Download Basic Physical Activity, Exercise, and Chronic Conditions

HESS 509
C
Basic Physical Activity, Exercise, and Chronic Conditions
Physical Activity and Exercise
H
A
P
T
The World Health Organization (WHO) defines physical activity as “bodily
movement produced by skeletal muscles that requires energy expenditure.”
Technically, then, exercise is a form of physical activity.
E
R
T
Exercise training, however, is regular physical activity and can be defined as
“planned, structured, and repetitive physical activity for the purpose of
developing physical fitness.”
W
O
Light, Moderate, and Vigorous Physical Activity
Most national and international guidelines categorize physical activity into
three general levels of exercise intensity: light, moderate, and vigorous.
Additionally, the reintroduction of research in the area of high-intensity
exercise makes it important to define this fourth level. These are the four
levels (see also Table 2.1, next slide)
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
Light: An aerobic activity that causes
a barely noticeable change in
breathing, involving increased depth
(volume of each breath) more than
rate; can usually be sustained by an
untrained individual for 60 min or
more
Moderate: An aerobic activity that
can be performed at a ventilatory
demand that allows carrying on a
conversation (also known
as talk test); can usually be sustained
by an untrained individual for 30 to
60 min
Vigorous: An aerobic activity that is sufficiently demanding of ventilation that
talking cannot be maintained during the activity; can usually be sustained by an
untrained individual for only 20 to 30 min.
High: An aerobic or combination activity (i.e., a combined exertion of muscle
contractions at or near their maximal strength for an extended number of
repetitions, such as circuit weight training); can be sustained only briefly, typically
<10 min
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
C
H
A
P
T
E
R
T
W
O
As an alternative way to estimate perceived exertion, a 0-10 scale. This scale is mainly
validated for use in pulmonary disease but can be helpful in other chronic conditions. In
this particular 0-10 scale, one would generally expect level 5 (hard) to be very near the
ventilatory threshold. In persons with neuromuscular disease or conditions, however,
where fatigue is a main symptom, level 5 may occur well below the ventilatory
threshold.
HESS 509
C
H
A
P
T
Basic Physical Activity, Exercise, and Chronic Conditions
Leisure-Time Physical Activity
Physical activity is achieved during leisure time (accumulated outside the work
environment) or occupationally (accumulated in the work environment).
R
Because modern societies have experienced a significant reduction in
physically demanding jobs to the point that most jobs are at most lightintensity exertion (or even sedentary), leisure-time physical activity (LTPA) is now
generally considered an indicator of the overall physical activity (leisure-time +
T
occupational physical activities, combined)
E
W
O
Depending on individual goals and the clinical severity of the chronic disease,
the medical management plan should provide guidance on how to increase
LTPA, provide a well-designed exercise prescription for exercise training, or do
both.
In class, review the terms in “ Glossary of Important Terms in Exercise Science”
on p. 17 of text.
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
Physical Activity Guidelines
C
H
A
P
T
E
R
T
W
O
In 2008, the U.S. Department of Health and Human Services (HHS) published
evidence-based guidelines on physical activity recommendations:
• Everyone should be physically active, defined as accumulating a minimum
weekly total of 150 min of moderate physical activity or, alternatively, 75
min of vigorous physical activity.
• Adults should participate in two or more days of muscle strengthening
activities that involve all major muscle groups.
• Individuals at risk for falls should incorporate activities to improve balance
Other leading scientific and governing bodies of organizations have also made
Recommendations on Physical Activity Guidelines. These recommendations are
listed in Table 2.3 (see next slide)
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
C
H
A
P
T
E
R
T
W
O
Guidelines from ACSM and the American Heart Association (AHA) for older adults seem more
appropriate for many individuals who have a chronic health condition. These guidelines also
include recommendations on maintaining flexibility and for balance training in individuals who are
at risk for falls.
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
Recommendations for Physical Activity or Exercise in Chronic Conditions
C
H
A
When making recommendations for exercise programming in chronic
conditions it is important to remember:
P
T
E
R
T
W
O
• There are thousands of chronic conditions and causes of
disability.
• The vast majority of recommendations seem similar for most
chronic conditions.
• Ultimately, exercise is fairly simple and needs to be seen as
elegantly powerful.
• The complexities and nuances are matters of clinical judgment
for safety’s sake.
• The main concern in the chronic conditions in CDD4 is loss of
independent living, which is primarily a function of light-intensity
physical activities
These Basic Exercise Programming Recommendations are summarized in
Table 2.4. (next slide)
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
Adverse events
from exercise
cannot be
completely
eliminated, but
there are two main
categories to
consider:
Activitydependent risks
(due to the nature of the
activity)
Diseasedependent risks
(those that relate to
the pathophysiology)
he best way to minimize activity-dependent risks is to encourage the patient to
practice safety precautions. If there is concern that the individual cannot do this
independently, then they need a supervised exercise program, at least to get started.
It is prudent to follow the Guidelines on exercise testing and prescription.
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
How to Prescribe Physical Activity or Exercise in Chronic Care
FITT Model of Exercise Prescription
The traditional method of prescribing exercise used is the FITT method: frequency,
intensity, time, and type of exercise
Frequency, or how many days per week of a particular exercise:
For aerobic activities, the recommendation is for all persons to participate in
activities requiring aerobic exertion on 4 or 5 days per week.
For strengthening or functional exercises, the recommendation is that all
persons do functional activities that require muscular strength two to three
times each week
Intensity, or how hard to exercise, which depends on the kind of exercise being
performed: The recommendation is that the intensity of exercise be based on
perceived exertion in persons with chronic conditions. The reasons for this are
multiple: 1) Many patients are on medications that alter the heart rate
response to exercise (e.g., β-blockers). Persons with a disability or those who
require a prosthetic are often markedly less efficient than people without
disabilities and thus have dramatically less efficient exercise economy. 3) Many
health conditions alter exercise heart rates.
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
How to Prescribe Physical Activity or Exercise in Chronic Care
FITT Model of Exercise Prescription
The traditional method of prescribing exercise used is the FITT method: frequency,
intensity, time, and type of exercise
Time, or duration or how long to exercise during each session:
For aerobic activities, the recommendation is to work up to a duration of 30 to
40 min per session and accumulate a minimum of 150 min of moderate-intensity
aerobic exercise each week.
For strengthening–functional activities, all persons should complete the
following (or an equivalent): a minimum of two sets of 10 repetitions of arm
curls, two sets of 10 repetitions of sit to stands, and two repetitions of a 10-step
stair climb (or step-ups).
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
How to Prescribe Physical Activity or Exercise in Chronic Care
FITT Model of Exercise Prescription
The traditional method of prescribing exercise used is the FITT method: frequency,
intensity, time, and type of exercise
Type, or what kind(s) of specific exercise to perform:
For aerobic exercise, the recommendation is walking as the primary type of physical
activity. The reason is that walking is the basic form of locomotion for humans and is
essential for independent living and maintaining quality of life.
Other activities with a similar amount of energy expenditure (cycling, swimming, and
so on) are acceptable substitutes for walking and are preferred in situations in which
weight-bearing activity is a problem.
For strengthening functional and patient-appropriate exercises can be invented.
There is almost no limit to functional types of exercises. If an invented form of
exercise is practical and efficient with regard to what an individual needs to live a
better quality of life and is safe, then it may be added to the exercise prescription.
HESS 509
C
H
A
P
T
E
R
T
W
O
Basic Physical Activity, Exercise, and Chronic Conditions
HESS 509
C
H
A
P
T
E
R
T
W
Basic Physical Activity, Exercise, and Chronic Conditions
Judging Exercise Intensity
Patients must learn to judge intensity level as part of monitoring their exercise,
and exercise monitoring is done in terms of absolute or relative intensity.
Measures of absolute intensity are based on the rate of energy expenditure.
Energy expenditure is classically measured in oxygen uptake (mL O2 · kg body
weight−1 · min−1) and is normalized in a unit known as a metabolic equivalent
(MET). In normal human biology, this is the resting rate of oxygen uptake:
O
~3.5 mL O2 · kg body weight−1 · min−1 = 1 MET
One can objectively rate effort or intensity by measuring the exertional heart
rate (HR) or rate it subjectively by using a psychophysical rating of perceived
exertion (RPE). There are two RPE scales that are used widely, one ranging from
6 to 20 (BORG) and the other ranging from 0 to 10.
In people who have a normal cardiopulmonary response to exercise, the 6- to 20-point scale is
recommended because this scale is perceived by patients as easier when making fine adjustments
in work rate at the higher ends of the scale. This scale is particularly helpful for higher-functioning
individuals who seek to do high-intensity interval training. The 0- to 10-point scale may be
particularly well suited, however, for persons with chronic pulmonary conditions (for whom this
scale was originally developed).
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
C
H
A
P
T
E
R
T
W
O
Remember that with subjective scales like RPE, persons who are less fit will have
a higher rating of effort at any given absolute level of exertion when compared
to the rating of effort among those who are more physically fit. Use of RPE also
allows for variability in symptoms such as fatigue that are common yet often
variable in people with chronic conditions.
HESS 509
Basic Physical Activity, Exercise, and Chronic Conditions
Graded Exercise Testing
C
H
A
P
T
E
R
T
W
O
Persons with chronic disease (signs and symptoms of disease and multiple major risk factors)
should consult their physician before beginning an exercise program.
When do I need to order an exercise test? And what kind of test?
• Detection of coronary artery disease (CAD) in people with chest pain syndromes or
potentially equivalent symptoms
• Evaluation of the anatomic and functional severity of CAD
• Prediction of cardiovascular events and all-cause death
• Evaluation of physical capacity and effort tolerance
• Evaluation of exercise-related symptoms
• Assessment of chronotropic competence, arrhythmias, and response to implanted
device therapy
• Assessment of the response to medical interventions
Exercise tests for such purposes are generally completed with a 12-lead ECG, but
valuable information from an exercise test can be learned without an ECG.
HESS 509
C
H
A
P
T
E
R
T
W
Basic Physical Activity, Exercise, and Chronic Conditions
When do I need to order an exercise test? And what kind of test?
Reasons for not performing an exercise test:
•
•
•
•
•
•
•
Extreme deconditioning
Orthopedic limitations
Left ventricular dysfunction that limits exertion by shortness of breath
Known coronary anatomy
Recent successful revascularization
Recent uncomplicated or stable myocardial infarction
Recent pharmacologic stress test
O
It is most important for the physician doing a pre-participation evaluation to
consider what exercise testing will achieve for an individual with a particular
chronic condition or set of chronic conditions. If the individual’s physical
functioning does not seem substantially limited by his chronic conditions and he is
interested in starting a vigorous-intensity program or high-intensity interval
training, obtaining an exercise test is prudent
Basic Physical Activity, Exercise, and Chronic Conditions
HESS 509
When do I need to order an exercise test? And what kind of test?
C
If the patient’s physical functioning is highly limited by chronic conditions, as
is very often the case, with the exercise test likely to be non-diagnostic, a
prudent course is to advise starting with light-intensity physical activities,
perhaps supervised by an exercise specialist, and wait to see if symptoms
develop that merit ordering a diagnostic exercise test.
H
A
P
T
E
R
This strategy can be conceived as T
Start low, progress slowly, and be alert (for symptoms)
W
O
Recommendation for evaluation of physical functioning is that all patients, regardless of
chronic condition(s), should be able to do the following physical function tests at a
minimum:
•
•
•
•
•
6 or 8 m gait speed >0.6 m/s
Eight sit-to-stand repetitions in 30 s
Eight arm curls with a 4 kg mass
Ascending a flight of 10 steps in under 30 s
Chair sit and reach to the toes (0 in.) on both sides
Muscular strength and endurance are important requirements for independent living, so it is
important to note to patients how quickly they’ve improved from their program
HESS 509
C
H
A
P
T
E
R
T
W
Basic Physical Activity, Exercise, and Chronic Conditions
Minimum Exercise Recommendations When an Exercise Test Is Not Available
The guidelines for prescribing exercise without an exercise test are extremely
limited and are generally based on an exercise specialist’s experience with a
particular chronic condition. Thus the information provided in the text from
The section “Minimum Exercise Recommendations When an Exercise Test Is
Not Available”, beginning on page 27, is FYI only.
Specific Recommendations for the various chronic diseases and disabilities
will be addressed in lecture respective to the various chapters of the
textbook discussed in the classroom.
O
END