Question

Outline the steps for creating a exercise program for a client with comorbidities and be sure to give an examples for each step.

Answer 1

Exercise is beneficial for many chronic conditions and can offer benefits that are comparable to pharmacologic interventions, yet exercise is underprescribed.
• Like medication and surgery, exercise is not a single entity and must be tailored to the condition. Exercise must be appropriately implemented to achieve outcomes that are consistent with those reported in intervention trials.
• To prescribe exercise for chronic conditions, clinicians must know sufficient details about the appropriate and effective exercise interventions and their components.
• We describe and discuss the evidence of effectiveness of exercise interventions for the following chronic conditions: osteoarthritis of the hip and knee, chronic nonspecific low back pain, prevention of falls, heart failure, coronary heart disease, chronic obstructive pulmonary disease, chronic fatigue syndrome and type 2 diabetes.

General considerations:
Although there are few absolute contraindications to prescribing exercise for people with chronic conditions, it is important that patients receive a proper assessment by a physician before starting an exercise program.
General considerations include an initial supervision period for most conditions, education about what the exercise program involves and how it can help, an understanding of the patient’s fears and beliefs (for many conditions, such as low-back pain, cardiac conditions, COPD and chronic fatigue syndrome) and incorporation of strate- gies that enhance longer-term adherence.

Osteoarthritis of the hip and knee

Exercise is beneficial for improving pain and function in patients with hip or knee osteoarthritis, regardless of their age, disease severity, pain or functional level.
1)It is important to ensure patients understand that osteoarthritis is not a wear-and- tear disease and that discomfort or pain during exercise does not indicate further damage to the joint.

2)A range of exercise types is suitable for patients with osteoarthritis, including muscle strengthening, and aerobic and range-of-motion exercises

3)Exercise can be performed on land or in water. Supervised exercise that is supple- mented with a home exercise program is prefera- ble where possible.

For those who are overweight or obese, combining exercise with weight loss is more effective than either treatment alone,Structured land-based exercises, usually delivered by a physiotherapist,

Contraindications
For patients with osteoarthritis of the hip or knee, there are no absolute contraindications to prescribing exercise, although comorbidities need to be taken into account. If the joint is acutely inflamed, the exercise program may need to be modified.
Adverse effects
Studies report few adverse events associated with exercise for osteoarthritis, and they are generally minor, usually increased pain or pain at other sites.

Exercise for chronic nonspecific low-back pain
Rationale for exercise: Each type of exercise has a different rationale. The two main types that can be used are motor control exercises and graded activity.
Motor control exercise: Aims to retrain control of the trunk muscles, posture and movement patterns, using principles of motor learning such as segmentation and simplification. A detailed assessment of recruitment of the trunk muscles, posture, movement pattern and breathing guides the specific treatment for each patient. As control is regained, the exercises progress to more functional activities. Exercises are typically guided by pain and are mostly performed pain-free.
Graded activity: Aims to improve a patient’s ability to complete functional activities and incorporates principles from cognitive behavioural therapy and exercise science. The program addresses physical impairments, such as impaired endurance, muscle strength and balance, but also considers psychological barriers to activity resumption, such as pain-related fear, low self-efficacy or misunderstandings about back pain. Principles of cognitive behavioural therapy, such as pacing, goal setting and self-reinforcement, are used. Exercises are progressed in a time-contingent rather than pain-contingent fashion.
Provider: Physiotherapist
Mode: Individual, supervised face-to-face sessions (and exercise practice at
home)
Where: Primary care physiotherapy clinic
Materials needed: Simple equipment found in a typical physiotherapy gym
Procedure:
Number of exercise sessions: 14 sessions
Schedule details: A typical program12 would comprise 12 sessions over an 8-week period, with 2 booster sessions at 4 and 10 months follow-up plus a concurrent home program.
Duration of each session: Sessions of 1 hour in duration,

COPD
Patients with COPD should be referred to pulmonary rehabilitation when the condition is stable or following a hospital admission for an acute exacerbation. Patients should be taught how to manage symptoms during exercise, especially  how to manage breathlessness.

Rationale for exercise: To improve exercise capacity and quality of life, and to reduce breathlessness, hospital admissions and length of hospital stay.
Provider: Physiotherapist or exercise physiologist trained in pulmonary rehabilitation and holding current cardiopulmonary resusitation (CPR) certification
Mode: Exercise prescription should be individually tailored based on initial assessment; however, a number of patients can be supervised at the same time. It should be delivered face-to-face, although some sessions can be performed unsupervised at home.

Contraindications
There are few absolute contraindications to exercise  training within a pulmonary rehabilitation program.
Most physical and medical comorbidities can be managed by expert clinicians; how- ever, unstable cardiac disease may put patients at risk, and participation may not be possible for those with severe arthritis or severe neurologic or cognitive disorders.

Type 2 diabetes
Evidence supports aerobic exercise, progressive resistance training or a combination of the two if it is structured (defined as planned, individualized and supervised) for the improvement of glycemic control.

Given the relative equivalency of meta- bolic benefits across aerobic and resistance exercise modalities, choice of exercise modality should be driven by patient choice or preference, and presence and type of comorbidities. For example, the presence of sarcopenia, mobility impairment, osteoporosis, frailty and osteoarthritis would suggest using resistance training rather than aerobic exercises, especially if the risk of falling is also present. Severe peripheral neuropa- thy or peripheral vascular disease with foot ulcers may also preclude weight-bearing aerobic exer- cise but still allows for resistance training to occur. There is a dose–response relation, with better outcomes associated with an exercise duration greater than 150 minutes per weekand higher intensity resistance training.
Exercise does not have to be performed in one session for benefits to accrue.

Rationale for exercise: Traditionally, improving glycemic control has been the main focus of exercise interventions in patients with type 2 diabetes. However, many of the associated comorbidities are also relevant to prescribing exercise (e.g., obesity, osteoarthritis, peripheral neuropathy, falls risk, peripheral vascular disease and depression).
Provider: Physician referral to allied health provider or community fitness facility with competence in managing older adults with chronic disease. Prior to referral, physician screening for proliferative retinopathy, unstable angina, uncontrolled blood pressure, hyperglycemia or hypoglycemia, extent of peripheral vascular and neuropathic disease, and the presence of autonomic neuropathy (e.g., orthostatic hypotension, bradycardia or lack of sweating) may be indicated in patients with these comorbidities.
Mode: Aerobic exercise, resistance training and a combination of both are the most effective for glucose control.
The combination offers the best treatment for both diabetes and common comorbidities and is recommended in current position statements.
The exercise needs to be structured, which is defined as planned, individualized and supervised.

Both group and individual training are effective. Patients with extensive comorbidities and frailty require more individualized training and supervision.

Chronic fatigue syndrome
The most effective type, duration and intensity of exercise for chronic fatigue syndrome are unclear.

Contraindications
There are no absolute contraindications to exercise for patients with chronic fatigue syndrome.

Coronary heart disease and heart failure
Patients should always work within their exercise tolerance and progress gradually. Initially, direct supervision of resistance training is advocated. Beneficial gains are possible in those at highest risk (e.g., a history of acute myocardial infarction with comorbidities or advanced heart failure) and in those who adhere to the prescription.

For optimal care, exercise is only one component of a comprehensive program.

Contraindications
Absolute contraindications to exercise for patients with coronary heart disease and Heart failure include unstable ischemia, uncontrolled heart failure or arrhythmias, uncontrolled hyper- tension or diabetes, acute systemic illness or fever, severe and symptomatic valvular heart disease or any other cardiac condition that the family physician believes is life threatening.

Summary of the topic:

Exercise is an effective but neglected treatment for many chronic conditions. However, similar to surgery, exercise is not a single entity but must be tailored to the condition. If exercise interventions are not implemented in a manner that is consis- tent with how they were used in trials (e.g., at a lower intensity, shorter duration or with different components), the fidelity of the intervention is compromised, and clinicians and patients cannot expect to realize outcomes similar to those achieved in the trials.
Unless clinicians can access sufficient details about exercise interventions to prescribe them, they either guess at how to use them or do not use them at all. General practitioners have identified the need for exercise details and resources to assist them with exercise prescription.

Even when a family physician may not be involved in delivering the exercise intervention, they should know the main elements of an evidence-based exercise intervention so they can discuss with patients and refer appropriately. We have sum- marized the available evidence to assist clinicians in using and prescribing exercise interventions in practice.
Exercise prescription also requires clinicians to be able to manage patients’ misconceptions, fears and motivation, particularly for those who are unwell. Although these are also challenges for pharmacologic interventions, the challenges are of a higher degree for exercise. However, the potential rewards for clinicians and patients make overcoming the challenges worthwhile.