1. health and fitness
2. exercise

How to Give Exercise Advice
To Every Patient
At Every Opportunity
A Handbook for Every
Health Professional
TAKE ONE SMALL STEP FOR EXERCISE, ONE LARGE LEAP TO HEALTH!
Exercise is a medicine!
Medical evidence clearly demonstrates that exercise
works for the majority of long-term conditions and certain
acute health problems. Every health professional has a
key role in helping patients to understand why it is
important to exercise, where they can exercise safely,
and how to exercise.
When health professionals give this support and advice,
patients are able to live healthier, more independent and
often happier lives.
This training handbook has been designed to inspire
health professionals to think about the clinical practice of
exercise services to patients and the public.
It covers the basic exercise information that doctors,
nurses, pharmacists and allied health professionals should
give to patients. The module includes the cost implications
of physical inactivity, simple exercise advice for chronic
diseases and how to keep patients motivated in enjoying
exercising.
Exercise is a vital part of a patient's life in staying fit, healthy
and independent.
This handbook helps you deliver quality exercise advice in
delivering evidence-based patient care.
How to Give Exercise Advice
To Every Patient
At Every Opportunity
A Handbook for Every
Health Professional
TAKE ONE SMALL STEP FOR EXERCISE, ONE LARGE LEAP TO HEALTH!
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CONTENTS
SECTION 1
HOW TO GIVE ADVICE TO EVERY PATIENT,
AT EVERY OPPORTUNITY
Introduction ....................................................................... 1 - 1
aims of this Handbook ...................................................... 1 - 2
What are the Health Benefits of Exercise? ...................... 1 - 4
Key Exercise Recommendations ..................................... 1 - 7
Safety advice to be given to all patients ........................... 1 - 9
Warm up ............................................................................. 1 - 10
Cool down .......................................................................... 1 - 11
Early Years (Under 5s) - For Infants Who Are Not Yet
Walking ............................................................................ 1 - 12
Early Years (Under 5s) - For Children Who Are Capable Of
Walking ............................................................................ 1 - 14
Children And Young People (5–18 Years) ...................... 1 - 16
Adults (19–64 years) ......................................................... 1 - 18
Older Adults (65+ years) ................................................. 1 - 20
Simple and Safe Exercises for Patients ............................ 1 - 22
How to start exercising ...................................................... 1 - 22
Walk to health! ................................................................... 1 - 23
Choose an exercise! ........................................................... 1 - 23
Endurance or ‘Stamina’ ..................................................... 1 - 24
Strength exercises .............................................................. 1 - 26
Muscle-strengthening Activities ....................................... 1 - 27
Arm Raise .......................................................................... 1 - 29
Strength exercises .............................................................. 1 - 29
Biceps Curl ......................................................................... 1 - 30
Chair Stand ......................................................................... 1 - 31
Knee Extension .................................................................. 1 - 32
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Triceps Extension .............................................................. 1 - 33
Alternative "Dip" Exercise For Back of
Upper Arm ...................................................................... 1 - 34
Hip Extension .................................................................... 1 - 35
Plantar Flexion ................................................................... 1 - 36
Hip Flexion ........................................................................ 1 - 37
Knee Flexion ...................................................................... 1 - 38
Side Leg Raise .................................................................... 1 - 39
Shoulder Flexion ............................................................. 1 - 40
Flexibility exercises ........................................................... 1 - 41
Plantar Flexion ................................................................... 1 - 43
Hamstrings ......................................................................... 1 - 44
Alternative Hamstring Stretch ......................................... 1 - 45
Calves .................................................................................. 1 - 46
Ankles ................................................................................. 1 - 47
Triceps Stretch ................................................................... 1 - 48
Wrist Stretch ....................................................................... 1 - 49
Double Hip Rotation ........................................................ 1 - 50
Single Hip Rotation .......................................................... 1 - 51
Shoulder Rotation ............................................................. 1 - 52
Neck Rotation .................................................................... 1 - 53
Quadriceps ......................................................................... 1 - 54
Quick Tips ......................................................................... 1 - 55
balance exercises ................................................................ 1 - 55
Plantar Flexion ................................................................... 1 - 57
Knee Flexion ...................................................................... 1 - 58
Hip Flexion ........................................................................ 1 - 59
Hip Extension .................................................................... 1 - 60
Side Leg Raise .................................................................... 1 - 61
About Floor Exercises ...................................................... 1 - 62
Anytime/Anywhere ........................................................... 1 - 62
Are there any risks with exercise for patients? ................ 1 - 64
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Some Other Points about Exercise .................................. 1 - 65
Contraindications to Exercise .......................................... 1 - 66
Further Help and Information ......................................... 1 - 68
References .......................................................................... 1 - 69
SECTION 2
ASSESSING PATIENTS FOR EXERCISE
Assessing Patients for Exercise ........................................ 2 - 1
Pre-participation Assessment Screening Procedures ..... 2 - 4
Exercise Assessment for Every Patient ........................... 2 - 6
Stages of change Model in decision making .................... 2 - 7
Compliance, adherence and concordance for exercise .. 2 - 10
Further Help and Information ......................................... 2 - 13
References .......................................................................... 2 - 15
TYPES OF EXERCISE ADVICE AVAILABLE FOR
SPECIFIC CHRONIC DISEASE CONDITIONS
SECTION 3
HYPERTENSION
Hypertension ...................................................................... 3 - 1
Haemodynamic Response to Exercise ............................ 3 - 2
Costs of Hypertension ....................................................... 3 - 2
Benefits of Exercise in Hypertension .............................. 3 - 3
Endurance or ‘stamina’ exercise recommendations for
hypertension ..................................................................... 3 - 5
Resistance training exercise recommendations for
hypertension ..................................................................... 3 - 8
Flexibility recommendations for hypertension .............. 3 - 9
CHEST flexibility .............................................................. 3 - 9
Additional Lifestyle Recommendations ......................... 3 - 10
Special Precautions for Hypertensive Patients ............... 3 - 13
Further Help and Information ......................................... 3 - 14
References .......................................................................... 3 - 14
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SECTION 4
PERIPHERAL ARTERIAL DISEASE
Peripheral Arterial Disease ............................................ 4 - 1
Costs of PAD ...................................................................... 4 - 2
Rationale for exercise in PAD .......................................... 4 - 2
Exercise and PAD .............................................................. 4 - 3
Walking exercise advice to be given to PAD patients ..... 4 - 4
Patients with PAD can significantly improve their
health through aerobic exercise ..................................... 4 - 7
Resistance Training and Flexibility recommendations
for patients with PAD ...................................................... 4 - 8
The main goals of the exercise programme for
PAD patients are .............................................................. 4 - 8
Contraindications to Exercise in PAD ............................. 4 - 8
Further Help and Information ......................................... 4 - 9
References .......................................................................... 4 - 9
SECTION 5
DIABETES
Diabetes .............................................................................. 5 - 1
What Types of Exercise Is Best for Diabetes? ................. 5 - 3
Strength Training and Type 2 Diabetes ............................ 5 - 6
Safety Issues in Exercise in Diabetic patients ................. 5 - 8
Safely Managing Blood Glucose Levels During
Exercise ............................................................................ 5 - 11
Aerobic Exercise Recommendations for Type 2
Diabetes ............................................................................ 5 - 12
Further Help and Information ......................................... 5 - 13
References .......................................................................... 5 - 13
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SECTION 6
OSTEOPOROSIS, FALLS AND FRACTURES
Osteoporosis, Falls and Fractures .................................... 6 - 1
Physical Activity and risk of falls ..................................... 6 - 7
Exercise advice in patients with osteoporosis or
risk of falls and fractures ................................................. 6 - 9
Strength training exercises ................................................ 6 - 10
Resistance or Strength Exercises Recommendations
for Osteoporosis .............................................................. 6 - 11
Weight-bearing Aerobic exercise recommendations
for Osteoporosis .............................................................. 6 - 12
Flexibility Exercises Recommendations for
Osteoporosis .................................................................... 6 - 13
Balance Exercises Recommendations for
Osteoporosis .................................................................... 6 - 14
These Exercises are Not as Beneficial for
Osteoporosis .................................................................... 6 - 15
Further Help and Information ......................................... 6 - 16
References .......................................................................... 6 - 16
SECTION 7
OSTEOARTHRITIS
Osteoarthritis ..................................................................... 7 - 1
What causes osteoarthritis? .............................................. 7 - 2
Patients are often on the following types of drugs: ......... 7 - 3
Exercise Recommendations for Osteoarthritis .............. 7 - 6
Flexibility Exercises Recommendations for
Osteoarthritis ................................................................... 7 - 8
Resistance Exercises Recommendations for
Osteoarthritis ................................................................... 7 - 9
Aerobic Exercises Recommendations for
Osteoarthritis ................................................................... 7 - 11
Summary of Guidelines for Use of Exercise to Treat
Osteoarthritis of the Knee and Hip ............................... 7 - 12
Further Help and Information ......................................... 7 - 13
References .......................................................................... 7 - 13
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SECTION 8
RHEUMATOID ARTHRITIS
Rheumatoid Arthritis ........................................................ 8 - 1
Co-morbidities ................................................................... 8 - 4
Clinical Presenting Features ............................................. 8 - 4
Treatment of RA ................................................................ 8 - 6
Exercise recommendations for RA ................................. 8 - 7
Contraindications to Exercise in RA ............................... 8 - 9
Flexibility Exercises Recommendations for
Rheumatoid arthritis ...................................................... 8 - 10
Resistance Exercises Recommendations for
Rheumatoid arthritis ...................................................... 8 - 11
Aerobic Exercises Recommendations for
Rheumatoid arthritis ...................................................... 8 - 13
Special Recommendations for Patients with RA ........... 8 - 14
Advise to Stop Exercising and Refer to a
Health or Fitness Professional ....................................... 8 - 15
Further Help and Information ......................................... 8 - 15
References .......................................................................... 8 - 16
SECTION 9
JOINT REPLACEMENT
Joint Replacement ............................................................. 9 - 1
Hip Resurfacing ................................................................. 9 - 1
The Rationale for Exercise ............................................... 9 - 3
Exercise Recommendations for patients with Joint
Replacements .................................................................. 9 - 4
Restrictions on weight bearing and exercise ................... 9 - 5
Rehabilitation Exercise Protocols ................................... 9 - 7
Measurement of Leg Lengths ............................................ 9 - 9
Total knee replacement exercise protocol ....................... 9 - 9
Exercise recommendations ............................................... 9 - 11
Exercise Recommendations Following Total Hip
Replacement .................................................................... 9 - 12
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Exercise Recommendations Following Total Knee
Replacement .................................................................... 9 - 13
Aerobic Exercise Recommendations
for Exercise following THR and TKR ........................ 9 - 14
Strength Exercise Recommendations
for Exercise following THR .......................................... 9 - 15
Flexibility Exercise Recommendations
for Exercise following THR .......................................... 9 - 17
Strength Exercise Recommendations
for Exercise following TKR .......................................... 9 - 18
Flexibility Exercise Recommendations
for Exercise following TKR .......................................... 9 - 20
Further Help and Information ......................................... 9 - 21
References .......................................................................... 9 - 21
SECTION 10
STROKE
Stroke ............................................................................... 10 - 1
Prevalence of Stroke ....................................................... 10 - 2
Factors affecting stroke risk ........................................... 10 - 2
Economic Costs of Stroke ............................................. 10 - 3
Post-Stroke Symptoms ................................................... 10 - 4
Long term complications during Stroke rehabilitation10 - 5
Exercise recommendations after Stroke and TIA ....... 10 - 7
Further Help and Information ...................................... 10 - 9
References ....................................................................... 10 - 9
SECTION 11
PARKINSON'S DISEASE
Parkinson's Disease ........................................................ 11 - 1
Prevalence of Parkinson’s Disease ................................ 11 - 1
symptoms of Parkinson Disease .................................... 11 - 2
Economic Costs of Parkinson Disease ......................... 11 - 2
Pathology and causes of Parkinson Disease ................. 11 - 4
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Symptoms of Parkinson’s disease .................................. 11 - 4
Treatment of Parkinson's disease .................................. 11 - 5
Exercise and PD Patients ............................................... 11 - 7
Exercise Recommendations for
Parkinson’s disease ....................................................... 11 - 11
Aerobic Exercises Recommendations for
Parkinson’s Disease ...................................................... 11 - 15
Strength training Exercises Recommendations
for Parkinson’s Disease ................................................ 11 - 16
flexibility Exercises
Recommendations for Parkinson’s Disease .............. 11 - 17
Further Considerations for Exercise in
Parkinson’s Disease Patients ....................................... 11 - 18
How Healthcare Professionals Can Support
Patients with Parkinson’s Disease ............................... 11 - 21
Further Help and Information ...................................... 11 - 22
References ....................................................................... 11 - 23
SECTION 12
ASTHMA
Asthma ............................................................................. 12 - 1
Prevalence of Asthma ..................................................... 12 - 1
Economic Cost of Asthma ............................................. 12 - 2
Causes of Asthma ........................................................... 12 - 3
Exercise recommendations for asthma ........................ 12 - 4
Contra-indications to exercise in asthma ..................... 12 - 6
Aerobic/Endurance/Stamina Exercises
Recommendations for Asthma ................................... 12 - 8
Resistance/strength Exercises
Recommendations for Asthma ................................... 12 - 9
Flexibility Exercises
Recommendations for Asthma ................................... 12 - 9
Further Help and Information ...................................... 12 - 10
References ....................................................................... 12 - 11
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SECTION 13
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD)
Chronic Obstructive Pulmonary Disease (COPD) ..... 13 - 1
Prevalence OF copd ....................................................... 13 - 1
Economic costs of COPD .............................................. 13 - 2
Exercise recommendations for COPD ......................... 13 - 3
4 Types of Exercises for COPD ..................................... 13 - 4
Pursed lip breathing: ...................................................... 13 - 4
Diaphragmatic Breathing: ............................................. 13 - 5
Aerobic Exercises Recommendations for COPD ...... 13 - 6
Strength Training Exercises Recommendations
for COPD ...................................................................... 13 - 7
Flexibility Exercises Recommendations for COPD ... 13 - 7
Further Help and Information ...................................... 13 - 9
References ....................................................................... 13 - 10
SECTION 14
STOMA
Exercise Recommendations for Stoma Patients ......... 14 - 1
Prevalence and Cost Implications of Stoma Care ....... 14 - 1
Specific Considerations for Co-Morbidities in
Stoma Patients .............................................................. 14 - 3
Exercise Hygiene and Preparation for Stoma Patients 14 - 4
Exercise recommendations for Stoma patients ........... 14 - 5
Further Help and Information ...................................... 14 - 7
References ....................................................................... 14 - 7
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SECTION 15
OBESITY
Exercise for Obesity Patients ........................................ 15 - 1
Prevalence of Obesity ..................................................... 15 - 2
Cost to the Nation of Obesity ........................................ 15 - 3
Overweight and Obesity Prevalence ............................. 15 - 3
Cost to the Nation ........................................................... 15 - 4
Obesity Strategy .............................................................. 15 - 6
The Rationale for Exercise in Obesity ......................... 15 - 8
Contraindications to Exercise in obesity ...................... 15 - 10
Aerobic Exercises Recommendations in obesity ....... 15 - 12
Resistance/strength Training Exercises
Recommendations in obesity ...................................... 15 - 13
Flexibility Exercises Recommendations in obesity .... 15 - 14
Further Help and Information ...................................... 15 - 15
References ....................................................................... 15 - 16
SECTION 16
CANCER
Cancer .............................................................................. 16 - 1
Prevalence of Cancer ...................................................... 16 - 3
Economic Costs of Cancer ............................................ 16 - 4
Rationale for Exercise in Cancer Patients ................... 16 - 6
Physical Activity Reduces the Risk of Bowel Cancer . 16 - 7
Physical Activity Reduces the Risk of Breast Cancer . 16 - 8
Recommendations for Exercise in Cancer ................... 16 - 9
Aerobic Exercises Recommendations for Cancer ..... 16 - 12
Resistance/strength Exercises
Recommendations for Cancer .................................... 16 - 13
Flexibility and stretching Exercises
Recommendations for Cancer .................................... 16 - 13
Further Help and Information ...................................... 16 - 14
References ....................................................................... 16 - 14
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SECTION 17
MULTIPLE SCLEROSIS
Multiple Sclerosis ........................................................... 17 - 1
Prevalence of Multiple Sclerosis ................................... 17 - 2
Multiple Sclerosis in the UK ......................................... 17 - 2
Causes of Multiple Sclerosis .......................................... 17 - 3
Symptoms of Multiple Sclerosis ................................... 17 - 3
Benign MS (BMS) .......................................................... 17 - 6
The Rational for Exercise in MS .................................. 17 - 6
Exercise Recommendations in MS ............................... 17 - 8
Aerobic Exercises Recommendations for
Multiple Sclerosis ........................................................ 17 - 9
Resistance/strength Exercises Recommendations
for Multiple Sclerosis ................................................... 17 - 10
Flexibility and stretching Exercises
Recommendations for Multiple Sclerosis ................. 17 - 11
Further Help and Information ...................................... 17 - 12
References ....................................................................... 17 - 13
SECTION 18
BACK PAIN
Back Pain ......................................................................... 18 - 1
Prevalence of Back Pain ................................................. 18 - 2
Cost to the Nation of Back Pain .................................... 18 - 3
Causes of Back Pain ....................................................... 18 - 4
Treatment of Back Pain .................................................. 18 - 6
Aerobic Exercises
Recommendations for back pain ................................ 18 - 8
Resistance Training Exercises
Recommendations for back pain ................................ 18 - 9
Flexibility and stretching Exercises
Recommendations for back pain ................................ 18 - 10
Further Help and Information ...................................... 18 - 11
References ....................................................................... 18 - 12
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SECTION 19
MENTAL HEALTH PROBLEMS
Mental Health Problems ................................................ 19 - 1
Prevalence of Mental Health ......................................... 19 - 2
Economic cost of mental health .................................... 19 - 3
Causes of Mental Health ................................................ 19 - 4
The Rationale for Exercise ............................................ 19 - 5
Considerations for Mental Health Patients and
Exercise ......................................................................... 19 - 7
Further Help and Information ...................................... 19 - 10
References ....................................................................... 19 - 11
SECTION 20
PREGNANCY
Pregnancy ........................................................................ 20 - 1
Economic Cost of Poor Health in Pregnancy .............. 20 - 3
Exercise Recommendations for Pregnancy ................. 20 - 4
General Advice in Pregnancy ........................................ 20 - 5
Jogging and Running ...................................................... 20 - 6
Swimming ........................................................................ 20 - 6
Yoga and Stretches .......................................................... 20 - 7
Pilates ............................................................................... 20 - 8
Weight training ................................................................ 20 - 9
Low-impact Aerobics ..................................................... 20 - 9
Further Help and Information ...................................... 20 - 11
References ....................................................................... 20 - 12
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APPENDICES
APPENDIX A
An example of an exercise prescription for a patient with
Parkinson's Disease
APPENDIX B
Physical activity readiness questionnaire
APPENDIX C
The Health Commitment Statement (HCS) Guidelines
(2009)
APPENDIX D
Sample health questionnaire used by health professionals and
gym chains
APPENDIX E
Exercise recommendations for osteoarthritis and rheumatoid
arthritis
APPENDIX F
Glossary
Bibliography
About Ann Gates - Founder of Exercise Works!
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ACKNOWLEDGEMENTS
I'd like to say a huge 'Thank you' to my Mum, Dad (who died
from a hip fracture at the age of 93), my son John, and my ex
husband David (a GP and my 'best' friend) for their support and
love in helping me write this book. I would also like to thank my
Gran- 'Granny Miff' (who died of a stroke at the age of 94) for
her inspiration and love of medicine.
This book would not exist if it were not for the belief and support
of all the great people at BOE Medical Publishing who have
helped me produce a practical guide for health professionals. I
would like to thank Anthony (Chairman), Paul, and John at
BOE for their hard work on editing and producing this module.
BOE have also produced all the Exercise Works! products on
'MRSA proof' paper to ensure safe use in clinical environments.
I would also like to thank Foxcreate (Hannah and Ian) for their
creative flair, Business Link Derby and the European Regional
Development Fund for grant support.
I would also like to thank NASA (the National Aeronautics and
Space Administration) and the National Institute of Aging for
allowing me to use excerpts from 'Exercise: A guide from the
National Institute on Aging and the National Aeronautics and
Space Administration' and to reprint with permission. If it wasn't
for Senator John Glenn's work to inspire older people to exercise
more, then we would not exist!
My love of evidence based, clinical medicine inspired this
handbook. The inspiration for the book comes from the great
clinicians, pharmacists, allied health professionals, health
planners and sports and exercise professionals that I have had
the privilege to work with since I qualified as a Pharmacist from
Nottingham University in 1982. The skills that I have learnt
over the years have taught me that patients deserve a world class
service from medicine and from the science of exercise research.
To be able to produce a book which will help patients receive
the best exercise advice has been my main goal. To the people
and patients that have helped me - Thank you!
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A big shout out to some of my colleagues from the Fitness
Industry, namely all the team at Virgin Active (UK) Derby and
from British Nordic Walking for keeping me fit and active, and
for inspirational advice from training their clients. A huge 'Thank
you and hug' goes to Virgin Active Personal trainers, Craig Hall
and David Smyth. David Smyth, sadly passed away suddenly in
June 2013 from cancer- he will greatly missed for his skills and
dedication.
I would also like to thank some medical colleagues for their
invaluable support and professional opinion- Dr David Gates,
Dr Ian Shand, Dr Bob Sallis, Professor Karim Khan, Professor
Tahir Masud, Dr Richard Weiler, and Professor Adam Perksey.
Many thanks also go out to all the great GPs and Consultants
that I have had the pleasure of working with along the years in
Derby and around the world.
Jim Dawton, from Designit UK, also provided invaluable
support and inspiration.
Dr Ruthie Cartwright edited, revised and contributed fantastic
training skills in the production of this handbook- many thanks
Ruthie!
Finally, I would like to thank the teachers of Churston Grammar
School, Devon for inspiring a love of science, sports and the sea
that enabled me to enjoy life to the full.
Some great quotes along the way...
From my son, training to
be a Physiotherapist
'I'd be more impressed if
you were meeting the
Ministry of Magic!'
'He who studies medicine
without books sails an
uncharted sea, but he who
studies medicine without
patients does not go to
sea at all' ~ William Osler
And via @exerciseworks
Every health professional, every patient, quality exercise advice
that helps nations, communities and individuals #getactive to
their health.
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