Exercise Prescription in Primary Care

Faculty/Presenter Disclosure

Faculty: Dr. Patrick Ling

Sept 24, 20152015 Annual Scientific Assembly

Regina, Saskatchewan

Relationships with commercial interests:•Grants/Research Support: none •Speakers Bureau/Honoraria: none•Advisory Boards: none• Other:

Disclosure of Commercial Support Potential for conflicts of interest:• NONE

• No products will be discussed in this presentation

Learning Objectives of this Section

1. Describe mental health benefits for exercise2. Review literature on exercise and osteoarthritis3. Describe the challenges with exercise prescription in the

primary care setting4. Describe an exercise prescription5. Discuss the elements of physical activity counseling

Why should physicians counsel patients about physical activity?

• Preferred source of health information (Blair et al., 1998)

• High population reach (CIHI, 2003)

– 75-80% of Canadians visit their family physician over the course of a year (Wilson and Ciliska, 1992)

– Avg Cdn visits FP 3.1x/yr, increases to 6x/yr for >65 yo

• Manage or involved with the care of chronic disease

• Physical Inactivity is an important risk factor

• Exercise is safe and affordable for most people

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Your Role and Influence

• Structured counselling by health care professionals effectively increases physical activity adoption

+55 mins

-14 mins

counselling nocounselling

From: Kirk et al. Diabetalogia. 2004;47:821-832

Change in exercise time per week

HSF Clinical Day – December 7, 2012

The Benefits of Exercise in ...

● constipation● fibromyalgia● osteoarthritis● lupus● depression● IBS – irritable bowel syndrome● insomnia● chronic fatigue● slows aging ● boost testosterone● preserves cognitive function● dysmenorrhea● fewer colds● cancer prevention?

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HSF Clinical Day – December 7, 2012

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Exercise and Depression• Exercise in some studies as effective as

anti-depressants, psychological therapies

• Exercise is more effective than no therapy for reducing symptoms of depression

• Compliance rate between 50-100%

• Ref: Cochrane Review Sept, 2013

Exercise and AnxietyPopulation based study:Exercisers were less anxious, less depressed

Meta-analysis:Exercise results in reduction in anxiety and depression

Ref: DeMoor 2006, Guszkowska 2004

Osteoarthritis

Exercise and Osteoarthritis

• Evidence supports aerobic and progressive strengthening exercise – results in pain reduction and improved function

• In patients with mild to mod knee OA

• Ref: Golightly 2012

Exercise and Osteoarthritis

• No association between OA and runners• muscle dysfunction vs wear & tear

• Ref: Willick 2010, Shrier 2004

Preventive Care Checklist CCFP (2012 update)

Exercise is part of lifestyle assessment on the PCC checklist but…

As of 2012, Moderate physical activity recommendations:

Doing moderate physical activity was a B recommendation

But physician counseling was a C.

However:

Brief advice in primary care is a cost-effective intervention.

(Anokye et al. BJSM 2014; 48: 202–6)

Doctors prescribing exercise?

Challenges to ExRx in Primary Care• For MD’s

– Lack of time– Lack of training & confidence in exercise design– Lack of training & confidence in PA counseling – Lack of billing codes, insurance coverage– Lack of resources to support counseling and referrals

• In the MD-patient dynamic– Perceived low response efficacy– Patient ‘readiness’ rarely elicited or revealed– Unclear or inconsistent recommendations– Difference between what is said and heard– Lack of resources to support exercise prescription

• Insurance, qualified individuals, information overload

Estabrooks et al JAMA,2003; Carrol et al., AFM 2011; Lawton BMJ 2008; Sallis BJSM 2011

Exercise Prescription in Primary Health

An MD ExRx can improve ‘uptake’ “Green prescription” in NZ ↑ PA in

“relatively inactive” adults by ~10% at 1 yr and is cost-effective (Elley et al., BMJ 2003; Elley et al.,

NZMJ 2004, Dalziel et al., 2006)

MD counseling on PA, weight loss & fitness,

improves outcomes Pinto et al., AJPM, 2005; Huang et al., 2004; Petrella et

al., AJPM, 2003;

HSF Clinical Day – December 7, 2012Petrella et al Am J Prev Med, 2007

Family Physicians, Sport Medicine Physicians, Allied Health Professionals

• Key role in promoting and Px physical activity

www.csep.ca

Sponsors of the Exercise Prescription Project

The Five A’s Model for PA Counseling

• Ask• ASSESS• ADVISE• AGREE• ASSIST• ARRANGE

Whitlock et al., 2002; Goldstein et al., 2004; Fortier, Tulloch & Hogg 2006

Ask Brief

Comprehensive

30 seconds

2-4 min

10-20 minutes

Counseling Opportunities

Assess - Exercise Vital Sign “There is no better indicator

of a person's health and likely longevity than the min/week of activity they engage in”

Sallis, Br J Sports Med, 2011

Are you achieving 150 minutes? 2 questions, 1 minute

How many times per week MVPA?

For how long each time?

• Determine patient’s current level of activity– Compare to Canada’s PA guidelines

• Willingness to exercise (i.e. ‘readiness’)• Helpful step to create a prescription or referral to qualified exercise professional

EXERCISE VITAL SIGN

ASKEVERY PATIENT

EVERY TIME

How can you determine if patient is fit to exercise independently?

Pre-Exercise Screening

Overcoming Barriers; Reframing FEAR Most people are at greater risk from sedentary

behaviour than from exercise. Aerobic Ex CV complication rate ~ 1/100,000 hours (ACSM & AHA, 2007) Resistance Ex injury rate <3 / 1,000 hours (Parkkari, 2006) (walking ~0.2)

Be aware of the short-term and long-term complications of disease. E.g diabetes : SMBG can be informative If on insulin (or secretagogues), have 15 gm glucose available

Goals of pre-exercise screening: To identify problems that might make exercise-associated risks

outweigh the benefits. To expedite treatment of such problems.

You may get referrals for clearance following a screening questionnaire…

Bredin SSD et al; PAR-Q+ and ePARmed-X+. Can Fam Physician 2013; 59: 273-277

The safe zone for mild to moderate intensity exercise

Pain and Discomfort• Pain

– Typically sharp, localized, and stops activity• Acute ‘Pain’- follow-up• Chronic ‘Discomfort’ – Prefer & Refer

• Discomfort– Normal, uncomfortable feeling felt during PA

or exercise that does not stop activity– Necessary to work through for gains in fitness– Decreases with time and improved fitness

• E.g. Arthritis large effect for exercise (increased ROM & Strength)