Physical Activity - Referral & Signposting

Absolute contra-indications to exercise

There are also several absolute contra-indications to exercise which referring health professionals should be familiar with, see list belowxi. Patients with absolute contraindications should not exercise until such conditions are stabilised or adequately treated.

Absolute contra-indications to exercise:• A recent significant change in a resting ECG, recent

myocardial infarction or other acute cardiac eventxii

• Symptomatic severe aortic stenosis• Acute myocarditis or pericarditis• Resting Systolic Blood Pressure ≥ 180mmHg / DBP ≥

100mmHg• Uncontrolled / unstable angina• Acute uncontrolled psychiatric illness• New or uncontrolled arrhythmias• Experiences significant drop in BP during exercise• Uncontrolled resting tachycardia ≥ 100 bpm• Febrile illness• Experiences pain, dizziness or excessive breathlessness

during exertion• Any unstable, uncontrolled conditionxiii

xi Absolute contraindications taken from BACR (2006) Phase IV Exercise Instructor Training Manual & ACSM (2006) Guidelines for Exercise Testing and PrescriptionxiiAppropriate guidance on this should be provided either by the patient’s cardiologist or cardiac rehabilitation teamxiiiDiabetes may be an exception here as exercise can help individuals’ in the management of uncontrolled Diabetes

Hertfordshire Exercise Referral Scheme: http://www.enhertsccg.nhs.uk/

Need for increased physical activity identified

& no contraindications

For contraindications see pathway Physical Activity -

Screening & Behaviour Change

http://www.enhertsccg.nhs.uk/

Risk stratify for safetyto exercise

High riskClick for

more info

Cardiovascular(not including hypertension)

Stable angina/ heartfailure

CABG/ stentingcoronary angioplasty

Heart valve replacement

Confirmed cardiacarrhythmia

Cardiac rehabilitationClick for

more info

See pathway Exercise Protocol for the

Management of CHD (Exercise for Cardiac

Conditions):http://www.enhertsccg.nhs.uk/

Falls associated risk

Osteoporosis(T score > -2.5)

65+ and at risk of falls

Fallen in past 12months

Severe osteoarthritisor inflammatory

arthritis

Treated hypertension,systolic 160-179

diastolic 95-100 mmHg

See pathway Hypertension in Adults -

Diagnosis and Initial Management:

http://www.enhertsccg.nhs.uk/

Neurological Stroke

Diabetic/ non-diabeticneuropathy; peripheral

or autonomic

Other significantneuromuscular difficulties

Assess for eligibility forexercise on referral

Assess for eligibility forexercise on referral

Exercise referral schemes by district council area

NB: Each district council currently has slightly different referral criteria for exercise on referral. Please check the criteria in the

next set of boxes before referring

Welwyn Hatfield exercise referral criteria

Click for more info

Stevenage exercise referral criteria

Click for more info

North Herts exercise referral criteria

Click for more info

Broxbourne exercise referral criteria

Click for more info

East Herts exercise referral criteria

Click for more info

Respiratory

MRC3, confirmedrespiratory condition

Moderate to severeasthma causing breathlessness

Pulmonary RehabilitationClick for

more info

See pathway Pulmonary Rehabilitation:

http://www.enhertsccg.nhs.uk/

Mental health

Significant cognitiveimpairment/ dementia

Active psychosis

Explore safe meansof increasing physical

activity

Stabilise condition, reassess risk, then

consider exercise on referral

Medium riskClick for

more info

Low riskClick for

more info

See pathway Physical Activity

Opportunities for Low/Medium Risk Patients:

http://www.enhertsccg.nhs.uk/

Click for info for GPs &

HCPs

Click for info for patients

Yes

No

No

No

Yes

No

Yes

No

Yes

Yes

Yes

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High risk

Refer patients categorised as high risk in the risk stratification to appropriate supervised physical activity

Factors• Cardiac - Stable angina with no chest pain at rest, myocardial infarction, coronary artery bypass graft, valve replacement, pacemaker, percutaneous

transluminal coronary angioplasty, heart failure• Cardiac arrhythmias - diagnosed by cardiologist• Hypertension - medicated but with BP of 160–180/ 95–100 mmHg• Transient ischaemic attack - with severe disability/cognitive impairment• Older people > 65 years at risk of falls - has fallen within the last 12 months• Osteoporosis - BMD T score > 2.5 SD• Claudication - with cardiac dysfunction• Type 1 or 2 diabetes - with accompanying autonomic neuropathy, advanced retinopathy• Severe osteoarthritis/rheumatoid arthritis - with associated immobility• Moderate to severe asthma - where ventilatory limitation restrains sub-maximal exercise• COPD/emphysema - with true ventilatory limitation• Severe psychiatric illness - cognitive impairment, dementia, schizophrenia• AIDS - with accompanying neuromuscular complications, severe depletion of CD4 cells, malignancy or opportunistic infection

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Cardiac rehabilitation

Criteria for phase IV

Most patients requiring cardiac rehabilitation will be referred to their closest service by the cardiac rehabilitation team at the hospital where the event occurred.

GPs will only need to refer if asked to do so on a discharge summary or by the patient because they have not been contacted.

Patients will be contacted, assessed by the cardiac rehabilitation team and offered an appropriate cardiac rehabilitation programme and then discharged after reassessment. Discharge information will be sent to the GP. Patients will be encouraged to maintain an exercise regime and offered exercise classes in community (phase IV classes or similar)

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Welwyn Hatfield exercise referral criteria

Inclusion criteria• Mild hypertension (unmedicated)• Hypertension (medicated)• Mobility• Mild asthma• Muscle strength• Diabetes• Stress / depression• Weight Loss• Post Heart Attack (subject to patient completing phase 4 cardiac rehabilitation programme)• GP recommends to improve overall health

Exclusion criteriaNone listed but GP should identify red flag reasons for not attending including conditions specified as high risk in 'Risk Stratification' within this pathway

Get Active referral form for Welwyn & Hatfield: http://www.enhertsccg.nhs.uk/

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Stevenage exercise referral criteria

Eligible Conditions

Patient who can be referred:Inactive AND at least one of these other criteria

• Controlled Hypertension• Osteoporosis• Smoker• Controlled Diabetes• Unhealthy Weight (BMI>28)• Stroke Osteoarthritis/ Rheumatoid Arthritis• High Cholesterol Levels• Cancer• Mild to Moderate Mental Health Condition• Musculoskeletal Rehabilitation• Heart Disease COPD• Back Pain• Other

Patient who cannot be referred• Unstable Angina• Uncontrolled Diabetes• Recent acute soft tissue injury• Systolic >180 and/or diastolic >100 at rest• Diastolic Blood Pressure 100mm/Hg at rest• Uncontrolled Tachycardia 100bpm at rest• Unstable or acute heart failure

SLL Exercise Referral form for Stevenage: http://www.enhertsccg.nhs.uk/

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North Herts exercise referral criteria

Inclusion Criteria• Overweight (BMI 25.0 to 29.9) or obese (BMI 30.0 to 39.9)• Raised normal blood pressure 130-139 / 85-89 mmHg (unmedicated – seated)• Hypertension less than 179/99 mmHg (stable – medicated)• Type 2 diabetes diet controlled or orally medicated and no coronary heart disease• High waist circumference• Males >94 cm;• Females > 80 cm• High cholesterol medicated• Asthma stable and controlled• Osteoarthritis mild enough for physical activity to provide symptomatic relief• Rheumatoid arthritis medication controlled, not during flare ups or active infection• Chronic low back pain in the absence of red flags• Type 1 diabetes stable and controlled• Muscular-skeletal pain In absence of red flags and/or impending surgical intervention• Mild to moderate anxiety and/or depression HAD Score between 8 – 15• PHQ9 Score between 5 – 14

Exclusion Criteria• Any unstable condition• Resting blood pressure ≥ 180/100 mmHg• Red flags in association with lower back pain - see Back Pain pathway: http://www.enhertsccg.nhs.uk/• Body Mass Index < 18.5 kg/m2 or morbid obesity (BMI usually >40)

SLL Exercise Referral form for Royston: http://www.enhertsccg.nhs.uk/SLL Exercise Referral form for Royston: http://www.enhertsccg.nhs.uk/

SLL Exercise Referral form for Hitchin: http://www.enhertsccg.nhs.uk/SLL Exercise Referral form for Hitchin: http://www.enhertsccg.nhs.uk/

SLL Exercise Referral form for Baldock: http://www.enhertsccg.nhs.uk/SLL Exercise Referral form for Baldock: http://www.enhertsccg.nhs.uk/

SLL Exercise Referral form for North Herts: http://www.enhertsccg.nhs.uk/SLL Exercise Referral form for North Herts: http://www.enhertsccg.nhs.uk/

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Broxbourne exercise referral criteria

Patient Eligibility

Anyone aged 16 years or above who is resident or who are registered with a GP practice in Broxbourne Borough.

Participants must meet the referral criteria and be sufficiently motivated to want to increase their physical activity levels.

Eligible Conditions

Patients who can be referred - all referrals must be aged 16+, motivated to increase activity, inactive (are not moderately active for a total of 30 minutes more than twice a week) and fulfil at least one of the following criteria:

• Exhibit at least one of the following risk factors for coronary heart disease:• Smoking• Family history of heart disease• High total cholesterol levels (consistently > 5.2mmol/L)• Overweight (BMI > 28 kg/m2)• Hypertension• Controlled diabetes

• Exhibit at least one of the following risk factors for osteoporosis:• Smoking• Heavy alcohol consumption• Family history of osteoporosis• Hysterectomy with removal of ovaries• Prolonged oral steroids• Early menopause• History of low trauma fracture• Prolonged amenorrhoea

• Controlled Diabetes• Suffer from mild to moderate rheumatoid arthritis or osteoarthritis• Has low back weakness and inflexibility• Controlled Asthma• Unhealthy Weight• Patients requiring musculo-skeletal rehabilitation• Suffer from mild to moderate mental health condition

Patient who cannot be referred• Established ischaemic heart disease• Latest Blood Pressure either:

• Systolic: >180mmHg orDiastolic: >100mmHg• Uncontrolled Type 1 diabetes• Severe or poorly controlled asthma• Chronic pulmonary disease• Cerebro-vascular disease• Peripheral vascular disease• Unstable or severe mental health state• Resting Heart Rate > 100 BPM• Febrile Illness• Heart Failure• Aortic Valve Stenosis• Patients who in Healthcare• Professionals opinion are not medically fit to undertake a physical activity programme

4 Point Plan: How to Refer a Patient• ASSESS Patient’s current activity levels, the GPPAQcan help and ensure the patient meets the referral criteria - https://www.gov.uk/government/

publications/general-practice-physical-activity-questionnaire-gppaq• EXPLAIN To the patient what is available; see ‘What’s on offer’ section below.

• ASK The patient if they are motivated and wish to be referred to the Active 4 Life scheme: http://www.enhertsccg.nhs.uk/• REFER The patient using the Active 4 Life Referral Form. Give the form to them and ask them to phone their preferred participating leisure centre in

Broxbourne Borough to arrange their first appointment. Patients must take their referral form along to the first appointment.

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East Herts exercise referral criteria

Eligible ConditionsPatient who can be referred:All referrals must be aged 16+, motivated to increase activity, inactive and fulfil at least one of the following criteria:

• Exhibit at least one of the following risk factors for coronary heart disease:• Smoking• Family history of heart disease• High total cholesterol levels (consistently > 5.2 mmol/L)• Overweight (BMI > 28 kg/m2)• Hypertension• Controlled diabetes

• Exhibit at least one of the following risk factors for osteoporosis:• Smoking• Heavy alcohol consumption• Family history of osteoporosis• Hysterectomy with removal of ovaries• Prolonged oral steroids• Early menopause• History of low trauma fracture• Prolonged amenorrhoea

• Controlled Diabetes• Suffer from mild to moderate rheumatoid arthritis or osteoarthritis• Has low back weakness and inflexibility• Controlled Asthma• Unhealthy Weight• Patients requiring musculo-skeletal rehabilitation• Suffer from mild to moderate mental health condition

Patient who cannot be referred• Established Ischaemic heart disease• Latest Blood Pressure either:

• Systolic: >180mmHg or• Diastolic: >100mmHg

• Uncontrolled Type 1 diabetes• Severe or poorly controlled asthma• Chronic pulmonary disease• Cerebro-vascular disease• Peripheral vascular disease• Unstable or severe mental health state• Resting Heart Rate > 100 BPM• Febrile Illness• Heart Failure• Aortic Valve Stenosis• Patients who in Healthcare Professional's opinion are not medically fit to undertake a physical activity programme

Active for Life Exercise Referral Form: http://www.enhertsccg.nhs.uk/

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Pulmonary Rehabilitation

Suitability • Pulmonary Rehabilitation is a therapy suitable for patients who feel breathless on exertion, as a result of a respiratory disorder. This disorder is most

likely to be COPD, but we will accept other lung conditions such as asthma and bronchiectasis• All patients should have their respiratory diagnosis confirmed by spirometry prior to referral• All patients should be on optimal inhaled medication before referral into Pulmonary Rehabilitation• Patients referred into Pulmonary Rehabilitation should have a functional need for this therapy, based on their quality of life and degree of

breathlessness, not based solely on their diagnosis• Pulmonary Rehabilitation inclusion/exclusion criteria should be checked with the patient before referral; in particular, their willingness to attend and any

transport issues they may have

Pulmonary Rehabilitation referral form: http://www.enhertsccg.nhs.uk/

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Medium risk

Factors• Asthma - Mild to moderate, controlled• NIDDM - Pharmacologically controlled• Surgery pre- and post- - General or orthopedic (not cardiac)• Depression - Medicated, without complications• Insulin-dependent diabetes mellitus (IDDM) - Ensure adequate instructions regarding modification of insulin dosage depending on timing of exercise

and warning signs• Hypertensive stage 1 - 140–159/90–99 mmHg – medication controlled• Osteopenic - T score < 2.5 S.D• COPD - Without ventilatory limitation but would benefit from optimisation of respiratory system mechanics and correction of physical deconditioning• Neurological conditions - Parkinson’s, multiple sclerosis• Moderate rheumatoid arthritis/ osteoarthritis - Intermittent mobility problems• Early symptomatic HIV -Moderately diminished CD4 cells, intermittent or persistent signs and symptoms, e.g. fatigue, weight loss, fever• Myalgic encephalopathy (ME) - Deconditioned due to longstanding symptoms• Fibromyalgia - Associated impaired functional ability, poor physical fitness, social isolation, neuroendocrine and autonomic system regulation disorders

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Low risk

Factors• Family history - Asymptomatic but may have family history of CHD• Cigarette smoker - Current or given up within the past 6–12 months• High normal BP - 130–139/85–89 mmHg (not medication controlled)• Hypercholesterolemia - Total > 5.2 mmol/L or HDL < 0.9mmol/L or LDL > 3.4 mmol/L• Overweight/obese - BMI between 25 and 40 white and black population BMI 35 for South Asian population• Non-insulin-dependent diabetes mellitus (NIDDM) - Diet controlled• Older person (aged > 65yrs) - Not at risk of falling• Antenatal - No symptoms of pre-eclampsia/no history of miscarriage• Postnatal - Provided 6/52 check complete and no complications• Osteoarthritis - Mild where physical activity will provide symptomatic relief• Mild bone density changes - BMD > 1SD and < 2.5 SD below young adult mean• Exercise induced asthma - Without other symptoms• Depression - Mild or moderate. Not medication controlled• Stress/mild anxiety - No complications• Seropositive HIV - Asymptomatic• Physical disabilities

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Information for GPs and Healthcare professionals

http://prescription4exercise.com/

http://gpcpd.walesdeanery.org/index.php/resources

Summary briefing for busy Healthcare Professionals:http://prescription4exercise.com/health-professional/

BMJ 9 e-learning modules for physical activity:http://learning.bmj.com/learning/course-intro/physical-activity.html?courseId=10051913&locale=en_GB

British Heart Foundation Resources: https://www.bhf.org.uk/publications

Macmillan Resources: http://www.macmillan.org.uk/information-and-support/coping/maintaining-a-healthy-lifestyle/keeping-active

Exercise: The miracle cure and the role of the doctor in promoting it: http://www.ukhealthforum.org.uk/prevention/pie/?entryid43=40193

The Lancet Series on Physical Activity: http://www.thelancet.com/series/physical-activity

Scientific evidence for physical activity: http://prescription4exercise.com/health-professional/educational-resources-2/

Scottish guidelines including risk factors and risk stratification: http://www.healthscotland.scot/search?q=physical+activity+pathway

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BHF National Centre for physical activity and health: http://www.bhfactive.org.uk/adults-resources-and-publications-results/39/index.html

Physical Activity guidelines: https://www.gov.uk/government/publications/uk-physical-activity-guidelines

Active Herts for Better Health: http://www.activeherts.org.uk/healthcare-professionals/resources/

Start Active, Stay Active: https://www.gov.uk/government/

Hertfordshire Keep Active: http://www.hertfordshire.gov.uk/

Information for Patients