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Exercise Prescription: What’s the Hype ?

Dr. Julia AlleyneUniversity of Toronto

Toronto Rehab University Health Network

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Disclosures

• No financial investment • No conflicts of interest

Objectives

• To describe the evidence supporting the use of exercise for preventive health measures through the lifecycle.

• To be able to prescribe exercise effectively in clinical practice.

• To identify the key benefits to integrating exercise into treatment protocols

What’s all the Hype ?

What’s the message ?

When did this start ?

What’s the evidence?

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What’s the Message?

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What’s the Message ?

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When did this start?

1928 NEJM

“Exercise will reduce blood plasma glucose levels”

1948 – 1968 Framingham study

- 20 year longitudinal study shows risk of CVD is reduced in exercisers.

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Hippocrates Quotes 460 – c. 370 BC

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“Walking is man’s best medicine”

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”

“If you are in a bad mood go for a walk. If you are still in a bad mood go for another walk.”

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Barrier to knowledge implementation

Knowledge- What to prescribe to who and when…without harm- Guidelines for ages and conditions- Not taught in medical school- Not seen as within scope of practice

Skills- Counseling Skill- Describe and Demo Skill

Attitude- Personal Values about Exercise- Readiness to Change

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What single medication is as effective?

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What’s the Evidence?

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Exercise used as a treatment

Irritable Bowel SyndromeFibromyalgiaAsthmaObesitySleep DisorderChronic Fatigue Syndrome

Exercise Benefits

• Increased Muscle– Cardiac Function/ Mobility and Activity Levels

• Increased oxygenation– Lung Function/ Vessel function

• Increased hormonal balance– Diabetes stability/ Fertility

• Increased neuro receptor function– Pain Modulation/Anxiety and Depression

• Increased immune system – Cancer Risk Reduction/Infection Reduction

Dose Response Exercise Prescription in Medical Conditionsa) Diabetesb) Cardiovascularc) Arthritisd) Cancere) Mental Health

Exercise Prescription

• Consider all health factors• Prescribe F-I-T-T• One intervention evaluated at a time• Measure your response• Refine your prescription

Reducing Risk with ExerciseExercise Heart Diabetes Arthritis Cancers

Aerobic **** **** ** ****

Strength *** ** **** **

Flexibility ** ** **** **

Exercise through the Ages

Exercise through the Stages

7 Stages of Development

InfancyChildhoodAdolescentsAdultPregnancyMid-LifeOlder Adult

First Year Pre-PubertyPubertyFull GrownReproductiveMenopause/AndropauseSacropenia

Prescription of Exercise

F

I

T

T

• Frequency

• Intensity

• Time

• Type

Recommendations Matrix

F I T TInfancy

Childhood

Adolescents

Adult

Pregnancy

Mid-Life

Older Adult

Recommendations Matrix

F I T TInfancy 8-10 x day Low-moderate 5-10 min Movement

Childhood Daily Low-moderate 30-60 min/day Primary Skills

Adolescents Most days of the week

Moderate-High

30-60 minutes Skill Specific/Complete

Adult 3-5 x week Moderate-High

30-45 min Complete

Pregnancy 2-4 x week Low to Moderate

30 minutes Complete

Mid-Life 3-5 x week Low to Moderate

30 minutes Cardio-ImpactStrength

Older Adult Most days Low-moderate 15-30minutes Strength/Flexibiltiy

Infancy

• Socialization• Family Lifestyle

Behaviours• Socialization• Growth and

Development

Baby Fitness – Crawl, Climb, Walk

Exercise Prescription

Frequency

Intensity

Type

Time

• Multiple daily interventions

• Low to moderate

• Arms/Legs/Movement

• 2 minutes per month of age

Childhood

Barriers to Physical Activity

Readiness To Exercise Screening

Par Q for Children

Completed by a Parent/Guardian of Child

Date of Birth …………………………… CHILD’S AGE: ……………….As your child is to be a participant in this project, would you please complete the following physical activity readiness questionnaire for your child.

• Has your doctor ever said that your child has a heart condition and that your child should only do physical activity recommended by a doctor? �

• Does your child ever experience chest pain during physical activity? � �

• Does your child ever lose balance because of dizziness or do they ever lose consciousness? � �

• Does your child have a bone or joint problem that could be made worse by a change in their physical activity participation? � �

• Does your child have uncontrolled asthma (i.e. asthma that is not easily controlled by an inhaler? � �

• Is your doctor currently prescribing any medication for your child’s blood pressure or a heart condition? � �

• Do you know of any other reasons why your child should not undergo physical activity? This might include diabetes, a recent injury, or serious illness. � �

Framingham Children’s StudyDemographics: 100 families. The subjects were age 3-5 years at the onset of the study and followed for a decade.

To identify early childhood determinants of eating and exercise behaviors that relate to cardiovascular disease.

Active Mother: 2.0 x GreaterActive Father: 3.5 Both Parents Active: 5.8

•Key Factor in Childhood Physical ActivityParental Support of child's choiceEmpowerment of Physical Activity Leadership DevelopmentFun and motivating

Development

• Body Image• Self Esteem• Breaking down Barriers• Physiological Considerations• 60- 90 minutes on most days

www.csep.ca/guidelines

Physical Activity and Sedentary Behaviour

Adolescents

Female Athlete Triad

Treatment Strategies

• Pre-season Physical• Risk Assessment

– Menstrual History– Nutrition History– Injury Inventory

• Education• Early identification

Strength Training

• Neuromuscular• 2 -3 x week• Sub-Optimal until

Puberty complete• Recovery is key• Outcomes are speed

and skill

Exercise Prescription

• Frequency

• Intensity

• Type

• Time

• Most Days

• Moderate to High

• Skill Specific

• 60 +

Adults

Issues to Consider

• Weight Management• Bone Health• Overuse Syndromes• Deconditioning• Disease Management• Stress Management

Risk Factors

• Abnormal joint anatomy • Joint instability• Underlying muscle weakness • Overweight • Intense prolonged exercise• Past sports injuries to joints

Exercise Prescription

Frequency

Intensity

Type

Time

Most Days

Moderate

Functional

30 minutes

Pregnancy

CSEP

HealthCanada

CASM

Absolute Contraindications

• Restrictive Heart or Lung Disease• Incompetent Cervix• Multiple Gestation• Placenta Previa after 26 weeks• Persistent Vaginal Bleeding• Ruptures membranes• Pregnancy Induced Hypertension

Relative Contraindications

• Severe Anemia• Poorly controlled Type I Diabetes• Morbid Obesity• Underweight• Poorly controlled hypertension• IUGR• Thyroid disease

CASM 1998 Guidelines

Prepregnant Active Inactive

Frequency Start week 0-12

Start week13-29

Intensity PerceivedExertion

60-65% ofMax. HR

Time 13-29, 5%increase

< 40 min.

Type Avoid highrisk

Cycle, walk,swim

CASM 2007 Updated Guidelines

• Approval in April 2007• Specific condition analysis of Risk• Exercise Hyperthemia• Third Trimester Conservative Exercise• 2-4 x Week frequency does not affect Birht Weight• Caution with high impact or contact• Post Partum Recommendations-Bone Density

Exercise Prescription

• Frequency

• Intensity

• Type

• Time

• 2-4 x week

• Light to Moderate

• Low Impact

• 30 minutes

Mid Life

• Weight Bearing• Resistance training• Posture• Flexibility• Coordination• Lifestyle Factors

Older Adult

Musculoskeletal Aging

Loss of skeletal mass with reduced strength Loss of Joint mobility Reduces endurance unless trained Cognitive decline Sensory System Decline

Exercise Adaptation

Reduces Reaction time

Increased cognitive processing time

Reduces sensory processing

Loss of sensitivity to deep pain

Directions Information Supervision Progression of

Exercise

Orthopedic Issues for the Older Adults

• Arthritic Concerns• Shoulder Syndromes• Feet First• The Tai Chi Model

System Issues for Older Adultsr Adults

• Urinary Incontinence• Cardiovascular Disease and Investigations• Tolerance for rehabilitation• Obesity and aging• Cognitive Processing

The older I get the better I look!

Exercise Prescription

• Frequency

• Intensity

• Type

• Time

• Daily

• Low to Moderate

• Strengthening/ADL

• 30-60 minutes

Recommendations Matrix

F I T TInfancy 8-10 x day Low-moderate 5-10 min Movement

Childhood Daily Low-moderate 30-60 min/day Primary Skills

Adolescents Most days of the week

Moderate-High

30-60 minutes Skill Specific/Complete

Adult 3-5 x week Moderate-High

30-45 min Complete

Pregnancy 2-4 x week Low to Moderate

30 minutes Complete

Mid-Life 3-5 x week Low to Moderate

30 minutes Cardio-ImpactStrength

Older Adult Most days Low-moderate 15-30minutes Strength/Flexibiltiy