When prescribing exercise, it is important to consider the following:[#american-college-of-sports-medicine.-2013]

• Ensure atrial fibrillation (AF) patients are compliant with all medications, especially those that help control HR
• Patients with undiagnosed AF should not exercise until adequately managed by their primary care physician
• Monitor for irregular and potentially rapid ventricular rates
• HR at rest should be adequately controlled (<100 bpm)
• Age-predicted maximal HR targets are not valid
• HR is unreliable for prescribing exercise intensity
• A may be intermittent
• Irregular ventricular responses render assessment of HR inaccurate when using pulse oximetry or HR monitors and may make BP assessment more difficult. For this reason HR should be assessed manually

Exercise is contraindicated under the following circumstances:[#durstine-jl-moore-g-painter-p-et-al.-2009,#hordern-m-dunstan-d-johannes-p-et-al.-2012]

• Active retinal haemorrhage or recent retinal therapy
• Current illness or infection
• Type 1 diabetes, if blood glucose >14 mmol/L and urinary ketones are present
• Blood glucose < 4mmol/L (hypoglycaemia risk)

If a patient's pre- or post-exercise blood glucose is <5.5 mmol/L, they should consume carbohydrates before exercising.

The exercise clinician should:

• Monitor blood glucose levels, observing the individual’s blood glucose response to exercise, medications and carbohydrate ingestion
• Check the patient's skin integrity before every exercise session
• Ensure that the patient wears appropriate footwear and clothing for exercising
• Be aware of the signs and symptoms of hypoglycaemia and ensure a carbohydrate source is available at exercise sessions in case it is needed

Beta-blockers may mask symptoms of hypoglycaemia.

Individuals with type 2 diabetes may exercise with higher-than-normal blood glucose levels providing they are feeling well and are adequately hydrated. Hyperglycaemia after a meal is likely to reduce during aerobic exercise.[#colberg-sr-sigal-rj-fernhall-b-et-al.-2010]

For patients with concomitant chronic obstructive pulmonary disease (COPD), the following should be considered:

• Prescribed bronchodilators should be given before exercise training starts. This medication should only be given if spirometry results confirm that such use provides benefits beyond that provided by the long-acting bronchodilators the patient may be prescribed
• Oxygen saturation should be monitored regularly especially during lower limb exercise training
• The benefit of supplemental oxygen for those patients who desaturate below an oxygen saturation of 88% during exercise training should be assessed. This can be done by trialling oxygen (2-4L/min) during the exercise that causes desaturation, and observing the response
• The exercise program should be modified accordingly. Desaturation during small muscle mass exercise (e.g., arm exercise) is not common. Cycling often induces less oxygen desaturation than walking in patients with COPD

Supplementary oxygen in patients with chronic lung disease is provided mainly for safety reasons and to decrease the work of the right heart (i.e., by minimising hypoxic vasoconstriction of the pulmonary vessels).

For more detailed information see The Australian Lung Foundation Pulmonary Rehabilitation Toolkit

Exercise prescription for patients with pulmonary artery hypertension (PAH) must be individualised based on current medical management, status of PAH-specific medications and other co-morbidities that would impact on the individual's ability to undertake exercise. Current evidence supports exercise in NYHA functional class II, III, and IV.

Exercise in patients with PAH:

• Improves cardiovascular fitness
• Improves right and left ventricular function
• Reduces pro-inflammatory cytokines
• Improves peripheral muscle function

Evidence currently supports aerobic exercise including walking, exercise bike and treadmill; and low resistance training.

A rating of perceived exertion of 11-13 on the Borg scale, or 3-4 on the modified Borg scale, is recommended to monitor exercise intensity. Interval training regimens are recommended to avoid marked increases in pulmonary pressures with exercise. High-intensity exercise, isometrics and Valsalva manoeuvres are to be avoided.

The exercise clinician should monitor:

• Oxygen saturation during exercise – aiming to maintain SpO₂ above 85%
• HR response – if bradycardia is observed during exercise, the patient should cease exercising and should be monitored. Recommencement of exercise should be carried out with caution and medical advice should be sought if necessary
• Evidence of right HF