In 2006, Fortier et al published a paper outlining a new approach to activate the Canadian people to improve population health and reduce health care costs.1 This model recommended forming a collaboration between traditional health care providers such as physicians and nurse practitioners, who can kick-start the physical activity behaviour change process, and recognized exercise professionals (REPs),* who are positioned to offer intensive counselling necessary to promote sustained physical activity.
The Physical Activity Counselling (PAC) randomized controlled trial was conducted from 2004 to 2006 to test this approach.2 Results from this trial, which have been published in many peer-reviewed journals,3 showed that having multiple sessions of physical activity counselling from a kinesiologist was effective at increasing patient confidence and motivation for physical activity and physical activity levels,4 and that this model was cost-effective.5 Moreover, in 2014, an environmental scan of physical activity services among Ontario family health teams (FHTs) concluded that registered kinesiologists (Rkins) are promising health care providers.6 Owing to a combination of the results from the PAC trial and other high-quality studies, Exercise is Medicine Canada strongly recommends alliances between physicians and REPs. In 2011, we were informed that the encouraging results from the PAC trial contributed to kinesiology becoming a regulated profession in Ontario in 2013 through the College of Kinesiologists of Ontario (personal communication; 2011). As of 2024 there are 5 Rkins who are part of FHTs or community health centres in Ottawa, Ont.
In 2018, Jattan and Kvern made a case for the importance of having REPs on health care teams as a way to help transform physician recommendations into actions and assist patients with safe and effective exercise.7 The authors noted that physicians already partner with allied health professionals such as dietitians and pharmacists and gave the example of exercise referral schemes in the United Kingdom and New Zealand that are administered and funded by the government.8-10 Despite this, the sustainable integration of REPs into the health care system in Canada has yet to happen.
The purpose of this article is to provide an update on the initial 2006 position paper to show the relevance of expanding the health system to include REPs in the present context. The intent is to encourage relevant stakeholders to devise a plan to move this proposal forward.
Physical activity evidence base is continually growing
Given that more science has emerged since 2006 showing the immense positive effects of regular exercise on physical and mental health,11,12 having REPs in health care settings is a worthy goal to help patients find and regularly engage in meaningful physical activities. For example, frequent exercise helps to prevent and treat cardiovascular disease, diabetes, and depression. Owing to the amount of high-quality evidence on this topic,11,12 the American College of Sports Medicine created a physical activity vital sign that can be incorporated into electronic medical records.13
In addition to the physical and mental benefits of including REPs in health teams, REPs are well-positioned to fight against climate change and greenhouse gas emissions by encouraging active transport, such as walking and cycling. Recognized exercise professionals can also help counter the current physical inactivity epidemic, which the World Health Organization ranks as the fourth leading cause of morbidity and mortality.14 By collaborating with multidisciplinary teams, REPs can help alleviate some of the present mental health crisis and assist with the management of chronic pain, both of which are burdens on the health care system.
Costs and consequences of physical inactivity
The rates of physical activity are still very low in Canada: only 11.8% do moderate-to-vigorous physical activity,15 with rates worsening because of the COVID-19 pandemic.16 The most recent estimate of the costs of physical inactivity in Canada is $3.6 billion in 2021.17 While behaviour change is very complex and influenced by many factors, having REPs embedded in the health care system would help activate the population and decrease inactivity health care costs, especially for individuals with disabilities, low socioeconomic status, or chronic conditions, as these people often experience the most physical activity barriers and have worse overall health. Experts agree it would be advantageous to have a specialized designated professional supporting patients given how challenging behaviour change is, especially in the long term. In line with this, the 2020 Canadian Cardiovascular Society included exercise physiology-kinesiology as part of their multidisciplinary care plan for patients.18
Physician exercise promotion remains a valued but underdelivered service
Despite physicians knowing the benefits of physical activity and having the efforts and interventions available to discuss exercise with their patients,19,20 as well as being aware that many patients (ie, 81%) think physical activity could help them manage their risk factors or illnesses,21 only 20% to 30% of physicians discuss fitness with their patients.22 Specifically, a Canadian study showed that only 12% of physicians prescribe physical activity,23 while Lindeman et al24 found that a mere 9.6% of patients had at least 1 mention of exercise at any time in their electronic medical records. In addition, physicians who do discuss physical activity take, on average, only 90 seconds to do so,25 and they typically make nonspecific recommendations.26
Unsurprisingly, a growing number of studies show that physician interventions are minimally effective at changing patient physical activity, especially in the long term.27 However, a recent study showed that most physicians (ie, 77.3%) think there are definite benefits of referring patients to an Rkin.28
Provider burnout and inability to sustain PAC
The Ontario Medical Association has recently published a worrisome report showing the high burnout rates of physicians over the past few years,29 with rates doubling throughout the height of the pandemic. Thus, in the present climate, it is less likely that doctors have the time or energy to discuss physical activity, let alone provide advice according to patient needs and preferences, provide behavioural support, or follow up with patients.30 It is evident that physicians need qualified partners to help them manage their high workload and promote patient health. There are currently around 3000 Rkins registered with the College of Kinesiologists of Ontario—this is an untapped resource that could help alleviate physician burden and allow for better patient care.
Having REPs on care teams could help physicians and other clinic employees with their own physical activity to mitigate the effects of stress on their physical and mental health. This would have a rippling effect on patients as a growing number of studies have shown that active physicians are the ones who discuss physical activity most frequently and confidently with their patients.31,32
It should be noted that since the initial 2006 paper,1 the Canadian Society for Exercise Physiology has encouraged engagement in 3 types of movement behaviour—physical activity, sedentary behaviour, and sleep—and, to improve population health and decrease health care spending, has disseminated evidence-based recommendations for each behaviour.33 Our team has been actively involved in the mobilization of the movement guidelines and developed a tool kit for primary care providers to discuss movement behaviour.34 Managing 1 lifestyle behaviour is difficult enough, improving 3 is challenging and requires dedicated, specialized guidance and follow-up that most physicians or other health care practitioners cannot provide, but REPs can. Specifically, REPs can help patients progress up to recommendations in a sustainable way.
While many options could and should be implemented to help Canadians optimize their physical activity, such as embedding more content on movement behaviour in the medical curriculum,35 changing accreditation standards to include movement behaviour promotion competencies, delivering live training to teach physicians how to use the primary care tool kit, or learning how to refer and incentivize this service,34 it is the position of the authors that more REPs should be systematically integrated into health care teams to help patients adopt and maintain healthy movement behaviour, and that this be funded by governments of provinces and territories. Doing so would fit with the health care pillar of delivering the most appropriate care by the most appropriate provider and would align with the American College of Sports Medicine’s advocacy for formalized collaboration and referrals between traditional health care providers and REPs.13 This would also follow the shared-care approach used in Australia where they strengthened the referral pathway to accredited exercise physiologists.36 Other experts across Canada have also proposed the solution of integrating REPs into health care.7,24,35,37-39
To close the gap between science and reality, we recommend that advanced-level kinesiology students trained in exercise prescription and behaviour change be paired with medical students as soon as possible to help them achieve and sustain healthy movement behaviour, improve their wellness, and better understand the scope of practice and competencies of REPs, considering trust has been recently found to be a barrier to Rkin integration.27 Until there is a movement for systematic integration of REPs into care teams, physicians can use the search function on kinesiology association websites to find kinesiologists in their area to whom patients can be referred.
Conclusion
While much is needed to activate the Canadian population, such as increasing access to and motivation for active transport and changing habits regarding screen time, we could start by having REPs in health care clinics to help with patient physical activity and assist overworked physicians.
To improve population health in Canada and reduce health care costs, we must change the paradigm toward prevention through lifestyle management by REPs integrated into the health system. We believe physicians in collaboration with experts in kinesiology need to lead this change and suggest that these and other relevant stakeholders take concrete steps to make this happen, such as increasing awareness of the scope of practice and abilities of Rkins, having relevant associations such as the Association for Family Health Teams Ontario and the Alliance for Healthier Communities build a case for the systematic integration of REPs into teams, lobbying the government for funding, allowing Rkins to be associated with FHTs or community health centres, and enabling Rkins to bill practices directly. We could save hundreds of millions of dollars in health care spending and improve the quality of life of so many Canadians.17 So, what are we waiting for?
Footnotes
↵* A recognized exercise professional in Canada refers to a registered kinesiologist in Ontario or a clinical exercise physiologist through the Canadian Society of Exercise Physiology in other provinces. Some might be a registered clinical exercise physiologist with the American College of Sports Medicine.
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro d’octobre 2024 à la page e136.
- Copyright © 2024 the College of Family Physicians of Canada
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