Impact case study database

Updating the UK Physical Activity Guidelines

Manchester Metropolitan’s research on habitual sedentary behaviour and bone health [1] informed the key shift in emphasis in the updated UK Chief Medical Officers’ (CMO) Physical Activity Guidelines, published September 2019. The revised guidelines emphasise that “any activity (even light) is better than none” and highlight the risks associated with prolonged sedentary periods, irrespective of overall activity [A]. The paper [1] provided the key evidence supporting two new recommendations for older adults: a) to spread higher volumes of light intensity activity throughout the day to maintain bone health; and b) that bone mineral density is greater in those who meet the moderate to vigorous physical activity thresholds. The significance of this shift in guidance is highlighted in the report’s executive summary: “We now know that even relatively small increases in physical activity can contribute to improved health and quality of life… we recognise the benefits that can be achieved at levels both above and below the thresholds.” The report also stresses the increased body of evidence that muscle strengthening activities can delay the natural age-related decline in muscle mass and bone density, and that balance and flexibility exercises are important for older adults [A].

According to NHS Digital, the updated guidelines averaged 200 views per day on the GOV.UK website in December 2019 (approximately 73,000 unique views per year compared to 60,000 for the 2011 version) indicating significant reach and sustained public and professional engagement with the guidelines (these figures do not take account of additional reach via access to copies hosted on other websites). Survey data suggests approximately 20% of UK GPs (approximately 7,000 FTE GPs according to the General Practice Workforce dashboard, December 2019) have good awareness and knowledge about the guidelines; 40% of GPs use the General Practice Physical Activity Questionnaire to inform their advice to patients [C].

An indicator of the significance of the new guidelines is the Government’s commitment to create two new Expert Committees for Communications and Monitoring & Surveillance to support better implementation of the guidelines compared to 2011 [A,C]. The revised guidelines have been incorporated into national programmes including All Our Health (a healthcare skills framework to prevent avoidable illness) and Moving Medicine (supports healthcare professionals to advise patients on physical activity for disease prevention and management). The Moving Healthcare Professional Programme takes a whole system approach to embed up-to-date evidence-based physical activity guidance into clinical training. It reaches over 6,000 healthcare professionals per year through continuing professional development and has embedded education materials in almost three-quarters of English medical schools [C].

Public communications campaigns with extensive reach indicate the national significance of the guidelines; they also show that the guidelines underpin public messaging. For example, current NHS exercise advice for older adults emphasises, “any activity is better than none. The more you do the better, even if it's just light activity” [D]. During the coronavirus pandemic, Public Health England made two publications available to encourage the population to stay physically active during the initial lockdown. The Health and Wellbeing at Home blog post had 8,332 views [E]. The Active at Home booklet drew on the national guidelines to help older people stay active and maintain their strength and balance during lockdown. It was downloaded 2,924 times, but 250,000 hardcopies were distributed to vulnerable and shielding adults in Department for Environment, Food & Rural Affairs (DEFRA) food boxes. A further 250,000 hardcopies were distributed by physical activity, health and wellbeing leads across local authorities, NHS organisations and charities [E].

Shaping local evidence-based best practice in frailty awareness and falls prevention

The impact of Manchester Metropolitan research on health interventions and outcomes is best illustrated in local falls prevention work taking place in Stockport. In 2014-15 McPhee advised the Greater Manchester Health and Social Care Partnership of the health benefits of physical activity for older adults. Initially shared in a white paper, the work was later adapted and published as an evidence review in Biogerontology (DOI: 10.1007/s10522-016-9641-0). This synthesis cited 16 Manchester Metropolitan research papers, including [2,3] and additional studies of Masters athletes. This work directly shaped the Stockport Physical Activity Strategy 2015-18 that advised engagement with older people to “provide and promote opportunities to reduce sedentary behaviour” and “ensure access for older/vulnerable people to locality level activities” [F]. This approach is now embedded in the current Stockport Active Communities Strategy [G].

In its Joint Strategic Needs Analysis (JSNA) in 2016, Stockport Clinical Commissioning Group (CCG) found there were 2,748 injuries from falls in the over 65 each year. The borough was in the worst performance quartile nationally for injuries from falls in older people, and falls prevention was thus adopted as a public health priority. Drawing again on McPhee’s research evidence and expertise, the local CCG established Steady in Stockport, a holistic service for falls and fracture prevention, and bone health improvement. Between November 2017 and April 2019, Steady in Stockport helped 2,670 residents (11.94% of 22,360 people aged over 65 with frailty). Stockport CCG Commissioning Lead for Community Services says, “we know we are reaching a significant proportion of people at risk of falling and injury” [G]. The JSNA 2020 analysis shows a significant 22% drop in emergency transportation for fall injuries since the launch of Steady in Stockport (205 to 159 conveyances per month). Latest NHS data show that injuries from falls in residents aged over 65 have decreased to 2,313 per year. Stockport is no longer in the worst performing quartile for this indicator. The total economic cost savings to the local NHS Trust from this service are estimated at GBP2,400,000 within five years of launch [G].

Stockport worked with its leisure services provider to create Stay Steady, a community-based falls prevention class, as advised by McPhee. In 2018-19, 297 residents participated; they had had an average of 2.5 falls during the 12 months prior to the course. Physical performance testing showed most participants improved, typically lowering their falls risk from ‘high-to-moderate’ to ‘moderate’. The majority of completers self-reported increased confidence in performing everyday activities without losing their balance, showing a significant improvement in their quality of later life, and a 20%-40% reduction in falls risk according to NICE guidance [G].

Changing the training routines of older runners

The surprise findings from studies of Masters athletes (as published in [4], see Section 3) led to a targeted awareness campaign delivered by Manchester Metropolitan and the British Masters Athletics Federation (BMAF) to encourage older competitive and leisure runners to incorporate specific balance training into their routines. Athletics Weekly (AW), the UK’s top running magazine, published three articles in magazines (circulation: 10,000; readership: 31,000 per week) and online (approximately 1,500 reads per article) [H]. An independent focus group of older athletes run by AW showed runners changed their training routines after reading about the research in the magazine. One female 75-year old athlete said: “I‘ve long suspected I was unbalanced in daily activities and needed to do something about it… since starting to concentrate on balance training I have found ordinary daily tasks better and feel my running is improving” [H]. A piece also appeared in the Times2 newspaper supplement (reach: 1,160,000 across all platforms) and the race information booklet distributed to 57,000 participants (6,500 aged over 65) in the Great North Run 2018, seeking to motivate behavioural change at scale.

BMAF distributed a printed booklet entitled Strong and Balanced, about the research, to athletes at UK and European competitions [H]. A retrospective survey showed that among athletes who received the booklet from BMAF, 86.1% were motivated to change their balance training habits; 44.4% said they had already implemented changes. After reading the booklet, the proportion of Masters athletes who now do up to 40 minutes of balance training per week increased from 50.0% to 83.3%. Extrapolating these findings to the 900 athletes who received a booklet suggests approximately 400 Masters athletes have increased their balance training duration and an additional 375 athletes intend to make changes (and may have done so already); this represents 15.5% of BMAFs 5,000 members. Most significantly, the survey suggests that 375 athletes have added a balance training component that was previously missing from their training programmes. The strong evidence of behavioural change at scale is also significant because better balance reduces the personal risk of falls and injuries for runners (see comment from focus group attendee above), but also contributes to NHS cost savings (approximately GBP26,000 per hip fracture avoided) [H].

Informing international exercise guidance for older adults

Evidence from 12 Manchester Metropolitan peer-reviewed papers, including [5,6] have directly informed current exercise practitioner position stands/statements for ACSM and NSCA (see Section 3). These two documents underpin the practice of more than 110,000 certified medical and healthcare professionals across 70 occupations in sports medicine and exercise science in 90 countries, regarding the use of resistance training to maintain muscles mass and strength in older people [I]. The ACSM position stand also informs the bulk of the clinical guidelines Exercise Prescription in Older Adults, published by The American Academy of Family Physicians (AAFP) in 2017, which has 136,700 active members across the USA [I].