John M. Heath, MD, and Marian R. Stuart, PhD

Disclosures

J Am Board Fam Med. 2002;15(3) 

In This Article

Specific Conditions Requiring Special Consideration

Chronic obstructive pulmonary diseases, such as chronic bronchitis and emphysema, are common conditions for which exercising specific breathing musculature and general skeletal muscles can result in major improvements in disease status. The limiting factor of breathlessness might require that oxygen desaturation be monitored during activity. Pulse oximeters attached to the finger tip can record heart rate as well as measure the level of oxygen saturation. Having supplemental oxygen available where the patient will be exercising is also recommended.

Patients who have ischemic heart disease also can benefit from breathlessness assessment by monitoring oxygen levels at the start of routine exercise activities. In addition, nitrates in either spray form or sublingual tablets should be immediately available. Finally, electronic pulse monitoring, either by the patient or by a supervisor, can ensure that the intensity of exercise does not result in excess tachycardia.

Diabetic patients who require insulin need to be aware of the potential for hypoglycemia during exercise training and during the hours after cessation of exercise. Patients should not exercise if their blood glucose levels exceed 250 to 300 mg/dL, and blood glucose levels should be monitored before and after exercise. High-carbohydrate foods should be available.[59] These patients should wear an identification tag or other means to alert those around them of their diabetic status should they become unresponsive after their exercise period. Diabetic patients with peripheral neuropathy need to take precautions with their footwear during weight-bearing activities. Weight-bearing activities such as treadmill or step exercise are relatively contraindicated, whereas general aerobic activates without weight bearing (eg, rowing, chair-based strengthening) are recommended. Physicians should also consider the temperature of the environment in which diabetic frail elders (and other frail elderly patients) will be exercising. Nursing homes in particular might need to ensure that the room used for exercise not be overly heated to the temperature required for sedentary activities.

Osteoarthritis of knees or hips will benefit most from both resistance and aerobic exercise when the weight-bearing load over the affected joint is reduced and when the range of motion is maintained to avoid painful rotational joint stresses.[60] Exercising in water provides the greatest reduction of weight over the joint, although nonaquatic programs that support the joint against gravity also are helpful. For example, knee resistance exercise might be done while lying on one's side on a padded surface, with the lower leg sliding along the surface. For weight-bearing exercise, wedge insoles or other forms of unloading orthotic devices designed to alter the alignment of stresses on the joint might have a disease-modifying effect for those who have osteoarthritis of the knee.[61] Splints that limit range of motion to specific planes and prevent hyperflexion of an impaired joint can also be used with muscle-strengthening exercises.

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