Hi, my name is Joe Im, I'm a physician at the Shirley Reinabilly Lab in Chicago, and myself and my two colleagues welcome you to this asynchronous online video conference. Topic is Exercises Medicine, the Use of Step Counts in Health Promotion and in the Treatment of Musculoskeletal Disorders. I will be speaking today with two of my colleagues. I feel very lucky to be sharing the screen and this video time with them. The first speaker after my introduction will be Rita Tomas. She is an attending physician at the Health and Performance Unit of the Portuguese Football Federation and she is in Lisbon, Portugal. She's going to speak on step counts and general health. After that, I will talk about step counts and musculoskeletal disorders. And after I finish speaking, Cindy Lin will be speaking next. She is at the University of Washington Medical Center in Seattle, Washington. She's the Associate Director of Clinical Innovation at the Sports Institute. She will be speaking on the role of step trackers and evidence for their use in supporting patients in their step count goals. We all want to thank the AAPMNR for accepting this topic, and we're all excited to talk about it today. So welcome to joining us. First before we get started with Dr. Tomas's lecture, I just want to do a little bit of background on the initiative, the Exercises Medicine initiative. I'm going to try not to read every word on the screen, but I'm probably going to read several of them verbatim. So the vision of this initiative is to make physical activity assessment and promotion a standard in clinical care, connecting healthcare with evidence-based physical activity resources for people everywhere of all abilities. This was initially in conjunction with the American Medical Association when it began in 2007, and it was developed to encourage healthcare providers to, number one, assess patients to see if they were meeting the U.S. National Physical Activity Guidelines, and secondly, to include a prescription for exercise when designing treatment plans for patients. So that's just a very brief background on the overall Exercises Medicine initiative, and that is the theme of our talk today. So I'm going to pass the screen off to Dr. Tomas, and she'll talk about the health benefits of walking. Thank you, Dr. Haim, for the kind introduction. It's a great pleasure and honor to participate at the APMNR Annual Meeting for the first time in a virtual meeting. We hope that we can meet again in person soon. In the meanwhile, this is still a great way to connect and to learn and to be with colleagues and friends around the world. So today I'm going to talk about the health benefits of walking. So I have no disclosures. This is an overview of my talk. I will address briefly walking as a physical activity, as a kind of medicine. Also review briefly the physiology of walking, the backgrounds of the motto 10,000 Steps a Day slogan. Also I will review the benefits of walking on health, mainly physical and mental health. Also provide a summary of the evidence regarding walking and mortality, and I'll provide some guidelines regarding how many steps a day and how step cadence and frequency of stepping in order to achieve those health benefits. So walking is known as a good medicine since Hippocrates, the father of modern medicine. So back in ancient Greece, Hippocrates already acknowledged the benefits of exercising and walking was one of the easiest ways to do it. So in his work published many centuries later, this was the first time that exercise and walking specifically was recognized as good for your health. But it only in 1997, some influential paper was published by Professor Jeremy Morris and Adrian Hartman. You probably remember Professor Morris from the London Bus Study, which was the first time that physical inactivity was linked to earlier cardiac vascular death. So this paper back in 1997, published in Sports Medicine, acknowledged the many benefits of walking, but also acknowledged many research gaps in this area, in the area of walking medicine. So Professor Morris and Adrian Hartman, they acknowledged that one of the biggest problems of today's society was the lack of physical activity, and walking was a good way to counterbalance that lack of exercise. So they mentioned that walking is a cyclic contraction and relaxation of the major muscles of the lower limb, the lower trunk, and also swinging of the shoulder girdle. Because you always have one foot on the ground, it poses less stress to your joints. So it leads to less injuries in comparison for running, for instance. Walking spends energy, but obviously it's going to depend on your speed, your pace, your body mass, the type of terrain, the incline, and also the duration of your walking. The physiological stress depends on the intensity of walking, the walking speed, and that is in relation to the individual's cardiovascular function. So walking three miles per hour for myself can be different from a senior. So it all depends on your own function. So walking fast, and walking fast is just a little bit beyond your comfort zone, that is roughly a little bit above 70% of your heart rate max, can develop and sustain physical fitness. As any physical activity, walking spends energy, so it helps with your weight control. Also muscle contraction enhances the metabolism of your lipids and also the glucose metabolism. As any weight-bearing activity, it also has the possibility to impact positively your bone health, regardless of your age. So where did the 1,000 steps a day slogan came from? Actually, it didn't come from the U.S. or Portugal, it came from Japan. Back in the 60s, Japan was on the eve of organizing their first Olympics, the 64 Tokyo Games, but they faced a big challenge. Their populations become overweight. So they were trying to counterbalance the fact, and Dr. Hatano from the Kyushu University realized that the average Japanese adult only took 3,000 to 5,000 steps a day. So if they could increase their steps a day up to 10,000 steps per day, they could burn up to 20% of their daily caloric intake. At the end of the day, that would mean they would burn up to 5,000 kilocalories, and it would help on the weight control. So back in 1965, the first pedometer was launched in Japan, and it was named Mampo-kei. And Mampo-kei stands exactly for 1,000 steps meter. So it was a good way to market the new gadget, and the slogan stuck. So does really walking confer any health benefits? Yes, indeed. So this is a very recent paper, systematic review paper, published in 2018 in the BJSM. This was a number that was celebrating the 21st anniversary of Professor Mori's influential paper. So they found 38 studies with a big variety of duration, session duration in terms of sessions per week, but actually found a benefit for cardiovascular risk factors in a big range, 100 to 1,300 minutes per week. So this is a big range, and keep in mind, if you follow the guidelines of 150 minutes of moderate physical activity per week, you're going to be on your 450 max minutes a week. So it seems that you could get benefits even if you are below the guidelines, which is important to encourage people to be more active. You don't necessarily need to meet the guidelines in order to have some benefits. So this review paper found beneficial effects on body mass, on BMI, on body fat, also in systolic and diastolic blood pressure, also on fasting glucose and VO2 max. So no effects were found on waist circumference, waist-hip ratio, or blood lipids. They also ran a metaregression analysis, and they could find some dose-response relationships, namely with intervention duration and also session duration. It's interesting to see that those relationships were with some variables, such as blood lipids. There were not such associations, one would not see it in the general analysis. This is probably related to the fact that blood lipids have, in order to change those risk factors, we need more time or more duration of the walking exercise. So also in the same number of BJSM, a narrative review was published regarding the mental health benefits. This paper was called Walking on Sunshine. In review, more than 50 papers. So they looked for the literature for several mental health outcomes, and they went to look if there was any benefits in terms of prevention or treatment of these conditions. And there is good evidence regarding the prevention and treatment of depression and anxiety regarding walking. There's more mixed and limited evidence when it comes to other outcomes, such as self-esteem, where there's no evidence that it can promote, can prevent problems with self-esteem. And there's mixed evidence regarding treatment. There's some papers about psychological stress and psychological well-being, but the evidence is still very limited. The authors acknowledge that there's still little known about other factors like resilience or well-being. And most of the studies focus on the negative aspects of mental health. So more studies are on anxiety and depression rather than on well-being. So interestingly, these authors of this review also came to the same conclusions as previous reviews of the concept of walking outdoors versus indoors. So it seems it's more beneficial for your mental health if you walk on the outdoors, in the natural environment, in the woods, in a park, instead of walking indoors, in a treadmill, in a gym, or a mall. So if you want to encourage your patients to be more active and walk, have them prefer more natural environments. So it's still to be known whether the social context is influential in terms of mental health benefits. So is it better if you walk alone or with friends or a walking group? There's still not enough evidence to draw any definite conclusions. Also the purpose of walking, you can walk to work to commute, you can walk to walk your dog, or you can walk just because you like to walk. So does it make a difference in terms of your mental health benefits? Probably it might, but we don't know the answer yet. So what about walking in mortality? So it seems that walking is beneficial and can decrease the all-cause mortality. We can see up to 11% reduction in the walking versus non-walking group. It also seems that the intensity of walking is also beneficial. So you could see a 20% reduction in the average versus a slow-paced walker. The benefits are more striking when you choose to look only at cardiovascular mortality. So you can see 31% reduction in the highest walking group versus the lowest walking group. These are results drawn from review papers. Also reduction when it comes to commuters to non-commuters, non-walking commuters, and also a reduction when you talk about the average versus the slow-paced walker. Regarding cancer mortality, no protective effect was seen in walking. This might be due to the fact that we're looking to all cancers altogether. So we know that exercise is beneficial for certain types of cancer, namely prevention such as colon or breast cancer. But when we look at the mortality caused by cancer, we see everything in the book. So maybe that's why this protective effect is not seen when you look at all cancer mortality. I bring this paper because it has not been included in the previous review. This was published afterwards in 2019. This is from the Harvard Group, the Women's Health Study. Interestingly enough, 41% reduction in all-cause mortality in older women that took 4,400 steps a day versus the ones that took 2,700 steps a day. And you can see a further benefit until you reach the threshold of 5,500 steps. This study assessed the step intensity through accelerometry, and no benefits were seen in terms of mortality and step intensity. So how much should we advise our patients to walk? So initially, there was the 10,000 steps a day keeps the doctor away, good for your health in adults. Initially, you know, it was not really evidence-based. But the first papers that addressed this topic back in 2004 by Tudor, Locke, and Bassett, they came across this baseline of the average adult, American adult, of 6,000 to 7,000 steps a day. And if you add the recommendations of 30 minutes of moderate activity, physical activity per day, there would be roughly 3,000 to 4,000 steps a day. You would get the magic range of 9,000 to 11,000 steps a day. So not really too much, very much different from the initial recommendations. So the authors reviewed these numbers a few years afterwards, and they realized that probably the average American didn't take 6,000 to 7,000 steps a day, but more so on the 5,000 steps a day number value. So below that, the 5,000 steps a day, consider someone to be sedentary, above that, you could consider someone to be somewhat active. So to that baseline, if you had the recommendations of 150 minutes of moderate vigorous physical activity per day, you're going to get 15,000 steps a week, which divided throughout the seven days of the week would get you to an average of 7,100 steps a day. If you are a bit more ambitious and you want to encourage your patients to be active 30 to 60 minutes a day, you know that's going to probably be on the 3,000 to 6,000 steps a day at a pace of roughly 100 steps a minute. And then you're going to get to another interval, another range of 8,000 to 11,000 steps a day. When it comes to children and teens, it's obviously a bit different because their baseline physical activity is different. So if you think about the 4 to the 6-year-old and you want them to exercise, to be active 60 to 100 minutes a day, you're probably going to be on a 10,000 to 4,000 steps a day. If you move forward, your 6-year-old to 10-year-old, it's going to be a bit different if you're talking about boys and girls because you already see a difference on the baseline physical activity in these ages. And for boys, your goal is going to be on the 1,300 to 1,500 steps a day, and girls a bit less, 11,000 to 12,000 steps a day. Adolescents, as you know, they become less active, so their range is going to be a bit lower than the younger children, somewhat between 10,000 to 11,700 steps a day. And what about older adults? So it all depends what you consider to be your baseline. So if you consider a baseline of 5,000 steps a day, and this could be a bit too much for certain older adults or people with disability, and then if you add up the 150 minutes of moderate physical activity per week, then you're going to be roughly on the 7,100 steps a day. Some studies where they directly observed older adults in their daily living activities and also performing 30 minutes of moderate physical activity per day, they estimated that that will be somewhere in the range of 7,000 to 10,000 steps a day. So how fast should we advise our patients to walk? So this review paper published recently came to the conclusion that if you walk roughly around 700 steps a minute, you're going to be on your moderate intensity, that's more or less 3 METs. And if you want to go faster, so up to 130 steps per minute, then you're going to be on the vigorous intensity, so roughly on the 6 METs range. And TutorLock, again, in our team, they review several papers and they come across some definitions regarding walking patterns. So you could distinguish between a more sporadical walking or a more purposeful walking. And so your brisk walking is going to be somewhere between 100 steps to 119 steps a minute, and your fast walking is going to be above 120 steps a minute. So how does step intensity or frequency relate to mortality? So we have a few studies regarding British cohorts, and this was a self-reported pace. And there was a reduction in the all-cause mortality in the average versus the slow pace, and also a decrease both in cardiovascular and all-cause mortality if you compare those who are on average or more on the slow pace. Women's health study, the one that I mentioned previously, so this was a study where the step intensity was directly observed or measured by a sonometry. They couldn't find such relationship between step intensity and cardiovascular all-cause mortality. So this is also a recent study now in men in order to establish some data about men as well. So the physician health study, this is, again, a self-reported pace. You can see how the reduction in terms of cardiovascular disease and also cardiovascular disease mortality decreases according to the velocity, the pace that the men mentioned. So if you are a fast walker, you'll have less cardiovascular disease and you'll die less of cardiovascular diseases. So just to wrap up some take-home messages, walking is the cornerstone of health promotion and physical activity promotion. So make sure you mention walking when you're promoting, you are encouraging your patients to be more physically active. And remember general goals for children, adults and teens and older adults, but keep in mind that some walking is better than none. So try not to focus too much already on the highest range, the highest number of the steps per day, trying to encourage your patients just to be more active. So taking consideration of their baseline steps and to increase their baseline up to 1,000, 2,000 steps a day, and also give feedback about intensity because you can get additional benefits if you walk at a faster pace. So thank you very much for your attention. Now I pass the screen back to Dr. Aimee. Thank you so much. Thanks, Dr. Tomas. I'm gonna be building on the things that you spoke about and then start to discuss more focused things like the musculoskeletal disorders and how step counts relate to that. What we're gonna find is some of the data as far as step counts go is similar. So Dr. Tomas provided a nice starting point to talk about general health. I'll focus on some specific musculoskeletal disorders. And then afterwards, Dr. Lynn is gonna help us figure out how do we help patients incorporate that because the studies that I'm gonna go over and most of these studies are done with research level step counters or activity trackers. These are not typically trackers that people would be able to go out and buy and use on their own. I have no financial disclosures. Let's just go over some general ideas that I'm gonna cover today. First off, for each area, I'm gonna talk about the rationale as to why walking may be beneficial for things like knee osteoarthritis or spine disorders. I'm gonna review, however limited it is, I'm gonna review the literature on evidence for use of step counts in thinking about musculoskeletal disorders. I don't know if I'm gonna say treating specifically, but certainly in the concept of, or in the construct of thinking about how do we help people be more functional and have less pain from these issues. And ultimately come up with recommendations for patients on step counts in the setting of these disorders, hopefully to help them feel better and be more functional. So thinking overall about this, the studies that I looked at do not use step counts specifically, but often look at sitting time or standing time or quartiles of activity. So there are very few studies that specifically are trying to report the actual number of step counts. They may use accelerometers or pedometers, but ultimately they end up putting people in general groups as opposed to saying you need some specific number of step counts. There was a study that looked overall at treating painful conditions by O'Connor in 2015. This review, or this meta-analysis also looked at things like fibromyalgia, but it did show overall that walking was effective for both knee osteoarthritis and low back pain. Again, in this setting, just for the sake of discussion, these are people with sort of ongoing symptoms. Obviously, if you saw somebody with two days of severe low back pain, that's a different discussion. Doesn't mean walking wouldn't be helpful, but that wouldn't be part of this discussion. These are people with relatively stable symptoms that have it on an ongoing basis. So we're thinking about step counts and musculoskeletal conditions when discussing this with patients. First off, think about factors that will affect their perceptions about increased activity. So a lot of us know this, but I'm just gonna review this somewhat quickly. So of course, for a lot of people, as you all know, a good chunk of the United States is not regularly active. So the idea of telling them to be more active, this is not a habitual thing that they're gonna be used to. It's certainly one of the reasons I shifted from only talking about 30 minutes, five days a week of moderate activity and shifted towards step counts. Some of that recommendation has been based on some of the data that Dr. Tomas has brought forward, including Ayman Lee's study from the Harvard Women's Health Study, as well as some other people around the world, because people do seem to find it more possible to just increase their step counts rather than getting in focused exercise. Of course, when it comes to painful conditions, there is a fear avoidance component, which means that people are gonna be either afraid of having more pain with exercise, or if they feel more pain with exercise, they're afraid of causing damage or making something worse long-term. And in some patients, there's a secondary gain issue, so I just throw that in there for completeness. Of course, there are things like self-efficacy and using external versus internal locus of control and how that might affect outcomes or patients' motivations. Some studies have shown that there can be a short-term increase in pain with exercise, but over the long-term, there's an overall decrease. So some of that needs to be kept in mind as you're prescribing exercise, and patients may ask questions about having pain, a slight increase in pain with or just after exercise, but overall are feeling better. And many of these studies, it's difficult to know if people who exercise more have less pain because they exercise more, or those who have less pain just tend to move around more and be more active. Some of the ways it's been postulated that exercise reduces pain is by affecting muscular strength in a positive way and reducing joint loads. Another is something that gets discussed in the literature among symptomatic and asymptomatic patients, and that is exercise-induced hypoalgesia. That's the idea that there's less pain that's induced specifically because of the exercise. That may play a role. Of course, exercise can have a positive effect on metabolic markers, such as weight, lipid profile, blood pressure, et cetera, and several of these issues have been associated with increased pain and the disorders I'll be discussing today. And as Dr. Tomas mentioned, can have a positive effect on mood, which generally has a positive effect on people with chronic pain. So starting with knee osteoarthritis. So when I looked at the literature for knee osteoarthritis, I did not see a study that says that the goal of the study was to have people walk some specific amount of step counts. For example, hey, I want all these patients to walk 5,000 steps a day. A lot of these studies are observational studies, and using the pedometer as an intervention to improve activity, but not necessarily having some specific number to shoot for. A lot of these articles do not review other contributors to pain, though some do, and some of these other contributors may be weight, specifically body mass index, general health, education status, and marriage status. One study by Dorn in 2013 looked at MRI findings before, sorry, looked at MRI findings before and after a specific period of time, and 10,000 steps or more seem to be associated with an increase in meniscal changes and an increase in what's called bone marrow lesions, which would be a subchondral bone change on an MRI. Now these changes tended to occur in people who had worse-looking knees at baseline. So while this is one study to make us sort of pause for a moment on pushing people above 10,000, I think we need more data to have a specific conversation on what it does in a more general sense. So interesting study, something to keep in mind, but I'm sure more data is going to become, I'm sure data will be coming forward. Strength training, as we know, does help knee pain and function in the knee. That means specific resistance exercise, excuse me, long-term walking can increase lower body strength, but that is a more mild improvement compared to regular strength training. The long-term walking might increase strength by up to 10%, whereas resistance exercise might improve it by 20% or more, typically. So just generally thinking about walking and knee osteoarthritis, this is a common thing that we tell our patients who have knee osteoarthritis. I picked this study because this was a sort of hybrid paper. This paper had a study with a small number of patients and looking at their activity and pain, and then at the end of their paper, they did a formal systematic review and meta-analysis of 13 studies up until that time, and this study came out this year. And overall, this paper and this study showed that the people who were more active had less pain. And again, the goal in this study was not to see if I push my patients to be more active, they had less pain. It was more of an observational thing that they were more active and those who were more active had less pain. Specifically looking at knee osteoarthritis and step counts, White, along with a couple of other prominent researchers, including Tudor Locke, which we saw in Dr. Tomas' talk, and David Felsen, who's done a lot of research on knee osteoarthritis, this was from a large osteoarthritis population. As you can see, 1,788 participants. They were about 67 years old, body mass index in the obese range, but overall, relatively mild pain. These were not people having severe pain, and as you probably all know, this is a nice amount of pain to have to try to have somebody initiate more walking, somebody with more severe pain, this may not be as feasible. And what they looked at specifically was a performance measure. So patients were limited. The limitation was thought to be present if they were walking less than 2.2 miles per hour, or if they had a self-reported score on the WOMAC of greater than 28, and this would be 28 out of 68. So again, not a great restriction in movement or limitation, so a low threshold to measure a worsening limitation in movement. The population were people who either had symptomatic knee osteoarthritis or had radiographic osteoarthritis. Not everybody had symptoms, but if they didn't have symptoms, they were at risk for osteoarthritis. So for example, they had trauma to the knee, surgery to the knee, they had a risk factor based on their weight. So these were people who could, if they didn't have it on radiographs, they were at least symptomatic from it. In this study, they looked at a couple of different ways of breaking down the data, but I thought this was probably one of the most helpful in our discussion today. So if people walk more than 5,000 steps per day, the risk of a functional limitation on follow-up at two years was 0.5 compared to those who walk less than 5,000. And we're seeing 5,000 in some ways come up at least a couple of times, not only in this study, but also in Dr. Tomas's review. In this study, they called less than 2,500 steps per day sedentary. As you saw from Dr. Tomas, some studies talk about 5,000. I've seen some studies talk about 3,000. So sedentary is not well-defined yet, but it seems to be around 2,500 to 5,000 steps per day. For every, so sorry, 14%, a fewer than 14% of the study walked 10,000 steps per day. So again, not an incredibly active group, but still a group that got benefits if they walked enough. And again, two-thirds of these participants did not walk more than 10 minutes a day at a moderate activity. So even in this group that were not doing a lot of exercise, if they walked enough, they got benefits from it. Very few participants had a functional limitation if they walked at least 3,000 steps per day. So again, a couple of different ways of looking at the data. And of course, we're always thinking about where do patients start? Obviously, if my patient's walking 6,000 steps a day, I'm not gonna say, hey, you really only have to get 3,200 or something. So it really is partly related to where they start, but keeping in mind some of these numbers in case people are starting out very low. This is a review of a few different things. They looked at four studies on knee osteoarthritis. The goals of these studies were very different from each other, so I just took this data all together. They did cover knee and hip osteoarthritis, and what they showed in general is consistent with what you've heard so far, that people who increased their steps had a decrease in pain and disability. Typically, with the introduction of a pedometer, the step counts increased an average of 2,000 steps a day, could be anywhere from about 900 to I think upwards around 3,000. An increase of 2,000 steps per day is not uncommon with a lot of the pedometer interventions, so that would be relatively typical for more than just these few studies. And in this review, an average of 6,000 steps a day was achieved, and that would be, in these studies, because these follow-up studies would be anywhere from four weeks to a few months, a 20 to 70% increase above the baseline. Shifting over to low back pain, I'm gonna go over some general concepts to get us prepared for why walking might be helpful. So low back pain is often subjectively worse with sitting or lack of movement in a lot of people, not everybody, but a lot of people. There is a correlation between increased time spent sitting and poor back muscle endurance, so that's helpful because if people have less endurance in their back and they're getting weaker over time, that may increase their chance of having pain, especially with sitting. Another study showed that there is an associated between increased aerobic fitness and decreased low back pain, and decreased fear avoidance, a psychological benefit. We've already talked a little bit about exercise having a positive effect on some risk factors for low back pain. Shifting gears slightly, certainly the core strengthening literature, such as Hyde's literature out of Australia and others, have shown that strengthening is usually part of PT, but not always, but often. But we need to think about a certain subgroup that may have low back pain with walking. In my experience, that tends to be the older individual, older, I mean, these are just rough categories, older than 65 or 70. In that age group, it's more likely that they're gonna have pain with increased walking at a distance compared to walking less. That's a harder one to talk about in detail, but they may need a different approach compared to your average patient with low back pain. Again, thinking about general concepts, low back pain is improved with a walking intervention, but in one study, it wasn't better than other focused interventions, such as typical advice about activity, classes about activity, or medical advice. Sitting in a car or in an unsupported seat results in greater flexion in the lumbar spine, but another study, so going along with that, there was a relative lordosis with walking in another study. So in other words, again, arguing that if somebody is worse with flexion, then sitting would be worse, whereas walking would be less flexion or a relative lordosis, which would tend to improve that person's pain. In the child's literature, so Childs and Fritz and others have talked about a directional preference, sometimes discussed as McKenzie physical therapy, many people are extension responders, so again, trying to figure out how to decrease lumbar flexion, so walking can be added to this idea of decreasing the amount of time that somebody spends in flexion, especially if they have a sedentary or seated job position. And then, of course, Nockibson has the early study showing that with sitting, that ended up in some of the highest disc pressures with somebody who's still not lifting anything. So the first study we're gonna look at is one that looked at some people around age 50 who are a little bit obese, had relatively significant pain, and let's see what happened with them. So what they did is they increased their step counts on average from 4,000 to 4,700 at 12 months and did notice a slight improvement of pain during that time period. Certainly, given the numbers we've talked about today, that's a relatively low level of activity, but again, some improvement with a relatively modest increase in step counts. Another study looked at a similar age population, a little bit lighter as far as their body mass index, but their baseline step counts were quite a bit higher, and this group greatly increased their step counts by an average of 2,800 steps per day during the eight-week study period, and at six months, they also showed a mild improvement compared to baseline. So depending on where people start, increasing their activity seems to help. This was an interesting study. This took a group of 387 workers who were relatively young, under 45 years of age, with a normal body mass index, and said, what if we look at some things and see what might prevent the onset of neck or low back pain? And as a preparation for that, since this is the only one I'm gonna talk about with neck pain, with sitting, the head forward is more flexed compared with standing, and some studies show that a head forward posture is associated with neck pain. So certainly, walking would break that up and get them out of that seated position and that flexed position, which could be provoking some of their pain. So in this study, they showed that increasing the daily steps by 1,000 per day reduced the risk of neck pain by 14%, but did not change the risk of low back pain. And their step counts were fairly high. These are a decent number of step counts based on the literature we've looked at. The only thing to focus on a little bit is, a lot of the literature is focusing on cardiovascular disease and mortality, and for people under 45, this step count may not be completely valid, but still a relatively active group in general. So looking at final recommendations for people as far as step counts and these sort of selected musculoskeletal disorders, you can see there's limited evidence on this as an intervention. When I was reviewing the literature, I saw several papers describing protocols on treatment of low back pain, probably more than knee osteoarthritis. I have a feeling we're gonna be seeing some studies coming out in the next couple of few years on step counts and these issues, because I saw the descriptions of the protocols in the literature without yet having data. So people are getting prepared to do more research on this. Step counts and activity can be increased through interventions with using pedometers and probably a little bit of motivational interviewing. So that could be done with wearables and the health app. Dr. Lin will talk about that a little bit more in her talk. Of course, the promotion of exercise is likely to be beneficial in affecting secondary contributors to these conditions. And so ultimately, what do I say to patients right now? So trying to bring together some of the data that Dr. Tomas talked about, along with some of the data that I found on specific musculoskeletal disorders, I'm usually telling people they should walk a minimum of 5,000 steps per day outside of their fitness activities. And that's an assumption that people are active and don't have any major limitations to movement. I know I'm using that word major sort of loose, but any major limitations to movement. So if I have an 85-year-old who gets 1,000 steps per day, I'm not going to say that. That's going to be a more graded increase in step counts over time. But for a number of patients, they're already, you know, they're not necessarily greatly limited from walking. Even if they do have some pain from knee arthritis, I'm usually looking for them to get 5,000 steps per day above their aerobic activity. And part of that is an indirect measurement of how much they're sitting. Because if somebody, for example, somebody with back pain runs, let's say five miles in the morning, they're well over 5,000. If they don't move the rest of the day, they may not realize how much they're not moving. So this is one way to get them moving throughout the rest of the day. The second thing I'll do for some patients is use the exercises medicine prescription form that I will directly give to patients. This is the form on the right here. You can see that form. You can download this form off of the exercises medicine website through the healthcare provider action guide. I put the link there for the healthcare provider action guide. It is fairly easy to find on the exercises medicine website, but there's the link if you'd like to go to that directly. Back to final recommendations. Realize that light activity can be good, but I also continue to promote formal exercise as well. So again, it is unique to the patient. Since many patients are not doing formal aerobic activity, it often is a discussion of movement and overall walking in general. But if somebody is already active, then it is a way to help them focus on breaking down the amount of time that they sit all day long and break that up. And then, of course, as I've been discussing, you would need to tailor this to the patient's current fitness level and degree of pain. Thank you for your time today, and again, thank you to AAPMNR for allowing us to speak today. It's been a pleasure speaking with my two colleagues, Dr. Tomas and Dr. Lin. I'm going to pass it on to Dr. Lin now. So I'm going to focus on the use of step count apps and wearables for promoting step count in your patients. I don't have any financial disclosures. So in terms of the framework of what I'm going to talk about today, I'm going to talk about the exercises medicine framework to support patients in increasing their step count, which Dr. Im just introduced earlier in his presentation. And then I'm going to talk about different tools that you can use to help support your patients in improving their step count. So that will include ranging from pedometers to different mobile health apps and fitness trackers. So to get more specific about the exercises medicine framework, which I think is really helpful to use in clinical practice, and I use this myself, basically what it involves is three things. So number one, assess, meaning ask your patients what they do for physical activity. You have to know where they're starting from, what their baseline is in order to be able to prescribe it and know where to go from there. Number two is counseling. So brief counseling on the importance of physical activity, always great to tie that into the chief complaint, you know, whether that's knee pain, back pain, fatigue, whatever they're coming in to your clinic for. And then lastly, prescribe. So refer them to appropriate community home-based activity resources, work with them on goal setting for what are reasonable ways to get moving and to get active. So in terms of number one, which is assessment. So and this is something I do often in clinic and just have a conversation with my patients and try to ask them, what is your baseline step count? And some of them do know because they have wearable trackers or they have it on their smartphone, but others don't. And that may involve talking to them about downloading an app or accessing a fitness tracker so they can actually figure out what their baseline is. Sometimes it's helpful to give them a rough estimate of what steps translate to. So 2000 steps translates to approximately one mile and 200 steps translates to approximately one city block. And going back to the exercise prescription framework. So once you know what their baseline is, you can start prescribing it and there's different ways of prescribing it. So you can prescribe it by the absolute number of steps. And I'll go through that a little bit later in my talk. Or you can prescribe it also based on duration of walking or intensity of walking. And so the exercises medicine FITT framework is very helpful. Typically it's similar to prescribing a medication as if I was going to prescribe an antibiotic. So I'm going to tell them how often they do it or how often they take this medication. So that could be walking three times a week, intensity, moderate. So oftentimes we're using rate of perceived exertion. So that would just be breathing harder than normal, you know, a little bit of intensity, getting their heart rate up type. So brisk walking, Dr. Tomas talked a little bit about intensity of walking cadence. So the brisk walking definitely has added benefits. And then in terms of time. So this is an example for a diabetic patient where I would recommend 15 minutes after every meal to really help with the hyperglycemia after meals. And in terms of prescribing exercise, I think this is a really helpful article. And to take a look at yourselves, because some of the behavioral health literature talks a lot about how if we try to sell physical activity or step counter patients based on things that we care about in the healthcare system, such as their blood pressure, their hemoglobin A1C, that's actually not going to really motivate them to make a sustained behavioral change. And it's really important to figure out a way to connect the benefits of activity to why they came to see you in clinic that day, because clearly they took the time to see you. And so they're concerned about something and how it's going to actually help them achieve their core daily needs and goals. And for most people, they view health as I mean, well, health is like our energetic reserve. So health enables us to stay physically active and enables us to do things that are important to us connect with our family, connect with others. And so it's really important to connect it to something positive, you know, step counts, something that is more fun or a way for them to relax depending on what their goals are versus something that's just purely exercise or workout, which some of the literature has shown for some people using the word exercise or workout kind of has this negative connotation where they feel like it involves more fatigue or just a association that's not necessarily positive. And it's also important to think about when we're prescribing step counts and activity to our patients, what the most common barriers are to physical activity. And the main barriers that people cite are lack of time, caregiving duties, lack of motivation or energy, feeling that exercise is tiring or fatiguing. And so it can be very helpful sometimes to say, well, you don't need to go out and do 30 minutes at a time for somebody who is sedentary. Even if they're just breaking up their sitting time, they're getting up every half hour walking around their house, that's better than not moving at all. So making sure we frame it in a very positive way that's achievable, sort of what we call now fitness snacks. So doing small bouts of activity. Another helpful exercise prescription that I use in my office is the choose to move. And this actually empowers the patient to fill out their own activity prescription. And so this is an example from one of my patients where they complete this self-prescription and they can align it with the positive experiences that they want to achieve from moving more. So whether that's vitality, feeling in a better mood, feeling less anxious, clearing their head. And usually I have my patients fill this out after the visit. So kind of while we're wrapping things up and I'm writing, I'm writing down the plan and their next steps. So they write down what types of movements will bring about these experiences. And she said walking, hiking, skiing, and what's a realistic goal for starting this week. She wants to walk three times a week. And so that's a good starting point because it forces them to set a goal for starting that week. And usually I'll say, let's follow up on this when I see you on the next telemedicine visit or in a month or two when we follow up. In terms of how many steps to prescribe, as Dr. Iman and Dr. Tomas talked about, it really depends on their baseline step count. So I usually try to make sure we know what their baseline is and build from there. And sometimes it's good to find out sort of average representative week of their baseline step count, because it may vary day to day depending on if they're at work or if they have other duties. Certainly, depending on what their baseline is, the goal is at least 7,000 steps a day. But if you have somebody who's starting at 2,000 steps a day, even going to 4,000 steps a day, as we know from the Iman Lee study, has benefits to it. In terms of how quickly to advance step counts, most of this is done in research studies, and it usually ranges from between 5% to 20% per week. So certainly one can advance steps either by a percentage or by an absolute amount of steps per week, meaning increasing by about 500 to 1,000 more steps a week on average. And typically in the studies, they have a ceiling of about 10,000 steps a day. But in real life, we know that it's going to be different depending on the individual. There's a whole range of activities for tracking methods of tracking step count that can be used to your patients, and they range widely in cost. So starting from the old-fashioned pedometers and accelerometers that you can wear on your hip or your belt to smartphone-based step count apps and wearable devices and fitness trackers. So starting with pedometers, those are, you know, they're really cheap. You can usually buy them for between $1 to $20 for the fancy ones. How they work is that you hook it on your hip, and it has a little spring-levered mechanism in it, and each step causes the spring-levered mechanism to open and close an electrical circuit and count steps. The main limitations of pedometers are that studies have shown that it tends to underestimate steps in obesity and very slow walking speed. So meaning if you're walking less than three miles per hour, it just doesn't do a good job picking up on steps. It doesn't work as well with irregular or really short stride lengths or step lengths, and it's very sensitive to tilt or angle. So if you're kind of bending up and down or doing gardening work, it's not going to do a great job picking that up. Certainly accelerometers, which is just one step above the pedometers, does offer better accuracy. There's several on the market. The main companies are New Lifestyles and Omron. And those are triaxial accelerometers, and those usually cost around $20 to $30. There's a whole host of free step count apps. Most patients are going to either obviously have an Apple-based phone or an Android-based phone, and so they do have access to the Apple Health app and also the Google Fit app, which leverages the phone's own intrinsic accelerometer to collect their step count. There's also a variety of free apps. So here's a few of the free ones that I've shown here. Accupedio, Sweatcoin, MapMyWalk that patients can download and will also track their step count, again, using the phone's native accelerometer. And in some cases, they also use GPS data to help better localize their activity and the number of steps. And there's also a large variety of pay-per-download apps that you can use as well that offer even more features beyond these. So in terms of the top health and fitness apps that are being used in the United States currently, Fitbit is very popular, MyFitnessPal, Samsung Health, Weight Watchers, and Google Fit are some of the most widely used health and fitness apps currently. There's a number of advantages and limitations to think about when we're prescribing step count apps for our patients. So certainly some of the advantages include that it's lower cost than some of these wearables and fitness trackers, and some of them are free. So it makes it very accessible to our patients. It's smartphone-based. Most patients have a smartphone, and they employ a wide variety of behavioral change strategies to help motivate different users. So whether that's social connection, whether it's gamification, there's really something for everybody because everybody responds differently to different kinds of motivators. Some of the major limitations of the step count app is that it does require carrying the phone on your body or in a purse or bag on your body. And most people don't carry their phone. So by and large, the studies show that they tend to undercount the actual steps, and that's well known. So certainly it's helpful to encourage your patient to try to carry their phone on their body so you can really get a good representative idea of their step count. But I think what's more helpful, obviously, if somebody just has their set pattern of carrying the phone, is that just look at their overall trend. So even if, like my phone, which I don't carry much, it'll say I only walk 2,000 steps, which I know isn't accurate. But if I use it in the same way and did increase my step count, at least you'd hopefully see that trend over time, even though the actual number itself isn't accurate. By and large, a lot of these wrist-worn devices, so that's kind of moving to the wearables that I'm going to talk about too, they don't do a good job of tracking activities such as pushing a stroller or use of a walking aid. So again, there are some major limitations to apps and these types of wearables. So in terms of consumer wearables on the market, so the costs range really widely. So you can get fitness trackers for $30 now. There's the recently released Apple 6, I think, Hermes watch, which is in the thousand plus range. And we do know from the literature that people who own wearables, it's a kind of a skewed demographic. So it tends to be younger population who are wealthier and more physically active at baseline. Some of the benefits of wearables is that there's a wide variety of what they can track currently. So they can give people information about their step count, their sedentary time, run and swim trackers, including wheelchair pushes, for instance, on the Apple watch. However, some of the limitations include that they don't give people credit for other activities they're doing. So for instance, if they're walking and they're getting their step counts in on a treadmill, it may not be able to accurately pick that up. Or if they decided to use an elliptical or stationary bike for activity instead. And as Dr. Im alluded to in his talk earlier, a lot of the published studies on step counts are done in research lab settings and using research grade wearables. So I really want to distinguish that research grade physical activity monitors are different than the consumer grade ones that I've just talked about. It's known that even for research grade monitors, step count accuracy is reduced in those who have variable gate patterns. So if they have antalgic gait or an uneven gait, if they have reduced gait speed, or they're using any kind of assistive gait device, such as a walker or a cane, that it's just not going to be as accurate. Two of the best research grade physical activity monitors are the step watch. And here's a picture of it. You can see it's actually ankle worn, which does relate to its accuracy and active pal, which is a device that you can tape onto your thigh. And those were shown to have the highest accuracy in older adults in a rehabilitation setting. So moving to the clinician side. So what do we do now? So we have all these patients who are increasingly downloading apps and bringing wearables into our own offices and showing us their step count data and other data that they're tracking. And by and large, doctors say most metrics aren't that helpful to them because they get kind of overwhelmed by all of this data. And I think that where we are moving in a lot of healthcare systems with digital front doors is that we're going to see more and more integration of patient reported data, telemonitoring, remote patient monitoring data from their home, whether it's oxygen saturation, their blood pressure and glucometer at home and including step counts. And so we need to stay on top of this and know how do we make sense of this? And so that's why it was so helpful to hear the talks earlier talking about what's the utility of step count? What are the benefits for health in different populations? And certainly in some healthcare systems, step count and other data is something that already appears in their EHR inbox of physicians. And so it's just more data for us to manage. That leads to this is a project that I'm working on at University of Washington in collaboration with some of the computer scientists and engineers, which is developing an app called Exercise Rx that provides some personalization of step count and home based exercise solutions. And basically, the focus of this app that I'm working on is to help support patients in long term physical activity behavior change by identifying specifically what barriers they're facing, whether it's time, fatigue, pain, and helping to troubleshoot that. And that will link with the electronic health record and provide an interface that will give physicians or the care team examples of how they can support their patients who are having difficulty advancing their step count or home exercise goals. So certainly, there's a lot of innovation in this space and I think opportunities to build and grow physiatry into the future in taking a lead and looking at how movement and step count is an important part of our patient's health. Some acknowledgments to my team at University of Washington. And in conclusion, so as we've heard today, taking adequate steps is very important for health. It can improve pain and disability and musculoskeletal disorders. So we really need to remember that we need to ask our patients about their step count. We need to help to prescribe appropriate amounts of activity to support them in their improvement of their musculoskeletal disorders and not just focus on pain medications, physical therapy, or injections. So we really need to think about their health in this broader sense. As we heard, it's helpful to recommend at least 7,000 steps daily for adults, but this really depends on their baseline. Certainly, you may want to shoot higher for patients who are very active at baseline and lower for patients who may be in the sedentary range. And the exercise medicine framework is very helpful to apply in clinical practice. It's a good framework for assessing, counseling, and prescribing activity. And there's a whole host of apps and wearables to explore and consider for supporting our patients in their movement goals. I wanted to thank my co-speakers today and Dr. Tamas, Dr. Im, and please feel free to email us for any questions. I realize we can't do a Q&A, which is always really great and interesting and fun to do, but please feel free to contact us for any questions. Thank you so much.

step counts

health promotion

musculoskeletal disorders

Exercises Medicine initiative

physical activity assessment

walking

health benefits

mobile health apps

fitness trackers