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Exercise for Multimorbid Patients in Primary Care: One Prescription for All?

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Abstract

The purpose of this article was to discuss guidelines for the management of the most prevalent chronic diseases treated by primary care physicians (PCPs) in order to identify the best exercise regimen for each clinical population, and to provide preliminary guidance for primary care providers on exercise counselling in the ‘real-world’ context of multimorbidity. After a search of the PubMed electronic database, the 11 most prevalent conditions currently treated by PCPs were identified. The recommendations provided by recognised learned/scientific societies for the management of each disease were then examined and any recommendations involving physical activity and exercise were identified. It was found that the best exercise regimen (i.e. exercise type, intensity, duration, and frequency) was very similar across chronic diseases, which suggests that elaborating and implementing a standardised, minimum exercise guideline for multimorbid patients in primary care may be an alternative approach to time-costly individualised exercise prescriptions. Based on this finding, I propose an example of standardised, cross-disease exercise prescription, and discuss how such a prescription could be operationalised by PCPs in their routine clinical practice.

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References

  1. Khan KM, Weiler R, Blair SN. Prescribing exercise in primary care. BMJ. 2011;343:d4141.

    Article  PubMed  Google Scholar 

  2. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major noncommunicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–29.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Warburton DE, Charlesworth S, Ivey A, et al. A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults. Int J Behav Nutr Phys Act. 2010;7:39.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Norton S, Matthews FE, Barnes DE, et al. Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data. Lancet Neurol. 2014;13(8):788–94.

    Article  PubMed  Google Scholar 

  5. Forouzanfar MH, Alexander L, GBD 2013 Risk Factors Collaborators, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(10010):2287–323.

    Article  PubMed  Google Scholar 

  6. Gielen S, Laughlin MH, O’Conner C, et al. Exercise training in patients with heart disease: review of beneficial effects and clinical recommendations. Prog Cardiovasc Dis. 2015;57(4):347–55.

    Article  PubMed  Google Scholar 

  7. Billinger SA, Arena R, Bernhardt J, et al. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(8):2532–53.

    Article  PubMed  Google Scholar 

  8. Focht BC. Effectiveness of exercise interventions in reducing pain symptoms among older adults with knee osteoarthritis: a review. J Aging Phys Act. 2006;14(2):212–35.

    Article  PubMed  Google Scholar 

  9. Giangregorio LM, Papaioannou A, Macintyre NJ, et al. Too fit to fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int. 2014;25(3):821–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Colberg SR, Albright AL, Blissmer BJ, et al. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282–303.

    Article  PubMed  Google Scholar 

  11. Smith AW, Borowski LA, Liu B, et al. U.S. primary care physicians’ diet-, physical activity-, and weight-related care of adult patients. Am J Prev Med. 2011;41(1):33–42.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Bock C, Diehm C, Schneider S. Physical activity promotion in primary health care: results from a German physician survey. Eur J Gen Pract. 2012;18(2):86–91.

    Article  PubMed  Google Scholar 

  13. van Dillen SME, Noordman J, van Dulmen S, et al. Examining the content of weight, nutrition and physical activity advices provided by Dutch practice nurses in primary care: analysis of videotaped consultations. Eur J Clin Nutr. 2014;68(1):50–6.

    Article  PubMed  Google Scholar 

  14. Galaviz KI, Jauregui-Ulloa E, Fabrigar LR, et al. Physical activity prescription among Mexican physicians: a structural equation analysis of the theory of planned behaviour. Int J Clin Pract. 2015;69(3):375–83.

    Article  CAS  PubMed  Google Scholar 

  15. Bardach SH, Schoenberg NE. The content of diet and physical activity consultations with older adults in primary care. Patient Educ Couns. 2014;95(3):319–24.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Hébert ET, Caughy MO, Shuval K. Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review. Br J Sports Med. 2012;46(9):625–31.

    Article  PubMed  Google Scholar 

  17. Yarnall KSH, Pollak KI, Østbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–41.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Ornstein SM, Nietert PJ, Jenkins RG, et al. The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report. J Am Board Fam Med. 2013;26(5):518–24.

    Article  PubMed  Google Scholar 

  19. Rizza A, Kaplan V, Senn O, et al. Age- and gender-related prevalence of multimorbidity in primary care: the Swiss FIRE project. BMC Fam Pract. 2012;13:113.

    Article  PubMed  PubMed Central  Google Scholar 

  20. van Oostrom SH, Picavet HSJ, van Gelder BM, et al. Multimorbidity and comorbidity in the Dutch population - data from general practices. BMC Public Health. 2012;12:715.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Fortin M, Stewart M, Poitras ME, et al. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med. 2012;10:142–51.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Schäfer I, Hansen H, Schön G, et al. The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study. BMC Health Serv Res. 2012;12:89.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Laux G, Kuehlein T, Rosemann T, et al. Co- and multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project. BMC Health Serv Res. 2008;8:14.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Garin N, Koyanagi A, Chatterji S, et al. Global multimorbidity patterns: a cross-sectional, population-based, multi-country study. J Gerontol A Biol Sci Med Sci. 2016;71(2):205–14.

    Article  PubMed  Google Scholar 

  25. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37–43.

    Article  PubMed  Google Scholar 

  26. Negewo NA, McDonald VM, Gibson PG. Comorbidity in chronic obstructive pulmonary disease. Respir Investig. 2015;53(6):249–58.

    Article  PubMed  Google Scholar 

  27. Kauppi P, Linna M, Jantunen J, et al. Chronic comorbidities contribute to the burden and costs of persistent asthma. Mediators Inflamm. 2015;2015:819194.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014;32(1):3–15.

    Article  CAS  PubMed  Google Scholar 

  29. National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management: clinical guideline. Published: 24 August 2011. http://www.nice.org.uk/guidance/cg127. Accessed 11 Feb 2016.

  30. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76–99.

    Article  PubMed  Google Scholar 

  31. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53.

    Article  PubMed  Google Scholar 

  32. National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification: Clinical guideline. Published: 18 July 2014. http://www.nice.org.uk/guidance/cg181. Accessed 11 Feb 2016.

  33. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Arlington: American Psychiatric Association; 2010.

    Google Scholar 

  34. National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical guideline. Published: 28 October 2009. http://www.nice.org.uk/guidance/cg90. Accessed 11 Feb 2016.

  35. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–28 (quiz 329).

    Article  PubMed  Google Scholar 

  36. National Institute for Health and Care Excellence. Gastrooesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline. Published: 3 September 2014. http://www.nice.org.uk/guidance/cg184. Accessed 11 Feb 2016.

  37. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care. 2010;33(12):2692–6.

    Article  PubMed  PubMed Central  Google Scholar 

  38. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline. Published: 2 December 2015. http://www.nice.org.uk/guidance/ng28. Accessed 11 Feb 2016.

  39. National Institute for Health and Care Excellence. Physical activity: brief advice for adults in primary care. Public health guideline. Published: 29 May 2013. http://www.nice.org.uk/guidance/ph44. Accessed 11 Feb 2016.

  40. Marwick TH, Hordern MD, Miller T, et al. Exercise training for type 2 diabetes mellitus: impact on cardiovascular risk: a scientific statement from the American Heart Association. Circulation. 2009;119(25):3244–62.

    Article  PubMed  Google Scholar 

  41. International Diabetes Federation, Clinical Guidelines Task Force. Global guideline for type 2 diabetes. Brussels: International Diabetes Federation; 2012.

  42. National Institutes of Health, National Heart, Lung, and Blood Institute. The clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. NIH Publication No. 98-4083. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1998.

  43. National Institute for Health and Care Excellence. Obesity: identification, assessment and management. Clinical guideline. Published: 27 November 2014. http://www.nice.org.uk/guidance/cg189. Accessed 11 Feb 2016.

  44. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71.

    Article  PubMed  Google Scholar 

  45. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129(25 Suppl 2):S102–38.

    Article  PubMed  Google Scholar 

  46. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil. 2014;22(3):363–88.

    Article  CAS  PubMed  Google Scholar 

  47. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee: evidence-based guideline. 2nd ed. Rosemont: American Academy of Orthopaedic Surgeons; 2013.

    Google Scholar 

  48. National Institute for Health and Care Excellence. Osteoarthritis: care and management. Clinical guideline. Published: 12 February 2014. http://www.nice.org.uk/guidance/cg177. Accessed 11 Feb 2016.

  49. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64(4):465–74.

    Article  CAS  Google Scholar 

  50. Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014;43(2):343–73.

    Article  CAS  PubMed  Google Scholar 

  51. National Institutes of Health, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 2007.

  52. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. British Thoracic Society and Scottish Intercollegiate Guidelines Network; 2014.

  53. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014.

    Google Scholar 

  54. Watts NB, Bilezikian JP, Camacho PM, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract. 2010;16(Suppl 3):1–37.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Scottish Intercollegiate Guidelines Network (SIGN). Management of osteoporosis and the prevention of fragility fractures: a national clinical guideline. Edinburgh: SIGN; 2015. (SIGN publication no. 142). http://www.sign.ac.uk.

  56. National Institute for Health and Care Excellence. Chronic heart failure in adults: management. Clinical guideline. Published: 25 August 2010. http://www.nice.org.uk/guidance/cg108. Accessed 11 Feb 2016.

  57. Piña IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation. 2003;107(8):1210–25.

    Article  PubMed  Google Scholar 

  58. Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873–934.

    Article  PubMed  Google Scholar 

  59. American College of Sports Medicine position stand. Exercise for patients with coronary artery disease. Med Sci Sports Exerc. 1994;26(3):i–v.

    Google Scholar 

  60. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–91.

    Article  PubMed  Google Scholar 

  61. National Institute for Health and Care Excellence. Low back pain in adults: early management. Clinical guideline. Published: 27 May 2009. http://www.nice.org.uk/guidance/cg88. Accessed 11 Feb 2016.

  62. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1435–45.

    Article  PubMed  Google Scholar 

  63. World Health Organization. Global recommendations on physical activity for health. Geneva: WHO; 2010. p. 58.

    Google Scholar 

  64. de Souto Barreto P. Time to challenge public health guidelines on physical activity. Sports Med. 2015;45(6):769–73.

    Article  Google Scholar 

  65. Grøntved A, Hu FB. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. JAMA. 2011;305(23):2448–55.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Chau JY, Grunseit AC, Chey T, et al. Daily sitting time and all-cause mortality: a meta-analysis. PLoS One. 2013;8(11):e80000.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Sallis R. Developing healthcare systems to support exercise: exercise as the fifth vital sign. Br J Sports Med. 2011;45(6):473–4.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  PubMed Central  Google Scholar 

  69. Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;175(6):959–67.

    Article  PubMed  PubMed Central  Google Scholar 

  70. de Souto Barreto P, Cesari M, Andrieu S, et al. Physical activity and incident chronic diseases: a longitudinal observational study in 16 European countries. Am J Prev Med. 2017;52(3):373–8.

    Article  Google Scholar 

  71. Moore SC, Lee I-M, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA. Intern Med. 2016;176(6):816–25.

    Google Scholar 

  72. Moore SC, Patel AV, Matthews CE, et al. Leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. PLoS Med. 2012;9(11):e1001335.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Kelly S, Martin S, Kuhn I, et al. Barriers and facilitators to the uptake and maintenance of healthy behaviours by people at mid-life: a rapid systematic review. PLoS One. 2016;11(1):e0145074.

    Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Philipe de Souto Barreto.

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de Souto Barreto, P. Exercise for Multimorbid Patients in Primary Care: One Prescription for All?. Sports Med 47, 2143–2153 (2017). https://doi.org/10.1007/s40279-017-0725-z

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