Exercise prescription in the management of chronic disease falling through an evidence-practice gap: Perspectives of doctors and nurses in specialist settings

Multifactorial benefits beyond scope of disease

There was broad acceptance of the importance of exercise in supporting patient health by doctors and nurses across all disease groups. Reported benefits were multifactorial spanning physical and mental domains, with potential to improve key cardiometabolic disease risk factors identified in addition to longevity. Exercise was often referred to as ‘medicine’. Specific recognised benefits included improvements in overall cardiovascular health, blood pressure, mental health, sleep quality, sense of wellbeing, muscle maintenance, strength and functional capacity, quality of life and social function.

I think it’s really important, obviously to get them moving, um, for a range of reasons…assists with…heart function, their, um, blood pressure, um, weight management if they need to as well. Also just the mental health…release of endorphins … get them out into the fresh air and doing something. (22, cardiac nurse)

Most practitioners described exercise as integral to disease-specific care in addition to general health; however, this view was not shared by all. Diabetes specialists consistently highlighted the role of exercise in improving glycaemic control and general diabetes management. Underpinning physiological mechanisms behind the role of exercise in disease management were raised, particularly for diabetes care.

I mean exercise has many benefits…we're going to get a lower blood glucose level for less medication if we do implement some exercise…Exercise is also something that has to be carefully taught to patients in terms of if they need monitoring of, um, adjusting of their insulin particularly. (24, diabetes nurse)

Evidence for the role of exercise prescription in chronic disease management was rarely raised specifically. In kidney transplantation, it was reported that the evidence base for exercise was poor. It was apparent that personal experience with exercise influenced clinician beliefs and emphasis on the role of exercise in disease management. Those who described personal engagement with exercise underscored its importance.

Generally that's [diet and exercise] the thing that interests them [patients] most in their management. It generally tends not to be given a high priority in clinical management, probably partly because the evidence is poor for exercise, physical activity, for diet. So I think that's, I think getting a better evidence base would be helpful. (25, kidney doctor)

Complements weight management

The role of exercise in weight management was asserted by most clinicians who acknowledged that exercise plays a role in weight management alongside diet. It was generally perceived that exercise alone was inadequate for weight loss, but the benefits of exercise were irrespective of weight loss. Some disease-specific considerations for the role of exercise in weight management were raised for kidney transplant recipients, given the weight gain associated with ongoing pharmaceutical management and the return of taste. Collectively diet was promoted as the principal weight loss strategy.

Similarly to diet obviously it, um, it uh, can be part of weight loss. Although on its own, it doesn’t actually contribute to weight loss significantly, but it is factor that at least leads to sustainability of weight loss. (43, diabetes doctor)

Rehabilitation versus long-term management

There was an emphasis on the role of exercise care in return to ‘normal’ function and work (i.e. a rehabilitation focus), particularly in post-acute coronary syndrome and post-transplant care. The role of exercise in the management of comorbidities associated with chronic disease was rarely raised and there was a lack of focus on preventative care. The objective of referral to tertiary-care physiotherapists in cardiac rehabilitation was to address mobility and musculoskeletal limitations rather than exercise prescription for broader management of coronary artery disease and associated risk factors.

Physio is something we refer patients to a lot, but a lot of it's more about, um, discharge planning and mobility assessment. It's, it's less commonly related to managing obesity and sedentary lifestyle and that sort of thing. It's usually about making sure that they are going to be safe at home. (59, cardiac doctor)

Limited and selective services in tertiary setting

There was a stark lack of access to exercise expertise or support in this public hospital and health service setting. It was noted by clinicians who have worked across multiple service districts that there was a high variability in practice with ‘siloed care’. Access to exercise programs and exercise specialists was described as selective and disease specific. Outside of cardiac rehabilitation, which has physiotherapists embedded and gym programs as part of acute post-care, and a single exercise physiologist in a specialist ‘integrated care clinic (ICC)’ for patients with MASLD, there were no exercise services available. For instance, patients under the care of diabetes specialists could only access exercise care if they also received post-acute cardiac care or were a patient attending the MASLD ICC. Physiotherapy services outside of cardiac rehabilitation were described as difficult to access with referrals based solely on acute issues. Across all disease groups, there was a desire for integration of exercise physiology services into the tertiary-care setting, although this was less frequently expressed by Cardiology clinicians.

We're better resourced with dietitians, we've often thought we'd like an exercise physiologist or someone of that sort of thing who could help construct programs for patients. So they really get what limited advice we can give them...has been identified…as a gap in what we really have in our department, um, and have not been able to get funding for. (29, kidney doctor)

Reliance on primary care diverts responsibility to general practitioners and patients

The broad expectation was that General Practitioners (GPs, i.e. primary care physicians) were responsible for managing the exercise component of care. GPs were viewed as the ‘captain of the patient’s ship’ and responsible for ongoing referrals to exercise professionals if deemed necessary, largely through the national Medicare-supported ‘chronic disease management plan’ scheme. Notably, the onus is placed on the patient to see their GP to initiate this process, despite the expressed lack of confidence in the patient to action recommendations to seek referral, or that the GP will prioritise exercise referral.

Normally I'll just advise patients to see their GP, so they can go and see an exercise physiologist in the community… you kinda have to leave it up to the patient…And/or just advise them to try and start doing some form of exercise or movement. (10, diabetes nurse)

Lack of community care continuity

No formal referral pathways between tertiary care settings and primary and community services were identified across clinicians and disease groups. Clinicians described a limited capacity for hospitals to host services, with a need to direct care back into the community given the growing service demand in line with the increasing burden of chronic disease. However, there was a lack of awareness of what community services exist, their costs, and the expertise associated with them. Non-Government Organisation-led national walking programs (e.g. National Heart Foundation) and community walking groups were identified as options, however the availability of these community services were reported to have declined, with no formal referral pathways to facilitate patient engagement.

I'm not actually aware of any community initiatives they can have that don't cost them money…Patients who don't qualify for cardiac rehab, I, I do struggle with where to send them. (66, cardiac doctor)

Little emphasis was placed on ongoing care for disease groups with existing exercise services (i.e. cardiac rehabilitation or the MASLD ICC). Moreover, distrust in ‘non-professional’ exercise practitioners (e.g. personal trainers) was expressed by some clinicians. Some nurses spoke of referring cardiac patients to a telephone-based coaching program that focuses on chronic disease self-management skills.

I might try and dissuade them or discourage them from going to like a local gym and getting a, um, personal trainer or somebody like that. Because I don't believe, majority of those people don't have the skills and knowledge to care for somebody post an event. (41, cardiac nurse)

Gap in workforce expertise remains unfilled

In addition to the lack of exercise service provision, there was a lack of patient-focused resources to provide patients with information about exercise care. In the cardiac setting materials from the National Heart Foundation were commonly used and considered reputable for exercise information. Diabetes specialists described information materials that were centred on the prevention and management of hypoglycaemia in type 1 diabetes or focused on blood glucose variation with exercise (rather than exercise prescription per se). Exercise brochures developed by staff were available for people with liver disease in the specialised ICC, and another liver clinician also referred to the ‘Move It AUS’ guidelines. Collectively there were no clear and consistent avenues for resource support to ‘fill the gap’ in lieu of exercise specialist care.

And I must admit we don't have, you know, pamphlets or resources to go into exactly what that is cause it's generally needing to be tailored to that individual according to their comorbidities, if they've got arthritis or whatever they've got going on. (39, diabetes doctor)

Local site-specific research linkages were also raised as a potential avenue for patents with diabetes or liver disease to access exercise support when available. Previous awareness of local research outcomes related to exercise prescriptions positively influenced the clinicians view on the capabilities of people with liver disease to exercise despite physical limitations.

There are many patients perhaps earlier that I might've looked at and said, you know, I just don't see you as becoming physically active. But my experience with referring to the [research] exercise physiologist has been that magic happens. That exercises can be developed even for upper body work that can improve someone's confidence and muscle development that I wouldn't have previously thought possible. (38, liver doctor)

Promoter not prescriber

Interviewed doctors and nurses did not consider themselves experts in exercise prescription and viewed their role as ‘promoters’ of exercise, namely through motivational interviewing, encouragement, goal setting or identifying patient-led preferences and barriers to physical activity, with an emphasis on enjoyment.

...trying to encourage, you know, general advice, you know, can you do some regular walking or hydrotherapy or swimming or whatever and trying to work out what might work for them, but it's certainly not in great detail with our level of knowledge. (39, diabetes doctor)

Limited consultation time dictated the prioritisation of exercise discourse, which varied across roles and disciplines. In the cardiac setting there was capacity for cardiac nurses to provide resistance bands and home exercise books, which in combination with links to a local walking group, or mobile-phone application, might facilitate ongoing adherence to exercise. No clinician viewed their role to include exercise prescription.

Unfortunately due to time, just, you know, complete honesty, maybe people are spending more time on the medications and so forth and less time on exploring those diet and lifestyle options. (20, diabetes nurse)

Exercise advice varies

Specific exercise advice (i.e. frequency, intensity, time and type) was generally restricted to the role of the doctor and mostly general in nature. Tailoring of exercise prescription was usually centred on participant self-reported current activity or functional capacity and individual preferences. Most recommendations were based on exercise type/modality or ways to modify activities of daily living. In patients with more advanced disease progressions (e.g. decompensated cirrhosis) advice centred on achieving basic activities of daily living and avoiding lifting heavy weights if there were concerns around varices. Some clinicians referenced either the Australian or the Heart Foundation physical activity guidelines and most promoted 30 min of light-moderate intensity physical activity on most days. Recommendations on exercise intensity were limited to subjective measures such as the ‘talk test’ and feeling sweaty, or were based on avoiding high-intensity exercise.

I just advise them the types of exercise, like your cardio and your, um, resistance. But I don't ever prescribe anything. (53, diabetes nurse)

The confidence of the clinician to advise on exercise appeared to be positively impacted by personal engagement in exercise, which also seemed to influence the prioritisation of exercise advice within the time-limited service.

I generally give general advice on diet and exercise and I'll probably give more specific advice to a degree on exercise cause I am interested in that and do a lot myself. So I'm probably feel more competent to give advice on that. (15, kidney doctor)

Exercise ‘assessment’ is limited to brief and unstructured history taking

Time restraints limited the capacity of clinicians to formally assess physical activity levels or quantify any component of fitness. The exception was in the cardiac rehabilitation setting where specific assessment tools (e.g. the 6 min walk test) with objective measures of heart rate response in addition to ratings of perceived exertion are undertaken as part of the program. The responsibility of exercise assessment in the cardiac setting is placed on the cardiac nurses and physiotherapists, and not the cardiac doctors. Most exercise ‘assessment’ involved clinicians asking the patient to self-report their current physical activity levels.

I will promote it but not particularly assess how much exercise they're doing. (19, kidney doctor)

Lack of belief in capabilities of patients with complex conditions

Given the complex and often multi-morbid nature of chronic disease in patients across the spectrum of disease groups, there was a general lack of confidence in patients’ capabilities to exercise. This appeared to deprioritise the time that clinicians spent discussing exercise with patients. Notably for people with co-morbid obesity, diet was prioritised with the belief that exercise is difficult and may cause injury without prior weight loss.

With their comorbidities sometimes it's a bit tricky for them to do, actually, like, you know, exercise. And that's why probably diet is more important in most patients. (50, diabetes doctor)

Orthopaedic limitations and mobility concerns linked to either age or disease status were also raised as reasons why exercise is either not an option, or particularly difficult, for some patients.

I mean, a lot of them are older, so exercising is not an option…Especially CKD [chronic kidney disease]. You know, they're an older population, they've got lots of co-morbidities, they can't run or hardly walk, sometimes. (08, kidney nurse)

Perceived patient-related barriers

Clinicians raised typical barriers to exercise uptake and maintenance by patients including lack of time, lack of motivation, low mood and low exercise-related self-efficacy. Additionally, complex comorbidities, pain, musculoskeletal issues, cost of exercise programs/gyms and low levels of literacy were also raised by clinicians as specific patient-related barriers to exercise across the disease groups.

I do mention it, but you don't want to mention something that you feel might be outside of a person's financial means…I guess you don't want to give the impression that you're, you know, elitist and out of touch and recommending all these expensive things when they can't afford it. (62, cardiac doctor)

Safety concerns across disciplines which influences scope of practice

The safety of exercise in specific disease groups was frequently expressed as a concern, further demonstrating the varied understanding (and/or access to) current best practice evidence. Given the ‘high risk’ status of most patients with chronic and complex disease, concerns were raised for cardiac events and injury. For people with diabetes, the risk of hypoglycaemia and need for insulin management with exercise were also raised as a safety concern. Some doctors (notably cardiac doctors) expressed a requirement for appropriate screening to verify safety prior to exercise and that this should be done by a cardiologist or GP. There was hesitancy to recommend vigorous-to-high intensity exercise, heavy weights or isometric loading, especially in cardiac and renal transplant patients.

A lot of our patients have underlying vascular disease or cardiovascular disease. And in many instances, I would want permission, approval or sign off from a cardiologist or the GP to say that yes, they're happy, that that patient can undertake a supervised exercise regime. (28, liver doctor).