Monitoring and prescribing preventive and rehabilitative physical activity for cardiovascular and neuromuscular diseases as a catalyst to being involved in national and international standards of practice
Submitting InstitutionUniversity of Chester
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Cardiorespiratory Medicine and Haematology, Clinical Sciences, Public Health and Health Services
Summary of the impact
This research into the effective management of exertion intensity,
symptoms and pain in the treatment of cardiovascular and neuromuscular
diseases has resulted in the setting of national and international
standards for safe and effective education, training and professional
Physical activity forms a core component in the prevention and
rehabilitation of cardiovascular disease and in genetically acquired
neuromuscular disorders. Physical activity benefits are linked to the
volume — frequency, intensity and duration — of participation, which will
bring about physiological and/or psychosocial improvements.
Dr John Buckley's research focuses on managing exercise intensity and
estimating exercise capacity for the purposes of primary and secondary
prevention, both in cardiovascular disease and with McArdle Disease, a
neuromuscular disorder. As a result, he has become increasingly involved
in national education and training programmes, national specialist
services for exercise in disease prevention and the rehabilitation of
cardiovascular and neuromuscular conditions.
The special, and sometimes unique, focus of this work has been around the
element of managing safe and effective exercise intensity through effort
and pain perception using Borg's rating, which measures perceived exertion
and pain scales. His work originated at Keele University in 1998 and, in
2006, was transferred to, and has continued at, the University of Chester
The concept of using effort and pain perception for people to regulate
their own exercise intensity is rooted ultimately in creating
self-efficacy and self-management in clients and patients. This approach
has recently been advocated in the recent scientific statement published
by the British Association for Cardiovascular Prevention and
Rehabilitation (BACPR) so that patients are neither over reliant on
specialised clinicians nor physiological monitoring devices.
So often, people are rendered long-term patients with perceptions of
`being ill' because clinicians inadvertently apply techniques and
measurements that make the patient reliant upon the established healthcare
system in the UK.
In relation to cardiovascular disease prevention and rehabilitation, the
research specifically focuses on the reliability and concurrently validity
of managing exercise intensity safely and effectively. The key finding
throughout is that participants need to be exposed to using ratings of
perceived exertion at least three times for a given level on the Borg
scale to represent the same exercise intensity.
From the perspective of concurrent validity, the Borg scale measures in
these studies have been performed in a novel way when compared against set
physiological criteria. They have been found to provide valid
representations of physiological strain, thus deeming the scale, with
practice, to be of good use in managing exercise intensity. Not only has
this shown to be true for aerobic exercise but also for use in strength
training exercise. This has resulted in the publication of the first study
using Borg's CR10 exertion and pain scale in strength training for older
people, over 55 years of age. The co-author was himself Professor Gunnar
Borg, the inventor of the Borg scale, which has received more than 35,000
citations in the world of sports medicine and exercise science.
In the referenced papers by Morris et al, all based at the University of
Chester, the Borg scale was used as the independent variable, where the
participant is, in reality, given the responsibility of controlling
intensity. In traditional research on the Borg scales, perceived exertion
is often used as a response/dependent variable, where the experimenter or
clinician controls the intensity. Dr Buckley's group has now extended this
research into the area of guiding exercise in older people with heart
In using Borg's scales to manage muscle pain in patients with McArdle
disease, Buckley has begun a completely unique area of study. His research
has demonstrated the practical use of this pain scale in managing
intensity in aiming to avoid exertion levels where serious muscle damage
could lead to a clinical emergency.
References to the research
References to the research, all of which have appeared in peer reviewed
1. Buckley J.P., Sim J., Eston R.G. Reproducibility of ratings of
perceived exertion soon after myocardial infarction: responses in the
stress-testing clinic and the rehabilitation gymnasium. Ergonomics,
2009 52(4): 421 - 427.
2. Godfrey R.J., Whyte G.R., Buckley J., Quinlivan R. The role of
lactate in the exercise-induced human growth hormone response: evidence
from McArdle's disease. Br. J. Sports Med. 2009; 43: 521-525
3. Morris M., Lamb K., Cotterrell D., Buckley J. Predicting
Maximal Oxygen Uptake Via a Perceptually Regulated Exercise Test (PRET) J.
Exerc. Sci. Fitness; 2009 7(2): 122-128
4. Quinlivan R.C.M., Buckley J.P., James M., Twist A., Ball S.,
Duno M., Vissing J., Bruno C.D., Cassandrini D., Roberts M., Winer J.,
Rose M., Sewry C. McArdle Disease; clinical review. J. Neurol.
Neurosurg. Psychiatry 2010 Nov;81(11):1182-8.
5. Morris M., Lamb K., Cotterrell D., Hayton J., Buckley J. The
validity and reliability of predicting maximal oxygen uptake from a
treadmill-based sub-maximal perceptually regulated exercise test. Eur.
J. Appl. Physiol. 2010: 109: 983 - 988
6. Buckley J.P. and Borg G.A.V. Borg's scales in strength
training; from theory to practice in young and older adults Appl.
Physiol. Nutrit. Metab. 2011 Oct; 36(5): 682-92
Details of the impact
This research has ensured Buckley is recognised nationally and
internationally in the area of health-based and rehabilitative exercise.
Since 1997 he has given numerous conference presentations in the UK and
abroad and has been involved in professional development education courses
for doctors, nurses, physiotherapists, exercise scientists and exercise
practitioners. It was these international contacts, and respect for his
practice-based research, which led to him taking on leading roles to
produce guidelines, education and training materials for the British
Association of Sport and Exercise Sciences (BASES) and the British
Association for Cardiovascular Prevention and Rehabilitation (BACPR).
Buckley's work with BASES led to the dissemination of health-based
guidance on exercise intensity through the BMJ's ABC of Sport and Exercise
Medicine, which is a popular resource for hundreds of general
practitioners and non-exercise specialist physicians who are involved in
health promotion and rehabilitation (reference 1).
As he joined the University of Chester in 2006, Buckley contributed
specifically to the BACPR cardiac rehabilitation Exercise Instructor
course training materials and manuals. Since then, this material has been
part of educating and qualifying more than 1,500 specialist instructors
who work mainly in community health settings throughout the UK. He
continues as a tutor on these courses and an advisor to other tutors. More
recently, increasingly advanced education materials, manuals, and practice
standards on monitoring exercise intensity have been created for clinical
practitioners involved in cardiac rehabilitation, including nurses,
physiotherapists and clinical physiologists (reference 2).
Similarly, Buckley has provided the BASES guidelines for using ratings of
perceived exertion in both sport and clinical populations. These
guidelines form the basis of all laboratory and clinical teaching/training
for the 20,000+ undergraduate and postgraduate sport and exercise science
students enrolled in higher education in any given year (reference 3).
In having made a significant contribution to writing these guidelines and
teaching resources of BASES and BACPR, Buckley has also been invited to
lead the writing of the National Occupation Standards, at Skills Active,
for the Advanced Exercise Instructor working in Cardiac Populations and
for Sport and Exercise Scientists. This work has led to the development of
the new BASES Certified Exercise Practitioner qualification which is being
rolled out across the UK as a means of quality assuring practice in newly
qualified sport and exercise science graduates. Some of the work applied
to this new qualification has also been part of the recent recognition of
BASES as a licensed body of the Science Council. In integrating Buckley's
work with BASES, BACPR and the Association of Chartered Physiotherapists
in Cardiac Rehabilitation (ACPICR), since 2011 he has played a leading
role in an inter-professional forum of these three groups known as the
BACPR — Exercise Professionals Group. This inter-professional forum's
terms of reference is underpinned by a Memorandum of Collaboration between
BASES, BACPR and ACPICR, the writing of which Buckley led. Following this
Buckley led in the development of a joint position statement on the
standards for qualifications, professional development and experience
required for working in the exercise component of cardiac rehabilitation
(2010, 2012). (references 2 and 3)
The group then went on to write a set of detailed national core
competences for the exercise component of cardiac rehabilitation and,
though Buckley was not part of this group, the above work he had
previously done with BASES, BACPR and ACPICR was a key catalyst to this
Overall, for the past decade Buckley has contributed to national
education resources and professional standards of practice in the
professional development and national qualifications of thousands of
practitioners in health-based exercise and cardiac rehabilitation to best
serve clients and patients throughout the UK. For these achievements, he
was appointed President of the BACPR from 2009 to 2011, and led the
drafting of the organisation's new integrated Standards and Core
Components, which were published in the highly acclaimed medical journal,
Heart. Linked to this development work, Buckley was an adviser to
the NHS England & Wales Department of Health Commissioning Pack for
Cardiac Rehabilitation (2010) (reference 4).
Buckley dovetails this work with 14 other similar associations from
around the world and has played a lead role in establishing an
International Council of Cardiovascular Prevention and Rehabilitation, for
which he is the current Chair. He has been a lead author of the recently
published (March, 2013) International Charter on Cardiovascular Prevention
and Rehabilitation. (reference 5)
The above impacts in cardiovascular health and rehabilitation have come
about by Buckley being initially recognised, and continuing in this light,
for his practice-based research.
In relation to the research on the neuromuscular disorder of McArdle
Disease, Buckley has played a lead role in the development and
establishment of the National McArdle Disease clinic, which is located at
the MRC Neuromuscular Institute of the University College London National
Hospital of Neurology and Neurosurgery. His research focus on patients
learning to manage their daily activity through pain perception forms a
core component of the patient education programme of this national service
Sources to corroborate the impact
1. Buckley J.P., chapter author, Benefits of Exercise in
Health and Disease in: ABC of Sports and Exercise Medicine (eds: G.
Whyte, M. Harries, C. Williams), BMJ/Blackwell Publishers, London,2005
2. Impact through the British Association for Cardiovascular Prevention
Buckley J.P. Chapters Contributor, BACR Exercise Instructor
Manual; Aerobic exercise and endurance training;
Monitoring exercise intensity, Exercise programming and prescription
(Human Kinetics, Leeds, 2006).
Buckley J.P. Contributing Author: Standards for Physical
Activity and Exercise in Cardiac Rehabilitation, The Association of
Chartered Physiotherapists in Cardiac Rehabilitation. London 2009,
Buckley J.P. Contributing Author: Education and training
manual; A Practical Approach to Physical Activity and Exercise in the
Management of Cardiovascular Disease of the British Association
for Cardiac Rehabilitation (BACR) (ed. J. Jones). Human Kinetics, Leeds,
2009. (for confirmation, contact the Director of Education at BACPR, www.bacpr.com).
Buckley J.P. Furze G, Doherty P, Speck L, Connolly S, Hinton S,
Jones JL. British standards for cardiovascular prevention and
rehabilitation; a scientific statement of the British Association for
Cardiovascular Prevention and Rehabilitation. Heart 2013 Feb 12.
[Epub ahead of print] PMID: 23403407
- Position statement of the BACPR on the qualifications and experience
required to work in the exercise component of cardiac rehabilitation http://www.bacpr.com/resources/CCZ_EPG_Position_Statement.pdf
3. Impact through the British Association of Sport & Exercise
Buckley J.P. Commissioned chapter co-Author (with R.G. Eston),
Ratings of Perceived Exertion in the Physiological Testing Guidelines
of the British Association of Sport & Exercise Sciences,
Routledge, London, 2006
Buckley J.P.. advisor and author to National Occupational
Standards for Level 4; Advanced Exercise Instructor in special
populations, the UK Sector Skills Council, London, UK 2008 (Refer to Ben
Gittus at Skills Active)
Buckley J.P. Commissioned editor and author from the British
Association of Sport and Exercise Sciences: Exercise physiology in
special populations, (Series editors Profs D McLaren and N
Spurway) Elsevier, London, 2008.
- Lead author of memorandum of collaboration between BASES, BACPR and
Buckley J.P. advisor and author National Occupational Standards
in Sport and Exercise Science, Skills Active, the UK Sector Skills
Council, London, UK 2010 (Refer to Ben Gittus at Skills Active)
- Advisor to modernising BASES Accreditation Scheme and lead convenor of
the BASES Certified Exercise Practitioner Scheme. http://www.bases.org.uk/Accreditation
(contact the BASES Executive Director for confirmation).
4. Panel member for the development of the NHS/Department of Health's
commissioning pack on cardiac rehabilitation http://www.improvement.nhs.uk/heart/HeartImprovementHome/CardiacRehabilitation/CardiacReha
5. Founding chair of the International Council of Cardiovascular
Prevention and Rehabilitation Grace S.L.,Warburton D.R., Stone J.A.,
Sanderson B.K., Oldridge N., Jones J., Wong N., Buckley J.P.
International Charter on Cardiovascular Prevention and Rehabilitation: A
CALL FOR ACTION. J Cardiopulm Rehabil Prev. 2013; 33 (2):128-131 www.globalcardiacrehab.com
6. Exercise physiology advisor to National McArdle Disease clinic since
1999 can corroborate the role of Buckley in the development and
establishment of the National McArdle Disease clinic.