Ensuring safe exercise participation in clinical populations: who is responsible?

An overview of recent advances and ongoing challenges in exercise participation-related risk

The benefits of regular physical activity are well established, and the advice to “move more” can be offered to most individuals with little risk. Exercise, where there is a structured movement and activity plan, is recommended as cornerstone management for people with many chronic conditions, but it carries inherent risks that must be considered.1 The responsibility for managing this risk should be shared between primary health providers, patients and exercise professionals, but how well does this work in practice?

The best available evidence suggests the absolute risk of adverse events during exercise in an apparently healthy individual is very low at 0.1–1 adverse events for every 10 000 hours of exercise.2 However, this risk is higher in people with many common chronic conditions.1 In a study of commercial fitness centres, 52% of new members were identified as “higher risk” and 17% as “moderate risk” and in need of a modified exercise prescription,3 yet there is an alarming lack of capacity and effective processes within the fitness industry to manage the increased risk in clients who present with chronic diseases. The highest level of fitness or exercise qualification commonly found in gymnasiums and fitness centres is certifications held by exercise instructors and personal trainers, but they have little or no capacity to manage increased risk (Box).

Historically, a common feature of exercise risk stratification systems is that anyone who is deemed to be at risk is encouraged to obtain clearance from their doctor before they commence exercise. This has placed general practitioners in a difficult position where they are asked to provide a “medical clearance to exercise”, without standardised guidelines. In the general practice setting, it is usually not feasible to establish a patient's response to an exercise challenge or stress test, and making a judgement about risk on the basis of the available medical history is not always appropriate. Further, the GP may have limited information about the intended exercise program, and who will be responsible for the patient's wellbeing. Indeed, patients themselves may not know the answer to these questions. GPs have been actively discouraged from providing clearance-to-exercise certificates on the basis that such a clearance represents a transfer of medicolegal responsibility from the exercise or fitness professional to the GP.4

In 2011, a new adult pre-exercise screening system (APSS) was developed by Exercise and Sports Science Australia, Sports Medicine Australia, and Fitness Australia. This system removes the requirement for higher-risk clients to seek a medical clearance. It has been replaced with an instruction to seek “guidance” from an appropriate medical or allied health professional. This reflects a shared responsibility for client care where exercise practitioners have a responsibility to satisfy themselves that they have sufficient information to provide a safe service for the client. However, problems with the use of the tool remain that require interprofessional collaboration and resolution to achieve further progress towards this goal.

Notably, a recent survey of fitness centres suggests that, in practice, the uptake of the new screening tool within the fitness industry has been poor. Of those fitness centres that responded (~10%), only 55% regularly applied the APSS tool, with only 65% regularly using any form of pre-screening at all.5 It is also unclear what type of “guidance” should be sought from medical or allied health professionals. For example, should a GP be providing instruction, and particularly restrictions, on the mode, intensity, duration and frequency of exercise? Or are they simply to provide an indication of the current clinical status of an individual? The former is likely beyond a medical practitioner's scope and training; the latter beyond the expertise of the non-clinically trained exercise practitioner to safely interpret.

It is clear that an integrated risk-mitigation process remains to be developed. In the interim, it is necessary that GPs have some insight into the goals and limitations of the current system to support their decision making when asked to provide a medical clearance or guidance; or indeed when referring or advising a patient toward engagement in exercise. As a minimum, it is worthwhile for GPs to become aware of the risk-screening protocols and staffing profiles of fitness centres in their communities and to direct patients toward the most appropriate options. GPs can manage the many uncertainties around this process by actively engaging their clinical allies in this field — in accredited exercise physiologists and physiotherapists.

The best model ultimately involves strong referral networks, and shared responsibility for patient risk and outcomes between the medical, allied health and fitness sectors. To ensure the integration of safe and effective exercise services within primary health care, there is a need for relevant professional bodies to work together to establish clearer referral pathways and universal assessment and decision-making guidelines for the identification and management of higher-risk individuals when commencing exercise.