Prescribing Exercise

The World Heath Organisation cites the leading cause of global mortality as high blood pressure (13% of total deaths), tobacco use (9%), high blood glucose (6%), physical inactivity (6%) and obesity (5%). Physically inactivity is 4th on the 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 association for physical activity

Advice on physical activity in primary care is a pillar of the WHOs global activity plan.

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 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: http://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.

A recent editorial in the British Medical Journal emphasised that the written 'green' prescription (which compromises exercise and lifestyle goals) is a crucial element to signal the importance of exercise in health when people have chronic diseases. The Swedish book also takes a very medical view on something that many would regard as a normal and optional activity. Do we need to prescribe exercise? Well if we do - certainly one prescription does not fit all, a useful tip in the Swedish book is to categories the prescription according to the 4 levels of patient frailty.

Kidney disease figures prominently in the Swedish monograph. It has its own chapter and is also covered extensively in the diabetes and hypertension sections. Muscle fatigue is the most restrictive factor for the majority of kidney patients. Hence exercise should initially emphasise muscle strengthening and endurance training plus balance and coordination to be complimented with fitness training at a later stage. There are some sensible tips including ways to reduce the risk of tendinitis and specimen programmes of activity to follow. The final section of the kidney chapter deals with risks. To date, no patient has had a serious incident during or after exercise. And yet the authors suggest all patients with chronic kidney disease should be seen by a physiotherapist and all exercise should be carried out in accordance with the guidelines, under the supervision of a specialist physiotherapist and on the recommendations of a doctor. Are we at risk of turning something that should be a normal and enjoyable activity of daily living into something akin to 'school games'? Not that I am against school games at all - indeed, going right up stream we need more - although I was a little bit irritated shall I say, when my school forbade football and we were only allowed to play rugby in the winter months!

Medicalisation of normal activities of living has its risks. In the UK there is a GP referral scheme to personal trainers who require higher level qualifications. To help get people with medical conditions back exercising. Unfortunately kidney disease isn't covered and therefore I understand personal trainers aren't covered by their insurance to work with renal patients. The result is that Gym's and personal trainers often won't except kidney patients! By contrast, a range of other conditions including cardiovascular disease, chronic lung disease and stroke have level four courses, which means gym and leisure centres can run classes specifically for those conditions and personal trainers can work with individuals at home or in groups, which ever suits them.

Maybe with the Olympics coming up and the growing body of evidence to support the positive role of exercise we should be upping our game. In kidney services the support to exercise for people with CKD or on dialysis is, to be kind, patchy. Maybe we do need to prescribe exercise. Linking with the physiotherapists might provide the stimulus to design a system that offers exercise to every suitable patient with kidney disease. Our scarce physiotherapy resources may be better employed developing the systems and strategy and answering research questions rather than supervising every single patient. Who benefits from direct hands on support is an urgent research question.