Guidelines for Exercise Prescription at the Office

Transcription

1 Guidelines for Exercise Prescription at the Office Joseph Ihm, MD Assistant Professor Rehabilitation Institute of Chicago Northwestern University Feinberg School of Medicine

2 Disclosures Nothing to disclose

3 Topics to be discussed! Does a physician s health matter?! Does counseling matter?! How active are we?! Screening prior to exercise! Guidelines for fitness and health! Ways to communicate with patients about activity, health and fitness

4 Physician habits and counselling What we do and know affects our patients! 23-42% familiar with ACSM guidelines (Williford, 1992; Costello 2012)! 96% felt it was responsibility but only 28% felt confident in their skills to prescribe exercise (Rogers, 2002)! If exercises more likely to counsel patients (Rogers, 2005; Abramson, 2000 (OR ))! If healthy more likely to counsel (Wells, 1984)! If trying to improve exercise habits more likely to counsel (Frank, 2000)! 70% more likely to comply if physician active (Harsha, 1996)! More likely to comply if well dressed or well groomed (Harsha, 1996)

5 Does counseling matter?! Number who counsel is increasing (Barnes, 2012)! After 3-5 minutes of counseling moved from contemplator to active (Calfas, 1996)! Improved fitness levels (JAMA, 2001)

6 How many are active?! 48% meet 2008 Physical Activity Guidelines (activity and resistance training)! % active! % inactive CDC website

7 Screening prior to starting exercise MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OF CARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE! Pain, discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia! Shortness of breath at rest or with mild exertion! Dizziness or syncope! Orthopnea or paroxysmal nocturnal dyspnea! Unusual fatigue or shortness of breath with usual activities! Ankle edema! Palpitations or tachycardia! Intermittent claudication! Known heart murmur

8 Screening prior to starting exercise Cardiovascular risk factors! Age! Family history! Cigarette smoking! Sedentary lifestyle! Obesity! Hypertension! Dyslipidemia! Prediabetes ACSM risk stratification for CVD! Low risk -- asymptomatic with < 2 risk factors! Moderate risk -- asymptomatic with >1 risk factor! High risk -- individuals with known cardiovascular, pulmonary, or metabolic disease, or one or more sign or symptom

9 Risk Stratification Low Risk Asymptomatic 1 Risk Factors Moderate Risk Asymptomatic 2 Risk Factors High Risk Symptomatic, or known cardiac, pulmonary, or metabolic disease Medical Exam & GXT before exercise? Mod Ex - Not Nec Vig Ex - Not Nec Medical Exam & GXT before exercise? Mod Ex - Not Nec Vig Ex - Rec Medical Exam & GXT before exercise? Mod Ex - Rec Vig Ex - Rec Mod Ex: Vig Ex: Not Nec: 8 th Edition, 2009 Moderate intensity exercise; 40-60% of VO 2max ; 3-6 METs; an intensity well within the individual s capacity, one which can be comfortably sustained for a prolonged period of time (~45 minutes) Vigorous intensity exercise; > 60% of VO 2max ; > 6 METs; exercise intense enough to represent a substantial cardiorespiratory challenge Not Necessary; reflects the notion that a medical examination, exercise test, and physician supervision of exercise testing would not be essential in the preparticipation screening, however, they should not be viewed as inappropriate

10 9 th Edition, 2013

11 Differentiate activity and exercise! Activity! Any bodily movement produced by skeletal muscles that results in increased energy expenditure! May not change fitness level greatly! Exercise! Planned, structured and repetitive activity! Should improve or maintain fitness

12 Recommendations for Adults! 150 minutes per week mod intensity! 75 minutes per week of vigorous intensity! Combinations of mod and vigorous can be done! If exceeded then greater fitness and health benefits Physical Activities Guidelines for Americans -Haskell, et al. Med Sci Sport and Exercise, 2007

13 Moderate METs Vigorous 96.0 METs Walking Walking, jogging & running Walking 3.0 mph = 3.3* Walking at very very brisk pace (4.5 mph) = 6.3* Walking at very brisk pace (4 mph) = 5.0* Cleaning heavy: washing windows, car, clean garage = 3.0 Sweeping floors or carpet, vacuuming, mopping = Walking/hiking at moderate pace and grade with no or light pack (G10 lb) = 7.0 Hiking at steep grades and pack lb = Jogging at 5 mph = 8.0* Jogging at 6 mph = 10.0* Running at 7 mph = 11.5* Shoveling sand, coal, etc. = 7.0 Carrying heavy loads such as bricks = 7.5 Carpentry general = 3.6 Heavy farming such as bailing hay = 8.0 Carrying & stacking wood = 5.5 Shoveling, digging ditches = 8.5 Mowing lawn walk power mower = 5.5 Badminton recreational = 4.5 Basketball game = 8.0 Basketball shooting around = 4.5 Bicycling on flat: moderate effort (12 14 mph) = 8.0; fast (14 16 mph) = 10 Bicycling on flat: light effort (10 12 mph) = 6.0 Skiing cross country slow (2.5 mph = 7.0; fast ( mph) = 9.0 Dancing ballroom slow = 3.0; Soccer casual = 7.0; competitive = 10.0 ballroom fast = 4.5 Fishing from river bank & walking = 4.0 Swimming moderate/hard = 8 11 Golf walking pulling clubs = 4.3 Tennis singles = 8.0 Sailing boat, wind surfing = 3.0 Volleyball competitive at gym or beach = 8.0 Swimming leisurely = 6.0 Table tennis = 4.0 Tennis doubles = 5.0 Volleyball noncompetitive = Haskell, 2007

14 Intensity Relative Intensity %HRR or Perceived Exertion %V O 2 R %HR max %V O 2max (Rating on 6 20 RPE Scale) Very light G30 G57 G37 GVery light (RPE G 9) Light Very light fairly light (RPE 9 11) Moderate Fairly light to somewhat hard (RPE 12 13) Vigorous Somewhat hard to very hard (RPE 14 17) Near maximal to maximal Q90 Q96 Q91 QVery hard (RPE Q 18) Absolute Intensity METs G to Q8.8 Table adapted from the American College of Sports Medicine (14), Howley (173), Swain and Frankl (347), and the US ACSM Position Stand, 2011

15 Increase aerobic fitness! 60-70% of max heart rate! 30y/o bpm! 50y/o bpm! minutes at 70% or minutes at 60%! 3+ days per week! Higher the intensity the greater the improvement! If more fit then more calories per workout

16 Measuring intensity! Borg rated perceived exertion scale! Talk test (Quinn, 2009)! Counting Talk Test (Loose, 2012)! Heart rate (by palpation or monitor)! Pedometer steps/min and recommended time

17 Resistance training! Most or all muscle groups (8-10 exercises)! 2 or more days per week! 1-3 sets per exercise! 65-75% of 1 rep max! reps per set! Screen for orthopedic and cardiac conditions! Variable motivation and tolerance

18 Flexibility! Two or three days each week! Hold for seconds to the point of tightness! Accumulate 60 seconds per stretch! Static, dynamic, ballistic and PNF! Most effective when the muscle is warm From ACSM website

19 Discussing activity with patients! Assess current activity level! Discuss ways to increase activity! Provide options for increasing fitness level! Do not accept I walk everywhere or My house has a lot of stairs as confirming adequate activity! Try to impress consequences of inadequate activity

20 Conclusions! Encourage patients to be active! Use other resources for patients! Exercise is Medicine website! guidelines/index.html