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Can we do better at “prescribing” exercise in primary care?

A constant frustration of working in general practice is the difficulty of “prescribing” anything other than pharmaceuticals. No wonder we turn to the prescription pad so often. One example is exercise, which is a highly effective, but poorly used, treatment for a number of chronic conditions. Systematic reviews of randomized trials show: exercise (as the central element of pulmonary rehabilitation) for chronic obstructive airways disease leads to a 78% reduction in hospital admissions and 72% reduction in mortality[1]; a 26% reduction in cardiovascular mortality after myocardial infarction[2]; improved function and quality of life in patients with heart failure[3]; reduced fatigue in patients with cancer[4], multiple sclerosis[5] and chronic fatigue syndrome. Despite being as effective, or more effective, than pharmaceuticals for these conditions, exercise is often neglected as an element of treatment. This is partly from lack of clinician awareness, and partly from the greater difficulty in “prescribing”, monitoring and titrating exercise compared to drugs.

Despite these trials and reviews, the “how to” details are hard to find.

The published trials often omit crucial details: what type? how long?

how often? how and when to increment? With the RACGP, we are trying to overcome these barriers by developing a Handbook of Non-Drug Interventions. But given the importance of exercise as a treatment for many chronic illness, we are holding a 1-day conference in 2014. The day is aimed at summarizing the existing controlled trial evidence, sorting out the essential “how to” details, and considering the policy and behavioural barriers to more widespread “prescribing” of exercise. While exercise for the healthy but unfit has received much attention, we will focus on exercise for chronic illness where the greater gains are too be made.

 

References

1. Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD005305.

2. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease.  Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001800.

3. van der Meer S, Zwerink M, van Brussel M, van der Valk P, Wajon E, van der Palen J. Effect of outpatient exercise training programmes in patients with chronic heart failure: a systematic review. Eur J Prev Cardiol. 2012 Aug;19(4):795-803.

4. Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012 Nov 14;11:CD006145.

5. Motl RW, Gosney JL. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler. 2008 Jan;14(1):129-35.

6. Hoffmann TC, Erueti C, Glasziou PP. Poor description of non-pharmacological interventions: analysis of consecutive sample of randomised trials. BMJ. 2013 Sep 10;347:f3755