Retraining the Automatic Reaction to Physical Activity and Sedentary Stimuli in Adults 60 Years of Age or Older
Phase: NA
Conditions: Aging
Sponsor: University of Ottawa

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25/10/2022 
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Retraining the automatic reaction to physical activity and sedentary stimuli in adults 60 years of 
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age or older: A cognitive bias modification protocol 
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ABSTRACT 
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Background: To counteract the pandemic of physical inactivity, current interventions mainly rely on 
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reflective processes that focus on increasing the motivation to be physically active. Yet, while these 
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interventions successfully increase intention, their effect on actual behavior is weak. Recent findings 
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suggest that this inability to turn the intention into action is explained by negative automatic reactions to 
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stimuli associated with physical activity. These automatic reactions could be particularly strong in older 
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adults, who are more likely to associate physical activity with fear, pain, or discomfort. Objective: The aim 
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of this program is to test the effect of an intervention that targets the automatic processes underlying 
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physical inactivity in older adults. Training older adults to inhibit the automatic attraction toward sedentary 
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stimuli is hypothesized to increase physical activity, thereby contributing to improving physical functioning 
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and quality of life. Methods: To test these hypotheses, older adults will be enrolled in a controlled double-
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blinded study with a 1, 3, 6, and 12-month follow-up. Participants will be randomized (1:1 ratio) to receive 
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a 12-session cognitive-bias modification training for 3-week based on a go/no-go task in an experimental 
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or a control condition (placebo). The primary outcome will be the number of steps per week. Secondary 
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outcomes include automatic approach-avoidance tendencies, explicit affective attitudes toward physical 
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activity, physical function, and quality of life. Discussion: The study is expected to inform public-health 
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policies and improve interventions aiming to counteract the pandemic of physical inactivity.  
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KEYWORDS: Attentional Bias, Aging, Exercise, Sedentary Behavior 
 
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Background 
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Over the past two decades, society has encouraged people to be more physically active [1-3]. As a 
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result, most individuals are now aware of the positive effects of regular physical activity and have the 
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intention to exercise [4]. Yet, this intention is not sufficient, as exercise plans are often not executed [5]. 
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Despite gradually scaling up actions that promote physical activity over the years, people are becoming less 
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active. From 2010 to 2016, the number of inactive adults has increased by 5% worldwide, currently 
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affecting more than 1 in 4 adults (1.4 billion people) [6]. This gap between intention and action is a 
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challenge that health professionals need to address in order to counteract the pandemic of physical inactivity 
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[7, 8].  
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Physical activity is one of the top contributors to health, reducing rates of cardiovascular disease 
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[9], cancer [10], hypertension [11], diabetes [12], obesity [13], and depression [14]. This wide spectrum of 
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benefits is particularly important for older adults, who often suffer structural and functional deterioration 
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in several physiological systems. Physical activity can reduce and delay the impact of this age-related 
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deterioration in health [15] and functional independence. However, in the Americas, more than 60% of 
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older adults are physically inactive [16]. Current interventions to enhance physical activity in older adults 
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rely mainly on reflective processes by providing rational information about the health benefits of a 
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physically active lifestyle [17]. From this perspective, changing conscious goals should lead to substantial 
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behavioral change [18]. Yet, meta-analyses indicate that these interventions are more effective in changing 
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intentions than actual behavior [19]. Thus, new interventions targeting alternative processes (e.g., automatic 
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processes) are needed. 
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The engagement in physical activity is governed not only by reflective processes, but also by 
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automatic affective reactions acting outside conscious awareness [20]. For example, in active individuals, 
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stimuli associated with physical activity attract attention [21, 22], trigger positive affective reactions [23, 
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24], and activate approach tendencies [25]. These automatic reactions are thought to facilitate the translation 
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of intention into action. From this perspective, physical inactivity is the result of an imbalance between 
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strong negative automatic reactions to stimuli associated with physical activity and a relatively weaker 
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intention to be physically active. This imbalance between reflective and automatic processes can be 
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particularly pronounced in older adults, who are more likely to spontaneously associate physical activity 
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with fear, pain, or discomfort felt during physical exercise. Therefore, older adults could be particularly 
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responsive to and benefit the most from an intervention targeting the automatic reactions to physical activity 
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and sedentary stimuli.  
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Interventions targeting automatic reactions to health-related stimuli have already proven to be 
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successful in changing behavior [26-32]. For example, interventions have been used to retrain the automatic 
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reaction to alcohol [27]. Using a joystick, patients were repeatedly asked to avoid pictures on a screen that 
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were related to alcohol and to approach pictures unrelated to alcohol. Results showed that adding to a 
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regular treatment an intervention targeting cognitive bias reduced the relapse rates one year after treatment 
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discharge by 9% to 13% [27-29]. These interventions have also proven to be useful in impacting smoking 
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[30], social anxiety [31], and eating behavior [32]. Based on these encouraging results, the current project 
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proposes to test the effect of a cognitive-bias intervention on another health behavior: physical activity.  
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Primary aim 
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The overall primary objective of this project is to investigate the effectiveness of an intervention 
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targeting automatic reactions to physical activity and sedentary stimuli in older adults.  
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Secondary aim 
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The secondary objective is to test the effects of the intervention on reflective and automatic 
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processes underlying physical activity, physical functioning, and quality of life. 
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Methods 
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Study design and settings 
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Our study follows a placebo (sham-controlled), double-blinded design with a 12-month follow-up 
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(Figure 1).  
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Figure 1. Study design 
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Participants 
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Older adults aged 60 years and older will be enrolled in the study.  
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Recruitment 
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Recruitment will occur by placing posters in a: strategic areas, such as public areas where permissible and 
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b: posting on social media (Facebook, Twitter). Interested seniors will be asked to contact the researcher 
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directly. Once the interested person initiates the contact leaving a phone message or sending an e-mail, we 
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will follow up on them and will invite them to attend in an in-person meeting aiming to increase their 
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intention to be physically active based on the “Ask-Assess-Advise” approach and to inform them about the 
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study. Participants will receive a copy of the consent form prior to the first meeting so that they know from 
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the onset what the study entails. Interested participants will be given an opportunity to ask any question 
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over the phone or in the meeting before written informed consent is obtained. Consent will be only obtained 
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once the participant has fully understood what the study entails and accept to take part in the study. If they 
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decide to participate, they can withdraw from the research at any time and/or refuse to answer any questions, 
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without suffering any negative consequences. 
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Eligibility 
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To participate in this study, volunteers must be 60 or over 60 years old and able to understand 
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instructions in English. We will not include people who a: present diagnosed psychiatric disorders or 
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neurological pathologies (cardiovascular accidents, Parkinson’s or Alzheimer’s disease, dementia), b: 
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unable to carry out the training program, or unable to understand the protocol, c: having motor deficit 
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preventing physical activity without external help, d: having physical health status preventing physical 
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activity and, e: alcohol or substance dependence.  
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Sample size 
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Based on a meta-analysis reporting the effect size of interventions using the go/no-go task (g = .39) 
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[32, 33], a desired statistical power of .9, and an alpha of .05 [34], a sample size calculation indicated that 
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a minimum of 108 patients per condition is needed.  
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Ethics and dissemination  
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This research will be performed in accordance with the Declaration of Helsinki. The study was 
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approved by the University of Ottawa (Canada) Research Ethics Boards (H-09-22-8453). Potential 
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participants will be informed of study details, including procedures, risks and benefits, confidentiality, and 
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the voluntary nature of participation, before signing the consent form. Data will be kept on the uOttawa 
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OneDrive, with access limited to team members. This system is protected by multi-factor authentication, 
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meets Personal Health Information Protection Act requirements, and is serviced by the uOttawa 
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cybersecurity team. To guarantee that the research output is fully accessible to the public, the manuscripts 
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will be published as preprints (e.g., SportRxiv) and data, material, and scripts will be made publicly and 
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freely available on open repositories (e.g., Zenodo). Results will be published in relevant scientific journals 
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and be disseminated in international conferences. 
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 Intervention 
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Cognitive-bias modification task 
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The intervention of the proposed project is based on a go/no-go task in which older adults need to 
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quickly decide whether or not they should react to a stimulus [40]. The task has been adapted to train 
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inhibitory processes counteracting the automatic attraction to sedentary stimuli and to promote the 
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automatic approach to stimuli related to physical activity. Specifically, a rectangle containing an image, or 
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a word will be presented on a screen.  
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Intervention group  
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In the intervention group, older adults will be instructed to restrain their actions when the rectangle 
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is tilted to the right and to react by pressing a key on the keyboard when the rectangle is tilted to the left, 
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irrespective of the content of the rectangle (because the training is meant to be implicit). In order to train 
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inhibitory processes counteracting the automatic attraction to sedentary behavior, 90% of the rectangles 
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tilted to the right (counterbalanced across participants) will contain a picture or a word related to sedentary 
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behavior (Figure 2). To foster the automatic attraction toward physical activity, 90% of the rectangles tilted 
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to the left will contain a picture or a word related to physical activity.  
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Control group 
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In the comparison group, instructions will be identical, but the percentage of physical activity and 
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sedentary stimuli will be equal in each tilt condition (i.e., 50% sedentary stimuli and 50% physical activity 
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stimuli in both right- and left-tilted rectangles) (Figure 2). 
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Figure 2. Go/No-go task based on images (left panel) and words (right panel). 
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Experimental protocol 
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Participants will be invited to attend a meeting aiming to increase their intention to be physically 
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active based on the “Ask-Assess-Advise” approach [17] and to inform them about the study. Those who 
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accept to participate will receive a physical activity tracker (GT9X-BT) [41]. Participants will be trained 
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for 3 weeks (4 sessions/week) in the go/no-go task (Figure 3). Each training session will consist of 2 blocks 
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of 400 trials for a total of 30 min. To assess the effect of the intervention, primary and secondary outcomes 
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will be collected for one week, the week before the first session, the week following the last session of the 
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intervention, as well as 1, 3, 6, and 12 months post intervention.  
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Figure 3. Protocol timeline. 
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Allocation and blinding 
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Participants and research assistant will be blinded to the groups’ allocation. The participant blinding 
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success will be appraised by asking them to guess in what group there were at the trial termination. Besides, 
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the research assistant blinding success will be appraised via detecting the group allocation (Experimental 
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vs. Control) by research assistant at the end of data collection phase. The randomization will be generated 
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on a computer and an independent coworker will carry out the randomization. The participant’s 
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identification number will be used to determine the sequence of randomization. Participants will be 
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randomized in a 1:1 ratio between the intervention and active control condition.  
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Outcomes 
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Participants will first respond to questions related to their age, sex (male, female), weight, and 
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height. 
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Primary outcome 
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The project focuses on device-based measures of physical activity and sedentary behaviors. 
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Specifically, the primary outcomes collected using a physical-activity tracker will be the number of steps. 
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Participants will be given the tracker and will be trained on how to wear the device (ie, over the right hip, 
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affixed to an elastic belt, preferably worn under their waistbands). Currently, the waist based Actigraph is 
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the most used device to objectively measure physical activity. Participants will be instructed to used it all 
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day long for 7 days and not to used it during shower or when they sleep at night. If the participant uses the 
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tracker less than for 4 days in a row for at least 7 hours per day, they will not be included in the study. The 
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number of steps measured in the week pre- and post-intervention, as well as 1, 3, 6, and 12 months after the 
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intervention will be used as the primary outcome. 
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Secondary Outcomes 
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The secondary outcomes will allow the examination of indirect health effects related to an increase 
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in physical activity and a decrease in sedentary behavior. 
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1. Reflective and automatic processes underlying physical activity  
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(a) Explicit Affective Attitude Toward Physical Activity: Explicit attitudes toward physical activity will 
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be calculated as the mean of two items (Cronbach’s alpha = 0.92) based on two bipolar semantic 
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differential adjectives on a 7-point scale (unpleasant-pleasant; unenjoyable-enjoyable). The 
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statement begins with “For me, to participate in regular physical activity is …” [42]. 
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(b) Approach-avoidance task: A contextual approach-avoidance task will be used to measure 
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automatic approach and avoidance tendencies toward physical activity and sedentary behaviors 
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[36]. Participants will be asked to move a manikin on the screen “toward” (approach condition) 
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and “away” (avoidance condition) from images depicting physical activity and sedentary behaviors 
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by pressing keys on a keyboard. Each trial will be started with a black fixation cross presented 
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randomly for 250–750 ms in the center of the screen with a white background. Then, the manikin 
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will be appeared in the upper or lower half of the screen. Concurrently, a stimulus depicting 
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“movement and active lifestyle” (i.e., physical activity) or “rest and sedentary lifestyle” (i.e., 
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sedentary behavior) will be presented in the center of the screen. Participants quickly must move 
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the human figure “toward” a stimulus (approach) depicting physical activity and “away” from a 
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stimulus (avoidance) depicting sedentary behaviors, or vice versa. After seeing the manikin in its 
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new position for 500 ms, the screen will be cleared. In case of an incorrect response, error feedback 
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(i.e., a cross) will be appeared at the center of the screen. 
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2. Physical Functioning 
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(a) Usual Level of Moderate-to-Vigorous Physical Activity: The usual level of physical activity 
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will be derived from the short form of the International Physical Activity Questionnaire 
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(IPAQ-SF). The IPAQ-SF is a self-administered questionnaire that identifies the frequency 
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and duration of moderate and vigorous physical activity, as well as sedentary time during the 
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past 7 days to estimate usual practice of physical activity and sedentary behavior [46]. The 
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usual level of moderate-to-vigorous physical activity (MVPA) in minutes per week will be 
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used as a control variable in the analyses. 
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(b) 6-Minute Walk Test: The 6-minute walk test (6MWT) has been adopted as the most widely 
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used functional test of exercise capacity given its ease of administration and its ability to 
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reflect function during daily activities. Additionally, the 6-minute walking distance is widely 
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used for measurement of treatment response in clinical practice and clinical trials. The test is 
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conducted by having the participant walk as far as possible on a flat indoor course for a period 
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of 6 minutes. Standardized encouragement will be provided at each minute. Total distance 
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walked in 6 minutes will be documented. The major outcome is the distance walked during 
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the 6 minutes. The major advantages of the 6MWT are that the test requires minimal technical 
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resources and involves a familiar daily activity [44]. 
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(c) Hand grip strength: Hand grip strength will be assessed with a dynamometer. Participants 
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will perform the test using their reported dominant hand in a seated position. Two tests would 
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be performed by each participant and the higher value will be recorded as hand grip strength 
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[45]. 
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3. Quality of Life 
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(a) World Health Organization Quality of Life (BREF): The scale assesses quality of life over four 
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domains: Physical Health (seven items), Psychological Health (six items), Social Relationships 
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(three items), and Environmental Health (eight items). Scores for each domain can range from 
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zero to 100, with higher scores indicating better QoL [46].  
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Data collection and management 
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All information will be gathered by research assistant. All identifying information from the study 
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data will be eliminated by using a code so that the identity will not be directly associated with the data the 
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participant provided. Each participant will be given a unique confidential identification code upon they 
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accept to take part in the study. All data including coded information will be kept in OneDrive account of 
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principal investigator which is protected by a two-factor authentication. The confidentiality of the 
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information collected will be guaranteed by using this unique confidential code for data storage and 
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analyses. Storage will be maintained for 10 years after the end of the study. 
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Data analyses 
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Primary analysis 
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Statistical analyses will be performed according to the intention-to-treat principle and abide by the 
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Consolidated Standards of Reporting Trials (CONSORT) guidelines. A sequential analysis will be 
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conducted with an interim analysis after 50% of the data is collected and the other analyses after all data is 
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collected [47]. Based on the Pocock boundary, the threshold for significant p-values will be .0294 [48]. If 
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the effect is significant at the interim analysis, thereby indicating that the data provide support for the 
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hypothesis, data collection will be terminated. Mean, SD, median and range values will be used to 
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summarize the continuous data. The primary outcome (number of steps per week) will be analyzed using 
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multiple linear regressions. Particularly, we will test whether the participants’ physical activity level 
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(number of steps) the week after intervention termination will be higher in the intervention group relative 
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to the control group, after adjustment for covariates (i.e., age, sex). Furthermore, we will test whether 
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participants’ automatic approach tendencies towards physical activity will be higher and participants’ 
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automatic approach tendencies towards sedentary behaviours will be lower in the intervention group 
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compared to the control group.  
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Secondary Analysis 
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The continuous outcomes will be analyzed using linear mixed-effects models, which account for 
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the nested structure of the data (i.e., multiple observations within a single participant), thereby providing 
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accurate parameter estimates with acceptable type-I error rates [49]. To examine the effect of the 
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intervention on the evolution of physical activity and sedentary behavior, models will include interaction 
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terms between group (intervention group vs. comparison group) and number of days within or after (follow-
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up) the intervention. We will treat the continuous secondary outcomes in the similar way to the primary 
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outcome. R software will be exploited for all analyses.  
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Data Monitoring 
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The principal investigator will instruct all project team members to ensure that the study will be 
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carried out according to the protocol. Research assistants will need to understand the protocol before 
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starting the data collection. The ethics committee may visit the research sites for quality assurance. No 
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serious adverse event resulting from the intervention is expected; however, all potential adverse events will 
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be documented. 
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 Discussion 
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Most individuals are aware of the benefits to health of regular physical activity and have good 
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intentions to exercise. Yet, 1.4 billion people worldwide are inactive, which suggests that turning intention 
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into action can be challenging. Recent findings show that the intention-action gap could be explained by 
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negative automatic reactions to stimuli associated with physical activity. This gap is particularly concerning 
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in older adults, who are more likely to spontaneously associate physical activity with fear, pain, or 
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discomfort. Current interventions targeting physical activity largely focus on providing rational information 
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to alter individuals’ conscious goals. However, these strategies have been shown to be insufficient to change 
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a behavior and urge that automatic reactions towards physical activity-related stimuli would be involved in 
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the physical activity regulation. Therefore, to promote physical activity, the current project proposes to train 
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older adults to suppress their automatic attraction toward sedentary stimuli and to respond positively to 
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physical-activity stimuli. The intervention is expected to reduce physical inactivity during the intervention 
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and at follow-up, thereby improving physical functioning. More broadly, the output of this program has the 
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potential to develop an evidence-based, large-scale, low-cost intervention that would complement current 
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reflective approaches in older adults to improve their quality of life. Finally, the results will inform public 
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health policies aiming to counteract a global health problem: The pandemic of physical inactivity. 
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Fundings 
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Matthieu Boisgontier is supported by the Natural Sciences and Engineering Research Council of 
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Canada (NSERC; RGPIN-2021-03153), the Banting Research Foundation, and the Canada Foundation for 
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Innovation (CFI). The funding sources had no role in the design of this study and will not have any role 
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during its execution, analyses, interpretation of the data, or decision to submit results. 
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Consent Form 
Please read this consent document carefully before you decide to participate in this study. 
 
 
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Retraining the automatic reaction to physical activity & sedentary stimuli  
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in adults 60 years of age or older 
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Name and contact information of the researchers: 
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- 
Principal Investigator:  
Matthieu P. Boisgontier, University of Ottawa & Bruyère 
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Research Institute  
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Telephone: (613) 562-5408. Email: matthieu.boisgontier@uottawa.ca  
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Co-Investigator:  
 Ata Farajzadeh, University of Ottawa & Bruyère Research 
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Institute  
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Telephone: (343) 987-0216. Email: afara098@uottawa.ca 
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Project funder: This project is funded by the Banting Research Foundation. 
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Invitation to participate: I am invited to participate in the above-mentioned research study 
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conducted for academic purposes by Professor Matthieu Boisgontier and Ata Farajzadeh. This 
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project is being conducted independently from the organizations and agencies from which 
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participants may be recruited. 
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Purpose of the study: The purpose of the study is to investigate the effectiveness of an 
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intervention targeting automatic reaction to physical activity and sedentary stimuli in adults 60 
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years of age or older.  
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Participation: My participation in this study will include the following: 
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1) On the first meeting of the study (30 minutes), I will be provided an accelerometer to count 
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the number of steps I make each day. I will be asked to wear this accelerometer at my waist 
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for 7 days and at least 7 hours per day. 
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2) After one week, I will return the accelerometer, respond to questionnaires focusing on 
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physical activity level and quality of life, and perform a reaction-time task (1 hour). Then, 
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I will be trained for 3 weeks, 4 times per week for 30 minutes on a computerized reaction-
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time task. The training task consists of sitting in front of a computer and react to images 
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by pressing some keys on the keyboard. At the end of the training, I will be asked to wear 
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the accelerometer for one week (at least 7 hours per day) and response to the questionnaires 
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at the end of that week (1-hour).  
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3) To assess the effect of the intervention in the long term, I will be invited to respond to the 
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same questionnaire and perform a reaction-time task in a single session occurring 1, 3, 6, 
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and 12 months after the intervention (1 hour). 
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Risks: My participation in this study will not cause me any risk or discomfort other than those of 
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everyday life.  
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Benefits: My participation in this study will provide new information contributing to the 
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development of intervention aiming to help older adults adopting a more active and healthier 
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lifestyle. In addition, this new information will contribute to better understand the factors that 
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facilitate and inhibit the engagement in physical activity as well as the effectiveness of a computer-
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based intervention. 
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Confidentiality and privacy: My anonymity will be guaranteed by a unique confidential 
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identification code provided by the research team. All data, including coded information, will be 
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kept in password-protected files on a secure computer. My responses to the questionnaires will 
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remain strictly confidential. I understand that the anonymized results of this study may be 
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published in scientific journals and may be presented at academic conference or meeting.  
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Conservation of data: Anonymous data will be stored indefinitely on the uOttawa OneDrive with 
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access limited to the team members. This system is protected by multi-factor authentication, meets 
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Personal Health Information Protection Act requirements, and is serviced by the uOttawa 
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cybersecurity team.  
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Voluntary participation: I am under no obligation to participate in this study. If I choose to 
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participate, I can withdraw from the study at any time and/or refuse to answer any questions 
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without suffering any negative consequences. If I choose to withdraw, all data gathered until the 
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time of withdrawal will be removed from the dataset and not used in the study. 
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Agreement: I have read the above description of the study and I voluntarily agree to participate. 
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Ethical conduct: If I have any questions related to the study, I may contact the research team 
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(Matthieu Boisgontier and Ata Farajzadeh). If I have any questions regarding the ethical conduct 
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of the study, I may contact the Office of Research Ethics and Integrity via email 
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(ethics@uottawa.ca) or telephone (613-562-5387). To get additional information about my rights 
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as a research participant in the study, I can email Dr. Matthieu Boisgontier 
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(matthieu.boisgontier@uottawa.ca).  
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Acceptance: By providing my name below and signing the current document, I agree to participate 
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in this scientific study. 
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A copy of this consent form has been provided to the participant. 
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Name of participant:                                                 Date:                                      Signature: 
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Name of researcher:                                                 Date:                                      Signature: 
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