Prescribing chiropractic exercises for certain conditions

For the most part, the general public is aware of the benefits associated with exercise: improved physical and emotional health, weight loss and stress reduction.

But for patients with chronic medical conditions, exercise, while potentially beneficial, is often under-prescribed. A recent study published in the Canadian Medical Association Journal evaluated the benefits, as well as the contraindications and adverse effects, of exercise in several diagnostic conditions.

Lead author Tammy Hoffmann, PhD, professor of clinical epidemiology at the Centre for Research in Evidence-Based Practice at Bond Universit, along with her co-authors report that, in spite of the proven mortality and morbidity benefits of exercise, clinicians often first resort to medication or surgery.

They suggest that lack of awareness among clinicians and patients, poor knowledge about what comprises an effective exercise program, lack of relevant training, and insufficient descriptions of appropriate exercise regimens in journals may be the root cause for this oversight.

Low back pain

In this study, the authors chose to focus on conditions that are most debilitating and ones that respond well to exercise, based on clinical evidence. Damian Hoy, a senior research fellow at the University of Queensland’s School of Population Health in Australia, found that nearly one in ten people worldwide suffer from low back pain. The  study examined whether a non-pharmacological approach could offer some relief for this common issue.

The authors report that eight to twelve weeks of motor control exercise involving the trunk and graded activity, in concert with cognitive behavioral therapy for 20 hours each week, did help reduce pain. They emphasized that the quality of implementation, including supervision, duration, and a home program, mattered more than the type of exercise.  A random controlled trial (RCT) showed an improvement in pain symptoms of 10.2 points in the exercise group versus the control.

Although benefits can be significant, patients with low back pain due to a serious medical condition should not engage in exercise. The most commonly reported adverse effect was a temporary increase in back pain.

Type 2 diabetes

The American Diabetes Association states that in 2012 approximately 29.1 million Americans were diagnosed with diabetes; with 1.4 million new cases reported each year and 86 million individuals over the age of 20 have pre-diabetes. Diabetes remains the seventh leading cause of death.

This medical condition may also benefit from “aerobic exercise, progressive resistance training or a combination of the two,” according to the study. The ultimate decision as to type of exercise should depend on patient preference. Forty-seven RCTs showed that a 12-week structured and supervised program was effective in improving glycemic control in the study group versus control.

A moderate or strenuous exercise program for those with Type 2 diabetes has few contraindications. However, those recovering from retinal surgery should avoid any activity that raises blood pressure for approximately two weeks. Also, patients with hypoglycemia, a systemic infection, exacerbation of inflammatory joint disease, a musculoskeletal injury, or heart-related issues should temporarily suspend an exercise regimen.

Most of the study participants reported no adverse effects. In some cases though, stable glucose levels may be negatively affected, which may induce harmful comorbid conditions. In two studies, subjects did report minor musculoskeletal injury.

Osteoarthritis

The Centers for Disease Control and Prevention (CDC) reports that in 1990 approximately 21 million Americans were diagnosed with osteoarthritis. By 2005, that figure rose to 26.9 million. While the condition can affect young adults, it’s more prevalent in those who are 65 and older.

The authors of this study emphasized that patients need to “understand that osteoarthritis is not a wear-and-tear disease and that discomfort or pain during exercise does not indicate further damage to the joint.” Muscle strengthening, aerobic, and range-of-motion exercises, performed on land or in the water, and augmented with a home program can be beneficial.

This study reviewed 54 RCTs for osteoarthritis of the knee and found immediate benefits on pain reduction and moderate effects on physical functioning. Pain reduction benefits subsided in the months following the trial, but physical functioning remained somewhat improved.

A review of ten RCTs for osteoarthritis of the hip reported results similar to trials related to the hip. The study authors found no contraindications for exercise in either population, although they pointed out that if a joint has acute inflammation or if other comorbidities exist, an exercise program should be carefully evaluated before implementation.

Heart failure

Heart failure affects 51 million Americans and half of those who have the disease die within five years of diagnosis, according to the CDC. The agency also reports that heart disease costs the country $32 billion annually.

Although exercise does provide some benefit, the authors urge caution for this patient population, emphasizing the importance of supervision, slow progression, and working within personal tolerance levels. They note, though, that the biggest gains might be seen in patients with the highest risk, if they maintain an exercise program.

When the authors reviewed 47 RCTs on coronary heart patients they found reduced mortality with participation in exercise-based cardiac rehabilitation. However, another review of 33 RCTs whose participants had heart failure due to reduced ejection fraction found no effect on mortality after a one-year follow-up. Hospital admissions were reduced though and there was a “statistically significant and clinically important improvement in disease-specific quality of life.”

The authors warn patients with life-threatening cardiac conditions, including unstable ischemia, heart failure, or arrhythmias, to forego exercise.

Education is key

The authors concluded that while exercise is often overlooked as a treatment option for chronic conditions, it should be viewed as part of an overall wellness plan. Proper clinician education is critical before implementing a program.

“The training needed will depend on the discipline of the clinician though. Doctors, for example, receive very little, if any, education about exercise as part of their regular training. For the most part, they probably won’t be the providers and supervisors of the exercise, so just need to know it’s an option and what it consists of, rather than every detail,” says Hoffman. “Whereas, physiotherapists and exercise physiologists, for example, receive a lot of relevant training as part of their study. Even those who have received training though should be aware of the actual exercise for which there is evidence.”

Hoffman explains further that not all exercise is the same and that evidence is dynamic. “New trials and systematic reviews are coming out all the time, so clinicians should try to keep up with the evidence about exercise.”

Chiropractors should also be mindful of and help to allay patients concerns and misconceptions about exercise. In spite of the challenges in understanding and implementing the best exercise program for patients with chronic conditions, the rewards can be significant.