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East Midlands Clinical Senate ReportPhysical activity and exercise medicine
Report byProfessor Mark E Batt Consultant Sport & Exercise Medicine
East Midlands Clinical Senate Council member
Suzanne HorobinEast Midlands Strategic Clinical Networks and Senate
3East Midlands Clinical Senate Report Physical activity and exercise medicine
1 Executive summary � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5
2 Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6
3 Background � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8
3.1 Facts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9
3.2 East Midlands Research institutions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12
3.3 Physical activity in the treatment of chronic disease � � � � � � � � � � � � � � � � � � � 15
4 The case for change in the East Midlands � � � � � � � � � � � � � � � � � � � � � � � � � � � � 17
4.1 East Midlands physical activity needs � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 17
4�1�1 Maintaining good health � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 18
4�1�2 Risk reduction, rehabilitation and treatment � � � � � � � � � � � � � � � � � � � � � � � 23
4.2 RCP Commissioning Guidance � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 26
5 Recommendations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28
5.1 The Clinical Senate is supportive of the following initiatives � � � � � � � � � � 28
5�1�1 Existing NICE guidelines � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28
5�1�2 Return on investment tools � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 29
5�1�3 Public Health England - Everybody active, every day � � � � � � � � � � � � � � � � 29
5�1�4 Third sector provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 30
5.2 The Clinical Senate recommends the following be developed � � � � � � � � 31
5�2�1 Lie less, sit less� Do more, more often (primary, secondary and tertiary
prevention) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 31
5�2�2 Support the development of a network for existing East Midlands groups
(enhanced secondary and tertiary prevention) � � � � � � � � � � � � � � � � � � � � � � 31
5�2�3 Making every contact count: (primary, secondary and tertiary prevention)
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 32
5�2�4 Signposting / messaging: physical activity on referral / sport & exercise
medicine � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33
5�2�5 Training curricula � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 34
5�2�6 Evidence the benefits / return on investment � � � � � � � � � � � � � � � � � � � � � � � 34
5�2�7 Physical activity as a treatment for mental health � � � � � � � � � � � � � � � � � � � 36
5�2�8 Thinking differently � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37
Content
4East Midlands Clinical Senate Report Physical activity and exercise medicine
Content
5.3 The Clinical Senate recommends the following be actively commissioned -
across health and social care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37
5�3�1 Education programme: Everybody active, every day: (primary, secondary
and tertiary prevention) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37
5�3�2 Healthy workplace � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 38
5�3�3 Review of existing service provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 38
5�3�4 Exercise medicine: (enhanced secondary and tertiary prevention) � � � � 40
6 Appendices � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41
6.1 Chief Medical Officer Physical Activity Guideline � � � � � � � � � � � � � � � � � � � � � � 41
6.2 Who is currently responsible for what? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 43
6.3 Examples of existing provision � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 45
6�3�1 Leicestershire and Rutland � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 45
6�3�2 Northamptonshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49
6�3�3 Derbyshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49
6�3�4 Nottinghamshire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49
7 Referenced evidence base � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 50
7.1 Literature review � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 50
7.2 Collation and summary of existing professional and national guidelines
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 51
8 Acknowledgements � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53
5East Midlands Clinical Senate Report Physical activity and exercise medicine
This report by the East Midlands Clinical Senate provides
background information, a case for change and
recommendations to encourage more people to be more
active more of the time�
The focus of the report is physical activity and the benefits
to be obtained through its use in prevention of ill health, in
risk reduction and as an active treatment�
The Council recommends the support of a number
of existing national initiatives, the development of
regional programmes and networks and specifically the
commissioning of:
• Educationprogrammeforhealthcareprofessionals
• Healthyworkplaceinterventions
• Reviewofexistingserviceprovision
• Exercisemedicineservices
Clinical commissioners are encouraged to work in
collaboration with Public Health colleagues to address the
gaps in the current system�
It is suggested that this report be read in conjunction
with Public Health England’s Everybody active, every day�
Specifically, this report provides a framework for an East
Midlands response�
https://www�gov�uk/government/publications/everybody-
active-every-day-a-framework-to-embed-physical-activity-
into-daily-life
1 Executive summary
6East Midlands Clinical Senate Report Physical activity and exercise medicine
2 Definitions
Physical Activity: body movement that expends energy
and raises the heart rate�
Inactivity: less than 30 minutes physical activity a week�
Sedentary: time spent in low-energy postures, eg, sitting or
lying�
Sport and exercise medicine (SEM): is a new speciality of
medicine involving the medical care of injury and illness in
sport and exercise�
In primary care, SEM physicians can:
• Workwithprimarycareteamsandpublichealth
to support effective physical activity prescription,
including providing education for the primary care
team so that consistent, evidence based and effective
physical activity interventions are provided�
• Provideexpertiseforpatientsrequiringspecialist
input; for example those identified as ‘high risk’ due
to medical conditions and co-morbidity and those
requiringmoreintensebehaviouralinterventions.
• Providelocallybasedmusculoskeletalservices,bringing
a range of additional skills such as leadership, triage,
rapid access to ultrasound scans, evidence based
injection therapies, specialised back pain services and
chronic pain services etc�
7East Midlands Clinical Senate Report Physical activity and exercise medicine
2 Definitions
In secondary care, SEM physicians can:
• Restructureandmoderniseexistingrehabilitation
services so they are patient-centred, evidence-based
and inclusive of all chronic disease areas effectively
treated by exercise�
• Establishmultidisciplinaryteamstoprovideasingle
pointofreferralforpatientsrequiringspecialisthelp
to overcome their medical, social or cultural barriers to
exercise�
• EstablishSEMledclinicstoworkalongsideexisting
orthopaedic, physiotherapy and emergency
department services in identifying, treating and
rehabilitating acute and chronic musculoskeletal
disorderswhichdonotrequiresurgery.
SEM physicians can support commissioners in specifying
services for people who are unwell including pathways for
personalising exercise interventions amongst those who
do not feel they are able to exercise (anxious, overweight,
musculoskeletal pain etc�)
8East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
This report should be read in conjunction with the Public
Health England publication Everybody active, every day - An
evidence-based approach to physical activity.
https://www�gov�uk/government/publications/everybody-
active-every-day-a-framework-to-embed-physical-activity-
into-daily-life
Physical inactivity poses a serious and growing threat to
our society - it is a pan-societal issue damaging our health,
economy and environment� Levels of physical activity are
declining and we need to act� Other high-income countries
like Finland, the Netherlands and Germany have shown that
the situation can be changed�
The All Party Commission on Physical Activity report Tackling
Physical Inactivity - A Coordinated Approach (2014) offered
five recommendations:
1. A national action plan
2. Getting the message out
3. Designing physical activity back into our everyday lives
4. Making physical activity a lifelong habit
5. Proving success
These recommendations have been followed by the
Everybody active, every day report which provides the
background and impetus for this report�
9East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
3.1 Facts
The Public Health report Everybody active, every day provides the following graphical
summary of the current levels of physical inactivity�
Everybody active, every day
5
64% of trips are made by car 22% are made on foot2% are made by bike
19% of men and 26% of women are
'physically inactive'
33% of men are not active enough for
good health
21% of boys and 16% of girls aged 5-15 achieve
recommended levels of physical activity
47% of boys and 49% of girls in the lowest economic group are
'inactive' compared to 26% and 35% in the highest
Walking trips decreased by 30%
between 1995 and 2013
45% of women are not active enough for
good health
23% of girls aged 5-7 meet the
recommended levels of daily physical activity, by ages 13-15 only 8% do
18% of disabled adults regularly take
part in sport compared to 39% of non-disabled
adults
The extent of the problem
Data sources: Health Survey for England 2012 (HSE); Active People Survey 8, April 2013-April 2014 (APS); National Travel Survey 2013 (NTS)
We want to engage with professionals, providers and commissioners in health, social care, transportation, planning, education, sport and leisure, the voluntary, community and cultural sectors as well as public and private employers to make the case for more – much more – physical activity, every day.
10East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
• 70% of NHS spend is on long-term conditions� As long
agoas2002theWanlessreport Securing our future
health (2002) (and later - Securing health for the whole
population (2004)) confirmed that with no increased
investment in chronic disease prevention our healthcare
economy is not sustainable in the long-term�
• Onaverage,aninactivepersonspends38%moredays
in hospital than an active person, and utilises 5�5%
more GP visits, 13% more specialist services and 12%
more nurse visits than an active individual�
• TheUKfacesanepidemicofphysicalinactivity-we
have dramatically ‘engineered’ movement out of our
lives, to the extent that humans have never been so
inactive� Only 39% of men and 29% of women in the
UKmeetminimumphysicalactivityrecommendations
when measured subjectively and 5% when measured
objectively�
• Thepopulationdoesnotunderstandtheconsequences
of physical inactivity - low fitness kills more people
than smoking, diabetes and hypertension combined�
• Healthylifeexpectancyisincreasedbyphysicalactivity
• Onlyonethirdofthepopulationtakeenoughphysical
activity to maintain good health�
• Thereexistsasignificantgapinperceptionandreality
regarding how active we are�
• Physicalinactivitycontributesto1:10prematuredeaths
(37,000 in England annually): a greater cause of death
intheUKcomparedtoUSA(moreobesity),Franceand
The Netherlands�
• Dietandphysicalinactivityaccountedfor14.3%(95%
UI12.8—15.9)ofUKdisabilityadjustedlifeyearsin
2010�
11East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
• Theeffectsofphysicalactivityarelargelyindependent
of obesity or weight loss� In other words, the benefits
of physical activity are achieved even in the absence of
weight loss; hence the advice that it is better to be ‘fat
and fit’ than ‘lean and unfit’�
• Ifthepracticalproblemsofchangingthebehaviourof
the population could be addressed, the benefits to the
NHS could be very significant:
- 30% to 50% reductions of risk in the
development of common chronic conditions,
including cancer, ischaemic heart disease, obesity
and diabetes, dementia and depression�
- Significant improvements in the efficacy of
treatment of those same chronic conditions
- Improved outcomes, patient satisfaction and
reduced costs (many fewer GP and orthopaedic
presentations) for musculoskeletal injuries�
• AMacmillanCancerSupportpublicationMove More
states that there are two million cancer survivors in the
UKandestimatesthat1.6millionarenotphysically
active to recommended levels
• InorderforthepopulationoftheEastMidlandsto
maintain good health 20 million hours of physical
activityperweekarerequired.
Sedentary behaviour is emerging as an important target in
the prevention and treatment of chronic disease� Although
often used interchangeably, “sedentary behaviour” and
“inactivity” are different constructs and need different
solutions�
12East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
Sedentary time refers to all non-exercise sitting time and
inactivity refers to those who fail to meet the physical
activity guidelines� Hence it is possible to be active, but still
have high sedentary behaviour�
A journal article for Diabetes Research and Clinical Practice
(2011) Stand up for your health: Is it time to rethink the
physical activity paradigm? confirms that although the
importance of physical activity in the prevention and
treatment of chronic disease is clear and must remain, there
is increasing evidence that it will not offset the deleterious
effects associated with sedentary behaviour� Strategies
based on simply sitting less and standing more are therefore
expected to revolutionise the health promotion field in
coming years�
3.2 East Midlands Research institutionsThe East Midlands could be heralded as the national
exemplar for attracting funding in the area of physical
activity, sedentary behaviour and health, particularly from
the National Institute for Health Research (NIHR)�
Wehaveinourregionaresourcewithwhichtotranslate
and commission evidence-based physical activity-based
interventions and programmes� The government has
invested substantial resources into developing and
evaluating physical activity-based therapies locally� This
reportposesthequestion-whyaren’ttheseservicesmore
commonly commissioned?
13East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
Some of the research infrastructure is listed below:
• NIHRLeicester-LoughboroughDiet,Lifestyleand
PhysicalActivityBiomedicalResearchUnit
- Focused on using experimental research to
extend the range of evidence-based physical
activity-based therapies
- TheonlyBRUfundednationallythathasa
specific focus on physical activity
- £4�5 million in funding over five years
- DESMOND (Diabetes Education and Self
Management for Ongoing and Newly
Diagnosed):Walkingawayfromdiabetes
http://www�desmond-project�org�uk/
walkingaway-280�html
• NIHREastMidlandsCollaborationforLeadershipin
Applied Health Research and Care (EM-CLAHRC)
- Focused on translating evidence-based medicine
into routine care
- Strong focus on lifestyle, including physical
activity
- £10 million in direct funding and £10 million in
matched funding over five years
- Specific interventions to empower individuals
focusing on chronic obstructive pulmonary
disease (COPD) self-management strategies and
post-cardiac rehabilitation options
- The use of technology to support self-
management in people with chronic disease�
14East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
• NationalCentreforSportandExerciseMedicineinthe
East Midlands (NCSEM-EM)
- Part of the Olympic legacy in conjunction with
sites in London and Sheffield
- Remit for extending the SEM profession into the
prevention and treatment of chronic disease
- £10 million for a state of the art facility on
LoughboroughUniversitycampus:opens2015.
• LeicesterDiabetesCentre
- One of the largest diabetes research centres in
Europe
- Strong track record in developing and evaluating
lifestyle intervention in the prevention and
management of type 2 diabetes and other
chronic diseases
- Includes a specialist group of physical activity and
sedentary behaviour researchers
- Developed the Leicester Prevention Pathway that
includes a range of fully evaluated resources
for: 1) identifying those within primary care that
have a high risk of type 2 diabetes, 2) confirming
risk status (blood test), 3) information leaflet
including physical activity, and 4) referral onto a
suite of prevention programmes that are based
on the promotion of increased physical activity
and other lifestyle behaviours, including the
WalkingAwayfromType2DiabetesProgramme.
Partsofthepathway,includingWalkingAway,
have been widely commissioned nationally�
However local provision has been patchy and
sporadic�
15East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
3.3 Physical activity in the treatment of
chronic disease
TheFacultyofSportandExerciseMedicineintheUK’s
recent report ‘A Fresh Approach in Practice’ (2013) states
that increasing activity levels can inexpensively treat chronic
disease, musculoskeletal conditions and sports injuries�
This is in addition to the decrease in chronic disease risk by
30-50%, prevention of co-morbidity and aiding recovery,
functionandimprovingqualityoflifeinthosewhodosuffer
from chronic disease�
The report shares a number of examples of services which
have delivered a return on investment� A community
musculoskeletalserviceinNewcastleWestreducedsecondary
care orthopaedic referrals by 40%, improved the efficiency
of the orthopaedic outpatient conversion to surgery to 82%,
and lowered rheumatology referrals by 8% and neurosurgery
by 44%� It also delivered a reduction in cost of £42k�
There exists a commonality of risk factors for chronic
diseases (1:2 cancer diagnoses have 2+ other chronic
diseases), thus treating these conditions in isolation is
nonsensical�
It is envisaged that savings may be found using physical
activity to treat chronic diseases� (Table 1)
16East Midlands Clinical Senate Report Physical activity and exercise medicine
3 Background
Table 1 - The effect of physical activity on chronic diseases - Faculty for Sport and Exercise Medicine
Long term physical activity adherence for those with chronic disease remains low�
Compliance can be improved by specific behavioural interventions, focusing on self-efficacy
and sensitivity to the complex and individual social, medical and cultural barriers which
preclude people with chronic disease from long term physical activity�
In their report Everybody active, every day, Public Health England outline four domains
foractiontocreatetherequiredculturalchangethatwillachievethesimpleoutcomeof
everyone being more active�
8
Physical activity in the treatment of disease
Section 2 of this document deals with the effect of exercise on the treatment of chronicdisease. The list of diseases effectively managed with physical activity continues to grow.There is Level 1 evidence for the effectiveness of physical activity in the management ofmost chronic disease areas and consequently exercise is now included in multiplespecialist treatment guidelines.
In primary care, GPs are likely to be asked to screen for physical inactivity usingquestionnaires and will then be asked to identify high risk patients. There is currently noroutine education or support for GPs, or other members of the primary care team, onphysical activity prescription for those identified by this screening procedure as high risk.
Ischaemic heart disease 35-40% reduction in risk of event
COPD Improvement in aerobic fitness, quality of life,symptoms of dyspnoea, CV risk factors
Breast cancer 50% reduction RR of breast cancer death
Bowel cancer 50% reduction in bowel cancer death Improvementof tolerance of cancer treatment
Cerebrovascular disease Improvement of aerobic capacity,sensorimotor function and CV risk factors
Diabetes 42% reduction in diabetes related mortality32% reduction in diabetes related complications
Impaired glucose tolerance 42% reduction in risk of developing diabetes
Hypertension Reduce systolic BP by 7.4mmHg anddiastolic BP by 5.8mmHg
Depression/anxiety disorders Effect as good as standard pharmacologicaltreatments for moderate depression
Rheumatoid arthritis Improved aerobic fitness, diseaseactivity, function and QoL
Osteoarthritis Improved aerobic capacity, reduce fatigue andpain. Improve muscle strength and function
Osteoporosis Reduction in risk of falls. Maintenance of BMDin men and postmenopausal women
Pregnancy Reduce risk of pregnancy induced diabetes
Chronic disease Effect of exercise therapy
17East Midlands Clinical Senate Report Physical activity and exercise medicine
The evidence for physical activity in the prevention and
treatment of chronic disease has been building over the past
few years, and is encapsulated by the Public Health England
report Everybody active, every day.
This report from the East Midlands Clinical Senate Council
is a call to action for commissioners in the East Midlands to
contributetotheoverallefforttoaffecttherequiredchange
in our region�
4.1 East Midlands physical activity needsTheUKActivereportTurning the tide of inactivity
www�ukactive�com/turningthetide confirms that:
• TheEastMidlandshasoneofthelowestproportional
public health spends on physical inactivity (1�8%)
compared to the national average (2�4%)
• Largeurbanareas,suchasLeicesterandNottingham,
have higher than average levels of adult physical
inactivity (33-34%)
• Physicalinactivityislowerinlessdenselypopulated,
affluent areas such as Rutland (24%)
• Theregionhasahigherthanaverageproportion
of green spaces (the proportion of region made up
of green and open spaces) (60%) compared to the
national average (46%)
4 The case for change in the East Midlands
18East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
4.1.1 Maintaining good health
Physical activity guidelines for the maintenance of good
health were set out by the four Home Countries Chief
Medical Officers (CMO) in the 2011 report ‘Start Active,
Stay Active’� These guidelines built on the previous advice
through the addition of age specific guidance, and activity
type recommendations� (Appendix 6�1)
It is acknowledged that some groups need relatively more
physical activity to gain benefits for health�
Table 2 below outlines the recommendations and identifies
the total physical activity needed for the maintenance of
good health across the East Midlands population - a total of
19�3 million hours of physical activity per week�
Age
group
East
Midlands
population
Recommended
daily activity
Recommended activity type Total weekly
physical
activity
requirement0-4s 297,485
total
(209,157
between 18
months and
5 years)
180 minutes
active once
walking (proxy
from 18
months)
Light activity such as standing
up, moving around, rolling
and playing, as well as more
energetic activity like skipping,
hopping, running and jumping�
Active play, such as using a
climbing frame, riding a bike,
playing in water, chasing games
and ball games, is the best
way for this age group to be
physically active�
4�39 million
hours
19East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
Age
group
East
Midlands
population
Recommended
daily activity
Recommended activity type Total weekly
physical
activity
requirement5-18s 788,122 Moderate to
vigorous activity
for 60 minutes
up to several
hours per day
Vigorous intensity including
bone and muscle strengthening
on at least 3 days / week�
Examples of energetic activities
suitable for most children who
can walk on their own include:
• active play (such as hide and
seek and stuck in the mud)
• fastwalking
• ridingabike
• dancing
• swimming
• climbing
• skippingrope
• gymnastics
Energetic activity for children will
make kids “huff and puff” and
can include organised activities,
like dance and gymnastics� Any
sort of active play will usually
include bursts of energetic
activity�
5�52 million
hours
19-64s 2,901,665 At least 150
minutes per
week moderate
intensity (or
75 minutes
vigorous) per
week
Bone and muscle strengthening
on at least 2 days / week�
7�25 million
hours
20East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
Age
group
East
Midlands
population
Recommended
daily activity
Recommended activity type Total weekly
physical
activity
requirement65+ 867,159 At least 150
minutes per
week moderate
intensity (or
75 minutes
vigorous) per
week
Bone and muscle strengthening
on at least 2 days /week, plus
balance exercise for those at risk
of falls�
2�17 million
hours
TOTAL 19.3 million
hours per
week
Table 2:PhysicalactivityrequirementsforthemaintenanceofgoodhealthfortheEastMidlands
Examplesofactivitiesthatrequiremoderateeffortformost
people include:
• walkingfast
• wateraerobics
• ridingabikeonlevelgroundorwithfewhills
• ballroomandlinedancing
• doublestennis
• pushingalawnmower
• hiking
• skateboarding
• canoeing
• rollerblading
• volleyball
• basketball
21East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
Moderate-intensity activity raises the heart rate and results
in breathing faster and feeling warmer� One way to tell if
activity is at the level of moderate intensity is if it is possible
to still talk but not sing the words to a song�
Examplesofactivitiesthatrequirevigorouseffortformost
people include:
• joggingorrunning
• aerobics
• swimmingfast
• ridingabikefastoronhills
• playingsinglestennis
• playingfootball
• hikinguphill
• energeticdancing
• martialarts
Vigorous-intensity aerobic activity means you’re breathing
hardandfast,andyourheartratehasgoneupquiteabit.If
you’re working at this level, you won’t be able to say more
than a few words without pausing for a breath�
Sport England data (Active People Survey 8 - 2014) shows
that less than a third of adults aged 16 and over are
achieving an average of 90 minutes of moderate intensity
physical activity per week (12 x 30 minutes moderate
intensity physical activity over the past 4 weeks) within the
East Midlands, a level well below the 150 minute per week
recommended for the maintenance of good health�
22East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
Local Authority % Achieving 3 x 30 mins
moderate activity per
week
CCGs
Rutland 30�7% East Leicestershire & Rutland MiltonKeynes 28�7% MiltonKeynesNorthamptonshire 27�61% NeneCorbyLeicestershire County 27�6% WestLeicestershireEast
Leicestershire & RutlandNottinghamshire County 27�4% Mansfield & AshfieldNewark & SherwoodNottinghamshire ErewashRushcliffeNottingham North and EastNottinghamWestDerbyshire County 25�7% South DerbyshireNorth DerbyshireErewashHardwickLincolnshire County 25�0% South LincolnshireSouthWestLincolnshireLincolnshire EastLincolnshireWestNorth LincolnshireNottingham City 24�6% Nottingham CityDerby City 22�6% South DerbyshireLeicester City 19�7% Leicester City
Table 3: The percentage of the adult (age 16 and over) population in a local area who participate in sport and
active recreation, at moderate intensity, for at least 30 minutes on at least 12 days out of the last 4 weeks
(equivalentto30minuteson3ormoredaysaweek).SportEnglandAPS8.
23East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
CASESTUDY
An exercise referral outreach
class takes place weekly in
a Leicestershire village hall�
Classes are run for GP referral
patients and for cardiac /
pulmonary rehabilitation
referral patients�
One of the patients attending
is living with cancer� She is
receiving palliative treatment�
She has been attending the
GP referral outreach class for
around 10 months when she
feels well enough and receives
chemotherapy treatment every
three weeks�
She was told by her doctor
that she needed to take
up some form of exercise
and was told that any
exercise which would help
to strengthen her bones
would help her condition�
The sessions provided are
at the right level for her to
participate and they help to
manage her condition� Her
consultant has confirmed that
her condition is stable�
The outreach class has helped
this lady to take up some
form of structured activity
which has in turn helped her
to undertake the necessary
exercise in order to strengthen
her bones as recommended by
her doctor�
4.1.2 Risk reduction, rehabilitation and
treatment
It is important to note that the Chief Medical Officer
recommendationsfocusonthephysicalactivityrequirements
for the maintenance of good health� (Appendix 6�1)
Physical activity can also be used to reduce risk of certain
conditions, for rehabilitation following the effects of injury
or acute health events (such as myocardial infaction or a
severe chronic obstructive pulmonary disease related event)
or as treatment to reduce or alleviate symptoms�
In these instances there may be a need for more specific
exercise prescription to ensure the achievement of clinical
benefit,withthefrequency,intensity,durationandtype
of exercise varying from and potentially exceeding the
recommended levels for the maintenance of good health�
Table 4 highlights the potential for health gain from physical
activity, identifying the GP registered prevalence (QOF
2012/13 data) for those conditions which are amenable
to prevention and/or treatment with physical activity and
exercise�
24East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
Conditions amenable to
prevention or treatment
with physical activity/
exercise
QOF register prevalence
for Midlands and East
region
Estimated number of
affected individuals for
the East Midlands
Asthma 6�2% 300,974Atrial Fibrillation 1�6% 77,671Cancer 2�0% 97,088Coronary Heart Disease 3�4% 165,050ChronicKidneyDisease(18+) 4�6% 176,146Chronic Obstructive
Pulmonary Disease
1�7% 82,525
Cardiovascular Disease 2�3% 111,652Dementia 0�6% 29,127Depression (18+) 6�0% 229,755Diabetes (17+) 6�3% 244,976Heart Failure 0�8% 38,835Hypertension 14�3% 694,182Hypothyroidism 3�4% 165,050Obesity (16+) 11�2% 442,107Osteoporosis (50+) 0�2% 3,555Peripheral Artery Disease 0�6% 29,127Stroke/TIA 1�7% 82,525
Table 4 - GP registered prevalence (QOF 2012/13 data) for those conditions which are amenable to prevention
and/or treatment with physical activity and exercise
A key issue is getting a population to be more physically
active, either as a preventative measure (wellness) or as a
part of the treatment of chronic disease or musculoskeletal
injury� The challenge is to persuade the sedentary, unfit and
unwell to change their behaviour� This behavioural change
requiresaninvestmentoftimeandtrainingtocreatethe
expertise to provide advice, encouragement and selective
long term monitoring�
25East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
CASESTUDY
Agnes Graham is known
as Nessa� Nessa is visually
impaired, which means that
she has absolutely no vision at
all� She joined a Leicestershire
exercise referral scheme in
March 2014 and has been
attending the gym twice a
week ever since then� Despite
her impairment, Nessa walks
with her guide dog which in
itself takes determination and
courage�
Through sheer hard work,
Nessa has managed to
increase her fitness levels and
lose over a stone in weight�
Attending the gym has made
a significant difference to
Nessa’s life and she has made
new friends� Nessa is a total
inspiration to everyone!
She recently won an Exercise
Referral and Healthy Heart
Scheme award at the
Leicestershire and Rutland
awards evening�
Whilstthisreportdoesnotseektomapcurrentprovision
across the whole of the East Midlands we would like to
highlightthatthereisinequityofprovision.
A report is expected from Health Education East Midlands
working with the British Heart Foundation and Oxford
Universitythatwilldescribecurrentexerciserehabilitation
service provision across the country�
Existing commissioned services are often ‘disease-based’�
For example, exercise rehabilitation services for cardiac,
pulmonary and renal diseases� A number of third sector
and private providers also offer silo-based physical activity
programmes, both commissioned and charitably funded�
There is an opportunity for alignment of physical activity
messaging and symptom based service delivery where it is
clinically appropriate to do so�
26East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
4.2 RCP Commissioning GuidanceThe Royal College of Physicians (RCP) advises that sport
and exercise medicine is not simply a specialty for the
management of elite athletes’ medical conditions but is
central to the promotion of physical activity as a means
of disease prevention, to enhance well-being and in the
management of disease�
Spanning primary, secondary and tertiary care, the role of a
sport and exercise consultant includes leading or supporting
multidisciplinary teams using expertise in physiotherapy,
nutrition, psychology, musculoskeletal and general medicine�
The work may involve promoting physical activity in special
groups such as pregnant women, those with diabetes,
cardiovascular disease and the overweight and obese (both
adults and children), as well as managing musculoskeletal
injuries, and working with sports men and women on all
aspects of performance, injury and illness minimisation�
Workingwithcolleaguesinpublichealth,theDepartment
of Health and the NHS to implement policies that enhance
health, sport and exercise medicine has a key role in
developing new approaches to healthcare and promoting
population health�
27East Midlands Clinical Senate Report Physical activity and exercise medicine
4 The case for change in the East Midlands
RCP advice on key points to consider when commissioning
sport and exercise medicine services:
• Globalphysicalinactivitycauses9%ofpremature
deaths, 5�3 million of the 57 million deaths that
occurred in 2008�
• Maintainingphysicalactivityatrecommendedlevels
canequatetothree-fouryearsinadditionallife
expectancy with risk reductions of the order of 20-
40% for over 22 non-communicable diseases�
• TheNHScouldmakesubstantialsavingsbytargeting
promotion of physical activity as part of chronic disease
models�
• Currentcostsofprovidinghealthcarecoverfor
a physically inactive ageing population are not
sustainable�
• TheNHSneedstoinvestproportionatelytotheburden
of physical inactivity to develop sustainable prevention
and treatment models for chronic disease�
• Sportandexercisemedicineconsultantsaretrainedin
providing evidence-based and effective physical activity
interventions for primary and secondary prevention of
chronic disease�
• Sportandexercisemedicineconsultantsofferunique
and specific skills in the diagnosis, treatment and
rehabilitation of musculoskeletal, soft-tissue and sport
injuries�
• Sportandexercisemedicineservicesmaybesituated
in both community and secondary care settings, and
tailored to meet local pressures and needs�
https://www�rcplondon�ac�uk/projects/clinical-
commissioning-hub/commissioning-sport-exercise-medicine-
services
28East Midlands Clinical Senate Report Physical activity and exercise medicine
The East Midlands Clinical Senate is supportive of physical
activity to enhance health and recognises the need for pan-
societal solutions� The provision of physical activity in the
prevention and treatment of ill-health is recognized as not
wholly a healthcare responsibility�
In addition to being supportive of a number of
initiatives already underway, this report makes specific
recommendations to commissioners relating to actions to
improve the availability of physical activity as a preventative
and a treatment measure�
These recommendations are based on an understanding of
the role of physical activity in primary, secondary and tertiary
prevention strategies for chronic diseases linked to physical
inactivity�
5.1 The Clinical Senate is supportive of the following
initiatives
5.1.1 Existing NICE guidelines
PH6 2007 Behaviour change: the principles for effective interventions
PH8 2008 Physical activity and the environment
PH13 2008 Promoting physical activity in the workplace
PH17 2009 Promoting physical activity for children and young people
PH41 2012 Walkingandcycling:localmeasurestopromotewalkingandcyclingas
forms of travel or recreation
PH42 2012 Obesity: working with local communities
PH44 2013 Physical activity: brief advice for adults in primary care
PH49 2014 Behaviour change: inidividual approaches
PH54 2014 Exercise referral schemes to promote physical activity
5 Recommendations
29East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.1.2 Return on investment tools
Public Health England has published a Guide to online tools
for valuing physical activity, sport and obesity programmes
which provides an overview of a number of resources
including:
• PublicHealthEnglandobesityeconomicimpacttool
• WorldHealthOrganisationHealthEconomic
Assessment Tool (HEAT) for walking and cycling
• SportEnglandModelforestimatingtheOutcomesand
Values in the Economics of Sport (MOVES)
• NICEPhysicalactivityreturnoninvestmenttool
• SportEnglandEconomicImpactofSport-LocalModel
• PHE/SustransHealthImpactofPhysicalInactivity(HIPI)
tool
http://www�noo�org�uk/gsf�php5?f=313207&fv=20622
5.1.3 Public Health England - Everybody active,
every day
Public Health England publishes their physical activity
implementation framework in October 2014� Senate
Council members have supported expert groups since
August 2014 to consider the detail of how this will be
rolled out� The Clinical Senate is supportive of the advice
and would welcome an East Midlands wide physical activity
programme�
30East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
The Clinical Senate Council is supportive of a social
movement for a more active society, creating a network of
trained professionals, all working in an environment more
conducive to physical activity�
5.1.4 Third sector provision
There is an interest within the Richmond Group of charities
(and others) in reviewing existing disease and condition-
based physical activity provision with a view to considering
whether symptom-based provision - such as fatigue,
weakness and breathlessness - would better meet patient
need and be more cost effective�
Alongside charities working to support health are
organisations with a responsibility for green spaces� The
Clinical Senate would be supportive of further discussions
between these two sectors to consider working together to
further enhance provision of services�
31East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.2 The Clinical Senate recommends the
following be developed
5.2.1 Lie less, sit less. Do more, more often
(primary, secondary and tertiary prevention)
An East Midlands wide physical activity awareness
programme is needed to encourage individuals to take
responsibility for appropriate levels of physical activity� Sticky
messages that complement campaigns already in existence
e�g� Change for Life (2009) www�nhs�uk/change4life and
campaignsaimedatallarerequired.
The NICE return on investment tool would suggest that
targeted promotion of messages is more effective at local
level - through schools, primary care lists and health check
programmes�
5.2.2 Support the development of a network
for existing East Midlands groups (enhanced
secondary and tertiary prevention)
In order to support commissioners and providers to
maximise the beneficial outcomes from existing services, it
is proposed that interested groups are brought together to
form an East Midlands network� It is recognised that some
servicesrequirespecialistservices(forexamplestroke).
There are however opportunities for currently silo based
services such as cardiac, pulmonary, renal and cancer to
be reconfigured to provide symptom specific services to
address, for example, fatigue, weakness and reduced
aerobic capacity�
32East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
There is significant evidence of the efficacy of networks in
achieving change at scale in the current Strategic Clinical
Network supported structures in areas such as cancer and
cardiovascular disease�
5.2.3 Making every contact count: (primary,
secondary and tertiary prevention)
Across the healthcare community, at each patient / client
encounter every health and social care professional should
feelconfidentaboutaskinglifestylequestionsthatinclude
physical activity level� They should be suitably informed to
be able to deliver physical activity advice where appropriate
and signpost supportive services�
The Making Every Contact Count website encourages
conversations based on behaviour change methodologies
(ranging from brief advice, to more advanced behaviour
changetechniques),empoweringhealthierlifestylechoices
and exploring the wider social determinants that influence
allofourhealth.Whilstitdoesnotdealspecificallywith
physical activity, it provides resources to assist individuals
and organisations to deliver their approach� For example,
the Making Every Contact Count self-assessment tool
provides a way to identify and review existing skills in
relation to Prevention and Lifestyle Behaviour Change: A
Competence Framework and plan how to improve those
skills.Ithelpsanswerthequestion“amImakingevery
contact count?”
http://www�makingeverycontactcount�co�uk/
33East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.2.4 Signposting / messaging: physical
activity on referral / sport & exercise medicine
It is recognised that the availability of activity on referral
schemes, which are commissioning by public health (local
authority), is not always well understood in healthcare
services� Availability and signposting of services is patchy�
There is an opportunity to make better use of available
services and to better embed them into clinical pathways�
There is a need to evaluate sustained change in physical
activity levels and to understand return on investment for
commissioners�
In order to maximise the use of available activity on
referral schemes and sport and exercise medicine expertise
it is recommended that commissioners ensure local
understanding of what is available, who should be referred
and how to go about doing so�
Suggested actions include:
• Stakeholderengagement,marketingand
communication about activity on referral schemes with
all healthcare professionals and provider organisations
- not just in primary care�
• Ensuringavailableservicesaresetuptoreceive
referrals from across the spectrum of healthcare
services/providers�
• Commissionsportandexercisemedicineservices,
specifically exercise medicine�
• Trainingtoensureunderstandingwhentoreferto
a network of sport and exercise medicine specialists
including patients with illness or injury preventing
physical activity�
34East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.2.5 Training curricula
Education training and support should be implemented
across the East Midlands to support these initiatives
including but not limited to:
• Medicalschoolcurricula
• Nursingcurricula
• Alliedhealthprofessionals’trainingcurricula
• Juniordoctorcontinuingprofessionaldevelopment
• GPvocationaltrainingscheme
There is a need to streamline and simplify existing advice
and resources to enable healthcare staff to respond to
patient need - what to advise patients to do and how to
accesssupport.Linkedtothisisanabsoluterequirementto
upskill the healthcare community to employ motivational
interviewing skills�
5.2.6 Evidence the benefits / return on
investment
Physical activity services delivering both prevention and
treatment of ill health should be contracted and managed
to ensure their value is evidenced� It is recommended that
servicesaremonitoredandprovidersrequiredtoevidence
performanceacrossthedimensionsofquality,cost,delivery,
safety and morale�
See examples on table 6
35East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
Quality Cost Delivery Safety Morale
QU
ALI
TATI
VE
Patient
feedback
Complaints
and
compliments
Patient
feedback
Description of
adverse patient
events
Patient
feedback
QU
AN
TITA
TIV
E
Individual
patient health
results (eg�
sedentariness
& associated
adverse health
parameters
- eg blood
pressure,
HBA1C)
Percentage
of patients
continuing
activity levels
post six months
Cost per
patient
Cost per
session
Fixed costs
Variable costs
Cost avoidance
(e�g� drugs
cost)
Waitinglists
Percentage
of patients
completing
programme
Percentage
of patient
referrals
accepted
Number of
adverse patient
events
Percentage
of patients
continuing
activity levels
post six months
Table 6 - Examples of measures
36East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.2.7 Physical activity as a treatment for
mental health
Whilstthereisagenerallackofwelldesignedandlarge
trials using clinical populations of people with mental
health problems, the largest trial with adults - the TREAD
trial(fundedbyHTAanpublishedinBMJ)questionedthe
valueofexercisefordepression.Subsequentreviewpapers
questionedtheconclusionsdrawn.Thereremainsaneed
for large scale, multi-centre trials in both adults and children
and young people with mental health problems�
It is accepted that engaging in exercise can have numerous
positive benefits on mental wellbeing and psychological
functioning both in children and young people� Specifically,
it has been reported that engaging in exercise can lead to
improvements in self-esteem and self-perception, mood,
sleep and insomnia and psychological stress� Exercise can
also lead to symptom improvement for people experiencing
mental health problems�
Studies have documented the effect of physical activity on
various mental health disorders� Exercise as a preventative
measure and a treatment for depression has been
increasingly researched in adult populations over the
previous three decades, with numerous studies reporting
positive and encouraging results� It has been established
that exercising, even at levels below those recommended
by the Chief Medical Officer, can be sufficient to elicit
reductions in depression�
37East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
5.2.8 Thinking differently
Commissioners are encouraged to consider alternative
approaches to directing patients to physical activity services�
Recognising the considerable pressure on GPs, it may be
possibletoengagepharmacists’support.Whenapatient
presents a prescription for hypertension for the first time
- for example, could a pharmacist make a judgement on
whether to swap their prescription for a “green” one?
Pharmacies could continue to monitor patient’s blood
pressure and receive payment for the prescription as they
would if providing drug therapy�
It should not just be the responsibility of primary care to
askquestionsofpatientsabouttheirlevelsofactivity:the
biggestcauseofliverdisease(cirrhosis)intheUKisobesity
(greater than alcohol and viral hepatitis combined)� Do
patients who see a physician get asked about activity levels
and do these professionals have access to referral schemes
for their patients?
5.3 The Clinical Senate recommends the
following be actively commissioned -
across health and social care
5.3.1 Education programme: Everybody active,
every day: (primary, secondary and tertiary
prevention)
Education programmes for all healthcare professionals to
enable provision of lifestyle advice to include physical activity
both as a preventative and as management for long term
conditions�
38East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
Motivational interviewing is an essential skill for health and
social care professionals to assist patients and clients to
develop positive habits�
5.3.2 Healthy workplace
All employers should consider how to create healthy
workplaces for their own staff in addition to provision of
therequirededucationandsupporttoensuretheyfeel
confident to make every contact count�
In the region there is an opportunity to link to the work
of the East Midlands Platform on Food, Physical Activity
and Health www�regionalplatform�org�uk.TheWorkplace
WellbeingCharterprovidesemployerswithaneasyand
clear guide on how to make workplaces a supporting and
productive environment www�wellbeingcharter�org�uk
WithintheNHSthereshouldbeafocusonaugmentingand
spreading areas of good practice in workplace wellness, with
a focus in return to work� A good example is Nottingham
UniversityHospitalswww�nuh�uk/healthandwellbeing
5.3.3 Review of existing service provision
Whilstitisrecognisedthatthereareexamplesofexcellent
services available within the East Midlands aimed at both
prevention and treatment of ill health we do not have
equitableprovisionacrosstheregion.Patientsoften
experience more than one health challenge and their needs
for support to access physical activity are likely to cut across
existing silo based provision� Consideration should be given
to co-morbidities and the development of symptom-based
services (rather than condition specific)�
39East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
It is recommended that commissioners seek to understand
the overall level of demand for both preventative and
treatment based physical activity services in their healthcare
community� Areas to consider might be
• whowouldbenefitfromphysicalactivity-preventative
and treatment focused?
• definepatientgroups
- primary prevention - by disease area, prevalence
and patient numbers
- current GP attendance by exercisers with a
problem preventing them from undertaking their
usual activities
- chronic medical problems that physical activity
would help - by disease area and prevalence and
patient numbers
- annual musculoskeletal injury numbers
- mental health
A review of existing provision should follow that takes in
all local provision - both directly commissioned services
and those contained within block contracts and disease
pathways to consider the benefits of re-commissioning
services on a symptom basis� It is felt that bringing pockets
of silo based activity together into larger services will enable
removal of multiple administrative efforts and increase
the percentage of time spent on patient facing delivery of
services�
Scope for greater innovation and partnership working
with commercial partners should be considered� For
example, providing physiotherapy services from a gym
might encourage people who have never been in such an
environment to increase their physical activity over and
above participation in therapy�
40East Midlands Clinical Senate Report Physical activity and exercise medicine
5 Recommendations
It is appreciated that some specialist services should remain
so - for example stroke rehabilitation and post myocardial
infarction cardiac rehabilitation�
5.3.4 Exercise medicine: (enhanced secondary
and tertiary prevention)
Commissioners are encouraged to support, develop, pilot
and evaluate exercise medicine services for those:
• wishing to become more physically active but with
medical and/or musculoskeletal issues preventing uptake
• needingphysicalactivityforthetreatmentofchronic
disease
• withrehabilitationneeds,includingreturntowork
There is an additional role for specialist sport and exercise
medicine services to provide support and leadership for the
delivery of wider physical activity in both prevention and
treatment�
The National Centre for Sport & Exercise Medicine (NCESEM)
can provide primary and intermediate care networking
opportunities�
Commissioned services should be embedded with local
authority run physical activity and lifestyle programmes�
The Faculty of Sport and Exercise Medicine offer the
following advice:
• Itisexpectedthatdifferentlocalitieswillchooseto
implement sport and exercise medicine services in
variable ways and over differing timescales according
to local needs�
• The development of sport and exercise medicine services
can be flexible according to local pressures and needs�
41East Midlands Clinical Senate Report Physical activity and exercise medicine
6.1 Chief Medical Officer Physical
Activity Guideline
For early years (under fives)
1� Physical activity should be encouraged from birth,
particularly through floor-based play and water-based
activities in safe environments�
2� Children of pre-school age who are capable of walking
unaided should be physically active daily for at least
180 minutes, spread throughout the day
3� All under fives should minimize the amount of time
spent being sedentary (being restrained or sitting) for
extended periods (except time spent sleeping)
These guidelines are relevant to all children under five,
irrespective of gender, race or socio-economic status, but
should be interpreted with consideration for physical and
mental capabilities�
For children and young people (five to 18 years)
1� All children and young people should engage in
moderate to vigorous intensity physical activity for at
least 60 minutes and up to several hours every day�
2� Vigorous intensity activities, including those that
strengthen muscle and bone, should be incorporated
at least three days a week�
3� All children and young people should minimize the
amount of time spent being sedentary (sitting) for
extended periods�
Based on evidence, the guidelines can be applied to disabled
children and young people, emphasising that they need
to be adjusted for each individual based on that person’s
exercise capacity and any special health issues or risks�
6 Appendices
42East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
For adults:
1� Adults should aim to be active daily� Over a week,
activity should add up to at least 150 minutes of
moderate intensity activity in bouts of ten minutes or
more - one way to approach this is to do 30 minutes
on at least five days a week�
2� Alternatively, comparable benefits can be achieved
through 75 minutes vigorous intensity activity spread
across a week or a combination of moderate and
vigorous intensity activity
3� Adults should also undertake physical activity to
improve muscle strength on at least two days a week
4� All adults should minimize the amount of time spent
being sedentary (sitting) for extended periods�
Based on the evidence, the guidelines can be applied to
disabled adults, emphasising that they need to be adjusted
for each individual, based on that person’s exercise capacity
and any special health risks or risk issues�
For older adults (65 plus years)
1� Older adults who participate in any amount of
physical activity gain some health benefits, including
maintenance of good physical and cognitive function�
Some physical activity is better than none, and more
physical activity provides greater health benefits�
2� Older adults should aim to be active daily� Over a
week, activity should add up to at least 150 minutes of
moderate intensity activity in bouts of ten minutes or
more - one way to approach this is to do 30 minutes
on at least five days a week�
3� For those who are already regularly active at moderate
intensity, comparable benefits can be achieved through
75 minutes of vigorous intensity activity spread across
the week or a combination of moderate and vigorous
activity�
43East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
4� Older adults should also undertake physical activity to
improve muscle strength on at least two days a week�
5� Older adults at risk of falls should incorporate physical
activity to improve balance and coordination on at
least two days a week�
6� All older adults should minimize the amount of time
spent being sedentary (sitting) for extended periods�
Based on the evidence, the guidelines can be applied to
disabled older adults emphasising that they need to be
adjusted for each individual based on that person’s exercise
capacity and any special health or risk issues�
6.2 Who is currently responsible for what?• Physicalactivityisnotmandatedinpublichealth
outcomes but health checks are
• Therearenoringfencedbudgetsforphysicalactivity
o Children’s services
Physical literacy is part of the health visitor offer
and early years foundation stage curriculum
Physical education curriculum in schools
School nurse role in picking up child obesity,
promoting positive health and making referral/
recommendation where risk identified
Sport England - activity targets including active
travel along with sports’ governing bodies
sport participation targets
Local authorities promote physical activity -
public health and prevention agenda
Local authority public health teams have
National Child Measurement Programme duty,
deliver weight management programmes and
lead healthy schools agenda
44East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
Promoting parental responsibility and
messages to parents through all partners, and
national Change for Life campaigns
Primary care role in promoting good health
and identifying risk
o Adults
Individual responsibility - supported by
national campaigns to promote 150 minutes
of physical activity per week message
Workplacehealth-Localauthoritypublic
health teams working with employers to
promote workplace policies (active travel, cycle
to work, etc)
Sport England have sport and recreation
activity targets
Local authorities as part of weight
management/lifestyle services including
exercise referral
Primary care - promotion of good health for
healthy adults - Making Every Contact Count -
and health checks for target population
Primary care, management of long term
conditions - need better understanding of
physical activity as treatment/management
e.g.WalkingAwayfromDiabetesinLeicester
Secondary care - part of treatment pathways
e�g� cardiac and pulmonary rehab, falls
pathways, re-ablement, and part of discharge
advice with respect to regaining/maintaining
independence and ongoing rehabilitation post
care episode - include in care plans and share
with GP and social care teams
Social care, supporting independent living
45East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
6.3 Examples of existing provisionThe following examples were made known to the author of
this report
6.3.1 Leicestershire and Rutland
• CountySportPartnerships-LeicestershireCounty
Council and Leicester-Shire & Rutland Sport, through
development of a countywide sport and physical
activity plan have developed a targeted approach
aimed at sectors of the community who currently do
little/no physical activity� The majority of the resources
focus on targeted individuals / groups or communities:
early years, inactive young people, people on low
income, supporting Leicestershire families, people with
disabilities, people with long term conditions, people
with continuing healthcare services, families, and
healthyweight.Eachlocalitywasrequiredtosubmita
'one stop sport and physical activity plan'�
o Over 2million attendances recorded at sessions
included in the sport & physical activity plans
from 2012-2014�
o A joined up local offer, that focuses on inactive
communities who can derive the greatest health
benefit�
o There has been a move to delivering more
targeted interventions with the focus on impact
rather than ‘numbers’�
o Development of an evidence based approach
supporting a local delivery model that offers:
Targeted physical activity programmes, age
and life stage appropriate, to a large and
dispersed population�
New targeted programmes, which can be
adapted for use with a wide range of age
groups and abilities�
46East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
A community based delivery model that will
provide services in community venue�
A community empowering approach,
by training local community providers to
deliver the programme and encourage user
involvement to expand the programme within
specific user-groups, through a cascade model
of training�
Interventions based on multi agency identified
need and complimentary programmes of
delivery�
Planned action, integral to a local multi agency
approach to public health brief interventions
delivered by a workforce competent in
community development/based approaches
that focus on future sustainability and impact
from the start�
A planned promotional campaign to raise
awareness of the health and wider benefits of
sport and physical activity�
o A number of specific interventions delivered are
linked to support the prevention / management
of:
Mental health
Dementia
Long term conditions
Coronary heart disease
Cardiovascular disease
Healthy weight
Diabetes
Falls prevention
o Specific Referral based programmes include:
Exercise referral
Heartsmart
47East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
Weightmanagementprogrammessuchas
LEAP & Flic
Get Healthy, Get Into Sport
• DESMOND-WalkingawayfromDiabetes
• Exercise(health)referralTier2-Commissioned
by Leicestershire County Council Public Health
Directorate.ProvidedbyNorthWestLeicestershire
District Council, Hinckley & Bosworth Borough Council,
Oadby&WigstonBoroughCouncil,Charnwood
District Council, Melton Borough Council, Harborough
District Council, Blaby District Council & Rutland
County Council� 12 week programme offering tailored
1-1 and/or monitored support and assessment by a
level 3 physical activity instructor� A growing range of
appropriate physical activity programmes are offered
to participants including gym based exercise, walking,
swimming, and cycling� All referrals must classed as
inactive*, be aged 16+ and exhibit at least one of the
following risk factors for coronary heart disease (CHD)
or metabolic syndrome :
o Smoking
o Family history of heart disease
o High cholesterol levels
o Obesity/overweight (BMI 25+)
o Hypertension (140/90 to 179/99mmHg)
o Controlled diabetes
o Have been diagnosed with osteopenia or
osteoporosis
o Mental illness /psychiatric disorders where
appropriate physical activity would be beneficial
e�g� depressive disorders or anxiety disorders�
o Locomotive and neurological disorders where
appropriate physical activity would be beneficial
o Controlled asthma
48East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
o Chronic pulmonary disease (subject to
assessment by pulmonary rehabilitation specialist
orequivalent)
• “Heartsmart”cardiacrehabreferral(Tier3)-
Commissioned by Leicestershire County Council
PublicHealthDirectorate.ProvidedbyNorthWest
Leicestershire District Council, Hinckley & Bosworth
BoroughCouncil,Oadby&WigstonBoroughCouncil,
Charnwood District Council, Melton Borough Council,
Harborough District Council, Blaby District Council &
Rutland County Council� 12 week programme offering
tailored 1-1 and/or monitored support and assessment
by a level 4 physical activity instructor� A growing range
of appropriate physical activity programmes are offered
to participants including gym based exercise, walking,
swimming, and cycling� All referrals must classed as
inactive*, be aged 16+ and have had a recent cardiac
event or surgery (patients should be directed initially to
phase IV by GP/cardiac rehabilitation services)
• Fundamentalmovementskillsfor5-11yearolds-
Commissioned by Leicestershire County Council Public
Health Directorate� Provided by SAQ International
Ltd� A pilot programme for seven primary schools in
Leicestershire� The service aims to develop an early
identification and intervention programme for young
children with deficient fundamental movement skills
in order to raise their physical abilities to the expected
norm� Programmes work with pupils, teachers and
parents� Trained interns embedded into schools to
support the monitoring assessment and intervention
programmes with pupils, to support and train school
staff and parents, and intensively work with at risk
children�
49East Midlands Clinical Senate Report Physical activity and exercise medicine
6 Appendices
6.3.2 Northamptonshire
• NorthamptonshireCountyCouncil-20millionsteps
challenge September 2014
6.3.3 Derbyshire
• MansfieldDistrictCouncil-GetActive
• DerbyshireSport-TheActiveDerbyshirePlanincluding
The Maternal Healthy Lifestyles Programme
6.3.4 Nottinghamshire
• GetActiveMansfield(GPexercisereferral-local
authority run/providers)
• HealthyChange-areferralandsupportcentrewhich
offers ongoing over-the-phone support to citizens who
want to make changes to the way they live� They can
also arrange for people to attend one or more of the
services below for free�
• Motivate offers a free 12 week weight management
programme of exercise and nutritional advice aimed
at overweight men, delivered by Notts County FC
Football in the Community sports coaches�
• Active For Life(YMCA)offersafree12-weekexercise
and motivational support programme to support
people in becoming more active�
• Be Fit offers free gym use, fitness classes and swimming*
atJohnCarroll,Victoria,andSouthgladeLeisureCentres
between 10am-12pm and 1pm-3pm Monday to
Saturday, for city residents who receive certain benefits�
• Best Foot Forward offers free weekly short guided
health walks around various open spaces in the city�
• Ridewise (Cycling for Health) offers free cycle training
sessions and organised group rides for people in
Nottingham�
50East Midlands Clinical Senate Report Physical activity and exercise medicine
7.1 Literature review1. BattMEandTanjiJ.Thefutureofchronicdisease
managementandtheroleofSEMphysicians.ClinJ
Sports Med 2011 21(1)
2. WeilerR,FeldschreiberPandStamatakisE.
Medicolegal neglect: the case for physical activity
promotioninprimarycare.BrJSportsMed2011:
doi:10�1136/bjsm�2011�084186
3� Blair SN - Physical inactivity: the biggest public health
problem of the 21st century
4. Yates,Wilmot,Khunti,Biddle,Gorely,Davies-Stand
up for your health: Is it time to rethink the physical
activity paradigm?
5. UKhealthperformance:findingsoftheGlobal
Burden of Disease Study 2010 - Lancet
6. Cooney,G.M.,Dwan,K.,Greig,C.A.,Lawlor,D.A.,
Rimer,J.,Waugh,F.R.,McMurdo,M.andMead,G.
E� (2013) Exercise for depression� Cochrane Database
of Systematic Reviews 9 Cd004366�
7. Larun,L.,Nordheim,L.V.,Ekeland,E.,Hagen,K.
B� and Heian, F� (2006) Exercise in prevention and
treatment of anxiety and depression among children
and young people� Cochrane Database Of Systematic
Reviews (Online) (3) CD004691�
7 Referenced evidence base
51East Midlands Clinical Senate Report Physical activity and exercise medicine
7 Referenced evidence base
7.2 Collation and summary of existing
professional and national guidelines1� Faculty for Sport and Exercise Medicine - A Fresh
Approach http://www�fsem�co�uk/media-resources/
publications�aspx
2� Public Health England Everybody active, every day
3� Moving More, Living More, The Physical Activity
Olympic and Paralympic Legacy for the Nation (2014)
4� Be Active, Be Healthy: A plan to get the nation
moving - HM Government
5� Change4Life - HM Government
6� Let’s Get Moving 2009 - HM Government
7� Royal College of Physicians - Exercise for Life� 2012
8� ACSM - Exercise is Medicine:
www�exerciseismedicine�org
9� FYSS-ProfessionalAssociationsforPhysicalActivity,
Sweden: Physical activity in the prevention and
treatment of disease� 2010
10� Tackling Physical Inactivity -A coordinated approach�
All-party commission on Physical Activity� 2014
11� Behaviour change: individual approaches� NICE public
health guidance 49 (2014)�
12� Physical activity: brief advice for adults in primary
care� NICE public health guidance 44 (2013)�
13� Walkingandcycling:localmeasurestopromote
walking and cycling as forms of travel or recreation�
NICE public heath guidance 41 (2012)�
14� Promoting physical activity for children and young
people� NICE public health guidance 17 (2009)�
15� Promoting physical activity in the workplace� NICE
public health guidance 13 (2008)�
16� Physical activity and the environment� NICE public
health guidance 8 (2008)�
52East Midlands Clinical Senate Report Physical activity and exercise medicine
7 Referenced evidence base
17� Behaviour change: the principles for effective
interventions� NICE public health guidance 6 (2007)
18� http://www�macmillan�org�uk/Cancerinformation/
Livingwithandaftercancer/Physicalactivity/
Physicalactivityandcancer/Benefits�aspx
19� http://www.macmillan.org.uk/Documents/AboutUs/
Commissioners/Physicalactivityevidencereview�pdf
20� http://www�macmillan�org�uk/Documents/
AboutUs/Health_professionals/
PhysicalActivityEvidenceBasedGuidance�pdf
53East Midlands Clinical Senate Report Physical activity and exercise medicine
The Clinical Senate would like to thank Senate Council and
Assembly members for their contribution to the preparation
of this advisory report�
Further thanks to the Physical Activity Panel -
Jo Spokes - Sports Development Manager - Leicestershire
and Rutland Sport (a County Sports Partnership (CSP) - Local
Authority provision of Sport and Physical Activity
Grace Hutchinson - Performance Info and Research Officer
- Leicestershire and Rutland Sport - providing statistical and
research support
Polly Todd - Manager of teams of health visitors and school
nurses - National Child Measurement Programme
Fiona Moor - Head of Dietetics - Derby Acute and
Community
Ben Anderson - Consultant in Public Health (Healthcare),
Public Health England Centre East Midlands
Jean Wong - GP Principal Pinfold Medical Practice
Loughborough, GPwSI Sports and Musculoskeletal Medicine,
Clinical Assistant Orthopaedics Leicester General Hospital,
International Health Rep RCGP Leicester Faculty
James Hopkinson - GP and Consultant in Sports Medicine
and CCG commissioning lead
Ann Goodwin - Consultant in Healthcare Public Health,
Public Health England Centre East Midlands
Sue Collington - Lead Occupational Health Nurse,
UniversityhospitalsofLeicesterNHSTrust
8 Acknowledgements
54East Midlands Clinical Senate Report Physical activity and exercise medicine
8 Acknowledgements
Anne Garland - Nurse Consultant in Psychological
Therapies, Clinical Lead Specialist Depression Service,
Nottinghamshire Healthcare NHS Trust
Meng Khaw - Public Health England’s Centre Director for
the East Midlands
Claire Porter - Specialist Nurse/Lead Nurse for Burns and
Plastic Surgery
Anne Willmott - Consultant Paediatrician and Paediatric
Gastroenterologist,UniversityHospitalsLeicester
Bernadette Armstrong - Extended Scope Physiotherapist,
Northamptonshire Healthcare Foundation Trust
Chaman Verma-EqualityandDiversityManager,Kettering
General Hospital
Tim Carter - Teaching and Research Associate (Mental
Health),UniversityofNottingham
Patrick Callaghan - Professor of Mental Health Nursing,
UniversityofNottingham
Mike Sandys – Director of Public Health, Leicestershire
County Council
Specific thanks to Ben Anderson, Consultant in Public Health
(Healthcare), Public Health England Centre East Midlands
andtoDrFu-MengKhaw.
Further thanks to both Professor Melanie Davies and
ProfessorKamleshKhuntiandteamsattheNIHRLeicester-
Loughborough Diet, Lifestyle and Physical Activity
BiomedicalResearchUnitfortheirexpertiseandinput.
SKYLINE. GRAPHIC DESIGN www�skylinedesign�org�uk
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