Prescribing exercise or physical activity What is physical activity? • Physical activity (PA) can be defined as any bodily movement produced by skeletal muscles that requires energy expenditure. • Physical activity encompasses all activities, at any intensity, performed during anytime of day or night • It includes both exercise and incidental activity integrated into daily routine. • Health benefits can be achieved through structured or non-structured physical activity; accumulated throughout the day, on most days of the week cntd • The significant health benefits of physical activity (PA), which includes exercise, have long been recognised. As well as reducing noncommunicable diseases (NCDs) such as heart disease, diabetes and specific cancers, regular physical activity leads to improvements in mental health and cognitive function • Popular ways to be active include walking, cycling, wheeling, sports, active recreation and play, and can be done at any level of skill and for enjoyment by everybody. What is exercise? • it can be defined as any planned, structured, repetitive and intentional movement that is intended to improve or maintain physical fitness • Different types of exercises • Can be classified according to what they do to the body i.e aerobic, anaerobic and flexibility cntd • Aerobic exercise is any physical activity that uses large muscle groups and causes the body to use more oxygen than it would while resting. The goal of aerobic exercise is to increase cardiovascular endurance. Examples of aerobic exercise include running, cycling, swimming, brisk walking, skipping rope, rowing, hiking, dancing, playing tennis, continuous training, and long distance running cntd • Anaerobic exercise, which includes strength and resistance training, can firm, strengthen and increase muscle mass. They can also improve bone density, balance, and co ordination. Examples of strength exercises are push-ups, pull-ups, lunges, squats, bench press. Anaerobic exercise also includes weight training, functional training, eccentric Training, interval training, sprinting, and high-intensity interval training which increase short-term muscle strength. • Flexibility exercises stretch and lengthen muscles. Activities such as stretching help to improve joint flexibility and keep muscles limber. The goal is to improve the range of motion which can reduce the chance of injury. What then is prescribing exercise/physical activity • Traditionally done by a fitness or rehabilitation specialist • An effective exercise prescription aims to integrate physical activity back into the individual’s daily life so that it becomes a daily habit, rather than a chore. • Most doctors would claim to be prescribing exercise already when they tell their patients to ‘exercise more’. how “5 As” approach • Ask (identify those who can benefit). • Assess (current activity level). • Advise (individualize plan). • Assist (provide a written exercise prescription and support material). • Arrange (appropriate referral and follow-up). Ask • Ask about physical activity at every consultation and take a physical activity history • To help assess the patient’s current level of physical activity • Take previous medical history and or if there are being followed up for any chronic conditions • A drug history is also important • Ask questions to determine a person’s motivation and barriers to PA. • It is also useful to determine the individual’s preferences, how does the individual want to increase their levels of PA? Assess • As with any clinical consultation, diagnosis is key. Physical inactivity is a modifiable vital sign. Assess The UK’s general practice physical activity questionnaire Assess Physical activity/exercise vital sign questionnaire • is a brief PA questionnaire that was developed to measure PA as a vital sign during a patient’s visit to a physician’s office and to further determine if a patient meets current PA recommendations Assess • The Physical Activity Readiness-Questionnaire (PAR-Q) or American College of Sports Medicine (ACSM) Pre-participation Screening Questionnaire can be used to identify individuals who are at higher risk of the adverse outcomes related to exercise. • Identify any contraindications using PAR-Q/PAEmed-X and refer on those who require medical clearance or a medically supervised exercise programme to a sport and exercise medicine consultant. Advise • The WHO developed the "Global Recommendations on Physical Activity for Health" • At present it recommends that all adults should undertake 150-300 min of moderate-intensity PA, or 75-150 min of vigorous-intensity PA, or some equivalent combination of moderate- and vigorous-intensity aerobic physical activity, per week. Advise The FITT principle • Frequency: number of sessions per week; • Intensity: perceived exertion e.g relative to walking, the ‘talk-sing’ test or heart rate data (if available); • Timing: duration of sessions; • Type: aerobic, resistance, lifestyle activity changes etc. Advise Intensity • Moderate PA refers to any activity that is performed at 3.0-5.9 times the intensity of rest, or around 60% of maximal effort. Examples include a brisk walk, mowing the lawn, heavy cleaning (e.g vacuuming or mopping), light cycling or recreational badminton. • Vigorous PA refers to any activity that is performed at more than 6 times the intensity of rest, or >75% of maximal effort. Examples include jogging, cycling fast and playing football, basketball, or a tennis singles match. Advise Intensity • Patients may also find it difficult to gauge what is moderate or vigorous PA. • It is therefore useful to use the “talk-sing test” as a relative measure of exertion. Clinicians should explain that during moderate PA, they should be able to talk but not sing. Likewise, during vigorous PA, you should have difficulty talking more than a few single words in response to any questions. Advise Intensity • Moderate PA can be more objectively described as activity that results in a HR that is 60-75% of their HRmax, whilst vigorous activity is activity that results in a HR that 75-90% of their HRmax. • To estimate maximum age-related heart rate, the patient’s age should be subtracted from 220 • Also energy output, as measured in kilocalories (kilojoules) per minute, METs or oxygen consumption (VO2, millilitres of oxygen per kilogram per minute); can also be used to objectively measure intensity • Other subjective tests including breathing rate, body temperature and patient’s rating of perceived exertion (RPE) Advise • incorporate motivational interviewing techniques, Assist • Provide patient with a written prescription • an exercise prescription should be the same as any other pharmacological medicine; it should be of the right class, the benefits should outweigh the drawbacks, and it should be prescribed at the correct dose and frequency to optimise compliance • Make sure your prescription has i) Type of exercise or activity ii) Duration and frequency iii) Intensity guidelines iv) Precautions Assist To help with adherence • Join a class or facility contract with a friend • Sched4ule time for exercise • Exercise at the same time each day • Listen to one’s body • Get advice if help is needed Arrange • Follow-up is crucial to signal the clinician’s conviction, determine the patient’s progress, solve problems, help identify social support, fine tune the dose, and reset goals. • Documenting reductions in body fat, resting blood pressure and lipoprotein levels can be used as encouragement to continue exercising. • Patient’s activity levels should be recorded in their records to facilitate the comparison of future activity levels Arrange • Whether a doctor should manage a patient alone or refer the patient usually depends on local skills, experience, services, and patient care pathways. • Although there is no need to medicalise physical activity for most people • Some patients may be considered high risk for complications during physical training should be followed in medically supervised programs in which close instruction, identification of contraindications and immediate treatment are available. • Refer on—consider appropriate physicians, physiotherapists, clinical exercise physiologists, and certified fitness instructors Arrange • Referral may also reach beyond health professionals • It is useful to link patients with appropriate community based resources. Only a few people have the resources to hire a health professional or a fitness instructor to design and supervise a workout. Communities, however, often have low cost public facilities • There is also evidence for high tech patient support applications, such as email and text message reminders, website support, and smart phone apps Last words • Adopt a whole-practice approach (eg, use practice nurses to assist) • Establish linkages with community agencies. • Please lobby for contextualized training and guidelines • Medical education curriculums need to include the promotion of physical activity • Clinicians must be active role models.
