Exercise Prescription for HealthExercise Prescription for HealthIrish Association of Cardiac Irish Association of Cardiac

RehabilitationRehabilitation

Joseph Cummiskey MDJoseph Cummiskey MDDean FSEM, RCSI and RCPIDean FSEM, RCSI and RCPI

President EFSMAPresident EFSMA1111thth November, 2013 November, 2013

The program this eveningThe program this evening

Introduction: Why exercise is good?Introduction: Why exercise is good? The big question which the FSEM The big question which the FSEM

faces “how much physician input?”faces “how much physician input?” Exercise talk: EPH, an initiative of Exercise talk: EPH, an initiative of

EFSMA; what is involved? EFSMA; what is involved?

ICGP

IntroductionIntroductionWhy exercise is goodWhy exercise is good

Part 1.Part 1.

No conflicts of interestNo conflicts of interest

Effect of fitness (CRF) Effect of fitness (CRF) on mortalityon mortality

The ethics of not prescribing exercise:The ethics of not prescribing exercise:

Is it negligence?Is it negligence? Large studies from Europe and the USA Large studies from Europe and the USA

have shown that low cardio-respiratory have shown that low cardio-respiratory fitness is the single biggest risk factor for fitness is the single biggest risk factor for all-cause mortality. all-cause mortality.

The importance of sports medicine, in The importance of sports medicine, in particular the benefits of physical activity particular the benefits of physical activity in non-communicable disease prevention in non-communicable disease prevention and chronic disease management, should and chronic disease management, should be incorporated into the core under and be incorporated into the core under and post graduate teachingpost graduate teaching

ExerciseExercise

Physicians and other health professionals can Physicians and other health professionals can contribute substantially to patients' adoption of contribute substantially to patients' adoption of exercise behaviours, just as they have provided exercise behaviours, just as they have provided smoking cessation advice and contribute to smoking cessation advice and contribute to smoking reduction in many countries.smoking reduction in many countries.

A straightforward but influential step forward A straightforward but influential step forward would be measurement of the exercise as the 5would be measurement of the exercise as the 5thth vital sign in every consultation. vital sign in every consultation.

Patients ought to report how many minutes of Patients ought to report how many minutes of physical activity they undertake in an average physical activity they undertake in an average day and how many days a week such activity day and how many days a week such activity takes place.takes place.

Nothing about exercise is newNothing about exercise is new As old as history itself As old as history itself

HippocratesHippocrates 5 5thth century “if one exercised century “if one exercised they become more healthy, well-they become more healthy, well-developed and age more slowly”developed and age more slowly”

HerodotusHerodotus 5 5thth century BC. The father of century BC. The father of histories “histories “If we could give every individual the right If we could give every individual the right amount of nourishment and exercise, not tamount of nourishment and exercise, not too little and not too much, we would have oo little and not too much, we would have found the safest way to health”.found the safest way to health”.

PlatoPlato: 5: 5thth BC. BC. ““Lack of activity destroys the good Lack of activity destroys the good condition of every human being, while movement condition of every human being, while movement and methodical physical exercise save it and and methodical physical exercise save it and preserve it”.preserve it”.

There has been an Acceleration There has been an Acceleration in knowledge technologyin knowledge technology

about exercise physiologyabout exercise physiology Occurred in 1968 after Karl Wasserman, Brian Occurred in 1968 after Karl Wasserman, Brian

Whipp and Antonius Van Kessel published their Whipp and Antonius Van Kessel published their paper on breath by breath analysis during paper on breath by breath analysis during exercise. This microprocessor now forms the exercise. This microprocessor now forms the basis for all clinical C-P ex tests machines.basis for all clinical C-P ex tests machines.

This was supplemented by the introduction of the This was supplemented by the introduction of the Hewlett Packard ear oximeter in 1970.Hewlett Packard ear oximeter in 1970.

At last we had non-invasive measurements of At last we had non-invasive measurements of heart (rate and rhythm) and lung (air volumn, heart (rate and rhythm) and lung (air volumn, oxygen utilisation, carbon dioxide production, oxygen utilisation, carbon dioxide production, respiratory rate, respiratory exchange ratio, respiratory rate, respiratory exchange ratio, prediction of anaerobic threshold) and their prediction of anaerobic threshold) and their ratios, that could be done during exercise.ratios, that could be done during exercise.

Why?Why?

Why is it if exercise is good for you we Why is it if exercise is good for you we all do not exercise enough.all do not exercise enough.

The answer lies in religion; all religions The answer lies in religion; all religions knew from the start of their religion knew from the start of their religion that “We must be constantly reminded that “We must be constantly reminded of what we believe in”.of what we believe in”.

If patients and the general public are If patients and the general public are not constantly reminded to exercise not constantly reminded to exercise they will not do so.they will not do so.

This is where the physician plays a roleThis is where the physician plays a role

The House of Lords, UK, Science The House of Lords, UK, Science and Technology Committeeand Technology Committee

The above group launched a new short inquiry into sports The above group launched a new short inquiry into sports and exercise science and medicine after the London and exercise science and medicine after the London Olympics in 2012. Olympics in 2012.

Commenting, Lord Krebs, Chairman of the Committee, said: Commenting, Lord Krebs, Chairman of the Committee, said: ““There is an ever-growing body of evidence showing There is an ever-growing body of evidence showing

that increasing the amount of exercise people take can be that increasing the amount of exercise people take can be of huge benefit in treating a wide range of chronic of huge benefit in treating a wide range of chronic conditions. conditions.

However, we are not convinced that health However, we are not convinced that health professionals currently have the skills or support to professionals currently have the skills or support to prescribe appropriate training regimes for their prescribe appropriate training regimes for their patients” patients”

(My, as President, emphasis).(My, as President, emphasis).

What does that tell you?What does that tell you?

Doctors need to be more knowledgeable Doctors need to be more knowledgeable about exercise and how to prescribe it.about exercise and how to prescribe it.

They must know what to tell their patientsThey must know what to tell their patients They must do PPE which include an ECG They must do PPE which include an ECG

and possibly a CP ex test in some patientsand possibly a CP ex test in some patients They must follow up after a prescription They must follow up after a prescription

has been completedhas been completed

Risks of exercise prescription is the Risks of exercise prescription is the reason exercise is not medicine for allreason exercise is not medicine for all

Sudden cardiac deathSudden cardiac deathExercise related cardiac eventsExercise related cardiac events

An important point is that SCA is seven fold more An important point is that SCA is seven fold more common in participants who do not have a pre-common in participants who do not have a pre-participation assessment.participation assessment.

A different etiology for SCA appears with PPE ECG A different etiology for SCA appears with PPE ECG (Italy v USA)(Italy v USA)

Exercise induced asthmaExercise induced asthmaExercise induced hypoxemiaExercise induced hypoxemiaHypoglycemia of exerciseHypoglycemia of exercise

(Corrado et al. NEJM 1998)

(Maron et al. JAMA 1996)

ARVD 23%ARVD 23% AnomalousAnomalousc.a. origin 12%c.a. origin 12%

HCM 2%HCM 2%

PrematurePrematureCAD 18%CAD 18%

HCM 36%HCM 36%AtheroscleroticAtheroscleroticc.a. disease c.a. disease 22%%

ARVD 3%ARVD 3%

AnomalousAnomalousc.a. origin 12%c.a. origin 12%

athletes athletes < 35 yrs35 yrs

The Big QuestionThe Big Question ““How involved should the doctor be in the How involved should the doctor be in the

exercise management of health and disease”exercise management of health and disease”.. I cannot see the case for not wanting I cannot see the case for not wanting

any medical input at all. This is the any medical input at all. This is the way it has been for years in most way it has been for years in most countries countries

The positive impact of Medical input at The positive impact of Medical input at start and follow up I believe is the next start and follow up I believe is the next step to getting the most from an step to getting the most from an exercise prescription. exercise prescription.

The European Federation of Sport The European Federation of Sport Medicine Associations approach to Medicine Associations approach to

exercise exercise Exercise Prescription for Health (EPH)Exercise Prescription for Health (EPH)

Part 2Part 2

European Federation of Sports European Federation of Sports Medicine Associations (EFSMA)Medicine Associations (EFSMA)Over 200 man hours of discussion on EPH and EIM in 2012Over 200 man hours of discussion on EPH and EIM in 2012Contained representatives from 10 of the 41 EFSMA affiliated Contained representatives from 10 of the 41 EFSMA affiliated

countries (included Italy, Germany, Austria, Belgium, countries (included Italy, Germany, Austria, Belgium, Turkey, France, Ireland, Norway, Portugal and Cyprus)Turkey, France, Ireland, Norway, Portugal and Cyprus)

Listened to all arguments for and againstListened to all arguments for and againstPPEPPETitle of the initiativeTitle of the initiativeAnalysed what was being used in Analysed what was being used in various countries by written various countries by written surveys and word of mouthsurveys and word of mouthPlanted the flag for EPH in Rome in 9.2012Planted the flag for EPH in Rome in 9.2012Follow up in Athens 3.2013Follow up in Athens 3.2013Follow up in Dublin 23.4.2013Follow up in Dublin 23.4.2013Major launch in Strasbourg 9.2013 to 35 Major launch in Strasbourg 9.2013 to 35 European countriesEuropean countriesSweden has requested a major role.Sweden has requested a major role.

The EFSMA logo for EPHThe EFSMA logo for EPH

Prof Norbert Bachl, Vienna Prof Norbert Bachl, Vienna University, RCPI 4.2013University, RCPI 4.2013

EPH and why it is the EPH and why it is the correct titlecorrect title

Exercise and/or physical activity are Exercise and/or physical activity are essential in a title.essential in a title.

Prescription suggests that a Prescription suggests that a thoughtful note is written by a doctor thoughtful note is written by a doctor for a certain course of actionfor a certain course of action

Heath was always the term used by Heath was always the term used by the ancient Greeks as distinct from the ancient Greeks as distinct from Medicine which implies a universal Medicine which implies a universal beneficial outcomebeneficial outcome

““Exercise Is Medicine” Exercise Is Medicine” and why it is a misnomerand why it is a misnomer

The title EIM is an oxymoron (a figure of speech where The title EIM is an oxymoron (a figure of speech where apparently contradictory terms appear in conjunction)apparently contradictory terms appear in conjunction)

If exercise causes death or disease can we call it a If exercise causes death or disease can we call it a medicine?medicine?

Exercise induced asthma or bronchospasm occurs in 3/100 Exercise induced asthma or bronchospasm occurs in 3/100 athletesathletes

3/100,000 people die from Sudden cardiac arrest syndrome 3/100,000 people die from Sudden cardiac arrest syndrome usually during or after exerciseusually during or after exercise

Exercise has side effects and therefore should be treated Exercise has side effects and therefore should be treated like a druglike a drug

EIM-USA is a dumbing down of the science of exercise. EIM-USA is a dumbing down of the science of exercise. It is written by sport scientists and sports medicine doctors It is written by sport scientists and sports medicine doctors

mainly for sport scientists to be the major prescribers.mainly for sport scientists to be the major prescribers.

Exercise is MedicineExercise is MedicineTMTM (EIM) (EIM)

It retains fiscal and legal control (68 page It retains fiscal and legal control (68 page Memorandum of Understanding) to be Memorandum of Understanding) to be signed before you can use the trade mark signed before you can use the trade mark EIM). EIM).

If EFSMA were to try to match this with a If EFSMA were to try to match this with a contract the estimate for legal expenses contract the estimate for legal expenses was said to be €50,000 euro.was said to be €50,000 euro.

EIM has only a history and family history EIM has only a history and family history as the preparticipation assessment. as the preparticipation assessment.

It has a lot of psychology, poor clinical It has a lot of psychology, poor clinical standards and no science. standards and no science.

EIMEIM It is a marketing tool for exercise. It is a marketing tool for exercise. EIM is a global trademark only in the USA. EIM is a global trademark only in the USA. It insists all printing is done in Indianapolis. It insists all printing is done in Indianapolis. It would take a maximum of 15% of all sponsors It would take a maximum of 15% of all sponsors

funds raised for EIM in your countryfunds raised for EIM in your country It has sport scientists deciding the exercise and It has sport scientists deciding the exercise and

sports medicine doctors signing the prescription sports medicine doctors signing the prescription and taking the responsibilityand taking the responsibility

It would be politically a disaster for European It would be politically a disaster for European Sport Medicine and that is why we believe EFSMA Sport Medicine and that is why we believe EFSMA were never contacted directly by EIMwere never contacted directly by EIM

Other European Other European groupsgroups

ECSS (European College of Sport Science) want to be ECSS (European College of Sport Science) want to be involved in the research of exerciseinvolved in the research of exercise

HEPA (Health-Enhancing Physical Activity) EU / C of E HEPA (Health-Enhancing Physical Activity) EU / C of E do not want to do the medical hands on part of do not want to do the medical hands on part of exercise but rather write the guidelines.exercise but rather write the guidelines.

EIM-E (Exercise is Medicine-Europe) only requires a EIM-E (Exercise is Medicine-Europe) only requires a clinical and family history. The end point is a feel clinical and family history. The end point is a feel good factor.good factor.

NICE (National Institute of Health and Care NICE (National Institute of Health and Care Excellence) UK: PA brief advice for adults in primary Excellence) UK: PA brief advice for adults in primary carecare

Who supports EPH?Who supports EPH? European Federation of Sport Medicine European Federation of Sport Medicine

Associations (EFSMA)Associations (EFSMA) International Federation of Sports Medicine (FIMS)International Federation of Sports Medicine (FIMS) European Olympic Committee, Medical European Olympic Committee, Medical

Commission (EOC, MC)Commission (EOC, MC) Council of Europe (C of E)Council of Europe (C of E) European Academy of Science and the Arts European Academy of Science and the Arts

(EASA)(EASA) European Union Medical Specialities (UEMS, MJC, European Union Medical Specialities (UEMS, MJC,

SM)SM) Medica, a Medical conference organiser, Medica, a Medical conference organiser,

DusseldorfDusseldorf

President of the Eur Academy of President of the Eur Academy of Science and the Arts, Prof UngerScience and the Arts, Prof Unger

EFSMAEFSMA FIMSFIMS Academy Academy FIMS FIMS

UEMS UEMS EFSMAEFSMA MedicaMedica

Council of EuropeCouncil of EuropeExercise in Europe Exercise in Europe 20072007

The concept of Exercise as a Health tool they said The concept of Exercise as a Health tool they said “was becoming increasingly important”. “was becoming increasingly important”.

They also stated that “SEM Physicians are able to They also stated that “SEM Physicians are able to – evaluate medical patients co-morbidities, evaluate medical patients co-morbidities, – perform exercise testing and perform exercise testing and – provide an provide an exercise prescriptionexercise prescription, together with , together with – a motivational programme and exercise classes”.a motivational programme and exercise classes”.

BUT Between 2007 to 2013 there has been an BUT Between 2007 to 2013 there has been an increase in obesity, Type II DM and lack of increase in obesity, Type II DM and lack of physical activity in the communityphysical activity in the community

This top down approach is not workingThis top down approach is not working

Precedent for no use of sciencePrecedent for no use of science

There is a precedent for not allowing the There is a precedent for not allowing the science of a subject be part of the science of a subject be part of the recommendations. recommendations.

For 10 years the sports medicine world For 10 years the sports medicine world discussed asthma. discussed asthma.

It was only after many millions of euro had It was only after many millions of euro had been spent on anti-doping protocols that the been spent on anti-doping protocols that the science was allowed to be used in diagnosis science was allowed to be used in diagnosis and management of asthma.and management of asthma.

Experts should write the guidelines and Experts should write the guidelines and non-experts may implement the guidelinesnon-experts may implement the guidelines

The prescriptionThe prescription

Part 3.Part 3.

Pre-Participation ExamPre-Participation Exam

HistoryHistory Physical examinationPhysical examination Tests to include ECG, possibly othersTests to include ECG, possibly others What to tell the patientWhat to tell the patient Write the prescription in detailWrite the prescription in detail Follow upFollow up

There are 12 key questions:There are 12 key questions:

1.1. RTRT Does the athlete have asthma Does the athlete have asthma (Wheezing), hay fever or coughing (Wheezing), hay fever or coughing spells after exercise?spells after exercise?

2.2. CVS CVS has anyone in the athlete’s family died has anyone in the athlete’s family died suddenly before the age of 50 yearssuddenly before the age of 50 years

3.3. DizzyDizzy Has the athlete ever passed out during Has the athlete ever passed out during exercise or exercise or stopped exercising because stopped exercising because of dizziness?of dizziness?

4.4. CNSCNS Does the athlete has a history of Does the athlete has a history of concussion concussion

5.5. GUGU Age of onset of menstruation and Age of onset of menstruation and frequency.frequency.

There are 12 key questions:There are 12 key questions:

7.7. Do you see a physician regularly for any particular Do you see a physician regularly for any particular problemproblem

8.8. Meds: Meds: Does the athlete take any medication?Does the athlete take any medication?9.9. Allergies Is the athlete allergic to any medication or bee Allergies Is the athlete allergic to any medication or bee

stingsstings10.10. Does the athlete have only one of any paired organ (eyes, Does the athlete have only one of any paired organ (eyes,

ears, ears, kidneys, testicles, and ovaries)?kidneys, testicles, and ovaries)?11.11. Has the athlete ever broken a bone, had to wear a cast, Has the athlete ever broken a bone, had to wear a cast,

or had an injury to any joint?or had an injury to any joint?12.12. Does the athlete wish to discuss anything with the Does the athlete wish to discuss anything with the

physician?physician?

Physical examinationPhysical examination

Emphasis on cardio-respiratoryEmphasis on cardio-respiratory Temp. Temp. BP, HR, RR at rest and with BP, HR, RR at rest and with

exercise, minutes of exercise per exercise, minutes of exercise per weekweek

Weight,Weight, Total body fatTotal body fat Abdominal girthAbdominal girth

The 90 second orthopedic The 90 second orthopedic screening examscreening exam

Athletic Activity instructionAthletic Activity instruction ObservationObservation Stand facing examinerStand facing examiner General habitus, General habitus, AC jointAC joint Look at ceiling, floor, over both Look at ceiling, floor, over both

shoulders,shoulders, Cervical spine motion Cervical spine motion Touch ears to shouldersTouch ears to shoulders Shrug shouldersShrug shoulders Trapezius strengthTrapezius strength Abduct shoulders to Abduct shoulders to Deltoid strength (Examiner resists at Deltoid strength (Examiner resists at

90 degrees 90 degrees 90 degrees) 90 degrees) Shoulder motionShoulder motion Full external rotation of armsFull external rotation of arms

Elbow motionElbow motion Flex and extend elbows Flex and extend elbows Arms at side, Arms at side, Elbows flexed at 90 degreesElbows flexed at 90 degrees

Pronate and supinate Pronate and supinate wristswrists

METSMETS The energy cost of an activity can be measured in The energy cost of an activity can be measured in

units called METS, which are multiples of your units called METS, which are multiples of your basal metabolic rate. basal metabolic rate.

One MET is the metabolic rate when one is sitting One MET is the metabolic rate when one is sitting quietly in a normal temperature room. quietly in a normal temperature room.

An increase in An increase in METs is based on speed and grade METs is based on speed and grade of thread mill (over estimate the oxygen capacity of thread mill (over estimate the oxygen capacity compared to oxygen consumption). compared to oxygen consumption).

The comparison of groups and the measure of The comparison of groups and the measure of exercise they are doing is important.exercise they are doing is important.

Original prescriptionOriginal prescription FITTFITT MinimalMinimal averageaverage top top FrequencyFrequency

/week/week 33 55 66

IntensityIntensity light light medium medium heavy heavy sweatingsweating

Type Type walkwalk light joglight jog heavy jog,heavy jog,runrun

TimeTimeminutesminutes 30 30 40 40 50 50

Tell the patientTell the patient

There are health-related benefits of There are health-related benefits of regular physical activity that did not meet regular physical activity that did not meet traditional criteria for improving fitness of traditional criteria for improving fitness of exerciseexercise

Exercise might also be considered as a Exercise might also be considered as a fifth vital sign and should be recorded in fifth vital sign and should be recorded in patients' electronic medical records and patients' electronic medical records and routine histories,routine histories,

Simple things like walking instead of Simple things like walking instead of taking transit, and walking the dog make a taking transit, and walking the dog make a big difference.big difference.

Tell the patientTell the patient

Patients ought to report how many minutes of Patients ought to report how many minutes of physical activity they undertake in an average physical activity they undertake in an average day and how many days a week such activity day and how many days a week such activity takes place. takes place.

This measurement provides a score (in minutes This measurement provides a score (in minutes per week) that can alert patients and clinicians to per week) that can alert patients and clinicians to potential risks related to physical inactivity."potential risks related to physical inactivity."

People who took up playing football two or three People who took up playing football two or three times a week experienced reduced risk factors for times a week experienced reduced risk factors for cardiovascular disease, diabetes and the brittle-cardiovascular disease, diabetes and the brittle-bone disease osteoporosis.bone disease osteoporosis.

Modifiable Risk FactorsModifiable Risk Factors HypertensionHypertension High fat saturated dietHigh fat saturated diet AbnormalAbnormal  bloodblood  lipidlipid  levels (high total levels (high total

cholesterol, high levels of triglycerides, high cholesterol, high levels of triglycerides, high levels of low-density lipoprotein or low levels of levels of low-density lipoprotein or low levels of high-density lipoprotein (HDL) cholesterol). high-density lipoprotein (HDL) cholesterol).

Tobacco use (smoking or chewing tobacco, Tobacco use (smoking or chewing tobacco, especially if started at a young age or in females).especially if started at a young age or in females).

Physical inactivity increases the risk of heart Physical inactivity increases the risk of heart disease and stroke by 50% (reference).  disease and stroke by 50% (reference). 

Modifiable Risk FactorsModifiable Risk Factors Obesity is a major risk for cardiovascular disease and Obesity is a major risk for cardiovascular disease and

predisposes to diabetes 2.predisposes to diabetes 2. Type 2 diabetes, which doubles the risk of coronary Type 2 diabetes, which doubles the risk of coronary

heart disease and stroke. heart disease and stroke. A chronically stressful life, social isolation, anxiety and A chronically stressful life, social isolation, anxiety and

depression increase the risk of heart disease and depression increase the risk of heart disease and stroke.stroke.

One or two units of alcohol may lead to a 30% One or two units of alcohol may lead to a 30% reduction in heart disease, but more than this level of reduction in heart disease, but more than this level of alcohol consumption may damage the heart.alcohol consumption may damage the heart.

Medications may increase the risk of heart disease eg. Medications may increase the risk of heart disease eg. contraceptive pill, hormone replacement therapy contraceptive pill, hormone replacement therapy (HRT).(HRT).

Left ventricular hypertrophy (LVH).Left ventricular hypertrophy (LVH).

Non-Modifiable Risk FactorsNon-Modifiable Risk Factors

– Age, the risk of stroke doubles every decade after age Age, the risk of stroke doubles every decade after age 55.55.

– Family’s history, cardiovascular disease indicates your Family’s history, cardiovascular disease indicates your risk. If a first-degree blood relative has had coronary risk. If a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for a heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative) your male relative) or 65 years (for a female relative) your risk increases.risk increases.

– Gender, males have a greater risk of heart disease than Gender, males have a greater risk of heart disease than pre-menopausal woman. Once females reach the pre-menopausal woman. Once females reach the menopause, the risk of cardiovascular disease is similar. menopause, the risk of cardiovascular disease is similar. Men and women have the same risk of stroke.Men and women have the same risk of stroke.

Psychology is importantPsychology is important

IdentificationIdentification– Pre-contemplation Phase– Contemplation Phase– Preparation Phase– Action PhaseAction Phase– Maintenance PhaseMaintenance Phase

MotivationMotivation– CompetenceCompetence– AutonomyAutonomy– RelatednessRelatedness

IdentificationIdentification Pre-contemplation Phase – the patient has not – the patient has not

yet considered a lifestyle change.yet considered a lifestyle change. Recommended action by the physician: Recommended action by the physician:

educate the patient on the benefits to be educate the patient on the benefits to be achieved by initiating lifestyle changes.achieved by initiating lifestyle changes.

Contemplation Phase – the patient thinks about – the patient thinks about commencing regular physical activity within the commencing regular physical activity within the next 6 monthsnext 6 months recommended action by recommended action by physician : as per Exercise Guidelines Document physician : as per Exercise Guidelines Document

Preparation Phase – the patient is ready to start – the patient is ready to start exercising regularly within the next 30 days exercising regularly within the next 30 days recommended action: as per Exercise Guidelines recommended action: as per Exercise Guidelines DocumentDocument

MotivationMotivation

CompetenceCompetence– The feeling that they are sufficiently The feeling that they are sufficiently

capable to affect a desired behavioural capable to affect a desired behavioural outcome. outcome.

– This may be experienced as a self-belief This may be experienced as a self-belief in the ability to exercise and to feel in the ability to exercise and to feel comfortable in exercise settings. comfortable in exercise settings.

– Competence enhances the intrinsic Competence enhances the intrinsic motivation for the behaviour (i.e., being motivation for the behaviour (i.e., being able to participate in physical activity).able to participate in physical activity).

The prescription containsThe prescription contains

Warm upWarm up FrequencyFrequency IntensityIntensity TypeType TimeTime Cool downCool down Stretch and agilityStretch and agility Strength and conditioningStrength and conditioning Flexibility Flexibility

Laboratory testsLaboratory tests

ECG and when a referral to a cardiologist is indicated ECG and when a referral to a cardiologist is indicated (appendix 4.)(appendix 4.)

Physiological assessmentPhysiological assessment Physician supervised physiological exercise test is done Physician supervised physiological exercise test is done

with continuous monitoring of cardiac, pulmonary and with continuous monitoring of cardiac, pulmonary and metabolic parameters as needed. metabolic parameters as needed.

There is no simple set of guidelines for a physiological There is no simple set of guidelines for a physiological exercise test. exercise test.

The risk of CV events with exercise increase as a direct The risk of CV events with exercise increase as a direct function of exercise intensity (vigorous > moderate > low function of exercise intensity (vigorous > moderate > low exercise intensity)exercise intensity)

Clinically it is used to decide the cause of dyspnea and Clinically it is used to decide the cause of dyspnea and limitation to exercise. limitation to exercise.

It is used to note ECG changes of exercise that may reflect It is used to note ECG changes of exercise that may reflect ischemia, cardiac arrhythmia, exercise induced asthma, ischemia, cardiac arrhythmia, exercise induced asthma, hypoxemia of exercise and other parametershypoxemia of exercise and other parameters

Clinical monitoringClinical monitoring

HistoryHistory Improved cardio-respiratory Improved cardio-respiratory enduranceenduranceImproved muscular endurance Improved muscular endurance without symptomswithout symptomsImproved ability to do daily activitiesImproved ability to do daily activities

Physical examinationPhysical examination BP, HR, RR at rest and with exercise, mins of exerciseBP, HR, RR at rest and with exercise, mins of exercise Weight,Weight, Reduced total body fatReduced total body fat Reduced abdominal girthReduced abdominal girth Blood testsBlood tests Repeat CP ex testRepeat CP ex test

The House of Lords, UK, Science The House of Lords, UK, Science and Technology Committeeand Technology Committee

The above group has launched a new short inquiry into The above group has launched a new short inquiry into sports and exercise science and medicine after the London sports and exercise science and medicine after the London Olympics. Olympics.

Commenting, Lord Krebs, Chairman of the Committee, said: Commenting, Lord Krebs, Chairman of the Committee, said: “There is an ever-growing body of evidence showing that “There is an ever-growing body of evidence showing that increasing the amount of exercise people take can be of increasing the amount of exercise people take can be of huge benefit in treating a wide range of chronic conditions. huge benefit in treating a wide range of chronic conditions.

However, we are not convinced that health rofessionals However, we are not convinced that health rofessionals currently have the skills or support to prescribe currently have the skills or support to prescribe appropriate training regimes for their patients” appropriate training regimes for their patients”

(My, as President, emphasis).(My, as President, emphasis).

SUMMARY of EPHSUMMARY of EPH

The science of exercise must not be The science of exercise must not be dumbed down againdumbed down again

The patient must be central to all exercise The patient must be central to all exercise endeavour and should includeendeavour and should include– PPE,PPE,– psychology, psychology, – exercise physiol principles being applied, exercise physiol principles being applied, – CPET as a clinical laboratory test available in CPET as a clinical laboratory test available in

clinical PFT laboritories and is our gold clinical PFT laboritories and is our gold standardstandard

– follow up and reassessment is essentialfollow up and reassessment is essential

Exercise prescription: roles and responsabilities