ACSM`s Exercise Management for Persons With Chronic Diseases and Disabilities (4th ed).pdf

ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities Fourth Edition Geoffrey E. Moore, MD, FACSM Healthy Living and Exercise Medicine Associates J. Larry Durstine, PhD, FACSM University of South Carolina Patricia L. Painter, PhD, FACSM University of Utah Human Kinetics ******ebook converter DEMO Watermarks******* Library of Congress Cataloging-in-Publication Data Names: Moore, Geoffrey E., 1957- , editor. | Durstine, J. Larry, editor. | Painter, Patricia Lynn, editor. | American College of Sports Medicine. Title: ACSM's exercise management for persons with chronic diseases and disabilities / Geoffrey E. Moore, J. Larry Durstine, Patricia L. Painter, editors. Other titles: Exercise management for persons with chronic diseases and disabilities Description: Fourth edition. | Champaign, IL : Human Kinetics, | Includes bibliographical references and index. Identifiers: LCCN 2015026995 | ISBN 9781450434140 (print) Subjects: | MESH: Exercise Therapy--standards--Practice Guideline. | Chronic Disease--rehabilitation--Practice Guideline. | Disabled Persons--rehabilitation--Practice Guideline. | Exercise Test--methods--Practice Guideline. Classification: LCC RM725 | NLM WB 541 | DDC 615.8/2--dc23 LC record available at http://lccn.loc.gov/2015026995 ISBN: 978-1-4504-3414-0 (print) Copyright © 2016, 2009, 2003, 1997 by the American College of Sports Medicine All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. The web addresses cited in this text were current as of December 7, 2015, unless otherwise noted. Senior Acquisitions Editor: Amy T. 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Box 5076 Champaign, IL 61825-5076 800-747-4457 e-mail: [email protected] Canada: Human Kinetics 475 Devonshire Road Unit 100 Windsor, ON N8Y 2L5 800-465-7301 (in Canada only) e-mail: [email protected] Europe: Human Kinetics 107 Bradford Road Stanningley Leeds LS28 6AT, United Kingdom +44 (0) 113 255 5665 e-mail: [email protected] Australia: Human Kinetics 57A Price Avenue Lower Mitcham, South Australia 5062 08 8372 0999 e-mail: [email protected] New Zealand: Human Kinetics P.O. Box 80 Mitcham Shopping Centre, South Australia 5062 0800 222 062 e-mail: [email protected] E5762 ******ebook converter DEMO Watermarks******* ******ebook converter DEMO Watermarks******* Contents Foreword Preface Acknowledgments Notice and Disclaimer Part I: Foundations of Exercise in Chronic Disease and Disability Chapter 1: Exercise Is Medicine in Chronic Care Exercise Is Medicine Take-Home Message Suggested Readings Chapter 2: Basic Physical Activity and Exercise Recommendations for Persons With Chronic Conditions Definitions Used in This Book Basic CDD4 Recommendations for Physical Activity or Exercise in Chronic Conditions How to Prescribe Physical Activity or Exercise in Chronic Care Graded Exercise Testing Minimum Exercise Recommendations When an Exercise Test Is Not Available Clinically Supervised Exercise Programming ACSM’s Exercise Personnel Certifications Suggested Readings Chapter 3: Art of Clinical Exercise Programming Step 1: Assess Current Health Status Step 2: Assess Current Level of Physical Activity Step 3: Identify Exertional Symptoms That Limit Physical Activity Step 4: Evaluate Physical Function and Performance Step 5: Selecting Physical Performance Assessments Activities of Daily Living and Instrumental Activities of Daily Living Commonly Used Tests of Physical Functioning Step 6: Considerations for Formal Exercise Tolerance Testing Step 7: Considerations for Program Referral Step 8: Develop a Strategy for Monitoring Progress Take-Home Message Suggested Readings ******ebook converter DEMO Watermarks******* Additional Resources Chapter 4: Art of Exercise Medicine: Counseling and Socioecological Factors Common Behavioral Techniques Used in Exercise Counseling Other Aspects of Exercise Counseling Socioecological Disparities and Exercise in Chronic Conditions Integration Into a Medical Home Model Suggested Readings Additional Resource Part II: Common Chronic Conditions and Comorbidities Chapter 5: Approach to the Common Chronic Conditions Nature of Multiple Conditions and Related Comorbidities General Recommendations for Exercise Recommendations for Exercise Assessment Recommendations for Exercise Programming CDD4 Alternative Recommendation: The Functional Exercise Trial General Solutions for Common Chronic Conditions Integration Into a Medical Home Model Suggested Readings Chapter 6: Chronic Conditions Strongly Associated With Physical Inactivity Hypertension and Dyslipidemia Overweight, Obesity, Prediabetes, and Type 2 Diabetes Mellitus Arthritis and Back Pain Osteoporosis Suggested Readings Additional Resources Web Resources Chapter 7: Chronic Conditions Very Strongly Associated With Tobacco Chronic Obstructive Pulmonary Disease Coronary Artery Disease and Atherosclerosis Angina and Silent Ischemia Peripheral Arterial Disease Suggested Readings Additional Resources ******ebook converter DEMO Watermarks******* Chapter 8: Cancer Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Suggested Readings Additional Resources Chapter 9: Significant Sequelae Related to Common Chronic Conditions Depression as a Comorbidity Lower-Limb Amputation Frailty Suggested Readings Additional Resource Part III: Cardiovascular Diseases Chapter 10: Chronic Heart Failure Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 11: Atrial Fibrillation Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming ******ebook converter DEMO Watermarks******* Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 12: Pacemakers and Implantable Cardioverter-Defibrillators Permanent Pacemakers Implantable Cardioverter-Defibrillators Combination Pacemaker–Defibrillator Devices Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Suggested Readings Additional Resources Chapter 13: Valvular Heart Disease Basic Pathophysiology Mitral Valve Disease Aortic Valve Disease Right-Sided Valvular Heart Disease Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 14: Heart Transplantation Effects on the Exercise Response Effects of Exercise Training Management and Medications Recommendations for Exercise Testing Recommendations for Exercise Training ******ebook converter DEMO Watermarks******* Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 15: Aneurysms Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Part IV: Pulmonary Diseases Chapter 16: Chronic Restrictive Pulmonary Disease Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Chapter 17: Asthma Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources ******ebook converter DEMO Watermarks******* Chapter 18: Cystic Fibrosis Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 19: Pulmonary Hypertension Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resource Part V: Immunological, Hematological, and Organ Failure Chapter 20: Chronic Kidney and Liver Disease Renal Disease Liver Disease Management and Medications for Kidney Disease Management and Medications for Liver Disease Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 21: Acquired Immune Deficiency Syndrome Basic Pathophysiology ******ebook converter DEMO Watermarks******* Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 22: Chronic Fatigue Syndrome Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 23: Fibromyalgia Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 24: Hemostasis Disorders Basic Pathophysiology of Hemorrhagic Disorders Basic Pathophysiology of Thrombotic Disorders Management and Medications Effects on the Exercise Response ******ebook converter DEMO Watermarks******* Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Part VI: Neuromuscular Conditions Chapter 25: Stroke, Brain Trauma, and Spinal Cord Injuries Basic Pathophysiology of Stroke Basic Pathophysiology of Traumatic Brain Injury Basic Pathophysiology of Spinal Cord Injury Common Elements Systemic Effects of Central Nervous System Injury Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Chapter 26: Peripheral Neuropathy, Myopathy, and Myasthenia Gravis Basic Pathophysiology of Peripheral Neuropathy Basic Pathophysiology of Myopathy Basic Pathophysiology of Myasthenia Gravis Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources ******ebook converter DEMO Watermarks******* Chapter 27: Cerebral Palsy Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 28: Multiple Sclerosis Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resource Chapter 29: Parkinson’s Disease Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 30: Muscular Dystrophy Basic Pathophysiology Management and Medications ******ebook converter DEMO Watermarks******* Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Part VII: Cognitive and Psychological Disorders Chapter 31: Dementia and Alzheimer’s Disease Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Chapter 32: Depression and Anxiety Disorders Basic Pathophysiology Management and Medications Effects on the Exercise Response Effects of Exercise Training Recommendations for Exercise Testing Recommendations for Exercise Programming Integration Into a Medical Home Model Take-Home Message Suggested Readings Additional Resources Part VIII: Case Studies Abdominal Aortic Aneurysm Senior Editor’s Comment Amyotrophic Lateral Sclerosis Senior Editor’s Comment ******ebook converter DEMO Watermarks******* Asthma Senior Editor’s Comment Atrial Fibrillation Senior Editor’s Comment Becker Muscular Dystrophy Chief Editor’s Comment Breast Cancer Survivor Senior Editor’s Comment Cerebral Palsy Chief Editor’s Comment Chronic Fatigue Syndrome Chief Editor’s Comment Chronic Heart Failure With Mild COPD Senior Editor’s Comment Chronic Kidney Disease: Stage 4, Renal Insufficiency Senior Editor’s Comment Chronic Kidney Disease: Stage 5, Treated With Hemodialysis Senior Editor’s Comment Chronic Kidney Disease: Status/Post–Renal Transplantation Senior Editor’s Comment Chronic Obstructive Pulmonary Disease Senior Editor’s Comment Coronary Artery Disease and Dyslipidemia, Status/Post-Angioplasty With Stent Placement Chief Editor’s Comment Cystic Fibrosis Chief Editor’s Comment Deep Venous Thrombosis Chief Editor’s Comment Dementia and Frailty Chief Editor’s Comment Fibromyalgia Chief Editor’s Comment Hearing Impairment Senior Editor’s Comment Heart Transplant ******ebook converter DEMO Watermarks******* Senior Editor’s Comment Human Immunodeficiency Virus Senior Editor’s Comment Hypertension, Dyslipidemia, and Obesity Chief Editor’s Comment Interstitial Lung Disease (Chronic Restrictive Lung Disease) Senior Editor’s Comment Major Depressive Disorder Chief Editor’s Comment Multiple Sclerosis Chief Editor’s Comment Myasthenia Gravis Senior Editor’s Comment Myocardial Infarction Chief Editor’s Comment Parkinson’s Disease Chief Editor’s Comment Peripheral Artery Disease Pulmonary Hypertension Chief Editor’s Comment Refractory Angina Senior Editor’s Comment Spinal Cord Injury Senior Editor’s Comment Stroke Senior Editor’s Comment Type 2 Diabetes and Disability From Morbid Obesity With Multiple Chronic Conditions Senior Editor’s Comment Type 2 Diabetes and Obesity With Osteoarthrosis Senior Editor’s Comment Valvular Heart Disease Senior Editor’s Comment Visual Impairment Senior Editor’s Comment Appendix A ******ebook converter DEMO Watermarks******* Cardiovascular Calcium Channel Blockers (CCB) Vasodilating Agents Others Blood Modifiers Respiratory Cough and Cold Products Hormonal Central Nervous System Unclassified References Additional Resources Appendix B About the ACSM Contributors Index ******ebook converter DEMO Watermarks******* Foreword If you are a primary care doctor, buy this book and keep it readily available in your clinic. It will become very dog-eared in short order. If you are an allied health care provider working with patients who have chronic conditions but you and your coworkers aren’t knowledgeable about exercise in chronic disease, then you too should buy this book. If you are a clinical exercise physiologist or a physical therapist, or if you are studying to become an exercise professional working with people who have a chronic disease or disability, you certainly need this book. If you already have an earlier edition, take a close look at this one because it is more than a simple update. Rather, it is a substantial rewriting designed to help forge your profession in tomorrow’s health care environment. Abundant epidemiological and clinical trial data prove that physical inactivity and lack of physical fitness are strong, independent risk factors for many chronic conditions, for disability, and for all-cause mortality (notably from cardiovascular disease and cancer). Exercise programs and regular physical activity are known to counteract metabolic states that cause cardiovascular disease, reduce disability, improve quality of life, help maintain physical independence, help maintain cognitive ability, delay loss of independence, and in some circumstances, increase longevity. These are the issues that patients with chronic conditions and their families really care about—maintaining the vitality, physical functioning, and independence that they sense are slipping away. The evidence for the role of exercise in maintaining health, well-being, and the physical functioning required to maintain independent living is overwhelming. While not all of these outcomes can be realized for all conditions discussed in this book, no other single health prescription has the potential to achieve all of these benefits. Medical schools and postgraduate training of physicians across the globe must begin to address exercise in the contemporary training of physicians, and health care systems must begin to incorporate exercise into chronic care management. If that describes a health care system you want to create, no other resource is so thoroughly focused on ******ebook converter DEMO Watermarks******* helping you achieve that transformation. Geoffrey E. Moore, MD, FACSM Healthy Living & Exercise Medicine Associates ******ebook converter DEMO Watermarks******* Preface The first edition of ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities (affectionately referred to by the editors as CDD) was an effort to encourage people working in cardiopulmonary rehabilitation to expand their skills and knowledge to other populations. Most of the recommendations in the first and subsequent editions came from professional experience and approached each chronic health problem in terms of a “special and unique population.” They provided minimal guidance on how to consider exercise for individuals with more than one condition. One major advance in the fourth edition is that it conceptually addresses how exercise can be managed in persons with various combinations of chronic conditions. People with multiple chronic conditions are numerous, and the medical literature does not provide much help in thinking about how to address the problem of exercise management in such people. Despite the fact that many people present to health and exercise professionals with multiple chronic conditions, this situation is rarely studied because of the scientific complexity of interacting pathophysiologies that result in quite heterogeneous exercise responses. Such individuals also have a high rate of intercurrent illness and thus are more likely to miss training sessions for extended periods of time. These issues make obtaining and interpreting research data very difficult, because technically these subjects may not follow the study protocol (even if they eventually complete all phases). As a result, scientists shy away from studying these complex health problems for good reasons: (a) It is difficult to obtain funding; (b) these types of studies are very difficult to design; and (c) study outcomes are not always publishable in peer-reviewed journals because of between-subject heterogeneity in the intervention. Regardless of these difficulties, much more evidence is presently available to support exercise in chronic conditions than was available 20 years ago when we developed the first edition of CDD. A second major advance in this fourth edition of CDD is the refocusing of goals of exercise beyond primary and secondary prevention of cardiometabolic disease, toward the goal of keeping patients and clients physically active in order to optimize their physical functioning and full participation in life activities. This approach parallels the modern practice of gerontology, in which a major goal is to preserve cognitive function and independent living. The accumulating evidence (from both research and ******ebook converter DEMO Watermarks******* anecdotal information) demonstrates that the most important benefit of exercise in people with chronic conditions is the ability to maintain or improve physical functioning and independence. In this perspective, exercise intolerance may not improve very much, nor will the pathology be cured, but preventing decline in cognitive and physical functioning helps maintain quality of life. Regardless of the condition, physical functioning—the ability to do activities of daily living for oneself and to participate in recreational activities—is highly predictive of longevity and the ability to live independently. Regular physical activity and exercise is the only prescription that can preserve these personal freedoms. The third major advance in this edition of CDD, and perhaps the most important, is the drafting of the book as a key resource for primary care providers. The American College of Sports Medicine has spearheaded the Exercise Is Medicine global initiative, with a goal of having doctors everywhere prescribing exercise to their patients. Most of what the world’s people need is exercise for primary prevention; but secondary prevention— exercise as a medicine in treating persons with chronic disease or disability— is an additional goal of the Exercise Is Medicine effort. Primary care medicine is changing dramatically, especially in the United States, but also around the world. Two major innovations, still evolving, are (1) the chronic care model and (2) the concept of the medical home. To some degree, these two concepts go together, with the medical home serving to help patients coordinate all aspects of their care and most especially chronic disease management. There remains a tendency, however, not to use exercise in patients who really would benefit from exercise training. Most physicians and even trained epidemiologists are underinformed on the power of exercise and physical fitness in the promotion of health, well-being, quality of life, and longevity. Patients need their physicians to advise them to be more active, and our aim is to help physicians know how to do this for their patients with complex chronic health problems. Accordingly, we have added a primer on exercise—why it’s important, how to follow proper exercise prescription protocols, and some guidance on knowing when and how to improvise. This is not simple for many, if not most, patients with multiple chronic conditions, whose needs for exercise programming aren’t to be found in a peer-reviewed guideline. Providers must have a sense of how to improvise. Readers who need information on how to prescribe exercise will find this in chapters 2 through 4. These chapters cover ******ebook converter DEMO Watermarks******* the basics of exercise prescription, explain when someone needs to have diagnostic exercise testing, discuss how to use existing exercise resources in the community, and provide a brief overview of counseling methods commonly in use by exercise professionals. A fourth major advance is that in chapter 2 we are putting forth a new Basic CDD4 Recommendation, which is based on consensus statements and streamlined to better suit a chronic disease population. The application of these recommendations is discussed for a number of very common chronic conditions, as well as the common combinations of chronic conditions. These recommendations are based in part on expert panel statements and opinions (and sometimes on the expert opinions of the authors and editors of this edition). The “art” of exercise counseling is presented to provide insight on how and when the “rules” presented in established guidelines might be adjusted to reduce barriers and to encourage people to adopt physical activity as part of the medical management of their condition. Finally, a variety of less common conditions are discussed, leaving out no condition that we’ve addressed in the past. The fifth major advance is in how we have chosen to present the case studies. In the past, case studies were presented in conjunction with the relevant chapter. This is convenient, but the format also has a tendency to convey the notion “Here’s how to manage someone with ____”. In this edition, we have collected the case studies into the new part VIII, called “Case Studies.” We also think of these as “exercise rounds.” Health professionals use meetings called rounds to share knowledge about a patient case both for ongoing care and to discuss the management of such situations. The purpose of the case studies, as in all clinical rounds conducted by health and exercise providers everywhere, is partly to discuss the “how to” of a case. But a more elegant function stems from the fact that real life isn’t neat and that every single person—everyone—has a unique story that reveals the challenges the individual faces and also the failings of medical knowledge. The most important function of part VIII is to help the reader see the gaps in care (and research findings) to help guide individualization and improvisation in care. From a liability perspective, readers must be aware that exercise management of persons with chronic conditions requires clinical training. Only a handful of patients with chronic conditions are "apparently healthy," and while exercise is generally safe, there is risk in working with such persons. Exercise and health professionals who work independently with these individuals need ******ebook converter DEMO Watermarks******* to understand both the pathophysiology (which is only briefly covered in this book), the medical management, and the risks of exercise—content far beyond the expertise of exercise professionals without clinical training. Exercise professionals without clinical training should not work independently with this population, but can provide exercise services under the supervision of an appropriately qualified clinician. From the perspective of the editors, the most important barrier our health care system needs to overcome is the lack of interaction between the medical and exercise professions. Few physicians are well trained in the use of medically directed exercise, and they could refer many more of their patients than they do. As a result, programs like cardiac rehabilitation, diabetes education, and intervention are underused, as are exercise programs for persons with arthritis, cancer survivors, and people with many other conditions. Many fitness facilities offer such programs, but almost none provide a full range of services covering all the conditions discussed in this book. Thus, perhaps the most important goal of this book is to reveal common ground and to create an approach involving more collaboration and teamwork between medical and exercise professionals. We therefore have strived to make CDD4 helpful for primary care physicians and staff working in a patient-centered medical home while retaining the same user-friendliness for allied health and exercise professionals who liked prior editions of this book. We hope this text will provide guidance for primary care practices to incorporate exercise specialists into their practice team and as a critical part of their referral network. We also hope this text will help exercise professionals see how to extend themselves to primary care practices that need their expertise. Beyond more communications, for medical and exercise professionals to become a “team,” some learning about each other’s professional culture will need to occur. If our work is to be adopted across the world, exercise management must become an embedded operation in primary care practices, specialty practices, and health and fitness businesses. To those on the medical team (doctors, nurses, physical therapists, clinical exercise physiologists, occupational therapists, counselors, and so on), the people this book is about are called patients; but after these patients go to a medical exercise program, these same people need to join a gym or go to a personal trainer who thinks of them as clients. Only when this pathway is heavily traveled will people with chronic conditions have the hope of optimizing their physical function so they can ******ebook converter DEMO Watermarks******* remain independent and have a reasonable quality of life. ******ebook converter DEMO Watermarks******* Acknowledgments On behalf of Larry Durstine, Trish Painter, and myself, I would like to thank ACSM’s Publications Committee for investing in this series of textbooks. Special thanks to that committee’s chairs—Larry Kenney, Jeff Roitman, and Walt Thompson—for all their support. Thanks to Katie Feltman (ACSM) and Amy Tocco (Human Kinetics) for their help and patience in the remaking of this edition, as I know the changes we came up with put us far behind the original time line. Thanks to Deb Riebe for collaborating with us to help blend this book with the 10th edition of ACSM’s Guidelines—this blending is such an important element and much more complicated than it sounds. Larry Durstine and I are particularly grateful for the inspiration and support of Loarn Robertson, former acquisitions editor at Human Kinetics, who guided us through the first three editions of this book and provided valuable senior leadership in the design of this series. On behalf of clinicians and exercise researchers everywhere, we thank the patients and research subjects for the priceless gift of allowing us to learn from them—there is nothing so generous as putting one’s trust in someone who is leading you into the unknown. Without you, this book couldn’t have been written. On a personal note, I thank John Rudd, CEO of Cayuga Medical Center at Ithaca, for allowing me to spend some office time working on this textbook. Lastly, I’d like to thank my best of friends, Trish Painter and Larry Durstine, for 25 years of devotion to the cause of creating this series of books—Trish for providing the inspiration and Larry for making it happen. I’ve learned so much from both of you. Geoffrey E. Moore, MD, FACSM ******ebook converter DEMO Watermarks******* Notice and Disclaimer Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. ******ebook converter DEMO Watermarks******* Part I Foundations of Exercise in Chronic Disease and Disability Part I of this textbook is a primer in exercise management, primarily for health care professionals who have little or no formal training in exercise physiology. But it’s also designed to help exercise specialists on the health care team collaborate with clinical staff in the process of exercise programming in persons with chronic conditions. The goal is for the entire health care team to function at “the top of their pay grade” with regard to exercise management. Physicians and primary care or medical home staff mainly serve to provide motivation, as well as to diagnose and resolve any exercise-related problems. Exercise specialists, such as physical therapists, clinical exercise physiologists, occupational therapists, personal trainers, and fitness professionals usually provide the vast majority of exercise intervention and counseling. Everyone needs to be comfortable working with complex patients and know when to confer with clinical staff or a physician to solve a problem. It is important that everyone working with a patient proceed with the same expectations, so one purpose of this section is to create common understanding of when exercise specialists should confer with physicians about additional exercise testing and diagnostic evaluation. What physicians usually want is to know when things are not going according to expectations, because that is a situation in which the physician needs to figure out why the patient is not responding as expected. It could be that the patient is not going to have a great response to exercise training, because many people with a severe burden of chronic disease show limited adaptation to training. But it could also be that there is a problem not fully diagnosed or not yet adequately managed medically, and the physician’s job is to figure that out. Some physicians want to be more involved in the day-to-day progress, but most want to be problem solvers, and problem solving is what they’re best trained to do. Another issue is the multidisciplinary nature of exercise management. Experts who have worked in this field a long time know that physicians and allied health care staff have very different professional cultures and training ******ebook converter DEMO Watermarks******* and don’t think in the same fashion. At first, it’s a little shocking to learn this, because one might think that all of health care would be based on the same “textbook.” But, in fact, that is often not the case, and it’s common to find various health care staff having very different takes on a situation. Some easy examples, not often mentioned in this book, are massage, mechanical modes of therapy, and prosthetic shoe inserts. The various health professions often have very strong differences of opinion on these treatment modalities. This section seeks to provide a foundation that will facilitate communication and help all members of the exercise management team. Lastly, primarily for physicians to get a deeper understanding of what happens in an exercise program, we have provided an elementary introduction to commonly used counseling techniques. This section may also be helpful to students who are new to dealing with patients, but it is only a superficial review intended to illustrate, not teach, how to be a good counselor. ******ebook converter DEMO Watermarks******* Chapter 1 Exercise Is Medicine in Chronic Care The ability to do physical activity, be it physical labor or leisure-time activity or recreation or sport, is one of the most central aspects of being a person. Early in youth, all of us have a natural urge to want to do things by ourselves, for ourselves, as we develop our own sense of autonomy and independence. Late in life, or in people of any age who suffer with the burden of a chronic condition, the decline in ability to do physical activity takes on increasing importance as patients draw closer to not being able to do things for themselves. The threatened loss of autonomy and independence is emotionally traumatic and is one of nearly everyone’s greatest fears in life. Vulnerability to this threat is closely related to the loss of ability to do activities of daily living, and thus is about exercise and physical functioning. Whether a patient has a disease of metabolism or of an organ or from a physical disability, the ability to preserve physical functioning sufficient to maintain independence is central to the human psyche. Beyond this spiritual element of life, abundant data now show that physical activity and physical fitness are immensely powerful in their ability to both lengthen life and enhance quality of life. Research over the last several decades has accumulated sufficiently to allow us to state confidently that there is no body tissue or system that does not benefit from regular physical activity. Further, there are extremely few chronic conditions in which the burden of the chronic condition, comorbidities related to the chronic condition, or the disease-related quality of life are not made better with some kind of exercise program. Benefits of Exercise Training With Chronic Conditions Increases longevity and mitigates disability in some conditions Increases the length of disability-free life Improves metabolic function, shifting away from diabetes and cardiovascular disease Improves physical functioning and quality of life ******ebook converter DEMO Watermarks******* In some cases, exercise prescription can be seen as secondary or tertiary prevention—averting coronary artery disease in a person who has hypertension, or preventing a second myocardial infarction. In some cases, exercise may be mainly helpful at retarding the rate of decline in functional capacity or cognitive decline. Thus, all physicians, especially primary care physicians, should help all patients with a chronic condition optimize their program of physical activity or exercise. From the perspective of helping the patient maintain vitality, it’s one of the most important jobs a physician can do. On these bases, it is clear that exercise functions like a medicine and has a far broader spectrum of application than any single medication. There is no other prescription with such pluripotent potential. Exercise Is Medicine A key purpose of this fourth edition of ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, known to the editors as CDD4, is to advance the goal of helping physicians use exercise as easily as they use medications. Here are three barriers to that goal: It’s easy to prescribe a pill. It’s difficult to counsel patients on lifestyle. Many societies don’t pay health care professionals for exercise management. For physicians, this situation creates a reliance on pills and causes an unintended consequence of transferring responsibility for health away from patient behavior and onto molecular chemistry. This often results in patients being less active because of their reliance on medications! The same can be said of nutrition and dietary supplements, intended to meet nutritional needs that aren’t being met by one’s diet, when most nutritionists feel it would be better to just eat well. There is debate about whether physicians should try to change the physical activity habits of their patients. The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to conclude that having physicians prescribe exercise is effective in actually getting patients to do more exercise. In contrast, other groups found evidence of benefit but were unable to conclude what system design best supports the patients and practices in the goal of increasing medically advised physical activity. We hold, however, that some physician behaviors should be driven by ******ebook converter DEMO Watermarks******* principle and moral imperative, not by an evidence base. This is not to say that evidence should be ignored, but rather that in some domains of health care, notably areas of healthy behaviors, physicians should always adopt an affirmation model. The ethical origins of this principle lie in a deontological rule that physicians should advise patients toward behavior choices that carry beneficence. In the case of physicians prescribing exercise, the issue is more how physicians should operationalize practice protocols to express this moral imperative on the value of exercise than whether or not they should express their advice to exercise. Physician encouragement is the number one reason that people cite for what prompted them to quit smoking. If physicians are able to persuade patients to take insulin or cholesterol-lowering or antihypertensive drugs and to quit smoking, shouldn’t physicians also advise patients to exercise? Brief counseling and pedometer programs significantly increase physical activity. Exercise Is Medicine in the Medical Home Care Model The Exercise Is Medicine (EIM) initiative was established “to make physical activity assessment and exercise prescription a standard part of the disease prevention and treatment paradigm for all patients.” This initiative was started in November 2007 by the American College of Sports Medicine (ACSM) in conjunction with the American Medical Association at a national launch held in Washington, DC, attended by acting U.S. Surgeon General Dr. Steve Galson, along with the directors of the President’s Council on Physical Fitness and Sports and the California Governor’s Council on Physical Fitness and Sports. In May 2008, the first World Congress on EIM was held in conjunction with the ACSM annual meeting to announce the global launch of this program. Exercise Is Medicine has been adopted in over 50 countries, including six regional centers around the world in North America, Europe, Latin America, Asia, Africa, and Australia, showing the worldwide acceptance of the basic tenets of EIM, including recommendations for weekly physical activity to improve health. Exercise Is Medicine was not conceived for patients with chronic diseases and disabilities, but more for apparently healthy individuals who are able to safely do activities such as walking. As such, the EIM recommendations for exercise are geared more to promote population health than to specifically address the exercise needs of persons with a chronic condition. Many people ******ebook converter DEMO Watermarks******* with a chronic condition have mild manifestations that are well controlled— for example, hypertension managed with a DASH (Dietary Approaches to Stop Hypertension) diet and a diuretic to achieve resting blood pressures of 126/84. Such an individual likely does not require any special accommodations for the condition in an exercise prescription, and for such a patient ACSM recommends following the ninth edition of ACSM’s Guidelines for Exercise Testing and Prescription. In contrast, CDD4 is for persons who do require some accommodation for their chronic condition. One important need, then, is to help physicians and health care professionals blend the skills needed for EIM with the skills needed for CDD4. Annual Wellness Visit Primary care physicians have long followed the practice of having an annual visit with a physical exam. Health care system redesign is increasingly moving toward viewing this encounter as an annual wellness visit, where the intent and focus are on creating or updating the patient’s plan for health promotion and disease prevention. With regard to promoting physical activity among the apparently healthy population, primary care physicians should look at this visit as a variation on the preparticipation physical exam, where the objective is to clear patients for the regular physical activity needed to stay healthy, and provide a prescription that will help the patient adopt and maintain an active lifestyle. In this visit, rather than clearing patients to participate in sport, physicians are either clearing and guiding them to participate in regular exercise, or referring them to a program that will help them make the transition. These are examples of programs that can help the transition: Physical and occupational therapy Cardiac and pulmonary rehabilitation A medically supervised exercise program (e.g., aquacise for patients who have arthritis or are obese) A carefully prescribed and monitored independent home program for those with stable disease The goal of such programs is to help patients increase their physical activity and improve physical functioning to the point that they can do their own self- directed program, or do so with the aid of an exercise specialist or personal trainer. For patients who have a chronic condition, physicians should consider exercise an essential part of the treatment plan and devise a plan to ******ebook converter DEMO Watermarks******* help the patient adopt and maintain a regular exercise routine. By looking at each patient as you would at an athlete, you can be much more effective in helping him achieve the physical activity he needs to stay healthy. Exercise Vital Sign and Health Risk Assessment A basic tenet of the EIM initiative is that physical activity should be regarded as a vital sign according to which every patient has her exercise habits assessed so that a proper physical activity or exercise prescription can be provided. The exercise vital sign (EVS) is a simple way to do this and to also get the topic of exercise into the exam room with every patient. The EVS can be administered by the medical assistant as part of the assessment of the traditional vital signs of blood pressure, pulse, respirations, and temperature. In part based on ACSM recommendations, the health informatics group at the National Institutes of Health recommends that all medical records include two simple questions (see “Exercise Vital Sign Questions”). Exercise Vital Sign Questions On average, how many days per week do you engage in at least moderate to vigorous physical activity like a brisk walk? (Response range: 0-7 days) On those days, for how many minutes do you engage in physical activity at this level? (Response range: 10, 20, 30, 40, 60, >60 min) Multiplying the two responses together gives the number of minutes per week of self-reported moderate to vigorous physical activity (MVPA) done each week by that patient. An electronic medical record can automatically display this value, and adults doing less than 150 min per week can be flagged with an alert. Practices that don’t have an electronic medical record should have the medical assistant flag such patients. Kaiser Permanente installed an EVS in their electronic medical records in 2009, and over 90% of adult patients had an EVS recorded on their chart after 3 years of use. In patients over 65, 96% had an EVS on their chart. Senior citizens, as the population most at risk and burdened with chronic conditions and disabilities, are patients who can especially benefit from doing regular exercise. Another popular tool is a health risk assessment (HRA) questionnaire; in the United States these are mostly in use by wellness programs sponsored by employers or health insurance plans. Many HRAs have the EVS questions ******ebook converter DEMO Watermarks******* built in to the questionnaire and thus can provide the MVPA score as a part of the report. Health risk assessment tools go beyond physical activity and also ask the patient questions about diet, tobacco, stress, and other lifestyle-related risk domains. For purposes of lifestyle-related health promotion, an annual (or periodic) wellness visit coupled with an HRA that includes a MVPA score is an excellent model to implement as a standard operating procedure for a primary care or medical home practice. Role of the Physician What can busy physicians do during a short office visit to encourage their patients to be physically active? Well, first off, they should insist that the practice implement annual or periodic wellness visits that employ an HRA with an EVS as a standard operating procedure, with participation in these visits a mandatory requirement for patients in the practice. Then, not only has the patient provided the necessary lifestyle information (including information on physical activity), but the physician (or designee) has an entire visit that focuses on health promotion and the provider has an opportunity to discuss exercise with the patient. If the health care system doesn’t compensate physicians for doing wellness visits, the practice can develop an employee with the necessary skills to do these visits and designate the role to that employee. Such a visit at least obtains the patient’s data and shows patients that their doctor is willing to devote special resources to assessing their lifestyle-related needs (including exercise). Outside of a wellness visit protocol, physicians often feel they have to squeeze a discussion about exercise into a visit scheduled for either acute or chronic care. “Tips on Bringing Up Physical Activity in a Clinic Visit” can help guide physicians regarding how to integrate a discussion about exercise into a disease care visit. Tips on Bringing Up Physical Activity in a Clinic Visit If the visit is for acute care (assuming it is not an injury): Consider skipping any discussion about physical activity. Maybe the patient should even take a few days off. Exercise training is a chronic phenomenon that presupposes a stable medical status. If the visit is for chronic care: It’s a perfect opportunity to discuss the role of exercise in the ******ebook converter DEMO Watermarks******* patient’s health! Table 1.1 includes some ideas for starting a discussion about exercise with an apparently healthy person or someone whose chronic condition does not constrain her ability to be active and exercise. ******ebook converter DEMO Watermarks******* For apparently healthy patients in whom the main goal is risk reduction, provide an exercise prescription (see chapter 2) or suggest useful resources: Buying a pedometer to measure walking steps (daily goal of 8,000- 10,000 steps) Joining an exercise class or getting an exercise video game or DVD Seeking a community resource such as a YMCA Getting advice from a local exercise professional or wellness coach If the physician has 5 min or more for brief counseling, or more appropriately chooses to spend substantial time on the subject of exercise for purposes of treating the patient’s chronic condition, then he can assess the patient's readiness for change regarding exercise habits. He might ask questions such as these: What would the patient want to do to be more active? What barriers are preventing this from happening? Consider brainstorming with patients on how to get around these barriers, or explaining in detail how exercise can affect the conditions they have or may be at risk for and how they can go about incorporating physical activity into their daily life. ******ebook converter DEMO Watermarks******* Exercise Prescription Physicians should write exercise prescriptions because a physician’s prescription carries with it the moral weight of the physician’s judgments designed to help the patient—it elevates exercise to the same stature as all the other recommendations the physician has for the patient. There are two simple ways to write an exercise prescription; this isn’t really any different than for any other prescription. These are discussed in detail in chapter 2 and are illustrated here in table 1.1 and “Two Styles of Exercise Prescription.” In brief, they use a mnemonic called FITT. The idea is just to think of exercise like any other medication: The type or kind of exercise (e.g., walking) is like the type of drug; the dose is how many minutes (duration) and how hard to go (intensity); and the frequency of dosing is every day (or however many days a week; maybe even twice a day if the patient has difficulty sustaining exercise). For more details on how to write an exercise prescription, including activities most appropriate for persons with chronic conditions and low physical functioning, see chapter 2. Two Styles of Exercise Prescription Here are two styles to consider when writing an exercise prescription. FITT Style Frequency—how often to do activities in number of days per week Intensity—the subjectively perceived or objectively quantified level of exertion Time—the duration for which each activity should be pursued on each day Type—the specific nature of the activity or activities to be performed Pharmacy Style Indication—the chronic condition for which exercise training is prescribed Specific exercises—the specific nature of the activity or activities to be performed Dose as measured by duration (time) or number of repetitions and intensity of subjectively perceived or objectively quantified level of exertion. ******ebook converter DEMO Watermarks******* Progression and renewals—the time course over which the program should continue Adverse effects—chronic conditions or exercise-specific risks worthy of caution Power of Walking Walking should be the default form of physical activity for anyone who can walk, just as pushing oneself in a wheelchair should be the default for those who use a wheelchair. Walking is extremely accessible for all ages and fitness levels and can be done alone or in groups. Walking is low cost and doesn't require a gym or specialized equipment. It is also easy to measure walking by using a pedometer or a watch. Walking has generally good long- term adherence and has been proven to benefit health. Finally, use of walking as a form of commuting (and also cycling) saves not only in terms of health care costs but also in fossil fuel consumption as an environmentally friendly way to commute. Exercise Is Medicine in the Chronic Care Model We have briefly reviewed the basis for EIM in the primary care or medical home environment, mainly aimed at apparently healthy persons or those with one or more chronic condition(s) that do not substantially alter the person’s ability to exercise safely. This material is a foundation for the far more challenging problem of exercise management in persons with a chronic disease or disability in whom the condition substantially affects their ability to exercise. The degree to which a patient’s condition affects her ability to exercise safely is a complex function of both the specific condition or combination of conditions and the relative burden of severity. Today there is no simple algorithm to quantify this, so physicians and exercise professionals who assist such patients must use their best judgment based on their knowledge of the condition, the patient’s physical exam, and any useful laboratory data (such as measures of physical functioning or exercise tolerance testing). This assessment of the patient’s disease burden then must be factored in together with the individual’s goals, socioecological status, and available resources to help the patient become more active (with a long-term goal of meeting physical activity guidelines). This coordination of exercise or physical activity with socioecological factors and available resources is a logical function of the medical home as part of the chronic care model. ******ebook converter DEMO Watermarks******* The chronic care model (figure 1.1) has risen to favor among health care system designers, layered onto what has become known as the medical home or patient-centered medical home (PCMH) model of primary care. Most readers are familiar with the basic concept that one key function of the PCMH is to serve as a coordinating center for all needs related to a patient’s health care. Examples include helping improve patient health literacy, assisting patients with obtaining social or mental health services, facilitating transportation to and from health care visits, arranging for home health aides, and performing many other complex care-coordination tasks. Modern health care systems and patient care plans are extremely complex, especially in situations that involve multiple chronic conditions or disability, and the task of making sure all aspects of care are well coordinated is often too difficult for patients and their families to accomplish. ******ebook converter DEMO Watermarks******* Figure 1.1 Chronic care model and population health. Adapted from V. Barr and the McColl Institute for Healthcare Innovation. The chronic care model is a generalized conceptual model rather than a care protocol, and objective evidence supporting the chronic care model is generally positive, albeit modest. Most chronic conditions involve far too much variability in socioecological situation to be formulaic, as almost every patient’s specific situation has an enormous number of socioecological variables beyond the influence of the PCMH. There are too many locally defined elements to make a simple case for the chronic care model. Lack of a firm evidence base that supports including exercise as a component of the chronic care model might cause one to have reservations on the best way to implement exercise management. But clinicians have the difficult task of turning a clinical guideline into operations that deliver better health care, and patients have immediate needs that cannot wait for outcomes research. The chronic care model has weaknesses, most of which are flawed assumptions or dilemmas that the model in and of itself cannot resolve. One example is the internal challenge (i.e., within the health care system itself) of using electronic medical records to share patient data, embed decision- making support with the system, and use advanced analytical techniques to improve population health. Meeting this challenge is not possible until sufficient technological investments have created the necessary data management infrastructure. Other challenges are more external to the health care system, such as the creation of a built environment that facilitates an active lifestyle, or one in which high-quality produce is abundant and ******ebook converter DEMO Watermarks******* inexpensive, thus facilitating healthy diets. These socioecological aspects of healthy living, especially an environment that promotes a healthy diet and exercise or physical activity, are things the health care community itself cannot provide but are essential elements if lifestyle interventions are to be successful. The chronic care model appropriately notes that these are essential linkages, but building them into a sustainable system is very difficult without a unifying economic force. Perhaps the biggest flaw in the chronic care model is that there is often no business model to sustain the linkages that figure 1.1 portrays. For example, delivery of exercise services can be particularly difficult when patients are aging and burdened with multiple chronic conditions that have led to disability. Such patients often have limited financial resources and are intimidated about starting an exercise program, but supervision of exercise services is not compensated by insurance. The patient needs guidance to get started; the primary care physician can provide an EIM type of prescription, but the patient can’t afford an exercise specialist, and insurance won’t cover the cost of the exercise specialist. In the United States this is a very common scenario, far too common to allow reliance on charity care without destabilizing the revenues that support exercise specialists. Unfortunately, this is not the only financial design flaw in the chronic care model. Another assumption in the model is that individual patients and communities will become “activated” to work toward enhanced health and well-being (see figure 1.1). With about one-fourth of the population totally sedentary and two-thirds of the population not meeting the recommended level of physical activity, getting (and keeping) these people “activated” about exercise is a formidable challenge. Behavior change specialists (especially in the area of exercise) know that the majority of people don’t sustain their efforts, so the concept of activation is far easier to diagram than to make happen in real life! This is another area in which redesign of the health promotion system, to provide economic incentives for everyone to be physically active, is an essential element missing from the PCMH-based chronic care model. Proponents of the chronic care model advocate disease self-management interventions, though implementation of such programs is easier in some environments and in some aspects of health than in others. In areas where low health literacy, lack of education, and low socioeconomic status are ******ebook converter DEMO Watermarks******* prevalent, such barriers can be difficult to overcome as a sustainable business. Mental health issues, often superimposed on low literacy, undermine cognitive behavioral techniques that are the core of lifestyle interventions. Add in cultural issues and the lack of stable business models in certain sectors of our societies, and key parts of the chronic care model (especially efforts to promote exercise) may not work well in environments burdened with disparity. The ACSM and its partner organization, the Clinical Exercise Physiology Association (CEPA), are actively striving to promote the inclusion of clinical exercise physiologists as full-fledged members of the care management team whose services are a benefit covered by health insurance. In many health care systems, especially in the United States, the services of clinical exercise specialists are not compensated by health care plans. If health care systems are to make use of therapeutic exercise in the care of chronic disease, this deficiency must be corrected. Primary care physicians need the support of clinical exercise physiologists as a referral resource if they are to implement wide-scale adoption of exercise prescriptions. Primary care physicians, more than any other group, need to call for inclusion of clinical exercise physiologists in the PCMH team and for insurance plans to compensate exercise physiologists for their services. Much of what this book seeks to help accomplish—getting patients with chronic conditions more active—will be a real challenge in societies where services of exercise professionals are not valued in the health care system. This is a most notable barrier in the United States, where the health care system undervalues physical activity (though it is arguably one of the best buys, if not the best buy, in all of medicine). Rationale for Including Physical Activity in Chronic Care Management In persons with a stable chronic condition or combination of chronic conditions, this advice should almost always be the first and most important aspect of their ongoing management: Incorporate a physically active lifestyle. The primary reason to emphasize a physically active lifestyle is to avoid what has been termed the disuse syndrome or, alternatively, the downward spiral of chronic disease (figure 1.2). ******ebook converter DEMO Watermarks******* ******ebook converter DEMO Watermarks******* Figure 1.2 The downward cardiometabolic spiral of chronic disease and disability. Increasingly, studies show that the special challenge for persons who develop a chronic condition or disability is that they are vulnerable to becoming increasingly sedentary, which has a cascade of adverse effects: Low functional capacity, which predicts poor outcomes and mortality Reduced gait speed and lower-extremity function associated with loss of independence Loss of independence, which has a negative impact on quality of life Increased risk of excessive weight gain Skeletal muscle insulin resistance or frank type 2 diabetes, with subsequent cardiovascular disease A gradual deterioration toward being disabled These findings explain the long-standing observation that in persons with disability, the most common cause of death is heart disease. Exercise Prescription, Counseling, and the Common Barriers to Exercise In the first three editions of this book, each condition had its own ******ebook converter DEMO Watermarks******* recommendations for testing and prescription. But in most cases these were very similar; and since we wrote CDD3, a number of national and global governments and nongovernmental societies have issued guidelines on physical activity. In general, all these recommendations are similar. Moreover, if the CDD series followed the condition-by-condition path of logic, one would eventually end up with thousands of special case recommendations, the vast majority of which would be similar. Accordingly, for CDD4, the editors elected to converge onto one basic recommendation (referred to in this book as the Basic CDD4 Recommendation), which is based on expert opinion of the editors and several authors who have worked on all the prior editions. This Basic CDD4 Recommendation is consistent with current Department of Health and Human Services (HHS) recommendations and ACSM Guidelines, though slightly different in the following ways: It advises 150 min/week of MVPA (lower limit recommended by HHS/ACSM). It advises 150 min/week of light-intensity activity for those who can’t do MVPA. It adds sit to stand, step-ups, and arm curls as the recommended strength training exercises. Thus, for the majority of patients with a chronic disease or disability, the Basic CDD4 Recommendation is not different from the guidelines for apparently healthy persons or persons with chronic conditions that have minimal impact. For individuals who are older and have more compromised functioning, the modified HHS Guidelines presented by the American Heart Association (AHA) for older individuals are appropriate. For deeper insight and understanding, the reader should see parts II through V, as well as the parts of CDD4 that are relevant to the chronic condition of interest. Counseling and behavioral intervention recommendations for persons with chronic conditions are mostly similar to those for the apparently healthy population (see chapter 4). What tends to be a somewhat more formidable obstacle for persons with chronic conditions are the barriers to becoming more active. This is because chronic conditions that pose a more severe burden on the patient tend to be associated with disability and subsequent disparities in resources. The chronic care model might prove a useful tool in addressing these challenges, but this remains to be proven. Very often patients relate a variety of barriers that prevent them from doing ******ebook converter DEMO Watermarks******* exercise. The most common barrier is a lack of time due to competing demands. Patients often describe having a job (or more than one job) that requires them to work long hours, often with a long commute and family duties that leave them with little free time. Such competing demands frequently leave the patient too tired and without the time needed to do regular physical activity. Patients with a chronic condition often complain of a physical limitation that prevents them from doing regular exercise, such as lower-extremity arthritis or a severe medical condition that makes physical functioning a challenge. Some patients find that exercise is simply too boring and unenjoyable. An important job for the physician, exercise professional, and chronic care management team is to help break down these barriers and to counsel the patient on how to get to the point where exercise is a habit and not an option. One simple recipe for getting apparently healthy patients to exercise is the following: Park their car farther away from their worksite each morning, then take a brisk 10-min walk to their work station At lunchtime, walk for 5 min and return before eating After work, take the same 10-min walk back to their car This gives them 30 min for the day, so if they do this on 5 days each week, they will be assured of getting 150 min of moderate exercise each week. Apparently healthy people and patients who have mild chronic conditions that don’t impair their physical functioning, and who simply cannot get their exercise done during the week, can opt to do 75 min of moderate exercise on Saturday and another 75 min on Sunday, achieving all 150 min on the weekend. It may help if these patients change their mindset from the weekend as a time to rest to a time to be physically active for at least part of both days. This “weekend warrior” approach is less appropriate and useful for patients who have lower physical functioning because it is likely too exhausting to attempt 75 min on 2 consecutive days. Other ideas to help minimize the time constraint include increasing intensity, especially for those who are apparently healthy or who don’t have much limitation in physical functioning. Another helpful idea is to find an exercise partner; each partner holds the other accountable and improves adherence to the program. Owning a dog can be very helpful because the dog becomes the exercise partner, and dogs tend to insist on going out for a walk. As a result, dog owners tend to do more walking. ******ebook converter DEMO Watermarks******* Take-Home Message Exercise is a very powerful tool to treat and prevent chronic disease, mitigate the harmful effects of obesity, reduce mortality rates, and improve physical functioning and quality of life. In effect, Exercise is Medicine. Unfortunately, physical inactivity is one of the major public health problems of our time. For these reasons, physicians, especially primary care physicians and the staff of the medical home, have a responsibility to assess physical activity habits in their patients, inform them of the risk of being inactive, and provide a proper exercise prescription. Physician practices should use the exercise vital sign to assess MVPA. Physicians should support patients who are meeting physical activity guidelines. Physicians should encourage those who don’t meet these guidelines. Patients who have a chronic condition that does not impair physical functioning or increase risk can be advised to walk or to do the same kinds of activities recommended for the apparently healthy population. Patients who have a more severe burden of chronic disease or disability often benefit from referral to resources in their community, such as physical therapy, occupational therapy, cardiopulmonary rehabilitation, or other medically supervised programs. Patients who have recently been hospitalized are often more willing to invest in physical activity, particularly if they obtain guidance, so transitions of care are important moments when the physician should be alert to encouraging more physical activity. Facilitating regular exercise in a physical activity program is one of the most important functions of health care providers using the chronic care model. Suggested Readings Anderson LH, Martinson BC, Crain AL. Health care charges associated with physical inactivity, overweight, and obesity. Prev Chronic Dis. 2005;2:A09. Bindman AB, Blum JD, Kronick R. Medicare payment for chronic care delivered in a patient-centered medical home. JAMA. Published online August 8, 2013 [Accessed August 9, 2013]. doi: 10.1001/jama.2013.276525. Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 2009;43:1-2. ******ebook converter DEMO Watermarks******* Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, Stave CD, Olkin I, Sirard JR. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298(19):2296-2304. Chin MH. Quality improvement implementation and disparities: the case of the health disparities collaboratives. Med Care. 2010 August;48(8):668- 675. doi: 10.1097/MLR.0b013e3181e3585c. Coleman KJ, Ngor E, Reynolds K, Quinn VP, Koebnick C, Young DR, Sternfeld B, Sallis RE. Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc. 2012;44(11):2071-2076. Foster C, Porcari JP, Anderson J, Paulson M, Smaczny D, Webber H, Doberstein S, Udermann B. The talk test as a marker of exercise training intensity. J Cardiopulm Rehabil Prev. 2008;28(1):24-30. Frølich A. Identifying organisational principles and management practices important to the quality of health care services for chronic conditions. Dan Med J. 2012;58(2):B4387. Fromer L. Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. Int J Chron Obstruct Pulmon Dis. 2011;6:605-614. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1081-1093. Originally published online August 1, 2007. doi: 10.1161/CIRCULATIONAHA.107.185649. Hatzakis Jr MJ, Allen C, Haselkorn M, Anderson SM, Nichol P, Lai C, Haselkorn JK. Use of medical informatics for management of multiple sclerosis using a chronic-care model. J Rehabil Res Dev. 2006;43(1):1-16. Joy EL, Blair SN, McBride P, Sallis RE. Physical activity counseling in sports medicine: a call to action. Br J Sports Med. 2013;47:49-53. Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future. Bipartisan Policy Center. 2012. McCorkle R, Ercolano E, Lazenby M, Schulman-Green D, Schilling LS, Lorig K, Wagner EH. Self-management: enabling and empowering patients living with cancer as a chronic illness. CA Cancer J Clin. 2011;61(1):50-62. Minkman M, Ahaus K, Huijsman R. Performance improvement based on ******ebook converter DEMO Watermarks******* integrated quality management models: what evidence do we have? A systematic literature review. Int J Qual Health Care. 2007;19(2):90-104. Physical activity. Lancet. July 18, 2012. www.thelancet.com/series/physical- activity [Accessed July 27, 2012]. Pollock ML, Wenger NK. Physical activity and exercise training in the elderly: a position paper from the Society of Geriatric Cardiology. Am J Geriatr Cardiol. 1998;7:45-46. Pratt M, Macert CA, Wang G. Higher direct medical costs associated with physical inactivity. Phys Sportsmed. 2000;28(10):1-11. Sabaté E, ed. Adherence to Long-Term Therapies: Evidence for Action. Geneva: World Health Organization; 2003. Sui X, LaMonte MJ, Laditka JN, Hardin JW, Chase N, Hooker, SP, Blair SN. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA. 2007;298(21):2507-2516. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. www.cdc.gov/nccdphp/sgr/index.htm [Accessed November 9, 2015]. ******ebook converter DEMO Watermarks******* Chapter 2 Basic Physical Activity and Exercise Recommendations for Persons With Chronic Conditions The American College of Sports Medicine (ACSM) published the first edition of The Guidelines for Graded Exercise Testing and Exercise Prescription (the ACSM Guidelines) in 1975. Since then, the Guidelines have evolved and become the standard in exercise management. The principles for exercise prescription established in the ninth edition of the ACSM Guidelines provide the foundation for the recommendations in ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, Fourth Edition (CDD4), but the Basic CDD4 Recommendation is slightly more conservative because the clinical population of interest in CDD4 is persons who have a more severe impact on their ability to do exercise. The Guidelines primarily focus on exercise prescription for normal adults (so-called apparently healthy adults) but also include recommendations on testing and prescription for persons with some chronic conditions. Most of the chronic conditions addressed in the Guidelines relate to conditions that increase cardiometabolic risk, and in many of those conditions the impact of the condition on exercise is small. Hypertension is a good example, in that well-controlled hypertension doesn’t appreciably alter physical functioning, and in such cases the CDD4 recommends using the Guidelines. The Basic CDD4 Recommendations, however, are mainly intended for clinical populations in whom the exercise response and exercise capacity are dramatically diminished because of the condition. While CDD4 also addresses hypertension, for example (see chapter 6), hypertension is not the sole entity that affects exercise capacity; rather, it is hypertension in combination with other comorbid chronic conditions that has the net effect of reducing exercise capacity. The role of hypertension in this situation is more complicated than for hypertension as a sole entity. Some patients demonstrate a brisk hypertensive response to exercise, but others have blood pressure that is pharmacologically well controlled, with normal exercise responses. Yet ******ebook converter DEMO Watermarks******* others have one or more additional comorbid conditions that substantially impair their capacity to do physical work; and, in addition, there are people who are unable to exert themselves hard enough to show much of a pressor response to exercise. This book is mainly about the latter two groups—those individuals with multiple comorbidities that complicate the standard guidelines for exercise. The editors of CDD4 expect the reader to be familiar with the Guidelines and to be able to judge when the Basic CDD4 Recommendations can apply to a particular patient. If there is uncertainty, the reader is advised to be conservative. As the awareness of the benefits of regular physical activity for people with chronic conditions increases, there will be more referrals for exercise in more complicated individuals for whom exercise may previously have been considered inappropriate. ******ebook converter DEMO Watermarks******* Definitions Used in This Book It is important for everyone on the health care team to have a common language for physical activity and exercise, but many clinicians have little or no formal training in exercise science. For this reason, we provide definitions of terms and phrases commonly used in exercise science. Physical Activity and Exercise The terms physical activity and exercise are widely used in reference to many different activities, but their meanings are often vague and they are sometimes used interchangeably. Before delving into the Basic CDD4 Recommendations, it is prudent to clarify the terms used in this book. The World Health Organization (WHO) defines physical activity as “bodily movement produced by skeletal muscles that requires energy expenditure.” Technically, then, exercise is a form of physical activity. Exercise training, however, is regular physical activity and can be defined as “planned, structured, and repetitive physical activity for the purpose of developing physical fitness.” Participation in exercise training, as a repeated series of individual exercise sessions over a period of days, weeks, and months, is usually done to improve physical fitness or functioning but can be done with other objectives in mind. One reason for confusion is that some sources refer to exercise training just as exercise. Light, Moderate, and Vigorous Physical Activity Most national and international guidelines categorize physical activity into three general levels of exercise intensity: light, moderate, and vigorous. Additionally, the reintroduction of research in the area of high-intensity exercise makes it important to define this fourth level. These are the four levels (see also table 2.1): 1. Light: An aerobic activity that causes a barely noticeable change in breathing, involving increased depth (volume of each breath) more than rate; can usually be sustained by an untrained individual for 60 min or more 2. Moderate: An aerobic activity that can be performed at a ventilatory demand that allows carrying on a conversation (also known as talk test); can usually be sustained by an untrained individual for 30 to 60 min 3. Vigorous: An aerobic activity that is sufficiently demanding of ventilation that talking cannot be maintained during the activity; can ******ebook converter DEMO Watermarks******* usually be sustained by an untrained individual for only 20 to 30 min 4. High: An aerobic or combination activity (i.e., a combined exertion of muscle contractions at or near their maximal strength for an extended number of repetitions, such as circuit weight training); can be sustained only briefly, typically 1.15 (where RER is the ratio of CO2 produced to O2 taken up, or CO2/ O2). six-minute walk: A test commonly used in cardiovascular studies of pharmaceutical agents because it is very inexpensive and is sensitive for folks who have low physical functioning. The basic format of this test is to have a measured walkway; the patient walks at his own pace with the objective of going as far as he can in 6 min. sit to stand: There are a number of variations of this simple test; one basic version measures how long it takes to rise from a sitting position to a standing position 10 consecutive times, trying to complete the test as fast as possible. Performance is assessed by time. One variation for those who cannot do 10 consecutive repetitions includes a timed test measuring how many repetitions are completed in 30 s. ******ebook converter DEMO Watermarks******* get-up-and-go : This is another simple test, requiring the individual to get up out of a chair and walk 12 ft [3.7 m], turn around, and return to sit back down. Performance is assessed by time, with the goal of completing the test as fast as possible. sit and reach: The sit and reach is a functional mobility test in which the patient sits in a chair against a wall with one leg extended, then bends forward to reach as far as she can. There are variations of this test to accommodate persons with back discomfort. Performance is measured by the distance the individual can reach forward from the seated position. Physical Activity Guidelines Over the last 40 years, the recommendations for the optimal type and volume of physical activity or exercise have evolved as research evidence on this subject has emerged. In 2008, the U.S. Department of Health and Human Services (HHS) published evidence-based guidelines on physical activity based on an exhaustive expert review of the research literature, with overwhelming findings pointing to the following recommendation: Everyone should be physically active, defined as accumulating a minimum weekly total of 150 min of moderate physical activity or, alternatively, 75 min of vigorous physical activity. Adults should participate in 2 or more days of muscle strengthening activities that involve all major muscle groups. Individuals at risk for falls should incorporate activities to improve balance. This recommendation has essentially become a worldwide consensus. Since 2002, the WHO has recommended 30 min of moderate-intensity physical activity on at least 5 days a week, or at least 20 min of vigorous-intensity exercise on 3 days a week. The European Union (EU)-approved guidelines, published in 2008 shortly after the HHS Guidelines, also recommend 60 min of daily physical activity for children and adolescents, as well as strength or balance conditioning (or both) for seniors over the age of 65. The EU Guidelines are more broad-reaching in that they extensively address the process of implementation of their recommendations. See table 2.3 for summary information on a variety of current guidelines on physical activity. ******ebook converter DEMO Watermarks******* ******ebook converter DEMO Watermarks******* Guidelines from ACSM and the American Heart Association (AHA) for older adults seem more appropriate for many individuals who have a chronic health condition. These guidelines differ from the HHS Guidelines in that the recommendations for intensity of aerobic activity take into account the current fitness level and focus on using perceived exertion to guide exercise intensity. They also include recommendations on maintaining flexibility and for balance training in individuals who are at risk for falls. The only national guidelines that specifically address chronic conditions are the Swedish National Institute of Public Health’s Physical Activity in the Prevention and Treatment of Disease. This document presents recommendations for most chronic diseases that are affected by physical activity and exercise. Unlike the U.S. Physical Activity Guidelines, these recommendations outline physical activity and exercise for specific diseases with the intent of better accommodating the varying pathophysiological effects (as well as treatments) of chronic disease. Basic CDD4 Recommendations for Physical Activity or Exercise in Chronic Conditions After four editions of the CDD series, with many decades of clinical experience on the part of the contributors to CDD4, the main working group of authors concluded that it is confusing and unnecessary to sustain disease- specific recommendations, for these reasons: ******ebook converter DEMO Watermarks******* There are thousands of chronic conditions and causes of disability. The vast majority of recommendations seem similar for most chronic conditions. Ultimately, exercise is fairly simple and needs to be seen as elegantly powerful. The complexities and nuances are matters of clinical judgment for safety’s sake. The main concern in the chronic conditions in CDD4 is loss of independent living, which is primarily a function of light-intensity physical activities. For these reasons, the Basic CDD4 Recommendations are consistent with but differ very slightly from the Guidelines and from the various physical activity guidelines discussed in the preceding section, because the CDD4 editors also want to make certain that sufficient attention is paid to light-intensity physical activity, especially the ability to perform instrumental activities of daily living with the goal of having patients remain independent. With these considerations in mind, the Basic CDD4 Recommendations are as follows: Every person with a chronic condition should be physically active, accumulating a minimum weekly total of 150 min of preferably moderate-intensity physical activity or, if that is too difficult, then 150 min of light-intensity physical activity may be substituted. At least 2 days per week of flexibility and muscle strengthening activities that should minimally involve chair sit-and-reach stretches on left and right, at least eight consecutive sit-to-stand exercises, at least 10 step-ups (or a flight of steps), leading with each foot, and at least eight consecutive arm curls with a minimum of 2 kg held in the hand; 4 kg is recommended. Individuals at risk for falls should be evaluated for causes of falls. Not all falls are caused by a condition that can be treated with exercise training. If the diagnosis of the causes suggests that exercise training can reduce the likelihood of a fall, then activities to improve balance should be incorporated into individuals’ exercise regimens, under the supervision of an exercise therapist trained in fall prevention. ******ebook converter DEMO Watermarks******* The higher the aerobic intensity, muscle forces, and required range of motion, the greater the likelihood of an adverse event. These Basic CDD4 Recommendations are summarized in table 2.4. Readers should always bear in mind the goals behind the Basic CDD4 Recommendations, because these goals are helpful in drafting an individualized program to meet the unique needs of each patient. Everyone should be physically active to an extent sufficient to maintain independent living: ******ebook converter DEMO Watermarks******* Let no barrier block someone from doing light-intensity physical activity. Independent living requires a minimum ability to perform activities involving (or demanding) light-intensity aerobic work (or exertion), combined with strength, flexibility, and balance and coordination. Adverse events from exercise cannot be completely eliminated, but there are two main categories to consider: 1. Activity-dependent risks (due to the nature of the activity) 2. Disease-dependent risks (those that relate to the pathophysiology) The best way to minimize activity-dependent risks is to encourage the patient to practice safety precautions. If there is concern that the individual cannot do this independently, then he needs a supervised exercise program, at least to get started. One major concern is whether or not the advice to do physical activity exposes the patient to the possibility of a disease-dependent risk. Such risks ******ebook converter DEMO Watermarks******* are associated with the intensity of exercise. Accordingly, if the recommendation is to complete vigorous- or high-intensity physical activities, it is prudent to follow the Guidelines on exercise testing and prescription. Most people with a chronic condition can safely participate in moderate-intensity physical activity, and if there is any concern that a particular individual cannot do so, she should either undergo some disease- specific diagnostic exercise testing or be referred to a supervised exercise program (or both). There are few data beyond anecdotal cases to support the concern that light- intensity physical activities are likely to precipitate a disease-dependent adverse event (especially sudden death or myocardial infarction). Discerning the epidemiological role of light activities in precipitating such events would be exquisitely difficult, because participation in light-intensity activities is so ubiquitous in daily life. If someone is medically unstable to the point that activities of daily living threaten injury or death, then the Basic CDD4 Recommendations do not apply because the individual is not able to maintain independence and belongs in either a hospital or a nursing home. Indeed, it is likely that many people end up in a nursing facility sooner than they need to because no one recommended that they do light-intensity physical activity. These nuances of safety are a key reason why an exercise professional is a necessary member of the chronic care team, because these staff are trained and have the experience to make good judgments regarding when exercise is safe and when it is not safe. See chapter 3 for a more in-depth discussion on how these judgments are made, which often involves more art than science. How to Prescribe Physical Activity or Exercise in Chronic Care It is important for everyone on the health care team to understand an exercise prescription, including primary care providers and allied health care staff who may not be familiar with exercise prescriptions. There are two basic methods, one that is traditionally used by exercise physiologists, which is known by the acronym FITT. The other method, which may seem more natural to some physicians, is to use their standard method for prescribing medications. These are outlined in the following sections. FITT Model of Exercise Prescription The traditional method of prescribing exercise used by many clinical exercise ******ebook converter DEMO Watermarks******* physiologists is the FITT method: frequency, intensity, time, and type (of exercise). Frequency, or how many days per week of a particular exercise: For aerobic activities, the recommendation is for all persons to participate in activities requiring aerobic exertion on 4 or 5 days per week. For strengthening or functional exercises, the recommendation is that all persons do functional activities that require muscular strength two to three times each week. Intensity, or how hard to exercise, which depends on the kind of exercise being performed: The recommendation is that the intensity of exercise be based on perceived exertion in persons with chronic conditions. The reasons for this are multiple: Many patients are on medications that alter the heart rate response to exercise (e.g., β-blockers). Persons with a disability or those who require a prosthetic are often markedly less efficient than people without disabilities and thus have dramatically less efficient exercise economy. Many health conditions alter exercise heart rates. Time, or duration or how long to exercise during each session: For aerobic activities, the recommendation is to work up to a duration of 30 to 40 min per session and accumulate a minimum of 150 min of moderate-intensity aerobic exercise each week. For strengthening–functional activities, all persons should complete the following (or an equivalent): a minimum of two sets of 10 repetitions of arm curls, two sets of 10 repetitions of sit to stands, and two repetitions of a 10-step stair climb (or step-ups). Type, or what kind(s) of specific exercise to perform: For aerobic exercise, the recommendation is walking as the primary type of physical activity. The reason is that walking is the basic form of locomotion for humans and is essential for independent living and maintaining quality of life. Other activities with a similar amount of energy expenditure (cycling, swimming, and so on) are acceptable substitutes for walking and are preferred in situations in which weight-bearing activity is a problem. For individuals with disabilities who cannot walk, pushing a ******ebook converter DEMO Watermarks******* wheelchair (i.e., propelling themselves) is their walking equivalent. For strengthening exercises: Work up to a total of 20 arm curls with a minimum of a 2 kg (~4 lb) object held in each hand (e.g., 2 L milk jugs filled with water). Handgrip exercises are an alternative if the person is not sufficiently strong to do all 20 arm curls with the 2 kg weight (weaker persons can use foam squeeze sponges, stronger individuals can use tennis balls or spring-loaded handgrip devices). When the patient can do all 20 arm curls on each side with 2 kg, she can repeat the process with a 4 L jug filled with 3 L water and then a full 4 L. For stretching, the recommendation is that all patients be able to reach their toes on the left and right sides in a chair sit and reach. For basic physical functioning exercises, recommendations are as follows: Do sit-to-stand

ACSM`s Exercise Management for Persons With Chronic Diseases and Disabilities (4th ed).pdf

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