I originally prepared this as a punch list for a YouTube video, but my recent upper respiratory congestion has made this article a better vehicle.
Obviously, this Substack is for linguistic concerns. And although not often obvious, exercise is a vast area of linguistic confusions. My specific health challenges underscore some of the most salient confusions.
(This article completed on December 23, 2022)
Inflammation is Integral to Exercise
I’m hoping that, once I get myself genuinely dug into a hole with what I’m about to express, emergency medicine specialist, Doug McGuff, will come along behind me and correct any misstatements I may make. Concerning inflammation, I know just enough to make a fool of myself, but its general relationship to exercise that I make should be solid.
In the late 1990s, Doug mentioned that exercise was an inflammatory process. I was at first shocked by this statement. If anyone else had stated this—as very few doctors at the time were intimate with our framework for exercise—I would have ignored them. And I suppose that—for the exact same reason of ignorance of our framework—almost all doctors don’t know of this.
Intertwined with the observation that exercise is an inflammatory process was Doug’s assertion that anti-inflammatories defeat the stimulus of exercise. Herein is the basis of my dilemma with communicating my health challenges to doctors.
[I’m not certain that Doug intended his remarks about inflammation and exercise to be directed at the process OR at the stimulus OR at both. Within the past three years (decades after Doug first made his remarks about inflammation and exercise), we have reconfigured what we call the real-erroneous objective argument to designating as real the process to acquire the desired objective. This is explained on the first two pages of:
Transitioning from TSC to Feedback Statics
Note that Doug has more recently posted interviews wherein he talks about myokines… a subset of cytokines, inflammatory mediators.]
My Illness Begins
On December 8, 2019, I was admitted to the hospital with a strep infection that damaged my heart, lungs, and kidneys. I was discharged 33 days later and on dialysis three days per week and with a diagnosis of streptococcal-glomeruli nephritis.
Upon discharge, my inflammation markers (ferritin, C-reactive protein) remained very high and my white blood cell count was still slightly elevated but steadily reducing. This perplexed the hospitalist, but I was discharged anyway.
After nine days at home, I was re-admitted with elevated temperature and low hemoglobin. After another 11 days in the hospital, I had the new diagnosis of acute rheumatic fever.
And once discharged again and after a few days of being home, I resumed my timed static contraction (TSC) exercise program. [TSC is a kind of isometric exercise program and is described in the aforementioned Transitioning… article.]
As I progressed to greater intensity in the brief (15-minute), once-weekly exercise bouts, I experienced associated and closely proximate fever spikes. This was very concerning as I feared spiking high enough (102°) to require re-admission to the hospital. Brenda (my wife) and I fought these spikes off with acetaminophen for a while, but they worsened, and eventually, the elevated temperature was continuous.
The Mysterious Diagnosis
My nephrologist admitted me a third time in May 2020 for the express purpose of finding the source of these spikes. My inflammation markers were still high as well.
In my two previous hospitalizations, I had been tested extensively, but after the strep was satisfactorily gone, nothing could be found to explain the elevated inflammation markers. Now the medical team was ordering a Karius test, a very expensive test that ruled on over 1,000 possible infectious agents. It came back negative. And as I already doubted the reliability of the test, one doctor (my gastroenterologist) confided to me that he did not have much respect for it.
At about this time, I wrote a somewhat flippant text, “I must be the only one in the world that can’t do his own exercise protocol,” to Doug about TSC and the temperature spikes.
Doug effectively replied by text: “Don’t laugh, interleukin-1 (IL-1) activation increases as much as 10,000-fold with high-intensity TSC and SuperSlow workouts.” [He may have also mentioned IL-6.]
On the surface, I could have taken Doug’s comment as merely artifactual. At first, I did not grasp it for its huge import. And it could have easily faded into the background of our private conversation. I’m sure that I took it seriously at first but not seriously enough to incorporate it deeply into the mystery of my expressed symptomatology.
After another day or so of recalling Doug’s comment and further rumination (while in the hospital bed), I came out of my brain fog enough to garner a focused mission to articulate the exercise-inflammation connection to the doctors. I remained mindful to corner my hospitalist on the topic, although I did not at the time know exactly how Doug wanted me to couch and to apply this isolated but crucial relationship.
Amazingly, fighting through my brain fog, I caught on to the full impact of Doug’s message, and it refined as I articulated it. I did not know if my hospitalist would see Doug’s observation as relevant.
With all my effort to enunciate the words to my hospitalist and to push them beyond my weak voice, he merely suggested I tell this to the rheumatologist when I next met with her. He seemed disinterested, even annoyed by the idea. I was disappointed that my extreme intellectual and physical effort was blown off.
[I sense that a doctor relegates a patient as being a kook if they preach about exercise. In almost all cases, I would too, even if the patient was a medical doctor. But I was not preaching about my exercise notions. I was articulating sophisticated information that was directly pertinent to my symptomatology. And I was afraid that I might be physically unable to repeat my message again if the hospitalist (who was reading my book, Critical Factors of Practice and Conditioning) did not convey the idea. At least with him, I thought I had a chance, but he seemed uninterested.]
I had one edematous metacarpal area as well as edema around an otherwise healthy knee. Finally, I met my rheumatologist, who tested me with Prednisone to show a positive sign for Still’s disease (not necessarily confirmational as Still’s is a diagnosis of exclusion) as the edematous sites abated.
Still’s disease, as it is called, is an inflammatory condition, not a true disease in my opinion as it lacks a pathogenic basis… It is an auto-inflammatory condition… a subset of auto-immune conditions.
Still’s is a condition wherein the normal and desirable reaction by the body to enact inflammation to defeat an infection goes on although there is no infection. The IL-1 gate is effectively stuck open. And this wreaks havoc throughout the body.
While still in the hospital, I confronted the rheumatologist regarding Doug’s assertion. When I mentioned the IL-1 connection with the workouts, she was immersed making the diagnosis of Still’s with the observation of the closely proximate reduction in the swelling of my joints with the administration of Prednisone.
Introducing Kineret
I also mentioned Doug’s idea to try the Kineret (also known as Anakinra), an IL-1 gate blocker. She seemed disinterested, perhaps because she was still in the midst of her diagnosis differential or because of her Turkish language barrier. (Her head was wrapped in a scarf and she wore a mask through which was difficult to understand her. We were in the midst of the Covid-19 lockdowns.)
I could not be sure, but I did not seem to be getting through to her. Again, I submit that a large barrier to her grasping the import of this was her disconnect with the inflammatory role of exercise. But there was the language barrier, my phonics limitation, and the ridiculous face masks that we were speaking through. [Face masks are ineffective against viruses unless they are respirators with integral P-100 filters. These respirators are rarely seen in the hospital wards and surgical suites, although all the medical staff foolishly wear the inferior N-95 masks to the defeat of good communication with the patients.]
After discharge, it required at least two clinic visits with the rheumatologist to get her to see Doug’s points. In desperation, I scrolled back to the text (from several weeks before when I was still hospitalized) between me and Doug and put my phone in her face to make her read about the Kineret idea. I would later learn that Kineret is commonly used for Still’s while she was pushing Methotrexate as the “treatment of choice.”
Ditching the Kineret
It took us many weeks (months) to get me onto the Kineret because of me requiring a charity program and other documentation. Once on it, my condition improved quickly, but it has since required even more effort to get my rheumatologist to agree to terminate it. And again, this is partly (greatly) due to her ignorance about the inflammatory effect of exercise. The once-weekly, 15-minute TSC workout that I do is still not recognized by her as the key sign of the Still’s disease that brought me to her and that instigated the use of the Kineret as suggested by Doug in the first place. After all, she used the test of the Prednisone-edema reduction and did not appreciate the TSC-precipitated fever spikes as the elephant in the room.
And now—after my elevated inflammation markers have corrected even as I have weaned off the Kineret to only three days per week—she wants me to “more gradually” wean down to twice weekly for 90 days and then to once weekly injections for 90 days before completely abstaining. As one of the criteria for selecting Kineret was its short half-life (3-7 hours), would it not merely be in essence yanking the body back and forth to alternately stop and start the injections? And while we will be most curious to watch the behavior of the inflammation markers measured via blood testing, the temperature can be conveniently measured daily, even hourly and without me driving across town for a blood draw.
And regardless of the ferritin and C-reactive protein response, the presence of fever is the big one, in my opinion, and the one not even on her radar with regard to the exercise.
Crucial Definitions
When I first defined exercise in ~1984, I did so without knowing that it is an inflammatory process. But to get to the relationship between exercise and this inflammatory process, one must understand intensity.
Intensity is used in many contexts. And it is widely misunderstood in the context of exercise and this misunderstanding allows for the common generalization that any sport or athletic endeavor can be intense, when, in fact, intensity is a degree of momentary physical effort.
Intensity, contrary to widespread misunderstanding, is not the volume of physical activity as an athletic coach might apply the word. Nor is it the degree of game strategery. It is not heart-rate elevation, as the steady-state aficionados and cardiologists might say. It is not force or load, as some engineers might apply the word.
Almost all people in the exercise field confuse intensity in different contexts. And, of course, the doctors are equally confused as they are perpetually bombarded by the pseudoscience of exercise physiology that never addresses these topics properly.
And the confusion surrounding intensity is most easily settled if we go to the issue of inroad (momentary fatigue during an isolation exercise) and with a quantifiable relationship of inroad/ time.
So, the definition of intensity is dependent upon the definition of inroad. And these concepts, once placed in a consistent framework, provide us with a definition of exercise:
A process whereby the body performs work of a demanding nature in accordance with muscle and joint function, in a clinically controlled environment, within the constraints of safety, meaningfully loading the muscular structures to inroad their strength levels to stimulate a growth mechanism within minimum time.
Note that I have set off the word, inroad. Inroad is the central theme of the definition as well as the central theme of the entire framework. Also note that inroad is a term and concept rarely if ever used in physical therapy, exercise physiology, cardiac rehab, athletics, or in mainstream medicine. To understand and articulate exercise, it is critical to fully understand the concept of inroad.
[For a primer in the derivation of the definition of exercise download the free article:
The First Definition of Exercise
An important complement to the definition is the following piece:
This article exposes the common fallacy of mixing exercise with recreational activity.
In my book, Critical Factors of Practice and Conditioning, I break out the major parts of the definition (preamble, qualifiers, process, and purpose) and then provide the Objectivist (Ayn Rand) breakdown.
Here is a YouTube discussion of inroad:
Discussing The Definition of Exercise, Exercise Versus Recreation, and Inroad with Ken Hutchins
These sources will provide better background than is possible herein.]
So here we have a medical community that is unable to see the relationships BETWEEN exercise intensity (as it is defined by inroad/ time) and inflammation (as the process of inroad is inflammatory) AND my Still’s disease. Discussing these relationships is impossible with the medical community when doctors have no command of the definitions that we employ for the following concepts: exercise, inroad, intensity. Without these definitions and the logical framework around them a discussion of exercise descends into babble.
And I now find myself at the personal consequence of medicine’s superficial romance with exercise. Medicine’s ignorance regarding the bare fundamentals of exercise has come home to roost with me. And this is ironic as I have feared being at mercy of the doctors and physical therapists for much of my life. I see this as particularly poignant, as one of the recommendations for dermatomyositis (a more recently proposed but now debunked diagnosis for me) is physical therapy… Yikes! Of course, none of my doctors will understand the rationality for my distrust of these people.
The Test
My last dose of Kineret was on December 5, 2022. And for the two years previously that I was on the Kineret, my temperature—as measured daily—has ranged from 96.1° to 97.3°…It has since normalized to 96.6° to 98.6°.
As December 5 was a Monday, by the end of that week I had developed a sinus congestion that assumably produced a mild (100.4°) fever on two evenings. This seemed strange as, other than the transient fever, I had no sore throat and my phlegm was clear. [Note that I douched my sinuses with a dilute Betadine solution and am on a perpetual regimen of penicillin to protect me from future infections of strep.]
The post-nasal drip from the sinus congestion elicited an annoying cough that has persisted since.
Finally, even with the persisting cough, I performed three TSC exercises on December 20. My pre-workout temperature was 97.1°, and four hours later it was 98.1°. It’s not been higher since. [Today is December 23, 2022.]
Before being treated with the Prednisone and Methotrexate for several months and then substituting these for the Kineret for two years, I would see such a workout produce a spike up to 102°. The only difference is that my recent workout included only three exercises while the pre-treatment workouts that produced the noted temperature spikes in early 2020 included seven exercises. I will increase the volume to include all seven exercises as the ultimate test on December 27.
I don’t expect my rheumatologist to pay any attention to this (unless I phone in a panic about a temperature spike); however, she will be interested to see the inflammation markers as measured by blood testing to be drawn on December 30. The exercise connection—no matter how much I have tried to draw her attention to it—is just not within her technical scope. Therefore, I should have the result of my test before she has the results of her tests.
Great article. Very similar to what I found while working in cardiac rehabilitation for 18yrs. I could never understand why a lot of consultants involved in the rehab process knew hardly anything meaningful about exercise. They were always against strength training and always favoured steady state exercise. They were ignorant to the benefits of strength training and didn't want to learn either.