And welcome back to the Wellness Paradox podcast . I'm so grateful that you could join us on this journey towards greater human flourishing . This is episode number four in our special 12-part series , in collaboration with the American College of Sports Medicine , on the September-October themed issue of the Health and Fitness Journal on professionalization and advocacy .
As always , I'm your host , michael Stack , an exercise physiologist by training and a health educator and health entrepreneur by trade , and I'm fascinated by a phenomena I call the wellness paradox . This paradox , as I view it , is the trust interaction , and I'm fascinated by a phenomenon I call the wellness paradox .
This paradox , as I view it , is the trust , interaction and communication gap that exists between exercise professionals and our medical community . This podcast is all about closing off that gap by disseminating the latest , most evidence-based and most engaging information in the health sciences .
And to do that , in episode number four of our series , we're joined by Dr Karen Wonders , and in this episode , I think this is really where the rubber meets the road for a lot of what we're talking about in the broader professionalization effort .
Dr Wonders , an exercise physiologist by training as well , works in the cancer exercise space at Maple Tree Cancer Alliance , which was a nonprofit . She founded and she co-authored an article with Barry Franklin , longtime exercise physiologist and past ACSM president , and Cheryl Brown from the Cooper Institute .
The article is entitled Making Exercise as Medicine a Clinical Reality .
This is a conversation at an article that talks about program development , developing evidence-based , outcome-oriented programs that are replicable and that are sustainable and , most importantly , produce those clinically meaningful outcomes that demonstrate the exercise professionals of value inside of healthcare , that demonstrate the exercise professionals of value inside of healthcare .
So many pearls of wisdom in this conversation from Karen , particularly as she learned over the years how to frame the narrative and the outcome measures , in fact , around what her organization was doing to really resonate with not only patients but also physicians . So I think you'll find parts of this conversation incredibly , incredibly enlightening .
Anything we'd like to share with you from today's episode can be found on the show notes page , that's , by going to wellnessparadoxpodcom . Forward slash , episode ACSM4 . Please enjoy this conversation with Dr Karen Wonders . Today we're delighted to be joined by Dr Karen Wonders . Karen , thank you so much for joining us .
Thanks for having me Very excited to have this conversation , particularly about this article , because I feel like this article we're going to talk about to a great extent is where the rubber meets the road in the professionalization effort , because ultimately , we're going to talk about how we produce outcomes in this conversation .
But before we dive into that , why don't you give us a little bit of an idea of your background , just to provide some context for the conversation ?
Well , sure . So I have a PhD in exercise physiology from the University of Northern Colorado , and for the last 19 years I've worked as an exercise science professor at Wright State University .
And then , 13 years ago , I started a nonprofit organization called Maple Tree Cancer Alliance , and at Maple Tree we provide individualized exercise training to patients as they go through their cancer treatment .
Yeah , and you guys are doing some amazing work . If you haven't been following the work that's being done at Maple Tree , it really is . Not only is it amazing work , but I think it's in a space that there's so much opportunity in our field , and so please check that out . We'll link up to Maple Tree on the show notes page .
I feel like at some point in time I want to have you back on the podcast to have that whole conversation . But to keep us focused on the topic at hand , we're going to talk about the article that you co-wrote with Barry Franklin and Cheryl Brown in the themed issue on professionalization and advocacy , entitled Making Exercise as Medicine a Clinical Reality .
And , as I said in the intro , this is really where the rubber meets the road , and this is such a big topic and the three of you , as an author team , did such a good job of getting this crammed into 2,200 words . Read the article , because Karen's not going to be able to tell you everything that was in here in this episode .
But why don't you walk us through some of the important themes that you and your co-authors talked about ?
Sure , well , I think this is such an important piece to write because you know there's so much momentum right now around the field of exercises , medicine and lifestyle medicine and what are some simple changes that people can implement in their daily lives so that they can live a healthier lifestyle .
And so , in this particular article , what we did is we really looked at the role of exercise and how it can help to manage chronic conditions . And so you know , as I mentioned , my background is primarily in cancer , but two-thirds of the patients that we work with at Maple Tree have at least one other chronic disease .
And if you look at exercise and the benefits that exercise can have in an individual , they're going to extend to someone whether they have zero chronic diseases or whether they have three or more chronic diseases .
And in spite of all of that , we know that , statistically , less than 95% of Americans are reaching the recommended physical activity levels that you know we have 150 minutes to 300 minutes of moderate intensity exercise , and so our article really looked at how can we make these exercise programs more accessible to patients who have chronic diseases , what does that look
like and how do we get these patients to actually participate then in exercise programs ?
Yeah , and so I think the way to maybe sum that up into a soundbite is we know exercise works , but what we need to do is get the people that need to do it to do it for long enough to actually have the beneficial effects .
Yes , absolutely , absolutely yes .
So let's get into some of the topic areas that you talked about in the article . How can our audience think about , how do we operationalize this concept of exercise as medicine ?
Well , I think it starts with just understanding the goal there . So the goal is to use exercise to help to mitigate some of the symptoms of chronic diseases . So , understanding what are the recommended levels of exercise , how can you work with patients to facilitate behavior change ?
That was something that we really dove into Everything from looking at the client's readiness to change in their lifestyle habits to overcoming the inertia , the resistance to exercise . Training with helping them to goal set . We also looked at credentialing . What are some of the credentialing of the trainers and the staff that should be involved ?
And then complimentary education programming . So how do we not only empower and equip patients to begin an exercise program , but how do we make that a long-lasting change that then they can adopt for the rest of their life ?
Yeah , and the behavior change piece is very interesting because our backgrounds academically are very similar .
I'm an exercise physiologist by trade and training as well , and I can tell you from my undergraduate experience , and I think you would probably agree , the amount of time we actually spent talking about behavior change psychology and just coaching psychology broadly is pretty limited and just coaching psychology broadly is pretty limited .
So when you think of that , not just as an author of this article but also as someone who is working with patients at a very challenging time in their life , how do you think of approaching the behavior change piece ?
Well , I think you're right in saying I don't know that we're getting enough education or we're equipped very well to handle this with a clinical population . And I know from my own experience .
I've exercised my whole life and it's just something I've always done , I've always loved to do , and when I initially began my nonprofit and started offering exercise for free for patients who are going through cancer treatment , I thought this is going to be so embraced .
People are going to know the benefits , they're going to see the benefits , they're going to love it . And one time about , I think , six years into running my organization , I had lunch with one of our patients who had been a longtime patient of ours . She had a very bad diagnosis but was able to overcome it and our program really helped her a lot .
And so I just kind of wanted to hear from her directly how did this help ? What advice would you have for me in working with other patients ? And she told me that she was more afraid to start her exercise program than she was to do her chemotherapy . Wow , and for me that was a thought that I never had .
I never thought someone would be intimidated by the idea of exercise . Someone would be . They would rather get chemotherapy than exercise , and that's when I started diving into this idea of behavior change . And how are we framing it ?
How are we approaching this conversation with patients who may have never done exercise before and might be completely intimidated by the idea ?
That's really when we started instituting it , and I think it's identifying some know , identifying some of these factors that come into play that , can you know , stand in the way of someone wanting to adopt a healthy lifestyle and an active lifestyle , whether it's depression , whether it's anxiety , whether it's just fear of the unknown .
What are you going to ask me to do ? What if I can't do it ? And really trying to speak to that , while you're talking to the patients and meeting them where they are , on their level and then helping them to progress as they're ready and as they are able to do some of these things ?
Yeah , that's such an amazing story . Again , you wouldn't think for a second that you know , everyone knows how devastating chemotherapy could be , but to think the psychological devastation of starting exercise for someone could , could trump that is .
It really puts into perspective something that I think you let off with , which is you've been an exerciser your entire life , so have I , so we don't have that same frame of reference . So that's an amazing experience to be able to have and share .
Yeah , I think it helps me anyway to step into her shoes and to realize that it's not as easy for everyone as it is for you and me and for other people who might even be listening to this podcast .
I mean , it's just something that's just a part of our lives , but that's not the case with everyone and if we act like it is , I think we're not , I think we're going to lose a lot of people . I think they're going to think we don't get it , we don't understand where they're coming from .
Yeah , absolutely so . Now I'm curious , you know , kind of with that as a bit of a pretext , as we dive a little bit deeper in order to make exercises , medicine , a clinical reality , like the work you've done at Maple Tree , that Barry Franklin has done here in Michigan at Corwell and Cheryl down at Cooper . You're not reinventing the wheel every time .
You have a program , you have a tested process that you use and you iterate on . So speak to that for a moment . How do you think about developing these programs , iterating them ? How do you think of outcome measures ? All these things are part of the process .
Yeah , exactly . So whenever we do our programs , everything is going to be individualized to that person . So when I said we meet them where they are , that's what we do our programs , everything is going to be individualized to that person .
So when I said , like we meet them where they are , that's what we do , we start off with a fitness assessment so that we can see exactly what their strengths and their weaknesses are Now being in the world of cancer , we also look at their cancer history and the treatments that they're undergoing and how they're handling those treatments , because you know , you can
be quote , unquote healthy and go through chemotherapy or go through radiation and then have a whole host of problems that you've never dealt with before , and so we want to know all of that information and then , based on that , the information that we get from the fitness assessment and the history forms , then we can create that personalized exercise program for them .
And you know , I think the exercise program is going to look similar to what we see probably in cardiac rehab or someone with diabetes . I mean , I don't think there's anything too unique to what we're doing , but I think it's that meeting that patient where they are understanding their conditions and then using exercise to help to mitigate the effects of it .
So I'll give you an example of one of the things that we do with our patients who are in chemotherapy . With chemotherapy obviously you're going to see a detriment to the immune system and sometimes that can be so bad that that can delay chemotherapy that they're supposed to get . It can cause reductions in the doses that they're supposed to get .
And we know through exercise that exercise , if you do it at that right window , that inverted J curve , that you can maximize the immune system . And so what we do with patients who are in chemotherapy is we keep them at a low to moderate intensity exercise to help to protect their immune system , to help to boost their energy levels .
And then we have outcomes data that we've been able to publish that look at reductions in dose delays and dose reductions in chemotherapy , which is then encouraging to other doctors , other hospitals to want to implement these type of programs for their patients so that they can stay on their medicine schedule just as well as the ones that we're working with .
I'd like to take a quick break from today's episode to tell you about a great offer from the American College of Sport Medicine . Until October 21st 2024 , the ACSM is offering a $30 discount on their Alliance membership .
This is a membership that's crafted specifically for health and fitness professionals , and getting this membership will give you access to all the articles in the themed issue on professionalization and advocacy that we're talking about in this podcast series , as well as a whole host of other member benefits .
To take advantage of this discount , go to acsmorg forward , slash , join . That's acsmorg forward , slash , join and enter in the discount code AllianceVE30 . Again , this is valid only through October , the 21st 2024 . So go to acsmorg forward , slash , join and enter in the discount code ALLIANCESAVE30 . Now back to today's episode .
Yeah , there's two things that you said there that I want to drill down on for a second .
The first thing that you said was that you have calibrated the dose of exercise properly , so it's in that sweet spot of not too much but not too little , and obviously that requires having a strong understanding of the science of the literature , and so that circles back around to the credentialing piece that you talked about earlier .
Yes , no , you're exactly right .
And then the other piece and this is the one I really wanna spend a second on , because I think it's so important . You chose an outcome measure there that was , essentially speaking , the medical professional's language , not the exercise professionals language .
And yes , I'm well aware that when you do your fitness assessment , I'm sure you get a body count measure and you get some measure of strength and some measure of , you know , endurance .
But you , you may or may not be reporting all that back to the physician , but what the physician really cares about is hey , was this person able to go through their chemotherapy more successfully and were they able to tolerate the dosing and so on ?
And so about is hey , was this person able to go through their chemotherapy more successfully and were they able to tolerate the dosing and so on ? And so that is . You found something that was relevant for the provider rather than relevant for the exercise professional .
I feel like that is a mistake that we often make , that , oh , they're going to want to know that VO2 max increased by two mLs per kg per minute , whereas they might not even remember what that means .
Yeah , well , you're exactly right . And when I first started my organization , that's the kind of stuff that I would get geeked out about , because I'd be like , well , two mLs per kg per minute when they're going through chemotherapy is amazing .
But to the medical community it was just kind of like , okay , well , that's very nice , but the way we started getting traction and the way that we've been able to grow Maple Tree now to 86 clinical locations across the US is speaking the language of the physicians . So what are the things that they care about ?
And , yeah , they care about dose delays and dose reductions . They care about treatment compliance . They care about healthcare utilization . Are there patients going to the ER every week for symptom management ? Are they staying in the hospital for an extended period of time ?
And if there's a way we can reduce that through exercise , then that really matters , not only to the physicians , but then to the hospitals who are trying to save money around all of their offerings and health care .
And that's really where we did start seeing the traction , not only with the hospitals that we're working with , but I think also on a broader scale , in trying to get this implemented into standard of care and to trying to get this covered by insurance reimbursement . That's the kind of language we have to use in those conversations as well .
Yeah , it's the conversations . Right Like to your point . You started this the same way I think any good exercise physiologist would start . This is like here's the standardized measures that we use in our field . And boy , aren't you excited that hand grip strength , you know , increased by you know eight Newtons . I know I am , and the physician says no , I'm not .
And so was that the iterative process for you at Maple Tree it was doing things , providing data , talking to physicians . Was that kind of how it unfolded ?
Yes , yes . So initially , when we had just our first hospital that we partnered with , and this was back in 2016 , that's the data that I would report back to them and I would just kind of get you know .
Well , that's very nice and then move on and it wasn't something that I felt we could build a physician champion around , and that's something that we have learned .
Having a physician champion and someone on the inside who's respected by the hospital to advocate for this program , to help get funding and help get patients into the program and to talk to their patients about it , I think has been so important , and so they need to see the direct benefit to their patient . And I will tell a quick story .
We had a physician that was the medical director of our very first hospital physician that was the medical director of our very first hospital and I noticed he would never send us referrals . We were getting referrals from everyone under him . He was a radiation oncologist . Never would send us referrals .
And so one day I met with him and I think it's important for exercise professionals to hear this , because sometimes I think we can be intimidated to talk to physicians , and I know I was going into the meeting and I wasn't trying to stir up anything .
I just wanted to talk to him , tell him about the program because maybe he didn't understand what we did and ask him if he would make referrals into the program . And his response was you know , I've seen your data . I think your data is great . I know you can have a positive impact on patients .
His hangup was he felt there was a selection bias going on so that if a patient would select into the program , they were quote unquote healthier than someone who maybe wouldn't exercise . And I think that that's fair . And so I said to him , I said , okay , give us a patient that you don't think we can help . And he did .
He gave us a young woman who was undergoing pelvic floor radiation for a cervical cancer that she had , and pelvic floor radiation can be very , very impactful on quality of life in a negative way . She had so much pain , she couldn't drive , she couldn't work , she couldn't .
You know , she was in a wheelchair most of the time and we started working with her and 12 weeks later she's back to work , she's driving , she's out of the wheelchair . She had a miraculous turnaround .
And now not only is that physician referring patients to us , but he is on our physician board that we have and you know is continually advocating for the program .
Yeah , that's a great story and it started with communication . It ended with outcomes .
I think that's the important thing is that you're able to put your money where your mouth is in terms of saying send us somebody challenging and we have the knowledge and the programming to produce the outcome that's going to show you that we can help this kind of person programming to produce the outcome that's going to show you that we can help this kind of
person , right , right and in a way that matters to the patient .
So probably the patient wouldn't care so much if her sit and reach score increased by two inches , but she does care that she can go back to work and she can drive now her kids to their sport practices . And things that matter to her also matter to the physicians as well . Yeah , it's .
The theme here is just creating that relevance for everyone in the process , not just you know , the exercise professional . Yes , so , karen , you know , if somebody is hearing this conversation for the first time around kind of making exercise as medicine reality , I think everyone who's listening has around making exercise as medicine a reality .
I think everyone who's listening has heard of exercise as medicine . I think everyone believes in that . But now they're inspired to say , okay , I want to start to actually do this and you have actually done this . You're an entrepreneur that has built this from the ground up . Where would you advise that somebody starts ? Where do they even start the process ?
Because it seems so big and it seems so scary and you're working with somebody who has terrible pelvic floor cancer . That can seem intimidating . Where should people think about starting ?
I think that's such a great question because we need more people working in this field .
I mean , when I start thinking about the workforce and the number of people that we need , not only in cancer but for all of chronic diseases , I mean think 129 million Americans have a chronic disease , and so I guess what I would say a good starting point would be to find your niche in that field .
You don't have to tackle all of the chronic diseases initially . But for me , when I started working in cancer , I kind of stumbled into that because that was the research that was done at the place where I did my PhD program and I'll be honest , I was very intimidated at the thought of working with someone with cancer .
I had a cardiac rehab background but when I thought of cancer I thought how am I going to do this ? Aren't they too sick and too tired ? And I was really scared .
And so you know it took me studying and learning about cancer and really working with patients and then seeing that direct impact that someone could come in and they were fatigued , but by the end of the session they had more energy or someone initially was diagnosed and they were angry and maybe they were mean to me .
I had a couple of patients who were mean to me , but I understood they're angry , not at me but because of what they're going through and the way that exercise turned their life around is what made me a believer , and so I think finding your niche .
And then you know there are certifications out there that you can get that will qualify you to work with particular subgroups of individuals . So I know there's cancer certifications that ACSM offers . We also have a training program at Maple Tree that we use to onboard our new trainers .
You can shadow someone who works in a field that you think you might be interested in .
You can talk to the patients there that are participating in those programs and find out what do they enjoy about the programs , what do they wish was different , and then take all of that information and use it to either build your own program or to help an existing program to do better and to serve more people .
Yeah , that's such a great starting point . We don't have to tackle everything . Start with an area you have passion on . There's one more question I want to ask in follow-up and this is a question I love to ask to kind of the frontline professionals that are out there working with patients , working with clients .
It's been my experience that , yes , we have guidelines around exercise for certain chronic diseases and I think every article on guidelines always ends with and more research is needed , and as practitioners , we don't have the luxury of sitting on the fence and saying more research is needed . We got a person in front of us right now that needs help .
So how have you found , you personally and your team at MapleTree , how do you deal with some of that ambiguity that exists between , like , the broad guidelines and the specific situation that somebody is dealing with ? I always found that to be very challenging when doing these exercises , medicine programs .
It's like , well , the guidelines don't exactly describe what's happening here and we're forced to deal with that ambiguity . So how do you think about that ?
Yeah , you know , I think as a whole , exercise is beneficial . It's beneficial to me who has zero chronic diseases , and it's beneficial to someone who has a whole host of chronic diseases . And so I think that's your starting point . And if you look at the guidelines for the healthy population and someone with a chronic disease , they pretty much match each other .
I mean it's 150 minutes whether you have a chronic disease or not . If you do have one , maybe you have to work up to it . I mean , we got to work there to get there . But on the surface I think those things are pretty well common across . In my experience with the cancer population . You know most cancer research .
There's a ton of research out there on exercises in cancer I think 32,000 PubMed articles right now . So the research is there , but I would say the majority of that research is early stage breast cancer patients and prostate cancer patients . In a couple of weeks I'm speaking to a sarcoma group . There's only 18,000 diagnoses of sarcoma every year .
There's very little research on that disease and exercise guidelines because you're dealing with people who may have amputations , may have had limb sparing surgeries I mean there's so many nuances that go on . And so basically what I'm going to tell them is this is the starting point .
We want to get you to 150 minutes , but we have to tweak it along the way , and I think that goes back to the individualization approach and meeting that person where they are . Here's the end goal .
We want to get you here , but if we're just starting out and you've just had limb sparing surgery , we have to start small and work our way up to get you there . So I think it's just that . I think it's meeting the person where they are .
Yeah , that brings us full circle to where we started . But yeah , I think you nailed it and it is . I've learned over the years that every medical issue , every orthopedic issue , is unique to that person and the guidelines are your starting point , but then it becomes , as you said , meeting somebody where they're at .
Right , right , exactly , exactly , and taking it slow . I mean , I'm someone who I want to jump in , and if the exercise guidelines are 150 minutes , well then let's do 150 minutes , but understanding that 30 minutes of continuous exercise is going to be difficult for some people , and so how do we get them there ?
I think another thing is people who exercise in their homes may or may not have any equipment . So what do you do in that scenario ? How do you get them to do resistance training when they don't have any equipment to do that ? And so it's being creative meeting them where they are and then using everyday objects to help them to see improvement .
Yeah , the going slow , I think , is a really good mantra . I always use the analogy to kind of say you know , exercise is kind of like cooking you can always cook more , but you can never cook less after you've cooked too much . So I think that that's an analogy that you could apply to an exercise program for somebody with chronic diseases . I like that .
Yeah , feel free to use it . I feel like a lot of my students have stolen that for things . So , karen , before we get you out , of here on the last question where can people go if they want to find out about you and all of the great work you're doing ?
Well , you can follow us on Instagram or Facebook , and we're even on TikTok now . So Maple Tree Cancer Alliance and Maple Tree Education . Maple Tree Education is more geared towards fitness professionals and teaching them how we do what we do , so check us out there , and then our website is wwwmapletreecancerallianceorg .
Perfect , and we'll link up to all that in the show notes page and really encourage everyone that's listening to engage with Maple Tree's content .
I think that the oncology population , the cancer population , I do think that is one of the areas that will emerge first in some of the professionalization effort and some of the opportunities for reimbursement Because , to your point , there is so much great data out there .
So I think for the exercise professional that is interested in the exercises medicine space , I think that would be wise to be looking at the cancer space as a potential entry point .
Absolutely . Yes , I agree with you wholeheartedly .
I think you're right and I think it's so important that we get fitness professionals and we build that workforce , because if we do that correctly and we build the workforce and we are able to work with cancer patients , that will then open the doors for all other chronic diseases as well , and so I think it's so important that we can get as many fitness
professionals as possible working in this space .
Well said , well said Well . Karen , before you get out of here , I'm going to end the podcast on the last question that I've been asking everyone in this series , and it's if you could give our listeners one piece of advice to advance and elevate the profession . What would that piece of advice be ?
My advice would be to lead by example , and so practice what you preach . Are you getting 150 minutes to 300 minutes of exercise a day or a week , and are you practicing what you preach ? When you don't feel like exercising , are you doing it anyway ? When you're not feeling well , are you doing it anyway ?
And I think leading by example will help to inspire others who are probably watching you and want to adopt a healthy lifestyle too .
Very well said , leading by example , indeed . Dr Karen Wonders , thank you so much for joining us on the Wellness Paradox . Thanks for having me . Well , I hope you enjoyed that conversation with Karen as much as I did . If you found it insightful and informative , please share with your friends and colleagues . Those shares make a real difference for us .
Any information we'd like to share with you from today's episode can be found on the show notes page . That's by going to wellnessparadoxpodcom . Forward slash , episode ACSM4 . That's forward slash , episode ACSM4 . Please be on the lookout for our next episode in this series when it drops next Monday , and don't forget to subscribe through your favorite podcast platforms .
Until we chat again next week , please be well .