QUALI RACCOMANDAZIONI PER

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1 5 CORSO GIROLAMO MERCURIALE MAGGIO 2011 PARMA, AUDITORIUM DEL CARMINE - VIA ELEONORA DUSE, 1 A QUALI RACCOMANDAZIONI PER UNA ATTIVITÀ FISICA EFFICACE? GIORGIO GALANTI AMSE

2 PERCHÉ L ATTIVITA FISICA?

3 PIRAMIDE DELLE ETÀ NEL anni Europa Italia anni

4 THEORETICAL RELATION BETWEEN MUSCULOSKELETAL FITNESS AND INDEPENDENT LIVING ACROSS A PERSON S LIFESPAN

5 THE NORMAL AGE-ASSOCIATED DECLINE IN CARDIOVASCULAR PERFORMANCE CMAJ March 14, 2006; 174(6)

6 THE NORMAL AGE-ASSOCIATED DECLINE IN CARDIOVASCULAR PERFORMANCE Ath NAth J Appl Physiol 82: , 1997

7 PUBLIC HEALTH SIGNIFICANCE OF PHYSICAL ACTIVITY PHYSICAL INACTIVITY IS ESTIMATED AS BEING THE PRINCIPAL CAUSE FOR APPROXIMATELY 21 25% OF BREAST AND COLON CANCER BURDEN, 27% OF DIABETES AND APPROXIMATELY 30% OF ISCHAEMIC HEART DISEASE BURDEN IN ADDITION, NCDS NOW ACCOUNT FOR NEARLY HALF OF THE OVERALL GLOBAL BURDEN OF DISEASE. IT IS ESTIMATED CURRENTLY THAT OF EVERY 10 DEATHS, 6 ARE ATTRIBUTABLE TO NCDS

8 LEADING RISK FACTOR FOR GLOBAL MORTALITY (%) HBP Tobacco HBG Obesity Inactivity 2 0 HBP Tobacco HBG Obesity Inactivity

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10 GLOBAL R ECOMMENDATIONS ON P HYSICAL ACTIVITY FOR HEALTH CARDIORESPIRATORY HEALTH (CORONARY HEART DISEASE, CARDIOVASCULAR, STROKE AND HYPERTENSION) METABOLIC HEALTH (DIABETES AND OBESITY) MUSCULOSKELETAL HEALTH (BONE HEALTH, OSTEOPOROSIS) CANCER (BREAST AND COLON CANCER) FUNCTIONAL HEALTH AND PREVENTION OF FALLS DEPRESSION

11 THE FOCUS OF THE GLOBAL R ECOMMENDATIONS ON P HYSICAL ACTIVITY FOR HEALTH IS PRIMARY PREVENTION OF NCDS THROUGH PHYSICAL ACTIVITY AT POPULATION LEVEL THE PRIMARY TARGET AUDIENCE FOR THESE RECOMMENDATIONS ARE POLICY-MAKERS AT NATIONAL LEVEL.

12 THESE GUIDELINES ARE RELEVANT TO ALL HEALTHY ADULTS AGED YEARS UNLESS SPECIFIC MEDICAL CONDITIONS INDICATE TO THE CONTRARY. PREGNANT, POSTPARTUM WOMEN AND PERSONS WITH CARDIAC EVENTS MAY NEED TO TAKE EXTRA PRECAUTIONS AND SEEK MEDICAL ADVICE BEFORE STRIVING TO ACHIEVE THE RECOMMENDED LEVELS OF PHYSICAL ACTIVITY FOR THIS AGE GROUP. INACTIVE ADULTS OR ADULTS WITH DISEASE LIMITATIONS WILL HAVE ADDED HEALTH BENEFITS IF MOVING FROM THE CATEGORY OF NO ACTIVITY TO SOME LEVELS OF ACTIVITY.

13 FOR ADULTS OF THIS AGE GROUP, PHYSICAL ACTIVITY INCLUDES RECREATIONAL OR LEISURE-TIME PHYSICAL ACTIVITY, TRANSPORTATION (E.G WALKING OR CYCLING), OCCUPATIONAL (I.E. WORK), HOUSEHOLD CHORES, PLAY, GAMES, SPORTS OR PLANNED EXERCISE, IN THE CONTEXT OF DAILY, FAMILY, AND COMMUNITY ACTIVITIES. IN ORDER TO IMPROVE CARDIORESPIRATORY AND MUSCULAR FITNESS, BONE HEALTH AND REDUCE THE RISK OF NCDS AND DEPRESSION THE FOLLOWING ARE RECOMMENDED: 1. ADULTS AGED SHOULD DO AT LEAST 150 MINUTES OF MODERATE- INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR DO AT LEAST 75 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUS-INTENSITY ACTIVITY. 2. AEROBIC ACTIVITY SHOULD BE PERFORMED IN BOUTS OF AT LEAST 10 MINUTES DURATION. 3. FOR ADDITIONAL HEALTH BENEFITS, ADULTS SHOULD INCREASE THEIR MODERATE-INTENSITY AEROBIC PHYSICAL ACTIVITY TO 300 MINUTES PER WEEK, OR ENGAGE IN 150 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY PER WEEK, OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUS-INTENSITY ACTIVITY. 4. MUSCLE-STRENGTHENING ACTIVITIES SHOULD BE DONE INVOLVING MAJOR MUSCLE GROUPS ON 2 OR MORE DAYS A WEEK.

14 HEALTHY ADULTS AGED 65 YEARS AND ABOVE. ADULTS AGED 65 YEARS AND ABOVE SHOULD DO AT LEAST 150 MINUTES OF MODERATE- INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR DO AT LEAST 75 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUSINTENSITY ACTIVITY. AEROBIC ACTIVITY SHOULD BE PERFORMED IN BOUTS OF AT LEAST 10 MINUTES DURATION. FOR ADDITIONAL HEALTH BENEFITS, ADULTS AGED 65 YEARS AND ABOVE SHOULD INCREASE THEIR MODERATE INTENSITY AEROBIC PHYSICAL ACTIVITY TO 300 MINUTES PER WEEK, OR ENGAGE IN 150 MINUTES OF VIGOROUS INTENSITY AEROBIC PHYSICAL ACTIVITY PER WEEK, OR AN EQUIVALENT COMBINATION OF MODERATE-AND VIGOROUS- INTENSITY ACTIVITY. ADULTS OF THIS AGE GROUP, WITH POOR MOBILITY, SHOULD PERFORM PHYSICAL ACTIVITY TO ENHANCE BALANCE AND PREVENT FALLS ON 3 OR MORE DAYS PER WEEK. MUSCLE-STRENGTHENING ACTIVITIES SHOULD BE DONE INVOLVING MAJOR MUSCLE GROUPS, ON 2 OR MORE DAYS A WEEK. WHEN ADULTS OF THIS AGE GROUP CANNOT DO THE RECOMMENDED AMOUNTS OF PHYSICAL ACTIVITY DUE TO HEALTH CONDITIONS, THEY SHOULD BE AS PHYSICALLY ACTIVE AS THEIR ABILITIES AND CONDITIONS ALLOW.

15 QUALE ATTIVITÀ FISICA EFFICACE?

16 DEFINITIONS OF CONCEPTS USED IN THE RECOMMENDED LEVELS OF PHYSICAL ACTIVITY TYPE OF PHYSICAL ACTIVITY (WHAT TYPE). THE MODE OF PARTICIPATION IN PHYSICAL ACTIVITY. THE TYPE OF PHYSICAL ACTIVITY CAN TAKE MANY FORMS: AEROBIC, STRENGTH, FLEXIBILITY, BALANCE. DURATION (FOR HOW LONG). THE LENGTH OF TIME IN WHICH AN ACTIVITY OR EXERCISE IS PERFORMED. DURATION IS GENERALLY EXPRESSED IN MINUTES. FREQUENCY (HOW OFTEN). THE NUMBER OF TIMES AN EXERCISE OR ACTIVITY IS PERFORMED. FREQUENCY IS GENERALLY EXPRESSED IN SESSIONS, EPISODES, OR BOUTS PER WEEK. INTENSITY (HOW HARD A PERSON WORKS TO DO THE ACTIVITY). INTENSITY REFERS TO THE RATE AT WHICH THE ACTIVITY IS BEING PERFORMED OR THE MAGNITUDE OF THE EFFORT REQUIRED TO PERFORM AN ACTIVITY OR EXERCISE.

17 VOLUME (HOW MUCH IN TOTAL). AEROBIC EXERCISE EXPOSURES CAN BE CHARACTERIZED BY AN INTERACTION BETWEEN BOUT INTENSITY, FREQUENCY, DURATION, AND LONGEVITY OF THE PROGRAMME. THE PRODUCT OF THESE CHARACTERISTICS CAN BE THOUGHT OF AS VOLUME. MODERATE-INTENSITY PHYSICAL ACTIVITY. ON AN ABSOLUTE SCALE, MODERATE INTENSITY REFERS TO ACTIVITY THAT IS PERFORMED AT MODERATE-INTENSITY PHYSICAL ACTIVITY. ON AN TIMES THE INTENSITY OF REST. ON A SCALE RELATIVE TO AN INDIVIDUAL S ABSOLUTE SCALE, MODERATE INTENSITY REFERS TO ACTIVITY PERSONAL CAPACITY, MODERATE-INTENSITY PHYSICAL ACTIVITY IS USUALLY A THAT IS PERFORMED AT TIMES THE INTENSITY OF 5 OR 6 ON A SCALE OF REST. VIGOROUS-INTENSITY ON A SCALE RELATIVE PHYSICAL ACTIVITY. TO AN INDIVIDUAL SPERSONAL AN ABSOLUTE SCALE, CAPACITY, VIGOROUSMODERATE-INTENSITY REFERS TO ACTIVITY PHYSICAL THAT IS PERFORMED ACTIVITY AT 6.0 IS OR MORE TIMES THE INTENSITY OF REST FOR ADULTS AND TYPICALLY 7.0 OR USUALLY A 5 OR 6 ON A SCALE OF MORE TIMES FOR CHILDREN AND YOUTH. ON A SCALE RELATIVE TO AN INDIVIDUAL S PERSONAL CAPACITY, VIGOROUSI NTENSITY PHYSICAL ACTIVITY IS USUALLY A 7 OR 8 ON A SCALE OF AEROBIC ACTIVITY. AEROBIC ACTIVITY, ALSO CALLED ENDURANCE ACTIVITY, IMPROVES CARDIORESPIRATORY FITNESS. EXAMPLES OF AEROBIC ACTIVITY INCLUDE: BRISK WALKING, RUNNING, BICYCLING, JUMPING ROPE, AND SWIMMING.

18 SCALA DI PERCEZIONE DELLA FATICA

19 GLOBAL R ECOMMENDATIONS ON P HYSICAL ACTIVITY FOR HEALTH R ECOVERY CARDIORESPIRATORY HEALTH (CORONARY HEART DISEASE, CARDIOVASCULAR, STROKE AND HYPERTENSION) METABOLIC HEALTH (DIABETES AND OBESITY) MUSCULOSKELETAL HEALTH (BONE HEALTH, OSTEOPOROSIS) CANCER (BREAST AND COLON CANCER) FUNCTIONAL HEALTH AND PREVENTION OF FALLS DEPRESSION

20 Exercise

21 "The paradox of physical exercise" In adults physical activity can be regarded as a two-edged sword: Vigorous exertion increases the incidence of acute coronary events in individuals who did not exercise regularly whereas: Habitual physical activity reduces the overall risk of myocardial infarction and sudden coronary death by preventing development of coronary artery disease and progression of coronary atherosclerotic lesions Herz 2006;31:553-8

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24 HABITUAL PHYSICAL ACTIVITY REDUCES CORONARY HEART DISEASE EVENTS, BUT VIGOROUS ACTIVITY CAN ALSO ACUTELY AND TRANSIENTLY INCREASE THE RISK OF SUDDEN CARDIAC DEATH AND ACUTE MYOCARDIAL INFARCTION IN SUSCEPTIBLE PERSONS.

25 Relative risk of MI associated with vigorous exertion (>6 METs) according to habitual frequency of vigorous exertion.

26 RISPOSTA CARDIOVASCOLARE ALL ESECIZIO ACUTO

27 1.Fase preparatoria iniziale Stimolazione adrenergica Vasocostrizione distrettuale 2.Fase intermedia metabolica Fattori locali Stimolazione adrenergica

28 Factors Affecting Neural Control of Cardiovascular Function

29 Distribution of Flow at rest and 22% 27% during Acute Exercise 20% 4% 6% 14% Muscle Heart Skin Brain Other Liver Kidneys 4% 5% 4% 1% Muscle 84% 7% Rest 3-5 Lmin Exercise Lmin

30 Exercise,Vasoconstriction and Coronary Flow in normal 25% Radius 63% Area Vasoconstriction (Acute Exercise) No Ischemia AMSE

31 Exercise,Vasoconstriction and Coronary Flow 25% Radius 63% Area Vasoconstriction (Acute Exercise) No Ischemia 17% Radius 96% Area Ischemia

32 Physiological alterations accompanying acute exercise and recovery and their possible sequelae.

33 Exercise and Blood Pressure (Blood Pressure=CO x Peripheral Resistance) IN NORMAL SUBJECTS ACUTE EXERCISE INCREASES CARDIAC OUTPUT AND/OR DECREASES PERIPHERAL RESISTANCE WITH MILD INCREASE OF MEAN ARTERIAL PRESSURE P.A Rec Rec Watts

34 Exercise and Blood Pressure in normal and hypertensive subjects P.A Normot Hypert normot hyp rec rec Watts Peak

35 Chronic Cardiac Adaptation to Exercise Morphological Functional Myocardial Neural Vascular AMSE

36 Dynamic and static exertion Dynamic or isotonic activity: physical exertion characterized by rhytmic,repetitive movements of large muscle groups Isometric or static activity: physical exertion characterized by sustained muscle contraction against a fixed load or resistance with non change in length of the involved muscle group or joint motion

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38 Myocardial Hypertrophy Adaptive: secondary to exercise Maladaptive: a)secondary to excess of emodinamic work load b)secondary to genetic mutations Gerald W. Dorn II and Thomas Force:JCI 2005

39 ADAPTIVE HYPERTROPHY:CARDIAC STRUCTURE AND FUNCTION EXERCISE (ISOMETRIC-ISOTONIC) OVERLOAD VOLUME/PRESSURE MYOCITE HYPERTROPHY ADEGUATE CAPILLARY DENSITY CARDIAC REMODELLING INCREASE CONTRATTILITY PHYSIOL HYPETROPHY

40 MALADAPTIVE HYPERTROPHY:CARDIAC STRUCTURE AND FUNCTION HYPERTENSION,MYOCARDIAL INFARCTION,VALVULAR DISEASE Overload Volume/pressure MYOCITE HYPERTROPHY MYOCARDIAL FIBROSIS MYOCITENECROSIS/ APOPTOSIS INADEGUATE CAPILLARY DENSITY CARDIAC REMODELLING IMPAIRED CONTRATTILITY PATHOLOGIC HYPERTROPHY

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42 What about resistance training?

43 ACUTE STATIC EXERCISE AND THE BLOOD PRESSURE RESPONSE ACUTE STATIC EXERCISE INCREASE BOTH SYSTOLIC AND DIASTOLIC PRESSURE.. DUE TO THE VALSALVA MANEUVER,PRESSOR REFLEXS FROM TENDOMS STRETCHING AND COMPRESSION OF ARTERIES BY CONTRACTING MUSCLES.. THE INTRAABDOMINAL PRESSURE IS SIMULTANEUSLY INCREASED AND THIS IS IMMEDIATLY TRASMITTED TO THE CEREBROSPINAL FLUID THROUGH THE INTERVETEBRAL FORAMINA:THE TRANSMURAL PRESSURE ACROSS CEREBRAL VESSELS IS REDUCED AND PROTECTS THE CEREBRAL VESSELS FROM ACUTE DAMAGE. CHINTANADILOK.J,LOWENTHAL.DT EXERCISE AND SPORT CARDIOLOGY 2003

44 Acute static exercise and the blood pressure response During heavy weightlifting with Valsalva maneuver, The pressor reflexs is extremely exaggerated but may be dramatically reduced when the exercise is performed with an open glottis or slow exalation With Valsalva 311/284 mmhg Without Valsalva 198/175 mmhg Chintanadilok.J,Lowenthal.DT Exercise and Sport cardiology 2003

45 Resistance Exercise in Individuals with and without Cardiovascular Disease Benefits,rationale,safety and prescription An advisory from the committee on exercise rehabilitation and prevention,council on Clinical Cardiology,American Heart Association Position paper endorsed by ACSM Circulation 2000;101:828

46 COMPARISON OF EFFECTS OF AEROBIC TRAINING WITH STRENGTH TRAINING ON HEALTH AND FITNESS VARIABLES 0 Variable Aerobic ex. Resistance ex. Bone mineral density Body composition % Fat LBM - Strength - Basal insulin levels Insulin sensivity HDL - - LDL - - Blood pressure VO2 max - Basal metabolism

47 Circuit weight training in borderline hypertensive subjects Subjects : 26 males with BL hypertension (140/90-160/95 mmhg) Exercise program: 9 weeks partecipation in circuit weight training Results Pre Post Upper and lower body strength + 12,5% and + 53% * Lean body mass 64 Kg 65,4 Kg = 2,2% * Treadmill VO2 max 40,9 ml x Kg x min 44,1 ml x Kg x min = + 7,8% * Arm ergometry VO2 max 1,9 L x min -1 2,3 L x min -1 = +21,1% * Diastolic blood pressure 95,8 mmhg 91,3 mmhg * Sistolic blood pressure no difference * p<0,05 Circuit weigth training does not exacerbate resting or exercise blood pressure and may have beneficial effects Med Sci Sports Exerc 01-Jun 1987; 19(3):246-52

48 AF moderata o AF vigorosa?

49 EVIDENCE REGULAR PHYSICAL ACTIVITY CONTRIBUTES TO THE PRIMARY AND SECONDARY PREVENTION OF SEVERAL CHRONIC DISEASES AND IS ASSOCIATED WITH A REDUCED RISK OF PREMATURE DEATH. THERE APPEARS TO BE A GRADED LINEAR RELATION BETWEEN THE VOLUME OF PHYSICAL ACTIVITY AND HEALTH STATUS, SUCH THAT THE MOST PHYSICALLY ACTIVE PEOPLE ARE AT THE LOWEST RISK. HOWEVER, THE GREATEST IMPROVEMENTS IN HEALTH STATUS ARE SEEN WHEN PEOPLE WHO ARE LEAST FIT BECOME PHYSICALLY ACTIVE. Evidence Based Sport Medicine D.MacAuley,T.B Best 2006

50 INCREASED PHYSICAL ACTIVITY WITH OR WITHOUT WEIGTH REDUCTION,IMPROVES INSULIN ACTION AND REDUCES INSULIN RESISTANCE IN OBESE PERSONS. (EVIDENCE A) ENDURANCE EXERCISE TRAINING WHEN COMBINED WITH WEIGTH LOSS OF > 4-5 KG IMPROVES THE LIPID-LIPOPROTEIN PROFIL BY RAISING HDL CHOLESTEROL AND LOWERING TRIGLICERIDIS AMONG OVERWEIGTH AND OBESE MEN AND WOMEN. (EVIDENCE A) DYNAMIC AEROBIC PHYSICAL ACTIVITY WITH OR WITHOUT WEIGTH LOSS,REDUCES BLOOD PRESSURE AMONG OVERWEIGTH AND OBESE WITH THE GREATEST EFFECT SEEN AMONG PERSONS WITH HYPERTENSION. (EVIDENCE A) Evidence Based Sport Medicine D.MacAuley,T.B Best 2006

51 EXERCISE/DRUG GENERICALLY SPEAKING, ANY EXERCISE PRESCRIPTION RESEMBLES A DRUG PRESCRIPTION:EXERCISE A, TAKEN N TIMES DAILY, FOR X DURATION OF WEEKS/MONTHS/YEARS. THE EXERCISE TYPE AND DOSE ARE CHOSEN BY THE PERSON S INDIVIDUAL NEEDS, GOALS, AND ABILITY LEVEL;THE FREQUENCY AND INTENSITY OF EACH SESSION ARE CHOSEN BY THE PERSON S INTRINSIC ENDURANCE AND ABILITY TO RECOVER; THE PROGRESSION AND DURATION OF THE PROGRAMME IS DETERMINED BY THE PERSON S INTERMEDIATE AND LONG TERM GOALS. ADVERSE EFFECTS ARE RELATED TO THE TYPE OF EXERCISE-FOR EXAMPLE, DELAYED ONSET MUSCLE SORENESS-AND THE SPECIFIC CHRONIC DISEASE-FOR EXAMPLE, CHEST PAIN IN ANGINA PECTORIS, JOINT PAIN IN ARTHRITIS, FATIGUE IN FIBROMYALGIA.

52 OVERALL, ACROSS ALL THE AGE GROUPS, THE BENEFITS OF IMPLEMENTING THE ABOVE RECOMMENDATIONS, AND OF BEING PHYSICALLY ACTIVE, OUTWEIGH THE HARMS. AT THE RECOMMENDED LEVEL OF 150 MINUTES PER WEEK OF MODERATEINTENSITY ACTIVITY, MUSCULOSKELETAL INJURY RATES APPEAR TO BE UNCOMMON. IN A POPULATION-BASED APPROACH, IN ORDER TO DECREASE THE RISKS OF MUSCULOSKELETAL INJURIES, IT WOULD BE APPROPRIATE TO ENCOURAGE A MODERATE START WITH GRADUAL PROGRESS TO HIGHER LEVELS OF PHYSICAL ACTIVITY. AMSE

53 NO STRATEGIES HAVE BEEN ADEQUATELY STUDIED TO EVALUATE THEIR ABILITY TO REDUCE EXERCISE-RELATED ACUTE CARDIOVASCULAR EVENTS. MAINTAINING PHYSICAL FITNESS THROUGH REGULAR PHYSICAL ACTIVITY MAY HELP TO REDUCE EVENTS BECAUSE A DISPROPORTIONATE NUMBER OF EVENTS OCCUR IN LEAST PHYSICALLY ACTIVE SUBJECTS PERFORMING UNACCUSTOMED PHYSICAL ACTIVITY. OTHER STRATEGIES, SUCH AS SCREENING PATIENTS BEFORE PARTICIPATION IN EXERCISE, EXCLUDING HIGH-RISK PATIENTS FROM CERTAIN ACTIVITIES, PROMPTLY EVALUATING POSSIBLE PRODROMAL SYMPTOMS, TRAINING FITNESS PERSONNEL FOR EMERGENCIES, AND ENCOURAGING PATIENTS TO AVOID HIGH-RISK ACTIVITIES, APPEAR PRUDENT BUT HAVE NOT BEEN SYSTEMATICALLY EVALUATED.

54 START SLOWLY THE INITIAL STAGE OF AN EXERCISE PROGRAM FOR A PREVIUOSLY SEDENTARY PERSON SHOULD BE DEVELOPMENTAL IN NATURE AND SHOULD NOT INCLUDE A HIGH TOTAL ENERGY OUTPUT. Mc Ardle W. Exercise Physiology

55 REGULARITY IS THE KEY ALTHOUGH IT IS DIFFICULT TO PRECISELY DETERMINE A THRESHOLD ENERGY EXPENDITURE FOR WEIGTH REDUCTION AND FAT LOSS, IT IS GENERALLY RECOMMENDED THAT THE CALORIE-BURNING EFFECT OF EACH EXERCISE SESSION SHOULD BE AT LEAST 300 KCAL. Mc Ardle W. Exercise Physiology

56 Caloric Stress of Physical Activity The calorie-expending effects of exercise are comulative.a caloric deficit of 3500 kcal is equivalent to a 0,45 kg body fat loss,whether the deficit occurs rapidly or systematically over time Mc Ardle W. Exercise Physiology

57 LA MEDICINA DELLO SPORT, PER IL SUO SCOPO DI PROTEGGERE I SOGGETTI CHE PRATICANO O VOGLIONO PRATICARE ATTIVITÀ FISICA E SPORTIVA, NON RAPPRESENTA UN IMPOSIZIONE LIMITATIVA MA UN AIUTO PER IL SOGGETTO INTERESSATO AFFINCHÉ SIA CONSIGLIATO NELLA SCELTA E SEGUITO NELLA PRATICA DELLO SPORT O DELL ATTIVITÀ FISICA. IL MEDICO DI MEDICINA DELLO SPORT,DEVE ESSERE IN GRADO DI FARE FRONTE A PROBLEMI CHE L ATTIVITÀ FISICO- SPORTIVA, ANCHE NON AGONISTICA, PUÒ PORRE NEI SOGGETTI SANI,NEI SOGGETTI CON UNA PATOLOGIA EVIDENTE O CLINICAMENTE SILENTE Neri Serneri e Galanti 2002

58 The Sport Medicine Team Friends Family Subject Physician Trainer Clinical support Research support Adapted Mellion MB Philadelphia 1988

59 AMS

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61 AMSE AMSE AMSE AMSE AMSE