EXERCISE PRESCRIPTION AND PROMOTION
It's been said that if the effects of exercise could be
packed into a pill, it would be the single most widely
prescribed, beneficial medicine in the nation. Scientific
data that supports this notion continues to mount. Thus,
when I travel across the country, I routinely ask groups of
physicians and other health-care professionals to think
about the last 25 prescriptions they have written and what
percentage were for some form of exercise. Predictably, the
number is lower than it could have been, and I ask the
groups why they don't recommend exercise more often a
medical remedy. Is it because their situations do not
warrant an exercise component to treatment, prevention, or
recovery? Or is it because we in the field of medicine have
a tendency to use the prescription pad in a more traditional
way, that is , to prescribe medication?
Unfortunately, I believe the latter is true. As we in the
medical community become more aware of exercise's myriad
positive effects, however, we will be more likely to include
it as a mainstay in our therapeutic resources-not just as an
afterthought.
FOCUS ON PREVENTION
In this era of health-care reform, any serious attempt to
control costs must urge individuals to take better care of
themselves, take more responsibility for their own health,
and must instill in health-care professionals the focus on
prevention as it relates to their patients.
The current reality is that only 3 percent of our almost
trillion-dollar health-care price tag actually goes toward
prevention services. This ratio may have been appropriate at
the turn of the century when we lived only into our 40s and
the major causes of death were tuberculosis, pneumonia, and
gastrointestinal infections. These infectious ailments were
essentially out of our control.
Things have changed considerably. More years have been added
to life in the past century than in the preceding 5,000
years. We now live to age 76 on the average (mid-80s in
Japan), and the all-too-well-known major causes of death
include heart disease, cancer, and stroke-each with strong
links to lifestyle.
To underscore the importance of prevention, in 1990 the U.S.
Public Health Service released "Healthy People 2000". This
document included 300 objectives for our nation's health for
the year 2000, with a strong emphasis on prevention. It's
akin to a repair manual for our nation's health woes
Exercise promotion is a cornerstone of this comprehensive
health promotion and disease prevention effort. The newest
national objectives, Healthy People 2010, continue to
emphasize this key role of exercise.
PHYSICIAN INVOLVEMENT
"Healthy People 2000 and 2010" objectives calls on
physicians and other health-care professionals to become
more involved in the promotion and prescription of exercise.
Currently, fewer than 30 percent actually discuss exercise
with their patients.
Physicians and other health-care-professionals must assume a
leadership role in this process. This need was evidenced by
two national surveys: the Prevention Index-89 and a study by
The President's Council on Physicial Fitness and Sports.
Both attempted to determine factors that would influence an
individual to become involved in a regular exercise program.
Patients reported the most influential factor to be their
doctor'' recommendation for exercise.
This is not a new concept. Hippocrates, called the Father of
Medicine, routinely prescribed exercise for patients who had
a wide variety of ailments. Scientific data substantiates
that Hippocrates was wise to emphasize exercise in the
course of his treatment. So why don't we prescribe exercise
more often? Why don't we turn to exercise as a remedy.
EXERCISE AS MEDICINE
We should be trained, even as medical students, to think of
exercise as a medicine. Dorland's Medical Dictionary defines
medicine as "any drug or remedy." Although the exact
relationship between exercise and disease has not been fully
defined, date continue to suggest enormous benefits when
exercise is used for health promotion and disease prevention
and treatment.
Like certain medications, exercise not only can be used to
prevent and treat many diseases, but regular exercise also
results in relatively predictable, specific changes in the
human body. These adaptations occur both centrally and
peripherally and include structural, hormonal, and
biochemical change. Also, as with medication, a does
response curve for exercise should be considered when
developing safe, sensible, and effective programs.
Current scientific work attempts to define optimal dose
ranges for a variety of exercise-related effects. It is
becoming more apparent that the quantity and quality of
exercise/activity levels required for certain health-related
outcomes may actually differ from what is needed for fitness
benefits. Interestingly, exercise has been linked to allergy
(exercise induced urticaria and exercise induced
anaphylaxis) and addiction (exercise addiction and
withdrawal) making the "exercise as medicine" concept even
stronger.
THE EXERCISE PRESCRIPTION
Once convinced of exercise's enormous role in the prevention
and treatment of many ailments, the next step is discovering
how to most effectively prescribe exercise. How much? How
often? And what type of exercise?
The ideal prescription should include a specific exercise
program for the individual based on his or her goals, health
and/or fitness needs, level of physical conditioning, and
past or present illness or injuries. It addresses the
frequency, intensity, and duration of exercise, as well as
the mode or type. It also adds advice for graduated
progression of the activity or activities. . Physicians also
need to be prepared to modify exercise programs and routines
for individuals with certain ailments. This is especially
true for those with musculoskeletal conditions such as
arthritis, tendonitis, back pain, osteoporosis, and other
bone and joint problems that limit ones ability to be
optimally active.
Although this can seem complicated, it's usually a simple
process. The key is to individualize the program and
identify activities the patient will enjoy and hopefully
continue for life.
Over the years, the American College of Sports Medicine (ACSM)
has provided excellent guidelines regarding exercise
prescription. Its 1978 position statement on exercise
focused on moderate to vigorous aerobic exercise as it
relates to fitness. In a 1990 update the ACSM refined its
aerobic exercise recommendations and added, as a major
objective, the development of muscular strength and
endurance. Thus, two cornerstones of any balanced adult
fitness program should include aerobic or cardiovascular
exercise and resistance or strength training.
More recent scientific data has confirmed significant
health-related benefits derived from exercise and activity
at levels lower than those recommended for fitness purposes
in the ACSM guidelines. These benefits, such as protection
against coronary artery disease, adult onset diabetes
mellitus, hypertension, certain cancers, and osteoporosis,
can be achieved with relatively moderate activity programs,
such as walking, cycling, or gardening. They can also add
years to your life, as well as life to your years.
Studies comparing three groups of individuals with different
activity levels (sedentary, moderate activity, vigorous
activity) have demonstrated reduced all-cause mortality
rates in the active groups versus the sedentary group. This
included lower death rates not only from heart disease, but
also from cancer, stroke, and all other causes of death. The
most dramatic improvement was apparent when comparing the
sedentary to the moderate activity group.
Because of studies like these, sedentary behavior has been
elevated to the status of major coronary risk factor equal,
in terms of potential damaging effects, to smoking, high
cholesterol, and hypertension. As a result, a new effort has
been focused on the almost 30 percent of our population that
is totally sedentary in an attempt to move them into the
moderate activity category.
In 1993, the ACSM, in conjunction with the Centers for
Disease Control and the President's Council on Physical
Fitness and Sports, recommended that every American adult
should accumulate 30 minutes per day or more of moderately
intense physical activity over the course of most days of
the week. The message is that you don't have to be an
Olympic athlete to reap the many health-related benefits
associated with exercise.
PROGRAM DESIGN: HEALTH PROTECTION VS. FITNESS
In recommending exercise or activity programs for patients,
it is useful to categorize the individual as sedentary or
active. This has practical applications for program design.
Also, consider the spectrum of activity levels as a
continuum from sedentary to activity to exercise to fitness.
If the individual is sedentary, my major emphasis is to
activate that person. In doing so, the new information on
moderate activity is helpful.
In the past, many were intimidated by vigorous exercise and
would drop out because of the difficulty in maintaining
high-intensity programs or because of orthopaedic ailments
that would arise. It is much easier to convince patients to
make minor adjustments in their lives and begin to increase
their activity levels.
This can be planned via exercise sessions or by initiating
daily routines: taking stairs at work, parking farther away
in the parking lot, or walking to the store. Individuals are
more likely to make these adjustments if they are reminded
on multiple occasions, if they include family or friends in
their program, if they keep an activity log, and if positive
support and feedback are provided. If you can move patients
to this level, you've done them a tremendous favor.
I see the activation phase as a hook. Once they are
activated, I have great success moving patients along the
activity continuum into more balanced exercise and fitness
programs, in which (in addition to the health protection
benefits) each patient can enjoy the benefits of a stronger,
more fit, functional body.
More comprehensive fitness programs are prescribed for those
already involved in exercise programs or, as noted above,
those who can be moved farther along in the fitness
continuum. Three basic components of a balanced fitness
program include cardiovascular or aerobic exercise, strength
training, and flexibility exercises.
AEROBIC EXERCISE
Aerobic exercise strengthens the most important muscle in
the body-the heart. Activities that can accomplish this
include walking, hiking, cycling, running, stairclimbing,
aerobic dance, and cross-country skiing. For a training
effect, exercise should be performed within a target heart
range and sustained at that level for at least 20 or 30
minutes, three times per week. Gradually increasing the
intensity and duration will increase he training effect.
Formulas are available for determining target heart rate.
Also, perceived exertion scales can be used. Aerobic
exercise improves cardiac function and because of its
metabolic effect with increased caloric consumption is
important in weight control and fat loss.
STRENGTH TRAINING
Exercise for muscular strength and endurance involves the
use of resistance exercise to build muscle tone and
strength. This can be accomplished with free weights and /or
machines.
Progressively overloading muscle tissue increases strength.
This structural response not only affects muscle but also
bone and surrounding ligaments and tendons.
Strength-training programs should include all major muscle
groups of the upper and lower extremities as well as torso
(lower back and abdomen).
Strength training is finally receiving the recognition it
has long deserved. Once only used by football players and
other select athletes, its indications have significantly
broadened. Strength training is equally important to men and
women. It has a vital role in strengthening bone tissue and
thus is useful in osteoporosis prevention and treatment.
Also, age is no barrier. Exercise is safe for children as
long as certain precautions are taken.
The greatest potential benefits of strength training may be
for the elderly. Studies have documented improved strength
and function- even in frail nursing-home residents age 90
and over. This effect is important as we try to maintain
functional independence in an aging population. Many of the
physiological changes we attribute to aging are, in large
part, due to inactivity rather than aging. These changes are
preventable and reversible to some degree. An active,
exercising 60-year-old can have better functional capacity
than an inactive 30-year-old couch potato. Exercise may be
the closest thing to the fountain of youth that we can find.
There are other resistance-training benefits. Strength
training is helpful in injury prevention, especially in
athletes. Also, increasing lean body tissue (muscle) helps
in weight and fat control. It should be an integral part of
any weight control or reduction program in conjunction with
aerobic exercise and dietary modifications.
FLEXIBILITY
Stretching improves muscles and joint flexibility. This will
reduce the likelihood of muscle strain and injury. Also,
stretching helps prevent muscle soreness sometimes
associated with exercise or activity. It also helps maintain
mobility and function in arthritic joints when used in
conjunction with range-of-motion exercises and
strengthening. Stretching should follow a brief aerobic-type
warm-up that will improve muscle elasticity.
Major muscle groups of the upper and lower extremities
should be stretched; typical adult problem areas include the
anterior shoulder, lower back, hamstrings, and calves.
Individuals are instructed to use a slow, static-type
stretch with no bouncy or ballistic movements. The stretch
should be held for 15 to 20 seconds. A slight pulling
sensation should be felt, but not pain. Repeat several times
and try to improve gradually with each session. Stretching
can safely be done every day.
BEFORE STARTING
Certain individuals need medical clearance and/or exercise
testing before initiating an exercise program. The ACSM has
issued excellent guidelines in this regard. Variables to
consider include the presence of risk factors or known
disease, the intended level of activity, and the age and sex
of the individual. Most healthy, previously sedentary people
can safely start a moderate activity program, such as
walking and stretching. The American Academy of Orthopaedic
Surgeons has developed sample exercise programs for the
increasingly large segment of our population with
musculoskeletal conditions. I believe that this concept of
modified exercise programs will become increasingly
important with our aging population, especially as it
relates to the musculoskeletal system. We have seen this
first hand the baby boom population, the first generation
ever to try to stay active (in droves) on an aging frame.
"Boomeritis" is a new term that describes the multitude of
musculoskeletal age and injury related problems and tissue
changes that have become very prevalent as the baby boomer
group has hit middle age. It is also very clear that these
issues span all generations, and as long as we continue to
live longer and rightfully stay active, we will need to find
strategies to contend with the vulnerabilities and
"weak-links" we pick up along the way. The future of fitness
and exercise prescription will need to adapt in this regard.
I can hardly think of anyone, including a person with a
variety of medical conditions, who would not benefit from a
well-designed, individualized exercise program. This
includes pregnant women, the elderly, and those with chronic
degenerative or handicapping conditions.
In the foreword of a book, "The Exercise Prescription",
Arnold Schwarzenegger, then chairman of the President's
Council on Physical Fitness and Sports, commented on his
vision for health-care providers in relation to exercise
prescription. He wrote, "My hope is that each time
physicians, regardless of their specialty, meet a patient, a
category of treatment in their mental checklist is exercise,
and a page of their prescription pad reflects this" With
effort we can reach this goal, and all of our patients will
reap the benefits.© Nicholas A. DiNubile, M.D. |
