Exercise referral – time to improve the outcome

John Searle Chief Medical Officer FIA

Exercise

Exercise is the most effective disease prevention ‘stuff’ there

is

Exercise in disease prevention

Heart attacks Stroke

Exercise in disease prevention

Obesity Type 2 diabetes

Exercise in disease prevention

Dementia Stress

Exercise in disease prevention

Depression Falls

Exercise in disease prevention

Various types of cancer

Exercise in disease management?

Exercise in disease

• Improves symptoms

• Slows progression

• Promotes physical activity and wellbeing

(British Journal of Sport and Exercise

Medicine 2009; 43: 550-555)

Exercise referral schemes

• 1990’s

• National Quality Assurance Framework

2001

• BHFNC Toolkit 2010

Do exercise referral schemes work?

NICE 2006

‘there is insufficient evidence to recommend

the use of exercise referral services to

promote physical activity other than part if

research studies where their effectiveness

can be evaluated’

HTA 2011 (in press) The National Institute of Health Research Health

Technology Assessment Agency

Little or no effect in increasing physical activity.

Serious lack of properly controlled, randomised

studies in exerciser referral.

Many studies have a poor methodology

Welsh National Exercise Referral Scheme (2010)

• Higher levels of physical activity in patients

with coronary risk factors

• Positive effects on depression and anxiety

particularly in those referred wholly or

partially for mental health reasons

Why don’t ER schemes work?

Toolkit 2010 – wide variation in

•Inclusion / exclusion criteria

•Programme duration

•Qualifications of instructors

•Adherence to the NQAF

•Scheme evaluation

Other concerns

Lack of GP training Risk to patients

Other concerns

Joint Consultative Forum (JCF)

Terminology

• Recommendation:

Advising a patient to be more physically

active in order to improve their health and

reduce the risk of disease

Terminology – exercise referral

Exercise referral is a formal process which uses exercise as a component of the management of a patient’s condition, with the objectives of improving or reducing the rate of its progression and achieving an independent and sustainable increase in physical activity

The process

Referral of a patient by a health care

professional to a service or an independent

exercise referral instructor for the process of

providing an exercise programme as part of

the management of people (i) with stable or

significant limitations related to a chronic

disease or disability and/or (ii) with one or

more CV disease risk factors

Professional & operational

standards in exercise referral

• Risk stratification

• Qualifications

• The process

• Record keeping

• Medico-legal issues

• Services and facilities

Risk stratification – the PAR-Q • ‘No’ to all the questions

• Heart rate < 100 bpm

• BP < 140/90

Remain in the ER service, undertake a range of activities programmed by but not necessarily supervised by the ER instructor

Answers ‘yes’ on the PAR-Q

Irwin Morgan assessment:

• Low risk – as in PAR-Q ‘no’

• Medium risk – personalised supervised programme

• High risk – (i) cardiac into cardiac rehab programme (ii) non cardiac, multidisciplinary assessment before exercise

Irwin Morgan assessment

• Not a validated tool but it is recommended in the Toolkit

• What else is there?

• ? PAR-Q + and PARMedEx in the future

Qualifications

Fitness instructors working in exercise referral must be a REPs registered Exercise Referral Fitness Instructor or a REPs registered Level 4 Specialist Instructor, meeting the National Occupational Standards for the knowledge, competence, and skills of good practice.

Assessment • Personal details

• BMI

• Waist circumference

• Pre ex HR

• BP

• PA questionnaire -IPAQ

• Quality of life – EQ-5D

Assessment

• Aerobic – not necessary

• ROM in musculoskeletal disease

• Requested by referrer

Goals

Short tern – attendance, sessional

Medium term

(i) condition specific

(ii) Patient specific

Long term – a sustainable increase in physical activity

Delivery

ACSM disease specific guidelines

Appropriate progression

Good communication

Trust and rapport

Monitoring

• Attendance

• During the session

• Repeat base line measurements at mid point and the end of the programme

• 6 and 12 months: physical activity and wellbeing questionnaires*

*using group sampling

Exit strategies

• Absolutely essential!

• Keep in view from the outset

• What would the patient like to do to keep physically active?

• What is available?

• On-going support

Medico-legal matters

Doctors must only refer patients for the purposes of using exercise as part of treatment to an appropriately qualified and registered exercise referral fitness instructor or a service which employs such instructors

Medical Defence Societies

Other matters

• Reporting to the referrer and to commissioners

• Service evaluation and appraisal – by

commissioners and professionally

• Instructor appraisal – fit to practice

Why – the objectives?

• Provision of high quality, safe and effective exercise referral services

• Exercise becomes a routine part of the management of chronic disease

• Bench mark for commissioners

How has it been done?

• JCF: drafting group + the Forum

• Advisory group from across the fitness sector

• Consultation process – to mid August.

(stephen.wilson@fia.org.uk)

Help – the bench mark is too high!

Implementation will be gradual

• Standard setting

• Training institutions

• Operators

• Health professionals

• Commissioners

–NHS reforms timetable

CHOICE

• Stay as we are and confirm the NICE judgment of 2006 and HTA 2010

OR

• Develop a modern professional service and provide long term benefits to patients