Promoting physical activity in primary care

Although it is widely recognised that physical activity is important for health, most of the population remains sedentary. Policy change has been proposed at several levels, including promotion of physical activity promotion in primary care.1 Exercise referral schemes are one method of doing this, and the linked systematic review by Pavey and colleagues (doi:10.1136/bmj.d6462) assesses their effectiveness.2

Primary care is well placed to promote physical activity for several reasons: in developed countries a large proportion of the general population consult their general practitioner every year; health promotion is an integral part of the primary care consultation; patients with chronic disease, such as diabetes, or risk factors, such as hypertension, are reviewed regularly; and simple screening questionnaires have been developed to record physical activity in primary care consultations.

A Cochrane systematic review of interventions promoting physical activity reported that they had a moderate effect on self reported physical activity and cardiorespiratory fitness in the short to medium term.3 However, the interventions included in this review were heterogeneous. They included individual or group counselling and advice, in addition to self directed or prescribed physical activity, which was supervised or unsupervised and based at home or in a healthcare or leisure facility. Which physical activity intervention is the most effective and cost effective for primary care? They can be broadly separated into advice or counselling and exercise referral.

Previous reviews of advice or counselling found that brief advice from a general practitioner that was supported by written materials had a moderate short term effect on physical activity, which lasted six to 12 months.4 Brief counselling that lasted three to 10 minutes was as effective as lengthier counselling.4 Greater short term improvements were found with interventions that considered participants’ readiness to exercise, baseline physical activity level, and physical activity preference.4 So brief exercise advice has a small effect on increasing physical activity, similar to advice to stop smoking.5 Such a small effect could be important if carried out on a large population of patients consulting their general practitioner. A systematic review of the cost effectiveness of physical activity interventions in primary care found that many were cost effective, particularly brief exercise advice delivered in person, by phone, or by mail.6

Exercise referral schemes consist of referral of sedentary adults by a primary care clinician to an exercise programme consisting of an initial assessment, a tailored programme of exercise, and regular monitoring and supervision by an exercise professional. Such programmes usually take place in public leisure centres or swimming pools, but they can also involve activities such as cycling, gardening, or walking. Pavey and colleagues’ systematic review of eight randomised controlled trials comparing exercise referral schemes with usual care found an increase in the number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week, with a pooled relative risk of 1.16 (95% confidence intervals 1.03 to 1.30).2 They found no consistent evidence of an increase in the amount of physical activity of moderate or vigorous intensity performed per week, or other outcomes such as physical fitness or health related quality of life, but they did find a reduction in the level of depression.2 These findings agree with previous systematic reviews that found a small but statistically significant increase in the number of people becoming active. The modest benefit in these reviews was partly explained by poor rates of uptake and adherence, with less than half of participants completing a full course of sessions.7

Exercise referral schemes not only target sedentary people at risk of developing disease, but also those with established disease such as asthma and diabetes. In this respect they have similarities with disease specific rehabilitation programmes in secondary care with a strong evidence base, such as cardiac and pulmonary rehabilitation.8 9 Patients are referred for cardiac rehabilitation after myocardial infarction or a revascularisation procedure; however, many with chronic obstructive pulmonary disease who would benefit from pulmonary rehabilitation are managed exclusively in primary care and are not routinely referred. Rehabilitation programmes have been designed for other chronic diseases,10 11 and it could be argued that all patients with any chronic disease should be referred. Because most stable chronic disease is managed in primary care it seems sensible that this rehabilitation should be coordinated from general practice. If so, it might be better to shift the focus from separate rehabilitation programmes for each disease to a unified programme that deals with individuals’ rehabilitation needs, using a suitable framework such as the World Health Organization’s International Classification of Functioning, Disability and Health (ICF).12

In conclusion, there is evidence that brief advice on physical activity, delivered in primary care, for sedentary people at risk of developing disease has a small beneficial effect. There is only limited evidence for exercise referral schemes for this at risk group, but there is increasing evidence that all patients with chronic disease should be referred to a rehabilitation programme which includes an exercise intervention.