Physio Network

#21 - Exploring physical exercise prescription with Dr. Jane Thornton

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In this episode we explore the physical exercise guidelines, barriers, benefits and how we are performing as health professionals with exercise prescription. Dr Jane Thornton discusses the latest research in relation to the current exercise prescription principles, specifically through the WHO guidelines. 

Dr. Thornton is a Clinician Scientist specialising in long-term athlete health, female athlete health, and physical activity in the prevention and treatment of chronic disease. She is an Assistant Professor in the Department of Family Medicine, with cross appointments in the Department of Epidemiology & Biostatistics and Department of Kinesiology at Western University in London, Canada. She is a Member of the Board of Directors of the Canadian Academy of Sport and Exercise Medicine (CASEM) and Editor of the British Journal of Sports Medicine (BJSM).

Dr. Thornton represented Canada for over a decade in the sport of elite rowing, becoming both a World Champion (2006) and Olympian (2008), and has been recognised nationally for her contribution to society by sport/volunteer initiatives.

Want to dive deeper into this topic? Jane recently did a brilliant Masterclass with us on Prescribing Physical Activity. You can watch her whole class now with our 7-day free trial: https://www.physio-network.com/masterclass/prescribing-physical-activity/

Our host is Michael Rizk from Physio Network and iMoveU: https://cutt.ly/ojJEMZs

SPEAKER_01:

Finding that patients in a primary care setting in family medicine overwhelmingly wanted their physician to talk to them about exercise as well. It just that it seems to be that they would like some more kind of tailored specific advice. And that's maybe why, you know, physicians and other allied health providers are a

SPEAKER_00:

Getting patients to follow the minimum recommended dosage of exercise can be a challenge, and we all know the benefits. Well, today we had Dr. Jane Thornton on. Now, she's a clinical scientist. She specializes in exercise for health of the female athlete and for chronic disease prevention. She's also published on several wonderful papers around exercise. She helped us with the barriers to getting patients to this level of exercise, as well as some practical tips. I think this is a really useful episode for all health professionals, wherever exercise exercises involved. My name is Michael Risk and this is Physio Explained. Welcome, Jane, and thank you for joining us.

SPEAKER_01:

Thank you for having me.

SPEAKER_00:

Now, a lot of your work has been in the exercise space. I wanted to start with how are we doing as health professionals prescribing exercises?

SPEAKER_01:

Right. So I think from a perspective of talking about physical activity to patients, there's a pretty big gap between what patients would like to hear and how often they would like to hear and how often healthcare providers are actually discussing it. And that's occurring for a variety of reasons. But some of the research that we've looked at on the physician side of things, for example, is that about 93% of patients want to hear about physical activity, but about 15 or 16% of physicians actually prescribe it. It's roughly the same for physiotherapists as well under a quarter. So even though it seems to be a welcome message, the healthcare providers in general aren't getting the message across on their end.

SPEAKER_00:

A distinction that I'll make upfront is my bias being a physio is we all prescribe exercises, but we're not talking about like glute exercises. We're talking about physical activity guidelines and exercise in that sense, right?

SPEAKER_01:

Yeah, and that's an important distinction. So instead of neuromuscular programming or actual exercises, sets and reps and things like that, which are critically important, as you know, for a variety of different conditions, injuries and prevention and so on, this is specific to physical activity for health. So more about aerobic exercise, plus or minus some strength training as well, but kind of the general guidelines that we internationally agree on, which is one of those unique things that we do agree on globally, but really that concept of about 150 minutes, the 300 minutes per week of moderate to vigorous physical activity, plus some resistance training. So that's basic physical activity guidelines for health that have been adopted pretty much globally. And that's the kind of physical activity prescription that seems to be a huge disparity in clinical work.

SPEAKER_00:

Really interesting you use the word gap, because I don't know why, but in my brain, I have a feeling that when I start to delve into physical exercise and the exercise guidelines that people don't want to hear it. But you're saying that the research is supportive that patients actually want to hear more about that.

SPEAKER_01:

Right. And I think the disconnect seems to happen for a few reasons. I think one of the issues, of course, is behavior change. It's extremely difficult. It's difficult for all of us. No one is perfect. And we all have things that we wish we could change about our own behavior, be it physical activity or nutrition or flossing or any kind of behavior that would make us healthier or more productive or things like that. So of course, that's going to be harder to adopt. And if you're a busy clinician or healthcare provider, you may not have the time or you may not know what's worth it. So one of the things that we found that has been reproduced in a lot of the research to date is that there are basically three main barriers which accounts for that gap. And One of it is, as I just mentioned, time being a critical factor, just not having the time to go through a lengthy behavioral change intervention like motivational interviewing or things like that. And the second is the lack of training that we may have. So through our professional schooling, we may not have had that time in the curriculum to be able to train future doctors, future physiotherapists, future allied health in that specific area. type of intervention. And then thirdly, it really comes down to our belief that patients or clients that will really adopt our advice, that they will actually want to change. So I think that's where it comes down to listening to our patients. And we did a study in Toronto in one of the hospitals finding that patients in a primary care setting in family medicine overwhelmingly wanted their physician to talk to them about exercise as well it just that it seems to be that they would like some more kind of tailored specific advice and that's maybe why you know physicians and and other allied health providers are a little bit hesitant if they don't know exactly the type of personalized advice they should give

SPEAKER_00:

yeah there's Some really good things there. I remember reading a recent study that I think it was physios or maybe health professionals, a large percentage couldn't cite the recommended dosage. So while we're at that, could you remind us what the recommended dosage is?

SPEAKER_01:

So the WHO actually came out with updated guidelines in December of 2020. And it's fairly similar to what we knew that it used to be 150 minutes of moderate to vigorous physical activity. And by moderate and vigorous physical activity, it's the type of activity that makes you break a sweat, raise your heart rate a little bit. And, you know, still with moderate physical activity, kind of a way to judge that is one simple way is to use something called a talk test, where you're able to have a conversation with someone real or imaginary beside you, but you're a little bit out of breath. You can still form sentences. Whereas if you get to the vigorous state, it's not a place where you can hold on too long to that type of intensity and Maybe you're just kind of getting out short sentences or in some cases, nothing at all. You're still just trying to focus on your exercise. So if you're able to maintain a conversation or feel quite a little bit out of breath beyond that, that's where you're hitting that kind of perfect zone. And beyond the aerobic recommendations, we often talk about adding two sessions per week of resistance training. So where you target... both upper body and lower body, but kind of the major muscle groups. And then I guess the last thing I would say is for older adults, so 65 plus, we generally talk about adding in some kind of balance training or yoga or things like that and flexibility training. So to think about preventing falls.

SPEAKER_00:

That's a good pearl right at the end there. I was thinking about time being the barrier, as you said, and I'm thinking health professionals are in my sitting here in Australia, we generally have half an hour, right? So that's not bad, but I know you work with a lot of GPs and physicians and they might not even have that. They might only have five or 10 minutes. It's something in my guts telling me that it's that context and that setting where that conversation might take place more at the GP or physician level. Is that what you see? And is that an even added barrier for GPs and physicians?

SPEAKER_01:

Yeah, that's a big barrier for sure. And I think one of the interesting studies that came out probably about a decade ago now is this concept of having it doing brief interventions versus the longer motivational interviewing. So even time spent in a minute or two minutes can have an impact on patient's health. And even just asking the question, how much physical activity they're getting per week, for example, has added effect of just putting it on the patient's radar that they're This is something that the physician or healthcare provider feels that's important. So in the context of a physiotherapist visit, for example, of course, much of that time has to be devoted to treating the injury at hand or rehabilitation or that kind of thing, more very specific. But I think where there's an added value is that making every contact count. And that means also that if we as in all of allied health, every time that a patient comes into contact, with a healthcare provider, the importance of physical activity is emphasized because especially in our day and age right now, in terms of how many people have more than one chronic condition. So this concept of multimorbidity and that presents in the hospitals, that presents in primary care settings. And so I think that's why it's crucial for all of us to have some understanding of what that looks like and to be able to add credibility to our messages.

SPEAKER_00:

Do you have any further tips around that? Because I love this idea that if all allied health got on board with this, there would be a big change. Do you have any other tips on bringing that up and what you might do if you receive some resistance as well?

SPEAKER_01:

Right. So, I mean, there's a couple of settings that this can happen, but you can imagine someone going in for even just total knee replacement or something along those lines. If they're coming into hospital, maybe they have a heightened cardiovascular risk that they're assessed by internist or one of the physicians. It could be a physiotherapist. It really depends on the setting, but that they're offered prehabilitation so that they have some kind of strategy before that they're getting stronger, they're becoming more active. which we know that influences surgical outcomes. So already you have that person on board, the patient on board, but also that provider on board. The surgeon's going to be on board because they're measured by clinical or surgical outcomes. And then you'll see that they'll have a better outcome. And then post-op, they could have follow-up either with your primary care physician. If everyone along that chain from that allied health and all of the healthcare providers involved in that participant, that patient's journey, talks to them even momentarily about physical activity, you can imagine the kind of impact that has on a patient. And I spent a year in Switzerland doing preventative medicine, and we'd find that people who had had a life-altering event, so it could be a myocardial infraction, a heart attack, or a stroke, or a pregnant patient on bed rest with multiple risk factors who's just rehabilitating and kind of getting back on her feet, just that concept of something out of the blue that they didn't expect, it's almost this critical moment where they are more open to hearing about ideas, including behavior change. So that's when physical activity as an intervention would be adopted. That question about resistance, I think too, is that it may not be that moment that they're going to decide to be physically active, but It really emphasizes the importance of follow-up, which is really nice with physiotherapists and other allied health that they do come back for further sessions. They may see a physician only once, but they'll come back for follow-up for repeat visits. So it may not be that first one, but each time kind of making every one of those contacts count that a patient may be more apt to say, you know what, this time I think I'm ready to adopt this.

SPEAKER_00:

I love the idea of the brief interventions and almost that if all allied health could include that question it would become the new norm and we're also getting them at that sensitive time point because even a musculoskeletal injury can be a significant emotional event and that can be a good time to plant the seed i have one little bias here that i wanted to ask you and it was that most of those conditions chronic conditions i wonder how much could be solved if everyone had the minimum exercise guidelines and everyone had decent nutrition advice. And I always felt like when we've got people with multi-illness pathology, should that just be the first port of call? It's like, we're not going to try any other medical intervention. This is the primary intervention. What's your stance on that?

SPEAKER_01:

I think that's absolutely the ideal approach. And it's a question I know in Canada, for example, so four out of five Canadian adults aren't physically active enough to make an impact on their health to reach those healthy guidelines. And so that question comes up a lot in the sense of when we look at the effect of physical activity on 30 plus chronic conditions, that physical activity is increasing. equivalent or sometimes superior than a lot of the medications we prescribe. So an example, in a recent systematic review and network meta-analysis, they looked at that concept of physical activity and how it stacks up against medications. And to get that same drop in blood pressure, you could be physically active versus taking any of the antihypertensive medications, that global effect. So I think that's why those are these important considerations to take into mind. And patients want to have that alternative treatment as well.

SPEAKER_00:

And I'm also thinking not just physical health, but mental health as well. If we can start out with the activity guidelines and good nutrition, we'll go a long way to solving a lot of things.

SPEAKER_01:

Absolutely. Yeah. A huge impact for depression and anxiety and so on. So especially in this era, I think we're finding that people want to be physically active for major mental and physical health benefits.

SPEAKER_00:

And Jane, just to wrap up, could you tell us about the Make Your Day Harder project?

SPEAKER_01:

Yeah, that was a project that I co-created. Dr. Mike Evans, he was a family doc in Toronto and now he's a health lead at Apple. So he and I and a few other creatives and patient advocates set up a website to just create a movement for people to talk about how to make their own day harder by being physically active. So kind of just movement hacks or ways that they could implement physical activity into their health. So it just was a social media kind of movement and people all around the world got behind it. So just a concept of saying, you know, patients driving the solutions versus top down from health care. I

SPEAKER_00:

like that. That's a great resource to check out. Make your day harder project. Jane, thank you so much for your time.

SPEAKER_01:

Thanks for having me. That's great. Thank you.