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EXERCISE AND CHRONIC
DISEASE

An evidence-based approach

EDITED BY JOHN M. SAXTON

First published 2011
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Simultaneously published in the USA and Canada
by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group
© 2011 John M. Saxton
The right of the editor to be identified as the author of the editorial
material, and of the authors for their individual chapters, has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and
Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Exercise and chronic disease: an evidence-based approach / edited by
John M. Saxton.
p. ; cm.
Includes bibliographical references.
1. Chronic diseases--Exercise therapy. 2. Exercise--Physiological
aspects. I. Saxton, John M., Prof.
[DNLM: 1. Chronic Disease--therapy. 2. Evidence-Based Medicine.
3. Exercise Therapy. 4. Exercise. WT 500]
RB156.E94 2011
616’.044--dc22 2010038188
ISBN 13: 978-0-415-49860-9 hbk
ISBN 13: 978-0-415-49861-6 pbk
ISBN 13: 978-0-203-87704-3 ebook
Typeset in Times New Roman
by Greengate Publishing Services, Tonbridge, Kent
Printed and bound in Great Britain
by CPI Antony Rowe, Chippenham, Wiltshire
CONTENTS

List of contributors vii

1 Introduction 1
John M. Saxton

2 Coronary heart disease 11

Gavin Sandercock

3 Hypertension 27
V. A. Cornelissen and R. H. Fagard

4 Stroke 56
Frederick M. Ivey, Alice S. Ryan, Charlene E. Hafer-Macko
and Richard F. Macko

5 Peripheral arterial disease/intermittent claudication 92

Garry Tew and Irena Zwierska

6 Chronic obstructive pulmonary disease 111

Rachel Garrod and Fábio Pitta

7 Asthma 129
Felix S. F. Ram and Elissa M. McDonald
vi Contents

8 Osteoarthritis 156
Marlene Fransen

9 Osteoporosis 175
J. Y. Tsauo

10 Rheumatoid arthritis 193

C. H. M. van den Ende

11 Ankylosing spondylitis 208

Hanne Dagfinrud, Silje Halvorsen and Nina K. Vøllestad

12 Multiple sclerosis 228

Ulrik Dalgas

13 Parkinson disease 248

Gammon M. Earhart

14 Type 2 diabetes 265

Stephan F. E. Praet, Robert Rozenberg and
Luc J. C. Van Loon

15 Obesity 297
Pedro J. Teixeira, R. James Stubbs, Neil A. King,
Stephen Whybrow and John E. Blundell

16 Chronic fatigue syndrome 322

Jo Nijs, Karen Wallman and Lorna Paul

17 Fibromyalgia syndrome 339

Borja Sañudo Corrales

18 Colorectal, breast and prostate cancer 364

Liam Bourke and John M. Saxton

Index 380
CONTRIBUTORS

Chapter 1: Introduction Chapter 4: Stroke

John M. Saxton Frederick M. Ivey, Alice S. Ryan, Charlene
School of Allied Health Professions E. Hafer-Macko and
Faculty of Health Richard F. Macko
Queen’s Building Baltimore VA Medical Center
University of East Anglia Geriatrics Service/GRECC BT (18) GR
Norwich, NR4 7TJ, UK 10 N. Greene St.
Tel: +44 (0)1603 593098 Baltimore MD 21201-1524, USA
Email: [email protected] Tel: +1 410 605 7297
Email: [email protected]
Chapter 2: Coronary heart disease
Gavin Sandercock Chapter 5: Peripheral arterial disease/
Department of Biological Sciences intermittent claudication
University of Essex Garry Tew and Irena Zwierska
Wivenhoe Park Garry Tew
Colchester, CO4 3SQ, UK Centre for Sport and Exercise Science
Tel: +44 (0)1206 872043 Sheffield Hallam University
Email: [email protected] Collegiate Crescent Campus
Sheffield, S10 2BP, UK
Chapter 3: Hypertension Tel: +44 (0)114 225 2358
V. A. Cornelissen and R. H. Fagard Email: [email protected]
UZ Gasthuisberg – IG Hypertensie
Irena Zwierska
Herestraat 49
Keele University
3000 Leuven, Belgium
Primary Care Musculoskeletal Research
Tel: +32 (0)16348707
Centre, Keele
Email: veronique.cornelissen@med.
Newcastle, Staffordshire, ST5 5BG, UK
kuleuven
Tel: +44 (0)1782 733972
Email: [email protected]
viii Contributors

Chapter 6: Chronic obstructive Hungkuang University, Taipei, Taiwan

pulmonary disease Tel: +886 2 33668130
Rachel Garrod and Fábio Pitta Email: [email protected]
Rachel Garrod
Consultant Respiratory Physiotherapist Chapter 10: Rheumatoid arthritis
Kings College Hospital NHS Foundation C. H. M. van den Ende
Trust Department of Rheumatology
Pulmonary rehabilitation Sint Maartenskliniek
Dulwich Community Hospital Hengstdal 3, 6522 JV Nijmegen,
East Dulwich Grove, SE22 8PT, UK Netherlands
Tel: +44 (0)208 725 0377 Tel: +31 (0)24 365 94 09
Email: [email protected] Email: [email protected]
Fábio Pitta
Chapter 11: Ankylosing spondylitis
Departamento de Fisioterapia
Hanne Dagfinrud1, 2, Silje Halvorsen1, 2 and
Universidade Estadual de Londrina
Nina K. Vøllestad2
Av. Robert Koch, 60, Vila Operária 1
National Resource Centre for
CEP 86038-440
Rehabilitation in Rheumatology
Londrina, PR, Brasil
Diakonhjemmet Hospital, Norway
Tel: +55 43 3371 2477 2
Institute of Health and Society
Email: [email protected]
University of Oslo, Norway
Chapter 7: Asthma Hanne Dagfinrud
Felix S. F. Ram and Elissa M. McDonald Section for Health Science
Massey University-Auckland University of Oslo
Private Bag 102 904 P.O.box 1153
North Shore Mail Centre Blindern
Auckland, New Zealand Gydas vei 8
Tel: +64 9 414 9066 Oslo, 0316, Norway
Email: [email protected] Tel: +47 22 45 48 41
Email: [email protected]
Chapter 8: Osteoarthritis
Marlene Fransen Chapter 12: Multiple sclerosis
Faculty of Health Sciences Ulrik Dalgas
Clinical and Rehabilitation Sciences Department of Sport Science
Research Group University of Aarhus
University of Sydney, Australia Dalgas Avenue 4
Tel: +61 2 93519829 8000 Aarhus N, Denmark
Email: [email protected] Tel: +45 27 11 91 21
Email: [email protected]
Chapter 9: Osteoporosis
J. Y. Tsauo Chapter 13: Parkinson disease
School and Graduate Institute of Physical Gammon M. Earhart
Therapy Anatomy & Neurobiology, and Neurology
College of Medicine Washington University School of Medicine
National Taiwan University and Program in Physical Therapy
Department of Physical Therapy Campus Box 8502
 Contributors ix

4444 Forest Park Blvd. Physiotherapy, Vrije Universiteit Brussel,

St. Louis, MO 63108, USA Belgium
4
Tel: +1 314 286 1425 Department of Physical Medicine and
Email: [email protected] Physiotherapy, University Hospital
Brussels, Belgium
5
Chapter 14: Type 2 diabetes Nursing and Health Care, Faculty
Stephan F. E. Praet1, Robert Rozenberg1 of Medicine, University of Glasgow,
and Luc J. C. Van Loon2 Glasgow, UK
1
Department of Rehabilitation Medicine &
Karen Wallman
Physical Therapy
School of Sport Science
Subdivision of Sports Medicine
Exercise and Health
Erasmus University Medical Center
The University of Western Australia
P.O.Box 2040
Stirling Highway
NL-3000 CA Rotterdam, Netherlands
Crawely, Western Australia
Tel: +31 (0)10 703 1887
2
Tel: +61 8 9387 1280
Department of Human Movement
Email: [email protected]
Sciences
Faculty of Health Medicine and Life
Chapter 17: Fibromyalgia syndrome
Sciences
Borja Sañudo Corrales
Maastricht University Medical Centre
Department of Physical Education
Maastricht, Netherlands
and Sport
Tel: +31 (0)10 703 18 87
Faculty of Educational Sciences
Email: [email protected]
University of Seville
Avenida Ciudad Jardin, 20-22
Chapter 15: Obesity
E – 41005 Seville, Spain
Pedro J. Teixeira, R. James Stubbs, Neil A.
Tel: +34 954556209
King, Stephen Whybrow and
Email: [email protected]
John E. Blundell
Exercise and Health Department
Chapter 18: Colorectal, breast and
Faculty of Human Movement
prostate cancer
Technical University of Lisbon
Liam Bourke and John M. Saxton
Estrada da Costa
Liam Bourke
1495-688 Cruz Quebrada, Portugal
Centre for Sport and Exercise Science
Tel: +351 21 414 9134
Sheffield Hallam University
Email: [email protected]
Collegiate Crescent Campus
Sheffield, S10 2BP, UK
Chapter 16: Chronic fatigue syndrome
Tel: +44 (0)114 225 5628
Jo Nijs2-4, Karen Wallman1 and Lorna Paul5
1
Email: [email protected]
School of Sport Science, Exercise
and Health, The University of Western John M. Saxton
Australia, Crawely, Western Australia School of Allied Health Professions
2
Division of Musculoskeletal Faculty of Health
Physiotherapy, Department of Health Queen’s Building
Care Sciences, Artesis University College University of East Anglia
Antwerp, Belgium Norwich, NR4 7TJ, UK
3
Department of Human Physiology, Tel: +44 (0)1603 593098
Faculty of Physical Education & Email: [email protected]
ACKNOWLEDGEMENTS

I would like to acknowledge several outstanding people who inspired me at dif-

ferent stages of my life. My parents and grandparents for their support and trust in
the choices that I made, and for the lessons I learned from them. Aidan Trimble,
Chris Hallam and Ken Johnson were early role models, who showed me what
remarkable achievements could be made through dedication. Alan Donnelly and
Priscilla Clarkson were magnificent supervisors and mentors during my doctoral
studies – and ‘Amherst 1993’ was a truly exceptional experience! Tom Cochrane
gave me a great opportunity for further personal and professional development at
an early stage in my career and two excellent career mentors, Graham Pockley and
Mike Smith, guided my path and provided me with lots of ‘food for thought’ dur-
ing my time in Sheffield. I would also like to acknowledge my students, who have
shown tremendous dedication and innovation in applying their skills as exercise
scientists within the realms of health and disease and in doing so, have ‘pushed
the boundaries’. Finally, I would like to thank all contributors to this volume for
taking time out of their busy schedules to produce a chapter which is based on the
solid foundation of their own experience and innovative thinking in this field of
research and extensive knowledge of the literature.

I dedicate this book to my wife Paula, my children John and Mary, and my family
for their understanding and support.
1
INTRODUCTION

John M. Saxton

The burden of chronic disease

Chronic diseases are long-term conditions that cannot be cured but can be control-
led with medication and/or other therapies (DoH 2010). Examples include coronary
heart disease (CHD), stroke, cancer, chronic respiratory diseases and diabetes,
which together constitute the leading cause of mortality worldwide (60 per cent
of all deaths) and are projected to increase by a further 17 per cent over the next
10 years (WHO 2010). In addition to the human cost however, chronic diseases
place a heavy economic burden on healthcare systems. In England, there are cur-
rently 15.4 million people living with a chronic condition (DoH 2010), accounting
for more than 50 per cent of all general practitioner appointments, 65 per cent of
all outpatient appointments and over 70 per cent of all inpatient bed days (DoH
2010). The treatment and care of individuals with chronic disease accounts for
70 per cent of the total health and social care costs, and this is projected to rise
dramatically over the next 12–15 years as the number of people aged over 65
years increases by an estimated 42 per cent (DoH 2010). In the USA, more than
109 million people report having at least one of the seven most common chronic
conditions (CHD, hypertension, stroke, pulmonary conditions, cancer, diabetes,
mental disorders), representing more than half the population, and a figure which
is expected to increase by 42 per cent by 2023 (DeVol and Bedroussain 2007).
The total impact of these diseases on the American economy is estimated to be
$1.3 trillion annually ($1.1 trillion due to lost productivity and $277 billion spent
annually on treatment). Table 1.1 shows 12 prevalent chronic disease conditions.
2 Introduction

TABLE 1.1 Twelve prevalent chronic diseases

Chronic heart disease (CHD)

Stroke
COPD
Depression
Lung cancer
Diabetes
Arthritis
Colorectal cancer
Asthma
Kidney disease
Oral disease
Osteoporosis
Adapted from Carrier (2009).

The role of exercise in management of chronic disease

The rapidly expanding population of older people, coupled with factors such as
health inequalities and poor health behaviours, means that the burden of chronic
disease is an escalating problem that presents one of the major healthcare chal-
lenges of the twenty-first century. Hence, there has been a shift away from the
traditional ‘medical’ model of care, with its emphasis on curative treatments and
patients being regarded as passive recipients of care, to a model which is aimed at
empowering patients with the skills and knowledge to manage their own condition
(Carrier 2009). Evidence suggests that the majority of people with long-term con-
ditions lead full and active lives (Corben and Rosen 2005) and over 90 per cent of
people with LTCs say they are interested in being more active self-carers (DoH
2010). The need for effective self-care strategies is exemplified in the follow-
ing quote taken from the UK Department of Health policy document Supporting
People with Long Term Conditions: an NHS and social care model to support
local innovation and integration:

When you leave the clinic, you still have a long term condition. When the
visiting nurse leaves your home, you still have a long term condition. In the
middle of the night, you fight the pain alone. At the weekend, you manage
without your home help. Living with a long term condition is a great deal
more than medical or professional assistance.
Harry Cayton, Director for Patients and the Public,
Department of Health (DoH 2005)
 Introduction 3

Although chronic diseases such as CHD, stroke, cancer, and diabetes are
among the most prevalent and costly conditions in modern society, they are also
among the most preventable of all health problems (CDC 2010). Major risk fac-
tors for these conditions include physical inactivity, unhealthy diets and tobacco
use and the World Health Organisation estimates that by eliminating these risk
factors, at least 80 per cent of all cases of CHD, stroke and type 2 diabetes and
40 per cent of cancers would be prevented (WHO website). Regular physical
activity is widely accepted as being beneficial for health and a substantial body of
epidemiologic research has demonstrated inverse associations of varying strength
between physical activity and the risk of several chronic diseases, including CHD,
stroke, hypertension, type 2 diabetes mellitus, osteoporosis, obesity, anxiety and
depression (Pate et al. 1995; Haskell et al. 2007; DoH 2004). Additionally, a
growing body of research during the past twenty years has provided ‘convinc-
ing’ evidence of an inverse association between physical activity and risk of
colon cancer (WCRF/AICR 2007). There is also evidence of a ‘probable’ inverse
association between physical activity and risk of other cancers, including post-
menopausal breast and endometrial cancer, and limited ‘suggestive’ evidence of a
similar association between physical activity and lung, pancreatic and pre-meno-
pausal breast cancer (WCRF/AICR 2007).
Aside from the important role it plays in the primary prevention of a range of
chronic diseases, a physically active lifestyle can bring manifold health benefits to
individuals who are carrying the burden of chronic disease. There is evidence that
regular exercise is associated with physical and psychosocial health benefits in
many chronic disease conditions (Pedersen and Saltin 2006) and hence, keeping
fit and healthy is now promoted by government health departments as an essential
element of self-care for boosting general wellbeing, improving mobility and eas-
ing of symptoms (NHS Choices 2010). A physically active lifestyle can have an
important role in controlling or reducing the impact of a chronic disease, prolong-
ing survival and enhancing overall health-related quality of life (secondary and
tertiary prevention). In this respect, ‘exercise rehabilitation’ is increasingly being
recognised amongst healthcare professionals as an effective adjuvant or adjunc-
tive treatment for a growing number of chronic conditions. Table 1.2 shows some
key research questions to consider when assessing the efficacy of exercise therapy
as an adjuvant or adjunctive treatment for chronic disease.
4 Introduction

TABLE 1.2 Some key research questions to address when assessing the efficacy of
exercise therapy as an adjuvant or adjunctive treatment for chronic disease

Can exercise training counteract the adverse physiological and psychological sequelae
of a chronic disease and its treatments? What is the role of exercise in chronic disease
modification?
How does exercise interact with drug treatments for chronic disease? Can exercise
counteract the side-effects of drug treatments?
How can exercise prescription be optimised to impact upon the broadest range of chronic
disease specific health outcomes, e.g. frequency, intensity, duration and type of exercise,
social setting, support structures, flexibility of provision, etc?
Why do some patients with a given chronic disease respond and/or adapt differently to
exercise?
What are the contra-indications to exercise in different clinical groups?

Exercise terminology
‘Exercise’ and ‘physical activity’ are terms that are commonly used in the scien-
tific literature. Caspersen et al. (1985) proposed definitions for physical activity
and exercise to provide a framework in which studies could be interpreted and
compared. Physical activity was defined as ‘any bodily movement produced by
skeletal muscles that results in energy expenditure’. Exercise was defined as a
sub-category of physical activity which is ‘planned, structured, repetitive and
purposive’ and which has the objective of improving or maintaining one or more
components of physical fitness.
Winter and Fowler (2009) highlighted the limitations of these definitions,
pointing out the shortfalls in relation to isometric exercise (static muscle actions)
and argued that the two terms should be interchangeable, depending on circum-
stances and context. Nevertheless, exercise is more commonly used to refer to
structured leisure time physical activities, such as swimming, jogging and rec-
reational sports, rather than to common activities of daily living, e.g. walking and
physical tasks in the home or work environment. The latter are more commonly
categorised under the umbrella term of physical activity. For the purpose of this
book, both exercise and physical activity are considered to mean any movement
(or isometric exercise) of the skeletal muscles, in the context of recreational,
occupational or activities of daily living, which increases energy expenditure.
Another term that is important in the context of exercise rehabilitation is phys-
ical fitness. Physical fitness generally refers to the characteristics of an individual
that permit good performance of a given task in a specified physical, social and
psychological environment (Bouchard et al. 1994). It is influenced by genetic fac-
tors but is sensitive to change in people of all ages and physical fitness levels who
engage in regular exercise. Physical fitness can be sub-divided into smaller meas-
ureable components, e.g. aerobic power and endurance, muscular strength and
endurance, speed, power, agility and flexibility. Health-related fitness is reserved
 Introduction 5

for aspects of physical fitness and psychological wellbeing that can be improved
by engaging in a physically active lifestyle. In a Scientific Consensus Statement
(Bouchard et al. 1994), health-related fitness dimensions were categorised into
morphological, muscular, motor, cardiorespiratory and metabolic. Whilst this
model includes the main physical dimensions of health-related fitness, it fails
to recognise psychosocial health benefits that can result from habitual exercise.
Hence, a revised model, encompassing both physical (physiological) and psycho-
social dimensions which can be influenced by exercise, potentially impacting upon
health-related quality of life (QoL) and survival is presented in Figure 1.1.

FIGURE 1.1 Physiological and psychosocial dimensions which can be influenced by

exercise, potentially impacting upon health-related QoL and survival.
Adapted from Saxton and Daley (2010).

Levels of evidence
A range of methodological approaches have been used to assess the impact of
a physically active lifestyle on health outcomes which are relevant to people
with chronic disease. These include observational studies (mainly case control
6 Introduction

and cohort studies), randomised controlled trials and non-randomised trials.

Observational studies do not investigate cause and effect relationships but asso-
ciations between outcomes and ‘exposures’ of interest (e.g. self-reported physical
activity) and the data should be interpreted in this context. Cohort studies (pro-
spective and retrospective) and case-control (or case comparison) studies are
commonly used observational designs. In prospective cohort studies, physical
activity status is assessed at some baseline time-point before participants are fol-
lowed up (often at regular intervals) to see if they reach a pre-defined clinical
endpoint (e.g. disease diagnosis, cardiovascular event, mortality). The frequency
with which the outcome occurs is then compared between physically active and
more sedentary participants to determine their relative chances of reaching the
clinical end-point. Retrospective cohort studies use pre-existing data ‘exposures’
of interest and outcomes, and are quicker and cheaper to conduct. Limitations of
cohort studies include failure to account for all potentially confounding variables
in the analysis (although a greater number of potential confounders can be con-
trolled for in larger cohort studies) and the time-scale needed to follow up large
numbers of people over many years (prospective studies). In case-control studies,
participants are selected on the basis of their disease status rather than exposure
and the main outcome measure is the odds ratio of exposure (odds of exposure
in cases divided by the odds of exposure in a matched or unmatched comparison
group). Case-control studies are not as scientifically robust as cohort studies and
are often nested within larger cohort studies.
Randomised controlled trials (RCTs) are considered to represent the ‘gold
standard’ study design for establishing a cause and effect relationship between
an intervention and an outcome. RCTs usually involve the random allocation of
participants to an intervention group or a standard treatment control group (e.g.
usual care, with or without placebo), although multiple intervention groups can
also be compared with each other and the control group. This allows for the rigor-
ous evaluation of a single variable (or complex intervention) in a defined patient
group, as the assumption is that all confounding variables (known and unknown)
are distributed randomly and equally between the different groups. RCTs are
useful for investigating the effects of exercise interventions on key health out-
comes in chronic disease populations and many examples of such studies will
be discussed in the following chapters. Study outcomes often include physi-
cal (and functional) fitness, exercise adherence, perceptions of fatigue, indices
of psychosocial wellbeing and health-related quality of life. A commonly used
generic quality of life measure which has been validated for use in many clinical
populations (e.g. Koloski et al. 2000; Ware et al. 1999) is the Medical Outcome
Study Short Form-36 (SF-36; Ware and Sherbourne 1992). The SF-36 comprises
eight health domains: physical functioning, role-physical, bodily pain, general
health perceptions, vitality, social functioning, role-emotional and mental health.
However, many other disease-specific health-related quality of life measures have
been validated for use in different chronic disease populations and examples of
these measures can be found in the following chapters.