Exercise and Chronic Disease

1. Exercise and Chronic Disease Mark A. Patterson, M.Ed., RCEP Clinical Exercise Physiologist – Kaiser Permanente President-Elect Rocky Mountain ACSM

2. Hippocrates

3. www.exerciseismedicine.org

4. Common Chronic Diseases Cardiovascular disease Heart Attack, Stroke, PAD Pulmonary disease Asthma, COPD, Emphysema Diabetes Neuropathies, CAD Neuromuscular disorders Multiple Sclerosis,Parkinsons Musculoskeletal conditions Arthritis Cancer Breast, Prostate, Leukemia Renal disease Kidney Failure, CAD Immunological AIDS Obesity All of the above?

6. Benefits of Exercise

7. Who is Best to Care for These People? Me! In an Ideal World Clinical Exercise Physiologists Physical Therapists Respiratory Therapists Registered Nurses Physicians Personal Trainers Massage Therapists Accupuncture Chiropractors

8. What is Clinical Exercise Physiology? The Registered Clinical Exercise Physiologist is an allied health professional who works with apparently healthy people and patients with chronic diseases and conditions where exercise has been proven to provide therapeutic benefit. The RCEP performs exercise assessments and prescribes exercise and physical activity, primarily in hospitals, clinics or other health-care provider settings. The RCEP assists individuals in developing self-management skills to promote good health. The RCEP is an integral part of the health care team and works closely with other health professionals including: Physicians, Nurses, Nurse Practitioners, Physician Assistants, Respiratory Therapists, Physical Therapists and Registered Dietitians. RCEP’s are trained to work with patients with chronic diseases such as: Cardiovascular disease, pulmonary disease, diabetes, neuromuscular disorders, musculoskeletal conditions, obesity, cancer, end stage renal disease, neoplastic / immunological / hematological disorders

9. CEP or PT?

10. Exercise and Death(Men)

11. Exercise and Death (Women)

12. What is the Best Way to Increase Physical Activity? Monitored rehab? Personal training? Case management? Doctor’s Advice / Guidance? Physical Therapy? Community Resources? Support Groups? Recreation Center Memberships?

13. Comprehensive Risk Factor Modification Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care MI / ACS / PCI / CABG Case Manager Monitored CR CEP CPCRS Dietician Cardiologist PCP Other Resources

14. Clinical Exercise Physiologist Role Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care Clinical Exercise Physiologist Exercise Rx / Consult (One-on-One) Monitored Sub-Max Exercise Testing ROM / Flexibility Evaluation Strength Evaluation Behavior Change Counseling Monitored Rehab Cardiologist PCP Other Resources

15. Functional Exercises What is a functional exercise? Exercise that is specific to and closely mimics task to be completed. Walking lunge better to strengthen muscles to assist in increasing efficiency of walking / running than leg extensions.

16. INDIVIDUALIZE!!!!!!!!! Each patient is a delicate snowflake! Make sure to get detailed history of disease, co-morbidities, check that risk factors are in control, prior exercise history, check for current symptoms and review support team and resources for exercise

17. What is the Risk of Exercise?

18. Exercise Prescription Tips Cardiovascular Medications (HR and BP) Symptoms (CAD, CHF, PAD) F.I.T. Principle Considerations Importance of Warm Up and Cool Down Do not hold your breath!

19. When can they start? Assuming Patient is Medically Stable: *All patients should start with slow progression of walking, stationary bike, etc. PCI without MI – exercise testing and more moderate exercise after about 4 weeks of consistent low intensity aerobic exercise. MI with or without PCI – exercise testing and more moderate exercise after about 4-6 weeks of consistent low intensity aerobic exercise. CABG – exercise testing and more moderate aerobic exercise about 4 weeks post surgery, moderate strength training about 12 weeks post surgery. CHF – Asymptomatic patients increase aerobic exercise very conservatively as can tolerate, if EF is below 30% strength training may be contraindicated.

20. Exercise Prescription TipsPeripheral Vascular Disease Claudication Walking is a must – Specificity 2 Most Important Measures 1. Onset of symptoms 2. Maximum walk time Intermittent Walking to Moderate Pain High Risk of Heart Disease (CAD) Add other modes of aerobic exercise to increase total conditioning time Role of Strength Training Non-Claudicant Can prescribe exercise like people with heart disease / or at high risk for heart disease

21. Claudication and Strength Training

22. Exercise Prescription TipsLung Disease Perceived Exertion vs. Shortness of Breath Reliability of HR? Aerobic Walking – Part of most activities of daily living. Stationary Bike Arm Ergometer Importance of Strength Conditioning 1. Improve efficiency of muscles / conservation of energy

23. Exercise Prescription TipsDiabetes Monitor Blood Sugar Before and After *>250 with Ketones, < 100 *Post Exercise Hypoglycemia Meals and Medications Autonomic Neuropothy and HR Peripheral Neuropothy and Wound Care

24. Exercise Prescription TipsDiabetes Autonomic Neuropathy Silent ischemia and infarction, tachycardia at rest and early in exercise, reduced max HR, exercise intolerance, exercise induced hypotension, thermoregulatory dysfunction, prone to dehydration and hypoglycemia unawareness. Peripheral Neuropathy Loss of peripheral sensation, poor healing of wounds, overstretching can cause musculoskeletal injury, loss of balance, falling

25. Exercise Prescription TipsDiabetes Aerobic Frequency 3-7 days per week Intensity 40-60% Moderate >60% Vigorous Time > 150 minutes / week moderate > 90 minutes / week vigorous Resistance Training Frequency > 3 days per week Intensity 8-10 repetitions Volume of Exercise > 8 exercises Up to 3 sets per exercise Aerobic Exercise Modes Choose exercises such as stationary bike and eliptical trainers - help with balance - less chance of falling Walking also a good choice as involved in most activities of daily living –specificity Resistance Training Modes Machine weights are preferred at start since they can help with balance

26. Exercise Prescription TipsMultiple Sclerosis Aerobic Exercise 1. Perceptual Scale better for Exercise Intensity 2. Adjust daily according to symptoms and energy levels 3. Avoid exercise in heat, exercise early in day better for symptoms of fatigue 4. Bladder issues can cause patients to not hydrate properly Strength Training 1. Optimize in unaffected muscle groups 2. Functional exercises best, Emphasize core groups 3. Increase rest period time 4. During times increased symptoms – focus stretching, ROM 5. Weight machines preferred.

27. Exercise Prescription TipsParkinson’s Disease Aerobic Safety – walking is preferred, but may need to use bike ergometer, eliptical, arm ergometer or others if symptoms warrant. Balance devices – harness, walking poles Strength Warm up important Focus on exercises that extend the trunk Functional exercises best Auditory cues may be needed to help with timing of repetitions Ensure good posture

28. Exercise Prescription TipsOsteoarthritis “Weight Bearing” Aerobic Exercise Continuous weight bearing aerobic exercise can be difficult Careful with those who have severe osteoporosis Water Walking against current may be a good option Exercises to improve balance Minimize forward flexion and twisting movements Can start with strength training Can do combination of short bouts of aerobic training with strength training done during rest periods.

29. Exercise Prescription TipsRheumatoid Arthritis Can follow same basic guidelines as with osteoarthritis Avoid exercise during “inflamatory phase”

30. Exercise Prescription TipsFibromyalgia Must customize to individual Careful to avoid overexertion Progress slowly (water to land walking)

31. Exercise Prescription TipsObesity *Walking important as is involved in most aspects of activities of daily living If balance is an issue then stationary bikes and eliptical trainers are good option Water walking and water aerobics ideal for those with problematic joints Watch carefully for signs of cardiopulmonary and metabolic disease.

32. Exercise Prescription TipsObesity Strength Training Machine weights may help with balance and help to ensure proper form Light weights recommended with moderate to high repetitions May be best option to concentrate on early as de-conditioning and joint issue may limit ability to perform aerobic exercise at onset of new program

33. Exercise Prescription TipsAIDS HIV Exercise Rx must be adapted per stage of disease Asymptomatic – usual general ACSM guidelines are fine Symptomatic – need to adjust day to day, should not exercise with fever above 100, or if having nausea, vomiting, uncontrolled diarrhea or dehydration

34. Exercise Prescription TipsAIDS Moderate better, overtraining increases likelihood of infections Environment Abrasions, tissue injuries Cross infection, sharing of water bottles Overseas travel

35. Exercise Prescription TipsAIDS Exercise and Sickness Common cold Mild to moderate exercise OK Intense exercise OK a few days after symptoms resolve Fever, extreme fatigue, muscle aches – best to wait 2-4 weeks before resuming intense exercise

36. Exercise and Dialysis Effects of Kidney Disease and Long Term Dialysis bone disease, fatigue, coronary artery disease and rhythm disturbances

37. Exercise and Dialysis “Because of the reduction in cardiovascular risk factors that results from exercise training, and because of the need to prevent progressive deconditioning, dialysis patients may actually be placed at a greater risk for cardiac events and adverse musculoskeletal outcomes in the are not participating in regular physical activity”Adv Ren Repl Ther, Vol 6, No 2, 1999: pp 165-171

38. Exercise and Dialysis

39. Exercise and Dialysis Exercise Tips Breathing is at conversational level Feel complete recovery in one hour post exericse Warm up and cool down essential Expect some mild soreness after exercise but not so much that it prevents activity. When Not to Exercise Body temperature >101.0 degrees (38.3 degrees C) Missed more than one treatment Newly undiagnosed illness Pain Not feeling well Blood Pressure <200/100 Unstable sugar levels

40. Exercise and Cancer 1. Follow the advice of Barbara Francis 2. Be consistent 3. Have Sean Swarmer take you for a little hike in Nepal

41. References ACSM’s Guidelines for Exercise Testing and Prescription, 7th Edition Manual of Exercise Testing, 3rd Edition – Froelicher and Myers ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, 2nd Edition – Durstine and Moore ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 5th Edition Exercise and the Heart, 4th Edition, Froelicher and Myers Cardiac Rehabilitation, Adult Fitness, and Exercise Testing, 3rd Edition – Fardy and Yanowitz NSCA’s Essentials of Strength Training and Conditioning Clinical Exercise Physiology Application and Physiological Principles – LeMura and Von Duvillard ACSM’s Resources for Clinical Exercise Physiology The American Physical Therapy Association Book of Body Maintenance and Repair – Moffat and Vickery Exercise Physiology Human Bioenergetics and Its Applications, 2nd Edition – Brooks, Fahey and White Good Ol’ Fashioned Experience since 1989