Exercise is Medicine

Naomi R. Clancy, MD, FAAFP

Disclosure Statement

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

Learning Objectives

1. Compare the four major types of exercise recommended for older adults: flexibility, strengthening, aerobic, and balance

2. Develop physical activity plans for older adults with DJD/OA, using evidence-based recommendations and guidelines, aimed at promoting and maintaining health and physical independence

3. Provide strategies to address common barriers to prescribing physical activity

4. Discuss need for pre-participation (cardiac) screening

AES Question

Question 1

I meet the federally recommended guidelines for exercise:

A. Nearly all of the timeB. Most of the timeC. OccasionallyD. Almost neverE. What federally recommended guidelines?

AES Question

Question 2

The percentage of my older patients meeting the federally recommended guidelines for exercise is:

A. Almost allB. MostC. SomeD. Almost noneE. What federally recommended guidelines?

AES Question

Question 3

During visits with older adults with chronic medical conditions, I write an exercise prescription:

A. Nearly all of the timeB. Most of the timeC. OccasionallyD. NeverE. What’s an exercise prescription?

“The fountain of youth runs with sweat.”David E. Leiberman, MD, PhDExercised, 2020

Good news: % US older adults exercising increased over the last 15 yearsBad news: not enough older adults exercise.

Aerobic activity: >/=150 minutes (2 hours and 30

minutes)/week moderate-intensity, OR 75 minutes (1 hour and 15 minutes)/week

vigorous-intensity aerobic physical activity

Ages 65–74 years: 42.5% Ages 75-84: 30.9% Age ≥85 19.4%

Muscle strengthening: Moderate/high intensity muscle-

strengthening activities that involve all major muscle groups on ≥2 days per week.

Ages 65–74 years: 19.3% Ages 75-84: 14.6% Age ≥85: 10.4%

% of US Older Adults Meeting Federal Guidelines for Exercise 2015

Why is Exercise Important? Inactivity: modifiable risk factor for: Diabetes mellitus Cancer (colon and breast) Obesity Hypertension Bone and joint diseases (osteoporosis and osteoarthritis) Depression Death

Exercise More, Die Less Less death among the most physically fit: (Blair 1989)

21% less for women adjusted for chronic diseases 29% less for men

Finnish twin cohort (Kujala 1998): 33% decreased mortality for occasional exercisers 44% decrease for physically active (30 min brisk walking 6x/month)

Slower walking speed predictive of increased mortality Ostir 2007, Cesari 2005

Exercise More, Die Better 186% increased likelihood of dying without disability among

those most physically active vs sedentary individuals (ESPSE studies, Leveille 1999)

Fraility Syndrome Lowered activity level Poor exercise tolerance Loss of lean body and muscle mass Leads to: Weight loss Exhaustion Slowness Weakness

Increases risk for: Loss of functional independence Decrease in quality of life

Is Frailty “Natural”?Modern day older hunter-gatherers: walk over 10K steps/day into old age (2x > than older Americans) No decline in walking speed into their 70s VO2max: no decline in elderly women, mild decline in men

Exercise reduces frailty by: decreasing muscle inflammation, increasing anabolism increasing muscle protein synthesis through suppression of TNF-alpha

and IL-6.

Exercise in Frail Older Adults

Aerobic exercise builds endurance, improves peak O2 consumption by 10-15%Strengthening: prevents falls, improves strength by 100% Flexibility exercises improve and maintain joint range of

movement.Balance exercises reduce risk of fallsCombination exercise is good: 12 months of balance, strength, and endurance improved physical

performance (Pahor 2006) Reduces frailty and improves mobility (Cameron 2013)

Types of exercise

Aerobic

Swimming BikingWalking, jogging Climbing stairs, hiking Dancing Yard work Tennis Basketball

Strengthening

WeightsCarrying groceriesGripping ballsArm curls, overhead arm curlsWall pushups Lifting body weightResistance bands

Types of exercise

Flexibility

Stretching Tai ChiYoga

Balance

Tai ChiYogaStanding on 1 foot (on a

pillow if easy)Heel to toe walkBalance walk (bring knee to

chest and step forward)Standing from seated position

Balance Exercise: Fall risk reduction High challenge, high dose exercise (>/=3 hours/week) most effective Choose exercises that involve safely:

reducing the base of support (eg, standing with two legs close together, standing with one foot directly in front of the other, standing on one leg);

Moving the center of gravity and controlling body position while standing (eg, reaching, transferring body weight from one leg to another, stepping up onto a higher surface); and

Standing without using the arms for support, or if this is not possible then aim to reduce reliance on the upper limbs (eg, hold onto a surface with one hand rather than two, or one finger instead of the whole hand)

Walking training may be included, but high-risk individuals should not be prescribed brisk walking programs Ongoing participation in exercise is necessary or benefits will be lost Balance training can reduce falls in Parkinson's disease or cognitive

impairment Sherrington 2000, systematic review and meta-analysis

Writing an Exercise PrescriptionWhy? Systematic counseling improves rates of exercise in Family Medicine

patients (Pinto 2005, Sabti 2010) USPFTF: “Medium- and high-contact multi-session behavioral

counseling interventions to improve diet and increase physical activity…are effective in reducing CVD events, blood pressure, total cholesterol, and adiposity-related outcomes” (O’Connor 2020)

AES Question

Question 4

Most deconditioned/frail older patients require pre-participation screening prior to starting a formal exercise program:

A. TrueB. False

Who Needs Pre-Participation Screening?EASY tool for patients https://www.easyforyou.info/scr

eening-toolAmerican College of Sports

Medicine PAR-Q+: Physical Activity Readiness

Questionnaire for Everyone https://www.acsm.org/docs/defa

ult-source/files-for-resource-library/par-q-acsm.pdf

Writing an Exercise Prescription Ask about exercise Address worries/barriers. Empathize! Set goals important to the patient. When achieved, self-reward and set new goals Make it easy: incorporate more movement into daily life Make it fun:

What do they like to do? Make it social: groups, exercise buddy, family

Make it habitual: same time of day Break it up: 10 minutes 3x/day is as good as 30 minutes/day (Bhammar 2012) Prescribe individualized program:

First Step to Active Health: http://www.firststeptoactivehealth.com/providers/

Refer to community resources, PT for “one time visit for HEP” Follow up

How Much and How Often? 2018 Physical Activity Guideline for Americans, 2nd Edition (HHS):

Adults: At least 150-300 minutes moderate-intensity OR 75-150 minutes vigorous-

intensity aerobic physical activity/week OR an equivalent combination of moderate- and vigorous-intensity aerobic

activity AND muscle-strengthening activities on 2 or more days a week. Chronic conditions or disabilities: when able, follow the key guidelines for adults

and do both aerobic and muscle-strengthening activities. Older adults: multicomponent physical activity that includes balance training as well

as aerobic and muscle-strengthening activities

Moving more and sitting less will benefit nearly everyone Individuals performing the least physical activity benefit most by even modest

increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial.

How Much and How Often? ACSM (2000): a well-rounded physical activity program for older adults

includes: Moderate cardiorespiratory activities 30 minutes at least 4 days/week Strengthening activities at least 2 days/week Warm-up & cool down with each workout Incorporating balance activities into daily activities

www.exerciseismedicine.org

Individualized Exercise ProgramExample:

Senior Fitness Test (Fullerton Functional Test)Chair Stand Test - testing lower body strengthArm Curl Test - testing upper body strengthChair sit and Reach to toes Test - lower body flexibility testBack Scratch Test - upper body flexibility test 8 Foot Get Up and Go Test - agility testWalk Test (6 min) - used to assess aerobic endurance

Rikli and Jones 2001

https://www.dnbm.univr.it/documenti/OccorrenzaIns/matdid/matdid182478.pdf

Exercise Prescription Aerobic exercise:

Frequency Intensity Minutes/day Type Steps/day

Muscle strength training: Days/week Community resources How will you get started this week? https://www.exerciseismedicine.org/wp-content/uploads/2021/02/EIM-

Prescription-2018-e-form.pdf https://www.exerciseismedicine.org/wp-content/uploads/2021/04/EIM-

Community-Exercise-Resources_d2.pdf

http://www.firststeptoactivehealth.com/downloads/files/PHYSICAL_ACTIVITY_LOG.pdf

Community Based Exercise Programs

Overcoming Barriers Treat exercise as part of your therapy for (condition). Mark a big X on your calendar every time you

exercise, and try to make sure every day has an X. My (knee, hip, feet) won’t let me exercise:

A slow meander every day will help your joint pain over time. Have you tried (swimming, recumbent exercise bike, rowing machine, gardening)?

I fall too much: Start with bed exercises, chair exercises

I work too much: Exercise before work or during lunch break. Keep exercise clothes in the car and don’t let yourself go home until you’ve exercised.

I’m too tired: I almost guarantee you’ll feel better when you get done—at least for a while. Get an exercise buddy (social affect, responsibility)

I don’t have time: What time do you spend waiting around during the day? Can you go for a quick walk during that time? Make exercise a family activity

It’s too hot/cold Time exercise for nicer part of day Give local resources with air conditioning/heating

Individualized Exercise Program for the Very FrailACSM: Progressive resistance training: 2-3 days/week with 2-3 sets/day, while

standing (if possible) Strengthening & flexibility activities can be performed while sitting or in

a bed. Balance training should also be incorporated under supervision,

particularly for the very frail. Once the individual can tolerate weight bearing activity, moderate

intensity aerobic training can begin.

Physical Activity in Osteoarthritis

AES Question

Question 5

Significant amounts of exercise both cause osteoarthritis and worsen symptoms of osteoarthritis.

A. TrueB. False

OA: an Increasing Problem

2015 National Health Interview Survey: Estimated 54.4 million US adults (22.7% population) have been

dx’d with OA or report OA sx (Barbour 2017) Will increase to 78.4% (25.9%) projected US population by 2040

not accounting for increases in obesity adjusted estimate 92.1 million (Jafarzadeh 2017)

37% of individuals with osteoarthritis are inactive Those with OA and RA are already at greater risk for

sarcopenia due to higher levels of inflammatory cytokines

Does exercise cause OA? Running increased articular cartilage and GAGs in knee in dog

studies (Kiviranta 1988) Running decreased intra-articular pro-inflammatory cytokine

concentration in knees (Hyldahl 2016) No progression of radiographic knee OA in long distance runners vs

controls Worsening OA seen with higher initial BMI Initial radiographic damage Greater time from initial radiographs (Chakravarty 2008)

Increase in radiographic OA in endurance sports athletes, but no related increase in symptoms (Cymet 2006 review)

OA If physical activity caused

osteoarthritis, we would expect rates to go down with modern increase of sedentary lifestyles Instead, OA rates increasing over

time: Prehistoric knee OA: 8% Early industrials knee OA: 6% Postindustrial knee OA: 16% Latter 2 controlled for age, BMI, ethnicity

Individuals from the postindustrial group were, on average, 6 y older and had 41% higher BMIs than their early industrial counterparts

Age-related change in knee OA prevalence controlling for BMI, sex, and ethnicity. Shading represents 95% CIs. Wallace et al 2017

Exercise in Arthritis Regular exercise is good for: All types of arthritis Chronic pain, including chronic low back pain, fibromyalgia, and peripheral

neuropathy Exercise: Improves pain and function:

Community based exercise programs improve pain and function as well as NSAIDS and acetaminophen in OA, RA, and FM (Kelley 2011 meta-analysis)

Both land and water exercise improves pain and function with no increase of joint damage in RA (Hurkmans 2009 Cochran review)

Reduces inflammatory markers: (Hu 2021 meta-analysis, Ambrose 2016 review)

Improves mood, reduces risk of chronic disease including CVD, DM, etc Improves endothelial dysfunction in RA (Metsios 2014)

How does Exercise Help in Arthritis? Increases muscle production of IL-6

Trigger for increasing hepatic gluconeogenesis and lipolysis Increases production of anti-inflammatory cytokines Decreases production of TNF-alpha and IL-1

Contrast: macrophage production of IL-6 is triggered by TNF-alpha through activation of NF-KB, and induces synthesis acute phase proteins including CRP (pro-inflammatory)

Downregulates toll-like receptor 4 Less activation of pro-inflammatory cascades

Releases cortisol Inhibits cytokine production Induces apoptosis of leukocytes Represses pro-inflammatory genes

Increases vagal tone: attenuation of stress hormones

2019 American College of Rheumatology/Arthritis Foundation Guideline for the

Management of Osteoarthritis of the Hand, Hip, and Knee

InterventionJoint

Hand Knee HipExerciseBalance TrainingWeight LossSelf-efficacy and self-management programsTai ChiYoga

Strongly Recommended

Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the hand, knee and hip

No Recommendation Conditionally Recommended

What Kind of Exercise is Best for OA? The one the patient will do. Strengthening (starting at 30-50% maximum, increasing to 80%) Cardio (55-90% max heart rate , >/= 15 min/day) Balance training Neuromuscular (core strengthening, balance, resistance, and speed

training) Land based vs water based Weight bearing vs non-weight bearing

How often? At least 2x/wk for at least 4 weeks Improvements wane once exercise stops; continued encouragement

important

Weight loss in ArthritisWeight loss through diet and exercise in obese and overweight

adults improved: Self reported physical function Pain 6 min walk distance IL-6 levels

Increasing % weight loss improved outcomesDiet-only group lost weight but did not have reported

improvements in pain or functionMeissner, 2004, 2018

Exercise in Osteoarthritis Osteoarthritis Research Society International (OARSI): Exercise is the core treatment for OA and is recommended for all

patients.

https://www.nia.nih.gov/health/exercise-physical-activity https://www.nia.nih.gov/health/exercising-chronic-

conditions#arthritis

Exercise in Knee Osteoarthritis Improve joint stability:

Strengthen quadriceps and hamstrings https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?HwId=bo1534

Medial OA: Decrease loading in medial compartment by strengthening lateral muscle chain

Lateral OA: Decrease loading in lateral compartment by strengthening medial muscle chain

Patellofemoral OA: Decrease loading on lateral patellofemoral compartment by strengthening quadriceps and medial muscle chain

Genu flexum: Postural exercises in extension Passive and active stretching, terminal knee extension with stretchy band

https://www.healthline.com/health/osteoarthritis/easy-excercises-knee#easy-exercises https://www.versusarthritis.org/media/21787/kneepain-exercise-sheet.pdf. https://mydoctor.kaiserpermanente.org/ncal/Images/knee_arthritis_tips_exercises_tcm75-

555863_tcm75-1225428.pdf

Genu flexum

Exercise in Hip Osteoarthritis Improve joint stability: Strengthen hip stabilizers

Decrease loading on hip joint: Strengthen pelvi-trochanteric musculature

Decrease extension deficit: Postural exercises in extension

https://www.healthline.com/health/osteoarthritis/hip-exercises-treatment#strength-training https://mydoctor.kaiserpermanente.org/ncal/Images/hip_arthritis

_tips_exercises_tcm75-1225489.pdf

Exercise in Hand OAGeneral strengthening Range of motion esp. opening the first web Improve joint stability: Strengthen the lumbricals

https://www.healthline.com/health/osteoarthritis/arthritis-hand-exercises#treatments https://www.arthritisnsw.org.au/wp-

content/uploads/2019/02/Exercise-Sheets-Hands.pdf

Physician Resources Info for you: First Step to Active Health: http://www.firststeptoactivehealth.com/ ACSM: Exercise is Medicine: Healthcare Provider Resources LA County: Exercise for Adults Healthcare Provider Manual

http://file.lacounty.gov/SDSInter/dmh/216745_ExerciseforOlderAdultsHealthCareProviderManual.pdf

Handouts for your patients ACSM Videos, blogs, and patient handouts:

https://www.acsm.org/read-research/trending-topics-resource-pages/physical-activity-guidelines

Get Fit for Life: National Institute on Aging Packet on starting exercise: https://order.nia.nih.gov/publication/get-fit-for-life-exercise-physical-activity-for-

healthy-aging VersusArthritis:

Knee OA: https://www.versusarthritis.org/media/21787/kneepain-exercise-sheet.pdf Hip OA: https://www.versusarthritis.org/about-arthritis/exercising-with-

arthritis/exercises-for-healthy-joints/exercises-for-the-hips/ Hand OA: https://www.versusarthritis.org/about-arthritis/exercising-with-

arthritis/exercises-for-healthy-joints/exercises-for-the-fingers-hands-and-wrists/#hand-and-wrist-pain_exercises-for-hand-and-wrist-pain

Web Based and Video Patient Resources Easy for You: https://www.easyforyou.info/screening-tool

National Institute on Aging: videos and tips https://www.nia.nih.gov/health/four-types-exercise-can-improve-your-health-

and-physical-ability https://www.nia.nih.gov/health/staying-motivated-exercise-tips-older-adults

Healthline WebMD Arthritis Society: online learning modules Bob and Brad Physical Therapists: Youtube videos Knee OA: https://www.youtube.com/watch?v=T3qKHLP8fVo Hip OA: https://www.youtube.com/watch?v=6GzDzV1wBOs Hand OA: https://www.youtube.com/watch?v=vA9uT4OZ9e4

Other conditions of aging improved with exercise

Other conditions of aging improved with exercise

Women: Genitourinary symptoms of menopause, including dyspareunia Sexual arousal, orgasm and satisfaction in peri- and postmenopause

pelvic floor exercises improve both Aerobic exercise, yoga may improve sexual function Resistance exercise: No change

Carcelén-Fraile, systemic review and meta-analysis

Men: Erectile dysfunction:

Any exercise beneficial Moderate-vigorous aerobic exercise appears best

Silva et al 2017, systemic review and meta-analysis

Other conditions of aging improved with exercise

Sleep apnea Sleep apnea SX that may improve with TX:

Daytime somnolence Impaired decision making, response time CV: resistant hypertension, pulmonary hypertension, nocturnal ventricular asystole

and bradycardia, a. fib ?ACS, MI, CVA (prospective trials show reduction with TX, RCTs don’t) AM headaches Depression GERD OAB Nocturnal enuresis (increased ANP) Erectile dysfunction

Exercise improves OSA by 32% in absence of weight loss (Iftikhar 2014 meta-anal)

Obstructive Sleep Apnea and the Risk for Cardiovascular Disease, Kohli P et al, Current Atheroscler Rep 2011 Apr; 13(2): 138-146Hypoxia and hypercarbia cause oxidative stress and inflammation, increasing risk of atherosclerosis

Other conditions of aging improved with exercise

Memory loss Exercise prevents both Alzheimers and Parkinson’s dementia

(Hamer 2009) Exercise slows cognitive and physical deterioration (Forbes 2013)

Brain Derived Neurotropic Factor: stimulates and controls neurogenesis Increased levels in exercise GPLD1 protein secreted by liver: reduces inflammation, improves cognition

Administration improved cognition in sedentary aged mice (Horowitz 2020) Aerobic or resistance exercise good

Insomnia: both short and long term exercise as effective as insomnia Rx Improves sleep latency, sleep time, sleep efficiency

Light exposure vs endorphin/serotonin release vs improved circulation Evening exercise is ok! (Stutz et al 2018 meta-analysis)

But higher temp at bedtime associated with decreased sleep efficiency

Other conditions of aging improved with exercise

Depression Increases:

Dopamine Serotonin Norepinephrine Glutamate GABA Endorphines Endocannabinoids

Prescription: Effect seen in 4 wks, continue at least 10-12 weeks Aerobic: 50%–85% of HRmax. Resistance: a variety of upper and lower body exercises, 3 sets of 8 repetitions at

80% of maximum American Psychiatric Association Treatment Guidelines, 2013

Practice RecommendationsAll patients should participate in daily exercise to prevent loss of

muscle mass, loss of independence, and falls.An individualized exercise prescription can improve adherence to

exercise recommendations.Contrary to conventional wisdom, exercise improves symptoms of

osteoarthritis. The best kind of exercise is the kind the patient will do.

Answers

1. No correct answer2. No correct answer3. No correct answer4. B5. B