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Exercise Prescription for Health Irish Association of Cardiac Rehabilitation


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Title: Exercise Prescription for Health Irish Association of Cardiac Rehabilitation

Exercise Prescription for HealthIrish
Association of Cardiac Rehabilitation
  • Joseph Cummiskey MD
  • Dean FSEM, RCSI and RCPI
  • President EFSMA
  • 11th November, 2013

The program this evening
  • Introduction Why exercise is good?
  • The big question which the FSEM faces how much
    physician input?
  • Exercise talk EPH, an initiative of EFSMA what
    is involved?

IntroductionWhy exercise is good
  • Part 1.
  • No conflicts of interest

Effect of fitness (CRF) on mortality
The ethics of not prescribing exercise Is it
  • Large studies from Europe and the USA have shown
    that low cardio-respiratory fitness is the single
    biggest risk factor for all-cause mortality.
  • The importance of sports medicine, in particular
    the benefits of physical activity in
    non-communicable disease prevention and chronic
    disease management, should be incorporated into
    the core under and post graduate teaching

  • Physicians and other health professionals can
    contribute substantially to patients' adoption of
    exercise behaviours, just as they have provided
    smoking cessation advice and contribute to
    smoking reduction in many countries.
  • A straightforward but influential step forward
    would be measurement of the exercise as the 5th
    vital sign in every consultation.
  • Patients ought to report how many minutes of
    physical activity they undertake in an average
    day and how many days a week such activity takes

Nothing about exercise is new As old as history
  • Hippocrates 5th century if one exercised they
    become more healthy, well-developed and age more
  • Herodotus 5th century BC. The father of histories
    If we could give every individual the right
    amount of nourishment and exercise, not too
    little and not too much, we would have found the
    safest way to health.
  • Plato 5th BC. Lack of activity destroys the
    good condition of every human being, while
    movement and methodical physical exercise save it
    and preserve it.

There has been an Acceleration in knowledge
technologyabout exercise physiology
  • Occurred in 1968 after Karl Wasserman, Brian
    Whipp and Antonius Van Kessel published their
    paper on breath by breath analysis during
    exercise. This microprocessor now forms the basis
    for all clinical C-P ex tests machines.
  • This was supplemented by the introduction of the
    Hewlett Packard ear oximeter in 1970.
  • At last we had non-invasive measurements of heart
    (rate and rhythm) and lung (air volumn, oxygen
    utilisation, carbon dioxide production,
    respiratory rate, respiratory exchange ratio,
    prediction of anaerobic threshold) and their
    ratios, that could be done during exercise.

  • Why is it if exercise is good for you we all do
    not exercise enough.
  • The answer lies in religion all religions knew
    from the start of their religion that We must be
    constantly reminded of what we believe in.
  • If patients and the general public are not
    constantly reminded to exercise they will not do
  • This is where the physician plays a role

The House of Lords, UK, Science and Technology
  • The above group launched a new short inquiry into
    sports and exercise science and medicine after
    the London Olympics in 2012.
  • Commenting, Lord Krebs, Chairman of the
    Committee, said
  • There is an ever-growing body of evidence
    showing that increasing the amount of exercise
    people take can be of huge benefit in treating a
    wide range of chronic conditions.
  • However, we are not convinced that health
    professionals currently have the skills or
    support to prescribe appropriate training regimes
    for their patients
  • (My, as President, emphasis).

What does that tell you?
  • Doctors need to be more knowledgeable about
    exercise and how to prescribe it.
  • They must know what to tell their patients
  • They must do PPE which include an ECG and
    possibly a CP ex test in some patients
  • They must follow up after a prescription has been

Risks of exercise prescription is the reason
exercise is not medicine for all
  • Sudden cardiac death
  • Exercise related cardiac events
  • An important point is that SCA is seven fold
    more common in participants who do not have a
    pre-participation assessment.
  • A different etiology for SCA appears with PPE ECG
    (Italy v USA)
  • Exercise induced asthma
  • Exercise induced hypoxemia
  • Hypoglycemia of exercise

(Corrado et al. NEJM 1998)
Anomalous c.a. origin 12
Premature CAD 18
Anomalous c.a. origin 12
athletes lt 35 yrs
Atherosclerotic c.a. disease 2
HCM 36
(Maron et al. JAMA 1996)
The Big Question
  • How involved should the doctor be in the
    exercise management of health and disease.
  • I cannot see the case for not wanting any medical
    input at all. This is the way it has been for
    years in most countries
  • The positive impact of Medical input at start and
    follow up I believe is the next step to getting
    the most from an exercise prescription.

The European Federation of Sport Medicine
Associations approach to exercise Exercise
Prescription for Health (EPH)
  • Part 2

European Federation of Sports Medicine
Associations (EFSMA)
  • Over 200 man hours of discussion on EPH and EIM
    in 2012
  • Contained representatives from 10 of the 41 EFSMA
    affiliated countries (included Italy, Germany,
    Austria, Belgium, Turkey, France, Ireland,
    Norway, Portugal and Cyprus)
  • Listened to all arguments for and against
  • PPE
  • Title of the initiative
  • Analysed what was being used in various
    countries by written surveys and word of
  • Planted the flag for EPH in Rome in 9.2012
  • Follow up in Athens 3.2013
  • Follow up in Dublin 23.4.2013
  • Major launch in Strasbourg 9.2013 to 35
    European countries
  • Sweden has requested a major role.

The EFSMA logo for EPH
(No Transcript)
Prof Norbert Bachl, Vienna University, RCPI 4.2013
EPH and why it is the correct title
  • Exercise and/or physical activity are essential
    in a title.
  • Prescription suggests that a thoughtful note is
    written by a doctor for a certain course of
  • Heath was always the term used by the ancient
    Greeks as distinct from Medicine which implies a
    universal beneficial outcome

Exercise Is Medicine and why it is a misnomer
  • The title EIM is an oxymoron (a figure of speech
    where apparently contradictory terms appear in
  • If exercise causes death or disease can we call
    it a medicine?
  • Exercise induced asthma or bronchospasm occurs in
    3/100 athletes
  • 3/100,000 people die from Sudden cardiac arrest
    syndrome usually during or after exercise
  • Exercise has side effects and therefore should be
    treated like a drug
  • EIM-USA is a dumbing down of the science of
  • It is written by sport scientists and sports
    medicine doctors mainly for sport scientists to
    be the major prescribers.

Exercise is MedicineTM (EIM)
  • It retains fiscal and legal control (68 page
    Memorandum of Understanding) to be signed before
    you can use the trade mark EIM).
  • If EFSMA were to try to match this with a
    contract the estimate for legal expenses was said
    to be 50,000 euro.
  • EIM has only a history and family history as the
    preparticipation assessment.
  • It has a lot of psychology, poor clinical
    standards and no science.

  • It is a marketing tool for exercise.
  • EIM is a global trademark only in the USA.
  • It insists all printing is done in Indianapolis.
  • It would take a maximum of 15 of all sponsors
    funds raised for EIM in your country
  • It has sport scientists deciding the exercise and
    sports medicine doctors signing the prescription
    and taking the responsibility
  • It would be politically a disaster for European
    Sport Medicine and that is why we believe EFSMA
    were never contacted directly by EIM

Other European groups
  • ECSS (European College of Sport Science) want to
    be involved in the research of exercise
  • HEPA (Health-Enhancing Physical Activity) EU / C
    of E do not want to do the medical hands on part
    of exercise but rather write the guidelines.
  • EIM-E (Exercise is Medicine-Europe) only requires
    a clinical and family history. The end point is a
    feel good factor.
  • NICE (National Institute of Health and Care
    Excellence) UK PA brief advice for adults in
    primary care

Who supports EPH?
  • European Federation of Sport Medicine
    Associations (EFSMA)
  • International Federation of Sports Medicine
  • European Olympic Committee, Medical Commission
    (EOC, MC)
  • Council of Europe (C of E)
  • European Academy of Science and the Arts (EASA)
  • European Union Medical Specialities (UEMS, MJC,
  • Medica, a Medical conference organiser, Dusseldorf

President of the Eur Academy of Science and the
Arts, Prof Unger
  • UEMS EFSMA Medica

Council of EuropeExercise in Europe 2007
  • The concept of Exercise as a Health tool they
    said was becoming increasingly important.
  • They also stated that SEM Physicians are able to
  • evaluate medical patients co-morbidities,
  • perform exercise testing and
  • provide an exercise prescription, together with
  • a motivational programme and exercise classes.
  • BUT Between 2007 to 2013 there has been an
    increase in obesity, Type II DM and lack of
    physical activity in the community
  • This top down approach is not working

Precedent for no use of science
  • There is a precedent for not allowing the science
    of a subject be part of the recommendations.
  • For 10 years the sports medicine world discussed
  • It was only after many millions of euro had been
    spent on anti-doping protocols that the science
    was allowed to be used in diagnosis and
    management of asthma.
  • Experts should write the guidelines and
  • non-experts may implement the guidelines

The prescription
  • Part 3.

Pre-Participation Exam
  • History
  • Physical examination
  • Tests to include ECG, possibly others
  • What to tell the patient
  • Write the prescription in detail
  • Follow up

There are 12 key questions
  1. RT Does the athlete have asthma (Wheezing),
    hay fever or coughing spells after exercise?
  2. CVS has anyone in the athletes family died
    suddenly before the age of 50 years
  3. Dizzy Has the athlete ever passed out during
    exercise or stopped exercising because of
  4. CNS Does the athlete has a history of
  5. GU Age of onset of menstruation and frequency.

There are 12 key questions
  • 7. Do you see a physician regularly for any
    particular problem
  • 8. Meds Does the athlete take any medication?
  • 9. Allergies Is the athlete allergic to any
    medication or bee stings
  • 10. Does the athlete have only one of any paired
    organ (eyes, ears, kidneys, testicles, and
  • 11. Has the athlete ever broken a bone, had to
    wear a cast, or had an injury to any joint?
  • 12. Does the athlete wish to discuss anything
    with the physician?

Physical examination
  • Emphasis on cardio-respiratory
  • Temp. BP, HR, RR at rest and with exercise,
    minutes of exercise per week
  • Weight,
  • Total body fat
  • Abdominal girth

The 90 second orthopedic screening exam
  • Athletic Activity instruction Observation
  • Stand facing examiner General habitus,
  • AC joint Look at ceiling, floor, over both
  • Cervical spine motion Touch ears to shoulders
  • Shrug shoulders Trapezius strength
  • Abduct shoulders to Deltoid strength (Examiner
    resists at 90 degrees 90 degrees)
  • Shoulder motion Full external rotation of arms
  • Elbow motion Flex and extend elbows
  • Arms at side, Elbows flexed at 90
    degrees Pronate and supinate wrists

  • The energy cost of an activity can be measured in
    units called METS, which are multiples of your
    basal metabolic rate.
  • One MET is the metabolic rate when one is sitting
    quietly in a normal temperature room.
  • An increase in METs is based on speed and grade
    of thread mill (over estimate the oxygen capacity
    compared to oxygen consumption).
  • The comparison of groups and the measure of
    exercise they are doing is important.

Original prescription
  • FITT Minimal average top
  • Frequency
  • /week 3 5 6
  • Intensity light medium heavy
  • sweating
  • Type walk light jog heavy jog,
  • run
  • Time
  • minutes 30 40 50

Tell the patient
  • There are health-related benefits of regular
    physical activity that did not meet traditional
    criteria for improving fitness of exercise
  • Exercise might also be considered as a fifth
    vital sign and should be recorded in patients'
    electronic medical records and routine histories,
  • Simple things like walking instead of taking
    transit, and walking the dog make a big

Tell the patient
  • Patients ought to report how many minutes of
    physical activity they undertake in an average
    day and how many days a week such activity takes
  • This measurement provides a score (in minutes per
    week) that can alert patients and clinicians to
    potential risks related to physical inactivity."
  • People who took up playing football two or three
    times a week experienced reduced risk factors for
    cardiovascular disease, diabetes and the
    brittle-bone disease osteoporosis.

Modifiable Risk Factors
  • Hypertension
  • High fat saturated diet
  • Abnormal blood lipid levels (high total
    cholesterol, high levels of triglycerides, high
    levels of low-density lipoprotein or low levels
    of high-density lipoprotein (HDL) cholesterol).
  • Tobacco use (smoking or chewing tobacco,
    especially if started at a young age or in
  • Physical inactivity increases the risk of heart
    disease and stroke by 50 (reference). 

Modifiable Risk Factors
  • Obesity is a major risk for cardiovascular
    disease and predisposes to diabetes 2.
  • Type 2 diabetes, which doubles the risk of
    coronary heart disease and stroke.
  • A chronically stressful life, social isolation,
    anxiety and depression increase the risk of heart
    disease and stroke.
  • One or two units of alcohol may lead to a 30
    reduction in heart disease, but more than this
    level of alcohol consumption may damage the
  • Medications may increase the risk of heart
    disease eg. contraceptive pill, hormone
    replacement therapy (HRT).
  • Left ventricular hypertrophy (LVH).

Non-Modifiable Risk Factors
  • Age, the risk of stroke doubles every decade
    after age 55.
  • Familys history, cardiovascular disease
    indicates your risk. If a first-degree blood
    relative has had coronary heart disease or stroke
    before the age of 55 years (for a male relative)
    or 65 years (for a female relative) your risk
  • Gender, males have a greater risk of heart
    disease than pre-menopausal woman. Once females
    reach the menopause, the risk of cardiovascular
    disease is similar. Men and women have the same
    risk of stroke.

Psychology is important
  • Identification
  • Pre-contemplation Phase
  • Contemplation Phase
  • Preparation Phase
  • Action Phase
  • Maintenance Phase
  • Motivation
  • Competence
  • Autonomy
  • Relatedness

  • Pre-contemplation Phase the patient has not yet
    considered a lifestyle change.
  • ? Recommended action by the physician educate
    the patient on the benefits to be achieved by
    initiating lifestyle changes.
  • Contemplation Phase the patient thinks about
    commencing regular physical activity within the
    next 6 months? recommended action by physician
    as per Exercise Guidelines Document
  • Preparation Phase the patient is ready to start
    exercising regularly within the next 30 days ?
    recommended action as per Exercise Guidelines

  • Competence
  • The feeling that they are sufficiently capable to
    affect a desired behavioural outcome.
  • This may be experienced as a self-belief in the
    ability to exercise and to feel comfortable in
    exercise settings.
  • Competence enhances the intrinsic motivation for
    the behaviour (i.e., being able to participate in
    physical activity).

Exercise prescription Patients flow
Society / Healthcare system
Physiotherapists Sport Exercise Graduates
Strength C Personal trainers
The prescription contains
  • Warm up
  • Frequency
  • Intensity
  • Type
  • Time
  • Cool down
  • Stretch and agility
  • Strength and conditioning
  • Flexibility

Laboratory tests
  • ECG and when a referral to a cardiologist is
    indicated (appendix 4.)
  • Physiological assessment
  • Physician supervised physiological exercise test
    is done with continuous monitoring of cardiac,
    pulmonary and metabolic parameters as needed.
  • There is no simple set of guidelines for a
    physiological exercise test.
  • The risk of CV events with exercise increase as a
    direct function of exercise intensity (vigorous gt
    moderate gt low exercise intensity)
  • Clinically it is used to decide the cause of
    dyspnea and limitation to exercise.
  • It is used to note ECG changes of exercise that
    may reflect ischemia, cardiac arrhythmia,
    exercise induced asthma, hypoxemia of exercise
    and other parameters

Clinical monitoring
  • History Improved cardio-respiratory
  • Improved muscular endurance without
  • Improved ability to do daily activities
  • Physical examination
  • BP, HR, RR at rest and with exercise, mins of
  • Weight,
  • Reduced total body fat
  • Reduced abdominal girth
  • Blood tests
  • Repeat CP ex test

The House of Lords, UK, Science and Technology
  • The above group has launched a new short inquiry
    into sports and exercise science and medicine
    after the London Olympics.
  • Commenting, Lord Krebs, Chairman of the
    Committee, said There is an ever-growing body
    of evidence showing that increasing the amount of
    exercise people take can be of huge benefit in
    treating a wide range of chronic conditions.
  • However, we are not convinced that health
    rofessionals currently have the skills or support
    to prescribe appropriate training regimes for
    their patients
  • (My, as President, emphasis).

  • The science of exercise must not be dumbed down
  • The patient must be central to all exercise
    endeavour and should include
  • PPE,
  • psychology,
  • exercise physiol principles being applied,
  • CPET as a clinical laboratory test available in
    clinical PFT laboritories and is our gold
  • follow up and reassessment is essential

Exercise prescription roles and responsabilities
Physios, SpExG, StrCond, PersTrai Exercise
program delivery and supervision
SEM Patients assessment Exercise prescription
Follow up
GPHD Patients screening Drug Therapy
Promotion and Education (Media, Schools, etc)
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