We have all seen and heard the story: a patient who is overweight and has heart problems (or arthritis, diabetes, low back pain or any number of other chronic conditions) is told by their doctor that they need to exercise.
The patient agrees, “Yes, I really will try to start an exercise program.”
Six months later, the patient is back in the doctor’s office, and the conversation goes something like this:
“Well, I started going to the gym, but it really didn’t help.”
“I started walking around my neighborhood, but the kids, work or any number of other life factors impeded the program.”
“I did try to exercise for a few weeks, but it just made me sorer and more tired.”
What happens after this follow-up discussion is where we most often fail our patients. It’s easy for health care providers to believe that patients just don’t try hard enough or really do not want to exercise. Too many physicians are ready to label an individual as “non-adherent.” I just read a well-intentioned blog from a physician who has decided that he will no longer prescribe exercise because patients don’t like to exercise. Instead, he will prescribe training or coaching to encourage adherence and change the conversation to better motivate patients. Is that what needs to change?
What if the problem isn’t one of intention or motivation on the part of the patient? What if the problem is in the way exercise is prescribed, or in my opinion “non-prescribed” by a physician.
Exercise is a physical modality that impacts body systems and functions. There are physiological responses that should be considered and can be manipulated through an appropriately prescribed exercise program to achieve desired outcomes. Conversely, if exercise is ill-prescribed, the effects can be harmful. Exercise can have a positive impact on myriad body structures and functions, from bone density, to lean muscle mass, to metabolism, endurance, as well as cognitive function. But each of these endpoints requires a different exercise prescription to achieve the desired outcomes.
Exercise is safe for most people and has many associated health and fitness benefits. However, when we are prescribing exercise as medicine — to impact a health condition, and we desire a specific health-related outcome — the nuances of the exercise prescription become significantly more important both for an individual’s safety but also to achieve meaningful gains.
A colleague of mine uses an apt metaphor when talking about exercise prescription. You would never just hand a bag of pills to a patient and say, “Take some of these for your medical condition to improve it.” Exercise is the same way. We cannot offer patients a blanket recommendation regarding exercise. Just as a medication is prescribed to be taken in specific dosages, frequency and timing to effectively impact a medical condition, exercise is too.
Physicians, while intimately familiar with drug prescription recommendations, are less well-versed in exercise prescription. Additionally, the general practitioner will typically refer to the specialist to better manage certain conditions, including more specialized drug management. In the case of exercise, prescription physicians should seek to leverage experts in this specialized area of practice.
Physical therapists and exercise physiologists are exceptionally educated — the vast majority of them at a doctorate level — in exercise prescription. Their facilities are well equipped with monitoring devices and exercise equipment to enable precision in assessment and exercise intervention. They are knowledgeable in health promotion theory and employ strategies to engage patients in exercise that contributes to meaningful outcomes. Perhaps most important, they understand the underlying chronic conditions that the majority of patients are dealing with and can create an exercise prescription well suited to achieve health and functional goals.
The U.S. Preventive Services Task Force and the U.S. Health and Human Services Office of Disease Prevention and Health Promotion offer guidelines for physical activity, but these efforts only go so far in enabling behavior for the patient population sitting in your office. The recommendation of 150 minutes of exercise per week is an excellent and evidence-based guide for a relatively healthy population to encourage disease prevention. However, for chronic conditions such as obesity, diabetes, hypertension, arthritis, etc., the recommendations must be adapted to adequately impact an individual’s physiological responses toward the desired outcome. Even for more functionally compromised populations — those with progressive neurological conditions like multiple sclerosis, Parkinson’s disease, cancer or spinal cord injuries, for example — exercise when prescribed at the right frequency, intensity and duration is safe and beneficial. This significantly impacts overall health as well as the disease trajectory.
If we are prescribing exercise as medicine, then let’s start treating it that way. It’s not good enough to tell our patients to exercise without giving them thoughtful direction to a specialist that can appropriately prescribe this intervention. The complexities of exercise physiology warrant specialty referral, and luckily there are exercise specialists with keen knowledge and skills ready to help our patients achieve impactful outcomes.
Nicole L. Stout is a physical therapist.
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