Myths and legacy of exercisemedicine in chronic diseases

Too Old? Too Sick?Excuses of the past?

Should exercise be recommended, or even prescribed, in illness and old

age?

© Exercise Works! Ann Gates

Sports and Exercise Medicine Society for London Medical and Physiotherapy Students

December 2014

why a paradigm shift?Meet… “Killer Bea”

http://www.rocksteadyboxing.org/

From her grandson Ben……..

“But it made me happy to see that Rock Steady

Boxing is allowing so many people to continue living

the way, or close to the way, they have been used to

living all their lives,

…..through independence and physical fitness”

“No Exercuses”

FACT!

Old or sick…

without

structured

physical activity

….

patients will

….die younger

and reduced

quality of life

Exercise

Training tomorrow’s doctors,in exercise medicine, for tomorrow’s patients

(Gates A, omline Editorial BJSM Jan 2015)

“to protect and

promote the

health of

patients and

the public

Too old?.............NO!

Too sick?....

No!

ENOUGH EVIDENCE for exercise as a medicine!

TIME to teach

every health

professional

8 ABSOLUTE CONTRAINDICATIONS TO EXERCISE IN CARDIOVASCULAR DISEASE PATIENTS

8 ABSOLUTE CONTRAINDICATIONS TO EXERCISE IN CARDIOVASCULAR DISEASE PATIENTS

In addition ANY co-morbidities that may affect the patient e.g. cancer

Adapted from British Association of Cardiac rehabilitation 2012

…………………..Febrile illness

“UNSTABLE”

OTHER CONTRAINDICATIONS

Contraindications Signs and symptoms

Uncontrolled or poorly controlled asthma Severe shortness of breath, chest tightness or pain, and coughing or wheezingWorsening symptoms

Unstable/Uncontrolled COPD Patients are required to be stable before training and oxygen saturation levels should be above 88-90%

Unstable cancer or blood disorders When treatment or disease cause leucocytes below 0.5 x109/L, haemoglobin below 60g/L or platelets below 20 x 109/L.6

Uncontrolled Diabetes If blood glucose is >13 mmol or <5.5 mmol/l then it should be corrected first. Patients with diabetic peripheral or autonomic neuropathy or foot ulcers should avoid weight bearing exercise. Any diabetic with acute illness or infection.

Osteoporosis/High fracture risk avoid activities with a high risk of falling or fracture (for example: caution in abdominal crunches)

Acute Pulmonary embolus or pulmonary infarction

Excessive or unexplained breathlessness on exertion

Unexplained symptoms that could cause risk of injury or exacerbation

For example: dizziness, any acute severe illness

“UNCONTROLLED”

150 minutes / fun / physical activities / week / works!

Twice a week / strength / balance / flexibility exercises!

Confident, competent and capable exercise advice!

1. Check absolute contraindications to exercise

2. Practise exercise as a ‘vital sign’ Sallis 2011

3. Rx…Start off gradually, increase wisely!

4. Support, signpost and advise patient, every consult

5. Make every contact count as a “teachable moment” APPC 2014, NICE PH44

In sickness?Cardiovascular disease, Hypertension, Type 2 Diabetes, Cancer, End of Life care, Osteoarthritis/Rheumatoid Arthritis OA/RA, COPD, Dementia, Parkinson’s disease, Falls prevention, Osteoporosis…….

Find out moreSearch: Exercise Works 2 Day course

Cardiovascular effects of exercise

• Lower heart rate at rest and during

exercise

• Lower blood pressure at rest and

during exercise

• Lower oxygen demand in the heart at

submaximal levels of exercise training

• Increase in plasma volume

• Increased myocardial contractility

• Increased peripheral venous tone

• Positive changes in fibrinolytic (blood coagulation) system

• Increased endothelium-dependent vasodilatation

• Increased gene expression for production of an

enzyme (NO synthase) that helps to produce nitric

oxide (NO)

• Increased parasympathetic activity

• Increase in coronary blood flow, coronary

collateral vessels and myocardial capillary density

• Metabolic effect

• Reduced obesity

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk http://fyss.se/wp-content/uploads/2011/06/21.-Coronary-artery-disease.pdfhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001800.pub2/abstract

Exercise prescription #

Overall aim 3-5 times per week

WARM UP

• 15 minutes

• Within 20 beats of training HR

CONDITIONING PHASE

• 20-30 minutes

• Cardiovascular • (interval progressing to continuous as able)

• 60-80% of HRmax

COOL DOWN

• 10 minutes

• Within 10 beats of pre-exercise

Achieved in many, fun ways:

Structured class, structured 1 to 1, structured home based programme, structured physical activities

http://www.bacpr.com/pages/page_box_contents.asp?pageid=737

ONLY

44%

attend!

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular and especially Hypertension Risk

• Aerobic physical activity decreases systolic and diastolic blood pressure

• Average 2–5 mm Hg and 1–4 mm Hg, respectively = ~10% risk of CVD

• 12 wk duration, with 3–4 sessions per wk, lasting on average 40 min/session and involving moderate- to vigorous-intensity physical activity

• Strength of Evidence: High

Exercise in the treatment of hypertension

…. works!

Hypertension and exercise outcomes compared with other medicines

InterventionAll-cause

mortality

Cardio-vascular

mortality

Myocardial

infarction

ACE-I 10% 19% NR

Thiazide 9% NR 22%

β-blocker 6% (NS) NR 8% (NS)

Ca2+ channel

blockers-6% (NS) NR 29% (NS)

Regular physical

activity

(self-reported) 29% 30% NRRegular physical

activity (fitness tests) 41% 57% NRBrooks, J. H. M. and A. Ferro (2012). JRSM Cardiovascular Disease 1(4).

Prevention of type 2 diabetes with physical activity and exercise

BMJ 2014

• 3 major trials of diabetes prevention with

intensive lifestyle counselling

• China, Finland and USA

• Each reported 40%-60% relative risk

reduction in the incidence of diabetes

• 1 case of diabetes “averted” by treating ~7

people with impaired glucose tolerance for

three years

China study, ADA 1997Finland study, 2001 US study, 2009

Type 2 diabetes and exercisehealth benefits

Umpierre 2011 landmark JAMA study

Aerobic, strength, or a combination of both exercises =

“Favorable change in HbA1c, lipids, blood pressure, cardiovascular events, mortality, cognition, quality of life, and physical performance”

Cancer and exercise…

“...walking or cycling for 30 mins/day

34% less likely to die of cancer…

33% more likely to beat the disease” (Orsini 2008)

80% cancer survivors not physically active enough

72% of GPs & 60% of oncologists don’t talk to cancer patients about increasing PA

Bowel Cancer in Adults

Prevention

• Those who increase their physical activity, can reduce their risk of developing colon cancer by 30-40% relative to those who are inactive (Schmid & Leitzmann 2014)

Management

• The protective effect of physical activity can be seen with only 6-9 MET-hours per week

• = moderate effort

• Colorectal cancer survivorship: Movement mattersCrystal S. Denlinger and Paul F. EngstromCancer Prev Res April 2011 4:502-511; doi:10.1158/1940-6207.CAPR-11-0098

Colorectal

Cancer

Breast Cancer Management

Active women had over 40% lower risk

breast cancer-specific mortality and

recurrence(Association between physical activity and mortality among breast

cancer and colorectal cancer survivors: a systematic review and

meta-analysis )

Uterine Cancer Prevention

Active women have around 30% lower risk than inactive women (Moore et al 2010)

Breast Cancer Prevention

Physical Activity reduces the risk by

around 24% overall

Every 2 hours/week a woman spends

doing moderate to vigorous activity,

the risk of breast cancer falls by 5% (Wu et al 2013)

• Lowers morbidity NICE CG101, van Wetering

2010 Santos 2014

• Fewer hospital admissions

• Patients maintain a healthy

weight and thus reduce load

on the heart

• Improves the patient’s sleep making them feel more relaxed

• Strengthens the patient’s bones

• Enhances the patient’s mental and emotional outlook Lacasse 2006

• Reduces the patient’s social isolation

– ‘exercise buddies’

NICE CG101, van Wetering 2010 , Santos et al 2014, Lacasse et al, 2006

“Rehabilitation forms an important component of the management of COPD”

Cochrane 2006

Gimeno-Santos E et al. Thorax

doi:10.1136/thoraxjnl-2013-204763

Copyright © BMJ Publishing Group Ltd & British

Thoracic Society.

All rights reserved.

Conceptual

model of

physical

activity in

patients with

COPD

OA/RAOsteoarthritis OA/

Rheumatoid Arthritis RA

Major considerations in designing individualized exercise

training in patients with rheumatoid arthritis

Metsios G S et al. Rheumatology 2008;47:239-248

© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology.

All rights reserved. For Permissions, please email: [email protected]

Risk factors for developing Alzheimer’s

Norton, S., F. E. Matthews, et al. (2014). The Lancet Neurology 13(8): 788-794.

1.46

1.59

1.59

1.60

1.61

1.65

1.82

1.00 1.20 1.40 1.60 1.80 2.00

Diabetes

Low educational attainment

Smoking

Midlife obesity

Midlife hypertension

Depression

Physical inactivity

Relative risk for Alzheimer’s disease

Treating dementia with exercise

1. Improved cognitive function

2. Enhanced mobility

3. Improved activities of daily living

4. No adverse effects

5. Likely to reduce the burden on caregivers

Forbes, D., E. J. Thiessen, et al. (2013). Cochrane Database Syst Rev 12: CD006489.

Meet Bert!heart healthy, strength and balance exercise works!http://www.ncbi.nlm.nih.gov/pubmed/23128427

Boxing training for patients with Parkinson disease: a case series. http://www.ncbi.nlm.nih.gov/pubmed/21088118

Falls preventionStrength and balance

exercises!

OTAGOFaMe (Falls Management Exercises)

= 38% reduction in fallsSherrington 2011

= falls cost NHS

£4.6million/day!

Osteoporosis and exercise

There is an inverse relationship of physical activity

relative risk of hip and vertebral fracture

Risk reduction for hip fracture of 36 - 68% at the highest level of activity

In sickness, in health, in immobility, in pain, in disability, and in old age….

prescribe physical activity!

#EverybodyActiveEveryday

• Arial 18pt

• Arial 18pt professionals

• patient education and support

• exercise advice, every patient, every opportunity

• when and where

• every health consult

• In hospitals, out patients, clinics, home visits

• the viral use of social media

Exercise-Works-Ltd

@exerciseworks

exerciseworks

See © Exercise Works! patient exercise sheets

All content and concepts intellectual copyright to © Exercise Works! www.exercise-works.org 2012, 2013, 2014.

Session 10

Acknowledgments and disclosures

resources

• FYSS Physical Activity in Disease Prevention and Disease Treatment

• http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move

• http://www.rcplondon.ac.uk/sites/default/files/documents/exercise-for-life-final_0.pdf

• Ann Gates ISBN: 1121850928 Copyright year: 2013, Patient Exercise Sheets, 1st Edition

• http://www.fsem.ac.uk/flipbook/medical_student_exercise_prescription_booklet/files/inc/65c1fc369c.pdf

• http://www.rcsed.ac.uk/the-college/news/2014/october-2014/exercise-surgery.aspx

• http://www.exercise-for-health.com/

• http://gpcpd.walesdeanery.org/index.php/uk-physical-activity-guidelines

• http://www.exercise-works.org/store/

• http://www.humankinetics.com/products/all-products/acsms-exercise-management-for-persons-wchrnc-diseasesdisab-3rd

• http://www.acsm.org/access-public-information/position-stands

• http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-adults.aspx

• http://www.healthscotland.com/physical-activity.aspx

• The role of exercise and PGC1α in inflammation and chronic disease Christoph Handschin1 and Bruce M. Spiegelman2

Dr Brian Johnson, General Practitioner and Honorary Medical Advisor to Public Health, Wales.

Dr John H. Brooks (together with existing Kings College Medical School undergraduate course resources in association

with Dr Ann Wylie and King’s Undergraduate Medical Education in the Community).

Dr Simon Rosenbaum PhD, Exercise Physiologist and Research Associate University of New South Wales, Australia.

Dr Jane Thornton MD PhD, Resident Physician and Clinical Researcher, Policlinique Médicale Universitaire, Lausanne,

Switzerland.

Mr Chris Oliver MD FRCS, Consultant Trauma Orthopaedic Surgeon, Honorary Senior Lecturer Department of Orthopaedic

Surgery, University of Edinburgh and Royal Infirmary of Edinburgh, Scotland.

Mr Ian Ritchie FRCS, President of the Royal College of Surgeons Edinburgh, Consultant Trauma and Orthopaedic Surgeon

at Forth Valley Hospital, Scotland.

Steffan Griffin, Medical Student at University of Birmingham, Director at Move Eat Treat, UK.