exercise for life.pdf

8/14/2019 exercise for life.pdf

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patient activity levels

and then:

advising on interventions based on this predicted risk

counselling for behaviour change

involving other health professionals such as counsellors, physiotherapists and practice nurses

encouraging patients to identify their own strategies to become more active, including identifying leisureindustry professionals to aid them

using formal exercise referral systems which could equally be accessed from primary or secondary care.

is process relies on the appropriate training of the professionals involved, and having the resources andfacilities available in which to refer. In reality, many doctors are not in the position to make these judgments.

ere is little or no undergraduate training in SEM or rehabilitation medicine (RM). e use of exercise-basedrehabilitation, although by no means new, is barely understood outside a few clinical specialists. e physiologyof exercise is poorly taught and the risks of exercise are not clear, and therefore tend to be overestimated.

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e specialty remains underdeveloped, but the main limitation to the use of these specialists is a reluctance onthe part of NHS trusts to establish consultant posts. e consequence is that many of the specialists trained inSEM have to seek employment either in the private sector (including working for professional sports teams) or

overseas.is is a waste of an NHS training programme and will ultimately place the specialty in jeopardy.

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In the last 20 years, there has been a significant growth in the number of exercise referral schemes based onmany different models which has led to requests for models of practice or guidelines. In 2001, the NationalQuality Assurance Framework (NQAF) for exercise referral schemes was published by the DH, and outlinedthe standards according to which clinicians should recommend exercise.26

Exercise referral systems were introduced in a number of sites around the UK to produce a more systematicapproach to the delivery of exercise to patients, and to link the medical team with the exercise deliverers usually from local authorities and the private sector.

e concept is to provide an individualised care pathway for those with mild to moderate medical conditionsfor which a conditioning programme would be helpful. Although usually not involving the local rehabilitationservices, it uses the principles of exercise-based rehabilitation. Many patients entering a referral scheme mayfind leisure facilities such as gyms undesirable for maintaining an increased level of physical activity.erefore,exercise referral schemes need to be tailored to provide an experience that motivates patients for long-termchange. Walking and cycling in the community may well be the most popular options, particularly if they areconvenient, safe, affordable and can be sociable. Long-term compliance remains a challenge, as is the case withany behavioural change.

e strength, and also the weakness, of the process is the link between healthcare and the local authorities(and other providers) who are not from a health background. Since this draws in professionals with experiencein exercise not held in the healthcare sector there may be issues around communication and standards.

Communication between GPs and the exercise provider is facilitated by referral criteria and proformas.However, GPs may be apprehensive about their ability to assess the fitness of their patients to participate inphysical activity. Fitness providers complain that GPs are reluctant to refer into the schemes, and some GPs donot have access or are unaware of local services. ere are also those who do not have trust in the care pathway.

is refl

ects a lack of confi

dence in the standards and quality of the service.

e 2001 framework sets outstandards for practice. It makes it necessary to establish a formally agreed process for the selection, screeningand referral of specific patients. It outlines how to conduct appropriate assessment of patients prior to theexercise programme, and provides a specific range of appropriate physical activities. is is with the aim ofmaximising the likelihood of long-term participation in physical activity.

e framework aims to ensure that the assessments and the exercise programmes are delivered by professionalswith appropriate competencies and training. e problem is that, although the framework is explicit on therequired standard of training, there is no statutory governing body, and industry standards for training vary.

Although there is evidence of the beneficial effects of exercise, it is difficult to demonstrate the effectivenessof exercise referral schemes, despite their popularity.24,25is problem was compounded by the NICE reportfrom June 2006, which questioned the health benefits of the relatively short-term UK exercise referralprogrammes.25


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In 2010/11, around one in ten pupils at Reception age (aged 45) were classified as obese (9.4%), whichcompares with around a fih of pupils in Year 6 (aged 1011) (19%).

For physical activity in England:

In 2010, 41% of respondents in Great Britain (GB) (aged 2+) said they made walks of 20 minutes or more atleast three times a week, and an additional 23% said they did so at least once or twice a week. However, 20% ofrespondents in GB reported that they took walks of at least 20 minutes less that once or year or never.

e most popular sports activity carried out by children aged 510 in 2010/11 outside school hours wasswimming, diving or life-saving, with 48% participating in the previous four weeks. is was followed byfootball (36%) and cycling or riding a bike (28%).

For children aged 1115, the most popular sport activities participated in during the past four weeks, both

in and out of school, were football (50%), basketball (27%) and swimming, diving or life-saving (27%) in2010/11.

Pupils in Years 113 of the schools surveyed spent an average of 117 minutes in a typical week in 2009/10on curriculum PE. e long-term trend shows and increase in the average number of minutes pupils takepart in PE each week.

Globally, there are more than 1 billion overweight adults, with at least 300 million of them being obese.45By2050, 9 out of 10 adults are predicted to be obese, and two-thirds of children will be overweight or obese. ecost to the UK of this obesity epidemic is likely to treble to 50 billion a year unless urgent action is taken.2,16,46

ere is a clear causal relationship between degree of physical activity and all-cause mortality. Increasing thephysical activity levels of all adults who are not meeting the chief medical officers recommendations is vital forthe health of the nation and the economy. However, targeting those adults who are most sedentary (ie engagein less than 30 minutes activity per week) will produce the greatest reduction in the risk of chronic disease.

ere is a significant inverse doseresponse relationship between total physical activity and disease in adults;the higher the level of physical activity or fitness, the lower the risk of disease.4,16,19

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most acceptable forms of physical activity are those that can be incorporated into everyday life. Examples includebrisk walking or cycling instead of driving. Physical activity does not have to be vigorous to confer protection.16

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Inequalities are greatest for South Asian women. Only 11% of Bangladeshi and 14% of Pakistani women werereported to have done the recommended amounts of physical activity, compared with 25% in the generalpopulation.

People with disabilities are at particular risk of inactivity.16Disabilities ranging from physical and neurologicalto sensory impairments and learning disabilities all create different barriers to participation in physical activity.eActive people surveyshowed that only 9.1% of people aged 16 years and over with a limiting long-standingillness or disability had participated in at least 30 minutes of moderate-intensity sport or active recreation onthree or more days per week.51is is compared with 23.6% of all adults.

Physical activity is lower in low-income household groups than in high-income household groups.

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falls in the elderly, anxiety, depression and dementia.1,2,4,6,7,1114,19,37 Increasing total volume of activity, increasingintensity of aerobic exercise from low to moderate and from moderate to high, and adding weight training tothe exercise programme, are among the most effective strategies to reduce the risk of CHD in men.34

Physical activity and physical fitness are inversely associated with the clustering of metabolic abnormalities.With regard to physical activity, it seems that intensity, and more specifically higher intensity, is the maincharacteristic of physical activity determining its effect on CVD risk factors. However, physical fitness exertsgreater effects on each of these individual CVD risk factors and its combination when compared withphysical activity.38

Morris et aldescribed exercise prescription in the prevention of CHD as todays best buy in public health backin 1994.28At the time it was recognised that, for those individuals who were inactive, their relative risk of CHDwas of the same order of magnitude as for hypertension, hypercholesterolaemia and smokers.

Exercise prescription in older people is particularly beneficial, improving overall health, exercise capacity,proprioception, balance, their quality of life (QoL) measures, and their level of independence.

e benefits of physical activity in chronic disease such as severe congestive heart failure is strongly supportedby research which demonstrates that exercise improves maximal exercise capacity,33decreases symptoms,30,31improves quality of life,53and decreases hospital admissions.

Additionally, exercise training has been shown to have a significant impact on pathophysiological mechanismsof CHF, including improvements in endothelial function29and autonomic activity, by reducing sympatheticactivation and improving heart rate variability. Resting levels of angiotensin II, aldosterone, vasopressin, andatrial natriuretic peptide32are reduced and respiratory function is also oen improved.

Patients with chronic obstructive pulmonary disease (COPD) have been shown to respond well to regularexercise therapy, with a notable reduction in their risk of COPD exacerbations. For those individualsexercising at a moderate to high intensity level, there was a reduced lung function decline, as well as a reducedrisk of COPD among smokers.36

Long-term regular physical activity, including walking, is associated with significantly better cognitivefunction and reduced cognitive decline in older women. Higher levels of activity are associated with bettercognitive function and a 20% lower risk of cognitive impairment in the highest quintile of activity.35,54,55

e evidence for the association between obesity and chronic disease is extensive and it is now a public healthproblem of epidemic proportions across the western world.45In addition to the cardiovascular and metabolicconsequences, there are many other diseases associated with obesity, including: carcinoma (endometrial,breast, colon) liver and gallbladder disease, sleep apnoea, osteoarthritis and gynaecological dysfunction(abnormal menses and infertility.4,6,12,19,4446

ese patients will benefit from participation in physical activity for the potential health benefits.16,19,46,56However, exercise prescription in this group should not be focused on weight management alone, but on thelong-term health benefits of engaging in a regular exercise programme. e data regarding exercise and weightmanagement suggests that there is a need for up to twice the volume of exercise activity, ie 5 x 60 minutes or atotal of 300 minutes per week of moderate-intensity activity, in conjunction with a reduction of daily calorificintake in order to effect a significant benefit.


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exercise for life.pdf