Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Nature of Multiple Conditions and Related Comorbidities In the United States, data from the Centers for Disease Control and Prevention show that about two-thirds of the population is overweight and one-third is obese by body mass index criteria; cardiovascular disease remains a leading cause of disability and death; and type 2 diabetes will soon affect more than 10% of American adults. Also, in part because of aging and in part because of changes in habitual physical activity levels, musculoskeletal pain in the joints and the lumbar spine is the most common reason for visits to a doctor’s office. Many such persons come to the clinic or gym or rehabilitation facility in search of help, and appropriately prescribed exercise will be beneficial for almost all of them. The challenge is to effectively interpret their situation and successfully implement a program.

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE As a review (from previous chapters) on exercise management for persons with a chronic condition. These are major aspects to keep in mind: Goals of the individual and the objective of increasing his activity level Careful attention to the contraindications and limitations Variability in exercise responses and adaptations to training Modification of exercise prescriptions in accordance with the observed exercise responses Flexible interpretation of guidelines Recommendations for Exercise Assessment There are many persons who are severely affected by their chronic conditions and have low physical functioning and a deconditioned state. Diagnostic exercise testing is recommended for many of the conditions of chronic disease, but for people who have low physical functioning and who are advised to start their program at their usual level of activities of daily living (ADLs), the Basic Recommendation is to proceed with a functional exercise trial without referral for diagnostic exercise testing.

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Recommendations for Exercise Assessment This Basic Recommendation (to proceed with a functional exercise trial) is especially applicable to the individuals most severely affected by chronic conditions, for the following reasons: Most exercise tests in this population are terminated due to peripheral limitations at well below 85% of predicted maximal heart rate, reducing the diagnostic utility of a 12-lead ECG for establishing cardiac ischemia Many conditions include pathophysiology that limit the ability to interpret the 12-lead ECG (i.e., chronic left ventricular hypertrophy, electrolyte abnormalities). Most people in this situation will not be prescribed vigorous activity—the goal is typically to increase low-level physical activity, at least as the starting point.

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Recommendations for Exercise Assessment Multiple types of physical performance and functional test are located on pp. 64-65 of text (repeat of functional texts reviewed in previous chapters) However, There are relative contraindications to physical performance testing, including: Extreme pain Risk of joint pain exacerbation Patient or client reluctance Risk of falls (use a waist belt or other precautionary measures) Common causes of early fatigue and volitional exhaustion during functional testing include the following: Morbid obesity and inactive lifestyle can cause a low power/weight ratio. Cardiovascular disease can limit aerobic function or endurance. Weakness due to inhibition or pain can lead to falsely low strength or endurance. Poor effort can come from depression. Neurovascular sequelae, especially of diabetes, can reduce performance. The individual can be just very out of shape from a sedentary lifestyle.

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Recommendations for Exercise Programming Mildly afflicted and adherent individuals do well in a home-based exercise program and in seeking to achieve higher levels of performance, but those who are severely afflicted usually benefit from being in a mentored or supervised program. The Functional Exercise Trial During a functional exercise trial, patients are started slowly with a low-dose, low-intensity bout of exercise at an intensity similar to that of their usual ADLs, with the goal of observing the physical accommodation to this during the session and during recovery over days to weeks. Any adverse effects of exercise (e.g., exertional dyspnea, knee pain, delayed-onset muscle soreness) become apparent and provide clues to how much each of the person’s chronic problems contributes to low functional capacity. A diagnostic exercise test is not required before starting a functional exercise trial because ADL levels of physical activity (e.g., walking) are not high-risk activities

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Exercise Program Choices Community-Based Musculoskeletal Programs Before starting, one key challenge is to distinguish if the individual’s limitations are an acute problem that can rapidly be overcome, or if deconditioning will cause a longer period of rehabilitation: Use maneuvers to see if the muscles are strong when the joint doesn’t hurt. Look for atrophy and muscle wasting that suggests deconditioning. Determine whether modified exercise programs (e.g., aquatic therapy) that unload the skeleton can enable exercise with less discomfort

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Exercise Program Choices Aquatic Programs In persons who have joint pain or overweight or obesity, non–weight-bearing and aquatic exercise programs are a mainstay for the exercise–physical activity aspect of multifactorial risk reduction. These are the major long-term goals for people with overweight-obesity and joint pain: Maintaining robust functional capacity, quality of life, and independent living Preserving mental wellness and averting progression to long-term disabilities Delaying the need for surgery to implant prosthetic joints Preventing progression of obesity and physical inactivity into type 2 diabetes Preventing heart disease and stroke as causes of disability and death Providing a social support to maintain long-term exercise behavior

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Program Options for Frailty and for Seniors Who Are Aging In both frail and non-frail seniors, gait speed, balance, and lower-extremity functional strength are good predictors of future disability. Thus, an exercise program for persons with multiple chronic conditions (even those who are young) should emphasize these aspects: Walking endurance Functional lower-extremity strength (e.g., sit to stand, stair climbing) Core stability and balance activities, particularly those that simulate ADL challenges Graduation to attempting short interval-style efforts to increase gait speed Persons who are frail or pre-frail may have difficulty doing specific exercises; they may need to: start with just muscular endurance such as sit to stand to facilitate ADL mobility, and set a goal of slowing their rate of deterioration

Approach To The Common Chronic Conditions HESS 509 CHAPTER FIVE Non-responders to Exercise Training Some patients with chronic conditions will not respond robustly to exercise training, not because of their underlying illness or deconditioning but because they are intrinsically not good responders to exercise training. This can be disappointing, but it is not sufficient reason to discontinue exercise training: Exercise has beneficial effects on psychosocial function and quality of life, which by themselves justify the program. It is good to remember that in people with chronic conditions, in whom the expected course is further deterioration in physical functioning, an exercise intervention that simply maintains current levels of physical functioning is a positive outcome. Integration Into a Medical Home Model The medical home must incorporate physical function assessments and provide recommendations and encouragement for increasing physical activity as a part of routine care in order to affect the lifestyle-related burdens of obesity, cardiovascular disease, and type 2 diabetes, as well as other conditions related to physical inactivity. END