the rise of the
clinical exercise practitioner

To meet the needs of clients with underlying health conditions, we need to develop the professional roles and qualifications of fitness instructors and personal trainers, argues Wendy Sweet.

With the plethora of evidence linking exercise to improvements in a range of medical conditions, it isn’t surprising that a new breed of exercise advisor is evolving – the clinical exercise practitioner. With a heightened interest in public health promotion and intervention, the clinical exercise practitioner has the skills and expertise to invoke change in the personal exercise and nutrition motivations of patients with underlying health conditions.

Already in vogue in the UK and US, and increasing in prominence in Australia and New Zealand, ‘clinical exercise practitioners’ differ in the specialist settings in which they work. Differences also exist in their qualifications and experience. In Australia, clinical exercise physiologists are university-trained practitioners who provide exercise services for people living with chronic disease, disability or injury (Selig & Torode, 2008). It must be noted that clinical exercise physiologists differ from the clinical exercise practitioner in qualifications, but not necessarily in practice. Like the clinical exercise physiologist, the exercise practitioner may also work in a variety of environments, liaising with other medical or health professionals in the delivery of lifestyle programs for at-risk clients. The clinical exercise practitioner may be a senior trainer or gym instructor who is tasked with working with different types of ‘special population’ clients, especially those referred by GPs – or, as is increasingly the case in New Zealand, the specialist exercise practitioner may be the nurse or physiotherapist at the medical centre. Alternatively, the specialist exercise practitioner may be practising in the local sporting organisation, a setting which houses increasing numbers of ‘lifestyle practitioners’ promoting more active lifestyles to community participants. These community exercise practitioners co-ordinate and implement prescriptive exercise for patients from GP referral schemes, such as New Zealand’s Green Prescription scheme, in which health professionals provide written advice to a patient to be physically active. Demand for exercise practitioners is set to increase as interest in the promotion of physical activity for ‘health’ continues to grow.

Establishing guidelines

Guidelines regarding the future role and competencies of clinical (or ‘advanced’) exercise practitioners are still in the early stages of development in New Zealand. Skills Active Aotearoa (the industry training organisation for fitness and sport in New Zealand), has collaborated closely with the fitness industry to design unit standards relating to training higher-risk population groups. The release of these for qualification purposes is in the pipeline. Additionally, the Register of Exercise Professionals (REPs) and Sport & Exercise Science NZ (SESNZ) are two accreditation organisations currently looking at the registration criteria for clinical or advanced exercise practitioners (both organisations differ in the name given to the ‘exercise specialist’ but the intent and purpose of the role, i.e. targeted to design exercise programs for higher-risk groups at an advanced level, remains the same).

The work that these organisations are doing to bring a more clinically-focused exercise practitioner through the ranks in the health and fitness domain is important. The need for this more advanced role has been felt in the fitness industry for a while now, as more and more clients present ‘at the coalface’ with underlying medical conditions. The conundrum, however, is that for this higher-risk group, the traditional exercise prescription model derived from the sports science vernacular (assess, prescribe and leave people to work through their programs), no longer applies. A different exercise prescription and follow-up paradigm needs to be explored and agreed upon. In the UK and the US the suggestion has been that the clinical exercise practitioner needs to engage in exercise prescription and intervention methods that follow a patient-centred approach. This contrasts with the contemporary, instructor-led prescription approach.

Practicing within a diverse team of medical and health professionals, overseas clinical exercise practitioners have become the educators, facilitators and motivators of new or renewed exercise behaviours for referred patients with medical conditions ranging from asthma and diabetes to hypertension and obesity. In some instances, the clinical exercise practitioner is integral to the entire process of planning, designing, implementing and evaluating the exercise program.

Developing competencies of the clinical exercise practitioner

Most current practices relating to exercise programming in fitness settings are designed for new members presenting with generally ‘healthy’ medical profiles and dispositions. They are relatively low-risk when it comes to commencing an exercise program. But times are changing, and with a growing interest in the design of programs and support required for higher-risk clients as they embark on new exercise (and nutrition) regimes, debate continues as to the necessary skills and competencies required for the clinical exercise practitioner.

These debates are not new and, interestingly, they also haven’t progressed far. Almost a decade ago, in a presentation to the Royal College of Physicians in London, health educator Bob Laventure queried the future role of the clinical exercise practitioner which he believed differed substantially from the traditional exercise practitioner role.

Working within the wider health team, Laventure saw the clinical practitioner role as a crucial one, whereby each must endeavour to:

  • collaborate with other professionals in the planning of ongoing patient exercise management
  • provide evidence-based exercise programming
  • provide continuity between secondary care and the community exercise setting
  • participate in ongoing patient reviews.

Further suggestions for the role and competencies of clinical exercise practitioners have also been voiced by the British Association of Sport and Exercise Science over the years. This organisation believes that clinical exercise practitioners should pursue the following ‘best-practice’ strategies:

  1. Understand and apply proven models of behaviour change
  2. Understand the efficacy of exercise in relation to health gain
  3. Understand the social (economic and cultural) characteristics of patients.

Many current exercise practitioners already working within clinical settings, as well as those working with patients from GP referral schemes, may already align their roles with the above strategies. In the range of New Zealand settings that deliver exercise programming to clients with underlying medical issues, however, these practices will not be universally practised or accepted. They potentially need to be. With an anticipated rise in GP referral schemes, and an ageing population, further work may have to be undertaken to develop the professional roles and qualifications of community-based fitness instructors and personal trainers to prepare them for the needs of higher-risk clients.

How is Australia meeting demand for exercise physiologists?

Designed to bridge the divide between personal trainers and allied health professionals by delivering the skills and qualification to work with people who have chronic health conditions, the Australian Institute of Fitness recently launched its Exercise Therapist (Diploma of Fitness) program.

Explaining the need for additional education before working with this population, exercise physiologist John Felton from The Exercise Clinic, says: ‘Exercise Therapists will encounter people who are on medication, people who are detrained or those who haven’t exercised in a long time, so they need that extra knowledge after becoming a personal trainer. They also need to be able to stabilise and improve the integrity of the joint they’re trying to rehabilitate.’

The Exercise Therapist program has been customised for the purposes of exercise therapy for a wide range of chronic conditions, and electives have been chosen for the specialty areas of disabilities, neurological impairment, children and older adults, as well as metabolic, cardiorespiratory and musculoskeletal conditions.

The program requires students to have achieved a Certificate IV in Fitness, and to have significant experience in exercise delivery/working in the fitness industry. If you are interested in progressing to a higher level of learning, call 1300 669 669 to see if you qualify to study for the diploma.

Approaches to behaviour change

Conversely, it must also be challenged that further professional development may also be needed for current health practitioners (physiotherapists, practice nurses, doctors) who are unfamiliar with the fitness environment to help them better understand best-practice exercise prescription. Additionally, this group of health professionals may need to develop their understanding of the specific coaching, motivational and behaviour change strategies that are implemented by experienced instructors and trainers in fitness settings. Although some motivational strategies used in fitness settings do align with current behaviour change interventions recommended by health behaviour researchers, differences also exist.

Behaviour change research is gaining momentum in public health promotion, but is still thin on the ground when it comes to looking at current practices used by those most experienced in fitness settings – gym instructors and personal trainers. Research undertaken by myself in 2008 explored the experiences of ‘successful’ long-term personal trainers in assisting clients to change exercise and nutrition behaviours. The research participants worked in various community settings throughout New Zealand’s North Island – and not all ‘worked in a gym’. Their personal experiences relating to the strategies they had each developed for changing client exercise and nutrition behaviours were compared with current strategies and interventions being promoted in behaviour change research. The outcome from the study was that each of these experienced trainers – all of whom had very limited or no awareness of theoretical models of behaviour change – had devised and implemented their own strategies to motivate and influence exercise and nutritional change with their clients. Some strategies aligned with current behaviour change practices, others did not. The most prominent difference (and possibly the most pertinent) related to that of client accountability practices. Every trainer participating in the research spoke of having to devise accountability measures for their clients in the early stages of change to ‘keep them on task’. Research undertaken by Dr Richard Pringle in 2008 presented the experiences of patients who had commenced Green Prescription GP-referral initiatives in New Zealand. Many felt that their cases had not been followed up for long enough, and that the scheme failed to demand accountability on their own part. These factors contributed to the patients disengaging with their physical activity programs.

These findings may not be surprising to fitness specialists experienced in assisting and motivating people to accommodate new exercise and nutrition behaviours. With many models of health/lifestyle behaviour change having been developed by isolating determinants associated with changing addictive behaviours such as smoking and substance abuse, the direct extrapolation of stage-based models and their application to planned exercise/physical activity behaviour in fitness settings is undoubtedly open to debate. While there is a plethora of behaviour-change research in relation to general health promotion in communities, there is still a paucity of behaviour change research relating to the how and why of exercise behaviour change within specific fitness settings such as fitness facilities.

Identifying the skills and competencies required by clinical exercise practitioners working with higher-risk populations may, therefore, require greater discussion. The decisions regarding the development of knowledge, protocols and guidelines for clinical exercise practitioners shouldn’t just remain in the medical or sports-science domain, as much successful behaviour change happens at the local level in gyms and recreation centres. Discussions on criterion for the development of specialist exercise practitioners, therefore, should include all parties: the medical and sports-science communities; the industry training organisations; fitness and gym practitioners; and fitness registration organisations.

Australia and New Zealand have some of the best personal trainers and fitness personnel in the world. Many fitness personnel without high-level qualifications are already great motivators and moderators of lifestyle behaviour change – it’s what they know and do best! These people have much to offer in relation to assisting people with underlying health conditions to make successful lifestyle changes, so it is essential that plans be established for enabling them to obtain clinical exercise practitioner qualifications. By so doing, we can achieve improved health outcomes for patients/clients and further the careers of our best fitness professionals, while elevating the standing of the fitness industry in the eyes of our allied health professionals.

 

Wendy Sweet, RGN/ BPhEd, MSpLS
The 2010 recipient of the FitnessNZ Award for Most Outstanding Contribution to the New Zealand Fitness Industry, Wendy has over 25 years industry experience, and is known for popularising personal training in New Zealand through the design and development of the Les Mills Personal Training program in the early 1990s. She has experience lecturing at both Waikato University and AUT University, and recently embarked on her PhD on baby-boomers experiences with the fitness industry.