Promoting physical activity: primary care interventions show some benefit but uncertainty remains over exercise referral schemes.

Before you get stuck into the demands of Monday morning, take a moment to think back over the weekend and ask yourself how much exercise you did. I did, let me see, loads. I cycled miles and miles to the National Library of Mythical Creatures, in search of some health information I couldn’t get on my elfPad, and walked for some hours engaged in a little light foraging, reminding myself of the more traditional elfin pursuits. How many hours? Oh, that must be about…seventeen, roughly.

Asking people how much exercise they did rather than measuring it (gadgets such as accelerometers can do this), or measuring something you are expecting the exercise might affect, such as oxygen consumption or body composition, can lead to over-estimates of the amount of activity. This is something to bear in mind when looking at the results of a new review, which explored physical activity promotion in primary care (settings such as GP practices, dental practices, community pharmacies and high street optometrists).

Physical activity promotion in primary care

With 70-80% of adults in the developed world visiting their general practitioner at least once a year, primary care settings have lots of potential for promoting physical activity. This can be done in a variety of ways, including the provision of advice, printed information and referral to an exercise programme. Exercise referral schemes are widely used in the UK, despite recommendations from the National Institute for Health and Clinical Excellence (NICE) in 2006 that such schemes should not be commissioned in primary care outside of well designed research studies. Little is known about the long-term effects of these schemes and of physical activity interventions in primary care compared to other interventions.

A new systematic review

A well-conducted systematic review and meta-analysis of randomised controlled trials (RCTs) has just been published, exploring whether physical activity promotion in primary care shows sustained effects on physical activity in adults and whether exercise referral schemes are more effective than other interventions.

A search of relevant databases produced 15 RCTs suitable for inclusion, involving 8745 adults. Six trials were conducted in the UK with others in New Zealand, Australia, the US, Canada, Switzerland and the Netherlands. Most of the interventions took place in primary care settings, involved health professionals and included written materials and two or more sessions of advice delivered face to face. Three trials assessed exercise referral schemes. Of these, one involved referral to a leisure centre based programme, one to a community walks programme, and one involved small group exercise sessions at an unspecified location. Outcomes were assessed at 12 months or the nearest time point after that.

Here’s what they found:

  • 13 trials found small to medium positive intervention effects on self reported physical activity (odds ratio 1.42, 95% confidence interval 1.17 to 1.73;standardised mean difference 0.25, 0.11 to 0.38)
  • 4 trials reporting cardiorespiratory fitness found no significant effect (standardised mean difference 0.51, 95% confidence interval −0.18 to 1.20)
  • 3 trials of exercise referral found small non-significant effects on self reported physical activity (odds ratio 1.38; 95% confidence interval 0.98 to 1.95; standardised mean difference 0.20, −0.21 to 0.61)
  • Only one study reported an objective measure of physical activity in all participants and found no significant effect
  • Adverse events varied among the six trials that reported them. Only one study found a significant intervention effect, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants between baseline and 12 months’ follow-up, compared with control participants
  • The best estimate of the number needed to treat with a physical activity promotion intervention for one additional sedentary adult to report recommended levels of activity at 12 months was 12

Some limitations of the included studies:

  • Methodological shortcomings, with all but two judged to be at high risk of bias in at least one aspect
  • Poor reporting of the content of the interventions
  • Where reported, most of the participants were white, so the findings may not be generalisable to non-white populations
  • Using self-reported measures of physical activity may over-estimate the effect of the intervention

The authors concluded:

“Promotion of physical activity to sedentary adults recruited in primary care significantly increases physical activity levels at 12 months, as measured by self report. We found insufficient evidence to recommend exercise referral schemes over advice or counselling interventions.”

I’m off now to get stuck into Monday and do ever such a lot of physical activity; just don’t ask me how much.

Links:

Orrow G, Kinmonth A-L, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012;344:e1389

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Sarah Chapman

My name is Sarah Chapman. I have worked on systematic reviews and other types of research in many areas of health for the past 17 years, for the Cochrane Collaboration and for several UK higher education institutions including the University of Oxford and the Royal College of Nursing Institute. I also have a background in nursing and in the study of the History of Medicine.

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