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Finally – for those who haven’t seen Mike Evans’ viral video ’23.5 hours’ - it fits beautifully with ‘Everybody Walk’. Click on this link to the BJSM blog and watch it for 9 minutes! It has had nearly 3 million views!
36 million people around the world die from preventable lifestyle diseases (non communicable diseases; NCDs) such as heart disease, cancer, obesity, diabetes and mental health problems. This means that 36 MILLION people would benefit from exercise advice and support in preventing and treating these diseases.
If EVERY doctor and EVERY health professional is able to ‘direct’ and ‘support’ patients to regular exercise, as part of every consultation, then the health and economic consequences of inactivity and sedentary behaviour could start to be addressed. Patients could then be supported, proactively, to better lifelong health. NCDs will cost health economies $47 trillion by 2030. This is an unsustainable approach to health care services.
When doctors and health professionals give advice as part of the consultation, patients don’t question that advice and direction. For example, a patient needing warfarin or aspirin in the treatment of atrial fibrillation doesn’t debate the clinical outcomes of that decision: they may discuss NNT’s and NNHs, but generally the patient will follow the doctor’s prescription.
If physiotherapists are giving advice to help a patient breathe easier, the patient will generally follow the advice to improve their symptoms.
This should come as no surprise to health professionals who use the ‘art of a medical direction’ in guiding and motivating patients to better health: this can be used to great success in primary care, secondary care, health clinics, communities, cities or nations. Follow this link for more information.
What can we do?
World Physical Activity Day on the 6th April 2012 is an opportunity for sports and exercise professionals to lead the way on global exercise advice. Every health professional should give exercise advice to patients and the public. The medicine behind exercise as a critical public health intervention is now no longer debatable. Here is some evidence.
Adult patients should be advised to ‘enjoy’ stamina or endurance exercises for the minimum of 30 minutes, on at least five days of the week (ensuring they get slightly breathless).
Strength, flexibility and balance exercises should be advised twice a week. Age specific UK physical activity guidelines can be found here.
For World Physical Activity Day 6th April 2012: Make a difference to every consultation: include exercise advice, every patient!
Exercise during pregnancy provides many benefits to the mother and baby. Fortunately, clinicians and mothers have moved well beyond the view that women should be confined, or cannot initiate activity and be active at any stage of pregnancy. Here are 10 ‘take home messages’ for both clinicians and mums from a recent BMJ podcast with Dr. Browyn Bell.
1. Consider type, frequency and duration; a combination of different types of exercise is important to:
Reap the different rewards of different types of exercise (pre, during, and post-partum)
Prepare women for the physical demands of pregnancy and motherhood
Maintain a healthy bodyweight which decreases likelihood of pregnancy complications
2. There are multiple benefits to exercise during pregnancy such as:
Prevention of Gestational Diabetes
Reduction of stress and fatigue
3. Keep core body temperature below 38.5 degrees Celsius (especially in the first trimester)
4. Avoid contact sports, scuba diving, and supine exercises during later pregnancy (listen to the podcast for specifics/details)
5. Consider pre-existing health conditions that may become more pronounced during pregnancy
6. For sedentary pregnant woman who want to start exercising, guidelines are the same as for non-pregnant women (gradual increase in activity)
7. One way to ensure a safe exercise intensity is by maintaining a conversation during exercise
8. Women are encouraged to continue exercise during all stages of pregnancy (even if performance ability is reduced)
9. As always, make healthy food choices
10. Everyone has different (pre-existing and unique) health and physical needs. Common sense activities such as walking are always a good idea. Consult a physician or physiotherapist to develop an individualized approach to exercise.
The UK trainee perspective (The BJSM blog features the trainee perspective every two weeks)*
As I edge closer to the crossroads of my own career, I muse aloud as to where Sport and Exercise Medicine (SEM) is heading? Is the majority of our workload going to involve musculoskeletal medicine or should the young generation coming through break free from the current mould and realize the vision of Exercise Medicine that the Faculty (FSEM) have fought so hard to promote and to what our specialty owes its existence? I feel the urge to answer the call of cynics …
It is hard to believe bygone statements like these (in the caption) in current times. However, I should say that Sir William Arbuthnot Lane started promoting exercise, fruit and vegetables and bran cereal as an answer to bowel problems in 1925, a good 40 years ahead of his time. We now know that exercise should be undertaken at a sufficient intensity to make one at least moderately breathless. Those who have gradually built endurance over time can be encouraged to perform vigorous intensity activity. My mission is to spread the word of exercise and share a way in which SEM will develop.
“My Best Move” is a pilot project to encourage exercise prescription in primary care for long-term conditions. The project was initiated to help Department of Health (DoH) recommendations to be translated into primary care practice. General guidance is sometimes just not enough and physical inactivity remains one of the five big risk factors for long-term conditions equal in importance to smoking, obesity and hypertension. Since its introduction, the project has been greeted with much enthusiasm in the primary care sector and the extra boost and guidance in the form of training is being welcomed. It is hoped that this will start a new wave in the community that will lead to more active lifestyles despite any chronic conditions that individuals may have, without them feeling hindered by their conditions.
Taking this vision forward, an Exercise Center of Excellence is needed. A place where both able bodied and persons with disabilities, no matter what long term conditions they have, are able to be seen and given specialist care to enable them to live life to the fullest. By tailoring individual exercise prescription and rehabilitation according to patients needs, the aim is to enhance quality of life, improve absenteeism and return individuals to work, which will reap significant economic gains.
Everyone needs to start taking ownership of their own health and start making small gains rather than relying on the policymakers, the health service or their doctor. The gains, after all, are to one’s own health and well-being.
Dr Pria Krishnasamy is a Sport and Exercise Medicine Registrar in London and enjoys long walks in the countryside, martial arts, playing tennis, and dinners with good friends.
Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” which runs every two weeks.
Three exciting updates from the frontlines of health promotion through physical activity.
Illustration by Liisa Sorsa, 23.5 hours video
First, congratulations to Professor Steven Blair for winning the Bloomberg Manulife Prize for the Promotion of Active Health. This international competition celebrates a researcher whose work promises to broaden understanding of how physical activity, nutrition or psychosocial factors influence personal health and well-being.
Professor Blair has tirelessly raised awareness of the burden of low fitness. His dedicated data gathering and adroit analysis has allowed him to deduce that physical inactivity is the biggest public health problem of the 21st century. His 2009 editorial in BJSM shares this title and has been downloaded more than 20,000 times (available free online).
Secondly, after garnering global attention, Mike Evan’s videos 23.1/2 hours is being translated into multiple languages. Sports Medicine colleagues will ensure the video can be enjoyed by speakers of Arabic, Spanish, Chinese, and Italian. And there will likely be more offers to come.
This will further enable the first physical activity ‘YouTube sensation’ – 23 1/2 - to promote behaviour change, while recognizing the physical activity challenges in a wide range of countries.
While 1.6 million hits demonstrates 23.1/2’s current success, translation into multiple languages may take this video to the ‘next level’ with a goal of 10 million views!
The video has already gained international traction as shown by the breakdown of views per country: US 844, 664, Canada 320, 000, UK 61, 345, Australia 49, 100, India 32,000, Netherlands 14, 977, Singapore 13,761, Germany 13, 345, Malaysia 11, 986, Sweden 11,589, Israel 11, 387, Saudi Arabia 10, 786, Mexico 10, 607…and the list goes on.
If you haven’t watched the video yet, check it out here (and note Steve Blair’s fun cameo at around 2 minutes 50).
And a third exciting sign of progess was Scotland appointing a physician to head their campaign against physical inactivity.
Doctor Andrew Murray (@docAndrewMurray) – who clearly has to differentiate himself from his colleague “Andy Murray” (@andy_murray).
The more important of the two, although seemingly not by # of Twitter followers, Doctor Murray, makes the point that “having a low level of fitness is equivalent in risk to having diabetes, smoking, and being obese combined”. BJSM likes that emphasis – amazing but true. All the best in the job DocAndy – we look forward to interviewing you for a BJSM podcast (with subtitles).
So – things are moving in the right direction – let’s all take up the cudgels and promote, promote, promote. Remember that Kotter said transformational changes takes 10 times as much communication as you expect it will need (plus 7 other things: see BJSM article on Kotter’s eight-step programme for transformational change).
The UK trainee perspective(A monthly BJSM blog feature)*
This morning I was walking through woods on one of those glorious crisp days. I stopped in a patch of sunlight, with my North Face hat pulled down over my ears, and I felt a physical upsurge of pure, simple, unadulterated bliss. And a thought floated in my head… “If I can still do this when I’m 80, I’d be happy.”
Photo courtesy of Florian Seiffert (Flickr CC)
So as we enter 2012, it’s worth pointing out that alongside the London Olympics, the UK is also hosting the World Congress on Active Ageing for the first time and it got me thinking about ‘active ageing’. What does it mean? How can we help as sport and exercise doctors? What might an active ageing programme look like?
I’m not suggesting for a minute that every person should be instructed to walk in woods (although I’d bet they would enjoy it). The approach needs to avoid being patronising or generic, but instead allow for an individual’s personal circumstances and preference. It needs to encourage inactive people to start fun, low-cost activities that suit them. But it also needs to guide already-active people who develop co-morbidities and give them the confidence to exercise safely despite their illness. It needs to work in partnership in the community with exercise programmes for older people that already exist. The approach should encourage a lasting change in behaviour and in the long-term should not require high levels of external organisation. So can we do this?
Dr Natasha Jones and Dr Julia Newton will be putting theory into practice this year. In December, Nuffield Orthopaedic Centre Sport and Exercise Medicine Department won the Oxfordshire Active Ageing Service bid in an exciting collaboration with Age UK. The service, launching in May, is called ‘Generation Games’.
It will involve an interactive website that will help individuals improve their fitness and health awareness by addressing individual barriers. To help those with chronic disease, there will be a progressive exercise pathway, integrated with current level 1-4 exercise schemes and established specialist rehabilitation schemes. A key piece of work will be the development of pathways for specialist departments not yet providing exercise rehabilitation schemes e.g. diabetes, cancer care, mental health, all of whom would benefit from improved physical activity levels.
The service will be launched through media, online, poster and leaflet-based information systems and promoted through peers, the media, primary care, secondary care, rehabilitation services, community care and Active Ageing partners in the community.
The over-arching ethos of the Generation Games service is self-efficacy and a user-centred approach that has to be the way forward. I wish them every luck in setting up this service, particularly as I may just be needing it in another decade or two…
Mike Evans circulated this to his hockey team of kids early in December 2011. #1 educational video on YouTube. Remember that low fitness (<30 mins of physical activity daily) kills more Americans that smoking, diabetes, and obesity combined (smokadiabesity).
Yesterday’s U.N. Side Event on Physical Activity and Noncommunicable Diseases (NCDs) brought together an extraordinary group of world ministers of health, public health professionals, physical activity advocates, scientists, elite athletes and other experts. The focus was on physical activity as a global health opportunity, informing the deliberations of the U.N. High-Level Meeting on Noncommunicable Diseases taking place today and tomorrow.
Live Webcast U.N. Roundtables
The U.N. sessions on NCDs will be webcast live at www.un.org/webcast ( http://www.un.org/webcast ) . Under Live Schedule at right, click on Channel 4 to access the roundtable discussions on NCDs (Monday at 10:00 a.m. and 3:00 p.m. EDT).
OK – I have to begin with a ‘competing interest’ statement – I’m blogging about a paper I coauthored. But, I think it is my first such post since we started blogging seriously at BJSM (2009). The objective measure is that the paper has been downloaded close to 5000 times each in full text and PDF. (Thanks Mum!).
Seriously though, there is increasing level 1 evidence that exercise is a powerful therapy for musculoskeletal conditions – for muscle strains, joint degeneration, sciatica, not to mention (shh! tendon injuries). The historical rationale to explain the mechanism of this was ‘strengthening’.
‘Strengthening’ as a mechanism for tissue repair didn’t make sense to me when I was in my busy clinical phase. How did ‘strengthening’ the hip external rotators remove the pain of ITB friction syndrome? What was it about ‘strength’ that would remove the pain of a hamstring strain?
Mechanotransduction is a well-recognized physiological principle that should have much more traction in physiotherapy/physical therapy courses and in medicine. This is how the body adapts itself to load. Why are Arnold Schwarzenegger’s muscles bigger than mine? His workouts signal his cells to hypertrophy and and multiply as needed and he gets bigger muscles. Mechanotransduction is the process. If it were genetics (the big myth!) it would mean he could have stopped working out from age 5 and have the body of a muscle-man.
The proximal phalanx of a negligent sawmiller – who has lost his distal phalanx — is vastly smaller than his or her intact proximal phalanges. Same hand, same genetics — less loading. Mechanotherapy trumps genetics! Note examples from different tissues – mechanotherapy is a universal principle. It’s why an elite distance runner has larger pipes than a sedentary academics about to have a cardiac arrest.
When clinicians prescribe exercise, the loading signals cell to repair and to function in response to load. Turning movement into repair.
Clinicians, you see the power of mechanotherapy daily in your practice. Mechanotherapy is when you apply the principle of mechanotransduction as a treatment – analogous to the use of ‘electotherapy’ or ‘pharmacotherapy’ (but way more powerful than either of those!). Normal physiology = mechanotransduction; Prescribing targeted exercise = mechantherapy. Simple.
Know that there is a very well-established scientific basis underpinning the success. Incontrovertible. (3851 citations in Pubmed). Stick with it – it can take time to work fully. Avoid the temptation to switch to snake-oil formulas or funky treatments. Trust in millions of year of evolution. The folks who couldn’t repair their injuries while moving on to the next feeding grounds aren’t with us any more. Mechanotherapy provides a powerful survival benefit!
I read with great interest your article ‘Developing healthcare systems to support exercise: exercise as the fifth vital sign’ (Sallis R. Br J Sports Med May 2011 45;6:473-4 – Free online).
My main concern is whether we should also be educating the physicians. I recently was involved in a discussion with 3 diabetes consultants and was suggesting that whilst working in their department, an exercise and nutrition section should be opened up. Eager to be part of such an initiative, I explained how this can reduce health care costs, morbidity and mortality in the long term for both patient and the health care system.
To my dismay, the idea was quickly shot down. Although they agreed that the evidence is there and there is a good positive outcome, the manpower, expertise and cost to the health care system to initiate such a programme was difficult to obtain.
This made me think deeply, and my main concern is whether we should be also educating the specialists who are not in the field of exercise medicine. The long term benefit clearly outweigh the initial costs, yet lack of initiative about an exercise programme makes me wonder where the problem lies.
We want to know what you think about developing healthcare systems to support exercise as the fifth vital sign!
Please leave comment below or
email: karim.khan@ubc.ca
or Tweet @BJSM_BMJ
Dr Danica Bonello Spiteri graduated from the University of Malta in medicine and surgery in 2004 and obtained her MRCP in 2009. She is pursuing the Masters level degree in sports and exercise medicine at Bath University. She is also a Specialty Registrar in Sports and Exercise Medicine in Leeds, UK. Dr. Spiteri is very active in the triathlon scene on a national and international level, and was the Malta National Sportswoman of the year in 2010.
