Exercise and Chronic Disease

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Exercise and Chronic Disease

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

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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
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www.exerciseismedicine.org
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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?

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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

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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
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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

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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

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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
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Exercise and Death(Men)
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Exercise and Death (Women)
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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?

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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

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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

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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.

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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

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What is the Risk of Exercise?
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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!

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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.

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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

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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
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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

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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

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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

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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

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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.

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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

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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.

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Exercise Prescription TipsRheumatoid Arthritis

• Can follow same basic guidelines as with
  osteoarthritis
• Avoid exercise during inflamatory phase

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Exercise Prescription TipsFibromyalgia

• Must customize to individual
• Careful to avoid overexertion
• Progress slowly (water to land walking)

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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.

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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

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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

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Exercise Prescription TipsAIDS

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

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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

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Exercise and Dialysis

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

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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

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Exercise and Dialysis
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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

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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

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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