Does Exercise Need to Be Fun?

Yes. I’ll look for your comments below.

Hahahaha, I turned the comments off years ago! Also, this is a bit more complicated than a simple yes or no. As a matter of fact, if you would push me to pick one, I would probably err towards no. Mainly because I don’t know what the word “fun” means.

“LOL! Erik doesn’t even know the meaning of the word fun!”

Yeah. Laugh it up. I know what I mean by fun, but that can be very different from what others mean by fun. And I think that this becomes very important when we are putting together exercise programs for our patients and athletes. Let’s get into the semantics!!!

So fun is usually lumped into the heading of “recreation”, the opposite of “work”. So I hear interesting arguments around this.

On the one hand:

“Exercise needs to be fun so that we get increased compliance.”

On the other hand:

“Sometimes exercise needs to be at an intensity that is high enough that it is no longer fun, it is work. There has to be some unpleasant struggle.”

Now, I’m not trying to create a false dichotomy here, where there is an assumption that one of these statements must be right and the other wrong. That this is somehow an either/or situation. Personally, I throw both arguments out as uninteresting.

The idea that compliance is important

It seems obvious that, for an exercise to be effective, it has to get done. I’m not arguing with that. But I will argue against the idea that evidence of compliant patients getting better than non-compliant patients is proof of effectiveness. Confused?

Ok, so what I’m talking about here are those studies where they take a large group of people with a diagnosis, give them all an exercise program, and track compliance with the program and patient reported outcome. When it results with compliant patients getting better than non-compliant patients, I’m like, “No shit. But that doesn’t mean that patient compliance caused that outcome. Nor does it mean that by forcing patients to be more compliant we will force better outcomes.”

I have two issues with the thinking here. First, think about what is happening in this situation. The patient comes in and says, “I hurt right now.” You give them a program. They go home and start that program. On follow up six weeks later, those who kept up with the program were doing better than those who stopped.

But why might the compliance be different? Put yourself in the patient’s shoes. If you start a program, and a week later you are noticing an improvement, wouldn’t you continue with the program? How about if you noticed no improvement? Would you still keep doing the program or would you say to yourself, “This isn’t working” and stop doing what appears to be a waste of your time?

Is compliance actually making the program effective, or is it just an indicator that the patient is getting better for who knows what reason? Could this be psychologically driven? Are the ones who get better having better compliance because they believe the program will work, but the driver is more the belief in the program than the program itself? It could have been a matching of belief system with intervention.

The other issue I have is that these people might be patients that would get better with time no matter what you do. I’m not saying just natural history here, they needed an intervention. But that intervention could’ve been anything. Potentially, all they needed was a distraction.

To be clear here, I’m not saying that this is what is actually happening. I’m saying that I don’t know what is actually happening, but I have my doubts about compliance being the key driver.

The idea that work isn’t fun

The other argument is that sometimes for an exercise to be effective, it needs to be work. You have to struggle through it. It isn’t fun. But…is it?

This is where that “fun” word becomes problematic. I know a number of lifters who work really really hard in the weight room. Although the word “fun” might not come out of their mouths, they do get some enjoyment out of it. A direct result of this activity is being generally happier. I see the same with the work that elite athletes do to perform at the level that they do. And although there is struggle, the result of the struggle is often joy.

But is that “fun”?

What the hell are we really talking about here?

We are not actually talking about fun with its playful connotation. In both scenarios we are talking about interest, meaning, context, fulfillment… In other words, being engaged. Exercise needs to be engaging. And I don’t just mean that in regards to rehab; I mean it for general health as well.

Think about someone’s occupation. If they are engaged, interested, and get personal fulfillment from their job, then it becomes more than work. If it lacks any personal interest, then it can be soul sucking.

Exercise for general health can be the same. I think as humans, we get fulfillment out of being engaged in physical activity. But it is different for everyone. You may hate lifting weights but be perfecting content doing backbreaking yardwork outside in the sun. I know athletes who previously hated the weight room, but have learned to love it in the context of improving performance.

Sometimes there is just something about a particular lift that they just like inherently, especially as they get better at it. They found a challenge that they like and they are now engaged.

Running for some people (me) is one of the most boring activities on the face of the Earth. For others it is meditative. Here is the important part, if running is painfully boring for someone, I have my doubts regarding its health benefits for them. I think that it is possible that a lot of the health benefits that runners get from running are enhanced by coupling it with the activity being mentally fulfilling in some way.

How does this relate to compliance?

Compliant patients are engaged and engaged patients are compliant. My personal feeling here is that engagement is dependent on feedback. If the feedback from an exercise is “This sucks. This hurts. This is boring,” compliance is probably not going to be great. I’m also not sure that forcing compliance would help here – as if that would even be ethical.

But if the feedback is “That was a cool effect. I feel stronger,” I would expect a much more engaged, and therefore compliant, patient. The compliance is almost a side effect here.

An example. Patient comes in and says, “The front of my knee hurts when I go downstairs.” You measure how much force their knee takes before it feels pain, then compare to the other side. Then you do some long hold isometrics and, lo and behold, it is tolerating more force before it feels pain. The patient leaves intrigued.

But let’s say that when they come back a week later, they are discouraged. They have been doing your “dumb exercises” for a week and they are still having pain going downstairs. To them, nothing has changed. You test them again and find that, actually, something has changed. They are tolerating more, but it is still a good bit less than the other side. The patient becomes re-engaged because they now recognize the progress.

I also like to give the patient several exercises that all accomplish the same thing then ask, “Which one do you like better?” Sometimes I’m surprised how much they prefer one over the others. And again, I don’t think “fun” is the right word.

Ultimately the question we are asking here is, “How can the patient and I find a way for them to want to take the most load possible and feel good about doing it?”

Figure that out, and you’ve solved the root problem. If you have a patient who is having a hard time finding interest engaging in anything, you likely have a deeper mental health problem that needs something more than the guidance of a physical therapist.

In Summary…

• I don’t know the meaning of the word “fun”
• Compliance may be more of a symptom than a cause
• Challenging and difficult work can be fulfilling and meaningful
• Goal-directed feedback is important
• How can the patient and I find a way for them to want to take the most load possible and feel good about doing it?
• If you have a patient who is having a hard time finding interest engaging in anything, you likely have a deeper mental health problem that needs something more than the guidance of a physical therapist