The benefits of physical activity for people living with long term conditions are well established. However, the fear of increasing symptoms or worsening long term problems commonly stops people from moving more. Many healthcare professionals also feel unsure about what advice they should give to people living with symptomatic medical conditions.
To help address concerns around risk, we led the development of a consensus statement to help us understand what safety advice healthcare professionals should give to people in clinical practice. Here are our results:
Physical activity is safe, even for people living with symptoms of multiple long-term conditions.
Regular physical activity, in combination with standard medical care, has an important role in the management and prevention of many long-term conditions.
People with long-term conditions are often fearful of worsening their condition or experiencing potentially undesired consequences from physical activity. In fact, when physical activity levels are increased gradually, the risk of serious adverse events is very low. Well informed, person-centred conversations with healthcare professionals can reassure people and further reduce this risk.
Successful opportunistic brief advice helps build motivation and confidence to become more physically active. This can be consolidated at further healthcare visits to support lasting behaviour change. Advice from healthcare professionals should consider the concerns of individuals and their carers, as well as individual preference, symptoms, functional capacity, psychosocial factors, social support, and environmental considerations.
Everyone has their own starting point, depending on their current activity level.
Help people identify where they are and agree a plan to begin there and build up gradually to minimise the risk of adverse events.
Advise people to stop and seek medical review if they experience a dramatic increase in breathlessness, new or worsening chest pain and/or increasing glyceryl trinitrate (GTN) requirement, a sudden onset of rapid palpitations or irregular heartbeat, dizziness, a reduction in exercise capacity or sudden change in vision.
Symptom specific considerations
People living with long term conditions may have specific concerns about the symptoms and signs they experience from their condition. The following statements summarise available evidence and recommend appropriate advice for healthcare professionals to share with people experiencing common symptoms.
For people who experience musculoskeletal pain as part of their medical condition, physical activity will not increase pain in the long term. A temporary increase in pain levels is common when starting a new physical activity, until the body adapts, and people should be counselled to expect this. There is no evidence to suggest this pain correlates with tissue damage or adverse events in the absence of new injury (acute fracture/acute soft tissue injury).
Reported evidence demonstrates that, regardless of disease severity, age, pain or level of function, physical activity (aerobic, resistance or range of motion, and land or water based) is likely beneficial for reducing pain and improving function in osteoarthritis.[25,26] Reported adverse effects are rare in studies with a physical activity component and usually relate to increased musculoskeletal pain with the physical activity intervention.[27–31] Activity modification should be considered during symptomatic exacerbations, or if the activity significantly worsens pain. Studies of physical activity interventions in inflammatory arthropathies refer to minor musculoskeletal events, with no serious adverse events.[33–36] There is limited data about adverse events in studies of people with fibromyalgia,[37,38] however some people experience increased pain sensitisation in the short-term,[39–44] which should be addressed as part of their holistic management.
Regular physical activity helps reduce fatigue and improves wellbeing and sleep. A temporary increase in fatigue is commonly experienced when starting a new physical activity until the body adapts. People should be counselled to expect this and advised to build up activity gradually. People experiencing fatigue related to chronic fatigue syndromes may benefit from specialist advice.
Increased sedentary behaviour is associated with higher levels of fatigue. Adults who are more physically active report better overall wellbeing [46,47] and improvements in wellbeing domains. Physical activity interventions are beneficial for fatigue in a broad range of long-term medical conditions, including rheumatoid arthritis, systemic lupus erythematosus, coronary heart disease (cardiac rehabilitation), inflammatory bowel disease, sarcoidosis, fibromyalgia and multiple sclerosis, and are associated with the greatest overall improvement in cancer-related fatigue (especially when compared to pharmacological treatments).
It is normal for all people to feel more breathless when increasing their activity level. The balance of evidence suggests that the risk of adverse events in breathless people when doing physical activity is very low. People should be counselled individually to gradually increase physical activity, taking into account their severity of symptoms and fear of breathlessness.
Shortness of breath in COPD can result in progressive avoidance of physical activity and worsening breathlessness due to deconditioning. Reduced activity level with increasingly severe breathlessness is an important predictor of mortality. There are very few reported general contraindications to physical activity in individuals with COPD provided the particular activity is tolerated, comorbidities considered and recommendations individualised.[53,54] Increased shortness of breath, muscle cramp and soreness have been reported in physical activity interventions, especially at the beginning of the intervention. The weight of evidence in this area is within pulmonary rehabilitation,[56,57] and although not universally reported, adverse events are rare, including after exacerbations of COPD. The physiological benefits of physical activity in heart failure are well reported  and is associated with reduced hospital admission and reduced all-cause and cardiovascular mortality in people with heart failure after adjustment for prognostic predictors. Regular physical activity is associated with fewer adverse events in those with both preserved and reduced ejection fraction compared to sedentary groups. In stable asthma, physical activity is not associated with adverse effects or exacerbation of symptoms, and no severe adverse events have been reported.[61–63] However, good asthma control and preventative strategies are important, as bronchospasm can occur.
The long-term benefits of increasing regular physical activity far outweigh the temporary, slight increased risk of adverse events even in those experiencing exertional chest pain as a result of ischaemic heart disease (angina). This risk increases with advancing age and exercise intensity, but overall remains very low. People should be counselled individually to gradually increase physical activity, taking into account severity of symptoms and fear of cardiac chest pain. Exercise is a good treatment option for stable angina to stimulate angiogenesis. However, increasing frequency and severity of angina should prompt a medical review with no further increase in physical activity.
In the six weeks after an acute cardiac event or cardiac surgery, all physical activity advice should be delivered by specialist services and outside of this document’s scope. There is an increased risk of an acute cardiac event in previously sedentary individuals with known cardiovascular disease who undertake unaccustomed vigorous intensity exercise. The increased risk is present both during the activity and for 1-2 hours afterwards. However, the absolute risk of a cardiovascular event during physical activity is very low. The incidence of sudden cardiac death has been reported as 1 in every 1.5 million episodes of vigorous physical activity in men and every 36.5 million hours of moderate/vigorous exertion in women. Reports suggest a 6-17x increased risk of non-fatal acute myocardial infarction and sudden cardiac death during vigorous-intensity physical activity, compared with being sedentary.[64,66] This risk reduces as physical activity levels are increased and cardiovascular fitness improves. It is essential that levels of physical activity are increased gradually.
Until controlled by appropriate medical management absolute contraindications to physical activity include recent acute cardiac event or ECG changes suggesting significant ischaemia, unstable angina, uncontrolled dysrhythmia causing symptoms or haemodynamic compromise, severe symptomatic aortic stenosis, acute pulmonary embolus or pulmonary infarction, acute myocarditis or pericarditis, suspected or known dissecting aneurysm and acute systemic infection.
An increased awareness of the heartbeat is normal during physical activity but can be frightening. Physical activity is contraindicated in people with symptomatic and untreated cardiac tachy- or brady-arrhythmia. Appropriate medical management should be established prior to recommending physical activity. Individuals with controlled atrial fibrillation (AF) benefit from regular physical activity, which should be started gradually.
With any perception of sudden onset or unusual change in heart rate, individuals should review how they are feeling and consider slowing down or pausing activity to let this settle. Physical activity can have a positive impact on atrial fibrillation (AF) both before and after its onset, although the optimal recommended physical activity prescription has not yet been defined. Regular physical activity is associated with a lower risk of all-cause mortality in patients with AF, with no serious adverse events reported.[70,71]
The benefits of physical activity outweigh the risks in both Type 1 and Type 2 diabetes. There is a risk of short-term dysglycaemia with physical activity. Hypoglycaemia is the most common adverse event associated with physical activity in people with any form of diabetes treated with insulin or insulin secretagogues. This can be recurrent if not managed appropriately. Guidelines are available to help reduce the risk of hypoglycaemia. Evidence suggests that the overall risk of severe hypoglycaemia is not increased in those who are more physically active. People with diabetes should be made aware that high intensity physical activity can cause a rise in blood glucose and offered strategies to combat this.
People with Type 1 or Type 2 diabetes should not start physical activity if they feel unwell or have had an episode of hypoglycaemia within the previous 24 hours.
Type 1 Diabetes
Hypoglycaemia is a rare but reported as an important adverse event.[73–75] People should have their blood glucose monitor with them and be vigilant with monitoring, carry diabetes identification and have a carbohydrate available. There may be increased risk of hypoglycaemia for 24h after exercise including risk of nocturnal hypoglycaemia, especially with afternoon activity. People should not start physical activity whilst ketones are abnormal, and the underlying cause should be found. Ketones may rise in endurance exercise, without a significant rise in serum glucose. After vigorous physical activity, hyperglycaemia may occur, so caution regarding overcorrection (potentially leading to hypoglycaemia) is required. Those with advanced neuropathy, autonomic dysfunction, end-stage renal failure or severe proliferative/non-proliferative retinopathy may require specialist advice.
Type 2 Diabetes
There are very few contraindications to physical activity in people with T2DM. Coexisting comorbidities should be considered. People taking insulin or insulin secretagogues have an increased risk of hypoglycaemia with physical activity. No significant adverse effects were reported in a systematic review of RCTs in people with T2DM undertaking physical activity interventions (aerobic, fitness or progressive resistance training) compared to inactive control groups. Minor adverse events include musculoskeletal symptoms and skin irritation. While those with peripheral neuropathy should be closely monitored for complications, they are no longer advised to avoid weight-bearing activities. Risk of skin breakdown should be considered, and well-fitted footwear that distributes load evenly is beneficial. No increased risk of falls, pain or neuropathic symptoms has been demonstrated in individuals with diabetic peripheral neuropathy undertaking weight-bearing activities.
The benefits of physical activity in people with cognitive impairment far outweigh the associated risks. Strategies to maintain motivation, engagement and safety are important and people will often benefit from support from others. Strategies should consider level of function, stage of disease, communication ability (including visual and hearing impairment), preferred environment, risk of falling and other health conditions.
Reports of serious adverse effects in physical activity intervention studies are rare in people with cognitive impairment. While most report no serious adverse events,[83,84] others include falls, musculoskeletal pain and chest pain after physical activity.[85–87] Despite this, strength and functional training has been associated with reduced risk of falls in those with mild-moderate cognitive impairment. Support and supervision may be required due to cognitive impairment, balance, gait and proprioception,[32,89] so appropriate equipment and safety are important, and participation may be limited by motivation, emotional control, orientation and impaired judgement.
Frail, inactive people have much to gain from increasing physical activity levels and building strength and balance, including those with osteoporosis. Even small improvements in strength and balance can reduce a frail individual’s risk of falling and improve their confidence. Recommendations for physical activity should be tailored to the functional and cognitive capacity of each individual. This can be further supported by environmental aids and adaptation, such as seated exercise plans, and it may be helpful for physical activity to be accompanied.
Fear of falling is a common concern for both patients and carers, both in the community and in hospitals. Falls are a common cause of morbidity and mortality. Evidence from a recent systematic review demonstrates that physical activity reduced the rate of injuries from falls, including injuries requiring medical care or hospital admission. A large study of physical activity interventions for falls prevention in the community mainly reported non-serious adverse events (commonly musculoskeletal) and two serious adverse events. No serious adverse outcomes were reported in a systematic review of falls prevention classes in residential care. Although adverse event reporting in physical activity interventions is highly variable, a systematic review and meta-analysis of frailty management strategies reported that, although physical activity interventions were associated with higher rates of adverse events than other interventions, overall rates of serious adverse events (hospital admission, death, acute myocardial infarction and fracture) were lower. Non-severe events included musculoskeletal issues, exacerbation of osteoarthritis, falls, fatigue, skin rash and vertigo.
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The list of medical conditions covered by this consensus statement is not exhaustive. For instance, Chronic Fatigue Syndromes/ME and Long COVID were excluded from this study as evidence regarding the risks of physical activity in these conditions is evolving. Existing guidance should be followed for those conditions. For more information about included conditions visit the consensus report.
There has previously been some concern that long-term conditions could be made worse by physical activity. However, the evidence is that physical activity has an important role to play in preventing and treating many conditions and that, for most people with long-term conditions, the benefits outweigh the risks. This expert consensus, supported by the Office for Health Improvement and Disparities, will help healthcare professionals to have informed, personal conversations with their patients living with long-term conditions.
Dr Jeanelle de Gruchy, Deputy Chief Medical Officer
We need to build our patients’ confidence and motivation to move more, because moving more makes nearly everybody feel better. The medical professions and the fitness industry will work together to create and support a new generation of empowered people, living with long term conditions, confident in their own ability to be more active
Dr Natasha Jones, President Elect, Faculty of Sport and Exercise Medicine UK
Breaking down the barriers that make it harder for the 15 million people living with long-term health conditions in England to get active is critical to tackling health inequalities: a key aim of our Uniting the Movement strategy. This new consensus statement is a really positive step – it will play a vital role in supporting healthcare professionals to empower their patients to get active in a way that is right for them. In future, our ambition is for this work to be embedded into the sport and physical activity sector too, ensuring a joined-up approach between the different sectors that support people’s health.
Tim Hollingsworth, CEO of Sport England
This guidance will help healthcare colleagues, in primary care and beyond, share the best available evidence when supporting people with long-term conditions to move more, every day. I commend all patient facing clinical staff to read the statement, share with their colleagues, and build the principles into their consultations, with the aim of making every contact count.
Dr Andrew Boyd, Physical Activity & Lifestyle lead, RCGP