Abstract
In this chapter we will review common comorbidities that may affect participation in physical activity, including diabetes mellitus, hypertension, atherosclerotic coronary artery disease, and obesity.
Key Concepts
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Comorbid conditions are increasingly common in today’s patient population.
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A multitude of comorbid conditions can affect both a patient’s ability to participate in physical activity and recovery from injury.
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While physical activity can reduce an individual’s risk of developing or worsening their comorbid conditions, exercise should be recommended in a safe manner.
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Health care providers must be able to safely develop an exercise program and encourage its execution in patients with a variety of diseases.
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Treatment of patients with increasing numbers of comorbidities becomes more complex. All of the following recommendations should be evaluated on a case-by-case basis with the complete patient situation in mind.
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A variety of physical activities have been categorized based on intensity regarding static and dynamic components as seen in Fig. 9.1 , which can be helpful when making exercise recommendations.
Fig 9.1
Classification of sports.
(Modified from Mitchell JH, Haskell W, Snell P, Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol . 2005;45:1364–1367. In Levine BD, Baggish AL, Kovacs RJ, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 1: Classification of Sports: Dynamic, Static, and Impact. A Scientific Statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol . 2015;66[21]:2350–2355.)
Diabetes Mellitus
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Exercise safety and recommendations differ depending on the underlying cause of diabetes mellitus (DM), traditionally classified as type 1 and type 2.
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Individuals with DM have an increased risk of specific orthopaedic concerns, including adhesive capsulitis of the shoulder, carpal tunnel syndrome, and Charcot foot.
Type 1 Diabetes Mellitus (5-10% of Patients With Diabetes Mellitus)
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Type 1 DM is due to autoimmune destruction of insulin-secreting β-cells, resulting in a lack of insulin production.
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Disease onset typically occurs in childhood, although it can develop at any age.
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Physical activity should be recommended for all individuals with type 1 DM.
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Various insulin and carbohydrate intake adjustments may be required to maintain a euglycemic state during physical activity due to variability in exercise intensity and duration.
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Blood glucose should be checked before exercise, with a goal level between 90 and 250 mg/dL.
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If blood glucose level is less than 90 mg/dL, 15 to 30 g of carbohydrates should be ingested prior to exercise, with subsequent rechecks throughout activity.
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If blood glucose level is greater than 250 mg/dL, the individual should test for ketones. If positive, exercise should be avoided. If negative, low- to moderate-intensity exercise can be started. If glucose level is greater than 350 mg/dL, consider insulin correction.
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Carbohydrate-based foods should be readily available during exercise as needed.
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Continuous glucose monitoring (CGM) is becoming more popular as technology advances. At this time, these devices should be used only as an adjunct to more traditional finger stick methods due to concerns regarding accuracy and calibration.
Type 2 Diabetes Mellitus (90-95% of Patients With Diabetes Mellitus)
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Type 2 DM is related to a reduction in circulating insulin along with insulin resistance.
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Onset has traditionally occurred in adulthood, although type 2 DM is becoming increasingly prevalent in the pediatric population.
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Prediabetes or impaired fasting glucose occurs when glucose levels are elevated beyond normal but do not reach the threshold for DM diagnosis.
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Exercise has been shown to prevent or delay onset of type 2 DM in individuals with prediabetes.
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In individuals in the late stages of DM, exercise has been shown to decrease insulin resistance and allow better blood glucose control.
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Low- or moderate-intensity programs are considered generally safe for well-controlled patients with DM who remain asymptomatic.
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While physical activity is encouraged in all patients with type 2 DM, special consideration should be given when additional comorbidities exist:
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Microalbuminuria/diabetic nephropathy—high-intensity activity should be avoided 24 hours before urine collection to avoid falsely elevated results.
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Peripheral neuropathy—daily foot checks and routine foot care are required, including keeping feet dry and protected to avoid foot ulcers. Maximizing non–weight-bearing activity may reduce potential trauma to the feet.
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Autonomic neuropathy—utilize caution with exercise in hot environments and rapid postural changes. Use ratings of perceived exertion (RPE) in the setting of blunted heart rate response to monitor exercise intensity.
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Diabetic retinopathy—regular follow-up with ophthalmology is required.
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Mild nonproliferative disease—all activities are considered safe.
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Moderate/severe nonproliferative disease—avoid activities that significantly elevate blood pressure (high static activities such as powerlifting).
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Unstable proliferative disease—avoid jumping and jarring activities, due to increased risk of vitreous hemorrhage and retinal detachment.
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Vascular disease
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Recent myocardial infarction or stroke—exercise should be initiated in a cardiac rehabilitation program with initial low intensity and progression under supervision.
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Exertional angina—heart rate should be maintained at least 10 beats per minute below symptom development. Exercise stress test can be helpful in determining individual threshold.
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All medications to treat type 2 DM are considered generally safe with exercise.
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Medication dose adjustments may be required with insulin and insulin secretagogues if previous exercise-induced hypoglycemia has occurred.
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