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.

2
Share

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

I’m already in pain and doing more will just make that worse...

Regular physical activity has been shown to reduce pain in most people with musculoskeletal pain, with research finding that it can give as much pain relief as paracetamol or ibuprofen. Importantly, physical activity does not come with the side effects of these medications. Pain does not necessarily suggest that there is any joint damage and some mild discomfort after activity does not mean there has been damage. It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new exercise. As people become accustomed to the activity this pain will reduce.

Tips you may wish to share:

  • Ensure an adequate warm up and cool down of 5-10 minutes
  • Exercise at the time of day when pain is usually least severe
  • If joints are sore, time activity with painkillers

References

Fransen M, McConnell S, Harmer AR, et al.Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med2015;49:1554–7. doi:10.1136/bjsports-2015-095424

Smith BE, Hendrick P, Smith TO, et al.Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med2017;51:1679–87. doi:10.1136/bjsports-2016-097383

Moore G, Durstine JL, Painter P. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, 4E:Human Kinetics 2016. https://books.google.co.uk/books?id=mEjZCwAAQBAJ

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

I am worried that my symptoms will get worse...

Very rarely do people’s symptoms stop them from undertaking regular physical activity. Being more active has been shown to reduce pain and fatigue, and to improve physical function, wellbeing and joint stiffness. However, some people do find that their symptoms appear worse. This can happen for a number of reasons, but often this is due to an individual’s body adapting to the new activity. It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new exercise 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.  If symptoms are too severe, the support of a professional such as a physiotherapist may help.

Key Message:

Consider a referral to a physical activity service with psychological support in those that are particularly fearful of moving, activity avoidant or low in confidence. The use of validated risk stratification tools, such as the StarT Back Screening Tool for those with back pain (https://www.keele.ac.uk/sbst/), can help identify those at higher risk of poor clinical outcome.

Tips you may wish to share: 

  • Regular physical activity does not damage joints
  • Stronger muscles help support joints, improving pain
  • Symptoms can be managed

References

Hill JC, Whitehurst DGT, Lewis M, et al.Comparison of stratified primary care management for low back pain with current best practice (STarT Back): A randomised controlled trial. Lancet2011;378:1560–71. doi:10.1016/S0140-6736(11)60937-9

I’ve been told that my scan shows damage and I don’t want to make that worse...

Despite these changes, the evidence suggests that pain, function and other symptoms are still improved with regular physical activity. Also, the link between changes on scans and symptoms is rarely straight forward. For example, 52% of those aged 30, 80% of those aged 50 and 93% of those aged 70 without back pain will have evidence of lumbar disc degeneration on their MRI.

Tips you may wish to share:

  • Changes on scans need not stop activity levels increasing
  • Scan changes do not necessarily represent symptoms
  • Improving the strength and support around joints can improve symptoms
  • See our ‘Explain How it Works’ page to understand how

Reference

Brinjikji W, Diehn FE, Jarvik JG, et al.MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A systematic review and meta-analysis. Am J Neuroradiol2015;36:2394–9. doi:10.3174/ajnr.A4498

I have been diagnosed with osteoporotic spinal fractures. Is it advisable for me to be active, or will it cause me to have more fractures or pain?

Exercise is still vitally important, even after spinal fractures, especially as it help helps to maintain your muscle strength and balance which reduces the likelihood of you falling over and makes further fractures less likely [1]. Weight bearing exercises, including walking, and resistance exercises help to prevent further loss of bone. As fractures heal and your pain improves you can build these up gradually to promote bone strength [2-5]. Building up spinal muscle strength with simple exercises may help with the muscle spasm pain and posture problems that sometimes come with spinal fractures [6-7]. Adapting forward bending type movements and learning simple techniques for everyday living and lifting, such as ‘the hip hinge’ (bending from the hip) can reduce strain on the spine and may reduce the risk of further vertebral fractures and pain [8].

 

Tips you may wish to share:

  • Plan movements and always lift properly, keeping objects close to the body and taking the strain through your legs.
  • Take a positive approach and learn ‘how to’ do rather than ‘don’t do’. Moving and bending are part of day to day living and generally won’t cause fractures.
  • Do what you can, anything is better than nothing. Build up gradually, increasing activity and confidence levels as you go.
  • If your require further advise, consider asking for a referral to a physiotherapist or contact the National Osteoporosis Society on 0808 800 0035 or via www.nos.org.uk

 

References

  1. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1749-1757. doi:10.1136/bjsports-2016-096547.
  2. Howe T, Shea B, Dawson L, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011;(7):CD000333. doi:10.1002/14651858.CD000333.pub2.www.cochranelibrary.com.
  3. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR. Physical Activity and Bone Health. Med Sci Sport Exerc. 2004;36(11):1985-1996. doi:10.1249/01.MSS.0000142662.21767.58.
  4. Giangregorio LM, Papaioannou A, MacIntyre NJ, et al. Too Fit to Fracture: Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int. 2014;25(3):821-835. doi:10.1007/s00198-013-2523-2.
  5. Beck BR, Daly RM, Singh MAF, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport. 2017;20(5):438-445. doi:10.1016/j.jsams.2016.10.001.
  6. Bonner Jr. FJ, Sinaki M, Grabois M, et al. Health Professional’s Guide to Rehabilitation of the Patient with Osteoporosis. Osteoporos Int. 2003;14(2):S1-S22. doi:10.1007/s00198-002-1308-9.
  7. Giangregorio LM, Macintyre NJ, Thabane L, Skidmore CJ, Papaioannou A. Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev. 2013;2013(1). doi:10.1002/14651858.CD008618.pub2.
  8. Giangregorio LM, Mcgill S, Wark JD, et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int. 2015;26:891-910. doi:10.1007/s00198-014-2881-4.

I’ve already tried this before, but I stopped because I saw no benefit...

The benefits of increasing activity levels may not necessarily be immediately apparent.

A common reason for people finding that things didn’t improve, or got worse, with physical activity is that they did too much too quickly. Encourage a slow, steady increase in activity to allow for adaptation to the new activity.

Tips you may wish to share:

  • Don’t be discouraged by previous failed attempts
  • Small changes now can lead to large benefits in the future
  • Start slowly and build up gradually
  • Find an enjoyable activity

I’m already very busy, how can I find the time to fit this in?

Finding time to be more active, especially at the beginning, can be a challenge. It is important to remember that exercise and activity are not necessarily the same things, and activities like walking to the bus stop, cycling to work and gardening all count towards health benefits and feeling better. Regular activity can be fitted into an individuals daily routine.

Tips you may wish to share:

  • Start slowly and gradually build up
  • Experiment with different activities
  • Build activity into daily routines. Review the ‘Next Steps’ page to see how this could be done

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

  1. 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
  2. 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
  3. 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?

Those who are currently physically inactive should start gently and build up slowly, enabling their body to gradually adapt to the higher levels of activity.

DOH. Start Active , Stay Active: a report on physical activity from the four home countries’ Chief Medical Officers. London: 2011.

"When you have OA, your joints already hurt, so I assume they’re not up to it"

Gay C, Eschalier B, Levyckyj C,et al.Motivators for and barriers to physical activity in people with knee osteoarthritis: A qualitative study. Jt Bone SpinePublished Online First: 2017. doi:10.1016/j.jbspin.2017.07.007

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.

"If I was more active I may have more pain and my knees might go."

ARUK Listening Panel 2017