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Rapid Responses: Rapid Responses published:
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Newcastle Exercise Project
- Marion McMurdo (12 October 1999)
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Exercise on Prescription
- Stephen Longworth, John A White (14 October 1999)
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Conclusions drawn from the Newcastle project findings are misleading
- Chris Riddoch (14 October 1999)
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Newcastle Exercise Project asked the wrong questions and so got the wrong answers
- Nanette Mutrie (26 October 1999)
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Exercise prescription in primary care
- Frank Smith (3 November 1999)
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Exercise on prescription
- Peter J S Baker (3 November 1999)
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Exercise Promotion and Longterm Adherence - The Jury Remains Out
- Marko Petrovic (17 November 1999)
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Newcastle exercise project conclusions misleading
- Ngaire Kerse (25 November 1999)
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Newcastle exercise project
- Mark Reeves (26 November 1999)
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Marion McMurdo
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Editor- Harland and colleagues report on an attempt to promote physical activity in one general practice1. Their choice of sessions of vigorous activity as part of their main outcome measure was a surprising perpetuation of a common misconception. It has been clear for some time that regular moderate-intensity (rather than vigorous) physical activity provides substantial health benefits, and that low- to moderate-intensity levels of activity are more likely to be continued than high-intensity activities2,3. In addition, levels of habitual physical activity in the general population are so low that to most people the prospect of vigorous activity is a major turn-off. Given that the health benefits gained from increased activity depend on the initial activity level, a more valuable approach would have been to focus on the number of subjects achieving the transition from sedentary state to regular moderate-intensity physical activity. Whilst accepting that the entry criteria to a research project may not always reflect practice in the real world, the fact that Harland and colleagues excluded one-third of patients from participation on health grounds seems like another lost opportunity. It is known that most adults do not need to see their physician4 before starting a moderate-intensity physical activity program. Those subjects excluded by Harland because of acute myocardial infarction within the last 12 months, angina and cerebrovascular disease are precisely the group that should be receiving strong positive encouragement from their physicians to be regularly physically active5. Marion McMurdo Competing interest: METM is co-director of D D Developments, a University of Dundee company whose mission is to provide exercise classes for older people, and the profits of which support research into ageing and health. 1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howell D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999;319:828-32. (25 September) 2. Physical Activity and Public Health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407. 3. Pollock ML. Prescribing exercise for fitness adherence. In:Dishman RK, ed.Exercise Adherence, Champaign, Ill: Human Kinetics Publishers;1988:259-277. 4. American College of Sports Medicine. Guidelines for exercise testing and prescription.4th ed. Philadelphia, Pa: Lea and Febiger; 1991. 5. Wannamethee G, Shaper AG. Physical activity and stroke in middle aged British men. BMJ 1992;304:597-601. |
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Stephen Longworth, General Practitioner, Senior Lecturer in Health Promotion The East Leicester Medical Practice, University of Nottingham, John A White
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Dear Editor The paper by Harland et al describing the Newcastle exercise project1 concludes that "brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of questionable effectiveness". The data presented do not support this gloomy assertion, and the bold heading on the "This Week" page in the same edition of the BMJ which states that "exercise on prescription is a waste of scarce resources" is totally unjustified and seriously misleading. Notwithstanding previous pessimistic views on the subject2, there is nevertheless evidence to suggest that general practice-based physical activity interventions may be both beneficial for public health gain3,4 and cost effective5. The recent Newcastle study sets out to see what effects various interventions have on increasing and maintaining activity levels in a GP population1. These are shown to be better than "control" at 12 weeks but no better at one year. However, the "control" group in fact received a considerable intervention, which consisted of an initial assessment (75 minutes of structured interview, physical measurements and a cycle ergometer test), and a follow up interview in which they received their baseline results (blood pressure, weight for height, activity level and aerobic capacity, smoking and alcohol consumption), and a pack containing information on the benefits of physical activity, other lifestyle factors, recommended activity levels, 19 leaflets on local leisure facilities, and brief advice comparing the individual's results with recommended levels. It might be that the "control" intervention (which superficially looks as though it is just a data collection exercise) is in itself a powerful motivation for change. A valid control group which received no intervention would have had just the baseline activity data collected, without the physical measurements, the cycle ergometer test and the follow up interview. That way a true baseline of "spontaneous converters" to increased activity levels amongst the study population could have been estimated, and the size of the "control intervention" effect could have been calculated. What the results show is that 23% of the "control intervention" group had an increase in their physical activity score at one year, which is an impressive improvement. If it could be repeated across the population as a whole the health benefits would be considerable. The fact that the extra interventions did not add any value to the "control" at one year is, on the one hand disappointing, but on the other suggests that the resources used to provide these extra interventions would be better spent on giving more people the "control" intervention instead. Yours faithfully Dr Stephen Longworth Dr John A White 1 Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-32. 2 Iliffe S, See Tai S, Gould M, Thorogood M. Prescribing exercise in general practice - look before you leap. BMJ 1994; 309: 494-495. 3 McKenna J, Naylor P-J, McDowell N. Barriers to physical activity promotion by general practitioners and practice nurses. Br J Sports Med 1998; 32: 242-247. 4 Eaton CB, Menard LM. A Systematic review of physical activity promotion in primary care settings. Br J Sports Med 1998; 32: 11-16. 5 Stevens W, Hillsdon M, Thorogood M, McArdle D. Cost-effectiveness of a primary care based physical activity intervention in 45-74 year old men and women: a randomised control trial. Br J Sports Med 1998; 32: 236-241. |
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Chris Riddoch, Senior Lecturer, Exercise and Health Science, University of Bristol
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Harland et al. (1) have questioned the effectiveness of 'exercise on prescription' schemes, based on the findings of a randomised controlled trial that assessed two levels (brief and intensive) of motivational interviewing and financial incentives, as adjuncts to knowledge of test results, activity information, advice, and leaflets. We welcome their findings as a contribution to the scarce literature on effectiveness, but question the validity of their conclusions, on two grounds. First, we feel that the results of the trial are extremely positive. We fail to see why a rather negative conclusion has been reached when the null hypothesis was rejected and the effect of the intervention to promote adoption of activity (the stated aim of the study) was strong. Forty percent of intervention and 23% of control participants improved activity status within a population that is notoriously difficult to influence. This level of success is far greater than other behaviourally focussed trials of physical activity, smoking or weight loss. It is misleading to dwell on the more disappointing long term adherence, as such effects can only be achieved by long-term intervention strategies, which were not evident in this trial. Second, the Newcastle trial is far from reflective of the great majority of UK schemes. Most existing schemes are leisure centre, rather than primary care, based and involve physical activity specialists working with clearly targeted groups. Social group settings and class activities are frequently used, and activity programmes are tailored to the health needs of the individual. In contrast, the Newcastle trial uses broad-based recruitment and a single health visitor to deliver motivational interviewing and financial incentives. The popular model, which has been clearly outlined (2,3), has therefore not been tested by this trial. We feel, therefore, that the authors' statement "brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of questionable effectiveness", is not substantiated from the results of their study. Although this is a well-designed study, we feel that a more appropriate conclusion would be that this combination of intervention elements has achieved positive, graded effects, and this can inform the design and increase the effectiveness of other schemes. We fear there is a serious danger of prematurely fuelling the armory of the physical activity "sceptics" and unfairly setting back genuine attempts to find successful ways of promoting physical activity from the primary care base. References 1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999;319:828-32. 2. Fox K, Biddle S, Edmunds L, Bowler I, Killoran A. Physical activity promotion through primary health care in England. Br J Gen Prac 1997;47:367-9. 3. Riddoch CJ, Puig-Ribera A, Cooper A. Effectiveness of physical activity promotion schemes in primary care: a review. London: Health Education Authority, 1998. Chris Riddoch: Senior Lecturer, Exercise and Health Science Jim McKenna: Lecturer, Exercise and Health Science Ken Fox: Professor, Exercise and Health Science Department of Exercise and Health Sciences, University of Bristol, 8
Woodland Road, Bristol, BS8 1TN.
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Nanette Mutrie, Senior Lecturer Centre for Exercise and Medicine, University of Glasgow
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We welcome the addition of this study to the debate on the efficacy of exercise referral. However, we believe that Harland et al 1 have asked the wrong questions and therefore have drawn the wrong conclusions. The first flaw in their questions was to ask whether there was a difference between the various interventions and control in changes in physical activity score from 12 weeks to one year. Since there were no differences, the today in the BMJ headline states that ‘exercise prescription is a waste of scarce resources’. A better question would be to ask whether any group had increased their activity at one year compared to baseline. According to the data the authors present in Table 2 (page 831), the percentage of participants who had increased physical activity scores at one year compared to baseline, ranged from 23% in control group to 31% in Intervention 3. If these are significant changes from baseline then the conclusion might have been that even the control condition can have a substantial impact in increasing physical activity over one year. Further economic analysis might then determine that the control (which seems to include the basis of many intervention techniques such as assessment, feedback and the provision of information) was the most cost-effective intervention. The authors’ conclusion that brief interventions are of questionable effectiveness is wrong since none of their interventions or even the control condition could be described as brief. In our own research we have shown that much briefer interventions (only the provision of an information booklet) can still increase physical activity up to six months2. Another flaw in the line questioning was to base the outcome measures on an outdated questionnaire which has no substantial validation. A better option would have been to use the current ‘Active Living’ message3 and to measure total physical activity via a validated recall4. This flaw means that it is hard to determine if participants have achieved the current targets5 for sedentary individuals of accumulating 30 minutes of moderate activity on most days of the week. The authors claim that the research is based on the stage of change model. However, they have not reported how interventions were tailored to stages, any details of pre or post intervention stages, effectiveness of interventions by stage, or of the other crucial elements of this model such as the processes of change and self-efficacy measures6. If these aspects of the stage of change model had been incorporated there would be more information available for future researchers and practitioners and perhaps different conclusions. These flaws mean that the key messages are very misleading and that the conclusions drawn are not evidence based. Such misinterpretation could severely limit future research and service developments. Given that government targets 5 for increasing physical activity have just been set, such limitations would be premature and unjust. References 1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-32. 2. Loughlan, C. & Mutrie, N. An evaluation of the effectiveness of three interventions in promoting physical activity in a sedentary population. Health Education Journal 1997; 56:154-165. 3. Pate RR., Pratt M., Blair SN., Haskell WL., Macera CA., Bouchard C et al., Physical activity and public health: a recommendation from the Centres for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273 (5):402-407. 4. Lowther, M & Mutrie, N. Development of a Scottish physical activity questionnaire: a tool for use in physical activity interventions. Br J Sp Med 1999; 33: 1-6. 5. The Scottish Office. Towards a healthier Scotland - a white paper on health. Edinburgh: The Stationary Office. 1999. 6. Marcus BH, Eaton, CA Rossi JS, Harlow LL. Self- efficacy, decision- making, and stages of change: an integrative model of physical exercise. Journal of Applied Social Psychology 1994; 24:489-508. Nanette Mutrie, Avril Blamey, Chris Loughlan, |
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Frank Smith
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Editor..We would like to take issue with your banner comment, 'Exercise on prescription is a waste of scarce resources' on Harland et al's physical activity article in the 25/9/99 issue . The article showed that all four intervention groups showed a significant increase in self- reported activity at 12 weeks, compared to a control group that itself increased reported activity in 16%. In addition there was a suggestion of a dose response effect as the greatest increase was seen in the group with financial inducement and multiple interventions. It was a pity that they did not report in this article on the physiological and exercise test outcomes. As the authors note, the control group had in effect a brief intervention akin to an exercise prevention. This trial produced no evidence that more intense intervention in the short term produces sustained effects, as reflected by the findings at one year. This is not surprising given the trial design. Numerous other studies , , show that frequent contact with the subjects, even by brief telephone calls limit drop outs, and that perhaps at least six months of profession contact is needed before the increased physical activity pattern becomes incorporated into behaviour. The key seems to be not so much intensity of contact, rather continuity over time. Such continuity is a feature of general practice: this should remain an arena for testing such interventions. Harland's trial shows that in UK general practice patients may be recruited from a relatively deprived inner city area, and their physical behaviour can be increased by intervention from a researcher, mirroring encouraging trials with primary care physicians from the USA & NZ , . What they haven't shown is how to maintain the increased activity. This requires further studies, and we believe your banner headline is misleading and discouraging to researchers and funding authorities. Frank Smith Jane Sims 1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999;319:828-32. 2. Murdo ME, Burnett L. Randomised controlled trial of exercise in the elderly. Gerontol 1992;36:292-8. 3. Hamdorf PA, Withers RT, Penhall RK, Plummer JL. A follow up study on the effects of training on the fitness and habitual activity patterns of 60-70 year old women. Arch Phys Med Rehab 1993;74:473-7. 4. King A, Haskell W, Taylor C, Kraemer H, DeBusk R. Group- vs home based exercise training in healthy older men and women. A community based clinical trial. JAMA 1991;266:1535-42. 5. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomised controlled trial of written exercise advice by general practitioners. Am J Public Health 1998;88:288- 91. 6. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counselling to promote the adoption of physical activity. Preventive Medicine 1996;25:225-33. |
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Peter J S Baker
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EDITOR --- I applaud Harland et al for attempting to appraise the efficacy of GP exercise prescription. However the programme that they studied in Newcastle is unlikely to be achieve long-term changes in life style because it is vitally flawed. To achieve compliance participants need to go through their exercise programme in mutually supportive groups. A scheme in Mid-Devon in which participants felt part of a group of about 15 has been extremely popular and successful. In 1994 a health script scheme was started in Cullompton, a market town in Devon pop. 6,000. 33 General Practitioners (GPs) with a total of 47,855 patients on their lists were invited to participate in the scheme, and 474 patients were referred to the Culm Valley Sports Centre over a 12 month period 1995-6 for the following reasons in rank order: generally unfit, overweight, depression/fatigue, back pain, post heart surgery, post injury, arthritis/immobile, hypertension, neurological problems, diabetes. The programme was set up with the help of a local physiotherapist who worked with an exercise trainer who was dedicated full-time to the scheme. A study of chronic back pain was carried out looking at pain on visual analogue scale (VAS), Oswestry disability score and hospital anxiety and depression score (HAD), and all these parameters were seen to improve after 12 weeks in the exercise scheme. There was very little fall out and 80% were attending the sports centre a year later. Funds for additional equipment were provided by the Mid-Devon District Council. Participants paid reduced charges (£1-95 instead of £2- 60) and in groups of about 10 attended twice a week for 10 weeks at off peak times. They had a free initial assessment (normally £9) which included BP, pulse rate before and after exercise, body dimensions, fat thickness, peak flow recording. Despite the reduction in charges the scheme has been self- funding. Fox et al.(1997) have studied exercise prescription schemes and they included amongst the advantages: o ease with which GPs can contribute o willingness of leisure centre to take on responsibility o availability of expertise and facilities o popularity amongst patients o motivational effect of group exercise o financial viability. The Mid-Devon scheme corroborates these. It was found that carefully selected patients usually do well, have fun, and report benefits to their physical and psychological well-being. There is no delay in starting the programme and this can be a benefit when deconditioning is taking place. There may be positive advantages in removing people from the medical arena. I suggest that the type of exercise programme is vital to the success of an exercise prescription scheme, and that long term changes in exercise behaviour may result from participants attending in cohesive groups. Peter JS Baker MB,BCh,BAO;DCH;DRCOG;DOccMed |
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Marko Petrovic, Specialist Registrar in Public Health Medicine North Wales Health Authority
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Editor – Harland et al. have made a valuable contribution to the evidence base that currently underpins the promotion of physical activity (1). Whilst welcoming their contribution, we are concerned that several features of their study may reduce the external and internal validity of the conclusions that have been reached. The study described does not examine an exercise on prescription scheme. All patients aged 40-64 attending surgeries were approached and considered. This is, therefore, a population sample, not a targeting of selected patients by a general practitioner. Furthermore, because the response to this initial invitation to participate was low, those who agreed to participate may have been the most enthusiastic, and not representative of the general population. This may have reduced both the likelihood of proving the effectiveness of the intervention and the validity of the findings with respect to the general population. The interventions that were evaluated were very intensive and are unlikely to be feasible in an average primary care setting. In addition, whilst the specific method of promoting physical activity is undoubtedly an important issue, it does not stand alone. It is also necessary to consider broader social factors that may mask the effect of an intervention at this level. These would include the availability of time to attend, and accessibility of, facilities. The authors have based sample size calculations on the number of participants that would be required to detect a difference between success rates of 40% - 60%. In addition to the fact that the required number of participants was not met, the prospect of achieving such a large difference in success rates seems rather ambitious. Although we agree with the authors’ conclusion that further research is necessary to develop interventions that promote long-term adherence to exercise, it is important that the exercise on prescription scheme is differentiated from population strategies that attempt to raise the level of exercise generally. Marko Petrovic
Jeremy Corson
Hilary Fielder
Lyndon Miles
Elwyn Williams
1. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-32. |
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Ngaire Kerse, Senior Lecturer in General Practice University of Auckland, New Zealand
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We welcome the article on promoting physical activity in primary care (1) and the responses to this article to date. We agree with the authors that few of the schemes being implemented in general practice have been rigorously evaluated. However, we also agree with several of the responses to this article, that the authors' conclusion 'that these schemes are of questionable effectiveness' is premature and that the banner comment, 'Exercise on prescription is a waste of scarce resources' in the same issue is misleading and not justified by evidence to date. Our response stems from concerns about their intervention approach and our experience in two research endeavours; implementing a physical activity prescription scheme in New Zealand, and a recently published randomised controlled trial resulting in long term improvement in physical activity for older people (2). Firstly, we question whether the level of intervention with the control group (i.e. giving them information on the benefits of physical activity, recommended activity levels and leaflets on leisure facilities and activities available locally), results in a "true" control. As the control group had a significant improvement in physical activity also, the comparison may have been with a lesser intervention, rather than a true control group. Secondly, we question whether lengthy motivational interviewing is an appropriate intervention and replicable in a general practice setting. It was not clear from the article whom exactly undertook the counselling. This approach is time-intensive for GPs and limits effective long-term follow-up. It is also questionable whether it is feasible for practice nurses to sustain such a programme. In New Zealand, where 51% of GPs are now prescribing physical activity through the Hillary Commission's Green Prescription scheme (3), one of the major barriers general practitioners give for not prescribing physical activity is lack of time during the consultation (4,5). We contend that interventions that are quick and simple to implement offer more potential for sustainability and long-term effectiveness. A recent RCT, set in Melbourne Australia, showed physical activity increases sustained for at least 12 months (2). The successful approach taken in Melbourne was to raise the consciousness of the GP about the importance of physical activity through an effective educational programme, but leave the details of whom to target and the exact content of advice given, to the professional judgement of the GP. This contrasts to the Newcastle programme where the GP appeared a virtual bystander to the intervention design and delivery. This raises the overall question as to whether interventions where the judgement of the GP is key may be more effective than strictly defined intervention packages aimed to be merely 'delivered' by the GP. It is clear that individualised assessment and program design benefit outcome in health promotion trials. We contend that the GP should play a stronger role in this area in future physical activity interventions. We recognise the need for outcome-based evaluations in this area of health promotion. A three-year study (funded by the National Heart Foundation, NZ Ministry of Health and the Hillary Commission) has just begun in New Zealand. This will evaluate the long-term effectiveness of Green Prescriptions in improving health outcomes of middle-aged and older people at risk from physical inactivity, comparing the intervention to a true control group, receiving no advice. Effectiveness will be measured by changes in cardiovascular risk index, and quality of life and health status assessments. It is hoped that information from our NZ study will add value and validity to the body of knowledge acumulating as to the effectivenes of primary care physical activity intervention. Ngaire Kerse, FRNZCGP, PhD, Senior Lecturer, Department of General Practice and Primary Health Care, University of Auckland Sue Walker, PhD, Research and Information Manager, Hillary Commission for Sport Fitness and Leisure References 1. "The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care" Jane Harland, Martin White, Chris Drinkwater, David Chinn, Lorna Farr, and Denise Howel. BMJ 1999; 319: 828-832 2. "Improving health behaviours of the elderly: a randomised controlled trial of a general practice educational intervention" NM. Kerse, D Jolley, B Arroll, L. Flicker, D Young. British Medical Journal 1999;319:683-7 3. IMS Health (NZ) Ltd. Green Prescriptions in General Practice. Summary Report, November 1999. 4. Swinburn BA, Walter LG, Arroll B, Tilyard MW, and Russell DG. Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. Br J of Gen Pract, 1997;47:567-9. 5. Swinburn BA, Walter LG, Arroll B, Tilyard MW, and Russell DG. The Green Prescription Study: A randomized controlled trial of written exercise advice provided by general practioners. Am J Public Health, 1998;88:288-291. |
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Mark Reeves
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EDITOR-Harland et al ably highlight the short-comings of exercise prescriptions as a means of promoting physical activity as used in the U.K. The long-term adherence of patients prescribed 'leisure centre' type referrals in their study even in the group with the most intensive intervention coupled with financial incentive, as in other studies (1) is disappointingly low. It mirrors exactly our experience with our own scheme. The proliferation of such schemes surely results from a combination of good intentions, ease of setting up, and most particularly because they have been cost-neutral to the scarce resources of the NHS. There are well-documented exercise prescription schemes of a different type being practiced in Europe and the US, often home-based, informal and unsupervised with limited intervention, which nevertheless yield good long -term outcomes and rates of adherence (2). There may subtle cultural reasons why such practice may not easily transfer to the U.K. Yet, given the well established health and social benefits associated with increased physical activity these types of schemes deserve evaluation here before prescribing exercise is labeled ineffective. Mark Reeves 1) Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. The Newcastle Exercise Project: a randomised controlled trial of methods to promote physical activity in primary care.BMJ 1999;319:828-832. 2) Taylor AH. Evaluating GP exercise referral schemes: findings from a randomised control study. Eastbourne: University of Brighton, 1996. 3) Hillsdon M ,Thorogood M, Antiss T, Morris J. Randomised controlled trials of physical activity promotion in free living populations: a review. J Epidemiol Community Health 1995: 49: 448-453. |
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