The PA as exercise advocate:
Prescribing exercise for patients

Review the latest exercise recommendations, learn practical solutions to common barriers against activity, and find out how to tailor your counseling to your patient’s readiness to make lifestyle changes.

Lee Lipton MA, PA-C

Ms. Lipton is an exercise physiologist and family practice physician assistant in Northern California. The author has indicated no relationships to disclose related to the content of this article.

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The old cliché is true: If we could take all the benefits of regular exercise and formulate them into a pill, it would instantly become the most widely prescribed medication in the nation. The many physical and psychosocial benefits of physical activity are well known. In addition to reducing morbidity and mortality from cardiovascular disease, a program of regular physical exercise has been repeatedly shown to both reduce the risk of, and help to treat, hypertension, type 2 diabetes, obesity, colon cancer, and osteoporosis. Additionally, regular physical activity can reduce symptoms of depression and anxiety as well as promote feelings of self-efficacy and well being.¹³

Exercise training mediates physiologic change on multiple organ systems and thus acts as a powerful primary, secondary, and tertiary clinical intervention. Consider a patient with type 2 diabetes who achieves tighter glucose control through exercise and eventually reduces or eliminates the need for medication. A patient with chronic hypertension may lose weight, improve BP, and increase HDL cholesterol levels with a walking program. An elderly, recently widowed woman may feel less lonely at a community center exercise class and thus cope more effectively with her feelings of depression and isolation.

As health care providers, PAs strive to help patients by treating discomforts and diseases. But are we doing enough to help our patients prevent morbidity and mortality through lifestyle change?

Background

Increasing the number of adults and teens who engage in regular exercise is a leading objective for Healthy People 2010.⁴ The 1996 US Surgeon General’s Report on Physical Activity and Health advocates a progressive exercise program leading up to moderate-intensity exercise for a minimum of 30 minutes on most days of the week. Many of the health benefits associated with regular physical activity can also be achieved with shorter bouts of exercise, such as dividing the 30 minutes of activity into three 10-minute sessions per day.²

The American College of Sports Medicine (ACSM) maintains that a complete physical training program should include a combination of aerobic and resistance training and flexibility exercises. Table 1 summarizes the ACSM guidelines for aerobic activity. Any exercise recommendations should be customized to each patient’s abilities and needs and should be designed to encourage a permanent change to an active lifestyle.⁵

Despite these clearly stated goals and guidelines, most Americans continue to include very little physical activity in their daily lives. Physical activity statistics for 2001 show that 54% of American adults do not meet the minimum exercise criteria to gain health benefits.⁶ Some states boast the dubious distinction of having inactivity rates as high as 62% to 71% and obesity rates greater than 24%.⁶ Skyrocketing obesity in children and adolescents also points to the need for lifestyle intervention. Clearly the trends are disturbing, and we have a long way to go before reaching the 2010 goals. Does clinical intervention in the form of counseling help to improve patients’ adoption of an active lifestyle?

What the literature shows

A consensus on the effectiveness of promoting and prescribing exercise to patients during a clinic visit has been difficult to achieve because published studies have used diverse intervention methods, patient populations, and follow-up criteria as well as because of the design limitations of the studies. The available research differs greatly in method of intervention, target population, and frequency of counseling.^1,7-11 However, there are some common themes and characteristics of clinical interventions that have had positive outcomes. Specifically, multiple clinical interventions have been shown to increase patients’ adherence to exercise regimens. Programs that provide verbal plus written exercise counseling advice in the form of a pamphlet or booklet, or that mail reminders or arrange telephone followup for patients after their counseling sessions, have been reported to be effective.^12-15 While some studies found that patients who received frequent counseling messages tended to exercise more often, others show that brief, simple advice interventions alone improve patient compliance.^13,16,17

The health benefits from exercise programs are evident only in persons who are consistently active over a long time.² Available research studies have not evaluated the effect of interventions lasting longer than 1 year, and the results of these studies are often extrapolated from patients’ self-reported levels of daily activities.⁸ Thus the true effectiveness of exercise counseling in enhancing clinically significant risk reduction is still unclear.

Provider barriers

The extent to which clinicians counsel patients about physical activity and prescribe exercise is not well documented.¹⁸ Published clinician surveys report very little counseling time devoted to an exercise prescription, and most report that approximately 30% of health care providers counsel sedentary patients to exercise. This figure is compatible with the frequency of patient-reported counseling sessions.^10,19

The most common reasons clinicians cite for failing to provide counseling and prescriptions for exercise include time constraints and lack of reimbursement for the time spent discussing exercise with patients.^3,15,18 Clinicians also note that they lack specific skills related to prescribing exercise. One study showed that only 12% of providers were aware of the latest ACSM recommendations for exercise.³

Perhaps the most important paradigm shift in redefining the role of preventive intervention is to that of the clinician becoming an advocate for exercise.²⁰ Learning to counsel patients about initiating and maintaining an exercise program, becoming familiar with recommended activity guidelines, and anticipating patient barriers to exercise are important initial steps that all health care providers can take to become advocates for an active lifestyle. Exercise is a useful adjunct therapy for many common patient complaints such as obesity, depression, hypertension, hyperlipidemia, and osteoporosis. Thus, exercise counseling can be specifically tied in to many patient encounters.

While an association between clinic-based counseling and permanent, physiologically significant patient lifestyle compliance may not be documented and clear, several important points are evident. Rising rates of inactivity and the concomitant increasing number of patients with obesity, type 2 diabetes, the metabolic syndrome, and other serious, related, preventable diseases are severe nationwide problems. The costs of failing to address the hazards of inactivity with our patients are incalculable in terms of morbidity and mortality from lifestyle-related preventable diseases. Failure on the part of clinicians to address the pivotal health issue of an active lifestyle may diminish its importance to patients.

The potential positive impact of counseling is too great to be ignored, irrespective of the equivocal research results regarding the efficacy of exercise counseling in mediating clinically significant long-term lifestyle change. Even though the efficacy of clinical counseling sessions is not clearly established, the US Preventive Services Task Force (USPSTF) notes that exercise prescription and counseling are worthwhile endeavors for clinicians based on “the proven benefits of regular physical activity.”²

Stages of change

Lifestyle change is a complex and time-consuming process that is described by the transtheoretical model of behavior change.¹⁷ This model describes the five stages of readiness to change behavior (see Table 2). Since more than half of patients who enter the action phase revert to termination within a few months, the clinician should aim to help patients move gradually through the stages of readiness and support them in the maintenance mode.²¹

Many studies have found that assessing a patient’s stage of readiness can help clinicians tailor the appropriate exercise message.^7,9,13,22 There is some indication that indiscriminate counseling without regard to patient readiness is not an effective technique.²³ See “Case studies in writing the exercise prescription” for examples.

Addressing patient barriers to exercise

Patients who have previously led sedentary lives may suffer from overwhelming inertia at the very idea of starting an exercise program. Although patients know they should exercise, most have a seemingly inexhaustible list of reasons why they cannot begin or sustain a regular program. Underlying issues include lack of motivation or negative selfperceptions such as the belief that they cannot sustain a healthy lifestyle change. Some patients fear the pain they associate with exercise, and still others cite a lack of time as the main contributing factor.¹⁹ Here are a few tips that can help your patients overcome these barriers and open the lines of communication.

In the office

• Systematically identify a patient’s exercise habits during each encounter. Modify chart forms to include patient education for active lifestyles.
• Decorate waiting rooms with pictures of active people of all shapes, sizes, and ages.
• Consider adding healthy lifestyle magazines to the reading material already available.
• Set computers in the waiting rooms to helpful Internet sites, such as the American Dietetic Association (www.eatright.org/Public/), the American Council on Exercise (www.acefitness.org/default.aspx),the CDC (www.cdc.gov/), and others.

In examination rooms

• Posters that promote exercise and activity can liven up an otherwise dull-looking room.
• Exercise-related pamphlets, publications, and handouts should be readily available.
• Exercise prescription forms can promote physical activity and are easy to complete (see “Exercise prescription form”).

Patient counseling

Strive to become a good role model for your patients. If you pursue an active lifestyle, you will better understand some of the barriers your patients face and you can share your own solutions for overcoming them. Your patients will consider your advice more credible if you “walk the walk.” Simple, direct messages such as, “It’s time for you to begin an exercise program,” or “Let’s talk about how you’re going to fit exercise into your life,” can be very effective for patients who are in the contemplation stage of readiness to make lifestyle changes. Remind patients that activities such as raking leaves, using the stairs, walking from the far end of the parking lot, and even doing housework can add up to enhanced health and fitness. For patient information that can be printed and handed out, see “Patient Information: Health benefits of exercise.”

Encouraging longterm adherence

For patients who are in the action or maintenance stages of lifestyle changes, point out what they have achieved by sticking to their program so far. To illustrate how they have decreased their health risks, share laboratory results, compare BP readings, use serial weight measurements, or utilize the Framingham risk analysis profile (available at http://hin.nhlbi.nih.gov/ atpiii/calculator.asp?usertype=prof).

Remind patients to plan for setbacks such as holidays, vacations, and lapses in motivation. Encourage them to continue pursuing activities, and remind them that any level of activity is better than no activity. Explain to patients that such factors as group involvement and listening to music while exercising may increase motivation. Also, a supportive network of friends and family can be very helpful, so encourage patients to involve others in their active lifestyles. An exercise log or calendar noting activity, time spent exercising, and intensity can be a powerful motivator for exercisers to continue their programs. Help patients avoid injury by advising them to “start low and go slow,” gradually increasing exercise time and intensity over a period of weeks. Encourage patients to wear appropriate, supportive footwear and to take time to adequately warm up before exercise and gradually cool down afterward.

Clinician resources

Identify community resources in your area; fitness centers and private gyms are not the only answer. Local YMCA facilities, parks and recreation departments, biking trails, activity clubs and even mall-walking groups are available at either low or no cost in many areas. List these programs in a handout for patients, so they have a place to start.

Create a list of reputable health-related Web sites for your patients. The Internet has a wealth of accurate information and resources such as online exercise support groups and exercise advice from clinical professionals. Screen Web sites for accuracy and content. Web sites and addresses change often, so make sure to review your resources periodically.

Network with local fitness professionals for patient referrals. Many qualified certified personal trainers and fitness instructors are available throughout the country to help your patients achieve active lifestyles. In return for your referrals, these professionals may be willing to present motivating lectures on the benefits of exercise for your patients in the precontemplation or contemplation stages of change. Do not forget to screen trainers and instructors for nationally recognized certifications, such as those offered by the ACSM, the American Council on Exercise, or the Aerobics and Fitness Association of America.

Conclusion

Physical inactivity is a leading, preventable cause of health problems. Promotion of exercise training is a pivotal health issue in this country and is more important than ever. Providers who take time to address the issue of risk reduction through exercise during a clinic visit may not change every patient’s life, but they will have a profound impact on some, including the prevention of lifestyle-related chronic disease and death. Just as we encourage each of our patients to take small steps toward the goal of an active life, so too can we take small steps toward becoming advocates for physical exercise.

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