Having a chronic disease increases the risk of complications, new diseases, dependency and social insecurity. In addition to the suffering of the sick, these pathologies weigh more and more heavily on the health care system and families.
On 14 February, Inserm published an unprecedented report on thethe importance of physical activity in the prevention and treatment of chronic diseases. This collective expertise, conducted according to a rigorous approach established by Inserm, took three years of work. A multidisciplinary group of 14 experts analysed more than 1,700 bibliographical references on eleven common chronic diseases. The experts relied on cohort studies, experimental studies in animals and humans, and clinical trials published in the world's best scientific and medical journals.
Their conclusion is simple: the benefits of adapted physical activity programs clearly outweigh the risks, regardless of age and health status. Here are the main lessons to be learned from this work.
The vicious circle of physical and psychosocial deconditioning
Over time, the impact of chronic disease often goes beyond the "simple" initial organic damage. Complications can arise, either as the disease progresses or as a result of the side effects of treatment. Gradually, other disorders become apparent.
In addition, there is a tendency to rest and withdraw into oneself. Patients gradually enter the deconditioning vicious circle physical and psychosocial. This process leads to physical inactivity.
For example, patients with chronic obstructive pulmonary disease are victims of shortness of breath on effort (dyspnea) which plunges them into the vicious circle of deconditioning. To avoid becoming out of breath, these patients become sedentary. Lack of exercise makes them even more sensitive to dyspnea. The slightest effort seems insurmountable, leading to disproportionate fear and loss of confidence. Everyday actions become difficult to accomplish. Little by little, metabolic, muscular and bone disorders can occur. Depression looms, quality and life expectancy deteriorate...
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The vicious circle of de-conditioning severely affects the 20 million French people weakened by a newly diagnosed chronic disease, and even more seriously those whose disease is advanced. This phenomenon can be stopped by the practice of an adapted physical activity program, which allows the patient to regain awareness of his or her abilities and improve them.
Doing everything possible to facilitate the active mobility of chronically ill people, through the development of adapted places, better accessibility of public and sports spaces and the promotion of the health benefits of regular physical activity has become a priority for an ageing French population, which is increasingly exposed to chronic diseases.
The work carried out by Inserm shows that, in the case of heart disease, cancer, respiratory diseases, joint diseases, diabetes, strokes or depression, adapted physical activity programmes are effective and safe.
Prescribed by doctors, personalised and adjusted to patients' lifestyles, applied by trained professionals, they improve quality of life, reduce symptoms, prevent the appearance of new pathologies and reduce unscheduled hospitalisations.
These specific programmes are not in opposition to conventional treatments (surgery, drugs, medical devices, etc.), they complement them. In certain cases, such as cancers, they even potentiate them (preparatory act for surgery, reduction of chemotherapy toxicities).
Ten concrete points to remember
What would be the ten lessons to be learned from this collective expertise for practice?
1. Prescribe early
If the benefits of adapted physical activity programmes are proven for severe chronic diseases, medical prescription, particularly by general practitioners, should be made as soon as the disease is announced. All the more so as the regulatory and procedural elements are now available respectively with the decree 2016-1990 and the HAS published in 2018. Physicians have a new range of relevant and effective treatments at their disposal in their therapeutic arsenal, which they are empowered to deliver appropriately in their patients' individual health pathways.
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2. "Primum non nocere" rather than "citius, altius, fortis"...
"First, do no harm" rather than "faster, higher, stronger": Adapted physical activity programmes must guarantee maximum safety for chronically ill participants and not seek sporting performance against other people or the clock.
3. Respecting the correct dose-response
The frequency, duration, intensity, nature of the practices and their context must be specific to a given disease, and focused on a primary health objective (e.g., the anti-fatigue effect during breast cancer treatment).
4. Physical activity is an effective complementary treatment
Physical activity programs that are adapted, validated and continuously improved by science are part of the non-drug interventions (NMIs). They directly improve the quality of life of patients with chronic diseases, who experience a direct benefit. Studies show significant effects on lifespan (31 % reduction in premature mortality in chronic obstructive pulmonary disease, which affects 1.5 million French people, for example). Prevention of the risk of recurrence is also improved (-38 % in breast and colon cancer for example), as is the cure rate (41 % remission rate equivalent to that of antidepressants and cognitive-behavioural therapies in mild to moderate depression for example).
5. Use numerical solutions to quantify activity
The massive arrival of digital solutions for measurement (connected watches, for example), traceability (such as the digital logbook) and evaluation (such as impedancemeter scales that allow body composition to be known) is consolidating the data collected through questionnaires. These data advance the specialization of programs in research and their personalization in clinical routine.
6. Maintaining motivation
Chronically ill people are more likely to abandon adapted physical activity programs and active mobility. The Inserm report takes stock of possible solutions to combat this abandonment. These include freedom of choice of practices (in accordance with therapeutic invariants), emphasis on pleasure, and support from "patient partners". Paradoxically, taking ownership of the disease (and ultimately making sense of it) can be a trigger for a practice that is part of a lifestyle habit, a bit like brushing your teeth every night before going to bed.
7. Clinical research is accelerating, becoming global and should be encouraged.
The exponential acceleration of clinical research and innovation in the world on the subject over the last twenty years or so should encourage young researchers in the life sciences, human sciences and technology to become involved.
8. Awareness raising and training are essential
Raising awareness among the general public and providing better training in the initial and ongoing curricula of health professionals (e.g. by integrating mandatory teaching into medical curricula) and physical activity professionals (evaluation, programming, monitoring, safety, therapeutic alliance, motivational approach) will be indispensable pillars following the abundance of evidence from clinical and interventional studies.
9. Physical activity is a vector of savings and employment.
There is economic data available, particularly abroad, to make appropriate physical activity programmes a means of limiting health and other expenses for families. Physical inactivity costs France 1.3 billion euros each year, much of which is avoidable. Clinical trials are beginning to show favourable cost-effectiveness ratios.
10. A lever for health system transition :
The development of physical activities for the chronically ill illustrates the migration of our health care system from "cure" to "care". Adapted physical activity programs are integrated at different stages of the patient's health trajectory, complementing other treatments. Indeed, the only way to respond to complex diseases is to combine relevant therapeutics and prevention actions.
This collective Inserm expertise is crucial. As was the case with smoking prevention a few years ago, we can no longer say that we did not know what measures to implement to improve the situation of chronically ill people...
Now it is time to take action to implement and repay these non-drug interventions (NMIs). This is no longer a question of science...
Gregory NinotProfessor of Health, Psychology and Sports Science, University of Montpellier
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