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Wednesday May 16, 2018

Exercise Is Medicine. Here's How I Get Patients Started

John was a 78-year-old patient I had been seeing for the past year. Three years ago he was diagnosed with stage 3 pancreatic cancer with local invasion into his aorta, and surgical tumor debulking was deemed too dangerous, given several other comorbidities. He underwent chemotherapy for a few months with little benefit and was miserable from the side effects. As a result, he decided to transition to home palliative and hospice care.

[elderly couple holding hands and walking in park]

Most of the oncologists thought he would survive only a few months, but John discovered a new treatment that no doctor had recommended and he had not tried before. This new treatment may have helped prolong his life -- and, more importantly, improved the quality of his life.

Was it a new miracle pill? Was it expensive?

No and no.

He started walking.

At first, he could barely walk to the next room. His wife and home nurse had to help him significantly.

Everyone told him, "Save your strength," or, "Don't waste your energy."

He didn't listen.

John was a stubborn man. He had read about the benefits of walking and wanted to see if it could help him. He and his wife walked nearly every day, although just a few minutes at a time initially. Little by little, he got stronger, walked a little bit farther and, most importantly, felt better.

He noticed that he started to sleep better, needed less pain medication and had more energy. He was discharged from home hospice because he was doing so well, and his prognosis significantly improved.

John defied his doctors' predictions and lived much longer than expected. Although he ultimately succumbed to his illness, he added quality to the years he had remaining. He and his wife attributed his unexpected longevity to daily exercise, an act as simple as walking.

There is a growing body of research about the benefits of exercise not just to preserve health and prevent disease, but to treat many medical conditions, including cancer,(www.ncbi.nlm.nih.gov) Parkinson's disease(www.ncbi.nlm.nih.gov) and chronic conditions. We need to get our patients moving because physical inactivity increases the relative risk(www.ncbi.nlm.nih.gov) of coronary artery disease, stroke, hypertension and osteoporosis by 45 percent, 60 percent, 30 percent and 59 percent, respectively.

Research has demonstrated that 150 minutes of physical activity a week is the recommended "dose." However, 90 percent of Americans(www.ncbi.nlm.nih.gov) do not meet these physical activity guidelines, and many physicians underestimate the importance of physical activity or do not have adequate time to discuss it with their patients.

I tell patients if I could choose only one medicine from all the medicine in the world, it would be walking for 30 minutes five days a week to get a full 150 minutes. The best part is that research has shown that it doesn't even need to be all at once. Five minutes in the morning, 10 minutes at lunch and 15 minutes after dinner, and the patient still gets the same benefit.

A visit rarely passes when I do not discuss exercise and physical activity with a patient. However, simply telling people to exercise more is not adequate. How often do we give a patient a medication and tell them to "take some?" As family physicians, we need to be more specific in our physical activity recommendations. Many patients who suffer from chronic disease need to have a careful risk assessment and guidance based on their individual needs and ability, and willingness to engage in regular physical activity safely. I often recommend practical and simple physical activity to all my patients, not only the young and healthy but also the chronically ill.

There are three components to fitness: strength, cardiovascular fitness and flexibility. The key to getting people to start -- and continue -- exercise is to identify something they will find fun, social and enjoyable. There are a variety of ways that I suggest people get moving: meet a friend at the gym, play pickup basketball at the park or join a master's soccer league. I ask patients if they enjoy a particular sport and recommend they try to find adult softball, soccer or Ultimate Frisbee leagues, or get some friends together and start their own.

If patients don't have time or financial means to participate in organized sport or exercise, I often give them a practical walking prescription. For example, I recommend parking at the far end of their parking lot, walking into work and taking the stairs for at least one or two flights. At lunch, they could walk five minutes away from their work environment, eat, then walk back. And at the end of the day, they would walk back to the car. I then suggest a 10-minute after-dinner walk with the family or dog. With minimal effort or expense, patients can build 30 minutes of walking into their daily routine.

For patients who have significant comorbidities, I often recommend that they start simply by walking just five minutes a day and then gradually increase their efforts over time. Once they have a basis of fitness, I recommend adding some gentle stretching exercises. I recommend gradually adding in strength training, be it at a gym or just exercises they can do at home, such as sit-ups, planks or pushups. Those starting at a lower level of fitness can use cans of soup as weight for bicep curls or can step up and down a single step. Strength training should be started once a week and then gradually increased to twice a week.

Lastly, and perhaps most importantly, I assess their activity level at every visit. Even if they're in just for a cold, I ask about physical activity and remind them of its importance in maintaining or improving their health.

I often use John and his experience as an example when discussing physical activity with patients, and they are amazed. Exercise and physical activity in our daily lives has been reduced or removed by technology and efficiency, and there is an epidemic of chronic disease stemming from inactivity. However, there is also over-medicalization of illness, particularly in the later stages. The benefits of starting exercise, even later in life, are often unrealized.

As physicians we need to do more to promote exercise and physical activity to our patients. We need to take a few extra minutes to stress the importance with not only our healthy patients, but also our sickest patients. This takes time, but it may be one of the best primary prevention tools we possess as family doctors.

Alex Mroszczyk-McDonald, M.D., practices comprehensive family medicine and sports medicine in Southern California, with a focus on health policy, physical activity and advocacy. You can follow him on Twitter @alexmmtri.(twitter.com)

Posted at 10:09AM May 16, 2018 by Alex Mroszczyk-McDonald, M.D.

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