Designing programs for clinical populations - This is someone you know.


As you read this post and learn a little more about chronic disease and about how an Exercise Physiologist fits into this picture, think about a loved one you know with a Chronic Disease, because this post is all about THEM.

You or someone you know is currently living with a chronic condition. Chronic disease is defined as a human health condition or disease that is persistent or otherwise long-lasting in its effects, or is a disease that progresses slowly with the onset not being sudden/acute. The term chronic is usually applied when the course of the disease lasts for more than three months. Chronic conditions can range from the Big Three: Cancer, Cardiovascular Disease and Diabetes, to pulmonary conditions (COPD, Asthma), to muscular diseases (Mitochondrial Disease, Muscular dystrophy, Cerebral Palsy affecting the musculature), to psychological diseases (Parkinsons, Dementia), to various metabolic (Diabetes), renal (Kidney failure), or other diseases affecting the human body. More than half of the Alberta Health Care budget is allocated to treatment of disease currently, and with the continual rising trend, this number is only expected to grow more steeply and exponentially.

As Exercise Physiologists, our jobs are to prescribe exercise to help manage, improve, or prevent the decline of people's functional abilities and activities of daily living. We like to use the phrase "EXERCISE IS MEDICINE" - because it actually is. Something I will often describe to my patients with Chronic Disease is: "As we talked about at your initial consult, there are numerous benefits to physical activity. You were able to name a few, including improved mood and well-being. I added to this by telling you that it is now recognized that there is a dose-response relationship between amount of physical activity, and improved health or decreased all-cause mortality, risk of overweight and obesity, fat distribution, Type 2 diabetes, colon cancer, quality of life, and independent living in older adults.

Did you know that some of the chronic conditions you have could be made better with exercise, and that your symptoms could be diminished? Aside from the improvements in organ function, cardiovascular and pulmonary system function, and chronic disease risk, other benefits include: Decreased anxiety and depression (to one day maybe minimize the use of anti-depressant medication), Enhanced physical function and independent living (so that you can keep up with your husband and dog), Effective therapy for many chronic diseases in older adults (to enhance your current therapies for your chronic conditions)."

As with anything, there must be a disclaimer. Although the chances are VERY low that any adverse event will occur while performing physical activity, there are some risks to being physical active. They include risk of sudden cardiac death or acute myocardial infarction, and these risks are higher in persons with a chronic disease. In Alberta, and in most places in Canada, there are very good and effective exercise programs for persons living with disease, where they are often monitored by a doctor during their first Exercise Stress Test, or during all exercise participation.

Here's an example of a client that an Exercise Physiologist might see. When you contact one of us for some exercise recommendations or programs, you might not have all these measures numbers, and that's okay. Whatever information you do have - we can work with.

When we get our client for the first time, we often do a "Risk Stratification". This includes taking Family History, Patient History, and sometimes collecting the results from lab tests, exercise tests, or medication lists. A Risk Stratification looks like this:

The more check marks on the persons Risk Stratification, the more at risk they are during an exercise session to experience an adverse event. Risk factors include obvious things like smoking, being overweight or obese, or having a waist circumference past the cutoff we look for. Other risk factors might be things not visible to the naked eye, such as triglycerides, blood sugars, and family history. Taking these among other things into consideration, we will sometimes refer them to get further testing by their doctor or Exercise Specialist, or we will start them on an appropriately programmed exercise regime.

Sometimes clients have LONG lists of medications. This is one example of a sample client (who does actually exist, but not under the fake name provided). Although we are not doctors, we as Exercise Physiologists are trained to recognize common drugs and drug-exercise interactions, as well as are given the tools to look up up other drugs and their action sites. No drug list is too long to start exercise:

After the above information is recorded, we might ask them about their readiness to change, using the Trans-theoretical Model with is composed of 5 main stages. These will aid us in counseling and using appropriate teaching points and referrals moving forward into exercise programming.

Pre-contemplation - In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.

Contemplation - In this stage, people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months). People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.

Preparation (Determination) - In this stage, people are ready to take action within the next 30 days. People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.

Action - In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.

Maintenance - In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.

Termination - In this stage, people have no desire to return to their unhealthy behaviors and are sure they will not relapse. Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.

As mentioned previously, with all the information gathered from the appointment and other tests we chose to perform, we may refer our client to a Stress Test (in Calgary, they can be done at a few places including Total Cardiology at Talisman). Stress Tests involve graded incremental exercise tests on bikes or treadmills most often, and are doctor-monitored. Often, if an individuals prescribed drug list has recently been changed, a Stress Test will be prescribed to determine the person's metabolism of the drug and reaction to the drug during exercise (because everyone is different). From a Stress Test, we can determine where the safe threshold to exercise is, and start our participant exercising below that threshold, to reap maximum benefits of exercise.

In conclusion, I know that there are individuals out there who have started some form of exercise recently and are loving it. Good examples of this are Crossfit, Spin classes, Zumba classes or HIIT training as of late. Just because an exercise program works for you, doesn't mean it is a good idea for someone you know living with a chronic disease. Conversely, our loved ones who are living with chronic disease and who tend to be sedentary, are experiencing increasing symptoms, increasing pain, decreased ability to perform activities of daily living, increasing depression and anxiety, among many other negative outcomes. We know that EXERCISE IS MEDICINE, so refer your loved ones to a professional for guidance as soon as possible. For more resources, send me a message, and go to http://www.exerciseismedicine.org/ for some strong evidence to support my case!

REFERENCES

Chakravarty, E. F., Hubert, H. B., Lingala, V. B., Fries, J. F. (2014). Reduced Disability and Mortality Among Aging Runners. American Merical Association, 168(15), 1638–1647.

Paterson, D. H., Jones, G. R., & Rice, C. L. (2007). Ageing and physical activity: evidence to develop exercise recommendations for older adults. This article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation fo. Applied Physiology, Nutrition, and Metabolism, 32(S2E), S69–S108. doi:10.1139/H07-111

Power, G. a., Dalton, B. H., & Rice, C. L. (2013). Human neuromuscular structure and function in old age: A brief review. Journal of Sport and Health Science, 2(4), 215–226. doi:10.1016/j.jshs.2013.07.001

Seals, D. R., Hagberg, J. M., Hurley, B. F., Ehsani, a a, & Holloszy, J. O. (1984). Endurance training in older men and women. I. Cardiovascular responses to exercise. Journal of Applied Physiology: Respiratory, Environmental and Exercise Physiology, 57(4), 1024–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6501023

Stathokostas, L., Jacob-Johnson, S., Petrella, R. J., & Paterson, D. H. (2004). Longitudinal changes in aerobic power in older men and women. Journal of Applied Physiology (Bethesda, Md. : 1985), 97(2), 781–9. doi:10.1152/japplphysiol.00447.2003

https://en.wikipedia.org/wiki/Chronic_condition

http://www.exerciseismedicine.org/

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