Explore concerns

Many people with health problems - and those without - have reasonable concerns about becoming more active

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1
Ask

“What concerns might you have about becoming more active, if you decided to?”

Saying “if you decided to” reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

 

For example say ‘Yes, that is a common concern’  or a reflection such as ‘you’re concerned that being more active may make your pain worse’ (said as a statement, not a question)

Your role is to help them feel listened to and understood rather than to immediately jump in to dismiss their concern or to offer information, advice and reassurance.  Acknowledging their views will help them to feel supported and may help them to be more receptive to any new information you might want to share with them.

Allow some space for people to talk about and explore new information, asking ‘what do you think about what I’ve just said?’ rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

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Share

If they mention one of these common concerns, click on it to see a useful response.

I don’t have the motivation to exercise

Undertaking physical activity is known to reduce falls in those at risk. It also reduces falls that result in fractures or other medical care1. Exercise improves an individual’s ability to participate in day-day life roles making them less dependent on others. So doing exercise will help keep people healthier and out of hospital.

Tips you may wish to share:

  1. Seeking support from family and friends can be helpful to increase motivation.
  2. A health professional encouraging exercise is a powerful influencer of behaviour change.
  3. Try to elicit a motivating factor that can be emphasised e.g. social interaction, maintaining independence, having fun.
  4. Aim to incorporate activity into daytime routine.
  5. Start with small achievable goals and gradually increase physical activity rather than making drastic changes.

I don’t know what I can do and how exercise can help

Ideally incorporate strengthening and balance activities, three times per week. Strengthening should target multiple muscle groups in the lower legs to be effective. Balance exercise examples are Tai Chi, one leg standing, toe and heel walking or tandem walking. Try and keep exercising for at least three months as research has shown this is the minimum duration for falls related benefits2.

Tips you may wish to share:

  1. If individuals have had greater than or equal to two falls over a year they should been referred for a strength and balance training programme.
  2. Below are some links which may help:

 

 

 

 

 

 

I’m worried that if I try to exercise I’ll fall

Strength and balance training has been shown to reduce falls and is a recommended part of falls prevention strategies. Healthcare professionals should assess the risk of falling in people 65 or over. The falls risk assessment should be done as part of a plan to help avoid falls.

There is no evidence that exercise has adverse effects on health in frail older adults. Some short lived joint pain or muscle soreness may be experiences after performing the advised training programme.

Tips you may wish to share:

  1. This is a commonly held view. Emphasise the positives and the lack of adverse effects.
  2. Other important factors can also increase the risk of falling so these should be addressed alongside exercise e.g. home modifications and medicines management.
  3. It may be appropriate to start with chair-based or exercises with support eg holding onto a chair prior to progressing.

I don't want to go to a gym

Home based exercises can reduce the rate and risk of falls just as well as group-based programmes so going to a gym isn’t necessary. Special exercises (sometimes called ‘strength and balance training’) can help to build up muscle strength and improve balance. These can make a person steadier on their feet and less likely to fall. They can be particularly helpful for older people who have already had one or more falls, or who have problems with balance or walking. These exercises should be designed specifically to take into account individual needs by a suitably trained healthcare professional would should also provide follow up support.

Tips you may wish to share:

  1. Exercise doesn’t have to mean going to the gym. It can be a household task such as gardening, going out for a walk with a friend/family member or climbing the stairs.
  2. The talk-test is a good way of identifying moderate intensity activity. This is when individuals can talk but not sing during exercise and feel sweaty. The target is to complete 150 minutes per week, broken down into a minimum of 10 minute bouts.

 

 

 

 

I'm too tired to do any exercise

Becoming more active is the most important treatment for persistent fatigue as it helps with body reconditioning and boosts energy levels. It can be a way for individuals to take back some control over their health

Tips you may wish to share:

  • Encourage a slow start with a gradual build up to small bouts of activity (this just needs to be a few minutes). This can increase over time
  • Increase the number of activity sessions first, then increase the duration each activity, followed by the intensity of an activity

I've never done any exercise

Often people feel it’s too late to start exercising. However, it’s never too late to start and the benefits, which are wide ranging, can be felt immediately. In the longer term, regular exercise will improve mobility and ability to do everyday tasks.

Tips you may wish to share:

  1. Make a start!
  2. Try and make it part of a routine.
  3. Get support from family and/or friends.
  4. Start slow and build up from 10 minutes. Progress the duration first then the intensity. Aim for 30-45 minutes three times per week.
  5. Aim to incorporate aerobic activity with resistance and balance training.

Won't it make things worse if I exercise?

No reports of death or cardiovascular events were found in a systematic review of 62 trials of resistance exercise5. In a randomized controlled trial studying the effect of a 12 month intervention of walking, resistance exercise, and flexibility, similar rates of serious and non-serious adverse events were found for both the intervention and control subjects6.Studies of exercise in older people with frailty show that both home-based and group-based programmes can improve mobility and functional ability. Research has shown that those at the lowest baseline starting point, the most frail, can actually gain the most from exercise. Strength and balance training is key to this. Although a wide range of approaches have been used, the exact optimal exercise regimen remains uncertain but doing something incorporating strength and balance is the key.

Tips you may wish to share:

  1. It is normal to get slightly out of breath during exercise. The talk-test is a good way of identifying moderate intensity activity. This is when individuals can talk but not sing during exercise and feel sweaty.
  2. Some muscle aches are also common and should settle within 1-2 days and are not dangerous. If they take longer to resolve then consider reducing the intensity of the activity next time and gradually build up to a higher intensity.

I'm all on my own

Many older people have lost friends and family which can mean they feel lonely. Having social support provided by friends and family may improve older adults’ health. Social networks have a significant positive effect on older adults’ survival. This support can also lead to beneficial changes in exercise behaviours. Undertaking exercise can be a good way of developing these networks.

Tips you may wish to share:

  1. Exercise can be an excellent way of meeting new people. You will have a common interest so conversation is easier.
  2. Exercising with others may make it more likely that individuals will continue to exercise.
  3. Many people are in the same position and feel the same as you.
  4. Exercise can improve your confidence and lift your mood making it easier to be sociable and make friends.

I already feel tired and you want me to do more….

Becoming more active is the most important treatment for persistent fatigue as it helps with body reconditioning and boosts energy levels. It can be a way for individuals to take back some control over their health

Tips you may wish to share:

  • Encourage a slow start with a gradual build up to small bouts of activity (this just needs to be a few minutes). This can increase over time
  • Increase the number of activity sessions first, then increase the duration each activity, followed by the intensity of an activity

No one in my community does exercise, it is not in our culture…

A daily routine such as using the stairs or walking to the shops are physical activity opportunities that are shared across all communities. Other activities such as dancing might be culturally acceptable activity.

Tips you may wish to share:

  • Do enjoyable activities
  • Build activities into your daily routine

 

My gym said I need medical clearance before being active: am I OK to exercise?

For the vast majority of people, medical clearance is not required to safely undertake progressive, moderate intensity activity. Important exceptions to this are people experiencing active symptoms (see below) or previously inactive people who disregard advice to build up gradually. An additional list of contraindications is listed below [1,2].

Significant events are so rare that medical screening has the potential to be an unnecessary barrier to physical activity. Screening is most effective when focussed on active symptoms and co-morbidity [3].

It is fairly common for gyms to request a medical letter for people to use their facilities. Consider the option of providing a signed letter to overcome this barrier for individuals. Encouraging a slow start with gradual build up of activity (over 3 months or so) reduces the chances of poor outcomes.

This flow diagram will help you decide who might need referral for formal assessment before increasing their physical activity levels and may help address queries from gyms:

Notes

Signs and symptoms, at rest or during activity; includes pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia; intermittent claudication; known heart murmur; or unusual fatigue or shortness of breath with usual activities

  1. An easy way to explain the intensity of exercise is the talk test:
  • Moderate intensity: breathing rate is increased but you can still talk
  • Vigorous intensity: breathing rate is further increased and it is not possible to talk in full sentences

 

  1. Patients with active symptoms or high risk necessitating medical screening will require formal investigations such as cardiac stress testing

Contraindications to physical activity include:

  • Unstable angina
  • Severe valvular stenosis or regurgitation
  • Active myocarditis or pericarditis
  • Ventricular tachycardia (uncontrolled)
  • Decompensated heart failure
  • Blood pressure >200/115 mmHg
  • Recent myocardial infarction (< six weeks)
  • Other clinical entities known to worsen during exercise
  • Acute Systemic infection

References

1) Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.

2) Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3:1-72.

3) Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-7.

How do I know when to stop exercising?

It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new activity and this pain will reduce as they become more accustomed to the activity.  Worsening symptoms may be due to increasing activity too quickly – reducing activity levels a little and then gradually increasing them again more slowly can help

Dizziness, sickness or excessive tiredness are signals to stop exercising and wait for symptoms to settle. Warning signs to seek urgent medical attention include blacking out, chest pain, or excessive shortness of breath.

Tips you may wish to share:

  • Encourage a slow, steady increase in activity to allow for adaptation to the new activity
  • During the first 2-3 months of increasing physical activity it is sensible to be physically active with other people

I am worried about having a heart attack if I become more active

The risk of dying during physical activity is very low. The risk to health from being inactive far outweighs the risk from regular physical activity.

For the majority of people starting moderate intensity activity, medical screening is not indicated. It is often an unnecessary barrier to physical activity.

Who has increased risk?

  • Habitually sedentary individuals may have unknown cardiovascular disease so should increase physical activity very gradually – suddenly doing vigorous intensity activity may increase risk of myocardial infarction in this inactive group by 100-fold
  • Those with active symptoms such as chest pain, acute breathlessness, palpitations signs of heart failure may have serious underlying pathology and should be referred for specialist investigation

Tips you may wish to share:

  • If starting physical activity for the first time build up very gradually over 3 months
  • Avoid sudden unaccustomed vigorous physical activity. Vigorous activity increases breathing to the level that it makes it hard to complete a sentence

References

Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.

Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361

Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-217.

3
Ask

“Has that helped?”

Did you know?

Start gently and build up slowly

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

  1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.
  2. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.