It has been said that ‘inactivity is the new smoking’, and there is no doubt about the medical problems caused by lack of physical activity. This is a growing problem, and one that is particularly difficult for many people with musculoskeletal diseases to deal with.
Historically, there used to be a feeling among doctors that exercise helped inflammation. Once upon a time, people with Ankylosing Spondylitis were put in plaster of paris spinal casts and patients with Rheumatoid arthritis were made to rest in bed for weeks upon weeks. Although the modern Rheumatologist would regard these practices are seriously misguided, it could be argued that our failure to actively promote exercise is also a failure to follow the evidence. If it affects both general and musculoskeletal health we should really be doing more to promote change.
Before the birth of modern Rheumatology, Physical Rehabilitation skills were very much part of the training of a doctor who treated patients with arthritis. Modern training leads us to regard ‘silos’ of physical rehabilitation, medical therapy and surgical therapy as mutually exclusive. We do refer to our physiotherapy colleagues, but is it possible that some patients need a more committed approach from their doctor to get them started? It is clear that a doctor’s advice about smoking is still reasonably effective. And for some patients who just need more general physical activity, perhaps we need to be finding ways for our patients to get involved in local Tai Chi classes, Pool exercise sessions and other ‘Gym Voucher’ schemes to help get people started. The 3 month ‘Gym Voucher’ incentive scheme funded by Public Health in this area is particularly imaginative and effective. The local gym instructors funded to lead these programmes can be a great asset.
From many years of experience in giving advice it has gradually dawned on me that for many people, major behavioural change is not easy. We’ve all seen the person who has just had a heart attack or developed cancer throw their 50cig./day habit in the bin without a second thought. Or the person who has been told by the orthopaedic surgeon that if they don’t lose X amount of weight they won’t get their knee replacement. For some patient it might be getting a dog and starting to walk regularly again. I like to think of this as ‘catching the right wave’ – waiting for a strong motivational push to get them going.
Clearly Staged Graduated programmes can be very effective. ‘Couch to 5k’ is a great example of this. When we are dealing with people with arthritis we need to be sensitive to the fact that their pain and stiffness will not help them to get started.
Using technology to motivate. There are now several studies which have shown that simple pedometer devices can be used to help motivate adherence to increased physical activity. These studies usually employ some sort of ‘target’, sometimes using social sharing of our achievements as a further motivator. There are many successful apps such as ‘Runtastic‘ that are helping athletes to improve: perhaps we need more help at the less active end of the scale!
Doctors in Sweden are all trained in the art of issuing an Exercise Prescription. The ‘Doctor’s Handbook’ from Hong Kong (in English) is an excellent booklet which should be required reading for every medical student and doctor.
One useful mnemonic to use when writing an exercise prescription is FITT-VP
Frequency – sessions per day or week
Intensity – rate of energy expenditure or force during resistance exercise
Types of Exercise (Aerobic, Muscle-Strengthening, Stretching, Neuromuscular activity
Volume – total amount
I would be interested to hear what you think. What motivators work for you? Perhaps you feel that this is not something rheumatologists have time to talk about. Should we just leave it to the physiotherapists? There is no doubt that the latter will give expert advice and this is very necessary with complex rehabilitation programmes, but simple generic advice should be within our remit.