Regular Exercise even jonas INTRODUCTION First Thoughts Regular exercise provides many health benefits to those who engage in the activity(1-3). In addition to its direct benefits, regular exercise is an essential part of healthy weight management and any effective program to lose weight The broad public health implications of exercise therefore include its pivotal importance in dealing with the obesity epidemic (see Chapter 8 for mor details The following definitions apply to the commonly used term exercise Physical activity is "any body movement produced by skeletal muscles that results in a substantive increase over the resting energy expenditure Leisure-time physical activity is"an activity undertaken in the individual's discretionary time that leads to any substantial increase in the total daily energy ex penditure Excrcise is a form of leisure-time physical activity that is usually performed on a repeated basis over an extended period of time(exercise training with a specific external objective such as the improvement of fitness, physical performance, or health""(1) It is important to note that regularity, exercising on a repeated basis over an extended period of time, is included in the standard definition for exercise. Sessions, workouts and going to the gym are terms that are used interchangeably with regular exercise throughout this chapter ounseling The most recent U.S. Preventive Services Task Force (USPSTF) recommendation on counseling for regular exercise, issued in 2002(4) concluded that "there is insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity in adult patients. "More 148
CHAPTeR 6. REGULAR EXERCISE 149 recent controlled studies suggested that counseling for regular exercise in clinical practice may be effective in helping patients to become regular exercisers(5-7). Whether there is high-quality evidence to support exercise counseling in the primary care setting, patients may request advice on how to become more physically active. The goal of this chapter is to guide clinicians on how to provide exercise counseling to their otherwise healthy patients: the sedentary person who wants to exercise; the sedentary person who needs to exercise for risk factor modification and the exerciser who is looking for advice because of injury, burnout or a need for consultation and reinforcement. This chapter presents a practical guide, based on 20 years of experience in the field and an extensive lay literature, on how to effectively offer physical activity counseling. The approach presented in subsequent text therefore reflects an experience-based consensus on fostering leisure-time, health-promoting, regular exercise, for its own sake This chapter does not specifically address the role of regular exercise in either the treatment or management of diseases or pathologic conditions(such as hypertension), or rehabilitation, although many of the basic principles for helping any patient to become a regular exerciser would hold true BASIC CONCEPTS IN EXERCISE Epidemiology of Exercise Epidemiologic data show that regular exercise promotes general health while its lack, known variously as physical inactivity or sedentary lifestyle, increases the risk of a variety of diseases and negative health conditions. At the beginning of the chapter on Physical Activity and Fitness in Healthy People 2010(2)it is stated that Research has demonstrated that virtually all individuals will benefit from regular physical activity... Moderate physical activity can reduce substantially the risk of developing or dying from heart disease, diabetes, colon cancer, and high blood pressure. Physical activity may also protect against lower back pain and some other] forms of cancer(for example breast cancer). On average, physically active people outlive those who are inactive. Regular physical activity also helps to maintain the functional independence of older adults and enhances the quality of life for people of all ages. The 2004"Best Practices Statement"of the American College of S Medicine(ACSM)(8)states Physical activity offers one of the greatest opportunities for people to extend years of active independent life and reduce functional limitations a substantial body of scientific evidence indicates that regular
150 SECTION II. WHAT TO DO WITH THE INFORMATION hysical activity can bring dramatic health benefits to people of all ages and abilities, with these benefits extending over the life span... and improve the quality of life The position taken in both of these reports was shaped by four important developments that have taken place over the past half century(9). First, the biomedical community identifed and clearly described those aspects of physical fitness that are related to health. Second, the scientific knowledge base underlying the original hypothesis that regular physical activity benefits health became firmly established. Third, the epidemiology of physical activity and inactivity has been studied and described in increasing detail over the years. Fourth, it has been recognized that both moderate and intense physical activity benefit health A major challenge is how to use all of our knowledge and understanding to actually help patients become regular exercisers at a level that is both comfortable and useful to them. Sound clinical advice, provided i an appropriate way by clinicians, can help patients unleash their own motivational process to become regular exercisers There are no known clinical trials of different approaches to the"nuts and bolts"of regular leisure-time exercise Controlled research comparing the effectiveness of one particular leisure-time exercise program versus another n fostering an ongoing pattern of regular exercise would be difficult to design and very expensive to conduct On the other hand, there is research on various exercise programs used as therapeutic interventions for the treatment of specific diseases and disorders. Therapeutic exercise regimens(and there are many very useful ones)are beyond the scope of this chapter Exercise: Aerobic and nongerobic There are two types of regular exercise based on level of intensity: "aerobic"" and"nonaerobic. "Exercise is considered aerobic when it is intense enough to lead to a significant increase in muscle oxygen uptake Nonaerobic exercise is any physical activity above the normal resting state involving one or more major muscle groups that is sustained but not so intense as to cause a significant increase in muscle oxygen uptake (Anaerobic exercise is intense physical activity, necessarily of very short duration [usually measured in seconds], fueled by energy sources within the contracting muscles, without the use of inhaled oxygen, most often incurred in competitive sports. It is not a factor in regular exercise. The heart rate is a simple measure to distinguish aerobic exercise from nonaerobic exercise. The exercise is considered to be aerobic when the pulse reaches or exceeds a level of 60% of the theoretical maximum normal, age adjusted heart rate(220- the persons age;0.6(220-age. It is important to note that this commonly used formula roughly approximates the true degree of increased oxygen uptake by the muscles (10) and is more accurate
CHAPTER 6. REGULAR EXERCISE 151 for measuring the intensity of exercise in beginners than in conditioned athletes. Most regular exercisers do not routinely measure their heart rate during their workouts, relying instead on subjective measures, such as deep breathing and sweating, to know when they are in the zone. Patients who are subject to extreme tachycardia should take their pulse while exercising To assure that exercise intensity remains at a safe level, the pulse rate should remain below 85% of the person's theoretical maximum age-adjusted heart rate(220- age) Although the evidence to date shows that exercise must be aerobic for it to be beneficial in reducing long-term risk for coronary artery disease exercise at any level above the sedentary state is helpful for weight loss and for producing the mental benefits associated with regular physical activity. An even modest level of regular exercise frequency(1 or 2 hours per week at nonaerobic intensity) probably reduces mortality. Moderate intensity physical activity other than regular leisure-time exercise, the so-called lifestyle approach, may also be beneficial for improving health and reducing mortality. Objectives for Reqular Exercise Given the known benefits of regular exercise and the harmful consequences of a sedentary lifestyle, the objectives for the activity can be set out in a straightforward manner. Regardless of the accumulated data about the long term health benefits of regular exercise, most regular exercisers engage in the activity because of the immediate benefits of feeling good and feeling better about themselves. When counseling patients about regular exercise, it is very important to bear this in mind. most regular exercisers do not engage in the activity in order to reduce their risk for future disease Risk reduction does not motivate most nonexercisers to start exercising either, unless a negative health event such as a heart attack shocks them into appropriate action,or they are exercising to promote weight loss. When patients ask about the benefits of regular exercise, the clinician should stress the short-term gains feeling good, improved personal appearance, and increased self-esteem. The clinician should point out though that most but not all sedentary people who become regular exercisers experience these gains. Long-term benefits will also motivate some patients and should be noted. Risks of reqular Exercise in the otherwise healthy Patient Regular exercise has its risks as well as its benefits. Virtually all of the risks are preventable or modifiable. The most common risk of exercise is injury. There are three types of injuries: intrinsic, extrinsic, and overuse. Intrinsic injury is that caused by the nature of the activity or sport, for example, shin splints in running. Extrinsic injury is that caused by an external factor, for example, a cyclist hit by an automobile. Overuse injury results from exercising too far
152 SECTION|· WHAT T○DOW| TH THE|NF○ RMATION too fast, too frequently. The latter is the most common cause of injury in most of the activities and sports used for regular exercise, such as running, fast walking, cycling, and swimming Intrinsic injury can be prevented by the use of proper equipment and correct technique. The risk of extrinsic injury can be significantly diminished by taking certain, mainly common sense, safety precautions, such as always wearing a helmet and never wearing a radio headset while riding a bicycle Overuse injury can be prevented by choosing a sport along with a workout schedule that are suitable to the exerciser, and by maintaining moderation in distance, intensity, and speed. The risk of a variety of pathologic problems is increased when a previously sedentary person engages suddenly in intense exercise or when a regular exerciser suddenly increases exercise intensity Therefore moderation and gradual change, if changes are to be made, are as always, good counsel GETTING UNDERWAY Recommendation"versus"Prescription Many clinicians use the term exercise prescription when discussing regular exercise with their patients. The term hails from the disease and medical models and appeals to many clinicians, especially those new to using the intervention. Prescription, however, usually means telling a patient to do something for a limited period of time. Regular exercise is by its very nature voluntary. No one can be forced to do it. Regular exercise requires more than just the temporary extra expenditure of time required to establish most other positive lifestyle changes such as engaging in healthy eating, achieving weight loss, and ' stopping cigarette smoking. For example, all people spend time food shopping, cooking, and eating. After learning about what changes to make, healthy eating requires only that the time be spent differently. After undergoing smoking cessation unseling and quitting tobacco use, no extra time need be spent again, Inless relapse occurs. In contrast, regular exercise requires a permanent commitment of time that would be otherwise spent doing something else. Of course, the maintenance of any successful behavior change requires constant attention for the rest of one's life, to a greater or lesser extent. However, in order to be most effective in counseling their patients to become regula exercisers, clinicians need to recognize the ongoing time commitment that regular exercise requires Therefore, because of its special nature, exercise cannot be prescribed like a drug. Rather, the clinician is recommending the effort to become a regular exerciser. The clinicians goal should be to develop a respectful and supportive partnership with their patients, using advice and counseling to assist them
CHaPTeR6. REGULAR EXERCISE 153 in the decision-making process. The primary need is for the clinician to spend time with patients communicating about regular exercise, recognizing bstacles to success, and equipping patients with the tools to overcome them Risk Assessment The clinician should assess patient before recommending a regular exercise program. Some will need a full medical examination(see subsequent text). Many otherwise healthy patients will not. According to the USPSTF, neither a resting electrocardiogram nor an exercise stress test provides information helpful in reducing the risk of an adverse outcome from regular exercise among asymptomatic persons. Although the USPSTF does not endorse them, these tests may be clinically indicated for men older than 40 years with two or more risk factors for coronary artery disease other than sedentary lifestyle. Coronary artery disease risk factors include elevated serum cholesterol, history of cigarette smoking, hypertension, diabetes,or a family history of early-onset coronary artery disease Furthermore, the clinician should conduct a thorough clinical evaluation of patients for whom regular exercise presents a definite risk, before advising these patients to start exercising. These high-risk patients may have a history of one or more of the following diseases or conditions Previous myocardial infarction Exertional chest pain or pressure, or severe shortness of breath Pulmonary disease, especially chronic obstructive pulmonary disease Bone, joint or other musculoskeletal diseases or other limitations These conditions are not necessarily contraindications to regular exercise but each patient's risk must be assessed on an individual basis Patients for whom regular exercise presents a possible risk may have a history of one or more of the following di Iscascs or co Hypertension Cigarette smoking Elevated serum cholesterol Prescription medication used on a regular basis Abuse of drugs or alcohol Any other chronic illness, such as diabetes Family history of heart disease Overweight in excess of 20 lb Current sedentary lifestyle Regular exercise is very useful in the management of a number of these diseases and conditions (3). For example, regular physical activity has been shown to reduce the rate of progression of diabetes by more than 50%(11) In fact, regular exercise may be a pivotal force in changing the natural
154SECT|oN‖· WHAT TO DO W| TH THE|NF○RMAT|ON history of a number of disease processes and possibly even obviate the need for therapeutic interventions. As mentioned earlier, the presence of these diseases may well bccomc a motivational factor in convincing a nonexerciscr to get started. Regular exercise in high-risk patients is beyond the scope of this chapter. However, it is important to stress that in initiating exercise such patients must follow a slow, gradual, and careful regimen with close medical supervision COUNSELING Getting Started GOAL SETTING In most cases, the first subject to discuss with patients is goal setting: why is the patient thinking about regular exercise? It may be because the clinician suggested it, but virtually no one becomes and remains a regular exerciser simply because they are told to do so. To succeed, the patient must mobilize internal motivation. What goals does the patient want to achieve, and why? Specifically, does the patient want to become fit, lose weight, look better and feel better, reduce future risk of various diseases and conditions, or join a friend or family member in a race? In both starting and staying with a regular exercise program, it is very helpful if patients have a good grasp of just why they are doing it in the first place. The same list can be used in the process of motivational interviewing with patients who are not yet prepared to make health-promoting lifestyle changes. Chapter 5 provides additional information about motivational interviewing and also discusses the"stages of change""delineated in Prochaska's Transtheoretical Model: precontemplation, contemplation, Preparation, action, and maintenance(see pages 132-133). For patients currently in the precontemplation or contemplation stages of change, addressing the questions mentioned earlier may be helpful to patients in advancing to the next stage REALISM The clinician should counsel patients to set realistic goals and define success for themselves. a good formulation of this concept is to explore your limits and recognize your limitations. " Consider the example of endurance versus speed After some reasonable period of training, say 3-4 months, most people can improve endurance, but they may not be able to improve their speed. Speed is the product of speed-specific training plus natural ability. Many people will be able to train fairly easily for endurance, because for most people endurance is not simply the product of natural ability. On the other hand, because natural ability is such an important element in speed, many exercisers will not be able to improve their speed no matter how hard they try. Clinicians should stress
CHAPTER 6. REGULAR EXERCISE 155 this point to their patients in order to avoid frustration, injury, and quitting On the other hand, if patients are encouraged to explore their limits graduall and carefully, they may discover abilities they never knew they had INNER MOTIVATION As noted in Chapter 5, the literature regarding positive lifestyle and behavior change clearly shows that the only kind of motivation that works in the long run es from within. The patient says, I want to do this for me, because I want to look better, feel better, and feel better about myself, not for anyone else. In contrast, a patient who is externally motivated says, "I'm doing this to make my [spouse, boy/girl friend, children/parents, employer/coworkers] feel better, but I don't anticipate getting much out of it for me. External motivation almost invariably leads to guilt, anxiety, anger, frustration, and, quitting, and TAKING CONTROL Taking controlis an important concept to stress with patients. In this formulation, patients decide to engage in physical activity on a regular basis perhaps in a physical activity that they have never done before or even contemplated doing. Many people find that"taking control"of the process motivator, both in starting a regular exercise program and sticking wIhi ?a for themselves, thinking"yes I can, because yes, I can do this"is an important GRADUAL CHANGE Gradual change leads to permanent changes"is another basic element leading to success in becoming a regular exerciser, losing weight Chapter 8), and making other lifestyle changes. It is recommended the previously sedentary person should start with ordinary walking, normal pace, for 10 minutes or so, three times a week(see Table 6.1).A a couple of weeks, the patient can increase the length of each session. After several more weeks, the patient can increase the frequency of sessions and the speed with which the exercise is performed. The hardier soul may move hrough this program more quickly, but all should be counseled against going out for an hour, at full tilt at the beginning. " Too much, too soon"may lead to muscle pain, injury, and an increased likelihood of quitting. Once again, a gradual increase in time spent, distance covered, and speed are the proven formula for adherence GETTING STARTED: IT IS THE REGULAR, NOT THE EXERCISE Further, the clinician should recognize that, for most people, the first challenge of becoming a regular exerciser is the "regular, and not the exercise. Indeed for most people who are regular exercisers, the hard part remains the regular, not the exercise. Most people are aware that exercise is good for them and that they will feel better and increase their self-esteem
156 SECTION II. WHAT TO DO WITH THE INFORMATION TABLE 6.1 The Pace Walking Plan(Phase I: Introductory rogram) Do Week M w Th F ss Total Comments Off 10 Off 10 Off Off 10 30 Ordinary walking 2 Off 10 Off 10 Off Off 1030Ordinary walking 3 Off 20 Off 20 Off Off 20 60 Ordinary walking 4 Off 20 Off 20 Off Off 20-60 Ordinary walking 5 Off 20 Off 20 OffOff 20 60 Fast walking 6 Off 20 Off 20 OffOff 2060 Fast walking 7 Off 20 Off 20 Off Off 30 70 Fast walking 8 Off 20 Off 20 OffOff 30 70 Fast walking 9 Off 20 Off 20 Off Off 20 60 Pace walking 10 Off 20 Off 20 OffOff [30170 Pace walking Off 20 Off 30 Off Off 30 80 Pace walking 12 Off 20 Off 30 OffOff 3080 Pace walking 13 Off 30 Off 30 Off Off 3090Pace walking Times in minutes. if they begin exercising. Despite these positive reinforcements, most people have busy schedules and other demands that make it difficult for them to make room in their lives for exercise on a regular basis The correct first step for many patients who are motivated to start exercis- ing is to discover that they can indeed find and make the time in their lives for exercise on a regular basis. They should define success for themselves by set ting reasonable goals, recognizing that change will not occur overnight, and placing themselves in control of the process. For most people, the focus of the first 2-4 weeks of an exercise program (Table 6.1)should include making the time to exercise and walking instead of learning a new sport or athletic activity Patients who live in poor neighborhoods or who have limited resources face special challenges in becoming physically active. They often lack a con- ducive and convenient place in their built environment or safe surroundings to engage in regular exercise of the type discussed here. Researchers and urban planners are beginning to deal with this important issue Duration and frequency y The original regular exercise recommendation of the acsm dates back to the early 1980s and stated that in order for exercise to have a health benefit, it
CHaPTeR 6. REGULAR EXERCISE 157 should be performed continuously for a minimum of 20-60 minutes at least hree times per week. As of 2005, the ACSM recommendation was to exercise for 30-60 minutes (including warm-up and cooldown) three to five times per week(12). This recommendation assumes that the exercise will be done at least at the lower end of the aerobic level of intensity. Some guidelines encourage even greater duration for daily exercise(e.g, 60 or more minutes).However they are problematic in terms of patient adherence and the heightened risk of overuse injuries. In the tables for regular exercise schedules presented in this chapter(Tables 6.1-6.4), the recommended duration and periodicity are also based on the assumption that the exercise will be done at the aerobic level of Intensity. As previously noted, since the early 1990s it has been recognized that physical activity, even at a moderate level of intensity can also be beneficial to health. The Centers for Disease Control and Prevention(CDC) and he ACSM(13)recommended that, for persons not engaging in regular aerobic exercise at the ACSm standard, an accumulated 30 minutes dail of moderate-intensity physical activity(below the aerobic level) should be performed on as many days of the week as possible. The so-called lifestyle TABLE 6.2 The Pace Walking Plan( Phase I: Developmental Program) Week W ThF Total Off Off Off Off Off Off Off Off Off 20 Off 20 Off Off20 Off 0OH20o2020 O20O20Or2030 90 0/20or30of203010 Off 20 Off 30 Off 20 110 Off O30O3030 120 Off 30Off 130 9or30o40of3040140 10 Off30Off Off 15 O40O30O30 160 Off 40 Off30 ff4060 oHf30of40or5060180 Times in minutes
