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Exercise Prescription: What’s the Hype ? Dr. Julia Alleyne University of Toronto Toronto Rehab University Health Network
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
