Exercise & Clinical Medicine
Bruce Helming, MD
Objectives:
Define Exercise
Benefits/Risks
Pre-participation Evaluation
How to Assess Readiness for Change
Helping to Motivate
Exercise Prescription (writing one)
Exercise for aging/arthritis/depression
Some Facts: - 200,000 deaths occur per year because of a sedentary life style
- 25% of people state they do no exercise
- 15% of people state they do minimal exercise
-Women, blacks, Hispanics, elderly, low income most likely not to exercise
-Physicians done ask about exercise!!
Def. Of Exercise: Denotes regular physical activity that is planned, structures, repetitive, purposeful, and is for the improvement/ maintenance of physical fitness.
-Vs. physical activity which could include cleaning etc
Benefits of exercise:
Muscular skeletal: Increases muscle fiber, capillary density, muscle, bone, ligament length
Metabolic: Increases mitochondria, muscle glycogen storage, muscle fat utilization, Vo2 and lactate threshold
Cardiovascular: Increases, SV, CO, contractility (hypertrophy), plasma volume, capillary flow, endothelial function (dilation), and HR variability
Also, Decreases resting HR, BP (especially in hypertensives
*Hypertrophy from exercise is different than LVH from hypertension!
Respiratory: Increases respiratory rate, tital volume, pulmonary blood flow
Immune system: moderate exercise will increase the functioning, while intense exercise has an adverse effect
Endocrine: Decreases serum insulin levels and secretion
Other benefits:
Increased: glycemic control, lipid profile, HDL
Decreased:coronary disease, cardiac events, medical costs, death (all- cause mortality), Type 2 diabetes
A Study: 10,269 Harvard alumni
-Those who were moderately active had a 23% decrease in mortality
Decreased: risk of thrombosis, stroke (ischemic and hemorrhagic), obesity
-Moderate exercise was found to facilitate smoking cessation in females
-Decreased the risk of symptomatic gallstones
Benefits for the elderly
-Decreased disability
-Increased autonomy, functional status
-Preserves bone density
-Delays/slows cognitive decline
More Benefits!
Aids with self esteem in adolescents, asthma, HIV, AIDS, pregnancy, low back pain, neuropathy, chronic fatigue, sleep, panic disorder, dizziness, etc!!
Risks of exercise:
- Muscular skeletal injury
-Strains, tears, inflammation, chronic strain, stress fractures, nerve palsies, tendonitis, bursitis
-#1 injury is sprains
-Ice is the most potent anti-inflammatory treatment available
- Arrhythmia
-Training reduces risk, acute exercise increases risk
- MI
-There is a temporary increased risk with infrequent exercisers with multiple cardiac risk (2-10 fold increase!
-Regular exercise is still protective against MI
- Sudden Death
-Jogging has the risk of 1 death per 396,000 hrs
-Health clubs risk is 1 per 887,526 hrs
-Vigorous exercise (up to 30 min after cessation) the risk is 16.9 (hrs not given)
-There is only 1 death per 1.51 million episodes of exercise
Causes of sudden death:
- Under 35, Hypertrophic Cardiac Myopathy
- Over 35, Coronary a. disease
- Rhabdomyolysis- muscle breakdown
-Labs would show: myoglobinemia, myoglobinuria, elevated serum CPK (CK) creatine phosphokinase
-Occurs following exertion
-Risk factors: untrained, heat, humidity, sickle cell trait, hypokalemia
-Presents with dark urine
-Condition can be normal, but enough will cause renal failure, can progress to death
-In early stages can be treated with hydration
Risks Cont.
- Bronchoconstriction
-Exacerbates symptoms in 70% of asthmatics
-Exercise induced bronchospasm (EIB) – onset 8-10 min. post-activity because of a decrease in epinephrine and adrenaline
-Treatment: inhaler, steroids
- Heat/cold illness
- Dehydration
- Female athlete Triad – Disordered eating, amenorrhea, osteoporosis
- Immunosuppression, urticaria, anaphylaxis
The benefits outweigh the risks!! Even after a heart attack and in advanced stage illnesses the patient should ALWAYS be doing SOMETHING.
Exercise Prescription:
Ask about: physical activity, exercise, barriers to exercise, benefits of exercise
Recommend: ‘30 minutes of moderate exercise most days of the week’
The Goal: Exercising 5-6 days per week, 30 minutes per day at 70-80% of maximum HR (220-age) focusing on aerobic exercise and the risk/benefit ratio of the individual
-This will increase HDL and is cardioprotective
For Weight Loss: Exercising 5-6 days per week, 45- 60 minutes per day at 60% of max. HR
-For aerobic, start with 15 minutes, and increase by one minute per session until you build up to required time
-Fatty acid utilization improves with conditioning!
For Arthritis: Exercise 5-6 days per week for 30 minutes each day at 70- 80% of the max HR. Focus on low impact, but you need to “load joint:”
Deconditioning Joint protection Joint Damage
-You want to build the muscles around the joint to protect it, but also avoid pain
-Suggest walking, jogging, bicycle
-Patient must get through the threshold of pain when they first start and then they will be creating joint protection
Nutrition:
-suggest balanced diet, carbs, protein, fat, fluid replacement, carb. Replacement after exercise
-Avoid fad diets and restriction diets
Stages of Change
Precontemplative – not aware of risky behavior, no intent to change in future
Contemplative – aware of risky behavior, foresees a point in the distant future when they might change
Preparation- will take action in the near future
Action- actually modifying the behavior, requires time and energy
Maintenance- taking various measures to keep the behavior from returning
Motivational Interviewing:
-Remember change is internal, the goal is the elicit change self talk, you should be nonjudgmental, supportive and reflective.
-Ask: How important is exercise? 1- 10 ; What are the benefits of NOT exercising? The Barriers? How can we overcome them?
-Respect patient autonomy, offer support, empathy, don’t take responsibility, your job is to help them help themselves!
More on Sudden Death
-10 –13 annual occurrences
-1: 100,00 – 300,000 HS athletes
-1:15,000 joggers
-1:50,000 marathoners (every year NY marathon expects someone to die!)
-Occurs in M > F
-Most ‘dangerous’ sports for sudden death: 1. Basketball 2. Football 3. (distant third) track
#1 cause is Hypertrophic Cardial Myopathy (most common in young adult)
- Septal hypertrophy that decreases the rt. ventricle capacity and puts pressure on the mitral valve
-Cause: coronary a. anomaly, a history of Marfan, long QT, carditis, murmers
-Most patients are asymptomatic, but some may be dizzy with exercise, history of fainting, chest pain
-Screen with ECG and a history
-Treatment: have to stop exercising or ICD
Screening for exercise
-After 35, screening is necessary for new exercisers (coronary a. disease, Family history of premature CVD
-Stress tests: start at age 40 for males, and 50 for females or 65 for athletes
Mononucleosis
-Airway obstruction and splenic enlargement/ rupture that occurs 4-21 days after infection
-Patients should be kept from exercising for 3-4 wks, and can expect a full return after wk 5
Acute Febrile Illness
-Restrict activities especially with GI illness which may cause increased risk of dehydration and thermo problems
Blood Borne Pathogens
-HIV – the only sport that excludes is boxing
-If patient feels well, then exercise is ok
Osteoarthritis
-Progressive but can be stabilized with exercise
-Avoidance of activity leads to weakness, which leads to joint instability
-Management: NSAIDS, topical analgesics, steroids injections, opioid analgesics
Extreme Exercise
-Exercise addiction
-Increased Injuries
-Risk of overtraining