Lack of Exercise as a Medical Condition

A recent editorial in the Journal of Physiology asked the question whether deconditioning should be medicalized.  The author, Dr. Michael Joyner, a medical doctor and researcher at the Mayo Clinic, points out that 3 months of exercise training can reverse or improve the syndrome of postural orthostatic tachycardia syndrome (POTS). This syndrome is an excessive heart rate response to standing, a high heart rate response to a given level of exertion, and also involves reduced exercise capacity. While a number of pathophysiological explanations for POTS exist, over the last 5–10 years several labs have noted that the pathophysiology of POTS bears a striking resemblance to extreme forms of deconditioning such as prolonged bed rest.

 In thinking of this syndrome, the author considers whether not exercising should be considered a medical condition, in the same way that diabetes or obesity are a condition.  In reading his editorial, I appreciated that the author did emphasize the importance of a supportive environment and that exercise is often a preferable intervention over medication.  I think it's wonderful that this pathway is being considered more often in medical decision making.

I will add that it's sometimes inappropriately prescribed, in that I've seen patients  presenting with acute lower back pain who have been told the cause of their pain is their weight, and that they first need to lose some weight.  While treating obesity is a worthwhile goal, it's inherently unkind to tell someone this.  While exercise is usually good for back pain, the expectation that weight loss is a prerequisite to reducing pain has certainly not been established.  Very often, a patient with acute pain can not exercise efficiently, not to the extent of leading to any significant weight loss.  While moderate exercise that does not increase pain is a recognized evidence based intervention for back pain, expecting that exercising to the point of reversing obesity while also experiencing severe pain is setting the patient up for failure.  It's not news to the vast majority of patients that obesity is a bad thing.  Most patients are starkly aware of it, and some dread talking about because they feel that any pain they have is their fault for being lazy.  It takes no effort for a doctor to say "lose some weight", but it difficult to do under the best of circumstances, it can be much harder with untreated pain.  Bad pain happens to good people.  Skinny patients have severe back pain too, and shaming a patient in pain is simply kicking them when they're down.  While I'll almost always try to find some pain free exercising/stretching to help with a condition, I will also make sure the patient isn't trying to do too much to soon.  Doing too much invariably leads to the patient getting the feeback that exercise=pain, and overall discourages healthy exercise. As a chiropractor also trained in physical therapy, my strategy in my Rockville office is to offer several modalities at once, some which are passive that help relieve pain as soon as possible, while also suggesting the proper dosage of recommended exercises that can be done in a close to pain free manner.

On the other hand, I've also had patients in pain who've had their doctor take off their favorite form of exercise, with no game plan to return them to it.  My brother, a lifelong runner, told me once of the adage "Never go to a doctor who doesn't run, cause they'll just tell you to stop running".  This is still true, and I still commonly hear bed rest being prescribed for back pain, despite several studies finding that it typically exacerbates the condition.  Some patients have essentially had "exercise deprivation" inflicted on them by their doctor.  Given the plethora of benefits that research has found that  exercise can bring (alleviation of diabetes, obesity, hypertension; improved mood, better sex life, lower incidence of cancer, exercise and falls), its frankly dangerous to take away exercise without having a strategy for it's resumption.  I was inspired to enter my field at least partly due to multiple medical doctors telling me to give up my form of exercise (martial arts).  While this was an obvious solution, it was not a helpful one.  It was a chiropractor who said "Charlie, if I told you to stop doing karate and teaching self-defense, I'm guessing you'd ignore me anyway, so here's how we'll treat it".  He was the first to explain the involed anatomy, the likely diagnosis, and how to exercise as I wanted with no problems.  Seventeen years later, I'm still in the same martial arts style.  This sensible approach is what I've emulated in my practice, and I'm happiest on hearing back from patients that they're once more doing the form of exercise they love.  

If you've a question on how I can help, whether you're leery of cracking, feel that you need it or aren't sure, please call,   301-545-0800 or emailcginsburg@abcclinics.com.