New Approaches to Cardiac Rehabilitation are Certainly Needed, but parkrun is not the Answer
I am an avid exerciser. I enjoy trying my hand at a host of different sports, I’ve played football since a young age and I love working out in the gym. My 79-year-old Grandmother does none of these things, and yet, despite our 55-year age gap, we both enjoy a good standard of health. If you asked her if she thought of herself as an exerciser, she’d respond with a resounding no. However, she does lead an incredibly physically active lifestyle. Whether it’s walking around the town carrying her shopping bags, or watering the plants out in the garden, if you were to compare our overall physical activity levels, or ‘total physical activity dose’, across the course of the average week, there wouldn’t be too much to separate us! It’s certainly not something I’m ashamed to say, because physical activity is far more than just structured exercise or sport, in fact, every single move we make matters for our health, and this personal example emphasises the importance of the total physical activity dose with great clarity.
The way in which physical activity and its health benefits are portrayed continue to be strongly influenced by the exercise and fitness industry. This is unfortunate, as the notion that physical activity must be structured, high intensity exercise to be of any benefit to our health is simply not true. This misconception has significantly damaged public perceptions of physical activity for health for generations and has been brought into sharp focus within a recent piece of research published in the BMJ. The article examines whether parkrun, a company which organises free 5-kilometre events at various locations around the world, could be recommended as a self-management phase for cardiac rehabilitation (CR). When you consider that only around ~50% of individuals who are eligible for CR in the UK take up traditional offerings, this presents an interesting proposition, especially when you consider the scalability of parkrun across the UK and worldwide. However, there are a number of serious causes for concern in the research article that could further compound the issues relating to the accessibility of physical activity for rehabilitation services and wider population health management.
Firstly, whilst the total sample size is large at 53,967 people, only 0.7% of people self-reported that they were living with a cardiovascular condition. The researchers do acknowledge that individuals with cardiovascular conditions are underrepresented in parkrun, which is perhaps the first indication that the event may not be the most accessible nor appealing to individuals entering a self-management phase of CR. This lack of accessibility and appeal is a major problem that continues to plague traditional exercise-based rehabilitation services, and is a key factor behind the sub-optimal uptake rates mentioned previously. My second concern is that whilst stating 81% of people with a cardiovascular condition felt they had improved their fitness sounds positive at first, the use of self-report data to draw conclusions regarding improvements in physical activity and fitness is fraught with danger. The limitations of self-report methods to assess physical activity are widely documented, with various types of reporting bias coming into play. Lastly, in a CR setting, objective monitoring, and appropriate understanding of relative intensity is vital to enable safe and effective physical activity. For many individuals who have suffered a cardiac event, knowing how to improve their physical activity safely can be incredibly challenging, with many lacking the confidence despite understanding the benefits. Equipping individuals with the tools to objectively assess physical activity intensity, coupled with a true understanding of the context behind the data can help alleviate these fears. Encouraging individuals in need of CR, many of whom will have low self-efficacy when it comes to physical activity, to attend parkrun for their CR self-management is difficult to comprehend, and could even be dangerous.
In my opinion, although the direction is somewhat misguided, the fundamental need for research into alternative means of CR self-management absolutely exists. Current CR uptake rates are concerningly low and the need to identify alternative options that can empower individuals to self-manage in a way that works for them is crucial if the NHS is to meet its 85% uptake target in the coming years. Even for those who do attend traditional CR, insufficient attention is given to the benefits of physical activity that occur outside of the clinical setting. Furthermore, the set of structured exercises that are often recommended for people to complete at-home still fail to account for all of the other possibilities to move more that already exist within our daily lives. By recommending parkrun for self-management, individuals are exposed to the same issue, with the 5-kilometre event only accounting for between 20-60 minutes of an individual’s waking week. By expanding the therapy window to account for all movement across the ~112 waking week, individuals can optimise their total dose of physical activity, rather than focussing on a narrow window of structured exercise alone as the only means of benefitting health.
So, this blog is by no means an assault on parkrun, nor is it intended as an assault on structured exercise more widely. With my own personal background in exercise science and human physiology, I understand that the benefits of more structured, high-intensity exercise are widely known and, as I said at the outset, I too consider myself an avid exerciser. Rather, we must collectively acknowledge that the health benefits of a physically active lifestyle can be experienced in a variety of different ways, and this should be promoted accordingly within rehabilitation services. In doing so, we can establish physical activity as an accessible and appealing pathway to better health, that enables everyone to lead a healthier, happier life, irrespective of capacity, preference or surroundings. From a cardiac care perspective, KiActiv® can play a key role, supporting individuals to rethink their exercise and make their everyday movement an effective medicine to enable effective self-care and sustained behavioural change. By equipping individuals with the tools to objectively self-monitor their physical activity, as well as the knowledge, skills and confidence to optimise their personal physical activity dose in the context of their condition, KiActiv® creates an effective digital alternative that is proven to enhance the accessibility and appeal of CR to reach people who are unable or unwilling to take up the current offering.
The scientific evidence for the importance of the total physical activity dose continues to mount, but many may still question the benefits of this approach versus the ingrained methods of exercise-based rehabilitation. To those in that camp, I’ll leave you with the example I opened up with. My Grandmother, very much your typical 79-year-old who, by all intents and purposes, hates exercise. If I was to invite her to do a parkrun with me, I’d get laughed out of the room! Yet, by learning how to effectively self-manage her physical activity through her normal activities of daily living, she has managed to sustain a healthy, physically active lifestyle long into her retirement and reap the associated health benefits! Food for thought and certainly the direction of travel I hope to see in future rehabilitation-based research.
Ewan Cranwell
Informatics Lead, KiActiv®
