Exercise and Disease II
Urho Kujala
Professor of Sports & Exercise Medicine
Department of Health Sciences, University of Jyväskylä
Urho.Kujala@sport.jyu.fi
Contents
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•
•
•
•
•
•
Musculoskeletal disease
Neurologic disease
Renal disease –bladder problems
GI-tract
Cancer
Infections
+ Pulmonary disease (separate presentation)
Exercise and musculoskeletal
disease
•
•
•
•
•
Relations to other diseases
Relations to functioning and disability
Immobilization
Sports and exercise in the prevention
Exercise in the treatment and rehabilitation
Wang et al.
www.plosbiology.org;
Oct 2004;vol 2; Issue 10;
e294
(WT=wild type
TG=transgenic)
The role of interspecies differences has to be taken into account
when attempting to extend the results of animal experiments to humans!
Muscle fibre-type distribution, weight gain and concentric
remodelling of left ventricle: a 19-year follow-up study
(Karjalainen J, Tikkanen H, Hernelahti M, Kujala UM: BMC
Cardiovascular Disorders 2006;6:2. doi:10.1186/1471-2261-6-2.)
30
20
,4
Mean change in BMI/year
Body fat %
40
10
20 30 40 50 60 70 80 90
Type-I%
,3
,2
,1
0,0
-,1
20 30 40 50 60 70 80 90
Type-I%
Basics on functions of skeletal
muscle
•
•
•
•
•
Movement, posture, stability
Communication
Heat production, cold tolerance
Important role in metabolism/energy balance
Endocrine organ; ”myokines”(IL-6, -8, -15) and
myostatin partly control/regulate inflammation,
energy expenditure, muscle growth and fat
deposition.
NOTE: Skeletal muscle is a major mass peripheral
tissue (about 36% for females and 42% for males)
Functions of bone
•
•
•
•
•
Support
Production of cells to circulation
Calcium reserve/metabolism
Associations to fat etc. Metabolism
Endocrine functions
Sarcopenia
• Decrease in muscle mass is an important age-related change
• Degreases in number and size of muscle cells and infiltration of fat
into muscle
• Associated with increased risk of disability and death
• Risk factors for sarcopenia; aging, nutrition, hormonal balance,
different diseases
• Physical activity is the best preventive means
• Muscle is important not only for producing work but olso for
metabolism, body temperature maintenance, and protein source
• Muscle training among older people important for maintaining
mobility
Disability 25 years later according to midlife grip strength tertiles
among 6089 initially healthy men, HHP
Difficulty in
Climbing 10 steps
Walking 800 m
Lifting 4.5 kg
Heavy housework
Using toilet
Eating
Dressing
Grip strength
tertiles
Washing
Highest
Functional limitations
Middle
Sit-to-stand
Lowest
Walking speed <0.5m/s
0
(Rantanen et al. JAMA 1999;281:558-560)
10
20
%
30
Biological Change
Risk of Injury
Benefit profile B
Net health benefit
Benefit
profile A
Risk of injury; profile A
Risk of injury; profile B
Light
Medium
Intensity of Exercise
High
What kind of evidence
do we need?
• Prevention; Observational studies to give
general advice for healthy people?
• Treatment of patients with chronic
disease using resourches of health care;
RCTs are needed?
• Studies on the effects of exercise on the
mechanisms of disease
Exercise recommendations and how
to follow the recommendations
• Recommendations for the prevention of
disease
• Recommendations in the treatment and
rehabilitation of disease
• Contraindications/safety rules
Reduction of maxVO2 during bed rest
(Greenleaf et al. J Appl Physiol 1989;67:1820-1826.)
0
-2
-4
No exercise
-6
Bicycle 30 min x 2 per
day
Max leg ext and flex
10 x 5 x 2 per day
-8
-10
-12
-14
Day 0
Day 7
Day 14
Day 21
Effects of immobilization on
musculoskeletal system
• Bone
• Cartilage
• Muscle
• Tendon
(See: Bloomfield et al. Changes in
musculoskeletal structure and function with
prolonged bed rest. Med Sci Sports Exerc
1997; 29: 197-206)
Osteoarthritis and exercise
• Osteoarthritis causes long-lasting physical
activity limitations more than any other
disease
Factors predisposing to osteoarthritis
•
•
•
•
•
Overweight
High work-related loading
Joint injuries (leisure/sports and work)
Genetic factors
Other diseases (diabetes etc.)
HERITABILITY: TWIN STUDIES
• The genetic influence explains 3965% of the variance in the
occurrence of radiographic hand or
knee OA in women
• OA-score; MZ - r=0.64 vs. DZ r=0.38
• (Spector et al. BMJ 1996;312:940-3)
Hospital discharge reports
ICD 8 (1970-1985)
ICD 9 (1986-1990)
Kujala et al. British Medical Journal 1994;308:231-234.
Impairments due to hip joint problems in
former elite athletes and controls
(adjusted for age, SES and BMI)
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
Endurance
Team
T&F Athletes
Strength
Shooters
All Athletes
Controls
OR
Impairments due to knee joint problems
in former elite athletes and controls
(adjusted for age, SES and BMI)
1,8
1,6
1,4
Endurance
Team
T&F Athletes
Strength
Shooters
All athletes
Controls
1,2
1
0,8
0,6
0,4
0,2
0
OR
Sports or physical activity in the
prevention of osteoarthritis
• Sports including high risk of joint injuries and
very high impact loads increases the risk of
osteoarthritis
• Low to moderate leisure physical activity without
joint injuries does not increase the risk
• High work-related loading increases the risk of
osteoarthritis
• Physical activity maintains function
Randomised Controlled Trial (RCT)
Patient group
Randomisation
Exercise
(+usual care)
Control/Placebo
(+ usual care)
Measurement of outcomes so that assessors are blinded
to treatment group, and all subjects are included into
the ’intention-to-treat’ -analysis
KNEE OA & EXERCISE
• Randomized 18 mo trial; aerobic exercise
vs. resistance exercise vs. education
• N = 439 subjects, age 60+
• Conclusion: Older disabled persons
participating in aerobic or resistance
exercise programs had modest
improvements in measures of disability,
performance and pain
• (Ettinger et al. JAMA 1997;277:64-66)
Statistical methods of meta-analyses
• Dichotomous (or binary) data; odds ratios (OR),
relative risks (or relative effects), risk differences
as well as absolute measures, such as the number
needed to treat (NNT).
• For continuous data; weighted mean difference
(WMD) is preferable when outcomes measured in
a standard way. In case continuous outcomes are
conceptually the same but measured in different
ways, standardized mean differences (SMD).
• Heterogeneity between different studies; fixed
effect vs. random effects analysis methods
Osteoarthritis – Contrast; Exercise
Outcome; Pain (Fransen et al.)
Osteoarthritis – Contrast; Exercise
Outcome; Physical function
Osteoarthritis
• Based on RCTs, land-based therapeutic exercise (with
manual therapy or balance training in some studies)
improved self reported pain and self-reported physical
function in patients with knee osteoarthritis (Fransen et al.,
2007).
• Both aerobic walking and home based quadriceps
strengthening exercise reduce pain and disability but no
difference between them was found on indirect comparison
(Fransen et al. 2008, Roddy et al. 2005, Lange et al. 2008).
• The effect size of exercise in alleviating pain in hip OA has
been shown to be compareable to that in knee osteoarthritis
(Hernandez-Molina et al. 2008).
Osteoarthritis
• Aquatic exercise gives rather similar benefits as land-based
exercise (Bartels et al. 2008). The effect of exercise on the
progression of osteoarthritis is unclear.
• On the basis of 11 RCT:s Pisters et al. (2007) have
analyzed long-term effects of exercise therapy in hip or
knee osteoarthritis patients. The analysis showed that
there is no long-term effectiveness on pain and selfreported physical function 6+ months after the
treatment ended.
• Additional booster sessions seem to maintain some of
the benefits and some benefit on patient global
assessment of effectiveness may remain without booster
sessions.
EXERCISE WITH OA:
TRAINING PRINCIPLES
• Individual programmes and group-based
programmes are equally effective; longterm compliance is a key factor. Utilise
local resources.
• Remember: Movement, progressive muscle
strengthening, ROM, aerobic training.
• Avoid: Injuries, high impact loads.
TAKE-HOME MESSAGE:
EXERCISE AND OA
• Exercise associated injuries may lead
to degenerative changes and OA
• Different types of training may help in
the prevention or treatment of
disability
• Can exercise help in the prevention of
degenerative changes? No final
evidence.
Yleinen liikuntasuositus
• Alaraajojen nivelrikkoa potevalle sopivat
hyvin esim. uinti, pyöräily (huom. erit.
ylipainoiset; ei kehon paino kipeän nivelen
päällä), kävely
• Huonommin sopivat juoksu, pallopelit yms.
• Yläraajojen nivelrikkoa poteville sopii
myös juoksu ym. esim. mailapelit
huonommin
Vasta-aiheet ja varoitukset
• Yleensä kyseessä iäkkäät henkilöt, aina
vähintään kardiovaskulaarianamneesi
• Kysytään kipeytymisistä, muunnetaan
ohjelmaa
• Jos nivelen lukkiutumisia, pahenevaa
nivelturvotusta ym. arvioidaan kliininen
tilanne ja harjoituskelpoisuus uudelleen
Ryhmäohjelman toteutus
• Aluksi esim. 3 x viikko x 1 tunti,
myöhemmin käyntejä harventaen ja
kotiohjelmaa opastaen
• Nousujohteinen
• Sisätö: Lämmittely (esim. kuntopyörä,
kävely), venyttely, kuntopiiri 2 x (2x10
liikettä) sisältäen mm. polven ojentajien ja
koukistajien harjoituksia + esim istumasta
ylös nousu, verryttely/venyttely
Exercise and the prevention of
rheumatoid arthritis
• There is no clear evidence on that exercise
pedisposes to or prevents from rheumatoid
arthritis
Rheumatoid arthritis
• On the basis of more than 10 RCTs exercise therapy seems to be
effective at increasing aerobic capacity and muscle strength in patients
with rheumatoid arthritis though good meta-analyses are lacking
(Kettunen and Kujala 2004, Van den Ende et al., 2004, Metsios et al.
2008).
• Also on the basis of 3 RCTs in patients with juvenile idiopathic
arthritis under 18 years of age the functional ability tended to be better
after exercise therapy (Takken et al. 2008).
• No detrimental effects on disease activity and pain were observed in
these trials.
• The effects of dynamic exercise therapy on radiological progression
and cardiovascular disease need further studies (Kettunen and Kujala
2004, Van den Ende et al., 2004, Metsios et al. 2008).
• Disease activity?
EXERCISE WITH RA:
TRAINING PRINCIPLES
• Individual programmes and group-based
programmes are equally effective; longterm compliance is a key factor. Utilise
local resources.
• Remember: Movement, progressive muscle
strengthening, ROM, aerobic training.
• Avoid: Injuries, high impact loads.
TAKE-HOME MESSAGE:
EXERCISE AND RA
• Different types of training may help in the
prevention or treatment of disability
• Aerobic exercise helps in maintaining
cardiovascular function (remember comorbid conditions)
• Can exercise help in the prevention of
degenerative changes? No final evidence.
Takken et al.: Exercise therapy in
juvenile idiopathic arthritis
Exercise after
total joint replacement
• There is some evidence based on RCTs that
perioperative (Gilbey et al. 2003) and
postoperative (Maire et al. 2003) exercise
therapy improves early functional recovery
after total hip arthroplasty.
Exercise after
total joint replacement
• Consensus statements say that participation in noimpact or low-impact sports (swimming, cycling
etc.) can be encouraged, but participation in highimpact sports (running, ball games, racquetball etc.)
should be prohibited after TJR (McGrory et al.
Mayo Clin Proc 1995;75:342-348).
• There is some evidence of increased surface wear
rate (Dubs et al. Arch Orthop Trauma Surg
1983;101:161-169) and of increased aseptic
loosening rates (Kilgus et al. Clin Orthop
1991;269:25-31) in active patients.
Ankylosing spondylolitis
• Four RCTs compared exercise program
with no intervention and reported some
increases in spinal mobility and physical
function (Dagfinrud et al., Cochrane
Review 2008).
• Training of ROM and muscle strength are
effective.
Low back pain
Exercise in the prevention of low
back pain
• Leisure physical activity does neither predispose
to nor prevent from LBP
• Good muscle function does neither predispose to
nor prevent from LBP
• High work-related loading predisposes to LBP
• Traumatic sports predisposes to degenerative
changes and pain episodes
• Physically active have better function
Low back pain
• Acute back pain – Exercise does not help (strong
evidence); subacute back pain – no help
• Chronic low back pain; effect on pain based on 8 RCTs 10.2 units (95% CI; -19.09, -1.31) on a scale from 0 to
100.
• Effect on function is smaller (target group has an effect)
• Exercise may be helpful for chronic LBP patients to
increase return to normal daily activities and work.
(Hayden et al. Cochrane Database Syst Rev)
LBP- Hayden et al. Updated review
EXERCISE WITH CHRONIC LBP:
TRAINING PRINCIPLES
• Non-traumatic exercise that helps in
increasing ordinary activity.
Best exercise programme?
• Indirect comparisons using Bayesian multivariable
random-effects meta-regression (Hayden et al.
Ann Intern Med 2005;142:776-786)
• Compared to non-supervised home exercises the
improvements were higher for:
 Individually designed programs 5.4 points
 Supervised home exercise 6.1 p.
 Group and individually supervised program 5.9 p.
TAKE-HOME MESSAGE:
EXERCISE AND LBP
• Exercise associated injuries may lead
to degenerative changes
• Different types of training may help in
the prevention or treatment of
disability
• Can exercise help in the prevention of
degenerative changes? No final
evidence.
Neck and shoulder pain
Chronic non-specific neck-shoulder
pain syndrome
• 5% of Finnish men and 7% of Finnish
women (Mini-Finland health survey)
• Patholic-anatomic causes can be determined
in only a small proportion of cases; imaging
methods focus on excluding severe
underlying causes
• Pain originates from muscles?, other soft
tissues?, facet joints?, intervertbral discs?
Classification
• Neck vs shoulder
• Neck pain:
1. Local
2. Radiating
3. Whiplash
4. Myelopathy
5. Others: generalized diseases, neoplasms, fractures
etc.
Neck pain and exercise/loading
• Severe neck pain is often associated with
mood problems and fear of exercising and
loading; choose activities that do not
provocate problems
• Risk-factors: static loading of upper
extremities (in upward positions), high wrkrelated loading, low socio-economic
position etc.
Physical activity and prevention of
neck pain
• No clear associations
Neck pain - treatment
• Avoid bed rest at acute phase – normal daily
activities if tolerated
• Associated symtoms such as headache may be
provocated/increased by exercise
• Training has been shown to be effective in the
treatment of chronic neck pain and whipplash
injury in case it focuses specifically on neck and is
repeated often and long enough
New Finnish RCTs on the effects of
training on chronic neck pain
• Viljanen et al. BMJ 2003; no effect (training
of upper extremities with low frequency)
• Ylinen et al. JAMA 2004; training
beneficial (specific training for neck
musculature with higher frequency; strength
training and endurance type training equally
effective on pain)
Fibromyalgia
• Fibromyalgia manifests as chronic pain and
fatigue/tiredness
• Symptoms are non-specific and the patophysiology is
unknown
• Peripheral muscles are normal
• The abnormality may be related to experiencing pain at the
level of CNS
• Diagnosis: rule out other specific diseases, no diagnostic
tests - typical symptoms and signs; wide-spread,
continuous, symmetrical pain symptoms – tender point
palpation often used
Exercise in the prevention of
fibromyalgia
• Exerise does not prevent from fibromyalgia
• Young athletes usually do not have
fibromyalgia?
• Explanation: Central mechanisms
Fibromyalgia – Contrast; Exercise
Outcome; Aerobic fitness
(Busch et al.)
Fibromyalgia – Contrast; Exercise
Outcome; Tender Points
Fibromyalgia
• Based on RCTs aerobic exercise improves
• Function
• Global well-being
• Pain
• Possibly tender-point pressure threshold
(Busch et al. Cochrane Database Syst
Review 2008)
EXERCISE WITH FIBROMYALGIA:
TRAINING PRINCIPLES
• Training is important for preventing
disability
• Different types of non-exhaustive aerobic or
strength training which is tolerated by the
patient, there may be daily variation in what
the patient tolerates
• Aerobic and muscular training response is
normal
Training program for fibromyalgia
• Regular frequency is preferred: daily 15-60 min (an
inactive day after exercise day may be difficult)
• More than 3 hours per week
• Low to moderate intensity (HR 110-130/min)
• Strength training max 2-3 times weekly with max 50%65% of one repetition maximum, 10-12 repeats, total
session duration may have daily variation, warm-up
necessary
• Exercise types: walking, swimming, strength training
TAKE-HOME MESSAGE:
EXERCISE AND FIBROMYALGIA
• Different types of training may help in
the prevention or treatment of
disability.
EXERCISE AND OSTEOPOROSIS
• Exercise helps in the prevention and
treatment of osteoporosis.
• Exercise may both predispose to or prevent
from falls and fractures.
• High activity level delays the occurrence of
hip fractures based on observational studies
Neurologic disease
MS
Parkinson
Impairment of congnitive function and dementia
Epilepsy
CP
Myopathies
Pheripheral nerve diseases
Headache
• Subjective symptom; primary vs. secondary
• Dynamic aerobic exercise seems to prevent
tension type headache. Low to moderately
intensive dynamic exercise without static
loading to neck-shoulder-upper extremities
Headache
• Postexercise headache (after static
loading/strength training exercise; 5 min –
one day)
• Effort headache (during running etc., 4-6
hours)
• Headache after contacts (soccer, boxing
etc.), prevalence ad 50%
MS
• Autoimmunologic demyalinization disease (CNS);
a) ralapsing intermittent, b) progressive
• Spasticity, balance and motor ability problems,
muscular weakness, fatique
• Exercise in the prevention of MS: no role
• Recommend: Dynamic aerobic exercise – interval
type in case of fatique
• Avoid: Contact sports, warm environments,
training during infection
• Morning is better
Exercise and MS – the evidence
• Based on six RCTs (157 patients) best evidence
synthesis showed strong evidence in favour of
exercise therapy compared to no exercise therapy
in terms of muscle power function, exercise
tolerance functions and mobility related activities
in patients with multiple sclerosis
• Moderate evidence - improving mood.
• No evidence - fatigue and perception of handicap.
Rietberg et al. Cochrana Database Syst Rev 2005).
Parkinson’s disease
• Chronic progressive degenerative disease of CNS;
dopaminergic tract between substantia nigra – striatum
• Tremor, rigidity, hypokinesia, fatique, disturbances in
proprioception and balance
• Exercise in the prevention: no role
• Treatment and rehabilitation: Regular daily
activities/exercises according to indiviual health status +
stretching
• Avoid: Sports and exercise with injury risk (hip fracture
risk!)
Parkinson’s disease
• According to meta-analysis exercise
therapy/exercise-based physiotherapy improved
physical functioning (7 trials; SMD -0.47 (-0.82, 0.12) ) and health-related quality of life (4 trials;
SMD -0.27 (-0.51, -0.04) ) in patients with
Parkinson’s disease (Goodwin et al. 2008). In
addition,exercise groups had improvements in
balance in 4 of 5 trials and in walking speed in
three of four trials (Goodwin et al. 2008).
Impairment of congnitive function
and dementia
• Based on RCT:s Exercise training increases
congnitive performance in elderly persons
with congnitive impairment and dementia
(Heyn et al. Arch Phys Med Rehabil 2004;85:1694-704)
• In observational cohort studies an
association betfeen high physical activity
and low incidence of dementia
(Larson EB et al. Ann Intern Med 2006;144:73-81)
Epilepsy
• Convulsions
• Side effects of medical treatment: tiredness,
hyponatremia
• Exercise does not provocate convulsions
• Normal health enhancing and school
exercises/sports
• Not recommended: contact sports, sports
with injury risk
Cerebral palcy (CP)
• CNS injury before birth or until the age of 2
years
• Spastic or dyskinetic-dystonic or atactic
• Physical exercise capacity usually lowered
• Rehabilitaion: exercise, physiotherapy,
surgery
Muscle diseases
• Different types of dystrophias and
myopatias
• Exercise has no role in prevention
• Exercise and physiotheraphy are the best
ways in maintaining motor abilities
Neuro-muscular synapse
• Myastenia gravis most common (antibodies
for acethylcholine receptors)
• Cholinergic medications: exercise optimally
1-2 hours after taking medicine, 10 mg
pyridostigmin if necessary
• Exercise important in rehabilitation but
avoid fatique
Innervation of
skeletal muscle
and
neuromuscular
junction
Disorders of the neuromuscular junction
Neuropathias
• Mechanical nerve injury (entrapment,
vulnus, fracture etc.); functional
deficiencies
• Polyneuropathy (common reasons:
alcoholism, diabetes); scin injuries
Renal diseases and exercise
•
•
•
•
Exercise proteinuria – benign
Exercise haematuria
Rhabdomyolysis
Chronic renal insufficiency and lowered
exercise capacity
Exercise and renal function
• Exercise -> sympathicus activation -> contraction
of renal artery -> lowered renal blood flow (ad
75%)
• Lowering of glomerular filtration rate (GFR) (ad
50%), increase in filtration fraction
• Increased antidiuretic hormone (ADH) – lowered
excretion of urine
• Increased aldosterone -> Na retention
• Incresed number of cells in urine
Exercise proteinuria
•
•
•
•
•
Plasmaproteins
Glomerular permeability increases
Tubular reabsorption decreases
Last maximally 24-48 hours after exercise
Normal 150 mg/day – exercise proteinuria usually less
than 500 mg/day.
• Test sensitivity 200 mg/l; wrong positive findings:
concentrated urine (ex), blood in urine (ex), alcalic urine
(infection).
• Among young; orthostatic protinuria (max 1.5 gr/day)
• => Overnight urine collection after a day without exercise
Exercise haematuria
•
•
•
•
Microscopic or macroscopic
Disappears usually within two days after exercise
From kidney or bladder
Hypoxic damage in nefrons -> increse in
glomerular permeability
• Contact sports – mechanical injuries
• Running etc. -> injury due to microtrauma,
epithelial bladder injury after marathon run
• Control sample 24-72 h after exercise -> in case +
rule out other reasons, such as glomerulonefritis
Acute renal insufficiency
• Rhabdomyolysis; common reasons are alcohol and
medications, exercise may cause alone or more
commonly contribute together with others
• Exercise -> swelling of muscle -> cell death ->
myoglobin out of muscle -> ferrihematin in acidic
urine -> tocsic for tubular cells -> tubular necrosis
(-> anuria -> death)
• Diagnosis; increase of creatine kinase (CK)
• Treatment; correction of dehydration + alcalisation
(natriumbicarbonate), sometimes dialysis or
fasciotomies
Chronic renal insufficiency
• Lowered physical capacity
• Reasons: accumulation of uremic toxins and
cardiovascular, endocrinic, metabolic, musculoskeletal,
neurologic, haematologic complications.
• Hypertension, left ventricular hypertrofy and function
abnormality, myocardial fibrosis, heart valve calcifications,
hyperlipidemia, glucose intolerance, hyperinsulinemia,
abnormalities in androgens  tiredness, headache,
muscular cramps, pericarditis, pleuritis, oedems, coronary
heart disease, secondary anemia, hyperkalemia, metabolic
asidosis, muscular athrophy
• Physical activity may delay occurrence of diasbility
Stress urinary incontinence
• More common in females (about 20% of
adults, among older people even more
common)
• Endurance running (38%), aerobic (22-36%
depending on the number of jumps)
• Other risk factors: age, number of children
(normal labours)
Stress urinary incontinence
• Problems in: aerobic, running, basket ball,
wolley ball, squash, badminton, hand ball,
tennis, dance, gymnastics, trambolin
• Recommend: walking, golf, joga, biking,
swimming
Urinary incontinence and PFMT
• Women who did pelvic floor muscle training
(PFMT) were more likely to report they were
cured or improved than women who did not.
PFMT women also experienced about one fewer
incontinence episode per day (Hay-Smith &
Dumolin, Cochrane Database Syst Rev, 2007)
• PFMT + bladder training consistently increased
continence rates (see meta-analysis by Shamliyan
et al. Ann Intern Med 2008;148:459-473)
Urinary incontinence - Treatment
• Stress incontinence:
prevention, pelveobuilding, medications
(contracting urethra),
operative treatment
(TOT), equipments
• Urge incontinence:
medications relaxing
bladder muscles
(anticholinergic)
Gastro-intestinal tract
•
•
•
•
Reflux-esophagitis
Gastro-duodenal function
Colon function
Exercise is associated with lower incidence
of: colon cancer, biliar stones, obstipation
Exercise and reflux/esophagitis
• Mild symptoms common, ad 50% of endurance
athletes; more common when exercise less than 3
hours after meal, risk 3 times higher 45 min after
meal.
• Other risk sports; weight lifting
• Causes: mechanical, gi-tract motor disturbances,
decrease in blood circulation
• Diagnostics: problems at rest or not?
• Note: Association with asthma
Exercise and gastroduodenal
function
• 70% of maximal oxygen uptake; delayed
emptying of ventricle; symptoms during
exercise (nausea, vomiting, pain)
• Acid secretion decreases during maximal
exercise
• Low to moderate exercise may increase
motility
Exercise and colon function
• Normal passing time 20-60 hours
• Exercise shortens
• Runners diarrea
• Sympathicus –parasymphaticus balance?
• Changes in circulation; ischemic colitis;
(->anemia)
Cancer
•
•
•
•
Colon
Breast
Prostata
Lungs
Exercise and colon cancer;
prevention
• Based on epidemiologic observational
follow-ups risk for colon cancer is 30-40%
lower in physically active males and
females compared to sedentary
• Mechanism(s): (?) passing time, immune
system, lower insulin and insulin like
growth factors, lower obesity, etc.
Exercise and breast cancer;
prevention
• Risk of breast cancer in physically active (at
least two hours/week moderate to vigorous
activity) women is 30-40% lower compared
to sedentary
• Mechanisms (?): lower estrogen levels,
lower obesity, lower insulin and insulin like
growth factors, immune system, etc.
Exercise and other cancers;
prevention
• Prostata ca: Lower testosterone helps in
prevention; contradictory evidence on the
association between ca and exercise
• Exercise and cancer of endometrium,
ovaria, testis, pancreas, kidney, bladder and
blood insufficiently studied
Exercise after ca-diagosis
• No evidence on that exercise has an effect on the
prognosis of cancer; other treatments of prmary
importance
• Physical activity can improve fitness, decrease
depression and disability
• Problems: tiredness, weight changes, anemia, catreatments have effects on fitness and side-effects,
risk of infections, etc.
• Exercise: low intensity, low progression,
individual problems
Exercise and breast cancer
• Improvements in quality of life parameters
(FACT-G and FACT-B scales)
• Improvements in aerobic fitness
McNeely et al. CMAJ 2006;175:34-41
Exercise and depression
• Patients with depression are less physically
active; regular exercise may prevent from
depression (observational data)
• Physical activity has a role in the treatment
of depression, can be combined with
medical treatment, effect compareable to
psychotherapy, combination of exercise and
light, long-term compliance is important
Depression
• Based on 9 low quality RCTs exercise
treatment decreased Beck depression
inventory score (weighted mean difference 7.3 (95% CI -10.0 to -4.6)
(Lawlor and Hopker. BMJ 2001;322:763-767)
Depression and exercise – Study example:
Dunn et al. Am J Prev Med 2005;28:1-8.
Exercise treatment for depression.
Efficacy and dose response.
• Mild to moderate major depressive disorder
• Randomized 2x2 factorial design; 5 groups: (1) low dose/3
x wk; (2) low dose/5 x wk; (3) public health dose/3 x wk;
(4) public health dose/5 x wk; (5) control/3 x wk flexibility
exercise
• 12 wk supervised laboratory (treadmill/bicycle) exercise
program
• 17-item Hamilton Rating Scale for Depression
• Public health dose exsercise was effective treatment, but
low dose was compareable to placebo. Frequency played
no role.
Exercise and anxiety
• Anxiety decreased during exercise and two
hours after exercise
• Regular long-lasting aerobic exercise has
long-term benefits
• Panic is first decreased more effectively
using medication but in long term (10
weeks) exercise is as good as medication
Chronic fatigue syndrome
• Illness characterized by persistent medically unexplained
fatigue of at least 6 months
• Exercise therapy vs. control (Edmonds et al. Cochrane
review):
Based on 5 studies (286 participants) those receiving 12 we
exercise therapy were less fatigued than controls (Chalder
fatigue scale; SMD -0.77; 95% CI -1.26,-0.28)
Based on 3 studies (162 participants) physical functioning
improved (Quality of life – SF-36 physical functioning
subscale; SMD -0.64; 95% CI -0.96, -0.33)
Dependence
• Compulsory exercise despite of tiredness -> predisposes to
social problems, fatique, injuries and even death when
older people or patients with infections exercise too
intensively
• Endorphins may contribute
• Exercise may be a means to handle with negative feelings
• Specific personality characteristics (demanding) may
predispose to exercise dependence
• Exercise seems to stimulate different pathways in CNS
some of which lead to positive feelings
Infections and exercise
• Fever: no exercise
• Generalized symptoms (muscle ache or pain,
headahe etc.): no exercise
• First 1-3 days of an infecton: be careful, follow
what is the course of infextion
• Cold; take it easy for three days, gradual start of
exercise (dd: allergic symptoms)
• Cold, sore throath, cough; follow the progression
of symtoms then as cold
Infections and exercise
• Sore throath alone: rest; in case of angina
antibiotics 10 days, rest 7 days
• Sinuitis, bronchitis, pneumonia; rest
• Mononucleosis; avoid strenuous exercise 1
month
• Lower urinary tract infection; rest until
symptoms are away
• Gastroenteritis; avoid strenuous exercise
Infections and exercise
• Scin infections: according to severity
• Erythema migrans/borreliosis: antibiotics 10 days, rest 7
days
• Herpes: no sports where skin contacts, in case of general
symptoms and enlarged lympho nodes – rest
• Genital infections; evoid strenuous exercise, during
antibiotic treatment of non-symptomatic clamydia
infection –rest
• HIV, hepatitis B and C positive; exercise allowed,
recommend non-contact sports (in case of wounds sports
not allowed for anybody)
Genetic/Social/Environmental Factors
Behavior
Fitness
Outcome
Morphologic
Components
Physical Activity
Muscular
Component
Diet
Smoking/Alcohol
consumption
Cardiorespiratory
Component
Motor Component
Stress
Management
Metabolic
component
Health Outcome