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Exercise Prescription Basics

Exercise Prescription Basics. Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship USUHS. Bottom Line Up Front (BLUF). Exercise is the best “medicine” around Assess physical activity in ALL patients Only RARE patients needs GXT before exercise

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Exercise Prescription Basics

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  1. Exercise Prescription Basics Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship USUHS

  2. Bottom Line Up Front (BLUF) • Exercise is the best “medicine” around • Assess physical activity in ALL patients • Only RARE patients needs GXT before exercise • GXT pts with symptomatic CV/pulm dz • The Prescription is: Be “FITT” • Frequency: 5 days a week (or more) • Intensity: moderate intensity, 5-6 on 10 scale • Time: 30 minutes aerobics (10-min chunks OK) • Type: • Aerobic activity • Muscular strengthening activity • Flexibility activity (in elderly/sick) • Balance training (if fall risky)

  3. Physicians and their Patients • 47% of primary care physicians include an exercise history as part of their initial examination (self report) • Only 13% of patients report physicians giving advice about exercise • Physically active physicians are more likely to discuss exercise with their patients

  4. ACSM & AHA 2007, HHS 2008Physical Activity RecommendationsHealthy Adults age 18-64 • Aerobic Physical Activity • Moderate intensity: 150 minutes/wk, OR Vigorous intensity: 75 minutes/wk (or a combo) • 10 min at least, preferably spread throughout week • Muscle Strengthening Activity • 2 or more days/wk • 8-10 exercises • 8-12 reps (one set) Physical activity and public health: Updated recommendation for adults from the ACSM and AHA. MSSE 2007. and HHS publication October 2008.

  5. Indications & benefits • Contraindication • Side-effects • Drug interactions • Cost • Dose, frequency, duration

  6. Indications for Exercise • Longevity • Quality of Life • Socialization • Weight control • Disease prevention • Disease management • ….(I could go on)

  7. LongevityThe more you exercise, the lower your risk of death

  8. Dose-response Curve for Exercise

  9. Death Prevention:Attributable Deaths (%) from various health conditions • Aerobics Center Longitudinal Study (ACLS), Cooper Institute • 40,842 men; 12,943 women

  10. Strong Evidence of Benefit from Physical Activity for… • Lower risk of: • Early death • Heart disease • Stroke • Type 2 diabetes • High blood pressure • Dyslipidemia • Metabolic syndrome • Colon and breast Ca • Prevention of wt gain • Wt loss w/dieting • Improved C-R & muscular fitness • Prevention of falls • Reduced depression • Better cognitive fxn (older adults)

  11. Moderate evidence for… • Wt maintenance after loss • Lower risk of hip fx • Increased bone density • Improved sleep quality • Lower risk lung and endometrial Ca

  12. Contraindications for Exercise • Acute cardiac event happening now • Uncontrolled arrhythmia causing sxs • Severe aortic stenosis • Uncontrolled heart failure • Acute pulmonary embolism • Acute myocarditis • Dissecting aneurysm

  13. Only RARE patients need GXT • AHA 2003: NOT NECESSARY for people doing moderate intensity • USPSTF 2004: • not recommended (class D rec) in pts at low risk • Insufficient evidence (class I rec) even in pts at increased risk Thompson PD et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation 2003;107:3109. USPSTF Screening for coronary heart disease: Recommendation Statement. Ann Int Med 2004;140:569.

  14. Who Needs a GXT first?(No evidence-based recommendations) • Symptomatic cardiac or pulmonary disease • Known CV dz, Diabetes, active chronic dz • ESP if Vigorous exercise • Unsure? Uncomfortable? • Refer to Sports Medicine

  15. Side effects of exercise • Slight risk of Musculoskeletal injury • Increases with duration & intensity • RARE cardiac events • FAR outweighed by benefits to heart! • 25-50% decrease in CVD in exercisers

  16. If we had a pill that conferred all the benefits of exercise, physicians would prescribe it to every patient. Our health care system would find a way to make sure that every patient had access to this “wonder drug.”

  17. Use the Sports and Exercise Medicineapproach to patients • Every patient is a potential “athlete” who needs exercise for HEALTH, not competition • Physical activity is a VITAL SIGN--a STRONG PREDICTOR OF HEALTH • Every exam is a pre-participation eval • Conclude exams with activity clearance and Exercise Rx

  18. How to Write an Exercise Prescription

  19. Rx: Be “FITT” • Frequency • Intensity • Time (duration) • Type

  20. Frequency • 5 days a week • Even more is even better! • Dose-response curve!

  21. Intensity • Moderate Exercise • Equivalent of BRISK WALK • Noticeably accelerates RH • Able to talk • “talk test” • RPE 5-6 out of 10

  22. Exercise Intensity:Relative Perceived ExertionUse 1-10 Scale

  23. Examples of Moderate Intensity • Brisk walking • Household cleaning: vacuum, mop, wipe • Mowing lawn • Shooting hoops • Recreational badminton • Ballroom dance • Golf & pulling clubs • Leisurely sports • Leisurely biking, swimming

  24. Intensity • Vigorous Exercise • Equivalent of jogging • Fail “talk test” • RPE 7-10 out of 10

  25. Examples of Vigorous Intensity • Jogging, running • Shoveling • Heavy farming • Competitive sports • Cross country skiing • Intense biking, swimming

  26. Time (Duration) • Accumulate 30 minutes a day • 10 minute chunks OK • More is better!

  27. Type • Aerobic Activity AND • Muscle Strengthening

  28. Muscular Strengthening • Exercise large muscle groups • 8-12 reps; should fatigue by last rep • Rest 2-3 minutes between exercises • 1 set good, 2 sets better • Rest day in between

  29. What about Older Adults >65,or those with chronic diseases? • Aerobic exercise: same • Strength exercise: same, except 10-15 reps • Slightly lighter weights • Flexibility activity 2 days/wk, 10 min • Balance exercise if at risk for falls, 3x/wk Nelson ME et al. Physical activity and public health in older adults: Recommendation from the ACSM and the AHA. Med Sci Sports Exer 2007;39(8):1435.

  30. What about Children/Adolescents? • Do 60 minutes or more of physical activity every day • Mostly moderate or vigorous • Vigorous activity at least 3 days/wk • Strength exercise 3 days/wk HHS guidelines October 2008

  31. Take Home Pearls • Exercise is the best “medicine” around • Assess physical activity in ALL patients • Only RARE patients needs GXT before exercise • GXT pts with symptomatic CV/pulm dz • The Prescription is: Be “FITT” • Frequency: 5 days a week (or more) • Intensity: moderate intensity, 3-6 on 10 scale • Time: 30 minutes aerobics (10-min chunks OK) • Type: • Aerobic activity • Muscular strengthening activity • Flexibility activity (in elderly/sick) • Balance training (if fall risky)

  32. Questions? Military Sports Medicine Fellowship “Every Warrior an Athlete”

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