Exercise Therapy for Chronic Diseases Instructor: Michael C. Riddell, Ph.D. 347 Bethune College (office) AS/SC KINE 4900 3.0

Why Do We Care? Canadian Fitness and Lifestyle Research Institute's Physical Activity Monitor

Physical Activity Statistics: 1986–2002 No Leisure-Time Physical Activity Trend Chart

Why Do we Care?

Relative Risks and Population Attributable Risks for Physical Inactivity Disease RR PAR (%) CHD 1.9 36 Stroke 1.4 20 Hypertension 1.4 20 Colon Cancer 1.4 20 Breast Cancer 1.2 11 Type 2 Diabetes 1.4 20 Osteoporosis 1.6 27 Katzmarzyk et al. CMAJ 2000;63:435-1440

Economic Costs of Physical Inactivity Cost Due To Disease Cost Inactivity CHD 2.5 0.9 Stroke 1.7 0.3 Hypertension 1.6 0.3 Colon Cancer 0.3 0.07 Breast Cancer 0.3 0.03 Type 2 Diabetes 0.6 0.1 Osteoporosis 1.3 0.4 TOTAL 2.1 Figures are $ billions. Katzmarzyk et al. CMAJ 2000;63:435-1440

Physical Inactivity-Related Mortality N Deaths Disease N Deaths Due to Inactivity CHD 44 061 15 774 Stroke 15 517 3 088 Colon Cancer 4 237 843 Breast Cancer 4 923 542 Diabetes 5 492 1 093 All Causes 207 408 21 340 (10.3%) Katzmarzyk et al. CMAJ 2000;63:435-1440

The cost estimates are direct costs: hospital services physician care drugs health research The indirect costs are larger: time off work loss of productivity

10% Change in Inactivity Reducing levels of physical inactivity from 62% to 56% would result in $150 million a year in savings Katzmarzyk et al. CMAJ 2000;63:435-1440

What Can Exercise Do? Regular physical activity can improve health and reduce the risk of premature death in the following ways:  Reduces the risk of developing coronary heart disease (CHD) and the risk of dying from CHD Reduces the risk of stroke Reduces the risk of having a second heart attack in people who have already had one heart attack Lowers both total blood cholesterol and triglycerides and increases high-density lipoproteins (HDL or the "good" cholesterol) Lowers the risk of developing high blood pressure Helps reduce blood pressure in people who already have hypertension Lowers the risk of developing non-insulin-dependent (type 2) diabetes mellitus Reduces the risk of developing colon cancer Helps people achieve and maintain a healthy body weight Reduces feelings of depression and anxiety Promotes psychological well-being and reduces feelings of stress Helps build and maintain healthy bones, muscles, and joints Helps older adults become stronger and better able to move about without falling or becoming excessively fatigued

“So, You Should Get More Exercise” Like saying “you should take some pills”. What is it about your condition that makes exercise valuable? What kind of exercise? What type of apparatus? For how long? At what intensity? What are the risks? What are the expected benefits?

Why This Course? There is a growing interest in the use of exercise for individuals with chronic disease This course provides the basic principles for exercise testing and exercise training (or programming) for these unique individuals. Advanced clinical exercise physiology jobs?

Ground rules Class participation is encouraged The only dumb questions are the ones you don’t ask From time to time you may be called upon to comment on … “What is the most important thing you learned in this lecture?” “What portion of the ‘lecture’ was most confusing?” “What question remains uppermost in your mind?” It would be nice if you got involved by… Bringing in newspaper clippings or journal articles to generate discussion in class Visiting a cardiac rehab clinic and report back Performing the “in class” group work

Can you explain this figure by using an example? Limited Exercise Deconditioning intolerance activity Disease process Endurance training

Core Components We will attempt to: Find and discuss clinical conditions that tend to have altered physiological responses to exercise Provide strategies for exercise testing Evaluate the typical exercise response Develop and illustrate rationales for exercise programming functional capacity reduce disease severity

Why Exercise Testing? Sample Case Study “58-year old man had been exposed to asbestos, sandblasting, and 35 years of cigarettes. He was not overweight and had no apparent disease. On questioning, he admitted to grinding chest pain, originating in the midback and radiating around the left chest into the substernal area. The pain, brought on when walking especially on cold days and was relieved in a few minutes by rest. He denied shortness of breath. He had no abnormal heart sounds and resting ECG was normal”

Sample Case Study Does this man have a disease that may be related to physical activity? Can exercise testing be useful to help determine the disease or the severity of the disease? Does physical inactivity contribute to the disease? Is exercise training (programming) useful as a form of treatment for this disease?

Historical Perspective A. Lavoissier (1784)- determined the energy cost of one legged exercise (respiratory exchange). Medically supervised exercise regimes introduced in the 1940s and 50s for war injuries and polio patients Now expanded to stroke, cardiac, pulmonary and metabolic patients.

Historical Perspective Cont’ Approximately 99% of all exercise physiology research has been published since 1960. Today- large number of medical rehabilitation facilities, health clubs, fitness centers, as well as sports medicine disciplines. Toronto Rehab Rouge Valley Health System The Cardiac Prevention and Rehabilitation Centre St. Michael's Hospital Cardiac Wellness and Rehabilitation Centre Trillium Health Centre http://www.cardiacrehabilitation.ca/rehab_centres.php

Link Between Research and Practice Objective data are available on the therapeutic role of exercise research vs practice The link is between the two is sometimes weak A number of “clubs” claim to be experts

Exercise Rehab Definition Definition of rehabilitation (DeLisa et al., 1998) - “Development of a person to the fullest physical, psychological, social, vocational, and educational potential, within his/her physiological or anatomic impairments and environmental limitations.” Cardiac rehabilitation “is the sum of activities required to ensure cardiac patients the best possible physical, mental, and social conditions so that they may, by their own efforts, regain a normal place in the community and lead an active, productive life” (WHO Expert Committee 1964)

Cardiac Rehabilitaiton Medical evaluation Education and support for risk factor modification nutrition Risk factor modification Risk factor stratification Exercise prescription Exercise programs smoking cessation Stress management Vocational counseling Cardiac Rehabilitaiton

Rehabilitation Programs Do they cure individuals of disease? What do you think? Exercise programming should be carefully assessed, medically approved, and regularly updated and tailored to the individual’s clinical state

Clinical Exercise Therapist Jobs Exercise Therapist and Personal Fitness and Lifestyle Consultant Health & Fitness Certified Exercise Physiologist ™ Canadian Society of Exercise Physiologists (www.csep.ca/) Registered Clinical Exercise Physiologist/Specialist American College of Sports Medicine (www.acsm.org) “…is an allied health professional who works in the application of exercise and physical activity for those clinical and pathological situations where it has been shown to provide therapeutic or functional benefit”

Other Professions That May Benefit From Information In the Course physicians researchers physical therapists occupational therapists recreational/sports therapists nurses exercise physiologists interested in clinical applications of exercise

Course Content Assessment techniques and Exercise Programming Emphasis is placed on the physiological assessment during, and adaptations to, exercise in clinical populations Assessment techniques and Exercise Programming Clinical sections: Cardiovascular Pulmonary Metabolic Immunological Neuromuscular

Course Objectives Cont. I want you to: 1) Understand the nature of adaptations to exercise and training 2) Develop a basic understanding of the pathophysiology of various clinical conditions 3) Develop a working knowledge of testing devices and procedures/protocols to evaluate functional capacity 4) Rationalize the matching of an exercise rehabilitative program to a clinical condition 5) Develop a knowledge of expected (realistic) outcomes