22.2: Factors Affecting Activity Level

Learning Objectives

By the end of this section, you will be able to:

• Describe physiological factors affecting activity level
• Recognize psychological factors affecting activity level
• Identify external factors affecting activity level

A profound interplay exists between physical activity and a person’s body, mind, and environment. For most people, much of the time, physical activity is beneficial. However, during any physical body movement, a simultaneous feedback loop attaches physical and emotional responses and mental images to the movement. The total experience—physical, emotional, social, and mental—may be stored in the brain as unpleasant and negative, or pleasant and positive. These past experiences with physical movement can impact an individual’s willingness to be physically active in the present.

Current conditions, including barriers to activity, can have a similar impact. Consider these two scenarios. Have you ever been sad, taken a walk to shake it off, and felt better after the walk? Alternatively, have you ever been sad and thought about taking a walk but not done it—perhaps you were physically unable to, or perhaps you simply did not feel up to it? These scenarios illustrate the double-edged nature of physical activity: there are many situations in which it will help, but only if the individual can overcome whatever barriers—whether past experiences or current health or environmental conditions—they experience to engage in it. Because physical activity has such enormous potential to positively impact the totality of a patient, it is important to help patients recognize and overcome their internal and external barriers.

Physiological Factors Affecting Activity Level

Despite the many well-known benefits of exercise, many people are reluctant to begin and stick with a prescribed exercise regimen. For many patients who are chronically ill, pain, weakness, and fatigue may negatively impact their activity (U.S. Department of Health and Human Services [DHHS], 2017). Others may be concerned that they are already too out of shape to be successful or that they will worsen preexisting conditions (American Diabetes Association, n.d.).

As the body ages, certain problems in the musculoskeletal system can have a negative impact on proper alignment and movement. Similarly, illness or trauma involving other body systems may interfere with movement because of either the underlying pathology or the treatment regimen. Nurses must be sensitive to how both acute and chronic health problems affect a patient’s general appearance and their ability to purposefully perform even the most basic self-care activities. For instance, patients experiencing pain may present with a lack of visible energy and enthusiasm. Body posture also may be affected. For example, a person with chronic pain may often sit with their head bowed and shoulders slumped and may lack the energy to eat or even to use the toilet.

Growth and Development

Physical activity depends on muscle growth and development. For example, babies do not have the muscle strength to carry their body weight until they are about a year old. All children in the United States are screened for development on a regular schedule as part of the recommendations from the American Academy of Pediatrics (Centers for Disease Control and Prevention [CDC], 2022b). Children who show delays in development may be referred for further screening or therapy, such as occupational or physical therapy. It is important to remember that every child develops at their own pace. However, a child who consistently misses milestones or loses skills should be evaluated by their healthcare professional for underlying conditions that might be contributing to the delays.

Link to Learning

The CDC’s Milestones in Action website offers a wonderful collection of pictures and short videos regarding a variety of age appropriate milestones.

Physical Health

Physical health is directly correlated to one’s physical activity level. Patients may experience any number of physical problems with the musculoskeletal system, which can all negatively influence their physical activity level. For example, trauma such as sprains and soft tissue injuries and chronic conditions such as degenerative bone disease all limit one’s level of activity. Nurses must perform comprehensive assessments to determine appropriate activity for each patient.

It is critically important that patients progress toward targets rather than trying to jump directly to them (DHHS, 2021). Pushing patients to perform at a higher level than they are capable of can lead to injury, frustration, and unwillingness to continue. For example, patients who are totally inactive should begin activity slowly, performing light-intensity activities such as slow walks (less than 2 mph). As their stamina (physical and mental capacity to endure prolonged periods of exertion or activity without experiencing fatigue) and endurance (ability to withstand or tolerate prolonged physical activity or hardship over time) improve, they can move up to faster walks. Nurses serve the unique role of understanding each individual patient’s limitations and can assist in developing a tailored plan of care.

Postural Abnormalities

Postural abnormalities such as contractures, scoliosis, or kyphosis often restrict range of motion and cause balance issues that make physical activity uncomfortable. Patients with postural abnormalities who have experienced a related fall, with or without injury, are often less willing to exercise because they do not want to risk further injury (Sherrington et al., 2020). As a result, their issues frequently become worse over time.

When working with these patients, educate them based on their health literacy and encourage them to find exercise opportunities in supervised group settings (where they may feel safer) that target strength and balance. These exercises can help patients be less likely to experience another fall (Sherrington et al., 2020). Yoga, tai chi, and qigong have all been shown to be effective in working with a variety of conditions, including postural abnormalities and balance issues. These types of exercises involve a variety of gentle movements that stretch muscles and encourage postural correction and stability. They are also modifiable for use with patients using a wheelchair or experiencing other disabilities.

Bone or Joint Abnormalities

A measurement of bone density studies the amount of hard minerals—specifically calcium and phosphorous—present in bone; these minerals account for bone’s strength and resilience. Patients who have lost bone density are at increased risk for fracture. Often, patients who have already experienced a fracture related to bone density are very careful not to engage in activities that may put them at risk of additional fracture. For patients who also have low health literacy, careful education is required to teach that age-related loss of bone density can be slowed down by regular physical activity, including aerobic, muscle-strengthening, and bone-strengthening activities. Studies indicate that the most significant changes are seen in patients who perform at least ninety minutes of these activities weekly (DHHS, 2021).

Joint abnormalities, such as osteoarthritis and various rheumatic conditions, result in pain. Studies have shown that participating in at least 150 minutes per week of aerobic activity and muscle-strengthening exercises decreases pain and improves overall joint function and patient quality of life (DHHS, 2021). However, it is frequently difficult to begin exercising because the idea that the exercises will decrease pain is counterintuitive for many patients, particularly those who have a history of pain with exercise.

Life-Stage Context

Osteoporosis Prevention in Older Adults

A common bone disease called osteoporosis makes bones weak and more likely to break, is characterized by low bone density and deterioration of bone tissue—particularly in the hips, wrists, and vertebrae (Figure 22.13). Ten million Americans currently have osteoporosis, including half of all adults over age 50; another forty-four million Americans with low bone density are at risk of developing it (Bone Health & Osteoporosis Foundation, 2022). The disease is more common in women than in men, and the chance of developing it increases with age (Pinheiro et al., 2020). Often it stays undiagnosed until an individual breaks a hip, vertebra, or wrist.

Figure 22.13 Note the difference in curvature between the normal bones and the bones with osteoporosis. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Patients with osteoporosis may have bone deformities that affect their posture. They may appear to be hunched over and frail from bone loss. To combat or prevent this, weight-bearing exercises are encouraged. These exercises stimulate the absorption of calcium back into bones, thus strengthening bones, stopping the loss of bone mass, and preventing fractures (Pinheiro et al., 2020).

Unfolding Case Study

Unfolding Case Study #4: Part 3

Refer back to Chapter 19 Oxygenation and Perfusion for Unfolding Case Study Parts 1 to 2 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the hospital and has just arrived in her room on the telemetry unit.

Past Medical History

Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis Family history: No significant family history reported. Social history: Widowed ten years ago, currently living in an assisted care facility. No children. Current medications: Lisinopril 20 mg PO once daily Metformin 500 mg PO twice daily Metoprolol 50 mg PO once daily Aspirin 81 mg PO once daily Furosemide 40 mg PO once daily Losartan 25 mg PO once daily Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain

Flow Chart

Time: 1300 Blood pressure: 142/80 mm Hg Heart rate: 98 beats/minute Respiratory rate: 20 breaths/minute Temperature: 98.9°F (37.1°C) Oxygen saturation: 94 percent on 2 L nasal cannula Pain: 6/10 (joint pain)

1.

Recognize cues: What cues are the priority for the nurse to recognize?

2.

Analyze cues: Based on the priority cues recognized in the first question, what other information would the nurse want to obtain from the patient at this time?

3.

Prioritize hypotheses: How do you think the patient’s osteoarthritis affects her quality of life and physical activity level?

Muscle Abnormalities

One of the most common disorders related to muscle abnormalities is muscular dystrophy, which describes a group of disorders that cause skeletal muscles to weaken and atrophy, and the myopathy, which is characterized by failure of the muscle fibers, causing muscular weakness (Siciliano et al., 2019). Traditionally, patients with these disorders have been discouraged from participating in physical activity, as it was thought to speed up the degeneration and dysfunction of the muscles. However, the newest guidelines encourage physical activity (Siciliano et al., 2019). The benefits of gentle balance, stretching, or aerobic activity to the muscles may outweigh the risks. Still, no single exercise prescription fits these patients due to variations in the disorders. Decisions about physical activity should be made under a physician’s supervision because, for these patients, inappropriate exercise can cause permanent damage.

The following guidelines are key when caring for patients with muscular abnormalities:

• Do not perform aerobic activities while moving downhill.
• Do not exercise to exhaustion.
• Do not exercise during acute exacerbations of the disorder.
• Do not force or try to hyperextend any muscle movement or muscle group.

Central Nervous System (CNS) Abnormalities

Diseases or injuries that affect a patient’s central nervous system (CNS) have a direct impact on their ability to perform exercise. This is because the CNS controls movement and balance. CNS abnormalities may occur because of diseases that affect neurons, such as multiple sclerosis (MS), a progressive disorder of the CNS characterized by weakness, numbness, decreased muscle coordination, and intermittent exacerbations. Other CNS disorders are related to injuries and problems with the spinal cord, such as paralysis. These and many more neuromuscular abnormalities affect the messaging and mechanics of movement, creating barriers to physical activity.

Real RN Stories

A Patient with Multiple Sclerosis

Nurse: Ashley, RN
Clinical setting: Ortho-neuro unit
Years in practice: 15
Facility location: Thibodaux, Louisiana

We used to have this patient, Livia. She was my age (around 43 then) and a single mother—like me. She was on disability because her multiple sclerosis was severe enough that she was unable to work consistently. She used many of the outpatient services available at my hospital, so I would occasionally see her then, or sometimes she would even drop by the unit to say hello. When she was in good condition, she did great. She used a cane, but it was almost exclusively for some balance help. When her MS was exacerbated, however, she could barely walk and needed to use a wheelchair for days or even weeks. She often visited the hospital for several days of high-dose steroids when she had a bad flare-up. It was always hard to see. She would feel so frustrated with herself—like she had done something wrong.

Livia and I spend a lot of time discussing her illness and her life’s stressors. Many things can cause MS to flare up, such as stress, infections, too much activity, and even getting your period. For a single mom with younger kids, it was like living in a minefield of things that could trigger her. I spent a lot of time considering how I would manage being in her situation. Her ability to adapt and overcome always amazed me. She pushed through barriers to activity and even engagement with the world—barriers that I often felt would have stopped me. Eventually, Livia met a lovely man, they married, and he adopted her children. She had fewer flare-ups after that. I heard that they moved out of state a while back. I still think of her and hope she is doing well.

Psychological Factors Affecting Activity Level

Have you ever heard that the whole is more than the sum of its parts? A concept called quality of life (QoL) reflects the meaning of that expression. In health care, QoL seeks to capture an individual’s overall well-being. It consists of the totality of the patient’s mental and physical health, as well as their beliefs and values about their health. Physical activity is a key component of QoL—done properly, it improves both physical and mental health.

Unfortunately, as with purely physiological factors, patients must often overcome psychological barriers to exercise before they experience the positive effects to their QoL (Table 22.4).

Barrier	Strategies to Overcome
Feelings of isolation or loneliness	Encourage patients to work with a family member or friend or participate in group activities. Encourage patients to discuss their needs or goals with family or friends and ask for support. Describe the benefits of joining a gym or activity club to meet other people like them. Suggest patients seek out others in their fitness groups to “buddy” with for support.
Fear of injury	Provide education regarding equipment and assistive devices. Encourage structured settings with supervision. Suggest balance and strength exercises to reduce the risk of falling. Recommend starting slowly and simply to build confidence. Encourage warming up and cooling down.
Feelings of embarrassment (e.g., regarding weight, ability, or current inactivity level)	Suggest exercising independently in the patient’s home using equipment or videos. Encourage joining a class designed for beginners so everyone is at the same level. Ask if they have a friend or colleague who might be similarly active and willing to work together. Suggest joining a social activity (such as bowling or a dance class) rather than more traditional forms of exercise.
Lack of motivation	Discuss activities the patient enjoyed when younger and might enjoy again. Suggest trying several types of activities. Encourage them to retrain how they think of exercise—not as drudgery but as fun—and to identify activities they enjoy. Suggest exercise equipment that can be used while they do things they enjoy, such as watch TV. Encourage getting an exercise buddy to work with consistently and motivate each other.

Table 22.4 Psychological Barriers to Exercise (Sources: DHHS, 2017; CDC, 2022b; AHA, 2021.)

Mental Health

Mental health and physical activity have a complicated relationship. Poor mental health is frequently a barrier to physical activity; however, physical activity can improve mental health conditions. A study performed during COVID-19 shows this relationship—and the related barriers to physical activity—quite clearly. This study found that people were less likely to be physically active during the pandemic than before it (Marashi et al., 2021). The respondents who had decreased their activity the most reported the greatest increases in anxiety, depression, and stress. These same people listed anxiety and lack of motivation as primary barriers to exercising. In contrast, the study participants who remained physically active experienced substantial relief from anxiety.

Lifestyle Variables

A lifestyle variable refers to the daily actions and activities related to work, leisure, and diet. For example, a diet largely consisting of processed foods may not provide enough energy or the increased metabolism needed for health-promoting activities. These variables can have a direct effect on health and exercise. People who do not exercise or remain seated for most of their daily activities have a sedentary lifestyle. On the other hand, people who incorporate exercise and physical activity into their daily life have an active lifestyle. These people will generally have more muscle mass and be stronger and in better health than those who are sedentary. Occupations that require an extended amount of sitting can contribute to a sedentary life in the same way that choosing energetic leisure activities such as hiking contribute to an active lifestyle.

Attitudes and Beliefs

The way individuals perceive physical activity greatly impacts their willingness to participate in physical activity (Quicke et al., 2017). Individuals who do not believe they can successfully be physically active, or who believe that activity will increase their pain, fatigue, or likelihood of injury, are less likely to participate in prescribed exercise. Thus, the expectation of a negative outcome may be a barrier to physical activity. When working with these patients, focus on the positive outcomes from physical activity, such as its positive impact on an individual’s self-concept, psychological well-being, and body satisfaction, which contribute to improving psychological well-being and overall QoL (Fernández-Bustos et al., 2019).

Fatigue

Fatigue is one of the classic double-edged swords of physical activity. It can be substantially decreased through regular physical activity. Unfortunately, it also poses one of the most common reasons individuals give for being unable to exercise. When working with patients, encourage them to think about when they are most fatigued and when they have the most energy. Suggest that they begin small by planning activities during times when they generally have the most energy. Educate them about the feedback loop in which sedentary behavior can make fatigue worse, whereas physical activity can make it better. For many this may be counterintuitive, and it is certainly possible to be physically active to the point of exhaustion. However, in general, when individuals start slowly, well within the level of their abilities, and advance their activity over time, they feel less fatigued all the time. Remind patients that they can perform physical activity in short bursts. They do not have to walk continually for sixty minutes; they can walk around the outside or even in their living room for two minutes at a time throughout the day.

Stress

Exercise and stress have an interesting relationship. Exercise decreases stress levels. Yet, high-stress levels decrease the likelihood of exercising (Burg et al., 2017). Even anticipation of stress the following day can decrease the likelihood of an individual engaging in physical activity. Further, high levels of psychological stress predict lower levels of physical activity and higher levels of sedentary behavior (Stults-Kolehmainen & Sinha, 2014). This holds true whether the stress is related to objective, external life events or to subjective internal states. People who are stressed may believe they have no time to exercise due to work schedules, family obligations, study obligations, or other commitments.

When working with individuals who are experiencing high levels of stress or who provide stress as a reason for lack of physical activity, try the following strategies:

• Remind them that any exercise is better than no exercise.
• Encourage them to lower the exercise intensity when they are feeling particularly stressed.
• Suggest they move a little daily, even if only by taking a few minutes during sedentary sessions to stretch their legs.
• Encourage them to plan their physical activity and schedule it as they do other parts of their lives.

Patient Conversations

Helping Patients Overcome Barriers to Physical Activity

Scenario: Nurse Susan Schindler is 44 years old and works in an outpatient clinic in Lexington, Kentucky. She has worked at the clinic for five years and is currently working with a new patient regarding physical activity. The patient has stated that she would like to be more physically active, but she does not have the time or know where to begin, and she is worried about how activity will impact her lower back pain. The physician has asked the nurse to give the patient the results of her x-rays and discuss options for physical activity.

Nurse: Hello, Ms. Mayberry. My name is Susan. Dr. Brunner asked me to come and chat with you about physical activity and exercise. Your back x-rays came back and there are no contraindications to a normal exercise program. If you are interested, Dr. Brunner would like to refer you to physical therapy. They can work with you on back pain, do manual manipulation, and teach you stretching and strength exercises if you would like.

Patient: Well, I guess that’s okay. I’m just not sure I have the time to go to physical therapy.

Nurse: If you don’t have time for physical therapy, you can try several other options, such as tai chi or yoga, that you can do with videos at home. Just be careful not to push yourself past the point where you feel any pain.

Patient: I just don’t know where to start. It has been a long time since I’ve been at all active.

Nurse: There are several places around town that offer low-impact aerobics or other types of group fitness classes for beginners. Maybe you could attend one of those once a week and then find some ways to do a few minutes of exercise at other times of the day. All it takes is a few minutes at a time to have a positive effect on your body.

Patient: Really? I thought I had to work out for at least an hour each time. I don’t know how I would do that even if I wanted to—between my pain and my schedule.

Nurse: Yes, really! Just a few minutes at a time, here and there, will go a long way to helping you feel better. Simple things, like parking farther away from stores to give yourself a bit longer to walk or walking around your yard for a few minutes with your dog or kids, are great ways to start.

Patient: Yes, I can do that easily. My daughter loves to run around the yard, but I never go out with her.

Nurse: She would probably like to have you out there with her occasionally. I also recommend seeing the physical therapist at least a couple of times. We work with a good one who has extended hours and can work around almost any schedule. May I schedule an initial consultation for you? Even a few sessions might give you the tools to really help your pain.

Patient: Yes, I think so. I would like that. Thank you.

Nurse: Excellent. If you have any other questions, feel free to call the office.

External Factors Affecting Activity Level

In addition to physical and psychological factors specific to the individual, external factors influence whether an individual engages in physical activity. Sadly, socioeconomic and environmental factors result in clear differences in the amount of physical activity performed by different groups of people.

Socioeconomic Factors

Physical activity is often presented in our culture as a luxury, requiring considerable time, expensive equipment, and a gym membership. Patients concerned about the perceived high costs of physical activity may avoid exploring inexpensive or even free options, such as jogging or working out with resistance bands, jump ropes, and water bottles as free weights. Lack of childcare can also be a significant barrier to physical activity. Simple activities such as walking and dancing can be ways to involve the whole family in exercise. Patients may also explore cooperative relationships with friends or relatives, trading babysitting for exercise time.

Environment

Environmental factors can also facilitate or inhibit physical activity. For example, access to safe walking paths, facilities, or trails may encourage local people to be physically active, just as lack of access may discourage them (Riverra-Torres et al., 2019). Individuals living in rural areas may not have walking paths or access to facilities (free or paid) where they can exercise (Pelletier et al., 2021). Understanding the local conditions and available resources enables the nurse to provide higher-quality education regarding physical activity in any environment.

Weather

An important component of the environment that is often overlooked when planning an exercise regimen is weather. Bad weather can completely derail an individual’s fitness plan, particularly if it is exclusively based on outdoor activities. Encourage patients to develop various fitness options, including ones that can be done indoors, such as exercise videos, walking around a mall, or dancing classes. That way, when they cannot bike, walk, run, or play tag with their kids outside, they do not have to miss their daily physical activity goals (CDC, 2022b).