John Searle - Exercise referral - time to improve the outcomes
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Transcript of John Searle - Exercise referral - time to improve the outcomes
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Exercise referral – time to improve the outcome
John Searle Chief Medical Officer FIA
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Exercise
Exercise is the most effective disease prevention ‘stuff’ there
is
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Exercise in disease prevention
Heart attacks Stroke
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Exercise in disease prevention
Obesity Type 2 diabetes
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Exercise in disease prevention
Dementia Stress
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Exercise in disease prevention
Depression Falls
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Exercise in disease prevention
Various types of cancer
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Exercise in disease management?
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Exercise in disease
• Improves symptoms
• Slows progression
• Promotes physical activity and wellbeing
(British Journal of Sport and Exercise
Medicine 2009; 43: 550-555)
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Exercise referral schemes
• 1990’s
• National Quality Assurance Framework
2001
• BHFNC Toolkit 2010
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Do exercise referral schemes work?
NICE 2006
‘there is insufficient evidence to recommend
the use of exercise referral services to
promote physical activity other than part if
research studies where their effectiveness
can be evaluated’
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HTA 2011 (in press) The National Institute of Health Research Health
Technology Assessment Agency
Little or no effect in increasing physical activity.
Serious lack of properly controlled, randomised
studies in exerciser referral.
Many studies have a poor methodology
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Welsh National Exercise Referral Scheme (2010)
• Higher levels of physical activity in patients
with coronary risk factors
• Positive effects on depression and anxiety
particularly in those referred wholly or
partially for mental health reasons
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Why don’t ER schemes work?
Toolkit 2010 – wide variation in
•Inclusion / exclusion criteria
•Programme duration
•Qualifications of instructors
•Adherence to the NQAF
•Scheme evaluation
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Other concerns
Lack of GP training Risk to patients
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Other concerns
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Joint Consultative Forum (JCF)
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Terminology
• Recommendation:
Advising a patient to be more physically
active in order to improve their health and
reduce the risk of disease
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Terminology – exercise referral
Exercise referral is a formal process which uses exercise as a component of the management of a patient’s condition, with the objectives of improving or reducing the rate of its progression and achieving an independent and sustainable increase in physical activity
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The process
Referral of a patient by a health care
professional to a service or an independent
exercise referral instructor for the process of
providing an exercise programme as part of
the management of people (i) with stable or
significant limitations related to a chronic
disease or disability and/or (ii) with one or
more CV disease risk factors
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Professional & operational
standards in exercise referral
• Risk stratification
• Qualifications
• The process
• Record keeping
• Medico-legal issues
• Services and facilities
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Risk stratification – the PAR-Q • ‘No’ to all the questions
• Heart rate < 100 bpm
• BP < 140/90
Remain in the ER service, undertake a range of activities programmed by but not necessarily supervised by the ER instructor
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Answers ‘yes’ on the PAR-Q
Irwin Morgan assessment:
• Low risk – as in PAR-Q ‘no’
• Medium risk – personalised supervised programme
• High risk – (i) cardiac into cardiac rehab programme (ii) non cardiac, multidisciplinary assessment before exercise
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Irwin Morgan assessment
• Not a validated tool but it is recommended in the Toolkit
• What else is there?
• ? PAR-Q + and PARMedEx in the future
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Qualifications
Fitness instructors working in exercise referral must be a REPs registered Exercise Referral Fitness Instructor or a REPs registered Level 4 Specialist Instructor, meeting the National Occupational Standards for the knowledge, competence, and skills of good practice.
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Assessment • Personal details
• BMI
• Waist circumference
• Pre ex HR
• BP
• PA questionnaire -IPAQ
• Quality of life – EQ-5D
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Assessment
• Aerobic – not necessary
• ROM in musculoskeletal disease
• Requested by referrer
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Goals
Short tern – attendance, sessional
Medium term
(i) condition specific
(ii) Patient specific
Long term – a sustainable increase in physical activity
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Delivery
ACSM disease specific guidelines
Appropriate progression
Good communication
Trust and rapport
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Monitoring
• Attendance
• During the session
• Repeat base line measurements at mid point and the end of the programme
• 6 and 12 months: physical activity and wellbeing questionnaires*
*using group sampling
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Exit strategies
• Absolutely essential!
• Keep in view from the outset
• What would the patient like to do to keep physically active?
• What is available?
• On-going support
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Medico-legal matters
Doctors must only refer patients for the purposes of using exercise as part of treatment to an appropriately qualified and registered exercise referral fitness instructor or a service which employs such instructors
Medical Defence Societies
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Other matters
• Reporting to the referrer and to commissioners
• Service evaluation and appraisal – by
commissioners and professionally
• Instructor appraisal – fit to practice
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Why – the objectives?
• Provision of high quality, safe and effective exercise referral services
• Exercise becomes a routine part of the management of chronic disease
• Bench mark for commissioners
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How has it been done?
• JCF: drafting group + the Forum
• Advisory group from across the fitness sector
• Consultation process – to mid August.
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Help – the bench mark is too high!
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Implementation will be gradual
• Standard setting
• Training institutions
• Operators
• Health professionals
• Commissioners
–NHS reforms timetable
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CHOICE
• Stay as we are and confirm the NICE judgment of 2006 and HTA 2010
OR
• Develop a modern professional service and provide long term benefits to patients