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Issue 1

Table of Contents

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Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • We can consider under loading our patients to be harmful, considering the negative side effects of being sedentary
  • For people living with long term conditions, the benefits of physical activity far outweigh the risks
  • Despite the risks being very low, perceived risk is high
  • Person-centered conversations are essential for addressing perceived risk

Wow! We have so much to cover. Let’s dive into the first article of our research review!

There is absolutely no question that physical activity is an important part of being alive, being healthy, and being able. There also is no question that it seems that physical activity and health follow what’s called a dose dependent relationship, meaning the more activity, the more healthy you become. Easy peasy.

The problem here is that the majority of the American and world population don’t participate in nearly enough physical activity. Not even close. Some statistics point toward the number of 18% being those who follow the WHO’s and The Department of Health and Human Services’ recommendations!

Briefly, those recommendations include:

  • 150-300 minutes per week of moderate intensity aerobic activity

OR

  • 75-150 minutes of vigorous aerobic activity

AND

  • At least 2 days per week of moderate intensity muscle strengthening activity to all major muscle groups

 

So what’s the hold up? Where is the bottleneck between the robust data that we have on the numerous benefits that physical activity have on morbidity and mortality (being sick and being dead)? Well it seems that there are many people fearful of not only participating in increased physical activity, but are also fearful of RECOMMENDING increased physical activity, clinicians included.

But why?

Well, increasing physical activity makes people breath heavy, makes their hearts beat faster, makes them sore and makes them tired. Not to mention comorbidities that exist in just about every patient that comes through our (your) door. When people have other things going on that are not necessarily things to get excited about, it can really tax their self efficacy (feelings of being able to manage their situation) and their confidence. They want to avoid making things worse, so they just kind of stop doing stuff. Or they are in a position of being less than ideally healthy because they aren’t doing stuff.

Enter our first paper

Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

We have a 2021 consensus statement from the supremely prestigious British Journal of Sports Medicine. Neat!

They are well aware of the issues absolutely plaguing medicine and they have taken it upon themselves to not only write up 5 Impact Points for clinicians like you, but they also made a helpful infographic for you to give or go over with your nervous patients!

So the authors come out swinging with this direct quote in the very first paragraph of the paper:

“Healthcare professionals cite a lack of the knowledge and skills required to reassure and motivate people with long term conditions who are concerned that physical activity may aggravate their symptoms or even cause sudden death”

 

Man if only there was some encompassing and transformative resource teaching the knowledge and skills required to reassure and motivate people to be more physically active. Oh well

Anyway, let’s get to these 5 Impact Points that they outline:

  • For people living with long term conditions, the benefits of physical activity far outweigh the risks
  • Despite the risks being very low, perceived risk is high
  • Person-centered conversations are essential for addressing perceived risk
  • Everybody has their own starting point
  • People should stop and seek medical attention if they experience a dramatic increase in symptoms.

Helpful? Yes. Groundbreaking? Far from it

While they might not be groundbreaking pointers, if it were as easy as just telling people to worry less and move more, I wouldn’t have to be typing out a synopsis of a 12 page consensus paper on how much of an issue this is. Yet we persist.

Let’s check out the things that the expert panel says are an ABSOLUTE CONTRAINDICATION TO PHYSICAL ACTIVITY:

  1. Recent acute cardiac event or ECG changes suggesting significant ischaemia
  2. Unstable angina
  3. Uncontrolled dysrhythmia causing symptoms or haemodynamic compromise
  4. Severe symptomatic aortic stenosis
  5. Acute pulmonary embolus or pulmonary infarction
  6. Acute myocarditis or pericarditis
  7. Suspected or known dissecting aneurysm
  8. Acute systemic infection
  9. Symptomatic and untreated cardiac tachy-arrhythmia or brady-arrhythmia.

 

So maybe write those on a sticky note and put them on your clipboard so that if someone mentions a feeling of impending doom that you not put them on the arm bike for 8 minutes because they may have a pulmonary embolism. Everything else is fair game.

Not only is it fair game, but increasing physical activity acts almost as a silver bullet, helping almost every symptom and system you can think of. Lets go through the ones listed in the paper!

Musculoskeletal pain:

  • “Physical activity is likely beneficial for reducing pain and improving function…”
  • “There is no evidence to suggest this [temporary increase in pain levels when starting activity] correlates with tissue damage or adverse events in the absence of new injury”

Fatigue:

  • “Regular physical activity helps reduce fatigue and improved well being and sleep”

Shortness of breath:

  • “The evidence suggests that the risk of adverse events in breathless people when doing physical activity is very low:

Cardiac chest pain:

  • The long term benefits of increasing regular physical activity far outweigh the temporary, slight increased risk of adverse events even in those experiencing exertional chest pain as a result of ischemic heart ideas (angina)”

 

Palpitations:

  • “Individuals with controlled atrial fibrillation benefit from regular physical activity, which should be started gradually”

Dysglycemia:

  • “The benefits of physical activity outweigh the risks in both type 1 and type 2 diabetes”

Cognitive impairment:

  • “Strength and functional training has been associated with reduced risk of falls in those with mild-moderate cognitive impairment”

Falls and Frailty:

  • “Frail, inactive people have much to gain from increasing physical activity levels and building strength and balance, including those with osteoporosis. Even small improvement in strength and balance can reduce a frail individuals risk of falling and improve their confidence”

None of these even get into the benefits that we all know and love, the greatest hits if you will, like increasing bone density, increasing ligament stiffness, increasing muscular force production ability etc etc

One of the more provoking aspects of this consensus statement was the fact that they seemed to think that the general population running exercise by their primary care physicians prior to beginning was an “unnecessary barrier” to becoming more physically fit!

“We challenge recommendations that individuals with stable LTCs require medical clearance before autonomously increasing their physical activity levels. We suggest that routine preparticipation screening in this group poses an unnecessary barrier to self-directed physical activity and engagement with the physical activity, sport and leisure sectors.”

 

If you thought that laying all of this information out nice and clearly for us clinicians to utilize, lets take a look at the infographic that they created for us to use as teaching tools for those that walk into our clinic!

 

Thankfully, it seems as though the writing is on the wall regarding fear around pushing our patients towards more frequent and higher intensity physical activity. We might even be able to consider under loading our patients to be harmful, considering the negative side effects of being sedentary, but we can get into that in a later issue.

 

References:
  1. Reid H, Ridout AJ, Tomaz SA on behalf of the Physical Activity Risk Consensus group, et alBenefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditionsBritish Journal of Sports Medicine 2022;56:427-438.

 

Musculoskeletal pain and exercise— challenging existing paradigms and introducing new

Dr. Joe Camoratto PT, DPT

Key takeaways:
  • Reframing pain during exercise as allowed can help to move patients back toward meaningful activities that they have been avoiding, helping to update their expectations about the movements.
  • We as providers can not only advertise painful exercise as a means of managing symptoms, improving self efficacy, work towards meaningful activities, but also as a method of pushing our patients towards increased physical activity.

 

If there was one phrase that could describe the method by which rehab clinicians interact with patients in pain, especially regarding exercise, it would be tip toeing. I honestly don’t blame most clinicians that go out of their way to avoid putting their patients INTO pain.

I mean, one of the largest reasons that we as providers get into the field of rehab is to help people get OUT of pain, among other things (decreased disability, increase quality of life, increase confidence etc). So it’s pretty understandable that when a patient mentions that something we are having them do is painful, that clinicians tend to modify or alter until things are comfortable again. Luckily there is much paradigm shifting that seems to be occurring within the MSK rehab world. One of the main shifts that we are happy to see and support is that pain needs to be avoided as much as possible while being physically active, including during exercise.

What exactly is painful exercise?

The authors define it a “exercises are prescribed with instructions for patients to experience pain or where patients are told that it is acceptable and safe to experience pain.”

This may be foreign to some of those reading right now, but the authors allude to a recent systematic review and meta-analysis that support with moderate evidence the benefits of painful exercise over pain free exercise. To better understand why this shift needs to occur, lets investigate a few of the implications, as a medical authority figure, for advising your patient to avoid pain while exercising/being physically active:

  • You can cause more damage to yourself
  • Physical activity should always be comfortable
  • Pain is a reliable indicator of tissue status
  • If you are experiencing pain or discomfort, it is a good idea to stop
  • Physical activity could potentially be dangerous if it’s done while in pain

While these might not be your intention while advising that if something hurts, you should stop, they are real and common things that we hear patients say.

All of these seem to be rooted in an outdated way of thinking about pain and symptoms, called the biomedical model of pain. The main message is that with every symptom, there is a physical/structural and identifiable source of that symptom. While this narrative dates to the 1400s, it is less useful in our career field as it doesn’t tell the whole story. To be brief, just because someone has a symptom, doesn’t mean that there is something broken, torn, out of place or what have you, and just because something is torn, broken, or not how it was 10 years ago, doesn’t mean that there will be symptoms.

If that one is outdated, then what should we be using?

The biopsychosocial model of pain is what we are trying to move all of medicine towards. The idea that there are multiple factors that play into someone’s perception of pain and symptoms, including their biological being, their societal influences and context as well as their psychological influence, including but not limited to, expectations and beliefs. While this doesn’t encompass all that we know about pain, it is a step in the right direction of understanding the relationship between tissue status and symptom presentation. With this updated lens with which to view symptom presentation under our belt, we can look back on those prior implications of advising that people avoid pain while exercising of being physically active and understand why it may not be helpful or accurate.

Let’s shift our focus to something the article spends a good bit of words on, central sensitization. With our new understanding of the ability for symptoms to be present or elevated without the occurrence of more tissue damage, we turn to some possible reasoning as to why symptoms might not match what tissue status we would expect. The authors define central sensitization as an increased responsiveness of nociceptive neurons in the central nervous system to normal input. The authors specifically discuss the following examples:

Hyperalgesia

  • Increased pain response to normally painful stimuli
  • May be a result of increased peripheral or central pain sensitivity

 

Allodynia

  • A pain response to a stimulus that is not normally painful
  • An example being a person who has chronic low back pain whose complains of pain while they are hugged

 

Temporal summation of pain

  • Progressive increase in pain perception in the response or repeated stimuli of the same intensity
  • An example being a patient with chronic knee pain performing knee exercises may complain of increasing levels of pain the more repetitions they perform

So how do we tie this back into our main goal here? Simply put, we need not worry about causing further damage when patients complain of pain during exercise. We can instead focus on reaping the rewards of performing painful exercise.

Sifting through the rewards is the best part of this whole article review. Reflecting on the ways that painful exercise can help patients increase their quality of life and manage their symptoms is eye opening. First and foremost, we have the ability to facilitate improved self efficacy (one’s ability to cope with the current situation). Patients don’t come into the clinic for help simply because they hurt or are having difficulty with some function. It is because they are uncertain and possibly fearful about their situation. Once they are able to realize that the issues they were faced with before aren’t as troublesome as they once knew, improved self efficacy is soon to follow.

How do we help them to improve their self efficacy? We reassure them and educate them that the pain that they are feeling isn’t something to be afraid of, and that the movements they are having difficulty tolerating aren’t things to avoid (decreasing kinesiophobia/reframing pain during activity). Not only do we reassure them, but we have the opportunity while in the clinic, a perceived safe and controlled environment, to introduce them to systemic benefits reviewed in the article.

Exercise induced hypoalgesia:

  • It has been recognized that an acute bout of exercise can result in analgesia and this phenomenon is termed exercise-induced hypoalgesia (EIH) and is one form of endogenous pain modulatory processes.

The release of beta endorphins:

  • Exercise can trigger the release of β-endorphins from the pituitary and hypothalamus, in turn activating μ-opioid receptors peripherally and centrally, triggering the endogenous opioid system.

Time and again patients come in while stuck in a loop of pain, avoidance, decreased tolerance to activity, and deconditioning only to restart the loop once they re-aggravate their symptoms. Our ability to communicate our new found knowledge of pain being ok while being physically active can help to break this loop. Reframing pain during exercise as allowed can help to move patients back toward meaningful activities that they have been avoiding, helping to update their expectations about the movements.

Last but not least, there is the dose dependent response that we should always be aware of when utilizing exercise as a form of intervention. 80% of the American population isn’t active enough. As we learned in the first article, the physical activity guidelines are ours and our patients’ yellow brick road to decrease morbidity and mortality in the form of decreased risk of obesity, diabetes, cardiac risk, osteoporosis, sarcopenia and frailty, to name a few. When viewed through the lens of public health, we as providers can not only advertise painful exercise as a means of managing symptoms, improving self efficacy, work towards meaningful activities, but also as a method of pushing our patients towards increased physical activity.

It can be as simple as this:

Patients autoregulate physical activity in the presence of symptoms in a downward direction. They take down the intensity, the volume, the frequency per week and sometimes they will take everything out altogether. This is usually due to fear of damaging something with their continued painful exercise. With this down regulation of physical activity, they are decreasing the dose of stress with which they are putting themselves under. That same stress that has a dose dependent response that we went over earlier.

I hope we can all follow the same thought process here.

With the go ahead from the medical authority figure (you), and the addition of things called safety cues (eg “you’re having symptoms because you’re not tolerating what you’re doing, not because something is being damaged and we can improve your tolerance with more exposure) we can put together a winning dynamic.

Let’s put it all together in a very simple one liner:

The benefits of physical activity outweigh the risk in almost every health related and long term condition scenario, and that physical activity does not have to be pain free, and likely shouldn’t be pain free, in an attempt to maximize rewards.

 

References:
  1. Smith BE, Hendrick P, Bateman M, et alMusculoskeletal pain and exercise—challenging existing paradigms and introducing newBritish Journal of Sports Medicine 2019;53:907-912.