E-13 cardiorespiratory exercise
Exercise benefits everyone, including people with chronic long-term conditions or persistent disabilities. The main issues concern practicalities and tailoring recommendations to the person’s abilities, preferences, lifestyle, and other contextual factors. This competency mainly concerns how to translate the evidence-based advice that “every minute counts” into “make it a daily habit” (quotations from the UK Chief Medical Officers’ Physical Activity Guidelines.) One vital message is that exercise is not detrimental to anyone with a disability, supported by evidence from Public Health England. Examples of the knowledge and skills needed for this competency, the indicative behaviours supporting competence, and relevant references are available for download.
Table of Contents
The competency
The competency is that the rehabilitation professional is “Able to assess a patient’s need for physical activity/exercise and to recommend ways of satisfying those needs that are concordant with the patient’s attitudes, interests, circumstances, disability and wishes.” In practice, the general need can be assumed, though, for some people, the professional might need to assess the need for particular types of exercise or exercise using specific muscles. Most of the learning will focus on how to alter someone’s behaviour and lifestyle.
Introduction
The influence of exercise and its absence on health and well-being cannot be overstated and is supported by much evidence. Much of the evidence comes from general population studies, and some studies may include people with chronic illness and disabilities but only incidentally. However, there is no rational reason why the findings should not apply to most people with long-term illnesses or disabilities; they have not lost their humanity simply through being ill. There are now many studies on many different chronic diseases and on people with many other disabilities that exercise reduces some of their problems and improves well-being.
Why promote cardiorespiratory exercise?
The evidence of benefit is strong from observational studies and randomised controlled trials. Crucially the benefits accrue in everybody, whether ill, disabled, or well and, equally important, the benefits extend across many aspects of health beyond muscle and cardiorespiratory performance, such as depressive symptoms. Many public health organisations have listed the health benefits of exercise, such as the US National Library of Medicine, the UK Chief Medical Officers, the US Centers for Disease Control and Prevention, and the World Health Organisation. These sites also advise on how to achieve a sustainable increase in exercise.
What about inactivity (sedentary behaviour)?
Sitting still, for example, watching television or looking at a computer screen, is sedentary behaviour, and the person is not exercising. However, the evidence suggests that long periods of being inactive cannot be compensated for by periods of exercise. Charles Matthews and colleagues analysed data from nearly 85,000 adults and found that increased sedentary time was associated with less good health even after controlling for reported levels of exercise.
Another study, by Dorothy Dunlop and colleagues, analysed data from 2286 adults over 60 years, measuring the time sitting using accelerometers. They found that the odds of being dependent in activities of daily living increased by 46% for each hour of being sedentary after controlling for time in moderate or vigorous physical exercise. In the whole population, the average sedentary waking time was nine hours daily, and 4.5% of the population was dependent in a daily activity.
Therefore, it is also important to advise people to refrain from sitting still for long periods, even if they do vigorous exercise at some point in the day.
What type of exercise?
The exercise should be something the person can do and wishes to undertake for reasons other than following your advice; this is the only essential characteristic. Exercise must be taken every day, preferably frequently during the day, so it must fit in with the person’s lifestyle. All other considerations pale into insignificance, however strong the evidence that a specific type of exercise is most beneficial.
On the other hand, if the person asks for your advice, you can discuss different forms of exercise such as aerobic or anaerobic, high intensity, etc. These matters will be of considerable significance in the context of sports, for example.
For people who are not concerned about high performance in sports, a more straightforward classification is given by the US National Institutes of Health:
- Endurance, a better term for aerobic exercise
- Strength is a better word than resistance training
- Balance, where they include Tai Chi – see below
- Flexibility, which refers to stretching
Tai Chi, classified as a balance exercise above, is one of many so-called mind-body exercises is another term used. The US National Cancer Institute defines it as exercise which “combines body movement, mental focus, and controlled breathing to improve strength, balance, flexibility, and overall health.”
The US National Center for Complementary and Integrative Health provides helpful information and evidence concerning mind-body interventions. Many originate in China, such as Tai Chi, but others, such as Pilates, developed elsewhere. The evidence base for specific benefits associated with these forms of exercise is limited and inconclusive. One probable reason is that they will all carry the benefits associated with any other activity, which means a large trial will be needed to determine any additional effect. Consequently, they should be encouraged to exercise using these exercises if they want to use them without implying any specific benefit.
Achieving competency.
The formal list of indicative behaviours expected and suggested knowledge and skills shows what is needed to become competent. Many skills are helpful throughout rehabilitation practice, such as educating and motivating the person. One area of expertise specifically associated with this competency is motivational interviewing.
Unfortunately, the evidence that motivational interviewing changes behaviour is inconclusive; a Cochrane review of its effect on smoking behaviour that includes 15,000 people found insufficient evidence of specific additional benefits compared with similar interventions to stop smoking. A Cochrane review of its impact on recovery after stroke identified only one study of 411 patients, which needed to provide more evidence. Thirdly, a systematic review of its effect in people with multiple sclerosis included ten trials and 987 people, concluding that evidence for sustained health or behavioural outcomes was limited.
Links with other rehabilitation expertise.
Exercise is beneficial in all conditions, so this competency applies to most of the seven problem-management and 13 condition-specific competencies given later in this section of the website.
Conversely, this competency requires you to be person-centred and, when planning rehabilitation, to tailor the exercise suggestions to the person’s abilities, interests, lifestyle, and cultural milieu. These skills are needed in all rehabilitation.
Conclusion.
The extent of specific expertise in exercise physiology a rehabilitation professional may need will be determined by their caseload and scope of practice. Everyone should be able to justify exercise recommendations, explain the benefits in general and for the person, know the general principles that each minute counts and that prolonged sedentary behaviour should be avoided, and be able to tailor what they recommend and how they convey their advice to the person they are seeing. Professionals working in cardiopulmonary rehabilitation, with people very active in sports, and younger people with musculoskeletal disorders, would benefit from a good understanding of exercise physiology.
