Exercise: A vitally important prescription

Hechanova, Rachel L. MPAP, PA-C; Wegler, Jennifer L. MMSc, MA, PA-C; Forest, Christopher P. MSHS, DFAAPA, PA-C

Journal of the American Academy of Physician Assistants: April 2017 - Volume 30 - Issue 4 - p 17–22
doi: 10.1097/01.JAA.0000513344.52255.cc
CME: Primary Care

ABSTRACT: Sedentary lifestyles and low physical activity have led to rising health concerns and increasing mortality risks. With the growing concern of the inactivity of adult Americans, it is important that physical activity be promoted to prevent disease and reduce health risks. This article reviews the benefits of physical activity and the steps that primary care providers should take to evaluate physical activity as the fifth vital sign in every patient encounter. The 5A's (assess, advise, agree, assist, and arrange) should be applied in order to implement an exercise prescription into the practice of medicine.

Rachel L. Hechanova practices emergency medicine in several hospitals in Los Angeles County, as well as in Goleta Valley, Calif. Jennifer L. Wegler practices orthopedics at the Kootenai Medical Center in Coeur D'Alene, Idaho. She previously was a clinical instructor of family medicine in the PA program at the University of Southern California (USC) in Alhambra, Calif. Christopher P. Forest is an assistant professor of clinical family medicine at USC's Keck School of Medicine and practices urgent care and family medicine in Los Angeles, Calif. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa.org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of April 2017.

Article Outline

Sedentary lifestyles have become the practice of Americans, despite the evidence and heightened public awareness of the importance of regular exercise.1 Many people do not realize that exercise, or physical activity, is imperative in not only enhancing well-being and health but also in preventing disease.2 This beneficial relationship between exercise and health is seen in the writings of Hippocrates in the 5th century BC: “Eating alone will not keep a man well; he must also take exercise. For food and exercise ... work together to produce health.”3

Physical inactivity, low cardiorespiratory fitness, and prolonged sedentary periods are a growing health concern and contribute to increasing mortality risk. According to the World Health Organization (WHO), physical inactivity is the fourth leading risk factor for mortality worldwide, placing patients at risk for developing noncommunicable diseases such as cardiovascular diseases, cancer, and diabetes.4 Physical inactivity is a growing public burden, causing hidden and growing medical care costs and loss of productivity, and contributing to a mortality as high as from tobacco smoking.5 More than 60% of American adults are not active on a regular basis (that is, did not engage in at least 150 minutes per week of moderate-intensity aerobic physical activity), and 25% of adults are completely sedentary.6,7 With these grim statistics, patients must implement exercise and physical activity into daily living to prevent disease and reduce health risks.

Healthcare providers are in a position to evaluate and counsel patients on the degree of exercise appropriate for their specific level of health.1 An appropriate exercise prescription can be generated based on the patient's health profile. Providers should approach patients with chronic diseases, such as cardiovascular disease, pulmonary disease, and advanced type 2 diabetes with caution and be aware that in some patients, such as those with class IV heart failure, exercise is contraindicated.8,9 Providing individualized exercise prescriptions can greatly improve patients' cardiovascular fitness and protect them from the development of and progression to chronic disease.10 The goal of an exercise prescription is to change patient behavior from sedentary to active. This can be done through a series of five steps centered on the concept that exercise is medicine and a vital sign.

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EXERCISE IS MEDICINE

Knowledge of the tremendous clinical benefits of exercise should not be denied to any patient, especially patients at risk for or with chronic diseases. In fact, physical activity should be considered part of the management plan for every patient unless exercise has been deemed unsafe for them due to a serious underlying condition. For patients at risk for chronic diseases, physical activity could be considered a vaccine that greatly lowers the risk of disease and improves quality of life.2 More emphasis should be placed by healthcare providers on implementing physical activity as a therapy for prevention and treatment, rather than the countless drug therapies that overwhelm patients' bathroom cabinets. Unfortunately, the healthcare system focuses on procedures and pharmaceuticals, while seemingly ignoring prevention and treatment through physical activity.11 Although much of the medical care in the United States is focused on treatment of chronic disease, the unhealthful behaviors that contribute to disease states are not adequately addressed. As healthcare evolves into a system that both demands and rewards preventive care, the focus on exercise should increase accordingly.

In 2008, the American College of Sports Medicine (ACSM) created the Exercise is Medicine (EIM) initiative to encourage primary care providers to include exercise when designing treatment plans for patients.12 The vision of EIM is to make physical activity a standard in global disease prevention and the medical treatment paradigm. Under the leadership of former ACSM president Robert Sallis, MD, this initiative has successfully highlighted the critical role that healthcare providers play in promoting the importance of exercise. An action guide was developed by EIM to help providers prescribe physical activity, a highly effective “drug” in the right dosage. Ultimately, if exercise as medicine can be integrated into patient management at all levels of healthcare, evaluating each patient's physical activity and writing an appropriate prescription for exercise will become a standard for patient care.13

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THE BENEFITS OF EXERCISE

The numerous benefits of physical activity have been found to far outweigh any possible adverse outcomes, such as potential injuries and overuse syndromes, and patients can significantly reduce their mortality risk by meeting recommended physical activity goals.2 Because low physical fitness is an important risk factor in men and women for all-cause mortality, regular exercise can decrease mortality.14

When counseling patients, describe the short-term and long-term benefits of exercise. Short-term benefits include improved cognitive ability, reduced anxiety, and a positive sense of well-being. Long-term benefits include reduced stroke risk, delayed onset of diabetes in high-risk populations, and reduced risk of colon cancer.15-17 According to the CDC, the benefits of physical activity include weight control; reducing the risk of cardiovascular disease, type 2 diabetes, metabolic syndrome, and some cancers; strengthening bone and muscle; improving mental health and mood; preventing falls in older adults and improving their ability to perform activities of daily living; and increased longevity. Studies of patients who had exercise prescriptions have found that regular physical activity can increase longevity, promote health, and be instrumental in the prevention and treatment of many chronic diseases.18 Regular exercise also can help patients succeed in overcoming harmful behaviors such as smoking.19

A related, and often unaddressed, major concern in the United States is obesity and its associated risk factors.20 According to the WHO, 39% of the adult global population is overweight and 13% is obese.21 With 34.9% of adults in America overweight or obese, obesity is a major risk factor for many cardiovascular diseases.22 As a result of this major public health concern, the American Heart Association (AHA) recommends that patients who are overweight or obese lose weight to reduce the severity of cardiovascular risk factors. A weight loss of 5% or more of baseline body weight is most effective in reducing the risk of cardiovascular disease and type 2 diabetes.10 Healthcare providers should encourage patients' attempts at safe weight reduction by encouraging lifestyle changes targeted at healthful eating and exercise.

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GUIDELINES ON EXERCISE

Health benefits can be gained from any amount of physical exercise, so some activity is better than none. Although there is no gold standard in guidelines for exercise, the question remains of how much exercise is actually enough. The universal suggestion by medical authorities is 150 minutes per week of moderate-intensity aerobic exercise to achieve health benefits.2 The ACSM, AHA, and American Diabetes Association (ADA) also provide variations of this recommendation.

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US Department of Health and Human Services (HHS)

The 2008 physical activity guidelines for Americans, issued by HHS, provide science-based guidance to improve health through appropriate physical activity for Americans age 6 years and older. Regular physical activity can produce long-term health benefits; therefore, these guidelines advocate that the risk of adverse health outcomes can be reduced through at least 150 minutes per week of moderate-intensity physical activity including aerobic and muscle-strengthening exercises.2 The guidelines include outlines for children, adolescents, adults, older adults, pregnant and postpartum women, and adults with disabilities and chronic medical conditions. The overarching theme to these guidelines is that some physical activity is better than none, and that avoiding inactivity is important. Although this concept is clearly defined, only 21% of adults in America meet the 2008 physical activity guidelines.23

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American College of Sports Medicine

The ACSM, the largest sports medicine and exercise science organization in the world, not only focuses on aerobic exercise, but also makes recommendations about resistance, flexibility, and neuromotor exercise to increase health benefits.

To meet the universal recommendations of 150 minutes of aerobic or cardiorespiratory exercise, adults can engage in 30 to 60 minutes of moderate-intensity exercise 5 days per week or 20 to 60 minutes of vigorous-intensity exercise 3 days per week.24 Resistance exercises, such as squats, push-ups, or pull-ups, improve strength and power and should be performed 2 to 3 days per week. To improve range of motion, patients should engage in flexibility exercise, such as static or dynamic stretching, at least 2 or 3 days per week. Older adults can improve physical function and prevent falls through 2 to 3 days per week of neuromotor exercise (such as tai chi or yoga) or functional fitness training that focuses on balance, agility, coordination, and gait.24

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American Heart Association

The AHA defines physical activity as “anything that makes you move your body and burn calories.”25 For overall cardiovascular health, the AHA recommends at least 30 minutes of moderate-intensity aerobic activity 5 days per week or at least 25 minutes of vigorous aerobic activity 3 days per week. For additional health benefits, the AHA suggests at least 2 days per week of moderate- to high-intensity muscle-strengthening activity. For lowering BP and cholesterol, AHA recommends an average of 40 minutes of moderate- to vigorous-intensity aerobic activity three or four times per week.25

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American Diabetes Association

The ADA recommends two types of physical activity for managing diabetes: aerobic exercise and strength training.26 By targeting a total of 150 minutes per week of aerobic exercise, patients can reduce their risk for heart disease by lowering blood glucose and BP, as well as improving cholesterol levels. If finding time to exercise is an issue, the ADA suggests that instead of a 30-minute period of exercise, patients do multiple shorter sessions of at least 10 minutes. Strength training or resistance training also is advised at least twice per week in addition to aerobic activity. Benefits of strength training include increasing sensitivity to insulin, lowering BP, and maintaining and building strong muscles and bones.26

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EXERCISE AS A VITAL SIGN

Physical activity and health have a positive relationship central to the intervention that primary care providers can put into practice. Part of the vision of EIM includes the initiative for all healthcare providers to consider physical activity as a modifiable vital sign in every patient visit. By assessing a patient's baseline physical activity and monitoring it at every visit, providers can counsel and make referrals according to each patient's health needs. This will lead to the overall improvement in public health, ultimately leading to a long-term reduction in healthcare costs.27

Every healthcare provider should obtain an exercise vital sign for each patient, evaluating the patient's level of physical activity along with pulse, BP, respirations, and temperature. Ask the patient these two questions:

* On average, how many days per week do you engage in moderate or greater physical activity?

* On those days, how many minutes do you engage in activity at this level?28

By asking these simple questions, primary care providers can address their patients' exercise habits and promote behavior change against inactivity.

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STEPS TO PRESCRIBING EXERCISE

To implement exercise prescription into practice, apply the 5A's—assess, advise, agree, assist, and arrange—to structure a lifestyle discussion when evaluating physical activity during a patient encounter.29 By following these steps, providers and patients can construct a climate of cooperation that opens the door to behavioral change.

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Step 1: Assess

First, assess the patient's current physical activity level and inclination to change. Both of these components are important to establish the patient's behavior. Determine the patient's amount of physical activity and amount of time spent in sedentary pursuits. Also assess whether the patient is willing to start an exercise program or increase their current level of activity. A key clinical concern is how providers can help patients see that they need to make changes to improve their health. Prochaska and DiClemente's transtheoretical model of change is a useful tool to help providers recognize patient readiness to change. The transtheoretical model embodies the five stages of change: precontemplation, contemplation, preparation, action, and maintenance.30 By effectively evaluating patient readiness, providers can develop the appropriate interventions to promote health behavior modifications.

To address patient ambivalence toward change, use motivational interviewing. By asking what importance a patient places on physical activity, providers should explore how willing the patient is to change. Evoking transformation should be the goal of this process by emphasizing that change is a personal choice and showing support for the patient to engage in regular physical activity.

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Step 2: Advise

Tell patients about interventions that are targeted to their readiness for change. Discuss the risks and benefits and let patients consider the information about their need for exercise and the options presented to them. Risk stratification, which assesses the patient's age, sex, body mass index, disease history, activity experience, and disabilities, as described in Step 1, is essential before the actual prescription for exercise is given.2 The Physical Activity Readiness Questionnaire Form (PAR-Q) can be used as a risk stratification aid (Figure 1).31 Patients who answer “No” to all seven PAR-Q questions can generally adopt a vigorous exercise program without supervision at any intensity. Those who answer “Yes” to any PAR-Q question may need preparticipation exercise testing and professional or clinical supervision during exercise.

For patients who need further workup, assess cardiovascular, pulmonary, and metabolic function. Patients who may have any of these diseases are considered high risk according to the ACSM guidelines for exercise testing and prescription and should be referred for further testing to help determine a safe intensity of activity.8 Further testing may include clearance from either a cardiologist or pulmonologist through pulmonary function tests, ECGs, echocardiograms, exercise treadmill tests, or cardiac catheterization. Patients with severe heart problems may need cardiac monitoring and referral for a cardiac rehabilitation program before an exercise prescription can be written.32 For patients without known cardiovascular, pulmonary, or metabolic disease, evaluate their risk factors for coronary heart disease. Having risk factors such as a family history of coronary heart disease, sedentary lifestyle, obesity, hypertension, or hyperlipidemia may be indication for further testing before exercise at any intensity.

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Step 3: Agree

Once patients are willing and ready to start an exercise program, they agree to a partnership with the provider that centers on realistic goals and activities. Overly optimistic expectations may result in disappointment and attrition; therefore, appropriate interventions must be made to ensure realistic expectations.

Patients must understand that physical activity is a process-focused treatment versus an outcome-focused treatment.33 The process of increasing physical activity is the drive to behavioral change. A major component of patients' agreement is the understanding of their health status and the direct effect of physical activity on current diseases and prevention. If patients have a full understanding of the importance of behavioral change toward physical activity, they will more readily form a partnership with their provider.

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Step 4: Assist

In this phase, patients are provided with various techniques to increase motivation and self-confidence. The goal is for patients to find social support and communities that can provide inspiration. Setting up a buddy system, making contracts with others to promote accountability to complete specific levels of physical activity, or setting up exercise groups for support are just a few examples. A dynamic and systematic relationship must be established between the patient and the provider to commit to achieving goals as a team.34

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Step 5: Arrange

Providers should arrange to follow up with patients, provide ongoing assistance and support, and refer patients to specialists as needed. Refer patients with disabilities or those who struggle to be active to a fitness professional or physical therapist. Exercise professionals can help patients start and maintain an effective exercise program. The significance of a relationship between the fitness industry and healthcare providers is paramount when using a team approach to help patients reach their physical activity goals.

Follow-up is crucial to identify patient progress and possible setbacks and to determine if the dose of exercise needs to be adjusted or the goals modified. Just as a provider would not prescribe a new dose of an antihypertensive without scheduling a follow-up visit to evaluate its effectiveness, exercise should not be prescribed without a formal follow-up to chart progress and solve problems.

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WRITING THE EXERCISE PRESCRIPTION

The plan created by patient and provider should be a written prescription for physical activity. The appropriate exercise prescription should be chosen carefully for each patient with the goal of meeting the ACSM guidelines of 150 minutes of moderate-intensity exercise per week through a plan that can regularly be completed.2 Time must be allowed for patients to gradually increase physical activity for the ultimate goal. Therefore, for optimum adherence and least injury risk, allow for a gradual progression of exercise time, frequency, and intensity when writing the prescription. With each visit, evaluate patients on the previous exercise dose and make adjustments, ultimately increasing physical activity to at least the recommended 150 minutes per week.

The prescription should specify:

* the type of physical activity suitable for the individual patient

* the dose, which can be measured by the intensity and duration of each activity session and the frequency (the number of times per week and minutes per day).29

Include referrals to a fitness professional if needed, along with follow-up information that secures an ongoing relationship between provider and patient. For exercise as medicine to be integrated in patient treatment, physically writing out a prescription is vital to provide a set guideline that the patient can easily follow, as well as to provide accountability to promote behavioral change.

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CONCLUSION

The importance of exercise is seen through its many health benefits, including improving quality of life and preventing disease. Because inactivity should be viewed as abnormal, patients with low cardiorespiratory fitness and prolonged sedentary times should be considered at high risk for disease. Stressing the harm of inactivity and the importance of physical activity should be a priority for primary care providers. Even more importantly, patients should be counseled to understand that exercise is medicine. With the exception of patients for whom exercise is contraindicated or patients who need further testing, providers should prescribe exercise to every patient. At each patient visit, providers have an opportunity to evaluate exercise as one of the vital signs. Through providing a written exercise prescription, providers can develop an individualized guideline to improve their patients' health. With the goal of disease prevention and health enhancement, primary care providers need to focus more on the role of exercise and how they can implement its prescription into practice.

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REFERENCES

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Keywords:

exercise prescription; sedentary; physical activity; cardiorespiratory fitness; fifth vital sign; 5A's

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