Exercise Psychology Considerations for Chronically Ill Patients
Summary and Keywords
There is no doubt that exercise, a vital health-promoting activity, regardless of health status, produces numerous well-established physical, functional, and mental health benefits. Many people, however, do not adhere to medical recommendations to exercise consistently, especially if they have chronic illnesses. Put forth to explain this conundrum are numerous potential explanatory factors. Among these are mental health correlates such as anxiety, fear, fatigue, pain, motivation, and depression, as well as various self-efficacy perceptions related to exercise behaviors, which may be important factors to identify and intervene upon in the context of promoting adherence to physical activity recommendations along with efforts to reduce the cumulative health and economic burden of exercise non-adherence among the chronically ill and those at risk for chronic illnesses.
The literature on the importance of the health benefits of exercise is replete with evidence that with few exceptions, major benefits can be anticipated by participation of the individual in regular exercise. This literature pertains not only to the healthy client who is urged to pursue exercise in efforts to minimize the risk of chronic illnesses; it is especially advocated for those with established chronic illnesses, such as heart disease, arthritis, and diabetes (Scully, Kremer, Meade, Graham, & Dudgeon, 1998), which are commonly incurable, but progressive, and unpredictable in terms of their severity. Since pharmacologic therapy—often recommended for relieving adverse illness symptoms—may produce undesirable side effects and does not commonly reduce the rate of illness progression or the extent of the prevailing disability, adjunctive strategies for optimizing the well-being of this highly prevalent cohort of chronically ill adults are indicated. Strongly recommended in this regard are various forms of exercise or physical activity participation, which are almost always advocated in some form for improving the health status of adults with one or more chronic illnesses, regardless of diagnosis (Pentecost & Taket, 2011).
Chronic illnesses, also termed chronic diseases, are health conditions that may arise slowly over time, often without any warning, or as a result of an acute illness, which is not reversible. Once established, chronic illnesses or disease states are highly debilitating, because they tend to persist over long time periods, regardless of treatment. As a result, they are usually discouraging states that slowly diminish life quality and functional capacity in various ways. Frequently highly disabling, and not commonly amenable to any cure, chronic illnesses such as heart disease, cancer, arthritis, and diabetes are the leading causes of premature disability in the United States and elsewhere. Unsurprisingly, they are deemed highly significant current health concerns in most nations.
Indeed, chronic illnesses, which may exist independently or as comorbid conditions, are not merely costly national and international social and economic problems, but problems that can severely impact the occupational and economic well-being of the individual, as well as their families, quite markedly. Caused by ever-present and often multiple overlapping challenges, including periods of intractable pain, aversive symptoms that wax and wane without any predictability, fatigue, shortness of breath, weakness, functional and neurological challenges, plus progressive physical disability, these persistent conditions are immensely challenging to ameliorate. In addition, the many harmful side effects of commonly used pharmaceutical strategies to allay one or more disease associated symptoms, along with the immense psychological impact of all of these disabling conditions, renders the successful management of all forms of chronic illness inordinately problematic.
To this end, current researchers in the field emphasize the importance of minimizing disability and maximizing independence and life quality of the affected individual by assessing and treating both the biological and psychological consequences of one or more of these conditions (e.g., Somers, Keefe, Godiwala, & Hoyler, 2009). Most commonly targeted in this regard are four modifiable health behaviors—lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption—behaviors responsible for much of the disability, pain, suffering, and early death related to chronic illnesses. This present discussion focuses on exercise as an intervention shown to benefit adults with chronic illnesses in multiple ways.
Exercise Benefits and Adherence
Among the many documented benefits of regular exercise participation are reductions in pain, stiffness, and immobility; better sleep health; reduced anxiety; improved well-being and energy; better weight control; and diminished risk of fatigue and depression, even among individuals with very poor prognoses (Rogers et al., 2017). Fasczewski, Gill, and Rothberger (2017), for example, found that people with multiple sclerosis, a highly disabling neurological disease, reported attaining a heightened life satisfaction and positive outlook when they were questioned about the benefits of physical activity in their lives. Other potential benefits of physical activity participation in the context of chronic illness self-management include the ability to cope with chronic illness challenges and to effectively carry out the many required adjustments that may be needed, as well as an improved sense of independence and autonomy plus life satisfaction and outlook (Fasczewski et al., 2017) These exercise-associated benefits can be categorized as physical, psychological, or social as well as functional benefits, and can occur independently as well as collectively (see Table 1).
Table 1. Observed Benefits of Exercise Participation in the Context of Chronic Illnesses
Bone health improvements
Diminished falls risk
Heightened capability to perform daily living tasks
Improved muscle strength and endurance
Improved weight status
Improved physical self-concept
Decreased anxiety and depression
Increased vitality and energy
Decreased sense of fatigue
Improved self-efficacy and coping ability
Improved body areas satisfaction
Reduced degree of sleep disturbances
Better stress control
Source: Annesi, Unruh, Marti, Gorjala, and Tennant (2011), Armbrust et al. (2016), Chipperfield et al. (2013), Fasczewski et al. (2017), Pisters et al. (2010), Ploughman et al. (2015), Scully, Kremer, Meade, Graham, and Dudgeon (1998).
Many authors in the past and present have tried to uncover why exercise adherence rates are so poor among adults with one or more chronic illnesses, even though immense benefits have been demonstrated in response to regular physical activity participation in the presence of various prevailing chronic health conditions that are clearly progressive and debilitating. In continuing this quest, many current efforts are underway to more clearly understand what barriers exist to the achievement of one or more of these beneficial proven post-exercise health outcomes by the chronically ill individual, other than possible physical challenges and fiscal issues.
The key question in this body of research is why evidence that shows non-adherence to physical activity recommendations potentially increases the burden of the illness, plus the mortality risk in some cases, is not sufficient to drive the desired actions.
Given that active adults with chronic illnesses are found to have lower disease manifestations than those who are inactive (Hutton et al., 2010), and those who are inactive are found to have more negative psychological profiles (Gyurcsik, Cary, Sessford, Flora, & Brawley, 2015), this question is not merely an academic one, but one that has far-reaching individual and societal consequences in the context of the urgent need to optimize the use of limited healthcare resources, as well as a need to minimize any preventable indirect and direct social, physical, and economic costs of chronic illnesses (Blackstock, ZuWallack, Nici, & Lareau, 2016).
Among the many explanations propounded to explain non-adherence to exercise recommendations, psychological factors have received considerable attention. Among the numerous well-established psychological impediments to exercise adherence are unintentional factors such as forgetting and possible confusion about the recommendations. Others are challenges understanding the value of the proposed regimen, depression, fatigue, pain, stress, or anxiety, normative beliefs, as well as feelings of powerlessness (Price, 2016; Trost, Owen, Bauman, Sallis, & Brown, 2002). Not wanting to do all that is required, having an unfavorable attitude to the recommended intervention, limited exercise- and health-related knowledge, along with other patient-specific beliefs and attitudes are also possible determinants of non-adherence (Trost et al., 2002).
Discounting the unmotivated patient, a considerable volume of research specifically shows that healthy persons as well as those who have chronic illnesses may choose to refrain from exercising or may stop exercising based on their erroneous or prevailing self-efficacy or confidence perceptions as well as their outcome expectation perceptions, which represent the extent to which the individual believes exercising will impact their health outcomes favorably or unfavorably.
In this regard, the individual’s past experiences with exercise, their fears that exercise will do more harm than good, the extent of their disability, and the presence of any dizziness, fatigue, and inflammation during or after exercise may determine adherence rates. The degree of pain at rest or when exercising may similarly influence an individual’s decision to participate or not in exercise on a regular basis, as well as their ability to integrate physical activity into their daily life (Boutevillian, Dupeyron, Rouch, Richard, & Coudeeyre, 2017). A summary of this vast array of overlapping factors that may predict or mediate adherence or non-adherence to exercise recommendations by individuals with chronic illnesses is depicted in Table 2. The items that are bolded are the key psychological variables that may interact or influence exercise adherence.
Table 2. Broad Array of Factors Influencing Exercise Adherence in Chronic Illnesses
Source: Albert, Forney, Slifcak, and Sorrel (2015), Ali et al. (2017), Boutevillian et al. (2017), Dobson et al. (2016), Ducharme and Brawley (1995), Ellis et al. (2013), Essery, Geraghty, Kirby, and Yardley (2017), Eynon, O’Donnell, and Williams (2016), Gay, Eschalier, Levyckyi, Bonnin, and Coudeyre (2017), Hannon and Bronas (2017), Hayton et al. (2013), Husebe, Karlsen, Allan, Soreide, and Bru (2015), Jouper and Hassmen (2009), Kampshoff et al. (2014), Palazzo et al. (2016), Pentecost and Taker (2011), Picorelli, Pereira, Pereira, Felicio, and Sherrington (2014), Ploughman et al. (2015), Skou, Rasmussen, Simonsen, and Roos (2015), Susin et al. (2016), Won and Son (2016), Trost et al. (2002).
The ensuing discussion focuses on the most-cited and best-researched psychological factor related to exercise adherence, namely self-efficacy. Other psychological factors related to suboptimal exercise adherence, such as exercise beliefs, anxiety, depression, fear, fatigue, lack of motivation, self-esteem, and pain, may all in turn influence or be influenced by self-efficacy beliefs. Nonetheless, the ability to carry these out as recommended is commonly related directly or indirectly to the nature of the individual’s self-efficacy cognitions for carrying out exercise.
Self-efficacy, a concept initially proposed by Albert Bandura (1977), is a person’s belief about his or her ability to successfully organize and implement a specific task, such as physical activity participation. Research has shown that self-efficacy, which can range from low to high, is a significant mediator of multiple behaviors in the realm of chronic illnesses as well as healthy behavioral practices. Indeed, this perceptual attribute, which can be strengthened, not only potentially explains the discrepancy between having knowledge about a desired behavior and the actual performance of this activity, but offers a mechanism for heightening or strengthening this attribute.
In terms of adherence to treatment recommendations, self-efficacy beliefs—which are found predictive of motivation levels, thought patterns, moods, emotional reactions, and attitudes that can mediate the capacity and willingness to elicit behaviors that promote health (Bandura, 1977, 1986a, 1986b, 1997)—can possibly explain efforts to persist or adhere to a task despite the presence of disconfirming experiences (Bandura, 1986b). Unsurprisingly, the role of self-efficacy in the context of strategies to optimize health outcomes of the chronically ill has emerged as one of key importance.
In particular, the specific confidence belief concerning one’s ability to carry out recommended exercise regimes or exercise recommendations, known as exercise self-efficacy, has been found of immense import in the pursuit of efforts to promote exercise adherence in the face of disabling health issues (Rajati et al., 2014). Another related attribute discussed by McAuley and Mihalko (1998) is exercise scheduling self-efficacy, denoting the extent to which a person has the confidence to carry out exercise recommendations regularly and to plan and prepare in advance so one’s exercise time is not compromised. A persons’ exercise self-efficacy can also be expected to affect confidence and ability to initiate exercise and recover from the effects of exercise (Rajati et al., 2014), as well as objectively assessed exercise time and sedentary behavior (Huffman et al., 2015). Disease-associated factors and feeling confident the requirements can be accomplished as planned are additional exercise adherence correlates.
In sum, the magnitude of a person’s self-efficacy for a particular task can impact their behavior, such as exercising regularly to improve their health status. Amenable to intervention through a step-by-step, well-researched set of strategies, this variable is emerging as one of great salience in efforts to improve regular exercise participation and adherence to exercise prescriptions among the chronically ill.
Correlation Studies Concerning Exercise Adherence Among the Chronically Ill
In terms of evaluating the contribution of self-efficacy beliefs in the context of adherence to physical activity or exercise recommendations, the literature reveals that self-efficacy can potentially influence exercise adherence in light of its ability to mediate the relationship between disease severity, pain, and functioning (Somers et al., 2010); to improve functional ability in patients with heart failure (Ha, Toukhsati, Cameron, Yates, & Hare, 2017); to influence exercise initiation (Ha, Hare, Cameron, & Toukhsati, 2017); and to influence self-regulatory ability (Gyurcsik et al., 2009). Won and Son (2016), who examined perceived social support and its relationship to physical activity adherence among adults with coronary artery disease, found that self-efficacy partially mediated this relationship.
Other data reveal that self-efficacy beliefs, which are related to self-regulatory imaging ability (Kosteli, Cumming, & Williams, 2018), may not only influence the extent of an individual’s activity participation (Dekker, van Dijk, & Veenhof, 2009; Hutton et al., 2010) but their willingness to participate in leisure-time physical activities (Reinseth et al., 2011), as well as the ability to schedule time for exercising. Self-efficacy beliefs can also influence performance ability (Gaines, Talbot, & Metter, 2002), pain ratings, ratings of task difficulty (Rejeski et al., 1996), and general perceptions about functional ability (Mendes Leon, Seeman, Baker, Richardson, & Tinetti, 1996), regardless of exercise knowledge (Frith et al., 2010), disease diagnosis, or functional status, and one or all of these situations can be expected to impact exercise adherence rates negatively and significantly. By contrast, attempts to reduce negative confidence perceptions, as well as the sense of fatigue that commonly accompanies chronic illnesses, can potentially enhance exercise participation and consequent physical activity adherence rates (Armbrust et al., 2016). Moreover, encouraging high rather than low post-exercise outcome expectations can potentially increase exercise self-efficacy estimates and with this exercise adherence rates (Marszalek et al., 2017).
Prospective Studies Linking Aspects of Self-Efficacy Attributes to Exercise Adherence
In terms of prospective studies linking perceived self-efficacy beliefs and exercise adherence, Selzer, Rodgers, Berry, and Stickland (2016) found that adults with chest conditions who had higher levels of task-related self-efficacy demonstrated better rehabilitation attendance than those with low self-efficacy perceptions. Furthermore, stronger coping self-efficacy predicted greater six-minute walking time improvements. It was concluded that baseline exercise self-efficacy ratings can predict exercise adherence, and hence can serve as a target for maximizing adherence and health outcome improvements in adults with health challenges.
Piyakhachornrot et al. (2011), who developed an integrated health education program including exercise based on self-efficacy theory that aimed to enhance self-efficacy expectations among patients with knee osteoarthritis, showed positive results in a recent quasi-experimental study. In terms of mastery experiences, patients were trained to precisely carry out their exercise regimens. The subjects received demonstrations on how to do this and watched a patient with a similar condition carry out the regimen. They were specifically encouraged to engage in exercise or perform activities related to reducing knee symptoms they had learned. To reduce emotional arousal, they discussed and shared strategies for reducing barriers to exercise, and participants were trained until they felt confident to exercise. Results showed this approach increased the participant’s self-efficacy expectations for exercise, as well as their exercise knowledge and physical function, and supported the application of self-efficacy theory for helping older impaired adults with knee osteoarthritis to have improved potential health outcomes.
In a more recently reported study, Loew et al. (2017) conducted an evidence-based walking program among older people with knee osteoarthritis called the PEP or participant exercise preference approach; they tried to evaluate if a participant who was randomly assigned to his preferred group would improve his or her adherence to the walking program compared to a participant who did not receive his or her preferred group. This was a nine-month pilot randomized trial. At six months, participants assigned to their preferred choice of program showed significantly higher adherence rates than those who did not obtain their preferred choice of program. After nine months, significant improvements were shown relative to baseline function among the adherent participants who were allocated to their preferred group, as compared to those who did not receive their preference. Having subjects’ preferences accommodated—which is believed to promote self-efficacy for a given behavior—appeared to produce more favorable outcomes than prescriptive approaches alone, thus supporting the value of efforts to consider strategies that might promote self-efficacy in the context of exercise adherence among older adults with knee joint pathology.
According to Kampshoff et al. (2016), who undertook to identify demographic, clinical, psychosocial, physical, and environmental factors associated with participation in and adherence to a combined resistance and endurance exercise program among cancer survivors, correlates of exercise adherence significantly associated with participation were having a higher education and being a nonsmoker; for high levels of activity, self-efficacy was a significant factor. Having lower psychological distress levels and higher outcome expectations and perceiving fewer exercise barriers were also associated with higher adherence (Marszalek, Price, Harvey, Driban, & Wang, 2017).
In sum, although type and complexity of the recommended exercises, plus the degree to which the patient is disabled, can mediate or moderate adherence to these recommendations, highly cited as a remediable barrier among those with chronic health challenges is low task or exercise specific self-efficacy.
Since self-efficacy is a key predictor of exercise adherence (Azizan, Justine, & Chua Siew, 2013) and predicts perseverance and commitment to one’s goals as well as the extent to which one dwells on shortcomings and failures, plus satisfaction and long-term adherence to prescribed regimens (Hoaas, Andreassen, Lien, Hjalmarsen, & Zanaboni, 2016), identifying any prevailing lack of confidence a patient may have prior to recommending they carry out a regular exercise program may be helpful (Cole, Robinson, Romero, & O’Brien, 2017; Huffman, Pieper, Hall, St. Clair, & Kraus, 2015). Providers can then better assist those with low self-efficacy to engage and adhere to such interventions (Picha & Howell, 2017). To this end, ample research implies that the perceived willingness and interest of the care provider, their ability and willingness to establish a long-term collaborative effort with the client, and being mindful of the negative influence of fatigue and any accompanying cardiovascular symptoms, along with exposure to consistent feedback, will be of potential help for fostering long-term exercise adherence. Linking clients with chronic illnesses to others in the social network with similar traits and problems, especially those who are motivated to succeed, might also highly beneficial.
As outlined by Hammond and Freeman (2001), offering patients a range of options for task performance and letting them select the method they feel will work best for them, followed by mental rehearsal, some form of contracting and goal-setting, and collaborative problem-solving methods, is likely to be especially helpful in assisting clients to gain mastery of the desired behavior.
Resnick (2002) conducted research to better understand the factors that can influence the efficacy beliefs of older adults as regards being motivated to participate in a rehabilitation program and identified 11 major themes amenable to intervention. These included motivation and verbal encouragement, having exposure to positive role models, being able to deal effectively with patient’s past experiences, and current aversive physical sensations.
Additional research has shown that for purposes of enhancing exercise adherence, a problem of major concern to all patients who suffer from pain, the clinician should assess the extent of pain experienced by a patient at rest and during the required activity; they should train the individual in pain reduction skills as required through relaxation, distraction, or imagery; and they should have the patient repeat the demanding activity while applying the acquired pain reduction skills and monitor the improvements in pain that result (O’Leary, Schoor, Lorig, & Holman, 1988). In addition to educating patients to better manage pain, educating them to cope with disease flares and any disease progression, helping them to understand why and how emotional reactions can affect their disease status, may be of additional value in helping to increase a patient’s repertoire of coping responses (Nichols et al., 2017). Countering pain by encouraging clients to adopt a calm state before exercising, helping them to focus on the goal of the activity rather than past experiences, and minimizing cognitive stresses may also be helpful in encouraging higher levels of exercise self-efficacy and adherence to emerge over time.
Moreover, structuring exercise treatments in such a way that mastery experiences and positive feedback are maximized, along with increased autonomy and competence for the activity, is recommended (Fasczewski et al., 2017; Picha & Howell, 2017). A patient-centered or tailored approach (Loew et al., 2016), along with cognitive-behavioral strategies designed to affect the perceptions of control and the individual’s coping patterns (Hammond & Freeman, 2006), is also reported to be helpful in this regard (Hoaas et al., 2016).
Other research shows that the negotiation of activity goals that align with the individual’s preferences may similarly foster a patient’s willingness to carry out a set of achievable short-term physical activity goals (Bandura & Schunk, 1981; Jensen & Lorish, 1994), as may implementing modest progressive behavioral goals with well-conceived manageable successive action steps (Jensen & Lorish, 1994).
Mastery aids that can be gradually withdrawn, plus role-plays and homework (Lorig, 1986), practicing the desired activities in venues and situations that closely approximate those encountered by patients in their daily lives, may also help in fostering long-term exercise adherence among the chronically ill (Gage & Polatajko, 1994), as may health coaching (Jansons, Robins, Haines, & O’Brien, 2018).
Furthermore, the role of any prior negative exercise experiences should be addressed by either the health coach or the provider early on (O’Brien, Finlayson, Kerr, Shortridge-Baggett, & Edwards, 2016); frank, empathetic discussions and demonstrations, reassurance about exercise capability, along with appropriate reinforcement strategies, should also not be discounted (Dobson et al., 2016; Price, 2016).
In addition, because not all chronically ill persons will be confident enough to exercise alone or have perceived abilities to limit or increase desirable exercise dosages over time, supervised programs in the community may be helpful (Davis, Palaganas, & Li, 2016; Loew et al., 2016). Educating spouses, family members, and caregivers about the importance of regular exercise and garnering their support to secure adherence may similarly be very helpful in this regard (Loew et al., 2016).
It is evident from the above research summary that it very challenging to account for the common finding of exercise nonadherence, even where this is highly salient. Hence, a need clearly exists for the clinician to carefully tailor their recommendations in light of the many factors that may converge to reduce the chronically ill patient’s motivation and willingness to pursue exercise recommendations. This may require garnering insight into their patient’s prior exercise experiences and patterns, along with their exercise beliefs, personal and tangible resources, lifestyles, personal goals and interests, and very careful initial assessment and planning (Lee, Lee, & So, 2016). Moreover, the prescribed regimen should be easy to follow and non-fatiguing, so that it can be repeated frequently, and designed in line with the patient’s goals and physical and tangible abilities (Murphy, Lyden, Smith, Dong, & Koliba, 2010; Price, 2016). Reminders, cues to action, and scheduled follow-ups to provide any necessary feedback, encouragement, reassurance, advice, and support for continued exercise participation are also strongly indicated (Albert et al., 2015; Husebø, Karlsen, Allan, Søreide, & Bru, 2015; Marks, 2012), as is planning for relapse, an additional intervention strategy in its own right (Chapman, Campbell, & Wilson, 2015).
• Adherence to an appropriate exercise program is often crucial to the well-being of the chronically ill patient.
• To optimize exercise adherence among the chronically ill patient, strategies to enhance exercise self-efficacy may prove of great benefit.
• To this end, clinicians can assist patients by serving as active partners in the confidence-building process and by adopting a favorable, albeit realistic, set of expectations, in line with the patient’s beliefs, personal goals, health issues, and values, among other salient factors.
• To further assist chronically ill patients to exercise on a regular basis, even when they feel sick or are in pain, benefits anticipated that are highlighted against the outcomes of failing to follow the recommended exercise regimen may prove helpful.
• Acknowledging the patient’s exercise preferences, plus helping them to carry out exercises without undue stress, is also likely to foster greater exercise confidence and adherence.
• Being available for consultation, follow-up sessions, and the provision of appropriate feedback, advice, and encouragement, while allaying any excess exercise fears or concerns, is also strongly indicated (Nichols, Williamson, Toye, & Lamb, 2017).
• Monitoring and strengthening a patient’s self-efficacy appraisals may offer a potentially important channel of opportunity for fostering long-term exercise adherence among the chronically ill.
Chronic illnesses in any form require a considerable degree of personal management, including regular exercise participation. In this regard, a large volume of research consistently shows that patients with one or more chronic health conditions frequently fail to adhere to exercise recommendations that are strongly indicated for a multitude of proven reasons.
Along with other modifiable factors, an apparently strong psychological determinant of exercise non-adherence by these patients is low exercise self-efficacy (Hammer, Bieler, Beyer, & Midtgaard, 2016; Kampshoff et al., 2014; Slovinec D’Angelo, Pelletier, Reid, & Huta, 2014). Hence, careful assessments followed by appropriate proven self-efficacy-enhancing strategies such as periodic reassessments, establishing a long-term rather than a short-term therapeutic relationship, as well as the provision of desirable levels of encouragement, may be paramount in attempts to foster greater rates of exercise adherence among the chronically ill, regardless of diagnosis.
To ensure those with excess challenges do not deteriorate inadvertently due to low self-efficacy perceptions and motivation towards consistent exercise participation, those who are isolated, depressed, anxious, in excess pain, obese, or experiencing periodic disease flare-ups or exacerbations should be specifically targeted (Gyurcsik, Cary, Sessford, Flora, & Brawley, 2015; Heerema-Poelman, Stuive, & Wempe, 2013; Ploughman et al., 2015; Picorelli et al., 2014; Simony, Pedersen, Dreyer, & Birkelund, 2015; Susin et al., 2016).
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