Episode 2 - Why exercise matters to someone with a Long Term Health Condition

David Watson, Director of a local Welsh School, discusses a podcast featuring physical social activities for people living with health organizations. He shares experiences from Leeds Beckett University and highlights themes of engagement, campaigns, and support in healthcare settings. He talks about connecting with individuals like Adrian Parsons, who uses physical community activities to manage Parkinson's. Watson emphasizes the importance of social support in health activities and shares personal experiences with Parkinson's and physical activities like boxing. He discusses barriers, benefits, and routine aspects of participating in these classes, emphasizing the intrinsic understanding of the benefits of physical activity. He also touches on practical factors like location and timing that influence participation in these activities. Watson reflects on the challenges of balancing different classes and the importance of providers coordinating schedules for diverse activities. Helo, fi yw David Watson, Cyfarwyddwr Ysgol Lleol Cymru, ac rydych chi'n clywed ar y sefydliad ddau oedran yn sefydliad podcast sy'n ymweld â rôl gweithgaredd cymdeithasol ffysigol mewn pethau gofal i bobl sy'n byw gyda sefydliadau iechyd llongyfyrdd. Mae'r sefydliad podcast hon yn cynnwys rhan o fy mhrofiadwr mewn gweithgaredd profesiynol ym Mhrifysgol Leeds Beckett. Yn y sefydliad cyntaf, rwy'n cynnwys sefydliadau cymdeithasol mewn pethau gofal iechyd llongyfyrdd ac rwy'n defnyddio enghraifft John i ddangos beth sy'n gallu digwydd pan yw rhywun yn cael ei ddweud ei fod yn agos, ond dydyn nhw ddim bob amser yn cael y cefnogaeth maen nhw ei angen pan ydyn nhw'n mynd ymlaen o'r sefydliad cymdeithasol neu'r ystafell ysbytai. Rwy'n cyflwyno chwe themau ychwanegol, ymgysylltu, ymgyrchu, ymgyrchu a'r cefnogaeth. Rwy'n cyflwyno ymgysylltu ymgyrchu ac ymgyrchu'r ystafell ychwanegol i ddeall mwyaf sut mae newidiadau newydd yn dod yn rhan o bywyd bywyd. Yn yr episod hon, rwy'n mynd o'r persbectif ymdrechion i brofiadau bywyd. Rwy'n cysylltu gyda Adrian Parsons, sy'n byw gyda Parkinson's ac yn defnyddio'r gweithgaredd cymunedol ffysigol i helpu i gyrraedd ei sefydliad. Ynghylch, rydyn ni'n ymdrechu sut mae cefnogaeth cymdeithasol a chymdeithas yn teimlo mewn bywyd bywyd a pam mae hynny'n bwysig i bobl, ymdrechion a gweithgareddau. Felly, Adrian, diolch i chi i fynd ymlaen heddiw ac rwy'n gobeithio bod yn rhan o'r sefydliad podcast yma. Dyma'r sefydliad podcast ddau sy'n brofi rôl gweithgaredd cymunedol ffysigol i bobl sydd gyda sefydliadau iechyd llawn, ond rydych chi'n fy nghaith gyntaf, felly diolch. Rwy'n gobeithio y gallwch chi ddechrau trwy ddewis ychydig am eich hun, eich mhwyrdd gyda'r Parkinson ac yr ymdrechion cymunedol ffysigol rydych chi'n ei wneud. Felly, rwy'n ymdrechu o weithio mewn sefydliadau cyfrifoldeb, sy'n cynnwys llawer o gofod, felly nad oedd hynny'n dda. Roeddwn i'n ymwneud â'r ymdrechion cyfrifoldeb yn ddiweddar, dim ond ddwy a hanner mlynedd yn ôl. Roeddwn i'n cael 10 mlynedd yn ogystal â'r ymdrechion cyfrifoldeb yn dweud wrthym fod Parkinson yn ddatblygu'n dda. Felly, fel y gallwch chi ei ddweud, mae wedi bod yn ddiweddar iawn, ac yn amlwg, mae hynny'n fwy fforddus i mi fod llawer o bobl eraill ddim yn y sefyllfa honno. Mae'r ymdrechion cyfrifoldeb rydw i'n ei wneud yw ymdrechion cyfrifoldeb a'r ymdrechion neuroactif, sy'n ymwneud â'r ymdrechion Parkinson yn benodol. Iawn, diolch. Yn ystod y peth cyntaf, roeddwn i'n siarad ychydig am y ddifrif sydd weithiau yn ymddangos pan fydd rhywun yn cael ei ddweud ei fod yn agos, ond nid yn ymwneud â'i gefnogi i wneud ei ddigwydd. A oeddech chi erioed wedi bod yn y sefyllfa honno, lle roeddech chi wedi bod yn dweud y byddai'r ymdrechion hynny'n helpu, ond nid yn ymwneud â'i ddangos sut, neu'n ysgrifennu sut i'w adeiladu i'ch bywyd bob diwrnod? Efallai llawer o flynyddoedd yn ôl. Roeddwn i bob amser yn defnyddio gym, felly rydw i'n defnyddio ymdrechion, oherwydd rydw i'n ei wneud llawer mwy nawr na'r fyddwn i'n ymdrech, ac roeddwn i'n gallu ei wneud pan oeddwn i'n gweithio. Rwy'n credu, rwy'n gwybod bod y llyfrgellau a'r ymdrechion bob amser yn ei ddweud i chi os ydych chi eisiau bod yn iechyd mae'n rhaid i chi ymdrechu. Ond nid ydw i'n ysgrifennu bod yn cael ei ddweud gan gyfweliadau iechyd i ymdrechu. Felly roeddech chi'n cael y math o ddeall bod ymdrech yn beth dda i'w wneud, ac roeddech chi'n cael hanes cyffredin o fod yn iechyd yn ôl i'w ddefnyddio. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. Ie. I was, when I moved up to Yorkshire only about three years ago, my daughter married a Yorkshireman, so we decided we wanted to be near the grandchildren. And I, one of the, I have two main symptoms, a tremor in my left arm and a cramp at the toes in my left foot. And the cramp, I didn't think was Parkinson's. I thought it was more to do with the back of nerves. And I went, I got in touch with a physio up here, as soon as I came up here, and she did a lot of tests and and suggested I ought to go and go back to a consultant about the possibility of Parkinson's being, having developed now. And I think it was she who suggested I look at the Parkinson's UK local website. And because I know that when I came to retire, I was already planning to start these classes. So you had a bit of a pre-idea that you wanted to be involved in something, and then that clinician gave you a bit more of a push. But I suppose when you first heard about the classes, so I'm guessing it was the neuro class first before, before the boxing. No, it wasn't actually. Okay. I mean, I would, I would, I would have done a lot of them. I fancy them all, the table tennis, the paddle. But there's just not enough time in the week. So, but again, I was trying to work out why boxing appealed so much. But yeah. Was there something about the boxing that, that, that, you know, didn't feel like rehab or it didn't feel like it actually, it was, it was just, it was exercise, it was social, it was. Yeah, it was something, it was, it was a new skill to learn. I mean, there is a lot to it. And it, I said, I can't work out why, but it just appealed to me. And I'd never done anything like that before. And it was a new class starting. So we were all sort of newbies together and it worked out well. Okay. That's really interesting. We'll come back to that kind of that competence, that understanding in a little while, I guess. So did you have any worries about joining the class when you first heard about it? You know, any potential barriers that might be related to cost, distance or confidence, this is something new. So anything that you felt, even slightly, you've had to get over that as a barrier yourself? Certainly in terms of distance, I live in Knaresborough, so it's right near. So that's good. I mean, we're very lucky in the Harrogate area to have these, all these classes. And cost is never an issue because it's these classes, all of them are so subsidised, they're so cheap. The confidence-wise, I think I'm happier being in a class, you know, an exercise class, rather than having to sort of sit around in, say, going to the Parliament's UK meetings and just relying on talking. You can always hide behind the physical activity. Yeah. So I didn't have, you know, it's always difficult when you meet new people and do new things. And so there's always a certain amount of trepidation. But no, I was just keen to do something. So again, that's interesting, that kind of how being in the class and doing the exercise makes it easier to feel part of something, and as you say, rather than necessarily sat around in a room with everybody talking about the condition. Actually, you all know you've got Parkinson's. Yes. And it's, you know, you're all dealing with the same challenges in the way that everybody's dealing with challenges all the time. Yeah. I mean, as it turned out, our initial class, we used to come and get here quite early, have a coffee beforehand, and sit around chatting outside here. And that's where we sort of learned a lot about each other's conditions and shared ideas. So we'll no doubt come up with that. Yeah. I mean, again, it's really interesting how the class creates the conditions for you to have those conversations without necessarily coming here to have those conversations. At what point, if it ever didn't feel like this, but at what point did coming to the class just feel like part of your normal routine rather than, I've got to make an effort to this, it feels like an appointment? I don't think it ever became that much of a chore. It hasn't done. Occasionally, it's sort of, you feel like, oh, I wish I could have a week off. But I know that I shouldn't because it's, you know, because it is good for me. Yeah. Especially in this hot weather, it's very difficult to keep up the stamina all the way through the boxing. Yeah. So yeah, it's so far so good. And I wonder if some of that's, again, because of your history of being physically active before, you already understand the benefits rather than it necessarily being somebody telling you you've got to do it. Yes. And also that bit about, I know it's good for me. And again, it is that it's not somebody telling you that. It's that you're saying, look, I just intrinsically understand it and therefore I'm going to do it. Yes. You don't always have to enjoy it, do you? No. Yeah. Are there any, and you touched on kind of it being in, you're living in Nashville and has been quite close, but are there practical things like the timing of the class, as I said, the location, how you're welcomed, that help it to become normal rather than a chore? Yeah. I think if it was a long distance, I think that would make it more difficult. The timing wise, again, there is, for example, some Parkinson's classes at our local gym that I go to the gym once or twice a week as well as doing the classes. I should go more. But they have some Parkinson's classes there, like there's a spin class. But it's exactly the same time as the boxing. So a lot of these things do clash. But yeah. Yeah. So there's something about providers of activity, perhaps talking to one another a bit more about when things are on. But yeah, there's a challenge there. Are there any times of day for you, I guess, in terms of how you manage your condition where exercise is easier or harder or is it fairly similar? I always like going to the gym in the afternoons, but the exercise classes are in the morning. So I think I prefer the afternoons. But it's been fine in the morning classes. Thinking about people that don't come to the classes that you may have come across at branch meetings or I know you said you kind of don't always attend that. Are there people that you're aware of with Parkinson's or other people, I guess, who would not find it as easy to attend? And what might be the things that make it more difficult, do you think, for them? I think the only people I know with Parkinson's are the ones I've met through these classes. But we did attend here, in fact, the meetings that the Parkinson's nurses do. And that was very good. But there were new people there because I'd already been attending these classes and knew a lot of it. But we could see from people's reactions, they gave a speech on all the classes. I could see that some people wouldn't be open to physical activity like that. So, I mean, it's difficult to persuade people if they're not, they need to maybe start by going to the gym or something to build up their own confidence in some form of physical activity before coming here, maybe. But having said that, we get picked up if we skive off and try and lessen the pace a bit. But that's only in jest. And if you feel exhausted, you just do your own thing, go and sit down, whatever. Yeah, that's interesting. I suppose, do you think that for those people who aren't predisposed to being physically active, how important are the people around them? How important would it be for you if your family was saying, actually, we think this is a good idea or your peers are saying, actually, we think this is a good idea? Yeah, I think that would help. Yeah, definitely. And looking back over the time that you've been attending the classes, are there any changes that, and this is always hard, isn't it, to think about personal changes, but are there any changes that you've seen in yourself, whether that be physical or emotional or social, that you would link back to, that's kind of because I attend the classes? Well, my legs are very strong now, which is great because I've got a bit of dodgy back, so it's very good to support that. And at some point last year, I think it was, I lost power in my left arm. I think it was mainly to do with a historic injury in the shoulder, but I couldn't, I had to use different weights in different arms, a much less weight in the left arm, and it was terrible. I couldn't really jab properly, but slowly I built it back up again, especially with the weights and that. And it's pretty much back to normal now. It's perhaps probably even stronger. I have trouble, I'm trying to build my arms up, but it's been more of a challenge than for my legs for some reason. But yeah, it's definitely made me stronger and fitter. Brilliant, great. And that makes life in general easier, doesn't it? I don't think, I'm not sure I really want to say this, touch wood, I can't remember the last time I had a cold. Brilliant, great, well. You touched a little bit on being called out if you're not putting maximum effort in, and I can imagine that with knowing coach, but it being in jest. How much do you feel in control in the exercise sessions in terms of your pace, the type of exercise you do, how hard you push yourself? Oh, totally in control. Yes, yes. I mean, I do, I'm disposed to try my best because I know it will, you feel better at the end of it and it does, you know, do you good. And does that feeling of being in control, is that important, that feeling of being in control, do you think? Uh, yeah, yeah, it's not like a competitive environment where you're, you know, you're trying to outdo other people, so. Just yourself. Yes, yes. Okay, brilliant, thank you. And it's, you know, as you say, it's all said in jest because, you know, you're the one who's going to benefit, not the coach or. Definitely, definitely. And have you, have you had moments in the group when you realised you could do more than you thought, you know, whether that be physically or otherwise? And how did, if so, how did that affect your confidence? I suppose thinking a little bit about perhaps when your arm was, when you were starting to recover with your arm, did doing the class make you realise, actually, if I push through that, it's going to get stronger, and actually now I can feel it's getting stronger. Yes, definitely, yeah, yeah, yeah, that's one good example, yeah. Because I guess the temptation would be, oh, actually, you know, my arm's hurting, I'm not going to do anything, because that's our natural response, isn't it, sometimes something hurts, I'm going to rest. It wasn't so much weakness, it was, it wasn't hurting so much, it was just, it was just weak for some reason, I just couldn't work it out. Okay, brilliant, thank you. Has your sense of what you're capable of doing physically, has that changed since you started doing the classes, or is that similar? Yeah, I can do more, more at the gym, because the boxing, I mean, all the classes are different, boxing is quite intense, particularly now that we've joined the class together, so we've sort of gone up to more of an intermediate level rather than a starter level. But yes, the, as I say, it's made my legs and arms stronger, and my fitness level is higher. And presumably that makes daily life easier, I guess. Yeah, yeah, yeah. Yes, gardening is still a bit of a challenge, but, because I think you do use different muscles all the time for different jobs, so you'll always be caught out by some activity. Yeah, okay, great. In the first podcast, I talked about having someone like me, and that being around people who share your condition, your daily reality. When you're in class, do you get that sense of connection? And if so, what does that feel like? Yeah, because we all sort of, whilst we're being told off by coach, we're sort of together, there's a togetherness. You know, we're all sympathising with each other, and some people have got worse symptoms and some people are not so worse. So there'll always be a mix of people that we can connect with. And presumably, because it's within the exercise class, there's a lack of, almost a lack of formality. And again, it goes back to what you said about, you can go to a ranch meeting and you sat around a room, and I'm guessing there's a danger it can feel a bit intense. Yes, whereas, yes, sure. We, in our neuro classes, we sort of, we start off by walking around the room. That's a time when we're generally chatting and we're encouraged to stop chatting and start exercising. Encouraged. So during those chats then, during those conversations, are there any particular conversations or jokes or shared experiences that make you think, yeah, I belong here, this feels right for me? Yeah, I mean, I, when I, when we moved up from London about three years ago, we didn't have any friends in Yorkshire, just had the family. But now I have, I feel like I've got quite a number of friends. Great, that feeling of connectedness. Yeah. So you talked a little bit right at the start about seeing a specialist and that possible initial conversation about exercise. What do you think is the difference or what feels like the difference between being told you should exercise by a doctor or a similar person and hearing encouragement from somebody within your group or within your peer network? I think, aside from the general benefit of exercise, the consultant will tell you that you can address your condition or alleviate your condition slightly by doing exercise. But Parkinson's is such a, everybody's got sort of different symptoms and there's such a range of symptoms that it's very difficult to, for them to tell you what specifically the exercise will do to you, you know, what benefit will give you other than in general terms. Whereas when you're with people who are in the same position and suffering the same way, you know, they'll tell you sort of firsthand what it is that does them good. Yeah, what it's doing for them. I suppose that's a challenge for doctors and specialists, isn't it? Without being, you know, it's very hard for them to say, if you do X, Y, Z, you will get A, B, C. Because as you say, everybody's different. So actually, sometimes it's just, it is those personal stories that say, well, this is what it did for me, might do that for you. But actually, you might get something different from it. Yeah, I don't know if we'll come on to it. But one of the early chats I had with the members of the boxing class, someone actually had a foot cramp, similar to mine. And she put me on to a chiropodist in Harrogate. And he's made me a molded thing to go under my toes to stop them from hurting so much. And it does alleviate the cramp. So that's really interesting, because you'd almost miss out on that. If you'd only ever been talking to the doctor, you miss out on that kind of knowledge. I think that's a bit, I think he's a bit maybe not mainstream. But yeah, it was, I don't know if it's actually solved the problem. Well, it hasn't solved the problem. But it's that every little bit helps. Yeah, that's right. And that extra advice you get, as you say, from somebody who's going through the same experience as them. Actually, I think all this really helps. And yeah, you might miss out on that if you're just doing that one to one. And I think the, I mean, you talk about specialists. I don't see, well, I see a specialist once a year now. But I think the, my main support for Parkinson's comes from the exercise classes. My physio who started me off, and I still do a bit, she gets me doing exercises. I'm supposed to do them every day, which is a challenge. And other people like the chiropodist, who I'll go back to, you know, a range of people who support you. Because although the NHS, especially for Parkinson's, are very good, they haven't got enough time to devote to you. So it's important to be proactive and get, go out and see all these other professionals and the exercise classes, particularly the neuro one, is being aimed specifically at Parkinson's, is a great extra support. Because I can ask our coach in neuro to, you know, if I've got any specific concerns. So it's creating that peer network and that broader group of people who can give you support, give you input. And essentially, it's not about doing the NHS's job, but it's about supplementing that. And it's important to recognise that, isn't it? Yes. So again, you talked about coming to some of the classes that are run by the NHS that are information classes for people who are relatively newly diagnosed. If you had to speak to some of them, what would you say about joining an exercise class? Particularly if they were a bit reticent, what would you highlight about it, do you think? I think it would be the chance to find out more about how people with similar symptoms deal with them. Medication is one discussion I've had with a number of people. And some people say, my medication gets rid of the symptoms entirely. Why have you still got a tremor? And I've found that with mine, I get to a certain number of tablets and it makes me nauseous. So at the moment, it's just keeping it at bay to a certain extent. Sorry, I've gone off track. No, no, no, not at all. I think it comes back to that bit you said, everybody is different. It isn't Parkinson's or any long-term health conditions. It isn't a linear thing of saying, well, if you've got that condition, you'll have this, this, this, and this. So everybody's different. So for some people, exercise will have a bigger impact than others, perhaps. But if you were talking to somebody who said, well, actually, I've got medication. It does so much for me, but I'd be really worried about coming to boxing because I'd be rubbish. I've never boxed before. I'd be worst in class. What would you say to them? Well, I wouldn't necessarily say that unless you had a particular bent on doing boxing, one of the other general exercise classes would be better, like the neuro act. And maybe that would be a better starter. I mean, boxing is one of the more intense ones, but it does really challenge you. It does involve both physical movement and coordination. So you're using your brain, trying to work out where your feet should be, trying to swing your hips, trying to get your punches right and keep your arms straight and then get back to your face to protect your face. So you're constantly thinking about what you should be doing as well as the physical part of it. And your experience of doing a number of different classes means that you could have that conversation with somebody and say, well, actually, that one might not be for you, but you might get that. And again, that would be you giving that peer support. And that's much harder for, again, that might be harder for a specialist or even a physio potentially because they've not necessarily experienced it the same way you have. Yes. When I started boxing, one of the other class members suggested to me that I should do neuroactive as well, which would help. And yeah, so I've been doing that ever since as well. Brilliant. Do you think, I keep using the word specialist and I get what you're saying, but actually that's a range of people. Do you think that people like your physio, the podiatrist and the specialist, do you think they really understand the value of peer support? Do you think they understand that it's really important that actually other people are having that conversation with people? Again, they wouldn't understand it firsthand, but I guess they must have some idea. I think obviously, I think my physio understands it because she does a lot, she deals with a lot of Parkinson's patients and the coaches here, these classes, they obviously know what's going on. So they'll understand it and they'll be encouraging you. Yeah. That's correct. If you could, and I think I asked you this question before on, I think I phrased it, if you had a magic wand, but if you could redesign the pathway from diagnosis through to community activity through to being exercised, is there a, based on your experience or what you've heard others say, is there anything you'd change or do you think it works? It might be helpful for the specialist to prompt you more, but again, they're sort of, they're up here somewhere rather than dealing with the daily issues of having Parkinson's. So I guess it may not be something that they would, you've probably got to mix and match. Yeah. So is there something about what level of information that different people at different tiers within the NHS, the different levels of information they might be giving about what's available, what exercise might do? Yeah. I think the NHS are fairly good. They're fairly coordinated as far as Parkinson's is concerned. I had a slightly different pathway if you like, because I originally, when I was working, I had private medical insurance. So I was originally diagnosed by a private consultant, but I don't have that now. And I now see the consultant at the NHS. So I think the NHS would be more likely to prompt you to do these classes because we've done, we've also been to an event at one of the schools in Harrogate of an evening, which had a range of speakers and gave you this feeler for the exercise classes and what the NHS do, what the consultants do. They were all there talking about it. So that was really good. So that's a really positive experience of particularly the NHS and almost that, maybe the NHS are more predisposed than perhaps private. I think they probably are, yes. Yeah, that's good. That's really good. We've talked about how this group is part of your routine. If I was to say, well, it's just normal now, what does that mean to you? What does that mean in everyday terms? It's normal in terms of getting up on a Wednesday and coming here. But it's always evolving in terms of the challenge that you have in class. There's always new things, new techniques to learn and, you know, keep challenging yourself to not, you know, to keep going until the end of the class. Because I find this, does the fact that it is a class and therefore there are your peers who are here expecting you to be here and the coaches expecting you to be here or the other classes, when you wake up in the morning and think, I'm not sure if I can be bothered today, does that have an impact that there's people perhaps even subconsciously expecting you to be here? I don't think so. It's, you know, we do say to each other, you know, where were you? You were right, you were away last week. We haven't seen you for several weeks. And a lot of us are off on holiday or have operations or whatever, which means we're not around for some time. But yeah, I think it's good that, you know, we will, even if we have something that stops us going for a while, we will do our utmost to get back. So there's a support mechanism from the group, but actually this intrinsic motivation is your own personal. Yeah, that's great. That's great. So thinking about autonomy, relatedness and competence, which basically is choice, we talked about your choice and your ability to determine how hard you work, that connection to your peers and your confidence in terms of ability to do the exercises and be part of it. Which of those feel the most important and keep you involved or do they all feel, do they all feel the same? Probably the keeping up the physical exercise is important. I mean, it's great to go to the gym, but it's a bit, you're on your own really there. And it's good to vary the exercise as much as possible. As I say, I would do more of the options that Parkinson's UK offer, but time is a limiting factor. So does that mean then that relatedness, that connection, so it isn't just I'm on my own over here in the gym, I'm actually part of something that's important? Yes. Brilliant. Adrian, thank you so much for joining me today and agreeing to record this. That's been brilliant. It's been really useful for me. Hopefully it hasn't been too painful for you. Thank you. In the first episode, I asked whether John's experience should be the exception or the norm. Listening to Adrian, it's clear that when access, integration, motivation and support, especially peer support, are in place, community-based physical activity can become a normal valued part of life for someone living with a long-term condition. My doctoral work shows that there are still systemic barriers, time pressures, patchy referral pathways, gaps in training, but conversations like this show what's possible. The challenge now is how we make this the norm across systems, services and communities, so that people living with long-term conditions have the same opportunity to be active, supported and connected. In the next episode, I'll be exploring the workforce, who delivers community-based physical activity, what support they need and what has to be in place for good practice to last. As part of that, I'll be speaking with Alan Graver, who has spent the last two years working with North Yorkshire Sport and Partners to understand the workforce in North Yorkshire. I hope you'll join me for what I know will be a really informative and useful conversation about the role the workforce plays in bringing community-based physical activity into care pathways.