Managing Exercise in Persons with Multiple Chronic Conditions

1. Managing Exercise in Persons with Multiple Chronic Conditions Chapter 04 Chapter 4

2. Multiple Chronic Conditions • There is very little published information on the efficacy of exercise therapy on multiple chronic conditions. The generic medical term for multiple pathologies is “comorbidities” • Common Types of Multiple Chronic Medical Conditions include: • Atherosclerosis + hypertension + hypercholesterolemia • May be compounded with Hx of MI • May be compounded with Hx of TIA / Stroke ( Cerebral Infarction) • Obesity + Type II Diabetes • May be compounded with osteoarthritis • May be compounded with COPD’s • There are really an infinite number of combinations and permutations of chronic comorbid conditions, thus specific exercise treatment therapies, are, at best, complicated. Chapter 4

3. Multiple Chronic Conditions • Complexity of Exercise Treatment • Because: • 1) the numerous pathologies may target similar organ systems, and • 2) there are interactions between the physiology of the comorbidites , and • 3) the medications, and • 4) the patient’s capacity to perform physical exercise • Exercise may be beneficial because: • 1) May slow disease progression and diminish the severity of the pathologies • 2) May improve the functional capacity of the patient and promote ADL. • 3) Even a “non-response” to exercise may be complimented that are psychological in nature ( managing depression, improving desire, hope, etc.) Chapter 4

4. Multiple Chronic Conditions • Overall Case Management • Exercise Therapist should: • 1) be aware of the patient’s multiple pathologies and treatment regimens • 2) communicate exercise regimen with all of the medical specialists involved in care for the patient ( team approach ) • 3) be aware of any contraindicated exercise protocols and risks of exercise therapy • 4) be flexible in custom designing an exercise therapy program for the patient, and communicate / follow-up with both the patient and the physician(s) on the progression /outcome of the exercise therapy program. • Delivery system • 1) Help the patient practice lifestyle modification behaviors that treat the disease and decrease the likelihood for disease progression, or assist disease regression • 2) Help the patient develop goals that address the issues listed in #1 above. • 3) Should include input from other professionals on the medical team. Chapter 4

5. Multiple Chronic Conditions • TEAM APPROACH • Case Manager • 1) Oversees the patients health care , communicates with various medical / health care providers (Allied Health Care Specialists) , and coordinates the various “team members” with patient care. • 2) Coordinates the lifestyle modification program for the patient, including patient education, goal planning / implementation, and exercise programming. Chapter 4

6. Multiple Chronic Conditions • BASIC APPROACH • 1. Preparticipation Physical Exam (PPE) • 2. Problem- Oriented Exercise Management (POEM) • 1) POEM – • Following the PPE, the case manager must summarize the medical findings (diagnoses) and compose an exercise plan that will minimize risk and maximize the therapeutic potential of exercise therapy. • Once the exercise plan is developed, the plan should be reviewed by the primary physician(s) and shared with the other allied health care staff. • SEE the additional “Summary Points” on pp. 34-35, text, that must be considered by the case manager. Chapter 4

7. Multiple Chronic Conditions • BASIC APPROACH • 1. Preparticipation Physical Exam (PPE) • 2. Problem- Oriented Exercise Management (POEM) • 1) PPE – • Physician may determine the inherent risks / benefits for the patient to engage in exercise testing / programming • Physician may determine if there are complications associated with the various pathologies and exercise programming, and define patient limitations • Physician may also identify other mental / emotional issues that should be addressed in patient care. Chapter 4

8. Multiple Chronic Conditions Communication of the POEM program with the patient Review what is know about the impact of exercise and the multiple chronic conditions of the patient Discuss the patient’s current “functional” level , and what type of improvements you expect them to experience. (ie. What is the “Role” of the exercise program? See examples , p.35, text) Determine with your patient their goals and objectives (discuss realistic goals) Prioritize the goals and objectives Help patient to develop a “home-based” activity program that coordinates and may replace the clinical program Emphasize the importance of re-evaluating goals and monitoring progression in the exercise therapy program. Chapter 4

9. Multiple Chronic Conditions To Test or Not to Test ? ( Exercise Testing) There are multiple reasons for conducting exercise tests. These may include, but are not limited to; 1) diagnosis of pathology; 2) prognosis / progression or regression of disease , and 3) functional capacity / limitations. If the patient is highly functional and not at high risk for sudden death, the physician may choose to perform a symptom limited GXT. Some patients may have very low functional capacity and higher risk, and can benefit from a low-level functional assessment, especially when addressing ADL concerns. END. Chapter 4