Exercise & Clinical Medicine
Bruce Helming, MD
Objectives:
Define Exercise
Benefits/Risks
Pre-participation Evaluation
How to Assess Readiness for Change
Helping to Motivate
Exercise Prescription (writing one)
Exercise for aging/arthritis/depression
Some Facts: - 200,000 deaths occur per year because of a sedentary life style
- 25% of people state they do no exercise
- 15% of people state they do minimal exercise
- Women, blacks, Hispanics, elderly, low income most likely not to
exercise
- Physicians done ask about exercise!!
Def. Of Exercise: Denotes regular physical activity that is planned, structures, repetitive,
purposeful, and is for the improvement/ maintenance of physical fitness.
- Vs. physical activity which could include cleaning etc
Benefits of exercise:
Muscular skeletal: Increases muscle fiber, capillary density, muscle,
bone, ligament length
Metabolic: Increases mitochondria, muscle glycogen storage, muscle fat
utilization, Vo2 and lactate threshold
Cardiovascular: Increases, SV, CO, contractility (hypertrophy), plasma
volume, capillary flow, endothelial function (dilation), and HR variability
Also, Decreases resting HR, BP (especially in hypertensives
*Hypertrophy from exercise is different than LVH from hypertension!
Respiratory: Increases respiratory rate, tital volume, pulmonary blood
flow
Immune system: moderate exercise will increase the functioning, while
intense exercise has an adverse effect
Endocrine: Decreases serum insulin levels and secretion
Other benefits:
Increased: glycemic control, lipid profile, HDL
Decreased: coronary disease, cardiac events, medical costs, death (allcause mortality), Type 2 diabetes
A Study: 10,269 Harvard alumni
-Those who were moderately active had a 23% decrease in mortality
Decreased: risk of thrombosis, stroke (ischemic and hemorrhagic), obesity
- Moderate exercise was found to facilitate smoking cessation in females
- Decreased the risk of symptomatic gallstones
Benefits for the elderly
- Decreased disability
- Increased autonomy, functional status
- Preserves bone density
- Delays/slows cognitive decline
More Benefits!
Aids with self esteem in adolescents, asthma, HIV, AIDS, pregnancy, low back
pain, neuropathy, chronic fatigue, sleep, panic disorder, dizziness, etc!!
Risks of exercise:
1. Muscular skeletal injury
- Strains, tears, inflammation, chronic strain, stress fractures, nerve
palsies, tendonitis, bursitis
- #1 injury is sprains
- Ice is the most potent anti-inflammatory treatment available
2. Arrhythmia
- Training reduces risk, acute exercise increases risk
3. MI
- There is a temporary increased risk with infrequent exercisers with
multiple cardiac risk (2-10 fold increase!
- Regular exercise is still protective against MI
4. Sudden Death
- Jogging has the risk of 1 death per 396,000 hrs
- Health clubs risk is 1 per 887,526 hrs
- Vigorous exercise (up to 30 min after cessation) the risk is 16.9 (hrs not
given)
- There is only 1 death per 1.51 million episodes of exercise
Causes of sudden death:
a. Under 35, Hypertrophic Cardiac Myopathy
b. Over 35, Coronary a. disease
5. Rhabdomyolysis- muscle breakdown
- Labs would show: myoglobinemia, myoglobinuria, elevated serum CPK
(CK) creatine phosphokinase
- Occurs following exertion
- Risk factors: untrained, heat, humidity, sickle cell trait, hypokalemia
- Presents with dark urine
- Condition can be normal, but enough will cause renal failure, can
progress to death
-
In early stages can be treated with hydration
Risks Cont.
6. Bronchoconstriction
- Exacerbates symptoms in 70% of asthmatics
- Exercise induced bronchospasm (EIB) – onset 8-10 min. post-activity
because of a decrease in epinephrine and adrenaline
- Treatment: inhaler, steroids
7. Heat/cold illness
8. Dehydration
9. Female athlete Triad – Disordered eating, amenorrhea, osteoporosis
10. Immunosuppression, urticaria, anaphylaxis
The benefits outweigh the risks!! Even after a heart attack and in advanced stage
illnesses the patient should ALWAYS be doing SOMETHING.
Exercise Prescription:
Ask about: physical activity, exercise, barriers to exercise, benefits of exercise
Recommend: ‘30 minutes of moderate exercise most days of the week’
The Goal: Exercising 5-6 days per week, 30 minutes per day at 70-80% of
maximum HR (220-age) focusing on aerobic exercise and the risk/benefit ratio of
the individual
- This will increase HDL and is cardioprotective
For Weight Loss: Exercising 5-6 days per week, 45- 60 minutes per day at 60%
of max. HR
- For aerobic, start with 15 minutes, and increase by one minute per
session until you build up to required time
- Fatty acid utilization improves with conditioning!
For Arthritis: Exercise 5-6 days per week for 30 minutes each day at 70- 80% of
the max HR. Focus on low impact, but you need to “load joint:”
Deconditioning  Joint protection  Joint Damage
- You want to build the muscles around the joint to protect it, but also
avoid pain
- Suggest walking, jogging, bicycle
- Patient must get through the threshold of pain when they first start and
then they will be creating joint protection
Nutrition:
-
suggest balanced diet, carbs, protein, fat, fluid replacement, carb.
Replacement after exercise
Avoid fad diets and restriction diets
Stages of Change
Precontemplative – not aware of risky behavior, no intent to change in future
Contemplative – aware of risky behavior, foresees a point in the distant future
when they might change
Preparation- will take action in the near future
Action- actually modifying the behavior, requires time and energy
Maintenance- taking various measures to keep the behavior from returning
Motivational Interviewing:
- Remember change is internal, the goal is the elicit change self talk, you
should be nonjudgmental, supportive and reflective.
- Ask: How important is exercise? 1- 10 ; What are the benefits of NOT
exercising? The Barriers? How can we overcome them?
- Respect patient autonomy, offer support, empathy, don’t take
responsibility, your job is to help them help themselves!
More on Sudden Death
- 10 –13 annual occurrences
- 1: 100,00 – 300,000 HS athletes
- 1:15,000 joggers
- 1:50,000 marathoners (every year NY marathon expects someone to
die!)
- Occurs in M > F
- Most ‘dangerous’ sports for sudden death: 1. Basketball 2. Football 3.
(distant third) track
#1 cause is Hypertrophic Cardial Myopathy (most common in young adult)
- Septal hypertrophy that decreases the rt. ventricle capacity and
puts pressure on the mitral valve
- Cause: coronary a. anomaly, a history of Marfan, long QT, carditis,
murmers
- Most patients are asymptomatic, but some may be dizzy with exercise,
history of fainting, chest pain
- Screen with ECG and a history
- Treatment: have to stop exercising or ICD
Screening for exercise
- After 35, screening is necessary for new exercisers (coronary a. disease,
Family history of premature CVD
- Stress tests: start at age 40 for males, and 50 for females or 65 for
athletes
Mononucleosis
- Airway obstruction and splenic enlargement/ rupture that occurs 4-21
days after infection
-
Patients should be kept from exercising for 3-4 wks, and can expect a
full return after wk 5
Acute Febrile Illness
- Restrict activities especially with GI illness which may cause increased
risk of dehydration and thermo problems
Blood Borne Pathogens
- HIV – the only sport that excludes is boxing
- If patient feels well, then exercise is ok
Osteoarthritis
-
Progressive but can be stabilized with exercise
Avoidance of activity leads to weakness, which leads to joint instability
Management: NSAIDS, topical analgesics, steroids injections, opioid
analgesics
Extreme Exercise
- Exercise addiction
- Increased Injuries
- Risk of overtraining