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Exercise prescription

One small step for a human, and a giant leap for humankind

16 Aug, 17 | by atarazia

Introducing the Physical Activity and Population Health BJSM Blog Series 

By Sonia Cheng (@soniawmcheng)

As you’ve likely read from these previous posts on the BJSM blog, the case to increase population-wide participation in physical activity is stronger than ever. And, like the unsung space heroes at NASA, who crunched the numbers and successfully launched humans into orbit and to the moon1, we as health professionals, researchers, and students play a pivotal role in developing and implementing strategies to address one of the leading risk factors for chronic disease and disability worldwide.

It is an honour to launch the new ‘Physical Activity and Population Health’  BJSM Blog Series. Throughout this series, we’ll bring to you the latest developments in physical activity research, resources, and policy in the area of public health – a small step to raise awareness, discussion, and action amongst researchers and clinicians to address a major health priority.

Some vital stats

The statistics related to physical inactivity are not new to us, but still shocking. Physical inactivity is a key risk factor for non-communicable disease (NCDs) – including cardiovascular disease, type 2 diabetes, cancers, respiratory disease, dementia, and poor mental health. This places it as the fourth leading cause of global mortality, contributing to over five million preventable deaths each year2.

However, physical inactivity is also one of the key modifiable risk factors for NCDs, and the health benefits of regular physical activityare evident across the lifespan (click here for current PA recommendations). Maintaining regular physical activity levels helps to (1) promote growth and development in children and young adults, (2) prevent weight gain in mid-life, and (3) maintain independence and quality of life in older adults and in those living with chronic disease3.

Yet, despite high-quality evidence to implement effective strategies, global efforts to reduce physical inactivity have not been sufficient. It is estimated that one in three adults and more than 80% of adolescents do not meet current physical activity recommendations4.

The call to action

Increasing physical activity at a population level requires a whole-of-community approach. We need to effectively implement our knowledge through policy and practice changes in healthcare delivery, education, environment, infrastructure and media. We need to support individuals and communities to be physically active every day in ways that are enjoyable, accessible, and safe in this highly urbanised and digitalised world of ours. We need to advocate for the development, financing and implementation of evidence-informed national plans so that all countries can achieve the World Health Organisation global target to reduce physical inactivity in children and adults by 10% by 20255.These key messages have been distilled into a seven-point plan developed by the International Society for Physical Activity and Health (ISPAH) in 2012, ‘Best Investments for Physical Activity – What Works’6 and the infographic is published here7.

The Physical Activity and Population Health’ BJSM Blog series supplements the brand new BJSM Editorial articles Bright Spots, Physical Activity Investments that Work Jointly8 that feature exciting and novel physical activity programmes from around the globe. Expect both series to keep you updated on research, policy, education, and practice developments in increasing population levels of physical activity.

We invite you to share and support the Physical Activity and Population Health BJSM Blog Series. Join the conversation on ‘how change happens’ at #PAblogBJSM and #brightspotsBJSM.

If you have ideas for this series please contact:

Sonia Cheng graduated from The University of Sydney with a Bachelor of Applied Sciences (Physiotherapy) (Honours Class I) in 2014. Sonia is currently employed as a physiotherapist with Royal Prince Alfred Hospital and Westmead Hospital in Sydney. 


  1. The True Story of ‘Hidden Figures’ and the Women Who Crunched the Numbers for Nasa
  2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219-29.
  3. World Health Organisation. Interventions on Diet and Physical Activity What Works? Summary Report Geneva, Switzerland: World Health Organization; 2009.
  4. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. The Lancet 2012;380(9838):247-57.
  5. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Geneva, Switzerland: World Health Organization; 2013.
  6. Investments that Work for Physical Activity. Br J Sports Med. 2012;46:709-712.
  7. Best Investments for Physical Activity – What Works
  8. Stamatakis E, Murray A Launch of new series: Bright Spots, Physical Activity Investments that Work Br J Sports Med Published Online First: 29 June 2017. doi: 10.1136/bjsports-2017-098096


For the “Body Matters” MOOC (McGill University, Prof Ian Shrier): Exercise is medicine, for the body and the brain by Nagamatsu and colleagues.

9 Mar, 15 | by Karim Khan

YourBrainLovesTheGym Each week over 23,001 folks are learning about the power of exercise via a Massive Open Online Course (MOOC).

Generously, BJSM helps out Professor Ian Shrier by answering one question each week on this blog. Prof Shrier just has to answer the other 23,ooo students’ questions.

This week’s question is:

“What are the effects of exercise on the brain’s ability for computation and memory?”

You could ‘Google it’ and you will find that the past 2o years has seen an explosion of literature on this topic. Fueled by? You guessed it – the wonder of MRI (magnetic resonance imaging) that provides structural images to complement tests of brain function (formerly pen and paper tests, now largely converted to computer/tablet tests). I don’t fully understand it yet, but MRIs can also show us changes in brain FUNCTION. So if exercise improves brain performance (which it does), some of these changes can be seen during ‘functional’ MRI of the brain. Wow!!  It used to thought that one exercised ‘for the heart’ but my feeling is that ‘exercise for the brain’ is even more important.

So, down to the nitty-gritty! “Show me the money” or, in this case – Show me the evidence!

And here I take you to a 2014 BJSM article –

LiuExerciseExercise is Medicine for the Body and the Brain


It is by Lindsay S Nagamatsu, Leon Flicker, Arthur F Kramer, Michelle W Voss, Kirk I Erickson, Chun Liang Hsu and my hero, Teresa Liu-Ambrose.

Cognitive decline is one of the most pressing healthcare issues   of the 21st century. Worldwide, one new case of major cognitive decline (ie, dementia) is detected every 4 s. Given that no effective pharmacological treatment to alter the progress of cognitive decline exists, there is much interest in lifestyle approaches for preventing or treating dementia. Ideally, such strategies should be cost-efficient and widely accessible at a societal level to have the largest benefit for older adults with varying income and functional status levels.

One attractive solution is exercise. However, despite a large and consistent pool of evidence generated over the past five decades linking exercise to improved cognitive functions in older adults, there is a reluctance among academics, healthcare practitioners and the public alike to embrace exercise as a prevention and treatment strategy for cognitive decline. For example, the National Institutes of Health (NIH) consensus statement from 2010 concedes that there appears to be preliminary data to support the efficacy of exercise in improving cognitive function. However, they caution that there is currently no strong evidence to suggest that modifiable lifestyle factors can alter the trajectory of cognitive decline.

Adding fuel to the fire are publications such as a 2013 systematic review of randomised controlled trials (RCTs) (prior to 31 October 2011) reporting ‘weak’ evidence for the effects of exercise on cognition. However, the search strategy used in that systematic review failed to capture many pertinent papers providing evidence from RCTs that exercise promotes cognitive and brain plasticity not only in healthy older adults but also in those with cognitive impairment. Animal studies that provide insight into the molecular and cellular mechanisms by which exercise promotes neuroplasticity.

In a previous commentary,(Liu-Ambrose, BJSM 2009)  we outlined studies that provided compelling evidence that exercise should undoubtedly be considered as a promising treatment strategy for cognitive decline. Our present commentary aims to provide a brief update, as well as to discuss factors that have continued to hinder the adoption of exercise as a legitimate medical strategy for the prevention of cognitive decline and dementia.

Since 2010, we have additional evidence from RCTs that exercise, both moderate-to-vigorous intensity aerobic and resistance training, promotes cognitive and brain plasticity and have gained further insight into underlying mechanisms. Notably, the behavioural and mechanistic outcomes converge and support a cohesive picture. In 2011, Erickson et al demonstrated that aerobic exercise resulted in increased hippocampal volume in healthy community-dwelling older adults. Furthermore, changes in hippocampal volume in the aerobic exercise group were significantly associated with increased levels of serum brain-derived neurotrophic factor and spatial memory performance. In the same RCT, Voss et al  demonstrated that aerobic exercise also improved the functional connectivity or temporal coherence of brain regions that are functionally related in a network known to decouple with ageing.

For resistance training, Liu-Ambrose et al  demonstrated increased functional plasticity after 12 months of training with corresponding improvement in selective attention and conflict resolution in healthy older women. Critically, the benefits of exercise extend to those with mild cognitive impairment (MCI) and dementia. Among older women with MCI, Nagamatsu et al  demonstrated that 6 months of resistance training led to improved executive functions, spatial memory and associative memory with concurring functional plasticity. In the same study, the authors also found that aerobic training improved verbal memory and learning. These findings indeed support the findings from a recent systematic review on exercise and cognition in those with dementia, although to our knowledge no such systematic reviews exist for those with MCI.

Despite these recent positive findings, scepticism remains. Enthusiasm for increased exercise as a prevention strategy is often tempered by the fact that no RCT until now has demonstrated that exercise can actually reduce the incidence of MCI or dementia. Is the absence of such a definitive trial reason enough to disregard the evidence until now? We contend that the answer to this question is a resounding ‘no’ when the following points are considered:

  • The number of individuals with dementia will exponentially increase in the next 20 years.

  • There is now a large and consistent pool of animal and human data demonstrating the cognitive benefit of exercise. Importantly, recent randomised studies show a convergence among behavioural, neuroimaging, and serum biomarker outcomes. Furthermore, large cohort studies have demonstrated significant associations between exercise and reduced risk of cognitive impairment and dementia.

  • Exercise has a multitude of established health benefits with minimal side effects and is cost-effective. Even in older adults, exercise increases the chance of survival and healthy ageing.

  • Exercise significantly reduces the key vascular risk factors (eg, hypertension, diabetes type II, hypercholesterolaemia, etc) for Alzheimer’s disease and vascular dementia—the two most common types of dementia.

In fact, exercise should be promoted as an essential component of healthy ageing given that reducing physical inactivity by 25% could prevent as many as one million cases of dementia worldwide.

Providing healthcare practitioners and seniors with specific and individualised recommendations regarding the type, intensity, and frequency of exercise for benefit is critical to successfully advocate exercise as a treatment for cognitive decline. (FOR MOOC STUDENTS, THIS IS WHAT PROF SHRIER WILL COVER NEXT WEEK – THE PRINCIPLES OF EXERCISE PRESCRIPTION)

However, we are limited by the fact that dose and type of exercise have been utilised in different studies with varying success. For example, Baker et al  found that older women with MCI who engaged in aerobic exercise four times per week exhibited improved cognitive function, whereas in a similar population, aerobic exercise twice per week did not yield the same benefits. Further, confusion centres around the type of exercise (eg, aerobic vs resistance training) and sex differences.

Evidence strongly suggests that exercise does have benefits for cognition—and critically, the magnitude of the benefit can exceed that of pharmaceutical approaches. It is estimated that if the onset and progression of dementia could be delayed by a mere 1 year, there would be nearly 9.2 million fewer cases in 2050. Given that exercise can be promoted at a population level with relatively low risks and costs, we highly recommend that older adults should be encouraged to engage in regular exercise to boost cognitive function as further research is concurrently conducted, rather than wait until all the intricacies of the relationship between exercise and cognition have been resolved.

We recognise that a large proportion of the population is sedentary and that successfully changing behaviour to a more active lifestyle is challenging. To effectively advocate exercise, we emphasise the need for a cross-disciplinary collaborative effort among researchers and healthcare workers to develop consistent standards and a united message of the multiple benefits of exercise. In light of the recent support for exercise in preventing cognitive decline, we stress that endorsing exercise as an effective strategy for improving health and well-being among older adults should be indisputable. Given that it may potentially have a high impact for mitigating multiple health concerns, including dementia, exercise should therefore be considered as a leading treatment strategy to delay or prevent dementia.

Thanks to BJSM for allowing us to reproduce the paper:

Exercise is medicine, for the body and the brain.

Nagamatsu LS, Flicker L, Kramer AF, Voss MW, Erickson KI, Hsu CL, Liu-Ambrose T.

Br J Sports Med. 2014 Jun;48(12):943-4. doi: 10.1136/bjsports-2013-093224. Epub 2014 Mar 21.

Karim Khan (@BJSM_BMJ)
One of the 3 lead editors at the BJSM – along with Babette Pluim (@DocPluim) and Jill Cook (@ProfJillCook).

If you use Google+, consider joining the Sports and Exercise Medicine community for sports medicine updates. (Search in ‘communities’ or follow this link).

Exercises to prevent sports injuries – lots of talk, but do they work?

20 Jul, 14 | by BJSM

Letter to the Editor

By Dr. Babette Pluim (@DocPluim)

In response to: Jeppe Bo LauersenDitte Marie Bertelsen, Lars Bo Andersen.

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trialsBJSM. 201448:11 871877 .

Strength training was the big winner in a recent BJSM systematic review and meta-analysis of Lauersen et al.1 The authors carefully quantified the preventive effect of several different forms of physical activity programs. They differentiated between the effect on acute and overuse injuries. Previous studies on musculoskeletal injuries, have focused on one particular intervention, one injury type or location, one specific sport, or were narrative reviews. This is a quantum step forward.

The field is relatively mature with 25 RCTs to study, including 26 610 participants with 3464 injuries. The studies were grouped into strength exercises, stretching exercises, proprioception exercises and multiple exposure studies.

Strength training was the most effective intervention and reduced sports injuries to less than one third (RR 0.315 (0.207-0.480). Proprioception exercises were also effective and reduced the number to almost half (RR 0.550 (0.347-0.869). Contrary to my expectations multiple exposure interventions were less effective (RR 0.655 (0.520-0.286) and stretching had no beneficial effect at all (RR 0.963 (0.846-1.095). Outcome analysis showed that both acute (RR 0.647 (0.502-0.836) and overuse injuries (RR 0.527 (0.373-0.746) could be reduced by preventative exercise programs.

exposure plot

Clinical implications

1. There is great potential in strength training — we should utilize this more. The results from the strength training studies were consistent, despite different programmes being used and despite different outcomes of interest, which points towards a strong generalisability of results. This means that many types of strength exercise have the potential to prevent many types of injuries.

2. Was it a nail in the coffin for stretching exercises? Stretching did not prevent injuries, whether done before or after training. However, this analysis included only two studies on army recruits and one internet-based study on the general population, so more data are badly wanted.2-4 Stretching may serve other purposes, and it may still be relevant for the upper extremity, but NOT for injury prevention of lower extremity exercises. It may be helpful in specific cases if there has been a previous injury. But today, there is no evidence supporting stretching for injury prevention.

It makes intuitive sense to combine several interventions to prevent all injuries, and I was therefore surprised that see that multiple intervention studies had smaller effect size that strength training or proprioception alone. However, the authors point out that each component may be reduced quantitatively or qualitatively by designing a program with an array of exposures (the proportion of effective interventions may be smaller, compliance may suffer etc). They therefore suggest these type of programs should be built from well-proven single exposures and they stress the importance of further research into single exposures.

The take home message for me as a sports physician is that I will take strengthening exercises to prevent injuries even more seriously than I already did:

– hip abduction, lunges, squats, step ups and step downs to prevent ACL injuries and anterior knee pain
– leg curls and Nordic hamstring exercise to prevent hamstring injuries
– proprioception exercises for the ankle (the ankle app!)5 to prevent ankle injuries

The recent data of Clarsen et al. on the shoulder are promising,6 and as a tennis doctor, I would love to see an RCT on the effect of external rotator cuff strengthening as a follow up to their cohort study :-).


Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer – Netherlands. She is Deputy Editor of BJSM. Follow her on twitter @DocPluim


1. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2014:48:871-7.

2. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sports Med 2010;44:1002–9. LaBella CR, Huxford

3. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 1998;44:65–72.

4. Pope RP, Herbert RD, Kirwan JD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000;32:271–7.

5. Verhagen E. Easy to use mobile app for ankle sprains prevention and rehabilitation.

6. Clarsen B, Bahr R, Andersson SH, et al. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med 2014. Published Online First 19 June 2014.



Referring patients for exercise from the emergency department: A pilot study

4 Apr, 13 | by Karim Khan

By James R Griffiths



In 2006 NICE concluded that there was insufficient evidence to recommend the use of exercise referral schemes (ERS) to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. Despite this, there are approximately 600 ERS in the UK that primary care have access to. We looked at referring patients into the ERS in Barnsley (run by Barnsley Premier Leisure) from the Emergency Department.


Patients who attended the Emergency Department over a six-month period were screened for the exercise referral scheme. Posters were placed in the department advertising the scheme and encouraging patients to get more detail from a member of staff. Patients who met the inclusion criteria had a referral form faxed to their GP or practice nurse asking them to refer the patient on to the scheme.


Over the six-month period, 26 patients were referred to their GP or practice nurse. Of these only 10 were subsequently referred on to Barnsley Premier Leisure and only 3 patients attended for an initial assessment. No patients completed the 24 gym or swim sessions.


The results of this pilot study are obviously disappointing. We have tried to identify the barriers preventing patients from completing the scheme and have made changes to the way patients are referred onto the scheme.

We are hopeful that with better engagement from patients and GPs, we will be able to recruit patients on to the exercise referral scheme from the ED.



“What exercise can I do Doc?”

1 Mar, 13 | by Karim Khan

By Ann Gates (@exerciseworks)

Can health care consultations change to incorporate best practice ‘exercise medicine?’


In 2012, we sent out a ‘call to action’ to ALL health professionals about the pandemic of obesity and non communicable diseases (NCDs) which results in 36 million patients (worldwide) dying from preventable and treatable diseases. This call was enthusiastically answered by many health professionals and health organisations. However, inactivity is still the world’s 4th leading cause of death and the recent global physical inactivity maps could be easily be superimposed across the world obesity maps, showing a similar distribution of chronic disease and inactivity. This is no medical coincidence.

It is well documented, (and we all know), that the relationships between preventable diseases, inactivity and the determinants of those diseases are complex and multi-factorial. The time has arrived for health professionals to give an ‘evidence based brief intervention’ exercise prescription. This ‘prescription to exercise’ should be championed by all health, sports and exercise, and fitness professionals. It is not a specialism that is just for a few to practice. Giving exercise advice should be as medically intuitive as writing a medicine prescription or providing a referral.

We know that in sustained behaviour change, brief interventions work! Consider the example of a patient with breast cancer; we treat the disease by advising the patient on the options of chemotherapy, surgery, radiotherapy and a variety of other key health care interventions. Patients follow and respect our advice during a time of despair, confusion and worry. That’s because health professionals are trained to help provide the best support and medical advice they can give to breast cancer patients. And, (in the majority of cases), patients are grateful and benefit clinically from that expert advice. However, in many breast cancer consultations, patients are still not offered exercise advice despite evidence that this supports the patient clinically and emotionally. So why aren’t we seeing brief intervention exercise advice in all consultations, when health professionals know that it can significantly reduce the risks of chronic diseases and their symptoms?

Consider the situation we have globally. Patients are facing the greatest risk of NCDs through inactivity, poor lifestyle habits and lack of access to suitable exercise and physical activity opportunities. If we think about the patient in the consultation, why is it that we can’t give exercise as a medicine? Patients are suffering from obesity, cancer, diabetes, heart disease, stroke, osteoporosis, and poor mental health. Yet we know that a variety of medicines and treatments are available. Is it not conceivable that trained health professionals can’t give disease specific, exercise advice?

And of course the basic answer is that all health professionals can give quality exercise advice to their patients: even if it’s just an enthusiastic endorsement of national and international exercise guidelines as a brief intervention!

We ought to be giving more to our patients. In 21st century medicine we should go beyond the basics.

We should know which exercises work best for a Parkinson’s disease patient or any other disease or ailment. Just like we know how to prescribe which medicines to an asthma patient. When exercise medicine is incorporated as part of clinical training for all health professionals, and supported by cultural change within health organisations and the public at large- we will then be moving to this ideal patient/health professional consultation scenario:

What exercise can I do Doc?” asked the patient

There are lots of fun exercises and physical activity opportunities to improve your symptoms/disease condition by…” replied the health professional.

And yes- health care consultations can change, evolve AND deliver better exercise advice to the majority of patients.

McGraw Medical Education Australia has published a series of ‘patient exercise sheets’ by Exercise Works!

For further details and licensing arrangements please contact: Mr Andy Santhosh +61 2 9900 1826


Ann Gates BPharm(Hons) MRPharmS

Founder of Exercise Works!

Exercise physiologists and chronic disease management in North America: A role of importance

6 Feb, 13 | by Karim Khan

Undergraduate perspective on Sports & Exercise Medicine  a BJSM blog series

By Lisa Campkin (@LisaCampkin)

rx exercise

Recently, the term ‘Exercise is Medicine’ was copyrighted by the American College of Sports Medicine. This particular initiative in exercise medicine focuses on the role of clinicians in helping increase their patients’ physical activity levels. Exercise is Medicine has growing influence in the prevention and treatment of non-communicable “lifestyle” disease, and the movement is currently progressing up north into Canada. But a major concern remains: how can physicians follow-up with patients diagnosed with multiple chronic conditions, who need further individualization and support in their exercise programs? Referral to an exercise professional may be an option!

North American organizations as change catalysts 

The Canadian Society for Exercise Physiology (CSEP) is a professional body of exercise physiologists. It is dedicated to the promotion of health, fitness, and performance through the application of knowledge and research related to exercise. As an organization based in scientific thought, applied evidence, and up-to-date advances in exercise physiology research, CSEP and its affiliate members are trained and have a scope of clinical practice related to exercise prescription; they are specialists in the field of health, exercise and rehabilitation. Specifically, a CSEP-CEP (Certified Exercise Physiologist) is certified to evaluate and treat individuals with chronic disease through tailored, progressive physical activity and exercise programs to improve the patients’ health and function.

Both CSEP and ACSM may be considered on the brink of changing the application of medical care and symptom management for those with chronic disease and/or suffering from “exercise deficiency.” Alongside the individual benefits, a patient could experience from increased structured and / or monitored physical activity (i.e. stabilized mood, increased independent living, stronger immune function, better quality of life, etc.) there follows an implication that exercise physiologists could help to decrease national health care costs long-term, through a decreased need for symptom-related prescriptions, fewer hospitalizations and decreased morbidity & mortality due to lifestyle-related disease.

Working models and available resources

Research from New Zealand and Great Britain exemplifies working models of physician-based exercise counselling and referral through the Green Prescription and Exercise Referral Scheme health promotion programs. In Canada, official and widespread programs are not yet in place for physical referral to exercise professionals.

Until such programs are developed, engaging an accredited exercise physiologist is relatively easy from a community and health care standpoint, says Katherine MacKeigan (Director of the Provincial Fitness Unit, located in Edmonton Alberta).  Interested individuals can access the online registry of CEPs or access services through widespread fitness appraisal centers; 27 of which are in the province of Alberta alone.

Although referral is not necessary for patients with varying chronic disease or physical disability, any practicing primary care physicians who can access the referral system can send patients with extended needs and long-term exercise supervision to a CEP. Costs range from CAN $20-150+ per session. Currently the services of a CEP are not covered under the provincial health care fee schedule. Although, certain employee benefits and extended health care may cover assessments for qualified individuals (e.g. through a health spending account). Katherine MacKeigan certainly encompasses a powerful idea with the question “How much is your health worth to you?”

Knowledge transfer as a way forward

The short and long-term positive health implications for persons affected by lifestyle-related disease could be huge if exercise professionals had increased contact with at-risk populations. How can we increase knowledge and awareness of this field of exercise medicine? How can we successfully promote healthy lifestyles through physicians and exercise professionals? One possible avenue is through knowledge transfer (KT), or academic detailing. This process involves an independent organization educating the professional or a group of professionals, using evidence-based and individualized methods to most effectively reach the target audience [1]. This process can help to bypass barriers that even the most experienced clinician can face on a daily basis; a lack of time, energy or desire to self-educate directly from the literature is a common issue in research-based clinical practice. KT helps bring the newest research into the practice of the clinician in a relevant, timely, packaged manner, and it could help to bring the advantages of exercise and exercise professionals to light in the field of medicine.

What do you think? Does exercise physiology and knowledge transfer seem like an important component of the medical field? Should we be teaching those students responsible for the future promotion of physical activity these skills during their undergraduate studies? Is there another avenue or profession that we can explore to help patients with chronic disease return to function and increase their quality of life?


  1. Campkin L, & Doyle-Baker PK. (Spring/Summer 2012). Five Reasons for Knowledge Transfer. Fitness Informer

Lisa Campkin is a MSc Student, University of Calgary under the supervision of Dr. PK Doyle-Baker. She is interested in exercise physiology, seeing it as a gateway to a decreased incidence of chronic disease worldwide, as well as decreased symptomology and better quality of life for previously diagnosed patients. She can be contacted at

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

Generation Games: An update on upcoming launch of innovative website

3 Jan, 13 | by Karim Khan

By Drs. Moiz Moghal and Natasha Jones

generation games There is rising awareness that physical inactivity is a major health problem. Momentum is gathering at a local level to try to reverse this trend. An exercise prescription or a brief intervention on its own is not enough. The challenge is to integrate an exercise medicine service with proactive partners who can successfully deliver the tools required to change behaviour to an activated community.

In Oxfordshire, the Department of Sport & Exercise Medicine at the Oxford University Hospitals NHS Trust in a unique collaboration with AgeUK Oxfordshire, have been commissioned by the PCT to develop a service to facilitate individualised exercise prescription and signposting for local opportunities to be active. This is targeting people over the age of 50 years and has been achieved through the development of an innovative website called Generation Games which is due to launch next month.

Generation Games is designed to be used by the individual or by the healthcare professional. It will take the user through PAR-Q and GPPAQ before asking about individual barriers to exercise. Following this, the individual will be given a personalised exercise prescription or will be advised to see their GP to ensure that it is safe for them to exercise. Once this has been confirmed, they will be given a detailed list of all opportunities to be active in their local area. The options will be widespread ranging from seated exercise to Nordic Walks to team sports. Working with a well established partner such as AgeUK Oxfordshire will help us to access hard to reach groups, in particular the lonely and isolated. Even a lack of IT access or knowledge is not a barrier as this service can also be accessed via local AgeUK Oxfordshire branches or by phone.

A key part of this project will be to get local healthcare professionals to use the service. We know that practitioners in primary care are best placed to deliver physical activity guidance (1). As such, we hope to visit GP practices across the county to spread the word and to demonstrate the website. The website also provides a useful learning resource regarding the role of physical activity in chronic disease and also references some key papers related to this topic. We hope that this will also provide valuable feedback in order to allow us to continually improve the service. The same will be done using patient focus groups through AgeUK Oxfordshire. We hope to establish firm links with well-established rehabilitation services but also to give access to other specialist departments whose patients we know may benefit, such as cancer and mental health services.

We believe that the message of the benefits of physical activity speaks for itself. In the development of Generation Games we hope that we have made it as easy and as safe as possible for the individual or the healthcare professional in Oxfordshire to access an exercise prescription and to find interesting and fun local activities that will keep them motivated to be active.

Please feel free to access the website on:


Dr Moiz Moghal is a Specialist Registrar Sport & Exercise Medicine, Oxford Deanery

Dr Natasha Jones is a Consultant in Sport & Exercise Medicine, Oxford University Hospitals NHS Trust

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.


1.         Green prescriptions: attitudes and perceptions of general practitioners towards prescribing exercise. British Journal of General Practice, 1997, 47, 567-569.

Personalised dose, prescription and administration of exercise using the MedExercise device: a pilot study

28 Nov, 12 | by Karim Khan

By Drs. Vadim N. Dedov and Irina V. Dedova


Background/Aim – Beneficial health effects of regular physical activity and exercise are well established. However, a variety of exercise types and modes complicates quantification of physical activity. Introduction of a single parameter for the objective measurement of exercise amounts might facilitate exercise prescription in primary care practice.

Methods – A novel exercise device with a friction resistance mechanism was equipped with a temperature sensor to measure heat production during the exercise. Heart rates were monitored with a fingertip pulse oximeter. Four healthy volunteers participated in this study.

Results – Heat production in the device during an exercise bout was used as a measure of exercise amount. An individual amount of device usage was determined in the respective fitness test and prescribed according to the current recommendations for daily physical activity. Automatic daily recordings showed significant variations in exercise intensity and duration in unsupervised conditions, but the prescribed amount of exercise has been exceeded on most days and weeks, indicating a full adherence to the exercise prescription. Upon completion of a three-month exercise prescription daily exercise amount was adjusted according to a new fitness test.

Conclusion – This study demonstrated for the first time that amount of physical activity can be calculated as a single parameter of exercise device usage. The results suggest that a personal amount of exercise can be determined and prescribed, and that adherence can be objectively monitored on regular basis.


Medical research has demonstrated that regular physical activity has a significant preventive and therapeutic effect.1 Nevertheless, the implementation of exercise recommendations and guidelines is not effective, especially in general practice.2 It was shown that ‘considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis’.3 It might be argued that in order to improve efficiency of exercise prescription it should be: (i) personalised and hence based on the assessment of patients’ fitness level,4 (ii) expressed in well-defined doses and (iii) followed by objective monitoring of compliance.

However, current methods for quantification of individual fitness levels and exercise amounts might be too complex for routine application. For example, the maximal oxygen consumption (VO2max) is considered a gold standard for assessing cardiorespiratory fitness, but respective VO2max protocols are not always feasible for many reasons, including limited time and staff, participant burden, possible medical oversight, costly equipment, and difficulty obtaining a maximal effort.5 Quantification of physical activity is also challenging because it takes many forms and varies in type, intensity, duration and frequency.6 It is a common practice to base the assessment of physical activity on self-reporting, which is prone to measurement error and can lead to incorrect inferences about physical activity behaviours.7 It was shown that healthy adults overestimated energy expenditure during exercise by 3-4 folds.8  Exercise-induced energy expenditure can be measured objectively, but it requires sophisticated equipment and complex technologies.9

Here, we report the development of a feasible approach for personalized exercise prescription, which might be suitable for wide implementation in primary care practice and for use in medical research.


A novel resistance exercise device MedExercise® ST (MDXD Pty Ltd, Australia) was used in this study (Figure 1A). Changes of temperature in the resistance unit were measured with a temperature sensor connected to the industrial multimeter IP57 (Digitech, Australia). Data was collected using respective software Multimeter V1.0 from Digitech and then converted into Excel databases (Microsoft, U.S.A.) for analysis. The average exercise-induced rise in temperature was calculated after subtraction of ambient temperature values. A fingertip pulse-oximeter CMS-50E (Contec, China) and corresponding SpO2 Review software were used for the continuous measurement of heart rates during the exercise. Overall, four healthy volunteers, aged between 36 and 49 years, participated in this study. Respective informed consents were obtained. Statistical analysis was performed using the Student’s t-test.


We hypothesised that the amount of exercise device usage achieved by the participant at particular intensity and duration would reflect participant’s level of fitness and could be used as the personalised amount of daily physical activity. MedExercise device was chosen for this study because it allowed continuous monitoring the intensity of usage through the measurement of exercise-induced rise of temperature in the friction resistance mechanism. During exercise the user repeatedly extended and flexed legs by moving foot platforms against graded resistance to their movement (Fig. 1A). Friction between the rails and foot platforms caused fast rise of temperature in the resistance mechanism, whereas stopping of exercise results in drop of temperature to pre-exercise level (Fig. 1B). Conversely, a total amount of device usage during the exercise bout correlated with the amount of heat produced in the resistance mechanism. The latter was reflected by an area under the curve and calculated by multiplication of an average exercise-induced rise in temperature and duration of recording in seconds.

For quantification of daily exercise amounts we used the current physical activity guidelines, which stated that: ‘all healthy adults aged 18 to 65 years need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week’.10 The definition of exercise intensity in literature varies considerably,11 but a heart rate of 100 beats per minute (bpm) might be assumed as an indicator of moderate physical activity for most healthy adults, whereas 120 bpm usually indicates a vigorous level of exercise. Therefore, usage of exercise device by the participant at 100 bpm for 30 minutes or at 120 bpm for 20 minutes would represent a recommended daily exercise amount according to the physical activity guidelines.10

Figures 1B represent a typical recording of temperature in the MedExercise device during moderate (trace 1) and vigorous (trace 2) exercise bouts, as monitored by respective heart rates (Fig. 1C), where a higher intensity of exercise caused temperature rise to the higher level (Fig. 1B). The respective amounts of device usage were calculated and expressed in kilo C⁰ (kC⁰). The amount of exercise at vigorous intensity was higher than during moderate physical activity: 139.5+16.4 kC⁰ and 113.8+7.9 kC⁰ (n=3, P<0.05), respectively. However, since the moderate intensity of exercise was better tolerated, the personal amount of 113.8 kC⁰ daily exercise was selected for the prescription. Therefore, according to the current physical activity guidelines,10 a personalised exercise prescription for this participant was: a minimum of 113.8 kC⁰ x 5 days per week = 569 kC⁰ weekly for three months of MedExercise device use.

Figure 1D exemplifies the patterns of device usage in unsupervised conditions during the exercise prescription. It was shown that the intensity and duration of usage varied to a great extent and included breaks (dents in the curve). Figure 1E and 1F shows daily and weekly amounts of device usage, respectively, for the full period of exercise prescription. The device was used for 4.9+1.2 days a week. An average amount of usage was 217.1+56.1 kC⁰ per day and 1067+251 kC⁰ per week. These results indicated that exercise prescription has been administered in full because the usage of device exceeded the prescribed amount. After completion of the three-month exercise prescription, a fitness level of the participant was retested and resulted at 132.7+15.1 kC⁰ (n=3). Accordingly, the next personalised exercise prescription was adjusted to a minimum of 132.7 kC⁰ x 5 days per week = 663.5 kC⁰ weekly of MedExercise device use for the next 6 months.


In contrast to prescription of conventional drugs, which are given in the specific doses and regimes, physical activity takes many forms and varieties, making it difficult to standardise.6 We have hypothesised that the amount of exercise device usage could serve as an objective and practical measure of exercise amounts. MedExercise device allowed direct measurement of heat production during the exercise through detection of temperature rise in its friction resistance mechanism. Conversely, the amount of heat produced in the device corresponded to the amount of exercise that participant performed with the device. A total amount of heat production during an each exercise bout depended on the intensity and duration of device usage, and could be calculated as an average rise in temperature multiplied by the durations of exercise. Therefore, a single parameter of heat production incorporated all variability of device usage such as resistance, frequency, duration and presence of breaks.

As a test for validity of our approach, we have determined a daily amount of exercise according to the most commonly used physical activity guidelines10 and selected the amount of device usage at a tolerable moderate intensity for three-month prescription. This exercise prescription was personalised because it was based on individual exercise capacity of the participant. Daily monitoring of device usage provided an objective insight into patterns and amounts of physical activity during exercise prescription. It is an important advantage because commonly used self-reporting is biased and prone to errors.7, 8 It was observed that the patterns of unsupervised exercise varied to a great extent due to fluctuations of intensity, different durations and presence of breaks. However, the amount of device usage consistently exceeded the prescribed daily and/or weekly amounts for the whole period of prescription that indicated a full adherence to exercise prescription and regular physical activity. After completion of previous exercise prescription the fitness test was repeated in order to adjust the dose for the next period of exercise prescription.

The limitation of this study is a small number of healthy participants that necessitates further clinical studies. The strength of our approach includes the measurement of exercise amounts as a single parameter, simplified assessment of fitness levels, personalised exercise prescription and objective monitoring of adherence. It is important that exercise prescription sets only a minimum amount of exercise so that other types of physical activity should be encouraged for better health effects.


1.    Lucini D, Pagani M. Exercise: Should it matter to internal medicine? Eur. J. Intern. Med. 2011;22:363-70.

2.    Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? The case for physical activity promotion and exercise medicine. Br J Sports Med 2012;46:228-32.

3.    Pavey TG, Taylor AH, Fox KR, et al. Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis. BMJ 2011;343:d6462.

4.    Buford TW, Pahor M. Making preventive medicine more personalized: Implications for exercise-related research. Prev Med 2012.

5.    Mitros M, Gabriel KP, Ainsworth B, et al. Comprehensive evaluation of a single-stage submaximal treadmill walking protocol in healthy, middle-aged women. Eur J Appl Physiol 2011;111:47-56.

6.    Slade SC, Keating JL. Exercise prescription: a case for standardised reporting. Br J Sports Med 2011.

7.    Ainsworth BE, Caspersen CJ, Matthews CE, et al. Recommendations to improve the accuracy of estimates of physical activity derived from self report. J Phys Act Health 2012;9 Suppl 1:S76-84.

8.    Willbond SM, Laviolette MA, Duval K, et al. Normal weight men and women overestimate exercise energy expenditure. J Sports Med Phys Fitness 2010;50:377-84.

9.    Levine JA. Measurement of energy expenditure. Public Health Nutr 2005;8:1123-32.

10.  Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports. Exerc. 2007;39:1423-34.

11.  Norton K, Norton L, Sadgrove D. Position statement on physical activity and exercise intensity terminology. J Sci Med Sport 2010;13:496-502.

Figure legend

Figure 1. (A) Position of the participant in the chair, while using MedExercise® device. (B, C) Typical changes of temperature in resistance mechanism of the device (B) and participant’s heart rate (C) recorded simultaneously during the moderate intensity (trace 1) and vigorous (trace 2) exercise bouts. Double headed arrows indicate duration of actual exercise. (D) Patterns of temperature traces during of unsupervised device use. Dents in the curves represent breaks in device usage. Double headed arrows indicate duration of recording. Background room temperatures were subtracted (all temperature curves). (E) Daily amounts of device usage during the three-month exercise prescription. (F) Weekly amounts of device usage during the three-month exercise prescription. Horizontal dotted lines indicate a single and double prescribed amount of device usage.

Competing interests

Dr Vadim Dedov has a stake in MDXD Pty Ltd, which designed and produced the equipment used in this study.


Vadim N. Dedov, M.D., Ph.D., MDXD Pty Ltd, NSW, Australia

Irina V. Dedova, M.D., Ph.D., School of Medical Sciences, University of New South Wales, NSW, Australia


Extreme Physical Activity Promotion: Doc Murray to run 7 Ultra Marathons on all 7 continents within 7 days

19 Nov, 12 | by Karim Khan

In the spirit of extreme physical activity promotion, Doc Andrew Murray is off today (weather permitting in Antarctica) to run 7 Ultra Marathons on all 7 continents within 7 days. He’s doing this to raise awareness of the benefits of exercise (he now works on this issue for the Scottish Government) and also for The Scottish Association for Mental Health.

His route is here

He massively appreciates the support he’s had for his previous challenges. If you and/or people you know are interested in supporting Andrew, you have the opportunity to do this in two ways:

1) BE PART OF IT with Andrew and a few well known faces. Visit www.5× <http://www.5×>  for full information and to join the challenge . By running, walking, cycling 5k a day for the 7 days from 23rd to 29th November we aim to cover the equivalent distance of 5 times round the world. Personally, I’ll be on the running, walking or cycling 5 km for those days to keep up my personal challenge of accumulating 60 minutes of physical activity daily. But this isn’t about me!

It’s about getting people engaged with all physical activity abilities

Please pass this onto your friends and colleagues, they can register here http://5× and take the Challenge with you – you can even create a team together.

 A 40 sec video explains why .

2) Andrew is raising money for Scottish Association for Mental Health- GetActive program. This is a great charity that he’s passionate about. His JustGiving page is here.

For a bit of a laugh here is a trailer for some TV he’s making about the trip.


And remember to also the share the ‘7 investments’ link for a balanced 🙂 comprehensive approach to eradicating physical inactivity.

Message to Andy – if you are looking for something to do, we have a new BJSM podcast up for you – sports cardiology – which includes a paper on whether too much exercise can be harmful. And other podcasts in the editing suite…enjoy!  A personal best wish to you – k2

Exercise Medicine: Inspiring the next generation, an interview with Dr. Mike Loosemore (Part 1 of 2)

14 Nov, 12 | by Karim Khan

By Liam West (@Liam_West) & Dr. Mike Loosemore

Undergraduate perspective on Sports & Exercise Medicine (a BJSM blog series)

The field of Sport & Exercise Medicine has two distinct areas. Namely, Exercise Medicine and Sports Medicine. To gain insights and get tips for students looking to follow in their footsteps, I interviewed two influential figures pushing the boundaries of each field.

The first of this two part interview series is with Dr. Mike Loosemore (ML) who is leading the “Exercise Is Medicine” initiative in the UK.

LW: Hi Dr. Loosemore. Could you describe to the undergraduate readers what Exercise Medicine entails?

ML: Exercise Medicine, or ‘Exercise Is Medicine’ as it’s promoted by the American College of Sports Medicine (ACSM), is the idea that exercise is important in preventing chronic non-communicable diseases (NCD) such as Type 2 diabetes mellitus, heart disease & cancer. Exercise can also be prescribed as a treatment for a NCD allowing the patient to simultaneously reap the additional benefits of regular moderate activity such as reducing co-morbidities and improving the patient’s sense of well being.

LW: So essentially undergraduates can view exercise as a more powerful treatment than handing out a single pill in many circumstances?

ML: Yes. Medical school essentially teaches students how to poison patients as that’s what you do by giving small doses of drugs; although obviously if you give them too much of the drug you poison them properly! It’s completely different with exercise. Using exercise we re-establish a natural process which allows the body to heal itself, returning it to the homeostatic state & often improving health considerable. Humans are exercising monkeys, we need to be active and if you don’t exercise enough important functions of your body start to degenerate!

LW: Powerful stuff! Would you be able to share with the readers some of the data surrounding exercise as a treatment for various NCDs?

ML: Here are some basic facts and figures for the undergraduates from the ACSM website. Regular physical activity reduces the;

  • Risk of heart disease by 40%
  • Incidence of diabetes by roughly 50%
  • Risk of developing Alzheimer’s disease by 30%
  • Incidence of high blood pressure by nearly 50%
  • Risk of stroke by 27%
  • Recurrence of breast cancer by almost 50%
  • Risk of colon cancer by approximately 60%
  • Depression as effectively as Prozac or Behavioural therapy

A pretty impressive intervention that has no medical equivalent that can do one of those things, never mind all of them! If you consider that medical inflation is going up significantly quicker than normal inflation and the population is ageing, we are reaching the edge of a financial cliff as far as healthcare costs are concerned. Currently the vast proportion of the NHS budget is spent on treating disease. Instead we should concentrate on preventing disease occurring in the first place which is relatively cheap! We cannot continue to be a disease service. It is called the National HEALTH Service not the National Disease Service!!!

LW: Hopefully that is a quote that will stick in the mind of many undergraduates! You have briefly touched upon some of the research, but are there any other resources students could use to find out about exercise medicine?

ML: I suggest they go to the ‘Exercise Is Medicine’ website where they can access lots of relevant resources & facts from evidence based research, read the BJSM blog and attend Sport & Exercise Medicine conferences, such as the Cardiff SEMS Olympic Conference 2012 on 15th December which is aimed primarily at undergraduates.

LW: Finally, if there was only one thing that we could do during our undergraduate career to spread the message of Exercise Medicine what would it be?

ML: Include it in your history paradigm. Every time you take history from a patient, ask about exercise. Two reasons for that;

  1. You will find out their individual activities levels and then can encourage them to do more. Any increase in exercise, no matter how small, will start to reduce the risks of chronic NCDs.
  2. A doctor asking about exercise sends a very powerful message to the patient and they clearly see that exercise is important.

LW: Thanks Dr. Loosemore for your expert opinion on Exercise Medicine and how undergraduate students can get involved.


Dr. Mike Loosemore MBBS DCH MRCGP MSc FFSEM(UK) is a Consultant in Sport & Exercise Medicine at the Institute of Sport, Exercise and Health, University College London. He is the lead Sports Physician (South of England) for the English Institute of Sport and currently the doctor to British Boxing. He is currently president of the Sports and Exercise Medicine section at the Royal Society of Medicine and leads the ‘Exercise is Medicine’ task force in the UK.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

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