The American College of Sports Medicine (ACSM) and the American Medical Association have launched a historic initiative called Exercise is Medicine™ (www.exerciseismedicine.org). Health-care professionals are encouraged to advocate for and to review every patient's physical activity program frequently during visits. Additionally, new physical activity guidelines from ACSM (1,2) provide ideas that broaden the options for living an active and healthy lifestyle. As part of the new recommendations, people who are just starting exercise, older adults, and people who have chronic conditions are encouraged to consult with health-care providers to develop individualized activity plans that are tailored for each person's condition, limitations, and preferences. As more people from our diverse population begin to seek help from trainers to meet these new initiatives, the art of communication between trainer and client will become an important tool.
Narrative communication methods, including storytelling, are being used more frequently as tools to acquire knowledge and to motivate health-behavior changes (3). Storytelling is a basic way that people communicate with one another and is a way for people to learn about themselves. Typically assessments are conducted to provide trainers with empirical information that can be used to design activity programs. But trainers who also understand their client's stories or experiences related to healthy (or unhealthy) behaviors may be better equipped to develop individualized programs. L.J. Hinyard and M.W. Krueter (3), discuss 19 studies comparing statistical and narrative evidence and found that 13 studies reported narrative evidence as being more persuasive, 2 studies found statistical evidence to be more persuasive, and 4 studies found no difference. Narrative communication methods that lead to motivating a person to change health-related behaviors hold promise as effective tools, yet this is a new area for health-behavior research (3,4).
Narrative medicine has emerged as a way for physicians to develop relationships based on the ability to recognize, absorb, and be moved by stories of illness from their patients. Rita Charon, M.D., Ph.D. (5), Columbia University, New York, pioneered methods that connect physicians with patients through storytelling, leading to more humane, ethical, and effective health care. Bernard Lown, M.D. (6), encourages physicians to take time to hear the stories inside their patients by making a heart-to-heart connection to understand the person. "Listening is the key to being sensitive. It's about the unshed tear, the story, the cues such as a glance, or body language."
A NARRATIVE COMMUNICATION FRAMEWORK
The clients I work with are mostly sedentary patients who are participating in a medically based weight loss program. As the exercise specialist, during my interviews, I'll ask clients to tell their story about barriers to, and opportunities for, activity. Dr. Charon's insights led me to the practice of inviting clients to write a letter, describing what they think I'll need to know about them to design their activity plan. This reduces office time and gives the client time to reflect in private. Personal interviews and written information, along with a format for discussion called WOW, provide opportunities to create individualized programs in a time-efficient manner.
The WOW approach provides a communication framework that integrates storytelling about the problem or barrier, creative thinking and ideas for solving the problem or overcoming the barrier, and a negotiated action plan that puts the client in charge of making the changes. Steps in this communication process include the following:
* W = What is the problem? The clients are allowed to tell their stories about what they currently do for physical activity. Encourage them to identify barriers, situations, or conditions that get in the way of activity. Some prompts might include the following: When you think about exercising, what prevents you from doing some? Can you describe a time when you felt uncomfortable exercising? How do you generally feel after exercise?
* O = Options? Together list the options that might work. Brainstorm ways to fit exercise into their environment. Address questions such as the following: Do you belong to a gym or have equipment at home? Do you have a buddy that would exercise with you? Do you watch TV? Do you have a lunch break? What activities do you enjoy? Discuss ways to make the program fun, to get active outside of a gym, and how to set a schedule.
* W = What are you willing to do? Negotiate a plan of action that the client agrees to do. Set goals based on gradual steps, so the client is successful.
WOW-THE ART OF WORKING WITH CLIENTS
I'd like to share with you brief notes from actual sessions with clients regarding barriers to exercise. To begin each interview, I ask the client to describe what physical activity they are currently doing. Typically, their responses begin with a phrase such as "I try to…," "I used to…," and "I was thinking about…" These comments are usually followed by "but, the problem is…" Ah ha! Problem solving calls for creative thinking with a willingness to help. Common barriers to exercise are problems that need to be solved creatively. Excuses may include the following (7):
* not enough time
* don't know how to get started
* don't know which exercise is best
* my feet hurt
* exercise is uncomfortable
* I'm not fit enough
* equipment is too expensive
* I get enough exercise at work
* it's dangerous
* it's inconvenient
* I don't believe in exercise
I DON'T HAVE ENOUGH TIME
"I'm a 45-year-old single mom who works part-time, and I have three kids in grade school. I get up at 5:30 a.m. to clean my house for an hour, then I pay bills, do laundry, and get the kids off to school. I then have to get myself to work. At the end of the day, on the way home, I stop at a place to pick up dinner. What do you want me to do…stop cleaning my house?"
* Limit house cleaning to 30 minutes a day, and use the extra 30 minutes for exercise at home.
* Pay bills on the computer to save time.
* Fit exercise into daily activities:
* Lunge as you carry the laundry and vacuum.
* Carry groceries into the house one bag at a time.
* Cook dinner at home (may lead to an extra energy expenditure of 160 Kcal per dinner).
Willing to do?
* Clean house more vigorously for only 30 minutes, and spend 30 minutes exercising with a DVD.
* Unload groceries one bag at a time.
I DON'T KNOW HOW TO GET STARTED
"I'm a single mom, and I work 10 hours a day in an office on a computer. I don't have time to go to a gym. How can I get started?"
Climb stairs on breaks. Based on her weight, she could expend 50 to 70 Kcal per 10-minute break. She gets two breaks per day, which adds up to an extra 100 to 140 Kcal per day plus some cardio and muscular endurance.
* Create opportunities for "walking meetings" when possible.
* After work, carve out mom and kid exercise time for family play.
* Fit exercise in at the office or during activities of daily life.
Willing to do?
* Client agrees to 20 minutes of stair climbing per day, 5 days per week.
* Perform three chair stretches at least once a day.
* Complete one set of 8 to 12 repetitions for three postural exercises using a red Thera-Band®, twice per week at the office.
I'M NOT FIT ENOUGH TO EXERCISE
"I went to a spinning class and had a hard time squeezing between the bikes to get on. It was awful. Someone said to me 'why don't you turn sideways?' But I have no sideways. Until I lose weight, I'll never go to fitness center again."
* Explore a size-sensitive environment with the client.
* Exercise at home and outdoors with a friend.
* Invest in home equipment such as a treadmill for walking, then progress outdoors.
* Find an activity that is fun. Rowing at Lake Tahoe with a friend is an option on weekends.
* Invest in a treadmill and some free weights for home exercise.
* Buy some exercise DVDs.
* Trainer is willing to explore local facilities that more adequately accommodate plus-sized clients and report back on options.
MY FEET HURT AND EXERCISE IS UNCOMFORTABLE
"My feet hurt so much that I can't walk without pain. My doctor says I have plantar fasciitis, but didn't suggest a treatment. Is there anything I can do?"
* Seek additional medical treatment for the condition.
* Try home activity solutions using evidence-based exercises (8).
* Exercise in water to reduce impact and pain.
* Perform the home exercises.
* Exercise 3 days a week (as tolerated) in the pool until healed.
Narrative communication provides opportunities for clients to learn about themselves and for trainers to be more sensitive to the problems the client faces. A simple communication structure may help unleash stories and ideas that lead to creative solutions within a reasonable period, allowing trainers to incorporate narration within a session. The art of good communication can compliment empirical information from assessments and provide an effective tool, so clients take charge of their own Exercise is MedicineTM activity.
The author thanks Catherine Gerweck, D.M.D., R.D., University of Nevada, Reno, for editorial assistance.