鍛煉和慢性病

1、Exercise and Chronic Disease,Mark A. Patterson, M.Ed., RCEPClinical Exercise Physiologist – Kaiser PermanentePresident-Elect Rocky Mountain ACSM,Hippocrates,“Eating alone will not keep a man well; he must also take exe

2、rcise. For food and exercise, while possessing opposite qualities, yet work together to produce health.” Hippocrates, Regimen, 5th Century B.C.Slide borrowed from Russ Pate and Robert Salis,www.exerciseismedicine.

3、org,Common Chronic Diseases,Cardiovascular disease Heart Attack, Stroke, PADPulmonary disease Asthma, COPD, EmphysemaDiabetes Neuropathies, CADNeuromuscular disorders Multiple Sclerosis,ParkinsonsMusculoskel

4、etal conditions ArthritisCancer Breast, Prostate, LeukemiaRenal disease Kidney Failure, CADImmunological AIDSObesity All of the above?,Cardiovascular disease – 79 million (2007 CDC Website) Pulmonary d

5、isease – 35 million (2007 American Lung Association),Diabetes – 14.6 Million (2005 CDC Website) Neuromuscular disorders (MS, 2.5 million national ms society / Parkinson’s 1.5 million +, National Parkinson Foundation)Mus

6、culoskeletal conditions (Rheumatoid 2.1 million, osteo 21 million, juvenile 300,000, national arthritis foundation) Obesity – 99 Million (Based off CDC and Census Bureau Sites) Cancer – 10.1 Million 2002 (American Canc

7、er Society Website) Renal disease – 20+ million (American Kidney Fund)Immunological (AIDS 36.1 Million AIDS.org,Chronic Diseases,Benefits of Exercise,Increased VO2Improved BP ControlIncreased HDLDecreased Body FatIm

8、proved Weight ControlImproved BS ControlImproved StrengthLess FatigueImproved Balance,Heart DiseaseLung DiseaseDiabetesNeuromuscularMusculoskeletalObesityCancerKidney DiseaseAIDs,Who is Best to Care for These

9、 People?,Me!In an Ideal WorldClinical Exercise PhysiologistsPhysical TherapistsRespiratory TherapistsRegistered NursesPhysiciansPersonal TrainersMassage TherapistsAccupunctureChiropractors,What is Clinical Exer

10、cise Physiology?,The Registered Clinical Exercise Physiologist is an allied health professional who works with apparently healthy people and patients with chronic diseases and conditions where exercise has been proven to

11、 provide therapeutic benefit. The RCEP performs exercise assessments and prescribes exercise and physical activity, primarily in hospitals, clinics or other health-care provider settings. The RCEP assists individuals i

12、n developing self-management skills to promote good health. The RCEP is an integral part of the health care team and works closely with other health professionals including: Physicians, Nurses, Nurse Practitioners, Phy

13、sician Assistants, Respiratory Therapists, Physical Therapists and Registered Dietitians.RCEP’s are trained to work with patients with chronic diseases such as: Cardiovascular disease, pulmonary disease, diabetes, neu

14、romuscular disorders, musculoskeletal conditions, obesity, cancer, end stage renal disease, neoplastic / immunological / hematological disorders,CEP or PT?,Physical therapy, which is limited to the care and services prov

15、ided by or under the direction and supervision of a physical therapist, includes:,Aerobic capacity/endurance ,anthropometric characteristics , arousal, attention, and cognition, assistive and adaptive devices ,circulatio

16、n (arterial, venous, lymphatic), cranial and peripheral nerve integrity,environmental, home, and work (job/school/play) barriers, ergonomics and body mechanics, gait, locomotion, and balance, integumentary integrity ,joi

17、nt integrity and mobility, motor function (motor control and motor learning), muscle performance (including strength, power, and endurance), neuromotor development and sensory integration, orthotic, protective, and suppo

18、rtive devices , pain, posture, prosthetic requirements, range of motion (including muscle length), reflex integrity, self-care and home management (including activities of daily living and instrumental activities of dail

19、y living) , sensory integrity, ventilation, and respiration/gas exchange, work (job/school/play), community, leisure integration or reintegration (including instrumental activities of daily living),2. Alleviating impairm

20、ent and functional limitation by designing, implementing, and modifying therapeutic interventions that include, but are not limited to,Coordination, communication and documentation, patient/client-related instruction, th

21、erapeutic exercise, functional training in self-care and home management (including activities of daily living and instrumental activities of daily living), functional training in work (job/school/play) and community an

22、d leisure integration or reintegration activities (including instrumental activities of daily living, work hardening, and work conditioning), manual therapy techniques (including mobilization/manipulation) prescription,

23、 application, and, as appropriate, fabrication of devices and equipment (assistive, adaptive, orthotic, protective, supportive, and prosthetic), airwayclearance techniques, integumentary repair and protection techniques,

24、 electrotherapeutic modalities, physical agents and mechanical modalities,3. Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of health, wellness, fitness, an

25、d quality of  life in all age populations,4. Engaging in consultation, education, and research,Exercise and Death(Men),Exercise and Death (Women),What is the Best Way to Increase Physical Activity?,Monitored rehab

26、?Personal training?Case management?Doctor’s Advice / Guidance?Physical Therapy?Community Resources?Support Groups?Recreation Center Memberships?,Comprehensive Risk Factor Modification

27、 Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care,MI / ACS / PCI / CABGCase ManagerMonitored CRCEPCPCRS Dietician Cardiologist PCP Other

28、 Resources,,,,,,,,,Clinical Exercise Physiologist Role Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care,Clinical Exercise PhysiologistExercise Rx / Consult (One-on-One)Mon

29、itored Sub-Max Exercise TestingROM / Flexibility EvaluationStrength EvaluationBehavior Change CounselingMonitored Rehab Cardiologist PCP Other Resources,,,,,Functional Exercises,What is a functional exercise?E

30、xercise that is specific to and closely mimics task to be completed.Walking lunge better to strengthen muscles to assist in increasing efficiency of walking / running than leg extensions.,INDIVIDUALIZE!!!!!!!!!,Each pa

31、tient is a delicate snowflake!Make sure to get detailed history of disease, co-morbidities, check that risk factors are in control, prior exercise history, check for current symptoms and review support team and resou

32、rces for exercise,What is the Risk of Exercise?,Exercise Prescription Tips,CardiovascularMedications (HR and BP)Symptoms (CAD, CHF, PAD)F.I.T. Principle ConsiderationsImportance of Warm Up and Cool DownDo not ho

33、ld your breath!,When can they start?,Assuming Patient is Medically Stable:*All patients should start with slow progression of walking, stationary bike, etc.PCI without MI – exercise testing and more moderate exercise

34、after about 4 weeks of consistent low intensity aerobic exercise.MI with or without PCI – exercise testing and more moderate exercise after about 4-6 weeks of consistent low intensity aerobic exercise.CABG – exercise

35、 testing and more moderate aerobic exercise about 4 weeks post surgery, moderate strength training about 12 weeks post surgery.CHF – Asymptomatic patients increase aerobic exercise very conservatively as can tolerate,

36、if EF is below 30% strength training may be contraindicated.,Exercise Prescription TipsPeripheral Vascular Disease,ClaudicationWalking is a must – Specificity2 Most Important Measures1. Onset of symptoms2. Maximu

37、m walk timeIntermittent Walking to Moderate PainHigh Risk of Heart Disease (CAD)Add other modes of aerobic exercise to increase total conditioning time Role of Strength Training,Non-ClaudicantCan prescribe exerc

38、ise like people with heart disease / or at high risk for heart disease,,,Claudication and Strength Training,Hiatt WR, et al, Peripheral Arterial and Aortic Diseases: Superiority of Treadmill Walking Exercise Versus Stren

39、gth Training for Patients with Peripheral Arterial Disease: Implications for the Mechanism of the Training Response. Circulation; 90(4); October 1994; 1866-1874,Exercise Prescription TipsLung Disease,Perceived Exertio

40、n vs. Shortness of BreathReliability of HR?AerobicWalking – Part of most activities of daily living.Stationary BikeArm ErgometerImportance of Strength Conditioning1. Improve efficiency of muscles / conservation

41、 of energy,Exercise Prescription TipsDiabetes,Monitor Blood Sugar Before and After*>250 with Ketones, < 100*Post Exercise HypoglycemiaMeals and MedicationsAutonomic Neuropothy and HRPeripheral Neuropothy a

42、nd Wound Care,Exercise Prescription TipsDiabetes,Autonomic NeuropathySilent ischemia and infarction, tachycardia at rest and early in exercise, reduced max HR, exercise intolerance, exercise induced hypotension, thermo

43、regulatory dysfunction, prone to dehydration and hypoglycemia unawareness.Peripheral NeuropathyLoss of peripheral sensation, poor healing of wounds, overstretching can cause musculoskeletal injury, loss of balance, f

44、alling,Exercise Prescription TipsDiabetes,AerobicFrequency3-7 days per weekIntensity40-60% Moderate>60% VigorousTime> 150 minutes / week moderate> 90 minutes / week vigorousResistance Training Freq

45、uency> 3 days per weekIntensity8-10 repetitionsVolume of Exercise> 8 exercisesUp to 3 sets per exercise,Aerobic Exercise ModesChoose exercises such as stationary bike and eliptical trainers- help with bal

46、ance- less chance of fallingWalking also a good choice as involved in most activities of daily living –specificityResistance Training ModesMachine weights are preferred at start since they can help with balance,

47、Exercise Prescription TipsMultiple Sclerosis,Aerobic Exercise1. Perceptual Scale better for Exercise Intensity2. Adjust daily according to symptoms and energy levels3. Avoid exercise in heat, exercise early in day

48、 better for symptoms of fatigue4. Bladder issues can cause patients to not hydrate properlyStrength Training1. Optimize in unaffected muscle groups2. Functional exercises best, Emphasize core groups3. Increase

49、rest period time4. During times increased symptoms – focus stretching, ROM5. Weight machines preferred.,Exercise Prescription TipsParkinson’s Disease,AerobicSafety – walking is preferred, but may need to use bike erg

50、ometer, eliptical, arm ergometer or others if symptoms warrant.Balance devices – harness, walking polesStrengthWarm up importantFocus on exercises that extend the trunkFunctional exercises bestAuditory cues may be

51、needed to help with timing of repetitionsEnsure good posture,Exercise Prescription TipsOsteoarthritis,“Weight Bearing” Aerobic ExerciseContinuous weight bearing aerobic exercise can be difficultCareful with thos

52、e who have severe osteoporosisWater Walking against current may be a good optionExercises to improve balanceMinimize forward flexion and twisting movementsCan start with strength trainingCan do combination of

53、short bouts of aerobic training with strength training done during rest periods.,Exercise Prescription TipsRheumatoid Arthritis,Can follow same basic guidelines as with osteoarthritisAvoid exercise during “inflamatory

54、 phase”,Exercise Prescription TipsFibromyalgia,Must customize to individualCareful to avoid overexertionProgress slowly (water to land walking),Exercise Prescription TipsObesity,*Walking important as is involv

55、ed in most aspects of activities of daily livingIf balance is an issue then stationary bikes and eliptical trainers are good optionWater walking and water aerobics ideal for those with problematic jointsWatch carefu

56、lly for signs of cardiopulmonary and metabolic disease.,Exercise Prescription TipsObesity,Strength TrainingMachine weights may help with balance and help to ensure proper formLight weights recommended with moderate t

57、o high repetitionsMay be best option to concentrate on early as de-conditioning and joint issue may limit ability to perform aerobic exercise at onset of new program,Exercise Prescription TipsAIDS,HIVExercise Rx must

58、be adapted per stage of diseaseAsymptomatic – usual general ACSM guidelines are fineSymptomatic – need to adjust day to day, should not exercise with fever above 100, or if having nausea, vomiting, uncontrolled diarrhe

59、a or dehydration,Exercise Prescription TipsAIDS,Moderate better, overtraining increases likelihood of infectionsEnvironmentAbrasions, tissue injuriesCross infection, sharing of water bottlesOverseas travel,Exercise

60、 Prescription TipsAIDS,Exercise and SicknessCommon coldMild to moderate exercise OKIntense exercise OK a few days after symptoms resolveFever, extreme fatigue, muscle aches – best to wait 2-4 weeks before resuming i

61、ntense exercise,Exercise and Dialysis,Effects of Kidney Disease and Long Term Dialysisbone disease, fatigue, coronary artery disease and rhythm disturbances,Exercise and Dialysis,“Because of the reduction in cardiovascu

62、lar risk factors that results from exercise training, and because of the need to prevent progressive deconditioning, dialysis patients may actually be placed at a greater risk for cardiac events and adverse musculoskelet

63、al outcomes in the are not participating in regular physical activity”Adv Ren Repl Ther, Vol 6, No 2, 1999: pp 165-171,Exercise and Dialysis,Exercise and Dialysis,Exercise TipsBreathing is at conversational levelFeel

64、 complete recovery in one hour post exericseWarm up and cool down essentialExpect some mild soreness after exercise but not so much that it prevents activity.,When Not to ExerciseBody temperature >101.0 degrees (38

65、.3 degrees C)Missed more than one treatmentNewly undiagnosed illnessPainNot feeling wellBlood Pressure <200/100Unstable sugar levels,Exercise and Cancer,1. Follow the advice of Barbara Francis2. Be consistent

66、3. Have Sean Swarmer take you for a little hike in Nepal,References,ACSM’s Guidelines for Exercise Testing and Prescription, 7th EditionManual of Exercise Testing, 3rd Edition – Froelicher and MyersACSM’s Exercise Man

67、agement for Persons with Chronic Diseases and Disabilities, 2nd Edition – Durstine and MooreACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 5th EditionExercise and the Heart, 4th Edition, F

68、roelicher and MyersCardiac Rehabilitation, Adult Fitness, and Exercise Testing, 3rd Edition – Fardy and YanowitzNSCA’s Essentials of Strength Training and ConditioningClinical Exercise Physiology Application and Physi

69、ological Principles – LeMura and Von DuvillardACSM’s Resources for Clinical Exercise PhysiologyThe American Physical Therapy Association Book of Body Maintenance and Repair – Moffat and VickeryExercise Physiology Huma