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.

“What do I do if I get chest pain?”

Stop,  Sit down and rest.

Use your GTN spray or tablets. Take the GTN
 as advised. The pain should go away within five minutes. If it doesn’t, take GTN again.

If the pain has not gone away within five minutes of taking the second dose of GTN, call 999 immediately.

Rest until the ambulance arrives.

Tips you may wish to share:

  1. 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
  2. Progress with duration first, rather than intensity of an activity

“I am already breathless, being active will just make it worse”

In most cases, regular physical activity helps improves fitness over the time and thus reduces breathlessness

Tips you may wish to share:

  1. Some mild breathless during activity does not mean damage. It is normal for anyone who is not used to exercising to experience some shortness of breathe after doing a new exercise, but this will reduce over time.
  2. Adequate warm up and cool down of 5-10 minutes helps to minimise breathlessness
  3. Avoid breath holding, especially prolonged where you tense your whole body

How much intensity is enough?

There is no evidence to suggest that regular, low to moderate intensity will cause harm.

Tips you may wish to share:

  1. Warm up by starting slowly and building up gradually over 5-10 minutes and cool down gradually too. Avoid sudden stopping of activity.
  2. Avoid strenuous exercise, especially suddenly without warming up.
  3. It is normal to feel a temperature rise and breathing and heart rates increasing.
  4. Start with low intensity (able to talk normally)
  5. Aim to gradually increase to moderate intensity (struggle to sing)
  6. Avoid high intensity (struggle to talk)

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

  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

  1. Durstine JL. ACSM’s exercise management for persons with chronic diseases and disabilities. 3rd ed. ed. Leeds: Human Kinetics; 2009.
  2. CV fitness references

Madssen et al., 2014, Adams et al., 2013, Erbs et al., 2010, Amundsen et al., 2008, Luk et al., 2008, Hambrecht et al., 2004, Marchionni et al., 2003, Belardinelli et al., 2001, Adachi et al., 1996

  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.
  4. 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.
  5. 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.
  6. Borg, GA. Borg’s Rating of Perceived Exertion and Pain Scales. Champaign, IL:Human Kinetics, 1998.

 

I can't be bothered to be more active

Regular physical activity improves mood which can improve motivation.

 Tips you may wish to share:

  1. Everyone can be active, start slowly with something that is enjoyable
  2. Try something like brisk walking or dance classes. Being active does not mean going to gym. Build being more active into daily routines.
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.

‘Exercising is good, both for the heart and the head’

A small amount of prevention is better than a large amount of treatment.