title: Exercise Evaluation Randomised Trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only.
abstract: OBJECTIVE
  To evaluate and compare the effectiveness and cost-effectiveness of a leisure centre-based exercise programme, an instructor-led walking programme and advice-only in patients referred for exercise by their GPs.
  
  
  METHODS
  A single-centre, parallel-group, randomised controlled trial, consisting of three arms, with the primary comparison at 6 months.
  
  
  METHODS
  Assessments were carried out at Copthall Leisure Centre in Barnet, an outer London borough, and exercise programmes conducted there and at three other leisure centres and a variety of locations suitable for supervised walking throughout the borough.
  
  
  METHODS
  Participants were aged between 40 and 74 years, not currently physically active and with at least one cardiovascular risk factor.
  
  
  METHODS
  The 943 patients who agreed to participate in the trial were assessed in cohorts and randomised to one of the following three arms: a 10-week programme of supervised exercise classes, two to three times a week in a local leisure centre; a 10-week instructor-led walking programme, two to three times a week; an advice-only control group who received tailored advice and information on physical activity including information on local exercise facilities. After 6 months the control group were rerandomised to one of the other trial arms. Assessments took place before randomisation, at 10 weeks (in a random 50% subsample of participants), 6 months and 1 year in the leisure centre and walking arms. The control participants were similarly assessed up to 6 months and then reassessed at the same intervals as those initially randomised to the leisure centre and walking groups.
  
  
  METHODS
  The primary outcome measures were changes in self-reported exercise behaviour, blood pressure, total cholesterol and lipid subfractions. Secondary outcomes included changes in anthropometry, cardiorespiratory fitness, flexibility, strength and power, self-reported lifestyle behaviour, general and psychological health status, quality of life and health service usage. The costs of providing and making use of the service were quantified for economic evaluation.
  
  
  RESULTS
  There was a net increase in the proportion of participants achieving at least 150 minutes per week of at least moderate activity in the sport/leisure and walking categories in all three study groups: at 6 months, the net increases were 13.8% in the leisure centre group, 11.1% in the walking group and 7.5% in the advice-only group. There were significant reductions in systolic and diastolic blood pressure in all groups at each assessment point compared with baseline. There were also significant and sustained improvements in cardiorespiratory fitness and leg extensor power, and small reductions in total and low-density lipoprotein cholesterol in all groups, but there were no consistent differences between the groups for any parameter over time. All three groups showed improvement in anxiety and mental well-being scores 6 months after the beginning of the trial. Leisure centre and walking groups maintained this improvement at 1 year. There were no differences between groups. Costs to the participants amounted to pound 100 for the leisure centre scheme and pound 84 for the walking scheme, while provider costs were pound 186 and pound 92, respectively. Changes in overall Short Form 36 scores were small and advice only appeared the most cost-effective intervention.
  
  
  CONCLUSIONS
  The results of this trial suggest that referral for tailored advice, supported by written materials, including details of locally available facilities, supplemented by detailed assessments may be effective in increasing physical activity. The inclusion of supervised exercise classes or walks as a formal component of the scheme may not be more effective than the provision of information about their availability. On cost-effectiveness grounds, assessment and advice alone from an exercise specialist may be appropriate to initiate action in the first instance. Subsidised schemes may be best concentrated on patients at higher absolute risk, or with specific conditions for which particular programmes may be beneficial. Walking appears to be as effective as leisure centre classes and is cheaper. Efforts should be directed towards maintenance of increased activity, with proven measures such as telephone support. Further research should include an updated meta-analysis of published exercise interventions using the standardised mean difference approach.
authors.affiliation: EXERT Project, School of Health and Social Sciences, Middlesex University, London, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: Isaacs
authors.forename: J A
authors.initials: JA
authors.lastname: Critchley
authors.forename: S See
authors.initials: SS
authors.lastname: Tai
authors.forename: K
authors.initials: K
authors.lastname: Buckingham
authors.forename: D
authors.initials: D
authors.lastname: Westley
authors.forename: S D R
authors.initials: SD
authors.lastname: Harridge
authors.forename: C
authors.initials: C
authors.lastname: Smith
authors.forename: J M
authors.initials: JM
authors.lastname: Gottlieb
mesh_terms: D000328:Adult; D000368:Aged; D003153:Community Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D003376:Counseling; D004734:Energy Metabolism; D005069:Evaluation Studies as Topic; D015444:Exercise; D006801:Humans; D008875:Middle Aged; D012017:Referral and Consultation; D011795:Surveys and Questionnaires; D016138:Walking