Tell patients to forget "no pain, no gain"

Washington -- Many people who resolve to embark on fitness programs at the start of the new year abandon such healthy thoughts when aching knees and backs bring them into their physician's offices after just a few weeks.

But it doesn't have to be that way.

As rising levels of obesity threaten to undermine the health of young and old, increased exercise could provide a route, though not an easy one, out of this morass. Physicians can help patients develop programs that avoid some common pitfalls and could spell the difference between success and failure, say those who see the damage wrought by imprudent exercisers.

"It is key to remind people that the adage 'no pain, no gain' is wrong," said Clarence L. Shields Jr., MD, an orthopedic surgeon at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles. "They should not try to push through with a painful swollen knee or increasing back pain."

He also sees patients who, despite having mild arthritis, embark on a running program when a low-impact exercise would have been a better choice. They should start off on an elliptical trainer, bicycle or perhaps swimming, Dr. Shields suggests.

X-rays might come in handy to determine the extent of a knee injury before any exercising is begun, he said. Patients should also be warned not to take pain medications and then continue to exercise.

They often think, " 'I'm out of shape, that's why my knees are sore,' " said Dr. Shields. They press on, causing greater damage. Dr. Shields recommends ice and, if that doesn't help alleviate pain, a medical evaluation is needed.

Patients can exacerbate back pain by increased walking. "As you get fatter, your back and abdominal muscles get worse," he said. For such patients, he recommends including exercises that strengthen these muscles.

Patients with a history of heart disease should receive a medical evaluation before embarking on a program of increased exercise and be cautioned to take their target heart rate into account when exercising, he advised.

Slow and steady

For many adults, their last significant encounter with exercise was in high school or college and now, years beyond, they try to pick up where they left off. Not surprisingly, they overdo it, said William O. Roberts, MD, president of the American College of Sports Medicine and a family physician.

"I always call it the too's: Too much, too soon and too hard," he said. "People start out and do a little bit too much, too fast or too vigorously and then they quit because it hurts."

Dr. Roberts sometimes tells his patients to begin with as little as five minutes of exercise a day and increase it by one minute on subsequent days. Improved fitness is very important for older people who need to increase strength and endurance, he said. And special equipment isn't necessary. "It can be partial weight lifts hanging onto the kitchen counter, or stepping up onto a box or aerobic step for leg strength, or walking."

There are also psychological aspects to consider when embarking on fitness programs, said James C. Rosen, PhD, professor emeritus of psychology at the University of Vermont. "Developing a new habit is challenging and takes some adaptation," he said.

An exercise program presents a host of stressors including the very fact that it takes time away from activities that are more pleasant and less demanding. And the initial effort can make an individual feel worse rather than better, he said.

"Many people don't have a self-image as an exerciser, and they have to accommodate to being in workout clothes, exercising in front of others or just using their bodies in a physical way," Dr. Rosen said.

"I see it as a grieving process and an acceptance that you cannot belong to every committee and club and watch television and still make substantial increases in exercise time."

Dr. Rosen also recommended working toward a goal of exercising up to six days per week for a total of six hours of activity per week. For those who never exercise, he would start with one day per week adding a day every two weeks.

He advises not worrying about the type of exercise or the amount of exercise at the beginning. "It's more important to increase the number of days," he said. "The psychological experience of making yourself get dressed for your walk and going out the door is more important than whether you walk one or two miles."