I Stopped Telling People to Exercise More

A woman in her fifties sat in my consulting room and told me she had failed three exercise programmes. She said it the way people say things about themselves they stopped arguing with years ago. Then, almost as an afterthought, she mentioned she couldn’t stand at the kitchen counter for ten minutes without her left knee starting to burn.

Three programmes. Nobody had asked her that.

For most of my working life the standard sentence in metabolic care has been: you need to exercise more. I have said it myself, probably a few hundred times. It isn’t wrong either. Activity matters for glucose handling, for strength, for still being independent at seventy. I am not going to argue against movement. I have spent twenty-six years arguing for it.

But correct is not the same as usable.

Someone can understand perfectly well that walking helps and still not manage twenty minutes of it. Stairs turn into a calculation. Bending becomes something you plan around. The evening walk everybody recommends becomes the thing you quietly stop doing and then feel bad about not doing. Telling that person to exercise more is describing a destination without mentioning the road is flooded.

Pain does not stay in its department

In most systems pain gets filed somewhere. Blood reports go to the physician. Food goes to the dietitian. Weight goes wherever weight goes. The knee comes to me.

The patient doesn’t experience their body in departments.

Pain decides how long they sit. Whether they sleep through the night. Whether they cook or order in, whether they go to the wedding or send someone with the gift. It shapes what is realistic, and it does this quietly, without ever appearing on a report.

So a plan can look excellent on paper and be impossible by Tuesday.

I have met a lot of people who were written off as unmotivated. Sit with them for twenty minutes and something else usually surfaces. The exercise hurt. The starting level was pitched at somebody else’s body. It progressed too fast. Or nobody told them which sensations were normal and which ones meant stop, so every twinge felt like damage and stopping felt safer than guessing.

They weren’t refusing to look after themselves. The plan had no door they could walk through.

What Physiotherapy Taught Me About Exercising with Chronic Pain

Movement isn’t only physical. It’s an experience the body files away.

When exercise has meant pain or embarrassment often enough, the nervous system starts bracing before the first repetition. Avoidance stops looking like weakness and starts looking like a reasonable prediction.

That doesn’t mean every ache is damage. It also doesn’t mean pain should be pushed through, which is the opposite error and, in my experience, the more expensive one. Pain needs interpreting. Not obeying, not ignoring.

I see both extremes in clinic. Some people are frightened of any sensation at all. Others have been told to push until it burns and have made a manageable joint problem into a long one. Neither group is being helped by the advice they were given.

The useful question is narrower than most people expect. What can this person do safely today, tolerate without paying for it tomorrow, and still be doing next week? Nearly everything else follows from the answer.

Ambition and capacity are different measurements

People choose exercise by ambition. Ten thousand steps. Running again. The workout their nephew forwarded. Whatever they were doing at thirty-five.

Ambition is useful. But bodies begin from capacity, and capacity is a duller number: what you can do now, with symptoms you can live with and recovery you can afford.

Sometimes capacity is five minutes of supported movement. A chair-based strength set. Three short walks instead of one long one. Water, if the joints are angry. Resistance work chosen carefully rather than enthusiastically.

That is not lowering the bar. It’s finding the floor. You cannot build upward from a floor that keeps giving way.

If there is one thing orthopaedic physiotherapy handed me for metabolic work, it’s this. The best starting point isn’t the impressive one. It’s the one the person is still doing six weeks later.

Walking is not automatically the answer

Walking is cheap, available, and right for most people. I recommend it constantly.

It still isn’t the correct first step for everyone. Heel pain, an irritable knee, poor balance, a walking tolerance of four minutes: these need preparing for. Strength first, sometimes. Load management. Occasionally a completely different aerobic option while the joint settles.

And even when walking is right, the dose is a clinical decision, not a slogan. Ten comfortable minutes most days will do more than forty painful ones followed by four days of nothing. I have watched that second pattern end more programmes than laziness ever has.

Shame is a poor prescription

Health talk turns moral very fast.

Someone doesn’t follow the plan, so they’re careless. The weight goes up, so they’ve given up. They skip the walk, so they’re lazy. Pain is invisible. So is broken sleep, and a parent at home who needs looking after, and the memory of the last three attempts that hurt.

None of this cancels responsibility. People still have to participate, still have to practise and report back honestly. But responsibility works when it’s matched to a plan the person can actually execute. Shame will buy you two good weeks. Understanding is what gets you the year.

What I ask now

I no longer open with how much exercise are you doing. The answer tells me almost nothing. I ask which everyday things have become difficult. Where the pain shows up, and at what point in the day. What they can already do without thinking about it. What happens that evening and the next morning, because the next morning is where most programmes give themselves away. Whether they enjoy any form of movement at all, since nobody sustains something they dread. What else is in the way, medically or practically. And then the question that matters most: what is the smallest version of this you could repeat, even in a bad week?

These questions don’t soften the plan. They make it accurate.

A good plan should ask enough of the body to force adaptation without repeatedly overwhelming it, and it has to keep moving. Week one is not the ceiling. I have seen clinicians set a sensible gentle starting point and then leave someone there for a year, which is its own kind of failure.

Where this leaves me

Pain changed more than my exercise prescriptions. It changed what I think the word sustainable is doing. Very few people need another lecture about effort. They need somewhere honest to start, one that accounts for the body they have, the hours they actually have, and what they are already carrying. That is as true of food and sleep as it is of movement.

Twenty-five years in, I believe in movement more than I did at the start. But I no longer judge advice by how demanding it sounds. I judge it by whether the person is more capable three months later than they were the day we met. Your body doesn’t have to earn the right to move by becoming lighter or fitter or pain-free first. It needs an honest starting point.

What comes after that is slower and less dramatic than anyone would like. It also tends to hold.

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This is a personal reflection, not a protocol.

Healthy Regards

Grinto Davy Chirakekkaren

Orthopaedic Physiotherapist

Clinical Nutritionist

Health & Wellness Coaching