Exercise referral – time to  improve the outcome     John Searle     Chief Medical Officer FIA
Exercise Exercise is the most effectivedisease prevention ‘stuff’ there               is
Exercise in disease           preventionHeart attacks    Stroke
Exercise in disease              preventionObesity             Type 2 diabetes
Exercise in disease           preventionDementia         Stress
Exercise in disease            preventionDepression        Falls
Exercise in disease        preventionVarious typesof cancer
Exercise in disease  management?
Exercise in disease• Improves symptoms• Slows progression• Promotes physical activity and wellbeing(British Journal of Spo...
Exercise referral schemes• 1990’s• National Quality Assurance Framework  2001• BHFNC Toolkit 2010
Do exercise referral schemeswork?NICE 2006‘there is insufficient evidence to recommendthe use of exercise referral service...
HTA 2011 (in press)The National Institute of Health Research HealthTechnology Assessment AgencyLittle or no effect in incr...
Welsh National ExerciseReferral Scheme (2010)• Higher levels of physical activity in patients  with coronary risk factors•...
Why don’t ER schemes work?Toolkit 2010 – wide variation in•Inclusion / exclusion criteria•Programme duration•Qualification...
Other concernsLack of GP training   Risk to patients
Other concerns
Joint Consultative Forum (JCF)
Terminology• Recommendation:Advising a patient to be more physicallyactive in order to improve their health andreduce the ...
Terminology – exercise referralExercise referral is a formal process whichuses exercise as a component of themanagement of...
The processReferral of a patient by a health careprofessional to a service or an independentexercise referral instructor f...
Professional & operationalstandards in exercise referral• Risk stratification• Qualifications• The process• Record keeping...
Risk stratification – thePAR-Q• ‘No’ to all the questions• Heart rate < 100 bpm• BP < 140/90Remain in the ER service, unde...
Answers ‘yes’ on the PAR-QIrwin Morgan assessment:• Low risk – as in PAR-Q ‘no’• Medium risk – personalised supervised  pr...
Irwin Morgan assessment• Not a validated tool but it is  recommended in the Toolkit• What else is there?• ? PAR-Q + and PA...
QualificationsFitness instructors working in exercise  referral must be a REPs registered  Exercise Referral Fitness Instr...
Assessment• Personal details• BMI• Waist  circumference• Pre ex HR• BP• PA questionnaire -  IPAQ• Quality of life –  EQ-5D
Assessment•   Aerobic – not    necessary•   ROM in    musculoskeleta    l disease•   Requested by    referrer
GoalsShort tern –attendance, sessionalMedium term (i) condition specific(ii) Patient specificLong term – asustainable incr...
DeliveryACSM disease specificguidelinesAppropriateprogressionGood communicationTrust and rapport
Monitoring• Attendance• During the session• Repeat base line measurements at mid  point and the end of the programme• 6 an...
Exit strategies• Absolutely essential!• Keep in view from the outset• What would the patient like to do to  keep physicall...
Medico-legal mattersDoctors must only refer patients for thepurposes of using exercise as part oftreatment to an appropria...
Other matters• Reporting to the referrer and to commissioners• Service evaluation and appraisal – by  commissioners and pr...
Why – the objectives?• Provision of high quality, safe and  effective exercise referral services• Exercise becomes a routi...
How has it been done?• JCF: drafting group + the Forum• Advisory group from across the fitness  sector• Consultation proce...
Help – the bench mark is too high!
Implementation will be gradual• Standard setting• Training institutions• Operators• Health professionals• Commissioners  –...
CHOICE• Stay as we are and confirm the NICE  judgment of 2006 and HTA 2010                   OR• Develop a modern professi...
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John Searle - Exercise referral - time to improve the outcomes

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John Searle - Exercise referral - time to improve the outcomes

  1. 1. Exercise referral – time to improve the outcome John Searle Chief Medical Officer FIA
  2. 2. Exercise Exercise is the most effectivedisease prevention ‘stuff’ there is
  3. 3. Exercise in disease preventionHeart attacks Stroke
  4. 4. Exercise in disease preventionObesity Type 2 diabetes
  5. 5. Exercise in disease preventionDementia Stress
  6. 6. Exercise in disease preventionDepression Falls
  7. 7. Exercise in disease preventionVarious typesof cancer
  8. 8. Exercise in disease management?
  9. 9. Exercise in disease• Improves symptoms• Slows progression• Promotes physical activity and wellbeing(British Journal of Sport and ExerciseMedicine 2009; 43: 550-555)
  10. 10. Exercise referral schemes• 1990’s• National Quality Assurance Framework 2001• BHFNC Toolkit 2010
  11. 11. Do exercise referral schemeswork?NICE 2006‘there is insufficient evidence to recommendthe use of exercise referral services topromote physical activity other than part ifresearch studies where their effectivenesscan be evaluated’
  12. 12. HTA 2011 (in press)The National Institute of Health Research HealthTechnology Assessment AgencyLittle or no effect in increasing physical activity.Serious lack of properly controlled, randomisedstudies in exerciser referral.Many studies have a poor methodology
  13. 13. Welsh National ExerciseReferral 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
  14. 14. 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
  15. 15. Other concernsLack of GP training Risk to patients
  16. 16. Other concerns
  17. 17. Joint Consultative Forum (JCF)
  18. 18. Terminology• Recommendation:Advising a patient to be more physicallyactive in order to improve their health andreduce the risk of disease
  19. 19. Terminology – exercise referralExercise referral is a formal process whichuses exercise as a component of themanagement of a patient’s condition, withthe objectives of improving or reducingthe rate of its progression andachieving an independent andsustainable increase in physical activity
  20. 20. The processReferral of a patient by a health careprofessional to a service or an independentexercise referral instructor for the process ofproviding an exercise programme as part ofthe management of people (i) with stable orsignificant limitations related to a chronicdisease or disability and/or (ii) with one ormore CV disease risk factors
  21. 21. Professional & operationalstandards in exercise referral• Risk stratification• Qualifications• The process• Record keeping• Medico-legal issues• Services and facilities
  22. 22. Risk stratification – thePAR-Q• ‘No’ to all the questions• Heart rate < 100 bpm• BP < 140/90Remain in the ER service, undertake a rangeof activities programmed by but notnecessarily supervised by the ER instructor
  23. 23. Answers ‘yes’ on the PAR-QIrwin 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
  24. 24. 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
  25. 25. QualificationsFitness 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.
  26. 26. Assessment• Personal details• BMI• Waist circumference• Pre ex HR• BP• PA questionnaire - IPAQ• Quality of life – EQ-5D
  27. 27. Assessment• Aerobic – not necessary• ROM in musculoskeleta l disease• Requested by referrer
  28. 28. GoalsShort tern –attendance, sessionalMedium term (i) condition specific(ii) Patient specificLong term – asustainable increasein physical activity
  29. 29. DeliveryACSM disease specificguidelinesAppropriateprogressionGood communicationTrust and rapport
  30. 30. 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
  31. 31. 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
  32. 32. Medico-legal mattersDoctors must only refer patients for thepurposes of using exercise as part oftreatment to an appropriately qualified andregistered exercise referral fitness instructoror a service which employs such instructorsMedical Defence Societies
  33. 33. Other matters• Reporting to the referrer and to commissioners• Service evaluation and appraisal – by commissioners and professionally• Instructor appraisal – fit to practice
  34. 34. 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
  35. 35. 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)
  36. 36. Help – the bench mark is too high!
  37. 37. Implementation will be gradual• Standard setting• Training institutions• Operators• Health professionals• Commissioners – NHS reforms timetable
  38. 38. 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

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