EXERCISE AS MEDICINE. Dr Prue Cormie Post Doctoral Research Fellow Vario Health Institute

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1 EXERCISE AS MEDICINE Dr Prue Cormie Post Doctoral Research Fellow Vario Health Institute

2 IMPACT OF CHRONIC DISEASE Preventable, non-communicable chronic diseases are currently responsible for over 70% of the illness and injury experienced by the Australian population Cause 60% of deaths worldwide Reduces quality of life for sufferers and carers The biggest driver of our spiralling health costs Cancer Cardiovascular Disease Type 2 Diabetes Obesity Osteoporosis Mental Illness Sarcopenia Wilson, A. and S. Hendy, Preventing chronic disease: a strategic framework. 2001, National Public Health Partnership.

3 PHYSICAL INACTIVITY & DISEASE Physical inactivity, poor nutrition & tobacco use account for: 80% of heart disease, stroke and type 2 diabetes 40% of cancer World Health Organization, Preventing Chronic Diseases In 1993 physical inactivity & poor nutrition was conservatively estimated to cause 28% of preventable deaths in the USA McGinnis & Foege, JAMA, 1993

4 PHYSICAL INACTIVITY & DISEASE The human genome evolved within an environment of high physical activity The current human genome expects and requires humans to be physically active for normal function and health maintenance Booth et al., Journal of Applied Physiology, 2000 Programmed for physical activity

5 PHYSICAL INACTIVITY 40-60% of Australians perform less than 150 minutes in a week (<20mins physical activity a day) Australian Institute of Health and Welfare 2000 National Physical Activity Survey

6 EXERCISE AS MEDICINE With the possible exception of diet modification, we know of no single intervention with greater promise than physical exercise to reduce the risk of virtually all chronic diseases simultaneously Booth et al., Journal of Applied Physiology, 2000

7 EXERCISE AS MEDICINE Increasing physical activity through a structured exercise program results in: Decreased risk of virtually all chronic diseases simultaneously Increased function Increased quality of life No adverse side effects Temporary muscle soreness

8 PROTECTIVE EFFECT OF EXERCISE Myers et al. New England Journal of Medicine. 2002

9 EXERCISE AS MEDICINE Exercise affects all of the major systems in the body but not all exercise is created equal The type and dosage of exercise determines the nature and magnitude of the adaptations that will occur Disease-specific and stage of disease-specific exercise prescription Integration with all aspects of patients health & medical care

10 PHYSIOLOGICAL ADAPTATIONS Aerobic Exercise: Heart mass & volume Pulmonary ventilation Efficiency of cardiovascular system Anaerobic Exercise: Muscle size & function Muscle activation Bone mineral density Strength

11 FUNCTIONAL & HEALTH BENEFITS Performance of activities of daily living Endurance & Fatigue Body composition Stress, anxiety & depression Blood pressure & cholesterol Risk of falling Morbidity & risk of mortality

12 RESEARCH AT VARIO The use of exercise as medicine to prevent, treat and manage chronic diseases. Develop disease specific exercise prescription to optimally integrate with pharmaceutical, surgical, nutritional, psychological and other treatments for best patient outcomes. Our aim is to make knowledge advances, inform and perform best practice, translate to community and shape public policy for meaningful improvements in the health of all Australians.

13 RESEARCH AT VARIO Prostate Cancer Breast Cancer Sarcopenia Parkinson s Disease Depression Childhood Obesity

14 PROSTATE CANCER Adverse treatment related side effects: Poor balance Decline in Physical Capacity Strength decline Fatigue ADT Hormone Muscle loss Metabolic Syndrome Osteoporosis Skeletal Fractures Cardiovascular morbidity

15 PROSTATE CANCER 2 arm randomised control trial n = week intervention Resistance & aerobic exercise 2 times/week Strength Body Composition Physical Function Galvão et al. J Clinical Oncology 2010

16 Musculoskeletal Fitness PROSTATE CANCER Normal Aging ADT Treated Resistance Trained ADT Treated Physical Reserve Capacity Disability Condition ADT Sarcopenia-Related Disorders Age, years Galvão et al. Prostate Cancer & Prostatic Diseases 2007

17 PROSTATE CANCER: CURRENT TRIALS A phase III clinical trial of exercise modalities on treatment side-effects n = month intervention & 6 month follow-up (1) Resistance & impact loading exercise vs. (2) Resistance & aerobic exercise vs. (3) Usual care Population-based exercise intervention for prostate cancer patients from the RADAR trial n = month intervention & 6 month follow-up (1) supervised resistance & aerobic exercise vs. (2) printed material outlining general physical activity recommendations

18 BREAST CANCER RELATED LYMPHOEDEMA Clinical guidelines strongly recommend patients against vigorous, repetitive or excessive upper body exercise Very conservative guidelines not based on any scientific evidence Resistance exercise is beneficial No change in limb volume Incidences of exacerbations Severity of related symptoms Schmitz et al. New England Journal of Medicine, 2010

19 BREAST CANCER RELATED LYMPHOEDEMA Impact of different intensities of upper body resistance training on lymphoedema status Low intensity: rep max High intensity: 6-8 rep max Strength of effect of low versus high intensity upper body resistance exercise on lymphoedema status & symptoms, physical function & quality of life 3 arm randomised control trial 12 week exercise intervention

20 SARCOPENIA Thigh CSA: 21yrs vs. 63yrs Age related loss of muscle mass Often associated with an increase in fat mass (but total body mass may not change) Affects 60% of over 80 year olds Cause of loss of function and independence Resistance exercise is a very effective strategy to prevent or reverse sarcopenia

21 SARCOPENIA: THE WICKING STUDY Examined the effects of a 12 month home- and clinic-based exercise program n = 300 healthy older adults (65+ years) Resistance training 6-8 major functional muscle groups Aerobic Training 15-30mins (walk or bike) 2-4 times/week

22 50 SARCOPENIA: THE WICKING STUDY Clinic-Based Program Home-Based Program % Improvement after 12 months Strength Physical function Home- and clinic-based programs equally effective 0 1RM Leg Press 1RM Chest Press Chair Rise Stair Climb 400m Walk

23 PARKINSON S DISEASE An extremely disabling disease which compromises function, independence and quality of life Motor symptoms - resting tremor, rigidity, bradykinesia and postural instability Physical activity Strength Physical function Bone mineral density Cognitive function A. Mild B. Severe STATIC BALANCE Armand et al. Parkinsonism Relat Disord. 2009

24 Randomised control trial 12 week intervention PARKINSON S DISEASE Combined resistance and aerobic exercise (1hr, 2/wk) Strength Balance % Improvement after 12 weeks * * Exercise Usual Care -20 Executive function (frontal) Unable to generalize these strength gains to movements not specifically practiced in the program Cruise et al. Acta Neurol Scand. 2010, Newton et al. Mov Disord (in review) 1RM Leg Press Balance Chair Rise Gait

25 Depression is common with a 16% lifetime prevalence (Kessler et al. JAMA 2003) Results in substantial personal & societal burden 50% depression score observed in: 61% of high intensity resistance training subjects 29% of low intensity resistance training subjects 21% of usual GP care subjects DEPRESSION following an 8 week intervention Relationship Between Reduction in Depression & Strength Gain Singh et al. Gerontol A Biol Sci Med Sci.2005

26 DEPRESSION: CURRENT TRIAL Promoting physical activity to improve the outcome of depression in later life (ACTIVE-DEP) Does physical activity decrease the likelihood of a major depressive episode? 2 arm randomised control trial Resistance & aerobic exercise Usual care 12 week intervention Follow-up at 3, 6 and 12 months

27 CHILDHOOD OBESITY Between 1985 & 1997 the proportion of overweight Australian children (7-15yrs) increased by almost 70% (Booth et al. 2003) 20-25% of Australian children & adolescents are overweight or obese (Venn et al. 2007) Children who are overweight are at a greater risk of remaining overweight as adults (Chakravarthy et al. 2005)

28 CHILDHOOD OBESITY n = 48 overweight/obese boys and girls (7-12yrs old, mean age 9.7yrs) 8-week resistance training program 3-12 rep max x 3 sets, 3 days/week Resulted in: % Fat by 2.6% Lean body mass by 5.3% Strength & power McGuigan et al. J Strength Cond Res, 2009 Well tolerated and enjoyed

29 TRANSLATION OF RESEARCH: VARIO CLINIC Vario Wellness Clinic acts as the vehicle to deliver evidence-based wellness programs Integrated approach incorporating disciplines of: Exercise physiology Dietetics Psychology, physiotherapy, occupational therapy and massage therapy. Over 22,000 client contacts in 2009

30 TRANSLATION OF RESEARCH: VARIO CLINIC Cancer Survivors Program Parky Pumpers Diabetes Program Weightloss for Wellness Living Longer Living Stronger Fighting Fit Veterans Osteoporosis Program Weigh to Go Kids

31 TRANSLATION OF RESEARCH: E-HEALTH Online community which aims to encourage men to adopt positive lifestyle changes Health and lifestyle information (e.g. health checks, exercise, nutrition, mental wellbeing) Downloadable resources (e.g. exercise programs)

32 CLINICAL GUIDELINES: STATE Guidelines for use by health professionals when considering an exercise program for cancer patients EP s, PT s, OT s, GP s and oncologists

33 CLINICAL GUIDELINES: NATIONAL 1 st guidelines of exercise prescription for cancer survivors Comprehensive review of over 70 studies Broad prescription incorporating: Low-moderate intensity Regular frequency (3-5 times/week) for at least 20 mins/session Involving aerobic, resistance or mixed exercise modes

34 CLINICAL GUIDELINES: INTERNATIONAL Exercise is safe during & after cancer treatments Results in improvements in physical functioning, quality of life and cancer-related fatigue in several cancer survivor groups Cancer survivors should follow physical activity guidelines, with specific exercise programming adaptations based on disease and treatmentrelated adverse effects Avoid inactivity even in cancer patients with existing disease or undergoing difficult treatments Schmitz et al. 2010

35 SUMMARY OF RESEARCH AT VARIO Develop disease specific exercise prescription to optimally integrate with other therapeutic treatments for best patient outcomes. Translate research findings to the community through the Vario Wellness Clinic, home based and e-health approaches. Generate knowledge to shape clinical guidelines for the use of exercise as medicine.

36 EXERCISE IS MEDICINE! There is no pharmacological intervention that holds a greater promise of improving health and promoting independence in the elderly than does exercise Evans & Campbell, Journal of Nutrition, 1993

37 EXERCISE GUIDELINES: HEALTHY ADULTS Moderately intense cardio 30 minutes/day, 5 days/week or Vigorously intense cardio 20 minutes a day, 3 days a week and 8-10 strength-training exercises, 8-12 repetitions of each exercise 2 days/week Haskell et al., Medicine & Science in Sport & Exercise, 2007

38 EXERCISE GUIDELINES: ELDERLY (>65) Nelson et al., Medicine & Science in Sport & Exercise, 2007 Moderately intense cardio 30 minutes/day, 5 days/week or Vigorously intense cardio 20 minutes a day, 3 days a week and 8-10 strength-training exercises, reps of each exercise 2-3 days/week and Balance exercises if at risk of falling and Have a physical activity plan

39 EXERCISE PHYSIOLOGISTS Exercise Physiologists (EP s) are recognised by the Australian General Practice Network and Royal Australian College of General Practitioners as the most appropriate allied health professionals for: Exercise Prescription and Management Prevention and Wellness Secondary Management of Chronic Disease

40 Prof Robert Newton ACKNOWLEDGEMENTS Assoc Prof Daniel Galvão Prof Dennis Taaffe Clinical Prof Nigel Spry Clinical Prof David Joseph Research Assistants: Greg Levin Misha Burns Paul Crabtree Holly Daniels Vario Clinic Staff

41 THANK YOU TOUR OF FACILITIES TO FOLLOW

42 WHAT DOES VARIO MEAN? Latin for the quality of being different or to make change Represents and supports the integrative approach of the institute towards the management of chronic disease. Reflects the underlying philosophy that to improve health, individuals must change behaviours, communities must change their social and physical environment, and industry and governments must change their policies and processes.