Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions, 2021, Reid et al

[Daisy]

Consensus statement
Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions, 2021, Reid et al

British journal of sports medicine

https://bjsm.bmj.com/content/early/2021/11/03/bjsports-2021-104281

Consensus statement includes the comment:

A limitation in the scope of this statement is that the list of medical conditions covered is not exhaustive. For instance, we do not include chronic fatigue syndrome and long COVID-19 since evidence on physical activity risk is limited and actively evolving in these areas. We cannot be sure that our symptom-specific statements translate effectively to clinical practice and subsequently to people living with these conditions.

Consensus statement endorsed by RCGP, RCP, RCN, Chartered society of physiotherapy, British association of sports and exercise medicine

 

[Andy]

Consensus statement endorsed by RCGP, RCP, RCN, Chartered society of physiotherapy, British association of sports and exercise medicine

So at least one of the Royal Colleges who are throwing a tantrum about the new NICE ME/CFS guideline.

 

[Trish]

Under Fatigue it says:

Regular physical activity helps reduce fatigue and improves well-being and sleep. A temporary increase in fatigue is commonly experienced when starting a new physical activity until the body adapts. People should be counselled to expect this and advised to build up activity gradually. People experiencing fatigue related to chronic fatigue syndromes may benefit from specialist advice.

In the discussion section it says:

A challenge for this study is that the risk of physical activity-related adverse events in people living with LTCs is seldom reported and poorly quantified. Much of the relevant literature is condition-specific, addressing the benefits of physical activity and heterogeneously reporting adverse events as secondary outcomes.100 The relationship between risk and clinical symptoms or syndromes is not transparent, so expert clinical consensus has been relied on to interpret this data

The bit about CFS and Long Covid that Daisy quoted is hidden away towards the end of the discussion and not mentioned in the abstract at all.

This project seems to have been based on opinions of exercise specialists and a small survey of patients. From reading the conclusion it seems that the main aim of the paper is this:

We challenge recommendations that individuals with stable LTCs require medical clearance before autonomously increasing their physical activity levels. We suggest that routine preparticipation screening in this group poses an unnecessary barrier to self-directed physical activity and engagement with the physical activity, sport and leisure sectors. Our findings suggest that the need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms.

It seems to be about removing requirements that gyms and sports clubs need to get medical clearance for people with long term conditions to join their activities.
Yet at the same time they admit there's not enough evidence about harms.

 

[chrisb]

How appropriate that the Delphi process was utilised. Didn't the Pythoness speak intoxicated gibberish which had to be interpreted by her priest? Better still they go on to use the SurveyMonkey. What fun they must have had.

 

[Peter T]

So this article is saying practitioners and clinicians believe that them telling people with long term conditions to be more physically active is likely overall to result in more benefits than harms, overall this may be true, however this does not necessarily entail that every individual with a long term disability will find that listening to them will in reality produce more benefits than harms.

It seems to me that the article is repeated assertions of benefits outweigh risk without any meaningful attempt at quantifying either and without any serious attempt at establishing any contra indications. This is rather like asserting that benefits of having shellfish in your diet outweighs the risks. Overall that might be true, but that does not mean that this advice is appropriate for everyone, certainly people allergic to shellfish or who live in areas of high marine pollution are at very real risk of being harmed or even killed by that advice.

Also the article makes no meaningful attempt at quantifying what is meant by physical activity. It is questionable that there is a simple linear relationship between amount of exercise and benefit and risk. For example there are some joint conditions where there may be an optimum amount of activity, too little may restrict joint motility but too much result in physical damage.

I am willing to accept that for human beings, all other things being equal, the more active your are the better health you are likely to have, but to assert this is true for everyone in all circumstances represents a dogma of faith, rather than a rational position.

[added - We are now in a culture that fetishises exercise, and we have no idea of the psychological harms this can result in. We increasingly see on social forums, very real distress experienced by new patients with ME and I assume Long Covid, when they are unable to train at the gym two or three times a week. When people’s sense of well being is tied to high levels of physical activity, if they lose the ability to achieve those levels of activity they lose their sense of well being.]

 

[chrisb]

The International Society for Physical Activity and Health identified the healthcare sector as one of the eight best investments to combat global population inactivity.

That sits oddly in even a pseudoscientific paper.

 

[Peter T]

I wonder if this article would be better regarded as a quasi political manifesto rather than a scientific review.

 

[Mithriel]

It is the usual sound bite science we are see more and more. The headline will be used alone as "proof"

 

[Jonathan Edwards]

This article seems to encapsulate the unhelpful beliefs in the physio and sorts medicine world that the NICE guideline made some progress in countering - although not enough.

I would like to see David Strain repudiate this sort of thing. It is exactly like the behaviour of some of the representatives at the NICE round table - basically a marketing pitch for gym teachers.

Is there actually any evidence for exercise being good for people with long term conditions?
Evidence that passes the basic tests of reliability?

 

[rvallee]

Seems like a very weak claim, made mostly to shift responsibility away from medicine. If it really were that simple, if it really did have massive health benefits that could be measured economically, hell even fiscally, if it were actually worth it to get people active as a health measure, this would be largely socioeconomic policy as it is incompatible with a "work everyone into the ground" culture.

Because the likely outcome of this is probably silly stuff like doctors "prescribing" exercise and thinking they're doing great. It's certainly true that it's good to be active, people who are feel it, but it's usually not as a choice that people aren't, almost entirely for socioeconomic factors, the balance being largely in the areas where medicine fails, like chronic illness. So this isn't medical or even health, it's a whole of society approach that, if it were really worth it, would be pushed as such by medical authorities, aimed mostly at governments. If there were credible evidence anyway.

But we know that won't happen because the claims are vastly inflated and probably more than anything simply reflect the fact that healthy people are more active, because if it weren't for taking causation backwards out of loose correlation there would be nothing to this damn BPS model.

Because there are similar issues with pollution, a health problem caused by socioeconomic factors. Pollution is massively expensive in terms of health care, and yet as far as medicine is concerned environmental issues are 100x less important than thoughts and beliefs and other woo, if at all. It would also be a socioeconomic policy, on public health grounds, but very little of this happens within health care systems, it goes to the very fabric of society. Which would be argued forcefully if it had any basis. But it doesn't, it's just something that sounds nice but makes public health a personal issue.

 

[Mij]

It depends on what they mean by 'physical activities'. I like to go out walking when I'm able, on my own terms.

I don't know if it's beneficial long term though, but it does help improve my balance and gait on a short term basis.

 

[chrisb]

In its favour is the fact that this paper gives us perhaps the most fatuous acronym yet. Are the these the rowdies who make watching Davis Cup tennis unbearable?

Stirling Physical Activity Research Knowledge and Learning Exchange (SPARKLE), University of Stirling,

 

[Three Chord Monty]

I wouldn't expect ME to be on the radar of the people retweeting one of the tweets about this (I copied the link to the list of retweets with quotes but that doesn't seem to show up here, you'd need to click through & click on 'quote tweets'), but the fervor with no mention of any exceptions is a tad disturbing less than a week after the guidelines were updated.

 

[5vforest]

I don't understand the point of making blanket, absolute statements like "Physical activity is safe, even for people living with symptoms from multiple medical conditions."

At first I thought that "multiple medical conditions" must be some established concept that I was not familiar with, but it doesn't appear that it is?

Is there really such a high incidence of people being "afraid" of exercise and avoiding it due to "false concerns" or whatever? Maybe I am living in a bubble but in my experience, people understand that exercise is a Good Thing unless it is actually contraindicated for a specific reason. Excluding those of us with ME, I don't know many people who are "fearful of their condition worsening". Even my 92 y/o grandmother stays as active as possible.

 

[Amw66]

Under Fatigue it says:

In the discussion section it says:

The bit about CFS and Long Covid that Daisy quoted is hidden away towards the end of the discussion and not mentioned in the abstract at all.

This project seems to have been based on opinions of exercise specialists and a small survey of patients. From reading the conclusion it seems that the main aim of the paper is this:

It seems to be about removing requirements that gyms and sports clubs need to get medical clearance for people with long term conditions to join their activities.
Yet at the same time they admit there's not enough evidence about harms.

Clears the way for social prescribing by therapists?

 

[Mithriel]

Looking at that diagram, the headings under adverse events seem carefully chosen to make the harms claimed by patients with ME sound like a misinterpretation of normal consequences of starting to improve fitness.

Fatigue - an increase in fatigue is normal. Well yes it is but what about not being able to lift your leg? Saying it causes fatigue is a dig at people with ME simply because they insist on packaging the very abnormal response we have to exercise into a word that people relate to their own experience, not ours.

Shortness of breath - everyone knows you get out of breath when you exercise. It is the way the body clears the oxygen debt you get when you rely on the emergency anaerobic system in the cell because you have reached your aerobic limit. The CPET research has shown that we slip into this reliance to carry out the activities of daily living not just after exercise and are not recovered even 24 hours later.

Hypoglycaemia - this only mentions diabetics, not the problem people with ME can have.

Cardiac chest pain - only relevant to people with heart disease. Again not acknowledging that people with ME have died of heart attacks after exercising too hard.

Palpitations - only takes into account the heart rate increase that is normal after exercise, not the problems with OI and POTS common to people with ME or the consequences they can have.

Falls and Frailty - balance is very bad in ME but I do not know how common falls are. Exercise will not help people with a positive Romberg's sign (fall over when eyes are shut) which is so common in ME it was once considered as counting towards a diagnosis.

Cognitive impairment - this is obviously only looking at people with cognitive disease, not the brain fog of ME where exercise can prevent someone from being able to count or plan.

A superficial glance could make this list of things that people think will cause them harm but don't into a description of what we call PEM so everything is explained away. It is obviously why they think harms to patients are unimportant. If they would only look at how ME actually affects us they could find what is safe and what is not.

 

[Ash]

Looking at that diagram, the headings under adverse events seem carefully chosen to make the harms claimed by patients with ME sound like a misinterpretation of normal consequences of starting to improve fitness.

Fatigue - an increase in fatigue is normal. Well yes it is but what about not being able to lift your leg? Saying it causes fatigue is a dig at people with ME simply because they insist on packaging the very abnormal response we have to exercise into a word that people relate to their own experience, not ours.

Shortness of breath - everyone knows you get out of breath when you exercise. It is the way the body clears the oxygen debt you get when you rely on the emergency anaerobic system in the cell because you have reached your aerobic limit. The CPET research has shown that we slip into this reliance to carry out the activities of daily living not just after exercise and are not recovered even 24 hours later.

Hypoglycaemia - this only mentions diabetics, not the problem people with ME can have.

Cardiac chest pain - only relevant to people with heart disease. Again not acknowledging that people with ME have died of heart attacks after exercising too hard.

Palpitations - only takes into account the heart rate increase that is normal after exercise, not the problems with OI and POTS common to people with ME or the consequences they can have.

Falls and Frailty - balance is very bad in ME but I do not know how common falls are. Exercise will not help people with a positive Romberg's sign (fall over when eyes are shut) which is so common in ME it was once considered as counting towards a diagnosis.

Cognitive impairment - this is obviously only looking at people with cognitive disease, not the brain fog of ME where exercise can prevent someone from being able to count or plan.

A superficial glance could make this list of things that people think will cause them harm but don't into a description of what we call PEM so everything is explained away. It is obviously why they think harms to patients are unimportant. If they would only look at how ME actually affects us they could find what is safe and what is not.

Yes. It fits us very badly, or well depending on the agenda.

I am quite sure this proclamation of guidance is equally unjustified or irrelevant to all the other ‘multiple chronic illnesses’.

Patients either have life circumstances economic privilege and required health status to benefit from exercise, or they do not.

No one with healthcare needs of any kind will benefit from this generalised un-evidenced opinion piece.

Where as others looking to create cover for cuts to healthcare budgets or sell commercial fitness products or deny compensation claims just might find it quite useful.

 

[CRG]

I suspect the motivation, at least in part, is the sense of services being overwhelmed by the obesity/heart disease/type 2 diabetes epidemic. The pressure is to remove, at least to some extent, the cautionary principle and avoid a default of sedentary behaviour by a population of symptomatic patients, the majority of who will derive some benefit by being physically or socially active. It's probably not good science but it might be the least worst public health option. The authors have at least been civil enough to acknowledge it's not a good fit for ME/CFS.

Edit to add link and quote: https://digital.nhs.uk/data-and-inf...esity-physical-activity-and-diet/england-2020

876 thousand hospital admissions where obesity was a factor, an increase of 23% on 2017/18, when there were 711 thousand admissions

 

[Jonathan Edwards]

I suspect the motivation, at least in part, is the sense of services being overwhelmed by the obesity/heart disease/type 2 diabetes epidemic.

I am not sure what services being overwhelmed would contribute. It doesn't seem a reason to encourage even more people attending physio sessions.

 

[CRG]

I am not sure what services being overwhelmed would contribute. It doesn't seem a reason to encourage even more people attending physio sessions.

I didn't read it as that was what was being promoted - rather that patients with a symptomatic condition which would previously have meant they didn't start exercising until consultation with a health care professional as to what was safe for them to do, should now be be given the message that for most conditions exercise is a benefit and don't wait for the NHS to give you an activity schedule just get on and exercise because on balance you'll be more well than if you wait for a consult.

Presumably ever increasing waiting lists mean that the time between a diagnosis of some relevant condition and referral to physio is increasing in lock step, meaning that sedentary behaviour on wait list is similarly increasing meaning that for those conditions where exercise is beneficial patients are arriving at physio consults less well than they need to be.