The exercise program was perfect. I considered all of the patient’s needs and goals. I provided easy-to-follow material with appropriate progressions. Yet, the adherence to the program was non-existent.
This is a common occurrence in physical therapy. As a physical therapist, it is easy for me to place the blame solely on the patient. This is a mistake.
A thought-provoking research paper
Consider the differences between the following patients from the paper Privileging the Privileged:
A high-earning professional living in a leafy suburb with a stay-at-home partner and safe access to a well- equipped gym, who easily finds opportunities to exercise after work and enjoys being active after sitting at work for much of the day.
A single parent looking after two young children and working three low-wage jobs, who is living in a small studio in an apartment block where it is unsafe to go outside after dark, and who has limited opportunities to exercise (and after paid work, looking after the house and caring for the children, is fatigued and just wants to rest).
How would you expect treatment recommendations to differ between these two patients? Would the plan of care prescription be the same? What about the advice and education for home exercise, activity level, sleep, and nutrition?
These examples highlight the importance of individualized healthcare.
Discipline is not the only requirement for exercise
I often read — and have even thought — that people who don’t regularly exercise lack discipline. Whether it be exercise, diet, or sleep, discipline alone is insufficient.
Resources matter.
It is easy to take for granted what many assume to be basic resources, like a safe sidewalk to walk or run on. It was not until I developed strong relationships with my patients and learned about their circumstances that I understood safe neighborhoods are not a given.
Time is a finite resource that is more strained for some people than others. I didn’t realize how much time I wasted until I had a full-time job and two kids. Even so, I am fortunate to have stability through a salaried job. I do not need to work 60+ hours a week away from my family or commute two hours a day.
I can fit workouts into my schedule easily. My decision is between exercise and reading a book. For others, it may be between exercise and seeing their kids or taking on another work shift to pay the rent. Not exercising regularly isn’t a simple matter of discipline.
I once completed a leadership seminar in which the speaker proposed substituting the phrase “I don’t have time” with “I don’t prioritize.” It was constructed as a shaming exercise to force people to stop making excuses. I used to embrace this philosophy. Now I cringe when I hear this substitution.
Many times something isn’t prioritized and it shouldn’t be. The problem is the shame-inducing message the substation often conveys. It is similar to the attitude I used to have towards my patients who were not adherent to a home exercise program.
I will grant you sometimes laziness is the culprit. That should not be the assumption, however.
These issues of health inequality and access to resources need to be addressed for many reasons. When it comes to physical activity, a large issue is the lack of a good substitute for the health benefits of leisure physical activity.
Work physical activity is not the same as leisure physical activity
While research supports leisure-time physical activity, the evidence is mixed on whether occupational physical activity is beneficial for your health. A recent study published in the European Heart Journal sought to provide clarity.
The research paper defines leisure time and occupational physical activity as follows:
“Leisure-time physical activity often includes dynamic movements at conditioning intensity levels sufficient to improve cardiorespiratory fitness over short time periods with enough recovery time. In contrast, work often requires static loading, monotonous and awkward working postures, and other non-conditioning activities over several hours per day without sufficient recovery time.”
Higher leisure-time physical activity associates with reduced major adverse cardiac events (e.g. a stroke or heart attack) and all-cause mortality risk, while higher occupational physical activity associates with increased risks, independent of each other.
What can we do about it?
First, recognition is key. By acknowledging these issues, we can avoid shaming people — intentionally or not — about “poor discipline” when other factors may be at play. Exercise is important for health and wellness, but we must acknowledge and address the big-picture barriers.
I see a lot of emphasis on “optimal” ways to sleep, eat, and exercise. There are many ways to do each effectively. Furthermore, there is individuality in each approach.
By understanding these barriers are present, healthcare providers and writers can help people develop appropriate strategies to achieve health and wellness. Again, there is no one-size-fits-all or exclusive optimal way to achieve health and wellness. We need to work together to better educate people and provide a variety of paths to their version of success.