HEALTH PROMOTION THE CLINICAL EXERCISE By Bob Laventure

Recent articles included in SportEX Medicine have highlighted the role of exercise for patients with specific clinical conditions including asthma, diabetes, cancer and hypertension. These provide evidence of the growth of understanding in the role of exercise, not only offering significant improvements in public health, but also in the treatment of a range of conditions and diseases.

The developments in both the medical and exercise establishments, particularly those of GP referral or exercise on prescription schemes, have contributed to the gradual appearance of the ‘clinical exercise practitioner’, a relatively new breed of exercise professional. This article sets out to explore the skills, experiences and competencies of such a practitioner and identifies what is required to develop fur- ther the role of exercise in a range of clinical settings.

A patient centred model The starting point of any clinical exercise intervention is the spe- cific needs of the patient being determined by health status and previous exercise history. These needs are, or should be, identified and met by the combined skills and experiences of a multi-discipli- nary professional team. Cardiac rehabilitation interventions, in addition to a programme of exercise, will often include education and advice on diet and smoking. Evidence indicates that falls pre- vention programmes among older people involving exercise are most effective when exercise is accompanied by the modification of other risk factors eg. vision problems (1). Moreover, work with patient groups with little or no physical activity and/or exercise history and who may well have very poor motivation to undertake an exercise programme, will need to employ models of patient coun- selling and address readiness to change.

The role of the clinical exercise practitioner The clinical exercise practitioner is someone who is able to work in

Dependence level Physically frail - housebound Independent with assistance Independent with assistive aids Independent older people Supervision

One to one or home based management instructors

a number of specialist settings and environments, including the physiotherapy gym, hospital ward or day setting, specialist rehabil- itation units and nursing homes. They will have qualifications, edu- cation and training on working within the therapies with specified patient groups. They are integral to the whole process of planning, design, implementation and evaluation of the exercise programme.

Within a multi-professional health team they are required to: ● collaborate with other professionals in the planning of coherent and holistic patient care ● provide evidence based exercise programmes ● provide continuity between secondary care and the community exercise setting ● participate in patient and programme review

Providing continuity between secondary care and community exer- cise settings is an essential element of long-term patient care. This is particularly so following discharge of the patient for example in the transition stage from Phase III to Phase IV of cardiac rehabili- tation. It will assist in optimizing the gains achieved in the reha- bilitation or clinical setting and provides a mechanism for a refer- ral back to the health setting in the event of a change or decline in health. Moreover the continuity of care can improve long-term com- pliance to regular exercise with an increased chance of new physi- cal activity behaviours being sustained throughout life. An example of the close collaboration required might include planning the inclusion of environmental improvements (to the home) or the use of assistive devices recommended by the occupational therapist.

Responsibility for exercise The recent debate concerning roles and responsibility for exercise referral in primary health care settings (2) is mirrored in the clini- cal exercise setting. In these circumstances, clinical responsibility for the patient remains with the referrer, responsibility for the design administration and delivery of the exercise programme rests with the exercise practitioner.

Competency level NVQ 3+++, rehabilitation and falls

Supervised sessions, health care setting NVQ3 Exercise for older people instructors (special populations)

Supervised sessions, community Unsupervised, community Table 1: The continuum of exercise provision and care (adapted from Dinan & Skelton, 1999) (5) 20 SportEX

Chair-based exercises for older people leaders (inc.assisted walking and games)

NVQ2 Exercise for general populations instructors

PRACTITIONER