Methods to Manage Exercise in Diseased Persons

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Methods to Manage Exercise in Diseased Persons
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JAMA, 2004 Nearly all heart risk due to bad
habits

• 9 out of 10 heart patients surveyed had one of
  the following risk factors
• Smoke
• HTN
• High cholesterol
• Diabetes
• 85 of 120,000 pts with angina or who underwent
  revascularization surgery had at least one of the
  four risk factors
• Challenges the frequent claim that only 50 of
  CHD is attributable to these conventional risk
  factors

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Risk Factor Assessment Testing

• Initial screening identify risk factors and/or
  symptoms for chronic CV, pulmonary metabolic
  diseases
• Low risk
• Moderate risk
• High risk
• Degree of medical supervision of exercise testing
  and participation may vary depending on the
  setting

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Problem-oriented Exercise Management

• Approach to exercise in persons with chronic
  disease and disability.
• Consists of five steps, commonly documented in
  the SOAP format
• 1) collection of Subjective data
• 2) collection of Objective data
• 3) Assessment and generation of a problem list
• 4) formulation of a diagnostic or therapeutic
  Plan, or both
• 5) Periodic reassessment (follow-up)

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Getting Subjective Data

• Uncover the nature of the problem as it relates
  to exercise
• Ask about old and new musculoskeletal injuries
  (what are the limitations now)
• Look at the person for obvious problems (that
  limit functional capacity)
• Determine present medicines being taken

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Getting Objective Data

• Select the families of exercise tests that
  provide insight into the problem
• Use modes and protocols that can be
  individualized
• Use tests that provide specific measures that
  will further define the problem

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Families of Exercise Test Measures

• Aerobic/Endurance
• Anaerobic
• Strength
• Flexibility
• Neuromuscular
• Functional performance

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Making the Assessment

• Generate a list of specific problems
• Organize either by family of exercise or by
  physiologic problem
• Consider possible need for additional tests

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Formulating a Plan

• Establish an Ex Rx that has realistically
  achievable long-term goals
• Establish shorter-term intermediate goals
• Design an exercise program incorporating the
  considerations identified
• Develop a schedule for follow-up reassessment

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Tips on SOAP Notes

• Be concise
• Avoid sentences use key phrases
• Leave out irrelevant information
• Discuss only current relevant problems
• Organize problems by exercise family
• Always follow up

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Exercise Medicines

• Biochemical and physiologic processes
• Different kinds of PA stimulate processes in
  different ways
• Drug-exercise interactions are determined by the
  blocked or stimulated processes
• Paradoxical Effects
• A drug can have opposite effects on exercise
  capacity b/c disease can alter physiologic axn
• Effects on Muscle
• Adverse Effects (i.e headaches, raised
  cholesterol, impaired ex response)

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Exercise Medicines, cont.

• Drugs that Affect Metabolism
• Ergogenic Aids
• Other Medications
• Effects of polypharmacy
• Complications
• Little is known about the effects of exercise on
  the metabolism of medicines

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Exercise Dose-Response

• Objective is to decrease limitations and improve
  physical capacity through specific therapies
• Dose is a function of intensity and duration
• Starting level, resistance to fatigue,
  adaptability to training

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Risk, Cost, and Benefit

• Two types of risks disease-dependent and
  activity-dependent
• Diabetics lose control of their blood sugar
• Arthritic joints can become more inflamed
• HTN persons can have a stroke or MI
• Costs include time, energy, and money put into
  the program
• Benefits usually related to
• functional capacity
• quality of life
• decreased dosage of meds
• decreased morbidity mortality