Exercise & Clinical Medicine



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:

1. 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

2. Arrhythmia

- Training reduces risk, acute exercise increases risk

3. 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

4. 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:

a. Under 35, Hypertrophic Cardiac Myopathy

b. Over 35, Coronary a. disease

5. 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.

6. 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

7. Heat/cold illness

8. Dehydration

9. Female athlete Triad – Disordered eating, amenorrhea, osteoporosis

10. 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

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