Write an exercise Rx to improve patients&#039; cardiorespiratory fitness

,; ,; ,

doi:doi: 10.12788/jfp.0323

Applied Evidence

Write an exercise Rx to improve patients' cardiorespiratory fitness

J Fam Pract. 2021 December;70(10):489-498 | doi: 10.12788/jfp.0323

PDF Download

References

1. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319:1024-1039. doi: 10.1001/jama.2018.1150

2. Tikkanen R, Abrams MK. U.S. health care from a global perspective, 2019: higher spending, worse outcomes? The Commonwealth Fund Website. January 30, 2020. Accessed November 16, 2021. www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019

3. Stoutenberg M, Stasi S, Stamatakis E, et al. Physical activity training in US medical schools: preparing future physicians to engage in primary prevention. Phys Sportsmed. 2015;43:388-394. doi: 10.1080/00913847.2015.1084868

4. Antognoli EL, Seeholzer EL, Gullett H, et al. Primary care resident training for obesity, nutrition, and physical activity counseling: a mixed-methods study. Health Promot Pract. 2017;18:672-680. doi: 10.1177/1524839916658025

5. Asif IM, Drezner JA. Sports and exercise medicine education in the USA: call to action. Br J Sports Med. 2020;54:195-196. doi: 10.1136/bjsports-2019-101104

6. Douglas JA, Briones MD, Bauer EZ, et al. Social and environmental determinants of physical activity in urban parks: testing a neighborhood disorder model. Prev Med. 2018;109:119-124. doi: 10.1016/j.ypmed.2018.01.013

7. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: US Department of Health & Human Services; 2018. Accessed November 15, 2021. https://health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf

8. Avis JL, Cave AL, Donaldson S, et al. Working with parents to prevent childhood obesity: protocol for a primary care-based ehealth study. JMIR Res Protoc. 2015;4:e35. doi:10.2196/resprot.4147

9. Ball TJ, Joy EA, Gren LH, et al. Concurrent validity of a self-reported physical activity ‘vital sign’ questionnaire with adult primary care patients. Prev Chronic Dis. 2016;13:e16. doi: 10.5888/pcd13.150228

10. Ball TJ, Joy EA, Gren LH, et al. Predictive validity of an adult physical activity “vital sign” recorded in electronic health records. J Phys Act Health. 2016;13:403-408. doi: 10.1123/jpah.2015-0210

11. Coleman KJ, Ngor E, Reynolds K, et al. Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc. 2012;44:2071-2076. doi: 10.1249/MSS.0b013e3182630ec1

12. Ross R, Blair SN, Arena R, et al; American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing; Council on Functional Genomics and Translational Biology; Stroke Council. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association. Circulation. 2016;134:e653-e699. doi: 10.1161/CIR.0000000000000461

13. de Souza de Silva CG, Kokkinos PP, Doom R, et al. Association between cardiorespiratory fitness, obesity, and health care costs: The Veterans Exercise Testing Study. Int J Obes (Lond). 2019;43:2225-2232. doi: 10.1038/s41366-018-0257-0

14. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12:38-48. doi: 10.4278/0890-1171-12.1.38

15. Riebe D, Ehrman JK, Liguori G, et al. Methods for evoking change talk. In: ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed. Wolters Kluwer; 2018.

16. Grandes G, Sanchez A, Sanchez-Pinilla RO, et al. Effectiveness of physical activity advice and prescription by physicians in routine primary care: a cluster randomized trial. Arch Intern Med. 2009;169:694-701. doi: 10.1001/archinternmed.2009.23

17. McNeill LH, Kreuter MW, Subramanian SV. Social environment and physical activity: a review of concepts and evidence. Soc Sci Med. 2006;63:1011-1022. doi: 10.1016/j.socscimed.2006.03.012

18. Garber CE, Blissmer BE, Deschenes MR, et al; American College of Sports Medicine. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Position stand. Med Sci Sport Exerc. 2011;43:1334-1359. doi: 10.1249/MSS.0b013e318213fefb

19. Donnelly JE, Blair SN, Jakicic JM, et al; American College of Sports Medicine. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Position stand. Med Sci Sport Exerc. 2009;41:459-471. doi: 10.1249/MSS.0b013e3181949333

20. Fox SM 3rd, Naughton JP, Haskell WL. Physical activity and the prevention of coronary heart disease. Ann Clin Res. 1971;3:404-432.

21. Karvonen MJ, Kentala E, Mustala O. The effects of training on heart rate; a longitudinal study. Ann Med Exp Biol Fenn. 1957;35:307-315.

22. The Borg RPE scale. In: Borg G. Borg’s Perceived Exertion and Pain Scales. Human Kinetics; 1998:29-38.

23. Ratamess NA, Alvar BA, Evetoch TK, et al; American College of Sports Medicine. Progression models in resistance training for healthy adults. Position stand. Med Sci Sport Exerc. 2009;41:687-708. doi: 10.1249/MSS.0b013e3181915670

24. Gym memberships & fitness programs. Medicare.gov. Baltimore, MD: US Centers for Medicare and Medicaid Services. Accessed November 16, 2021. www.medicare.gov/coverage/gym-memberships-fitness-programs

25. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise preparticipation health screening. Med Sci Sports Exerc. 2015;47:2473-2479. doi: 10.1249/MSS.0000000000000664

26. Physical Activity Related Current Procedural Terminology (CPT®) Codes. Physical Activity Alliance website. Accessed November 16, 2021. https://paamovewithus.org/wp-content/uploads/2020/11/PAA-Physical-Activity-CPT-Codes-Nov-2020-AMA-Approved-Final-1.pdf

27. Blair SN. Physical inactivity: the biggest public health problem of the 21st century Br J Sports Med. 2009;43:1-2.

28. Vuori IM, Lavie CJ, Blair SN. Physical activity promotion in the health care system. Mayo Clin Proc. 2013;88:1446-1461. doi: 10.1016/j.mayocp.2013.08.020

Physicians and physical therapists can use the therapeutic exercise code (Current Procedural Terminology code 97110) when teaching patients exercises to develop muscle strength and endurance, joint range of motion, and flexibility²⁶ (TABLE 4²⁶).

Table 4: Coding and billing pointers

Conclusion

Physical activity and CRF are strong predictors of premature mortality, even compared to other risk factors, such as cigarette smoking, hypertension, hypercholesterolemia, and type 2 diabetes.²⁷ Brief physical activity assessment and counseling is an efficient, effective, and cost-effective means to increase physical activity, and presents a unique opportunity for you to encourage lifestyle-based strategies for reducing cardiovascular risk.²⁸

The AHA has asserted the importance of assessing cardiorespiratory fitness as a “vital sign.”

However, it is essential to meet patients where they are before trying to have them progress; it is therefore imperative to assess the individual patient’s level of activity using PAVS. With that information in hand, you can personalize physical activity advice; determine readiness for change and potential barriers for change; assist the patient in setting SMART goals; and arrange follow-up to assess adherence to the exercise prescription. Encourage the patient to call their health insurance plan to determine whether a gym membership or fitness program is covered.

Research is needed to evaluate the value of using digital apps, in light of their cost, to increase physical activity and improve CRF in a clinical setting. Prospective trials should be initiated to determine how routine implementation of CRF assessment in primary care alters the trajectory of clinical care. It is hoped that future research will answer the question: Would such an approach improve clinical outcomes and reduce health care expenditures?¹²

a Defined as O2 consumed while sitting at rest; equivalent to 3.5 mL of O₂ × kg of body weight × min.

CORRESPONDENCE
Matthew Kampert, DO, MS, Sports Medicine, 5555 Transportation Boulevard, Cleveland, OH 44125; kamperm@ccf.org