1. Exercise is Medicine in Chronic Care
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Research over the last several decades has accumulated sufficiently to allow us to state confidently that there is no body tissue or system that does not benefit from regular physical activity. Further, there are extremely few chronic conditions in which the burden of the chronic condition, comorbidities related to the chronic condition, or the disease-related quality of life are not made better with some kind of exercise program.
OUR goal is helping physicians use exercise as easily as they use medications. Here are three barriers to that goal:
1) It’s easy to prescribe a pill.
2) It’s difficult to counsel patients on lifestyle ) Many societies don’t pay health care professionals for exercise management.

2. Exercise is Medicine in Chronic Care
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In the case of physicians prescribing exercise, the issue is more how physicians should operationalize practice protocols to express the moral imperative on the value of exercise than whether or not they should express their advice to exercise.
Exercise Is Medicine in the Medical Home Care Model
The Exercise Is Medicine (EIM) initiative was established “to make physical activity assessment and exercise prescription a standard part of the disease prevention and treatment paradigm for all patients.” This initiative was started in November by the American College of Sports Medicine (ACSM) in conjunction with the American Medical Association.
EIM was not conceived for patients with chronic diseases and disabilities, but more for apparently healthy individuals who are able to safely do activities such as walking. As such, the EIM recommendations for exercise are geared more to promote population health than to specifically address the exercise needs of persons with a chronic condition.

3. Exercise is Medicine in Chronic Care
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Annual Wellness Visit
Primary care physicians have long followed the practice of having an annual visit with a physical exam
In this visit, rather than clearing patients to participate in sport, physicians are either clearing and guiding them to participate in regular exercise, or referring them to a program that will help them make the transition These are examples of programs that can help the transition:
1) Physical and occupational therapy ) Cardiac and pulmonary rehabilitation ) A medically supervised exercise program
4) A carefully prescribed and monitored independent home program for those with stable disease
The goal of such programs is to help patients increase their physical activity and improve physical functioning to the point that they can do their own self-directed program, or do so with the aid of an exercise specialist or personal trainer.

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Exercise Vital Sign and Health Risk Assessment
A basic tenet of the EIM initiative is that physical activity should be regarded as a vital sign so that a proper physical activity or exercise prescription can be provided.
The exercise vital sign (EVS) is a simple way to get the topic of exercise into the exam room with every patient. The EVS can be administered by the medical assistant as part of the assessment of the traditional vital signs of blood pressure, pulse, respirations, and temperature. It requires only two simple questions .
Multiplying the two responses together gives the number of minutes per week of self-reported moderate to vigorous physical activity (MVPA) done each week by that patient. An electronic medical record can automatically display this value, and adults doing less than 150 min per week can be flagged with an alert

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Health Risk Assessment
(HRA) questionnaire; in the United States these are mostly in use by wellness programs sponsored by employers or health insurance plans.
Many HRAs have the EVS questions built in to the questionnaire and thus can provide the MVPA score as a part of the report.
Health risk assessment tools go beyond physical activity and also ask the patient questions about diet, tobacco, stress, and other lifestyle-related risk domains.
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6. Exercise is Medicine in Chronic Care
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Starting a discussion about exercise with an apparently healthy person or someone whose chronic condition does not constrain her ability to be active and exercise
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What would the patient want to do to be more active?
What barriers are preventing this from happening?
For apparently healthy patients in whom the main goal is risk reduction, then one should develop and provide an exercise prescription.

7. Exercise is Medicine in Chronic Care
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Physicians should write exercise prescriptions (in conjunction with the exercise leader, if applicable) because a physician’s prescription carries with it the moral weight of the physician’s judgments designed to help the patient—it elevates exercise to the same stature as all the other recommendations the physician has for the patient. (More details in constructing exercise prescriptions in chapter two.)
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Example - Walking is low cost and doesn't require a gym or specialized equipment. It is also easy to measure walking by using a pedometer or a watch. Walking has generally good long-term adherence and has been proven to benefit health.

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Exercise Is Medicine (EIM) in the Chronic Care Model
The degree to which a patient’s condition affects her ability to exercise safely is a complex function of both the specific condition or combination of conditions and the relative burden of severity.
The assessment of the patient’s disease burden then must be factored in together with the individual’s goals, socioecological status, and available resources to help the patient become more active (with a long-term goal of meeting physical activity guidelines).
This coordination of exercise or physical activity with socioecological factors and available resources is a logical function of the medical home as part of the chronic care model
The chronic care model (next slide) has risen to favor among health care system designers, layered onto what has become known as the medical home or patient-centered medical home (PCMH) model of primary care.

9. Exercise is Medicine in Chronic Care
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The key function of the PCMH is to serve as a coordinating center for all needs related to a patient’s health care.
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Perhaps the biggest flaw in the chronic care model is that there is often no business model to sustain the linkages
Modern health care systems and patient care plans are extremely complex, especially in situations that involve multiple chronic conditions or disability, and the task of making sure all aspects of care are well coordinated is often too difficult for patients and their families to accomplish.

10. Exercise is Medicine in Chronic Care
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Rationale for Including Physical Activity in Chronic Care Management
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The primary reason to emphasize a physically active lifestyle is to avoid what has been termed the disuse syndrome or, alternatively, the downward spiral of chronic disease.
Increasingly, studies show that the special challenge for persons who develop a chronic condition or disability is that they are vulnerable to becoming increasingly sedentary.

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Rationale for Including Physical Activity in Chronic Care Management
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Cascade of adverse effects: Low functional capacity, which predicts poor outcomes and mortality
Reduced gait speed and lower-extremity function associated with loss of independence
Loss of independence, which has a negative impact on quality of life
Increased risk of excessive weight gain
Skeletal muscle insulin resistance or frank type 2 diabetes, with subsequent cardiovascular disease
A gradual deterioration toward being disabled

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General Recommendations
This Basic CDD4 (reference to textbook) Recommendation is consistent with current Department of Health and Human Services (HHS) recommendations and ACSM Guidelines, though slightly different in the following ways:
It advises 150 min/week of MVPA (lower limit recommended by HHS/ACSM).
It advises 150 min/week of light-intensity activity for those who can’t do MVPA.
It adds sit to stand, step-ups, and arm curls as the recommended strength training exercises
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An important job for the physician, exercise professional, and chronic care management team is to help break down these barriers and to counsel the patient on how to get to the point where exercise is a habit and not an option

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Take-Home Message
Exercise is a very powerful tool to treat and prevent chronic disease, mitigate the harmful effects of obesity, reduce mortality rates, and improve physical functioning and quality of life.
Primary care physicians have a responsibility to assess physical activity habits in their patients, inform them of the risk of being inactive, and provide a proper exercise prescription.
Physician practices should use the exercise vital sign to assess MVPA.
Physicians should support patients who are meeting physical activity guidelines.
Physicians should encourage those who don’t meet these guidelines.
Patients who have a chronic condition that does not impair physical functioning or increase risk can be advised to walk or to do the same kinds of activities recommended for the apparently healthy population.
Patients who have a more severe burden of chronic disease or disability often benefit from referral to resources in their community, such as physical therapy, occupational therapy, cardiopulmonary rehabilitation, or other medically supervised programs.
Patients who have recently been hospitalized are often more willing to invest in physical activity, particularly if they obtain guidance, so transitions of care are important moments when the physician should be alert to encouraging more physical activity.
Facilitating regular exercise in a physical activity program is one of the most important functions of health care providers using the chronic care model
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