Marcus et. Al. “Training physicians to conduct physical activity counseling” 1997. We successfully overcame some of the barriers to physician based exercise counseling including lack of counseling skills, perceived ineffectiveness and lack of confidence in counseling.” “The time spent in counseling was relatively brief (5 minutes) and yet, results demonstrated a significant improvement in self-reported levels of physical activity.”
Halm J, Amoako E. Physical activity recommendation for hypertension management: does healthcare provider advice make a difference? Ethnicity and Disease 2008 Summer; 18(3): 278-82.
This is an exercise prescription that was signed by…Dr. Robert Sallis, The past President of the ACSM. This prescription appeared in the November/December issue of a magazine called Fitness. Dr. Sallis was interviewed about exercise is medicine and he included this visual. Your patients might read this and have question. They might even ask you for a prescription. So let’s get familiar with exercise prescriptions.
90% felt it was important they felt only about 10% of students would be able to do it effectively
-- Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al
Modifiable behavioral risk factors are leading causes of mortality in the United States. (JAMA, 2000 Mokdad et al. CDC) www.cdc.gov/cancer/ breast/statistics/ http://www.cdc.gov/cancer/Prostate/publications/decisionguide/
In 2005-2008 11% of adults 20 years of age or older had diabetes. In 2005-2008 the percentage of adults with dm increased with age from 4% of persons 20-44 to 27% of adults 65 years of age or older http://meps.ahrq.gov/mepsweb/ Medical Expenditure Panel survey
http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf The prevalence of hypertension (defined as high blood pressure or taking antihypertensive medication) increases with age. In 2005–2008, 33%–34% of men and women 45–54 years of age had hypertension, compared with 67% of men and 80% of women 75 years of age and over (Table 67).
( Journal of the American Medical Association JAMA: 2000, Vol. 283. No. 22, pp. 2961-2967) http://www.news.harvard.edu/gazette/1999/10.21/diabetes.html http://www.reuters.com/article/healthNews/idUSTRE53E71N20090415?feedType=RSS&feedName=healthNews http://www.nature.com/bjc/index.html http://www.ncbi.nlm.nih.gov/pubmed/18599492?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://jap.physiology.org/content/103/2/693.short Marathoners/Ultramarathoners increased risk of URI’s post event
Highest force on the muscle with a rapid eccentric contraction……..
Untrained…….can only fire around 71% of muscle csa
Enthesis…..tethers…pulling on bone may be component of dynamic bone changes……
cortisol = catabolic……..lipolysis 3-4 forms of GH…..various kiladaltons
Prochaska: Trantheoretical model of change
Example…if you take up running for the first time…success should not be running a marathon in 2 hours……rather 15 minutes without running may be a legitimate goal etc
SpecificWell definedClear to anyone that has a basic knowledge of the project MeasurableKnow if the goal is obtainable and how far away completion is Know when it has been achievedAgreed UponAgreement with all the stakeholders what the goals should be RealisticWithin the availability of resources, knowledge and time Time BasedEnough time to achieve the goalNot too much time, which can affect project performance
Must be high enough to actually see gains Studies demonstrate must at least be at 40% of max to see increases in cardiovascular endurance….. Moderate intensity is 64-76% of HR max http://www.mehn.org.au/images/stories/mehn/Ex_RPE_Scale.jpg http://lh4.ggpht.com/_hbZ_aIisSu8/Sj4dT9_2kPI/AAAAAAAAAbo/r-Hmqox_oJs/Table_thumb.jpg http://www.cvtoolbox.com/cvtoolbox1/exercise/supports/Exercise_METS.gif
----http://www.cdc.gov/nccdphp/dnpa/physical/health_professionals/index.htm over half of US adults do not engage in physical activity at levels consistent with public health --http://books.nap.edu/openbook.php?record_id=1627&page=118 IOM: Greater then 1/2 of all US children do not get enough exercise to develop a healthy heart and lungs --http://www.cdc.gov/nccdphp/sgr/intro.htm Daily enrollment in physical education classes has declined among high school students from 42 percent in 1991 to 25 percent in 1995. --Only 19 percent of all high school students are physically active for 20 minutes or more, five days a week, in physical education classes. high school students are physically active for 20 minutes or more, five days a week, in physical education classes.
(Rogers & Evans, 1993) (Bemben et al., 1991)
http://www.walterbortz.com/ Disuse and AgingWalter M. Bortz II, MD JAMA. 1982;248(10):1203-1208. Abstract
Page 1 1 Aging, Atrophy and Apoptosis:Failing “A’s” for FrailtyCharlotte A. Peterson, Ph.D.and Esther E. Dupont-Versteegden, Ph.D.University of KentuckyLexington, KYPage 2
Goals• Plant Seeds• Stimulate Dialogue Have Fun• Harvest Ideas• Identify Opportunity• Unravel a Solution• Empower you to empower others
Goals• Provide applicable knowledge• Equip you with tools to promote change• Practice skills• Develop a plan of action• Take it home• Apply it
Goals• Review foundational ideas in muscle physiology• Explore concepts in Exercise as medicine• How your habits affect patient success• ACSM criteria and patient selection• Review the basics of patient change and motivation• Develop Exercise prescription writing skills
What this is NOT!• The END• The final word• Everything you need to know• For that……..
Why none of us do what we know we should do and want to do ALL the time
Reasons NOT to Counsel on Exercise• Time Limitations• Inadequate reimbursement• Personal Fitness• Don’t feel adequately prepared (lack of confidence, training, instruments and materials)• Physician Specialty• Perceived lack of success at advising exercise• Lack of confidence in the exercise provider
Breakout: 2 minutesAsk what your neighbor’s reasons are for NOT counseling on Physical Activity
Efficacy of Physician Counseling• Recent study of hypertensive patients, only a third received counseling to engage in physical activity as a way to manage their hypertension.• However, 71% of the patients who were counseled followed the recommendations to exercise and reduced their blood pressure. – Halm, Ethnicity and Disease 2008
• A recent study showed that diabetic patients received counseling/referral for nutrition only 36% of the time, and for exercise only 18% of the time. Peek, J Gen Intern Med, 2008
1975-Teach medical students about exercise as preventive medicine – 74 medical school participated in questionnaire – 16% offered a course geared to exercise as preventive medicineBurke EJ, Hultgren PB. Will Physiciansof the Future Be Able to PrescribeExercise? J Med Educ. 1975;50:624-6.
Exercise Courses in Medical Schools• 2001-Medical school leaders including Deans and Directors of Medical Education have reported – 72 out of 128 medial schools participated in questionnaire – 6% of medical schools polled reported having a core course addressing the exercise prescription • Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription Competence as Perceived by Deans and Directors of Medical Education in the United States: Implications for Healthy People 2010. Public Health Reports. 2001;116:226-234.
Deans Report of Medical Student’sCompetency in Exercise Prescription 10% 90%Connaughton AV,Weiler RM, Connaughton D. Graduating Medical Students’ Exercise Prescription Competence asPerceived by Deans and Directors of Medical Education in the United States: Implications for Healthy People 2010. Public Health Reports. 2001;116:226-234.
Our Obligation• The physician is obligated to broach critical lifestyle areas.• Avoidance or lack of comment by the physician may be perceived as tacitly condoning the unhealthy behaviors.• The physician has an important opportunity to promote behavior change and be supportive of the change process.• Need to ask about physical activity and to prescribe exercise.
• Effective and efficient delivery of message from physician to improve health behaviors. “Talk the Talk.”• Need to establish physicians as role models of healthy behaviors. “Walk the Walk.”
“A global response to a global problem: the epidemic of overnutrition.” WHO It is estimated that by 2020 2/3rds of the global burden of disease will be attributable to chronic non-communicable diseases, most of them strongly associated with diet. The nutrition transition towards refined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other non- communicable conditions. Sedentary lifestyles and the use of tobacco are also significant risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
Top Ten Causes of Death for Men in the United States
Waist Circumference > 40” M > 35” W > 34%Triglycerides > 150 HDL < 40 M or < 50 W of Americans BP ≥ 130/85 Fasting Glucose of ≥ 100
Perspective• We eat more – Sugar, Salt, Fat, Meat, Dairy – 1970-2006: • ↑ 24.5 % C/day ≈ 617K/day• We get less then ideal Physical Activity – 18.8% of adults achieved CDC reccs on Exercise – 10% of adults >65 y/o
Michelangelo’s David:12 month 20 city tour of the US
“A global response to a global problem: the epidemic of overnutrition.” WHO It is estimated that by 2020 2/3rds of the global burden of disease will be attributable to chronic ……if…….Lifestyle is the noncommunicable diseases, most of them strongly Problem associated with diet. The nutrition transition towardsrefined foods, foods of animal origin, and increased fats plays a major role in the current global epidemics of obesity, diabetes and cardiovascular diseases, among other noncommunicable conditions. Sedentary What of tobacco are also significantlifestyles and the use is the answer……..?risk factors. …….. A concerted multi-sectoral approach, involving the use of policy, education and trade mechanisms, is necessary to address these matters.
Surgery PharmaceuticalsPhysical ModalitiesLifestyle Medicine
Exercise and Physical Health• Reduces risk of – Heart Disease ≈ 40% – Obesity: ≈ 30-100% – Stroke ≈ 50% – Type 2 Diabetes ≈ 50% – Hypertension ≈ 50% – Disability delayed ≈15 years – Colon Cancer ≈ 25-40% – Breast Cancer ≈ 20%-44% – Osteoporosis ≈ 20+%• As many as 250,000 deaths per year in the United States are attributable to a lack of regular physical activity
Muscle anatomy and physiology Sarcomere: The basicfunctional unit of a muscle The A Band does NOT shorten Z-Lines: Borders of each Sarcomere http://media.tumblr.com/tumblr_ll9jc5uZcM1qcfmqz.gif
Muscle anatomy and physiology• Fiber Types: – Type I: slow, oxidative fibers • mitochondria, myoglobin, capillaries • resistance to fatigue – Type IIA: fast, oxidative fibers • myoglobin • Intermediate fatigue resistance – Type IIB: very fast, glycolytic fibers • glycogen, anaerobic action • Rapidly fatigue
Basic Principles• Size Principle: – Motor units are recruited in order of fiber size, Type 1 smaller, Type 2 larger – Inc firing in response to demands
Muscle anatomy and physiology• Fiber Types Continued: – Force Production: • Low: Type I • High: Type IIA • Very High: Type IIB – Concentration: • Average: 60% fast twitch, 40% slow – Location/Function: • UE: Fast Para-vertebrals: Slow
Muscle anatomy and physiology• Can you change Fiber Types? – Endurance Training: • ’d oxidative potential • Debatable change in fiber type distribution – Resistance Training: • ’d muscle fiber hypertrophy/cross-sectional area • Debatable change in fiber type distribution
What we Know?• The need for exercise• The benefits of exercise• The basic science of muscle
Defining Exercise• Exercise: – movement of the body resulting in the enhancement of health and/or improvement of function
Exercise• Leisure time Exercise: organized sports, running, gym activities, rehabilitation etc.• Lifestyle Exercise: activity incorporated into our daily pattern of life – eg: parking in the distant portion of the parking lot rather then the first bumper, taking the stairs instead of the elevator etc.
Cardiorespiratory Adaptations• High, acute stress to the CV system• Inc HR, SV, CO, BP• Chronic: – Inc. Vo2Max, SV – Decr. Resting HR, BP (HTN -4%/-5%, NT -2%/-1%),
Immune System Changes/Adaptations• Beneficial Effects: Regular, Moderate• Harmful Effects: Extreme, Excessive – Decr. neutrophil respiratory burst, lymphocyte proliferation, monocyte antigen presentation – >1.5 h, of moderate to high intensity (55–75% maximum O2 uptake), and performed without food intake
Basic Principle• Progressive Overload: (Delorme Principle) – Gradual increase in stress upon the body results in increases in tolerance and eventual plateau – SAID (Specific Adaptations to Imposed Demands) – Greater Demand = Greater Adaptation within genetic potential
Basic Principles• Hyperplasia: Inc in the number of muscle fibers within a given muscle ≈ 5%• Hypertrophy: Inc in the size of individual muscle fibers/or an entire muscle ≈ 95%
Lingo• Weight: ………• Repetitions (Reps): Number of times each motion/exercise performed• Sets: Number of times a group of repetitions is performed• Rep. Max (RM): Highest weight with which an exercise can be performed (usually one time)
Basic Principles• Low Weight/High Repetition = greater focus on cardiovascular/endurance benefits – Eg: > 15 reps• High Weight/Low Repetition = greater focus on anabolism, strength – Eg: 5-8 reps
Neuromuscular Adaptations• Early Adaptations: Week 1-8 – Inc. neural drive: motor unit recruitment and rate of firing, synchronization of motor units, coordination of agonist/antagonist firing – Alterations in myosin heavy chains and ATPase enzymes – 16 workouts for significant muscle hypertrophy• Late Adaptations: > 8 weeks – Primarily muscle hypertrophy
Cardiorespiratory Adaptations• High, acute stress to the CV system• Inc HR, SV, CO, BP• Chronic: – Dec resting HR of 5-12% – Dec SBP and DBP by 2% and 4%
Connective Tissue Adaptations• Bone is dynamic responding to compression, strain – Increased intensity = increased response – Goal > 60% 1RM – Stress results in inc. BMD – Takes time ≈ 6 months, begins with Inc serum alk phos. and osteocalcin at 1 month• Soft Tissue: – Inc. collagen size, number and packing density
Endocrine Adaptations• Testosterone/ GH/ IGF/ Insulin / Cortisol• Acute Changes: – Inc T and GH during and for 15-30 minutes post in men – Affects in women less studied/less clear – Magnitude of change greatest when large muscle mass is exercised at mod/high intensity and volume with short rest periods• Chronic Changes: – Resting T  variable – No change in resting GH, however various sizes/forms – Inc IGF-1 at rest. – No clear change in resting cortisol
Immune System Changes/Adaptations• Inc circulating Leukocytes 8-14% over next 24 hrs• Inc circulating Lymphocytes 50-200% – NK cell cytotoxic activity by 40% 2 hrs post
What we know!• The value of movement• The basic science of muscle• Foundational terms and principles Next• Goals• Patient Selection
Our Goals• For the overwhelming majority of patients the benefits of exercise outweigh risk• We must identify those at risk and appropriately screen and select them• We must help establish goals and assist in their achievement
Phases of Activity• Phase I: Contemplation, screening and motivation• Phase II: From start to ACSM/AHA exercise recommendations• Phase III: Maintaining or going beyond ACSM/AHA recommendations
Up Next• Risk Stratification• Readiness for Change• Exercise Prescription Writing• Motivation: Improving Engagement
RISK STRATIFICATION FOR SEDENTARY PATIENTS Patient answered NO to all seven Low risk: questions on the Client can begin PAR-Q < 2 risk factors for exercise program CV, pulmonary or unsupervised metabolic disease Patientcompletes the PAR-Q ≥ 2 risk factors for CV, pulmonary or metabolic disease Moderate risk: Client requires Uncomplicated supervision or Patient answered YES to one or pregnancy modifications to more questions Other medical exercise program on the PAR-Q conditions Complicated Pregnancy High risk: Client requires further Symptomatic or medical assessment known cardiovascular, prior to initiating pulmonary or metabolic disease exercise program
Risk Factors• Family History – Relative with early CAD (M<55, W<65)• Smoking: present or last 6 months• Dyslipidemia: LDL >130, HDL<40, Tch>200• Hypertension: SBP>140, DBP>90• Elevated Blood Glucose: > 100 2x’s• Obesity
Low Risk• Men < 45 y/o • With ≤ 1 risk factor• Women < 55 y/o – With ≤ 1 risk factor
Moderate Risk• Men ≥ 45 and Women ≥ 55• ≥ 2 risk factors
High Risk• Known CAD, CVD, PVD• Known Pulmonary Disease• Signs/Symptoms suggestive of the above
RISK STRATIFICATION FOR SEDENTARY PATIENTSCARDIOVASCULAR/METABOLIC RISK FACTORS:<2 risk factors = LOW RISK; ≥2 = MODERATE RISK• male > 45 years old• female > 55 year old, or has had hysterectomy, or is post menopausal• smoker (or quit within past 6 months)• BP > 140/90mmHg• on BP medication• blood cholesterol >200mg/dL• close blood relative who had heart attack or heart surgery before age 55 (male) or 65 (female)• >20 pounds overweight• pre-diabetes• sedentary lifestyle
RISK STRATIFICATION FOR SEDENTARY PATIENTSOTHER RISK FACTORS (MODERATE RISK)• pregnancy• musculoskeletal problems that limit physical activity• client takes prescription medication that may influenceexercise tolerance• client has concerns about the safety of exercise
RISK STRATIFICATION FOR SEDENTARY PATIENTSCARDIOVASCULAR and PULMONARY S/S (HIGH RISK):• heart attack or heart failure• heart surgery or transplantation• cardiac catheterization• coronary angioplasty• pacemaker/implantable cardiac• defibrillator/rhythm disturbance• heart valve disease• congenital heart disease• chest discomfort with exertion• unreasonable breathlessness• dizziness, fainting or blackouts• takes heart medications• burning or cramping sensation in lower legs when walking short distances• asthma or other lung disease
Risk Stratification AlgorithmMAJOR SIGNS and SYMPTOMS of CARDIOVASCULAR, PULMONARY or METABOLICDISEASE (HIGH RISK):•chest discomfort with exertion• dizziness, fainting or blackouts• takes heart medications• bilateral ankle edema• unreasonable breathlessness (at rest, with mild exercise, or when recumbent)• burning or cramping sensation in lower legs when walking short distances• pain or discomfort in the chest, neck, jaw, arms, or elsewhere that may be d/t ischemiaAdapted from: American College of Sports Medicine. ACSMs Guidelines for ExerciseTesting and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins; 2009.(chapter 2)
Risk Stratification• Low Risk: No additional testing needed• Moderate Risk: Exercise testing if planning for vigorous intensity activity• High Risk: Exercise testing prior to engaging in moderate or vigorous
Present Recommendations• Cardiovascular: – 150 minutes of moderate-intensity exercise per week. – 30-60 minutes of moderate-intensity exercise (five days per week) or 20-60 minutes of vigorous- intensity exercise (three days per week).
Present Recommendations • Resistance Training: – 2-3 days per week – All major muscle groups – 2-4 sets of each exercise – 48 hours in between sessionshttp://www.acsm.org/about-acsm/media-room/news-releases/2011/08/01/acsm-issues-new-recommendations-on-quantity-and-quality-of-exercise
Present Recommendations• Flexibility: – 2-3 days/week to improve range of motion• Balance: – 2-3 days/week – Eg: Tai Chi, Yoga
Physical Activity Vital Sign• “Over the last week on how many days did you do at least 30 minutes of moderate physical activity?” • 0-2 Days: Sedentary • 3-4 Days: Somewhat active • 5-7 Days: Meets recommended levels
Other Basics• Type of Exercise they perform• What they enjoy/don’t enjoy• Why/Why not• What have they tried• What would they like to try
The Pre-contemplators• Ask if the patient would like to hear about or read about the benefits of exercise• “I understand that you are not ready to change, but please know that when you are ready, I will be here to help.”• “I think that it is important for your health….” Key: Empathy
Physicians’ Empathy Influences Clinical Outcomes• 891 Diabetic patients• 29 Family physicians• Hgb-A1c, LDL-C• Jefferson Scale of Empathy• High empathy scores for MD correlated with good control of Hgb A1c and LDL-C in patients Hojat et al. Acad Med. 2011;86:359-364
Contemplators• Ask the patient to consider what things would be like if they did not begin an exercise program• Ask the patient how important exercise is to them• Work with the patient to identify a powerful, intrinsic motivator Key: Vision and Motivators
My Reasons to Exercise• Feel good in my skin• Increase energy, Reduce stress• Increase my confidence, discipline• Be a role model, socialize, family time• It’s fun, I love to sweat and work hard• I love challenges• Reduce disease risk• Lower disability risk• Maintain independence
Defining Success• What is success for you?• Are such goals achievable, legitimate?• What will you do if you fail to “succeed”?
The People in Preparation• Ask the patient how confident she is in her ability to perform exercise• Ask how the patient can increase her confidence in her ability to perform exercise• Develop a SMART exercise goal for the patient• Identify possible obstacles and brainstorm strategies around them Key: A solid plan with SMART goals
4 minute breakout• Identify a Physical Activity Goal for yourself!• Using the SMART acronym write a plan for achieving it!• Share it with your neighbor
The People in Action• Review physical activity guidelines• Write an exercise prescription• Follow up on the patient’s progress• Congratulate patients on their exercise• Encourage patients to meet the guidelines• Ask about walks or runs for non-profits (AHA) Key: Motivators, rewards, goals
The People in Maintenance• Discuss the patients exercise routine• Consider recommending cross training• Review health benefits with patient• Congratulate patient• Write an exercise prescription• Recommend becoming a mentor to family or friends Key: Motivators, rewards, goals + variety and mentoring
Physician Prescribed Exercise• Acceptable, familiar format for physicians• Limited time required• Elevates from recommendation to “order”• Supports metaphor that exercise is indeed the best medicine
Medication Prescription:Medicine: IbuprofenStrength: 600mg tabletsRoute: By mouthDispense: 90 tabletsFrequency: Three times per dayPrecautions: Discontinue for stomach upsetRefills: 3Exercise Prescription:Exercise: Walk 30 minutes per day to improve mood and general health.Strength: Moderate intensityFrequency: Five days per weekPrecautions: Increase duration of walking slowly to avoid injuryRefills: Refill at next visit.
Frequency Ask for a confidence • Cardiovascular: rating? 0-10 Document it in the chart – 150 minutes of moderate-intensity exercise per week. – 30-60 minutes of moderate-intensity exercise (five1: As days peras they will minutes of vigorous- much week) or 20-602: Gradually exercise (three days per week). intensity Increase3: Achieve the reccs.
Intensity of Exercise Talk Test: -Easy: Can Talk and Sing -Moderate: Can Talk but not sing Maximal Heart Rate: -Intense: Can’t age) or sing 220-Age or 206.9-(0.67x talk Heart Rate Reserve (HRR): Max. HR- Resting HR = HRRTarget HR=HRR x % intensity + HR @ rest
Exercise Progression Once the threshold is reached, exercise 35 intensity can be TARGET / THRESHOLD ZONE: increased, enabling totalTotal minutes of exercise(per day) 30 30 m in of m oderate intensity ≥5x/w eek, OR exercise time to 20 m in high intensity ≥3x/w eek, OR decrease (from 150 20-30 m in combined m oderate and high min/week to 60 25 intensity 3-5x/w eek min/week if all exercise is high intensity) 20 The average healthy, inactive adult should start here 15 10 EXERCISE INTENSITY 5 n Low <3x/week n Moderate <−−−−−− Ε xercise 3-5x/w eek, w orking up to 150 m in/w eek) −−−−−− 0 n High/vigorous 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Exercise level TO DETERMINE STARTING LEVEL: Determine PROGRESS: to the next level (move 1 bar to the right) how many minutes (see X-axis) you are comfortable every week. Ensure that you continue exercising 5x/week. exercising at least 3x/week. This is your starting level. If you begin the program very deconditioned or sedentary Increase to 5x/week before progressing to the next level. and over the age of 65, then progress every 2-4 weeks.
Time• As little as 10 minutes per session has shown benefit1: As much as they will2: Gradually Increase3: Achieve the reccs.
Type • Ask….don’t tell • Disclose your own habits – Physicians who exercise are most likely to encourage pts to exercise – You are most likely to counsel about the form of exercise you perform • Be relatable and maintain optimism • Consider keeping a folder of “successes” • Take a lesson from Big PharmaPersonal Exercise Habits and Counseling Practices of Primary Care Physicians: A National Survey Clinical Journal of SportMedicine:January 2000 - Volume 10 - Issue 1 - pp 40-48Physician disclosure of healthy personal behaviors improves credibility and ability to motivate.Archives of Family Medicine [2000, 9(3):287-290]
Breakout: 4 minutes• Ask your neighbor about their physical activity goal• With this in mind, write an Exercise Prescription for your neighbor using the FITT approach
Practical Advice:• Not counseling the benefits of exercise may be perceived as condoning a sedentary lifestyle.• Do not emphasize exercise threshold.• Change the emphasis from vigorous to moderate intensity e.g. walking 3-4 miles per hour.• Sedentary patients should not be counseled to initially exercise at a hard level as this leads to higher dropout rates.
Motivating your patients• Set realistic goals- accumulating moderate activity (e.g., pedometer)• Talk about general and mental health benefits of exercise and risks of remaining sedentary, but also about the pleasure of exercise• Ask about physical activity levels.• Write exercise recommendations on a script
Motivating your patients at each visit:• Ask about exercise just as inquiries about sleep, concentration, etc.• Document details in chart note• Explore barriers to exercise• Positive reinforcement• Incorporate socialization
“Physical fitness can neither beachieved by wishful thinking nor outrightpurchase.” Joseph Pilates
CDC Exercise Stats• <20% of all adults achieve recc. Levels• > 60% of adults are not regularly active• By age 75 1:3 men and 1:2 women engage in NO physical exercise
• “You have to work at living, period. You’ve got to train like you are training for an athletic event. Most older people just give up. They think, “I’m too old for that,” because they have an ache here or a pain there. Life is a pain in the butt; you’ve got to work at it.” - Jack LaLanne -
The Physiology of Aging• Cardiovascular: – 20-30% in CO by 65 – Max. 02 uptake by 9-5% per decade, for sedentary men and women – Vascular elasticity = 10-40 mm Hg SBP/DBP – Maximum HR app.10 bpm/decade
Physiology of Aging• Respiratory: – FVC of 40 to 50% by age 70 – in chest wall compliance – Maximum Ventilation – in Alveolar size and conc.
Physiology of Aging• Muscles –40% in muscle mass by 70 – muscle fiber size & # –30% in strength by 70
Physiology of Aging• Skeletal health: – 1% in bone mass/yr after 35 – Post-menopause 2-3% per year for 5- 10 yrs – rates of OA, sponylo-arthropathy, general joint dysfunction and degeneration
Physiology of Aging• Connective Tissue: – elasticity – shortened muscle fibers – synovial fluid volume – Up to 15% reduction in nerve cond. – Hgb, Hct, RCM
Disuse• Bedrest: – BMD, increased bone resorption – muscle mass and strength – muscle fiber size – fatty infiltration of muscle – Impaired O2 exchange – Cardiac function, efficiency
• “A review of biologic changes commonly attributed to the process of aging demonstrates the close similarity of most of these to changes subsequent to a period of enforced physicalDisuse and Aging inactivity. The coincidence of these changes from the subcellular to the whole-body level of organization, and across a wide range of body systems, prompts the suggestion that at least a portion of the changes that are commonly attributed to aging is in reality caused by disuse and, as such, is subject to correction. There is no drug in current or prospective use that holds as much promise for sustained health as a lifetime Walter Bortz MD program of physical exercise.”(JAMA 1982;248:1203-1208)
“There may be no single feature of age-related decline that could more dramatically affect ambulation, mobility, calorie intake, and overall nutrient intake and status, independence, breathing, etc. than the decline in lean body mass.” Aging, Atrophy and Apoptosis:Failing “A’s” for Frailty National Conference on Aging
Sports Med. 2000 Oct;30(4):249-68. Strength training in the elderly: effects on risk factors for age-related diseases. • (i) produces substantial increases in the strength, mass, power and quality of skeletal muscle • (ii) can increase endurance performance • (iii) normalizes blood pressure in those with high normal values • (iv) reduces insulin resistance • (v) decreases both total and intra-abdominal fat • (vi) increases resting metabolic rate in older men • (vii) prevents the loss of BMD with age • (viii) reduces risk factors for falls • (ix) may reduce pain and improve function in those with osteoarthritis in the knee regionInfluence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci SportsExerc. 2011 February; 43(2): 249–258.
What we know!• The value of movement• The basic science of muscle• Foundational terms and principles• How to Evaluate Readiness for Change• ACSM Risk Stratification and Pt Selection• How to Write and Exercise Script• Exercise and Aging
Goals• Provide applicable knowledge• Equip you with tools to promote change• Practice skills• Develop a plan of action• Take it home Have Fun• Apply it
Now What• You are powerful• Our collective message is one of optimism and opportunity• We can empower our patients• Together we can alter the course of American healthcare
Now What• Develop 3 actionable items you can incorporate in your practice when you return• Develop 3 actionable items you can incorporate in your practice over the next 6 months
With Thanks!• The Institute of Lifestyle Medicine – Dr Edward Philips MD – Dr Elizabeth Frates MD• My Wife
References• Bull World Health Organ. 2002;80(12):952-8. Epub 2003 Jan 23. Chopra M et al• http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/obesity.pdf• http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf• http://www.ers.usda.gov/Publications/EIB33/EIB33_Reportsummary.pdf• http://www.springerlink.com/content/w26525u488gq2024/• http://www.ingentaconnect.com/content/nrc/cjpp/2001/00000079/00000005/art00003• http://biomedgerontology.oxfordjournals.org/content/55/7/B347.short• http://www.ingentaconnect.com/content/adis/smd/2007/00000037/00000002/art00004• http://www.ncbi.nlm.nih.gov/pubmed/2311599• http://onlinelibrary.wiley.com/doi/10.1111/j.1520-037X.2001.00529.x/full• http://jap.physiology.org/content/103/2/693.short• American College of Sports Medicine. ACSMs Guidelines for Exercise Testing and Prescription, 8th edition. Philadelphia: Lippincott Williams & Wilkins; 2009.(chapter 2)• James O. Prochaska and Wayne F. Velicer (1997) The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion: September/October 1997, Vol. 12, No. 1, pp. 38-48.• http://www.nationalatlas.gov/articles/people/a_age2000.html• Influence of Resistance Exercise on Lean Body Mass in Aging Adults: A Meta-Analysis Med Sci Sports Exerc. 2011 February; 43(2): 249–258.• Changes in skeletal muscle with aging: effects of exercise training.Exercise and Sports Science Reviews 1993, 21:65-102• Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Archives of Family Medicine[2000, 9(3):287-290]• Disuse and AgingWalter M. Bortz II, MD JAMA. 1982;248(10):1203-1208.• http://www.plosone.org/article/fetchArticle.action?articleURI=info:doi/10.1371/journal.pone.0000465
A few Resources• ACLM: www.lifestylemedicine.org• ILM: www.instituteoflifestylemedicine.org• ACSM: www.acsm.org• Abeforfitness.com• Let’s Move: www.letsmove.gov• President’s Challenge: www.presidentschallenge.org• Body and Mind: www.bam.gov