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USP115X Exercise referral schemes and the management of chronic health conditions

Unit reference number: D/615/0937

Level: 3

Guided Learning (GL) hours: 60

Overview

This unit provides learners with the knowledge and understanding of how exercise referral schemes operate. Learners will know the purpose of exercise referral schemes and the range of chronic health conditions managed by these schemes. Learners will also understand the exercise referral process and the professionals involved in providing exercise referral.

Learning outcomes

On completion of this unit, learners will: LO1 Know the purpose of exercise referral schemes in the management of chronic health conditions

LO2 Know the chronic health conditions managed by exercise referral schemes

LO3 Understand the exercise referral process

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Assessment requirements

Learners must complete the assessment requirements related to this unit.

Learners must produce a portfolio of evidence which contains assessed evidence covering all the assessment criteria in this unit.

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Unit content

LO1 Know the purpose of exercise referral schemes in the management of chronic health conditions

Describe the history and development of exercise referral schemes in the UK:

Allied Dunbar Fitness Survey (1990’s) reporting on the health and activity/inactivity levels of the nation

National Quality Assurance Framework (2001) setting the initial guidance for exercise referral schemes; the qualifications required by instructors to work in exercise referral; medico-legal issues; initial risk stratification tool

Development of various schemes across the UK, including the National Exercise Referral Scheme in Wales – first home country to have a centrally organised and nationally co-ordinated service; location of current referral schemes in the UK

The role of the Register of Exercise Professionals (REPs) and SkillsActive in the development of National Occupational Standards (NOS) for exercise referral instructors

Promotion of exercise and activity for improving health – Chief Medical Officer reports on the nation’s health and the role of activity – ‘At least 5 a week’ (2004); ‘Be Active, Be Healthy’ (2009); ‘Start Active, Stay Active’ (2011)

Reports criticising the effectiveness of exercise referral (NICE, 2006)

Development of British Heart Foundation National Centre (BHFNC) Exercise Referral Toolkit (2010) – developed to standardise operational procedures and establish criteria for evaluation of exercise referral

Exercise Referral Advisory Group and Joint Consultative Forum (JCF) (2011) established to review operational procedures and develop a standardised model (work started, and provisional document drafted but not published)

Methods and data used to report on the effectiveness of exercise referral, e.g. attendance and adherence records, client reported benefits, assessed changes (mid-term and end reviews and long term behaviour change)

Impact of changes in structure to the National Health Service (NHS) on service provision and delivery, e.g. Joint Strategic Needs Assessment (JSNA) and Clinical Commissioning Groups and impact of the Health and Social Care Act 2012, for services in England

Conditions managed by exercise referral schemes – low to medium risk (conditions listed

in LO2) Explain the benefits of exercise for the prevention and management of chronic health conditions:

General fitness benefits, e.g. improved mobility, flexibility, endurance, strength, cardiovascular fitness, balance and skills

Health and total fitness benefits, e.g. social, mental, nutritional, emotional, medical

Condition specific benefits – reference Government white papers (2004, 2009, 2011), NICE guidance, NHS Patient UK websites

Reported benefits (Sourced from: Lawrence, 2013) - Reduced risk of premature death (approximately 30%); coronary heart

disease (CHD) and stroke (20–35 per cent); diabetes (30–40 per cent)

- Improved functional capacity

- Reduced risk of back pain

- Increased independence; reduced falls risk; reduced risk of hip fracture (36–68 per cent); reduced risk of dementia in older adults

- Increased bone density and reduced risk of osteoporosis

- Improved psychological well-being

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- Lower risk of colon cancer (30 per cent) and lower risk of breast cancer (20 per cent)

- Reduced risk of osteoarthritis

- Reduced risk of stress, anxiety and clinical depression

- Improved weight loss and weight management Explain the risks of exercise in the management of chronic health conditions:

Health and safety executive risk assessment tool (likelihood of incident x severity of incident – low, moderate, high, very high risk)

- Minor injury, e.g. strains and sprain, fainting

- Major injury or incident, e.g. Hypoglycaemia or hyperglycaemia

- Disability or death, e.g. coma, fatal heart attack, permanent disability

Contra-indications that prevent exercise (see ACSM guidance)

Comorbidities that may increase risk stratification e.g. multiple CVD risk factors and/or multiple conditions, such as, obesity and diabetes

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LO2 Know the chronic health conditions managed by exercise referral schemes

Describe the chronic health conditions managed by exercise referral schemes:

List of conditions (low to moderate risk) - Hypertension

- Hypercholesterolaemia

- Chronic obstructive pulmonary disease

- Asthma

- Obesity

- Diabetes type 1

- Diabetes type 2

- Osteoarthritis

- Rheumatoid arthritis

- Osteoporosis

- Simple mechanical back pain

- Joint replacement

- Depression

- Stress

- General anxiety disorder

Clinical signs and symptoms of all listed conditions - Physical

- Psychological

Risk factors and causes of all listed conditions - Lifestyle factors, e.g. smoking, alcohol, inactivity, diet

- Environmental factors, e.g. socio-economic factors – low income, harder to reach populations, e.g. travellers

- Individual factors, e.g. age, gender, ethnicity, heredity/genetics

Progression of all listed conditions - Acute

- Chronic

Treatment interventions for all listed conditions - Surgical

- Medication (including side effects)

- Alternative therapies, e.g. massage

- Therapeutic, e.g. counselling

- Nutritional

- Exercise and physical activity (including exercise guidelines, considerations and restrictions and dealing with comorbidities)

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Describe exercise guidelines and considerations for working with clients with chronic health conditions:

All conditions (conditions listed on previous page); using ACSM guidance and NICE guidance

Reasons for exclusion, e.g. high risk, contra-indications

Reasons for temporary deferral, e.g. feeling unwell

Effects of medication on exercise and exercise response

Exercise programming – frequency, intensity, time and type, NICE and ACSM guidance

Adapting session structure and content

Working with comorbidities Identify contra-indications for exercise:

Unstable and uncontrolled conditions

Resting blood pressure – systolic at (or above) 180mmHg/diastolic at (or above) 100mmHg

Significant drop in blood pressure during exercise

Recent significant change in a resting ECG, recent myocardial infarction or other acute cardiac event

Symptomatic severe aortic stenosis

Acute pulmonary embolus or pulmonary infarction

Acute myocarditis or pericarditis

Suspected or known dissecting aneurysm

Uncontrolled/unstable angina

Acute uncontrolled psychiatric illness

Unstable or acute heart failure

New or uncontrolled arrhythmias

Rapidly progressing terminal illness

Uncontrolled resting tachycardia at or above 100 bpm

Febrile illness

Pain, dizziness or excessive breathlessness during exertion

ACSM guidance

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LO3 Understand the exercise referral process

Describe the exercise referral process:

Initial assessment and referral of clients from health professional

Entry of client to the scheme and assessment - Checking client records transferred from GP

- Health assessment checks

- Referral back to GP if information incomplete or more information required

- Acceptance to scheme and booking appointment with exercise referral instructor if all inclusion criteria met

Participation (10-16 weeks) and assessment reviews (mid-term and end) - Types of activity available in different schemes

- Appropriateness of range of activities for client needs, preference and medical conditions

Exit routes - General activity programmes

- Specialist activity programmes

- Referral back to GP to re-enter scheme

Follow-up assessment - 6 months and 12 month reviews to check longer term behaviour change

State the roles and boundaries of the range of professionals and others involved in exercise referral:

Range of professionals and others - Clinical commissioning groups

- General Practitioner (GP)

- Practice nurse

- Physiotherapist

- Dietician

- Counsellor

- Exercise referral scheme manager

- Exercise referral scheme co-ordinator

- Exercise referral instructor

- Clients attending exercise referral

- Scheme evaluators and researchers

Specific roles of all listed professionals and others - Medical responsibility for client – GP

- Responsibility for exercise safety – exercise referral team

Importance of maintaining role boundaries - Client safety

- Respect limitations of own competence, knowledge and skills

- Professional etiquette, respect to other professionals

- Legal reasons, e.g. risk of prosecution

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Describe how risk is stratified in exercise referral:

Levels of risk - Low

- Moderate

- High

- Very high

Risk stratification tools - Health and safety executive (likelihood or risk, severity of risk)

- Pyramid (NQAF, 2001)

- Logic model (ACSM)

- Irwin and Morgan risk stratification tool

Inclusion criteria - Scheme specifics

- Qualifications of staff

When to signpost to other professionals - Clients of higher risk than managed by scheme or instructor (exclusion

criteria)

- Change in condition or symptoms

- Non-compliance to prescribed medication

- Unstable or uncontrolled conditions

- Contra-indications

- Client or instructor concerns

- Other needs, e.g. counselling, diet State medico-legal requirements relating to exercise referral:

Qualifications of exercise referral staff

Insurance

Registration with professional bodies

Continuing professional development

Record keeping

Data protection

Confidentiality

Transfer of information

Informed consent

Screening Describe the skills and knowledge required for a personal trainer to work in exercise referral:

Qualifications – Level 3 Diploma in Exercise Referral – anatomy and physiology, applying the principles of nutrition, professional practice for exercise referral instructors, understanding medical conditions for exercise referral, planning exercise programmes, instructing exercise referral

Personal qualities – empathy, positive regard, patient, approachable, positive, enthusiastic, hopeful, sensitive, committed

Communication skills – active listening (using reflective statements and summaries to demonstrate listening); open questions; observation and awareness of body language

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Skin cancer awareness

Please note this information will not be assessed for the achievement of this unit. Public awareness of skin cancer has never been higher, and yet skin cancer remains the

fastest growing cancer in the UK, especially amongst young people. The chances of a

positive outcome can be dramatically increased with early identification and diagnosis.

Professionals in hair, beauty, sports massage and health and wellbeing industries work

closely with clients and in many cases have sight of areas of skin which may not be easily

visible to the client. An informed awareness of the signs, symptoms and changes of

appearance to be aware of when checking for early signs of cancer is a crucial tool for the

conscientious practitioner in order to provide the most thorough service and in some cases,

possibly lifesaving information signposting.

Signs to look for when checking moles include utilising the ABCDE guide:

A - Asymmetry – the two halves of the area/mole may differ in their shape and not match.

B - Border – the edges of the mole area may be irregular or blurred and sometimes show

notches or look ‘ragged’.

C - Colour – this may be uneven and patchy. Different shades of black, brown and pink may

be seen.

D - Diameter – most but not all melanomas are at least 6mm in diameter. If any mole gets

bigger or changes see your doctor.

E - Elevation/evolving – elevation means the mole is raised above the surface and has an

uneven surface. Looks different from the rest or changing in size, shape or colour. Anyone

can get a suspicious mole or patch of skin checked out for free by the NHS by visiting their

doctor, who may then refer to a dermatologist (an expert in diagnosing skin cancer).

If you require any additional NHS information please refer to https://www.nhs.uk/be-clear-on-

cancer/symptoms/skin-cancer

If your learners are interested in learning more about skin cancer awareness alongside this

qualification, VTCT runs the following qualification: VTCT Level 2 Award in Skin Cancer

Awareness for Non-Healthcare Professionals.

This qualification has been specifically designed for those working in the sports massage,

health and wellbeing, beauty, hairdressing and barbering sectors. It will enable learners to

identify any changes to their client’s skin and to highlight those changes to the client using

appropriate language and communication skills. It will enable the learner to raise awareness

of skin cancer and signpost their clients to public information about skin cancer.

This qualification will enable hair, beauty and wellbeing professionals to gain the appropriate

knowledge and communication skills required to provide non-diagnostic, professional advice

and information to clients in a discrete, empathetic and confidential manner.

For more information please refer to the Record of Assessment book:

https://qualifications.vtct.org.uk/finder/qualfinder/1Record%20of%20Assessment%20Book/A

G20529.pdf

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Assessment criteria

In order to pass this unit, learners must achieve all pass criteria. The pass criteria relate to the proficient demonstration of skills and knowledge.

Learning outcome

The learner must:

Pass

The learner can:

LO1 Know the purpose of exercise referral schemes in the management of chronic health conditions

P1 Describe the history and development of exercise referral schemes in the UK

P2 Explain the benefits of exercise for the prevention and management of chronic health conditions

P3 Explain the risks of exercise in the management of chronic health conditions

LO2 Know the chronic health conditions managed by exercise referral schemes

P4 Describe the chronic health conditions managed by exercise referral schemes

P5 Describe exercise guidelines and considerations for working with clients with chronic health conditions

P6 Identify contra-indications for exercise

LO3 Understand the exercise referral process

P7 Describe the exercise referral process

P8 State the roles and boundaries of the range of professionals and others involved in exercise referral

P9 Describe how risk is stratified in exercise referral

P10 State medico-legal requirements relating to exercise referral

P11 Describe the skills and knowledge required for a personal trainer to work in exercise referral

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Resources

The special resources required for this unit are access to a real or realistic working environment which supports the development of knowledge to understand the needs and requirements of clients referred to exercise. Ideally, learners would have the opportunity to work alongside and shadow an exercise referral instructor, who could act as a workplace mentor.

Recommended text books: British Medical Association. (2011). New Guide to Medicines and Drugs. London, UK:

Dorling Kindersley

Durstine, L. J., Moore, G. E. (2009). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd ed. (Champaign, Ill.: Human Kinetics)

Exercise Referral Advisory Group. (2011). Professional and Operational Standards for Exercise Referral. UK: FIA Joint Consultative Group. Available from www.bases.org.uk/.../Consultation%20Draft%20JCF%20Exercise%20Referral%2023...\l

Lawrence, D. (2013). The Complete Guide to Exercise Referral. London, UK: Bloomsbury Publishing

Recommended websites: American Diabetes Association (ADA): www.diabetes.org.uk

Arthritis Research UK: http://www.arthritisresearchuk.org

Asthma UK: http://www.asthma.org.uk

Blood Pressure Association: http://www.bpassoc.org.uk

British Lung Foundation (BLF): www.lunguk.org

British Association of Sports and Exercise Science (BASES): http://www.bases.org.uk

British Heart Foundation (BHF): http://www.bhf.org.uk

British Hypertension Society (BHS): http://www.bhsoc.org

British National Formulary: http://bnf.org/bnf/extra/current/450002.htm

Canadian Society for Exercise Physiology: www.csep.ca

The Cochrane Library: http://www.thecochranelibrary.com

Department of Health (DoH): www.dh.gov.uk

Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND): www.desmond-project.org.uk

Diabetes UK: www.diabetes.org.uk

Dose Adjustment for Normal Eating (DAFNE): www.dafne.uk.com

EuroQol Group EQ5D: http://www.euroqol.org/eq-5d/how-to-obtain-eq-5d.html

IPAQ International Physical Activity Questionnaires: http://www.ipaq.ki.se/scoring.pdf

Joint consultative forum via ukactive: http://www.ukactive.com/policy-insight/ukactive-for-health/the-joint-consultative-forum

Map of Medicine: http://www.mapofmedicine.com

Medinfo.co.uk: http://www.medinfo.co.uk

Mental Health Foundation (MHF): www.mentalhealth.org.uk

MIMS: http://www.mims.co.uk/drugs/a

MIND: www.mind.org.uk

National Institute for Health and Clinical Excellence (NICE): www.nice.org.uk

National Obesity Forum: http://www.nationalobesityforum.org.uk

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The National Osteoporosis Society: www.nos.org.uk

National Rheumatoid Arthritis Society (NRAS): http://www.nras.org.uk

NHS Choices: www.nhs.uk

NHS National Library for Health: www.evidence.nhs.uk

Patient UK: www.patient.co.uk

Scottish Intercollegiate Guidelines Network (SIGN): http://www.sign.ac.uk

World Health Organisation (WHO): http://www.who.int

Recommended Government white papers: Department of Health. (2001). Exercise Referral Systems: A National Quality Assurance

Framework. London: Department of Health

Department of Health. (2004). At Least Five a Week. Evidence on the Impact of Physical Activity and Its Relationship to Health, Report from the Chief Medical Officer. London: Department of Health

Department of Health. (2009). Be Active, Be Healthy. Available from http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_094359.pdf, accessed on 5 June 2011

Department of Health. (2011). Start Active, Stay Active. Available from http://www.bhfactive.org.uk/userfiles/Documents/startactivestayactive.pdf, accessed on 18 February 2012

Recommended useful journals: British Journal of Sports Medicine

British Medical Journal (BMJ)

Journal of Public Health

Medicine and Science in Sports and Exercise

Psychology of Sport and Exercise

Research Quarterly for Exercise and Sport

Delivery guidance

Teachers are encouraged to use innovative, practical and engaging delivery methods to enhance the learning experience. Learners may benefit from:

Meaningful employer engagement so they relate what is being learned to the real world of work and understand commercial competency required to work with clients referred to exercise

Work experience within an exercise referral scheme so they can develop their knowledge and understanding in a real environment

Using interactive information and technology, systems and hardware so they can learn about concepts and theories; research medical conditions; gather information on health demographics and produce visual aids, e.g. handouts or factsheets on medical conditions for inclusion in their assessment portfolio

Guest speakers, including scheme coordinators, exercise referral instructors and expert patients/clients who can share their experiences of the exercise referral process

Teacher presentations to introduce and explore medical conditions and exercise guidelines relating to exercise referral

Discussion groups to share information on exercise referral and medical conditions

Opportunities to participate in exercise sessions designed for clients with medical conditions, so they are able to recognise the necessary adaptations to session structure and content

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Links with other units

This unit is closely linked with the following units and should be assessed in line with the following guidance:

USP111M Applied anatomy and physiology for exercise and health science

Learners will be required to apply their knowledge of anatomy and physiology when learning about medical conditions. The content of the anatomy and physiology unit should be delivered before the exercise referral schemes unit.

USP56M Programming personal training with clients

Learners will be required to apply their knowledge and skills of programming personal training when learning about exercise guidelines and considerations for referred clients. The content of the programming personal training unit should be delivered before the exercise referral schemes unit.

USP57M Delivering personal training sessions

Learners will be required to apply their knowledge and skills of delivering personal training when learning about how to apply exercise guidelines and adapt exercises for referred clients. The content of the delivering personal training unit should be delivered before the exercise referral schemes unit.

USP58M Applying the principles of nutrition to a physical activity programme

Learners will be required to apply their knowledge of nutrition and healthy eating when learning about exercise referral. The content of the applying the principles of nutrition unit should be delivered before the exercise referral schemes unit.

USP59M Behaviour change and adherence

Learners will be required to apply their knowledge and skills of behaviour change when learning about how to manage clients who attend exercise referral schemes. The content of the behaviour change and adherence unit should be delivered before the exercise referral schemes unit.

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Version Details of amendments Date

v6 Skin cancer information page added

13/06/17