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Exercise prescription in primary care (1)

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The presentation was directed towards Saskatchewan family physicians on exercise prescription for mental health and osteoarthritis in the primary care setting.

Published in: Health & Medicine
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Exercise prescription in primary care (1)

  1. 1. Exercise Prescription in Primary Care Faculty/Presenter Disclosure Faculty: Dr. Patrick Ling Sept 24, 2015 2015 Annual Scientific Assembly Regina, Saskatchewan Relationships with commercial interests: •Grants/Research Support: none •Speakers Bureau/Honoraria: none •Advisory Boards: none • Other:
  2. 2. Disclosure of Commercial Support  Potential for conflicts of interest: • NONE • No products will be discussed in this presentation
  3. 3. Learning Objectives of this Section 1. Describe mental health benefits for exercise 2. Review literature on exercise and osteoarthritis 3. Describe the challenges with exercise prescription in the primary care setting 4. Describe an exercise prescription 5. Discuss the elements of physical activity counseling
  4. 4. Why should physicians counsel patients about physical activity? • Preferred source of health information (Blair et al., 1998) • High population reach (CIHI, 2003) – 75-80% of Canadians visit their family physician over the course of a year (Wilson and Ciliska, 1992) – Avg Cdn visits FP 3.1x/yr, increases to 6x/yr for >65 yo • Manage or involved with the care of chronic disease • Physical Inactivity is an important risk factor • Exercise is safe and affordable for most people
  5. 5. HSF Clinical Day – December 7, 2012 6 Your Role and Influence • Structured counselling by health care professionals effectively increases physical activity adoption +55 mins -14 mins counselling no counselling From: Kirk et al. Diabetalogia. 2004;47:821-832 Change in exercise time per week
  6. 6. HSF Clinical Day – December 7, 2012 The Benefits of Exercise in ... ● constipation ● fibromyalgia ● osteoarthritis ● lupus ● depression ● IBS – irritable bowel syndrome ● insomnia ● chronic fatigue ● slows aging ● boost testosterone ● preserves cognitive function ● dysmenorrhea ● fewer colds ● cancer prevention?
  7. 7. HSF Clinical Day – December 7, 2012
  8. 8. HSF Clinical Day – December 7, 2012
  9. 9. HSF Clinical Day – December 7, 2012 10
  10. 10. HSF Clinical Day – December 7, 2012 13
  11. 11. Exercise and Depression • Exercise in some studies as effective as anti-depressants, psychological therapies • Exercise is more effective than no therapy for reducing symptoms of depression • Compliance rate between 50-100% • Ref: Cochrane Review Sept, 2013
  12. 12. Exercise and Anxiety Population based study: Exercisers were less anxious, less depressed Meta-analysis: Exercise results in reduction in anxiety and depression Ref: DeMoor 2006, Guszkowska 2004
  13. 13. Osteoarthritis
  14. 14. Exercise and Osteoarthritis • Evidence supports aerobic and progressive strengthening exercise – results in pain reduction and improved function • In patients with mild to mod knee OA • Ref: Golightly 2012
  15. 15. Exercise and Osteoarthritis • No association between OA and runners • muscle dysfunction vs wear & tear • Ref: Willick 2010, Shrier 2004
  16. 16. Preventive Care Checklist CCFP (2012 update) Exercise is part of lifestyle assessment on the PCC checklist but…  As of 2012, Moderate physical activity recommendations:  Doing moderate physical activity was a B recommendation  But physician counseling was a C.  However: Brief advice in primary care is a cost-effective intervention. (Anokye et al. BJSM 2014; 48: 202–6)
  17. 17. Doctors prescribing exercise?
  18. 18. Challenges to ExRx in Primary Care• For MD’s – Lack of time – Lack of training & confidence in exercise design – Lack of training & confidence in PA counseling – Lack of billing codes, insurance coverage – Lack of resources to support counseling and referrals • In the MD-patient dynamic – Perceived low response efficacy – Patient ‘readiness’ rarely elicited or revealed – Unclear or inconsistent recommendations – Difference between what is said and heard – Lack of resources to support exercise prescription • Insurance, qualified individuals, information overload Estabrooks et al JAMA,2003; Carrol et al., AFM 2011; Lawton BMJ 2008; Sallis BJSM 2011
  19. 19. Exercise Prescription in Primary Health An MD ExRx can improve ‘uptake’  “Green prescription” in NZ ↑ PA in “relatively inactive” adults by ~10% at 1 yr and is cost-effective  (Elley et al., BMJ 2003; Elley et al., NZMJ 2004, Dalziel et al., 2006)  MD counseling on PA, weight loss & fitness, improves outcomes  Pinto et al., AJPM, 2005; Huang et al., 2004; Petrella et al., AJPM, 2003;
  20. 20. HSF Clinical Day – December 7, 2012 Petrella et al Am J Prev Med, 2007
  21. 21. Family Physicians, Sport Medicine Physicians, Allied Health Professionals • Key role in promoting and Px physical activity
  22. 22. www.csep.ca
  23. 23. Sponsors of the Exercise Prescription Project
  24. 24. The Five A’s Model for PA Counseling • Ask • ASSESS • ADVISE • AGREE • ASSIST • ARRANGE Whitlock et al., 2002; Goldstein et al., 2004; Fortier, Tulloch & Hogg 2006
  25. 25. Ask Brief Comprehensive 30 seconds 2-4 min 10-20 minutes Counseling Opportunities
  26. 26. Assess - Exercise Vital Sign  “There is no better indicator of a person's health and likely longevity than the min/week of activity they engage in”  Sallis, Br J Sports Med, 2011  Are you achieving 150 minutes?  2 questions, 1 minute  How many times per week MVPA?  For how long each time?
  27. 27. • Determine patient’s current level of activity – Compare to Canada’s PA guidelines • Willingness to exercise (i.e. ‘readiness’) • Helpful step to create a prescription or referral to qualified exercise professional ASK EVERY PATIENT EVERY TIME
  28. 28. How can you determine if patient is fit to exercise independently? Pre-Exercise Screening
  29. 29. Overcoming Barriers; Reframing FEAR  Most people are at greater risk from sedentary behaviour than from exercise.  Aerobic Ex CV complication rate ~ 1/100,000 hours (ACSM & AHA, 2007)  Resistance Ex injury rate <3 / 1,000 hours (Parkkari, 2006) (walking ~0.2)  Be aware of the short-term and long-term complications of disease.  E.g diabetes : SMBG can be informative  If on insulin (or secretagogues), have 15 gm glucose available  Goals of pre-exercise screening:  To identify problems that might make exercise-associated risks outweigh the benefits.  To expedite treatment of such problems.
  30. 30. You may get referrals for clearance following a screening questionnaire…
  31. 31. Bredin SSD et al; PAR-Q+ and ePARmed-X+. Can Fam Physician 2013; 59: 273-277 The safe zone for mild to moderate intensity exercise
  32. 32. Pain and Discomfort • Pain – Typically sharp, localized, and stops activity • Acute ‘Pain’- follow-up • Chronic ‘Discomfort’ – Prefer & Refer • Discomfort – Normal, uncomfortable feeling felt during PA or exercise that does not stop activity – Necessary to work through for gains in fitness – Decreases with time and improved fitness • E.g. Arthritis large effect for exercise (increased ROM & Strength)

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