exertion and moderate intensity exercise during a medically supervised treadmill test. 35 Researchers noted they aimed to educate participants about perceived exertion such that they could continue to exercise at moderate intensity once the intervention was complete. 35
Instruments Used
The studies reviewed used either pedometers or mp3 players to assist participants with self-guiding cadence. The types of devices used in each study can be found in Table 1. In five studies, pedometers were the primary device implemented to assist participants in self-guiding their cadence.31-34 In one study, a portable music-playing device was used to assist participants with self-guiding cadence. 30
Physical Activity Outcomes
PA outcomes were reported in five of the included studies (Table 1; 31 – 35 ). Four of these studies reported statistically significant changes in PA levels.31-34 Three studies reported significant increases in time spent in MVPA compared to the controls.31-33 One study reported a statistically significant difference in PA levels when compared to other treatment groups. 34
Discussion
This narrative review aimed to describe how cadence has been implemented in PA promotion interventions, including its impact on participants’ PA levels. Results of this review show that the implementation of cadence in PA interventions is still relatively new, and further research is needed to identify best practices for its implementation. At the time of this review, 6 studies were identified that used cadence as a strategy to target MVPA in a behavioral intervention. Within these 6 studies, methods for defining and describing cadence to participants differed. Several innovative and promising strategies for teaching participants how to self-monitor cadences emerged including the use of music and visual icons to guide participants in reaching and maintaining targeted cadences.
Consensus on the best way to define cadence may lead to broader adoption of cadence as an intervention target in lifestyle physical activity interventions. Laboratory-based research has established that a heuristic cadence of 100 steps per minute is equivalent to moderate-intensity PA for adults between the ages of 20 to 85.14,18-24 However, within the studies reviewed, participants’ targeted MVPA cadence was defined in various ways. Within the studies reviewed, only 3 implemented the heuristic cadence of 100 steps per minute.31,34,35 The other 3 studies reviewed did not implement the 100 steps per minute cadence target and defined cadence to participants through individualized cadences based either on stride-rate calculations or through aerobic fitness testing.30,32,33 Although each methodology used resulted in participants reaching a MVPA cadence, future work may aim to investigate the benefits and limitations of employing such methods.
Further, evidence suggests that immediately after structured interventions, walking and activity may decline.12,36 To avoid this, strategies are suggested to support continued PA after interventions, such as peer groups or a maintenance phase, a period following the intervention to encourage activities included in the intervention, which could combat diminishing levels of activity post-intervention.12,36 Therefore, while interventions incorporating cadence to reach MVPA are promising, other factors need to be considered to gain a fuller picture of long-term adherence and the feasibility of incorporating cadence methods post-intervention into everyday life.
Other evidence gaps that emerged include the lack of consistent terminology and implementation methods, which have the potential to cause confusion and result in miscommunications across the realm of PA research and professions. 37 To prevent inconsistencies in the application of cadence in behavioral interventions, future research should endeavor to establish a consistent methodology for identifying, defining, and implementing target cadence for different age groups and populations. Given the narrow, yet consistent evidence from laboratory-based cadence research to date, researchers planning future behavioral interventions with adults should consider using cadence via the implementation of the heuristic target cadence of 100 steps per minute14,18-24 to standardize the approach until more is known about the most effective practices or recommendations.
Studies reviewed in this narrative used similar devices for measuring and assisting participants in reaching a MVPA cadence. However, the methodology in which devices were used varied. In two of the studies, pedometers were primarily used to indicate to participants when they had reached and maintained the targeted cadence for at least 10 minutes.32,33 This informed participants that they were walking at the targeted cadence and provided them with an objective to complete. However, it should be noted that the specific model of pedometer used in these studies (PiezoRX) contained additional features beyond a standard pedometer, allowing it to assess PA intensity levels. 38 In comparison, the other 3 studies used traditional pedometers to track steps taken.31,34,35 Although step tracking is a viable strategy for the promotion of PA, step tracking via a standard pedometer does not allow for the assessment of PA intensity. 39 It is worth noting that more advanced wearable PA devices such as Fitbit include features that record time spent in device-defined levels of PA intensity (the “Active Zone”), roughly equivalent to MVPA. 40 Using these devices to target and monitor MVPA may be a viable alternative to using cadence, although a benefit of cadence is that it is device agnostic and accessible with even the least expensive of step counting devices. It also makes the process of perceiving and monitoring MVPA more tangible and transparent as it is directly tied to something the participant can control—their pace of walking. Studies targeting cadence also used a variety of promising strategies for assisting self-guiding participants in reaching and maintaining targeted cadences. In general, strategies focused on achieving broader PA goals such as increasing the total number of daily steps, time spent in MVPA, and the completion of exercise-related tasks. These strategies were successful in assisting participants to reach the target cadence and resulted in statistically significant increases in MVPA. However, when cadence treatment groups were compared to other treatment conditions PA results varied.31,34
Strengths and Limitations
There are limitations to this narrative review that should be considered. The primary limitation of this review is the small number of studies available. Furthermore, the current review was a narrative review rather than a systematic review. Given that the implementation of cadence within interventions is still in the formative stages, a narrative review was used to gain a broad understanding of the evidence to date of cadence implementation in behavioral interventions. 41 Additionally, only articles in English on PubMed, PsychInfo, and SCOPUS were reviewed, so it is possible that search restrictions led to missed literature. Inclusion criteria were broad given the early stages of the research to include both intervention and non-intervention programs that directly targeted cadence. However, we did not find any non-intervention studies that met the criteria of directly targeting cadence. Therefore, we attempted to capture how cadence was implemented in other settings. Despite these limitations, this review provides insight into the formative use of cadence within behavioral interventions focused on promoting MVPA. Given that the implementation of cadence within behavioral interventions is relatively new, this review provides insights for the development of future interventions using cadence as a PA tool to continue to expand this important area of research and offers potential recommendations for standardizing this approach until more effective practices are established. Additionally, while step-cadence is not currently an explicit part of national PA guidelines (e.g., for the US, Canada, or Australia),3,42,43 recent calls have been made suggesting that future PA guidelines should incorporate step-based including cadence, 44 further underscoring the need for information about how best to promote uptake of these metrics to change behavior.
Conclusion
Although cadence is a promising strategy for targeting MVPA within behavioral interventions additional research is necessary to determine best practices for its implementation. Given that the use of cadence within behavioral interventions is in the formative stage, it is important to inform future behavioral interventions using cadence on previously used practices for communicating, self-guiding, and measuring cadence. However, the studies reviewed did not provide sufficient details to replicate methods beyond recommending that future researchers might consider implementing the heuristic target cadence of 100 steps used in some studies.14,18-24 Future behavioral interventions implementing cadence should provide detailed information regarding how cadence is defined and implemented to assist participants in reaching and maintaining targeted cadences. Transparency in defining and implementing cadence may aid future researchers in replicating and evaluating the effectiveness of such methods. Despite the limited details provided, studies reviewed showcased a variety of potentially promising and cost-effective strategies for self-guiding and measuring cadence. Reviewed practices for implementing, communicating, self-guiding, and measuring cadence in behavioral interventions warrant future exploration, refinement, and evaluation.
Footnotes
Acknowledgments
The authors wish to thank Danielle Guess for her assistance with the formative searches and development of the review strategy. Partial support for this project was provided by a grant from the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R21HD100743, PI Jake-Schoffman). There was no additional funding for the project. A poster reporting on the preliminary results of this study was presented at the Annual Meeting of the Society of Behavioral Medicine, April 27, 2023 in Phoeniz, AZ. The authors declare they have no conflicts of interest.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; (R21HD100743).
