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Table 1 Articles selected for review of ERS effects on (1) CV disorders

From: The effects of exercise referral schemes in the United Kingdom in those with cardiovascular, mental health, and musculoskeletal disorders: a preliminary systematic review

Study Design Comparison Time points N, age (mean, SD) Disorder Length weeks Prescription Measures Effect Outcomes
Anokye, et al. 2011 [42] Decision analytic model, Quantitative Retrospective Completion N = 701
40–60 years
Mean age = 50
SD = n/a
Cardiovascular Mental health 12 Gym based exercise, 2× weekly QLAY 51–88% cost-effective ERS is associated with modest increase in lifetime costs and benefits. Cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness. ERS cost is subject to significant uncertainty mainly due to limitations in clinical effectiveness evidence base.
Duda, et al. 2014 [25] RCT, Quantitative ERS SDT (N = 184) vs. Standard ERS (N = 163) Baseline
3 months
6 months
N = 347 30–65+
Mean = n/a
SD = n/a
Cardiovascular Mental health 10–12 Gym based exercise, 2× weekly 7D PAR
BP (mmHg)
BMI (kg/m2)
Weight (kg)
HADS anxiety
HADS depression
a 120 ***
a − 0.24*
a -0.77*
Standard ERS: No sig. Changes in BP, but reductions in weight and BMI (reduced sig. at 6 months compared to baseline). 3 months’ follow-up: increase of 187 min (from baseline) in self-reported moderate/vigorous PA. 6 months’ follow-up: increase of 120 min. Sig. reduction in HADS depression scores, no sig. Diff. in anxiety.
SDT-ERS: 3 months’ follow-up: increase of 196 min in self-reported moderate/vigorous PA compared to baseline. Sig. improvements in HADS anxiety and depression scores. 6 months’ follow-up: No sig. Diff. from baseline to 6 months’ in BP, BMI or weight. Increase of 114 min in self-reported moderate/vigorous PA. Sig reduction in HADs anxiety and depression.
Edwards, et al. 2013 [24] RCT, Quantitative Between time points Baseline
6 months
12 months
N = 798
16+ years
Mean = n/a
SD = n/a
Cardiovascular Mental health 16 Gym based exercise & exercise classes, 1–2 x weekly EQ-5D Adherence a
Participants with risk of CHD, were more likely to adhere to the full programme than those with mental health conditions/combination of mental health and risk of CHD. Those living in areas of high deprivation were more likely to complete the programme. Results of cost-effectiveness analyses suggest NERS is cost saving in fully adherent participants. Adherence at 16 weeks was 62%.
Hanson, et al. 2013 [44] Observational cohort study, Quantitative Between time points Baseline 12 weeks Completion N = 2233
Mean = 53
SD = 15.9
Cardiovascular 24 Gym based exercise, 2× weekly GLTEQ Adherence a***
ERS was more successful for over 55 s, and less successful for obese participants. Completers increased PA at 24 weeks. Leisure site attended was a significant predictor of uptake and length of engagement. Uptake n = 181, 12-week adherence n = 968, 24-week adherence n = 777.
Littlecott, et al. 2014 [40] RCT, Quantitative Between time points and ERS vs. usual care Baseline
6 months
12 months
N = 2160
16–88 years
Mean = n/a
SD = n/a
Cardiovascular Mental health 16 Group aerobic exercise sessions, 2× weekly Adherence BREQ a, b
Improved adherence and improved psychosocial outcomes. Significant intervention effects were found for autonomous motivation and social support for exercise at 6 months. No intervention effect was observed for self-efficacy. Greatest improvements in autonomous motivation observed among patients who were least active at baseline. Individuals with CHD risk in the control group participated in more PA per week than those in the intervention group with CHD risk factors.
Mills, et al. 2013 [45] Observational cohort study,
Mixed method
Prediction of completion Baseline N = 1315
31–68 years
Mean = 54
SD 12.4
Cardiovascular 26 Group, 1-to-1, gym, studio, swimming, 1–2 x weekly BP (mmHg) Body mass (kg) Adherence a 1.87***
a 3.541***
Increased confidence and self-esteem. Link between age and attendance. Increased age, increased likelihood of adherence. 57% completed scheme, 33% achieved weight loss, 49% reduced BP. Those with CVD, more likely to attend and adhere, compared to pulmonary disorders.
Murphy, et al. 2012 [41] RCT, Quantitative ERS vs. usual care 12 months N = 2160
16–88 years
Mean = 52
SD = 14.7
Cardiovascular (N = 1559) Mental Health (N = 522) 16 1-to-1, aerobic and resistance exercise, 1–2 x weekly 7D PAR
HADS depression
HADS anxiety
b 1.19*
a, b1.46*
a − 0.71*
a − 0.54
Increase PA observed among those randomised to ERS intervention compared to usual care, and those referred with CHD only. For those referred for MH alone, or in combination with CHD, there were sig. Lower levels of anxiety/depression, but no effect on PA.
Rouse, et al. 2011 [46] Exploratory, Quantitative SDT theory based program Baseline N = 347
Mean = 50.4
SD = 13.51
Cardiovascular Mental Health 12 Gym based exercise sessions, 1× weekly IOCQ BREQ-2 SVS HADS a
a 0.24 **
a 0.17 *
a **
Autonomy support increased intrinsic motivation. Autonomous motivation was positively associated with vitality and PA intentions. Those who scored high on HADS, had high scores for PA intentions. Regression analyses revealed that the effects of autonomy support on mental health and PA intentions differed as a function of who provided the support (offspring, partner or physician), with the offspring having the weakest effects. Autonomy support and more autonomous regulations led to positive mental health outcomes.
Tobi, et al. 2012 [43] Retrospective, Quantitative Adherers vs. non-adherers 13 weeks Completion N = 701
Mean age = 46.4
SD = 13.85
Cardiovascular (n = 111) Musculoskeletal (orthopaedic n = 164) Mental health (n = 141) Respiratory (n = 34) Other (n = 23) Metabolic (n = 228) 20–26 1-to-1, aerobic and resistance exercise, 1–2 x weekly Adherence (DV) BMI (kg/m2) BP (mmHg) b **
Longer term schemes increased adherence. Longer-term adherence was found for increasing age and medical condition. For every 10-year increase in age, the odds of people continuing exercise increased by 21.8%. Participants referred with metabolic conditions were more likely to adhere than those with orthopaedic, CV and other disorders. Longer-term schemes offer the opportunity to maintain adherence to exercise.
Webb, et al. 2016 [47] Evaluation, Quantitative NERS vs. community-based exercise vs. continuously monitored exercise programme Baseline Completion N = 107 Mean = 44.6 SD = 11.4 Cardiovascular 8 Group exercise sessions, 2× weekly IPAQ (min/week) BMI (kg/m2) Systolic BP (mmHg) Diastolic BP (mmHg) Adherence a, b 540***
a, b 0.4 + 0.1**
a, b -6.1 + 2.6*
a -0.6 + 1.8
b *
CV health benefits were observed in all three interventions. CV health benefits achieved in laboratory based studies were achieved in ERS settings. BMI had bigger reductions in NERS compared to the other two conditions. Systolic BP and Diastolic BP were also reduced more in NERS compared to the other two conditions.
  1. aall comparisons are with baseline value -not available in the results
  2. ball comparisons are with control ***p < 0.001, ** p < 0.01, * p < 0.0
  3. CVD cardiovascular disease, CHD coronary heart disease, QALY quality adjusted life-year, 7D PAR 7-day physical activity recall scale, IPAQ international physical activity questionnaire, BMI body mass index, BP blood pressure, HADS hospital anxiety and depression scale, EQ-5D EuroQol 5 dimension, GLTEQ Godin leisure-time exercise questionnaire, BREQ-behavioural regulation in exercise questionnaire, SVS subjective vitality scale, IOCQ important other climate questionnaire
  4. = reductions in scores, = increase in scores, no change