Exercise Prescription

Evidence Based Approach to Exercise Prescription

All exercise prescriptions should follow the FITT (frequency, intensity, type, time) principles. This framework is the basics through which a clinician can prescribe exercise in a structured manner.
American College of Sports Medicine & National Strength and Conditioning Association recommend 3 principles when prescribing exercise:

1. Establish a routine
2. Increase the volume (gradually!)
3. Optimize the intensity

Contraindications which would require assessment/discussion with a physician prior to initiating exercise:

• Unstable/Uncontrolled asthma/copd/hypertension/cardiac disease/arrythmias
• Symptomatic valvular disease
• Severe musculoskeletal injury or other illness (fractures, infections, cauda equina syndrome, cancer resulting in bony metastatic spread with concern for fracture)
• Progressive proliferative retinopathy
• End-stage heart failure
• There are no true absolute contraindications to exercise! Exercise is a treatment modality that can be part of any chronic disease!

Special Considerations:
COPD:

• consider pulmonary rehab when patient is stable or following hospital admission. Patients should be aware how to manage symptoms during exercise.
• Consider indoor options for safety
  • This can include machines like Stairmaster or elliptical based on a patients comfort level and current fitness level
• Unstable cardiac disease may put patient at risk of acute cardiac event.
• Discuss how to implement O2 or inhalers while exercising w/ pulmonary rehab specialists
• Resistance training has been shown to improve function & quality of life in patients with chronic diseases
  • Caution with Valsalva manoeuvre (prolonged breath holding) due to risk of syncope

Asthma

• Ensure asthma is appropriately controlled
• Patient education around use of rescue inhalers (salbutamol)
• Be aware of environmental allergens that may exacerbate or worsen asthma

Hypertension:

• If uncontrolled or resting BP > 220/105 consult healthcare provider prior to initiating exercise
• Stop exercise if experiencing chest pain/palpitations/syncope/light headedness

Diabetes:

• Know how to manage your blood sugars
• Know symptoms of hypoglycemia – if low take 15 grams of carbohydrates
• If experiencing diabetic retinopathy, neuropathy, micro/macrovascular complications exercise selection may be needed to be modified

Osteoarthritis

• Be active when pain and stiffness are lowest
• If you have a flare of OA, do not cease all activity. Find modifications or continue with movements below the level that caused the flare.
• Discomfort with activity does not mean there is worsening damage in the joint
  • With time pain will begin to decrease especially for those who are sedentary
• May need to consider non-weight bearing aerobic exercise modalities (e.g. swimming or water based exercise)

Obesity

• Gradually increase activity level – e.g. 5 minute increments
• Non-weight bearing exercise to decrease orthopedic load – e.g. water based exercise
• Selection of modalities based on mobility, pain, and access (applies to all chronic diseases)

Pregnancy

• Physical activity during pregnancy is safe and beneficial
• 150minutes/week of moderate intensity is associated w/ decrease risk of gestational diabetes, hypertension, excess weight gain, or depression
• Activity can be started as early as the first trimester.
• Absolute Contraindications for physical activity in pregnancy
  • Placenta previa after 28 weeks
  • Premature labour
  • Preeclampsia
  • Ruptured membranes
  • Incompetent cervix
  • High order multiple pregnancy (triplets)
  • Intrauterine growth restriction
  • Uncontrolled type 1 diabetes
  • Uncontrolled thyroid/hypertension disease
• Stop Physical activity if & consult HCP if:
  • Persistent shortness of breath doesn’t resolve with rest
  • Severe chest pain
  • Regular painful uterine contractions
  • Vaginal bleeding
  • Loss of fluid from vagina indicating rupture of membranes
  • Persistent dizziness or faintness that doesn’t resolve with rest.

Aerobic Activity:

Benefits:

• Improved cardiorespiratory fitness
• Improved glycemic control
• Decrease in blood pressure
• Regulate weight/promote weight loss
• Improvements in metabolic health (increased HDL, decreased LDL/TG)
• Improvement in mood
• Potential for plaque stabilization & regression (improved endothelial function)

Canadian Society of Exercise Physiologists (CSEP) recommend one of the following for patients with chronic diseases:

• 150 minutes of moderate intensity (50-69% of HrMax) aerobic exercise 3-5x per week
• 75-90 minutes of vigorous intensity (70-89% HrMax) aerobic exercise 3-5x/week

All chronic disease have shown evidence to improve with aerobic exercise!

Resistance Training

Benefits:

• Improved muscular strength  improved functional capability
• Decrease rate of sarcopenia  decrease loss of functional decline
• Improved glycemic control
• Improved bone development – increased BMD
• Improved mood
• Weight loss or stabilization
• Reduction in musculoskeletal pain
• Potential improved glycemic control
• Decrease resting BP
• Improve HDL, decrease LDL/TG

CSEP recommends:

• Muscle and bone strengthening exercises using major muscle groups at least 2-3 days per week
• Consideration should be made to include balance exercises to prevent risk of falls
• E.g. moderate intensity 8-10 exercises, 2-4 sets of 8-10 repetitions per set.

Evidence for benefit is stronger for osteoarthritis, type 2 diabetes, & osteoporosis. There is a presumed benefit for all chronic disease however patient preference and comfort with resistance training must be taken into account.

See below for a strength training chart created by Dr. Matt Jordan (Canadian Sport Institute – Calgary) which reviews the various parameters to illicit specific changes with strength training. Although this is used for training athletes, the same principles can be used for individuals with chronic diseases by a healthcare professional with sufficient expertise in strength/resistance training.

www.jordanstrength.com

High Performance

Specific considerations need to be made when dealing with high performance athletes. Training volume, load, sport, meso/microcycles within their sport will have an impact on how training is adapted.

Periodization: this principle is critical for training adaptations for trained individuals (including high performance and highly active individuals). This revolves around planned periods of sequential overload to illicit training adaptations that are complementary to one another. This can involve increased or decreasing the various training parameters to illicit a training response. The ultimate goal being peak performance for a competition period.

Author: Dr. Sumeet Gill (May 14, 2020 – PRND)

References

American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, Fiatarone

Singh MA, Minson CT, Nigg CR, Salem GJ, Skinner JS. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009 Jul;41(7):1510-30. doi: 10.1249/MSS.0b013e3181a0c95c. PubMed PMID: 19516148.

Mottola, Michelle F.Davenport, Margie H.Ruchat, Stephanie-MayDavies, Gregory A.Poitras, VeronicaGray, CaseyJaramillo Garcia, AlejandraBarrowman, NickAdamo, Kristi B.Duggan, MaryBarakat, RubenChilibeck, PhilFleming, KarenForte, MilenaKorolnek, JillianNagpal, TaniyaSlater, LindaStirling, DeannaZehr, Lori. (2018). Canadian Guidelines for Physical Activity throughout pregnancy. Journal of Obstetrics and Gynaecology Canada , Volume 40, Issue 11, 1528 – 1537

Hoffmann TC, Maher CG, Briffa T, Sherrington C, Bennell K, Alison J, Singh MF,Glasziou PP. Prescribing exercise interventions for patients with chronic conditions. CMAJ. 2016 Apr 19;188(7):510-518. doi: 10.1503/cmaj.150684. Epub 2016 Mar 14. Review. PubMed PMID: 26976965; PubMed Central PMCID: PMC4835280.

Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep. 2012 Jul-Aug;11(4):209-16. doi:10.1249/JSR.0b013e31825dabb8. PubMed PMID: 22777332.

CSEP Position Statements on Physical Activity. https://www.csep.ca/view.asp?ccid=519.

www.exerciseismedicine.com

www.jordanstrength.com