Fourteen empty chairs spaced out in a north Dublin car park before sunrise on a chilly winter’s morning await the dedicated participants of a 7.30am workout class with a difference.
For each one who arrives in the darkness by bike, car or on foot, as bird song heralds the dawn, it is a doctor who has sent them. They have all been prescribed "ExWell" – exercise for wellness with medical oversight.
“With any long-term illness, a lot of the disability and unwellness is caused by deconditioning,” says Dr Noel McCaffrey, founder of ExWell Medical and former Dublin GAA footballer.
People are afraid of becoming breathless and, unfortunately, he says, too often they are told to take it easy and not to go out. “It disempowers them, worsens their physicality and causes social isolation and that brings mental illness.” Many coronavirus “cocooners” would identify with that.
While most participants are enrolled in the programme after a diagnosis and maybe surgery, others are there to build up their strength in preparation for an operation. They are assessed through an induction process and there are follow-ups every three-four months, which chart their progress and provide feedback not only to the individuals but to the prescribing physicians as necessary.
“ExWell corrects deconditioning through an appropriate exercise programme but an amazingly important part of it is that they get to meet people, have a cup of tea afterwards and have a bit of craic. That is almost as important as the exercise itself,” he says. “It restores hope and connectedness, builds resilience and the whole thing is just magnificent.”
It’s hard not to agree after witnessing – and participating in – what unfolds at this early morning “advanced” class that McCaffrey always leads himself, to stay tuned in at the organisation’s grassroots. For a start, the sight of those chairs is deceptive – nearly all the physical routines are done on foot, some with light weights, and there is non-stop movement over a full hour, with only the briefest of water breaks.
While, initially, McCaffrey's minimal attire of T-shirt and shorts appears only for the hardy, those in front of him soon start to shed layers. He jokes that we'll know things are really warming up here in the grounds of the Irish Wheelchair Association (IWA) in Clontarf when Vincent Cronin (77) takes off his woolly hat.
Sure enough, at 8.05am the hat disappears off the head of the sprightly Cronin, who has been doing exercise programmes for years – ever since suffering a heart attack at the age of 62. Dressed with leggings under his shorts, he brings his own, heavier dumb-bells for the exercises with weights.
The passion of the quiet-spoken McCaffrey for this project is obvious. A member of the team that developed the concept at Dublin City University for over a decade, his vision for a national roll-out was not something that could be achieved on campus. At the beginning of 2019 he took the plunge of leaving a secure job to drive the expansion.
“It has become my passion and taken over my life and I love it. It is the most wonderful, fulfilling way to practise medicine.”
Originally called MedEx, the programme was rebranded as ExWell Medical and was “flying” in the first year of its new existence, building on its ongoing, cemented success in Tallaght and Santry. It started operating at a new site in Kilkenny and in collaborations with Sligo and Waterford ITs.
Then the pandemic hit last March and while they did what they could online to lead participants in exercising at home and did enrol some new people into the programme, the in-person interaction was sorely missed. They were able to resume, smaller, outdoor group classes in September and then, with special permission from the HSE, to continue when Level 5 was imposed.
“It was just the most amazing success,” says McCaffrey, observing that participants feel safer outside and also relish the fresh air. The IWA allows them to use its grounds, where there are gazebos that can be rapidly erected if it is raining, and classes are also running in the car park at the Square in Tallaght. He thinks outdoors may be the way to go in the future and sessions in the car park of Sean McDermott Street church will start this month as part of a new inner city project.
“The craic some of the people get out of it is just great,” says McCaffrey, father of Dublin footballer Jack, who has won five All-Ireland senior medals while also forging a career in medicine.
It is important to understand that the exercise content should be the same for everybody. We all need aerobic work, strength work and core stability and balance
Ciarán Newman (71) from Malahide, Co Dublin, is one of those enjoying the exercise and banter in Clontarf. It has done “so much up here”, he says, pointing to his head.
In January 2019, he and his wife, Beth, were both diagnosed with cancer. She was to live only another 110 days with what was pancreatic cancer and died the same week that Ciarán was scheduled for surgery for his prostate cancer in April.
Understandably he was very down when recovering from his rescheduled surgery. He was attending the Arc Cancer Centre when they mentioned the “MoveOn” programme that ExWell runs specifically for cancer survivors. He got a referral and has not missed his twice-weekly sessions since. “Everybody here is flying on one wing,” says Newman, who loves the tight bond within this group who always exercise together.
When the sessions had to stop for the pandemic, he “missed the camaraderie, the banter and the discipline. You can’t say to Noel, ‘I’ll just sit this one out…’,” he laughs.
Indeed, the dedication of every participant to follow all the moves to the best of their ability is impressive. “It is important to understand that the exercise content should be the same for everybody,” says McCaffrey. “We all need aerobic work, strength work and core stability and balance.” Small tweaks are made to exercises for individual circumstances.
They used to run different programmes for different conditions, he explains, but now they designate classes according to functional ability not illness, and people can move up or down levels. “We feel that model of different intensities is the way to go.”
However, there are separate groups for cancer patients because the specific peer support for them is so important. There has been a huge growth in the understanding of the role of exercise in both recovery from cancer as well as preparation for surgery, he says.
Clare Quinn (58) from Swords, Co Dublin, who uses a wheeled walker, is determined to follow McCaffrey’s moves. She has been coming to ExWell since 2017, although her official diagnosis of Parkinson’s disease came a year later.
She attends classes three times a week and says “I love it; it’s the main part of my day”. She has no doubt that it improves her flexibility. “If I don’t do it, I am not able for anything during the day.” While ExWell did a great job online, she says it wasn’t the same without the rest of the group around her. And she could feel her body seizing up, as it was hard at home to keep up the pace at which McCaffrey does it.
“He pushes you that bit,” she adds. “There’s no hiding here – he doesn’t miss a trick.”
A round of applause ripples through the group when McCaffrey winds up the session. Some stop for a quick chat in twos and threes, before they disappear into a morning now lit by the rising sun. And 14 empty chairs stand waiting for the next group of individuals determined to be as well as they can for life.
Frail but motivated at Tallaght University Hospital
Tallaght University Hospital in Dublin has led the way in embracing community exercise for patients after Prof Seán Kennelly, a consultant in geriatric and stroke medicine, first went looking for a maintenance programme for a “frail but motivated” group of patients.
Hospitals can work very hard with patients on rehabilitation for six-eight weeks, he says, but then have to let them go as they address the more acute needs of patients behind them. “We get them a certain distance up the hill, then essentially we have to let them back out into the community,” says Kennelly. The question was how could these patients be maintained in their improved health, without falling backwards and having to be seen in hospital again some months later.
His desire to find a way to stop this cycle led him to Dr Noel McCaffrey in DCU, fortuitously at a time that South Dublin City Council was interested in running such a scheme. Between them, they set one up in Tallaght Leisure Centre and within 12 months up to 500 people were doing MedEx – now ExWell – on a weekly or monthly basis. It took off from there.
“It really exploded with the support of Seán out there,” agrees McCaffrey, acknowledging Tallaght hospital as a fantastic ally, which, “without question, have had the most spectacular success”.
Kennelly’s colleagues across the different areas of medicine started to get involved, supported by the hospital management. “With something like ExWell, you need executive leadership to give something space to develop.”
Develop it has, and 85 per cent of participants in the Tallaght programme have been referred from the hospital. The fact that these referrals are made by the consultant treating a patient’s primary condition helps, he believes, with motivation.
“Sometimes for dramatic effect I will give them the prescription for the medicines and then I will say ‘this is actually the important one’,” he says about the written referral for ExWell. “That is not being facetious; from the point of view of bang for buck, you get so much more from ExWell – if you can get over the initial hurdle of going to it.”
Dementia and falls are the two primary reasons why people tip over from managing at home to ending up in a nursing home.
“ExWell is one of those things that targets both. We know that the most important thing you can do for brain health is exercising; it significantly reduces our risk. From the point of falls, it counteracts sarcopenia – muscle wastage – and means their likelihood of falling, and even if they do fall the likelihood of suffering significant injury, is far less because they are stronger.”
Widower Paddy Downey (85), a former double All-Ireland medal winner with Dublin (1958 and 1964), is one of a celebrated “three amigos” who met through ExWell. While none of them has resumed sessions since the March lockdown, their strong bond and motivation to keep active has sustained them through the many months of the pandemic.
It was developing pneumonia that landed Downey in hospital “in a mess” two years ago. He doesn’t remember the first five days of that 12-day stay but he knows he left on a Zimmer frame. Back home he started to build his strength up walking up and down the hallway.
I have an unbelievable improvement in my health. I won't say I am remarkably fit but I am extremely active for my age
“When eventually I could do more than five minutes, I said I’d chance it out the back lane at night when nobody could see me. Just because you’re old, it doesn’t mean you lose your sense of pride.”
He was trying to force himself “to get back to a physical condition I could accept for my age. I wasn’t having great success, as I think I was genuinely weak and worn out.”
Prof Ronan Collins at Tallaght hospital suggested he try ExWell and referred him. At the induction he managed to walk up and down the basketball court in the Tallaght Leisure Centre for the requested six minutes but had to stop a few times.
However, after two months of attending twice weekly, he started to notice a definite improvement. His five-minute walks became 10 minutes and he could do some weight lifting, aerobics, bicycle work and a bit of boxing work in the gym.
Now he walks 50 minutes every day “at a very good pace – my breathing is by and large very good”. He set up a little gym at home with weights.
“I can do all my gardening – and I have a big garden to do. So, I have an unbelievable improvement in my health. I won’t say I am remarkably fit but I am extremely active for my age.”
He attributes it all to ExWell “and my own bloody mindedness”. He and his other two great mates there – Justin Dawson and Paddy Flannery – don’t only share banter and rally around each other, they also go out of their way to encourage the newbies and promote the programme.
It’s a “team mentality” that Kennelly observes all the time and how people will “rave about the 11 o’clock group on a Wednesday”, as they develop bonds with fellow participants.
The social connection and mental health benefits are huge, he adds, “and it’s so simple – and so inexpensive”.