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A Closer Look at Basic CDD4 Recommendations for Physical Activity or Exercise in Chronic Conditions

This is an excerpt from ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities 4th Edition eBook by American College of Sports Medicine,Geoffrey E. Moore,J. Larry Durstine & Patricia L. Painter.

Basic CDD4 Recommendations for Physical Activity or Exercise in Chronic Conditions


After four editions of the CDD series, with many decades of clinical experience on the part of the contributors to CDD4, the main working group of authors concluded that it is confusing and unnecessary to sustain disease-specific recommendations, for these reasons:

  • There are thousands of chronic conditions and causes of disability.
  • The vast majority of recommendations seem similar for most chronic conditions.
  • Ultimately, exercise is fairly simple and needs to be seen as elegantly powerful.
  • The complexities and nuances are matters of clinical judgment for safety’s sake.
  • The main concern in the chronic conditions in CDD4 is loss of independent living, which is primarily a function of light-intensity physical activities.


For these reasons, the Basic CDD4 Recommendations are consistent with but differ very slightly from the Guidelines and from the various physical activity guidelines discussed in the preceding section, because the CDD4 editors also want to make certain that sufficient attention is paid to light-intensity physical activity, especially the ability to perform instrumental activities of daily living with the goal of having patients remain independent. With these considerations in mind, the Basic CDD4 Recommendations are as follows:

  • Every person with a chronic condition should be physically active, accumulating a minimum weekly total of
    • 150 min of preferably moderate-intensity physical activity or, if that is too difficult, then
    • 150 min of light-intensity physical activity may be substituted.
  • At least 2 days per week of flexibility and muscle strengthening activities that should minimally involve
    • chair sit-and-reach stretches on left and right,
    • at least eight consecutive sit-to-stand exercises,
    • at least 10 step-ups (or a flight of steps), leading with each foot, and
    • at least eight consecutive arm curls with a minimum of 2 kg held in the hand; 4 kg is recommended.
  • Individuals at risk for falls should be evaluated for causes of falls. Not all falls are caused by a condition that can be treated with exercise training. If the diagnosis of the causes suggests that exercise training can reduce the likelihood of a fall, then activities to improve balance should be incorporated into individuals’ exercise regimens, under the supervision of an exercise therapist trained in fall prevention.


The higher the aerobic intensity, muscle forces, and required range of motion, the greater the likelihood of an adverse event.


These Basic CDD4 Recommendations are summarized in table 2.4. Readers should always bear in mind the goals behind the Basic CDD4 Recommendations, because these goals are helpful in drafting an individualized program to meet the unique needs of each patient. Everyone should be physically active to an extent sufficient to maintain independent living:


  • Let no barrier block someone from doing light-intensity physical activity.
  • Independent living requires a minimum ability to perform activities involving (or demanding)
    • light-intensity aerobic work (or exertion), combined with
    • strength, flexibility, and balance and coordination.


Adverse events from exercise cannot be completely eliminated, but there are two main categories to consider:

  1. Activity-dependent risks (due to the nature of the activity)
  2. Disease-dependent risks (those that relate to the pathophysiology)


The best way to minimize activity-dependent risks is to encourage the patient to practice safety precautions. If there is concern that the individual cannot do this independently, then he needs a supervised exercise program, at least to get started.


One major concern is whether or not the advice to do physical activity exposes the patient to the possibility of a disease-dependent risk. Such risks are associated with the intensity of exercise. Accordingly, if the recommendation is to complete vigorous- or high-intensity physical activities, it is prudent to follow the Guidelines on exercise testing and prescription. Most people with a chronic condition can safely participate in moderate-intensity physical activity, and if there is any concern that a particular individual cannot do so, she should either undergo some disease-specific diagnostic exercise testing or be referred to a supervised exercise program (or both).


There are few data beyond anecdotal cases to support the concern that light-intensity physical activities are likely to precipitate a disease-dependent adverse event (especially sudden death or myocardial infarction). Discerning the epidemiological role of light activities in precipitating such events would be exquisitely difficult, because participation in light-intensity activities is so ubiquitous in daily life. If someone is medically unstable to the point that activities of daily living threaten injury or death, then the Basic CDD4 Recommendations do not apply because the individual is not able to maintain independence and belongs in either a hospital or a nursing home. Indeed, it is likely that many people end up in a nursing facility sooner than they need to because no one recommended that they do light-intensity physical activity.


These nuances of safety are a key reason why an exercise professional is a necessary member of the chronic care team, because these staff are trained and have the experience to make good judgments regarding when exercise is safe and when it is not safe. See chapter 3 for a more in-depth discussion on how these judgments are made, which often involves more art than science.

Learn how to prescribe physical activity or exercise in chronic care in ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, Fourth Edition.