Exercise as treatment John Searle Chief Medical Officer Fitness Industry Association Personal 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 REPs requires trainers to be Level 3 ER qualified 20% of schemes used Level 2 instructors

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 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

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 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

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 delivery 1:1 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