1

Exercise Medicine for

Students
A one-stop resource for the knowledge
and promotion of physical activity

Extra online resources can be found at:

www.motivate2move.co.uk
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Contents
Introduction ............................................................................................................................. 4
Chapter 1 `The UK Physical Activity Guidelines .......................................................................... 5
The Evidence of the Health Benefits of Physical Activity ......................................................... 6
Chapter 2 Cancer ................................................................................................................... 7
Chapter 3 Cardiovascular Health ................................................ Ischaemic Heart Disease 10
 ..................................................................................................................Heart failure 11
 ................................................................................................................. Hypertension 11
 ............................................................................................................................ Lipids 12
 ............................................................................................ Peripheral Arterial Disease 13
 ........................................................................................................................... Stroke 13
Chapter 4 Type 2 Diabetes ................................................................................................... 15
Chapter 5 Mental Health...................................................................................................... 17
 .................................................................................................................... Depression 17
 ......................................................................................................................... Anxiety 17
 ................................................................................................................ Schizophrenia 17
 ................................................................................ Sleep and psychological well-being 18
 ...................................................................................................................... Dementia 18
Chapter 6 Musculoskeletal Health ........................................................................................ 20
 ................................................................................................................. Fibromyalgia 20
 ................................................................................................................ Osteoarthritis 20
 ................................................................................................................. Osteoporosis 21
 ..................................................................................................... Rheumatoid Arthritis 22
 ...................................................................................... Prevention of falls and fracture 23
Chapter 7 Obesity ................................................................................................................ 24
Chapter 8 Chronic Obstructive Pulmonary Disease (COPD) .................................................... 28
Chapter 9 Exercise during Pregnancy .................................................................................... 30
Chapter 10 Surgery and Exercise........................................................................................... 33
Chapter 11 Sedentary Behaviour .......................................................................................... 35
Chapter 12 Motivation to Change Health Behaviour ............................................................. 37
Motivational Interviewing (MI) by Prof S Rollnick ................................................................. 37
Example MI Dialogue. By Prof S Rollnick .............................................................................. 38
Chapter 13 Starting to Exercise ............................................................................................. 42
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Getting Started.................................................................................................................... 45
The Referral Pathway .......................................................................................................... 46
Absolute Contraindications of Exercise ................................................................................... 47
Case histories. ..................................................................................................................... 48
Case 1 Hypertension or Not? .............................................................................................. 48
Case 2 Depression. ............................................................................................................. 49
Case 3 Obesity. ................................................................................................................... 49
References................................................................................................................................. 50
Introduction ........................................................................................................................ 50
Chapter 1 The UK Physical Activity Guidelines ...................................................................... 50
Chapter 2 Cancer ................................................................................................................ 50
Chapter 3 Cardio Respiratory Health .................................................................................... 52
Chapter 4 Type 2 Diabetes ................................................................................................... 53
Chapter 5 Mental Health ..................................................................................................... 54
Chapter 6 Musculoskeletal Health........................................................................................ 56
Chapter 7 Obesity................................................................................................................ 58
Chapter 8 Respiratory disease.............................................................................................. 59
Chapter 9 Pregnancy ........................................................................................................... 60
Chapter 10 Surgery .............................................................................................................. 60
Chapter 11 Sedentary Behaviour.......................................................................................... 61
Chapter 12 Motivation ........................................................................................................ 61
Chapter 13 Starting to exercise ............................................................................................ 62

Authors and contributors; Dr Brian Johnson, Prof Steven Rollnick, Dr Alex Wright, Prof Andrew
Lemmey, Dr Eleanor Tillet, Mr Andrew Tullo, Dr John Brooks and Dr Christopher Speers
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“If we could give every individual the right amount of nourishment and
exercise, not too little and not too much, we would have found the safest way
to health”
Hippocrates 460-377 BC

Introduction

Primarily designed for General Practitioners and their teams and based on a comprehensive research
approach, the purpose of this document is to give all health professionals the tools and information
to enable them to educate, motivate and encourage patients about the benefits of physical activity.

Why encourage physical activity?

 The World Health Organisation ranks physical inactivity as the fourth largest cause of global
mortality. 1
 In the UK 60-70% of our population take insufficient exercise. 2
 Physical inactivity is linked with many chronic health problems including cardiovascular
diseases, type 2 diabetes, obesity, cancer, dementia, depression and osteoporosis. 2
 The present cost of physical inactivity in the UK and the NHS, when indirect costs to the
economy are added to health costs, has been estimated to be £8.2 billion. 3
 Physical activity is known to be essential for improved health, preservation of function and
there is evidence of prolonged life resulting from as little as 15 minutes of regular and
moderate daily exercise. 4
 Long term studies of men and women in the USA have shown a positive linear relationship
between physical activity and health and conversely, a low cardio respiratory fitness level as
the largest attributable factor for all causes of death. 5
 Physical inactivity kills more than smoking, diabetes and obesity combined. 5
 Exercise as prevention or as a treatment now features in 39 UK national guidelines. 6
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Chapter 1 The UK Physical Activity Guidelines

This summary of the guidelines is drawn from the 2011 updated UK Physical Activity Guidelines
supporting documents,1, 2 and the British Association of Sport and Exercise Scientists consensus
report .3

The UK Physical Activity Guidelines advice for adults (19-65) recommend:

 Aim to be active daily. Activity should add up to over 150 minutes per week by participating
in at least 30 minutes of moderate intensity physical activity on 5 or more days a week, or in
multiple bouts of 10 minutes or more.

 Comparable benefits can be achieved through vigorous activity of 75 minutes a week, or in a

combination of moderate and vigorous activity.

 Adults should also undertake physical activity to improve muscle strength on at least two
days a week.

 All adults should minimize extended sedentary (sitting) periods.

-Moderate intensity physical activity causes adults to feel warmer, breathe harder and the heart
beats faster, with the example of brisk walking being the easiest to recognize.

-Vigorous intensity physical activity causes adults to get warm quickly, breathe much harder,
perspire and find it difficult to maintain a conversation.

Depending on body weight, 150 minutes of moderate aerobic activity or 75 minutes of vigorous
activity will expend about 800-1200 kcal. 3

The dose-response relationship between physical activity and health is clear across all ages and
there are therefore guidelines for all ages of life. The main differences are summarized below.

 UK Guidelines for Under-fives not yet walking

Physical activity should be encouraged from birth, particularly through floor based play and
water based activities in safe environments. All under 5s should minimize the time spent
being sedentary (restrained or sitting) for extended periods (except sleeping).

 UK Guidelines for Under-fives capable of walking

180 minutes (three hours) – each day, once a child is able to walk.
For non-walkers, physical activity should be encouraged from birth, particularly through
floor-based play and water-based activities in safe environments.

 UK Guidelines for Children and young people (5-18 year olds)

There is a greater emphasis on encouraging 60 minutes a day and up to several hours every
day of moderate to vigorous intensity physical activity. Three days a week should include
vigorous intensity activities that strengthen muscle and bone. This age group should also
minimize the amount of time spent being sedentary (sitting) for extended periods.
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 UK Guidelines for Older people (65+)

150 minutes (two and half hours) – each week of moderate to vigorous intensity physical
activity (and adults should aim to do some physical activity every day). Muscle strengthening
activity should also be included twice a week. Any individual at risk of falling should
incorporate activity to improve balance and coordination on at least two days a week. All
adults should also minimize the amount of time spent being sedentary (sitting) for extended
periods.

For most health outcomes, additional benefits occur as the amount of physical activity increases via
increased intensity, frequency and or duration.

The Evidence of the Health Benefits of Physical Activity

The UK guidelines were drawn up to promote physical activity because of the overwhelming
evidence of the health benefits. The following chapters present the evidence of the main health
benefits in brief key messages for undergraduate health professionals. This evidence summary was
initially drawn from the 2011 updated UK Physical Activity Guidelines supporting documents,1, 2 the
British Association of Sport and Exercise Scientists consensus report 3 and large scale reviews from
USA, 4 Canada,5 Sweden, 6 and Denmark ,7 which have used major systemic reviews, meta-analysis
and consensus statements to reach their conclusions. Major reviews up to July 2015 have now been
included.
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Chapter 2 Cancer

Cancer develops at a cellular level influenced by genetic, environmental and lifestyle factors via a
number of interacting biological mechanisms.
A sedentary lifestyle is now widely recognised as a key component in the risk factors of several
cancers.
There is clear data for the positive effects of physical activity both on the prevention of some
cancers and on clinical outcomes after diagnosis.
1. Colon cancer. There is strong evidence that physically active men and women have a 30-40% lower
risk of colon cancer compared to inactive individuals. 1 - 5

 Studies indicate a positive dose-response relationship so that the longer the duration and the
higher the intensity of physical activity, the better the protective effect found for colon cancer.
4

 Likely biological mechanisms of physical activity reducing the risk of colon cancer include a
reduced intestinal transit time, increased insulin sensitivity and cell proliferation of the
intestinal epithelium. 6, 7

2. Breast cancer. Physically active women have a 20-30% lower risk of breast cancer, with the
evidence strongest in post menopausal women. 1 - 5

 Likely mechanisms include the impact of physical activity on the metabolism of sex hormones.
High oestrogen levels are associated with breast cancer and physical activity reduces the
cumulative oestrogen dose that women experience via a number of pathways. 4

3. Endometrial cancer. There is moderate evidence of a 30% lower risk of endometrial cancer. 2- 4, 8

 High levels of oestrogen are also associated with uterine cancers. A potential mechanism for
the lower risk with increased physical activity is the lower lifetime accumulation of oestrogen.
Increased insulin sensitivity is also thought to contribute. 4

4. Prostate cancer. There is moderate evidence of a lower risk of high grade prostate cancer, but
with higher doses of activity required. 4, 5

 30 minutes or more of walking or cycling per day during adult life is associated with a reduced
incidence of prostatic cancer. Compared to those who did 30 minutes of walking or cycling
per day, every additional 30 minutes reduces the risk of prostate cancer by 7%. 9
 Plausible mechanisms include the effect of physical activity on testosterone and insulin
sensitivity. 4

5. Lung cancer. There is some evidence of a lower risk of lung cancer, but the problems of adjusting
for the risk factor of smoking makes it difficult to draw firm conclusions. 2, 4
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 Potential mechanisms relate to how physical activity affects the time that potential
carcinogens are in contact with lung cells through improved blood capacity and blood flow.
6. Oesophageal cancer. There is emerging evidence based on meta-analysis of observational studies
that the risk of oesophageal adenocarcinoma may be 21-32% lower in the most physically active
people compared to the least.10, 11 It remains unclear which type, intensity, frequency and time
period of physical activity is required to achieve a risk reduction.

7. Gastric cancer. Meta-analysis of observed studies has also suggested that gastric cancer risk may
be 13-28% lower in the most physically active people compared to the least.10,12,13,14 As with
oesophageal cancer, the evidence of required doses of physical activity are needed to prove the
observed associations.

Physical activity pre treatment: Pre surgical exercise, through aerobic, resistance or pelvic floor
training, may benefit cancer patients through effects on function and cardiovascular and pulmonary
fitness with significant improvements shown in: 15

 Rates of incontinence in prostate cancer

 Functional walking capacity
 Cardiorespiratory fitness

Physical activity during treatment: Although patients often feel unwell before or during treatment
for cancer, we know that physical activity during treatment: 16 - 19

 Significantly improves fitness and muscle strength

 Shows small improvements in anxiety levels and self esteem
 Shows no worsening of fatigue levels and some small evidence of an improvement
 Increases lean muscle mass
 Improves arm function with no worsening of lymph oedema in breast cancer patients

Physical activity after treatment: Patients often experience loss of physical function as a result of
their cancer treatments, but evidence shows that physical activity after treatment can improve
several aspects: 16, 17, 20

 Increase in fitness and muscular strength

 Reduced fatigue
 Improvements in quality of life, anxiety and depression
 Some reductions in body fat and increase in muscle mass

Physical activity has been shown to improve cancer patients’ quality of life during both the
treatment and rehabilitation phase and should therefore be encouraged. 7, 9, 21 - 24

Physical activity and survival rates: A number of recent studies have looked at whether physical
activity benefits actual cancer survival, something that had previously been uncertain. There are
three meta-analyses available on either breast, 25 colon26 or both types of cancer. 27 Each has shown
an inverse relationship between physical activity and mortality in patients going on to develop
breast or colon cancer. With survivors of breast and colon who increased their physical activity from
any level from pre to post diagnosis, a decreased mortality risk of 39% was shown. 27
 9

NICE guidelines CG80 (2009)28 and CG81 (2014)29 back up the advice to patients with early and
advanced breast cancer, that we should provide the information and access to an exercise
programme to help with cancer related fatigue, lymph oedema and quality of life.

Safety considerations during and after treatment 30

To avoid symptom exacerbation

• Modify exercise
• Start moderately and progress slowly
During immunosuppression
• Avoid high load/intensity
• Monitor bloods
To prevent falls
• Practice balance exercises
• Practice strength exercises
For patients with lymph oedema
• Progress slowly
• Wear compression garments

Contraindications
Disease or treatment causing Hb < 80 g/L, wbc < 0.5x109/L , or platelets < 60 x 109 (4)
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Chapter 3 Cardiovascular Health

 Ischaemic heart disease

Primary prevention: There is a clear inverse relationship between physical activity and
cardiovascular disease which is dose responsive. The reduction in cardiovascular mortality is of the
order of 20-35%, depending on the level of physical fitness. 1
Mechanisms which contribute to this effect are multiple: 2,3

 Direct actions on the heart (increasing myocardial oxygen supply, myocardial contraction
and electrical stability)
 Increased high density lipids
 Decreasing harmful low density cholesterol
 Lower blood pressure
 Decreased blood coagulability
 Improved insulin sensitivity
Secondary prevention: in established heart disease, regular adapted exercise is required to reduce
mortality, and habitual physical activity has been shown to reduce all-cause mortality by 25-30%. 4
The evidence of cardiac rehabilitation if it is used, is associated with a reduction in morbidity, cardiac
mortality (26-36%), total mortality (13-26%) and reduces hospital readmissions (28-56%).5 Despite
this, 55% of adults in the UK having had a cardiac event do not attend cardiac rehabilitation exercise
programmes. 6

NICE guideline CG172 on secondary prevention for patients following a myocardial infarct 7
recommend:

 Offer cardiac rehabilitation programmes designed to motivate people to attend and

complete the programme. Explain the benefits of attending
 Patients should be advised to undertake regular physical activity sufficient to increase
exercise capacity
 They should be advised to be physically active for 20-30 min a day to the point of
breathlessness
 Patients not achieving this should be advised to increase their activity in a gradual step-by-
step way, aiming to increase their exercise capacity
 They should start at a level that is comfortable, and increase the duration and intensity as
they gain fitness
 The benefit of exercise may be enhanced by tailored advice from a suitable qualified
professional

Contraindications
Heart disease: Acute myocardial infarction or unstable angina until stable for at least 5 days,
dyspnoea at rest, pericarditis, myocarditis, endocarditis, symptomatic aortic stenosis. 8, 9
 11

 Heart failure

Trials support the evidence of the beneficial effect of physical activity training in patients with stable
heart failure in NYHA class I, II and III. 8, 10, 11

Although there is no evidence of increased or decreased all cause mortality in the short term (up to
12 months), the benefits of exercise have been shown by meta-analysis to;11, 12, 13
 Physiologically increase VO2 max
 Functionally increase walking speed and tolerance
 Significantly reduce hospital admissions

Improve quality of life.

And have an emerging trend towards reducing mortality in trials longer than 1 year. 11

NICE guideline CG 10 14 on chronic heart failure recommend:

 Offer a supervised group exercise-based rehabilitation programme designed for patients
with heart failure
 Patients should be stable
 This can be incorporated within an existing cardiac rehabilitation programme

Contraindications
Heart failure which is uncontrolled or NHHA class 1V 10

 Hypertension

The evidence supports an inverse relationship between physical activity and the incidence of
hypertension. Apart from prevention, it is also effective in treatment with clinically relevant
reductions in blood pressure.

 The acute effect of physical activity causes a decrease in blood pressure lasting 4-10 hours,
but may last up to 22 hours; thus daily activity may achieve clinically significant
improvement 1, 15
 For a long term effect, regular exercise is required
 The effect seems to be greatest in those with established hypertension
 Inactive individuals have a 30-50% increased risk of hypertension 16
 Review data support the observation that physical activity training in hypertensive patients
can show a reduction of 7 / 5 mmHg in systolic and diastolic blood pressure respectively 17
 The main recommendation is for aerobic fitness training but dynamic resistance and
isometric resistance at moderate intensity training is also beneficial 18, 19, 20
 Reductions of this magnitude have important clinical implications
1. They are of a similar magnitude to conventional medication
2. A 2mmHg reduction in systolic blood pressure is associated with reductions of 10% and
7% in the risks of stroke and coronary heart disease respectively 21
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Pharmacology v physical activity

There is plenty of strong randomized controlled trial data showing reductions in stroke risk in those
taking antihypertensive medication.22 There is less evidence that they significantly reduce the risk of
all-cause mortality and myocardial infarction, with the exception of thiazide diuretics and
angiotensin-converting enzyme inhibitors. 23 However, there is strong prospective cohort evidence
that regular physical activity can reduce the risks of all-cause mortality and cardiovascular
mortality.24

The comparison of the mortality and morbidity risk reduction between long-term antihypertensive
medication and physical activity is made below and reinforces of the need for physical activity as a
treatment in hypertensive patients.23

Table 1: Mortality and morbidity risk reductions with long-term anti-hypertensive medication and
physical activity 23

Intervention Cardio-vascular Myocardial

All-cause mortality
mortality infarction

ACE-I * 10% 19% NR

Thiazide * 9% NR 22%

β-blocker * 6% (NS) NR 8% (NS)

Ca2+ channel blockers * -6% (NS) NR 29% (NS)

Regular physical activity

29% 30% NR
(self-reported) #

Regular physical activity

41% 57% NR
(fitness tests) #

NS: Not significant; NR: Not reported. *: Randomised control trials. #: Prospective cohort studies

NICE guideline CG127 25 on the clinical management of primary hypertension in adults recommends
that appropriate guidance and written or audiovisual materials to promote lifestyle changes are
offered.

Contraindications
Blood pressures of a systolic >180 or diastolic >100 or higher should receive medication before
regular physical activity 9, with particular restrictions on heavy weights strength conditioning
which can create particularly high pressures. 19

 Lipids
 13

Isolated hypercholesterolaemia and mixed dyslipidaemia with high LDL cholesterol, high triglycerides
and low HDL cholesterol are associated with an elevated risk of atherosclerosis.

Aerobic fitness training has been shown to be beneficial in reducing triglycerides 26, 27 and elevating
the protective HDL cholesterol, 28 with some effect in also lowering LDL cholesterol. 26

Best results are achieved with regular daily moderate intensity aerobic exercise or vigorous exercise
at slightly higher volumes of the present UK guidelines, expending 1200-2000 kcal per week which
equates to 360 minutes moderate activity per week. This workload is associated with a 5-8%
increase in HDL cholesterol and a decrease in triglycerides of approximately 10%. 29 It should still
supplement other interventions.

 Peripheral Arterial Disease

Risk factors for peripheral arterial disease (PAD) are similar to cardiovascular disease and are an
important marker of overall cardiovascular disease, with about 65% of patients with PAD also having
clinically relevant cerebral or coronary artery disease. 30

There is a strong consensus view that physical training in the form of walking is important in the
management of peripheral arterial disease. 30, 31 This is important as the disease responds poorly to
pharmacotherapy. 30 Three large reviews concluded that physical exercise increased the walking
distance to the onset of pain by 179% or 225m and the maximum walking distance by 122% or
398m. 32, 33, 34

NICE guideline CG 147 on lower limb peripheral artery disease recommend: 35

 Offering a supervised exercise programme to all patients with intermittent claudication.

 Consider providing a supervised exercise programme which involves:
1. 2 hours of supervised exercise a week for a three month period
2. Encouraging people to exercise to the point of maximal pain

Exercise should continue lifelong, with expected improvement in walking distance with higher
quality of life and reduced pain. It may also slow the progression of further atherosclerotic disease.

 Stroke

Primary prevention: the benefits of physical activity on the prevention of stroke are well
documented. 1, 8, 36, 37, 38 Risk factors for stroke include hypertension, type 2 diabetes and
hyperlipidaemia all of which are beneficially affected by physical activity. It is not surprising then
that there is a clear inverse relationship between activity and risk of stroke. It is also clearly dose
dependent and depending on the amount of activity, the effect is a 20 - 35% lowering of risk. 39

Secondary prevention: the adverse vascular disease profile of many stroke patients remains after a
first stroke and, physical activity should continue to be encouraged.
 14

Treatment: there is a huge variation in the degree of disability after a stroke. Once stabilized, an
individualised aerobic fitness training programme can increase the endurance for day to day
activities. This can improve self confidence of patients to take part in physical activity themselves. 40
Similarly, muscle strengthening of the lower limbs has been shown to increase function thereby
improving quality of life. 38

NICE guideline CG 162 on stroke rehabilitation recommend: 41

Strength training:
 Consider strength training for people with muscle weakness after stroke
 Include progressive strength building through increasing repetitions of body weight activities
(for example, sit-to-stand repetitions), weights (for example, progressive resistance
exercise), or resistance exercise on machines such as stationary cycles
Fitness training:
 Encourage people to participate in physical activity after stroke
 Cardiorespiratory and resistance training for people with stroke should be started by a
physiotherapist
 Aim that the person continues the programme independently based on the physiotherapist's
instructions
 Physiotherapists should supply any necessary information about interventions and
adaptations so that where the person is using an exercise provider, the provider can ensure
their programme is safe and tailored to their needs and goals
Walking therapies:
 Offer walking training to people after stroke who are able to walk, with or without
assistance, to help them build endurance and move more quickly
 Consider treadmill training as one option of walking training for people after stroke including
those who require body support
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Chapter 4 Type 2 Diabetes

It is well known that physical inactivity is a major risk factor for developing type 2 diabetes. 1

Primary prevention: many studies have shown that type 2 diabetes can be prevented in high risk
(obese) patients by taking regular exercise and following dietary guidelines. 2, 3 In all, there have
been four major trials of diabetes prevention with intensive lifestyle counselling in China, 4 Finland,2
India 5 and the US.6 In the largest trial,6 the US Diabetes Prevention Program, high risk individuals
were assigned to a placebo control, a lifestyle intervention (which included aerobic activity of at
least 150min/week) or a third group who were given metformin 850mg twice daily. Lifestyle advice
was nearly twice as effective in preventing diabetes compared to metformin drug therapy in high
risk individuals (58% v 31% reductions in incidence) over 3 years of study. 6

In three of these trials there was a 40-60% relative risk reduction in the incidence of diabetes in the
lifestyles intervention group. This translates into one case of diabetes being averted by treating
around seven people with glucose impairment for three years. 7, 8, 9 In the Indian study the relative
risk reduction of diabetes was a little lower at 28.5% but the Indian population was generally
younger, with a relatively lower BMI and higher insulin resistance. 5 The long term follow up studies
show that lifestyle interventions delayed on average the onset of diabetes by two to four years
rather than preventing it totally.8, 9, 10

In the treatment of type 2 diabetes, regular physical activity remains a major part of treatment,
alongside dietary and pharmacological interventions. Aerobic training remains the mainstay of
treatment, but benefits also occur with strength training and are greatest when combined. 11 A
meta-analysis comparing physical activity advice against structured exercise training consisting of
 16

aerobic exercise, resistance exercising or a combination, showed all were associated with a
reduction of HbA1c. 12 Longer programs than the recommended 150 minutes per week were
associated with a greater reduction of HbA1c. 12 This study also confirmed physical activity is
associated with lower HbA1c but only when combined with dietary advice.12

Physical activity improves insulin sensitivity. It is increased sensitivity to insulin, once achieved, that
is important in obtaining good metabolic control, but physical activity also impacts on lowering the
risk of cardiovascular complications by improving the blood lipid profile, Hba1c, body weight and
lowering blood pressure. 13

Precautions: Hypoglycaemia rarely occurs in diet controlled, metformin or gliptin-treated diabetes

unless any exercise is prolonged or strenuous, such as in marathon running. 14 In patients on
sulphonylureas, glinides or insulin, moderate to vigorous exercise may cause a drop in blood glucose
(sugar) with the effect lasting up to 12 hours post exercise. 15 Those wanting to take prolonged
exercise may need to halve or further reduce oral medication, depending on their blood glucose
levels and will need to monitor themselves more frequently. They should also be able to recognize
the symptoms of hypoglycaemia. Suitable alteration of carbohydrate intake before, during and after
exercise may then be required.

Foot care and exercise: peripheral neuropathy is a common complication of type2 diabetes and
patients with this may have a decreased ability to exercise but a greater need for exercise instruction
and monitoring. Care should be taken to promote safe good foot care by encouraging patients to
check their feet before and after exercise. 16

NICE guideline PH38 on Preventing type2 diabetes: risk interventions for individuals at high risk
recommend: 17
 Give information about increasing physical activity and reducing the amount of time spent
being sedentary
 Consider referring those who want structured or supervised exercise to an exercise referral
scheme or supervised exercise sessions, as part of an intensive lifestyle-change programme
 At least once a year, review the lifestyle changes people at high risk have made
 Raise awareness of importance of physical activity
 Help individuals to find other ways to identify and overcome any barriers to physical activity

Contraindications
Uncontrolled blood glucose of >13 mmol or <5.5 mmol/l, which should be corrected first. 18
Patients with diabetic peripheral or autonomic neuropathy or foot ulcers should avoid weight
bearing exercise.
Any acute illness or infection in a diabetic. 13
 17

Chapter 5 Mental Health

 Depression

There is good supporting evidence for the use of regular moderate intensity physical activity in the
acute treatment of mild to moderate depression1, 2 and in helping reduce the risk of relapse. 2
However, there has been little evidence on the most effective form of exercise with low intensity
exercise appearing to have no effect 3 and in children and young adults different exercise intensities
failing to show any significant effect.4 Physical activity matched to an individual’s preferred intensity
has been shown to improve mental health outcomes and exercise adherence rates. 5. When
preferred intensity exercise was combined with motivational support it improved depression
symptoms severity, quality of life and exercise adherence rates. 6 Advice on exercise should be given
in parallel to antidepressant medication and or psychotherapy treatments. 7

Studies examining whether physical activity might be protective against the risk of depression later
in life have shown a promising positive effect 8. Evidence appears effective from childhood (9-15yrs)
up to twenty years later 9.

NICE guideline CG90 on Depression in adults: The treatment and management of depression in
adults recommend: 7

For people with persistent sub threshold depressive symptoms or mild to moderate depression, one
choice is to offer referral for a structured group physical activity programme which should:

 Be delivered in group with support from a competent practitioner

 Consist typically of three sessions per week of moderate duration (45 minutes to 1 hour) over
10 to 14 weeks (average 12 weeks)

 Anxiety

A lot of studies have evaluated the effect of physical activity on anxiety and many link physical
activity to a consistent reduction of anxiety symptoms 10, 11 This is best seen in state anxiety with less
evidence in trait states 10, 11. But the research remains certainly limited for children and young adults 4
so physical activities may be more effective as an adjunctive treatment for anxiety disorders and
appears less effective when directly compared with antidepressant treatment 12.

 Schizophrenia

Physical activity can play an important role in the treatment of schizophrenia. Physical activity has
been shown to significantly reduce negative symptoms of mental state and improve the control of
positive symptoms13, 14.
 18

The physical health of people with severe mental illness such as schizophrenia, depression and
bipolar disorder is often poor with a high risk of premature death and a shorter life expectancy of at
least 10 years 15, 16. This excess cardiovascular mortality in schizophrenia and bipolar disorder is
attributed in part to the increased modifiable coronary risk factors of: unhealthy diets, obesity,
smoking, diabetes, hypertension and hyperlipidaemia 16, 17. In most of these conditions lifestyle
factors of physical activity plays an important role.

A small number of studies on people with schizophrenia taking part in exercise programs have so far
shown a positive effect on both physical health, quality of life and positive and negative symptoms 14,
15
and therefore increasing physical activity should be advocated 18.

NICE guideline CG 178 on Psychosis and Schizophrenia in adults: treatment and management
recommend: 19

 Before starting antipsychotic medication: an assessment of nutritional status, diet and level
of physical activity
 People with psychosis or schizophrenia, especially those taking antipsychotics, should be
offered a combined healthy eating and physical activity programme by their mental
healthcare provider

 Sleep and psychological well-being

Physical activity has been shown to improve the quality of sleep, 20, 21 whilst many studies have
shown improved well being with physical activity training 22. Improved psychological well being is
also the most common comment made on self reported feedback questionnaires 10.

The Well-being feelings of Exercise

Relaxed Satisfied Clear Minded
Positive Fitter
Calm Worthwhile
Invigorated Healthy
Alive Good

 Dementia

Dementia is a word used to describe a group of symptoms including memory loss, confusion, mood
changes and difficulty with day to day tasks. It encompasses several forms with Alzheimer’s disease
being the commonest and vascular dementia the second. The risk of dementia rises with age, with 1
in 3 people over 65 affected 23.

There is a higher risk of vascular dementia for those with a family history, hypertension, high
cholesterol, smoking and diabetes, with vascular factors being potentially modifiable by physical
 19

activity 24. Up to a third of patients with Alzheimer’s, the disease may also be attributable by
modifiable risk factors, the highest factor being physical inactivity (see diagram) 25.

Physical inactivity

Depression

Midlife hypertension

Midlife obesity

Smoking

Low educational attainment

Diabetes
1.00 1.20 1.40 1.60 1.80 2.00
Relative risk for Alzheimer’s disease 25

There is clear strong evidence that people who follow recommended levels of physical activity have
a reduction in risk of cognitive decline in the order of 18-30% 26, 27, 28. Higher levels of physical activity
are associated with better cognitive function and a 20% lower risk of cognitive impairment in the
highest quartile of activity 29, 30, 31.

A review of exercise programs for this population has demonstrated that exercise can lead to: 32
 A significant improvement in cognitive functioning
 Enhanced mobility
 An improved ability to perform activities of daily function
 A likelihood of reducing the burden on family members
 No adverse effects

The prevention of falls with exercise for the healthy elderly is well established but a recent meta-
analysis suggests that physical activity may also have a positive effect on the prevention of falls in
the older adult with cognitive impairment. 33

NICE guideline CG42 on Dementia recommend: 34

Promoting and maintaining independence of people with dementia. Care plans should always
include: Physical exercise, with assessment and advice from a physiotherapist when needed
 20

Chapter 6 Musculoskeletal Health

 Fibromyalgia

Fibromyalgia consists of a multi symptom syndrome characterized by widespread diffuse treatment-

resistant, non-inflammatory joint and muscle pains of at least 3 months duration. 1 Two common
symptoms are: reduced muscle strength and rapid fatigue with patients typically being unfit. 2, 3, 4

Fibromyalgia is difficult to manage, but physical training combined with cognitive behavioural
therapy has been recognized as being the most promising treatment. 5 Evidence from a meta-
analysis of random controlled trials concluded that aerobic training had a beneficial effect on
fibromyalgia. The highest quality trials show significantly better improvements in the exercise groups
for fitness and tender point pain thresholds. 6

 Osteoarthritis

Contrary to common belief, there is no evidence that regular physical activity promotes the
development of osteoarthritis (OA), provided there is no associated major joint injury. 7

Major joint osteoarthritis is the commonest chronic disease in older people. 8 The evidence is best
for OA of the knee, but studies on hip and hand point to the same conclusions. 8, 9 Once present,
both fitness training and dynamic strength training have been shown to: 10
 Reduce pain
 Improve function

Improve overall well-being.

Aerobic activity is thought to increase endorphin levels which reduce the sensation of pain, whilst
increased muscle strength and improved neuromuscular function improve the stability around a
joint. These factors, coupled with any associated weight control, will help reduce the load through
the joint and hence reduce pain, improve function and improve well-being. 11

Exercise training also reduces pain and improves function (strength, gait, balance) in the absence of
weight loss. A key message about exercise and weight loss is that it is better to talk about fat loss,
as weight loss is often compromised by an increase in lean mass (i.e. muscle mass). For example,
exercise might produce very impressive improvements in body composition, e.g. a 2kg increase in
lean mass and a 2.5kg decrease in fat mass, but an unimpressive overall change in body weight,
tending to discourage patients who are primarily motivated by weight loss and not an improvement
in health.

There appears to be a dose-response relationship where strength and fitness improvements, lead to
better gains. 12, 13 Training is best planned with small but steady increases in load on the joint and
with exercise; there is a greater reduction in pain compared to NSAID treatment occurring after 6-8
 21

weeks of activity. 12, 14 This gives a clear choice of activity over NSAID medication for many patients
and a choice with relatively few side effects.14

Perhaps the greatest incentive for exercise in osteoarthritic patients from 35 upwards with co-
morbidities of cardiovascular disease, diabetes, cancer and walking disability is that they are at
significantly enhanced risk of dying prematurely. 15 It has been suggested even light exercise eg:
moving around the house during commercial breaks for those patients with OA who watch many
hours of TV, might mitigate the risk.16 Practical recommendations have been made regarding specific
exercise prescription in terms of type, duration and delivery and can be discussed by the clinician or
refer to a physiotherapist. 9

NICE guideline CG 137 on Osteoarthritis and management in adults recommend: 17

Advise people with osteoarthritis to exercise as a core treatment irrespective of age, co morbidity,
pain, severity or disability. Exercise should include:
 Local muscle strengthening and general aerobic fitness

 Osteoporosis

Prevention: The peak bone mass is achieved by 20 – 30 years of age, so to achieve maximum bone
mass during adolescence, a balanced diet and multi-activity physical education in schools with
weight bearing exercise needs to be encouraged from early years and even from first walking. 7
Once our peak bone mass is achieved, a gradual bone loss commences and there is now increasing
evidence that physical activity can help prevent the bone loss associated with ageing across the
lifespan of individuals., 18, 19, 20, 21, 22, 23, 24,25

Weight bearing exercise, especially resistance exercise, appears to have the greatest effect on bone
mineral density. 26 There is an inverse relationship of physical activity with the relative risk of hip and
vertebral fracture with risk reduction for hip fracture of 36 - 68% at the highest level of activity. 7

Warning: excessive physical activity can have an unintentional negative effect on bones in girls, who
may develop exercise dependent secondary amenorrhoea and then lose bone most commonly
around a weight of 45kg. 1

Established disease: weight bearing exercise is still encouraged to minimize further bone loss, but
also to help prevent falls 27 and subsequent fractures.25, 28 Balance, strength and coordination
exercise combined with walking is complementary. 1

NICE clinical knowledge summary on Osteoporosis – prevention of fragility fractures 28 recommend:

Advise the person to: Take regular exercise (tailored to the individual) to improve muscle strength
and reduce pain and stiffness:
 Encourage walking, especially outdoors, as this will increase exposure to sunlight, increasing
vitamin D production.
 Encourage strength training of different muscle groups (for example hip, wrist, and spine).

Contraindications
Avoid high impact activities or those with a high risk of falling
 22

 Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterised by reduced joint
flexibility, muscle function and aerobic fitness. There is also an increased risk of cardiovascular
disease, 29 which combined with an increased risk of type 2 diabetes, metabolic syndrome and
osteoporosis and its related fractures, provides a very strong indication for promoting physical
activity in patients with this common condition. In addition, exercise can counter the important
effect of rheumatoid cachexia, whereby 2/3 of patients with controlled RA have significant muscle
wasting and increased obesity. 30 This low muscle mass and adiposity are strong independent
predictors of disability in RA patients 31, 32 and controlling disease activity by standard drug therapy
including ant-TNF therapy fails to restore either muscle mass or reduce fat mass. Consequently there
is a strong case for progressive resistance training in patients with RA. 33, 34, 35

Historically, it has been widely held by many that increasing the level of stress on the joints would
increase pain, disease activity and joint damage 36. However, major reviews on dynamic exercise
therapy, have found a positive effect on aerobic capacity, muscle strength and functional ability. 36,
37,38, 39
Exercise training has been shown to redress the adverse effects of rheumatoid cachexia on
body composition and also to restore normal levels of physical function in established RA patients. 40
Importantly there has been no increase in pain or disease activity and with long term exercise
programs no significant differences in radiological progression were observed. 36

Despite being aware of the importance of exercise, many RA patients are less active than the general
population. 41 Patients’ perceptions of the effects of exercise are a fear of exacerbation of pain,
fatigue and joint damage. 42 They also perceive that health professionals lack exercise knowledge
regarding specific exercise recommendations and the occurrence of joint damage. 42

All patients with RA should be encouraged to be physically active. Low intensity exercise can be
recommended for all patients with RA regardless of their disease state. However, to increase aerobic
function and muscle function the patient needs to be encouraged to progress into moderate to high
intensity exercises, with the knowledge and evidence of improved muscle function and quality of
life 36, 37, 38, 39, 43 without evidence of progression of joint destruction.39, 44

Precautions and considerations:

 Increased physical activity should be introduced slowly to minimize the risk of aggravating
symptoms and in smaller increments than normally recommended.
 Caution also needs to be taken after any cortisone injections and joint replacement surgery
that may not stand up to intense exercise initially.45
 Physical activity programmes should include a range of activity including stretching,
resistance exercises and aerobic conditioning
 High impact activities or contact sports are not recommended

NICE guideline CG79 on Rheumatoid arthritis – The management of rheumatoid arthritis in adults.46
 23

People with RA should have access to specialist physiotherapy, with periodic review to:
 Improve general fitness and encourage regular exercise
 Lean exercises for enhancing joint flexibility, muscle strength and managing other functional
impairments
 Prevention of falls and fracture

In the elderly, with or without other health conditions, diminishing muscle function with or without
coexisting pain can limit daily activity and increase the risk of a fall and fracture. General physical
activity such as walking and cycling is not thought to have any effect of falls prevention. 47 However,
the available evidence for this age is that group and home based programmes with muscle
strengthening and balance reduces the rate of falls and risk of falling. 48 Tai Chi has been also shown
to reduce the risk of falling and overall exercise interventions significantly reduced the risk of a falls
related fracture. 48

Although most evidence on fall prevention has been with cognitive healthy elderly people, recent
evidence supports the evidence that physical activity also has a positive effect in the prevention of
falls in the elderly with cognitive impairment. 49

Strength training may need to precede walking exercise to make the physical activity possible. In the
elderly two decades of loss of strength and muscle mass can be regained by two months of strength
training. 50

Identifying the optimum characteristics of an exercise intervention for falls prevention has been
assessed on present research and it is thought that: 51

 Exercising for a minimum of 1 hour/week for at least 40 hours of an intervention programme

is required to reduce the risk of falling
 The optimum frequency of exercise is three times a week, but duration time of a session
remains unclear

Balance training should be of moderate to high challenge 52
 Strength training is most effective when combined with balance training

NICE guidance CG161 on Falls: assessment and prevention of falls in older people recommend: 53

 Multifactorial interventions with an exercise component are recommended for older people in
extended care settings who are at risk of falling.
 A muscle-strengthening and balance programme should be offered
 This should be individually prescribed and monitored by an appropriately trained professional
 There is no evidence that brisk walking reduces the risk of falling; however, there may be
other health benefits of brisk walking by older people
 24

Chapter 7 Obesity

Overweight and obesity are defined as ‘abnormal or excessive fat accumulation that may impair
health’. 1 Using Body Mass Index (weight (kg) / height2 (m) )(BMI) overweight is classified as a BMI of
25-30 and obesity as >30.

Obesity is a major risk factor for many non communicable diseases (NCD) such as: 1
 Cardiovascular disease (mainly heart disease and stroke)
 Diabetes
 Musculoskeletal disease (mainly osteoarthritis)
 Some cancers (mainly colon and breast) 2

Childhood obesity is associated with a higher chance of obesity, premature death2 and disability in
adulthood.1,2 However, in addition to future risks,3 childhood obesity is associated with considerable
emotional and behavioural problems including in boys, conduct problems, hyperactivity and
inattention problems, peer relationship problems, prosocial behaviours and total social difficulties. 4

Weight loss in obesity has been associated with improvements in most cardiometabolic factors, 5
whilst significant weight loss (>5% of baseline weight) has been shown to be more effective in
reducing cardiac and diabetic risk factors, and even death rates. 6, 7

Weight gain: An increase in weight is affected by the amount of energy expended verses the amount
of calories consumed. 8 If energy expended is low and diet consumption excessive then weight gain
will occur.

Physical activity alone or with diet: There is no strong evidence that physical activity of 150 minutes
or less a week, on its own achieves any significant weight loss. 9,10 Without a dietary plan involving
calorific restriction individuals will experience weight loss in a range of nil to no more than 2kg. 10, 11
Exercise when combined with diet plans may result in a slight greater weight loss than diet alone 10
but the amounts are small and confirm that the majority of weight loss is to be gained from the
calorific restriction.11

Physical activity and increased intensity: Significant weight loss can occur with aerobic exercise
without calorific restriction, but it requires a high exercise volume of the order of >225 minutes a
week. For the majority, these levels may not be practical or achievable. 12 Physical activity and
prevention of weight gain: To prevent the shift from normal weight to overweight and obesity, it is
recommended that levels of 150-250 min/week of moderate to vigorous physical activity are
required.12

Physical activity and weight maintenance: After successful weight loss physical activity levels of
200-300 min/week should be maintained to avoid regaining weight. 12 NICE guidelines suggest even
higher levels of 300-450 min/week.13
 25

Aerobic exercise or resistance training and weight loss: Aerobic exercise is most beneficial by virtue
of energy expenditure and health benefits of important risk factors. 11 There is little evidence that
resistance training alone produces any significant weight loss. 11 However, resistance strength
training has also been shown to maintain overall health, muscle strength (preventing sarcopenia),
preserve bone strength 14 and reduce mortality in men. 9, 15

THE REAL HEALTH MESSAGE OF PHYSICAL ACTIVITY IN OBESITY: It is very important to stress that
aerobic physical activity offers substantial health benefits even if weight loss is not achieved, 10 as
patients often have unrealistic weight loss expectations. 16 However, weight loss is still
recommended in obese patients to reduce the risk of NCD’s and premature death. 5, 6

Many trials of exercise therapy have reported little or no weight loss (<5kgs) but still have reported
many health benefits including: 10
 Endothelial function 17
 Lipoprotein particle size 18
 High density lipoprotein 19
 Triglycerides
 Improved cardiovascular fitness 20
 Lower blood pressure
 Glucose control
 Quality of life 21, 22

Exercise may produce impressive improvements in body composition, e.g. a 2kg increase in lean
mass and 2.5kg decrease in fat mass but with an unimpressive change in total body weight which
might discourage patients who are often primarily motivated by weight loss. This is the key concept
to get across to overweight patients, that they can reduce their disease potential if they are active,
compared to an inactive individual of similar weight.

An example of this is a study of 58 sedentary and overweight men who undertook a supervised
aerobic exercise programme for 12 weeks. 23 The mean reduction in weight was 3.63kg. However, 26
of the 58 failed to achieve predicted weight loss and only had a mean weight loss of 0.9kg. However
other health parameters showed the following significant findings:

 Increased aerobic capacity (6-3 ml/kg/min, p<0.01)

 Deceased systolic blood pressure (-6 mm Hg, p<0.05)
 Decreased diastolic blood pressure (-3.9 mm Hg, p<0.01)
 Decreased waist circumference (-3.7 cm, p<0.01)
 Decreased resting pulse (-4.8 bpm, p<0.001)

In addition, these individuals experienced an acute exercise induced increase in positive mood. An
example case study is shown in Case histories 3 in Resources.

Advice to obese individuals must be realistic as they are often unfit and have coexisting co-
morbidities present. Be aware of the effort required to lose weight, what is a reasonable expectation
of weight loss and of the stigma patients that may be felt by overweight or obese. 24
 26

Small steps in gained activity through everyday changes should be encouraged and maintained even
if more formal physical activity remains difficult. See The Paradigm of Sitting. Guidance on managing
the overweight and obese has been summarized in NICE guidelines and the areas relative to physical
activity are summarized below.

NICE clinical guidance CH 189 on managing overweight and obesity in adult’s recommend: 13

Encourage adults to increase their level of physical activity even if they do not lose weight as a
result, because of the other health benefits it can bring (for example, reduced type 2 diabetes and
cardiovascular disease).

Encourage adults to do at least 30 minutes of moderate or greater intensity physical activity on 5 or

more days a week. The activity can be in 1 session or several lasting 10 minutes or more.

Advise that to prevent obesity most people have to do 45-60 minutes/day of moderate-intensity
particularly if they do not reduce their energy intake. Advise people who have been obese and lost
weight that they may need to do 60-90 minutes/day of moderate-intensity physical activity to avoid
regaining weight once lost.

Encourage adults to build up to the recommended activity levels for weight maintenance, using a
managed approach with agreed goals. Recommend types of physical activity, including:
 Activities that can be incorporated into everyday life, such as brisk walking, gardening or
cycling
 Supervised exercise programmes
 Other activities, such as swimming, aiming to walk a certain number of steps each day, or
stair climbing

Take into account the person’s current physical fitness and ability for all activities. Encourage people
to also reduce the amount of time they spend inactive, such as watching television, using a
computer or playing video games.

NICE clinical guidance CH 189 on managing overweight and obesity in children recommend: 13

Encourage children and young people to increase their level of physical activity, even if they do not
lose weight because of reduced risk of type 2 diabetes and cardiovascular disease.

Encourage children to do at least 60 minutes of moderate or greater intensity physical activity

each day.
 Can be split into several sessions
 Be aware children already obese may need to do more than 60 min/day
 The activity can be in 1 session or several sessions lasting 10 minutes or more
 Encourage children to reduce inactive behaviours, such as sitting and watching television or
playing video games
 Give children the opportunity and support to do more exercise in their daily lives
 Give children the opportunity and support to do more regular, structured physical activity
 Make the choice of activity with the child, and ensure it is appropriate to the child’s ability
and confidence
 27

Summary
 No strong evidence that physical activity of 150 minutes a week, on its own achieves any
significant weight loss
 High levels of physical activity are required to lose weight alone
 45-60 minutes/day of moderate-intensity physical activity required to prevent weight
gain
 60-90 minutes/day of moderate-intensity physical activity to avoid regaining weight
once lost
 Weight loss with physical activity is best when combined with dietary & behavioral
interventions

Adults, who find it difficult to maintain their weight, should be encouraged to:
 Reduce energy intake
 Minimise sedentary behavior
 Work on progressively increasing their physical activity, initially up to and then past 30
minutes up to 60 minutes a day or more.
 Aerobic physical activity offers substantial health benefits even if weight loss is not
achieved
 28

Chapter 8 Chronic Obstructive Pulmonary Disease (COPD)

COPD leads to damaged airways and lung tissue resulting in obstruction to airflow and consequently
dyspnoea. As COPD progresses, patients have increasing dyspnoea which often makes them anxious
about moving and becoming more sedentary. 1 This in turn causes a decreasing cardiovascular
capacity and reduced peripheral skeletal muscle strength, contributing to a worsening functional
level, which in turn exacerbates their dyspnoea. 2 From a patients perspective this creates a vicious
cycle of inactivity.3

You feel breathless

Weak muscles use You become fearful of

more oxygen and are activity that makes you
less efficent breathless

The vicious cycle of

inactivity3

You avoid those

Your muscles become
activies which make
weaker
you breathless

You do less activity

Conversely, physical exercise training programmes have clearly shown patients can become less
afraid of exerting themselves and more physically active. 4, 5, 6, 7 The effect is largely on muscle and
mental well being. By improving their cardio respiratory muscles and peripheral skeletal muscle,
exercise programmes have shown patients can have: 5,6,7,8,9,10,11,12,13

 a better quality of life

 increased well-being
 fewer symptoms of fatigue and dyspnoea
 29

 an increase in exercise tolerance

 an increase in physical activity levels
 a reversal of COPD associated wasted muscles or sarcopenia in select patients
 lower morbidity with fewer hospital admissions

Physical activity programmes however, have not been shown to affect a change in lung function. 5

Physical activity is important for all patients with COPD as their physical activity level has been
shown to be the strongest predictor of all-cause mortality 14 Thus, NICE recommendations15 are for
all patients with a Medical Research Council (MRC) dyspnoea grading 3-5 who are functionally
breathless, should be offered outpatient pulmonary rehabilitation. Whilst the British Thoracic
Society guidelines 16 also includes patients with a MRC grading of 2 who are functionally breathless.
However, all patients with level 1-2 should also be encouraged to increase their activity to slow their
decline in pulmonary function and progression of COPD 17 with evidence that community based
programmes can also help. 18

Grade Degree of breathlessness related to activities

1 Not troubled by breathlessness except on strenuous exercise

2 Short of breath when hurrying on the level or walking up a slight hill

3 Walks slower than most people on the level, stops after a mile or so, or
stops after 15 minutes walking at own pace

4 Stops for breath after walking about 100 yards or after a few minutes on
level ground

5 Too breathless to leave the house, or breathless when undressing

NICE guidelines CG101 on Chronic obstructive pulmonary disease recommend: 15

 Pulmonary rehabilitation should be available to all appropriate people with COPD, including
those with recent hospitalization for an acute exacerbation
 Pulmonary rehabilitation should be offered to all patients who consider themselves
functionally disabled by COPD (MRC grade 3 and above)
 The rehabilitation process should incorporate a programme of physical training, disease
education, nutritional, psychological and behavioral intervention

Contraindications
Exercise should be stopped or modified with O2 saturation of 88% or less 2
 30

Chapter 9 Exercise during Pregnancy

Many pregnant women are concerned about the effects of exercising during pregnancy, but there is
clear evidence that moderate physical activity is not only safe, but also beneficial for both mother
and baby. 1, 2 The recommendation from the Royal College of Obstetricians and Gynaecologists 1 is
that pregnant women should do 30 minutes of moderate intensity exercise most days of the week.

Benefits of Exercise during Pregnancy 3

For the woman reduced…

• tiredness, varicose veins, ankle swelling and breathlessness
• risk of developing gestational diabetes 4
• excessive maternal weight gain
• risk of pre-eclampsia 5
• rate of pelvic and low back pain
• reduced labour time
• stress, anxiety and depression
For the baby…
• Potentially reduced chance of foetal distress during delivery
• May help to enhance brain development during infancy
 31

1. Pre Exercise Evaluation Box 1: Cautions and Contraindications to exercise

There are very few absolute Pregnancy related…

contraindications to exercise during • Incompetent cervix
pregnancy and these are mostly related • Persistent bleeding in the 2nd or 3rd trimester bleeding
to the pregnancy itself e.g. risk of • Placenta praevia after 26wks
premature labour or presence of pre- • Premature labour during current or previous pregnancies
eclampsia. However there are a number • Ruptured membranes
of medical conditions where women • Pre-eclampsia/pregnancy induced high blood pressure
• Multiple gestation at risk of premature labour
need to be cautious and specialist input
• Restricted growth of the baby during current pregnancy
may be required 1 (box 1). In addition,
Medical…
any woman undertaking exercise for the • Significant heart or lung disease, poorly controlled
first time should be screened in the hypertension
usual way to consider any risk factors • Haemoglobin <10
from their general health e.g. by using • Poorly controlled Type 1 diabetes, epilepsy or
PAR-Q as a starting point.6 hyperthyroidism
• BMI >40 or <12
• Severe back, pelvic or other joint pains

2. Risk Management

Outside the conditions listed, there is no evidence that there is an increased risk of complications for
the mother or the baby if the woman exercises during her pregnancy; however, there are a few
types of exercise that should be avoided (box 2).

The babies of mothers who exercise regularly throughout their pregnancy or have strenuous physical
jobs may be born slightly smaller (but still of a healthy weight). However, the evidence is mixed on
this point 7.
 32

2.1 Hyperthermia (>39.2°C): During the first trimester in particular, hyperthermia can increase the
risk of developmental problems (e.g. spina bifida). There is no evidence that becoming slightly warm
during exercise can cause this, however, the woman should be advised to not become
uncomfortably hot. Keeping hydrated will help.
Box 2: Type of Exercise to Avoid
2.2 Advise to stop exercising if there is:
• Chest pain, palpitations, presyncope or dizziness, • Scuba diving
excessive breathlessness • Exercising at high altitude (>6000feet)
• Painful uterine contractions / preterm labour, • Exercising in hot temperatures
abdominal pain especially accompanied with back (including Bikram yoga)
• Exercises lying on your back after 16
and/or pubic pain
weeks
• Amniotic fluid leakage, PV bleeding
After first trimester:
• Reduced foetal movement
• Contact sports e.g. rugby, martial arts
• Pelvic pain (unless practiced alone)
• Headache • Sports where there is a risk of falling
• Calf pain or swelling e.g. riding, skiing
• Excessive fatigue • Sports where there is a risk of being
• Muscle weakness hit in the abdomen by equipment e.g.
tennis, squash
3. ‘F.I.T.T.’ For Pregnancy
As with any exercise advice, consider the woman’s exercise history and preferences. If they are used
to exercising, then they can probably just adapt what they are already doing. During the first
trimester morning sickness and fatigue may limit exercise ability but otherwise women can do most
of what they have done previously. In later trimesters they may need more modifications, but most
women will naturally reduce the intensity and impact of the exercise as it becomes more
challenging.

FREQUENCY – most days of the week

INTENSITY – moderate; an easy way of monitoring the intensity is telling the woman that they
should still be able to talk but their sentences will be shorter. Those women who are training more
seriously may be used to monitoring their heart rate in which case they should be advised to work at
50% - 70% of their heart rate max. However there is no indication for someone to start monitoring
their heart rate just because they are pregnant.
TYPE – mixture of cardio, strength and stability, for example;
• Swimming / aqua aerobics (water temp not >32deg)
• Walking
• Jogging / running
• Yoga / Pilates / pelvic floor exercises
• Gym and gym classes (inform the instructor)
• Dancing etc
TIME – 30-60 minutes

3.1 Advice for those not used to exercising regularly prior to becoming pregnant; walking is a
good way to start. Begin with 10 minute walks every other day and then build up to 30 minutes on
 33

most days at a moderate intensity. Once they are used to doing some walking on a regular basis they
can add in other types of exercise.

3.2 Modifications and Considerations:

 Due to the production of relaxin, ligaments around the spine, hips and pelvis will soften in
preparation for delivery so reducing their stability and potential increasing the risk of injury.
Stability exercises (e.g. Pilates – as long as it is modified for pregnancy by an experienced
instructor) will help to counter this. Also, this softening will effectively increase a woman’s
flexibility so to protect their joints they should not stretch beyond their normal range.
 Avoid exercising lying supine or standing still for long periods after 16/40 weeks due to
venous compression and pooling7.
 The combination of increasing lumbar lordosis and weight puts more strain on the joints,
especially in the back and pelvis. In addition as the pregnancy progresses, stress
incontinence will become more likely (prevalence 32-64%8). Stability and pelvic floor
exercises will help to protect against this; back and pelvic pain is not inevitability during
pregnancy (prevalence 45%9). As the woman progresses through the second and third
trimesters they should reduce the amount of any weights they are lifting.

4. Post Partum Exercise Advice Box 3: Restarting Exercise Post Partum

Hormone levels remain high for at least 4 to 6 weeks after Uncomplicated vaginal delivery (ie no
delivery meaning ligaments will still be relatively soft, forceps/suction, no tearing)…
increasing the risk of injury. These effects will last longer  Pelvic floor exercises and walking as soon as
feels ready
if the woman is breast feeding. Coupled with recovery
 Increase walking gradually, e.g. 10 - 30
from the birth and fatigue from caring for a new born,
minutes a day, low to moderate intensity
regular training should not be restarted for 6 weeks after
 Add in other exercise when feels ready and
delivery (longer if there were complications) (see box 3).
after 6 week check
Pelvic floor exercises should be restarted as soon as Complicated vaginal delivery / Caesarean-
possible and when feeling ready the woman can start section…
going for short walks (before 6 weeks if they want to).  Pelvic floor exercises as soon as feels ready
 After 6 week check and when feels ready,
gradually build up activity levels, starting
with walking

Chapter 10 Surgery and Exercise

The evidence for physical activity and health is well established across many areas which may
prevent or affect surgery: 1

 All cause mortality – 30% risk reduction comparing most active with least active
 Risk reduction of hip fracture is up to 68% at the highest level of activity
 34

 Lower risk of falls and fractures in elderly patients who regularly participate in physical
activity
 Colon cancer – 30% lower risk in those who are active
 Breast cancer – 20% lower risk in those who are active
 Cardiovascular disease – 20-35% lower risk of cardiovascular disease, coronary heart disease
and stroke

There is emerging evidence that exercise both pre and post surgery improves surgical outcomes and
reduces in patient times in hospital. Surgical patients increasingly have complex medical co-
morbidities that may predispose them to post operative complications after surgery, delayed
discharge and surgical survival rates. 2, 3

It has been shown that poor preoperative physical performance increases the risk of complications
after major non cardiac surgery 4, 5 and prolongs recovery after abdominal surgery. 6 There is also
strong evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of
complications in the postoperative period in several settings. 7-13

The assessment of CRF preoperatively has been shown to offer significant advantage when
compared to age alone in predicting mortality after major surgery. 14 This same study also showed;
firstly, CRF to be a significant independent predictor of length of stay in hospital with patients older
than 75 and secondly a low CRF to be associated with a median of 11 days longer in hospital and 2
days longer in critical care.14

Another study of pre-operative fitness and outcomes after major abdominal surgery also showed
that physical fitness was an independent predictor of postoperative recovery in addition to
conventional predictors of age and co-morbidities. 15 Prediction models for mortality, discharge
destination and length of hospital stay were once again all significantly improved by the physical
activity and fitness factors.

With the increasing evidence of benefits of better preoperative CRF, it follows that a reasonable
intervention for improving surgical outcomes is to introduce exercise training preoperatively.

However in a major review 16 of the many studies which have looked at a preoperative training
aerobic training intervention, the frequency, duration, intensity of exercise and outcomes have
varied considerably. Also the period between a patient being listed and their operation may be very
limited, for instance in cancer patients. As a result, evidence for improved postoperative clinical
outcomes after preoperative aerobic training interventions is presently limited. 16 However, several
useful points are already apparent:


The largest random controlled trial found a reduced hospital and intensive care length of
stay in the intervention group. 17
 Preoperative aerobic training improved at least one reported measure of fitness in the
majority of studies
 Preoperative aerobic training benefited or maintained health related quality of life
 Preoperative aerobic training appears to be both feasible and safe
 35

In the area of cancer surgery, aerobic exercise programs undertaken prior to surgery have mainly
shown improved function and physical capacity. 18 But patients often now require neo-adjuvant
chemo and radiotherapy before major rectal cancer surgery, which can reduce physical fitness,
potentially increasing their complications. However, in a recent and important intervention study it
has been shown that structured exercise intervention post chemo radiotherapy is both feasible and
can restore fitness to baseline levels again. 19 This work correlates with the evidence found in the
cancer section on this website where physical activity has been shown to improve function before,
during and after treatment for cancer. It has also been shown to reduce mortality risk in breast and
colon cancer.20

There are no specific NICE guidelines on surgery itself but for vascular surgeons NICE guideline
CG147 on lower limb peripheral arterial disease recommend: 21

 Offering a supervised exercise programme to all patients with intermittent claudication.

 Consider providing a supervised exercise programme which involves:
3. 2 hours of supervised exercise a week for a three month period
4. Encouraging people to exercise to the point of maximal pain

Conclusions Key points

 Poor cardiorespiratory fitness (CRF)
Surgeons and those giving advice in primary care
increases the risk of complications of
should consider pre surgical exercise interventions as
major surgery
a useful adjunct to therapy.
 Conversely improving CRF preoperatively
To help introduce this to your patients the Royal has been associated with reduced
College of Surgeons of Edinburgh have a guide leaflet complications
for patients on exercise and surgery and can be  CRF assessment offers a better prognosis
downloaded here. than age alone in major surgery
 CRF is an independent predictor of
mortality and length of stay in hospital

Chapter 11 Sedentary Behaviour

In the UK Physical Activity Guidelines of 2011,1 an emphasis is made in every age group to “minimize
the amount of time spent being sedentary (sitting) for extended periods.”

Why?
 36

Adults and children increasingly spend time in a sitting position: at a desk or laptop, driving,
watching TV or DVD’s, playing computer games or social networking. Many occupations have
changed from being physically based to office working and an ever increasing dependence working
at computers.

Evidence has shown that prolonged sitting and a lack of whole-body muscle movements are
associated with obesity, metabolic syndrome, type 2 diabetes, cardiovascular disease, cancer and
total mortality which is usually independent of daily moderate to vigorous intensity physical
activity (MVPA). 2,3,4,5,6,7 In particular, TV viewing time is implicated in obesity, with the concurrence
of the snacking on sweet or fatty foods, low levels of physical activity and inadequate sleep.8, 9, 10

It has been thought that this sedentary time is likely to be in addition to the risks associated with
insufficient MVPA. An Australian study estimated the extent to which TV viewing times reduced life
expectancy. The research compared people who watched no TV, with those who spend a lifetime
average of 6 hrs viewing a day, and found the latter are predicted to live 4.8 years less. The authors
concluded that ‘TV viewing time may be associated with a loss of life that is comparable to other
major risk factors such as physical inactivity and obesity’ 11

Research now suggests that with the strong evidence of sedentary time being adversely associated
with poor cardiometabolic health, that this may be a more important indicator of poor health than
MVPA levels. 12 Thus it may be more effective in the prevention of type 2 diabetes to target both
reducing sedentary time rather than solely focusing on promoting MVPA.

What can we do practically in the workplace and at home to change this behaviour?

One simple way is to introduce the

Examples:
concept of NEAT (Non Exercise
 Promote and support standing meetings. (Standing burns 15
Activity Thermogenesis), a term that calories an hour compared to 5 an hour sitting)
refers to daily physical activities that  Get up from a desk to walk across the office to speak to a
are not perceived as exercise or colleague rather than phone or email
training. By promoting more standing,  Use a standing desk to work from
less sitting and more moving we now  Read your ipad on top of the filing cabinet
know that these activities, however  Stand whilst speaking on the phone if on a cord
small, are better than sitting still and  Walk and talk if using a cordless phone
 Use manual buttons on televisions rather than a remote
these small activities accumulate and
 Get up and move during commercial breaks on the TV
count towards our daily energy
 Park the car on the far side of a car park at eg: a
expenditure as well as reduce the supermarket
sedentary risk factors.  Using the stairs instead of the lift or escalator

Summary

Doctors’ may be able to do little to alter the social changes that have occurred over the past few
decades. But by understanding the health problems which have developed from this, we can do
more by advising and guiding patients to think about their lifestyles and to address their health risks.
Changing patterns of behaviour is not easy, but if small changes are made and this is spread over
large populations, then the effect will be significant.
 37

Useful resources for students:

The Chartered Society of Physiotherapists has postcards to buy and a free pdf download for desk
workers or even use by yourself! http://www.csp.org.uk/publications/do-you-sit-desk-all-day

A - fun 4 minute cartoon video about avoiding being sedentary – ‘Let’s Make our Day Harder’ on You
Tube, which may be preferred by some patients.

A sitting poster from the Washington Post, display it in offices!

Chapter 12

Motivation to Change Health Behaviour

Health promotion forms part of many primary care consultations, be it advice about exercise, weight
loss, smoking or alcohol. These consultations are often fraught with difficulty, as many patients are
resistant to being told what to do or what is good for them. Moving from this direct style of
 38

consultation to a more guiding style that encourages patient motivation is thought to increase the
success of health promotion.

Motivational interviewing was originally developed in the field of addiction counselling, but has also
been used to promote behaviour change in a wide range of healthcare settings, such as smoking
cessation, weight loss and promoting increased physical activity.

There is increasing evidence of its effectiveness, 1, 2 with 80% of 72 studies finding that motivational
interviewing outperformed traditional advice-giving. 3 It is associated with a more respectful and less
combative consultation – this feels professionally better and is certainly more enjoyable for both
doctors and their patients.

Motivational Interviewing (MI) by Prof S Rollnick

A consultation that leans on MI has one strong characteristic that supercedes all else: instead of
adopting an expert position and using a directing style to persuade the patient why or how they
might get more exercise, you adopt a guiding style. It is a more collaborative process of helping the
patients to say why and how they might get more exercise. You structure the consultation and
provide information (with permission) but most of the time you are eliciting their own motivation to
change. This is often expressed in the form of change talk. 4 The more change talk you can elicit from
the patient, the better the outcome is likely to be. There is emerging evidence to support this focus
on the language used by the patient. 5

One useful aid might be the recently developed framework for MI 6 that describes four processes in
a constructive conversation about behaviour change:

Engaging

Focusing

Evoking

Planning

They do not always emerge in a linear sequence, but the logic is this: step one is to engage with the
patient and establish an agreed focus for the conversation; then the central task is evoking the
patient’s own motivation to change, followed by planning if the person is ready for this. These
processes are highlighted in the example below, alongside other key skills.

Example MI Dialogue. By Prof S Rollnick

This example is based on a fictitious consultation between a 51 year old male and his doctor. He is
overweight, with borderline raised BP, who gets short of breath when walking secondary to his poor
cardiovascular fitness and sedentary job. He travels to work on the bus and works on the third floor
of an office.
 39

Doctor: OK, so that’s your tablets sorted out, and now I wanted to ask you whether it’s ok with you
to spend just a couple of minutes talking about something completely different….. Would that be
OK? (Asking permission will help a lot)
Patient: Yeah OK, what’s that then?
Dr: It’s about exercise. Would you mind if we chatted about that if I promise not to nag at you about
it?
Pt: Yeah OK, as long as you keep to that promise (laughs). (The focus is clear. Engagement is not
strong, yet.)
Dr: So rather than me talk about it, could you? Could you tell me how you feel about getting more
exercise?
Pt: Hate the thought to be honest with you.
Dr: You’re not persuaded about this one (That’s a reflective listening statement, not a question)
Pt: Well I do know that it would help my health (change talk), but the effort is really too much.
Dr: You get quite a lot done each day, and adding exercise doesn’t seem like it could fit (another
reflective listening statement)
Pt: Yeah you guessed right, I don’t just sit around all day and the thought of going to the gym just
doesn’t fit for me.
Dr: Going to the gym isn’t for you, you are busy enough and yet you know it would be good for your
health to get more exercise, have I got you? (A summary that also includes the change talk)
Pt: Yeah you’ve got me for sure. (Engagement is now much better, as a result of listening and then
summarising).
Dr: Can I ask you how do you see the benefits of just a slow and steady increase in exercise? (A
question that allows the Dr to start evoking change talk)
Pt: Me? Well if it was slow, and I didn’t have to go crazy like at a gym, it might help me (change
talk).
Dr: It would help you to feel healthier (a listening statement again, to reflect the change talk and it’s
also a guess about why it might help)
Pt: Sort of, but at least I could fit it in, and I might succeed, and I could feel good about that. (More
change talk)
Dr: Because you don’t want to take on some big task like the gym. What suits you more is
something smaller to start with. (Reflecting again, trying to understand how he really feels)
Pt: If I decide to do it and I haven’t yet. (Patient backs off)
Dr: You don’t want to be pushed into this (Dr doesn’t try to win the argument or be clever – just
uses a listening statement)
Pt: Exactly, but it might be worth thinking about. Thanks for not lecturing me Dr (laughs)
 40

Dr: Dr summarises how patient feels and keeps the door open for another time.
___________________________________________________________________________

Six weeks later the patient returns for another check on his borderline blood pressure.

Dr: Well thanks for coming back again. I saw you six weeks ago, didn’t I?

Pt: Yes, you asked me to come back to check the blood pressure.

Dr: (Doctor checks BP) Well it’s still on the high side, so we could now ask the question what will help
you to get it down and avoid this becoming a cause for concern in the future?

Pt: Well I know I don’t want any of those tablets for blood pressure if possible Doc.

Dr: Sure, that’s fine for now. Can I raise the subject of exercise again, if I promise not to lecture you?

Pt: You told me that last time, but fair game, you didn’t lecture me, so yes fine (laughs)

Dr: I promise again!

Pt: I believe you again, but what now?

Dr: My question would be this: are there some simple small steps you can take to introduce a little
more exercise into your daily life?

Pt: I’m glad you are not on about the gym.

Dr: Sure, that’s too drastic for you (reflective listening)

Pt: I don’t do drastic, my life’s busy enough.

Dr: Small things might be possible (reflective listening again – a guess about what might work)

Pt: Yes, maybe but I’m not sure what you mean by small things?

Dr: Presents a range of options, not a single idea, with the aim of encouraging the patient to select
thus: So that’s a number of possibilities. You will be the best judge of what might work for you.
(Reinforcing autonomy is a critical aspect of skilful consulting about behaviour change).

Pt: Well of all those things you mention, there’s only two that make sense to me: walking up the
stairs rather than the lift and getting off the bus 2 stops before work and walking the last part
(patient emits change talk).

Dr: You can see a way of doing these simple things (the best response to change talk is a simple
reflection).
 41

Pt: I guess I can, and if it works I might try walking that same distance after work again (more change
talk).

Dr: You want to experiment and see what works for you (more reflection).

Pt: Yeah I am happy to try those two things (change talk).

Dr: Summarises all the change talk that has emerged. So you don’t want tablets, and you think you
might be able to walk up the stairs at work, and get off the bus two stops early, and walk into work.

Pt: Knowing me, I’ll give it a go. It might help me to feel better about myself (change talk).

Dr: And would you mind coming to see me for a brief catch-up in six weeks?

Pt: Sure......Etc etc

___________________________________________________________________________

In addition to motivational interviewing, GP’s may have their own favourite method of motivation to
elicit behaviour change that they wish to use. In promoting exercise, alternative socio-behavioural
approaches have also been developed to help people change physical activity patterns. The
following case study is an example of such a technique:

Edith

In recent years, 50 year old Edith has experienced more and more bouts of prolonged unhappiness.
She has not been diagnosed with clinical depression, but her GP has recommended she becomes
physically active. She has done little if no purposeful exercise since her teenage years when she used
to hate sport and physical education at school, finding it threatening and embarrassing. Edith is on
the borderline between overweight and obesity with a BMI of 29 and has been recently been
diagnosed with mild hypertension. She has a family history of type 2 diabetes.

The start point for Edith is to construct an activity programme with the help of an exercise
professional using a person-centred approach.

The first step is to discuss with Edith her past history in sport and exercise and help her to work out
which activities she might be interested in starting. During this discussion, we discover she has not
been involved in any sport or exercise since leaving school (her 7-day recall of activity revealed less
than 10min of activity- only walking- each day) and that she never enjoyed team games such as
hockey at school. She says she might enjoy some group activity, but feels she is not confident to join
a group at the moment. She would like to think she could join a group of women with similar kinds
of issues at some point.

The second step is to weigh up the pros and cons Edith perceives in becoming more active. Edith
agrees that being more active is important for her and might help her feel more positive about
 42

herself and life in general, as well as help her lose some weight and get her blood pressure down.
However, Edith does not feel very sporty or athletic and finds it difficult to see ways in which she can
be more active, so the conversation turns to walking as a starting strategy.

The next important task is short-term goal setting that can provide a sense of steady but safe
improvement. Short term goals have to have a flavour of where, when, and what. They need to be
specific and agreed (following the SMART principle of being Specific, Measurable, Agreed, Realistic
and Time phased).

The discussion moves to time difficulties, as Edith is still holding a demanding full-time job and
finding it difficult to cope. The key motivational issue, then, is to ensure small goals for the early
weeks that are achievable but that will move her forwards. Goals that are too demanding at this
point may undermine confidence and disappoint if they are not reached. It is important to
emphasize that mental health or mood benefits may be experienced fairly quickly and there will be
changes in exercise capacity in a matter of a few weeks.

Case study reference7

Summary

NICE guidelines recommend using techniques that create attitude and behaviour change within
health care interventions. 8 Whilst no single method can be universally applied, a combination of
motivational interviewing and written physical activity on prescription has been used effectively in
Sweden for the past 10 years. A follow up study there has shown a majority (65%) still adhering to
the advice after 6 months, with partial adherence at 19% and non adherence 16%. This, as they
point out, “is as good as adherence to other treatments for chronic diseases. This is significant
because even a small increase in physical activity is important both on an individual level and for
public health”. 9

Chapter 13 Starting to Exercise.

For many patients the thought of starting to exercise can be overwhelming. It is perceived as being
difficult, painful, largely gym-based, with only demanding regimes producing real benefits.

These are false beliefs and much of the advice about exercise should be about incorporating more
physical activity into everyday life, with alternative choices if required, to gym-based exercise. This
section will aim to give brief guidance on the main principles of exercise, how to start exercise and
how to dispel these beliefs.
 43

Assessment of present levels of activity;

 The UK General Practice Physical Activity Questionnaire (GPPAQ) 1 can be used to categorise
patients into levels of activity.

 ‘The Exercise Vital Sign’. 2 A brief assessment using 2 questions:

1 “On average how many days/ week do you engage in moderate or greater physical activity (like
a brisk walk)?”
2 “On those days, how many minutes do you engage in activity at this level?”

Then multiply the two measures to arrive at an average minutes per week of moderate exercise that
you can compare with the recommended guidelines on physical activity or use to monitor progress.

Four important aspects of exercise;

 Cardiovascular fitness
 Muscular strength
 Endurance
 Flexibility

Many of the health benefits of exercise come from improved cardiovascular fitness using aerobic
exercise (see Health Benefits). However muscle strength and resistance exercises also benefit bone
formation, glucose metabolism, hypertension and maintenance of weight.

Muscle strength and endurance are also essential to maintain mobility and prevention of falls, which
increases in importance as we grow older. Flexibility is often overlooked, but is also important as it
reduces the possibility of injury, stiffness and an inability to perform simple tasks like turning around
to enable you to park your car.

There are some simple basic principles that can be used in ‘prescribing exercise’, which if patients
can grasp, will promote more enjoyment and increase motivation, cutting through some of their
beliefs/fears of pain or difficulty.

Warm up and Cool down

It is desirable that individuals include a warm up and cool down as part of their activity. This may be
the same activity performed at a lower intensity. For example, walking at a slow pace for your warm
up and cool down, with a moderate intensity walk for 30 minutes as the main activity.

Apply the FITT principle.

 44

Frequency – How many times a week for an activity?

Intensity ---- How hard to exert?

Type --------- Which type of activity agreed with the patient?

Time --------- How long in minutes?

The current UK physical activity guidelines are for moderate intensity activity on 5 or more days a
week. For individuals who have led a sedentary lifestyle this may be difficult to establish initially.
Here, the advice may be to exercise aerobically three times a week, allowing a day or two in
between exercise days. However, once this is established individuals should be encouraged to
increase the frequency to 5 or more days.

Frequency is the most important aspect to establish as without a routine pattern it will not become a
lifestyle change. Motivation is what gets you started but habit is what keeps you going.

Time or how long to exercise, should be established but should not include any warm up or cool
down. Present guidelines have recently changed and people can be advised that bouts of physical
activity of 10 min or more accumulated throughout the day are as effective as longer sessions.

Newcomers to exercise may need to start at low intensity but need to be aware that the evidence
for health change is mostly from moderate exercise, so if walking they won’t improve their
cardiovascular fitness with a gentle stroll for 30 minutes. If walking, aim to increase the number of
minutes of walk before increasing the intensity (by walking faster or uphill).

There are many activities that can be started and it is most important to find a type of exercise that
the individual finds enjoyable convenient, affordable and achievable. Walking, cycling and swimming
are three of the commonest and known to virtually everyone, but dancing, yoga, Pilates and Tai Chi
are also very popular and help prevent falls and encourage core strength.

Definitions of moderate and vigorous intensity:

 Moderate intensity physical activity causes adults to feel warmer, breathe harder and the
heart beats faster with the example of brisk walking being the easiest to recognize.
 Vigorous intensity physical activity causes adults to get warm quickly, breathe much harder,
perspire and find it difficult to maintain a conversation

Monitoring

Some people find it helpful to monitor their progress and use it to motivate themselves.

Ways of monitoring progress:

 45

 Keep an exercise diary – cheap and easy to record your progress, success, feelings and
identify barriers to exercise.
 Pedometers – cheap easy to use, but not always reliable.
 Accelerometers – more reliable and can be linked to a computer program for monitoring.
 Walk4life – the walking web based site which is free to join in and uses ordinance survey
maps and routes and has a ‘track your progress’ page to monitor your own fitness.

The above advice is partly taken from Bandolier.3 Further advice on Starting to exercise available
from their fuller version at: www.medicine.ox.ac.uk/bandolier/booth/hliving/startoex.html and the
Swedish guidance at:

http://fyss.se/wp-content/uploads/2011/06/2.-General-recommendations-regarding-physical-
activity.pdf

Disclaimer

Health professionals are not trained in giving exercise programmes to individuals and this resource is
not intended to encourage anyone to go beyond their own experience. However, guiding someone
to walk, swim, cycle or dance is within everyone’s understanding.

Getting Started

Increasing physical activity for many is difficult and we need encouragement and ideas that can be
integrated into daily life.

There are many ways of increasing activity and walking is one of the easiest ways. If 30 minutes all at
once seems too much, then try short bouts in the day. For example:

 Leave the car at home for short trips to shops or friends

 Walk to school with the children when you can
 Park the car when used, at the far side of a car park
 If commuting, get off the train or bus one or two stops early to fit in a walk to work
 46

 If you work in a large office, walk to talk to colleagues rather than use the phone
 Promote and support standing meetings. (Standing burns 15 calories an hour compared to 5
an hour sitting)
 Get up from a desk to walk across the office to speak to a colleague rather than phone or
email
 Use a standing desk to work from
 Read your Ipad on top of the filing cabinet
 At home or work if you have a cordless phone, walk and talk
 Avoid lifts and escalators –use the stairs
 Meet friends for a walk
 Use an exercise bike whist watching TV; don’t store it in the spare room!

Around the house many jobs involve activity and can help get you going.

 Cleaning and polishing furniture, floors and windows.

 Cutting the grass or the hedge.
 Brushing the yard or raking up leaves.
 Washing and polishing the car by hand.
 DIY – carpentry, sanding, painting, building etc.

There are many other activities but most important is finding a form of exercise that the individual
finds enjoyable, social and achievable.

 Walking – walk with a friend or join a walking group. http://www.walk4life.info has

information on local walks and walking groups for many areas.
 Cycling – many cycle paths have or are being developed across the UK and it is a fun activity
for all the family. http://www.sustrans.org.uk/ncn/map/national-cycle-network
 Dance – increasingly popular, enjoyable and social with many alternative types such as salsa,
zumba, line dancing and ballroom.
 Swimming – traditional fun for the family and water aerobics for some.
 Golf – 18 holes is five miles on most courses
 Tennis, squash, badminton – many clubs and courts all around the country for fun and
competition.
 Football – the nation’s most popular sport, so get out with your children and kick a ball
again!
 Yoga and Pilates – excellent activities for flexibility, core strength and posture to relieve and
prevent many back problems.

Remember every activity counts.

The Referral Pathway

 47

High Risk Small Numbers

Specialized physiotherapists, cardiac rehabilitation,
Patients of Patients
pulmonary rehabilitation or SEM Consultants

Level 4 gym instructors

GPwSI or level 3 gym instructor or physiotherapists

Local exercise referral schemes

Self management of exercise with your local gym,

Low Risk walks, cycle ways, swimming pools and dance etc Large Numbers
Patients of Patients

In Primary Care across the UK, there are almost 900,000 GP consultations daily. 4 The average
patient visits their GP about 4 times per year. 5 During these visits there is ample opportunity for the
GP, practice nurse and health care assistant to promote exercise as a beneficial lifestyle and as a
form of treatment in many diseases. In Secondary Care there are many thousands of outpatients and
inpatient consultations where exercise advice should be incorporated into the treatment plan.

The majority of patients need encouragement towards being more active through simple guiding
techniques of Motivational Interviewing and straight forward advice on promoting activity or taking
up exercise. Many patients do not want to go to a gym, but prefer to participate in walking, cycling,
swimming and dancing, the advice for which falls comfortably within the role of any health
professional.

As patients present with more complex problems, with one or more co-morbidities, doctors or
nurses may prefer to refer to Local Exercise Schemes or physiotherapists depending on the
conditions and level of risk for more detailed advice on specific exercise plans. However, there is still
plenty of simple encouragement regarding walking, gardening and housework, which can be done in
parallel, as any activity provides a valid health benefit.

For a small number of patients their activity needs require rehabilitation through specialised
physiotherapists or high level 4 gym instructors, or through pulmonary or cardiac rehabilitation
units. Assessments of these patients may need to be made by Cardiac, Respiratory or, if available,
Sport and Exercise Medicine (SEM) consultants.

Absolute Contraindications of Exercise

 48

 Uncontrolled or poorly controlled asthma. 6

 Cancer or blood disorders: when treatment or disease cause leucocytes below 0.5 x 109/L,
haemoglobin below 60g/L or platelets below 20 x 10 9 /L. 6
 COPD: patients are required to be stable before training and oxygen saturation levels
should be above 88-90%. 7
 Diabetes: if blood glucose is >13 mmol or <5.5 mmol/l then it should be corrected first. 8
Patients with diabetic peripheral or autonomic neuropathy or foot ulcers should avoid
weight bearing exercise. Any diabetic with acute illness or infection. 6
 Heart disease: acute myocardial infarction or unstable angina until stable for at least 5
days, dyspnoea at rest, pericarditis, myocarditis, endocarditis, symptomatic aortic stenosis,
cardiomyopathy, unstable or acute heart failure, uncontrolled tachycardia. 6
 Hypertension: resting blood pressures of a systolic >180 or diastolic >100 or higher should
receive medication before regular physical activity, 8 with particular restrictions on heavy
weights strength conditioning, which can create particularly high pressures. 9
 Osteoporosis: avoid activities with a high risk of falling. 6
 Fever: should be settled to avoid a risk of developing myocarditis. 8
 Unexplained dizzy spells. 8
 Acute pulmonary embolus or pulmonary infarction. Excessive or unexplained
breathlessness on exertion. 8
 Any acute severe illness.

(Absolute contraindications taken from BACR (2006) Phase IV Exercise Instructor Training Manual
and ACSM (2009) Guidelines for Exercise Testing and Prescription) Courtesy of Wales NERS
guidelines.8

Case histories. Examples can motivate some patients and are useful for nurses to quote.

Case 1 Hypertension or Not?

A 52 old man was referred by the practice nurse for initiation of blood pressure medication after
having had 3 raised blood pressures recorded, 170/96, 176/100, 178/98.

This gave a conventional diagnosis of mild hypertension. He had a busy job but denied being
stressed. Ambulatory blood pressure monitoring was not available in this case.His initial treatment
plan:
 49

 Lifestyle advice of low salt, losing weight and regular exercise was advised. The patient
was keen to avoid medication if possible.
 Motivation for the patient came from a desire to avoid medication.
 Specific advice on exercise was given for 30 minutes of moderate exercise on 6-7 days a
week. He presently did no regular exercise. Different forms of exercise were explored
and walking chosen as being the most practical.
 A follow up appointment was made for 4/52.

Repeat BP and weight recordings were made at monthly follow up appointments.

 The following recordings were made. 164/92, 162/90, 156/86, 154/86, 146/ 82, 144/ 82.
 He noted he was sleeping better, felt much better and hadn’t realised he had been
stressed with his job. He lost 2kg.
 NICE recommends ambulatory 24hr monitoring before a diagnosis of hypertension. This
may have picked up a white coat hypertension diagnosis. Lifestyle intervention would
still be indicated.

“Discharged” with a normal BP profile but follow up check at 6/12.

Potential cost savings:

 Cost of drug prescription for hypertension treatment for 12/12 each year until maybe he
becomes hypertensive in the future.
 Blood test monitoring of electrolytes if he had ACE or diuretics per year.
 Clinical time for future monitoring 2 x BP checks and problems or side effects.

Costs incurred:

Appointments x 6 to initially monitor, but if initially he was treated, then follow up and
stabilisation after initiating anti-hypertensive’s may have cancelled these out.

Case 2 Depression.

A 46 year old man presented with mild depression. His PHQ9 score for depression was 9/30.One
normal mode of practice would have been to start an antidepressant and follow up monthly.

Instead, an alternative behaviour lifestyle approach was chosen with an emphasis on exercise which
the patient previously enjoyed but had allowed to relapse. His initial treatment plan:

 Exercise discussed with motivational interviewing and 7/7 of 30 minutes moderate

exercise was ‘prescribed’ with cycling being the chosen exercise in the form of
commuting to and from work.
 Follow up monthly was undertaken with the addition of the Welsh bibliography
prescribing scheme (self help books from the local library).
 50

 Slow resolution of depression occurred and the patient episode resolved after 12/12.

Cost savings:
 Antidepressant medication for 12 months or more.
 Appointments cost neutral, same number of patient follow up appointments used as this
doctor’s normal practice.

Case 3 Obesity.

A - 38 old female type 2 new diabetic presented following a diagnosis of diabetes and being
overweight. Wt 154kg, BMI= 51.6

For the first 2 years despite advice on diet and exercise, her weight fluctuated with crash diets and
intermittent exercise between 154kg and 137kg, but after 2 years it was back to 151kg and with ever
rising Hba1c she had progressed onto metformin with increasing doses. One year ago with
metformin at 1gm bd and an abnormal hba1c yet again she was given motivational interviewing
guidance on activity.

Prior to this she;

“Used to dread getting out of bed in the morning. I wish I wouldn’t wake up.”

Now for the first time she has exercised regularly and consistently.

“I look forward to the day. I have lost inches from my waist and my back pain has gone.”

Her Hba1c has dropped for the first time and is now normal on metformin 1gm bd. Her weight is
141 kg. She has decided to increase her activity time with a target of 300 minutes a week.

References

Introduction

1 World Health Organisation. (2009) Global health risks: mortality and burden of disease attributable to selected major
risks. Available at: www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf Last accessed on
10/08/2013.
2 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
3 Department of Health. (2005) Choosing activity: a physical activity action plan. London: HMSO.
4 Wen, C.P., Wai, J.P.M., Tsai, M.K., Yang, Y.C., Cheng, T.Y.D., Lee, M., Hui, T.C., Chwen, K.T., Tsai, S.P., Wu, X. (2011)
Minimum effort of physical activity for reduced mortality and extended life expectancy. The Lancet; 378:(9798): 1244-
1253.
 51

5 Blair, S.N. (2009) Physical inactivity: the biggest public health problem of the 21st century. British Journal of Sports
Medicine; 43:1-2
6 Weiler, R., Feldschreiber, P., Stamatakis, E. (2011) Medicolegal neglect? The case for physical activity promotion and
Exercise medicine. British Journal of Sports Medicine; 46:228-232

Chapter 1 The UK Physical Activity Guidelines

1. Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
2.. Department of Health. (2011) UK physical activity guidelines. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127931
3.. O’Donovan, G., Blazevich, A.J., Boreham, C., Cooper, A.R., Crank, H., Ekelund, U., Fox, K., Gately, P., Giles-Corti, B., Gill,
J.M.R., Hamer, M., McDermott, I., Murphy, M., Mutrie, N., Reilly, J.J., Saxton, J.M., Stamatakis, E.(2010) The ABC of physical
Activity for Health: a consensus statement from the British Association of Sport and Exercises Sciences. Journal of Sport
Sciences; 28:6: 573-591
4. United States Department of Health and Human Services. (2008) Physical Activity Guidelines for Americans. Available at:
http://www.health.gov/paguidelines/guidelines/default.aspx
5. Warburton, D.E.R ., Katzmarzyk, P.T., Rhodes, R.E., Shephard, J. (2007) Evidence-informed physical activity guidelines for
Canadian adults. Applied Physiology, Nutrition and Metabolism; 32:(2): S16-S68.
6. Swedish National Institute of Public Health. (2010) Physical Activity in the prevention and treatment of disease. Available
at: http://www.fyss.se/fyss-in-english/
7. Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.

Chapter 2 Cancer

1 O’Donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, et al.(2010) The ABC of physical Activity for
Health: a consensus statement from the British Association of Sport and Exercises Sciences. Journal of Sport Sciences; 28:6:
573-591
2 United States Department of Health and Human Services. (2008) Physical Activity Guidelines for Americans. Available at:
http://www.health.gov/paguidelines/guidelines/default.aspx
3 Warburton DER, Katzmarzyk PT, Rhodes RE, Shephard J. (2007) Evidence-informed physical activity guidelines for
Canadian adults. Applied Physiology, Nutrition and Metabolism; 32:(2): S16-S68.
4 Thune I. Cancer Ch 19. Swedish National Institute of Public Health. (2010) Physical Activity in the prevention and
treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/19.-Cancer.pdf
5 Pedersen BK, Saltin B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
6 World Cancer Research Fund, American Institute for Cancer Research. (2007) Food, nutrition, physical activity and the
prevention of cancer: A global perspective. Washington D.C (U.S.): American Institute for Cancer Research (AICR).
7 World Cancer Research Fund, American Institute for Cancer Research . (2011) Colorectal Cancer: Food, nutrition, physical
activity, and the prevention of colorectal cancer. http://www.wcrf.org/int/research-we-fund/continuous-update-project-
findings-reports/colorectal-cancer
8 Parkin DM. Cancers attributable to inadequate physical exercise in the UK in 2010. (2011) Br J Cancer 105 (Suppl 2): S38-
S41
9 Orsini N, Belloco R, Bottiai M, Pagano M, Andersson SO, Johansson JE, et al. (2009) A prospective study of lifetime
physical activity and prostate cancer incidence and mortality. British Journal of Cancer; 101(11):1932-1938.
10 Behrens G, Jochem C, Keimling M, Ricci C, Schmid D, Leitzmann MF. (2014) The association between physical activity
and gastroesophageal cancer: systematic review and meta-analysis. European Journal of Epidemiology; 29 (3): 151-70
11 Singh S, Devanna S, Edakkanambeth Varayil J, Murad MH, Iyer PG. (2014) Physical activity is associated with reduced risk
of esophageal cancer, particularly adenocarcinoma: a systematic review and meta-analysis. BMC Gasterentology; 14:101
12 Chen Y, Yu C, Li Y. (2014) Physical activity and risks of esophageal and gastric cancers: a meta-analysis. PLoS One. 2014
Feb 6;9(2):e88082. doi: 10.1371/journal.pone.0088082. eCollection 2014
13 Abioye AI, Odesanya MO, Abioye AI, Ibrahim NA. (2015) Physical activity and risk of gastric cancer: a meta-anaysis of
observational studies. British Journal of Sports Medicine. 49:224-229
 52

14 Singh S, Devanna S, Edakkanambeth Varayil J, Murad MH, Iyer PG. (2014) Physical activity is associated with reduced risk
of gastric cancer: a systematic review and meta-analysis. Cancer prevention research; (1) 12-22
15 Singh F, Newton RU, Galvão DA, Spry N, Baker MK (2013). A systematic review of pre-surgical exercise intervention
studies with cancer patients. Surgical Oncol 22, 92-104
16 Speck RM, Courneya KS, Masse LC, Duval S, Schmitz KH. (2010) An update of controlled physical activity trials in cancer
survivors: a systematic review and meta-analysis. Journal of Cancer Survivorship 4(2):87-100.
17 Cramp F, Byron-Daniel J. (2012) Exercise for the management of cancer-related fatigue in adults. Cochrane Database
Syst Rev. 2012 Nov 14;11:CD006145. doi: 10.1002/14651858.CD006145.pub3
18 Chan DNS, Lui LYY, So WKW.(2010) Effectiveness of exercise programmes on shoulder mobility and lymphoedema after
axillary lymph node dissection for breast cancer: systematic review. Journal of Advanced Nursing. 66(9):1902–1914
19 McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, et al. Exercise interventions for upper-limb
dysfunction due to breast cancer treatment.Cochrane Database of Systematic Reviews.Issue 6 2010. Article number.:
CD005211.DOI: 10.1002/14651858.CD005211. pub2.
20 Fong DYT, Ho JWT, Hu BPH, et al. Physical activity for cancer s urvivors: meta-analysis of randomised Controlled Trials.
Br Med J 2012; 344; e70
21 Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B, et al (2006) Nutrition and physical activity
during and after cancer treatment. An American cancer society guide for informed choices. CA: A Cancer Journal for
Clinicians; 56:(6):323-353.
22 Thorsen I, Skovlund E, Strømme SB, Hornslien K, Dahl AA, (2005) Effectiveness of physical activity on physical activity on
cardiorespiratory fitness and health-related quality of life in young and middle-aged cancer patients shortly after
chemotherapy. Journal of Clinical Oncology; 23:2378-88.
23 Thue I, Smeland S. (2000) Can physical activity prevent cancer? Tidsskr Nor Laegeforen; 120:3296-301.
24 Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS. (2003) Randomized controlled trial of exercise training in
postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. Journal of Clinical Oncology;
21:1660-8.
25 Ibrahim EM, Al-Homaidh A. (2011) Physical activity and survival after breast cancer diagnosis: meta-analysis of
published studies. Medical Oncology; 28:3:753-65
26 Je Y, Jeon JY, Giovannucci EL, Meyerhardt JA. (2013) Association between physical activity and mortality in colorectal
cancer: A meta-analysis of prospective cohort studies. International Journal of Cancer. 133: 1905-1913
27 Schmid D, Leitzmann MF. (2013) Association between physical activity and mortality among breast cancer and
colorectal cancer survivors: a systematic review and meta-analysis. Annals of Oncology. 25:7:1293-1311
28 National Institute for Health and Clinical Excellence. (2009): Early and locally advanced breast cancer. NICE clinical
guideline 80. London: National Institute for Health and Clinical Excellence
29 National Institute for Health and Clinical Excellence. (2014): Advanced breast cancer (update): Diagnosis and treatment.
NICE clinical guideline 81. London: National Institute for Health and Clinical Excellence.
30 http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf

Chapter 3 Cardio Respiratory Health

1. Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
2 Paffenbarger RS, Lee IM. Exercise and fitness. In: Manson JE, Ridker PM, Gaziano JM, Hennekens CH, eds. Prevention of
Myocardial Infarction. New York, NY: Oxford University Press; 1996:172-202
3 Wilson MG, Ellison GM, Cable NT. Basic science behind the cardiovascular benefits of exercise. Heart 2015; 101: 758-765
4 Warburton, D.E.R ., Katzmarzyk, P.T., Rhodes, R.E., Shephard, J. (2007) Evidence-informed physical activity guidelines for
Canadian adults. Applied Physiology, Nutrition and Metabolism; 32:(2): S16-S68
5 The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012. 2 nd Ed.
Available at; http://www.bacpr.com/resources/15E_BACPR_Standards_FINAL.pdf
6 National Audit of Cardiac Rehabilitation (NACR). The 2014 Annual Report.
 53

7 National Institute for Health and Clinical Excellence. (2013) MI-secondary prevention: Secondary prevention in primary
and secondary care for patients following a myocardial infarction. NICE clinical guideline 172 . London: National Institute
for Health and Clinical Excellence
8 Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
9 BACR (2006) Phase IV Exercise Instructor Training Manual and ACSM (2009) Guidelines for Exercise Testing and
Prescription. Courtesy of Wales NERS guidelines.
10 Cider Ά, Tyni-Lenné, Schaufelberger M. Ch 29 Heart failure. Swedish National Institute of Public Health. (2010) Physical
Activity in the prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/29.-Heart-
failure.pdf
11 Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJS, Dalal H, Lough F, Rees K, Singh S. Exercise-based rehabilitation for
heart failure. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD003331. DOI:
10.1002/14651858.CD003331.pub4.
12 Pina, I.L., Apstein, C.S., Balady, G.J. (2003) Exercise and heart failure: a statement from the American Heart Associated
committee on exercise, rehabilitation and prevention. Circulation; 107:1210-6
13 Heart Failure Society of America (HFSA). (2010) Comprehensive heart failure practice guideline. Journal of Cardiac
Failure; 16:e1-194.
14 National Institute for Health and Clinical Excellence. (2010) Chronic heart failure: Management of chronic heart failure
in adults in primary and secondary care. NICE clinical guideline 108 . London: National Institute for Health and Clinical
Excellence
15 Pescatello, L.S., Franklin, B.A., Fagard, R., Farquhar, W.B., Kelley, G.A. and Ray, C.A. (2004) American College of Sports
Medicine position stand. Exercise and hypertension. Medicine and Science in Sports and Exercise; 36: 533-553.
16 Whelton SP, Chin A, Xin X, He J. (2013) Effect of aerobic exercise on blood pressure: A meta-analysis of randomized,
controlled trials. Ann Int Med. 136 (7): 493-503
17 Fagard, R.H., Cornelissen, V.A. (2007) Effect of exercise on blood pressure control in hypertensive patients. European
Journal Cardiovascular Prevention and Rehabilitation; 14:12-17
18 Cornelissen VA. Fagard RH. (2005) Effect of resistence training on resting blood pressure. A meta-analysis of randomised
controlled trials. Journal of Hypertension. 23:251-9
19 American College of Sports medicine. Position stand. (1993) Physical activity, physical fitness and hypertension.
Medicine and Science in Sport and Exercise. 25:i-x
20 Cornelissen VA, Smart NA. (2013) Exercise training for blood pressure: A systemic review and meta-analysis. J American
Heart Assoc. 2 (1) e004473. doi:10.1161/JAHA.112.004473
21 Lewington, S., Clarke, R., Qizilbash, N., Collins, R. (2002) Prospective studies collaboration. Age-specific relevance of
usual blood pressure to vascular mortality. A met-analysis of individual data from one million adults in 61 prospective
studies. The Lancet; 360: 1903-1913.
22 Musini VM, Tejani AM, Bassett K, Wright JM. (2009) Parmacotherapy for hypertension in the elderly. Cochrane Database
of Systematic Reviews 2009, Issue 4. Art. No.: CD000028. DOI: 10.1002/14651858.CD000028.pub2
23 Brooks JHM, Ferro A. (2012) The physician’s role in prescribing physical activity for the prevention and treatment of
essential hypertension. JRSM Cardiovascular Disease.1:4:12
24 Nocon M, Hiemann T, Mϋller-Riemenschneider F, Thalau F, Roll S, Willich SN. (2008) Association of physical activity with
all-cause and cardiovascular mortality: a systemic review and meta-analysis. European Journal of Cardiovascular Prevention
and Rehabilitation.15:239-46
25 National Institute for Health and Clinical Excellence. (2011) Hypertension. The Clinical Management of Primary
Hypertension in Adults. NICE clinical guideline 127. London: National Institute for Health and Clinical Excellence
26 Durstine JL, Grandjean PW, Davis PG, et al. (2001) Blood lipid and lipoprotein adaptations to exercise. A quantitative
analysis. Sports Med ;31:1033-62.
27 Shaw KA, Gennat HC, O'Rourke P, Del Mar C. (2006) Exercise for overweight or obesity. Cochrane Database of
Systematic Reviews 2006, Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3
28 Kodama S, Tanaka S, Saiko K, et al. (2007) Effect of aerobic exercise training on serum levels of high-density lipoprotein
cholesterol: a meta-analysis. Arch Int Med. 167:999-1008
29 Björck L, Thelle DS. Ch 33 Lipids. Swedish National Institute of Public Health. (2010) Physical Activity in the prevention
and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/33.-Lipids.pdf
30 Peach, G., Griffin, M., Jones, K.G., Hinchcliffe, R. (2012) Diagnosis and management of peripheral artery disease. British
Medical Journal; 345.36-41.
 54

31 Trans Atlantic InterSociety Consensus (TASC). (2000) Management of peripheral arterial disease. European Journal of
Vascular and Endovascular Surgery; 19:S1-S250
32 Leng, G.C., Fowler, B., Ernest, E. (2000) Exercise for intermittent claudication. Cochrane Database Systematic Review;
2:CD000990
33 Brandsma, J.W., Robeer, B.G., van den Heuvel, S., Smit, B., Wittens, C.H., Oostendorp, R.A. (1998) The effect of exercise
on walking distance with intermittent claudication: a study of randomised clinical trials. Physical Therapy; 78:278-286.
34 Gardner, A.W., Poehlman, E.T. (1995) Exercise rehabilitation programs for the treatment of claudication pain. A meta-
analysis. Journal of the American Medical Association; 274: 975-980.
35 National Institute for Health and Clinical Excellence. (2012) Lower limb peripheral arterial disease: diagnosis and
management: NICE clinical guideline 147. London: National Institute for Health and Clinical Excellence.
36 O’Donovan, G., Blazevich, A.J., Boreham, C., Cooper, A.R., Crank, H., Ekelund, U., Fox, K., Gately, P., Giles-Corti, B., Gill,
J.M.R., Hamer, M., McDermott, I., Murphy, M., Mutrie, N., Reilly, J.J., Saxton, J.M., Stamatakis, E.(2010) The ABC of physical
Activity for Health: a consensus statement from the British Association of Sport and Exercises Sciences. Journal of Sport
Sciences; 28:6: 573-591
37 United States Department of Health and Human Services. (2008) Physical Activity Guidelines for Americans. Available at:
http://www.health.gov/paguidelines/guidelines/default.aspx
38 Grimby G, Willén C, Engardt M, Summerhagen KS. Ch 47. Stroke. 1 Swedish National Institute of Public Health. (2010)
Physical Activity in the prevention and treatment of disease. Available at http://fyss.se/wp-content/uploads/2011/06/47.-
Stroke.pdf
39 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers.Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
40 Potempa, K., Lopez, M., Braun, L.T., Szidon, J.P., Fogg, L., Tincknell, T. (1995) Physiological outcomes of aerobic exercise
training in hemiparetic stroke patients. Stroke; 26:101-105
41 National Institute for Health and Clinical Excellence. (2013) Stroke rehabilitation: Long term rehabilitation after stroke:
NICE clinical guideline 162. London: National Institute for Health and Clinical Excellence.

Chapter 4 Type 2 Diabetes

1 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers.Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
2 Tuomilehto, J., Lindström, J., Eriksson, J.G.,m Valle, T.T., Hamalanien, H., Ilanne-Parikka, P., Keinanen-Kiukaanniemi, S.,
Laasko, M., Louheranta, A., Rastas, M., Salminen, V., Aunoal, S., Cepaitis, Z., Moltchanov, V., Hakumaki, M., Mnnelin, M.,
Martikkala, V., Sundvall, J., Uusitupa, M. (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among
subjects with impaired glucose tolerance. New England Journal of Medicine; 344: 1343-1350.
3 Williamson, D.F., Vinicor, F., Bowman, B.A. (2004) Primary prevention of type 2 diabetes mellitus by lifestyle intervention;
implications for health policy. Annals of Internal Medicine: 140:951-957.
4 Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. (1997) Effects of diet and exercise in preventing NIDDM in people
with impaired glucose tolerance: the Da Qing IGT and Diabetes study. Diabetes care. 20:537-544
5 Ramachandran A, Snehalatha C, Mary S, et al. (2006) The Indian Diabetes Prevention Programme shows that lifestyle
modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1).
Diabetologia 49: 289-297
6 Diabetes Prevention Program Research Group. (2002) Reduction in the incidence of type 2 diabetes with lifestyle
intervention or metformin. New England Journal of Medicine; 346: 393-403.
7 Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Erikkson G, Hemiö K, et al. (2006) Sustained reduction in the
incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet.
368:1673-86
8 Diabetes Prevention Program Research Group. (2009) 10 years follow-up of diabetes incidence and weight loss in the
Diabetes Prevention Outcomes Study. Lancet 374:1677-86
9 Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, et al.(2008)The long-term effect of lifestyle interventions to prevent
diabetes in the China Da Qing Prevention study: a 20-year follow-up study. Lancet 371:1783-9
10 Yudkin JS, Montori JM. (2014) The epidemic of pre-diabetes: the medicine and the politics.BMJ. 349:g4485
 55

11 Sigal ,R.J., Kenny, G.P., Boulé, N.G., Wells, G.A., Prud'homme, D., Fortier, M., Reid, R.D., Tulloch, H. (2007) Effects of
aerobic training, resistance training, or both on glycaemic control in Type 2 diabetes: a randomised trial. Annals of Internal
Medicine; 147(6): 357-369
12 Umpiierre D, Ribeiro PAB, Kramer CK, Leitāo CR, Zucatti ATN, Azevedo MJ, Gross JL, Ribeiro JP, Schaan BD. (2011)
Physical Activity Advice Only or Structured Exercise Training and Association With HbA 1c Levels in Type 2 Diabetes. JAMA
305:17:1790-1799
13 Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
14 Pierce, N.S., (1999) Diabetes and exercise. British Journal of Sports and Medicine; 33:161-172: Quiz 172-3, 222.
15 Őstenson CG. Birkeland K, Henriksson J. Ch 26 Diabetes mellitus – type 2 diabetes. Swedish National Institute of Public
Health. (2010) Physical Activity in the prevention and treatment of disease. Available at: http://fyss.se/wp-
content/uploads/2011/06/26.-Diabetes-mellitus-–-type-2-diabetes.pdf
16 Bowman AM (2008) Promoting safe exercise and foot care for clients with type 2 diabetes.The Canadian Nurse. 104 (2)
23-7
17 National Institute for Health and Clinical Excellence. (2012) Preventing type2 diabetes: riskidentification and
interventions for individuals at high risk: NICE public health guideline 38. London: National Institute for Health and Clinical
Excellence.
18 BACR (2006) Phase IV Exercise Instructor Training Manual and ACSM (2009) Guidelines for Exercise Testing and
Prescription. Courtesy of Wales NERS guidelines.

Chapter 5 Mental Health

1 Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9.
Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6.
2 Kjellman B, Martinsen EW, Taube J, Andersson E. Ch 24 Depression. Swedish National Institute of Public Health. (2010)
Physical Activity in the prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/24.-
Depression.pdf
3 Dunn AL, Trivedi MH, Kampert JB, et al. (2005) Exercise treatment for depression: efficacy and dose response. American
Journal of Preventative Medicine; 1:281-288
4 Larun L, Nordheim LV, Ekeland E, et al. (2006) Exercise in prevention and treatment of anxiety and depression among
young children and people. Cochrane Database Syst Rev.(3):CD004691
5 Callaghan P, Norman P. (2004) A prospective evaluation of the Theory of Planned Behaviour (TBP) and the
Transtheorectical Model of Change (TTM) on exercise in young people. Psychology and health 19 (Suppl): 29-30
6 Callaghan P, Khalil E, Morres I, Carter T. (2011) Pragmatic randomised controlled trial of preferred intensity exercise in
women living with depression. BMC Public Health 11:465 doi:10.1186/1471-2458-11-465
7 National Institute for Health and Clinical Excellence. (2009) Depression in adults: The treatment and management of
depression in adults. NICE clinical guideline 90. London: National Institute for Health and Clinical Excellence.
8 Mammen G, Faulkner G. (2013) Physical activity and the prevention of depression. American Journal of Preventative
Medicine; 45(5): 649-657
9 McKercher C, Sanderson K, Schmidt MD, et al. (2014) Physical activity patterns and risk of depression in young adulthood:
a 20-year cohort study since childhood. Social Psychiatry and Psychiatric Epidemiology. DOI 10.1007/s00127-014-0863-7.,
10 Warburton DER, Katzmarzyk PT, Rhodes RE, Shephard J (2007) Evidence-informed physical activity guidelines for
Canadian adults. Applied Physiology, Nutrition and Metabolism; 32:(2): S16-S68.
11 Martinsen EW, Taube J. Ch 16 Anxiety. Swedish National Institute of Public Health. (2010) Physical Activity in the
prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/16.-Anxiety.pdf
12 Jayakody K, Gunadasa S, Hosker C. (2014) Exercise for anxiety disorders: systemic review. Br J Sports Med 48: 187-196
13 Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 5.
Art. No.: CD004412. DOI: 10.1002/14651858.CD004412.pub2.
14 Vancampfort D, Probst M, Skjaeven L, et al (2012) Systemic review of the benefits of physical therapy within a
multidisciplinary approach for people with schizophrenia. Physical Therapy. 92:1:11-23
15 Martinsen EW, Taube J. Ch 44 Schizophrenia. Swedish National Institute of Public Health. (2010) Physical Activity in the
prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/44.-Schizophrenia.pdf
 56

16 De Hert M, Dekker JM, Wood D, et al. (2009) Cardiovascular disease and diabetes in people with severe mental illness
position statement from the European Psychiatric Association (EPA), supported by the European Association for the Study
of Diabetes (EASD) and the European Society of Cardiology (ESC). European Psychiatry; 24 (6): 412-424
17 Compton MT, Daumit GL, Druss BG. (2006) ; Cigarette smoking and overweight/obesity among individuals with serious
mental illnesses. A preventive perspective. Harvard Review of Psychiatry. 14:212-22
18 Vancamfort D, Stubbs B, Ward PB, et al. (2015) Why moving more should be promoted for severe mental illness. The
Lancet Psychiatry 2 (4) 95
19 National Institute for Health and Clinical Excellence. (2014). Psychosis and schizophrenia in adults: treatment and
management. NICE clinical guideline 178. London: National Institute for Health and Clinical Excellence
20 United States Department of Health and Human Services. (2008) Physical Activity Guidelines for Americans. Available at:
http://www.health.gov/paguidelines/guidelines/default.aspx
21 King AC, Oman RF, Brassington GS, et al (1997) Moderate-intensity exercise and self-rated quality of sleep in older
adults. Journal of the American Medical Association; 277:32-7.
22 Jonsdottir IH, Ursin H. Ch 46 Stress. Swedish National Institute of Public Health. (2010) Physical Activity in the prevention
and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/46.-Stress.pdf
23 http://www.alzheimers.org.uk/infographic
24 Aarsland D, Sardahaee FS, Andersenn S, Ballard C and the Alzheiner’s Society Systematic Review group. (2010) Is
physical activity a potential preventable factor for vascular dementia? A systemic review. Aging and Mental Health.
14:4:386-395
25 Norton S, Matthews FE, Barnes DE, et al. (2014) Potential for primary prevention of Alzheimer’s disease: an analysis of
population-based data. The Lancet Neurology. 13:8:788-794
26 O’Donovan G, Blazevich AJ, Boreham C, et al.(2010) The ABC of physical Activity for Health: a consensus statement from
the British Association of Sport and Exercises Sciences. Journal of Sport Sciences; 28:6: 573-591
27 Helbastad JL, Taraldsen K, Saltvedt I. Ch 23 Dementia. Swedish National Institute of Public Health. (2010) Physical
Activity in the prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/23.-
Dementia.pdf
28 Blondell SJ, Hammersley-Mather R, Veerman JL. (2014) Does physical activity prevent cognitive decline and dementia?:
A systemic review and meta-analysis of longitudinal studies. BMC Public Health. 14: 510
29 Saxena S, Van Ommeren M, Tang MC, Armstrong TP (2005) Mental health benefits of physical activity. Journal of
Mental Health; 14(5):445-52
30 Weuve J, Kang JH, Mansom JE et al. (2004) Physical activity, including walking, and cognitive function in older woman.
Journal of the American Medical Association; 292(12): 1454-61.
31 National Institute for Health and Clinical Excellence (2008) Mental well-being and older people: Public health guidance
16. London: National Institute for Health and Clinical Excellence.
32 Forbes D, Thiessen EJ, Blake CM, Forbes SC, Forbes S. Exercise programs for people with dementia. Cochrane Database
of Systematic Reviews 2013, Issue 12. Art. No.: CD006489. DOI: 10.1002/14651858.CD006489.pub3.
33 Chan WC, Yeung JWF, Wong CSM, et al. (2015) Efficacy of Physical Exercise in Preventing Falls in Older Adults With
Cognitive Impairment: A Systemic Review and Meta-Analysis. JAMDA 16 (2) 149-154
34 National Institute for Health and Clinical Excellence (2006) Dementia: Supporting people with dementia and their carer
in health and social care: Clinical guidance 42. London: National Institute for Health and Clinical Excellence

Chapter 6 Musculoskeletal Health

1 Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
2 Bennet, R.M., Clark, S.R., Goldberg, L., Nelson, D., Bonafede, R.P., Porter, J., Specht, D.(1989) Aerobic fitness in patients
with fibrositis. A controlled study of respiratory gas exchange and 133xenon clearance from exercising muscle. Arthritis
Research and Therapy; 32:454-460.
3 Clark, S.R., Burckhardt, C.S., O’Rielly, C., Bennett, R.M. (1993) Fitness characteristics and perceived exertion in women
with fibromyalgia. Journal of Musculoskeletal Pain;1(3/4): 191-197.
4 Clark, S.R. (1994) Prescribing exercise for fibromyalgia patients. Arthritis Care Research; 7:221-225.
5 Rossy, L.A., Buckelew, S.P., Dorr, N., Hagglund, K.J., Thayer, J.F., McIntosh, M.J., Hewett, J.E. Johnson, J.C. (1999) A meta-
analysis of fibromyalgia syndrome. Annals of Behavioural Medicine; 21:180-191
 57

6 Busch, A.J., Barber, K.A., Overend, T.J. (2002) Exercise for treating fibromyalgia syndrome. Cochrane Database Systematic
Review; CD003786
7 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers.Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
8 Roos E. Ch 37. Swedish National Institute of Public Health. (2010) Physical Activity in the prevention and treatment of
disease. Available at: http://fyss.se/wp-content/uploads/2011/06/37.-Osteoarthritis.pdf
9 Bennell, KL. Dobson, F. Hinman, RS. (2014). Exercise in osteoarthritis: Moving from prescription to adherence. Clinical
Rheumatology; 28(1): 93-117
10 Devos-Comby, L., Cronan, T., Roesch, S.C. (2006) Do exercise and self management interventions benefit patients with
osteoarthritis of the knee? A metanalysize review. Journal of Rheumatology; 33:744-56.
11 Fransen M, McConnell S, Harmer AR, et al. (2015) Exercise for osteoarthritis of the knee. Cochrane Database of
Systematic Reviews, Issue 1. Art. No.: CD004376. DOI: 10.1002/14651858.CD004376.pub3
12 Pendleton, A., Arden, N., Dougados, M., (2000) EULAR recommendations for the management of knee osteoarthritis.
Report of a task force of the standing Committee for International Clinical Studies including Therapeutic Trials (ESCISIT).
Annals of the Rheumatic Diseases; 59:936-944.
13 Juhl C. Christensen R. Roos EM. et al (2014). Impact of exercise type and dose on pain and disability in knee
osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol 66(3):
622-36
14 Zhang W, Nuk G, Moskowitz RW, et al. (2009) OARSI recommendations for the management of hip and knee
osteoarthritis: Part III: changes in evidence following systematic cumulative update of research published through.
Osteoarthritis Cartilage. 2010: 476–499
15 Nϋesch E, Dieppe P, Reichenbach S, et al. (2011) All cause and disease specific mortality in patients with knee or hip
osteoarthritis: population based cohort study. BMJ 342:d1165
16 Badley E. (2014) Inactivity, disability, and death are all inter liked. If you must watch a lot of television, move between
commercial breaks. BMJ. 348.g2804
17 National Institute for Health and Clinical Excellence (2014) Osteoarthritis Care and management in adults: Clinical
guidance 177 . London: National Institute for Health and Clinical Excellence.
18 Vainionpau, A., Korpelainen, R., Leppaluoto, J., Jamsa, T. (2005) Effects of high-impact exercise on bone mineral density:
A randomised controlled trial in premenopausal woman. Osteoporosis International; 16:191-197.
19 Heinonen, A., Kannus, P., Sievanen, H. (1999) Good maintenance of high-impact activity-induced bone gain by
voluntary, unsupervised exercises: An 8-month follow-up of a randomized controlled trial. Journal of Bone and Mineral
Research; 14(1):125-128.
20 Heinonen, A., Kannus, P., Sievanen, H. Oja, P., Pasanen, M., Rinne, M., Uusi-Rasi, K. (1996) Randomised controlled trial
of effect of high-impact exercise on selected risk factors for osteoporotic fractures. The Lancet; 348:1343-1347
21 Engelke, K., Kemmler, W., Lamber, D. (2006) Exercise maintains bone density at spine and hips EPOPS: a 3-year
longitudinal study in early postmenopausal women. Osteoporosis International; 17:133-42
22 Brooke-Wavell, K., Jones, P.R., Hardman, A.E. (1997) Brisk walking reduces calcaneal bone loss in post-menopausal
women. Clinical Science; 92:75-80.
23 Farahmand, B.Y., Persson, P.G., Michaelsson, K. Baron, J.A., Alberts, A., Moradi, T.(2000) Physical activity and hip
fractures: A population-based case-control study. Swedish hip fracture study group. International Journal of Epidemiology;
29:308-14.
24 Gregg, E.W., Cawley, J.A., Seeley, D.G. (1998) Physical activity and osteoporotic fracture risk in older women. Study of
osteoporotic fractures group. Annals of Internal Medicine; 129:81-88.
25 Howe TE, Shea B, Dawson,LJ, et al (2011). Exercise for preventing and treating osteoporosis in postmenopausal women,
in: The Cochrane Collaboration (Ed.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK.
26 Warburton, D.E.R ., Katzmarzyk, P.T., Rhodes, R.E., Shephard, J. (2007) Evidence-informed physical activity guidelines for
Canadian adults. Applied Physiology, Nutrition and Metabolism; 32:(2): S16-S68.
27 Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community.
Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3
28 National Institute for Health and Clinical Excellence (2015) Osteoporosis- prevention of fragility fractures: Clinical
knowledge summaries. London: National Institute for Health and Clinical Excellence.
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29 Peters, M.J., Symmons, D.P., McCarey, D, Dijkmans B.A., Nicola, P., Kvien TK, et al. (2010) EULAR evidence-based
recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of
inflammatory arthritis. Ann Rheum Dis,69:325-31
30 Walsmith, J and Roubenoff, R.(2002) Cachexia in rheumatoid arthritis. International Journal of Cardiology; 85:89-99
31 Giles, JT, Bartlett,SJ, Andersen, RE, Fontaine, KR and Bathon, JM. (2008) Association of Body Composition With Disability
in Rheumatoid Arthritis: Impact of Appendicular Fat and Lean Tissue Mass. Arthritis and Rheumatism; (Arthritis Care and
Research) 59:10:1407-1415
32 Stavropoulos-Kalinoglou, A, Metsious, GS, Panoulas, VF, Douglas, KMJ, Nevill, AM, Jamurtas, AZ, Kitas, GD, ( 2009)
Association of obesity with modifiable risk factors for the development of cardiovascular disease in patients with
rheumatoid arthritis. Annals of the Rheumatic Diseases; 68:2:242-245
33 Marcora SM, Chester K, Mittal G, Lemmey AB and Maddison PJ. (2006) A randomized pfasw II trial of anti-TNF therapy
for cachexia in patients with early rheumatoid arthritis. American Journal of Clinical Nutrition 84:1463-1472
34 Metsios, GS, Savropoulos-Kalinoglou, A, Douglas, KMJ, Koutedakis, Y, Nevill, AM, Panouls, VF, Kita, M, and Kitas,
GD.(2007) Blockade of tumour factor-x in rheumatoid arthritis: effects on components of rheumatoid cachexia.
Rheumatology: 46: 1824-27
35 Engvall, IL, Tengstrand, B,l Brismar, K, Hafstomet , I. (2010) Infliximab therapy increases body fat mass in early
rheumatoid arthritis independently of changes in disease activity and levels of leptin and adiponectin: a randomised study
over 21 months. Arthritis Res earch and Therapy, 12 (5):R197
36 Hurkmans E, van der Giesan FJ, Vliet Vlieland TPM, Schoones J, Van den Ende ECHM ( 2009) Dynamic exercise programs
(aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database Systematic
Review; CD006853
37 Gaudin P, Leguen-Guegan S, Allenet B, Baillet A, Grange L, Juvin R. Is dynamic exercise beneficial in patients with
rheumatoid arthritis? Joint, Bone, Spine: Revue du Rhumatisme 2007;75(1):11-7
38 Hakkinen A. Effectiveness and safety of strength training in rheumatoid arthritis. Current Opinion in Rheumatology
2004;16(20:132-7.
39 Stenstrom, C.H., Minor, M.A. (2003) Evidence for the benefits of aerobic and strengthening exercise in rheumatoid
arthritis. Arthritis Rheumatology; 49:428-34
40 Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F and Maddison PJ. (2009) Effects of high intensity resistance
training in rheumatoid arthritis patients – a randomised controlled trial. Arthritis and Rheumatism, 61(12):1726-1734
41 Sokka, T, Hakkinen, A, Kautiainen H et al (2008) Physical inactivity in patients with rheumatoid arthritis: data from
twenty-one countries in a cross-sectional, international study. Arthritis Care Res; 59:42-50
42 Law, RJ, Breslin A, Oliver, E.J, Mawn, L, Markland, D.A, Maddison, P, Thom, J.M (2010) Perceptions of the effects of
exercise on joint health in rheumatoid arthritis patients. Rheumatology; 49:2444-2451
43 Brodin, N., Eurenius, E., Jensen, I., Nisell, R., Opava, C.H. (2008) Coaching patients with early rheumatoid arthritis to
healthy physical activity. A multicenter randomized, controlled study. Arthritis Rheumatology; 59:325-31.
44 deJong, Z., Vliet-Vlieland, T.P.M. (2005) Safety of exercise in patients with rheumatoid arthritis. Current Opinion
Rheumatology; 17:177-82.
45 Opava CH, Nisell R. Ch 43. Rheumatoid arthritis. Swedish National Institute of Public Health. (2010) Physical Activity in
the prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/43.-Rheumatoid-
arthritis.pdf
46 National Institute for Health and Clinical Excellence (2013) Rheumatoid arthritis – The management of rheumatoid
arthritis in adults: Clinical guidance 79. London: National Institute for Health and Clinical Excellence
47 Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. (2011) Exercise for improving balance in older people. Cochrane
Database of Systematic Reviews 2011, Issue 11. Art. No.: CD004963. DOI: 10.1002/14651858.CD004963.pub3.
48 Gillespie LD, Robertson M, Gillespie WJ, et al. (2013) Interventions for preventing falls in older people living in the
community. Cochrane Database of Systemic Review; DOI: 10.1002/14651858.CD007146.pub3
49 Chan WC, Yeung JWF, Wong CSM, et al. (2015) Efficacy of Physical Exercise in Preventing Falls in Older Adults With
Cognitive Impairment: A Systemic Review and Meta-Analysis. JAMDA 16 (2) 149-154
50 Hunter, G.R., Wetzstein, C.J., Fields, D.A. Brown, A., Bamman, M.M. (2000) Resistance training increases total energy
expenditure and free-living physical activity in older adults. Journal of Applied Physiology; 89:977-984.
51 Power V, Clifford AM. (2013) Characteristics of optimum falls prevention exercise programmes for community-dwelling
older adults using the FITT principle. European Review of Aging and Physical Activity; 10;2: 95-106
52 Sherrington C, Tiedermann A, Fairhall N et al. (2011) Exercise to prevent falls in older adults: an updated meta-analysis
and best practice recommendations. NSW Public Health Bulletin 22(4) 78-83 http://dx.doi.org/10.1071/NB10056
 59

53 National Institute for Health and Clinical Excellence (2013) Falls: prevention of falls and fractures: Clinical guidance 161.
London: National Institute for Health and Clinical Excellence.

Chapter 7 Obesity

1 World Health Organization. Obesity and overweight. Fact sheet 311

http://www.who.int/mediacentre/factsheets/fs311/en/
2 Campbell PT. (2014) Obesity; a certain and avoidable cause of cancer. The Lancet. 384 (995): 727-728
3 Reilly JJ, Kelly J. (2011) Long-term impact of overweight and obesity in childhood and adolescents on morbidity and
premature mortality in adulthood: systemic review. International Journal of Obesity. 35 (7):891-8
4 Griffiths LJ, Dezateux C, Hill A (2011) Is obesity associated with emotional and behavioural problems in childhood.
International journal of pediatric obesity 6 (2-2) e423-32
5 Klein S, Burke LE, Bray GA, et al. (2004) Clinical implications of obesity with specific focus on cardiovascular disease: a
statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism:
Endorsed by the American College of Cardiology Foundation. Circulation. 110 (18): 2952- 67
6 Wing RR, Lang W, Wadden TA, et al. (2011) Benefits of modest weight loss in improving cardiovascular factors in
overweight and obese individuals with type 2 diabetes. Diabetes Care. 34 (7) 1481-6
7 Kritchevsky SB, Beavers KM, Miller ME, et al. (2015) Intentional Weight Loss and All-Cause Mortality: A Meta-Analysis of
Randomized Controlled Trials. PLoS One 10 (3) e0121993
8 Thomas DM, Bouchard C, Church T, et al. (2012) Why do individuals not lose more weight from an exercise intervention
at a defined dose? An energy balance analysis. Obesity Review. 13:835-47
9 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers.Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
10 Shaw KA, Gennat HC, O’Rourke P, Del Mar C. (2006) Exercise for overweight or obesity. Cochrane Database of
Systematic Reviews Issue 4. Art. No.: CD003817. DOI: 10.1002/14651858.CD003817.pub3
11 Swift DL, Johannsen NM, Lavie CJ, et al. (2014) The Role of Exercise and Physical Activity in Weight Loss and
Maintenance. Prog Cardiovasc Dis. 56(40: 441-447
12 Donnelly JE, Blair SN, Jakicic JM, et al. (2009) American College 0f Sports Medicine Position Stand. Appropriate physical
activity intervention strategies for weight loss and prevention of weight gain for adults. Medicine and science in sports and
exercise.41(2): 459-71
13 National Institute for Health and Clinical Excellence (2014): Clinical guidance 189. Obesity: identification, assessment
and management of overweight and obesity in children, young people and adults. London: National Institute for Health and
Clinical Excellence
14 Winett RA, Carpinelli RN. (2001) Potential health-related benefits of resistance training. Prev Med. 33:503–13.
15 Ruiz, J.R., Sui, X., Lobela, F., Jackson, A.W., Sjostrom, M., Blair, S.N. (2008). Association between muscular strength and
mortality in men: prospective cohort studies. British Medical Journal; 337:a439.
16 Foster, G.D., Wadden, T.A., Voght, R.A., Brewer, G. (1997) What is reasonable weight loss? Patient’s expectations and
evaluations of obesity treatment outcomes. Journal of Consultant Clinical Psychology; 65:79-85
17 Swift DL, Earnest CP, Blair SN, et al. (2012) The effect of different doses of aerobic exercise training on endothelial
function in postmenopausal women with elevated blood pressure: Results from the drew study. Br J Sports Med.;46:753–8.
18 Kraus WE, Houmard JA, Duscha BD, et al. (2002) Effects of the amount and intensity of exercise on plasma lipoproteins.
N Engl J Med.;347:1483–92
19 Kraus WE, Houmard JA, Duscha BD, et al. (2002) Effects of the amount and intensity of exercise on plasma lipoproteins.
N Engl J Med.;347:1483–92
20 Johannsen NM, Swift DL, Lavie CJ, et al. (2013) Categorical analysis of the impact of aerobic and resistance exercise
training, alone and in combination, on cardiorespiratory fitness levels in patients with type 2 diabetes mellitus: Results
from the hart-d study. Diabetes Care. 36(10):3305-12
21 Myers VH, McVay MA, Brashear MM, et al. (2013) Exercise training and quality of life in individuals with type 2 diabetes:
A randomized controlled trial. Diabetes Care. 36(7):1884-90
22. Martin CK, Church TS, Thompson AM, et al. ( 2009)Exercise dose and quality of life: A randomized controlled trial. Arch
Intern Med;169:269–78
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23 King, N.A., Hopkins, M., Caudwell, P., Stubbs, R.J., Blundell, J.E. (2009) Beneficial effects of exercise: shifting the focus
from body weight to other markers of health. British Journal of Sports Medicine; 43:924-927.
24 National Institute for Health and Clinical Excellence (2014): Public Health 53. Managing overweight and obesity in adults
– lifestyle weight management services. London: National Institute for Health and Clinical Excellence

Chapter 8 Respiratory disease

1 Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
2 Emtner M. Ch 20. Chronic obstructive pulmonary disease (COPD). Swedish National Institute of Public Health. (2010)
Physical Activity in the prevention and treatment of disease. Available at: http://fyss.se/wp-content/uploads/2011/06/20.-
Chronic-obstructive-pulmonary-disease.pdf
3 http://www.blf.org.uk/Page/Exercise
4 Bendstrup, K.E., Ingemann, J.J., Holm , S. (1997) Out-patient rehabilitation improves activities of daily living, quality of life
and exercise tolerance in chronic obstructive pulmonary disease. European Respiratory Journal; 10:2801-6.
5 Hill, N.S. (2006). Proceedings of the American Thoracic Society. Pulmonary Rehabilitation; 3:66-74.
6 Troosters T, Gooselink R, DeCramer M (2000) Short and long term effects of outpatient rehabilitation in patients with
chronic obstructive pulmonary disease: a randomized trial. The American Journal of medicine 109 (3): 207-12
7 McCarthy B, Casey D, Devane D, et al. (2015) Pulmonary rehabilitation for chronic obstructive pulmonary disease. The
Cochrane database of systemic reviews. 2:CD003793. doi: 10.1002/14651858.CD003793.pub3
8 Griffiths, T.L., Burr, M.L., Campbell, I.A., et al. (2000) Results at 1 year of outpatient multidisciplinary pulmonary
rehabilitation; a randomised controlled trial. The Lancet; 355:362-368.
9 Griffiths, T.L., Phillips, C.J., Davies, S., Burr, M.L., Campbell, I.A. (2001) Cost effectiveness of an outpatient
multidisciplinary pulmonary rehabilitation programme. Thorax; 56:779-784.
10 Gloeckel R, Marinov B, Pitta F. (2013) Practical recommendations for exercise training in patients with COPD. European
respiratory review. 22(128): 178-186
11 Seymour JM, Moore L, Jolley CJ, et al. (2010) Outpatient pulmonary rehabilitation following acute exacerbations of
COPD. Thorax 65 (5) 423-8
12 Corhay JL, Dang DN, Van Cauwenberge H, Louis R. (2013) Pulmonary rehabilitation and COPD: providing patients a good
environment for optimizing therapy. International Journal of Chronic Obstructive Pulmonary Disease. 9:27-39
13 Jones SE, Maddocks M, Kon SS, et al. (2015) Sarcopenia in COPD: prevalence, clinical correlates and reponce to
pulmonary rehabilitation. Thorax 70(3): 2132-18
14 Waschki B, Kirsten A, Holz O, et al. (2011) Physical activity is the strongest predictor of all-cause mortality in patients
with COPD: a prospective cohort study. Chest. 140 (2):331-42
15 National Institute for Health and Clinical Excellence (2010) Chronic obstructive pulmonary disease: Management of
chronic obstructive pulmonary disease in adults in primary and secondary care: Clinical guidance 101. London: National
Institute for Health and Clinical Excellence.
16 Bolton CE, Bevan-Smith EF, Blakey JD, et al. (2013) British Thoracic Society guideline on pulmonary rehabilitation in
adults. Thorax 68: ii!-ii30
17 Garcia-Aymerich J, Lange P, Benet M, et al. (2007) Regular physical activity modifies smoking-related lung function
decline and reduces risk of chronic obstrutive pulmonary disease: a population-based cohort study. American journal of
respiratory and critical care medicine. 175(5): 458-63
18 van Wetering CR, Hoogendoorn M, Mol SJM, et al. (2010). Short- and long-term efficacy of a community-based COPD
management programme in less advanced COPD; a random controlled trial. Thorax .65::7-13

Chapter 9 Pregnancy

1 Royal College of Obstetricians and Gynaecologists. Exercise in pregnancy. Statement 2006 January; 4.
2 Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database of Systematic Reviews
2006; 3.
3 Josefsson A, Bø K. Ch 12. Pregnancy. Physical activity in the treatment and prevention of disease. Swedish National
Institute of Public Health 2010. Available at; http://fyss.se/wp-content/uploads/2011/06/12.-Pregnancy.pdf
4 Ceysens G, Rouiller D, Boulvain M. Exercise for diabetic pregnant women. Cochrane
Database of Systematic Reviews 2006;3.
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5 Meher S, Duley L. Exercise or other physical activity for preventing pre-eclampsia and its complications. Cochrane
Database of Systematic Reviews 2006;2.
6 Physical Activity Readiness Questionnaire (PAR-Q) http://www.fbpt.co.uk/PARQ.pdf
7 Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy
and the postpartum period. Br J Sports Med 2003;37:6-12.
8 Hunskaar S, Burgio K, Clark A, Lapitan MC, Nelson R, Sillen U, et al. Epidemiology of urinary (UI) and faecal (FI)
incontinence and pelvic organ prolapse (POP). In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Incontinence. Vol 1. Basic
and evaluation. Plymouth (UK): Health Publication Ltd; 2005. Chapter 5, pp. 255-312.
9 Wu WH, Meijer OG, Uegaki K, Mens JMA, van Dieen JH, Wuisman PIJM, et al. Pregnancy-related pelvic girdle pain (PPP),I:
Terminology, clinical presentation, and prevalence. Eur Spine J 2004;13:575-89.

Chapter 10 Surgery

1 Department of Health. (2011) Start Active, Stay Active. A report on physical activity for health from the four home
countries’ Chief Medical Officers.Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209
2 Pearse RM, Harrison DA, James P, et al. (2006) Identification and characterisation of the high-risk surgical population in
the United Kingdom. Crit Care. 10:R81
3 Khuri SF, Henderson WG, DePalma RG, et al. (2005) Determinants of long-term survival after major surgery and the
adverse effect of postoperative complications. Ann Surg. 242:326-341
4 Girish M, Trayner E Jr, Dammann O, Pinto-Plata V, Celli B. (2001) Symptom-limited stair climbing as a predictor of
postoperative cardiopulmonary complications after high-risk surgery. Chest 120:1147-51
5 Reilly DF, McNeely MJ, Doerner D, et al. (1999) Self-reported exercise tolerance and the risk of serious perioperative
complications. Arch Intern Med 159:2185-92
6 Lawrence VA, Hazuda HP, Cornell JE, et al. (2004) Functional independence after major abdominal surgery in the elderly. J
Ann Coll Surg 2004;199:762-72
7 Older P, Smith R, Courtney P, Hane R.(1993) Preoperative evaluation of cardiac failure and ischemia in elderly patients by
cardiopulmonary exercise testing. Chest 1993; 104:701-4
8 Carlisle J, Swart M. (2007) Mid-term survival after abdominal aortic aneurysm surgery predicted by cardiopulmonary
exercise testing. Br J Surg 94:966-9
9 Datta D, Lahiri B. (2003) Preoperative evaluation of patients undergoing lung resection surgery. Chest 123:2096-103
10 Hennis PJ, Meole PM,, Grocott MP. (2011) Cardiopulmonary exercise testing for the evaluation of perioperative risk in
non-cardiopulmonary surgery. Postgrad Med J 87:550-7
11 Snowdon CP, Prentis JM, Anderson HL et al. (2010) Sub maximal cardiopulmonary exercise testing predicts
complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg 251: 535-41
12 Wilson RJT, Davies S, Yates D, et al. (2010) Impaired functional capacity is associated with all-cause mortality after major
elective intra-abdominal surgery. Br J Anaesth 105: 297-303
13 West RJT, Lythgoe D, Barbara C, et al. (2014) Cardiopulmonary exercise variables are associated with postoperative
morbidity after major colonic surgery: a prospective blinded observational study. Br J Anaesth 101:1166-72
14 Snowden CP, Prentis J, Jacques B, et al. (2013) Cardiorespiratory fitness predicts mortality and hospital length of stay
after major elective surgery in older people. Ann Surg 257(6):999-1004.
15 Dronkers JJ, Chorus AMJ, van Meeteren NLU, Hopman-Rock M. (2013) The association of pre-operative physical fitness
and physical activity with outcome after scheduled major abdominal surgery. Anaesthesia 68: 67-73
16 O’Doherty AF, West M, Jack S and Grocott MPW. (2013) Preoperative aerobic exercise training in elective intra-cavity
surgery: a systemic review. Br J Anaesth 110: 679-89
17 Arthur HM, Daniels C, McKelvie R, et al. (2000) Effect of a preoperative intervention on preoperative and postoperative
outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. Ann
Intern Med 133: 253-62
18 Singh F, Newton R, Galvao D et al. (2013) A systematic review of pre-surgery exercise intervention studies with cancer
patients. Surg Oncol 22: 92-104
19 West MA, Loughney L, Lythgoe D, et al. (2015) Effect of prehabilitation on objectively measured physical fitness after
neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth. 114: 244-
51
20 Schmid D, Leitzmann MF. (2013) Association between physical activity and mortality among breast cancer and
colorectal cancer survivors: a systematic review and meta-analysis. Annals of Oncology. 25:7:1293-1311
 62

21 National Institute for Health and Clinical Excellence. (2012) Lower limb peripheral arterial disease: diagnosis and
management: NICE clinical guideline 147. London: National Institute for Health and Clinical Excellence

Chapter 11 Sedentary behaviour

1 http://gpcpd.walesdeanery.org/index.php/uk-physical-activity-guidelines
2 Jakes RW, Day NE, Khaw KT, (2003) Television viewing and low participation in vigorous recreation are independently
associated with obesity and markers of cardiovascular risk. EPIC-Norfolk population-based study. European Journal of
Clinical Nutrition; 57:1089-1096.
3 Hu FB, Leitzmann MF, Stampfer,MJ, et al.(2001) Physical activity and television watching in relation to risk for type 2
diabetes mellitus in men. Archives of Internal Medicine; 161:1542-1548.
4 Bertrais S, Beyeme-Ondoua JP, Czernichow S, et al. (2005) Sedentary behaviour, physical activity and metabolic syndrome
in middle-aged French subjects. Obesity Research; 13:936-944.
5 Dunstan DW, Salmon J, Owen N, et al. (2004) Aus Diab Steering Committee. Physical activity and television viewing in
relation to risk of undiagnosed abnormal glucose metabolism in adults. Diabetes Care; 27:2603-2609.
6 Katzmarzyk PT, Church TS, Craig CL. (2009) Sitting times and mortality from all causes, cardiovascular disease and cancer.
Medicine and Science in Sports and Exercise; 41:998-1005.
7 Edwardson CL, Gorely T, Davies MJ, et al. (2012) Association of Sedentary Behaviour with Metabolic Syndrome: A Meta-
Analysis. PLoS ONE 7(4): e34916. doi:10.1371/journal.pone.0034916
8 Pearson N, Biddle SJH. (2011) Sedentary behaviour and dietary intake in children, adolescents and adults: a systematic
review. Am J Prev Med :41:178-88.
9 Melkevik o, Torsheim T, Iannotti R, et al. (2010) Is spending time in screen-based sedentary behaviours associated with
less physical activity: a cross national investigation. Int J Behav Nutr Phy 7:46.
10 Foti KE, Eaton DK, lowry R, et al. (2011) Sufficient sleep, physical activity, and sedentary behaviours. Am J Prev Med
41:596-602.
11 Veerman JL, HealyGN, Cobiac LJ, et al. (2012) Television viewing time and reduced life expectancy: a life table analysis.
Br J Sports Med 46:927-30.
12 Henson J, Yates T, Biddle SJ, et al. (2013) Association of measured sedentary behaviour and physical activity with
markers of cardiometabolic health. Diabetologia 56:5:1012-1020.

Chapter 12 Motivation

1 Rollnick, S., Mason, P., Butler, C. (1999) Health Behaviour Change: A guide for practitioners. London: Churchill
Livingstone.
2 Resnicow, K., Diiorio, C., Soet, J.E. Ernst, D., Borrelli, B., Hecht, J. (2002). Motivational interviewing in health promotion: it
sounds like something is changing. Health Psychology; 21:444-451.
3 Rubak, S., Sandback, A., Lauritzen, T., Chitensen, B. (2005) Motivational interviewing: a systemic review and meta-
analysis. British Journal of General Practitioners; 55(513):305-312.
4 Rollnick, S., Butler, C., Kinnersley, P., Gregory, J., Mash, B. (2010) Motivational interviewing. British Medical Journal;
340:c1900.
5 Miller, R., Rose, G. (2009) Towards a theory of motivational interviewing. American Psychological Association; 64:527-37
6 Miller, W., Rollnick, S. (2012) Motivational Interviewing. Third Edition. Motivational Interviewing: Helping people change.
New York: Guildford Press.
7 O’Donovan, G., Blazevich, A.J., Boreham, C., Cooper, A.R., Crank, H., Ekelund, U., Fox, K., Gately, P., Giles-Corti, B., Gill,
J.M.R., Hamer, M., McDermott, I., Murphy, M., Mutrie, N., Reilly, J.J., Saxton, J.M., Stamatakis, E.(2010) The ABC of physical
Activity for Health: a consensus statement from the British Association of Sport and Exercises Sciences. Journal of Sport
Sciences; 28:6:591 Appendix 1
8 National Institute for Health and Clinical Excellence. (2007) Behaviour change at population, community and individual
levels: NICE public health guidance 6. London: National Institute for Health and Clinical Excellence.
9 Kallings, L.V., Kallings, M.E., Kowalski, J., Hellenius, M.L., Stahle, A. (2009) Self Reported Adherence: A Method for
Evaluating Prescribed Physical Activity in Primary Care Patients. Journal of Physical Activity and Health; 6:483-492.

Chapter 12 Starting to exercise

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1 Physical Activity Policy and Health Improvement Directorate. (2009) The general practice physical activity questionnaire
(GPPAQ); a screening tool to assess adult physical activity levels within primary care. Available at:
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitala
ssets/@dh/@en/@ps/documents/digitalasset/dh_112134.pdf
2 Sallis R. (2010) Developing healthcare systems to support exercise: exercise as the fifth vital sign. British Journal of Sports
and Medicine; 45:473-4
3 Adapted from Bandolier ‘Starting to exercise’ available at;
http://www.medicine.ox.ac.uk/bandolier/booth/hliving/startoex.html
4 Department of Health. (2007) Our NHS, our future: NHS next stage review – interim report. London: The Stationery
Office.
5 Royal College of General Practitioners. You and your GP. Patient Information leaflet. London: RCGP, 2010.
www.rcgp.org.uk/pdf/NI GP Leaflet.pdf
6 Pedersen, B.K., Saltin, B. (2006) Review. Evidence for prescribing exercise as therapy in chronic disease. Scandinavian
Journal of Medicine and Science in Sports; 16:(1): 3-63.
7 Swedish National Institute of Public Health. (2010) Physical Activity in the prevention and treatment of disease. Available
at: http://www.fyss.se/fyss-in-english/
8 BACR (2006) Phase IV Exercise Instructor Training Manual and ACSM (2009) Guidelines for Exercise Testing and
Prescription. Courtesy of Wales NERS guidelines.
9 American College of Sports Medicine (1993) Position stand. Physical activity, physical fitness, and hypertension. Medicine
and Science in Sports and Exercise; 25: i-x.

Further resources:
These chapters are extracts from the Welsh Deanery CPD module Motivate2Move information found at:
http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move where more bite size sections on the other
benefits of exercise can be found. There are also patient resources and links into more detailed information and other
relevant organizations.