Starting With the Medical Picture, Not the Routine
When a client with chronic pain or fatigue asks whether they can take up yoga or a walking routine, the answer doesn't begin with the activity itself. It begins with the chart.
Megan Wilkes, MOT, OTR/L, CBIS, of Archway Occupational Therapy, said she first reviews the client's medical documentation for restrictions tied to their diagnoses or risks specific to the planned activity. With permission, she may also contact the client's primary care or specialty providers to talk through concerns about increasing activity.
Only after that does the conversation turn to day-to-day symptoms and a plan the client can realistically succeed with. She offered a concrete example: a client with frequent dizziness might do best starting with chair-based or yin yoga rather than a standing flow.
She framed the payoff plainly. "I love helping people return to physical activity. For many people it improves mood, strength, and often fatigue and pain too. Luckily there are lots of ways to be more active, so it's usually possible to find a way for the client to re-engage."
For readers weighing a new routine, the takeaway is sequencing: check for medical restrictions and activity-specific risks first, then match the format to current symptoms. General guidance on graded activity and pacing is widely available, but the starting point should be the individual's clinical picture.
The Boom-Bust Cycle That Online Advice Misses
Much of the advice people find online assumes a steady trajectory: start small, build up, stay consistent. Wilkes said what she sees in practice is less linear.
"Something I often talk about with clients is the boom-bust cycle. Especially as folks start to feel better after a long down period, it's easy to go all-in on the things you feel like you've missed out on. This can result in a flurry of activity (the 'boom') followed by a crash (the 'bust') of very high pain and/or fatigue. It's especially demoralizing for someone who thought they were finally on a roll."
The work at Archway, she said, is helping people find a sustainable pace and recognize the warning signs of "too much" sooner. "The goal is to consistently be engaged in their life with fewer crashes (or, ideally, none at all)."
That reframing matters for anyone who has treated a good day as a green light to catch up on everything. The boom-bust pattern is a familiar concept in fatigue and pain management, and Wilkes's point is that the crash is not a personal failure but a predictable response to an abrupt spike in load.
Goals First, Symptoms Second
Asked what people tend to decide too quickly or in the wrong order, Wilkes pointed to habit-building.
"It's so easy to get pulled into the idea of keeping a streak or developing a new habit you'll do every. single. day. because it's going to help in some way (less pain, more strength, better mood). The intention is fantastic, but when you're living with chronic conditions, there will be harder days where that habit may feel impossible. Once the streak breaks, people again feel defeated, which can understandably turn to 'why even bother.'"
The ordering problem, she said, is that people often choose a goal first and only later consider how, or whether, it fits their symptoms and energy. Archway's approach is to incorporate the client's current situation into the ultimate goal and build habits that move toward it.
"We help clients focus on big-picture progress over perfection, and encourage flexibility in thinking. For example, I might create different versions of someone's new habit (walking 20 minutes a day) so they have something approachable to hang on to during the harder days (stepping outside for 2 minutes)."
That tiered-habit idea is one readers can apply without a referral: define the full version of a routine, then define a smaller version that remains possible on a bad day. The habit-building literature increasingly emphasizes consistency of cue and context over unbroken streaks, which aligns with Wilkes's point about flexibility.
What to Take Away
Three practical threads run through Wilkes's answers. First, screen before you start: medical restrictions and activity-specific risks come before enthusiasm. Second, expect the boom-bust cycle and plan for it rather than treating a crash as evidence that activity doesn't work. Third, build habits in layers so a hard day doesn't end the effort.
Wilkes's framing throughout was less about pushing through and more about staying engaged. "The goal is to consistently be engaged in their life with fewer crashes," she said — a standard that leaves room for two-minute walks on the days when twenty isn't available.