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An Office-Based Instrument for Exercise Counseling and Prescription in Primary Care
The Step Test Exercise Prescription (STEP)
Robert J. Petrella, MD, PhD;
Douglas Wight, MSc
Arch Fam Med. 2000;9:339-344.
ABSTRACT
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Background Available evidence suggests that despite physicians' positive attitudes toward exercise as an important part of promoting a healthy lifestyle, few physicians actually prescribe exercise for their patients. One barrier may be lack of a standard office instrument.
Objectives To determine the (1) exercise counseling habits among a large group of Canadian family physicians and (2) acceptance and utilization of an exercise counseling instrument geared to primary care practice.
Design Randomized control trial.
Setting Primary care practice.
Participants Family physicians (N=400) from 3 regions of Canada, representing both rural and urban practice (ratio of 1:3). Patients (10 per practice) were healthy community dwellers older than 65 years obtained as a convenience sample in their family practice.
Interventions In phase 1, 400 physicians listed as being in general or family practice by their provincial registries were randomly selected from a larger group listed by these registries and contacted by telephone. A total of 362 completed a 10-minute questionnaire that detailed practice demographics, preventive practice, and exercise counseling habits. In phase 2, 293 agreed to further participate in the administration of an exercise prescription randomly assigned to them by the study team. Two methods of exercise prescription were compared: counseling using the American College of Sports Medicine guidelines (control) and counseling using guidelines and an office-based step test (Step Test Exercise Prescription [STEP]) to determine fitness level and prescribe an exercise training heart rate. Physicians were asked to deliver their assigned exercise prescription to a convenience sample of the next 10 healthy patients older than 65 years who presented to the office.
Main Outcome Measures Primary outcome measures were physician exercise counseling confidence and knowledge before and after the study. Secondary outcomes included details of the exercise counseling sessions (eg, time required).
Results In phase 1, more than 90% of the 362 physicians claimed to practice preventive health counseling, and 70% claimed to include exercise counseling. Only 67.4% felt confident regarding their exercise prescribing, and most (93.8%) were interested in improving their exercise prescribing skills. The leading barriers to exercise prescription were described in order as inadequate time, lack of necessary skills and tools, and lack of reimbursement. In phase 2, no difference in physician profile, patient profile, or indications for exercise counseling were observed between control (n=145) and STEP (n=148) groups. STEP was significantly longer (16.4 vs 12.9 min; P=.001) to administer; however, improvement in physician confidence (P=.01) and knowledge (P=.009) were significantly greater compared with controls.
Conclusions Most family physicians practiced preventive exercise counseling but reported lack of time and skills as barriers to this practice. Physicians randomized to the STEP group took longer to deliver exercise advice but felt more confident and knowledgeable compared with controls.
INTRODUCTION
AVAILABLE EVIDENCE suggests that primary care physicians have positive attitudes toward preventive health care practices in general and believe that physical activity is an important determinant of health and preventive practice.1-2 However, most primary care physicians do not regularly counsel their patients about exercise.3-4 This is in contrast to other preventive health behavior counseling, where physicians have shown more activity.5-7 Barriers to exercise prescribing that may account for some of the difference in counseling practices include perceived lack of time, lack of training and skills, and an absence of counseling tools.5-11 To address these last 2 factors, while being conscious of time constraints, one group has studied the implementation of a behavioral model8, 12 counseling tool, Provider Assisted Counseling for Exercise (PACE), to increase exercise prescribing among physicians in a format that is easily accomplished in the primary care practice setting in about 5 minutes.4, 8, 13 Hence, PACE could increase opportunities for physicians to discuss exercise in the context of patient readiness.8 However, PACE does not include specific performance information (ie, an exercise training heart rate) to guide patient discussions of the intensity component of the exercise counseling.14 This aspect may be important in guiding the prescription in those patients with risk factors and special populations, including the elderly or those patients taking medications that could alter exercise function. Furthermore, prescription of an exercise heart rate could provide the physician with baseline functional data to complement counseling,14 and the tailored message could even improve physiologic gains and perceived improvement.15-18 The present study describes the difference in exercise counseling practice, including counseling time, confidence, and perceived knowledge among a large group of family physicians from Canada randomized to an exercise prescription using the determination of an exercise training heart rate compared with a control group. We chose to study this model among older adults for 2 reasons. First, older adults represent a group at risk of functional decline and could therefore benefit from exercise interventions to improve general health. Second, chronic diseases of aging are not only preventable with exercise but as a therapeutic modality exercise is underused in the elderly, despite evidence of a substantial positive impact.2 If this model of exercise prescription among family physicians and their older patients is effective and practical in clinical practice, adoption among other patient groups would be supported.
POPULATION, MATERIALS, AND METHODS
The study was approved by the University of Western Ontario Review Board for Health Sciences Research Involving Human Subjects.
SAMPLE PHYSICIANS AND OVERVIEW
The study schema is shown in Figure 1.
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Figure 1. Study schema. STEP indicates Step Test Exercise Program.
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Primary care physicians were identified from lists in a national directory of physicians in 2 western provinces (British Columbia and Alberta), 2 central provinces (Manitoba and Ontario), and 1 eastern province (Nova Scotia) who listed their principal medical practice as family medicine or general. Physicians were grouped to those practicing in urban areas (population,  25 000) and rural (population, <25 000) and then randomly selected using a computer program until 400 names were obtained (250 urban and 150 rural). This group was contacted by telephone by a trained assistant to determine if they (1) currently practiced prevention counseling, (2) specifically performed exercise counseling, and (3) would be interested in participating in a study of exercise counseling for family physicians. Physicians were also asked to indicate their number of years in practice, whether they were certificants of a university program in family medicine, their practice size, and whether they were in group or solo practice. The physicians were then sent a questionnaire. Physicians who completed and returned the questionnaire and confirmed their interest in participating in the exercise counseling study were then randomized to the second part of the study. The intervention involved establishing an exercise heart rate and counseling the patient for exercise using the American College of Sports Medicine (ACSM) guidelines.14 The control consisted of exercise counseling alone. Physicians were instructed to administer their exercise prescription to a convenience sample of the next 10 patients older than 65 years and in good health who presented to the office for usual care. Specific reasons for identification were to improve general health or some specific disease issue (ie, glucose control). No reimbursement was received for involvement in the study.
MATERIALS
Two questionnaires were used to generate practice demographic data and exercise counseling habits.
Phase 1
In questionnaire 1, data collected included the following: practice profile: physician sex, years in practice, qualifications (certificant in family practice), solo or group practice, number of patients in practice, and academic affiliation; exercise counseling profile: did the physician practice prevention counseling (yes or no), did the physician counsel patients about activity (yes or no), what percentage of patients did the physician currently discuss exercise with, where did exercise rank in a list of 4 cardiovascular risk factors, did the physician feel confident in his or her exercise prescribing (a scale of 0-10, 0 signifying no confidence and 10, complete confidence), was the physician satisfied with his or her exercise counseling knowledge (a scale of 0-10, with 0 signifying perceived complete lack of knowledge and 10, completely knowledgeable), would the physician be interested in obtaining more information to assist counseling patients about exercise (yes or no), what did the physician perceive to be the one primary barrier to exercise counseling in clinical practice, what would the physician like to receive to improve his or her counseling (ie, continuing medical education, literature, guidelines), what did the physician perceive to be the most important element of an exercise prescription (ie, frequency, duration, intensity, mode, safety), and would the physician be interested in participating in a study to determine the effect of an exercise prescription for family practice (yes or no).
Phase 2
Those giving a positive response to the final question were randomized to either the intervention group, who received the ACSM guidelines14 in addition to an exercise training heart rate using the Step Test Exercise Prescription (STEP),19 or a control group, who received the ACSM guidelines to complement their counseling. Physicians were instructed to use the assigned materials with the next 10 patients whom they determined "appropriate" for exercise counseling. Reasons for exercise counseling were documented by the physicians. Physicians were also asked to record the patient profile (ie, age; sex; medical problems such as high blood pressure, excess weight, diabetes, and osteoarthritis; medications; and reason for the counseling), the duration of the encounter, and any follow-up visits. Following recruitment of the 10th patient, the physician completed a second questionnaire.
In questionnaire 2, data collected included the following items from questionnaire 1: (1) exercise counseling confidence and knowledge, perceived effectiveness of the counseling materials (ie, whether the counseling effected a desired change and what the change was), perceived patient satisfaction (positive, indifferent, or negative), appropriateness of the materials to their practice, (2) continued use (including whether they would continue using the intervention tools in 3 months), what 1 or 2 items in the materials they would change, whether they need further exercise counseling support and in what form (ie, continuing medical education, script pads, support, and literature), what outcomes they would measure (ie, patient satisfaction and clinical measures), and (3) practice economics (including the time required for counseling, any associated staff time required, whether follow-up was arranged, over what period, and the number of follow-up visits scheduled).
Finally, 20 physicians from each group were randomly contacted 4 months after completing the questionnaire regarding the 10th patient and asked how many times they used the exercise prescription materials in the previous month.
INTERVENTIONS
For group 1 (control group), physicians were given a package containing a paper on the recommendations from the Centers for Disease Control and Prevention and ACSM2; a flow sheet adapted from the ACSM14 guidelines, including a list of mild, moderate, and high-intensity exercise activities; and an age-specific fitness level chart.
For group 2 (guidelines and STEP counseling), physicians were given materials similar to those given the control group plus a package that contained a description of STEP, instructions for administration of the STEP and data collection, and a stopwatch and programmed calculator to input the heart rate and exercise test duration. These data were used to estimate the fitness level (maximum oxygen consumption [ O2max]) and to calculate an exercise heart rate. STEP has been previously described.19 Briefly, patients are asked to ascend and descend 2 small steps at a pace considered normal or comfortable (not slow or too fast) 20 times. The heart rate before and immediately after the test and the duration of the test in seconds are recorded. The heart rate, time, sex (female=1, male=2), age (in years), and weight (in kilograms) are then entered in the following equation to predict the maximal fitness level (O2max):O2max=3.9 + (1511/time) x (O2 pulse [mass/heart rate] x 0.124) - (age x 0.032) - (sex [male=2, female=1] x 0.633).19 The O2max was used to provide a baseline level of fitness to aid counseling and determine the assignment of an exercise heart rate equivalent to 65% of the O2max.20 The exercise training heart rate was given as the number of beats during 10 seconds from a radial or carotid pulse. Physicians in both groups were also given a list of local facilities where patients could exercise, including public parks, health clubs, and senior centers.
STATISTICAL ANALYSIS
Because no documentation was available in the literature on which to base power calculations for the population of interest and because this study was hypothesis generating in anticipation of a larger intervention of exercise prescription in family practice, no formal sample size was chosen. However, we have previously reported19 that a sample of 20 family physicians could recruit 10 older patients during 2 months and subsequently find significant changes in fitness following an exercise prescription using STEP in 200 healthy elderly patients. In addition, we wanted to recruit 1 urban to every 3 rural family physicians from each province. Hence, we estimated that approximately 400 physicians would be required (90 family physicians per province or 320 total plus a 20% dropout rate, which equals 384). Analysis of variance was used to evaluate between-group differences at baseline and after the intervention. Analysis of covariance procedures were used to assess changes across the intervention period. In analyzing change, main effects for group assignment were evaluated with baseline levels of the dependent variables set as covariates. Significance was accepted at P<.05.
Data are given as mean ± SD.
RESULTS
PHYSICIAN RESPONSES
A total of 362 (90.5%) of 400 physicians completed the initial questionnaire (77.7% urban and 122.1% rural). These included the following provincial distributions: British Columbia, 86; Alberta, 49; Manitoba, 26; Ontario, 133; and Nova Scotia, 68. Those who did not respond at first attempt were contacted by telephone, resulting in another 38 questionnaires returned (100%). However, 13 of the returned questionnaires were not completed (reasons included lack of time or a policy rejecting questionnaires of any kind), and 25 were incomplete. Of the 362 physicians who completed the questionnaire, 293 (80.9%) accepted the invitation to participate in the second part of the study. Those who did not participate identified lack of time, lack of perceived need, or lack of interest as reasons for refusal. The physicians who agreed to participate were randomly assigned to the intervention (n=145) or control (n=148) group. Of those who accepted the invitation, 253 physicians (control group included 58 rural and 92 urban physicians; intervention group included 62 rural and 81 urban physicians) completed the study. Thirty physicians did not complete the required 10 counseling encounters by 6 months, and 10 either could not enroll 10 patients or became disinterested in the study.
PHYSICIAN PROFILE
No significant difference was observed between control and intervention groups and there were no differences between the respondents and nonrespondents for any of the demographic variables selected. Overall, physicians were male (177 men and 116 women), had practiced a mean of 14 ± 6 years, were in solo practice, had a mean practice size of 1300 ± 316 patients, and saw a mean of 38.7 ± 8.1 patients per a 6.3 ± 0.7–hour day. Approximately 50% were certificants in family medicine, and only 20% had a university academic affiliation (ie, full-time or part-time teaching).
EXERCISE COUNSELING PROFILE
No differences were observed between groups at baseline. Overall, most physicians (97.0%) claimed to practice preventive counseling regularly, and 74.5% of physicians claimed to practice exercise counseling regularly with patients. The most common reasons for exercise counseling included weight loss, general improvement in health, and high blood pressure control. Sixty-seven percent of physicians were confident in their exercise counseling advice; however, physicians ranked sedentary lifestyle fourth in importance as a risk factor for cardiovascular disease (behind hypertension, hyperlipidemia, and smoking). Physicians requested formal education (continuing medical education) activities, exercise prescription aids, and supportive literature to improve their prescription activities. They perceived the appropriateness of the activity (or mode) and the amount or intensity of activity and safety as important elements of the exercise counseling. They did not mention patient readiness for exercise (ie, behavior change), but some did mention that motivation for some patients would be a limiting factor in adherence. The 3 most common barriers to physical activity counseling in order were inadequate time, insufficient knowledge or tools, and inadequate reimbursement.
INTERVENTION CHARACTERISTICS
The reasons for prescribing exercise were similar between the groups and were the same as described herein (weight loss, improve general health, and blood pressure control). The mean time required to recruit 10 patients was 6.3 ± 2.0 weeks (range, 4-17 weeks) in the STEP group and 7.1 ± 3.1 weeks (range, 3-11 weeks) in the control group (P=.7), or 1 patient every 3.5 days (STEP) and 1 every 5.6 days (control). Most patients were approached during a routine office visit regarding a specific chronic medical problem (eg, weight loss or hypertension) (84%) vs annual health examination (22%). No difference was observed between groups.
PRACTICE ECONOMICS
The mean time required to complete the intervention during an office visit was significantly longer (P=.03) in the STEP group (16.4 ± 5.0 min) compared with the control group (12.9 ± 2.6 min). There did appear to be a learning effect in that the last 3 patients recruited were counseled significantly faster (13.1 ± 2.2 minutes) than the first 3 patients (17.8 ± 3.1 minutes) in the STEP group (P=.01) (Figure 2). Regardless, most physicians in both groups claimed that the counseling did not significantly "slow" their practice.
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Figure 2. Comparison of key outcome variables by condition (Step Test Exercise Prescription [STEP] vs control) at baseline and posttest. A, Duration represents time (in minutes) spent counseling (last 3 indicates mean time final patients recruited; first 7, mean time of first 7 patients recruited). B, Confidence represents physician confidence using a 0- to 10-point scale, with 0 indicating no confidence and 10, complete confidence. C, Knowledge represents physician knowledge using a 0- to 10-point scale, with 0 indicating perceived complete lack of knowledge and 10, completely knowledgeable. Asterisk indicates significant within-group difference; dagger, significant between-group difference (P<.05).
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CONTINUED USE
All physicians claimed they would continue using both the counseling aids, but some admitted they would adapt them somewhat to their own practice (develop flow sheets and have the nurse or office staff do some of the counseling). Some requested information regarding progression of the exercise counseling intensity and advice regarding patients taking  -blockers and those with angina or patients unable to complete STEP. Eighty-two percent (control) vs 97% (STEP) of physicians believed (P=.01) the intervention improved their confidence in prescribing exercise, and 88% (control) vs 100% (STEP) felt their knowledge was improved (P=.009) (Figure 2). Only 2% (control) and 4% (STEP) of physicians claimed the intervention did not change their prescribing characteristics.
PATIENT CHARACTERISTICS
There were no significant differences between groups. Overall, the mean age was 67 ± 4 years (range, 64-79 years), the male-female ratio was 1:2.1, and cardiovascular disease occurred in 38% (79% hypertension and 12% hyperlipidemia), diabetes mellitus in 15%, and osteoarthritis in 42%. No difference was observed in perceived patient satisfaction with the intervention between groups.
No attempt was made to collect baseline or follow-up physical data, including predicted O2max, heart rate, and weight.
FOLLOW-UP TELEPHONE INTERVIEWS WITH PHYSICIANS
We did not ask specific details of the prescription information and we did not attempt to corroborate the responses given. Twelve of 20 physicians in the guideline and STEP group had used the protocol in the previous month compared with 7 of 20 in the control group. Other aids that were suggested by both groups of physicians contacted were wall charts, printed examples of appropriate devices to monitor pulse without palpation, and how "younger" or other family members could be managed with these tools.
COMMENT
Regular physical activity has long been regarded as an important component of a healthy lifestyle. Recently, this impression has been reinforced by new scientific evidence that links regular physical activities to a wide array of physical and mental health benefits.2 Helping patients change their physical activity behaviors is a difficult task for health care practitioners. Primary care physicians represent a large pool of professionals who have credibility with their patients regarding the recommendations of certain health care practices. Furthermore, patients want to receive activity counseling from their health care practitioners.1 Because patients respect their physicians' advice, a succinct message from a physician can be a potent catalyst in motivating change in health behaviors, but the focus of the message has been sparsely investigated to date.1, 4-6,21
The present study was performed to identify current exercise prescribing practices among a large group of Canadian family physicians and to prospectively investigate perceived confidence, knowledge, and use of a novel exercise counseling instrument (STEP) compared with controls. Specifically, we found that most physicians in our random sample practiced prevention and that 70% specifically practiced exercise counseling. Barriers to exercise counseling were similar to previous reports,3, 5-6,11 including lack of standard protocols for exercise counseling. Our high response rate may suggest a high level of preventive practice among these physicians. Indeed, our group was young, and most had qualified for certification with the Canadian College of Family Medicine, attributes that may have contributed to preventive care practices.
Our findings are provocative, since only a few studies have addressed the question of whether physicians discuss exercise practices with their patients, and available data suggest that most do not.3, 5-6,9, 11 Furthermore, there are few data regarding delivery of specific information, such as an exercise heart rate prescription.22 Physician practices have been shown to be responsive to the introduction of standardized clinical protocols in other areas,23 and this may be true for physical activity as well. Physicians see exercise counseling and physical activity as important but indicate that they are generally not well prepared to counsel patients or prescribe physical activity24-25; yet, they do suggest that standard protocols would help them in these areas.26-27 These findings appear to be supported by the present study. Curiously, family physicians in the present study did not rank sedentary lifestyle as a more significant cardiovascular disease risk factor (ranked fourth) compared with population prevalence.28 We are, however, encouraged that this group of family physicians reported planned future use of exercise counseling, and a follow-up of 20 study physicians revealed continued use had occurred.
A family physician's active interest and encouragement of exercise behavior, including tailoring activity to patient needs and limitations, may be helpful in increasing adherence and health outcomes.29 Although the personal benefits to the patient may be self-evident (eg, greater endurance and well-being), the additional encouragement and objective support of the physician may be a potent reinforcement.30-31 Pender et al32 have stated that the difficulty clinicians may have in implementing physical activity interventions may not be due to the prescription but how one then monitors progress. This could also extend to the monitoring of progress and supporting the stage of change promoted by PACE4, 8, 13 by objective end points provided by the STEP model.19 Indeed, the most important exercise counseling skills for a physician may be setting realistic goals using patient-specific data and problem solving to surmount barriers and boosting confidence with objective reinforcement.4
We present evidence in this study that STEP is a practical instrument for family physicians. Although it may initially increase significantly the delivery time, this may improve with regular administration and learning. More important, STEP significantly improved confidence among physicians compared with controls, was acceptable to physicians, and was used more at 4 months after intervention compared with controls. Certain parallels with the goals of the PACE program4 and the present study should be considered. STEP is distinguished by the determination of patient-specific clinical data and assignment of a O2max and exercise heart rate in the exercise prescription. PACE determines the stage of readiness the patient has regarding exercise behavior12 and then tailors the exercise counseling to activities that will complement the appropriate behavioral stage.
We see the STEP approach as complementary to PACE. Whereas PACE is aimed at delivery appropriate to the stage of readiness in a 2- to 5-minute encounter, STEP is aimed at determining the level of fitness of the patient and prescribing an exercise heart rate to complement the counseling. STEP may be complementary to PACE, particularly in patients in the active, maintenance, and contemplative stages. The ability to deliver both PACE and STEP programs within a 10- to 15-minute patient encounter in the office setting is exciting. Indeed, examination of these potentially complementary exercise counseling programs in primary care could add substantially to the activity levels of large numbers of patients and have, if used together, a greater clinical and public health impact than either one alone.
AUTHOR INFORMATION
Accepted for publication November 17, 1999.
This study was funded in part by a grant from the Medical Research Council of Canada/PMAC, Ottawa, Ontario.
We thank all physicians who volunteered their time and offered their valuable input to this study.
Corresponding author: Robert J. Petrella, MD, PhD, 1490 Richmond St N, London, Ontario, Canada N6G 2M3 (e-mail: petrella{at}julian.uwo.ca).
From the Centre for Activity and Ageing, Lawson Research Institute, St Joseph's Health Centre, The University of Western Ontario, London.
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