The presentation was directed towards Saskatchewan family physicians on exercise prescription for mental health and osteoarthritis in the primary care setting.

1. Exercise Prescription in
Primary Care
Faculty/Presenter Disclosure
Faculty: Dr. Patrick Ling
Sept 24, 2015
2015 Annual Scientific Assembly
Regina, Saskatchewan
Relationships with commercial interests:
•Grants/Research Support: none
•Speakers Bureau/Honoraria: none
•Advisory Boards: none
• Other:

2. Disclosure of Commercial Support
 Potential for conflicts of interest:
• NONE
• No products will be discussed in this presentation

3. Learning Objectives of this Section
1. Describe mental health benefits for exercise
2. Review literature on exercise and osteoarthritis
3. Describe the challenges with exercise prescription in the
primary care setting
4. Describe an exercise prescription
5. Discuss the elements of physical activity counseling

4. Why should physicians counsel
patients about physical activity?
• Preferred source of health information (Blair et al., 1998)
• High population reach (CIHI, 2003)
– 75-80% of Canadians visit their family physician over the course
of a year (Wilson and Ciliska, 1992)
– Avg Cdn visits FP 3.1x/yr, increases to 6x/yr for >65 yo
• Manage or involved with the care of chronic disease
• Physical Inactivity is an important risk factor
• Exercise is safe and affordable for most people

6. HSF Clinical Day – December 7, 2012 6
Your Role and Influence
• Structured counselling by health care professionals effectively
increases physical activity adoption
+55 mins
-14 mins
counselling no
counselling
From: Kirk et al. Diabetalogia. 2004;47:821-832
Change in
exercise
time per
week

7. HSF Clinical Day – December 7, 2012
The Benefits of Exercise in ...
● constipation
● fibromyalgia
● osteoarthritis
● lupus
● depression
● IBS – irritable bowel syndrome
● insomnia
● chronic fatigue
● slows aging
● boost testosterone
● preserves cognitive function
● dysmenorrhea
● fewer colds
● cancer prevention?

8. HSF Clinical Day – December 7, 2012

9. HSF Clinical Day – December 7, 2012

10. HSF Clinical Day – December 7, 2012 10

13. HSF Clinical Day – December 7, 2012 13

15. Exercise and Depression
• Exercise in some studies as effective as
anti-depressants, psychological therapies
• Exercise is more effective than no therapy
for reducing symptoms of depression
• Compliance rate between 50-100%
• Ref: Cochrane Review Sept, 2013

16. Exercise and Anxiety
Population based study:
Exercisers were less anxious, less depressed
Meta-analysis:
Exercise results in reduction in anxiety and
depression
Ref: DeMoor 2006, Guszkowska 2004

18. Osteoarthritis

19. Exercise and Osteoarthritis
• Evidence supports aerobic and
progressive strengthening exercise –
results in pain reduction and improved
function
• In patients with mild to mod knee OA
• Ref: Golightly 2012

20. Exercise and Osteoarthritis
• No association between OA and runners
• muscle dysfunction vs wear & tear
• Ref: Willick 2010, Shrier 2004

21. Preventive Care Checklist CCFP (2012 update)
Exercise is part of lifestyle assessment
on the PCC checklist but…
 As of 2012, Moderate physical
activity recommendations:
 Doing moderate physical
activity was a B
recommendation
 But physician counseling
was a C.
 However:
Brief advice in primary care is a
cost-effective intervention.
(Anokye et al. BJSM 2014; 48: 202–6)

22. Doctors prescribing exercise?

27. Challenges to ExRx in Primary
Care• For MD’s
– Lack of time
– Lack of training & confidence in exercise design
– Lack of training & confidence in PA counseling
– Lack of billing codes, insurance coverage
– Lack of resources to support counseling and referrals
• In the MD-patient dynamic
– Perceived low response efficacy
– Patient ‘readiness’ rarely elicited or revealed
– Unclear or inconsistent recommendations
– Difference between what is said and heard
– Lack of resources to support exercise prescription
• Insurance, qualified individuals, information overload
Estabrooks et al JAMA,2003; Carrol et al., AFM 2011;
Lawton BMJ 2008; Sallis BJSM 2011

28. Exercise Prescription in Primary Health
An MD ExRx can improve ‘uptake’
 “Green prescription” in NZ ↑ PA in
“relatively inactive” adults by ~10%
at 1 yr and is cost-effective
 (Elley et al., BMJ 2003; Elley et al., NZMJ
2004, Dalziel et al., 2006)
 MD counseling on PA,
weight loss & fitness,
improves outcomes
 Pinto et al., AJPM, 2005; Huang et al., 2004; Petrella et
al., AJPM, 2003;

29. HSF Clinical Day – December 7, 2012
Petrella et al Am J Prev Med, 2007

31. Family Physicians, Sport Medicine
Physicians, Allied Health Professionals
• Key role in
promoting
and Px
physical
activity

33. www.csep.ca

36. Sponsors of the Exercise
Prescription Project

38. The Five A’s Model for PA Counseling
• Ask
• ASSESS
• ADVISE
• AGREE
• ASSIST
• ARRANGE
Whitlock et al., 2002; Goldstein et al., 2004; Fortier, Tulloch & Hogg 2006

39. Ask
Brief
Comprehensive
30 seconds
2-4 min
10-20 minutes
Counseling Opportunities

40. Assess - Exercise Vital Sign
 “There is no better indicator
of a person's health and
likely longevity than the
min/week of activity they
engage in”
 Sallis, Br J Sports Med, 2011
 Are you achieving 150
minutes?
 2 questions, 1 minute
 How many times per week
MVPA?
 For how long each time?

42. • Determine patient’s current level of activity
– Compare to Canada’s PA guidelines
• Willingness to exercise (i.e. ‘readiness’)
• Helpful step to create a prescription or
referral to qualified exercise professional
ASK
EVERY PATIENT
EVERY TIME

44. How can you determine if patient is fit to exercise
independently?
Pre-Exercise Screening

46. Overcoming Barriers; Reframing FEAR
 Most people are at greater risk from sedentary
behaviour than from exercise.
 Aerobic Ex CV complication rate ~ 1/100,000 hours (ACSM & AHA, 2007)
 Resistance Ex injury rate <3 / 1,000 hours (Parkkari, 2006) (walking ~0.2)
 Be aware of the short-term and long-term
complications of disease.
 E.g diabetes : SMBG can be informative
 If on insulin (or secretagogues), have 15 gm glucose available
 Goals of pre-exercise screening:
 To identify problems that might make exercise-associated risks
outweigh the benefits.
 To expedite treatment of such problems.

47. You may get referrals for
clearance following a screening
questionnaire…

48. Bredin SSD et al; PAR-Q+ and ePARmed-X+. Can Fam Physician 2013; 59: 273-277
The safe zone for mild to moderate
intensity exercise

49. Pain and Discomfort
• Pain
– Typically sharp, localized, and stops activity
• Acute ‘Pain’- follow-up
• Chronic ‘Discomfort’ – Prefer & Refer
• Discomfort
– Normal, uncomfortable feeling felt during PA
or exercise that does not stop activity
– Necessary to work through for gains in fitness
– Decreases with time and improved fitness
• E.g. Arthritis large effect for exercise (increased
ROM & Strength)