Exercise Training for Comorbidities

Definition

Exercise training for comorbidities refers to exercise programming for persons with multiple chronic conditions, such as a person with Type 2 diabetes and Parkinson's disease.

Purpose

The purpose of exercise training for comorbidities is to identify critical measures that can be taken to design safe and effective exercise programs for persons with multiple health challenges.

Demographics

Current trends show that Americans are living longer, whereas the number of individuals with chronic diseases continues to increase. In the past century, life expectancy in the United States increased from less than 50 years to greater than 76 years. The U.S. Census Bureau has projected that by 2030, the number of adults 65 years of age and older will be approximately 70 million. Approximately 80% of individuals aged 65 years or older are living with at least one chronic health problem, and another 50% are living with two chronic conditions. Moreover, the presence of specific chronic conditions are linked with an even greater propensity of comorbidities. For instance, almost all individuals with Type 2 diabetes have at least one other chronic condition, and nearly half have three or more comorbidities. Presently, the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) list a sedentary lifestyle as a controllable risk factor for many chronic health conditions. Accordingly, exercise is a common therapeutic intervention strategy, and although there are exercise program guidelines for older adult and various chronic-diseased populations, these recommendations exclusively address each group separately. The prevalence of common chronic and clinical populations is displayed in Table 1 .

 


Table 1. Prevalence of Common Chronic Conditions





Table 1. Prevalence of Common Chronic Conditions
Modified from American College of Sports Medicine 2014; Mozaffarian, D., et al. 2016.

The prevalence of common chronic and clinical populations is displayed in Table 1

Risks

 


Table 2 summarizes the basic evidence-based guidelines for common clinical populations.





Table 2 summarizes the basic evidence-based guidelines for common clinical populations.
Modified from American College of Sports Medicine 2014; Mozaffarian, D., et al. 2016.

Table 2

The presence of comorbidities may serve as competing demands on a client's self-management resources, thus reducing the time and energy an individual has to devote to each and every condition. Thus, these individuals will require additional guidance and resources to ensure that their other conditions are managed effectively. An individual with a severe and symptomatic condition will have difficulty handling other health challenges. In these circumstances, a severe limitation should not preclude the fitness professional from designing a routine that targets each individual condition. The fitness professional may need to be creative in modifying the routine to sufficiently accommodate limiting factors, yet ensure thresholds for frequency, intensity, and time are also met to elicit positive training effects. Individuals with multiple comorbidities may possess conditions (e.g., arthritis) that fluctuate significantly from day-to-day in terms of severity. Fitness professionals must be prepared to accommodate an ever-changing chronic condition and continually adjust the session to best serve the client on any given day. Persons with comorbidities will require a high degree of monitoring to ensure proper adherence to the established exercise regimen and to determine that the physiological responses to each session are normal. Fitness professionals should be knowledgeable of, and able to educate persons on, the potential signs that warrant the termination of exercise.

Treatment

A shortcoming to the overall current healthcare model for the management of chronic conditions is that the treatment has historically been approached in a singular fashion. For example, an endocrinologist might provide recommendations for a Type 2 diabetic, whereas a rheumatologist provides guidance to an arthritic patient; yet, it would be rare for either medical professional to make note of the concurrent chronic condition when devising a therapeutic intervention. In fact, it has been noted that patients infrequently receive guidance from medical professionals on prioritizing and managing multiple chronic conditions. It is important to recognize that this philosophy also extends to current exercise guidelines for chronic conditions. As is summarized in Table 2 , the ACSM exercise prescription guidelines for common chronic conditions are presented in a separate and uniform manner. Fitness professionals should be prepared to meet the challenge of developing a suitable comprehensive exercise program that addresses each of the client's chronic conditions.

A requisite task is to initially create two separate lists, which prioritize the chronic conditions of a client in terms of (1) long-term mortality risk and (2) symptom limitations. The chronic condition topping the list in terms of mortality risk should ideally be the primary focus of the exercise program. For example, an individual with heart disease, osteoporosis, and arthritis should be most concerned about management of the heart disease. Epidemiological data clearly shows an individual is more likely to die from heart disease compared to the two other chronic conditions. Yet a primary focus on the management of the heart disease in this instance should not be misinterpreted to mean a singular and exclusive focus on only that condition. The exercise program similarly needs to be formulated with the aim of positively modifying each of the other two conditions. Concurrent to designing an exercise program based upon the long-term-mortality-risk list is also the requirement for adjusting parameters of the training routine in accordance with the symptomlimitations list. Nevertheless, there will be occasions where an individual's unstable condition (e.g., arthritis) dictates that the exercise session or program revolves around the limiting symptom(s). For instance, although specific weekly energy expenditure volume and exercise intensity thresholds must be surpassed to positively modify coronary heart disease, these limits may be unattainable amid an arthritic flare-up. In view of these circumstances, the fitness professional may elect to amend the routine in various manners, including decreasing the exercise volume and/or intensity, altering the exercise modality from land- to water-based, or rescheduling the exercise session to another day when the symptoms are less restrictive.

KEY TERMS
Alzheimer's—
A progressive disease that destroys memory and other important mental functions.
Arthritis—
Inflammation of one or more joints. The most common types of arthritis are osteoarthritis and rheumatoid arthritis. Symptoms may include joint pain and stiffness.
Dyslipidemia—
Abnormal amount of lipids (e.g., triglycerides, cholesterol) in the blood.
Heart rate reserve (HRR)—
A method used to prescribe exercise intensity (also referred to as the Karvonen method). The heart rate reserve is the difference between maximal heart rate and resting heart rate.
Hypertension—
High blood pressure; systolic blood pressure greater than or equal to 140 mmHg, and diastolic blood pressure greater than or equal to 90 mmHg.
Metabolic syndrome—
Collection of factors that increase risk of diabetes and heart disease.
Neuropathy—
Abnormal and usually degenerative state of the nervous system or nerves.
Osteoporosis—
Age-related disorder that results in the gradual loss of bone density and strength.
Oxygen uptake reserve—
A method used to prescribe exercise intensity. The oxygen uptake reserve is the difference between maximal oxygen uptake and resting oxygen consumption.
Parkinson's disease—
Slowly progressive neurologic disease that is characterized by a fixed inexpressive face, tremor at rest, slowing of voluntary movements, gait with short accelerating steps, peculiar posture and muscle weakness, and low production of the neurotransmitter dopamine.
Type 2 diabetes—
Long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin.

In general, the exercise prescription for individuals with comorbidities can follow the Frequency, Intensity, Time, and Type (FITT) framework. Table 2 summarizes the basic evidence-based guidelines for common clinical populations and establishes the parameters of the exercise prescription around the various conditions of an individual. If that individual has arthritis, dyslipidemia, hypertension, and Type 2 diabetes, different strategies can be used in establishing the overall exercise program. Type 2 diabetes is generally considered to increase the risk for heart disease and all-cause mortality more so than the other conditions. Concomitantly, the other chronic conditions and specific limiting symptoms must also be carefully considered when formulating the program. In this instance, the frequency and time parameters of the exercise prescription for each condition is comparable. Yet, some pronounced differences are evident in the exercise intensity recommendations between conditions. Although both moderate (40%–>60% heart rate reserve [HRR] or oxygen uptake reserve [VO2R]) and vigorous (60%–80% HRR or VO2R) exercise intensity are recommended in Type 2 diabetic and dyslipidemic populations, as can be noted from Table 2 , vigorous-intensity exercise is not recommended for either hypertensive or arthritic populations.

An alternative strategy is to use the exercise prescription guidelines for a single chronic condition that proves to be the most limiting of the multiple conditions for each client. In particular, this approach is warranted when the client is symptomatic or the condition is not stable. Arthritis is characterized by periodic episodes of acute inflammation. Pain and discomfort are common throughout these flare-ups, and without sufficient caution, exercise can actually exacerbate the symptoms. Under these circumstances, it would be ill-advised to pursue the exercise guidelines for Type 2 diabetes despite it topping the greatest-risk-for-mortality list. Thus, an exercise prescription resembling the guidelines recommended for arthritis would be more suitable.

Overall programming recommendations for fitness professionals include many different considerations. In implementing programs, fitness professionals need to keep the following in mind:

QUESTIONS TO ASK YOUR DOCTOR
  • Is it safe to commence exercise training given my medical conditions?
  • Are there any specific exercises contraindicated?
  • What extra monitoring or other precautions are required based on my multiple chronic conditions?
  • Can you refer me to a fitness professional who can assist with safely designing and implementing an effective exercise-training program?

Resources

BOOKS

American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2014.

PERIODICALS

Haskell, W.L., et al. “Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports Medicine and the American Heart Association.” Circulation 116, no. 9 (August 28, 2007): 1081–93.

Mozaffarian, D., et al. “Heart Disease and Stroke Statistics—2016 Update: A Report from the American Heart Association.” Circulation 133, no. 4 (January 26, 2016): e38–e360.

WEBSITES

Millar, A. Lynn. “Managing Comorbidities for the Older Adult.” American College of Sports Medicine. http://www.acsm.org/public-information/articles/2016/10/07/managing-co-morbidities-for-the-older-adult (accessed February 5, 2017).

ORGANIZATIONS

American College of Sports Medicine (ACSM), 401 W. Michigan St., Indianapolis, IN, 46202-3233, (317) 6379200, Fax: (317) 634-7817, http://www.acsm.org .

U.S. Department of Health and Human Services, 1600 Clifton Rd., Atlanta, GA, 30329-4027, (800) 232-4636, CDC-INFO, https://www.cdc.gov .

Lance C. Dalleck, PhD

  This information is not a tool for self-diagnosis or a substitute for professional care.