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Prescription of exercise by physicians improves fitness in elderly people
EVIDENCE -BASED HE ALTH PROMOTION
Prescription of exercise by physicians improves fitness in elderly people Abstracted from: Petrella RJ, Koval JJ, Cunningham DA, Paterson DH. Can primary care doctors prescribe exercise to improve fitness? The step test exercise prescription (STEP) project. Am J Prev Med 2003; 24: 316 ^322.
BACKGROUND Although improving physical ¢tness leads to improved health, changing people’s exercise behaviour is di⁄cult. It is not known whether a simple prescription of exercise by primary care physicians is su⁄cient to improve people’s exercise behaviour and ¢tness.
to exercise to a predetermined target heart rate (estimated to achieve 75% predicted VO2max). Participants in the STEP group were instructed to record their heart rate during exercise. Targets were adjusted at 3 and 6 months. In the control group, participants received exercise counselling according to their physician’s usual practice.
OBJECTIVE To compare e⁄cacy of the Step Test Exercise Prescription (STEP) and usual-care exercise counselling given by primary care doctors in elderly people.
OUTCOMES Change in aerobic ¢tness, (VO2max) measured using a treadmill.
SETTING Four large academic primary care practices (three urban, one rural) in Canada;1998 to 1999.
MAIN RESULTS At 12 months, the STEP programme signi¢cantly increased VO2max compared with usual care (improvement in VO2max from baseline: 3% with control versus 15%; po0.001).
METHOD Randomised controlled trial. PARTICIPANTS Two hundred and eighty-four healthy people aged over 65 years living in the community, not participating in regular exercise. People with unstable medical conditions or those unable to walk on a treadmill unaided were excluded. INTERVENTION All participants received exercise counselling and a list of local physical activity facilities and all were free to choose how and where to exercise. In the STEP group, participants were advised
Commentary 1 Despite the known benefits of regular aerobic exercise, most adults do not participate in levels of physical activity that are sufficient to improve health.1 In addition, fewer than 20% of people with heart disease participate in exercise-based cardiac rehabilitation programs, highlighting the vast underutilization of these services, especially in older adults and women.2 Although the fervor of the primary care physicians’ recommendation appears to be a powerful predictor of exercise participation,3 few physicians actually prescribe exercise. Barriers to counseling
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Evidence-based Healthcare (2003) 7,172^173 doi:10.1016/j.ehbc.2003.08.003
AUTHORS’ CONCLUSIONS STEP improves ¢tness compared with usual care in elderly people. Sources of funding: Medical Research Council of Canada, Pharmaceutical Manufacturers Association of Canada. Correspondence to: RJ Petrella, Canadian Centre for Activity and Aging, 1490 Richmond Street, North London, Ontario, Canada N6G 2M3. E-mail: [email protected] Abstract provided by Bazian Ltd, London
may include time constraints, insufficient knowledge/training about fitness assessment and exercise prescription, and lack of a simple, easily-administered test to estimate aerobic capacity (VO2max). Numerous interventions aimed at increasing physical activity levels using counseling in the primary care setting have been previously described, with mixed (and generally unimpressive) results.4 Petrella and associates5 examined the effect of an exercise prescription instrument (i.e., StepTest Exercise Prescription [STEP]) compared with usual-care exercise counseling delivered by primary care physicians on elderly (465 years) people. In this 1462-9410/$ - see front matter & 2003 Elsevier Ltd. Allrights reserved.
randomized, controlled trial, the STEP intervention groups underwent a baseline step test to estimate VO2max and were prescribed an exercise training heart rate corresponding to 75% of their aerobic capacity. In contrast, physicians in the control group were instructed to provide participants with exercise counseling and prescription as per their ‘usual care’. Both groups were given a list of available exercise facilities in their community. The post intervention follow-up was conducted at 3, 6, and 12 months. Implications Although there was no attempt to assess ‘readiness to change’ or provide reinforcement strategies in either group, the STEP group demonstrated a 15% increase in VO2max at 12 months, compared with a 3% improvement in the usual care exercise counseling control group. Greater improvements in measures of exercise selfefficacy, systolic blood pressure, and body mass index were also observed in the STEP group. These provocative results suggest that providing an office-based fitness test and an individualized exercise prescription may improve exercise counseling by the primary care physician, especially when provided at the point of care. However, the generalizability of these findings to busy, primary care settings is tenuous at best.Challenges may include lack of reimbursement, cost containment issues, competing ‘priorities’, the provision of follow-up, and escalating time constraints on physicians. Perhaps one solution may lie in the use of specially trained health-care professionals (e.g., nurses, exercise physiologists, physician assistants) to conduct the office-based fitness as
Commentary 2 There has been an increased recognition amongst health professionals of the benefits of physical activity and exercise to health along with calls for primary care physicians to address physical activity and other behavioural risk factors.1 However a major challenge is to improve the generally poor understanding of doctors in this area. Most recent reviews have highlighted that interventions in the primary care setting may make an important contribution to the promotion of physical activity 2^ 4 but signif|cant impediments exist. Lack of knowledge, the need to promote greater attention to physical activity in primary health care,1 lack of time, poor resources, and a perceived lack of patient interest 5 are problems. Petrella et al reported significantly greater improvements in fitness and exercise self-efficacy among elderly community-dwelling patients in the ‘exercise’ group. However, what is the true potential for further enhancement? They rightly suggest that ‘few physicians actually prescribe exercise,’ in fact most are not trained to promote physical activity. In preparation for the intervention, physicians were provided with an extremely brief 30 minute workshop. Accurate general advice will be valuable for many inactive adults however doctors are challenged by a double-edged sword. How can they provide motivational counseling for increased activity, let alone individualized prescription of exercise in a consultation lasting a few minutes? This approach pays ‘lip-service’ to exercise with an over simplication of messages to sedentary people. A better scenario may be a consistent upskilling of doctors to promote increased physical activity. Some may benefit from
sessment and provide the exercise prescription, under the direction of the primary care physician. Barry A. Franklin PhD Cardiac Rehabilitation and Exercise Laboratories William Beaumont Hospital Royal Oak, Michigan, USA Literature cited 1. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,1996. 2. Wenger NK, Froelicher ES, Smith LK et al. Cardiac Rehabilitation Guideline No.17. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute (AHCPR publication No. 96 - 0672, October 1995). 3. Ades PA, Waldmann ML, McCann WJ, Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med 1992; 152:1033^1035. 4. The Writing Group for the Activity CounselingTrial Research Group. Effects of physical activity counseling in primary care. The Activity Counseling Trial: a randomized controlled trial. JAMA 2001; 286:677^ 687. 5. Petrella RJ, Koval JJ, Cunningham DA, Paterson DH. Can primary care doctors prescribe exercise to improve fitness? The StepTest Exercise Prescription (STEP) Project. Am J Prev Med 2003; 24:316 ^322.
the addition of heart rate monitoring and the basics of intensity, duration and frequency of exercise. The best scenario would be to utilize the skills of the exercise scientist/physiologist. Exercise prescription is the province of these professionals and in a multidisciplinary general practice context could provide an extension of activity promotion to exercise prescription. Andrew P. Hills PhD Queensland University of Technology, Brisbane, Australia Literature cited 1. Smith B, Eakin E, Bauman A. Physical activity is important, but can it be promoted in general practice. Med J Aust 2003; 179: 70 ^71. 2. Smith B, Merom D, Harris P, Bauman A. Do physical activity interventions to promote physical activity work? A systematic review of the literature. Melbourne: National Institute of Clinical Studies, 2003 (See http://www.cpah.unsw.edu.au/ NICS.pdf) 3. Eakin E, Glasgow R, Riley K. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000; 49: 158 ^168. 4. Simons-Morton D, Calfas K, Oldenburg B, Burton N. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med1998; 15: 413^ 430. 5. Bull F, Schipper E, Jamrozik K, Blanksby B. Beliefs and behaviour of general practitioners regarding promotion of physical activity. Aust NZ J Public Health 1995; 19: 300 ^304.
Evidence-based Healthcare (2003) 7,172^173
173
Prescription of exercise by physicians improves fitness in elderly people Abstracted from: Petrella RJ, Koval JJ, Cunningham DA, Paterson DH. Can primary care doctors prescribe exercise to improve fitness? The step test exercise prescription (STEP) project. Am J Prev Med 2003; 24: 316 ^322.
BACKGROUND Although improving physical ¢tness leads to improved health, changing people’s exercise behaviour is di⁄cult. It is not known whether a simple prescription of exercise by primary care physicians is su⁄cient to improve people’s exercise behaviour and ¢tness.
to exercise to a predetermined target heart rate (estimated to achieve 75% predicted VO2max). Participants in the STEP group were instructed to record their heart rate during exercise. Targets were adjusted at 3 and 6 months. In the control group, participants received exercise counselling according to their physician’s usual practice.
OBJECTIVE To compare e⁄cacy of the Step Test Exercise Prescription (STEP) and usual-care exercise counselling given by primary care doctors in elderly people.
OUTCOMES Change in aerobic ¢tness, (VO2max) measured using a treadmill.
SETTING Four large academic primary care practices (three urban, one rural) in Canada;1998 to 1999.
MAIN RESULTS At 12 months, the STEP programme signi¢cantly increased VO2max compared with usual care (improvement in VO2max from baseline: 3% with control versus 15%; po0.001).
METHOD Randomised controlled trial. PARTICIPANTS Two hundred and eighty-four healthy people aged over 65 years living in the community, not participating in regular exercise. People with unstable medical conditions or those unable to walk on a treadmill unaided were excluded. INTERVENTION All participants received exercise counselling and a list of local physical activity facilities and all were free to choose how and where to exercise. In the STEP group, participants were advised
Commentary 1 Despite the known benefits of regular aerobic exercise, most adults do not participate in levels of physical activity that are sufficient to improve health.1 In addition, fewer than 20% of people with heart disease participate in exercise-based cardiac rehabilitation programs, highlighting the vast underutilization of these services, especially in older adults and women.2 Although the fervor of the primary care physicians’ recommendation appears to be a powerful predictor of exercise participation,3 few physicians actually prescribe exercise. Barriers to counseling
172
Evidence-based Healthcare (2003) 7,172^173 doi:10.1016/j.ehbc.2003.08.003
AUTHORS’ CONCLUSIONS STEP improves ¢tness compared with usual care in elderly people. Sources of funding: Medical Research Council of Canada, Pharmaceutical Manufacturers Association of Canada. Correspondence to: RJ Petrella, Canadian Centre for Activity and Aging, 1490 Richmond Street, North London, Ontario, Canada N6G 2M3. E-mail: [email protected] Abstract provided by Bazian Ltd, London
may include time constraints, insufficient knowledge/training about fitness assessment and exercise prescription, and lack of a simple, easily-administered test to estimate aerobic capacity (VO2max). Numerous interventions aimed at increasing physical activity levels using counseling in the primary care setting have been previously described, with mixed (and generally unimpressive) results.4 Petrella and associates5 examined the effect of an exercise prescription instrument (i.e., StepTest Exercise Prescription [STEP]) compared with usual-care exercise counseling delivered by primary care physicians on elderly (465 years) people. In this 1462-9410/$ - see front matter & 2003 Elsevier Ltd. Allrights reserved.
randomized, controlled trial, the STEP intervention groups underwent a baseline step test to estimate VO2max and were prescribed an exercise training heart rate corresponding to 75% of their aerobic capacity. In contrast, physicians in the control group were instructed to provide participants with exercise counseling and prescription as per their ‘usual care’. Both groups were given a list of available exercise facilities in their community. The post intervention follow-up was conducted at 3, 6, and 12 months. Implications Although there was no attempt to assess ‘readiness to change’ or provide reinforcement strategies in either group, the STEP group demonstrated a 15% increase in VO2max at 12 months, compared with a 3% improvement in the usual care exercise counseling control group. Greater improvements in measures of exercise selfefficacy, systolic blood pressure, and body mass index were also observed in the STEP group. These provocative results suggest that providing an office-based fitness test and an individualized exercise prescription may improve exercise counseling by the primary care physician, especially when provided at the point of care. However, the generalizability of these findings to busy, primary care settings is tenuous at best.Challenges may include lack of reimbursement, cost containment issues, competing ‘priorities’, the provision of follow-up, and escalating time constraints on physicians. Perhaps one solution may lie in the use of specially trained health-care professionals (e.g., nurses, exercise physiologists, physician assistants) to conduct the office-based fitness as
Commentary 2 There has been an increased recognition amongst health professionals of the benefits of physical activity and exercise to health along with calls for primary care physicians to address physical activity and other behavioural risk factors.1 However a major challenge is to improve the generally poor understanding of doctors in this area. Most recent reviews have highlighted that interventions in the primary care setting may make an important contribution to the promotion of physical activity 2^ 4 but signif|cant impediments exist. Lack of knowledge, the need to promote greater attention to physical activity in primary health care,1 lack of time, poor resources, and a perceived lack of patient interest 5 are problems. Petrella et al reported significantly greater improvements in fitness and exercise self-efficacy among elderly community-dwelling patients in the ‘exercise’ group. However, what is the true potential for further enhancement? They rightly suggest that ‘few physicians actually prescribe exercise,’ in fact most are not trained to promote physical activity. In preparation for the intervention, physicians were provided with an extremely brief 30 minute workshop. Accurate general advice will be valuable for many inactive adults however doctors are challenged by a double-edged sword. How can they provide motivational counseling for increased activity, let alone individualized prescription of exercise in a consultation lasting a few minutes? This approach pays ‘lip-service’ to exercise with an over simplication of messages to sedentary people. A better scenario may be a consistent upskilling of doctors to promote increased physical activity. Some may benefit from
sessment and provide the exercise prescription, under the direction of the primary care physician. Barry A. Franklin PhD Cardiac Rehabilitation and Exercise Laboratories William Beaumont Hospital Royal Oak, Michigan, USA Literature cited 1. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,1996. 2. Wenger NK, Froelicher ES, Smith LK et al. Cardiac Rehabilitation Guideline No.17. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute (AHCPR publication No. 96 - 0672, October 1995). 3. Ades PA, Waldmann ML, McCann WJ, Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med 1992; 152:1033^1035. 4. The Writing Group for the Activity CounselingTrial Research Group. Effects of physical activity counseling in primary care. The Activity Counseling Trial: a randomized controlled trial. JAMA 2001; 286:677^ 687. 5. Petrella RJ, Koval JJ, Cunningham DA, Paterson DH. Can primary care doctors prescribe exercise to improve fitness? The StepTest Exercise Prescription (STEP) Project. Am J Prev Med 2003; 24:316 ^322.
the addition of heart rate monitoring and the basics of intensity, duration and frequency of exercise. The best scenario would be to utilize the skills of the exercise scientist/physiologist. Exercise prescription is the province of these professionals and in a multidisciplinary general practice context could provide an extension of activity promotion to exercise prescription. Andrew P. Hills PhD Queensland University of Technology, Brisbane, Australia Literature cited 1. Smith B, Eakin E, Bauman A. Physical activity is important, but can it be promoted in general practice. Med J Aust 2003; 179: 70 ^71. 2. Smith B, Merom D, Harris P, Bauman A. Do physical activity interventions to promote physical activity work? A systematic review of the literature. Melbourne: National Institute of Clinical Studies, 2003 (See http://www.cpah.unsw.edu.au/ NICS.pdf) 3. Eakin E, Glasgow R, Riley K. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000; 49: 158 ^168. 4. Simons-Morton D, Calfas K, Oldenburg B, Burton N. Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med1998; 15: 413^ 430. 5. Bull F, Schipper E, Jamrozik K, Blanksby B. Beliefs and behaviour of general practitioners regarding promotion of physical activity. Aust NZ J Public Health 1995; 19: 300 ^304.
Evidence-based Healthcare (2003) 7,172^173
173