ABC of prescribing exercise as medicine: a narrative review of the experiences of general practitioners and patients

Andrew O'Regan, Michael Pollock, Saskia D'Sa, Vikram Niranjan, Andrew O'Regan, Michael Pollock, Saskia D'Sa, Vikram Niranjan

Abstract

Background: Exercise prescribing can help patients to overcome physical inactivity, but its use in general practice is limited. The purpose of this narrative review was to investigate contemporaneous experiences of general practitioners and patients with exercise prescribing.

Method: PubMed, Scopus, Science Direct and Cochrane reviews were reviewed using the terms 'exercise prescription', 'exercise prescribing', 'family practice', 'general practice', 'adults' and 'physical activity prescribing'.

Results: After screening by title, abstract and full paper, 23 studies were selected for inclusion. Qualitative, quantitative and mixed-methods studies revealed key experiences of general practitioners and patients. Barriers identified included: physician characteristics, patients' physical and psychosocial factors, systems and cultural failures, as well as ambiguity around exercise prescribing. We present a synthesis of the key strategies to overcome these using an ABC approach: A: assessment of physical activity: involves asking about physical activity, barriers and risks to undertaking an exercise prescription; B: brief intervention: advice, written prescription detailing frequency, intensity, timing and type of exercise; and C: continued support: providing ongoing monitoring, accountability and progression of the prescription. Multiple supports were identified: user-friendly resources, workshops for doctors, guidelines for specific illnesses and multimorbidity, electronic devices, health system support and collaboration with other healthcare and exercise professionals.

Discussion: This review has identified levers for facilitating exercise prescribing and adherence to it. The findings have been presented in an ABC format as a guide and support for general practitioners to prescribe exercise.

Keywords: exercise; medicine; physical activity; sports medicine.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
The ABC (assessment, brief intervention and continued support) approach to exercise prescribing.

References

    1. Tipton CM. The history of "Exercise Is Medicine" in ancient civilizations. Adv Physiol Educ 2014;38:109–17. 10.1152/advan.00136.2013
    1. Thornton JS, Frémont P, Khan K, et al. . Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of sport and exercise medicine. Br J Sports Med 2016;50:1109–14. 10.1136/bjsports-2016-096291
    1. Pratt M, Norris J, Lobelo F, et al. . The cost of physical inactivity: moving into the 21st century. Br J Sports Med 2014;48:171–3. 10.1136/bjsports-2012-091810
    1. Kohl HW, Craig CL, Lambert EV, et al. . The pandemic of physical inactivity: global action for public health. Lancet 2012;380:294–305. 10.1016/S0140-6736(12)60898-8
    1. GBD 2015 Risk Factors Collaborators . Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1659–724. 10.1016/S0140-6736(16)31679-8
    1. Anderson LH, Martinson BC, Crain AL, et al. . Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis 2005;2:A09.
    1. Ding D, Lawson KD, Kolbe-Alexander TL, et al. . The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016;388:1311–24. 10.1016/S0140-6736(16)30383-X
    1. Lindsley CW. 2013 statistics for global prescription medications: CNS therapeutics maintain a leading position among small molecule therapeutics. ACS Publications, 2014.
    1. Ferriolli E, Pessanha F, Marchesi J. Diabetes and exercise in the elderly. Diabetes and Physical Activity: Karger Publishers, 2014: 122–9.
    1. Piercy KL, Troiano RP, Ballard RM, et al. . The physical activity guidelines for Americans. JAMA 2018;320:2020–8. 10.1001/jama.2018.14854
    1. Ding D, Mutrie N, Bauman A, et al. . Physical activity guidelines 2020: comprehensive and inclusive recommendations to activate populations. Lancet 2020;396:1780–2. 10.1016/S0140-6736(20)32229-7
    1. Eley DS, Brooks KD, Zink T, et al. . Personality profiles of rural longitudinal integrated clerkship students who choose family medicine. Fam Med 2015;47:194–203.
    1. Sallis RE, Matuszak JM, Baggish AL, et al. . Call to action on making physical activity assessment and prescription a medical standard of care. Curr Sports Med Rep 2016;15:207–14. 10.1249/JSR.0000000000000249
    1. Stoutenberg M, Shaya GE, Feldman DI, et al. . Practical strategies for assessing patient physical activity levels in primary care. Mayo Clin Proc Innov Qual Outcomes 2017;1:8–15. 10.1016/j.mayocpiqo.2017.04.006
    1. Sallis R. Exercise is medicine: a call to action for physicians to assess and prescribe exercise. Taylor & Francis, 2015.
    1. Frémont P, Fortier M, Frankovich RJ. Exercise prescription and referral tool to facilitate brief advice to adults in primary care. Can Fam Physician 2014;60:1120–2.
    1. Mattli R, Farcher R, Syleouni M-E, et al. . Physical activity interventions for primary prevention in adults: a systematic review of randomized controlled trial-based economic evaluations. Sports Med 2020;50:731–50. 10.1007/s40279-019-01233-3
    1. Sørensen JB, Skovgaard T, Puggaard L. Exercise on prescription in general practice: a systematic review. Scand J Prim Health Care 2006;24:69–74. 10.1080/02813430600700027
    1. Anokye NK, Lord J, Fox-Rushby J. Is brief advice in primary care a cost-effective way to promote physical activity? Br J Sports Med 2014;48:202–6. 10.1136/bjsports-2013-092897
    1. Garrett S, Elley CR, Rose SB, et al. . Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence. Br J Gen Pract 2011;61:e125–33. 10.3399/bjgp11X561249
    1. Orrow G, Kinmonth A-L, Sanderson S, et al. . Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389. 10.1136/bmj.e1389
    1. Phillips EM, Kennedy MA. The exercise prescription: a tool to improve physical activity. Pm R 2012;4:818–25. 10.1016/j.pmrj.2012.09.582
    1. Arsenijevic J, Groot W. Physical activity on prescription schemes (pars): do programme characteristics influence effectiveness? results of a systematic review and meta-analyses. BMJ Open 2017;7:e012156. 10.1136/bmjopen-2016-012156
    1. Orkaby AR, Forman DE. Physical activity and CVD in older adults: an expert's perspective. Expert Rev Cardiovasc Ther 2018;16:1–10. 10.1080/14779072.2018.1419062
    1. Hébert ET, Caughy MO, Shuval K. Primary care providers' perceptions of physical activity counselling in a clinical setting: a systematic review. Br J Sports Med 2012;46:625–31. 10.1136/bjsports-2011-090734
    1. Waryasz GR, McDermott AY. Exercise prescription and the patient with type 2 diabetes: a clinical approach to optimizing patient outcomes. J Am Acad Nurse Pract 2010;22:217–27. 10.1111/j.1745-7599.2010.00490.x
    1. McDermott AY, Mernitz H. Exercise and older patients: prescribing guidelines. Am Fam Physician 2006;74:437–44.
    1. Petrella RJ, Lattanzio CN, Shapiro S, et al. . Improving aerobic fitness in older adults: effects of a physician-based exercise counseling and prescription program. Can Fam Physician 2010;56:e191–200.
    1. Carroll JK, Lewis BA, Marcus BH, et al. . Computerized tailored physical activity reports. A randomized controlled trial. Am J Prev Med 2010;39:148–56. 10.1016/j.amepre.2010.04.005
    1. Knight E, Stuckey MI, Petrella RJ. Prescribing physical activity through primary care: does activity intensity matter? Phys Sportsmed 2014;42:78–9. 10.3810/psm.2014.09.2079
    1. Knight E, Stuckey MI, Petrella RJ. Health promotion through primary care: enhancing self-management with activity prescription and mHealth. Phys Sportsmed 2014;42:90–9. 10.3810/psm.2014.09.2080
    1. Harris T, Kerry S, Victor C, et al. . A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT. Health Technol Assess 2018;22:1–274. 10.3310/hta22370
    1. Yaman H, Atay E. The effect of exercise prescription of primary care physician on the quality of life in patients. London J Prim Care 2018;10:93–8. 10.1080/17571472.2018.1464731
    1. Leijon ME, Bendtsen P, Ståhle A, et al. . Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care. BMC Fam Pract 2010;11:38. 10.1186/1471-2296-11-38
    1. Persson G, Ovhed I, Hansson EE. Simplified routines in prescribing physical activity can increase the amount of prescriptions by doctors, more than economic incentives only: an observational intervention study. BMC Res Notes 2010;3:304. 10.1186/1756-0500-3-304
    1. Elley CR, Garrett S, Rose SB, et al. . Cost-Effectiveness of exercise on prescription with telephone support among women in general practice over 2 years. Br J Sports Med 2011;45:1223–9. 10.1136/bjsm.2010.072439
    1. Attalin V, Romain A-J, Avignon A. Physical-Activity prescription for obesity management in primary care: attitudes and practices of GPs in a southern French City. Diabetes Metab 2012;38:243–9. 10.1016/j.diabet.2011.12.004
    1. Windt J, Windt A, Davis J, et al. . Can a 3-hour educational workshop and the provision of practical tools encourage family physicians to prescribe physical activity as medicine? A pre-post study. BMJ Open 2015;5:e007920. 10.1136/bmjopen-2015-007920
    1. Lanhers C, Duclos M, Guttmann A, et al. . General practitioners' barriers to prescribe physical activity: the dark side of the cluster effects on the physical activity of their type 2 diabetes patients. PLoS One 2015;10:e0140429. 10.1371/journal.pone.0140429
    1. Arciniegas Calle MC, Lobelo F, Jiménez MA, et al. . One-Day workshop-based training improves physical activity prescription knowledge in Latin American physicians: a pre-test post-test study. BMC Public Health 2016;16:1224. 10.1186/s12889-016-3883-2
    1. Lundqvist S, Börjesson M, Larsson MEH, et al. . Physical activity on prescription (PAP), in patients with metabolic risk factors. A 6-month follow-up study in primary health care. PLoS One 2017;12:e0175190. 10.1371/journal.pone.0175190
    1. Rödjer L, H Jonsdottir I, Börjesson M. Physical activity on prescription (PAP): self-reported physical activity and quality of life in a Swedish primary care population, 2-year follow-up. Scand J Prim Health Care 2016;34:443–52. 10.1080/02813432.2016.1253820
    1. Fowles JR, O'Brien MW, Solmundson K, et al. . Exercise is medicine Canada physical activity counselling and exercise prescription training improves counselling, prescription, and referral practices among physicians across Canada. Appl Physiol Nutr Metab 2018;43:535–9. 10.1139/apnm-2017-0763
    1. O'Brien M, Shields C, Crowell S, et al. . The effects of previous educational training on physical activity counselling and exercise prescription practices among physicians across nova Scotia: a cross-sectional study. Can Med Educ J 2018;9:e35–45. 10.36834/cmej.43098
    1. Smith BJ, Owen AJ, Liew D, et al. . Prescription of physical activity in the management of high blood pressure in Australian general practices. J Hum Hypertens 2019;33:50–6. 10.1038/s41371-018-0098-2
    1. Lundqvist S, Börjesson M, Larsson MEH, et al. . Which patients benefit from physical activity on prescription (PAP)? A prospective observational analysis of factors that predict increased physical activity. BMC Public Health 2019;19:482. 10.1186/s12889-019-6830-1
    1. Patel A, Schofield GM, Kolt GS, et al. . General practitioners' views and experiences of counselling for physical activity through the New Zealand green prescription program. BMC Fam Pract 2011;12:119. 10.1186/1471-2296-12-119
    1. Persson G, Brorsson A, Ekvall Hansson E, et al. . Physical activity on prescription (PAP) from the general practitioner's perspective - a qualitative study. BMC Fam Pract 2013;14:128. 10.1186/1471-2296-14-128
    1. Joelsson M, Bernhardsson S, Larsson MEH. Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study. Scand J Prim Health Care 2017;35:64–74. 10.1080/02813432.2017.1288815
    1. Knight E, Petrella RJ. Prescribing physical activity for healthy aging: longitudinal follow-up and mixed method analysis of a primary care intervention. Phys Sportsmed 2014;42:30–8. 10.3810/psm.2014.11.2089
    1. Orchard JW. Prescribing and dosing exercise in primary care. Aust J Gen Pract 2020;49:182–6. 10.31128/AJGP-10-19-5110
    1. Swinburn BA, Walter LG, Arroll B, et al. . Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. Br J Gen Pract 1997;47:567–9.
    1. Allen M, Mann K, Putnam W, et al. . Prescribing exercise for cardiac patients: knowledge, practices, and needs of family physicians and specialists. J Cardiopulm Rehabil 2000;20:333–9. 10.1097/00008483-200011000-00001
    1. Wattanapisit A, Thanamee S, Wongsiri S. Physical activity counselling among GPs: a qualitative study from Thailand. BMC Fam Pract 2019;20:72. 10.1186/s12875-019-0968-x
    1. Slade SC, Keating JL. Exercise prescription: a case for standardised reporting. Br J Sports Med 2012;46:1110–3. 10.1136/bjsports-2011-090290
    1. American College of Sports Medicine, Sawka MN, Burke LM, et al. . American College of sports medicine position stand. exercise and fluid replacement. Med Sci Sports Exerc 2007;39:377–90. 10.1249/mss.0b013e31802ca597
    1. O'Regan A, García Bengoechea E, Clifford AM, et al. . How to improve recruitment, sustainability and scalability in physical activity programmes for adults aged 50 years and older: a qualitative study of key stakeholder perspectives. PLoS One 2020;15:e0240974. 10.1371/journal.pone.0240974
    1. Litt MD, Kleppinger A, Judge JO. Initiation and maintenance of exercise behavior in older women: predictors from the social learning model. J Behav Med 2002;25:83–97. 10.1023/A:1013593819121
    1. Lion A, Vuillemin A, Thornton JS, et al. . Physical activity promotion in primary care: a utopian quest? Health Promot Int 2019;34:877–86. 10.1093/heapro/day038
    1. Belfrage ASV, Grotmol KS, Tyssen R, et al. . Factors influencing doctors' counselling on patients' lifestyle habits: a cohort study. BJGP Open 2018;2:bjgpopen18X101607. 10.3399/bjgpopen18X101607
    1. McFadden T, Fortier M, Sweet SN, et al. . Canadian medical students' perceived motivation, confidence and frequency recommending physical activity. Prev Med Rep 2019;15:100898. 10.1016/j.pmedr.2019.100898
    1. Lobelo F, de Quevedo IG. The evidence in support of physicians and health care providers as physical activity role models. Am J Lifestyle Med 2016;10:36–52. 10.1177/1559827613520120
    1. Smith F, Iliffe S. Exercise prescription in primary care. Br J Gen Pract 1997;47:272.
    1. Joyce CL, O'Tuathaigh CM. Increased training of general practitioners in Ireland may increase the frequency of exercise counselling in patients with chronic illness: a cross-sectional study. Eur J Gen Pract 2014;20:314–9. 10.3109/13814788.2014.900534
    1. Barker K, Eickmeyer S. Therapeutic exercise. Med Clin North Am 2020;104:189–98. 10.1016/j.mcna.2019.10.003
    1. Worobetz A, Retief PJ, Loughran S, et al. . A feasibility study of an exercise intervention to educate and promote health and well-being among medical students: the ‘MED-WELL’ programme. BMC Med Educ 2020;20:1–12. 10.1186/s12909-020-02097-2
    1. Wylie A, Leedham-Green K. Health promotion in medical education: lessons from a major undergraduate curriculum implementation. Educ Prim Care 2017;28:325–33. 10.1080/14739879.2017.1311776
    1. Jones PR, Brooks JHM, Wylie A. Realising the potential for an Olympic legacy; teaching medical students about sport and exercise medicine and exercise prescribing. Br J Sports Med 2013;47:1090–4. 10.1136/bjsports-2013-092386
    1. Booth J, Moseley GL, Schiltenwolf M, et al. . Exercise for chronic musculoskeletal pain: a biopsychosocial approach. Musculoskeletal Care 2017;15:413–21. 10.1002/msc.1191
    1. Mulder JA, Griffin R. Prescription of home exercise therapy for cardiovascular fitness. J Fam Pract 1981;13:345–8.
    1. Hansen D, Dendale P, Coninx K, et al. . The European association of preventive cardiology exercise prescription in everyday practice and rehabilitative training (expert) tool: a digital training and decision support system for optimized exercise prescription in cardiovascular disease. concept, definitions and construction methodology. Eur J Prev Cardiol 2017;24:1017–31. 10.1177/2047487317702042
    1. de Souto Barreto P. Exercise for multimorbid patients in primary care: one prescription for all? Sports Med 2017;47:2143–53. 10.1007/s40279-017-0725-z

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