While there are some risks associated with participation in regular physical activity, the risks associated with a sedentary lifestyle far exceed them [8]. Physical activity risks are related to level of intensity, with lower-intensity physical activity being associated with the lowest risk. Low-intensity physical activity reduces the risks of injury and muscle soreness and may be perceived as less threatening than moderate-to-high intensity routines. While lower risk is associated with low intensity, the consensus is that moderate physical activity has a better risk/benefit ratio, and moderate-intensity physical activity should be the goal for older adults. Although having an ongoing dialogue with a health care provider is recommended, the involvement of a primary care provider before beginning a program of physical activity depends on a person’s health condition(s) and the level of intensity and mode of physical activity. Sedentary older adults typically engage in short sessions (<10 min) of various types of low-intensity physical activity. There are rarely medical concerns about performing low-intensity activities because virtually everyone engages in them and therefore low-intensity physical activity can be safely performed regardless of whether an older adult has recently had a medical evaluation.
There is no evidence-based strategy to screen for risk before older adults begin or increase their physical activity, so practice depends on the opinion of experts [10, 23, 25]. While some experts and organizations recommend having physical examination and exercise test before beginning or increasing physical activity, exercise tests have a substantial level of false positives for heart disease that may lead to further testing and in turn increase the risk for older adults [14]. Simply having a screening requirement may impose a barrier that reduces the number of people who will begin a program. Because all physical activity is associated with a slight increase in acute injury risk, this small increase must be weighed against the more substantial benefits associated with long-term physical activity. Injury- and risk-management strategies should be proportionate to the risks involved, and care should be taken not to discourage participation by establishing overly stringent risk- and injury-prevention programs. For healthy, asymptomatic adults of any age, the US Preventive Services Task Force [31] does not recommend any type of cardiac screening (ECG, exercise test) before the initiation of physical activity. Although ongoing dialogue between a patient and his/her health professional is always desirable, pre-exercise screening by a physician should not be a prerequisite for participation in low-intensity physical activity. For sedentary older people who are asymptomatic, low-intensity physical activity can be safely initiated regardless of whether an older person has had a recent medical evaluation.
Before starting or increasing their level of physical activity, older adults should, however, have a strategy for risk management and prevention of activity-related injuries. Several standard approaches may be used. The most important strategy is to start with low-intensity physical activity and increase the intensity gradually. Whenever possible, physical activity bouts should include a warm-up and cool-down component. Increasing muscular strength around weight-bearing joints, particularly the knee, also reduces the risk of musculoskeletal injury. Other strategies include active stretching during the warm-up and cool-down portions of aerobic exercise programs, participating in a variety of activities, and avoiding high-intensity vigorous exercise. Vigorous activities, including running and jogging and vigorous participation in sports, should be recommended only to older adults who have progressed to and are accustomed to these activities, or who have sufficient fitness, experience, and knowledge required to perform vigorous activities.
Musculoskeletal “overuse” injuries, which can occur at all ages, are the most common and should be the major focus of risk management. Preventing fall-related injuries, which occur primarily in older adults, is also an important focus for the prevention of injury. Sudden death during exercise is extremely rare, and regular (as opposed to sporadic) physical activity reduces this risk. To minimize the likelihood of injury, changes in physical activity levels should be gradual, not rapid. Programs that allow for a variety of different activity choices are most likely to reduce the risk of injuries. Overuse injuries are specific to the activity being performed, that is, someone won’t develop tennis elbow from running. So if a person spends 150 min (30 min, 5 days/week) in two different activities, the risk of overuse injuries is theoretically reduced compared to concentrating the entire 150 min to the same activity.
Every community setting that offers opportunities for physical activity should be prepared to handle an emergency should it arise. Whenever possible, physical activity leaders and other staff should be trained in CPR and first aid. Table 5 lists suggested strategies for emergency preparedness. Written emergency procedures should be developed and posted in a readily accessible location. Although emergency procedures will vary from location to location, most plans will include the following elements: (1) clear instructions on how to access emergency medical services, including directions to the nearest telephone and how to give the exact address and location to the emergency responders, and (2) a well-stocked first aid kit that is readily accessible.
Table 5 Emergency procedures and precautions
Risk management for adults with chronic conditions and disabilities
Participating in physical activity is an excellent way for older adults with disabilities to maintain their physical function and improve their overall health. All older adults with disabilities should be encouraged to develop a physical activity plan. Based on discussions with their health care provider or exercise professional(s), older adults with chronic conditions or disability should understand the amount and types of activity that are appropriate for them. Preferably, the physical activity recommendation or “prescription” should be documented in the medical record and provided to the patient in writing. The recommendation should be developed proactively at the time of diagnosis of the chronic condition or when a change in clinical condition occurs. Also, the patient should understand that the physician should be consulted if certain problems or questions arise. Regular provider–patient communication about changes in physical activity level is prudent. Physical activity is therapeutic for many chronic conditions, so increasing physical activity levels can be comparable to increasing the dosage of a medication [16]. Unstable medical problems, such as elevated blood pressure or rapid atrial fibrillation, are generally temporary contraindications to exercise. These problems should be diagnosed and treated whether a person seeks to start an exercise program. Once problems are stabilized, the person can begin or resume exercise.
Because of the wide variety of disabling conditions, describing specific components of an exercise prescription for each condition can be complex. An excellent resource for information about physical activity and disability or chronic health conditions is the National Center for Physical Activity and Disability (NCPAD at http://www.ncpad.org or 1-800-900-8086). Both older adults and health care professionals should consider seeking expert advice when addressing issues related to physical activity in older adults with disabilities.