Doctors should be able to prescribe exercise like a drug
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2468 (Published 05 May 2016) Cite this as: BMJ 2016;353:i2468
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Doctors are now able to prescribe targeted exercise against cancer. On 10 May 2016, The Australian ABC TV science show ”Catalyst” reported on a highly and demonstrably effective specifically targeted exercise, taylor-made for the type of cancer. It starts on the same day as the patients get their chemo or radiation.
How does it work? These are just a few comments:
“The muscles are producing chemicals, and they are actually destroying tumour cells.”
”The trial is still ongoing, but the early results are so impressive”.
“The doctors think it will be a game-change.”
“This is our exercise medical clinic here at the cancer care centre. As far as I know, this is a world first to have that close to the actual chemotherapy, radiation therapy suites.”
“In this program we will show you what professionally prescribed exercise is doing for a group of Australians with cancer…”
The full transcript of this show is easily accessable on Google. It is a highly recommended viewing and reading.
Competing interests: No competing interests
There is clear and compelling evidence that regular physical activity improves health and wellbeing, yet one in four adults do less than 30 minutes per week, and a greater proportion are not active at recommended levels (1). NICE recommends that brief advice delivered in primary care can make an effective contribution to tackling population inactivity levels (2), but also sets out the need for local opportunities to be available and for environmental barriers to be addressed.
Nunan’s article in this week’s BMJ identifies a need for further scrutiny of the evidence so that a taxonomy of interventions can be derived. Such a taxonomy could then inform a formulary for prescribing physical activity. This is identified as key to overcoming clinician scepticism, and ensuring greater engagement in promoting physical activity (3).
In Hertfordshire we have found that the role of clinicians in promoting physical activity is broadly accepted. But this has required significant work on both sides to understand what works for busy clinicians. We have been developing a whole system approach to tackling physical inactivity, with clinicians as key informants. This approach is overseen by a multi-agency Health and Physical Activity Group, following extensive engagement in 2014, with GPs and a range of other interested parties. There are several threads to this approach, including:
• Physical activity embedded within all general practice point of care decision making systems, as part of the prevention and treatment of long term conditions
• Continued professional development sessions offered opportunistically, and on a systematic basis in one locality. Attendees report significantly higher personal value for physical activity, as well as greater confidence that they can promote it in available time. Sharing examples of how busy clinicians themselves fit physical activity into their working lives can be a useful way to promote physical activity with patients.
• Training in behaviour change skills – for clinicians to apply “Healthy Conversations” in immediate practice, and to introduce options for developing more in-depth skills, should they be interested
• Embedding physical activity into clinical pathway re-design (such as diabetes), so that the value of physical activity and the most timely intervention points are clearly set out
• A three year project involving physical activity behaviour change specialists working within twenty general practices in the most deprived/least active areas. Clinicians identify appropriate individuals who are inactive and considering change, but who need more specialist support than currently available within the practice. The project has substantial Sport England grant funding, matched by the two Clinical Commissioning Groups and Public Health.
• Health in Herts webpages for signposting people to key appropriate activities in their area
Clinician involvement and endorsement of this approach has been vital to better embedding physical activity into routine care, but further progress is still needed. Our training and interventions draw on behaviour change techniques that have the most impact on targeted behaviours, such as goals and planning, frequent feedback, social support, and rewards. With time at such a premium in primary care, our view is that the active choice must become the easiest choice, for participant and effective promoter alike.
In highlighting the key issues, Nunan gives us an opportunity to explore together how we can support clinicians to promote physical activity more effectively. We feel that there may be value in bringing together key informants for a symposium to determine how to best progress this issue, which we would be happy to host.
References:
(1) Public Health England. Everybody Active, Every Day: an evidence-based approach to physical activity. London: PHE, 2014
(2) National Institute for Health and Care Excellence. Physical activity: brief advice for adults in primary care. London: NICE, 2013
(3) Nunan D. Doctors should be able to prescribe exercise like a drug. BMJ 2016;353:i2468
Competing interests: No competing interests
Readers may be interested to hear that York City Council runs 'HEAL' (Health Exercise Activity Lifestyle) - a course funded by Sport England - which I find hugely beneficial. Through HEAL, people with long term medical conditions can access a variety of activities suitable for their needs for a nominal payment. One of the courses is a group activity involving weekly, individually tailored exercise sessions, supported by a qualified trainer. The sessions are held at a gymnasium outside the city and one of the facilities which is of particular benefit to me, is the extra warm swimming pool.
There must be many older people like me who, through age or infirmity (or both) find the normal temperature of corporation swimming pools far too cold to use. For those of us with multi-morbidities, a really warm pool can provide the only opportunity for exercise. My list of ailments, past and present, includes radical treatments for 2 cancers, radiotherapy-induced midline lymphoedema, cervical spondylosis, osteoarthritis, osteoporosis (with spinal fracture), bursitis, bronchiectasis and allodynia (oversensitivity, especially to pain and temperature, due to cancer treatments ). So my ability to exercise is severely restricted; also one medical condition exacerbates another. I find swimming and exercising in water supported by a long float is possible and, although not weight-bearing, this helps clear my lungs so aids breathing and helps to combat fluid build-up, which in turn means less weight affecting my joints; plus there are benefits to my overall health, including well-being. Lymphoedema, alone, is a distressing, progressive condition and it would be easy to succumb to depression, especially since I have found it impossible to access a repeat of the effective treatment I had in 2005, due to NHS cuts.
Although I am lucky to have access to a pool at the gymnasium, it is a forty-five minute drive away from my home (sitting has a negative impact on my lymphoedema – compressed lymph nodes). There are two corporation swimming pools nearby which are far too cold for me, but though both are trying to encourage people to join another scheme to get everyone active, neither offers even one session per week when the pool temperature is raised especially for older/infirm people. Why not? There must be many people like me who would like to keep active, who could benefit from access to a really warm swimming pool close to home. The potential gains for the NHS could be immeasureable. Time for some joined-up thinking?
“HEAL aims to help people overcome barriers to exercise by making it easier for them to get started.”
https://www.york.gov.uk/info/20244/sport_and_physical_activities/431/hea...
Competing interests: No competing interests
Prescribing exercise like a drug: a very bad idea!
Nunan dangerously ignored the state of practice when calling for doctors to prescribe exercise like a drug.(1)
First, drug prescriptions frequently exhibit poor for quality.(2)
Second, patients are poorly compliant with drug prescriptions. About half of the patients who were prescribed an antihypertensive drug had stopped taking it within one year.(3) On the patient level, educational interventions with behavioural support through continued patient contact over several weeks or months are effective in improving medication adherence.(4) Accordingly, Nunan’s subtitle “brief advice can change behaviour” is a deadly misconception. Brief advice has at best brief and little effect! In contrast, motivational interviewing, a cornerstone for treating chronic conditions or the addicted,(4) is effective, yet the improvement of healthcare providers’ skills remains a major issue.(5)
Brief advice for patient-centred care is an oxymoron!
1 Nunan D. Doctors should be able to prescribe exercise like a drug. BMJ 2016; 353:i2468
2 Malhotra A, Maughan D, Ansell J et al. Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine. BMJ. 2015;350:h2308.
3 Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ 2008;336:1114-7.
4 Marcum ZA, Sevick MA, Handler SM. Medication nonadherence: a diagnosable and treatable medical condition. JAMA. 2013 22;309:2105-6.
5 Hall K, Staiger PK, Simpson A, Best D, Lubman DI. After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing? Addiction 2015. Online Jul 28. doi: 10.1111/add.13014.
6 Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ 2010;340:c1900.
Competing interests: No competing interests
Thank you for your comment. Again and again, exercise should be promoted during medical visit but I do not think that the biggest problem is dose/risk question (i.e., WHAT) but HOW to promote physical exercise and active lifestyle.
Two major determinants of exercise promotion in care givers (GP, nurse, psychologist, oncologist…) are their physical activity habit (see Fie et al. 2013 Health Educ J) and physical activity education occurring in (medical) education (Cardinal et al 2015 JPAP, ‘If Exercise is Medicine, Where is Exercise in Medicine?’). For instance, more than one-half of the physicians trained in the US in 2013 received no formal education in physical activity and most courses focused on exercise physiology. Behavior change interventions are efficient to promote physical exercise (see meta-analysis from Gourlan et al 2016 Health Psy Rev) but these results and implementation strategies are mainly known in health psychologists, much less in medicine and exercise specialists.
In brief, providing more information about benefits/risks/dose/targeted intensity … is not enough, maybe not the priority. To prescribe a health behavior change like a drug could be a reductionist and biomedical view. Health behavior change (especially for physical activity) needs multilevel interventions (see Sallis et al., 2012 Circulation and 'Behavior Change Wheel' from Michie et al 2011 Impl Sc) (e.g., adapted goal setting, decisional balance, habit development, active travel, active break against sedentary, environmental changes…). In parallel, it is also very important to include more exercise specialists (with initial training focusing more on behavior change techniques than physiology) (e.g. Exercise Referral System in UK) in the health care system, they could be become the ‘catalyst’ for exercise promotion.
Competing interests: No competing interests
Of course we should all be doing more exercise - the evidence for the benefits of exercise is overwhelming!
The best exercise is something that people incorporate into their lives, and do because it's routine and they enjoy it (or, next best, because they have to).
So I hesistate to mention gyms - it's probably more appropriate for many people that they find a way to exercise that is part of a daily routine, not something special that they do in a gym.
However... It would help enormously if gyms didn't try to absolve themselves of any liability by asking patients to bring a note from their doctor declaring that they are fit to attend a gym. These notes are meaningless, they are not NHS work (so they should be charged for), and they waste doctors' time. Some doctors feel that they may be held accountable if something bad happens to the patient while at the gym, and are therefore reluctant to provide such notes.
Gyms should drop policies that require such; and until they do, a standard (?BMA) response that patients can download at no cost, declaring that most people will benefit from exercise and should be considered responsible enough to decide for themselves what is too much might help.
Competing interests: No competing interests
Should we prescribe exercise like a drug? – Response to Nunan
It is widely accepted that the population should be more physically active, and few would argue against any attempts to encourage and promote physical activity. To this end, it would appear to be reasonable for clinical teams to promote physical activity. With regard to the article by Nunan, there are three separate points that require further elaboration. The first is the issue of whether physical activity should be prescribed; the second, whether physical activity should be prescribed like a drug; and the third, whether a taxonomy of interventions is possible and desirable.
Traditionally, is has been assumed that human behaviour is based on rational decisions. Therefore, if we do not act in health promoting ways, it must be because we do not understand the link between the behaviour and health, or do not have the necessary skills. Traditional approaches to change behaviour have focused on information giving, persuasion, or teaching skills (Marteau et al., 2015). However, recent surveys demonstrate that the majority of people do recognise the importance of physical activity (O’Donovan., 2017). Furthermore, our recent research suggests that people may be less motivated to improve their health (via physical activity) than clinical teams assume (Denford et al unpublished). Physical activity promotion may therefore be more effective if focusing on the enjoyment element of physical activity; rather than its health benefits.
Secondly, whether or not we should prescribe exercise like a drug depends largely on how drugs are prescribed. Various authors have written about compliance, adherence, and concordance; the former referring to doctors’ desire for patients to follow their instructions; the latter referring to a compromise between doctors and patients with regard to patients’ medicine use. Concordance (or adherence) to medications is low - with up to 50% of patients not using their medications as prescribed (e.g., Haynes et a., 2008; Holloway et al., 2011). It is hard to see how physical activity, prescribed in a similar way would be any more effective. In 2005, Pound et al discussed various approaches used by patients to modify their medicines in accordance with their own goals, beliefs and agenda (Pound et al., 2005). This led to initiatives such as shared decision making (Elwyn et al., 2010), and individualisation of treatments (Denford et al., 2013) in which doctors’ work with patients to agree how medicine should be taken – even if not “medically optimal.” Physical activity prescribed in this way, could potently be more effective than if presented prescriptively.
Finally, there has been a lot of debate in the field of Health Psychology as to whether taxonomy-based approaches are both feasible and / or desirable for health promotion (see Ogden 2016 for details). The foundations underpinning this argument is that variability in clinical practice and patient behaviour is both necessary and desirable. Attempts to systematise the process is arguably impossible, and Ogden suggests that such variability should be “celebrated rather than removed” (Ogden 2016., pp245).
Physical activity prescription is clearly a positive move in the fight against inactivity. However, we must be cautious about how we physical activity is prescribed. Caution must be taken to ensure adherence to physical activity is not as low as it is for certain medications. Ultimately, physical activity should be fun! Any attempts to medicalise physical activity should not diminish the enjoyment factor.
Competing interests: No competing interests