Prescribing exercise in primary careBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4141 (Published 15 July 2011) Cite this as: BMJ 2011;343:d4141
- Karim M Khan, professor1,
- Richard Weiler, specialist in sport and exercise medicine2,
- Steven N Blair, professor3
- 1Department of Family Practice, University of British Columbia, Vancouver, BC, Canada V6T 1Z4
- 2Sport and Musculoskeletal Medicine Clinic, Homerton University Hospital NHS Foundation Trust, London, UK
- 3Arnold School of Public Health, Public Health Research Center, University of South Carolina, Columbia, SC, USA
Chronic diseases—the leading causes of morbidity and mortality—are strongly linked to unhealthy lifestyles. The World Health Organization recently published a report on global health risks.1 Leading causes of global mortality are high blood pressure (13% of total deaths), tobacco use (9%), high blood glucose (6%), physical inactivity (6%), and obesity (5%). Physical inactivity is fourth on this list, but it influences most of the other causes. The importance of physical activity in preventing and treating many diseases and conditions is indisputable, as documented by the authoritative, accessible, and practical guide of the Swedish Professional Associations for Physical Activity.2 Reports from the United States,3 Canada, and the United Kingdom concur.4
Physical activity is a complex behaviour, and modern physical and social environments discourage it. Countering these influences will require a coordinated approach involving multiple societal, institutional, and departmental collaborations.5 Clinicians need to contribute. Healthcare is one of eight sectors listed in the US national physical activity plan that aims to influence activity (www.physicalactivityplan.org/theplan.php).6 Advice on physical activity in primary care is a pillar of WHO’s global physical activity plan (2010).7 Physical activity counselling in clinical settings provides “exceptional value for money.”4
Based on the recommendation of the Swedish physical activity book,2 key principles of the US physical activity plan, and the UK’s Department of Health’s Let’s Get Moving,8 the following steps can help general practitioners encourage patients to initiate and maintain a physically active lifestyle (box).
Practical steps for immediate exercise prescription in general practice
Ask about physical activity at every consultation; consider it a vital sign
Apply the “6As” to guide counselling—assess, advise, agree, assist, arrange, and assess again
A written (“green”) prescription is crucial—it takes just 30 seconds
Display a poster with the physical activity guidelines prominently in the waiting room
Consider categorising patients into frailty levels. There is no need to medicalise physical activity for most people
Refer on—consider appropriate physicians, physiotherapists, clinical exercise physiologists, and certified fitness instructors
Know your local resources for activity—the people and the places
Remember that walking is free; find tips at: www.everybodywalk.org
Follow up the patient to chart progress, set goals, solve problems, and identify and use social support
Lobby to make low cost, evidence based, cognitive and behavioural interventions widely available for referral by healthcare providers
As with any clinical consultation, diagnosis is key. Physical inactivity is a modifiable vital sign. Thus, GPs should begin by administering the UK’s general practice physical activity questionnaire (GPPAQ) 9 or asking the exercise vital sign (EVS) questions.10 The GPPAQ takes 30 seconds to administer plus two to three minutes to categorise patients into one of four levels of activity. The “exercise is medicine” initiative (www.exerciseismedicine.org) recommends asking two EVS questions,10 so that each patient’s weekly activity can be compared with the recommended guideline. The results should be incorporated into the electronic medical record.10 From this diagnosis, management begins.
General practitioners should use their counselling method of choice and apply it to physical activity. Most general practitioners are familiar with the “6As” to guide counselling—assess, advise, agree, assist, arrange, and assess again. This approach is discussed using a case study in the Swedish book. Motivational interviewing is an increasingly popular method for GPs to counsel patients about their lifestyles.2 This, and other behavioural therapy techniques, are valuable skills and provide a worthy CME (continuing medical education) activity.
The written “green” prescription (which comprises exercise and lifestyle goals) is a crucial element to signal that exercise is medicine. As outlined in chapter 3 of the Swedish book, the written prescription may vary from simple advice on activity, including written information on health benefits and national guidelines, to highlighting local physical activity opportunities. The national physical activity guidelines should be prominent in the waiting room.
As one prescription does not fit all, a useful tip in the Swedish book is to categorise the prescription according to four levels of patient frailty.2 The frailest are referred to appropriate health professionals (such as physiotherapists). For patients with stable conditions, general practitioners can provide customised “exercise on prescription,” (outlined by condition in the book). Healthier patients are encouraged to join community support groups and to manage their own physical activity programme.
Whether a doctor should manage a patient alone or refer the patient depends on local skills, experience, services, and patient care pathways. Doctors not skilled and trained in exercise prescription, probably a majority in most countries, should feel confident to refer on. In many countries including the UK, referral might be to a sports and exercise medicine specialist, in others such as the US, referral may be to a primary care sports medicine physician.
Referral will generally reach beyond health professionals alone. It is useful to link patients with appropriate community based resources. Only a few people have the resources to hire a health professional or a fitness instructor to design and supervise a workout. Communities, however, often have low cost public facilities. Walking is free and now being promoted on a very practical, user friendly, and unbranded website (www.everybodywalk.org).
Follow-up is crucial to signal the clinician’s conviction, determine the patient’s progress, solve problems, help identify social support, fine tune the dose, and reset goals. The exercise vital sign should be obtained at every follow-up visit.9 10Doctors do not prescribe an antihypertensive drug at one dose and then ignore the patient for ever.
At the medical society level, general practitioner organisations should take time to vote on whether they support exercise as medicine and are prepared to commit resources to appropriate political action. If they do, it would be logical to lobby to make low cost, evidence based, cognitive and behavioural interventions widely available for referral by healthcare providers. There is also evidence for high tech patient support applications, such as email and text message reminders, website support, and smart phone apps.11 Such innovations align with the current UK government’s approach to “nudge” people towards healthier behaviour by subtly changing environments.
In addition to these steps, medical education curriculums need to include the promotion of physical activity. A new generation of doctors must avoid the knee jerk reaction of prescribing ‘‘preventive’’ drugs as a first response to diseases of inactivity. There is strong economic evidence that to manage lifestyle diseases, doctors should first encourage patients to adopt a healthy lifestyle and then help them to maintain it.8 This is particularly relevant given the budget based debates on health system reform in the NHS and in the US right now.
It is obvious that clinicians must be active role models. As well as improving their own health, 22 minutes of physical activity daily provides credibility when prescribing and highlights the problems faced by patients.3
Cite this as: BMJ 2011;343:d4141
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.