Working with Chronic Disease Populations: Important Tools for your Toolkit
Dear aspiring exercise professionals,
When it comes to working with chronic disease populations, you may find it exciting, dreadfully boring or maybe even complex and intimidating. I’ve always found myself drawn to working with chronic disease populations - I love the simplicity of seemingly insignificant changes in activity level that produce such a meaningful outcome for these individuals. However, there are some important considerations and tools that I’ve learned along the way that have improved the way I interact with and educate my clients living with chronic diseases. After reading this, I’m hoping you will walk away with some new insights or maybe even just some reinforcement of things you’ve already learned and apply in your own studies, practicums, or workplaces.
Disclaimer: My experiences are unique to my career and the opportunities I’ve been presented with. They are not factual information. Keep in mind that someone else may have similar but unique experiences to what I am describing in this blog post.
What is a Chronic Disease?
A chronic disease is defined as a health condition or diagnosis that persists longer than 3 months and has lifelong implications for health. Examples include: Arthritis, osteoporosis, diabetes, kidney disease, heart disease, chronic obstructive pulmonary disease, cancer, multiple sclerosis, Parkinson’s disease, and so much more! Even though each of these conditions vary in pathology, most of them share a common beneficial treatment method… EXERCISE!
Exercise has important health benefits for everyone. For those living with a chronic disease, exercise can help reduce risk factors and manage symptoms related to the condition. The long-term benefits of exercise include: A lower heart rate and blood pressure, improved glucose tolerance, improved oxygen uptake and ventilation at a given submaximal intensity, increased muscle mass, decreased risk of falls, and improved quality of life.
For example: An individual living with Type 2 diabetes may take up regular exercise to lower their blood pressure and improve glucose tolerance.
Mentors Tip: If you are looking to learn about any of the chronic diseases and their corresponding exercise considerations, a great resource is the ACSM’s Guidelines to Exercise Testing and Prescription.
Now that we’ve established the benefits of exercise, we want to be aware of how each individual and their corresponding condition will respond to exercise, as this will be different from a healthy individual. Some considerations with exercise could be: Flare-ups of pain or fatigue, local tingling/numbness, changes in blood pressure, blood glucose levels, or breathing rate to name a few. It’s important to know what to expect with certain conditions so that you can properly educate your client and monitor changes as necessary.
Pain - A Common Symptom
Pain is a common symptom that accompanies various chronic diseases, which we refer to as chronic pain (pain that is persistent and lasts longer than 3 months). This pain could be in the joints (arthritis) or in the bones (osteoporosis) or various other parts of the body depending on the condition. During exercise, it is normal for healthy individuals to feel some amount of pain/discomfort/fatigue as the muscles are being challenged. This type of pain can be present while exercising, but decreases once exercise stops. There might also be a delayed onset of muscle soreness 24-48 hours after the exercise session (usually presents as muscle stiffness or achiness). However, when an individual with a chronic disease exerts themselves too hard or for too long, they can develop a flareup of pain or fatigue that is persistent, debilitating, and lasts long after the exercise session is finished. This could present as: The inability to get out of bed for 1-2 days, interruption or inability to complete activities of daily living, interrupted sleep or mood state, and more.
One way to monitor pain is by using a 10 point scale. These are easy enough to find on Google, depending on what you prefer visually. I use these by asking the client how they would rate their pain at the beginning of the exercise session and compare with how they feel after a challenging exercise and/or after the exercise session is complete. As a rule of thumb, I was always taught that if pain increases greater than 2 points on the scale within the exercise session, then it may be too much for the client and intensity and/or duration should be reduced.
For example: An individual with arthritis comes in for her exercise session reporting a 2/10 pain. After trying out a new exercise, she reports her pain as a 5/10. You may want to consider reducing the intensity or duration of the new exercise to make it more tolerable for her.
Graded Exercise Exposure & Managing Symptoms
In order to help the client manage any symptoms that may occur with exercise, there are important strategies that we can use as qualified exercise professionals to help make this a success for the client. As a new graduate entering the workforce, I learned a lot by trial and error and luckily some direction from brilliant physiotherapists and exercise physiologists along the way. In my opinion, the best approach is to set up a graded exercise exposure program for the patient. This involves assessing the client’s current abilities and goals. It starts with exercising at a level within their capabilities and gradually progressing. You want to:
(1) Determine the client’s abilities, goals, and type of activity they are interested in
(2) Determine symptoms and related triggers (if any)
(3) Start SLOW, monitor symptoms, and progress
Now, say that you’ve prescribed an exercise program and your client reports back with an increase in a symptom… what do you do? The answer is modify. It’s important to educate your client that it is safe to exercise with pain or fatigue, but there are acceptable ranges to be aware of. Consider these tips for the client:
Bottom line: Exercise should provide benefit(s) to the individual and not consistently exacerbate symptoms.
Tools for Educating on the Benefits and Expectations with Exercise
How do we make sure the client understands all of this? It can be a delicate balance between educating the client but not overwhelming them with information. Ultimately, educating the client and working with them over time will help to build a trusting therapeutic relationship. I’ve definitely had some clients that think I’m crazy for asking them to exercise with tolerable pain and others who understand it completely. Education is important, that way clients understand the value of exercise and the ways in which it can be modified so that they don’t fear exercise or stop exercising entirely. Some educational tools in my toolkit that I use with my clients are:
- Motion is lotion - our bodies are made to MOVE
From the beginning of time, human bodies have been designed to move. As society progresses to a more sedentary lifestyle, more health issues arise. For those that spend a lot of time sitting at a computer for work, there are increases in neck, hip, and back pain due to lack of movement. Sometimes I like to include that the human body is similar to a car - you need to drive a car in order to get the fluids circulating and maintain the engine to avoid parts degrading or breaking down. Human bodies are the same!
- Let’s find your window of tolerance for exercise - it’s an experiment
Each individual will have a different window of tolerance for an activity for which there is minimal or no pain/fatigue. They will have to experiment with different types of exercise, intensity, and duration. Sometimes an activity feels good in the moment, so the client pushes themselves but might pay for it the next day with a flareup of pain or fatigue. This makes it tricky to find the appropriate window of tolerance for exercise. The more we work within the window of tolerance, the more we can start to expand it. Not only is it hard to find, but it shifts with time as well!
- Symptoms like pain or fatigue are multidimensional - they are not signs of damage or injury
The biggest concern that clients fear with exercise is that pain or fatigue is a sign of damage, whether it be re-injury of a certain area or just the association that pain equals damage. The thing is that there are many factors that contribute to pain and fatigue. My favorite analogy for this is the “cup”. The cup representing pain or fatigue may overflow if any of these factors become unmanageable:
(Image retrieved from Recovery Strategies Pain Guidebook by Greg Lehman)
You can encourage your clients to build their cup bigger by working on stress management, having a consistent sleep schedule, giving the body permission to explore new movements, incorporating a healthy diet, etc. The options are endless for the client to explore their triggers for pain and/or fatigue. An important thing to note is that avoidance of exercise or stressful situations will make sensitivity to pain worse, and your window of tolerance/threshold for tolerating that stressor will decrease.
Disclaimer: When referring to pain, I am talking about chronic pain (greater than 3 months) and NOT acute pain (less than 3 months). Considerations and precautions will be completely different for acute versus chronic pain.
- Focus on function rather than pain
This is a big one in the rehabilitation world, where clients come in looking for someone to “fix” them and take away their pain. What they don’t realize is that unfortunately not all pain can be resolved with exercise or different types of therapy. Pain is a very complex system mediated by the brain and is very individualized. There’s still a lot that we don’t know about pain. For physiotherapy, the goal is always function. How can we get someone fit to return to work or be able to move in a way that allows them to complete daily activities. If the pain resolves with these processes, fantastic! But if we based our outcomes on a client's subjective levels of pain, they could be in physiotherapy for their entire lives, which is not practical. As you’ll see in the diagram below, it’s easy for pain to encourage a client to perform less activity and less exercise which produces more pain. We want to break this cycle to include more activity, more exercise, and less pain! I’ve yet to find a great way to educate clients on this concept, as their pain is real to them and I would love for them to be pain free just as much as they do. Sometimes explaining this concept during the initial visit is a good way to set up the patient’s expectations surrounding function and pain.
To wrap up this post, I think one of the most valuable lessons we learned in school and through practical experience is the importance of treating the individual, not the condition. This can be applied when it comes to creating an individualized exercise program and supporting the individual as they adapt to healthy lifestyle changes. It can also be applied with the language we use when describing the individual and how we interact with them. For example: “the diabetic” vs “the individual living with diabetes.” We don’t want to dehumanize the individual and define them by their chronic disease, but rather identify the person first and what they are living with second.
Hopefully you’ve found some of these tips helpful or reinforcing what you already know. It will always be a work in process, developing ways of educating clients with chronic diseases on how to exercise safely and effectively, while helping them understand how to manage any symptoms that may arise. You’ll find new challenges with each individual. I love finding new ways of explaining various considerations with exercise! If you are looking to learn more, here are some helpful resources that I have come across during my time as a practitioner:
- Explain Pain by David Butler
- Recovery Strategies Pain Guidebook by Greg Lehman
- ACSM’s Guidelines to Exercise Testing and Prescription
As always, feel free to reach out if you have questions or concerns you want to discuss more!
Sincerely,
Victoria Boyce
Your Kines Mentor