توانا

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 patient’s 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.

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:
  • Accumulated time in physical activity is more important than the intensity of the activity.
  • Activity can be accumulated in increments of as little as 10 minutes.
  • 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.
  • 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.
  • The greatest relative benefits from exercise occur in previously inactive persons, even when the degree of initial activity is modest.
  • Strength and flexibility training can enhance health but should not replace aerobic activity.
  • 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.
  • 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:
  • Assessment should include current physical activity, contraindications to exercise, social support, and self-efficacy.
  • Advice should follow national recommendations but be tailored to an individual's needs.
  • 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.
  • Assistance can come in the form of a written prescription for exercise or self-monitoring tools such as a pedometer.
  • 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.