CME/CE Physical Activity Counseling Improves Patients' Physical Health
The 5 A's (Assess, Advise, Agree, Assist, Arrange) counseling model can
help primary care clinicians provide their patients with improved ways
to increase their physical activity. (Am Fam Physician. April 15,
2008;77:1029-1136.)
Medscape Medical News 2008
http://mp.medscape.com/cgi-bin1/DM/y/eBkjQ0SeOHF0F6A0JNTu0GK

Extract only:

April 25, 2008 ‹ The 5 A's (Assess, Advise, Agree, Assist, Arrange)
counseling model can help primary care clinicians deliver brief,
individually tailored physical activity messages to patients, according to a
review published in the April 15 issue of the American Family Physician.

"Physical activity improves mental health and control of diabetes,
hypertension, and lipid levels; prevents osteoporosis; and, especially in
older patients, sustains mobility, reduces disability, and decreases the
risk of falls," write Rebecca A. Meriwether, MD, MPH, from the University of
South Carolina School of Medicine in Columbia, and colleagues. "The Centers
for Disease Control and Prevention, American College of Sports Medicine,
U.S. Surgeon General, and American College of Preventive Medicine recommend
that adults participate in at least 30 minutes of accumulated
moderate-intensity physical activity (i.e., walking fast [3 to 4 miles per
hour] or the equivalent) on five or more days of the week. The following are
key principles for physical activity: (1) the more activity the better, (2)
accumulated time is more important than intensity, (3) activity can be
accumulated in 10-minute increments, and (4) lifestyle activities (e.g.,
substituting walking or biking for short car rides, using a push rather than
a riding lawn mower) are more likely to be sustained than structured
activities (e.g., exercising at a gym)."

In the United States, lack of physical activity may cause at least 250,000
deaths annually. Despite the existence of national guidelines recommending
participation in 30 minutes of accumulated moderate-intensity physical
activity on at least 5 days per week, most Americans do not achieve this
goal. Furthermore, most report that their clinicians have not counseled them
to increase their physical activity.

Even brief clinician counseling causing modest changes in physical activity
could significantly affect public health, considering that 84% of Americans
consult a clinician each year. However, limitations in time, reimbursement,
knowledge, confidence, and practical tools may prevent many clinicians from
delivering physical activity counseling.

The 5 A's model may assist clinicians in delivering brief, specifically
tailored messages on physical activity to patients.

Specific clinical recommendation for practice are as follows:

* Adults should take part in 30 minutes or more of accumulated
moderate-intensity physical activity, such as brisk walking, on at least 5
days per week (level of evidence, B, based on systematic reviews of evidence
from observational studies, with strong quality, quantity, and consistency
of the evidence).
* Clinicians should advise their patients to meet recommended levels of
physical activity (level of evidence, C, based on randomized controlled
trials varying in quality and with short duration of follow-up).
* The 5 A's model should be used to counsel patients about physical
activity (level of evidence, C, based on theory, observational studies, and
randomized controlled trials of counseling regarding physical activity and
smoking cessation).
* Expert advice from professional associations is conflicting with
regard to medical clearance before patients with risk factors begin exercise
programs (level of evidence, C).

Specific components of the 5 A's Model for Helping Patients Change Physical
Activity Behavior are as follows:

* Assess: The type, frequency, intensity, and duration of current
physical activity should be evaluated, as well as contraindications to
physical activity, the patient¹s degree of readiness for change, specific
benefits to the patient, and their social support system and willingness to
help others. Self-efficacy (or the patients' level of confidence that they
can change their physical activity level) should also be assessed. The
authors of the review describe tools that are available for the assessment
of physical activity.
* Advise: The clinician should deliver a structured, individually
tailored counseling message. Although the national recommendation is for 30
minutes or more of accumulated moderate-intensity physical activity on at
least 5 days per week, this amount may be modified based on specific
findings from each patient's assessment, as described above.
* Agree: The clinician should lead shared decision making based on the
patient's stage of change. When the patient is not ready for change
(precontemplation stage), the clinician should ask the patient for
permission to discuss physical activity in the future. When the patient is
thinking about changing (contemplation stage), the next steps should be
discussed. In the preparation stage, the patient intends to change soon, so
the clinician should assist the patient in planning and in setting a start
date. In the action/maintenance stage, the patient is already meeting goals
and should be congratulated, encouraged, and asked about his or her
readiness to start another healthy behavior.
* Assist: The clinician should give the patient a written prescription
for physical activity; printed support materials; a pedometer, calendar, and
other self-monitoring tools; and Internet-based resources.
* Arrange: This phase of the model includes scheduling a follow-up
visit, using telephone or email reminders, and using Internet-based
counseling. Patients who are deconditioned, injured, or have comorbid
conditions affecting physical activity, such as arthritis or back pain,
should be referred to a dietitian, physical therapist, or other specialists
as appropriate.

"Using a structured counseling message based on patient answers to the PAAT
[Physical Activity Assessment Tool] and incorporating the other elements
mentioned in this article can be delivered in the one and one half to three
minutes devoted to health education and promotion in a typical primary care
visit," the study authors conclude. "The message should include the
following: national physical activity recommendations, social support,
helping others, printed materials and self-monitoring tools, agreement on
next steps, and arrangement of follow-up and referrals."

The authors of the review have disclosed no relevant financial
relationships.

Am Fam Physician. 2008;77:1029-1136.
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:

1. Identify strategies to help patients achieve physical activity goals.
2. Counsel patients effectively to reach recommended levels of physical
activity.

Clinical Context

Current recommendations call for adults to participate in at least 30
minutes of accumulated moderate-intensity physical activity on 5 or more
days per week. However, less than one half of Americans meet this minimal
goal. Clinician visits have significant potential to reduce this trend of
inactivity because 84% of Americans visit a clinician annually. The average
number of clinician visits per individual is 2.1 per year, and clinicians
usually spend 1.5 to 3 minutes in health education and counseling during
these visits.

The current review examines the potential effect of clinician counseling in
influencing patients' activity levels.
Study Highlights

* Factors to remember in counseling patients regarding physical activity
include the following:
o Accumulated time in physical activity is more important than the
intensity of the activity.
o Activity can be accumulated in increments of as little as 10
minutes.
o Lifestyle changes with physical exercise in everyday activities
such as walking to the store or mowing the lawn using a push mower are more
likely to be sustained than structured activities such as exercise classes
at a gym.
o No more than 2 days should elapse between episodes of physical
activity because metabolic rate and insulin activity can return to baseline
within 3 days after exercise.
o The greatest relative benefits from exercise occur in previously
inactive persons, even when the degree of initial activity is modest.
o Strength and flexibility training can enhance health but should
not replace aerobic activity.
o Moderate physical exercise should approximate the same level of
exertion as walking quickly. Examples of moderate exercise include walking
downstairs, gardening, housework, tai chi, weight lifting, and performing
automotive work.
o Vigorous exercise should approximate the same level of exertion
as jogging or running. Sports such as tennis, soccer, and basketball provide
vigorous exercise, as does walking upstairs.
* The US Preventive Services Task Force found insufficient evidence that
clinician counseling leads to sustained changes in patient physical activity
behavior. However, the authors of the current review recommend using the 5
A's model for counseling regarding physical activity:
o Assessment should include current physical activity,
contraindications to exercise, social support, and self-efficacy.
o Advice should follow national recommendations but be tailored to
an individual's needs.
o Agreement depends on the patient's stage of change. Patients not
ready for change may only agree to discuss physical activity again in the
future, whereas patients preparing to change benefit from setting a plan and
start date. Initially setting high goals for physical activity can be more
effective than incremental change.
o Assistance can come in the form of a written prescription for
exercise or self-monitoring tools such as a pedometer.
o Arranging a follow-up visit to discuss physical activity is
beneficial. Patients might also benefit from telephone or email reminders
regarding exercise, and these reminders may be performed by clinicians or by
staff members.
* Although patients with unstable or uncontrolled medical conditions may
be at higher risk for adverse events with physical exercise, most patients
can safely participate in symptom-limited, moderate physical activity
without exercise stress testing before initiating physical activity.

Pearls for Practice

* Current recommendations call for adults to pursue physical activity of
at least moderate intensity for at least 30 minutes on 5 or more days of the
week. Patients may be more successful in achieving this goal if they
remember that the duration of physical activity is more important than the
intensity of the activity and that everyday activities can be more effective
than structured exercise programs.
* The current review recommends the use of the 5 A's model for
counseling regarding physical activity: Assess, Advise, Agree, Assist,
Arrange. Patients who are not contemplating a change to become more active
should not necessarily receive an active plan for exercise. Instead,
clinicians should continue to advise these patients at subsequent visits
regarding increasing their level of physical activity.