"Exercise is Medicine" seminar presented by Dr John Searle OBE, Prof Alfonso Jimenez and Ben Jones at Leisure Industry Week 2011

1. “Exercise is Medicine” Sponsored by:

2. Coming up? Dr. John Searle OBE Prof. Alfonso Jimenez Ben Jones Sponsored by:

4. Case studiesWhat lessons do we take back to our business? Sponsored by:

5. What can exercise do in chronic disease? John Searle Chief Medical Officer, FIA and Personal Trainer Sponsored by:

6. Exercise in disease prevention Coronary artery disease / stroke Obesity and type 2 diabetes Dementia Depression Some cancers Osteoporosis Sponsored by:

7. Exercise in disease prevention Healthy & independent older age Sponsored by:

8. Physical activity and seniors’ health care needs Canadian study 2010: 24,281 65+ over 1 year Mean number of health visits: Active = 8 Inactive = 11 Active have shorter hospital stays and faster illness recovery times Sponsored by:

9. Physical activity levels for health Evidence based guidance: ACSM 2011 BASES 2010 Start Active, Stay Active 2011 Sponsored by:

10. Exercise in chronic disease Recommendations: Nice Guidelines: non-specific ACSM’s Exercise Management for Persons with Chronic Disease (2009) Swedish National Institute of Health, Physical Activity in the Prevention and Treatment of Disease (2010) Sponsored by:

11. Which diseases are we talking about? Osteoarthritis (OA) Rheumatoid arthritis (RA) Ankylosing spondylitis Fibromyalgia Coronary artery disease Hypertension Stroke Obesity & type 2 DM Asthma COPD Parkinson’s disease Multiple sclerosis Breast and bowel cancer Depression Sponsored by:

12. Review article Kujala UM, Evidence of the effects of exercise therapy in the treatment of chronic disease. Br J Sports Med 2009; 43: 550-555. Sponsored by:

13. But it was not always like this! Sponsored by:

14. REST! Sponsored by:

15. Rheumatoid arthritis Sponsored by:

16. Appendicitis Sponsored by:

17. Objectives To achieve: An active life style & a sustainable increase in physical activity Improvement in symptoms Reduction in the rate of disease progression Sponsored by:

18. But is it risky? Greater risk not to exercise Graded progression Supervision and monitoring Proper precautions Sponsored by:

19. Does it work? Cardiovascular disease Rheumatoid arthritis Depression Sponsored by:

20. Coronary artery disease National Exercise Referral Scheme in Wales (2010) Increased levels of physical activity at 12 months Positive effects on depression and anxiety Cost effective Sponsored by:

21. Rheumatoid arthritis Synovial joints symmetrically Pain & stiffness Fatigue Decreased activity –loss of muscle Sponsored by:

22. What does exercise achieve in RA? Literature summary: Increases aerobic capacity Increase in muscle strength and lean body mass Increase in exercise endurance Weight control Improved quality of life Sponsored by:

23. And it really does work! Sponsored by:

24. But at a price Sponsored by:

25. Depression: exercise and mental health Mental Health Foundation: less tension, stress and mental fatigue a natural energy boost improved sleep a sense of achievement focus in life and motivation less anger or frustration a healthy appetite better social life having fun. Sponsored by:

26. Cancer: case study 82 year old man Previously well, played golf twice a week December 2010 cancer in the mouth 6 months aggressive chemotherapy Serious weight loss, lethargy, loss of appetite Sponsored by:

27. Cancer: case study Exercise programme at home, June 2011 Gradual increase in daily walking Resistance bands – progression Stretching and motor skills Healthy eating Lass week: 18 holes of golf Sponsored by:

28. So what? Exercise plays a vital in role as part of the management of chronic disease But how do you do it? Sponsored by:

29. The Importance of Measurement in Exercise ReferralBen Jones, Blue skies Fitness Sponsored by:

30. Overview The business of exercise referral VARTEC – a reminder Deciding what to measure Sponsored by:

31. Not so NICE NICE recommendation 2006: …insufficient evidence to recommend the use of exercise referral schemes other than as part of research studies where effectiveness can be evaluated… Sponsored by:

32. The business of exercise referral Public money typically PCT/LA funded Establishing what represents ROI Desired outcomes Key Performance Indicators The need to measure & monitor Sponsored by:

33. VARTEC Validity Accuracy Reliability Time efficient Equipment considerations Cost comparison Sponsored by:

34. Validity Does the measurement pass the Ronseal test? Who’s responsibility is it to measure the effectiveness of an ER scheme? Financial impact Clinical effectiveness Anthropological risk factors Lifestyle risk factors Psychological/QOL Sponsored by:

35. Accuracy/Reliability Determined by a number of factors that need to be controlled adequately in an exercise referral scheme Equipment quality Equipment consistency Equipment maintenance Suitability of environment Standardised testing protocol used Consistency of person testing Record keeping & confidentiality Sponsored by:

36. Time/Equipment/Cost All come down to the same issue Tests must be efficient and cost-effective to deliver without sacrificing validity or accuracy of measurements Does this answer the ‘who’ question? Clinical tests must be conducted by GP/Specialist Anthropological tests/questionnaires can be administered by appropriately trained fitness professionals Sponsored by:

37. What to measure Decision starts with the Validity question – why are we measuring? Requires us to first answer the question – Who are we measuring for? Patient Fitness Professional Doctor Commissioner Greater medical/scientific community? The future? All of us? Sponsored by:

38. What to measure for the patient Patient wants to know… Is exercise worth the time & effort?! How can we influence them to conclude ‘yes’ Demonstrate reduced pain/signs/symptoms? Demonstrate reduction in disease markers? – clinical Demonstrate improvement in general health? – both Demonstrate personal achievement/improved functional fitness Sponsored by:

39. What to measure - fitness professional Is the exercise programme effective? How can we determine yes/no? How well have they adhered to it? Has the patient progressed toward their individual goals? Does the patient have a measurable improvement in function? Does the patient have a measurable improvement in health? Is the programme sustainable for the patient? Do they have a robust action plan to continue to be active? Sponsored by:

40. What to measure for the Doctor Has the patient’s chronic condition improved or shown slowed progress? Have signs/symptoms or risk factors of other conditions reduced? Are patients more active than baseline at 6, 12, 24+ months? Sponsored by:

41. What to measure for the Doctor How can we determine yes/no? Improved clinical markers Improved signs or symptoms of comorbidities Improved predictors of risk for comorbidities Increase in long term moderate-vigorous PA behaviour Sponsored by:

42. What to measure for commissioners The easier it is to demonstrate ROI the better… Challenge – we don’t have direct access to the data that shows this: Decrease in frequency of visits to GP and other NHS services Reduced dosages of medications Reduced need for surgical interventions Co-morbid conditions prevented Sponsored by:

43. What to measure for commissioners Attendance/adherence Anthropological predictors of chronic conditions Psychological/QOL questionnaires Long-term follow-up of patient’s activity levels (questionnaires) Sponsored by:

44. What to measure - future development As much as possible, in a standardised format that can be compared in a meaningful way across schemes to evaluate effectiveness Why? To allow controlled adaptation and comparison of scheme variables and development of increasingly effective & targeted exercise referral services Sponsored by:

45. Final thought We may believe that exercise referral schemes are beneficial but there is a lack of evidence to support this Unless we begin to evidence these benefits financial pressures will continue to force scheme closures Sponsored by: