Exercise prescription - a pilot collaboration between medical practitioners and physiotherapists

Alice Y M Jones 鍾斯綺文, Dorothy F Y Chan 陳鳳英, Siu N Fu 符少娥, Shirley P C Ngai 魏佩菁, Steven Y K Ho 何耀強

HK Pract 2007;29:291-301

Summary

Objective: A properly prescribed exercise programme goes well beyond simple recommendations as to the mode, intensity and frequency of exercise; however detailed assessment of musculo-skeletal function, cardiopulmonary status, and particularly supervision and monitoring of the response to exercise are often not logistically feasible for medical practitioners. Physiotherapists are specialists in exercise prescription for populations of illness and normal health. This article reports the success of collaboration between medical practitioners and physiotherapists in exercise prescription.

Design: One group pre-test post-test design.

Subjects: Subjects with a body mass index (BMI) >28 kg/m2, attending a University Health Service for medical consultation were referred to the Campus Rehabilitation Clinic for prescription and implementation of an 8-week individualised exercise programme.

Main outcome measures: BMI, abdominal girth, resting heart rate and blood pressures, muscle strength and flexibility, cholesterol profile, and peak oxygen consumption during exercise.

Results: Subjects demonstrated improved cardiopulmonary fitness, cholesterol profile, and muscle strength and flexibility at the end of the programme. They also expressed greater confidence in achieving a positive outcome from a programme led jointly by doctors and physiotherapists.

Conclusion: Collaborative efforts by medical practitioners and physiotherapists could effectively promote primary health care and should be widely adopted in the community.

Keywords: Exercise prescription, primary health care.

摘要

目的： 適當的運動計劃處方，不僅是提供運動方式、強度和頻率的簡單建議， 更要對肌肉—骨骼功能及心肺狀況進行詳盡的評估，尤其是要監督和監測運動時的身體反應， 這在醫生的日常工作中是難以兼顧的。物理治療師是為患者和健康人仕提供運動處方的專家。 本文報告了醫生和物理治療師在運動處方方面成功合作的例子。

設計： 單組，半用實驗前後測試設計。

研究對象： 體重指數(BMI) > 28kg/m2，到大學衛生服務部就醫而被轉診到校園康復診所，接受運動處方並參加一項為期8周的個體化運動計劃的人仕。

主要測量內容： BMI、腹圍、靜態心率和血壓、肌力和靈活性、膽固醇水平、運動時最大氧耗。

結果： 計劃結束時，參加者的心肺健康狀況、膽固醇水平、肌力和靈活性均得到改善，而且更有信心通過醫生和物理治療師合作計劃獲得好的成績。

結論： 醫生和物理治療師共同合作，可以有效地促進基層醫療服務，應該在社區內廣泛推廣。

主要詞彙： 運動處方，基層醫療服務。

Introduction

The role of exercise in maintenance and improvement of cardiopulmonary fitness in the healthy population has been studied extensively and benefits of exercise are well documented.¹ Appropriate exercise programmes have also been an integral component of rehabilitation for people with acute and chronic illness. Regular walking exercise programmes decrease body weight and body mass index (BMI),² and in patients with type-2 diabetes, exercise improves lipid metabolism, and reduces systolic and diastolic pressures as well as BMI.³

The role of exercise in disease prevention has also received increased attention and recognition under the current health care system in Hong Kong. The Hong Kong Medical Association encourages general and family medicine practitioners to equip themselves with the skills required for proper exercise prescription and "Exercise Prescription Certification" courses are regularly organised for private practitioners.⁴ Medical practitioners are the most appropriate personnel to assess a patient's system function and provide appropriate indicative information for exercise.

Exercise prescription is a major component of physiotherapy care.⁵ Physiotherapists in Hong Kong play an active role in exercise promotion for people with normal health as well as those with acute and chronic musculo-skeletal injuries and rehabilitation of cardiopulmonary and neurological disorders.^6-8 The physiotherapy undergraduate curriculum prepares its graduates for exercise prescription by way of a comprehensive educational programme in movement science, exercise physiology, prevention and management of sports injuries, and exercise prescriptions for maintenance of health and for people with special needs (such as diabetes, renal dysfunction, pregnancy etc).

The foregoing would suggest that a close relationship between medical practitioner and physiotherapist in the prescription, supervision, monitoring and evaluation of exercise programmes might optimise patient benefit. If an interdisciplinary pilot collaboration proves effective, this model could be applied broadly in the community to promote primary health care; a current focus of the health care system which is shared globally.

This article describes the outcome of a collaborative project between a medical practitioner-led Health Service centre and a physiotherapy clinic on a University campus, in prescription and supervision of exercise programmes for clients who were over-weight.

Methods

Ethics approval was obtained from the associated university Human Subjects Ethics sub-committee prior to the commencement of the project. Meetings were held between the University Health Service (UHS)'s Centre director, three medical practitioners, a physiotherapy clinic manager and an academic physiotherapist who specialises in cardiopulmonary physiotherapy, to consider a) logistics for the project, b) inclusion and exclusion criteria for subject recruitment and c) safety guidelines for both the assessment procedures and exercise programme.

Subjects with BMI 28 kg/m², attending the UHS for medical consultation between 1^st May to 30^th June 2006, were recruited for detailed assessment by the three participating physicians. Assessment included history and physical examination, a 12-lead ECG, blood analysis for the estimation of fasting plasma glucose (GLU), serum insulin (INS), aspartate transaminase (AST), alanine transaminase (ALT), gamma glutamyl transferase (GGT) activity and serum lipid profile [total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL) concentrations]. Exclusion criteria included (a) history of ischaemic heart disease, (b) heart block, (c) arrhythmia, (d) asthma or chronic obstructive airway disease. The nature of the project and associated risks and benefits were explained to invited participants. Written consent to participate in the project was obtained from subjects prior to the assessment procedures.

Willing subjects were referred to the physiotherapy clinic for cardiorespiratory and musculo-skeletal function assessment and prescription of an appropriate 8-week exercise programme. Prior to testing, all subjects were required to complete a risk stratification assessment⁹ which identified any specific indications for termination of the exercise testing protocol for a particular individual (Table 1). Cardiorespiratory assessment included spirometric lung function assessment (Pony Spirometer, Cosmed, Italy) for clinically undetected airways disease and a sub-maximal exercise stress test employing the modified Bruce protocol.¹⁰ Oxygen consumption (VO₂) during the stress test was measured by breath-by-breath gas analysis using the K4B2 metabolic cart (Cosmed, Italy). At the end of the stress test, the protocol stage, peak heart rate, peak VO₂, estimated maximal VO₂ (VO₂max) and reasons for test termination were recorded. Heart rate (Polar Electro Oy, 90440, Kempele, Finland), systolic and diastolic blood pressures were measured using a sphygmomanometer (PTA102, China) and rate of perceived exertion were recorded before, immediately after, and 10 minutes after each exercise session. All parameters were allowed to return to pre-exercise levels before the subject was permitted to leave the clinic. Assessment of musculo-skeletal function included:

a) Flexibility: sit-and-reach test;¹¹ Thomas test for knee angle and hip angle.¹²
b) Upper limb and lower limb muscle strength: assessed by performance of one repetition maximum (1 RM) of 'chest press', 'shoulder press' and 'leg press' (M870, M869, M851 Technogym, Italy).

Body fat and lean mass composition was measured by a body composition analyser (InBody 3.0, Biospace Co., Ltd. Korea) and abdominal girth was measured (by tape) before and after the 8-week exercise programme.

At the end of the assessment procedure, a physiotherapist discussed with the subject their work and study routine, normal exercise pattern (if appropriate) and the feasibility of conducting the exercise programme at home or at the physiotherapy clinic. Based on this discussion, individual exercise programmes were prescribed to subjects with the general objective of improving cardiopulmonary fitness and muscular strength. Each subject was encouraged to perform at least two (if possible three) exercise sessions at the physiotherapy clinic.

All assessment procedures were conducted by the same physiotherapist while the exercise programme was supervised by a different physiotherapist.

Exercise protocols

The mode of exercises in the physiotherapy clinic included cross trainer, treadmill running, upper limb ergometer, stationary bike, chest press, shoulder press, leg press, pulley exercise and exercise ball, proportionately adjusted to the assessment. For example, a subject with poor posture due to an imbalance between abdominal and back musculature (as identified by the physiotherapist), would be prescribed a pulley and exercise ball protocol (Figure 1); subjects with knee pain or obese patients were excluded from treadmill running in order to minimise the impact injury to the knee joints; and subjects with underdeveloped upper limbs were prescribed upper limb strengthening exercises such as chest press and shoulder press.

Home exercises included aerobic exercise, Theraband resisted exercise and partial curl ups. All subjects were asked to complete an exercise log and record the time they spent exercising during the eight weeks.

The medical practitioner and physiotherapists communicated via email with regard to the programme progress, any untoward incident during training or modification of training intensity as necessary.

Statistical analysis

Variables including body weight, BMI, blood analysis, abdominal girth, percentage of body fat, knee and hip angles, performance of chest, shoulder and leg press (kg at 1RM), resting heart rate, systolic and diastolic blood pressures, peak VO₂, and VO₂ recorded before and after the 8-week exercise programme were compared using the paired-t-test. The change of HR over 8 weeks was analysed by one-way repeated measure. The statistical significant value was set at p<0.05. Data were analysed using the SPSS for Windows version 11.

Results

During the two-month period, a total of 10 subjects were recruited for the project. Two subjects were unable to complete the programme or the follow up assessments due to overseas travel and were thus excluded from the analysis.

The mean age of the remaining eight subjects (5 females) was 27.9 +8.3 years, and mean BMI was 31.66 +4.23 kg/m². All subjects commenced the exercise programme with initial exercise intensity at 60 to 70% of their maximal heart rate (220-age). The intensity was gradually increased over the 8-week period to 70- 80% of their maximal heart rate (HR_max).

Collectively, the blood profiles of our subjects demonstrated a mean decrease of total cholesterol level (TC) by 3%, improved HDL by 1.5%, and reduced LDL by 1.8%. There was also a statistically significant decreasing trend in resting heart rate (p<0.001) (Figure 2). Upon completion of the exercise programme, the resting heart rate reduced by 10%, MET achieved improved by 13.6%, peak VO₂ improved by 11.1%, body fat and abdominal girth were reduced by 7% and 3% respectively; and the improvement in shoulder, chest and leg strength was 51%, 35% and 29% respectively. The angle between the bed and the hip was reduced by a mean of 60%. The improvement in measured variables reached a statistical significance only for changes in the hip angle, shoulder and chest press strength (p values are 0.014, 0.008 and 0.017 respectively).

Four subjects were able to continue with daily exercise at home and attained an overall exercise duration of over 40 days in the two-month period. Changes in variables in subjects who exercised for 40 or more days in the 8-week period were compared with those who exercised for less than 40 days. Improvement in muscle strength, diastolic pressure and hip angles were similar in both groups. Those who exercised more appeared to have a greater decrease in percentage of body fat, abdominal girth, resting heart rate and resting systolic blood pressure, improved peak VO₂ achieved during stress test and number of sit ups in 20 seconds (Figure 3). Spearman correlation analysis also demonstrated a statistically significant inverse relationship between the number of days of exercise with both body weight and BMI (r= -0.79, p = 0.021).

A semi-structured post-programme interview showed that subjects expressed confidence in achieving a satisfactory outcome, having participated in an exercise programme led by both medical practitioners and physiotherapists.

The greatest weight loss amongst the subjects was 5.8 kg during the 8-week programme. This subject's abdominal girth was reduced by 11%, resting heart rate by 45%, systolic blood pressure by 9.4%, with a 57% increase in both MET achieved and peak VO2 during the sub-maximal exercise test. His TC and LDL were reduced by 10% and 20% respectively. Improvement in muscle strength and flexibility was also remarkable; with shoulder and chest press strength improved by over 50% and hip angle by 100%. This subject exercised 5-6 days a week during the exercise programme.

One subject, during one exercise session at the end of the 3rd week of training, complained of 'lower lip twitching' when the exercise intensity was increased to about 80% HR_max but physiological parameters remained stable and there were no other adverse effects apart from a feeling of mild anxiety. The intensity was reduced to 70% HR_max and gradually increased to 75% the following week. Reassurance was given to the subject to continue with exercise with incremental increases in training intensity. This subject completed the exercise programme uneventfully and lost 2 kg. Her total cholesterol level reduced from 5.1 to 4.5 mmol/L.

Discussion

This collaborative project between medical practitioners and physiotherapists showed that a supervised programme significantly reduced resting heart rate, restored normal lipid profile and improved muscle flexibility and strength in our subjects. The findings of this project further support the positive role of exercise in reduction of cardiac risks and the potential for reducing future medical expenses associated with obesity. The thorough assessment procedures ensured that the exercise programme was safe and that the progression of exercise intensity was appropriately maximised.

In July 2005, the Hong Kong Government published a Discussion Paper soliciting comment on a service model for the delivery of primary health care in Hong Kong in the future.¹³ The Paper stated that while the current health care system in Hong Kong "is an enviable system that provides accessible and quality health care to all", it relied heavily on the publicly funded health care system. With an ageing population and tendency to early occurrence of chronic illness, there is a need to strengthen the primary health care system and the role of the medical practitioner in health promotion and disease prevention.

The beneficial effects of exercise are well documented both in healthy subjects and in people with chronic illness.^1,14,15 Medical practitioners in Hong Kong are encouraged to 'prescribe' exercise programmes to their clients.⁴ Effective exercise prescription however, requires an understanding of an individual's willingness to engage in a healthy life style, matched with the mode, intensity and frequency of a proposed exercise programme, encompassing considerations of safety as regards musculoskeletal and cardiopulmonary function, together with supervision, monitoring and evaluation of the programme. This form of comprehensive exercise prescription should result in optimal patient benefit at minimal risk. Given the nature of medical clinical practice, continuous supervision, monitoring and evaluation of a comprehensive exercise prescription is neither cost effective nor logistically practical.

Physiotherapy "provides services to people and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan".⁵ A major educational training component for a physiotherapist involves assessment (examination of individuals with actual or potential impairment of functional disability), diagnosis (on movement dysfunction and limitations), planning of intervention (with measurable outcome goals), implementation (of appropriate interventions for promotion and maintenance of health, fitness, and quality of life at all ages in the population), and evaluation (of the outcome of interventions). A physiotherapist is therefore an appropriate professional collaborator with the medical practitioner, whose role of identifying the patient's system function status, providing indicators for exercise (such as hypercholesterolaemia) and precautions to consider (such as complications from diabetes, cardiac myopathy or pulmonary hypertension) ties in with the physiotherapist's planning and implementation of a prescribed exercise programme.

It has been suggested that health promotion should target people with disabilities as well as healthy individuals and that physiotherapists should move into the "gymnasium industry" where those with disabilities are encouraged to participate.¹⁶ With a paradigm shift in health from acute care to disease prevention, many physiotherapists are now engaged in services in private clinics and in the community, rather than in hospitals. This is evidenced in Hong Kong where 68% of the new physiotherapy graduates in 2005 service the private sector and non-government organisations, while only 16% of graduates were absorbed by the Hospital Authority.¹⁷ The successful collaboration between the medical practitioners and physiotherapists demonstrated in this study showed the potential for such collaboration in the wider community.

We considered our pioneer collaborative experience a success as all subjects demonstrated an improvement in muscle strength and flexibility, and in accord with other studies, those who complied with the exercise programme demonstrated a significant improvement in cardiopulmonary fitness and cholesterol profile.^3,18,19 The patient who lost most weight in our cohort was the one who exercised most diligently. The two patients whose cholesterol levels normalised after the exercise programme also demonstrated improved liver enzyme levels, suggesting a possible improvement in hepatic fat deposits with exercise.²⁰ Surprisingly two patients had higher cholesterol levels after the 8-week exercise period, but they only attended the clinic twice each week and one declared she ate more than usual because of concomitant 'life stress'.

Apart from beneficial patient outcomes, this collaboration demonstrated the potential for medical practitioners and physiotherapists to perfect a team approach to exercise prescription in the community. The physiotherapist monitored each subject's physiological response before and after each exercise session, and the subjects were also taught how to self monitor their exercise at home. Practically it is not possible for a medical practitioner to effectively provide advice on exercise progression without being intimately aware of a subject's individual response to exercise by direct supervision. This pilot project demonstrated that the close supervision and monitoring of exercise progression by the physiotherapist complimented the medical practitioner's integrated approach to health care and improved patient confidence in the overall conduct of their health care programme. Modification of the mode and intensity of the programme could be introduced in a timely manner with an opportunity for the patient to discuss with the physiotherapist any difficulties or outcomes, permitting a programme closely tailored to the patient's needs to appropriately modify their behaviour.

Study limitation

One major limitation of this study was the small number of subjects who participated in the programme during this two-month period. As the study was conducted during the summer, many potential University clients travelled outside Hong Kong and were unavailable for study induction. The limited cohort numbers deterred a significant statistical result in many of the variables measured. However, the positive trends as well as the dramatic improvement in those who exercised regularly, encouraged us to continue with this project. There is obviously a need for a larger scale longitudinal study to follow up the progress of our clients.

All fees were waived in this pilot study. The establishment cost of this 8-week physiotherapy-supervised exercise programme was about HK$3,200 per student. This compares favourably with commercial sliming programmes or say, the costs of long term anti-hypertensive care, bearing in mind that the Hospital Authority estimated average cost per general ward patient per day was approximately HK$3,360 in 2007/08.²² We are of the view that our programme will be cost-effective in the long term if any cardiopulmonary illness associated with lack of exercise is averted or ameliorated because of the relatively high costs of hospitalization and treatment of cardiopulmonary disease in the Hong Kong community.

Another study draw back was that we did not have the opportunity to incorporate a dietician in the research team. The importance of diet in weight control is well established. We envisage greater patient benefit when diet modification is advised in conjunction with our exercise prescription.

Despite the above limitations, this project successfully demonstrated the effectiveness of collaboration between medical practitioners and physiotherapists in prescription of an exercise programme. Our collaboration ensures the programme is safe and exercise activity and intensity is appropriately monitored and progressed, to achieve an optimum result.

Conclusion

This is the first reported collaborative project between medical practitioners and physiotherapists in prescription of exercise programmes. The majority of the obese subjects referred to physiotherapy demonstrated improvement in cardiopulmonary fitness, muscle flexibility and strength, as well as an improved blood lipid profile. Results of this project suggest that collaboration between medical practitioners and physiotherapists could cost-effectively benefit primary health care.

Acknowledgements

The team is grateful to the support provided by Dr Simon Chung who was involved in the initial planning and patient referral of the project. The authors are indebted to Mr Barry Chan, Physiotherapist, for the assistance he provided during the data collection process, and Mr Brian Choi, Physiotherapist and statistician, for his assistance in the statistical analyses conducted in this study.

Key messages

1. A patient-centered exercise programme can reduce resting heart rate, restore blood lipid profile to normal and improve muscle flexibility and strength.
2. A comprehensive exercise prescription includes a thorough assessment of body system function, supervision and monitoring of exercise and appropriate progression of exercise intensity.
3. Collaboration between general practitioners and physiotherapists promotes safe delivery and optimal progression of exercise intensity.
4. Physiotherapists and general practitioners form a complimentary partnership in the promotion of primary health care.