myths and legacy of exercisemedicine in chronic diseases
TRANSCRIPT
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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
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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”
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“No Exercuses”
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FACT!
Old or sick…
without
structured
physical activity
….
patients will
….die younger
and reduced
quality of life
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Exercise
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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
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Too old?.............NO!
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Too sick?....
No!
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ENOUGH EVIDENCE for exercise as a medicine!
TIME to teach
every health
professional
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8 ABSOLUTE CONTRAINDICATIONS TO EXERCISE IN CARDIOVASCULAR DISEASE PATIENTS
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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
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“UNSTABLE”
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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
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“UNCONTROLLED”
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150 minutes / fun / physical activities / week / works!
Twice a week / strength / balance / flexibility exercises!
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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
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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
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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
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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!
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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!
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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).
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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
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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”
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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
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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
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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)
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• 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
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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
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OA/RAOsteoarthritis OA/
Rheumatoid Arthritis RA
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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]
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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
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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.
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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
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Falls preventionStrength and balance
exercises!
OTAGOFaMe (Falls Management Exercises)
= 38% reduction in fallsSherrington 2011
= falls cost NHS
£4.6million/day!
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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
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In sickness, in health, in immobility, in pain, in disability, and in old age….
prescribe physical activity!
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#EverybodyActiveEveryday
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• 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
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Acknowledgments and disclosures
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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.