锻炼和慢性病

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 exercise. 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,,Common Chronic Diseases,Cardiovascular disease Heart Attack, Stroke, PADPulmonary disease Asthma, COPD, EmphysemaDiabetes Neuropathies, CADNeuromuscular disorders Multiple Sclerosis,ParkinsonsMusculoskeletal conditions ArthritisCancer Breast, Prostate, LeukemiaRenal disease Kidney Failure, CADImmunological AIDSObesity All of the above?,Cardiovascular disease 79 million (2007 CDC Website) Pulmonary disease 35 million (2007 American Lung Association),Diabetes 14.6 Million (2005 CDC Website) Neuromuscular disorders (MS, 2.5 million national ms society / Parkinsons 1.5 million +, National Parkinson Foundation)Musculoskeletal 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 Cancer 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 FatImproved Weight ControlImproved BS ControlImproved StrengthLess FatigueImproved Balance,Heart DiseaseLung DiseaseDiabetesNeuromuscularMusculoskeletalObesityCancerKidney DiseaseAIDs,Who is Best to Care for These People?,Me!In an Ideal WorldClinical Exercise PhysiologistsPhysical TherapistsRespiratory TherapistsRegistered NursesPhysiciansPersonal TrainersMassage TherapistsAccupunctureChiropractors,What is Clinical Exercise 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 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 in 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, Physician Assistants, Respiratory Therapists, Physical Therapists and Registered Dietitians.RCEPs are trained to work with patients with chronic diseases such as: Cardiovascular disease, pulmonary disease, diabetes, neuromuscular 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 provided 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 ,circulation (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 ,joint 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 supportive 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 daily 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 impairment 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, therapeutic 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 and leisure integration or reintegration activities (including instrumental activities of daily living, work hardening, and work conditioning), manual therapy techniques (including mobilization/manipulation) prescription, application, and, as appropriate, fabrication of devices and equipment (assistive, adaptive, orthotic, protective, supportive, and prosthetic), airwayclearance techniques, integumentary repair and protection techniques, electrotherapeutic modalities, physical agents and mechanical modalities,3. Preventing injury, impairment, functional limitation, and disability, including the promotion and maintenance of health, wellness, fitness, and 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?Personal training?Case management?Doctors Advice / Guidance?Physical Therapy?Community Resources?Support Groups?Recreation Center Memberships?,Comprehensive Risk Factor Modification Kaiser Permanente Colorado Cardiac Rehabilitation Model of Integrated Delivery of Health Care,MI / ACS / PCI / CABGCase ManagerMonitored CRCEPCPCRS Dietician Cardiologist PCP Other 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)Monitored Sub-Max Exercise TestingROM / Flexibility EvaluationStrength EvaluationBehavior Change CounselingMonitored Rehab Cardiologist PCP Other Resources,Functional Exercises,What is a functional exercise?Exercise 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 patient 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 resources 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 hold 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 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 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, 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. Maximum 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 exercise 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 Strength 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 Exertion 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 of energy,Exercise Prescription TipsDiabetes,Monitor Blood Sugar Before and After*250 with Ketones, 60% VigorousTime 150 minutes / week moderate 90 minutes / week vigorousResistance Training Frequency 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 balance- 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,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 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 rest period time4. During times increased symptoms focus stretching, ROM5. Weight machines preferred.,Exercise Prescription TipsParkinsons Disease,AerobicSafety walking is preferred, but may need to use bike ergometer, 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 needed to help with timing of repetitionsEnsure good posture,Exercise Prescription TipsOsteoarthritis,“Weight Bearing” Aerobic ExerciseContinuous weight bearing aerobic exercise can be difficultCareful with those 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 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 phase”,Exercise Prescription TipsFibromyalgia,Must customize to individualCareful to avoid overexertionProgress slowly (water to land walking),Exercise Prescription TipsObesity,*Walking important as is involved 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 carefully 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 to 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 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 diarrhea or dehydration,Exercise Prescription TipsAIDS,Moderate better, overtraining increases likelihood of infectionsEnvironmentAbrasions, tissue injuriesCross infection, sharing of water bottlesOverseas travel,Exercise 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 intense 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 cardiovascular 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 musculoskeletal 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