Exercise as treatment

John SearleChief Medical Officer

Fitness Industry AssociationPersonal Trainer

Sir Liam Donaldson

‘the benefits of regular physical activity on health, longevity and wellbeing easily surpass the effectiveness of any drugs or other medical treatment.’

Medicine in the 1960s

REST!

Post heart attack

Musculoskeletal disease

Post surgery

Br J Sport Med August 2009

• Lung disease• MS• Parkinson’s disease• Depression• Chronic fatigue

syndrome

• OA /RA• Coronary heart disease• Heart Failure• Hypertension• Type 2 DM

NHS 2010

• We know the theory but don’t do it!

• 4% of GPs prescribe exercise as first line treatment for depression

Key developments

• 1990’s: ‘Exercise referral’ • 2001: NQAF• 2006: NICE Report• 2010: BHF Toolkit

HTA Review

Joint Consultative Forum

NQAF 2001

• Set out the clinical, operational, ethical &l legal framework for ER practice

• Distinguished between recommending exercise and prescribing exercise

NICE 2006

there was insufficient evidence to recommend the use of ER schemes to promote physical activity other than as part of research studies where their effectiveness can be evaluated.

British Heart Foundation National Centre Toolkit

158 exercise referral schemes• Inclusion & exclusion criteria• Programme duration• Exit strategies• Qualifications• Evaluation

Inclusion/exclusion criteria

• Low risk:• COPD/asthma• Osteoporosis• DM• Hypertension• Raised cholesterol• Obesity• Stress

• Arthritis• Depression• Anxiety• Inactivity

71% of schemes had definite exclusion criteria

Exit strategies

• 63%: reduced gym membership rates• 40%: signposted to other activity• 10%: no exit strategy

• ?? Follow up system

Qualifications

Evaluation

Evaluation

• 93% of schemes had an evaluation process

• 22% of schemes had an external evaluation process

Health professionals concerns

Lack of robust, peer reviewed research about effectiveness of ER schemes

The risks of exercise, particularly in more advanced disease

Qualifications of fitness instructors

Professionalism of fitness instructors

Confusion!‘You’re not making any sense at all’

2010: Joint Consultative Forum - JCF

• Fitness sector - deliverers• Royal Colleges of General Practice, Physicians,

Psychiatrists, Pediatrics and Child Health - prescribers• Faculties of Public Health, Sport & Exercise Medicine

– prescribers• Chartered Society of Physiotherapy – prescribers and

delivers

JCF

• Key source of advice on exercise in the management of disease and disease prevention

• Professional and Operational Standards in Exercise Referral

Some key areas

Exercise referral or exercise recommendation?

Risk stratification

Qualifications

The process – making it work

Records

Referral or recommendation

Referral: patient referred for exercise (a) as part of disease treatment (b) disease prevention of cardiovascular disease where there are 2 or more risk factors present

Recommendation: recommendation that a patient is more active

Risk stratificationUse PAR-Q and Irvin-Morgan system

Low risk: sees ER instructor, range of activities

Medium risk : planned, structured, monitored programme

High risk: MDT assessment

Qualifications

Fitness instructors must have Level 3 exercise referral registration or Level 4 specialist registration with REPs

The process – making it happen

Referral

Consent

Goals

Assessment and measurement

Programme design

Delivery – 1:1 and groups

Exit strategy

Goals Enabling the patient to understand why they have been

referred

Process goals: attendance and completion

Out come goals

Short term – what is achieved in a sessionMedium term – (a) condition specific – eg weight

has fallen, range of joint movement increased, BP down (b) patient specific – eg energy to play with grandchildren, going on a holiday

Long term – sustained life style change and increase in activity/exercise, eg 30 x 5

Assessment and measurement

Read and review the referrers report: what is wrong, what is the treatment, what outcome is needed?

‘Readiness’ assessment – how ready is the patient to start exercising?

How active are they? Use an activity questionnaire

Quality of life questionnaire

Assessment and measurent

Pre-exercise heart rate

Blood pressure

BMI

Waist measurement

Aerobic fitness ???

Programme design

ACSM Disease Specific Guidelines

Within the limitations of the disease the programme should

Address all the components of fitness

Be progressive

Programme delivery1:1

Individual attention – motivation, monitoring and progress

More expensive

Lacks group support, motivation and social engagement

Medium and high risk

Group

Individual assessment necessary

Personal supervision more difficult

High degree of group motivation, support and social engagement

Low risk

Exit strategy

Keep the long term outcome in view from the start

What does the patient enjoy doing?

What activities are available outside the gym or ‘club’?

Agree an activity / exercise programme for the long term

Assurance of support after the programme is finished

Regular follow up

Refresher sessions

Other sections

Medico-legal matters

Records

Schemes, coordinators and facilities

Summary of disease specific evidence

Resources

When

Ongoing review by an advisory group

Agreed draft complete by beginning of July

Consultation

Publication Autumn 2011

The objectives

Clear standards for health professionals, fitness instructors and operators

Bench marks for commissioners

Standards against which schemes can be evaluated and audited

Accreditation schemes and appraisal of instructors can be developed

Exercise becomes a normal part of the management of chronic disease