Exercise Prescription Basics

1. Exercise Prescription Basics Kevin deWeber, MD, FAAFP Director, Primary Care Sports Medicine Fellowship USUHS

2. Bottom Line Up Front (BLUF) • Exercise is the best “medicine” around • Assess physical activity in ALL patients • Only RARE patients needs GXT before exercise • GXT pts with symptomatic CV/pulm dz • The Prescription is: Be “FITT” • Frequency: 5 days a week (or more) • Intensity: moderate intensity, 5-6 on 10 scale • Time: 30 minutes aerobics (10-min chunks OK) • Type: • Aerobic activity • Muscular strengthening activity • Flexibility activity (in elderly/sick) • Balance training (if fall risky)

4. Physicians and their Patients • 47% of primary care physicians include an exercise history as part of their initial examination (self report) • Only 13% of patients report physicians giving advice about exercise • Physically active physicians are more likely to discuss exercise with their patients

5. ACSM & AHA 2007, HHS 2008Physical Activity RecommendationsHealthy Adults age 18-64 • Aerobic Physical Activity • Moderate intensity: 150 minutes/wk, OR Vigorous intensity: 75 minutes/wk (or a combo) • 10 min at least, preferably spread throughout week • Muscle Strengthening Activity • 2 or more days/wk • 8-10 exercises • 8-12 reps (one set) Physical activity and public health: Updated recommendation for adults from the ACSM and AHA. MSSE 2007. and HHS publication October 2008.

6. Indications & benefits • Contraindication • Side-effects • Drug interactions • Cost • Dose, frequency, duration

7. Indications for Exercise • Longevity • Quality of Life • Socialization • Weight control • Disease prevention • Disease management • ….(I could go on)

8. LongevityThe more you exercise, the lower your risk of death

9. Dose-response Curve for Exercise

10. Death Prevention:Attributable Deaths (%) from various health conditions • Aerobics Center Longitudinal Study (ACLS), Cooper Institute • 40,842 men; 12,943 women

11. Strong Evidence of Benefit from Physical Activity for… • Lower risk of: • Early death • Heart disease • Stroke • Type 2 diabetes • High blood pressure • Dyslipidemia • Metabolic syndrome • Colon and breast Ca • Prevention of wt gain • Wt loss w/dieting • Improved C-R & muscular fitness • Prevention of falls • Reduced depression • Better cognitive fxn (older adults)

12. Moderate evidence for… • Wt maintenance after loss • Lower risk of hip fx • Increased bone density • Improved sleep quality • Lower risk lung and endometrial Ca

13. Contraindications for Exercise • Acute cardiac event happening now • Uncontrolled arrhythmia causing sxs • Severe aortic stenosis • Uncontrolled heart failure • Acute pulmonary embolism • Acute myocarditis • Dissecting aneurysm

14. Only RARE patients need GXT • AHA 2003: NOT NECESSARY for people doing moderate intensity • USPSTF 2004: • not recommended (class D rec) in pts at low risk • Insufficient evidence (class I rec) even in pts at increased risk Thompson PD et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation 2003;107:3109. USPSTF Screening for coronary heart disease: Recommendation Statement. Ann Int Med 2004;140:569.

15. Who Needs a GXT first?(No evidence-based recommendations) • Symptomatic cardiac or pulmonary disease • Known CV dz, Diabetes, active chronic dz • ESP if Vigorous exercise • Unsure? Uncomfortable? • Refer to Sports Medicine

16. Side effects of exercise • Slight risk of Musculoskeletal injury • Increases with duration & intensity • RARE cardiac events • FAR outweighed by benefits to heart! • 25-50% decrease in CVD in exercisers

17. If we had a pill that conferred all the benefits of exercise, physicians would prescribe it to every patient. Our health care system would find a way to make sure that every patient had access to this “wonder drug.”

18. Use the Sports and Exercise Medicineapproach to patients • Every patient is a potential “athlete” who needs exercise for HEALTH, not competition • Physical activity is a VITAL SIGN--a STRONG PREDICTOR OF HEALTH • Every exam is a pre-participation eval • Conclude exams with activity clearance and Exercise Rx

19. How to Write an Exercise Prescription

20. Rx: Be “FITT” • Frequency • Intensity • Time (duration) • Type

21. Frequency • 5 days a week • Even more is even better! • Dose-response curve!

22. Intensity • Moderate Exercise • Equivalent of BRISK WALK • Noticeably accelerates RH • Able to talk • “talk test” • RPE 5-6 out of 10

23. Exercise Intensity:Relative Perceived ExertionUse 1-10 Scale

24. Examples of Moderate Intensity • Brisk walking • Household cleaning: vacuum, mop, wipe • Mowing lawn • Shooting hoops • Recreational badminton • Ballroom dance • Golf & pulling clubs • Leisurely sports • Leisurely biking, swimming

25. Intensity • Vigorous Exercise • Equivalent of jogging • Fail “talk test” • RPE 7-10 out of 10

26. Examples of Vigorous Intensity • Jogging, running • Shoveling • Heavy farming • Competitive sports • Cross country skiing • Intense biking, swimming

27. Time (Duration) • Accumulate 30 minutes a day • 10 minute chunks OK • More is better!

28. Type • Aerobic Activity AND • Muscle Strengthening

29. Muscular Strengthening • Exercise large muscle groups • 8-12 reps; should fatigue by last rep • Rest 2-3 minutes between exercises • 1 set good, 2 sets better • Rest day in between

30. What about Older Adults >65,or those with chronic diseases? • Aerobic exercise: same • Strength exercise: same, except 10-15 reps • Slightly lighter weights • Flexibility activity 2 days/wk, 10 min • Balance exercise if at risk for falls, 3x/wk Nelson ME et al. Physical activity and public health in older adults: Recommendation from the ACSM and the AHA. Med Sci Sports Exer 2007;39(8):1435.

31. What about Children/Adolescents? • Do 60 minutes or more of physical activity every day • Mostly moderate or vigorous • Vigorous activity at least 3 days/wk • Strength exercise 3 days/wk HHS guidelines October 2008

32. Take Home Pearls • Exercise is the best “medicine” around • Assess physical activity in ALL patients • Only RARE patients needs GXT before exercise • GXT pts with symptomatic CV/pulm dz • The Prescription is: Be “FITT” • Frequency: 5 days a week (or more) • Intensity: moderate intensity, 3-6 on 10 scale • Time: 30 minutes aerobics (10-min chunks OK) • Type: • Aerobic activity • Muscular strengthening activity • Flexibility activity (in elderly/sick) • Balance training (if fall risky)

33. Questions? Military Sports Medicine Fellowship “Every Warrior an Athlete”