Doctors and Exercise

I last wrote about incidental exercise, but what about a more structured approach to exercise? Many of us with chronic conditions would benefit from exercise. Most of us also probably have doctors in our lives, either general practitioners or specialists (called consultants in some countries) such as a rheumatologist.

Over the Easter weekend an interesting report appeared in the Medical Journal of Australia, “Exercise: an essential evidence-based medicine”. Naturally, I was excited to see exercise receiving coverage in the medical media!

Regular physical activity is highly beneficial for the primary, secondary and tertiary management of many common chronic conditions. There is considerable evidence for the benefits of physical activity for cardiovascular disease, diabetes, obesity, musculoskeletal conditions, some cancers, mental health and dementia. Yet there remains a large evidence–practice gap between physicians’ knowledge of the contribution of physical inactivity to chronic disease and routine effective assessment and prescription of physical activity.

There was a similar report last year out of the UK, “GPs in England ‘unconfident’ discussing physical activity with patients – report”.

Now a nationwide study has revealed that 80% of GPs in England say they are unfamiliar with the national guidelines, and more than one in seven doctors say they are not confident raising the issue of physical activity with their patients.

“Many people have described [physical activity] as the most cost-effective drug we have, yet we are not implementing it properly,” said Justin Varney, co-author of the research from Public Health England (PHE). “This is as appropriate as having a conversation about smoking,” he added.

The medical advice I was given when I became sick was, literally, “Get some exercise.” Not how, what, when, frequency, intensity – just “Get some exercise”. As we know, I did better than that, I went and got an exercise qualification. After that, I asked my rheumatologist what weight he thought it would be safe for me to lift on the leg press, without negatively impacting my condition. His response? “I have confidence in you, you’ll work it out”. Which, in my case given my qualifications and experience, is fair enough. To a patient that is an exercise novice, I know my doctor would not have said that particular phrase. He and I have known each other quite some time now and have a very good patient/doctor relationship. I wouldn’t be writing this article if he had not set me on the exercise path in the first place. I share these conversations to provide real world examples of the above two articles.

Exercise is not a discipline many doctors are trained in, which is fair enough – they can’t be experts in everything and I need my rheumatologist to be an expert in rheumatology! Apart from anything else, a medical specialist would be a very expensive personal trainer. I really do not want to pay his medical charge rate for exercise advice. Look at it this way: a specialist or general practitioner may also send you to a physiotherapist, but do you expect that doctor to BE a physiotherapist? No, you don’t. So we should not expect our doctors to be able to write us a tailored exercise program either.

A member of a chronic illness support group today shared a similar experience, having essentially been told to “figure it out” by one of her doctors.

I recently wrote an article titled “Preventing Tomorrow’s Pain”. I didn’t really write it – I recorded a video. NOW, some time later, when I look back at that video, I can clearly see the improvement in my demeanour/attitude before I walk (after sitting in a conference all day) and while I am walking. Yes, I was pain free the next day and I swam 1,000 metres.

If your doctors don’t mention exercise, raise the topic with them. Really, your doctors don’t need to be exercise trainers, they just need to reassure you and encourage you that exercise will help you manage your conditions. They need to give you a medical clearance to undertake exercise. People like me can do the rest.

The above two articles, from opposite sides of the world, provide clear evidence that just because your doctor may not have mentioned exercise does not mean exercise should be ignored. Exercise may be the best medicine for you, just not mentioned by your doctor. Another contact told me when she offered to do exercise, her doctor was so surprised and said “You’re prepared to do that?” giving my contact the impression maybe he’d just given up over time trying to get patients to exercise. Doctor was very excited, patient exercises and her body does not “turn to concrete”. On a side note, I love that phrase, as it explains so well how many of us can feel if we don’t MOVE!

I use this graphic often: this is what happens if you don’t move. No, you don’t have to be lifting weights, start with simple stretches. Just MOVE it!

de-conditioning

Patients can be reluctant to try exercise as medicine. After all, instinctively we know pain is a warning signal and we believe rest will make it better even though science shows the opposite is true more often than not. We may fear those first few painful steps. A friend said the other day, “the cave you fear to enter holds the treasure you seek”. This, I feel, applies to exercise for so many people. We want the treasure: minimal pain, to be free of opioids, regain functional movement and retain quality of life. The cave is exercise and movement.

You may be reading this because you are searching for a solution. You are researching, perhaps. Do not be afraid to enter the cave. Ask your doctors, raise the topic of exercise with them. If they raise it with you, listen to them. Bear in mind the “how to” of exercise is not their specialty.

If you are ready and willing to try movement as medicine, call me or send me an email.

This article constitutes general advice only and may not be suitable in all situations. You should always seek a medical clearance to undertake exercise if you have medical conditions. Always apply the pain management principles of pacing when starting an exercise program.

Let’s Stretch

Stretching helps us get our movement back. We don’t have to do Olympic level stretches: to start, do what you feel comfortable with. Day by day you will improve. Your aim is to increase your flexibility and functional range, not run the marathon or climb Mount Everest. It can be discouraging when we see “everyone else” able to do things we can’t. It isn’t everyone else, though – there are plenty of people in a very similar situation to ourselves. We need to let go of the “everyone else” comparison because it does us no good at all.

Range of motion can even lead us to not buying clothes we like. I tried on a dress I loved. BIG problem: it had a full length zip up the back. I no longer have the range of motion in my shoulder joint to be able to zip that dress up by myself. So I had to buy a different dress. Still bugs me every time I think about it!

David Tom MD, an Arizona-based chronic pain specialist, says patients who are successful in managing their conditions see movement as medicine. I love that phrase. Movement is the one of the best drugs we can use.

What stretches should you do? This is will depend on your particular situation, but a good set to start is listed below. Hold each for three calm breathes, do each stretch twice. That is, twice each side where the stretch is a side-to-side stretch. Do stretches in a controlled slow manner, paying heed to your body. This is a not a race, the only aim here is to getting our body moving.

  1. Neck stretch 1 – simply tuck your chin to your chest.
  2. Neck stretch 2 – tilt your head to the side, turning your chin towards your armpit and your ear to your shoulder. Be careful not to lift your shoulder to your ear! If you are tilting to the right, you can place your right hand on your head to gently add some additional “pull” to the stretch.
  3. Shoulder rolls – rotate your shoulders in a circle backwards, with your arms at your sides. In gyms you may see people doing full arm rotations, forwards and backwards. This is not necessary to achieve your short-term objective. Do not rotate shoulders forwards, the body prefers backwards and we want to give the body what it prefers at this stage.
  4. Shoulders, chest, biceps – stretch your arms straight behind you. You can retract your shoulder blades if you are able, and clasp your hands behind your back but this is not necessary. Again, watch those shoulders – make sure you aren’t lifting your shoulders. Take you arms back only as far as you can comfortably.
  5. Side bend – sitting or standing is fine, depending on your current ability. I won’t describe this one in words as I demonstrate it in the video above.
  6. Back rotation – this can be done lying down or sitting. I prefer lying down. Lay on the floor arms outstretched, knees bent. Roll your knees to one side as close to the floor as you can, hold. Return your knees to the centre, roll to the other side. This may be too challenging, so the seated version is to hug yourself and rotate your upper body to one side, hold. Return to the centre and repeat the other side.
  7. Hamstring stretch – the hamstrings are the big muscles that run down the back of your legs. These can get very tight, especially if you haven’t discarded those high heels yet! That was a not-so-subtle reminder to check out my KyBoot recommendation. There are many ways to do a hamstring stretch, here are two.  You can sit on the edge of a chair and place one leg out in front of you, heel only on the floor, toe pointing towards you, straighten the knee and bend slightly forward at the waist. A second option is to lay on the floor and raise one leg at right angles to your body, your hands behind your thigh to gently encourage your leg towards a 90 degree angle to your body, knee as straight as possible.
  8. Quad stretch – quads are the muscles at the front of your thighs. My favourite place to do these is in the warm water gentle exercise pool with ankle floats. On land, stand behind a chair or beside something you can hold on to for support. Lift you foot up behind you towards your bottom. If you are able, you can catch hold of your ankle and lift the foot higher. You will feel the stretch in the front of your leg above the knee.
  9. Calf stretch – another stretch with options. Option 1 is to stand facing the wall, hands about head head height against the wall, one knee bent, the other leg stretched out behind you, heel to the ground. Press your heel into the floor and bend the other knee. Option 2 is to stand on a step on your toes and drop your heels below the step. The is my preferred version. You will need something to hold onto.
  10. Glute (the muscles in your buttocks) stretch – sitting in a chair, lift one your left foot up and place it on your right knee. You can push down on the left knee to increase the stretch if you wish, providing that is comfortable. Repeat for the other side. If this is too much, simply lift your left knee up and point it towards your right side. A more advanced version is to lay on the floor, bend your knees with your feet close to your buttocks, place your left ankle on your right knee then place your hands either side of the right left and pull your right knee towards your chest just until you feel the stretch in your left buttock.
  11. Thoracic Stretch/Snowangels – our upper back can get quite stiff when we are not as active as we should be or we spend too much time at a keyboard. You will need a long foam roller for this one. The pictures illustrate, I hope! Just laying on the foam roller is a good start. Snowangels add arm movements: start with your arms positioned at your sides, palms facing the floor, then take you arms in a wide arc to stretch out behind your head, palms facing the ceiling. This needs a bit of floor space as you may be surprised just how far your reach is when your arms are at a right angles to your body! This is not a “three calm breaths” one – stay on the roller as long as you feel comfortable. Perhaps start with 30 seconds if you’ve never done it before.

In the first image I have moved my arm so you can see the roller. In the second you can see my head is totally supported – hence the need for the long roller.

This is not the easiest to do and may be too advanced for beginners. Some readers will have difficulty getting on the roller and will need to build up flexibility and strength. The aim is not to hurt ourselves, so BE CAREFUL! I still prefer to hold onto something while lowering myself onto the roller. I love the way my upper back feels when I get off the roller.

Stretching daily is a very good thing. Build the time into your daily schedule and stick to it, even on the “bad” days. Design a simple spreadsheet and place it on the fridge, mark each day off as you go. Stretching isn’t the only activity we need, but it is a good place to start.

If you would like some help, Contact Limberation.

This article constitutes general advice only and the stretches outlined above may not be suitable in all situations. You should always seek a medical clearance to undertake exercise if you have medical conditions.