The issue of pre-exercise screening and assessment is potentially contentious, writes Director of Later Life Training Bex Townley (pictured).
As the evidence for exercise strengthens and the awareness of its benefits in improving health outcomes widens, so the demand for longer-term community exercise provision increases. Leisure trusts, community projects, public health commissioners and clinical commissioning groups are all in the frame for funding and establishing evidence-based exercise interventions to support people living with long-term conditions.
For Later Life Training [LLT] trained instructors working with clinical populations, this takes the form of the L4 Postural Stability Instructor (PSI) and Exercise and Fitness after Stroke (EfS) qualifications. However, the issues raised in this article are relevant for any instructor working with clients that may require liaison with health care professionals (HCPs) – ie, L3 Exercise Referral Instructors and Specialist Exercise Instructors.
This growing need for community provision should be good news for the fitness sector – clients and specialist exercise instructors delivering evidence-based programmes (stroke survivors, frailer older people at risk of falls). It should also be good news for our partners in health: the referrers (physiotherapists, GPs) who can direct those with the most to gain to targeted exercise programmes. But like most good things, along with the benefits are the challenges and compromises.
This article sets out to open the discussion and urge specialist exercise instructors, services and leisure facilities to consider their pre-exercise screening and assessment practice. It cannot provide all solutions to the challenges of pre-exercise screening and liaison with referral partners but LLT feels it essential to raise this amongst fitness sector organisations spearheading the current changes to training frameworks, and also the insurance providers who have an invested interest in safe/best practice.
From our experiences with students and conversations with service leads around the UK, time dedicated to pre-exercise screening and assessment is being reduced and in some regions assessment is being replaced with a ‘health commitment statement’ or service written ‘waivers’. These are designed to reduce the burden on GPs and health care providers/professionals (HCPs) and thus increase participation. What this also means is that potentially essential information is not passed onto the specialist exercise instructor.
It is expected that someone holding a L4 specialist exercise instructor qualification will have the knowledge and expertise to tailor and adapt a programme to suit the client’s health needs and preferences.
For LLT PSI/EfS specialist exercise instructors working with frailer older people at risk of falls, and stroke survivors of all ages, a meaningful pre-exercise interaction or consultation should include:
- a fully completed clinical referral form from the clients’ HCP (eg, physiotherapist) ideally at point of discharge
- for self-referrals: completion of the physical activity readiness questionnaire (PAR-Q) to ascertain if liaison with GP is required or referral from GP or HCP from health care setting (ie, physiotherapist from falls team or stroke team)
- assessment of motivation and the application of person-centered goal-setting and other behavior change strategies
- completion of agreed relevant outcome measures (monitoring and documenting client success, and service performance/impact).
The current move towards the use of health commitment statements in clinical populations is of concern to us.
Pre-exercise screening and assessment should be presented as a positive means to build professional relationships in order to support the long exercise journey ahead.
Dr Andy Scott, a Principal Lecturer and course leader of the MSc Clinical Exercise Science course at the Universityof Portsmouth, says: “The health commitment has been used for a number of years in health and fitness facilities to allow apparently healthy individuals with no knowledge of any significant health complaints to exercise, since in these cases the risks of not becoming regularly physically active are greater than any transient risk associated with commencing a moderate intensity exercise programme.
“This removes the need for health care professionals to become unnecessarily involved in the fitness facility induction process and the obligatory charge for signing the often under-detailed referral note. This process has been further strengthened by the American College of Sports Medicine (ACSM, 2016) recently updating their pre-exercise screening recommendations to allow anybody not presenting symptomatic cardiorespiratory or renal impairments to commence exercise, providing that this started at a low-to-moderate intensity and slowly progressed.
“From our experiences and discussion across the UK, agreed referral pathways are at best patchy, at worst non-existent. LLT supports any initiative aimed at increasing participation and we acknowledge the need to reduce barriers and unnecessary burden placed on GPs.
"But from our experiences exercise professionals are not clear about the appropriate use of statements/waivers that are written to replace the PARQ and more significant is that service commissioners seem as equally unclear in many cases. This results in the exercise instructor being bound to a process that they do not fully understand.”
Responsibilities of a specialist exercise instructor (PSI, EfS)
Training of PSIs and EfS instructors includes discussions about the role of the specialist exercise instructor and associated medico-legal requirements as detailed in the National Quality Assurance Framework for Exercise Referral (NQAF) (DoH, 2001).
For us there is no doubt that meaningful pre-exercise assessment is a requirement and a responsibility to ensure a successful and enjoyable exercise experience, and to take positive steps to reducing risk. For example, for an older person embarking on a targeted balance programme, it is important to know if they present with any vestibular problems, poor vision, or painful feet.
The self-referring client has become perhaps the biggest challenge for exercise services when their GP is not willing to provide information as a result of PARQ completion, leaving the instructor with blanks in information. It is because of this that perhaps the current industry move towards the use of commitment statements and waivers is becoming the easiest option or path of least resistance – and is, therefore, the most fundamental area in need of addressing in the fitness sector.
What Guidance do we have?
If you are a L3 Exercise Referral Instructor you probably have a copy of the NQAF sitting with pride of place on your desk (see references below if not!). Published in 2001 by the Department of Health it set out to provide guidance for GPs and exercise instructors to work together in order to promote and encourage people with common conditions to exercise safely and detailed medico-legal requirements and referrer responsibilities.
Since 2001, of course, the exercise training framework has developed to extend beyond common co-morbid conditions. Although the framework has increased knowledge and skill sets for exercise instructors, without clear referral guidance about responsibilities in referral pathways with clinical conditions, instructors are unaware or unclear of what best practice should be.
In 2016 the ACSM updated their pre-exercise screening recommendations (ACSM, 2016). The benefits of exercise far outweigh the risks for most people. This message has not changed and this is a common sense approach and an evidence-based one. Guidelines are guidelines – they help us make decisions – but as helpful as they can be, for instructors ‘how’ these guidelines are interpreted and at operational level (by facility managers) is really the main thrust of this article. Ahead of the review of the National Occupational Standards to produce Professional Standards, clear, standardised best practice guidance would support instructors in better understanding their parameters of practice and associated insurance requirements to safeguard themselves and the interests of their clients.
Reframing pre-exercise screening with a purposeful interaction
The fundamental principles of fitness inform us that achieving specific gains in components of fitness requires specific training. Clients presenting with movement impairments, fear of falling, cognitive impairment etc, usually report a desire to achieve easier performance of activities of daily living and maintain independence. Taking the time to understand what a person wants is the most basic requirement of person-centered approaches, improves adherence, and depending on the cognitive and physical impairments that present, the time required to have the interaction will vary.
Without adherence there are limited or no health outcomes. It is in the interest of commissioners and service leads to ensure instructors get the time they need to have meaningful interactions with clients, covering health history, physical activity history (starting point for exercise), baseline functional outcomes, goal setting and conversations addressing behavioral change approaches. Without this important interaction we as instructors miss out on critical insight likely to contribute to adherence and behaviors related to physical activity and fitness goals.
For commissioners and leisure trusts funding training for, and implementation of, exercise programmes for clients with long-term conditions; instructor assessment time is critical for targeted/specific health outcomes and sustained adherence.
What of duty of care?
When working with clinical populations, exercise instructors have a higher duty of care and there are more considerations and measures that should be taken in order to ensure safety, whilst maintaining choice.
Dr Scott says: “Specialist exercise instructors do not sign a Hippocratic oath, eg, ‘first do no harm’, however we are duty-bound to provide exercise that is safe and effective, not general and destructive, which may occur if we do not get to know our clients. Very soon insurance providers might begin to look at the profession and enquire, with respect to minimal safety standards, is a health commitment statement fit for purpose with people with known long term conditions, hence their reason for self-referring to supervised exercise sessions?”
Case Study Example
Claudine Aherne, founder of Vida Wellness, has been running Strong Foundations exercise classes (informed by the evidence-based PSI training) since 2009. These community-based classes, led by specialist exercise instructors, help independent older adults to improve their strength, balance and functional fitness.
“All new members who come to our Strong Foundations classes are self-referred," she says.
“When people come to us they are motivated and want to get started. If, using our professional judgment, we consider them to be appropriate for the programme, we want to help them get started as soon as is practicably possible. At the same time, we have a fundamental duty to understand their health status prior to participation.We need to know that they will be able to take part safely in the class, firstly by ruling out any absolute contraindications and then by ensuring that they are functionally appropriate for the class.
“We also need this information to help us to adapt sessions and tailor exercises for each individual, thereby maximising safety, optimising the customer experience and obtaining the best results we can for our members. For all these reasons a ‘waiver/or statement’ passing responsibility to the client without any questions or conversation is neither appropriate for us, as trained specialist providers, nor for our clients who come to us with bespoke needs and high expectations.”
One of the greatest skills that a specialist exercise instructor possesses is their ability to gather and interpret information provided from their clients, many of which are likely to be presenting with multiple conditions. The ultimate aim of the pre-exercise assessment and screening is to support success and to provide enjoyable, effective and safe exercise in the long term.
Specialist instructors with knowledge of assessment, monitoring and evaluation would be no more effective than a standard entry level fitness instructor if they do not have an opportunity to critically analyse information received and make informed exercise design decisions. Care should be taken to not remove such safeguards just to save time at the start of an exercise programme or indeed before each exercise session.
The costs might be larger than the gains.
Exercise referral systems: A national quality assurance framework. Department of Health (2001).