Exercise Prescription. James Moriarity MD University of Notre Dame

Exercise Prescription James Moriarity MD University of Notre Dame

Disclosures None

What is an Exercise Prescription?

2011 ACSM Positions Statement Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise This pronouncement was written for the American College of Sports Medicine by Carol Ewing Garber, Ph.D., FACSM, (Chair); Bryan Blissmer, Ph.D.; Michael R. Deschenes, Ph.D., FACSM; Barry A. Franklin, Ph.D., FACSM; Michael J. Lamonte, Ph.D., FACSM; I-Min Lee, M.D., Sc.D., FACSM; David C. Nieman, Ph.D., FACSM; and David P. Swain, Ph.D., FACSM. http://journals.lww.com/acsmmsse/fulltext/2011/07000/quantity_and_quality_of_exercise_for_developing.26.as px

Summary of the general evidence relevant to the exercise prescription. Copyright 2015 Medicine & Science in Sports & Exercise. Published by Lippincott Williams & Wilkins. 6

Table 2 Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise Garber, Carol Ewing; Blissmer, Bryan; Deschenes, Michael R.; Franklin, Barry A.; Lamonte, Michael J.; Lee, I-Min; Nieman, David C.; Swain, David P. Medicine & Science in Sports & Exercise. 43(7):1334-1359, July 2011. doi: 10.1249/MSS.0b013e318213fefb TABLE 2. Evidence statements and summary of recommendations for the individualized exercise prescription. Copyright 2015 Medicine & Science in Sports & Exercise. Published by Lippincott Williams & Wilkins. 7

What do you need to know in order to write an exercise prescription? High Level Athlete?...Refer for metabolic performance testing Everyone else. Assess their medical risk Consider their age and level of current functional activity Ascertain what their goals are.not yours! What do they like to do for recreation? Design a program that gives them the best chance of being successful!!

Motivation!!!

Assessing Risk

Physical Activity Readiness Questionairre The Par-Q was developed by the Canadian government in the 1970s as a public health movement (ParticipAction) to encourage exercise across the country. PAR-Q & YOU Ages 15-69 PAR-Q+ All ages

"some is good; more is better" Multiple studies have shown that an expenditure of ~1000 calories per week is associated with maximal reduction in cardiovascular risk However, trending in improved cardiovascular risk begins with as little as 500 calorie expenditure/wk Remember, 1 MET of activity =1 Kcal/Kg/hr burned. 5 METS = 5 Kcal/Kg/hr burned. So,,, if you weigh 75 Kg and bicycle at an easy rate (5 METS) it would require about 3 hrs (180 minutes) a week to burn a 1000 calories

Rationale for 150 minutes /week 150

150 min/week: Is more better? Exercise of the intensity, duration, and frequency recommended results in improvements in cardiorespiratory fitness (i.e., V O 2max ). Moreover, a plateau in the training effect occurs, whereby additional increases in exercise volume result in little or no additional improvements in V O 2max.

So what s the best way to measure exercise intensity? % Maximum Heart Rate? % Heart Rate Reserve? % VO2 max METS (metabolic equivalent) Kcal Perceived exertion scales Step Counts Full Scale Exercise Testing with a Metabolic Cart

Heart Rate Tests Maximum heart rate has a wide range of normal which has a marked affect on recommended exercise HR intensities Requires a graded exercise test to determine maximum rate Heart Rate Reserve incorporates both HR max and HR rest Target Heart Rate = [(HRmax HRrest) x %Intensity] + HR rest

Age: Delay it as long as you can!! Copyright 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. 20

% HR max overestimates exercise intensity at lower Heart Rates % HR reserve a more accurate predictor of exercise intensity in the lower to middle levels of intensity categories

METS METS (metabolic equivalent) is a quick way to describe the intensity of a particular exercise relative to rest. 1 MET is defined as the energy (Kcal, O2, Watts or joules) generated by the average person sitting quietly at rest. 1 MET = 3.5ml/O2/min, or 1 Kcal/Kg/hr, or 58 Watts/m 2 (bodysurface area) /hr. Intensity of exercise can be expressed as multiples of 1 MET. A person exercising at 6 METS is expending 6x the amount of energy compared to rest. Maximal exercise capacity in METS would approximate an individuals VO 2 max Exercise Prescription\Watts_to_METs_Conversions.pdf Categories of Exercises in METS

Physical activity MET Light intensity activities < 3 sleeping 0.9 watching television 1.0 writing, desk work, typing 1.5 walking, 1.7 mph (2.7 km/h), level ground, strolling, very slow walking, 2.5 mph (4 km/h) 2.9 Moderate intensity activities 3 to 6 bicycling, stationary, 50 watts, very light effort 3.0 walking 3.0 mph (4.8 km/h) 3.3 calisthenics, home exercise, light or moderate effort, general 3.5 walking 3.4 mph (5.5 km/h) 3.6 bicycling, <10 mph (16 km/h), leisure, to work or for pleasure 4.0 bicycling, stationary, 100 watts, light effort 5.5 sexual activity 5.8 Vigorous intensity activities > 6 jogging, general 7.0 calisthenics (e.g. pushups, situps, pullups, jumping jacks), heavy, vigorous effort 8.0 running jogging, in place 8.0 rope jumping 10.0 2.3

Perceived exertion scales: Valence Valence, as used in psychology, especially in discussing emotions, means the intrinsic attractiveness or aversiveness of an event, object, or situation.

10,000 Steps Most adults will walk a few thousand steps/day. 2000 steps/mile 120 steps minute is a moderately intense pace (3-6 METS)

10,000 Steps: starting from scratch

Relative vs Absolute Cost of an Exercise Activity Which car uses more of its horsepower to travel 30 mph? Copyright 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. 30

Relative vs Absolute Cost of an Exercise Activity For individual exercise prescription, a relative measure of intensity (i.e., the energy cost of the activity relative to the individual's maximal capacity) is more appropriate, especially for older and deconditioned persons An older person working at 6 METs may be exercising at a vigorous to maximal intensity, while a younger person working at the same absolute intensity will be exercising moderately Absolute measures can result in misclassification of exercise intensity (e.g., moderate, vigorous) because they do not consider individual factors such as body weight, sex, and fitness level Copyright 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. 31

Sedentariness is detrimental even among in individuals who meet current physical activity recommendations When sedentary activities are broken up by short bouts of physical activity or standing, attenuation of these adverse biological effects can occur. This evidence suggests it is not enough to consider whether an individual engages in adequate physical activity to attain health benefits but also that health and fitness professionals should be concerned about the amount of time clients spend in activities such as television watching and sitting at a desk.

What about Metabolic Disease? Favorable improvements in hypertension, glucose intolerance, insulin resistance, dyslipidemia, and inflammatory markers have been reported in middle-aged and older persons exercising within the volumes and quality of exercise recommended). The benefits of exercise on cardiometabolic risk factors are acute (lasting hours to days) and chronic, highlighting the value of regular exercise participation on most days of the week (as opposed to one long exercise activity a week)

Muscular fitness Injury?? Aerobic Fitness Muscular Fitness http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahukewib4onbxc_jahvhnymkhwjqa7sqjrwib w&url=http%3a%2f%2fwww.milsurps.com%2fshowthread.php%3ft%3d21249&psig=afqjcnekyyers61tp729xymdk0gg_iyslw&ust=1449776692956831 Copyright 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. 34

It works, but at what level? Higher levels of muscular strength are associated with significantly better cardiometabolic risk At present, there is insufficient data for the existence of a threshold for a minimal level of health-related muscular strength Copyright 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. 35

Classification of exercise intensity: relative and absolute exercise intensity for cardiorespiratory endurance and resistance exercise. Copyright 2015 Medicine & Science in Sports & Exercise. Published by Lippincott Williams & Wilkins. 36

Exercise Prescription: Assess the risk Assess fitness and functional activity level Ask about exercise and recreational interests Ask what would be a good starting level of effort Emphasize the regular and daily, not the exercise Suggest enlisting friends or partners in an exercise activity Encourage, educate, empathize!! It s all about the fun!!!