Exercise Prescription for Individuals with Arthritis and Other Comorbidities

11/8/2011

Exercise Prescription for Individuals with Disclosures Arthritis and Other Comorbidities: What are the Considerations?  None

MARY CHRISTENSON, PT, PHD REGIS UNIVERSITY SCHOOL OF PHYSICAL THERAPY

ACR/ARHP NATIONAL SCIENTIFIC MEETING NOVEMBER 2011

Evidence-based Medicine Objectives

 Boyd CM, Leff B, Wolff JL, et al. Informing clinical practice  Identify consequences of physical activity for persons guideline development and implementation: Prevalence of with arthritis in combination with other coexisting conditions among adults with coronary heart disease. JAGS. 2011;59:797-805 comorbidities  Thompson WR, senior ed., Gordon NF, Pescatello LS,  Examine the current evidence related to prescribing associate eds. ACSM’s Guidelines for Exercise Testing and exercise in individuals with arthritis and other Prescription. 8th ed. Philadelphia, PA: ACSM; 2010. comorbidities  Van Dijk GM, Veenhof C, Schellevis F, et al. Comorbidity,  Discuss recommendations for exercise testing and limitations in activities and pain in patients with prescription, based on risk stratification osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders. 2008;9:95. http://www.biomedcentral.com/1471-2474/9/95. Accessed Oct. 12, 2011.

Concept Introduction

 Focus on co-existence of chronic disease processes  Exercise prescription  Tailored exercise programs to optimize healthful living, function, and quality of life  Why important?  Physical activity, including structured exercise, can increase years of healthful living  Addresses awareness of safety and effects of exercise on multiple systems  Intent of this presentation  2 main areas of focus with considerations for exercise prescription: osteoarthritis and rheumatoid arthritis  Overarching consideration: Co-existing chronic disease adds to the complexity of exercise prescription

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Interactions Between Various Disease Processes: Introduction An Example5

 Arthritis leading cause of disability in the US1  Coronary Heart Disease (CHD)  Heart disease is the leading cause of death in the US2  Other concurrent disease processes may:  “worsen the specific pathophysiology of CHD”  Adults > 65 years of age:3  “reduce the individual’s ability to compensate for CHD”  48% clients with Medicare had 3+ chronic diseases  interact with treatment for CHD which changes its effect  21% = 5+ chronic diseases  change priorities of treatment strategies  “compete” with treatment for CHD  “…there has been little work to frame how  “Ignoring concomitant diseases while applying comorbidities that may confer health status single-disease guidelines may lead to harm.”4 complexity at the patient level affect clinical decision-making.”5

CHD Example “Complexities”5 Boyd5 take home message…

Comorbidity - Disease Prevalence  “To develop clinical practice guidelines more Arthritis 56.7% relevant to people with CHD (or any index condition) Congestive heart failure 29% and comorbidities, first it must be decided what the Chronic lower respiratory 25.5% common and clinically relevant conditions to Diabetes mellitus 24.8% consider are.”5 Cerebrovascular accident 13.8%

Clinical/health status Prevalence  Consider how to incorporate complexities into Use of more than 4 medications 54.5% clinical trials to increase relevance to targeted Urinary incontinence 48.6% population Mobility difficulties 40.4% Dizziness or falls 34.8%

Multimorbidity Examples4: Women 65+ Multimorbidity Examples:4 Men 65+

Prevalence % Number Arthritis CHD CLRT Diabetes Prevalence % Number Arthritis CHD CLRT Diabetes

27.9 1 X 19.1 1 X

7.3 2 X X 5.9 2 X X

5.4 2 X X 3.8 2 X X

4.3 2 X X 2.7 2 X X

2.3 3 X X X 2.2 3 X X X

1.9 3 X X X 1.6 3 X X X

0.98 4 X X X X CHD = coronary heart disease; CLRT = chronic lower respiratory tract disease CHD = coronary heart disease; CLRT = chronic lower respiratory tract disease

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Arthritis and Heart Disease6 Literature: Co-occurring Disease

 Data source: The National Health Interview Survey  MMWR: Data from combined 2005 and 2007 Disability Supplement  Arthritis, heart disease, and activity level  Individuals with arthritis and heart disease  Diagnosed arthritis affected >50% persons with HD  Adjusted likelihood of physical inactivity 30% higher than persons  Lower socioeconomic and health status with HD and no arthritis7  Increased barriers to perform activities  Increased severity, numbers, and scope of disabilities  Evidence suggests that co-occurring diseases are  Needed higher levels of assistance and services under-treated8  Important to expand knowledge and skills to consider multiple diagnoses in plan of care

Individual Beliefs: Physical Activity in Chronic Disease9 Terminology

 Theoretical perspective  Comorbidity  Theory of Planned Behavior  “Any distinct additional clinical entity that has existed or that  Behavior, normative, and control constructs may occur during the clinical course of a patient who has the  Chronic diseases index disease under study”10  Arthritis, cancer, diabetes, cardiovascular  Implies interest is on effects other disorders have on the index 11  More than one diagnoses condition including prognosis of index condition  Survey, n = 5,204  Multimorbidity11  Purpose  Concordant coexisting conditions  Findings  Discordant coexisting conditions  Greater health barriers to PA for persons with arthritis than  Shift of interest: from given index condition to individual with other disease processes, as associated with control construct multiple disorders

Focus on Osteoarthritis (OA) OA and Comorbidities

 Prevalence: ~27 million individuals in the US12  Osteoarthritis and comorbidities (OA)  Comorbidities often associated with OA13,14 12  More common in older adults  Cardiovascular disease (CVD) 13  Type II diabetes mellitus (T2DM)  Note relatively high rate of comorbidity  Hypertension (HTN)  Individuals diagnosed with OA have a “significantly  Respiratory disease  Obesity higher risk of developing comorbidity” than those  Sample population13,14 without OA13  n = 288, mean age = 66 years, BMI = 27.8 kg/m2  Cardiac disease = 54%  HTN = 31.9%  Respiratory disease = 28.8%  Obesity = 23.9%  T2DM = 9.7%

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Exercise Prescription for Osteoarthritis Impact of PA on Select Comorbidities

 Recommended for conservative, nonpharmalogical  Coronary and other atherosclerotic vascular disease management  AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006  Primary goals include update17  Reduce pain  Hypertension (HTN)  Improve function  “…general agreement that exercise is a cornerstone for the  Improve quality of life prevention, treatment, and control of HTN.”18  Evidence suggests aerobic and resistance exercise to  Meta-analysis indicates a reduction of exercise and resting address goals15,16 blood pressure in individuals performing aerobic training19  Individualized component for safety, effectiveness  Dynamic resistance training demonstrates BP-lowering effects20

Impact of PA on Select Comorbidities Impact of PA on Select Comorbidities

 Type 2 diabetes  Chronic lung disease

 Aerobic: reduces HbA1c, increase VO2max, increase in insulin  Chronic obstructive pulmonary disease (COPD) 21 sensitivity  Evidence supports aerobic exercise training for individuals with 24  Strength: increase (31%) muscle glycogen storage, decrease COPD to improve quality of life and functional capacity 22  25 HbA1c (from 8.7 to 7.6%) Resistance training improves force production and muscle mass 21   Combined: additional benefit to reduce HbA1c Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)  Obesity  Limited research available  Combination of dietary changes and exercise – more effective  23 ILD: some evidence significant change in 6 minute walk test in weight loss dyspnea26  Reduction in weight can provide multiple health benefits  PAH: research in early phases

ACSM Screening for Risk Factors27 Exercise Prescription?? Atherosclerotic Cardiovascular Disease

 Where do we begin? • Positive – Age (Men > 45, women > 55) – Family History (Hx) – Cigarette smoking – Hypertension (> 140/ >90) – Dyslipidemia – Prediabetes (>100 mg/dL and <126 mg/dL, fasting) – Obesity (BMI > 30 kg/m2)  Risk screening – Sedentary lifestyle • Negative – High serum HDL cholesterol (> 60 mg/dL)

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ACSM Risk Stratification27 Disease Diagnosis, Signs, Symptoms27 Atherosclerotic Cardiovascular Disease High Risk

 Disease diagnosis Low Risk Moderate Risk High Risk  Cardiovascular: cardiac, peripheral vascular, or cerebrovascular disease  Pulmonary: COPD, Asthma, interstitial lung disease, or cystic fibrosis  Metabolic: DM (type 1 and 2), thyroid disorders, renal or liver disease Asymptomatic males and Asymptomatic males and Persons who have  Signs/symptoms females who have < 1 females who have >2 risk diagnosed cardiovascular, CVD risk factor factors pulmonary, or metabolic  Ischemic pain Ankle edema disease or one or more  Shortness of breath Palpitations or tachycardia designated  Intermittent claudication Diagnosed heart murmur signs/symptoms  Severe fatigue/SOB with normal activities

Screening History27 Exercise Testing

 AHA/ACSM Health/Fitness  May be recommended based on the risk category and Facility Preparticipation planned intensity of exercise… Screening Questionnaire

 ACSM27: Model to determine exercise testing and supervision recommendations based on risk stratification

Monitoring the Response to Exercise 27 ACSM Model Based on Risk Stratification when Initiate Program

 Low risk: generally, no medical exam and exercise  Important 200 test before moderate or vigorous exercise 180  BP – normal response  Moderate risk: generally, medical exam and exercise 160  HR – normal response 140 test recommended prior to starting vigorous  Rate of Perceived Exertion 120 exercise; MD supervision recommended at 100 80 maximum exercise test 60  40 High risk: recommend medical exam and exercise  Drug therapy may alter 20 test before start of moderate or vigorous exercise; response 0 MD supervision of max or submax exercise test 1 MET 4 MET 8 MET 12 MET Always error on the side of caution HR SBP DBP

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PA Guidelines for Older Adults: Considerations PA Guidelines : Considerations28

 PA and Public Health in Older Adults.  Flexibility Recommendation From the American College of  2+ days per week, 10+ minutes Sport Medicine and the American Heart  Balance Association28  Perform activities that reduce risk of falls (recommended for adults at risk)  Aerobic activity  General recommendations  Moderate activity x 30+ minutes, 5 days/week, 5-6/10 OR vigorous activity x 20+ minutes, 3 days/week, 7-8/10  With medical issues amenable to PA, perform at safe and  Strengthening activity effective doses  Perform 2+ non-consecutive days/week using major muscle  Perform as recommended to avoid developing problems groups  If minimum recommendations cannot be met (for example,  10-15 repetitions, moderate to high level of effort (5-6/10, 7-8/10) due to chronic conditions), work at tolerable, safe level to  Can exceed minimum guidelines under certain conditions to avoid inactivity achieve greater gains  Recommend consult with health care provider

Effect of PA Guideline on Fxn Older Adults National Frameworks

 Effect of Physical Activity Guidelines on Physical  “Increase the proportion of adults with doctor- Function in Older Adults29 diagnosed arthritis who receive health care provider  SF-36 PF subscale counseling.  Association between physical activity and physical function  A) For weight reduction among overweight and obese persons  The association between physical function and  B) For physical activity or exercise”32 lifestyle activity and exercise in the health, aging and  A National Public Health Agenda for Osteoarthritis body composition study30 201033  Association of Changes in Exercise Level With  Physical activity and weight management: recommended Subsequent Disability Among Seniors: A 16-Year interventions Longitudinal Study31  Low impact moderate intensity aerobic; resistance training

Summary Questions?

 Suggests exercise is a component of treatment strategy in isolated disease processes  Common to have multimorbidity  Older adult population with arthritis may have additional co-morbidities that need to be taken into consideration when developing an exercise prescription  Risk screening to determine direction for exercise prescription  Modifications  Consult  Literature evolving on complexity of multimorbidity

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References References

 1CDC. Chronic Disease Prevention and Health Promotion. Web site  8Redelmeier DA, Tan SH, Booth GL. The treatment of unrelated disorders in patients http://www.cdc.gov/chronicdisease/resources/publications/AAG/arthritis.htm. with chronic mdical diseases. NEJM. 2998;338:1516-1520. Accessed October 11, 2011.  9Rhodes RE, Blanchard CM. Just how special are the physical activity cognitions in  2CDC. National Vital Statistics Report. Web site diseased populations? Preliminary evidence for integrated content in chronic disease http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf. Accessed October 11, 2011. prevention and rehabilitation. Ann Behav Med. 2007;33:302-311.  3Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older  10Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J patients with multiple comorbid diseases: Implications for pay for performance. JAMA. Chron Dis. 1970;23:455-468. 2005;294:716-724.  11Marengoni A, Rizzuto D, Wang H, et al. Patterns of chronic multimorbidity in the  4Weiss CO, Boyd CM, Yu A et al. Patterns of prevalent major chronic disease among older elderly population. JAGS. 2009;57:225-230. adults in the United States. JAMA. 2007;298:1160-1162.  12Lawrence RC, Felson DT, Helmich CG, et al. Estimates of the prevalence of arthritis and  5Boyd CM, Leff B, Wolff JL, et al. Informing clinical practice guideline development and other rheumatic conditions in the United States Part II. Arthritis & Rheumatism. implementation: Prevalence of coexisting conditions among adults with coronary heart 2008;58:26-35. disease. JAGS. 2011;59:797-805.  13Van Dijk GM, Veenhof C, Schellevis F, et al. Comorbidity, limitations in activities and  6Verbrugge LM, Juarez L. Arthritis disability and heart disease disability. Arthritis & pain in patients with osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders. Rheumatism. 2008;59:1445-1457. 2008;9:95. http://www.biomedcentral.com/1471-2474/9/95. Accessed Oct. 12, 2011.  7CDC. Arthritis as a potential barrier to physical activity among adults with heart disease  14Reeuwijk KG, de Rooij M, van Dijk GM, et al. Osteoarthritis of the hip or knee: which – United States, 2005 and 2007. MMWR. 2009;58:165-169. coexisting disorders are disabling? Clin Rheumatol. 2010;29:739-747.

References References

 15Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for the role of  21Zanuso S, Jimenez A, Publiese G, Corigliano G, Balducci S. Exercise for the exercise in the management of osteoarthritis of the hip or knee – the MOVE consensus. management of type 2 diabetes: a review of the evidence. Act Diabetol. 2010;47:15-22. Rheumatology. 2005;44:67-73.  22Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of  16Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis resistance exercise training to improve glycemic control in older adults with type 2 of the hip and knee. Journal of Science and Medicine in Sport. 2011;14:4-9. diabetes. Diabetes Care. 2002;25:2335-2341.  17Smith SC Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for  23Church T. Exercise in obesity, metabolic syndrome, and diabetes. Progress in patients with coronary and other atherosclerotic vascular disease: 2006 update. Cardiovascular Diseases. 2011;53:412-418. Circulation. 2006;113:2363-72.  24Arena R. Exercise testing and training in chronic lung disease and pulmonary arterial  18Fagard RH. Exercise therapy in hypertensive cardiovascular disease. Progress in hypertension. Progress in Cardiovascular Diseases. 2011;53:454-463. Cardiovascular Diseases. 2011;53:404-411.  25Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR  19Cornelissen BA, Fagard RH. Effects of endurance training on blood pressure, blood evidence-based clinical practice guidelines. Chest. 2007;131;4S-42S. pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension.  26Ferreira A, Garvey C, Connors GL, et al. Pulmonary rehabilitation in interstitial lung 2005;46:667-675. disease: benefits and predictors of response. Chest. 2009;135:442-447. 20  Cornelissen V, Fagard RH, Vanhees L. The impact of dynamic resistance training on  27Thompson WR, senior ed., Gordon NF, Pescatello LS, associate eds. ACSM’s Guidelines blood pressure and other cardiovascular risk factors: a meta-analysis of randomized for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: ACSM; 2010. controlled trials. Presented at the 20th European meeting on hypertension, Oslo, Norway,  28Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older June 20; 2010. adults. Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1-12.

References Case

 29Morey MC, Sloane R, Pieper CF, et al. Effect of physical activity guidelines on physical function in older adults. JAGS. 2008;56:1873-1878.  30Brach JS, Simonsick EM, Kritchevsky S, et al. The association between physical function and lifestyle activity and exercise in the health, aging and body composition study. JAGS. 2004;52:502-509.  31Berk DR, Hubert HB, Fries JF. Associations of changes in exercise level with subsequent disability among seniors: a 16-year longitudinal study. Journal of Gerontology: Medical Sciences. 2006;61A:97-102.  32Healthy People 2020. Arthritis, Osteoporosis, and Chronic Back Conditions Web site. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId= 3. Accessed Sept. 9, 2011.  33CDC/Arthritis Foundation. A National Public Health Agenda for Osteoarthritis 2010. Web site link http://www.cdc.gov/arthritis/osteoarthritis.htm. Accessed Sept. 24, 2011.