Exercise Referral: An Introduction 

Senior Physiotherapy

Understanding the Exercise Referral Model


Engagement in physical activity (PA) and exercise has been widely acknowledged to be effective in the prevention, management and treatment of numerous chronic health disorders [1-4]. The World Health Organisation [5]  defined PA as any bodily movement which is created by the muscles that demand energy expenditure. This is, in contrast, to exercise which according to Caspersen et al. [6] involves a series of physical actions that are cyclic and structured, with the overall aim of improving or maintaining an individual's physical fitness. There is a large body of scientific evidence that has reported that PA and exercise have positive effects on physiological and psychological wellness [2]. These outcomes include a decrease in blood pressure [7] and heart rate [8], reduced associated risk of falls [7], pain reduction [8], reduced depression [9] and anxiety [10].


The engagement in PA has unfortunately decreased globally across the various populations resulting in an epidemic of non-communicable diseases [11]. This has lead to international support with greater importance required towards the promotion of healthier lifestyles and increased levels of PA [12]. The WHO has reported that inadequate levels of PA are one of the main risk factors for death globally [13]. Within the United Kingdom, there are almost 20 million adults that are physically inactive and this sedentary lifestyle proliferates the risk of them developing cardiovascular disease, obesity and ultimately premature death [14]. This lack of physical activity cost the National Health Service (NHS) in 2015, nearly £900 million [15] and this risen to over £1.2 billion in 2017 [14].


Many chronic disorders can be managed and treated with PA incorporated within public health pathways, through exercise referral schemes (ERS). The ERS is not a new model and was initially established in the 1990s in the primary care environment to assist in the promotion of increasing PA levels [16]. It is important to understand that ERS work differently from other clinical exercise interventions as they are frequently employed in a non-clinical environment. This can be beneficial for clients who may have problems in access to hospitals or other clinical settings. Conversely, this may be detrimental to clients due to the ERS normally being delivered in a leisure environment that may be a barrier to PA adherence in ERS [17].


ERS primary aims include increasing PA levels and consequently producing positive impacts on overall health outcomes [18]. Generally, referrals are arranged by general practitioners (GPs), physiotherapists, condition-specific specialists and nurses to third-party service providers to increase PA and thus improve individuals health disorders. This leads to a pathway (Figure 1) to PA engagement via personalised exercise programmes at local leisure and sports provisions [18].

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Figure 1. Model of exercise referral.

ERS normally last between 10-12 weeks within England [2] and Ireland [19]. Whereas within Wales the National Exercise Referral (NERS) Programme lasts 16-weeks, which has been reported by Edwards et al. [20] to be more cost-effective than schemes that conclude prior to this period [20]. Edwards et al. [20] investigated the cost-effectiveness of NERS in Wales using subgroup analysis to explore the effects of medical diagnosis, gender, age, inequalities, referral route and adherence on effectiveness and cost-effectiveness. The results suggested that NERS is likely to be cost-saving in fully adherent participants leading to the overall conclusion that NERS can be cost-effective particularly for participants with mental health and CHD risk factors. However, it should be noted that there is a need for caution in the interpretation of results. The National Institute for Health and Care Excellence (NICE) [18] recommended ERS last a minimum of 12-weeks. However, there is no emphasis on schemes to last longer than the suggested 12-weeks.


Investigations concerning the type of activities offered on ERS and participation rates are mixed. For example, Duda et al. [21] reported that significant gains in PA, improvements in life and well-being outcomes emerged in both standard provision and the self-determining theory-based exercise referral (SDT) programmes. Participants perception of the autonomy support by the health and fitness advisor did not differ between interventions. The between-group changes over 6-months revealed a significant difference for reported anxiety only. Significant improvements in anxiety in the SDT intervention at 6-months which were not observed in the standard exercise group.


The type and mode of PA which are accessible in ERS typically include a one-to-one supervised gym-based exercise programme, group classes, swimming, walking groups and chair-based exercise [2]. Unfortunately, within the existing ERS policy [18] there are no recommendations on the specific type and mode of exercise which should be implemented within ERS. Consequently, there is a demand for a greater body of research that investigates the various exercise modes in terms of effectiveness and adherence to ERS.


Elderly Woman at Gym

Presently, the literature reviewing the impact of ERS is inadequate due to inconsistent and weak evidence regarding the impact ERS has on PA levels, well-being, quality of life or health outcomes [2,22]. However, the success of any ERS is highly oscillated by participant uptake to the programmes being offered and also exercise adherence.  For example, Pavey et al. [23] conducted a meta-analysis on the levels of ERS uptake and adherence. The authors reported that the pooled level of uptake in ERS was 66% (95% CI 57-to-75%) across the observational studies and 81% (95% CI 68-to-94%) across the randomised controlled trials (RCTs). The pooled level of ERS adherence was 49% (95% CI 40-to-59%) across the observational studies and 43% (95% CI 32-to-54%) across the RCTs. However, it is important to note that few studies measured anything other than gender and age. Females were more likely to begin an ERS but were less likely to adhere to it than males. Older people were more likely to begin and adhere to an ERS.


There is a large body of studies that have reviewed participants with specific health disorders, however, there is an apparent lack of evidence that fully supports the effectiveness of ERS on specific health disorders [23]. Therefore, NICE [18] suggested that additional research is needed out with research that exams the impact of ERS that assesses the impact of ERS in improving specific health outcomes in specific populations. It is, therefore, imperative that there is a bridge between research and policy that helps develop a greater understanding of the role ERS has on the management of specific health disorders.


There are numerous reasons for referral into an ERS. These include various health conditions that can be categorised according to the ICD-10 Versions:2010 [24]. These include cardiovascular (CV), respiratory, musculoskeletal (MSk), metabolic, digestive and mental health (MH) disorders. ERS is regularly recommended with these various health conditions without fully studying the different aetiologies, symptoms and co-morbidities of each disorder. Essentially, the effectiveness of ERS is evaluated on the overall impact in populations undertaking them as opposed to their effectiveness of specific disorders or health outcomes [2]. It is paramount that we should examine the effectiveness of ERS in specific disorders and specific outcomes as this can inform guidelines on management and treatment.


Presently, the NHS is under substantial pressure [25] and as such referral of more patients into ERS may have the potential to reduce this burden. The cost of specific health disorders can be substantially reduced by engaging in ERS. For example, the British Heart Foundation reported that CV disorders affect almost 5.9 million people within the United Kingdom with an estimated health care cost of £9 billion each year [26]. CV disease costs the economy a further £19 million each year [26]. The cost of hypertension can equate to £2040 per person with a heart attack costing the NHS £2390 per incidence. In the UK, MSk disorders affect nearly 23 million with over 30 million workdays lost as a result each year [27]. MH disorders  pre-COVID-19 are one of the causes of overall disease globally particularly depression [28]. The Mental Health Taskforce reported that MH cost to the economy is approximately £105 billion per year.


As previously discussed, the lack of PA amplifies the associated risk of non-communicable diseases. For many individuals that have these disorders the first point of contact is their GP. If an exercise can be applied as part of a management tool to aid several health disorders, then this positively impacts on GP visits. The Personal Social Services Research Unit [25] reported that it costs the NHS £242 per hour of patient contact in comparison to putting an individual through 12-weeks of an ERS for £225. If ERS can be found to effective then the NHS could reduce the outgoings spent of GP contact time and invest into referring individuals into PA and exercise.

Key point

Being part of an ERS offers fitness professionals the opportunity to play an essential role in the promotion of regular PA to individuals with a fundamental need to improve their health and well-being. These individuals range from sedentary to those for whom chronic disease has already impacted upon their quality of life. Therefore, ERS may be viewed as a means of preventing non-communicable condition.


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Participation in Physical Activity/ Exercise For Health Improvements

Image by Anupam Mahapatra

The Benefits of Being Physically Active

The health benefits of participating in PA have been shown to surpass that of any pharmacological drug. The Academy of Medical Royal Colleges has stated that PA is a “miracle cure” [1]. In contrast, physical inactivity contributes to as many deaths in the United Kingdom as smoking [2] and has been reported as the fourth leading risk factor for mortality globally [3]. Unfortunately, over 25% of adults in the UK are inactivity and fail to achieve even 30 minutes of PA per week [2]. This chapter provides a perspective on current PA levels and discusses some barriers that impinge on PA engagement. 

Defining the term “physical activity’

It's important to differentiate between physical activity [PA] and exercise as these terms are often used interchangeably, but have very distinct meanings. This interchangeable use of these terms can however be off-putting to some individuals as you do not need to be doing exercise to be physically active. 

The WHO as previously stated in chapter one has defined PA as “anybody movement performed by skeletal muscles that expend energy”. Whereas exercise is defined as  ‘physical activity with the primary purpose of improving or maintaining physical fitness or performance” [4]. Moderate PA requires the individual to perform “a moderate amount of effort” and markedly accelerates the heart rate” [5], which leads to accelerated breathing, increase blood flow to the peripherals and elevates the metabolic rate by three-to-six times more than at rest [4]. 

Health Benefits of Being PA

There is a large and compelling body of evidence that suggests that individuals that are more physically active have lower rates of all-cause mortality, CVD, metabolic disease, colon and breast cancer, and depression (Table 1 and Table 2). Importantly, any level of PA is beneficial. For example, Wen et al. [6] assessed the health benefits of varying volumes (inactive, low, medium, high, or very high) of PA in a large (n = 416175) cohort in Taiwan. The authors reported that compared with individuals in the inactive group, those in the low-volume activity group (mean PA = 92 min per week [15 minutes a day]) had a 14% reduced risk of all-cause mortality and importantly three-year increase of life expectancy. Crucially, every further 15 minutes of daily exercise beyond 15 minutes per day further reduced all-cause mortality by 4% and all-cancer mortality by 1%. Wen et al. [6] further stated that inactive individuals had a 17% increased risk of mortality compared with individuals in the low volume group. 

A recent meta-analysis by Ekelund et al. [7] examined the dose-response relationship between accelerometer assessed total PA, varying intensities of PA and sedentary time and all-cause mortality. Pooled data of eight studies (total n = 36383; mean age = 62.6 years; 72.8% females) and a median follow-up of 5.8 years and 2149 (5.9%) deaths were analysed. The authors reported that any PA regardless of intensity was associated with lower risk mortality with a non-linear dose-response (Figure 2). 

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Figure 2. Dose-response associations between total PA (top left), light intensity PA (LPA) (top right), low LPA (middle left), high LPA (middle right), moderate-to-vigorous intensity PA (MVPA) (bottom left), and sedentary time (bottom right).  Cpm = counts per minute.

Table 1. Benefits of achieving recommended levels of PA

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Table 2. Epidemiological Studies of Males Fitness, Body Fat and CHD (>1989 studies)

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How Does PA Improve Individuals Health


As previously noted regular PA generates positive alterations in body composition including reduced visceral adiposity. It also improves metabolic dysfunction and has anti-inflammatory effects that result in reduced measures of systemic inflammation [10].  Additionally, Silverman and Deuster [11] reported tar these changes are protective in chronic conditions as visceral adiposity is associated with impaired glucose and lipid metabolism. Lastly, low-grade systematic inflammation is connected with metabolic syndrome, cognitive dysfunction and depression.


Positive adaptions from regular PA are located in the sympathetic nervous system and the hypothalamic-pituitary axis. This leads to increased resilience to both physiological and psychological stressors. Chronic disorders where dysregulation of these systems is observed including autoimmune, metabolic and CVD and also stress-related mental health problems including depression are reduced. Silverman and Deuster [11] also stated that there is increased neuroplasticity and growth factor expression in the brain which may further improve both cognition and the individual's mood.


Examining the Long-Term Benefits of PA


Within the last century, most of the Western countries have encountered significant demographic changes with a continuing drift towards the ageing population who face medical and functional challenges. This is in addition to age-specific diseases that have initiated from their earlier years [11], including CVD, obesity and type 2 diabetes [12]. The WHO has identified these three diseases as the most severe non-communicable diseases that are causes problems in contemporary Western society [13]. Non-communicable are mostly a result of unhealthy lifestyles including overconsumption of unhealthy food, elevated alcohol consumption and excessive smoking habits [14, 15]. More specifically, physical inactivity and unhealthy eating habits are associated with weight gain that is a main underlying cause of contemporary diseases [i.e. CVD and type 2 diabetes mellitus].


Effect of PA on Coronary Heart Disease


Of all contemporary diseases, CHD has received the most scientific inquiry, with most studies reporting a negative relationship between PA and the incidence of CHD for PA levels above minimum energy expenditure. Kannel et al. in 1948, founded the National Heart, Lung and Blood Institute and established the Framingham Heart Study [FHS]. This research cohort investigated the causes and the development of CHD in 5,209 males and females aged 2-to-62 years at baseline [16]. This pioneering research suggested a negative relationship between the PA level and the development of CHD events and overall cardiovascular mortality [16].

2.4.2 – Historical Studies on Cardiovascular Disease


The Framingham Heart Study


The Framingham heart study in 1948, was the first long-term study that attempted to identify common factors or characteristics that contributed to cardiovascular disease. The initial research involved 5,209 males and females aged between 28-62 from the town of Framingham, Massachusetts [17]. The subjects were comprehensively examined physically and also completed relevant lifestyle reviews that would later be analysed for patterns correlated to CVD development. Subjects returned every two-to-six years to further detail their medical history and allow further medical examinations to be performed. Females were included within the FHS which at the time was in contrast to other epidemiological studies.

Table 3. The Framingham Heart Study Cohorts

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In 1957, almost ten years from the initial subject examinations the first study outcomes were published. Hypertension was defined as systolic blood pressure of ≥160/95 mmHg and the authors observed almost a four fold increase in heart disease per 1000 persons among hypertensive subjects [18]. Furthermore, Kannel et al. [19] in 1965 noted that stroke was also a major outcome of high blood pressure.  In 1971, FHS researchers further analysed 14-years of follow-up data to demonstrate increased risk of CHD morbidity with elevated baseline blood pressure values. When blood pressure [systolic and diastolic vales] were analysed for a correlation with CHD events. The investigators found that systolic blood pressure had a stronger association than diastolic pressure with CHD events (Figure 3).  Additionally, FHS investigators found evidence from two other studies that elevated systolic blood pressure was a predictor of cerebrovascular incidents as well as heart failure [20-21].

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Figure 3. Systolic pressure as a superior marker for average annual incidence for CHD (Kannel et al. 1971)

At the end of the 20th century, FHS researchers identified a need to develop knowledge concerning genetic and environmental risk factors for CVD [22]. Consequently, in 2002, a new generation of subjects was recruited, the Third Generation cohort (Table 3). The cohort involved the children of offspring cohort subjects [22]. Acknowledging the power of the family-based methodology, investigators gave priority to 879 large, extended families that previously had multiple family members in the study. FHS researchers also recognised the limitations of a cohort that was primarily white of European descent. The Omni 1 cohort was recruited in 1994 and included 506 minority residents of Framingham. Ten years later, an additional 410 minority subjects were recruited through the Omni 2 cohort.


The Harvard Alumni Health Study


The Harvard alumni health study (HAHS) is an ongoing epidemiological study of 36,000 males who matriculated at Harvard University [1916-to- 1950]. The study was established in the 1960’s when the lifestyle and health questionnaires were sent to surviving alumni. The researchers investigated the association between PA and stroke and other CHD. The HAHS is an ongoing cohort study and is presently researching associations between PA and reduced incidences of CHD, stroke and other multiple coronary risk factors.


Sesso, Paffenbarger and Lee [23]


Sesso, Paffenbarger and Lee [23] sought to update previous findings of Paffenbarger, Wing and Hyde [24] on PA and risk of CHD in the HAHS. The authors assessed the quality, type and various PA intensities attained from 1977 data. Due to the multifactorial aetiology of CHD, Sesso and colleagues also examined PA in the presence of other coronary risk factors. They dichotomised six coronary risk factors: cigarette smoking (current smoker or non-smoker), history of hypertension (yes or no), history of diabetes (yes or no), body mass index (≥25 or <25 kg/m2), alcohol consumption (none or any), and early parental death (yes or no). Men were categorised according to the number of coronary risk factors. Men without these risk factors served as the control. Risk ratios [RR] were then computed separately by baseline PA (<4200 or ≥4200 kJ/wk) and age (<60 or ≥60 years) to equally distribute CHD events and enhance statistical power. In an additional analysis, the authors excluded males developing CHD during the initial three years of follow-up to reduce any bias due to illnesses that may have affected baseline PA. Sensitivity analyses assessed whether altering the cut points for the various types of PA significantly changed the RR estimates. Lastly, the updated PA in a subset of 6897 men returning both the 1977 and 1988 questionnaires who were free of CHD through 1988 and monitored them for five years through the end of 1993 (424 cases).


The results of this analysis found an L-shaped association between PA and risk of CHD, with a 20% reduction in CHD risk for total PA levels >4200 kJ/wk. In addition, there was a nonsignificant 10% reduction in men expending 2100 to 4199 kJ/wk. This study also suggests that vigorous activities are associated with a reduced risk of CHD, whereas moderate or light activities have no clear association with the risk of CHD. Finally, PA may positively affect CHD risk even in the incidence of other coronary risk factors. Thus, an active lifestyle may improve the adverse effect of associated coronary risk factors. Especially, men aged ≥60 years who expended ≥4200 kJ/wk may have smaller increases in CHD risk in the presence of coronary risk factors.


Lee and Paffenbarger [25]


Lee and Paffenbarger [25] compared light and moderate activity for longevity  [from 1977-to-1992]. This study assessed a total of 13,485 alumni who returned a 1977 questionnaire. The data suggest that greater energy expenditure is correlated with increased longevity. Walking and climbing stairs each separately predicted longevity. Participation in light activities [<4 multiples of resting metabolic rate (METs)], regardless of energy expenditure, appeared unassociated with mortality rates. In contrast, greater participation in moderate activities [moderate activities (4-to-<6 METs)] displayed a trend toward lower mortality rates, while greater energy expended in vigorous activities (> 6 METs) clearly predicted lower mortality rates. Additionally, physical inactivity and overweight adversely affected longevity to a similar extent (Table 4). These data provide some support for current day recommendations that emphasise moderate-intensity activity; they also clearly suggest a benefit of vigorous activity.


Table 4. Harvard Alumni 1977-1992 (Rates and Relative Risks of All-cause Mortality)

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Physical Activity: Applying ‘All Our Health’

Current guidelines from both the United Kingdom and the WHO recommend that adults engage in 150 minutes of moderate-intensity PA per week of at least 10-minute sessions with the inclusion of strengthening activities a minimum of two non-consecutive days. Notably in the United Kingdom, 33% of males and 45% of females do not achieve this level of PA. WHO also supported this by recommending that individuals should distribute the dose of exercise throughout the week, with 30 minutes of PA recommended on a minimum of five days per week. However, Wilmot et al. [9] reported via their meta-analytical study that even if individuals are sufficiently active the sedentary period is associated with an increased risk of diabetes, CVD and all-cause mortality. This association of inactive is most coherent for diabetes.

Physical inactivity has recently been updated with evidence suggesting that one in six deaths with a cost of £7.4 billion as a result of this factor. Regrettably, this activity level is 20% less than in the 1960s and by 2030 will rise to 35%. Many individuals are not aware that PA has significant benefits to their own health (Figure 4)

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 Section 1 - References


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