Explore concerns

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

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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 you feel even more tired’ (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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If they mention one of these common concerns, click on it to see a useful response.

I wasn’t active before I had my amputation, so why should I start now?

It’s never too late to start. You don’t have to play sport or use a gym to be active, lots of activities count. Incorporating activities into your daily routine, such as walking or using your wheelchair to visit the local shops or the park with family/friends, can be a very useful way of being more physically active. You may have previously been doing more activity than you thought. It is very easy to lose your confidence and do less without even realising it. We know that doing a bit more can have a big impact on your physical and psychological wellbeing, confidence and ability to carry out day to day tasks. Speaking to your local prosthetic centre or physiotherapy department can be very helpful, as they may be able to discuss with you a range of activities that are available close to you and they can share their experience of what others have found helpful in the past.

Tips you may wish to share:

  • Try to incorporate activity into your daily routine
  • Start small and build up gradually
  • Speak to your local prosthetic centre or physiotherapy department to find out what opportunities are available for you locally

I don’t know what activity I should or shouldn’t do…

When people think about doing more activity, they often think of going to the gym or playing sport but being physically active is much more than that and can be easily incorporated into your daily routine. Walking or using your wheelchair to visit the local shops or walk the dog counts. An activity that one person enjoys may not be something that is enjoyable for everyone. Consider speaking to LimbPower, the Limbless Association, your local prosthetic centre and other lower limb amputees to find out about activities you may enjoy or that others have found helpful in your local area. Being active with your family and friends is another good way of getting started.

Tips you may wish to share:

  • Try to incorporate activity into your daily routine
  • Find something that you enjoy and that is right for you
  • Speak to LimbPower, the Limbless Association, your local prosthetic centre and established lower limb amputees to find out what opportunities are available for you locally

I don’t know how much activity I should be doing…

Start by trying to do a bit more than you are already. Start gently, and as your body gets used to you being more active you will find that you are able to do more. When people think about doing more activity, they often think of going to the gym or playing sport but being physically active is much more than that and can be easily incorporated into your daily routine. Walking or using your wheelchair to visit the local shops or walk the dog counts.

Tips you may wish to share:

  • Try to incorporate activity into your daily routine
  • Start small and build up gradually
  • Speak to your local prosthetic centre to find out what opportunities are available for you locally

I’m worried about people looking at me and what they might think…

Undergoing a lower limb amputation is a life changing event that results in a visible change in appearance, and it is not uncommon for amputees to feel conscious about how they look. We live in a multi-cultural and diverse society with people of all different shapes and sizes, and there have been significant improvements in access to different activities for everyone. Being physically active can help you become more comfortable with your appearance and improve your self-confidence. Some people find it helpful to be active with friends and family or in groups, as they help to give encouragement and motivation to continue. Others may find it helpful to speak to established amputees that are physically active about their experiences and advice. Speaking to your local prosthetic centre can also be very helpful, as they may be able to discuss with you a range of activities that you may find helpful and share their experience of how their patients have managed this concern in the past. This advice isn’t enough for everyone, and some people find it helpful to discuss their concerns with a counsellor. If you wish to explore this further, discuss it with your GP or local prosthetic centre.

Tips you may wish to share:

  • Find something that you enjoy and that is right for you
  • As you become more confident, consider trying new things
  • Seek advice from your family and peers
  • Speak to your local prosthetic centre to find out what opportunities are available for you locally

I don’t know many people with a disability exercising…

Being physically active includes far more than exercising in a gym, going for a run or playing sport. Incorporating physical activity into your daily routine, such as walking or using your wheelchair to visit the local shops or walk the dog, counts and we have frequently seen people doing this. There have been significant improvements in access to different activities for everyone, regardless of whether they have a disability. If you wish to find an activity that you would enjoy in your local area, speak to your local prosthetic centre as they will have a good knowledge of what is available and what others have previously enjoyed.

Tips you may wish to share:

  • Try to incorporate activity into your daily routine
  • Find something that you enjoy and that is right for you
  • Speak to your local prosthetic centre to find out what opportunities are available for you locally and what other lower limb amputees have found helpful

I’m worried that being more active will cause discomfort around my socket…

Being more active may lead to changes in the size of your limb and extra sweating, both of which could potentially cause discomfort around your socket. However, anticipating these changes can enable you to be more active without experiencing any problems. Speak to your prosthetist about what you may expect to experience during activity and how you can overcome this, including sock management, anti-perspirants and the different activities that are more or less likely to cause problems. They may try to make alterations, but everyone’s body will respond to activity in different ways, and your body may even respond differently at different times of the day. Some people find it helpful to keep a diary of activities they have performed, the techniques they used and the impact they had on their discomfort. By reflecting on this, and through experience, you will be able to find the combination that works right for you.

Tips you may wish to share:

  • Speak to your local prosthetist for advice on how to minimise socket discomfort during activity
  • Carry extra socks when doing dedicated physical activity
  • Keep a diary of how your residual limb responds to different types of activity, at different times of the day and to different techniques you’ve used to improve socket comfort
  • Consider chair-based exercises or activities performed without your prosthesis

I’m not sure whether my prosthesis is fit for physical activity…

Most prostheses are fit for activity, but your comfort and confidence are very important when considering new activities. It is important to be aware that you don’t have to play sport or use a gym to be active, lots of activities count. If you’re looking to do a specific activity and you’re concerned that your current prosthesis would be unsuitable or would cause discomfort, it is important to contact your local prosthetist for advice. They can discuss any concerns you may have and may even suggest an alternative prescription, particularly if any of the components may come into contact with water or if you’ll be carrying heavy weights.

It’s also important to remember that you don’t need to be a prosthetic user to be active, and many activities can be performed by prosthetic users without wearing their prosthesis. Using a wheelchair, chair-based exercises and swimming all count. Consider speaking to your local prosthetic centre and the local council to see what activities are available local to you. LimbPower and the Limbless Association may also be able to give you advice on activities that you may enjoy.

Tips you may wish to share:

  • Physical activity can be performed without a lower limb prosthesis
  • Contact your local prosthetist for advice if you’re considering a new activity and are concerned that your prosthesis may be unsuitable or cause discomfort
  • Contact LimbPower, the Limbless Association or your local council to find out about activities you may enjoy close to your home

I don’t want to be more active if it will have an impact on the benefits payments that I receive…

Many people that improve their activity levels also experience an improvement in physical function and their ability to perform everyday tasks. Some benefits payments are related to the level of assistance required with everyday tasks, such as washing, dressing and preparing food, and level of mobility. If you have concerns that this may affect you, it is best to seek some advice from the Limbless Association or the Citizen’s Advice Bureau who will consider your situation as an individual and be able to assist.

Tips you may wish to share:

  • Contact the Limbless Association or the Citizen’s Advice Bureau for advice if you’re concerned that this may affect you

I am already in pain being active will just make it worse...

It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new exercise, and pain does not necessarily suggest that the activity has caused any damage. As you become accustomed to the activity this pain will usually reduce. Many of those that have musculoskeletal pain actually find that being more active helps to reduce their pain, as stronger muscles help to better support their joints and the spine.

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

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 thing, and activities like walking to the bus stop, cycling to work, doing the housework and gardening all count towards health benefits and feeling better. This form of regular activity can be fitted into an individuals daily routine. Some people even find that doing regular activity helps to make them more confident and efficient with specific tasks, actually saving them time in the long term.

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

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. Many people find it a good way to take back some control over their health.

Tips you may wish to share:

  • Start slow and build up gradually in 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 the duration of each activity, followed by the intensity

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, so it is important to try to stick with it. 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. Start slow and increase steadily by listening to your body, allowing you to adapt to the new activity. Another reason that people stop is that they didn’t enjoy it. Find something that you enjoy, then you’ll find it’s easier to stick with it.

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 don't have the confidence to exercise...

Some people find that being active with friends, family and other people can build confidence, increase social activity and provide a chance to make new friends. Others benefit from doing activities on their own to start with. When they are more confident in their ability to be active they may feel ready to join others. Consider speaking to LimbPower, the Limbless Association, your local prosthetic centre and other lower limb amputees to find out about activities that others have found helpful in your local area, and also how others have overcome low confidence.

Tips you may wish to share:

  1. The ‘arrange support‘ section will help to identify activities that you may enjoy
  2. Find ways to be active with friends or family
  3. Build extra activity into your daily routine, such as housework, gardening or exercise at home

I can't find the motivation to exercise...

Try starting slow and building up gradually. Group activities can be motivating and a way to meet new people, and finding an activity that you enjoy may mean that you look forward to it. Some people find that setting a realistic activity related goal and trying to meet it helps to keep them motivated.

Tips you may wish to share:

  1. Start slow and build up gradually
  2. Find an activity that you enjoy
  3. Consider setting yourself a goal/target and using this as your motivation

How do I know when to stop exercising?

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. If you notice any skin changes around your socket or residual limb, such as sores or broken skin, or worsening pain/discomfort you should contact your local prosthetic centre for advice.

Tips you may wish to share:

  • Start slow and increase your activity steadily to allow you to adapt to the new activity.
  • During the first 2-3 months of increasing physical activity it is sensible to be physically active with other people
  • Contact your local prosthetic centre for advice if you notice any skin changes or worsening discomfort around your socket or residual limb

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

The risk of dying during exercise is very low [1,2]. The risk to health from being inactive far outweighs the risk of regular physical activity. For the majority of people wishing to start moderate intensity activity, medical screening is not indicated and is often an unnecessary barrier to physical activity.

Who has an 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 [3]
  • 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 [3]

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

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

  2. 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.

  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):215-217.

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 focused 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.

I get put off by the weather!

If it’s too hot, cold, wet or windy outside, or pollution levels are high, choose an inside activity. Many activities do not require you to be outside, such as swimming, home exercises, dance classes and many more. Many people find that being active outside is important to them, but having an alternative plan for when the weather is not good can help to keep you active until it improves.

Tips you may want to share:

  • Dress for the weather, but remember expensive clothing is not needed
  • Check the local weather forecast for ‘breaks’ in inclement weather
  • Chose activities according to the season
  • Consider indoor activities that you may enjoy

I can't afford it...

Being more active doesn’t need any special equipment or clothing. Wear comfortable clothes and be active anywhere, even at home. For those that are inactive and wishing to become more active, GPs in some parts of the country may be able to refer you to an exercise programme. Speak to your local GP to see if this is something that you can access.

Tips you may wish to share:

  • Free smart phone apps, pedometers or a notebook can be used to track progress/the number of steps
  • Community activities can be free or subsidised
  • When watching TV, stand up at every ad break
  • Most exercises can be done using just your own body weight or a water bottle, or something you have in your house
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Ask

“Has that helped?”

Did you know?

Evidence has demonstrated that unsupervised physical activity at an appropriate intensity is safe for disabled adults

Smith B, Kirby N, Skinner B, et al. Physical activity for general health benefits in disabled adults: summary of a rapid evidence review for the UK Chief Medical Officers’ update of the physical activity guidelines. London: Public Health England, 2018

<40% of lower limb amputees are sufficiently active and 33% are considered sedentary

Langford J, Dillon MP, Granger CL, et al. Physical activity participation amongst individuals with lower limb amputation. Disability and Rehabilitation 2019;41(9):1063-70. doi: 10.1080/09638288.2017.1422031

‘I can't live my life thinking what others will think. It's my life and this is how I want to live my life. And I'm going to live my life. Regardless, if I've got two prostheses or not’

Wadey R, Day M. A longitudinal examination of leisure time physical activity following amputation in England. Psychology of Sport and Exercise 2018;37:251-61. doi: 10.1016/j.psychsport.2017.11.005

‘This is your new normal, that's what you have to learn. It doesn't mean it's going to be worse, it's just new.’

Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disability and Health Journal 2017;10(4):600-06. doi: 10.1016/j.dhjo.2017.03.004