London Sports and Exercise Medicine Presentation. December 2015. Copyright Exercise Works Ltd. All rights reserved. Contact ann@exercise-works.org for permissions.

1. Too Old? Too Sick?
Excuses of the past?
Should exercise be recommended, or
even prescribed, in illness and old
age?
© Exercise Works! Ann Gates
Sports and Exercise Medicine Society for London Medical and
Physiotherapy Students
December 2014

2. why a paradigm shift?
Meet… “Killer Bea”
http://www.rocksteadyboxing.org/
From her grandson Ben……..
“But it made me happy to see that Rock Steady
Boxing is allowing so many people to continue living
the way, or close to the way, they have been used to
living all their lives,
…..through independence and physical fitness”

3. “No Exercuses”

4. FACT!
Old or sick…
without
structured
physical activity
….
patients will
….die younger
and reduced
quality of life

5. Exercise

6. Training tomorrow’s doctors,
in exercise medicine, for tomorrow’s patients
(Gates A, omline Editorial BJSM Jan 2015)
“
to protect and
promote the
health of
patients and
the public

7. Too old?
.............NO!

9. Too sick?....
No!

10. ENOUGH
EVIDENCE for
exercise as a
medicine!
TIME to teach
every health
professional

12. 8 ABSOLUTE CONTRAINDICATIONS TO EXERCISE
IN CARDIOVASCULAR DISEASE PATIENTS

13. 8 ABSOLUTE CONTRAINDICATIONS TO EXERCISE
IN CARDIOVASCULAR DISEASE PATIENTS
…………………..Febrile illness
In addition ANY co-morbidities that may affect the patient e.g. cancer
Adapted from British Association of Cardiac rehabilitation 2012

14. “UNSTABLE”

16. OTHER CONTRAINDICATIONS
Contraindications Signs and symptoms
Uncontrolled or poorly controlled asthma Severe shortness of breath, chest tightness or pain,
and coughing or wheezing
Worsening symptoms
Unstable/Uncontrolled COPD Patients are required to be stable before training and
oxygen saturation levels should be above 88-90%
Unstable cancer or blood disorders When treatment or disease cause leucocytes below
0.5 x109/L, haemoglobin below 60g/L or platelets
below 20 x 109/L.6
Uncontrolled Diabetes If blood glucose is >13 mmol or <5.5 mmol/l then it
should be corrected first. Patients with diabetic
peripheral or autonomic neuropathy or foot ulcers
should avoid weight bearing exercise.
Any diabetic with acute illness or infection.
Osteoporosis/High fracture risk avoid activities with a high risk of falling or fracture
(for example: caution in abdominal crunches)
Acute Pulmonary embolus or pulmonary
infarction
Excessive or unexplained breathlessness on exertion
Unexplained symptoms that could cause
risk of injury or exacerbation
For example: dizziness, any acute severe illness

17. “UNCONTROLLED”

18. 150 minutes / fun / physical activities / week / works!
Twice a week / strength / balance / flexibility exercises!

19. Confident,
competent
and capable
exercise advice!
1. Check absolute
contraindications to exercise
2. Practise exercise as a ‘vital
sign’ Sallis 2011
3. Rx…Start off gradually,
increase wisely!
4. Support, signpost and advise
patient, every consult
5. Make every contact count as
a “teachable moment”
APPC 2014, NICE PH44

20. In sickness?
Cardiovascular disease, Hypertension, Type 2 Diabetes, Cancer, End
of Life care, Osteoarthritis/Rheumatoid Arthritis OA/RA, COPD,
Dementia, Parkinson’s disease, Falls prevention, Osteoporosis…….
Find out more
Search: Exercise Works 2 Day course

21. Cardiovascular effects of exercise
• Lower heart rate at rest and during
exercise
• Lower blood pressure at rest and
during exercise
• Lower oxygen demand in the heart at
submaximal levels of exercise training
• Increase in plasma volume
• Increased myocardial contractility
• Increased peripheral venous tone
• Positive changes in fibrinolytic (blood
coagulation) system
• Increased endothelium-dependent vasodilatation
• Increased gene expression for production of an
enzyme (NO synthase) that helps to produce nitric
oxide (NO)
• Increased parasympathetic activity
• Increase in coronary blood flow, coronary
collateral vessels and myocardial capillary density
• Metabolic effect
• Reduced obesity
2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk
http://fyss.se/wp-content/uploads/2011/06/21.-Coronary-artery-disease.pdf
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001800.pub2/abstract

22. Exercise prescription #
Overall aim 3-5 times per week
WARM UP
• 15 minutes
• Within 20 beats of training HR
CONDITIONING PHASE
• 20-30 minutes
• Cardiovascular
• (interval progressing to continuous as able)
• 60-80% of HRmax
COOL DOWN
• 10 minutes
• Within 10 beats of pre-exercise
Achieved in many, fun ways:
Structured class, structured 1 to 1, structured home
based programme, structured physical activities
http://www.bacpr.com/pages/page_box_contents.asp?pageid=737
ONLY
44%
attend!

23. Exercise in the treatment of hypertension
…. works!
• Aerobic physical activity decreases systolic and
diastolic blood pressure
• Average 2–5 mm Hg and 1–4 mm Hg, respectively
= ~10% risk of CVD
• 12 wk duration, with 3–4 sessions per wk, lasting on
average 40 min/session and involving moderate- to
vigorous-intensity physical activity
• Strength of Evidence: High
2013 AHA/ACC
Guideline on Lifestyle Management to Reduce Cardiovascular and especially Hypertension Risk

24. Hypertension and exercise outcomes
compared with other medicines
Intervention
All-cause
mortality
Cardio-vascular
mortality
Myocardial
infarction
ACE-I 10% 19% NR
Thiazide 9% NR 22%
β-blocker 6% (NS) NR 8% (NS)
Ca2+ channel
blockers
-6% (NS) NR 29% (NS)
Regular physical
activity
(self-reported) 29% 30% NR
Regular physical
activity (fitness tests) 41% 57% NR
Brooks, J. H. M. and A. Ferro (2012). JRSM Cardiovascular Disease 1(4).

25. Prevention of type 2 diabetes
with physical activity and exercise
BMJ 2014
• 3 major trials of diabetes prevention with
intensive lifestyle counselling
• China, Finland and USA
• Each reported 40%-60% relative risk
reduction in the incidence of diabetes
• 1 case of diabetes “averted” by treating ~7
people with impaired glucose tolerance for
three years
China study, ADA 1997
Finland study, 2001
US study, 2009

26. Type 2 diabetes and exercise
health benefits
Umpierre 2011 landmark JAMA study
Aerobic, strength, or a combination of both exercises =
“Favorable change in HbA1c, lipids,
blood pressure, cardiovascular
events, mortality, cognition, quality
of life, and physical performance”

27. Cancer and exercise…
“...walking or cycling for 30 mins/day
34% less likely to die of cancer…
33% more likely to beat the disease”
(Orsini 2008)
80% cancer survivors
not physically active
enough
72% of GPs & 60% of
oncologists don’t talk
to cancer patients
about increasing PA

28. Prevention
• Those who
increase their
physical
activity, can
reduce their
risk of
developing
colon cancer
by 30-40%
relative to
those who are
inactive
(Schmid & Leitzmann 2014)
Management
• The protective
effect of
physical activity
can be seen
with only 6-9
MET-hours per
week
• = moderate
effort
• Colorectal cancer survivorship: Movement matters
Crystal S. Denlinger and Paul F. EngstromCancer
Prev Res April 2011 4:502-511; doi:10.1158/1940-
6207.CAPR-11-0098
Colorectal
Cancer
Bowel Cancer in Adults

29. Breast Cancer Management
Active women had over 40% lower risk
breast cancer-specific mortality and
recurrence
(Association between physical activity and mortality among breast
cancer and colorectal cancer survivors: a systematic review and
meta-analysis )
Uterine Cancer Prevention
Active women have around
30% lower risk than inactive
women (Moore et al 2010)
Breast Cancer Prevention
Physical Activity reduces the risk by
around 24% overall
Every 2 hours/week a woman spends
doing moderate to vigorous activity,
the risk of breast cancer falls by 5%
(Wu et al 2013)

30. “Rehabilitation forms an important
component of the management of COPD”
Cochrane 2006
• Lowers morbidity NICE CG101, van Wetering
2010 Santos 2014
• Fewer hospital admissions
• Patients maintain a healthy
weight and thus reduce load
on the heart
• Improves the patient’s sleep
making them feel more relaxed
• Strengthens the patient’s bones
• Enhances the patient’s mental and
emotional outlook Lacasse 2006
• Reduces the patient’s social
isolation
– ‘exercise buddies’
NICE CG101, van Wetering 2010 , Santos et al 2014, Lacasse et al, 2006

31. Conceptual
model of
physical
activity in
patients with
COPD
Gimeno-Santos E et al. Thorax
doi:10.1136/thoraxjnl-2013-204763
Copyright © BMJ Publishing Group Ltd & British
Thoracic Society.
All rights reserved.

32. OA/RAOsteoarthritis OA/
Rheumatoid Arthritis RA

33. Major considerations in designing individualized exercise
training in patients with rheumatoid arthritis
Metsios G S et al. Rheumatology 2008;47:239-248
© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

34. Risk factors for developing
Alzheimer’s
1.46
1.65
1.60
1.59
1.59
Physical inactivity
Depression
Midlife hypertension
Midlife obesity
Smoking
Low educational attainment
Diabetes
Norton, S., F. E. Matthews, et al. (2014). The Lancet Neurology 13(8): 788-794.
1.61
1.82
1.00 1.20 1.40 1.60 1.80 2.00
Relative risk for Alzheimer’s disease

35. Treating dementia with
exercise
1. Improved cognitive function
2. Enhanced mobility
3. Improved activities of daily
living
4. No adverse effects
5. Likely to reduce the burden
on caregivers
Forbes, D., E. J. Thiessen, et al. (2013). Cochrane Database Syst Rev 12: CD006489.

36. Meet Bert!
heart healthy, strength and
balance exercise works!
http://www.ncbi.nlm.nih.gov/pubmed/23128427
Boxing training for patients with Parkinson disease: a case series. http://www.ncbi.nlm.nih.gov/pubmed/21088118

37. Falls prevention
Strength and balance
exercises!
OTAGO
FaMe (Falls Management Exercises)
= 38% reduction in falls
Sherrington 2011
= falls cost NHS
£4.6million/day!

38. Osteoporosis and exercise
There is an inverse relationship of physical activity
relative risk of hip and vertebral fracture
Risk reduction for hip fracture of 36 - 68% at the highest level of activity

39. In sickness,
in health,
in immobility,
in pain,
in disability, and
in old age….
prescribe
physical activity!

40. #EverybodyActiveEveryday

41. • Arial 18pt
@exerciseworks
Exercise-Works-Ltd
• Arial 18pt professionals
• patient education and support
• exercise advice, every patient, every opportunity
• when and where
• every health consult
• In hospitals, out patients, clinics, home visits
• the viral use of social media
exerciseworks
Session 10
See © Exercise Works! patient exercise sheets
All content and concepts intellectual copyright to © Exercise Works! www.exercise-works.org 2012, 2013, 2014.

42. Acknowledgments and disclosures

43. resources
Dr Brian Johnson, General Practitioner and Honorary Medical Advisor to Public Health, Wales.
Dr John H. Brooks (together with existing Kings College Medical School undergraduate course resources in association
with Dr Ann Wylie and King’s Undergraduate Medical Education in the Community).
Dr Simon Rosenbaum PhD, Exercise Physiologist and Research Associate University of New South Wales, Australia.
Dr Jane Thornton MD PhD, Resident Physician and Clinical Researcher, Policlinique Médicale Universitaire, Lausanne,
Switzerland.
Mr Chris Oliver MD FRCS, Consultant Trauma Orthopaedic Surgeon, Honorary Senior Lecturer Department of Orthopaedic
Surgery, University of Edinburgh and Royal Infirmary of Edinburgh, Scotland.
Mr Ian Ritchie FRCS, President of the Royal College of Surgeons Edinburgh, Consultant Trauma and Orthopaedic Surgeon
at Forth Valley Hospital, Scotland.
Steffan Griffin, Medical Student at University of Birmingham, Director at Move Eat Treat, UK.
• FYSS Physical Activity in Disease Prevention and Disease Treatment
• http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move
• http://www.rcplondon.ac.uk/sites/default/files/documents/exercise-for-life-final_0.pdf
• Ann Gates ISBN: 1121850928 Copyright year: 2013, Patient Exercise Sheets, 1st Edition
• http://www.fsem.ac.uk/flipbook/medical_student_exercise_prescription_booklet/files/inc/65c1fc369c.pdf
• http://www.rcsed.ac.uk/the-college/news/2014/october-2014/exercise-surgery.aspx
• http://www.exercise-for-health.com/
• http://gpcpd.walesdeanery.org/index.php/uk-physical-activity-guidelines
• http://www.exercise-works.org/store/
• http://www.humankinetics.com/products/all-products/acsms-exercise-management-for-persons-wchrnc-diseasesdisab-3rd
• http://www.acsm.org/access-public-information/position-stands
• http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-adults.aspx
• http://www.healthscotland.com/physical-activity.aspx
• The role of exercise and PGC1α in inflammation and chronic disease Christoph Handschin1 and Bruce M. Spiegelman2