1、Exercise and Chronic Disease,Mark A. Patterson, M.Ed., RCEP Clinical Exercise Physiologist Kaiser Permanente President-Elect Rocky Mountain ACSM,Hippocrates,“Eating alone will not keep a man well; he must also take exercise. For food and exercise, while possessing opposite qualities, yet work togeth
2、er to produce health.” Hippocrates, Regimen,5th Century B.C.Slide borrowed from Russ Pate and Robert Salis,www.exerciseismedicine.org,Common Chronic Diseases,Cardiovascular disease Heart Attack, Stroke, PAD Pulmonary disease Asthma, COPD, Emphysema Diabetes Neuropathies, CAD Neuromuscular disorders
3、Multiple Sclerosis,Parkinsons Musculoskeletal conditions Arthritis Cancer Breast, Prostate, Leukemia Renal disease Kidney Failure, CAD Immunological AIDS Obesity All of the above?,Cardiovascular disease 79 million (2007 CDC Website) Pulmonary disease 35 million (2007 American Lung Association),Diabe
4、tes 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
5、 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,Chronic Diseases,Benefits of Exercise,Increased VO2 Improved BP Control Increased HDL Decreased Body Fat Improved We
6、ight Control Improved BS Control Improved Strength Less Fatigue Improved Balance,Heart Disease Lung Disease Diabetes Neuromuscular Musculoskeletal Obesity Cancer Kidney Disease AIDs,Who is Best to Care for These People?,Me! In an Ideal World Clinical Exercise Physiologists Physical Therapists Respir
7、atory Therapists Registered Nurses Physicians Personal Trainers Massage Therapists Accupuncture Chiropractors,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 diseas
8、es 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 sk
9、ills 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 wor
10、k 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,CEP or PT?,Physical therapy, which is limited to the
11、 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 n
12、erve integrity,environmental, 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 enduranc
13、e), 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 d
14、aily 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 thera
15、peutic 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),
16、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,
17、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, imp
18、airment, 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,Exercise and Death (Men),Exercise and Death (Women),What is the Best Way to Increase P
19、hysical Activity?,Monitored rehab?Personal training?Case management?Doctors Advice / Guidance?Physical Therapy?Community Resources?Support Groups?Recreation Center Memberships?,Comprehensive Risk Factor Modification Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of He
20、alth Care,MI / ACS / PCI / CABGCase Manager Monitored CRCEP CPCRS Dietician Cardiologist PCP Other Resources,Clinical Exercise Physiologist Role Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care,Clinical Exercise PhysiologistExercise Rx / Consult (One-on-O
21、ne) Monitored Sub-Max Exercise Testing ROM / Flexibility Evaluation Strength Evaluation Behavior Change CounselingMonitored Rehab Cardiologist PCP Other Resources,Functional Exercises,What is a functional exercise?Exercise that is specific to and closely mimics task to be completed.Walking lunge bet
22、ter to strengthen muscles to assist in increasing efficiency of walking / running than leg extensions.,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 s
23、ymptoms and review support team and resources for exercise,What is the Risk of Exercise?,Exercise Prescription Tips,Cardiovascular Medications (HR and BP)Symptoms (CAD, CHF, PAD)F.I.T. Principle ConsiderationsImportance of Warm Up and Cool DownDo not hold your breath!,When can they start?,Assuming P
24、atient 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
25、 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
26、EF is below 30% strength training may be contraindicated.,Exercise Prescription Tips Peripheral Vascular Disease,Claudication Walking is a must Specificity2 Most Important Measures1. Onset of symptoms2. Maximum walk timeIntermittent Walking to Moderate PainHigh Risk of Heart Disease (CAD)Add other m
27、odes of aerobic exercise to increase total conditioning timeRole of Strength Training,Non-Claudicant Can prescribe exercise like people with heart disease / or at high risk for heart disease,Claudication and Strength Training,Hiatt WR, et al, Peripheral Arterial and Aortic Diseases: Superiority of T
28、readmill 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,Exercise Prescription Tips Lung Disease,Perceived Exertion vs. Shortness of BreathReliability of HR?A
29、erobic Walking Part of most activities of daily living. Stationary Bike Arm ErgometerImportance of Strength Conditioning 1. Improve efficiency of muscles / conservation of energy,Exercise Prescription Tips Diabetes,Monitor Blood Sugar Before and After *250 with Ketones, 100 *Post Exercise Hypoglycem
30、iaMeals and MedicationsAutonomic Neuropothy and HRPeripheral Neuropothy and Wound Care,Exercise Prescription Tips Diabetes,Autonomic Neuropathy Silent ischemia and infarction, tachycardia at rest and early in exercise, reduced max HR, exercise intolerance, exercise induced hypotension, thermoregulat
31、ory 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,Exercise Prescription Tips Diabetes,AerobicFrequency 3-7 days per week Intensity 40
32、-60% Moderate 60% Vigorous Time 150 minutes / week moderate 90 minutes / week vigorousResistance Training Frequency 3 days per week Intensity 8-10 repetitions Volume of Exercise 8 exercises Up to 3 sets per exercise,Aerobic Exercise ModesChoose exercises such as stationary bike and eliptical trainer
33、s- help with balance- less chance of fallingWalking also a good choice as involved in most activities of daily living specificityResistance Training ModesMachine weights are preferred at start since they can help with balance,Exercise Prescription Tips Multiple Sclerosis,Aerobic Exercise1. Perceptua
34、l Scale better for Exercise Intensity2. Adjust daily according to symptoms and energy levels3. Avoid exercise in heat, exercise early in day better for symptoms of fatigue4. Bladder issues can cause patients to not hydrate properly Strength Training 1. Optimize in unaffected muscle groups 2. Functio
35、nal exercises best, Emphasize core groups 3. Increase rest period time 4. During times increased symptoms focus stretching, ROM 5. Weight machines preferred.,Exercise Prescription Tips Parkinsons Disease,Aerobic Safety walking is preferred, but may need to use bike ergometer, eliptical, arm ergomete
36、r 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,Exercise Prescription Tips Osteoarthritis,“Weight B
37、earing” 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 optionExercises to improve balance Minimize forward flexion and twisting movementsCan start with strength trainingCan do co
38、mbination of short bouts of aerobic training with strength training done during rest periods.,Exercise Prescription Tips Rheumatoid Arthritis,Can follow same basic guidelines as with osteoarthritisAvoid exercise during “inflamatory phase”,Exercise Prescription Tips Fibromyalgia,Must customize to ind
39、ividualCareful to avoid overexertionProgress slowly (water to land walking),Exercise Prescription Tips Obesity,*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 optionWater walking and water ae
40、robics ideal for those with problematic jointsWatch carefully for signs of cardiopulmonary and metabolic disease.,Exercise Prescription Tips Obesity,Strength TrainingMachine weights may help with balance and help to ensure proper form Light weights recommended with moderate to high repetitions May b
41、e best option to concentrate on early as de-conditioning and joint issue may limit ability to perform aerobic exercise at onset of new program,Exercise Prescription Tips AIDS,HIV Exercise Rx must be adapted per stage of disease Asymptomatic usual general ACSM guidelines are fine Symptomatic need to
42、adjust day to day, should not exercise with fever above 100, or if having nausea, vomiting, uncontrolled diarrhea or dehydration,Exercise Prescription Tips AIDS,Moderate better, overtraining increases likelihood of infectionsEnvironment Abrasions, tissue injuries Cross infection, sharing of water bo
43、ttles Overseas travel,Exercise Prescription Tips AIDS,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,Exercise and Dialysis,Effects of Kid
44、ney Disease and Long Term Dialysis bone disease, fatigue, coronary artery disease and rhythm disturbances,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 patien
45、ts may actually be placed at a greater risk for cardiac events and adverse musculoskeletal outcomes in the are not participating in regular physical activity” Adv Ren Repl Ther, Vol 6, No 2, 1999: pp 165-171,Exercise and Dialysis,Exercise and Dialysis,Exercise Tips Breathing is at conversational lev
46、el 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 N
47、ot feeling well Blood Pressure 200/100 Unstable sugar levels,Exercise and Cancer,1. Follow the advice of Barbara Francis2. Be consistent3. Have Sean Swarmer take you for a little hike in Nepal,References,ACSMs Guidelines for Exercise Testing and Prescription, 7th Edition Manual of Exercise Testing,
48、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 Reha
49、bilitation, 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,
