Diana Phillips
March 22, 2016
Exercise can be an effective component of treatment for many chronic conditions from knee osteoarthritis to type 2 diabetes, but physicians must be aware of the details of evidence-based interventions for the specific condition to properly prescribe it for their patients, according to a multidisciplinary review and how-to guide published online March 14 in the Canadian Medical Association Journal.
“Unless clinicians can access sufficient details about exercise interventions to prescribe them, they either guess at how to use them or do not use them at all,” lead author Tammy Hoffmann, PhD, from the Centre for Research in Evidence-Based Practice, Bond University, Robina, Australia, and colleagues write. “Even when a family physician may not be involved in delivering the exercise intervention, they should know the main elements of an evidence-based exercise intervention so they can discuss with patients and refer appropriately.”
The researchers searched PubMed and the Cochrane library from 2000 to 2015 for evidence supporting exercise interventions for osteoarthritis of the hip and knee, chronic nonspecific low back pain, prevention of falls, heart failure, coronary heart disease, chronic obstructive pulmonary disease, chronic fatigue syndrome, and type 2 diabetes.
They present summary findings for each condition, highlighting key outcomes and providing practical details for an effective disease-specific exercise. “Simply prescribing exercise, in a generic sense, to a patient is insufficient guidance and is unlikely to achieve the desired outcomes,” they explain.
The researchers caution that when prescribing exercise to patients, clinicians should be mindful of some general considerations, including:
- Patients should be assessed by a physician before beginning the exercise program.
- Initial supervision is warranted for most conditions.
- Patients should receive education about what the exercise program involves and how it might help their condition.
- Clinicians should seek to understand patients’ fears and beliefs about the influence of exercise on their conditions, and they should incorporate strategies to support patient adherence to their exercise programs.
For some of the chronic conditions (lower back pain, chronic obstructive pulmonary disease, diabetes), the guide offers practical details, including the rationale for exercise, who should be overseeing it, the necessary materials, the exercise procedure, and the number and duration of sessions. For the other conditions (osteoarthritis, falls prevention, chronic fatigue syndrome, heart disease), the authors provide information on evidence of benefit, contraindications, and adverse events, along with links to online appendices.
“Where possible, we chose a single intervention for each condition that had evidence of effectiveness and for which adequate details of the intervention were available,” the authors write. “Where this was not possible, a typical intervention or a range of practical details from various studies are presented.”
For example, the guidance for osteoarthritis of the knee and hip recommends muscle strengthening, aerobic, and range-of-motion exercises to help alleviate pain and improve function. “It is important to ensure patients understand that osteoarthritis is not a wear-and tear disease and that discomfort or pain during exercise does not indicate further damage to the joint,” the authors write. “Supervised exercise that is supplemented with a home exercise program is preferable wherever possible.”
For patients with chronic obstructive pulmonary disease, exercise can improve quality of life. These patients “should be referred to pulmonary rehabilitation when their condition is stable or following a hospital admission for an acute exacerbation,” the authors explain, noting that patients should be taught how to manage symptoms such as breathlessness during exercise.
Although there are few absolute contraindications to exercise within a pulmonary rehabilitation program, patients with comorbidities such as unstable cardiac disease may be put at risk, and “participation may not be possible for those with severe arthritis or severe neurologic or cognitive disorders,” the authors add.
In the section focusing on exercise for patients with coronary heart disease and heart failure, multiple contraindications are noted, including unstable ischemia, uncontrolled heart failure or arrhythmias, uncontrolled hypertension or diabetes, acute systemic illness or fever, severe and symptomatic valvular heart disease, “or any other cardiac condition that the family physician believes is life threatening.”
For all the conditions, “exercise is not a single entity but must be tailored to the condition,” the researchers stress. “If exercise interventions are not implemented in a manner that is consistent with how they were used in trials (e.g., at a lower intensity, shorter duration or with different components), the fidelity of the intervention is compromised, and clinicians and patients cannot expect to realize outcomes similar to those achieved in the trials.”
In addition to the practical and clinical considerations associated with prescribing exercise to patients with chronic illness, clinicians must “manage patients’ misconceptions, fears and motivation.” Although this may be especially challenging, “the potential rewards for clinicians and patients make overcoming the challenges worthwhile.”
The authors have disclosed no relevant financial relationships.
CMAJ. Published online March 14, 2016. Abstract
CMAJ. Published online March 14, 2016. Full Text Article