Exercise Philosophy

Imagine a fitness program. Devotees of the program are committed, and tend to see impressive results in various metrics of health and fitness (decreased body fat, increased muscle mass, improved cardiorespiratory endurance, improved strength, etc.) However, the program is plagued by claims of injury.

As a former CrossFit affiliate owner, who now works with a large number of athletes who compete in CrossFit, as well as CrossFit gyms, I don't need to do any imagining. This is a conversation I've been having for over a decade now. And although the reduction of risk of injury is certainly an important task which should be pursued by any exercise professional, I will try to argue here that discussion of exercise-induced injury is usually poorly framed, and fails to take into account factors which could drastically change the perspective from which we view the concepts of injury, safety, and risk.

Although my personal experience in this discussion centers primarily around CrossFit, my aim is not to mount a defense of that particular activity. Partially, that is because it turns out that the risk is fairly low, roughly similar to the risk involved in many other commonly employed fitness regimens (see studies on injury risk in CrossFit here* and here, and a literature review on injuries in running here), and so the arguments herein can be applied much more broadly. But in a larger sense, the argument which I wish to present need not depend on the empirical facts about injury rate in CrossFit or other forms of exercise, but instead depend on two other characteristics of injury: type and magnitude.

Type is the likely nature of injuries which may result from the activity. Magnitude is the severity of the effects of the injury. These factors are the primary concerns when considering injury, because they are what have the ability to impact a person's quality of life. Rate is a secondary concern which comes into play only when the type and magnitude of potential injuries are deemed to be sufficiently detrimental that they must be guarded against. If an activity had an injury rate of 100%, but the type and magnitude of the injury were such that they did not at all impact the participant's well-being, there would be no reason to avoid those injuries.

Safety and risk are often presented as two dichotomous, mutually exclusive potential features of an activity. Something is either "safe" or it is "risky". But in reality, they exist not in strict juxtaposition to each other, but on a spectrum. All activities involve some degree of risk (and therefore some degree of safety.) We might say an activity that has a 5% risk is 95% safe. The understanding of safety/risk as a spectrum is of great importance, because it begins to shape the context of questions about injury in a more pragmatic way: when we ask questions about injury, we must first be concerned with type and magnitude, and only then with rate. Risk is the intersection of rate, type, and magnitude, which is to say that risk is measured in the actual negative impact the injuries in a given activity may have on a person’s quality of life. Without accounting for type and magnitude, the mere rate of injury is meaningless.

Once we have a robust understanding of risk, and have assessed the risk within a given activity, we must add a dimension of compare and contrast: risk versus reward. Just as we cannot meaningfully calculate risk with only the injury rate, it is impossible to make a well informed decision about whether or not to take that risk without understanding the potential payoffs.

The National Institutes of Health reports that heart disease is the leading cause of death in the United States for persons between ages of 1-85 years. Unsurprisingly, the American Heart Association holds that exercise can play a significant part in reducing the risk of heart disease.

Heart disease is followed by malignant neoplasms (cancer) at number two, chronic lower respiratory disease (asthma, bronchitis, emphysema, sometimes called “chronic obstructive pulmonary disease) at number four, Alzheimer's at number six, and diabetes at number seven. Of the top seven leading causes of death, at least five can be positively impacted through exercise (cancer and exercise, CLRD and exercise, Alzheimer’s and exercise, diabetes and exercise**). The tenth leading cause of death (fourth among adults aged 18-65) is suicide, and it seems that exercise can play a role in preventing/reducing depression.

In Weisenthal et al (the first linked study on injury rates in CrossFit), the authors describe the type of injuries in CrossFit as “acute and fairly mild.” This can be reasonably extrapolated to exercise-induced injuries in general. When assessing risk as the potential for injury to reduce a person’s quality of life, it seems clear that the type and magnitude of exercise-induced injury constitute a very low risk when contrasted with the reward of avoiding far the more dangerous effects of the diseases outlined above.

When risk assessment accounts for the larger perspective of protection from disease, virtually any type of exercise is very safe indeed, assuming that our measure of the value of exercise is grounded in longevity and quality of life. Given that exercise rates among American adults are worryingly low, and that American children are getting less healthy and fit on average, there seem to be clear ethical grounds for encouraging any mode or model of exercise which gets people moving, with relatively little concern for the rate of exercise-induced injury.

There are at least two potentially troublesome questions which arise from this conclusion. First, if it is true that the ethical import of getting people exercising so heavily outweighs the concern for injury, does it then follow that individual fitness professionals should focus most or all of their time and effort on gaining new clients, rather than honing their craft to offer their clients a safer and more effective product?

There are two suitable responses to this question. First, we can safely draw a distinction between the fitness industry at large, and individual fitness professionals. Although any mode or model of exercise should be encouraged because the upsides so heavily outweigh the downsides, there are strong grounds on which to argue that individual coaches and trainers have a responsibility to provide the best service they can to their clients. The contract (explicit or implicit) between trainer and client can reasonably be seen to create an obligation for the trainer to not only provide exercise, but the most effective exercise they are capable of providing (where effectiveness takes safety into account), and therefore that the trainer should be consistently striving to improve the quality of their service/product.

Second, the question suggests mutual exclusivity between improving the service/product and gaining more clients. There is no reason to believe that these two objectives are opposed to each other, and in fact the inverse may be true. There is no inherent contradiction between promoting exercise of all types, while also insisting that it is incumbent upon fitness professionals to provide the safest, most effective product/service possible.

The second challenge is to ask whether exercise-induced injuries, which is to say musculoskeletal injuries of low magnitude and tolerable type, may cause people to stop exercising. If it turns out to be the case that relatively mild musculoskeletal injuries tend to discourage clients from continuing exercise in the long term, injury rate becomes a more significant ethical concern, since these mild injuries now have the potential to indirectly cause far greater harm by driving the injured persons back into a sedentary lifestyle.

I was not able to find any data specifically pertaining to this question, but it is a issue about which I feel confident depending on anecdotal experience. Though some clients who suffer exercise-induced injury may choose to stop exercising entirely, the vast majority will tend to overcome the injury, improve (often with the help of their trainer) the aspects of their practice which may have led to the injury, and continue exercising more or less unabated. I suspect that the experiences of many or most fitness professionals mirror my own.

The promotion of exercise for public health is an ethical priority. Given the measurement of risk as the intersection of type, rate, and magnitude of injury, and the contrast of the risk of exercise-induced injury against the rewards of improved physical fitness and reduced risk of dangerous disease, there are no moral grounds on which to oppose any form of exercise which falls within the normal parameters of exercise-induced injury. Although individual trainers should be expected to provide the best possible service to their clients, as a community we should support any individual or group efforts to encourage more people to participate in any mode or model of exercise.

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*I am indebted to Russ Greene and Russell Berger of The Russells for making it very easy to find the pertinent research on injury rates in CrossFit, and for their article “CrossFit, Injury, and Risk: A Paradigm Shift”, which discusses the issue of reframing the discussion of risk in exercise.
**Most of the evidence for exercise preventing or improving diabetes is with regard to type 2 diabetes. Type 1 diabetics likely see health benefits from exercise, but as of now the magnitude of the impact of exercise on type 1 diabetes seems to be significantly smaller.