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Case studies in writing the exercise prescription

To use your counseling time most effectively, spend a few moments determining the patient’s stage of readiness for change before you prescribe an exercise regimen.

Lee Lipton, MA, PA-C

Ms. Lipton is an exercise physiologist and family practice physician assistant in Northern California. The author has indicated no relationships to disclose related to the content of this article.

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Case 1: Contemplation

Mr. C. is a 42-year-old computer software engineer who is new to your practice. He is here today to discuss laboratory results from his complete physical examination 2 weeks ago. His examination was unremarkable except for a body mass index (BMI) of 29.8. His lipid panel reveals the following values: a total cholesterol of 230 mg/dL, LDL cholesterol of 148 mg/dL, HDL cholesterol of 45 mg/dL, and triglycerides of 150 mg/dL.

Mr. C. has a history of chronic obesity and occasional low back discomfort relieved with anti-inflammatory medication. He reports no history of hypercholesterolemia and does not smoke. His family history is negative for cardiovascular disease (CVD), hypertension (HTN), and diabetes (DM). He has no physical limitations to activity.

In reviewing Mr. C’s lipid profile and risk for CVD, you decide that lifestyle therapy is the most appropriate first step. Mr. C. says that he knows about the importance of exercise and a healthy diet. He reports having been physically active in college, but he became sedentary when he started working. He feels concerned about his cholesterol levels and agrees that a lifestyle change is in order. However, he is unsure about how and where to begin. “I don’t know how I can fit exercise into my day,” he says. “And I have gained so much weight, it seems like a huge project to lose it all.”

Care plan: Motivate to action You ask the following questions to elicit information from Mr. C. that can help to formulate his exercise prescription:

Exercise activities: “What type of exercise do youenjoy the most?” Mr. C. says he enjoyed regular bicycling and weekend hiking during his college days. He enjoys playing with his dog in his backyard.
Commitment: “Lifestyle change means that you need to be ready to make a commitment to the exercise plan. When will you be able to find time each day for some activity?” Mr. C. reveals that although he has a demanding job, he rarely works longer than 10 hours a day and has some flexibility with his lunch and break times. He decides that he would be more likely to exercise in the evening after work and on the weekends.
Setbacks: “What factors do you think will challenge an active way of life?” Mr. C. notes that he travels for business for 3 to 4 days once a quarter. He admits being a “results-oriented person,” and he wonders if he will give up his exercise program prematurely if he doesn’t see a change right away. He worries about being bored with a daily routine.

Case 2: Action

Mrs. A. is a 38-year-old part-time cashier and mother of three children, ages 8, 12, and 15. Motivated to lose weight for her 20-year high school reunion, she started an exercise program 3 months ago and is now walking for 20 minutes three times a week in the mornings before going to work. She is in the office today for a medication refill and a BP check.

Mrs. A is generally healthy. She has a history of prehypertension, evidenced by in-office BP measurements of 135/85 mm Hg on several separate occasions. Her BMI 2 months ago was 28. She has a history of depression and been taking fluoxetine for the past 2 years with good results. She takes no other medications and does not smoke. Her father has HTN and survived an MI at age 60 years. Her family history is negative for DM and cancer (CA).

You look at Mrs. A’s chart and note that she has lost 7 lbs since her last visit 3 months ago, which moves her BMI to 27. Her BP reading today is 130/80 mm Hg. She seems pleased to hear the good news, but she shares that it is sometimes difficult to fit the exercise in along with working and taking care of her family. Her confidence wavers, and she is worried that she will lose the positive momentum she has started.

Care plan: Support and encourage You ask the following questions to help Mrs. A. focus on the positive aspects of her new lifestyle change and redesign her exercise prescription:

Acknowledgement: “How do you feel about what youhave already accomplished?” Mrs. A. shares that some days she just doesn’t feel like walking, but afterwards, she always feels “good about myself.” She thinks that the regular exercise and medication helps control feelings of depression, and she hopes to wean herself from the antidepressant someday in the future with the help of exercise. She is happy with her weight loss, but she admits to feeling “a little impatient” about how slowly the weight is coming off.
Support: “Who can help you stay committed to yourexercise goal?” Mrs. A. decides that she can involve her children and husband in her new active way of life and include them in walks around the neighborhood after dinner. She plans to invite her neighborhood friends to join her for her morning walk. She decides she will be less likely to skip her workout if somebody is meeting her.
Fun Factor: “What would make your program morefun?” Mrs. A. feels a goal would make her more focused. She decides to pick an organized walking event benefiting a good cause and train to walk a 5-km distance. Mrs. A. always enjoyed ice-skating as a child and now thinks it would be fun to borrow her son’s in-line skates some day.

Case 3: Relapse/recycling

Ms. R. is a 48-year-old small business owner who has exercised “on and off” for years. Her main form of exercise has been weekend tennis, but she suffers from osteoarthritis in her knees and lower back. As a result, she doesn’t play as often as she used to. Her back is “acting up” again, so she is in to see you.

Ms. R has a history of type 2 DM, which is controlled by oral medication. She has a history of recurrent weight loss and regain, and her current BMI is 32. She has osteoarthritis in both knees and mild degenerative disk disease, controlled by anti-inflammatory medication when indicated. She has a history of right plantar fasciitis. Both her father and brother have type 2 DM.

Care plan: Reassess stage and encourage You ask the following questions to help Ms. R. find new alternatives for lifestyle therapy and give her assistance to start again:

Starting over: “Do you feel ready to try a new approach to exercise?” Ms. R. has not tried any forms of exercise other than tennis. She is open to trying again, but she admits her confidence and motivation are low. Ms. R shares that she feels tired of trying and failing repeatedly at a regular exercise program.
A new approach: “What other forms of exercisemight be appealing to you?” Ms. R. feels she is a social person and enjoys the camaraderie of tennis. She wonders if a group fitness class might be a good alternative to tennis but worries that it might exacerbate her knee and back problems. Ms. R. enjoyed swimming as a teenager. She has noticed that her fitness facility offers group water aerobics conditioning classes and says, “it looks like fun.”
Exercise is therapy: “Remind me why exercise isgood for your health.” Ms. R. acknowledges that regular exercise is important in controlling her diabetes and risk for heart disease. Ms. R knows that lower-impact movements will help keep her joints healthy. She also knows that weight loss will help reduce the strain on her spine.