Exercise as treatment

1. Exercise as treatment John Searle Chief Medical Officer Fitness Industry Association Personal Trainer

2. 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.’

3. Medicine in the 1960s REST! Post heart attack Musculoskeletal disease Post surgery

5. Br J Sport Med August 2009 • OA /RA • Coronary heart disease • Heart Failure • Hypertension • Type 2 DM • Lung disease • MS • Parkinson’s disease • Depression • Chronic fatigue syndrome

6. NHS 2010 • We know the theory but don’t do it! • 4% of GPs prescribe exercise as first line treatment for depression

7. Key developments • 1990’s: ‘Exercise referral’ • 2001: NQAF • 2006: NICE Report • 2010: BHF Toolkit • HTA Review • Joint Consultative Forum

8. NQAF 2001 • Set out the clinical, operational, ethical &l legal framework for ER practice • Distinguished between recommending exercise and prescribing exercise

9. 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.

10. British Heart Foundation National Centre Toolkit • 158 exercise referral schemes • Inclusion & exclusion criteria • Programme duration • Exit strategies • Qualifications • Evaluation

11. 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

12. Exit strategies • 63%: reduced gym membership rates • 40%: signposted to other activity • 10%: no exit strategy • ?? Follow up system

13. Qualifications • REPs requires trainers to be Level 3 ER qualified • 20% of schemes used Level 2 instructors

14. Evaluation

15. Evaluation • 93% of schemes had an evaluation process • 22% of schemes had an external evaluation process

16. 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

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

18. 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

19. JCF • Key source of advice on exercise in the management of disease and disease prevention • Professional and Operational Standards in Exercise Referral

20. Some key areas • Exercise referral or exercise recommendation? • Risk stratification • Qualifications • The process – making it work • Records

21. 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

22. Risk stratification • Use PAR-Q and Irvin-Morgan system • Low risk: sees ER instructor, range of activities • Medium risk : planned, structured, monitored programme • High risk: MDT assessment

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

24. The process – making it happen • Referral • Consent • Goals • Assessment and measurement • Programme design • Delivery – 1:1 and groups • Exit strategy

25. 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 session • Medium 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

26. 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

27. Assessment and measurent • Pre-exercise heart rate • Blood pressure • BMI • Waist measurement • Aerobic fitness ???

28. Programme design • ACSM Disease Specific Guidelines • Within the limitations of the disease the programme should • Address all the components of fitness • Be progressive

29. Programme delivery 1:1 Group Individual assessment necessary Personal supervision more difficult High degree of group motivation, support and social engagement Low risk • Individual attention – motivation, monitoring and progress • More expensive • Lacks group support, motivation and social engagement • Medium and high risk

30. 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

31. Other sections • Medico-legal matters • Records • Schemes, coordinators and facilities • Summary of disease specific evidence • Resources

32. When • Ongoing review by an advisory group • Agreed draft complete by beginning of July • Consultation • Publication Autumn 2011

33. 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