The script for getting fit: Help your patients move off the couch
■ Sometimes getting patients to exercise takes more than just talk. It requires giving specific tips for starting a fitness program and sticking with it injury-free.
By now, physicians are familiar with the push to treat patients' physical activity level like any other vital sign measured at each visit. The idea is to encourage people to exercise to improve their health status.
But talking about the importance of exercise and getting a patient to exercise are two different things. The latter can be difficult. "The biggest thing that we've recognized is that most patients hate exercise," says American Medical Association President-elect J. James Rohack, MD, a cardiologist from Bryan, Texas.
So what can doctors do to get patients off the couch? And once they do, how can physicians help patients avoid injuring themselves?
One way to motivate patients is to discuss the benefits of activity, says Robert S. Gotlin, DO, director of the orthopedics and sports rehabilitation program at Beth Israel Medical Center in New York. "There are definitive correlations with healthy living and longevity." Centers for Disease Control and Prevention data show that regular exercise can decrease the risk of cardiovascular disease, diabetes and certain cancers, while improving mental and bone health.
Once that message has sunk in, it's time to work with the patient to set goals and discuss what activities he or she likes. If the patient enjoys the exercise, he or she is more likely to stick with it, Dr. Gotlin says.
But how much exercise is enough? The Dept. of Health and Human Services in October 2008 issued its Physical Activity Guidelines for Americans. They recommend that adults get 2½ hours of moderate-intensity aerobic activity or 1¼ hours of vigorous activity weekly.
People can determine whether they're exercising hard enough by keeping tabs on their heart rates, which during moderate exercise should be 50% to 75% of their optimal maximums. The maximum heart rate can be calculated by subtracting one's age from 220. Multiplying that figure by 0.5 and by 0.75 will give the beats-per-minute range for moderate activity.
But that can be confusing, says Robert E. Sallis, MD, immediate past president of the American College of Sports Medicine and chair of Exercise is Medicine, an initiative founded by the ACSM and the AMA. An easier technique to share with patients is the sing/talk test, he says. "You should exercise at an intensity level high enough that you couldn't sing, but not so intense that you couldn't talk."
Although getting aerobic exercise to maintain cardiovascular health is the most important component of a regimen, activities that promote muscle strength also are necessary, Dr. Sallis says. HHS recommends that adults work muscle-strengthening exercises into their routine at least two days a week.
Working out for 30 minutes five times a week might seem like too much for some people. In this case, doctors can suggest that patients break it into three 10-minute bouts of activity. The benefits from these bursts are indistinguishable from those derived from a half-hour of sustained exercise, Dr. Sallis notes.
For particularly resistant patients, Dr. Rohack doesn't even talk about exercise. Instead, he promotes "quality movement." He discusses how patients can work it into their daily lives. For example, they can park farther from the store, take the stairs instead of the elevator, walk in the mall, or garden.
The HHS recommendations are a good standard to have in mind, says Brian Halpern, MD, a primary care sports medicine specialist who serves as assistant attending physician at the Hospital for Special Surgery in New York. If some patients won't buy into the five-days-a-week plan, it's OK, as long as they start doing something. "A little bit of exercise is better than none," he says. After time, the physician can try to escalate the patient's program.
So once patients get on board with the concept of regular exercise, how can physicians help them proceed safely? One of the first issues to consider is whether a physical exam is necessary. Doctors disagree slightly on this point. Some always recommend that patients get a physical before starting an exercise program. Others say patients who see their physicians regularly and are otherwise healthy can get started without one. Doctors do agree that patients with a personal or family history of certain conditions, such as cardiovascular disease or high blood pressure, should get checked out first.
Physicians also should be on the lookout for medical red flags, Dr. Rohack says. For example, if a person in his 40s or 50s says he needs to start exercising because he's so out of shape that he gets winded easily, the physician should screen the patient for heart disease or other problems.
Doctors should go over warning signs with patients who have a known condition, Dr. Gotlin says. A patient "may be taking their blood pressure medication and thinking they're immune to anything going wrong. No. You've got to be aware of chest pain, shortness of breath, arm pain, tingling in the hand."
But having a chronic disease does not rule out exercise in most cases, and indeed physical activity helps control several conditions, such as diabetes, high blood pressure and heart disease. These patients just have to be more prepared. "If you're a diabetic, make sure you have something sweet with you," Dr. Gotlin says. "If you're an asthmatic, make sure you have your inhaler."
Osteoarthritis of the knee or hips also can complicate exercise. The easiest activity to prescribe -- walking -- can be too hard for arthritic patients. Swimming and water aerobics, which take weight off the joints, are good alternatives.
Doctors have to give special consideration to heavy patients, Dr. Rohack notes. They get hot faster, and their weight puts more stress on their joints. Water activities are a good option for these patients.
Starting at square one
Once the patient starts being active, the risk of injury is always present. Dr. Halpern frequently sees people who have hurt themselves exercising. Common problems include knee pain, arthritis flare-ups, sciatica, neck strain, tendonitis in the elbow and rotator cuff injuries.
Most often, the injured patient is someone who tried to go from zero to 60 when they first started exercising or is a weekend warrior who hasn't conditioned properly.
"Somebody says, 'I'm going to start a running program,' and they start running every day for a mile or two," Dr. Halpern says. They end up developing a stress fracture or some other type of overuse injury. "The bad part of that is it can turn a person off to exercise permanently."
For the patient starting out, the best advice is to begin slowly. Patients who decide their exercise goal is to return to a sport after years of hiatus will need help working up to a safe participation level.
Basketball is an example of a wonderful aerobic sport, Dr. Rohack says. "But if you haven't played in a while and you say, 'I'm going to go start doing the stuff I did 10 years ago,' sorry, but the body, the hand-eye coordination and the endurance isn't going to be there." The sport requires a lot of stamina, so the patient should start out walking, and work up to a fitness level at which he or she can jog for 45 minutes, he recommends.
Weekend warriors are prone to making the same mistake as exercise newbies. "On the weekend, suddenly they're going to weight lift, they're going to jog, they're going to bike, and they're not used to that high intensity," says Kevin Plancher, MD, associate clinical professor in orthopedic surgery at Albert Einstein College of Medicine in New York. These patients, too, need to condition properly to avoid injury.
People also get hurt when they haven't warmed up before exercise, Dr. Rohack says. He advises patients to do simple stretching for a couple of minutes to get the blood flowing and the joints limber.
Another valuable bit of counsel doctors can give patients is to cross train to avoid overuse injuries. "Don't put all your eggs in one basket," Dr. Gotlin says. Patients should vary their activities so that different muscle groups are targeted on different days.
Dangers lurk at the gym, too. The most common mistake is improper use of weights. Some people lift heavy weights and do few repetitions, Dr. Plancher says, when they should be using lighter weights and doing more repetitions. People also use bad form. When lifting weights on a machine, patients' hands should be in their peripheral vision to avoid shoulder injury, he says.
Leg extensions are another frequent misstep because they put too much strain on the patella tendon, Dr. Plancher cautions. People also err by doing deep squats and knee bends instead of simply doing one-third squats and bends, which are safer and work the quadriceps just as well.
At the gym, patients also should take the same precautions to avoid catching communicable diseases -- from coughs and colds to methicillin-resistant Staphylococcus aureus -- as they use everywhere else. People should wipe equipment with an alcohol-based product before using it, wash their hands after working out, and avoid touching their eyes or mouth, Dr. Halpern says.
How a person exercises isn't the only factor in injury prevention. Personal equipment is important as well. For most people, all that's required is a pair of good shoes with ample arch support and padding. This is especially important for patients with plantar fasciitis or arthritis, doctors say. Patients with orthopedic problems might need a referral to a specialist to make sure they have the right shoes and inserts. Other advice is common sense -- wear a helmet when cycling and layer clothing in cold weather.
Once patients are active, doctors may want to check periodically on their progress. The conversation could alert the physician to a problem resulting from exercise, says Matthew J. Matava, MD, associate professor of orthopedic surgery at Washington University School of Medicine in St. Louis. Asking a patient how his or her golf game is going could lead to a discussion about how the patient has back pain on the course, he says.
Some physicians might not be comfortable taking on exercise counseling in the first place, Dr. Rohack notes. For these doctors, referrals are always an option. Most communities have choices -- exercise physiologists, physical therapists or athletic trainers. In this circumstance, the doctor can make a "fitness prescription," noting any underlying conditions or necessary limitations, and let the exercise professional develop the program.