Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysisBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6462 (Published 07 November 2011) Cite this as: BMJ 2011;343:d6462
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Re: Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis
This paper presents an interesting review of RCTs in exercise referral schemes on the basis of 8 controlled trials. Yet, this thorough and rigorous review represents a small proportion of the ERS evidence base. Question marks have been raised about the RCT approach being the most appropriate method of assessing effectiveness in this area of physical activity promotion and basing recommendations for practice/policy on reviews with such restrictive inclusion criteria (Gidlow et al 2008). Indeed, there is exercise/physical activity referral schemes research published in the last 5 years which challenges many of Pavey et al.’s conclusions (Gidlow et al., 2007, James et al., 2009, James et al., 2008, Harrison et al., 2005, Crone et al., 2008).
However, for some years now, the RCT approach has been questioned as being the most effective method of assessing effectiveness in this area of physical activity promotion (Gidlow et al., 2008, Dugdill et al., 2005). Unlike the 2007 review by Williams (Williams et al., 2007), observational and population cohort studies were not included in the Pavey et al. review. Whilst the inclusion criteria may have rendered their addition in the body of the review inappropriate, it seems surprising that given the number of studies regarding the evidence for exercise referral schemes that these were not mentioned in the introduction, or discussion and implications sections of this systematic review. This is especially surprising given that the findings from some of these papers provide evidence where Pavey et al. reports that there is none. For example there is a criticism of a lack of subgroup analysis in the evidence (see under Characteristics of reported studies p.3), but James et al., (2009) report subgroup analyses for referral reason including hypertension and respiratory disease, Crone et al., (2008) for mental health condition and Gidlow et al., (2007) for socio-economic status.
The review concludes by voicing concern over the future funding of such schemes. However it fails to identify that due to recent recommendations from the Department of Health (DoH) and the emergence of evidence surrounding behavioural interventions, current practice is changing. Since publication of the physical activity care pathway recommendations document Let’s Get Moving (DoH, 2009) which has resulted in motivational interviewing being incorporated into many ERS’s. To date however there is limited evidence available in peer-reviewed publications due to the contemporary nature of this development. Only three papers are currently published on physical activity care pathways (Curry et al., 2011, Bull and Milton, 2011, Bull and Milton, 2010). Presently, many ERS’s are developing to include motivational interviewing. They are therefore moving away from the traditional facility-based interventions and tend to offer one-to-one support and signpost patients to existing programmes, which include exercise referral schemes. Through training provided for physical activity referral staff; referral schemes increasingly have staff with skills to address internal motivation for change with referred patients, rather than a sole reliance on the previous prescriptive (supply-led) approach to exercise recommendations.
It is our opinion, as the study rightly acknowledges that more research is required in this area. However we argue that this evidence should be drawn from a range of types of study design, in addition to randomised controlled trials. In isolation, the inclusion criteria used in this paper, does not allow the full picture of evidence for physical activity referral schemes to be presented. We believe that acknowledgment of these issues would have presented a more balanced perspective of the current state of evidence and practice in primary care physical activity promotion, and would enable health commissioners to have more information regarding such services and the evidence underpinning them.
Competing interests: No competing interests