Activity

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

Disclosures

Nothing to disclose

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

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 4.55-5.72)) !  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)

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)

How many are active?

!  48% meet 2008 Physical Activity Guidelines (activity and resistance training) !  2010 – 64.5% active !  2010 – 24.5% inactive CDC website

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

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

Low Risk Asymptomatic ≤1 Risk Factors

Low Risk& GXT Medical Exam Asymptomatic before exercise? ≤1 Risk Factors Mod Ex - Not Nec Vig Ex - Not Nec

Moderate Risk Risk Asymptomatic Stratification ≥ 2 Risk Factors

High Risk Symptomatic, or known cardiac, pulmonary, or metabolic disease

Moderate Risk Medical Exam & GXT Asymptomatic before exercise? ≥ 2 Risk Factors

High Risk Symptomatic, Medical Exam & or GXT known cardiac, before exercise? pulmonary, or metabolic Mod Ex disease - Rec

Mod Ex - Not Nec Vig Ex - Rec

Vig Ex - Rec

Medical Exam & GXT before exercise? MD Supervision of

Medical Exam & GXT before exercise? MD Supervision of

Medical Exam & GXT before exercise? MD Supervision of

Exercise Test? Mod Ex - Not Nec Vig Ex - Not Submax - NotNec Nec

Exercise Test? Mod Ex - Not Nec Vig Ex- -Not RecNec Submax

Exercise Test? Mod Ex - Rec Vig Ex - -Rec Submax Rec

Max - Not Nec

Max - Rec

Max - Rec

• MD Supervision of MD Supervision of MD Supervision of Mod Ex: Moderate intensity exercise; 40-60% of VO2max; 3-6 METs; “an intensity Exercise Test? Exercise Test? Exercise Test? well within the individual’s capacity, one which can be comfortably sustained for a prolonged period of time (~45 minutes)” Submax - Not Nec Submax - Not Nec Submax - Rec Max - Not Nec Max - Rec • Max - Rec Vig Ex: Vigorous intensity exercise; > 60% of VO2max; > 6 METs; “exercise intense enough to represent a substantial cardiorespiratory challenge”

•

Mod Ex: Moderate intensity exercise; 40-60% of VO2max; 3-6 METs; “an intensity Not Nec: Not Necessary; reflects the notion that a medical examination, exercise well within the individual’s capacity, one which can be comfortably test, and physician supervision of exercise testing would not be essential sustained for a prolonged period of time (~45 minutes)” in the preparticipation screening, however, they should not be viewed as th • inappropriate 8 Edition, Vig Ex: Vigorous intensity exercise; > 60% of VO2max; > 6 METs; “exercise intense enough to represent a substantial cardiorespiratory challenge” 2009 Recommended; when MD supervision of exercise testing is Rec:

9th Edition, 2013

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

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

-2008 Physical Activities Guidelines for Americans -Haskell, et al. Med Sci Sport and Exercise, 2007

cal activities classified as light, moderate or vigorous intensity.

k using

s , 2.5

0–2.5

Moderate 3.0 – 6.0 METs

Vigorous 96.0 METs

Walking Walking 3.0 mph = 3.3*

Walking, jogging & running Walking at very very brisk pace (4.5 mph) = 6.3*

Walking at very brisk pace (4 mph) = 5.0*

Walking/hiking at moderate pace and grade with no or light pack (G10 lb) = 7.0 Hiking at steep grades and pack 10–42 lb = 7.5–9.0 Jogging at 5 mph = 8.0* Jogging at 6 mph = 10.0* Running at 7 mph = 11.5*

Cleaning — heavy: washing windows, car, clean garage = 3.0 Sweeping floors or carpet, vacuuming, mopping = 3.0–3.5

Shoveling sand, coal, etc. = 7.0

Carpentry — general = 3.6 Carrying & stacking wood = 5.5 Mowing lawn — walk power mower = 5.5

Heavy farming such as bailing hay = 8.0 Shoveling, digging ditches = 8.5

Badminton — recreational = 4.5 Basketball — shooting around = 4.5

Basketball game = 8.0 Bicycling — on flat: moderate effort (12–14 mph) = 8.0; fast (14–16 mph) = 10 Skiing cross country — slow (2.5 mph = 7.0; fast (5.0–7.9 mph) = 9.0 Soccer — casual = 7.0; competitive = 10.0

Bicycling — on flat: light effort (10–12 mph) = 6.0 Dancing — ballroom slow = 3.0; ballroom fast = 4.5 Fishing from river bank & walking = 4.0 Golf — walking pulling clubs = 4.3 Sailing boat, wind surfing = 3.0 Swimming leisurely = 6.0† Table tennis = 4.0 Tennis doubles = 5.0 Volleyball — noncompetitive = 3.0–4.0

Carrying heavy loads such as bricks = 7.5

Swimming — moderate/hard = 8–11† Tennis singles = 8.0 Volleyball — competitive at gym or beach = 8.0

Haskell, 2007

and absolute exercise intensity for cardiorespiratory andexercise resistance exercise. TABLE 5. Classification of exercise intensity: relativeendurance and absolute intensity for cardiorespiratory endurance Cardiorespiratory Endurance Exercise Intensity (%V˙O2max)) Relative to MaximalIntensity Exercise Capacity in METs Relative

elative Intensity ˙ O2max %V Intensity

Perceived 20 METs 10 METsPerceived5Exertion METs %HRR Exertion or ˙ O2RRPE Scale) (Rating on%V 6–20 %V˙RPE O2max %HRmax%V˙O2max%V˙O2max%V˙O(Rating Scale) 2max on 6–20

GVery lightG30 (RPE G 9) Very light–fairly 30–39 light (RPE 9–11) Moderate 46–63 Fairly light40–59 to somewhat hard (RPE 12–13) Vigorous 64–90 Somewhat60–89 hard to very hard (RPE 14–17) Near–maximal Q91 QVery hardQ90 (RPE Q 18) to maximal G37light Very 37–45 Light

G34 G37 G57 57–63 34–42 37–45 64–76 43–61 46–63 77–95 62–90 64–90 Q96

Q91

Q91

G37 GVery light (RPEG44 G 9) 37–45 Very light–fairly44–51 light (RPE 9–11) Fairly light to somewhat 46–63 52–67 hard (RPE 12–13) Somewhat hard68–91 to very 64–90 hard (RPE 14–17) QVery hard (RPEQ92 Q 18) Q91

Cardiorespiratory Absolute Intensity Intensity Maximal E 20 METs ˙ O2max METs %V

G2 G34 2.0–2.9 34–42 3.0 43–61 to 5.9 62–90 6.0–8.7 Q91 Q8.8

Table adapted from the American of Sports Medicine Howley (173), Swain Medicine (14), Howley (173), SwainCollege and Franklin (344), Swain (14), and Leutholtz (346),Swain Swainand et Franklin al. (347),(344), and the US a ˙ O2max maximal HR; , percentoxygen of maximal HR;%V HRR, HR reserve;ofV˙Omaximal ˙ O2max max,HR 2max, maximal R; HR HRR, reserve; V˙O%HR maximal uptake; , percent oxygenoxygen uptake;uptake; V˙O2R,%V oxygen 2max,max

ACSM Position Stand, 2011

Increase aerobic fitness !  60-70% of max heart rate !  30y/o – 114-133 bpm !  50y/o – 102-119 bpm !  20-30 minutes at 70% or 45-60 minutes at 60% !  3+ days per week !  Higher the intensity the greater the improvement !  If more fit then more calories per workout

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

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 !  10-15 reps per set !  Screen for orthopedic and cardiac conditions !  Variable motivation and tolerance

Flexibility !  Two or three days each week !  Hold for 10-30 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

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

Conclusions !  Encourage patients to be active !  Use other resources for patients !  Exercise is Medicine website !  www.health.gov/paguidelines/guidelines/ !  www.cdc.gov/physicalactivity/everyone/ guidelines/index.html