Exercise Prescription Basics

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Exercise Prescription Basics

• Kevin deWeber, MD, FAAFP
• Director, Primary Care Sports Medicine Fellowship
• USUHS

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Bottom Line Up Front (BLUF)

• Exercise is the best medicine around
• Assess physical activity in ALL patients
• Only RARE patients needs GXT before exercise
• GXT pts with symptomatic CV/pulm dz
• The Prescription is Be FITT
• Frequency 5 days a week (or more)
• Intensity moderate intensity, 5-6 on 10 scale
• Time 30 minutes aerobics (10-min chunks OK)
• Type
• Aerobic activity
• Muscular strengthening activity
• Flexibility activity (in elderly/sick)
• Balance training (if fall risky)

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Physicians and their Patients

• 47 of primary care physicians include an
  exercise history as part of their initial
  examination (self report)
• Only 13 of patients report physicians giving
  advice about exercise
• Physically active physicians are more likely to
  discuss exercise with their patients

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ACSM AHA 2007, HHS 2008Physical Activity
RecommendationsHealthy Adults age 18-64

• Aerobic Physical Activity
• Moderate intensity 150 minutes/wk, OR
• Vigorous intensity 75 minutes/wk (or a combo)
• 10 min at least, preferably spread throughout
  week
• Muscle Strengthening Activity
• 2 or more days/wk
• 8-10 exercises
• 8-12 reps (one set)

Physical activity and public health Updated
recommendation for adults from the ACSM and AHA.
MSSE 2007. and HHS publication October 2008.
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• Indications benefits
• Contraindication
• Side-effects
• Drug interactions
• Cost
• Dose, frequency, duration

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Indications for Exercise

• Longevity
• Quality of Life
• Socialization
• Weight control
• Disease prevention
• Disease management
• .(I could go on)

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LongevityThe more you exercise, the lower your
risk of death
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Dose-response Curve for Exercise
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Death PreventionAttributable Deaths () from
various health conditions

• Aerobics Center Longitudinal Study (ACLS), Cooper
  Institute
• 40,842 men 12,943 women

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Strong Evidence of Benefit from Physical Activity
for

• Lower risk of
• Early death
• Heart disease
• Stroke
• Type 2 diabetes
• High blood pressure
• Dyslipidemia
• Metabolic syndrome
• Colon and breast Ca

• Prevention of wt gain
• Wt loss w/dieting
• Improved C-R muscular fitness
• Prevention of falls
• Reduced depression
• Better cognitive fxn (older adults)

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Moderate evidence for

• Wt maintenance after loss
• Lower risk of hip fx
• Increased bone density
• Improved sleep quality
• Lower risk lung and endometrial Ca

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Contraindications for Exercise

• Acute cardiac event happening now
• Uncontrolled arrhythmia causing sxs
• Severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolism
• Acute myocarditis
• Dissecting aneurysm

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Only RARE patients need GXT

• AHA 2003 NOT NECESSARY for people doing moderate
  intensity
• USPSTF 2004
• not recommended (class D rec) in pts at low risk
• Insufficient evidence (class I rec) even in pts
  at increased risk

Thompson PD et al. Exercise and physical
activity in the prevention and treatment of
atherosclerotic cardiovascular disease.
Circulation 20031073109. USPSTF Screening
for coronary heart disease Recommendation
Statement. Ann Int Med 2004140569.
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Who Needs a GXT first?(No evidence-based
recommendations)

• Symptomatic cardiac or pulmonary disease
• Known CV dz, Diabetes, active chronic dz
• ESP if Vigorous exercise
• Unsure? Uncomfortable?
• Refer to Sports Medicine

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Side effects of exercise

• Slight risk of Musculoskeletal injury
• Increases with duration intensity
• RARE cardiac events
• FAR outweighed by benefits to heart!
• 25-50 decrease in CVD in exercisers

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• If we had a pill that conferred all the benefits
  of exercise, physicians would prescribe it to
  every patient. Our health care system would find
  a way to make sure that every patient had access
  to this wonder drug.

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Use the Sports and Exercise Medicineapproach to
patients

• Every patient is a potential athlete who needs
  exercise for HEALTH, not competition
• Physical activity is a VITAL SIGN--a STRONG
  PREDICTOR OF HEALTH
• Every exam is a pre-participation eval
• Conclude exams with activity clearance and
  Exercise Rx

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How to Write an Exercise Prescription
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Rx Be FITT

• Frequency
• Intensity
• Time (duration)
• Type

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Frequency

• 5 days a week
• Even more is even better!
• Dose-response curve!

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Intensity

• Moderate Exercise
• Equivalent of BRISK WALK
• Noticeably accelerates RH
• Able to talk
• talk test
• RPE 5-6 out of 10

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Exercise IntensityRelative Perceived
ExertionUse 1-10 Scale
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Examples of Moderate Intensity

• Brisk walking
• Household cleaning vacuum, mop, wipe
• Mowing lawn
• Shooting hoops
• Recreational badminton
• Ballroom dance
• Golf pulling clubs
• Leisurely sports
• Leisurely biking, swimming

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Intensity

• Vigorous Exercise
• Equivalent of jogging
• Fail talk test
• RPE 7-10 out of 10

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Examples of Vigorous Intensity

• Jogging, running
• Shoveling
• Heavy farming
• Competitive sports
• Cross country skiing
• Intense biking, swimming

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Time (Duration)

• Accumulate 30 minutes a day
• 10 minute chunks OK
• More is better!

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Type

• Aerobic Activity AND
• Muscle Strengthening

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Muscular Strengthening

• Exercise large muscle groups
• 8-12 reps should fatigue by last rep
• Rest 2-3 minutes between exercises
• 1 set good, 2 sets better
• Rest day in between

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What about Older Adults gt65,or those with
chronic diseases?

• Aerobic exercise same
• Strength exercise same, except 10-15 reps
• Slightly lighter weights
• Flexibility activity 2 days/wk, 10 min
• Balance exercise if at risk for falls, 3x/wk

Nelson ME et al. Physical activity and public
health in older adults Recommendation from the
ACSM and the AHA. Med Sci Sports Exer
200739(8)1435.
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What about Children/Adolescents?

• Do 60 minutes or more of physical activity every
  day
• Mostly moderate or vigorous
• Vigorous activity at least 3 days/wk
• Strength exercise 3 days/wk

HHS guidelines October 2008
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Take Home Pearls

• Exercise is the best medicine around
• Assess physical activity in ALL patients
• Only RARE patients needs GXT before exercise
• GXT pts with symptomatic CV/pulm dz
• The Prescription is Be FITT
• Frequency 5 days a week (or more)
• Intensity moderate intensity, 3-6 on 10 scale
• Time 30 minutes aerobics (10-min chunks OK)
• Type
• Aerobic activity
• Muscular strengthening activity
• Flexibility activity (in elderly/sick)
• Balance training (if fall risky)

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Questions?
Military Sports Medicine Fellowship
Every Warrior an Athlete