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How to Work with Clients Who Have Chronic Conditions

How to Work with Clients Who Have Chronic Conditions | Dr. Erin Nitschke | Expert Articles | 4/17/2017

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Working with clients who suffer from one or more chronic disease conditions presents unique and serious challenges. When it comes to training a client who fits a chronic disease profile, the purpose of exercise becomes one of a therapeutic nature versus a performance nature you would typically see with a generally healthy, low-risk client.

As a certified health and fitness professional, you are part of the client’s healthcare and health-promotion team. While you do not have a medical scope of practice, you are responsible for taking the necessary steps to consult with a client’s physician on a regular and continual basis while the client is in your care. As with any client, you begin by gathering a complete and robust health-history inventory, which includes primary and secondary diagnosis’ and any past complications the client has experienced with exercise and general activity. Once these steps are completed and you identify the appropriate risk profile based on the known risk factors, you can start to design a safe and effective exercise program.

Chronic diseases are numerous and present different challenges to both the sufferer and the health and fitness professional. This article discusses the basic principles and considerations associated with the following chronic disease types:

Arthritis

The most common types of arthritis are osteoarthritis (a degenerative joint disease that breaks down cartilage and leads to the development of bone spurs) and rheumatoid arthritis (autoimmune disease characterized by crippling pain, swelling, stiffness and contractures). Many people are surprised to learn that exercise is a crucial and therapeutic component to the management of arthritis.

To ensure a client is working within his or her functional level and the program is safe and effective, work in partnership with the client’s physician to create a program focused on cardiorespiratory fitness, muscular endurance and strength, and joint range of motion (American Council on Exercise, 2014).

Exercise Guidelines

  • Obtain medical clearance before beginning work with a client suffering from arthritis.
  • Incorporate a variety of low-impact aerobic activities (avoid jarring activities such as running or plyometric exercises) three to five days a week, and up to 30 minutes each session. Start slowly with deconditioned clients (10- to 15-minute bouts).
  • Extend the warm-up and cool-down sessions beyond the general recommendations.
  • For aerobic exercise, focus on duration.
  • For resistance exercise, focus on increasing the number of repetitions versus the amount of weight lifted. Start with two to three reps and increase to 10 to 20 (based on client’s abilities).
  • Consider the use of isometric exercises when appropriate.
  • Monitor your client’s response to exercise. If he or she experiences pain for more than two hours after exercise, modify the intensity.
  • Encourage warm-water exercise.
  • Encourage movement through a full range of motion.

(American Council on Exercise, 2014)

Precautions

  • Monitor a client’s response to exercise. If he or she experiences pain for more than two hours after exercise, modify the intensity and report pain experience to the client’s physician.
  • Stay in touch with the client’s primary care physician to ensure that a change in medications won’t interfere with the protocol you have in place.
  • Clients afflicted with arthritis are generally less active and are likely to present with other mild-to-moderate risk factors. For less-fit individuals, participating in physical activity increases the metabolic cost by 50% due to pain, stiffness, inefficient biomechanical patterns and poor gait patterns.
  • Repetitive motions may be problematic, so use variety in all activities.

(American Council on Exercise, 2014)

Asthma

The limitations associated with asthma, like many other chronic conditions, depend upon the severity of the client’s condition. It is important to understand that asthma itself is not a contraindication to exercise; however, those suffering from asthma should receive medical clearance prior to beginning an exercise regimen. A physician will have a better understanding of what might trigger a client’s asthma and can prescribe specific medications to mitigate those triggers. In general, exercise is a benefit to those with controlled asthma.

Exercise Guidelines

  • Encourage proper and continuous hydration before, during and after exercise.
  • Extend the warm-up and cool-down periods beyond general recommendations.
  • Keep the intensity low (before the point at which breathing becomes challenging).
  • Consider pool-based exercise as the air is moist and may lessen the likelihood of an attack.
  • Encourage three to four days a week of aerobic activity. Incorporate resistance training a few days a week, aiming for one to three sets of 15-20 repetitions.
  • Reduce the intensity of your client’s activity if you notice asthma symptoms occurring.
  • Keep in contact with the client’s primary care physician and report any attacks.
  • When possible, scheduling training sessions in the mid- to late-morning (due to natural daytime release of cortisol).

(American Council on Exercise, 2014)

Precautions

  • If an asthmatic client is recovering from an attack or an infection, exercise should be avoided.
  • Do not allow a client to exercise if his or her symptoms are poorly controlled.
  • Monitor the weather as well as the level of pollutants and allergens in outdoor environments as these can trigger an attack.
  • Make sure your client has his or her rescue inhaler or medication within reach at all times.

(American Council on Exercise, 2014)

Cancer

This category of chronic conditions is extremely complicated because there are numerous types of cancers, each with its own associated treatment path. For many cancer patients, the ability to participate in exercise will greatly depend on their day-to-day stamina (mental and physical), health and where they are at in their journey. Certain cancer treatments may affect the lungs and heart, so before starting even the most conservative of exercise programs, contact the client’s physician to find out which activities are considered safe and which ones should be avoided (American Cancer Society, 2012). 

Exercise Guidelines

  • Ask the client’s primary care physician for exercise recommendations and contraindications.
  • Start slowly and gradually increase the duration (try not to focus on the intensity of exercise).
  • Provide frequent breaks and hydration periods.
  • Keep the intensity light to moderate and adjust based on the client’s current health status and fatigue level.
  • Utilize lighter weights and keep the reps between 10 and 15.
  • Focus on proper technique and include adequate warm-up and cool-down periods.
  • If the client experience numbness in the feet or difficulty performing balancing exercises, try using a stationary bike or walking outdoors (weather depending) to avoid increasing his or her risk of falling.
  • Do not encourage swimming activities with clients who have exposed skin that has recently been treated with radiation or is healing from surgery.
  • Always encourage a balanced diet and regular fluid consumption.

(American Council on Exercise, 2014; American Cancer Society, 2012)

Precautions

  • Clients with a low red blood cell count should not exercise until cleared by a doctor.
  • Clients with low white blood cell counts or those taking medications that suppress the immune system may not want to exercise in a public facility.
  • A client who has a fever should not exercise.
  • Exercise is not recommended for those who have an electrolyte imbalance due to frequent vomiting or diarrhea. Ask the client’s physician for clearance prior to resuming activity.
  • Monitor edema in the ankles, weight gain and shortness of breath at rest or upon limited activity. Report these symptoms to the client’s doctor immediately.
  • Avoid exercise above a moderate level and the use of heavy weights. If a client has bone cancer, be mindful of osteoporosis.
  • Be aware if a client is taking blood-thinning medications as these can cause increased bruising and bleeding; therefore, avoid activities that increase the risk of falls.

(American Council on Exercise, 2014; American Cancer Society, 2012)

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is defined as a dysfunction of the pulmonary system and often includes chronic bronchitis, emphysema and even asthma. While guidelines for working with these types of clients vary between organizations, at minimum, before beginning an exercise program, confirm that your client has been seen by a doctor, cleared for physical activity, and given recommendations for appropriate activities and/or activities to avoid. Clients with COPD are likely to be on medications that can affect his or her response to exercise. Confirm these side-effects with the client’s doctor. Depending on the severity of an individual’s COPD, he or she may be required to exercise in a formal pulmonary and respiratory rehabilitation clinic, rather than under the direction of a health and fitness professional.

Minimum Exercise Guidelines

  • Recommend swimming activities as this allows clients to inhale moist air and avoid triggering an attack.
  • Incorporate low-intensity, low-impact aerobic activities three to four days a week for 30 to 50 minutes per session. Consider intermittent activity as well.
  • Include resistance-training activities a few times a week (one to three sets of 15-20 reps).

Precautions

  • If a client experiences severe fatigue, recommend a break from activity and resume slowly when the fatigue improves.
  • Watch for nausea, dizziness, shortness of breath, pain or irregular heartbeat during exercise. If these symptoms appear during a workout, terminate the session immediately.
  • Avoid exercising in the cold or in polluted areas.

Diabetes

Diabetes is a group of diseases characterized by high blood glucose resulting from dysfunctional insulin production, insulin action or both. There are three types of diabetes: type 1, type 2 and gestational diabetes, which occurs in pregnancy. It is necessary to work with your client’s healthcare team to establish the most effective and safest exercise program possible. To begin, obtain medical clearance for any client with diabetes.

Type 1 diabetes is a condition where the body attacks the beta cells of the pancreas, which are responsible for producing insulin. Clients with this form of diabetes require insulin injections (or a pump) to regulate and manage blood glucose levels. Research has not yet revealed a specific role exercise has in controlling blood sugar levels associated with type 1 diabetes; however, we do know exercise helps lower the risk for heart disease and improve functional capacity. In other words, exercise is still recommended.

Exercise Guidelines

  • Encourage regular and consistent aerobic (low-impact) exercise three to five days a week.
  • Keep the intensity between an RPE of 11-14 (6 to 20 scale).
  • Avoid long-duration exercise as this increases one’s risk of experiencing low blood sugar.
  • Over time, gradually increase the exercise session to 30 minutes.
  • Include resistance training two to three days a week (one to three sets of 15-20 reps) for clients who are not experiencing complications.
  • Encourage proper hydration.

Precautions

  • Promote proper foot care, as these individuals can experience neuropathy.
  • Reduce insulin intake or increase carb intake before workouts.
  • Keep juice or candy on hand in the event of low blood sugar.

(American Council on Exercise, 2014)

Type 2 diabetes is the most common form of diabetes and generally presents as insulin resistance, which means the cells stop using insulin properly. To combat this issue, individuals are generally placed on oral medication. In more severe cases, injectable insulin is prescribed. As with type I diabetic clients, a full medical evaluation and appropriate diagnostic studies are necessary. Obtain physician clearance and any exercise recommendations from the primary care provider or endocrinologist (American Diabetes Association, 2017).

Unlike type 1 diabetes, research has consistently shown substantial benefits of exercise to those with type 2 diabetes. Exercise helps reduce body weight, control cholesterol and reduce triglycerides. Furthermore, exercise reduces the risk of coronary artery disease, stroke and peripheral vascular disease.

Exercise Guidelines

  • Depending on a client’s health and management of his or her diabetes, encourage low- to moderate-intensity of low-impact aerobic exercise, five to seven days a week for 40-60 minutes (also dependent on client’s physical condition). Work up to 300 minutes per week.
  • Incorporate resistance-training exercise two to three days a week (two to three sets of eight to 12 reps). Begin with body-weight resistance exercises and progress.
  • Include eight to 10 multijoint exercises for all major muscle groups.

(American Council on Exercise, 2014)

Precautions

  • Ensure client’s blood glucose is stable and controlled.
  • Avoid exercise if client is unusually fatigued or is suffering from an acute illness.
  • Monitor and address signs and symptoms of hypoglycemia (e.g., hunger, palpitations, anxiety, confusion, blurred vision, headache, tachycardia, tremor, convulsion, syncope, coma).

The following are contraindications to exercise for clients with diabetes:

  • Blood glucose >250 mg/dl and ketones in urine for type 1 diabetes
  • Blood glucose >300 mg/dl without ketones for type 1 diabetes
  • Clients with type 2 diabetes can participate in exercise if they are feeling well and are properly hydrated.
  • Clients with diagnosed or suspected cardiovascular disease, proliferative retinopathy, severe kidney disease, loss of feeling in the feet, acute illness, infection or fever should avoid strenuous high-intensity exercise.

While type 1 diabetes appears most often in childhood and type 2 diabetes typically arises in adulthood and is associated with a lack of physical activity and poor nutritional habits, gestational diabetes occurs during pregnancy. This condition is a result of insulin resistance, but symptoms usually resolve after the birth of the baby. However, affected mothers are at an increased risk for developing type 2 diabetes later in life. This condition can also be addressed through diet, exercise and, if necessary, insulin injections. For these clients, it is best to work closely with the client’s obstetrician and follow established prenatal exercise guidelines and recommendations.

Disabilities

This category of chronic conditions is probably the most complicated because disabilities can include a wide range of issues, such as uncontrolled hypertension, certain heart conditions, progressive diseases such as multiple sclerosis, stroke, cerebral palsy, muscular dystrophy, sensory nerve damage, depression and more. To best address exercise and these conditions, the first step is to always obtain medical clearance and identify what is within your scope of practice to handle effectively and safely. Secondly, to work with clients living with a specific disability, you must learn about the condition itself. Exercise guidelines frequently vary between organizations and between specific disabilities. For example, it is not appropriate to write a program for a hypertensive client and then use the same or similar guidelines for a client who has had a stroke.

Further, the presence of a disability is often accompanied by other comorbidities. Working closely with other medical personnel associated with each client’s case will help you to design and execute an exercise program that minimizes potential negative effects and complications.

Hypothyroidism

Hypothyroidism, or underactive thyroid, is a dysfunction of the thyroid gland characterized by a number of symptoms including thinning hair, extreme fatigue, weight gain, forgetfulness, slow heart rate, deepening voice, intolerance to cold, irregular menstrual cycles, infertility, constipation, depression/anxiety and dry or itchy skin. This condition is particularly frustrating for clients who wish to lose weight. An underactive thyroid directly impacts the metabolic rate and can cause it to slow down. However, hypothyroidism is not a contraindication to exercise.

Exercise Guidelines

  • Encourage aerobic activity as it burns calories and helps circulation.
  • Add resistance exercise to help build lean tissue and boost the metabolic rate.
  • Encourage a balanced diet.

Precautions

  • Clients with this condition often suffer from extreme fatigue. Make sure to balance exercise with rest.
  • Depression is also a component to hypothyroidism. Exercise will improve mood, but monitor your client and refer him or her to appropriate mental health personnel, if necessary.

Osteoporosis

Osteoporosis is defined as a “bone mineral density (BMD) that is 2.5 standard deviations or more below the mean for young adults” (American Council on Exercise, 2014). As research demonstrates, physical activity is crucial to the maintenance of bone health; therefore, engaging in regular weight-bearing exercise plays a role in primary prevention. As with any chronic condition, if you feel uncomfortable or lack experience working with special populations, connect with your client’s physician.

Exercise Guidelines

The following guidelines are for clients with osteoporosis and are intended to help prevent the progression of the disease.

  • Incorporate weight-bearing aerobic exercises three to five days a week and resistance-training exercises two to three days a week (begin with one to three sets of 15-20 reps; progress to eight to 12 reps to promote strength and an increase in bone density).
  • Keep the intensity at a moderate level for both aerobic and resistance-training exercises. This is client-dependent, as some may be able to tolerate a higher level of intensity.
  • Aim for 30- to 60-minute sessions.

(American Council on Exercise, 2014)

Precautions

  • Do not include exercises that exacerbate pain.
  • Avoid exercises with abrupt explosive forces or those with high-impact.
  • Avoid exercises that involve twisting, spinal flexion, trampolines, slippery floors, and abducting or adducting the hip against resistance.

(American Council on Exercise, 2014)

Regardless of which conditions you encounter in your work with clients, it is essential that you always obtain medical clearance from each client’s physician prior to recommending any exercise regimen. Working with individuals who are dealing with chronic conditions requires you to maintain a consistent and regular open line of communication between the client and his or her healthcare team. However, if you do not feel comfortable working with any client with a chronic condition, use your professional judgement and refer to other health and fitness professionals who have more experience with these types of conditions.

Become an expert in creating programs for post-rehabilitative clients recovering from cardiovascular, pulmonary, metabolic and musculoskeletal conditions; identifying postural imbalances; and implementing programs that can prevent and manage disease with ACE’s Medical Exercise Specialist Certification

 

 

References

American Cancer Society (2012). Summary of the ACS Guidelines on Nutrition and Physical Activity.

American Council on Exercise. (2014). ACE Personal Trainer Manual (5th ed.). (C.X. Bryant, Ed.) San Diego, Calif.: ACE.

Centers for Disease Control and Prevention (2017). Arthritis.