Can primary care doctors prescribe exercise to improve fitness?: The step test exercise prescription (STEP) project

Abstract

Background Sedentary lifestyle is associated with adverse health outcomes. Available evidence suggests that, despite positive attitudes toward regular exercise in promoting a healthy lifestyle, few physicians actually prescribe exercise for their patients. Barriers include lack of skills and standard office instruments. Because primary care physicians have regular contact with a large proportion of the population, the impact of preventive health interventions may be great. Objectives To determine the effect of an exercise prescription instrument (i.e., Step Test Exercise Prescription [STEP]), compared to usual-care exercise counseling delivered by primary care doctors on fitness and exercise self-efficacy among elderly community-dwelling patients. Design Randomized controlled trial; baseline assessment and intervention delivery with postintervention follow-up at 3, 6, and 12 months. Setting Four large (>5000 active patient files) academic, primary care practices: three in urban settings and one in a rural setting, each with four primary care physicians; two clinics provided the STEP intervention and two provided usual care control. Participants A total of 284 healthy community-dwelling patients (72 per clinic) aged >65 years were recruited in 1998–1999. Intervention STEP included exercise counseling and prescription of an exercise training heart rate. Main outcome measures The primary outcome measure was aerobic fitness (VO 2max). Secondary outcomes included predicted VO 2max from the STEP test, exercise self-efficacy (ESE), and clinical anthropometric parameters. Results A total of 241 subjects (131 intervention, 110 control) completed the trial. VO 2max was significantly increased in the STEP intervention group (11%; 21.3 to 24ml/kg/min) compared to the control group (4%; 22 to 23ml/kg/min) over 6 months ( p <0.001), and 14% (21.3 to 24.9ml/kg/min) and 3% (22.1 to 22.8ml/kg/min), respectively, at 12 months ( p <0.001). A similar significant increase in ESE (32%; 4.6 vs 6.8) was observed for the STEP group compared to the control group (22%; 4.2 vs 5.4) at 12 months ( p < 0.001). Systolic blood pressure decreased 7.3% and body mass index decreased 7.4% in the STEP group, with no significant change in the control group ( p <0.05). Exercise counseling time was significantly ( p <0.02) longer in the STEP (11.7±3.0min) compared to the control group (7.1±7.0min), but more ( p <0.05) subjects completed ≥80% of available exercise opportunities in the STEP group. Conclusions Primary care physicians can improve fitness and exercise confidence of their elderly patients using a tailored exercise prescription (e.g., STEP). Further, STEP appears to maintain benefits to 12 months and may improve exercise adherence. Future study should determine the impact of combining cognitive/behavior change strategies with STEP.