Safety considerations and adverse events associated with exercise across medical disciplines, 2026, Soliman

Dolphin

Dolphin

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Safety considerations and adverse events associated with exercise across medical disciplines - The Egyptian Journal of Internal Medicine

Exercise (Ex) is widely recommended across medical specialties as a core component of disease prevention and management. However, Ex prescription is freque
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Safety considerations and adverse events associated with exercise across medical disciplines


Abstract​

Background​

Exercise (Ex) is widely recommended across medical specialties as a core component of disease prevention and management. However, Ex prescription is frequently generalized, with limited consideration of disease-specific contraindications, baseline fitness, comorbidities, and potential adverse effects. This gap increases the risk of overlooked complications, particularly in patients with chronic, multisystem, or advanced disease.

Methods​

This narrative review synthesizes available evidence on Ex-related adverse effects across cardiovascular, respiratory, renal, hepatic, rheumatic, neurological, psychiatric, and endocrine, and pediatric conditions. Reported complications range from musculoskeletal injury and disease flares to serious events including arrhythmias, myocardial infarction, sudden cardiac death, exercise-induced hypertension, hypoglycemia, rhabdomyolysis, hypoxemia, bronchoconstriction, seizures, and neurovascular symptoms. Special populations including children, transplant recipients, patients with advanced organ failure, and those receiving anticoagulation or psychotropic therapy, exhibit narrower safety margins. Across specialties, adverse outcomes are inconsistently reported, contraindications are poorly defined, and high-risk patient groups are frequently excluded from clinical trials, limiting the generalizability of existing recommendations.

Conclusion​

Exercise is a powerful therapeutic intervention that requires individualized prescription to maximize benefits and minimize potential risks. Safe implementation depends on structured pre-exercise evaluation, condition-specific risk stratification, recognition of absolute and relative contraindications, appropriate supervision, and ongoing monitoring. A coordinated, multidisciplinary approach and improved communication between physicians and exercise professionals are essential to maximize benefit while minimizing harm. Further research is urgently needed to establish evidence-based, disease-specific exercise safety frameworks.

Highlights​

Exercise prescription across medical disciplines requires individualized, condition-specific risk stratification.

Adverse events range from musculoskeletal injury to life-threatening arrhythmias, hypoglycemia, and rhabdomyolysis.

Special populations—children, transplant recipients, elderly with comorbidities—warrant narrower safety margins.

Structured pre-exercise evaluation, absolute and relative contraindication recognition, and multidisciplinary coordination are essential.

Substantial evidence gaps exist in hepatology, advanced ILD, and rare neurological conditions, necessitating urgent RCT data.
 
In fibromyalgia (FM) and chronic fatigue syndrome (CFS) patients suffer from post-Ex fatigue, malaise and muscle soreness due to alterations in serum elastase, complement activity and inflammatory cytokine release induced by Ex [59,60,61].
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Additionally, the central descending nociceptors were unsuccessfully inhibited during aerobic Ex which explains flare of their symptoms after aerobic Ex with subsequent avoidance of physical activity (Table 2; Fig. 1-E) [62].
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Fear of movement and avoidance behaviour towards PA was reported in 39% of FM patients [63]. The prevalence of fear avoidance behaviour underscores the discrepancy between recommendations and patient experience, suggesting graded exposure protocols may be more appropriate than standard prescription.
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They seem very confused.
 
I skimmed through it and it's frankly very light on evidence. It's clear that exercise is assumed to be good for health, mainly based on how commonly it's recommended, but the actual evidence is pretty much non-existent outside of physiological measures of fitness, with most of the benefits seeming to come from a 'healthy' weight.

So exercise is good at enhancing fitness, and if healthiness is defined as fitness then fitness is health. But of course it's not the case. Fitness is fitness, and although there are measures of fitness, there are no reliable measures of health, only the absence of measures of disease.

What's most baffling is that, barring health problems, fitness is actually pretty quick to develop. But most people don't need it, so it all seems rather moot, and a whole lot of effort for little actual gain.

So overall the evidence is frankly shockingly low, especially for something that is constantly hailed as miraculous. Which fits nicely with the age of misinformation. Here it's clear that 'healthy' misinformation is seen as good, entirely missing out on why misinformation is problematic, how it ruins trust and credibility. Never lie from an office in which the truth matters. Never, ever do that, even if it feels good.

For sure exercise is a great way to develop the physiological ability to do things that machines can now easily do far better, cheaper and faster. Rule #1 in Zombieland is cardio, and that is sure a great asset when running for one's life is a constant need, but it all seems to me to be mostly sand in people's eyes, and consists mainly of post-hoc rationalization, where healthy people are far more able to exercise to fitness.

And for a study built on adverse reactions to exercise, their major confusion, and clear indifference, on what PEM is looks like a giant red flag. It's the classic problem of listening to experts and finding them smart until they start talking about things I know and can see through and now I have to wonder whether much of what they said is any valid.
 
Jonathan Edwards said:
It could but does it stop anything getting worse?
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Osteoporosis? Astronauts lose bone density in space. I guess there's the issue of whether you need a programme of exercise though versus just tasks of daily living in a full gravity environment.

We've been thinking about emphysema elsewhere, I hope a member who raised it won't mind me talking about it here (let me know if you do mind and I'll delete it). There are plenty of authorities claiming that exercise prevents worsening of emphysema. But the evidence provided is sounding a bit questionable. It's not easy to find good studies on this.

National Emphysema Foundation
Shortness of breath and weakness are two common problems of people with chronic lung diseases. As a result, many people avoid participating in physical activities that cause them shortness of breath. In turn, these people become weaker and their shortness of breath greater with even less activity.

A program of regular exercise can help break this vicious cycle.

Even in small amounts, exercise can help strengthen your muscles and make them more efficient—requiring less oxygen to perform the same activities. Further, by stretching muscles that are not regularly used, including the breathing muscles, everyday activities such as walking will become easier and lung function will improve.

While exercise may seem overwhelming at first, even walking at a very slow pace will benefit your overall quality of life. Exercise will improve your appetite, giving you the “fuel” and building blocks you need to repair and maintain your body’s lung function. Mild to moderate exercise has also been proven to improve mental function.

The benefits of light to moderate exercise will be apparent rather quickly after beginning a regular exercise routine. However, these positive effects can be lost just as quickly as they appeared. As such, once you begin the healthy habit of regular exercise, you should continue daily unless otherwise advised by your doctor or physician.
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Suggesting that 'exercise will improve your appetite, giving you the "fuel"' needed to repair and maintain lung function sounds rather like grasping at straws when it comes to reasons to exercise. As in, if that's the best they have got, it's not looking compelling. If good nutrient intake is the aim, then that can be achieved by improving the diet, by reducing alcohol intake.

I'm not too sure about this 'stretching of the breathing muscles' benefit of exercise, or for 'breaking the vicious cycle' of doing less, becoming less fit, so then doing even less again.

I think you are right @rvallee, that the benefits of exercise are confounded with the benefits of maintaining a healthy weight. I can see that not having a very high BMI would make a number of health conditions easier, with less stress on joints and less energy needed to move. I think exercise does help manage Type 2 diabetes, but probably it is mostly via weight management, and we have more reliable tools for that now.

I think there is a big difference between 'a programme of exercise' and ' undertaking your tasks of daily living'. The latter is very important for independent health, whereas I think for exercise, there are some significant downsides to maintaining the undeniably occasionally useful and enjoyable capacity to do more than those everyday tasks when required. Not least the amount of time it takes in a day.

I've tended to think the argument of 'exercise actually doesn't seem to have a net benefit for any health condition' is one best avoided in our advocacy, partly because it is such an entrenched view and there are too many possibilities for the one instance where it is true. We don't have to prove that wider contention for it to be true for ME/CFS.
 
Hutan said:
Osteoporosis? Astronauts lose bone density in space. I guess there's the issue of whether you need a programme of exercise though versus just tasks of daily living in a full gravity environment.
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+2

Exercises have never been part of the recommendation for osteoporosis as far as I know. If you have osteoporosis and do a lot of exercises you will probably increase the risk of breaking things. Keeping thin actually makes osteoporosis worse. It makes sense that keeping reasonably active will be better for osteoporosis than lying in bed all day but that is a far cry from recommending 'exercise'.

I think it extremely unlikely that exercise has any beneficial effect on emphysema.

Hutan said:
I've tended to think the argument of 'exercise actually doesn't seem to have a net benefit for any health condition' is one best avoided in our advocacy, partly because it is such an entrenched view and there are too many possibilities for the one instance where it is true. We don't have to prove that wider contention for it to be true for ME/CFS.
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Surely entrenched views are the ones that need fighting against?
We do not need to prove the wider contention maybe but the myth that exercise is good for other things has led to a huge amount of disinformation in relation to ME/CFS advocacy. We used to hear constantly about how important it was to use the right criteria because 'ordinary fatigue' could be treated with exercises - so criteria affected management. The real reason why PACE was negative - it showed that exercise helped nobody - was obscured.
 
Jonathan Edwards said:
Exercises have never been part of the recommendation for osteoporosis as far as I know.
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That recommendation is everywhere. e.g. Mayo Clinic

Osteoporosis is a major cause of disability in older women. Osteoporosis is a bone-weakening disorder that can result in broken bones, such as in the hip and spine. When this happens, it be hard to move freely and live independently.

How can you lower your risk of these injuries? Exercise can help.

Certain types of exercise strengthen muscles and bones. Other types can improve balance, which can help prevent falls.

Benefits of exercise

It's never too late to start exercising. Regular physical activity can:

  • Increase muscle strength.
  • Improve balance.
  • Decrease the risk of broken bones.
  • Improve posture.
  • Lessen pain.
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Hutan said:
That recommendation is everywhere. e.g. Mayo Clinic
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Well, Mayo seems to put out all sorts of guff these days. In the days when I was involved in setting exam questions relating to osteoporosis pathways exercises were not on the list.

That just looks like a trotting out of the 21st century mantra that exercise is great for everything.
 
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