Date post: | 11-Jan-2016 |
Category: |
Documents |
Upload: | dwain-dorsey |
View: | 213 times |
Download: | 0 times |
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