Transcript Exercise Prescriptions for Chronic Medical Problems

Exercise Prescriptions for Chronic
Medical Problems Including
Chronic Pain
Larry Gordon D.O.
No conflicts to disclose
Objectives
• Formulate a rationale to motivate patients to
increase physical activity
• Select specific exercise options for chronic
medical problems
• Identify specific benefits of exercise in chronic
diseases such as Heart disease, COPD,
Diabetes and osteoarthritis
Physical Activity vs Exercise
• Physical Activity - bodily movement produced by the
contraction of skeletal muscle that increases energy
expenditure above the basal level.
– Categories of physical activity include occupational,
household, leisure time, and transportation
• Exercise – a form of physical activity that is planned,
structured, repetitive, and purposeful with a main
objective of improvement or maintenance of one or
more components of physical fitness.
Measuring Physical Activity
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Basketball – 3 to 9
Bowling - 2 to 4
Cycling 3 to 8
Fishing 2 to 4
Golf 2 to 7
Hunting - 3 to 14
Raquetball 8 to
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Running 8 to 16
Skiing 5 to 12
Snowshoeing - 7 to
14
Soccer 5 to 12
Table Tennis - 3 to 5
Effect of exercise on Mortality
• Observational Studies
– No high quality, long term, randomized trials
• Large studies suggest reduced mortality
among all groups of people
• Beneficial effects seem to be dose dependent
• At least moderate level
• Dependent on disease state
Risks of exercise
• Musculoskeletal injury
• Arrhythmia
• Sudden Cardiac Death – 1 in 1.51 million
episodes of exercise
• Myocardial Infarction
• Rhabdomyolysis
• Bronchoconstriction
Medical Evaluation Prior to Exercise
• General consensus based on large observational studies that a
screening medical evaluation prior to exercise is not necessary
for asymptomatic patients at low risk for coronary heart
disease.
• the Lipid Research Clinics Coronary Primary Prevention Trial
found
– 3617 asymptomatic men with hypercholesterolemia cumulative
incidence of activity-related acute cardiac events was only 2 percent
during a mean follow-up of 7.4 years
Medical Evaluation Prior to Exercise
• However, there may be certain groups in which screening is
warranted.
– Two screening tools, the American Heart Association/American
College of Sports Medicine Preparticipation Questionnaire (AAPQ) and
the Physical Activity Readiness Questionnaire (PAR-Q)have been
developed
– However, in one study that entered data from the National Health and
Nutrition Examination Survey (NHANES) for respondents older than 40
years into the AAPQ criteria, over 90 percent would have met criteria
for a physician evaluation, making this tool of questionable value. The
AAPQ and PAR-Q produced similar results for about 70 percent of
respondents.
Exercise Prescription
• No one prescription for all individuals
– 150 minutes of moderate intensity aerobic activity or
75 minutes of vigorous intensity activity per week
– Moderate increases in physical activity are associated
with improved outcomes
• Should select activities they enjoy so to be more
likely to participate in them
• Resistance (strength) training appears to add to
the benefits of aerobic (endurance) training for
cardiovascular fitness
Exercise Benefits in Cardiovascular Disease
• Potential Benefits
– Improvement in Lipid profile
• Decrease triglycerides
• Increase HDL
– Reduction in Blood Pressure
• 5 to 15 mm Hg in 4 weeks
– Treatment and possible prevention of Type 2 Diabetes
– Reduction in Inflammation
• Reduces atherogenic activity
Exercise Benefits in Cardiovascular Disease
• Primary Prevention
– INTERHEART study of patients from 52 countries;
regular physical activity was associated with an odds
ratio for first MI of 0.86
– Men
• 10,269 Harvard alumni (mean age 58) in a retrospective
study over 12 years. Those who engaged in moderately
vigorous sports activity (defined as total physical activity
levels >4200 kJ/week or brisk walking, recreational cycling or
swimming, home repair, and yard work for 30 min/day on
most days) had a 23 percent lower risk of death than those
who were less active
Exercise Benefits in Cardiovascular Disease
• Primary Prevention
– Women
• Nurses' Health Study of 72,488 women between 40 and 65
years of age found that brisk walking or vigorous exercise
was inversely related to the risk of a coronary event;
• women in increasing quintile groups for energy expenditure
had age-adjusted relative risks for coronary events of 0.88,
0.81, 0.74, and 0.66, indicating a graded benefit from
exercise.
• Sedentary women who became active in mid-life or later had
a lower incidence of coronary events compared to those
who remained inactive
Type, Intensity and Duration of Exercise
• In a cohort of 44,452 men (age 40 to 75) enrolled in the
Health Professionals' Follow-up Study (475,755 patientyears of follow-up), several types of physical activity were
associated with a significant reduction in CHD risk [29]:
– Running for one hour or more per week – relative risk (RR) 0.58;
95% CI 0.44-0.77
– Rowing for one hour or more per week – RR 0.82; 95% CI 0.680.99
– Brisk walking for 30 minutes or more per day – RR 0.82; 95% CI
0.67-1.00
– Lifting weights for 30 minutes or more per week – RR 0.77; 95%
CI 0.61-0.98
Exercise Benefits in Cardiovascular Disease
• Secondary Prevention
– 772 men (mean age 63) with documented coronary
heart disease followed for up to five years found that
the lowest incidence of all-cause and cardiovascular
mortality was seen in those who engaged in light and
moderate activity
• activity included recreational (nonsporting) activity (≥4
hours/week), regular walking (>40 min/day), or moderate or
heavy gardening (adjusted relative risk 0.42 and 0.47
compared to inactivity or occasional light activity)
Exercise Benefits in Cardiovascular Disease
• Secondary Prevention
– A 2005 meta-analysis evaluated trials of cardiac rehabilitation
(including exercise with or without risk factor education) among
patients with coronary disease (most post-MI).
• Exercise rehabilitation alone produced a significant reduction in all-cause
mortality (6.2 versus 9.0 percent, summary risk ratio 0.72, 95% CI 0.54- 0.95)
and an almost significant reduction in recurrent MI (summary risk ratio 0.76,
95% CI 0.57-1.01).
• A combined program of exercise rehabilitation and risk factor education
produced an almost significant reduction in all-cause mortality (9.3 versus 10.8
percent, summary risk ratio 0.88, 95% CI 0.74-1.04) and a significant reduction
in recurrent MI (summary risk ratio 0.62, 95% CI 0.44-0.87).
• The overall mortality benefit from cardiac rehabilitation was present at two
years (summary risk ratio 0.53, 95% CI 0.35-0.81) but not at one year
Exercise in Diabetic Adults
• Short Term effects
– Type 2
• Improves Insulin Sensitivity
• Lower Blood Glucose
– Type 1
• Fall in blood glucose more than a non-diabetic
– May speed insulin absorption
– Cannot shut off exogenous insulin
– In contrast it may cause a paradoxical increase in
blood glucose with poor control
• hypoinuslinemia
Exercise in Diabetic Adults
• Long Term effects
– Type 2
• Understand disease effects
– Insulin-resistant - Decrease in number and function of insulin receptors
and glucose transporters
– Decreased activity of some intracellular enzymes
– Low maximal oxygen uptake (VO2max) during exercise
• Some improve with exercise lasting 2-24 weeks
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Increased activity of mitochondrial enzymes
Increased insulin sensitivity
Muscle capillary recruitment
Addition of resistance training increases glucose disposal
Improves glycemic control
Exercise in Diabetic Adults
• Long Term effects
– Type 2
• Cardiovascular Disease and Mortality
– 5125 women with type 2 diabetes in the Nurses’ Health Study
» women who spent at least four hours per week performing moderate
(including walking) or vigorous exercise had a 40 percent lower risk of
developing cardiovascular disease
• Prospective cohort study of 2896 diabetic adults
– Those who walked for at least two hours per week had lower cardiovascular
mortality rates when compared with inactive individuals (hazard ratio [HR] 0.66,
95% CI 0.45- 0.96; 1.4 versus 2.1 percent per year, respectively).
– Rates were even lower for those who walked three to four hours per week (HR
0.47, 95% CI 0.24-0.91).
– The protective effect was independent of sex, age, race, body mass index, duration
of diabetes, comorbid conditions, and physical limitations.
– The authors calculated that one death per year would be prevented for every 61
adults with diabetes who could be persuaded to walk at least two hours per week.
Exercise in Diabetic Adults
• Long Term effects
– Type 1
• Much less evidence of benefit.
• Same as general population benefits
Pulmonary Rehab in COPD
• Components
– Lower Extremity Exercise
• Increases exercise endurance
• Improvements in walking distance, dyspnea score,
quality of life
– Upper Extremity Exercise
• Unsupported arm training (against gravity) decreased
oxygen uptake more than arm cranking training at the
same workload
Pulmonary Rehab in COPD
• Components
– Continuous vs Interval exercise
• Traditionally continuous but evidence points to interval as an
acceptable alternative
– Breathing retraining
• In a meta-analysis that included sixteen studies with a total
of 1233 participants, three months of yoga with timed
breathing techniques was associated with a significant
improvement in six-minute walk distance, but there was no
consistent improvement in dyspnea or health-related quality
of life
Pulmonary Rehab in COPD
• Components
– Ventilatory Muscle Training
• A meta-analysis of 25 studies that assessed the efficacy of
inspiratory muscle training in patients with stable COPD found
significant increases in inspiratory muscle strength, exercise
capacity, and one measure of quality of life and a significant
decrease in dyspnea
– A meta-analysis of 17 randomized studies of ventilatory
muscle training (VMT) revealed nonsignificant changes in
muscle strength in 11 studies and in respiratory muscle
endurance in the 9 studies in which that outcome was
assessed. However, in 5 studies in which there were
improvements in strength or endurance of the breathing
muscles, gains in functional capacity were noted.
Pulmonary Rehab in COPD
• Mortality
– Impact is uncertain
– 1218 patients, pulmonary rehabilitation did not confer a
mortality benefit, but was associated with improved
exercise capacity, dyspnea, and quality of life
• Quality of Life
– Cochrane meta-analysis of 23 randomized controlled trials
concluded that pulmonary rehabilitation was more
effective than standard community-based care with
respect to quality of life and functional exercise capacity
Pulmonary Rehab in COPD
• Health Care Utilization
– randomly assigned 99 patients to a 6-week
program of pulmonary rehabilitation, while 101
patients received usual care. After one year, there
were no differences in the number of patients
hospitalized, although the length of stay was
significantly shorter among hospitalized patients
who had been randomized to rehabilitation.
Chronic Pain
Steve Vandenberg P.T.