People have long known that exercise is good for them, and increasingly the evidence is making the case that it is is also good medicine. Three years ago, the authors of this medical review in JAMA said of exercise, “No other single intervention or treatment is associated with such a diverse array of benefits.” And this sentiment has only gotten empirically stronger since.
“There is a huge sea-change in recognition of the importance of exercise in neurology,” says Lisa M. Shulman, MD, professor of neurology and director of the Parkinson Disease and Movement Disorders Center at the University of Maryland. “It has occurred over the last 10 years or so. There was a period of time where the non-pharmacologic front, like exercise, was seen as being very second tier, but I think those days are over.”
Having said that, she cautions, “We still have a long way to go.” There are still a lot of unanswered questions. “There’s the obvious questions about what types of exercise are effective, and how long we need to exercise to obtain these effects.” Another question she and her research team in Maryland are trying to answer is “When is the right time to refer people for rehabilitation therapies?”
“It’s after they’ve fallen. It’s reactive, instead of proactive. We are interested in looking at the predictive value of questions about near falls and stumbles,” she says, in an effort to “find the proper timing to recommend people see a physical therapist to prevent falls.”
In addition to this question of when, Shulman wants to know how to get patients to follow through with exercise recommendations. “We have a big problem with adherence.” It is difficult to know what patients are actually doing between their office visits. Communication between physicians and therapists tends to be poor unless they are working in the same rehab facility. And even when patients are motivated they tend to overestimate the amount of exercise they are doing.
Shulman and her colleagues conducted a pilot study comparing subjective and objective measures of exercise between office visits. “We saw people for two visits. They were using an activity monitor, and we also had them complete a questionnaire where they reported their levels of activity. The study aim was to use activity monitors to motivate the study subjects to increase their activity over time. On the second visit they reported they had increased their activity. However, “when we compared their actual step count (from the activity monitors) to their report, they hadn’t increased their activity at all. In other words, subjective data is not always reliable.”
What you can do now
So, what can you do about the mismatch between objective and subjective measures? Shulman recommends taking advantage of the fact that so many patients are wearing activity monitors already. “More and more people are using activity monitors, but they literally go in and out of my office, wearing a monitor and don’t mention what their average daily activity is.” Instead of waiting for your patients, you can bring it up and use these monitors to help track as well as motivate patients to increase activity.
Another way to integrate exercise into your treatment approach is to have discussions about exercise and its importance with your patients. This may sound obvious, but many physicians are skeptical that this will work. The evidence, though, says that it does, even in small doses.
During the Activity and Counseling Trial, adding just 3-4 minutes of lifestyle and physical activity counseling during office visits resulted in improvements in cardiorespiratory fitness over a two-year period. Similarly, this study published in Circulation showed that short sessions of physical activity counseling resulted in a nearly 15 percent reduction in cardiovascular risk among adults with hypertension.
According to the authors of this review on the importance of adding exercise counseling into practice, “the lack of physical activity counseling in clinical settings represents a lost opportunity to improve the health and well-being of patients, and with minimal cost.”
They offer six strategies to easily incorporate exercise counseling into your practice:
- Make physical activity a vital sign. After taking blood pressure and weight, a nurse should routinely ask about physical activity.
- Ask about the type and frequency of exercise and the patient’s openness to doing exercise.
- Explain the health benefits of physical activity.
- Write a prescription for agreed-upon daily physical activity.
- Encourage use of a pedometer, mobile device or other tracking system.
- Recognize success and give encouragement.
Shulman has another suggestion: Make exercise more doable for your patients. Even 15 minutes a day of moderate exercise can reduce the risk of mortality. In this study of weekend warriors, the authors concluded that even when done just once a week, exercise improved all-cause mortality by 29 percent.
“There’s a lot of emphasis in the literature that exercise has to be intense for benefits. Not everybody can do intense exercise.” In this 2013 randomized clinical trial, Shulman looked at the effects of three different levels of exercise on Parkinson patients with gait impairment. Sixty-seven patients were randomly assigned to one of three exercise groups: 1) higher-intensity treadmill 2) lower-intensity treadmill and 3) stretching and resistance exercise.
After exercising three times a week for three months, the researchers looked at gait speed (as measured by the six-minute walk test), muscle strength, and cardiovascular fitness. What was most striking about this study was that the lower-intensity treadmill exercise resulted in the greatest improvement in gait speed.
Exercise isn’t a panacea but there is no doubt that it can be used to directly improve the health and function of patients. With time research will answer more of the when, what and how questions about exercise, but in the meantime, don’t wait. It’s important to take advantage of the tools and strategies that we have right now.