ࡱ> @B? $bjbjUqUq ">77 lFFFFFFFZ <Z2*,,,,,,$ vPFP$FFe$$$rFF*$*$$:,FF* V"TZHhv *{0RsFs*$ZZFFFFExercise & 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, dont 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 0<L[1A7  R _   < = G H  @ F _ { ^i@N3L.Nz{)q~&'(89:1$528$ j5\5\U/0<L[xK 01%^(^( & F$a$$a$$ R =    ;  E F _ u z {  & F(^( ^`^{ !^i@AN~34Lt+s & F & F(^( & F & F.X Nxz{q]^T & F^^(^(^ & F^ & FTH12=%KLg^^ & F`^ & F&7}2C !r!!!!*""""#^`(^( & F##&#S#~#### $X$Y$j$}$$$ & F 1h/ =!"#$% i8@8 NormalCJ_HaJmH sH tH 2`2 Heading 1$@&5\<A@< Default Paragraph Font<C`< Body Text Indent 8^8,B`, Body Text5\ > /0<L[xK 01%R =;EF_uz { ! ^ i  @ A N ~ 3 4 L t  + s .X Nxz{q]^TH12=%KLg^&7}2Cr*&S~ X Y j } 0000000L0L0L0L0L0L0L0L0L 0L 0L0L0L 0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L0L 0L 0L0L0L 0L 0L 0L 0L0L0L0L0L0L 0L 0 L 0 L 0 L 0L 0 L 0L 0 L 0L0L 0L 0L 0L 0L 0L0L0L 0A L 0A L0L 0L 0L 0L 0L 0L 0L 0L0L 0L 0L 0L 0L 0L 0L 0L 0 L0L0L0L0L0L0L0L0L0L0L 0L0L 0L 00L0L0 0L 0 L 0!L0L0L 0"L 0#L0L0L00000000 0$ 0% 0&000 0' 0( 0) 0* 0+ 0,000 0- 0. 0/ 0000 01 0200 03 0400 0500 0 0700 0 0 0:00 0; 0< 0${ T#$$/4 V b k s    g r -iuN_aj|%TY|  8> &19;BF L   T=D  33333333y'-RX islab%R:\AutoRecovery save of Document1.asdislab4C:\Documents and Settings\islab\Desktop\Exercise.doc$Ip@,k^`OJPJQJ^Jo(- ` ` ^` `OJQJo(o 0 0 ^0 `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( pp^p`OJQJo( @@^@`OJQJo(o ^`OJQJo(88^8`o(.^`. 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