Treating chronic disease with physical activity

Being active is not only very important in the prevention of disease, it is as effective as many other therapies in treating long term conditions 1

Cancer and Physical Activity

Summary
  • Physical activity has a strong protective effect against colon, breast, and endometrial cancers and a moderate effect against prostate lung and ovarian cancer.
  • More recent research has shown that regular physical activity before and after cancer diagnosis not only improves function and wellbeing but significantly improves survival.
  • 90 minutes of brisk walking a week appears to be the minimal activity to create most of these benefits.
  • Physical activity does not cause excessive tiredness in those patients undergoing treatment.

Physical activity during treatment (Chemotherapy, Radiotherapy and Hormone therapy)

Most patients are told to rest during chemotherapy to avoid fatigue. This is usually a compassionate response to the patient’s condition. However there is no evidence to support this advice and it may exacerbate the treatment-related losses of physical conditioning and muscle strength leading to a perpetual cycle of deteriorating function and accumulating fatigue that is very hard to escape 2 Patients who are more physically active during chemotherapy, radiotherapy and hormone therapy are no more tired than those that rest 3.

How can physical activity help prevent cancer? The table below outlines the percentage risk reduction and strength of the evidence of physical activity’s role in helping prevent certain cancers.

Cancer Type % Reduction Strength of evidence Notes
Breast 4 20-50 Strong Particularly for post-menopausal women
Colon 5 30-50 Strong Physical activity reduces time carcinogen in contact with bowel wall
Endometrial 6 20-30 Strong
Prostate 7 10-20 Moderate Reduces effect of testosterone
Lung 20-40 Moderate
Ovarian 20 Moderate
Others Weak evidence

How can physical activity treat cancer survivors?

Cancer survivors often improve their diet and stop smoking after diagnosis but physical activity levels are reduced significantly. 8 Breast Cancer Physical activity is associated with 41% reduced all-cause mortality, 34% fewer breast cancer deaths and 24% reduced risk of disease recurrence. 9 10 It also reduces hospitalisation, anxiety and side effects such as nausea, lymphedema, fatigue and pain. Results of the two largest studies suggested that women reaching the equivalent of the recommended minimum levels of physical activity (i.e. 150 minutes of moderate-intensity activity per week) had over 40% lower risk breast cancer-specific mortality, and breast cancer recurrence, compared with women active for less than one hour a week. 11 12 All women diagnosed with breast cancer can benefit from physical activity and risk of adverse events and poorer quality of life are higher in those who do not exercise. Those that decrease their levels of activity after diagnosis have a fourfold greater risk of mortality. 13

Colorectal cancer

Results of two studies suggested that risk of disease recurrence, cancer mortality was reduced by about 50%, by performing the equivalent of six hours of moderate intensity physical activity per week. 14 15

Prostate Cancer

Findings from two studies indicated a lower risk of prostate-specific mortality of approximately 30% 16 and a lower rate of disease progression of 57% 17 with three hours per week of moderate intensity physical activity (e.g. brisk walking). Some vigorous activity appeared to add further benefits to reduce death specifically from prostate cancer.

Cardiovascular Disease and physical activity

  • Physical inactivity carries a similar risk of cardiovascular disease as smoking and hypertension.
  • 150 minutes of moderate activity a week with or without vigorous activity can reduce the risk of CAD by 22% in men and up to 33% in women.
  • Following a cardiac event all should be invited to participate in Cardiac Rehabilitation, however currently only 38% of eligible patients participate.
  • Almost all inactive patients with CVD should be able to participate in some activity by starting at 10 minutes walking a day and then slowly introducing other activity. It is important to educate the patient about the warning signs of cardiovascular disease (e.g. chest pain and faintness) which need immediate follow up.

How Can Physical Activity Prevent Cardiovascular Disease?

Physical activity reduces the risk of cardiovascular disease with a magnitude of risk reduction comparable to that of reducing hypertension and quitting smoking. 18 19 More than 25% of the population-attributable risk for MI is due to physical inactivity compared to 13% due to diet 20. If the total amount of physical activity exceeds 1000kCal per week (brisk walking for 180 minutes a week) then the risk of developing CAD is reduced by 22% for men 21, and up to 33% for women 22. There is a dose response for CVD mortality reduction so that even a small amount of activity makes a considerable difference in mortality 23. The greatest benefits are moving from inactive to undertaking 60 minutes moderate activity a week. Aerobic fitness is a better predictor of cardiovascular mortality than self-report of physical activity 24 with a 19% fall in CVD mortality for every 1 MET increase in cardiorespiratory fitness 25. Inactive men who become active at 50 years old have a 49% reduction in mortality at the age of 60 years compared to those who remained inactive . This is actually a greater benefit than for those who stopped smoking at the same time (36% reduction). Similar results are found in women who become active later in life. 26 Physical activity is known to have a modest effect on individual risk factors such as blood glucose (mean reduction of HbA1c of 0.8%{ref]Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes Care. 2006;29: 2518 –2527.[/ref]), lipids (HDL raised by 2.5mg/dl 27), blood pressure (reduction of 3.4/2.4 mmHg 28) and obesity (6.7kg weight loss/year 29). In addition physical activity reduces the pulse rate through increased vagal tone. This increases the amount of time it takes to fill the ventricle so increasing stroke volume which when combined with a reduction in blood pressure reduces the amount of oxygen required by the heart. However newer mechanisms such as anti-inflammatory, endothelial dysfunction and reduced reactive oxidative species (free radicals) appear to be more important and explain the large benefits of regular physical activity on cardiovascular disease.

How can physical activity treat Cardiovascular Disease? (Secondary prevention)

Secondary prevention includes treating patients following a myocardial infarct, coronary intervention, heart failure or persistent angina. Most patients will be referred to cardiac rehabilitation initially and then discharged with the advice to continue physical activity.

Cardiac rehabilitation

The WHO (World Health Organisation) definition of cardiac rehabilitation is ‘the sum of activity and interventions required to ensure the best physical, mental and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume their proper place in society and lead an active life’ 30 Cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality by 20-30% provided it includes an exercise component. Cardiac rehabilitation is both safe and cost effective. 31 Cardiac rehabilitation (CR) should not be regarded as an isolated form or stage of therapy, but be integrated within secondary prevention services. Evidence suggests that home- and centre-based cardiac rehabilitation appear to be equally effective. The incidence of cardiovascular non-fatal and fatal events is very low, being 1/50,000 and 1/750,000 person hours of supervised exercise or 1 sudden death per 15 000 to 18 000 participants 32. The risk can be decreased by paying attention to new symptoms and gradually increasing the intensity of the physical activity. The risks of exercise are considerably outweighed by the potential benefits.

COPD and physical activity

Summary
  • Physical activity is the strongest predictor of mortality in patients with COPD and exercise training (pulmonary rehabilitation) can help improve functional capacity and quality of life.
  • When exercise training is provided as part of a pulmonary rehabilitation (PR) programme after a COPD exacerbation, only four patients need treatment to avoid a further admission and only six to prevent a death 33.

Encouraging even the smallest increase in daily levels of physical activity can incur significant benefits for patients with COPD. The current BTS guidance is to offer patients with MRC 3, 4, 5 to PR and those with MRC 1 and 2 for general exercise programmes. However national guidelines (BTS and ATS/ERS) are likely to move away from MRC scale and instead recommend PR to patients who consider themselves to have functional impairment and who wish to undergo supervised pulmonary rehabilitation.

How physical activity can treat COPD

Functional Capacity Low levels of physical activity are associated with a low FEV1 34 35
Physical activity reduces FEV1 decline and therefore slow disease progression 36
Higher FEV1 values are associated with 30 min of walking every day 37
Reduced physical activity can occur in COPD patients with minimal abnormality in FEV 1 38
Exacerbations and Hospital Admission Patients who are more active are less likely to be admitted to hospital. 39
Less than 2 hours of physical activity per week is a significant predictor (OR: 0.60) of hospitalizations in patients with severe COPD 40
Dyspnoea Increased physical activity is associated with reduced symptoms of dyspnoea 41
Co-morbidities Only 6% of COPD patients do not have co-morbidity with the average patient having 3.7 conditions including COPD 42
COPD patients who report lower levels of physical activity have more comorbidities (cardiac dysfunction, diabetes, joint problems, osteoporosis, CHD, cataracts and glaucoma) than those with moderate or high levels of physical activity. 43
Mortality Physical activity is the strongest predictor of all-cause mortality in patients with COPD. 44
Quality of Life There is a strong association between levels of physical activity and quality of life 45

Mechanisms

Aerobic training is beneficial for patients with COPD through the following mechanisms 46:

  • Increased oxygen uptake and endurance capacity
  • Decreased minute ventilation (VE), heart rate, dyspnoea, blood lactate and hyperinflation
  • Improvement of oxygen extraction from skeletal muscle
Strength training is beneficial for patient with COPD through improved muscle strength and endurance. Pulmonary Rehabilitation (PR):   It is estimated that about 40% of a GP COPD register would be suitable for PR. It is best to avoid over-emphasis on the word “exercise” .. Expert patients can also help. Let them know it will make them “Breathe better, feel good, do more”. Referral to, and timely availability of pulmonary rehabilitation in the post hospitalisation setting has been shown to reduce the three month readmission rate in COPD from 33% to 7% and a cost per QALY of £13,000. Positive outcomes of Pulmonary Rehabilitation
  • Decreased exertional dyspnoea and dyspnoea associated with daily activities
  • Increased exercise performance
  • Improved health-related quality of life
  • Enhanced functional status
  • Reduced health care use
  • Patients often consider it changes their life – it encourages them to confront fears and to make changes in their behaviour.

Depression and Physical Activity

Summary
    • NICE recommends physical activity as an effective treatment for depression.
    • There is strong evidence that regular physical activity reduces the risk of depression possibly by as much as a third.
    • 150 minutes of moderate activity and/or 75 minutes of vigorous activity is recommended with possible greater benefit from being outdoors in green space.

Can Physical Activity Prevent Depression?

Physical activity is inversely related to depression. 47 48 49 50In a German population group, Weyerer found that those who reported no physical activity ran three times the risk of developing moderate to severe depression as those who reported being physically active 51. A well-known study is that of Paffenbarger 52 and colleagues from 1994 in which they followed Harvard students of physical activity and exercise to depressive illness. The conclusion was that those who engaged in regular physical exercise had a lower risk of developing depression. The effect was clearly dose-dependent. However there is one study published by Cooper-Patrick and colleagues 53 with a 15-year follow-up that showed no relationship between inactivity and depression. In a 2007 report from the Caerphilly Study in Wales that there is a relation between a high level of physical activity in leisure time and at work, and reduced incidence of mental disorders (mainly depression and anxiety), at a 5-year follow-up but not after 10 years 54. A more objective study from Japan measured the physical activity of 184 individuals, aged 65–85 years, with an accelerometer and pedometer, for one year. They found a significant negative relationship between physical activity and depressive symptoms. 55 However although there is strong evidence that inactivity is related to depression it is not so clear whether it is physical inactivity that leads to depressive symptoms or whether it is depression that leads to inactivity.

Can Physical Activity Treat Depression?

NICE Guidelines 56 recommend the following: For people with persistent sub-threshold depressive symptoms or mild to moderate depression and a chronic physical health problem, and for people with sub-threshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering structured group physical activity programme (along with CBT and group based peer support) , guided by the person’s preference. The activity programme should:

  • be modified for different abilities according to the physical programme health problem, in liaison with the team treating the physical health problem
  • be delivered in groups supported by a competent practitioner
  • typically consist of 2–3 sessions per week (lasting 45 minutes to 1 hour) over 10–14 weeks
  • be coordinated with any rehabilitation programme for the physical health problem

A meta-analysis 57, and a Cochrane collaboration 58 showed that regular physical activity has similar efficacy to cognitive behavioural therapy in treating depression. The Cochrane review for the 23 trials (907 participants) comparing exercise with no treatment or a control intervention, the pooled SMD was -0.82 (95% CI -1.12, -0.51), indicating a large clinical effect. However, when they included only the three trials with adequate allocation concealment and intention to treat analysis and blinded outcome assessment, the pooled SMD was -0.42 (95% CI -0.88, 0.03). A study in which 156 patients aged 50–77 years were randomly divided into three treatment groups. The trial lasted for four months. Group 1 was treated with sertraline 50–200 mg per day. The second group received exercise training in the form of 30 minutes of walking and jogging, 3 times a week. The third group received both sertraline and exercise training. They found no significant difference in treatment effect between the three groups, and all showed a good effect from the treatment 59. The recent TREAD study 60 confirmed these findings by demonstrating that the addition of physical activity to usual care of depression in primary care showed no significant benefit. It appears that there is benefit to using physical activity as a sole treatment for mild to moderate depression but no evidence to show benefit when it is added to usual care.

Diabetes and Physical ActivitySummary

    • Physical activity benefits patients with pre-diabetes (impaired glucose tolerance and impaired fasting glucose), type I and type II diabetes.
    • In those patients with pre-diabetes, increased physical activity and a good diet can reduce the incidence of type II diabetes by 58% compared to 31% for those individuals taking metformin. 61
    • There is clear evidence from prevention clinical trials that healthy lifestyle change can prevent the development of type II diabetes in a cost effective manner in high risk individuals. 62
    • For individuals with type II diabetes, there is strong evidence that physical activity can reduce HbA1c by approximately 0.6% even without associated weight loss and can lead to reduced medication.
  How Can Physical Activity prevent Diabetes?  
  • There is strong and consistent evidence that type II diabetes incidence and progression can be reduced with physical activity in those with impaired glucose tolerance (IGT) and that the effects are independent of weight loss 63.
  • In a meta-analysis 64regular physical activity halves the risk of developing diabetes (HR = 0.49). This compares favorably to diet only (HR = 0.67), but identical to combined diet and exercise (HR 0.49).
  • In the same study numbers needed to treat (NNT) to prevent a case of diabetes in patients with are 6.4 for diet and exercise, 10.8 for anti-diabetic medication (e.g. Metformin) and 5.4 for Orlistat.
  • 150 minutes a week of physical activity and diet induced weight loss of 5-7% reduces the risk of progression from Impaired glucose tolerance to type II DM by 58% 65 66
  • In one major study lifestyle intervention groups had a 43% lower diabetes incidence (age and clinic adjusted) for up to 14 years after the active intervention ceased, and diabetes onset was delayed an average of 3∙6 years. 67
How Can Physical Activity Treat Diabetes?  
  • Physical activity improves blood glucose control in type II DM due to improved insulin sensitivity and this may enable reduction and even discontinuation of medication in a substantial proportion of patients. 68 69
  • Either aerobic or resistance training improves glycaemic control (measured with HbA1c) in type II DM, but the improvements are greatest with combined aerobic and resistance training. 70
  • Exercise programmes can reduce HbA1c levels by approximately 0.6% as well as reducing adipose tissue and triglyceride levels. 71
  • Cohort studies show that among patients with diabetes the least active and least fit have the highest mortality 72 Church et al 73found that men in the lowest, second, and third quartiles of cardiorespiratory fitness had 4.5, 2.8 and 1.6-fold greater risk for overall mortality than men in the highest quartile of cardiorespiratory fitness. “Essentially all of the association between higher BMI and higher mortality was explained by confounding with cardiorespiratory fitness; there was no difference in mortality among normal-weight, overweight, and obese men after adjustment for cardiorespiratory fitness”.

Osteoarthritis and Physical Activity

Summary
    • Regular moderate physical activity not only helps to prevent the development of osteoarthritis but also reduces pain and increases function in patients with existing hip or knee osteoarthritis.
    • 150 minutes a week of low impact activity such as walking is recommended. Patients with OA tend to be very inactive. In some studies only 8% achieve these guidelines and over 57% of women with OA do not even complete 10 minutes of activity a week.
    • Many patients think that rest is better for their joints because of the association of joint pain with increased activity. This belief may be reinforced by the widespread term of ‘wear and tear’. It is better to use the term ‘wear and repair’.
    • Moderate activity increases the quality of cartilage and muscle strength. There are no contraindications to moderate strengthening or aerobic exercise.
  How can physical activity prevent or initiate osteoarthritis?  
  • There is good evidence that people who undertake moderate PA have a lower risk of developing osteoarthritis. 74
  • Excessive vigorous activities such as rowing, skiing or long distance running can increase the risk of osteoarthritis due to micro-trauma to the cartilage 75. Likewise any injuries to either knee or hip can induce osteoarthritis.
How can physical activity treat osteoarthritis?  
  • Several systematic reviews have demonstrated that physical activity reduces pain and increases function in both hip and knee osteoarthritis 76 77 78
  • In one study of 1000 patients only 13% of men and 8% of women with knee OA were undertaking enough physical activity to meet the guidelines. 40% of men and 57% of women were totally inactive. 79
  • The effect of physical activity on pain is similar to the treatment of NSAID. 80 When asked, most patients would prefer to treat their osteoarthritis with exercise compared to being treated with an NSAID. 81 82
  • Patients need to be told that starting physical activity may initially cause pain but that this does not equate to damage. The pain may improve over time as the muscles strengthen and the joint stabilizes.
  • The Arthritis Research leaflet 83 helps GPs interpret the data for patients ‘If we take 100 people like you with knee OA, then without treatment 33 people are going to have less pain after 2 years but 67 won’t. However, with exercise an extra 12 people will have less pain after 2 years but 55 still won’t’. Unfortunately we don’t know which 12 will benefit!

Osteoporosis and Physical Activity

Summary
  • Physical activity improves muscle strength, mobility and balance, all of which help reduce the risk of falls and thereby reduced the risk of fractures 84 85 and improves quality of life.
  • Lack of physical exercise is associated with low BMD and increased risk of osteoporosis in later life. 86
  • Complete bed rest results in calcium loss of 200-300mg per week. BMD in trabecular bone is lost at the rate of 1-2 % per week, while BMD in cortical bone is lost at the rate of 1% per month.273
  • Women can lose up to 20% of their bone mass in the five to seven years after menopause. Together with lower peak bone mass in young adulthood, this can result in higher incidence of osteoporotic fractures in women as compared to men. 87

How does physical activity prevent Osteoporosis?

A gradual loss of bone density takes place from around the age of 20, when the maximum bone mass is fully developed until menopause. Studies have shown that weight bearing activities maintain existing bone mass. 88 89

How does physical activity benefit Osteoporosis?

Regular aerobic, weight-bearing and resistance exercise training has been shown to have a positive effect on the bone mineral density (BMD) of the spine in post-menopausal women. Walking is effective for hip BMD. Balance, strength training and lumbar 90 stabilization exercises lead to an improved daily functional capacity and quality of life with better balance and less pain.

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