Exercise is medicine (EiM) has gained a significant amount of attention since its launch by the American College of Sports Medicine in 2007. A global health initiative that has since been adopted by many other countries throughout the world to address the growing problem of chronic disease and inactivity.
According to the World Health Organisation chronic disease such as Diabetes, Heart Disease, Cancer, chronic lung disease and stroke collectively account for 70% of deaths worldwide (http://www.who.int/ncds/introduction/en/). Chronic musculoskeletal pain continues to increase with low back pain ranked highest and other musculoskeletal disorders ranked 6th for years lived with disability (Vos et al., 2012).
The concept of EiM is not new. It has been around for centuries (Tipton, 2014). Yet there is something off about the concept of EiM. Are Physiotherapists making a change by encouraging exercise as part of a treatment protocol? Is it being over-prescribed or inappropriately reasoned? Has Biomedicalism spread it’s patho-anatomical feelers into something that should be rewarding, social and most of all fun (Williams, Hunt, Papathomas, & Smith, 2017)? Yes of course you’re bloody intrigued! I want to have a crack at exploring these questions.
Look at any EiM research study (and shit there’s a lot of it!), they all share a similar message that exercise is good for us. Through a musculoskeletal lens it has mechanotransductive and chemotransductive effects in that it builds, adapts and increases the resilience of our tendons/bone/muscle (Khan & Scott, 2009; Warden & Thompson, 2017). Exercise research identifies many positive benefits of EIM as a treatment for chronic disease including Cancer (Dodd, Cho, Miaskowski, Krasnoff, & Bank, 2010; Lemanne, Cassileth, & Gubili, 2013; Mishra et al., 2012; L. Pedersen et al., 2016; Schmitz et al., 2010; Spence, Heesch, & Brown, 2010; Winzer, Whiteman, Reeves, & Paratz, 2011) Heart Disease (Anderson et al., 2016; Artero et al., 2012; Lee et al., 2014; B. K. Pedersen & Saltin, 2015; Sattelmair et al., 2011) Osteoarthritis (Fingleton, Smart, & Doody, 2016; Fransen et al., 2015; B. K. Pedersen & Saltin, 2015; Quicke, Foster, Thomas, & Holden, 2015; Van Ginckel et al., 2010) Diabetes (Aune, Norat, Leitzmann, Tonstad, & Vatten, 2015; Gebel et al., 2015; Hemmingsen, Sonne David, Metzendorf, & Richter, 2017; Lee et al., 2014; B. K. Pedersen & Saltin, 2015) Obesity (Atlantis, Barnes, & Singh, 2006; Ismail, Keating, Baker, & Johnson, 2012; Ross, Freeman, & Janssen, 2000; Shaw, Gennat, Rourke, & Mar, 2009; Tomiyama, 2014) and Chronic Musculoskeletal Pain (Bidonde et al., 2017; Busch et al., 2013; Daenen, Varkey, Kellmann, & Nijs, 2014; Khan & Scott, 2009; Rio et al., 2013; Vaegter, 2017; Vaegter, Handberg, & Graven-Nielsen, 2014).
The EiM movement began in the United States in 2007 (Segar, Guerin, Phillips, & Fortier, 2016; Tipton, 2014) but EiM can be traced back to antiquity (Tipton, 2014). The drive behind EiM was to recognise the health benefits of exercise and to encourage all health professionals to advocate exercise to address the growing chronic disease epidemic. Physiotherapy naturally, should be at the centre of this drive.
Strangely, as more and more research highlights the health benefits of short and long term commitment to exercise it appears that this is not making the impression it was meant to (Kamerow, 2015). People just don’t appear to reciprocate when told to engage in exercise. The issue according Segar et al., (2016) is that exercise is no less a behavioural science than a medical one or as Williams et al., (2017) explains ‘the EiM initiative thereby ignores any societal aspects of sport and exercise participation leaving the individual solely accountable for being physically active’
There is absolutely no doubt that exercise has many benefits, yet there are still questions hovering as to why people don’t engage in exercise.
Do Physiotherapists know how much is enough?
Healthcare is changing. Research is identifying that many treatments that are used by health and medical professionals are no more effective than no treatment or placebo. Take physiotherapy for example. The profession continues to use orthodox treatments like ultrasound, acupuncture, manipulative therapy and massage all of which show poor efficacy as single use interventions and in the long term for treating musculoskeletal conditions (A D Furlan, Imamura, Dryden, & Irvin, 2008; Andrea D Furlan et al., 2005; Green, Buchbinder, & Hetrick, 2003; S Rubinstein, Van Middelkoop, Assendelft, DeBoer, & Van Tulder, 2011; SM Rubinstein, Terwee, Assendelft, de Boer, & van Tulder, 2012).
A recent study of Australian Physiotherapists found that they demonstrated poor knowledge of physical activity guidelines and that physical activity was infrequently promoted (Freene, Cools, & Bissett, 2017). I am very intrigued to see what the outcome would be in other countries. One of the recommendations of the paper was to provide training to physiotherapists in ‘physical activity counselling and behaviour change’. Hmmmm, counselling and behaviour change? Now if I’m not mistaken that’s psychosocial factors. Ah, the pieces are slowly coming together. Interestingly, the same was said about Doctors in an editorial in the BMJ (MacAuley, Bauman, & Frémont, 2015). It seems doctors are confident in their knowledge about prescribing exercise, but they just weren’t prescribing it enough.
So yes, I am asking physiotherapists to down their hammer and chisel (not permanently) and to broaden their world view beyond medicine and into areas of counselling, behaviour change, philosophy, socio-cultural and socio-economics to enhance our critical thinking and clinical reasoning skills, beyond inductive or hypothetico-deductive reasoning (here). Through adopting a more humanistic approach to exercise and our reasoning processes we may be able to gain a foothold in the real-time contextually changing kaleidoscope of people’s lives and then determine why, how and when exercise will be of value to them.
Are we reasoning exercise appropriately?
I would say no at this stage. It seems that we do know that exercise is good but according to Freene, Cools, & Bissett, (2017) as a profession we may not know what the minimum recommended amount is in relation to the guidelines. My other query is whether we are really reasoning exercise appropriately? Are we just giving it to people because we know that it’s good? Are we taking the time to listen to the person’s story and deconstructing it into a causal mind map (here) that could provide a more comprehensive formulation of what the person needs? Does it fit into their world view?
Let’s look at an example – a mid 30s male patient comes to see you with a 1 year history of knee pain of insidious onset, they are overweight, exercise very little and have a history of type II diabetes. He has had an x-ray of his knee which shows no arthritic changes, yet he is concerned that they might end up like their father “who’s knees are stuffed”. He doesn’t particularly warm to working out in gyms because he finds them intimidating, but he does walk to work every day. He works in a warehouse which involves repeated kneeling and lifting, his boss is not particularly empathetic making masculine comments about being tough, his diet is poor tending to eat what he can whilst on the go at work and having large portions at home with a mixture of macro and micro-nutrients, yet tending to opt for carbohydrate rich foods. He and his partner have 2 children (6 and 9), and the older child has recently been disruptive at school, they live in a low socio-economic demographic and want to raise their children in a quiet rural town. His partner is expecting their third child and works part-time, she also lives with back pain. They struggle financially, yet they do receive a child benefit but this is not enough to cover their needs. They own a car which has recently failed its warrant of fitness. The patient doesn’t sleep very well, having frequent bouts of insomnia +/- disruption of knee pain. The patient scored high on a pain catastrophizing scale, low self-efficacy score and also high on a pain anxiety symptoms scale for avoidance and physiological anxiety.
So quite a lot going on here. Saying to this patient if you lost some weight this would help your knee pain is likely going to result in you losing the patient (or a smack in the face!) and telling them to exercise more may also result in the same outcome.
There is more to just addressing the biological in this situation. This person is struggling with regulating their lifestyle. It appears they are under quite a lot of distress and the financial, environmental, work, social aspects are compounding the problem. It is evident that psychosocial factors are predictors of pain and disability in a number of pain presentations including the knee, shoulder and lumbar spine (Chester, Jerosch-Herold, Lewis, & Shepstone, 2016; Costa, Maher, McAuley, Hancock, & Smeets, 2011; Doménech, Sanchis-Alfonso, & Espejo, 2014; Graves, Fulton-Kehoe, Martin, Jarvik, & Franklin, 2012; Jarvik et al., 2005; Menendez, Baker, & Oladeji, 2015; Piva, Fitzgerald, Wisniewski, & Delitto, 2009) and as such are crucial to identifying causal factors to the patient’s presentation.
Furthermore, there is evidence to suggest that exercise if not appropriately tailored to the individual could have a negative effect. I’m not talking muscle strains here I’m talking neurophysiological changes that occur or are perpetuated as a result of increased allostatic load (Aartun et al., 2015; Murison, 2016; Na & Oliynyk, 2011; Pickering, Vojtovich, Tower, & A Davies, 2013; Soligard et al., 2016; Staud, Robinson, & Price, 2005). Now this may be a stretch to castigate exercise, however I’m making this point because exercise needs to be reasoned appropriately like any other intervention. I’m not detracting that it is an important part of maintaining a healthy lifestyle but as we are all too familiar one size does not fit all.
Taking the fun out of it
Exercise as a concept has nuances of discourse and application. As we have already explored EiM can be viewed as a therapeutic tool to increase tissue resilience and general health. Exercise should be a ‘creative learning, fun and engaging activity’ however EiM has political agenda it is viewed as a ‘preventative and outcome driven health strategy’ aimed at easing the strain on stretched healthcare services (Nicholls, Jachyra, Gibson, Fusco, & Setchell, in press).
EiM has certainly achieved its premise of being ‘perceived as medicine’. The biomedicalisation of exercise has caused an understanding that exercise will cure disease or illness (Williams et al., 2017). This polarized view of exercise being viewed as the answer to a lot of health problems can lead to ambivalence, confusion and lack of motivation. People are bombarded by media campaigns, tabloid reports and health magazines overwhelmed by medicalised health messages and health initiatives and yet it seems they fail to see the value in exercise.
Perhaps this is the problem? Unfortunately, it seems that cure is not always a realistic outcome. Many chronic diseases do not result in cure and the best possible outcome is to learn to live well. Thus, bringing creativity and enjoyment back into exercise may help to reduce any false hope, stress, anxiety and/or depression that could potentially come with such a journey of uncertainty with chronic disease.
Exercise can be painful
Despite the positive effects of exercise in chronic disease (Pedersen & Saltin, 2015) and the effects exercise has on endogenous pathways (Jones, Booth, Taylor, & Barry, 2014; Lemley, Hunter, & Bement, 2015; Smith et al., 2017; Vaegter, 2017), some pain conditions do not receive the same benefits, this includes fibromyalgia (Lannersten & Kosek, 2010; Staud et al., 2005) low back pain (Daenen et al., 2014) Chronic Fatigue Syndrome (Daenen et al., 2014) Osteoarthritis (Petursdottir, Arnadottir, & Halldorsdottir, 2010) chronic whiplash (Smith et al., 2017). Pain flare ups are also common when exercising, this can be associated with biological changes in the nerve system (Moseley & Vlaeyen, 2015; Woolf, 2011) and if there are psychosocial factors that have not been identified flare ups can be a real hindrance. Furthermore, prolonged and repeated periods of pain flare ups can induce further fear and anxiety either from the belief of further damage (Vlaeyen et al, 2013) or because of anxiety to pain itself (McCracken, Zayfert, & Gross, 1992).
I want to plug another blog at this point. mycuppajo.com is a blog about Joletta Belton’s experiences with learning to live well with pain. The post I want to bring into sharp focus is her blog on shame http://www.mycuppajo.com/shame/.
Joletta writes about her experiences of attempting to control her pain, pushing through, losing her identity as a firefighter and all the while it wasn’t exercise that gave her wiggle room it was understanding what pain was, the affective side of pain, the social side of pain that broadened her view on life and facilitated an engagement with exercise that was pleasurable not painful.
So, is exercise medicine? Yes, but it is so much more. It’s recreation, activity, fun, engagement, social, relaxing. Clinicians should be encouraging it but should also be reasoning when it’s appropriate, how it is dosed and being creative to suit the values of the person.
Thanks for having a read.
I want to thank everyone for your support over 2017. It has been a real rollercoaster for my partner and I with her cancer diagnosis. Strangely, coming to terms with the thought of yesterday you had cancer, today all appears back to normal best put the washing on is a somewhat surreal experience. None the less we are looking forward to a bright start in 2018, which has already delivered some exciting news!
Have a Happy Christmas and a wonderful New Year! Looking forward to bring ing you more blogs in 2018.
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