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Exercise and Chronic Disease

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Title: Exercise and Chronic Disease


1
Exercise and Chronic Disease
  • Mark A. Patterson, M.Ed., RCEP
  • Clinical Exercise Physiologist Kaiser
    Permanente
  • President-Elect Rocky Mountain ACSM

2
Hippocrates
Eating alone will not keep a man well he must
also take exercise. For food and exercise, while
possessing opposite qualities, yet work together
to produce health. Hippocrates, Regimen, 5th
Century B.C. Slide borrowed from Russ Pate and
Robert Salis
3
www.exerciseismedicine.org
4
Common Chronic Diseases
  • Cardiovascular disease Heart Attack, Stroke,
    PAD
  • Pulmonary disease Asthma, COPD, Emphysema
  • Diabetes Neuropathies, CAD
  • Neuromuscular disorders Multiple
    Sclerosis,Parkinsons
  • Musculoskeletal conditions Arthritis
  • Cancer Breast, Prostate, Leukemia
  • Renal disease Kidney Failure, CAD
  • Immunological AIDS
  • Obesity All of the above?

5
Chronic Diseases
  • Cardiovascular disease 79 million (2007 CDC
    Website) Pulmonary disease 35 million (2007
    American Lung Association),Diabetes 14.6
    Million (2005 CDC Website) Neuromuscular
    disorders (MS, 2.5 million national ms society /
    Parkinsons 1.5 million , National Parkinson
    Foundation)
  • Musculoskeletal conditions (Rheumatoid 2.1
    million, osteo 21 million, juvenile 300,000,
    national arthritis foundation) Obesity 99
    Million (Based off CDC and Census Bureau Sites)
    Cancer 10.1 Million 2002 (American Cancer
    Society Website) Renal disease 20 million
    (American Kidney Fund)
  • Immunological (AIDS 36.1 Million AIDS.org

6
Benefits of Exercise
Increased VO2 Improved BP Control Increased
HDL Decreased Body Fat Improved Weight
Control Improved BS Control Improved
Strength Less Fatigue Improved Balance
Heart Disease Lung Disease Diabetes Neuromuscular
Musculoskeletal Obesity Cancer Kidney
Disease AIDs
7
Who is Best to Care for These People?
  • Me!
  • In an Ideal World
  • Clinical Exercise Physiologists
  • Physical Therapists
  • Respiratory Therapists
  • Registered Nurses
  • Physicians
  • Personal Trainers
  • Massage Therapists
  • Accupuncture
  • Chiropractors

8
What is Clinical Exercise Physiology?
  • The Registered Clinical Exercise Physiologist is
    an allied health professional who works with
    apparently healthy people and patients with
    chronic diseases and conditions where exercise
    has been proven to provide therapeutic benefit.
    The RCEP performs exercise assessments and
    prescribes exercise and physical activity,
    primarily in hospitals, clinics or other
    health-care provider settings. The RCEP assists
    individuals in developing self-management skills
    to promote good health. The RCEP is an integral
    part of the health care team and works closely
    with other health professionals including
    Physicians, Nurses, Nurse Practitioners,
    Physician Assistants, Respiratory Therapists,
    Physical Therapists and Registered Dietitians.
  • RCEPs are trained to work with patients with
    chronic diseases such as Cardiovascular
    disease, pulmonary disease, diabetes,
    neuromuscular disorders, musculoskeletal
    conditions, obesity, cancer, end stage renal
    disease, neoplastic / immunological /
    hematological disorders

9
CEP or PT?
Physical therapy, which is limited to the care
and services provided by or under the direction
and supervision of a physical therapist,
includes
Aerobic capacity/endurance ,anthropometric
characteristics , arousal, attention, and
cognition, assistive and adaptive devices
,circulation (arterial, venous, lymphatic),
cranial and peripheral nerve integrity,environment
al, home, and work (job/school/play) barriers,
ergonomics and body mechanics, gait, locomotion,
and balance, integumentary integrity ,joint
integrity and mobility, motor function (motor
control and motor learning), muscle performance
(including strength, power, and endurance),
neuromotor development and sensory integration,
orthotic, protective, and supportive devices ,
pain, posture, prosthetic requirements, range of
motion (including muscle length), reflex
integrity, self-care and home management
(including activities of daily living and
instrumental activities of daily living) ,
sensory integrity, ventilation, and
respiration/gas exchange, work (job/school/play),
community, leisure integration or reintegration
(including instrumental activities of daily
living)
2. Alleviating impairment and functional
limitation by designing, implementing, and
modifying therapeutic interventions that include,
but are not limited to
Coordination, communication and documentation,
patient/client-related instruction, therapeutic
exercise, functional training in self-care and
home management (including activities of daily
living and instrumental activities of daily
living), functional training in work
(job/school/play) and community and leisure
integration or reintegration activities
(including instrumental activities of daily
living, work hardening, and work conditioning),
manual therapy techniques (including
mobilization/manipulation) prescription,
application, and, as appropriate, fabrication of
devices and equipment (assistive, adaptive,
orthotic, protective, supportive, and
prosthetic), airwayclearance techniques,
integumentary repair and protection techniques,
electrotherapeutic modalities, physical agents
and mechanical modalities
3. Preventing injury, impairment, functional
limitation, and disability, including the
promotion and maintenance of health, wellness,
fitness, and quality of  life in all age
populations
4. Engaging in consultation, education, and
research
10
Exercise and Death(Men)
11
Exercise and Death (Women)
12
What is the Best Way to Increase Physical
Activity?
  • Monitored rehab?
  • Personal training?
  • Case management?
  • Doctors Advice / Guidance?
  • Physical Therapy?
  • Community Resources?
  • Support Groups?
  • Recreation Center Memberships?

13
Comprehensive Risk Factor Modification Kaiser
Permanente Colorado Cardiac Rehabilitation Model
of Integrated Delivery of Health Care
  • MI / ACS / PCI / CABG
  • Case Manager Monitored CR
  • CEP CPCRS Dietician Cardiologist
    PCP Other Resources

14
Clinical Exercise Physiologist Role Kaiser
Permanente Colorado Cardiac Rehabilitation Model
of Integrated Delivery of Health Care
  • Clinical Exercise Physiologist
  • Exercise Rx / Consult (One-on-One)
  • Monitored Sub-Max Exercise Testing
  • ROM / Flexibility Evaluation
  • Strength Evaluation
  • Behavior Change Counseling
  • Monitored Rehab Cardiologist PCP Other
    Resources

15
Functional Exercises
  • What is a functional exercise?
  • Exercise that is specific to and closely mimics
    task to be completed.
  • Walking lunge better to strengthen muscles to
    assist in increasing efficiency of walking /
    running than leg extensions.

16
INDIVIDUALIZE!!!!!!!!!
  • Each patient is a delicate snowflake!
  • Make sure to get detailed history of disease,
    co-morbidities, check that risk factors are in
    control, prior exercise history, check for
    current symptoms and review support team and
    resources for exercise

17
What is the Risk of Exercise?
18
Exercise Prescription Tips
  • Cardiovascular
  • Medications (HR and BP)
  • Symptoms (CAD, CHF, PAD)
  • F.I.T. Principle Considerations
  • Importance of Warm Up and Cool Down
  • Do not hold your breath!

19
When can they start?
  • Assuming Patient is Medically Stable
  • All patients should start with slow progression
    of walking, stationary bike, etc.
  • PCI without MI exercise testing and more
    moderate exercise after about 4 weeks of
    consistent low intensity aerobic exercise.
  • MI with or without PCI exercise testing and
    more moderate exercise after about 4-6 weeks of
    consistent low intensity aerobic exercise.
  • CABG exercise testing and more moderate aerobic
    exercise about 4 weeks post surgery, moderate
    strength training about 12 weeks post surgery.
  • CHF Asymptomatic patients increase aerobic
    exercise very conservatively as can tolerate, if
    EF is below 30 strength training may be
    contraindicated.

20
Exercise Prescription TipsPeripheral Vascular
Disease
  • Claudication
  • Walking is a must Specificity
  • 2 Most Important Measures
  • 1. Onset of symptoms
  • 2. Maximum walk time
  • Intermittent Walking to Moderate Pain
  • High Risk of Heart Disease (CAD)
  • Add other modes of aerobic exercise to increase
    total conditioning time
  • Role of Strength Training
  • Non-Claudicant
  • Can prescribe exercise like people with heart
    disease / or at high risk for heart disease

21
Claudication and Strength Training
Hiatt WR, et al, Peripheral Arterial and Aortic
Diseases Superiority of Treadmill Walking
Exercise Versus Strength Training for Patients
with Peripheral Arterial Disease Implications
for the Mechanism of the Training Response.
Circulation 90(4) October 1994 1866-1874
22
Exercise Prescription TipsLung Disease
  • Perceived Exertion vs. Shortness of Breath
  • Reliability of HR?
  • Aerobic
  • Walking Part of most activities of daily
    living.
  • Stationary Bike
  • Arm Ergometer
  • Importance of Strength Conditioning
  • 1. Improve efficiency of muscles / conservation
    of energy

23
Exercise Prescription TipsDiabetes
  • Monitor Blood Sugar Before and After
  • 250 with Ketones,
  • Post Exercise Hypoglycemia
  • Meals and Medications
  • Autonomic Neuropothy and HR
  • Peripheral Neuropothy and Wound Care

24
Exercise Prescription TipsDiabetes
  • Autonomic Neuropathy
  • Silent ischemia and infarction, tachycardia at
    rest and early in exercise, reduced max HR,
    exercise intolerance, exercise induced
    hypotension, thermoregulatory dysfunction, prone
    to dehydration and hypoglycemia unawareness.
  • Peripheral Neuropathy
  • Loss of peripheral sensation, poor healing of
    wounds, overstretching can cause musculoskeletal
    injury, loss of balance, falling

25
Exercise Prescription TipsDiabetes
  • Aerobic
  • Frequency
  • 3-7 days per week
  • Intensity
  • 40-60 Moderate
  • 60 Vigorous
  • Time
  • 150 minutes / week moderate
  • 90 minutes / week vigorous
  • Resistance Training
  • Frequency
  • 3 days per week
  • Intensity
  • 8-10 repetitions
  • Volume of Exercise
  • 8 exercises
  • Aerobic Exercise Modes
  • Choose exercises such as stationary bike and
    eliptical trainers
  • - help with balance
  • - less chance of falling
  • Walking also a good choice as involved in most
    activities of daily living specificity
  • Resistance Training Modes
  • Machine weights are preferred at start since they
    can help with balance

26
Exercise Prescription TipsMultiple Sclerosis
  • Aerobic Exercise
  • 1. Perceptual Scale better for Exercise
    Intensity
  • 2. Adjust daily according to symptoms and energy
    levels
  • 3. Avoid exercise in heat, exercise early in day
    better for symptoms of fatigue
  • 4. Bladder issues can cause patients to not
    hydrate properly
  • Strength Training
  • 1. Optimize in unaffected muscle groups
  • 2. Functional exercises best, Emphasize core
    groups
  • 3. Increase rest period time
  • 4. During times increased symptoms focus
    stretching, ROM
  • 5. Weight machines preferred.

27
Exercise Prescription TipsParkinsons Disease
  • Aerobic
  • Safety walking is preferred, but may need to
    use bike ergometer, eliptical, arm ergometer or
    others if symptoms warrant.
  • Balance devices harness, walking poles
  • Strength
  • Warm up important
  • Focus on exercises that extend the trunk
  • Functional exercises best
  • Auditory cues may be needed to help
  • with timing of repetitions
  • Ensure good posture

28
Exercise Prescription TipsOsteoarthritis
  • Weight Bearing Aerobic Exercise
  • Continuous weight bearing aerobic exercise can be
    difficult
  • Careful with those who have severe osteoporosis
  • Water Walking against current may be a good
    option
  • Exercises to improve balance
  • Minimize forward flexion and twisting movements
  • Can start with strength training
  • Can do combination of short bouts of aerobic
    training with strength training done during rest
    periods.

29
Exercise Prescription TipsRheumatoid Arthritis
  • Can follow same basic guidelines as with
    osteoarthritis
  • Avoid exercise during inflamatory phase

30
Exercise Prescription TipsFibromyalgia
  • Must customize to individual
  • Careful to avoid overexertion
  • Progress slowly (water to land walking)

31
Exercise Prescription TipsObesity
  • Walking important as is involved in most aspects
    of activities of daily living
  • If balance is an issue then stationary bikes and
    eliptical trainers are good option
  • Water walking and water aerobics ideal for those
    with problematic joints
  • Watch carefully for signs of cardiopulmonary and
    metabolic disease.

32
Exercise Prescription TipsObesity
  • Strength Training
  • Machine weights may help with balance and help to
    ensure proper form
  • Light weights recommended with moderate to high
    repetitions
  • May be best option to concentrate on early as
    de-conditioning and joint issue may limit ability
    to perform aerobic exercise at onset of new
    program

33
Exercise Prescription TipsAIDS
  • HIV
  • Exercise Rx must be adapted per stage of disease
  • Asymptomatic usual general ACSM guidelines are
    fine
  • Symptomatic need to adjust day to day, should
    not exercise with fever above 100, or if having
    nausea, vomiting, uncontrolled diarrhea or
    dehydration

34
Exercise Prescription TipsAIDS
  • Moderate better, overtraining increases
    likelihood of infections
  • Environment
  • Abrasions, tissue injuries
  • Cross infection, sharing of water bottles
  • Overseas travel

35
Exercise Prescription TipsAIDS
  • Exercise and Sickness
  • Common cold
  • Mild to moderate exercise OK
  • Intense exercise OK a few days after symptoms
    resolve
  • Fever, extreme fatigue, muscle aches best to
    wait 2-4 weeks before resuming intense exercise

36
Exercise and Dialysis
  • Effects of Kidney Disease and Long Term Dialysis
  • bone disease, fatigue, coronary artery disease
    and rhythm disturbances

37
Exercise and Dialysis
  • Because of the reduction in cardiovascular risk
    factors that results from exercise training, and
    because of the need to prevent progressive
    deconditioning, dialysis patients may actually be
    placed at a greater risk for cardiac events and
    adverse musculoskeletal outcomes in the are not
    participating in regular physical activityAdv
    Ren Repl Ther, Vol 6, No 2, 1999 pp 165-171

38
Exercise and Dialysis
39
Exercise and Dialysis
  • Exercise Tips
  • Breathing is at conversational level
  • Feel complete recovery in one hour post exericse
  • Warm up and cool down essential
  • Expect some mild soreness after exercise but not
    so much that it prevents activity.
  • When Not to Exercise
  • Body temperature 101.0 degrees (38.3 degrees C)
  • Missed more than one treatment
  • Newly undiagnosed illness
  • Pain
  • Not feeling well
  • Blood Pressure
  • Unstable sugar levels

40
Exercise and Cancer
  • 1. Follow the advice of Barbara Francis
  • 2. Be consistent
  • 3. Have Sean Swarmer take you for a little hike
    in Nepal

41
References
  • ACSMs Guidelines for Exercise Testing and
    Prescription, 7th Edition
  • Manual of Exercise Testing, 3rd Edition
    Froelicher and Myers
  • ACSMs Exercise Management for Persons with
    Chronic Diseases and Disabilities, 2nd Edition
    Durstine and Moore
  • ACSMs Resource Manual for Guidelines for
    Exercise Testing and Prescription, 5th Edition
  • Exercise and the Heart, 4th Edition, Froelicher
    and Myers
  • Cardiac Rehabilitation, Adult Fitness, and
    Exercise Testing, 3rd Edition Fardy and
    Yanowitz
  • NSCAs Essentials of Strength Training and
    Conditioning
  • Clinical Exercise Physiology Application and
    Physiological Principles LeMura and Von
    Duvillard
  • ACSMs Resources for Clinical Exercise Physiology
  • The American Physical Therapy Association Book of
    Body Maintenance and Repair Moffat and Vickery
  • Exercise Physiology Human Bioenergetics and Its
    Applications, 2nd Edition Brooks, Fahey and
    White
  • Good Ol Fashioned Experience since 1989
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