Evidence-based approach to strength training for people with chronic conditions

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Evidence-based approach to strength training for
people with chronic conditions Prof Steve
Selig Clinical Exercise Physiologist (AEP,
PhD) Centre for Ageing, Rehabilitation, Exercise
and Sport (CARES), Victoria University Central
Bayside Community Health Services, Tuesday 9 Sept
2008
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• What does the AEP know and do?
• Exercise Variables
• Ratings of Perceived Exertion
• Generic questions for providing a safe and
  effective exercise service
• Exercise and obesity
• Exercise and type 2 diabetes
• Exercise and chronic heart failure
• Exercise and lipids
• Exercise and hypertension
• Exercise and peripheral arterial occlusive
  disease (PAOD)
• Exercise and cystic fibrosis
• Exercise and depression
• Exercise and Cancer
• Exercise and aortic stenosis
• How to find an AEP

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• Where does the AEP acquire / reinforce knowledge?
• University courses (new AEP courses)
• Supervised clinical practice and other mentoring
• Self-directed learning (PubMed)
• Research (PhD professional doctorate)
• Continuing Education Programs (CEP)
• AAESS, SMA other conferences
• Practice
• Self
• Others

What does the AEP know?
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• The AEP uses exercise therapy to improve
  clients
• clinical status (through 10 and 2o prevention and
  rehabilitation)
• function (fitness)
• quality of life

What does the AEP do?
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Generic questions for providing a safe and
effective exercise service for people with
chronic conditions

• What is the evidence concerning benefits of
  strength (and aerobic) training for this client?
• What are the main risks with participation?
• What are the critical factors in the clients
  medical condition(s) that will influence exercise
  (mode, intensity, duration, frequency, volume and
  progression)?
• What are the critical factors in the persons
  treatments (medical, allied health and
  ?alternative therapies) that will influence
  exercise (mode, intensity, duration, frequency,
  volume and progression)?
• Is there any reason not to start exercise with
  this client? Elaborate.
• Should the person undergo a maximal (eg stress
  test in a hosptial or max test in an exercise
  facility) or submax exercise test before
  starting? Give reasons.

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Generic questions for providing a safe and
effective exercise service for people with
chronic conditions

• What exercise test protocols and other
  assessments should you provide (include both
  exercise and functional tests)?
• What adverse signs and symptoms are the most
  likely to appear as a result of exercise for this
  client (immediate, delayed up to 72 hr and
  chronic)?
• Which of these would cause you to STOP exercise
  and refer to a medical practitioner or other
  health professional?
• What are the likely barriers for exercise for
  this client?
• What are likely enablers for exercise for this
  client?
• What practitioner goals are desirable /
  achievable?
• What client goals are desirable / achievable?
• How should the AEP interact with other health
  professionals in this case?

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Exercise Variables
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Aerobic ? Resistance ? Power
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Moderate intensity ? High intensity
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Volume ? Intensity
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Continuous ? Interval
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Supervised ? Unsupervised
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Group ? Individual
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Hospital Gym ? Community Centre?Home-based
15
Home-based aerobic and strength exercise
training 12 month RCT
Hospitalisations
Exercise
Control
Intervention 12 month home-based exercise _at_
40-60 of HRpeak plus strength training _at_ 80
1RM. Clinical endpoints include mortality,
hospitalisation, ED admissionsFunctional
endpoints include 6MWT, symptom-limited cycle
ergometer test, QOL
Dracup K, Evangelista LS, Hamilton MA, Erickson
V, Hage A, Moriguchi J, Canary C, MacLellan WR,
Fonarow GC. Effects of a home-based exercise
program on clinical outcomes in heart failure.
American Heart Journal. Nov 2007154(5)877-883.
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Men ? Women
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Young ?Old
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Men ? Women Young ? Old
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Structured ? Unstructured
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Monitored ?Unmonitored
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Self-ratings of Perceived Breathlessness
Self-ratings of Perceived Exertion
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Exercise and obesity
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Case Study Obesity

• 49 yr ? 136 kg 177 cm
• Primary school teacher
• Studying for an M.Ed and eating while studying
• Put on weight with each pregnancy (4 children)
• Ex-smoker with mild emphysema
• Husband still smokes (but not in the home)
• Hypertension 145/95 started with beta-x in 2008
• Normal lipids
• Normal glucose
• Kids are all involved in sport, but she sits and
  watches

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Wing RR, Jakicic J, Neiberg R, Lang W, Blair SN,
Cooper L, Hill JO, Johnson KC, Lewis CE. Fitness,
fatness, and cardiovascular risk factors in type
2 diabetes look ahead study. Medicine and
science in sports and exercise. Dec
200739(12)2107-2116
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(No Transcript)
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Summary exercise training for obese / overweight
people
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Exercise and type 2 diabetes mellitis
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Avoiding hyperglycemia and hypoglycemia during
exercise and recovery

• Blood glucose monitoring
• delay exercise if BG gt 14 mmol.l-1 with ketosis
  OR delay if BG gt 17 mmol.l-1 without ketosis
• eat CHO if BG lt 5.5 mmol.l-1
• learn BG patterns in your exercise training

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Avoiding hypoglycemia during exercise and recovery

• Insulin or insulin stimulating drugs
  (sulfonylureas and especially meglitinides)
• ? doses of short acting, intermediate acting and
  injectible bolus doses of insulin or meglitinides
  just before exercise
• do NOT exercise at time of peak insulin level
• do NOT exercise skeletal muscle that underlies
  the site of insulin injection

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Exercise Precautions for patients with DM

• Retinopathy
• avoid high intensity resistance exercise,
  breatholding exercise, exercise with head held
  low (eg diving), or body contact or combat sports
• Hypertension
• avoid high intensity resistance exercise,
  breatholding exercise, exercise with head held
  low (eg diving), or body contact or combat sports

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Exercise Precautions for patients with DM

• Autonomic neuropathy
• avoid exercise in the heat and cold
• beware of hypoglycemia
• heat intolerance due to defective sympathetic
  thermoregulation and sweating
• resting tachycardia and decreased maximal heart
  rate

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Exercise Precautions for patients with DM

• Peripheral neuropathy
• avoid exercise that can cause trauma to the feet
• avoid swimming with foot ulcers
• avoid prolonged weight bearing exercise
• Nephropathy
• avoid high intensity exercise and breatholding

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High-intensity resistance training ? HbA1c in
older patients with T2DM
Exercise Group
Control Group
3 months
? HbA1c at 3 and 6 months
6 months
Dunstan DW, Daly RM, Owen N, Jolley D, De Courten
M, Shaw J, Zimmet P. High-intensity resistance
training improves glycemic control in older
patients with type 2 diabetes. Diabetes Care.
2002251729-36
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High-intensity resistance training ? fat mass and
? lean mass in older patients with T2DM
Exercise Group
Control Group
fat mass
Fat or Lean Mass at 6 months
lean mass
Dunstan DW, Daly RM, Owen N, Jolley D, De Courten
M, Shaw J, Zimmet P. High-intensity resistance
training improves glycemic control in older
patients with type 2 diabetes. Diabetes Care.
2002251729-36
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Hospital Gym ? Community Centre?Home-based
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Dose-response of exercise intensity for T2DM
risk. Female nurses (n 70,102, 40-65 yr),
healthy at entry. Followed up for 8 yr for T2dM
Adjusted for age, smoking, alcohol use, Hx of ?
BP, Hx of ? cholesterol
Adjusted Hazard Ratio
Moderate
Low
High
LTPA
Hu FB, Sigal RJ, Rich-Edwards JW, Colditz GA,
Solomon CG, Willett WC, Speizer FE, Manson JE.
Walking compared with vigorous physical activity
and risk of type 2 diabetes in women a
prospective study. Jama. 19992821433-9
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Case Study T2DM

• 35 yr ? 142 kg 180 cm, BP 140/90
• 1996 morbid obesity (BMI gtgt 40)
• 2006 T2DM
• 2006 gastric band surgery still occasionally
  attending bariatric clinic for band adjustment
  and counselling
• 2006 foot ulcer that took 7 months to heal
• Stopped exercise altogether while foot ulcer was
  healing!

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Summary exercise with diabetes
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Summary exercise with diabetes
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Exercise and chronic heart failure (CHF)
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Moderate intensity strength training RCT n
39 3x/wk for 12 weeks

P lt 0.01

VO2peak ml.kg-1.min-1
CHF Exercise
CHF Inactive
Aged healthy
Selig S, Carey M, Krum H, Hare D et al.
Moderate-intensity resistance exercise training
in patients with chronic heart failure improves
strength, endurance, heart rate variability and
forearm blood flow. Journal of Cardiac Failure.
10(1)21-30, 2004.
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High intensity aerobic training Dubach et al.,
1997 RCT n 25 2x1 hr walks plus 4x 40 min
high intensity cycle sessions _at_ 70-80 of
VO2peak 2 months
VO2peak ml.kg-1.min-1
High Intensity Dubach et al., RCT n25
Meta-analysis van Tol et al., 31 studies n1240
Aged healthy
van Tol BA, Huijsmans RJ, Kroon DW, Schothorst M,
Kwakkel G. Effects of exercise training on
cardiac performance, exercise capacity and
quality of life in patients with heart failure a
meta-analysis. Eur J Heart Fail. Dec
20068(8)841-850
Dubach P, Myers J, Dziekan G, Goebbels U,
Reinhart W, Vogt P, Ratti R, Muller P, Miettunen
R, Buser P. Effect of exercise training on
myocardial remodeling in patients with reduced
left ventricular function after myocardial
infarction application of magnetic resonance
imaging. Circulation. Apr 15 199795(8)2060-2067.
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Changes to EDV and ESV with aerobic alone versus
combined aerobic / resistance exercise training
(meta-analysis of 7 RCTs n 569
Aerobic
Changes in Cardiac Volumes (ml)
Combined (aerobic resistance)
EDV
ESV
Haykowsky MJ, Liang Y, Pechter D, Jones LW,
McAlister FA, Clark AM. A meta-analysis of the
effect of exercise training on left ventricular
remodeling in heart failure patients the benefit
depends on the type of training performed.
Journal of the American College of Cardiology.
Jun 19 200749(24)2329-2336
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Moderate intensity strength training RCT n
39 3x/wk for 12 weeks
Elderly CHF 65 yr, NYHA 2.3 Exercise 3x/wk 12
wk Intensity 13-15 Borg RPE Limitations
Small n 39 Mostly males n 33
Strength (Nm) all four movements combined
P lt 0.01
CHF Exercise
CHF Inactive
Aged healthy
Selig S, Carey M, Krum H, Hare D et al.
Moderate-intensity resistance exercise training
in patients with chronic heart failure improves
strength, endurance, heart rate variability and
forearm blood flow. Journal of Cardiac Failure.
10(1)21-30, 2004.
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High intensity strength training RCT n 16
3x/wk for 10 weeks, elderly females with CHF
All females Exercise 3x/wk 10 wk n
9 Intensity 80 1RM Sham Exercise control n
7 Also non-CHF controls n 80 Limitations
Very small n 9 for exercise group
Strength (N) leg press
Aged Controls
CHF Exercise
CHF Inactive
Pu CT, Johnson MT, Forman DE, Hausdorff JM,
Roubenoff R, Foldvari M, Fielding RA, Singh MA.
Randomized trial of progressive resistance
training to counteract the myopathy of chronic
heart failure. J Appl Physiol. Jun
200190(6)2341-2350
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Whole Body Moderate intensity strength training
RCT n 39 3x/wk for 12 weeks
Submax exercise
Rest
PRH
Forearm blood flow ml.100ml-1.min-1
Age-matched Controls
CHF after training
CHF before training
Selig S, Carey M, Krum H, Hare D et al.
Moderate-intensity resistance exercise training
in patients with chronic heart failure improves
strength, endurance, heart rate variability and
forearm blood flow. Journal of Cardiac Failure.
10(1)21-30, 2004.
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Handgrip (only) strength training RCT n 12
with just 6 patients in EX group daily for 8
weeks
Forearm blood flow ml.100ml-1.min-1
CHF after training
CHF before training
Contralateral (non-trained) limb No changes to
rest, stimulated or peak blood flows ? training
effects were local
Katz SD, Yuen J, Bijou R, LeJemtel TH. Training
improves endothelium-dependent vasodilation in
resistance vessels of patients with heart
failure. J Appl Physiol. May 199782(5)1488-1492
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Increased intensity ? high intensity resistance
training
Exercise intensity of 1RM
Levinger I, Bronks R, Cody DV, Linton I, Davie A.
Resistance training for chronic heart failure
patients on beta blocker medications. Int J
Cardiol. Jul 20 2005102(3)493-499.
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Continuous ? Interval
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High Intensity Interval Training HIT versus
Moderate Intensity Continuous Exercise MCT in
elderly CHF patients (RCT n 27 76 yr)
change
Exercise 3x/wk 12 wk HIT 95 HRpeak MCT 70
HRpeak Inactive controls Isocaloric
design Limitations Small sample n 27
Mostly males n 20
VO2peak
ESV
Wisloff U, Stoylen A, Loennechen JP, Bruvold M,
Rognmo O, Haram PM, Tjonna AE, Helgerud J,
Slordahl SA, Lee SJ, Videm V, Bye A, Smith GL,
Najjar SM, Ellingsen O, Skjaerpe T. Superior
cardiovascular effect of aerobic interval
training versus moderate continuous training in
heart failure patients a randomized study.
Circulation. Jun 19 2007115(24)3086-3094
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High Intensity Interval Training HIT versus
Moderate Intensity Continuous Exercise MCT in
elderly CHF patients (RCT n 27 76 yr)
BNP
FMD
change
Exercise 3x/wk 12 wk HIT 95 HRpeak MCT 70
HRpeak Inactive controls Isocaloric
design Limitations Small sample n 27
Mostly males n 20
Wisloff U, Stoylen A, Loennechen JP, Bruvold M,
Rognmo O, Haram PM, Tjonna AE, Helgerud J,
Slordahl SA, Lee SJ, Videm V, Bye A, Smith GL,
Najjar SM, Ellingsen O, Skjaerpe T. Superior
cardiovascular effect of aerobic interval
training versus moderate continuous training in
heart failure patients a randomized study.
Circulation. Jun 19 2007115(24)3086-3094
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Case Study CHF

• 72 yr ? 62 kg 175 cm
• 1992-1996 AMI x 4
• 1993 CABG
• 1995 CABG and Dx CHF
• 1996 aF
• 1997 defibrillation ? sinus rhythm
• 1998 coeliac disease (???Hb 7)
• 2007 BP105/60 Chol 3.3 TG0.7
• 2007
• exercised to heart rate of 110 bpm Borg RPE
  16/20
• HR jumped to 150 during first minute of recovery
  (atrial flutter)

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Exercise and lipids
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Acute versus chronic effects of exercise training

• A single exercise session ?
• ? TGs
• HDLchol
• ?LDLchol
• ? BP
• ? insulin sensitivity and glucose handling

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Summary exercise training for people with
dyslipidemias
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Exercise and hypertension
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Chronic changes in blood pressure with exercise
training (meta-analysis of 44 RCTs ? 2,677
people 21-79 yrs)
SBP
DBP
? Blood Pressure mmHg
Normotensive
Hypertensive
Kesaniemi YK, Danforth E, Jr., Jensen MD,
Kopelman PG, Lefebvre P, Reeder BA. Dose-response
issues concerning physical activity and health
an evidence-based symposium. Med Sci Sports
Exerc. 200133S351-8
57
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Prevention of stroke in urban, elderly people
(post-hoc incidence study of n 369 men and women
with history of ischaemic stroke, compared to 678
controls)
Intensity of LTPAs
Physical activity ? frequency and duration of 14
activities over the 2 weeks prior to
enrolment Odds Ratio controlled for
cardiovascular disease, diabetes, obesity,
smoking, alcohol use
Adjusted Odds Ratio
LTPA
Inactive
LightModerate
Heavy
Sacco RL, Gan R, Boden-Albala B, Lin IF, Kargman
DE, Hauser WA, Shea S, Paik MC. Leisure-time
physical activity and ischemic stroke risk the
Northern Manhattan Stroke Study. Stroke.
199829380-7
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Summary exercise training for people with ? BP
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Exercise and peripheral arterial occlusive
disease (PAOD)
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Case Study PAOD JH54 year old male110kg, 181
cm (BMI 33), WG 108 cm1974 smoker (40 pack
years) 2001 T2DM 2007 PAOD

• This case study is based on evidence in
  Sandri M, Adams V, et al. Effects of Exercise and
  Ischemia on Mobilization and Functional
  Activation of Blood-Derived Progenitor Cells in
  Patients With Ischemic Syndromes. Circulation.
  Jun 28 2005111(25)3391-3399

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Bone marrow-derived endothelial progenitor cells
(EPCs) contribute to angiogenesis (new vessel
formation)

• Endothelial progenitor cells (EPCs purple
  circles) arise in the bone marrow.
• These cells are induced to leave the bone marrow
  and enter the vasculature by circulating
  angiogenic factors such as vascular endothelial
  growth factor (VEGF).
• Once in the circulation, these cells arrive at
  sites of ischaemia where there is ?? VEGF.
• These cells then can participate in new vessel
  formation by differentiating into branching blood
  vessels.

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• EBP ischaemic treadmill training Sandri M,
  Adams V, et al. Effects of Exercise and Ischemia
  on Mobilization and Functional Activation of
  Blood-Derived Progenitor Cells in Patients With
  Ischemic Syndromes. Circulation. Jun 28
  2005111(25)3391-3399
• Ischaemic training ? ? release (from bone
  marrow), ? mobilization, ? activation of
  blood-derived progenitor cells ? ? angiogenesis
• Non-ischaemic training ? did not change release,
  but did ? activation
• Both ischaemic and non-ischaemic training ? ?
  incorporation of progenitor cells ? ?
  angiogenesis, but ischaemic training exerts more
  powerful effects by ? ? release of progenitor
  cells
• Need at least 30 mins of continuous exercise
  Laufs U, Urhausen A, Werner N, Scharhag J, Heitz
  A, Kissner G, Bohm M, Kindermann W, Nickenig G.
  Running exercise of different duration and
  intensity effect on endothelial progenitor cells
  in healthy subjects. Eur J Cardiovasc Prev
  Rehabil. Aug 200512(4)407-414.

JH54 yr male PAODT2DM WG 108smoker
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• Other exercise and physical activity should
  include
• high volumes (gt2,000 kcal / wk) of exercise and
  physical activity for WG http//www.americanheart.
  org/presenter.jhtml?identifier1226
• resistance exercise (Dunstan DW, Daly RM, Owen N,
  Jolley D, De Courten M, Shaw J, Zimmet P.
  High-intensity resistance training improves
  glycemic control in older patients with type 2
  diabetes. Diabetes Care. Oct 200225(10)1729-1736
  )
• episodal activity and exercise (breaks in
  sedentary behaviour (Healy GN, Dunstan DW, Salmon
  J, Cerin E, Shaw JE, Zimmet PZ, Owen N. Breaks in
  Sedentary Time Beneficial Associations with
  Metabolic Risk. Diabetes Care. Feb 5 2008)
• Use exercise and physical activity to reduce
  stress (helps with smoking cessation)

JH54 yr male PAODT2DM WG 108smoker
65

• Apply your understanding / knowledge / awareness
  of-
• Exercise assessment
• In hospital
• Peripheral ischaemic threshold ? angina threshold
  ? STOP intensity (but limit exercise to ? angina
  threshold)
• Out of hospital
• Peripheral ischaemic threshold ? STOP intensity ?
  angina threshold
• Be careful if patient is on warfarin
• At high intensity exercise ? thrombogenic to
  fibrinolytic balance ? thrombogenic dominance

JH54 yr male PAODT2DM WG 108smoker
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Exercise and cystic fibrosis
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Case study 20 year old Lorin Haire with
cystic fibrosis Case from http/www.cysticfibrosi
s.org.au/
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Cystic Fibrosis diagnosis

• sweat test ??? sodium chloride
• detection of urinary para-aminobenzoic acid
  (PABA) after ingestion of benzoyl-tyrosyl-PABA
• detection of 14CO2 after ingestion of
  14C-palmitate

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• Presentation
• 20 yrs old
• CF diagnosed at 2 ½ years with sweat test ???
  salt in sweat failure to thrive
• Pancrease capsules
• She hated having chest physiotherapy
• 3 admissions to hospital in her life at 2, 8 and
  12 yrs of age for a tune up of intravenous
  antibiotics, physiotherapy and reassessment of
  dietary habits
• Her motto is Never Give Up

Case study 20 year old Lorin Haire with cystic
fibrosis
70

• Exercise
• She participated in school swimming, cross
  country and athletics at primary and secondary
  school
• But her passion is netball
• State Age Championships
• State League
• At 15 yr torn ACL in my L knee ? full knee recon
  and rehab for 14 months
• During this time, she put a high priority on
  maintaining good lung clearance and preventing
  chest infections, even though she was not able to
  exercise

Case study 20 year old Lorin Haire with cystic
fibrosis
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• Her thoughts on active lifestyle and CF
• I believe with the amount of exercise, training,
  and mental strength I have learnt over the years
  while playing netball has helped me stay fit,
  healthy and reduced the severity of CF episodes
  in my life.
• I hope everyone gets the opportunity to develop
  a passion for something they love like I have
  with netball.
• Remember Never Give Up!

Case study JD 20 year old Lorin Haire with
cystic fibrosis
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• Goals of exercise for people with CF
• ? well being and QoL
• ? breathing using exercise
• ? breathing demand at low and moderate
  intensities of exercise
• move and expel mucus ? alternative to chest
  physiotherapy
• ? exercise tolerance
• preserve bone density
• Breathing aids for people with CF during exercise
• O2 therapy
• bronchodilator

Goals for people with CF Exercise
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Exercise and depression
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Case Study depression

• 2001 Sleep disturbance (poor sleep quality)
• 2005 Stillnox (irregular had good sleep)
• 2008 Temazepam replacing Stillnox
• 2008 July sleep study ? moderate obstrucutve
  sleep apnoea (OSA) client is exhausted and
  stressed and anxious and wants to sleep unable
  to fall asleep due to anxiety, over-reactive
  mind work stress.
• Deficiency in Vitamin D (less sunlight in the
  office)
• Aug 2008 selective serotonin reuptake inhibitor
  (SSRI) for depression (Lexapro, Cipralex)
• Diet is heavily linked to anxiety and stress
  whilst food quality is not bad, he eats to
  relieve stress and anxiety and this is not
  helping his body weight and probably exacerbating
  his OSA

Willey KA, Singh MA. Battling insulin resistance
in elderly obese people with type 2 diabetes
bring on the heavy weights. Diabetes care. May
200326(5)1580-1588.
75
Case Study depression

• Current exercise
• 20- 25 times gets up to go to printer which is
  20m away in 1 direction (accrues to 1 Km a day)
  low intensity.
• Walking in the mornings 2-3 times a week for
  1hour, apart from personal training.
• Walks regularly to the car.
• Twice a week (5-6pm) personal trainer
  combination of 20-25 min aerobic (14 -16 Borg
  6-20 point RPE scale) weight training, free
  weights (15-16 on Borg scale) core stability
  with exercise ball. Prefers to do exercise at
  that time of day. He is with personal trainer for
  past 3 years.

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Exercise and Cancer
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VO2peak ? effects on cancer mortality in men
(n2,890). Follow-up period 1972-6 (exercise
test) to 1998.
Adjusted Hazard Ratio
Evenson KR, Stevens J, Cai J, Thomas R, Thomas O.
The effect of cardiorespiratory fitness and
obesity on cancer mortality in women and men. Med
Sci Sports Exerc. 200335270-7
77
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BMI ? effects on cancer mortality in women
(n2,585). Follow-up period 1972-6 (BMI) to 1998.
Adjusted Hazard Ratio
Evenson KR, Stevens J, Cai J, Thomas R, Thomas O.
The effect of cardiorespiratory fitness and
obesity on cancer mortality in women and men. Med
Sci Sports Exerc. 200335270-7
78
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Exercise and aortic stenosis
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Case Study Aortic Valve Stenosis

• Male 57 yr, 85 kg, previously enjoyed very active
  life ? adventure activities such as
  mountaineering and rock climbing
• Aortic Valve Stenosis ? Aortic Valve Replacement
  in 2005
• Heart murmur prior to and after the surgery
• Early stage LVH
• Medications
• Metoprolol
• Beta receptor antagonist
• Quinapril
• angiotensin-converting enzyme inhibitor (ACEI).
• Aortic stenosis can cause
• Dizziness / Syncope
• Angina
• Congestive heart failure
• Cure ? replacement with a synthetic heart valve
• Emphasis here is on pre-operative exercise

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Aortic Valve Stenosis
82
Aortic stenosisLV Aorta pressure gradient
83
Aortic Valve Stenosis

• Aortic Valve Stenosis ? LV and arterial blood
  pressures?
• Do we know BPLV using this technique?
• Do we bother with measuring BPart?
• Can we measure BPLV?
• Are people with severe AS at risk of a
  haemmorhagic stroke when straining during
  exercise?
• What are the cardiovascular factors that we need
  to address when designing
• resistance exercise training plan?
• aerobic exercise training plan?

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How to find an AEP
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Find an AEP http//aaess.com.au
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Find an AEP http//aaess.com.au
87
Questions and Discussionthe most important
slide!!

• ? !