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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. ’.

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exercise as treatment

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


Post heart attack

Musculoskeletal disease

Post surgery


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

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


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


  • 93% of schemes had an evaluation process
  • 22% of schemes had an external evaluation process
health professionals concerns
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

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


  • Key source of advice on exercise in the management of disease and disease prevention
  • Professional and Operational Standards in Exercise Referral
some key areas
Some key areas
  • Exercise referral or exercise recommendation?
  • Risk stratification
  • Qualifications
  • The process – making it work
  • Records
referral or recommendation
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
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

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

the process making it happen
The process – making it happen
  • Referral
  • Consent
  • Goals
  • Assessment and measurement
  • Programme design
  • Delivery – 1:1 and groups
  • Exit strategy
  • 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
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
Assessment and measurent
  • Pre-exercise heart rate
  • Blood pressure
  • BMI
  • Waist measurement
  • Aerobic fitness ???
programme design
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
Programme delivery



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
exit strategy
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
Other sections
  • Medico-legal matters
  • Records
  • Schemes, coordinators and facilities
  • Summary of disease specific evidence
  • Resources
  • Ongoing review by an advisory group
  • Agreed draft complete by beginning of July
  • Consultation
  • Publication Autumn 2011
the objectives
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