Exercise And Chronic Disease

An abundance of scientific literature has overwhelmingly confirmed the health related benefits of exercise for apparently healthy populations. And likewise, individuals with a diagnosed chronic disease or disability benefit as much if not more from regular physical activity as do apparently healthy individuals. As a result, these individuals as determined and directed by their physician often choose health dub settings to carry out their exercise program. As a fitness instructor, it is imperative to develop a basic understanding of certain-chronic diseases and disabilities, and the effects that exercise has on them.

Understanding the precautions that exist with those individuals with a chronic disease will help to provide safe and effective exercise instruction. Although an in-depth discussion of the specific diseases is warranted, it is beyond the scope of this manual. The following discussion is to provide a brief overview of some of the major chronic diseases fitness instructors might encounter in a fitness facility. Fitness instructors should keep in mind that their role is to improve participant well-being through the design and implementation of exercise services-not to treat or alleviate adverse health conditions or disease.

General Guidelines Review the medical history questionnaires before the first exercise session. 

  • Follow the American College of Sports Medicine’s (ACSM} guidelines for risk factor stratification and the recommendations for seeking a medical clearance. Know the emergency procedures of your facility. 
  • Use the Borg RPI scale and 
  • be able to teach participants how to use lr. 
  • Don’t pretend to know everything; ask questions. If you don’t feel comfortable working with certain individuals. explain why, and have them obtain specific exercise recommendations from their doctors, or refer them to a medically supervised program or to a clinical exercise physiologist. 
  • Remember the team approach- physician, particlpant or patient, and instructor all work together to make the exercise training safer and more effective.


Asthma is a common respiratory problem affecting more than 20 million Americans, including 9 million children under the age of 18 (American Lung Association, 2005). It is a reactive airway disease caused by constriction of the smooth muscle around the airways, swelling of the mucosal cells, and increased secretion of mucus. Persons diagnosed with asthma experience defining characteristics, including coughing, wheezing, and dyspnea (shortness of breath). Extrinsic or intrinsic factors cause asthma. Extrinsic factors are external irritants, such as pollen, cigarette smoke, and air pollution, whereas intrinsic asthma is the result of internal factors, such as a bacterial respiratory tract infection attacking the body. A large percentage of the population experiences exercise-induced asthma (ETA, also known as exercise-induced bronchospasm) which is a moderate obstruction of the airway that is not life threatening. Although asthma is not a contraindication to exercise, those who have been diagnosed with asthma should first consult with a physician, then follow specific guidelines for their exercise program.

Exercise Guidelines for Asthma

1. Prior to beginning the exercise program, the participant should consult with his/her physician and, in accordance with that consultation, develop a medication and treatment plan to prevent EIA attacks.
2. A bronchodilating inhaler should be available at all times during the exercise session. It should be used at the onset of symptoms.
3. Exercise intensity should start low then gradually increase as the participant’s body adapts to physical activity.
4. Avoid exercising outdoors in extreme cold or when pollen levels are high.
5. A humid exercise environment is best. Many people with asthma find that water exercise is especially well-tolerated.
6. Use of an inhaler prior to exercise often reduces the likelihood of experiencing an EIA attack.
7. Breathing through the nose or with pursed lips may reduce or dissipate symptoms during exercise.
8. An extended warm-up and cool-down should be practiced.

Heart Disease

Heart disease affects one out of every two people in the United States. It’ is the leading cause of death in the U.S. and in most of the developed world, and the number of cases continues to increase despite repeated warnings reported by scientific research. Atherosclerosis, narrowing of the coronary arteries, is the primary contributing factor for the development of the disease. This narrowing causes reduced blood flow to the heart, producing angina (chesteain), and ultimately myocardial infarction or heart attack. Atherosclerosis of the cerebral blood vessels can lead to a stroke, or death of brain tissue. The risk of stroke is greatly increased with people with hypertension (high blood pressure). Cardiorespiratory fitness has been found to significantly influence risk of death, and offers strong support that both regular physical activity and high levels of fitness protect against atherosclerotic heart disease. As a result, sedentary lifestyle, or physical inactivity, has been labeled a primary risk factor for heart disease. Other risk factors are (a) age, (b) family history, (c) hypertension, (d) high cholesterol, (e) cigarette smoking, (f) prediabetes, and (g) obesity.

Exercise Guidelines for Heart Disease

1. Participants should be screened for heart disease risk factors prior to beginning an exercise program. Participants who are male and 45 years of age or older, or who are female and 55 years of age or older, or who report two or more major atherosclerotic cardiovascular disease (CVD) risk factors are considered to be at moderate risk for heart disease. Participants with known cardiac, pulmonary, or metabolic disease and/or symptoms suggestive of heart disease are considered to be at high risk for heart disease and complications. The ACSM recommends that both moderate and high risk participants obtain a release from a physician before starting an exercise program.

2. Guidelines prescribed by the physician for a participant with heart disease, pulmonary disease, or metabolic disease should be strictly followed.

3. A record of current medications and their effects on exercise should be developed and reviewed with a participant in conjunction with his/her health care provider before initiating the exercise program.

4. Comply with the target heart rate range and RPE guidelines for each participant, recommended by his or her physician.

5. The participant should be instructed to alert the fitness instructor should any signs or symptoms develop before, during, or after exercise.

6. Do not exceed your level of expertise. It may be more prudent to refer high-risk participants to a medically supervised program or to a clinical exercise physiologist.

7. Exercise intensity should start low then gradually increase as the participant’s body adapts to physical activity. High-intensity exercise is not recommended without specific permission from the participant’s physician.


Osteoarthritis  may happen to adult over 70 years of age, and rheumatoid arthritis for about 3% of women and 1% of men in the U.S. population. A degenerative process, osteoarthritis is the wearing away of cartilage between two bones, allowing bony contact to occur, whereas rheumatoid arthritis is caused by inflammation of the membrane surrounding joints. This inflammation is often associated with pain and swelling in one or more joints. Exercise is generally recommended by health care providers for those with arthritis to improve muscular strength and endurance around the affected joints, increase joint range of motion and flexibility, decrease pain and stiffness, improve motor coordination, and improve total body fitness. During a severe arthritic bout, vigorous exercise should be avoided as it can exacerbate flare-ups. However, gentle stretching is usually well tolerated and may help relieve pain.

Exercise Guidelines for Arthritis

1. Exercise classes, such as low-impact cardio, stationary indoor cycling, and water exercise, should be encouraged. These classes should avoid quick, ballistic movements that can be painful for the arthritic participant.

2. Frequent, low-intensity exercise sessions should be performed. Decrease intensity and duration of exercise during severe bouts of pain or inflammation.

3. Gently move every joint every day, enhancing mobility of both muscles and joints.

4. Help the participant with appropriate weight loss and weight management strategies, if necessary.

5. An extended warm-up and cool-down period is advised to help minimize pain.

6. Monitor all changes in medication and fluctuations in pain levels with the disease, and have the participant consult with his or her appropriate medical professional.

7. Be aware of the 2 hour pain rule: if pain persists, reduce the intensity or duration in future sessions.

8. Obesity and overweight are risk factors for osteoarthritis.

Diabetes Mellitus

The two most common forms of diabetes mellitus include (a) insulin dependent diabetes mellitus (IDDM), or type I, and (b) non-insulin dependent diabetes mellitus (NIDDM), or type 2. Both types of diabetes are characterized by high blood glucose levels, also known as hyperglycemia. Approximately 7% (21 million) of the American population has diabetes mellitus, and the numbers continue to increase (National Diabetes Fact Sheet, 2005). IDDM, commonly known as juvenile-onset diabetes, occurs when the body does not produce insulin. As a result, daily injections of insulin must be taken to regulate glucose levels in the body. Approximately 10°/ri of people with diabetes are diagnosed with type 1 diabetes. Type 2 diabetes is the most common form, affecting about 90-95% of those with diabetes. Largely due to obesity and physical inactivity; persons with type 2 diabetes cannot efficiently use the insulin they produce. Type 2 diabetes usually requires nutrition therapy and occasionally pharrnaco-logical therapy. However, current research suggests that type 2 diabetes can be prevented, and even alleviated, through proper nutrition and regular participation in an exercise program. While the provision of service to prevent or treat such conditions by non-licensed personnel is prohibited by Jaw, fitness professionals can assist in improving the well-being of people with diabetes. It is important to note that individuals with diabetes require special attention in exercise programming due to special needs. As a fitness instructor, adherence to these guidelines will provide safe and effective exercise for the participant with diabetes.

Exercise Guidelines for Individuals with Diabetes

Frequency: 3-7 days per week
Intensity: 50-80% HRR or RPE of 12-16 on the 6-20/15-point scale
Duration: 20-60 minutes per day continuous or accumulated in bouts of atleast 10 minutes to total 150 minutes per week of moderate physical activity
Type: Activities that use large muscle groups in a rhythmic and continuous fashion
Resistance training should be encouraged, following the general guidelines for apparently healthy individuals, as long as the participant is free from any contraindications (e.g., signs/symptoms of cardiovascular disease, retinopathy, and recent laser treatments).
Frequency: 2-3 days per week
Intensity: low resistance; gradual progression; 2-3 sets of 8-12 repetitions (at 60-80% I-RM)
Time: 20-60 minutes (or time to complete 8-10 multi-joint exercises; sessions may vary based on training protocol)
Type: Free weights, weight machines, elastic tubing


Hypertension, or high blood pressure, is a disease affecting approximately 65 million individuals in the U.S. Hypertension occurs more frequently in African American individuals, and it is a major risk factor for cardiovascular disease and stroke. Hypertension places undue stress on the heart, increasing left ventricular wall thickness, and reducing diastolic filling. Recent research reports that regular physical activity can decrease blood pressure.

Exercise Guidelines for Hypertension

1. Emphasize cardio exercise, such as walking, jogging, cycling, or swimming, in order to help reduce high blood pressure. Individuals exhibiting elevated blood pressure should exercise at lower intensities (40-70% of HRR).
2. Exercise should be performed on most days of the week in 30-60-minute sessions.
3. High-intensity activities and isometric activities should be avoided.
4. For resistance training, repetitions should be high and weight should remain low. Avoid resistance training to the point of failure, even if the weights are light.
5. Avoid the Valsalva maneuver, as it increases vascular pressure.
6. Utilize RPE as certain hypertensive medications alter heart rate during exercise.
7. Avoid positions in which the feet are higher than the head.
8. Teach relaxation and stress management techniques.


Exercise therapy for individuals with chronic disease is accepted and practiced by clinicians in many diverse health care settings. More than likely, fitness instructors will encounter individuals who have been diagnosed with a disease that requires special considerations and guidelines regarding exercise. It is to such instructors’ advantage to continue learning about special populations. For more information on certification programs and workshops in this field, instructors should contact the American College of Sports Medicine.


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