Type 2 Diabetes and Disability From Morbid Obesity With Multiple Chronic Conditions 356
Type 2 Diabetes and Obesity With Osteoarthrosis 358
Valvular Heart Disease 360
Visual Impairment 361
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 helping you achieve that transformation.
Geoffrey E. Moore, MD, FACSM Healthy Living & Exercise Medicine Associates
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 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, wellbeing, 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 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 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 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 remain independent and have a reasonable quality of life.
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
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.
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 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.
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.
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
Benefits of Exercise Training With Chronic Conditions
• Increases longevity and mitigates disability in some conditions
• Increases the length of disability-free life
• Impr oves metabolic function, shifting away from diabetes and cardiovascular disease
• Improves physical functioning and quality of life
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 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 Washing-
ton, 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 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 pulmonar y rehabilitation
• A medically super vised exercise program (e.g., aquacise for patients who have arthritis or are obese)
• A carefully pr escribed 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 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”).
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
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 day s, for how many minutes do you engage in physical activity at this level?
• (Response range: 10, 20, 30, 40, 60, >60 min)
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.
S◆enior 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 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.
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. For apparently healthy patients in whom the main goal is risk reduction, provide an exercise prescription (see chapter 2) or suggest useful resources:
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 patient’s health!
• 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.
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.
