Physical Inactivity Is Deadly! Strategies For Physiotherapists To Get Patients Active

http://www.physio-pedia.com/conferences/ifompt/

This Parallel Session from Day 4 of IFOMPT 2016 was entitled: Physical Inactivity Is Deadly! Strategies For Physiotherapists To Get Patients Active. The provided Learning Objectives were as follows:

• Understand epidemiologic and public health issues associated with physical inactivity, and discuss the public health role of musculoskeletal physiotherapists in primary prevention of non-communicable diseases
• Measure physical activity and identify barriers to patient adherence to physical activity participation
• Implement interventions to enable/support patients in increasing their physical activity and decreasing sedentary behaviour

The full abstract can be found here.

This session had what I thought was a surprisingly low turnout given that this topic is so pertinent to many of our patients; as Dr Debra Shirley noted during her introduction, many MSK patients are at risk of comorbidities such as noncommunicable disease (NCD) therefore addressing the risk of these NCDs through physical activity education should be a cornerstone of physiotherapy. As she also commented, however, there were other interesting sessions in the same time slot as always happens at content-packed conferences such as IFOMPT, therefore it is difficult for delegates to choose between them.

Dr Shirley first posed the question: “are adults sufficiently active?” The above map shows countries that have the lowest proportions of inhabitants meeting physical activity guidelines in darker colours (apologies that the photo is a little blurry). Dr Shirley pointed out that some improvement has occurred compared to a few years ago when 2/3 of the world’s population were insufficiently active but even with this positive change, there is room for further improvement. She also provided some data from the World Health Organization which has found that in general terms, women are more inactive than men and that the Americas and Eastern Europe are the least active areas.

Dr Shirley then went on to note that physical activity has been shown to reduce the risk of mortality due to NCDs. Inactivity is the 4th highest risk factor for death after hypertension, tobacco use and high blood glucose. There are many known health benefits of physical activity which can be seen in the slide below. Despite the obvious advantages of being physically active, we have just seen in the above map that people are still not active enough. As Dr Shirley commented, if only it was as easy as getting patients to take a pill!

Risk of Disease Relative to Amount of Physical Activity

The Many Health Benefits of Physical Activity

She then asked: “Who should be responsible for getting patients more active?” She shared a slide listing the seven best investments in physical activity. Number four on this list was integration of physical activity and NCD prevention into primary health care systems. She also showed a position statement from the World Confederation for Physical Therapy that included promoting health and emphasising the importance of physical activity within the scope of physiotherapy. Dr Shirley noted that health care professionals can reach and influence large numbers of people in the population for the following reasons;

• 70-80% of adults visit their GP each year in developed countries.
• Patients are often inactive and at risk of NCDs
• Patients consider primary care professionals appropriate to discuss health promotion with
• Physical activity interventions based in primary care can potentially generate larger health gains

Dr Shirley shared the estimated number of occasions of service in physiotherapy private practice in Australia in 2008 at 15.6 million* according to statistics from the Australian Physiotherapy Association. Clearly these numbers show that there is a huge number of opportunities to discuss physical activity with patients.

(*Please note that this number is awaiting confirmation from Dr Shirley)

Dr Shirley encouraged audience participation by asking us “What are the Physical Activity guidelines?” and had us respond through www.socrative.com. She was encouraged to see that a lot of people answered along the right lines.

When Professor Dean started speaking, she mentioned again the draw of the other parallel sessions running at the same time as the Physical Inactivity one. She said that as manual physiotherapists we obviously embrace learning about manual techniques but she also noted that things have changed and that we clearly need to redirect our practice to expand our scope of practice to include physical behaviour change.

Professor Dean and the Activity Pyramid

Professor Dean noted that even if you follow the physical activity guidelines but are sedentary the remainder of the time, you’re still at risk of NCD. She also rhetorically asked, “how much sitting is ok?”  and went on to report that humans were not designed to sit, not from endocrine, cardiopulmonary or biomechanical perspectives. She discussed changes that are being implemented in some workplaces to combat excessive sitting such as walking a minimum of five minutes every hour or the use of standing desks. Wearable technology such as pedometers are also used to encourage more activity. 10,000 steps per day are considered in the active range while < 5000 steps per day is a criterion for sedentary lifestyle; most of us average 6000-65oo steps per day.

Professor Dean discussed the notion of micro-exercise and how small bouts of moderate physical activity add up. She gave the example of Stockholm Airport where you can charge your own electronic devices using cycle ergometers. More examples of micro-exercises can be seen in the slide below.

Professional Dean also discussed some tools that can be used for tracking and promoting physical activity. These can be seen in the slide below, although she noted that observations are obviously not practical in a clinical setting. Assessment tools and other resources that were discussed included;

• Sedentary Behaviour Assessment
• Occupational Sitting and Physical Activity Questionnaire
• International Physical Activity Questionnaire –
• WHO STEPS Instrument – this is a 12 page instrument but step four can be used in isolation for behavioural measurements
• Physical Therapy Practice in the 21st Century: A New Evidence-informed Paradigm and Implications – Special Edition of Physiotherapy Theory and Practice from May 2009
• Chapters in Grieve’s Modern Musculoskeletal Physiotherapy 2015 discussing NCD and MSK risk factors – Ch11 Lifestyle and Musculoskeletal Health and Ch37 Role of Physiotherapy in Lifestyle and Health Promotion in Musculoskeletal Conditions
• Health Improvement Card , particularly the biometrics and lifestyle scorecard
• Taking vital signs in every patient interaction

Professor Ann Moore first joked that one of the health behaviour questions Professor Dean should have asked was: “Have you attended an IFOMPT conference, sat through all the sessions, booked a hotel right next to the conference and eaten a highly calorific meal every day for five days?!” Indeed. I admittedly felt pretty slovenly at that moment in time.

Professor Moore emphasized the idea of making every consultation count by tailoring interventions to each patient, creating individualized self-management strategies to support the interventions, providing advice on weight loss etc and providing sufficient education, advice and discussion as needed to ensure the full understanding of both parties. The latter point is particularly important when it comes to discussions of self-management. Professor Moore noted that at least in England, there is pressure to see patients for fewer visits and a shorter amount of time under the NHS. She said there was a maximum of 1.5 treatments available for patients with low back pain and she pointed out that so few visits would clearly be insufficient for setting up and supporting a good self-management program. Printing exercises off a website and giving the patient a handout simply doesn’t work and she said she found it worrying if this was considered reasonable. In contrast, a well-structured and patient-centred self-management program will benefit patients and their families, health care professionals, the NHS (or other health care system) as well as the government and policy makers .

Benefits of Self-Management Program

One major challenge of self-management is that there is often a difference in understanding of self-management between health care professionals and patients. A recent study found different viewpoints on this matter is summarized below.  .

Professor Moore and Different Viewpoints of Self-Management

Clearly, if some of these negative viewpoints are possible, and particularly if a therapist does not educate the patient about what self-management is relative to what the patient thinks self-management is, then the management program won’t work. Patients must understand that you’re not “abandoning” them and this can be done by leaving more time available for discussion in the first session and also by making more information available for patients about their condition and treatment.

In the final portion of the session, Dr Shirley discussed implementation of interventions. Various formats can be utilized for physical activity education and are overviewed in the following slide. All have been shown to be effective but none have been shown to be superior over other formats.

Dr Shirley also discussed the sequence of promotion in primary care by Stevenson and Roach (2012) which is shown below.

Sequence of Promotion in Primary Care

Again, knowing that any behaviour change can be difficult to effect, Dr Shirley discussed the NICE guidance on Behaviour Change and the stages of change (Precontemplation, Contemplation, Preparation, Action and Maintenance). She noted that we need to focus on patients in the first three categories using education, finding/removing barriers and motivation. Many perceived barriers prevent people from forming new positive behaviours such as physical activity, including work commitments, lack of leisure time, caring for children or older people, lack of money, poor health and lack of motivation. There are many suggestions for removing these barriers (see below) and Dr Shirley noted that a key point to emphasize is that being physically active does not have to cost much money.

Additional strategies for increasing physical activity levels at home, at work and while traveling can be found below. Dr Shirley noted that over 1/3 of Australian households own a dog and likened a dog to a living breathing physical activity reminder. So many of these strategies sound like common sense and yet it is amazing how few people actually apply them.

Strategies for Increasing Physical Activity at Home

Strategies for Increasing Physical Activity at Work

Strategies for Increasing Physical Activity while Traveling

To finish her part of the session, Dr Shirley mentioned various resources available for the promotion and adoption of a physically active lifestyle. These included;

• NHS physical activity guidelines for adults
• BBC Make Your Move public awareness campaign
• Monthly activity planner 
• Local information websites such as www.glasgowlife.org.uk

The Implication/Conclusions for this session were listed as: Physiotherapists are ideally positioned to incorporate physical activity advice for health promotion into practice. Evidence-based approaches and tools that are amenable to integration into contemporary physiotherapy practices need to be exploited in every patient as indicated, and incorporated into entry-to-practice physiotherapy professional education. In this way, physiotherapists could have a major impact on preventing/reversing inactivity as a major public health issue.

Personally, I have attended conference sessions on Physical Activity before and I admittedly am still not bringing up the subject with the majority of my patients. There is a research finding from many years ago indicating that on average, people need to be told about the benefits of a certain behaviour change three times before they actually get serious about making the change. Perhaps it is similar for physiotherapists adapting changes in their clinical practice. For me, I’ve listened to speakers on this topic enough times that I’m at the stage where I need to get serious about making this change and this session was a great springboard for that.