03(02): There’s more to it than “just exercise more”

Nicholas Loh Avatar

Today is the last day of the 1-week-long ICOPE (Integrated Care of Older Persons) component of my Family Medicine posting. While I spent my time at the community hospital (specifically at St. Andrew Community Hospital from Monday through Thursday), today was spent entirely at home, where I participated in the following lectures virtually via Zoom:

  1. Intro to Rehabilitation Medicine (0900-0930)
  2. Deconditioning and Orthopaedic Rehabilitation (0930-1030)
  3. Brain Injury Assessment & Rehabilitation (1100-1200)
  4. Spinal Cord Injury Rehabilitation (1400-1600)
  5. Exercise Prescription (1600-1630)

Pretty long day of just being in front of the screen.

As you might guess from the title, I would like to share my thoughts on the ‘Exercise Prescription’ lecture I had the privilege of attending. Though it was only half an hour, I felt that it was such a great and practical lecture. The lecturer, Dr Yen Jia Min, introduced us to how exercise can be classified into four types. It was fascinating to hear of the theory and evidence that underlie exercise recommendations for adults. In this blog post, I would like to share my main takeaways from that lecture.

We are all quite familiar with the general non-pharmacological management of countless chronic conditions. Such non-pharmacological management also plays a significant role in, by extension, the promotion of good health. When the management is non-pharmacological, the principle is invariably to modify one’s lifestyle, and that manifests in multiple ways: engaging in exercise, cessation of smoking and alcohol (the protective effect of moderate amounts of alcohol consumption against cardiovascular disease incidence is deemed by some to be dubious), and ensuring good nutrition. In this blog post, I will be focusing on the specific lifestyle modification of exercising.

Doctors, allied health professionals, and well-meaning peers often tell patients that they have to “just exercise more” to be healthier. In my opinion, telling people to just exercise more without supplementing such vague advice with personalised details on how one should go about doing it is problematic because is not constructive. It is 2021, and virtually every human being in any given developed country would know that exercising is beneficial to one’s health. It’s been drilled into our heads by countless health promotion campaigns. So, to tell patients (or even one’s friends who are generally healthy) that they just need to exercise more risks triggering the perception that they are being infantilised.

Imagine being good-intentioned and then being met with: “Duh! Everyone knows that exercise is good. You don’t have to tell me that. I know that. Do you think I’m a little child who doesn’t know that?”

When the person on the receiving end of such vague advice feels that he is being infantilised, this could make him resist the idea of exercising even more. This is because transitioning from a state of not exercising enough to commencing an exercise routine (or exercising more) after hearing that vague advice to “just exercise more” would superficially lend credence to the notion that one didn’t know that earlier. Yes, I know. In such a scenario, it would indeed be objectively better to start exercising, but do bear in mind that human beings aren’t totally rational. They have feelings too, and I’m sure the typical person doesn’t like being infantilised, or being on the receiving end of vague ‘common sense’ advice, particularly if it’s unsolicited.

With that being said, it is thus important to ensure that the person who requires such advice is receptive to hearing advice regarding lifestyle modification in the first place. Then, to ensure that the advice is personalised and contains the relevant details, it is important to elaborate on the nature of the exercise. This is where today’s 30-min lecture has been rather helpful. Let me share with you what I learnt.

Incorporating the FITTP acronym in the context of establishing an exercise prescription

This is so important precisely because systematically incorporating the FITTP acronym would allow one to elaborate on the nature of the exercise. This allows a goal to be much more clearly-defined, and allows one to know if one has met the goal or not. It also allows the goal to be tweaked as needed.

The FITTP is: Frequency (number of days in a week), Intensity (mild, moderate, and severe), Time (how long is each session going to be?), Type (what type of exercise is this), Progression.

Something that I quite liked was when Dr Yen shared that there are generally four types of exercise. I did not know this previously. The four types of exercise are:

  • endurance (aerobic) exercise
  • resistance or strength exercise
  • stretching exercise
  • balancing exercise

I have heard of aerobic exercises and resistance exercises previously but I did not know that exercise could be neatly classified into four categories. This is a useful structured framework for both doctors and patients to think about exercise. During the lecture, Dr Yen remarked, “If you can only remember one thing, but forget everything else about this lecture, please remember this table”. Here is the table:

Please pay particular attention to the first two rows of the table! The recommendations for aerobic and resistance exercises apply to the typical adult and it would behove us to try to adhere to it as much as possible (good for you if you can exceed the minimum recommendations)! At least currently in medical school, everyone seems to know about the 150 minutes of moderate-intensity aerobic exercise per week recommendation. However, what doesn’t seem to be as well known is the recommendation on resistance training: moderate-intensity resistance exercise involving all major muscle groups for at least two days a week.

Both aerobic exercise and resistance exercise are important components of the physical activity guidelines for adults. This table outlines the physical activity guidelines for adults in the United States. Nevertheless, the recommendations are highly similar for that of Singapore.

Another useful learning point from this second table is how the 150 minutes of moderate-intensity exercise is equivalent to 75 minutes of high-intensity exercise. Recall earlier the ‘I’ in the FITTP acronym. The intensity of exercise can be graded as mild, moderate, or high/vigorous.

In making exercise prescriptions, one of the most common questions that we would likely face is, “How do we gauge the exercise intensity?” That’s a good question, and a good rule of thumb we can use is as follows:

  • Mild-intensity exercise = can sing and talk
  • Moderate-intensity exercise = cannot sing, but able to talk
  • High-intensity exercise = cannot talk, let alone sing (if you can still talk, try harder lol; you’re not there yet)

It’s also important to remember that the guidelines as given above are appropriate for the typical healthy adult. If one, for example, has a chronic disease such as osteoarthritis, then the recommendations may have to be tweaked slightly and personalised for the individual. In a patient whose knees are implicated in osteoarthritis, it is important to still engage in aerobic exercise. However, running would not likely be recommended. Instead, activities which do not result in much mechanical impact on the knee (e.g. cycling, swimming) could be recommended.

One last thing that I want to talk about is the issue of ‘exercise progression’ (c.f. the ‘P’ in FITTP).

The above is one of the slides in the lecture and I think it’s useful. Important points include how in the case of resistance exercise, increasing repetitions is preferred to increasing load. It’s also important to note that progression in exercise isn’t just about the frequency of the exercise. The intensity and duration of each session can also be varied.

In sum, I enjoyed this afternoon’s lecture on exercise prescription thoroughly. It taught me a lot about exercise and as such, I now have a much clearer mental framework about exercise that would prove beneficial not just in my own personal life, but also in interactions with my patients, friends, and colleagues where elaborating on the nature of exercise is both solicited and warranted.

I hope you have found this post useful!

8 October 2021

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