Exercise Promotion in Primary Care

Abstract

Physical activity levels have been decreasing significantly for at least 50 years as advances in technology have allowed our lives to become more sedentary. Physical inactivity is a known risk factor for many diseases and regular exercise is known to have significant benefits. Promotion of physical activity by doctors can be limited, often by time and lack of knowledge. Additionally, practitioners' own participation has a significant effect on both exercise promotion and ability to provide a credible role model.

The GP curriculum and exercise promotion

The importance of exercise promotion is addressed within four statements of the GP curriculum:

Curriculum statement 5: Healthy people—promoting health and preventing disease includes the need for the GP to be aware of the risk factors for disease including exercise and the role of health promotion programmes.

Curriculum statement 8: Care of children and young people requires GPs to understand the importance of diet and exercise in young patients.

Curriculum statement 9: Care of older adults requires that GPs:

Ensure that personal opinions regarding risk factors for cardiovascular problems (e.g. smoking, obesity, exercise, alcohol, age, race) do not influence management decisions

Understand the physical factors, particularly diet, exercise, temperature and sleep, that affect the health of older people

Curriculum statement 15 includes several requirements for GPs within its sub-statements:

15.1 and 15.6: Cardiovascular disease and metabolic problems stipulate that GPs should be able to manage risk factors for cardiovascular disease and diabetes and give appropriate health promotion advice, including information about exercise. GPs should be able to negotiate a programme of weight reduction sensitively with patients.

Curriculum statement 15.9: Rheumatology, musculoskeletal and trauma requires GPs to be able to advise patients regarding appropriate levels of exercise and facilitate self-help strategies to empower the patient

Benefits of physical activity

Increasing individual participation in physical activity is the first priority in the 2009 Chief Medical Officer's Report. The physiological and metabolic consequences of physical activity are significant with lack of exercise being a risk factor for a wide range of diseases (Department of Health, 2004). These diseases cause substantial individual suffering making the promotion of physical activity extremely important. Economically, physical inactivity is thought to cost the National Health Service (NHS) £8.2 billion per year (Health Survey for England, 2008). Table 1 and Box 1 highlight the diseases for which there is evidence for the benefits of physical activity in either prevention or management.

Table 1.

Benefit of physical activity in the management of chronic conditions

Condition	Benefit
Osteoarthritis	Decreased pain Increased physical function
Rheumatoid arthritis	Increased aerobic capacity Increased muscle strength
Ankylosing spondylitis	Increase in spinal mobility
Chronic low back pain	Improvement in pain
Fibromyalgia	Increased physical function Increased global well-being Improvement in pain
Coronary heart disease	Decreased all-cause and cardiac mortality
Heart failure	Physiological benefit
Intermittent claudication	Increase in walking time and distance
Stroke	Improved walking time and distance
Hypertension	Lowering of blood pressure
Cholesterol	Increased high-density lipoprotein (HDL) cholesterol and decrease in triglycerides
Type 2 diabetes	Decreased glycosylated haemoglobin (HbA1c) Reduction in low-density lipoprotein (LDL) cholesterol
Asthma	Increase in cardiorespiratory fitness
Chronic obstructive pulmonary disease (COPD)	Increase in exercise ability Decrease in shortness of breath
Parkinson's disease	Improved physical functioning Improved quality of life Improved balance and walking ability
Multiple sclerosis	Improved muscle power Increased exercise tolerance
Elderly with cognitive impairment/dementia	Improved cardiovascular fitness, strength, flexibility Improved functional, cognitive and behavioural outcomes
Depression	Reduced symptoms
Chronic fatigue	Decreased fatigue Increased physical functioning
Cancer	Improvement in cancer-related fatigue

Source: Kujala (2009).

Box 1.

Conditions in which physical activity can play a preventative role

Coronary heart disease

Stroke

Obesity

Type 2 diabetes

Osteoporosis

Back pain

Depression

Mental function

Colonic cancer

Breast cancer

Lung cancer

Endometrial cancer

Source: Department of Health (2004).

Exercise brings benefits throughout a lifetime by reducing risk factors and obesity, increasing bone mass and mental well being in children and preventing diseases and obesity in adults. Adults who take recommended levels of exercise are at 20–30% lower risk of premature death and up to 50% less likely to develop major chronic diseases such as stroke, diabetes, some cancers and coronary heart disease.

Physical inactivity is estimated to cause 22% of ischaemic heart disease globally (World Health Organization, 2002). Consequently, increased physical activity is part of the National Service Framework for Coronary Heart Disease as both a preventative and a rehabilitation measure. Obtaining cardiovascular fitness could have more effect than stopping smoking, a healthy diet or decreasing blood pressure in those at cardiovascular risk (Blair, 2009).

Throughout life, moderate physical activity can help the immune system and exercise can increase social inclusion and improve self-confidence. In older adults, maintenance of fitness can help to prevent osteoporosis, depression and circulatory disease, all important factors for maintaining independence. Physical activities that promote strength, balance and coordination are important for preventing falls.

Recommended levels of activity

The British Association for Sport and Exercise Sciences (BASES) has recently published new guidelines for recommended levels of activity that take into account current levels of activity. These are summarized in Box 2. It is important to remember that this is a minimum and that the more that people exercise, in terms of duration, frequency and intensity, the more that they may benefit.

Box 2.

Guidelines for physical activity

Children and adolescents aged 5–16 years should accumulate at least 60 minutes of moderate-to-vigorous intensity activity per day, including vigorous-intensity aerobic activities that improve bone density and muscle strength

All healthy adults should take part in at least 150 minutes of moderate-intensity aerobic activity each week or at least 75 minutes of vigorous-intensity aerobic activity each week or equivalent combinations of moderate- and vigorous-intensity aerobic activities. Weight training, circuit classes and other resistance exercises are a complement to aerobic exercise, and it is recommended that all healthy adults perform 8–10 different exercises on two or more non-consecutive days each week. A resistance (weight) should be selected that brings about local muscular fatigue after 8–12 repetitions of each exercise

Beginners should steadily work towards meeting the physical activity levels recommended for all healthy adults

Conditioned individuals who have met the physical activity levels recommended for all healthy adults for at least 6 months may obtain additional health benefits by engaging in 300 minutes or more of moderate-intensity aerobic activity each week or 150 minutes or more of vigorous-intensity aerobic activity each week or equivalent combinations of moderate- and vigorous-intensity aerobic activities

Adults with increased risk of cardiovascular disease or type 2 diabetes may benefit in particular from going beyond the levels of activity recommended for all healthy adults and gradually progressing towards meeting the recommendations for conditioned individuals

Adults who find it difficult to maintain a normal weight may also need to meet the physical activity recommendations for conditioned individuals, reduce energy intake and minimize sedentary time to reduce the risk of overweight and obesity

O'Donovan, G., Blazevich, A., Boreham, C. et al. The ABC of physical activity for health: a consensus statement from the British Association of Sport and Exercise Sciences. Journal of Sports Sciences (2010). Reprinted with permission of the publisher (Taylor & Francis Group, www.informaworld.com).

How many of us exercise enough?

Although when asked, 39% of the UK population report that they meet the minimum requirements for exercise, when this is measured objectively using accelerometers, only 5% actually do (Health Survey for England, 2008). There is little geographical variation in the proportion who report that they meet minimum exercise requirements, but there are significant health inequalities in relation to physical activity as the prevalence of adequate participation varies significantly between ages, genders, ethnicity and socio-economic groups. For example, higher levels of exercise are reported among children and lower levels of exercise among the elderly (Fig. 1).

Figure 1.

Percentage of the population reaching the recommended levels of physical activity Scottish Active (2003).: Crown copyright material is reproduced under the terms of the Click-Use Licence.

Men participate in exercise more than women, and participation lessens among black and minority ethnic groups. Higher socio-economic groups exercise more than lower ones but this effect may be offset to some degree by the increased rate of manual jobs in lower socio-economic groups.

Encouraging patients to exercise more

It can be very hard to encourage patients to increase the amount of physical activity they undertake and patients can find numerous excuses to justify their lack of exercise. Patients are often of the opinion that physical activity means vigorous exercise such as running or competitive sport. Daily activities such as walking to work, housework and gardening can be taken into account.

It is important to discuss existing activity levels with the patient and the benefits of increased activity levels. Then find out their thoughts about increasing their physical activity. Table 2 describes how feelings towards physical activity can be fitted into Prochaska and Diclemente's transtheorethical model of behavioural change. Understanding the stage at which the patient is at is important and research has shown that people are more likely to participate in exercise if it is tailored to their stage of contemplation. However, most GPs are not trained in behavioural change techniques, thus limiting their effectiveness.

Table 2.

Stages of behavioural change related to physical activity

Stage of behavioural change	Characteristics	Needs	Appropriate initiatives
Stage 1	Is aware that inactivity and its consequences are a health problem	Information about the problem	National and local media, leaflets, posters, advice from GP
Stage 2	Personalizes the problem (I need to get more exercise)	Opportunities to personalize	Taster sessions, promotional events and campaigns, fitness testing
Stage 3	Balances the potential benefits of taking exercise against the costs (time, money, effect on others)	Opportunities for discussion	Discussions with an exercise or health professional, exercise counselling
Stage 4	Prepares to take action and then takes action	Knowledge of facilities or opportunities and prompts to take action	A variety of opportunities and events
Stage 5	Continues to be active or take part in exercise activities (or both)	Support to continue new actions	Clubs, support groups

Scottish Active 2003. Crown copyright material is reproduced under the terms of the Click-Use Licence.

The dangers of physical inactivity

So far, the discussion has been only about physical activity. It is important to realize that prolonged periods of inactivity, such as sitting, can themselves be a risk factor. It is likely that even if patients meet the guidelines for physical activity, if they spend the rest of the day in a state of inactivity the benefits will be lost. Therefore, it may be prudent to think of physical inactivity as a separate entity to physical activity and in the future advice may be tailored to addressing both aspects.

Interventions for increasing exercise participation

The London 2012 Olympic Games and 2014 Glasgow Commonwealth Games have been heralded as events which will leave a legacy of improved exercise participation throughout the country. The Olympic Committee's aim is to get 2 million more people participating in exercise. Therefore, interest in encouraging exercise participation has increased and a Cochrane review (Foster et al., 2005) has cautiously suggested that some interventions can have a positive, moderate-sized effect on self-reported physical activity and cardiorespiratory fitness. This review indicated that a mixture of professional guidance and self-direction plus on-going professional support can produce consistent results, at least in the short term, although there was no definite evidence for any specific intervention.

Recent National Institute for Health and Clinical Excellence (NICE) guidelines assessed interventions for increasing physical activity (NICE, 2006). They recommend giving brief advice and identifying and encouraging inactive adults to aim for the recommended ‘five-a-week’.

These patients can be identified using a validated tool such as the General Practice Physical Activity Questionnaire (GPPAQ) which can be downloaded from the Department of Health website. Patients may need to be counselled about changing their behaviour. Advice should be tailored to patients taking into account their needs and preferences. It is useful to set specific goals and review patients at regular intervals, for example, every 3 months. Written information should be provided.

The GP should know what exercise facilities are available in the local area, such as leisure centres or swimming pools, and suggest the use of these where suitable. Leaflets highlighting the benefits of exercise for specific groups can be given opportunistically to patients and are readily available from the British Heart Foundation and sportEX.

However, uptake of the GPPAQ has been slow with less than 0.01% of patients coded on GP computer systems. On a positive note, last year physical activity was incorporated into the Quality and Outcomes Framework (QOF) for the first time under ‘cardiovascular risk assessment and management’ which should increase advice given by GPs.

The Department of Health has acted upon the NICE guidance and recently published their ‘Lets Get Moving’ campaign and in Scotland, the Scottish government has instituted the ‘Active Nation’ campaign in association with the Commonwealth Games legacy. The former is a physical activity care pathway designed to screen patients for inactivity using GPPAQ, followed by patient-centred motivational interview if they do not reach the recommendations for physical activity. This highlights the benefits of exercise, works through key behavioural change steps and sets appropriate goals, taking into account locally available facilities. Exercise referrals can be incorporated into this pathway. The interviewer will have been given training in the pathway including motivational interviewing. The patients are then reviewed at regular time intervals. Figure 2 shows the ‘Let's Get Moving’ pathway. In England, a website, www.nhs.uk/change4life, has been developed to encourage people to live healthier lives by giving information on local activities.

Figure 2.

Schematic diagram of the ‘Let's Get Moving’ pathway.: Let's Get Moving. Commissioning Guidance A new physical activity care pathway for the NHS (2009).: Crown copyright material is reproduced under the terms of the Click-Use Licence.

Other interventions assessed in the guidelines include the use of pedometers and encouragement to use local walking and cycling schemes. However, NICE only endorses such schemes if they are part of research trials as there is still insufficient evidence for their effectiveness. Although the patient must take most of the responsibility for undertaking physical exercise, it is important that the GP counsels patients about exercise plans and makes sure that they increase their physical activity in a sensible manner and are aware of the relevant risks.

Exercise referral schemes

A common intervention is that of exercise referral schemes which have become increasingly favoured in recent years. Over 600 such schemes exist throughout the UK. There is insufficient evidence to prove the effectiveness of exercise referral schemes for the general population so NICE does not recommend routine referral solely for increasing physical activity. However, exercise referral schemes should continue to be used in the management of specific diseases such as Type 2 diabetes, obesity and osteoporosis or to prevent specific disease, such as falls prevention.

An exercise referral scheme involves assessment of a patient by a health professional, usually a GP, and then referral onto a specialist service, such as a leisure centre, which is set up to tailor and monitor specific exercise programmes for the individual. Patients must give consent for referral as their medical information is shared with relevant exercise professionals. The Department of Health has produced specific guidance relating to exercise referral schemes.

Although there are likely to be local policies for referral, validated tools such as the physical activity readiness questionnaire (PAR-Q), which is also used by the fitness industry as a safety questionnaire, can be used as a screening tool. If patients answer ‘no’ to all the questions on the PAR-Q, they should be able to start exercising safely although they are advised to have their blood pressure checked. Patients over 69 years of age, with health concerns, or who are unused to physical activity are advised to see their GP first.

If health concerns are flagged up, this can be followed up with a physical activity readiness medical examination (PARmed-X). This tool filters patients who would benefit from a referral and gives special advice for patients with co-morbidities. The PARmed-X also highlights which diseases are absolutely and relatively contraindicated for exercise and when patients should be referred on to an exercise specialist for further tests or supervised programmes in hospital. A specific PARmed-X for pregnancy is available. Table 3 gives an indication of low-, medium- and high-risk patients depending on their physical illness.

Table 3.

Risk stratification criteria

Low risk

Overweight	No complications
High-normal blood pressure	(130–139/85–89 mmHg) not medication controlled
Deconditioned	Due to age or inactive lifestyle
Type 2 diabetes	Diet controlled
Aged over 65 years	No more than two coronary heart disease (CHD) risk factors and not risk of falls
Antenatal	No symptoms of pre-eclampsia/miscarriage
Post-natal	Six week check complete and no complications
Osteoarthritis	Mild—here physical activity will provide symptomatic relief
Exercise-induced asthma	No other symptoms
Stress/mild anxiety
Seropositive human immunodeficiency virus (HIV)	Asymptomatic

Medium risk

Hypertension stage 1	(140–159/90–99 mmHg). Medication controlled
Type 2 diabetes	Medication controlled
Type 1 diabetes	Instruction about exercise and insulin given
Physical disabilities	No other risk factors
Moderate osteoarthritis or rheumatoid arthritis	With intermittent mobility problems
Clinical diagnosis of osteoporosis	Bone mineral density −2.5 at spine, hip or forearm or greater than 4 on FRACTURE index. No history of low trauma fracture.
Surgery—pre and post	General or orthopaedic—not cardiac
Intermittent claudication	No symptoms of cardiac dysfunction
Stroke/transient ischaemic attack	Less than 1 year ago. Mobile. Cardiovascularly stable
Asthma	Mild
Chronic obstructive pulmonary disease (COPD)	Without ventilatory limitation
Neurological conditions	System mechanics and correction of physical deconditioning
Early symptomatic HIV	Moderately decreased CD4 count, intermittent or persistent symptoms and signs
Chronic fatigue symptoms	Significantly deconditioned due to symptoms
Depression	Mild or moderate
Fibromyalgia	Impaired functional ability, poor physical fitness

High risk

Older people at risk of falls	Refer directly to the falls service
Frail older people with osteoporosis and fractures	Refer directly to the falls service
Unstable or uncontrolled cardiac disease
Claudication with cardiac dysfunction
Orthostatic hypotension	Fall in systolic blood pressure of greater than 20 mmHg
Stroke/transient ischaemic attack	Recent (within 3 months)
Severe osteoarthritis or rheumatoid arthritis	With associated immobility
Type 1 and type 2 diabetes	With neuropathy, advanced retinopathy
Moderate to severe asthma	Ventilatory impairment
Chronic obstructive pulmonary disease/emphysema	Ventilatory impairment
Acquired immune deficiency syndrome (AIDS)	With neuromuscular complications, severe depletion of CD4 cells malignancy or infection
Psychiatric illness/cognitive impairment/dementia	Abbreviated mental test score of less than 8

Reproduced from Developing a risk tool for GP exercise referral, sportEX health, issue 12 (2003) with permission from Centor Publishing Ltd.

Low-risk patients are considered those with minor, stable physical limitations or two or fewer of the chronic heart disease risk factors mentioned in Table 4. These patients are suitable for exercise referral. Medium-risk patients have significant physical limitations related to chronic disease or disability; however, they too can be referred. High-risk patients are not suitable for exercise referral. Most patients with cardiac disorders are more suitable for cardiac rehabilitation than exercise referral. If the GP has any concerns about the referral, he or she should either contact the specialist who looks after the patient at a secondary care level for advice or refer on to an exercise specialist if there is one available in the area.

Table 4.

Coronary heart disease risk factors

Family history	Older than 55 years male or 65 years female
Cigarette smoking	Current or given up within past 6 months
Hypertension	Blood pressure greater than 140/90 mmHg
Hypercholesterolaemia	Total cholesterol greater than 5.2, high-density lipoprotein cholesterol less than 0.9 or low-density lipoprotein cholesterol greater than 3.4
Sedentary lifestyle	Not meeting minimum recommendations
Obesity	Body mass index greater than 30 kg/m² or waist girth greater than 100 cm
Impaired fasting glucose	Greater than 6.1 mmol/l

Reproduced from Developing a risk tool for GP exercise referral, sportEX health, issue 12 (2003) with permission from Centor Publishing Ltd.

With the recent recognition of Sport and Exercise Medicine as a specialty and the introduction of registrar training schemes in the UK, exercise referral is an area that may be supervised by future consultants in this specialty. This would be achieved through a multidisciplinary team approach involving advanced nurses, physiotherapists, dieticians and podiatrists. Currently, there are few consultants practising Sport and Exercise Medicine within the NHS; however, it is hoped that this will change in the near future with the creation of new posts.

At the current time, once patients have been referred to an exercise scheme, they will be assessed by an exercise professional who will have undertaken specific training and should be registered with a professional body, such as the Register of Exercise Professionals. This professional will then be responsible for designing, implementing and monitoring the patient's exercise progress. The exercise professional should report back to the referrer to maintain good communication links. From a medico-legal perspective, it is important to ensure that the patient is assessed by someone with correct training as the GP has a ‘duty of care’, similar to referral to any other healthcare professional.

Children and adolescents

The Department of Health recommends that children should aim to participate in at least 1 hour of physical activity per day. However, the vast majority are not achieving this. Physical activity is especially important in children as it helps with healthy growth of the musculoskeletal and cardiovascular systems, weight maintenance, avoidance of risk factors, good psychological well being and social inclusion. Both girls and boys, at average ages of 12 and 14, respectively, rapidly increase their bone mineral density and activities that physically stress the bones are very important for bone health.

Schools take the majority of the responsibility for encouraging children to exercise, but patients with co-morbidities such as asthma should receive exercise promotion advice tailored to their specific condition, especially as the child reaches adolescence. It is especially important in obese children to encourage them to be more active. For example, there can be some reduction in body fat with interventions designed to reduce television watching time. Participation in sport and exercise is associated with increases in children's self-esteem and positive body image.

However, parents must take some responsibility for the activity levels of their children. Parental support is the most positive correlate to maintaining physical activity levels. This is followed by participation in sport, previous activity levels, male gender, enjoyment and positive body image. Negative correlations include age and smoking (British Heart Foundation, 2009). Interestingly, they found that out-of-school sedentary behaviour had little effect on physical activity.

The sharp drop in physical activity at age 12–13 years in girls is very significant and a specific time when exercise should be encouraged. Physical activity levels in children and adolescents sets the pattern for life and may help them to continue to exercise throughout their lives. Attitudes that have developed by the end of secondary school often continue into adulthood.

Elderly

Elderly patients are a particularly vulnerable group as major diseases have a greater incidence and impact. Quality of life is significant as cognitive dysfunction and disability become more common. Many of the causative diseases are preventable with physical activity playing a major role and age-related decline in physical activity does not have to be inevitable. Indeed, in some cultures, physical activity actually increases with age.

The elderly should be encouraged to be active and the British Heart Foundation publishes useful information about physical activity for older people. In addition, these patients should be given information about what facilities are available for them and when they should be referred on for specialist advice.

For older adults, it is important to participate in both aerobic and anaerobic exercise to maintain cardiovascular fitness and muscle strength as this can have positive effects on mobility, falls and independent living. Walking is a particularly good exercise as it is associated with increased strength and aerobic capacity and decreased functional limitation. Swimming provides cardiovascular benefits for people who cannot exercise in a weight-bearing manner (for example, those with arthritis or decreased mobility). Strength training maintains muscle mass and repetitive muscle exercise two or three times per week has been shown to be extremely effective. In addition, exercise training which combines strength and balance exercises can decrease the likelihood of falls significantly (Department of Health, 2004) and there is some evidence that Tai Chi can reduce falls by 47%.

Encouragement to participate in group exercise classes can be beneficial psychologically as a significant problem in the elderly is loneliness. Physical activity also reduces depression and anxiety—especially after a life-threatening event such as a heart attack or breast cancer diagnosis. Finally, there is some evidence that cognitive decline can be slowed down by physical activity especially if that activity has been continued throughout life.

Pregnant women

Physical activity during pregnancy is very important as excessive weight gain during pregnancy is known to result in obesity, which in turn is a risk factor for complications during pregnancy and childbirth. In addition, many common symptoms of pregnancy such as fatigue, swelling, insomnia and anxiety are reduced in those who exercise.

Guidance from the Royal College of Obstetrics and Gynaecology (RCOG) states that for most women, exercise is safe for both mother and foetus and should be encouraged. Patients can be advised that there is no increased adverse outcome in low-risk women who exercise during pregnancy. There is a PARmed-X form specifically for pregnancy that can be used for screening and also highlights contraindications and exercises to avoid. The patient should aim to maintain fitness rather than achieve peak fitness and training for events is not recommended. Exercises that minimize loss of balance and foetal trauma should be chosen. However, as shown in Table 5, there are changes in physiological function during pregnancy that the patient should be aware of when exercising.

Table 5.

Physiological changes during pregnancy that could affect physical activity

Change	Preventative strategy
Increased joint laxity and hypermobility	Avoid contact sports. Weight-bearing overseen by professional. Pelvic support belts.
Increased core temperature increasing risk of hyperthermia	Good hydration. Avoid exercise in hot humid countries.
Increased risk of hypoglycaemia	Adequate calorific intake and limit sessions to 45 minutes
Vena cava compression	Avoid supine exercise
Circulatory changes	Avoid exercise at altitude greater than 2500 m for 4–5 days for acclimatization

Source: RCOG; 2006).

Nevertheless, there are pregnancy-related conditions where exercise is not recommended or requires medical supervision (Box 3). Women should also be advised that if they suffer any symptoms during exercise such as chest pain, dizziness or vaginal bleeding, they should stop exercising immediately and seek medical advice.

The patient's midwife is probably best placed to advise her on an appropriate exercise routine taking the patient's health status, current activity and goals into account. NICE guidelines on antenatal care state that most women without any obstetric or medical complications can safely begin or maintain a regular exercise regimen without causing harm to the foetus. As a rough guide, a sedentary expectant mother with an uncomplicated pregnancy could begin with 15 minutes exercise three times a week, increasing this to 30 minutes, four times a week if no problems are encountered.

Box 3.

Conditions requiring medical supervision for exercise in pregnancy

Cardiac disease

Restrictive lung disease

Persistent bleeding in the second and third trimesters

Pre-eclampsia or pregnancy-induced hypertension

Preterm labour (previous/present)

Intrauterine growth restriction

Cervical weakness/cerclage

Placenta praevia after 26 weeks

Preterm prelabour rupture of membranes

Heavy smoker (more than 20 cigarettes a day)

Orthopaedic limitations

Poorly controlled hypertension

Extremely sedentary lifestyle

Unevaluated maternal cardiac arrhythmia

Chronic bronchitis

Multiple gestation (individualized and medically supervised)

Poorly controlled thyroid disease

Morbid obesity (body mass index greater than 40 kg/m²)

Malnutrition or eating disorder

Poorly controlled diabetes mellitus

Poorly controlled seizures

Anaemia (haemoglobin less than 100 g/l).

Reproduced from: Royal College of Obstetricians and Gynaecologists. Statement No. 4: Exercise in Pregnancy. RCOG; 2006, with the permission of the Royal College of Obstetricians and Gynaecologists.

Scuba-diving should be avoided as the foetus is not protected against decompression sickness and gas embolisms. Caution should be given about the risks of falls, abdominal trauma and excessive joint stress in sports such as horse riding, downhill skiing, ice hockey, gymnastics, contact sports, racket sports and cycling. Elite athletes who wish to continue to train should be referred on for specialist care.

The RCOG recommend that if the pregnancy and delivery were uneventful, a programme of walking, gentle stretching and pelvic floor exercises can begin immediately postpartum, with no effect on breast milk or infant growth. However, if the pregnancy was complicated or delivery was by caesarean section, the patient should be seen and cleared for exercise at the 6–8 week check-up. All patients should be advised to return to exercise slowly and avoid high-impact activity too soon. Core stability and back exercises are particularity important to prevent back pain when returning to weight-bearing exercises.

Risks of exercise

Although for most people, the benefits of exercise greatly outweigh the risks, there are some groups who need to be more careful. Those at greatest risk are those who undertake significant vigorous exercise, change intensity of exercise suddenly, do excessive amounts of exercise or have existing musculoskeletal disease or other illness. It is therefore important that patients seek professional advice, increase exercise gradually, use common sense and allow the body time to recover and adapt.

Musculoskeletal problems

Sporting injuries do occur and are often determined by the sport itself. Risks that can be minimized are training too hard, poor technique, change in training, poor condition, exercising on hard surfaces, poor footwear or poor equipment.

As the vast majority of injuries are musculoskeletal, the risk can be minimized by encouraging low-intensity activities such as walking, where the injury rate is small. Patients should be advised to stop the activity if they develop new or worsening symptoms. Sports injuries, if relatively mild, can often be treated with early rehabilitation and a graded return to exercise with input from Sports Medicine specialists or physiotherapists as required. Caution should be maintained with head injuries and the Scottish Intercollegiate Guideline Network (SIGN) has published useful guidelines about returning to sport after a head injury.

Although there is some evidence that participation in sporting activities does increase the risk of degenerative bone changes in later life, this is maybe compensated to some degree by the increase in muscle mass and is not usually a good reason for giving up physical activity. However, there is a small increased risk of osteoarthritis in elite athletes who suffer significant injuries, but this is not seen in those who participate in moderate recreational activity such as walking, swimming and cycling, which could, in fact, protect against it. Table 6 summarizes the thresholds at which the risk of osteoarthritis is significantly increased.

Table 6.

Thresholds for increased risk of osteoarthritis

Type of activity	Risk
Three hours physical activity a day. Twenty miles running per week	Increased risk of knee and hip osteoarthritis
At work—2 hours walking, lifting or climbing stairs more than 10 times per week	Increased risk of all osteoarthritis
Significant housework	Increased risk of osteoarthritis in women

Source: Department of Health (2004).

Sudden death

A concern for many doctors who encourage physical activity is the risk of sudden death. The risk of sudden death is 1 death per 1.5 million exercise hours in middle-aged men (Albert et al., 2000). Thus, although the risk of sudden death is increased, this increase is extremely small. The risk is lower in younger patients and women. Although in many cases no cause is found for sudden death, it is likely that underlying congenital cardiac problems are responsible.

Following a number of high-profile fatalities, there is ongoing debate about whether cardiac screening should be compulsory, especially in elite athletes. Currently, medical and sporting bodies do recommend pre-participation screening for those aged less than 35 years for identification of potential fatal abnormalities as research from Italy has shown a reduction in the number of sudden cardiac deaths since screening became compulsory. However, this is yet to become compulsory in the UK and will remain the responsibility of the relevant sporting body.

The fitness of the patient prior to exercise is also important as those who are less fit are significantly more likely to suffer from sudden cardiac death than those who regularly undertake vigorous exercise. There is also some evidence that the risk of a heart attack is raised, although this again seems to be in those who do not regularly participate and already have high blood pressure. In patients where the doctor feels that exercise may be a risk due to pre-existing medical conditions, pre-exercise screening should involve a thorough physical examination, pulse and blood pressure measurement, serum glucose and cholesterol and if possible an electrocardiogram (ECG).

Environmental factors

Environmental factors can increase the risks of injury and patients should be advised about wearing high-visibility clothing, making sure the weather is suitable and an awareness of traffic and other hazards. Joggers, in particular, should be aware of their environment and women are advised not to jog alone in the dark or in poorly lit areas. Varying routes and time of day are other suggestions for improving personal safety.

Psychological risks

For small groups of the population, there are psychological risks associated with exercise. Patients who suffer severe injury can be absent from work for long periods and their mental state can suffer as a result. Some patients can develop an ‘addiction’ to exercise which can interfere with their everyday functioning as they put their exercise before relationships, exercise excessively and suffer withdrawal if they are unable to complete their planned activity. It is thought that this is most likely due to an underlying psychological disorder rather than a physiological phenomenon.

GPs should also be aware that excessive exercise can also be used by patients as a way to control weight in disorders such as anorexia and bulimia. Preoccupation with body shape is seen in some athletes especially where the body is displayed, such as gymnastics and swimming. Elite female athletes can suffer from the ‘female athlete triad’ of disordered eating, amenorrhoea and osteoporosis.

Other risks of exercise

Other, more general, risks of increasing exercise regimens include sunburn, dehydration, hyperthermia, hypothermia or heat stroke. Some activities such as swimming can increase risks of bacterial infections. At high levels of exercise, there can be a degree of immunosuppression leading to recurrent viral infections, some sports can cause haematological disturbance, such as haematuria, and intestinal disturbances have been reported in long-distance endurance athletes.

Summary

For the vast majority, the risk/benefit ratio of undertaking an exercise programme is low and the benefits of exercise are unequivocal. Taking time to counsel and encourage patients could pay significant dividends by improving the health of the general population and reducing the cost burden to the NHS from chronic disease management.

Key points

Adequate physical activity plays a significant role in the prevention, management and rehabilitation of many diverse illnesses

A GP must be able to assess a patient for the risks and benefits of increasing physical activity and address inequalities where appropriate

GPs should be aware of situations where physical activity is important, e.g. children, older adults, pregnancy

Patients should be aware of the risks involved in physical activity and minimize the likelihood of these where appropriate

It is important to be aware of local policies for promoting physical activity and the framework for exercise referral if appropriate

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