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Integrating Lifestyle Intervention into our Scope of Practice:

Conducting a fitness physicalArizona PT Association

Fall Meeting

October 6, 2017

Karen Mueller, PT, DPT, PhD

Objectives:

• Describe the impact of lifestyle factors on chronic disease prevalence

• Define the specialty of lifestyle medicine and its structure

• Outline the structure of a wellness physical

• Describe fitness measures for • Cardiorespiratory capacity

• Strength

• Flexibility

• Neuromotor performance

50% of Americans live with one or more chronic diseases (CDC, 2012)

5% of the population consume 49% of health care costs (DHHS, 2009)

99 cents of every Medicare dollar spent on chronic disease management (RWJ Foundation, 2010)

79 cents of every Medicaid dollar spent on chronic disease management (RWJ Foundation, 2010)

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Lifestyle factors are a major contributing factor to our most prevalent chronic diseases

Lifestyle Medicine (ACLM, 2012)

https://www.lifestylemedicine.org/What-is-Lifestyle-Medicine

Lifestyle medicine is an interdisciplinary approach to whole patient management

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National Physical Activity Guidelines

Children and Adolescents (ages 6-17)• 60+ minutes Daily

• Moderate/Vigorous aerobic activities *

• Muscle strengthening activities*

• Bone strengthening activities*

• *at least 3 days/week

Adults (ages 18-64)• Weekly:

• 150 minutes moderate intensity

• 75 minutes vigorous activity

• An equivalent combo of both

• Aerobics can be split into 10+ minute sessions

• Muscle strengthening 2/3 days a week (all major muscle groups)

National Physical Activity Guidelines

Older adults (age 65+)• Same as other adults unless

chronic conditions are present

• Be as physically active as conditions and abilities allow

• Modulate for fitness level

• Include activities to decrease fall risk

Persons with disabilities (all ages)• Same as age appropriate peers

based on conditions and abilities

• Work with health provider to determine what is safe and effective

Evidence on various exercise volumes: (ACSM position stand on recommended volumes of exercise, 2011)

• For Fitness: 500-800 cal/week

• For Glucose management in type 2 diabetes: 1000 cal/week

• Weight loss: 1500-2000 cal/week

• Cardio-protection and reversibility of disease: 2000cal/week

A 130-pound person, walking at a pace of 3.5 mph burns 160 to 180 calories per hour. A 200-pound person burns 240 calories per hour at that pace.

http://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/exercise/art-20050999?p=1

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Elements of Fitness

•Cardiorespiratory endurance

•Muscular Strength

• Flexibility

•Neuromotor performance

ACSM Guidelines for Strengthening

ACSM guidelines for stretching

• A minimum of 2-3 days a week; daily is most effective

• Stretch all major muscle groups 2-4 times

• Static stretch of 10-30 seconds; older adults may need 30-60 seconds

• Recommended after a warm up but before strengthening

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Neuromotor Exercise (ACSM, 2014)

• Practice of motor skills such as balance, coordination, gait, agility and proprioceptive training

•Results in improvements in all of these domains, and reduces fear of falling/fall risk in older adults

Neuromotor training (ACSM, 2014)

•Frequency: 2-3 days/week

•Optimal duration or number of reps has not been established; ACSM recommends 60 min a week (in 2-3 sessions)

How fit are we?

• Percent of US adults who met the Physical activity guidelines for aerobic physical activity

• Percent of adults who met guidelines for both strength and aerobic activity

• Percent of kids ages 6-11 who meet 60/min day activity guidelines

• Percent of teens who meet (ages 12-15) who meet 60 min/day activity guidelines

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Elements of a fitness physical

• Family history• Current medical history • Biometrics

• Height• Waist circumference• Weight/height ratio• Weight• Resting BP and HR

• Fitness Assessment• Cardiorespiratory• Strength• Flexibility• Neuromotor performance

Predictive value of family hx

• Diseases that occur at an earlier age than expected (10 to 20 years before most people get the disease)

• Disease in more than one close relative

• Disease that does not usually affect a certain gender (for example, breast cancer in a male)

• Condition that occurs widely among family members (multiple miscarriage, stillbirth, childhood death in more than one family)

• The presence of these might be indications for genetic testing

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Impact of Family History

• Study in Utah by (Williams et al., 2001 Am J Cardiology)

• Utah families with a positive family history of CHD represented only 14 % of the general population but accounted for 72 % of persons with early CHD (men under 55, women under 65).

• For strokes, 11 % of families with a family history accounted for 86% of early strokes (<75 years) and 68% of all strokes.

http://www.reynoldsriskscore.org/

Elements of a family history

• Should include three generations: grandparents, parents, siblings

• Family origin/racial background

• Health status, medical conditions and age of onset

• Age and cause of death of all deceased family members

• Pregnancy outcomes of family and genetic relatives

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Screening for Safe Participation in an Exercise Program• Determine need for physician clearance and

graded exercise testing (ACSM guidelines)

• Assess areas of disease risk that can be mitigated by appropriate exercise prescription (ie weight, HTN, waist to height ratio)

• Determine areas of physical performance that require targeted intervention, (weakness, poor endurance, low flexibility

ACSM Risk Stratification Questionnaire: PAR-Q

ACSM Risk Stratification Guidelines

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Basic Adult Fitness Assessment

•Height (inches): •Legs together, hands at sides, chin

tucked, look straight ahead •Weight (pounds)•Resting heartrate•Resting BP

Waist Circumference

NIH Protocol:Highest point of Iliac crest

Waist to Height Ratio is a Better Predictor of Visceral Adipose Tissue (VAT) mass and Whole-Body Fat Percentage (Swainson, 2017 PLosOne)

• BMI not accurate measure of body fat; errors for muscular and frail individuals

• WHtR: Waist Height Ratio= Height in inches /Waist in inches

• Risk for cardiovascular disease and diabetes increases after .50

• Whole body obesity cut off for men = .53 ; women= .54

• Optimal healthy ratio = between .4 and .5

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Tests for cardiorespiratory fitness

• 3 minute step test (all ages)

• 2 minute march test (adults 60 or older)

• Cooper 1.5 mile run test

3 Minute Step Test

• Start with resting pulse• 12 inch step (one foot up, followed by

foot; one foot down, followed by foot)• Use a metronome set at 96 beats/min

(24 step-ups/min)• Test runs for 3 minutes• Take pulse for full minute immediately

after three minutes• Score is your heart rate after three

minutes

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3 minute test results for men (YMCA)

3 minute test results for women

Cooper 1.5 Mile Walk/Run Test (2.4 km)

•Running and/or walking 1.5 miles on track or other firm surface

•Record time to complete

• Score is time to complete

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2 minute march test

Prepare target for march height: • Measure distance between ASIS and patella (i.e., 20 inches)• Divide by two for mid-femur height (10 inches)• Place tape on wall at mid-femur heightTo conduct test: • Count the times each knee hits the mid-femur point for 2

minutes (lower marches don’t count)• Score = total number of correct height steps

2 Minute March Test Norms

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Strength testing

•Pushup test: Healthy adults

•Grip strength (Healthy Adults)

•Chair stand (older adults)

•Arm Curl Test (older adults)

Push-up test

• Men test in plank position• Women test in bent knee position• Lower until elbows are at right

angles or touching another person’s fist, thumb up, at chest level

• Do as many as possible until exhaustion

Push up test norms

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Grip Strength

• Use of dynamometer

• Squeeze for 10-15 seconds

• Best of three trials

• A predictor of mortality (Leong et al, 2015; Lancet)• Every 5 kg decrease linked to 17% increase in cardiovascular mortality and

non-cardiovascular mortality

• Even more powerful a predictor of cardiovascular mortality than of incident cardiovascular disease

Grip Strength Test Norms

Arm Curl Test for older adults

• Patient is seated in a chair holding a weight (4lb for women, 8lb for men)

• Arm is held next to trunk to avoid substitution

• Beginning in extended position, arm is brought through full

• Range of flexion motion, ending with supination

• Score = number of full range repetitions in 30 seconds

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Chair stand test of LE strength

• Equipment: Chair with a seat height of 17 inches (regardless of subject height)

• Subject crosses arms in front of chest (not allowed to use arms or allow them to swing upwards)

• Subject is timed for 30 seconds while repeatedly coming from sit to stand. Bottom must touch seat each time

Chair Stand Test Norms

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Apley test for shoulder mobilityTest done bilaterally for comparison

Scoring (men and women)

Excellent: Fingers overlappingGood: Fingers touchingAverage: fingers less than 2 inches apartPoor: Fingers more than 2 inches apart

Test for Hamstring Length (SLR)

• Test person supine with non-tested leg in full extension, in contact with the floor

• Raise leg with knee in extension and ankle dorsiflexion

• Dowel or plumb line is placed next to medial malleolus and allowed to dangle vertically to floor.

Neuro-motor fitness: Sit and Rise (Arujo, 2012)

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Scoring

• 10 total points • 5 points for lowering

• 5 points for rising

Ability to sit and rise from the flooras a predictor of all-cause mortality (deBrito et al, European

Journal of Preventive Cardiology, 2014)

• SRT partial scores begin with a maximum of 5 points, separately for sitting and rising.

• One point is subtracted for each support utilized, that is, hand, forearm, knee, or side of leg

• .5 points deducted for loss of balance during either maneuver

• 10 is highest score

Three categories of exercise prescriptions

• Improve Fitness: May already be exercising, but need support to improve effectiveness of workouts. High in readiness and confidence, lower in competence

• Lowering Disease Risk: Persons who may not have exercised before, possibly not high in activation (vulnerable exercisers).

• Maximize Performance: Highly motivated in all areas, possibly training for athletic event.

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Improving Fitness

• Aerobic Activity (likely not intense or long enough)• Encourage exercise 3-5 times a week (dose dependent

gains)

• Exercise at 60-80% of MaxHR or 12-17 RPE

• Introduce interval training; 4 bouts of 30s at 80-90% MaxHR with 3-4 minutes in between (10 total minutes)

• Strengthening: (not likely intense enough)• Power: 8-12 reps at 60-80% 1RM

• Endurance: 15+ reps at 30-50% of 1RM

• Strength: : 1-5 reps with heavy loads (80-100% of 1RM)

Maximize Performance

• Moderate to vigorous intensity depending on performance goals

• Frequency and duration dependent on performance goals

• Primary goals: Prevent injuries and avoid training ceilings

• Accumulate 300 min/week of mod intensity, 150 min/week of vigorous intensity

• Strength train 2x week

• Tool for athletes: ACL play it safe (free)

• Tool for runners: McMillan calculator: https://www.mcmillanrunning.com/

Here’s to your health!!

Thank you!