Post on 18-Nov-2014
description
Exercise referral – time to improve the outcome
John Searle Chief Medical Officer FIA
Exercise
Exercise is the most effective disease prevention ‘stuff’ there
is
Exercise in disease prevention
Heart attacks Stroke
Exercise in disease prevention
Obesity Type 2 diabetes
Exercise in disease prevention
Dementia Stress
Exercise in disease prevention
Depression Falls
Exercise in disease prevention
Various types of cancer
Exercise in disease management?
Exercise in disease
• Improves symptoms
• Slows progression
• Promotes physical activity and wellbeing
(British Journal of Sport and Exercise
Medicine 2009; 43: 550-555)
Exercise referral schemes
• 1990’s
• National Quality Assurance Framework
2001
• BHFNC Toolkit 2010
Do exercise referral schemes work?
NICE 2006
‘there is insufficient evidence to recommend
the use of exercise referral services to
promote physical activity other than part if
research studies where their effectiveness
can be evaluated’
HTA 2011 (in press) The National Institute of Health Research Health
Technology Assessment Agency
Little or no effect in increasing physical activity.
Serious lack of properly controlled, randomised
studies in exerciser referral.
Many studies have a poor methodology
Welsh National Exercise Referral 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
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
Other concerns
Lack of GP training Risk to patients
Other concerns
Joint Consultative Forum (JCF)
Terminology
• Recommendation:
Advising a patient to be more physically
active in order to improve their health and
reduce the risk of disease
Terminology – exercise referral
Exercise referral is a formal process which uses exercise as a component of the management of a patient’s condition, with the objectives of improving or reducing the rate of its progression and achieving an independent and sustainable increase in physical activity
The process
Referral of a patient by a health care
professional to a service or an independent
exercise referral instructor for the process of
providing an exercise programme as part of
the management of people (i) with stable or
significant limitations related to a chronic
disease or disability and/or (ii) with one or
more CV disease risk factors
Professional & operational
standards in exercise referral
• Risk stratification
• Qualifications
• The process
• Record keeping
• Medico-legal issues
• Services and facilities
Risk stratification – the PAR-Q • ‘No’ to all the questions
• Heart rate < 100 bpm
• BP < 140/90
Remain in the ER service, undertake a range of activities programmed by but not necessarily supervised by the ER instructor
Answers ‘yes’ on the PAR-Q
Irwin 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
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
Qualifications
Fitness 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.
Assessment • Personal details
• BMI
• Waist circumference
• Pre ex HR
• BP
• PA questionnaire -IPAQ
• Quality of life – EQ-5D
Assessment
• Aerobic – not necessary
• ROM in musculoskeletal disease
• Requested by referrer
Goals
Short tern – attendance, sessional
Medium term
(i) condition specific
(ii) Patient specific
Long term – a sustainable increase in physical activity
Delivery
ACSM disease specific guidelines
Appropriate progression
Good communication
Trust and rapport
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
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
Medico-legal matters
Doctors must only refer patients for the purposes of using exercise as part of treatment to an appropriately qualified and registered exercise referral fitness instructor or a service which employs such instructors
Medical Defence Societies
Other matters
• Reporting to the referrer and to commissioners
• Service evaluation and appraisal – by
commissioners and professionally
• Instructor appraisal – fit to practice
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
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)
Help – the bench mark is too high!
Implementation will be gradual
• Standard setting
• Training institutions
• Operators
• Health professionals
• Commissioners
–NHS reforms timetable
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