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“Hey Doc, those exercises you suggested…….” ~ Ann Gates (@exerciseworks)

This post was originally published on the BJSM blog site. Used with permission.

Many diseases and long term health conditions respond clinically to exercise medicine. Just like medicines, such as statins, different exercises and physical activities have the ability to transform patient’s lives, control their symptoms and prevent and treat disease successfully.

Photo by inkknife_2000. Used with permission. All rights reserved. Source: flickr

Photo by inkknife_2000. Used with permission. All rights reserved. Source: flickr

The evidence for the clinical practice of ‘exercise as a medicine’ is supported by the UK Chief Medical Officers, the World Health Organization and many international medical organisations. However, it is ultimately prescribed and supported by the health care team that provides direct patient care.

For this reason, within medicine and health care settings we must encourage the perspective that exercise advice and support are critical aspects of ‘world class, personalised patient care’. Many patients may benefit from exercise advice as part of the management and treatment protocols for their diseases and lifestyles. This includes non-communicable diseases and acute problems, such as surgery.

The list of medical evidence supporting specific exercises and fun physical activities for improving quality of life and physical and mental health on personal, national and international levels includes: type 2 diabetes, cancer, heart disease, stroke, osteoporosis, Parkinson’s disease, hypertension, obesity, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), back pain, anxiety, depression, asthma, peripheral arterial disease, pre and post operative surgery…..

Many health professionals practice medicine because they love patient care and using their skills and knowledge to help patients improve their health. Providing quality exercise advice has a similarly clinically satisfying outcome. Patients can improve their mobility, experience life changing better health and more importantly see their symptoms improve and their risks of serious health problems diminish. This may be demonstrated through improved blood pressure control, better lipid profiles or just simply improved strength and balance that helps reduce falls risk.

A great, inspiring video shows how careful motivational support, together with the right exercise advice, at the right time, can transform patient health.

After all, when that patient says:

“Hey Doc, that exercise advice you suggested…….”

“It worked! I can now take my grandchildren to the park, and share in the joy of them growing up…”

“Well, that’s just fantastic!” replied the doctor. “Your blood pressure readings are down, I see you’ve lost weight, and management of your blood pressure is looking good.”

Because patients are worth that ‘brief intervention!”

Ann Gates is a Chronic Disease Exercise Specialist and Founder of “Exercise Works!” (@exerciseworks). Exercise Works! is dedicated to educating and supporting health professionals to understand the benefits and the ability to give constructive exercise advice to patients. They also produce a variety of products to help clinicians give safe and effective, brief intervention, exercise support to each patient consult. To learn more about Exercise Works! check out their website.

Video kindly provided with permissions via FitBehavior : promoting health through inspiring patient stories! @FitBehavior

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How can we get school children physically active? ~ Sigmund A Anderssen, PhD

Regular physical activity in school has the potential of improving health outcomes in children and youth, including overweight and obesity. Recent research shed light upon the opportunities and challenges of implementing physical activity interventions in schoolchildren.

Regular physical activity is necessary for normal growth and the development of cardio-respiratory endurance, muscle strength, flexibility, motor skills and agility.  In addition, regular physical activity has an impact on a range of health outcomes in children and youth 1 including overweight and obesity. Children are seen as a critical target group for public health efforts to prevent overweight and obesity.

Photo by Kris Krug. Used with permission. All rights reserved. Source: flickr

Photo by Kris Krug. Used with permission. All rights reserved. Source: flickr

Grydeland et al recently reported the effect of a 20-month school-based intervention on body composition outcomes 2. The intervention succeeded in increasing the overall physical activity among the participants and in particular among girls and low-active participants. Furthermore, the study demonstrated beneficial effects on BMI in girls.

These results on body composition outcomes are promising. However, no intervention effects were seen among boys or among participants of parents with lower levels of education. There appear to be some reasons why the impact was not better and did not reach boys.  Among them were that low cost and applicability in the public school system had high priority in the study by Grydeland, and the intervention components were primarily delivered through the school teachers and dependent on their devotion.

Even with ambitious goals for what activities the children should engage in, the impact depends on what the children actually do.  Just like when patients take their medications it works, if they do not, the treatment does not work. The challenge is to implement physical activity with strong enough impact.

From the literature 3-6 we know:

  • Children become less physically active as they approach adolescence and adulthood
  • Girls are generally less active than boys
  • Children that are physically active during childhood and adolescence are more likely to be physically active as adults
  • Learning different types of physical activities in childhood may help you dare join in activities later in life
  • Mandatory physical activity in school is not prioritized
  • There is no evidence that added physical activity to school curriculum by taking time from other subjects hinder academic performance

The school represents the only available arena where all children, irrespective of social background, can be reached continuously over a long period of time. Therefore we should urge the decision makers to prioritize physical activity at school and ensure that the PE teachers have enough competence. However, if this is just lip service and halfhearted whitewashing, the likely outcome is an increase in social inequalities rather than a reduction in them.

For more information on sports medicine and the younger athlete, turn to Chapter 42 in Clinical Sports Medicine.

Sigmund A Anderssen is Professor in Physical Activity and Health, and Department Head of Sports Medicine at the Norwegian School of Sport Sciences. His main research areas are physical fitness and physical activity surveillance and physical activity in relation to risk factors for diabetes and cardiovascular disease in both children and adults.

References:

  1. Strong WB, Malina RM, Blimkie CJ et al. Evidence based physical activity for school-age youth. J Pediatr 2005; 146:732-37.
  2. Grydeland M, Bjelland M, Anderssen SA, Klepp KI, Bergh IH, Andersen LF, Ommundsen Y, Lien N. Effects of a 20-month cluster randomised controlled school-based intervention trial on BMI of school-aged boys and girls: the HEIA study. Br J Sports Med. 2013 Apr 27. [Epub ahead of print]
  3. Kolle E, Steene-Johannessen J, Andersen LB, Anderssen SA. Objective measures of physical activity level and directly measured aerobic fitness in a population based sample of Norwegian 9- and 15-year olds. Scand J Med Sci Sports. 2010 Feb;20(1):e41-7. doi: 10.1111/j.1600-0838.2009.00892.x.
  4. Telama R, Yang X, Viikari J, et al. Physical activity from childhood to adulthood. A 21-year tracking study.  Am J Prev Med 2005;28:267–73.
  5. Ahamed Y, Macdonald H, Reed K, Naylor PJ, Liu-Ambrose T, McKay H. School-based physical activity does not compromise children’s academic performance. Med Sci Sports Exerc. 2007 39:371-6.
  6. François Trudeau F, Shephard RJ. Physical education, school physical activity, school sports and academic performance. Int J Behav Nutr Phys Act. 2008; 5: 10.
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How do I decide to treat? ~ Peter Brukner OAM, MBBS, FACSP

This post was originally published on the BJSM blog site. Used with permission.

The decision on how to treat a particular condition is sometimes very clear. For that particular condition e.g. a bacterial infection, there is a treatment e.g. specific antibiotic, that is simple, safe and effective in nearly every case.

In musculoskeletal (MSK) medicine, frequently it is not clear which is the best form of treatment. Let’s take tennis elbow as an example. Suggested treatments include anti-inflammatory medication, massage, strengthening, dry needling, corticosteroid or PRP injection, shock wave, surgery and probably a few others. How do I decide?

There are four main factors that I consider when I am deciding on a treatment.

The first is evidence-based medicine (EBM). We live in an era of evidence in medicine. However for various reasons, MSK medicine is generally lacking in evidence for many conditions. This is partly because it is a relatively new specialty, and secondly because most research trials are funded by drug companies and involve their particular drug.

Peter Brukner with Carling Cup 2012

Peter Brukner with Carling Cup 2012

There are minimal funding sources for non- pharmaceutical treatment trials. Anyone who has read Ben Goldacre’s book Big Pharma1 would be somewhat disillusioned about the role of the big pharmaceutical companies in drug research anyway.

The volume of EBM in MSK medicine is slowly growing, but it is probably safe to say that it lags behind other branches of medicine. The other reason why EBM is lacking in musculoskeletal medicine is the difficulty of the research. No two injuries are identical so large numbers are required. There are also fewer objective measures such as blood tests. MSK medicine relies on pain (notoriously unreliable) and various markers of function (range of motion, strength etc.) as outcome measures.

The quality of much of the evidence in MSK medicine while slowly improving is still relatively low. Good RCTs (Oxford Level 1) are rare and much of the evidence is case series (levels 3-4) or individual cases.

When dealing with high level athletes, sometimes it is not appropriate to make the same assumptions about their response to treatment as others. Some would argue that the elite athlete is a different physiological animal and therefore may respond differently to treatment.

There will never be good research evidence for treatment of elite athletes as the concept of a blinded placebo trial will not be tolerated by the elite athlete who is desperate to return to his or her sport as soon as possible.

The second factor that I use is personal experience. Obviously the longer you practice, the more exposure you have to each condition and the broader your experience is in treating that condition. Ultimately you will have seen the more common conditions many times, treated them in various ways and you will know what works or does not work, in your hands anyway.

The third factor that influences how I treat someone is expert opinion. That can be in the form of a textbook, a review or opinion article, a lecture or conference presentation from an expert in the field, or simply discussion with learned colleagues.  I am not shy in picking up the phone and calling a colleague who is more experienced in managing a particular condition. Nowadays with email, messaging and Skype it is nearly always possible to discuss with a colleague. Expert opinion is only Level 5 on the Oxford levels of evidence, but this does not diminish its importance.

The fourth and final factor is the patient’s choice2. The degree of patient involvement varies considerably from case to case.  In situations where there is a clear cut evidence-based expert opinion supported form of treatment then it is fair to firmly recommend the desired treatment. When the research is equivocal or non-existent and opinion divided, then it is reasonable to explain the different alternatives to the patient and invite their involvement in the decision making.

Elite athletes in particular will often be quite knowledgeable about their particular condition due to their own or their colleagues’ past experiences, and may also have been exposed to various folklore treatments common in their particular sport. When their careers could be affected by the choice of treatment then it is certainly reasonable for them to be heavily involved in the choice.

In most situations we use a combination of these four factors to decide on a particular treatment. In the ideal situation there is strong evidence for a particular form of treatment, you have had good experience with that treatment yourself, the experts advocate this treatment and the patient is keen to go ahead. Unfortunately that ideal scenario is the exception rather than the norm.

We must also be aware of our own biases3,4. This may be towards a treatment we enjoy doing (e.g. dry needling), it may be more highly remunerated (shockwave, injections, surgery) or one in which we have a research interest.

For those working with professional athletes and teams there will also be pressure from the athlete, coach, team owner etc to make a decision that maximises the chances of the athlete returning to play as soon as possible5. Sometimes this is not actually in the patient’s best interests6 and there are some startling stories for this paragraph but  not for public consumption. This pressure can be uncomfortable in any setting; it is particularly so when an official threatens that the doctor’s job is in jeopardy unless a certain decision is made. Irrespective of the pressure, it is imperative to remember that as physicians our first duty is to our patient.

Many of you will use the same approach and we recognise the appearance of three of these four factors in Sackett’s7 definition of evidence-based practice – “the integration of best research evidence with clinical expertise and patient values”.

Dr Peter Brukner is an experienced team physician and writing in his capacity as CSM co-author, BJSM Senior Associate Editor, and regular blogger. @PeterBrukner

References

  1. Goldacre B. Big Pharma. HarperCollins, London, 2012
  2. Quill TE, Holloway RG. Evidence, preferences, recommendations – finding the right balance of patient care. NEJM 2012;366(18):1653-5
  3. Kahneman D. Thinking, Fast and Slow Penguin, London 2012
  4. Kahneman D, Lovallo D, Sibony O. Before you make that big decision… Harv Bus Rev 2011;89(6):50-60
  5. Levy D, Delaney JS. A risk/tolerance approach to the pre-participation examination. Clin J Sport Med 2012;22(4):309-10
  6. Matheson GO, Shultz R, Bido J et al. Return-to-play decisions: are they the team physician’s responsibility? Clin  J Sport Med 2011; 21(1):25-30
  7. Sackett DI, Straus S, Richardson WM et al. Evidence-based medicine: how to practice and teach EBM. London. Churchill Livingstone. 1995
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Sit Less to Move More ~ Maureen Ashe, PhD

 Abundant evidence exists extolling the benefits of physical activity, and specifically to include more exercise into daily life. Despite this, ample data highlights that many people are inactive [1 2], sedentary, [3], and the group who are most at risk are older adults.

Fortunately, evidence suggests that health behaviours adopted earlier at midlife reduce the risk for developing chronic disease [4]. Prevention strategies to increase physical activity in middle-aged can result in downstream benefits across many domains such as increased fitness, enhanced social engagement, and a positive impact on quality of life.

The question remains: how do we implement sustainable solutions for people to uptake and adhere to a physically active lifestyle? One possible solution is to “re-engineer energy expenditure” [5] back into our lives through activities of daily living and utilitarian walking.

Photo by “AlmaGamil_Philippines”. Used with permission. All rights reserved. Source: flickr

Photo by “AlmaGamil_Philippines”. Used with permission. All rights reserved. Source: flickr

Recently the science [6] and epidemiology [7 8] of sedentary behaviour has emerged in the literature and mass media, challenging previous terminology used to denote someone who did not engage in physical activity. Historically people have used the words sedentary or inactive interchangeably. Guidelines published in 2012 by the Sedentary Behaviour Research Network [9] propose that inactivity is defined by an individual not meeting current recommendations for physical activity, ie, not meeting 150 minutes per week of moderate to vigorous physical activity (MVPA).

In contrast, sedentary behaviour refers to waking activities in a sitting or reclining posture, which are low in energy expenditure defined by less than or equal to 1.5 metabolic equivalent of task (MET) [9].

For some older adults, it may be insurmountable to tackle 150 minutes per week of MVPA at least in the beginning. In contrast, it may be easier to suggest that an activity program begins by simply sitting less throughout the day. If watching TV, have standing breaks during the commercials (or even reduce total TV time altogether!); wash the dishes by hand instead of loading up a dishwasher; and/or walking to the local mailbox or store.

A feasibility study by Gardiner and colleagues [10] highlighted that a brief behavioural intervention for older adults 65 years plus resulted in a three percent reduction in sitting time over a two-week period. An interesting detail of this study was that the sitting time reduction was replaced by a two percent increase in light activity and a one percent increase in MVPA.

Starting with reduced sitting time is a potential way towards increasing physical activity. The science of sedentary behaviour and physical activity, although distinct, still operate collectively when taking a full day approach to active living and health.

Recently, Robinson [11] coined the term “stealth intervention” to describe his behavioral programs designed to tackle the obesity epidemic. He posits interventions such as traditional dancing or raising awareness of food-related environmental issues provide positive health benefits, without actually setting the long-term goal of improving health. Does this make reducing sedentary behaviour a stealth intervention?

For older adults, and especially those with mobility challenges, a “Sit Less to Move More” strategy may be an optimal approach to slowly adopt physical activity, and especially exercise, as a way of life.

Maureen Ashe is an Assistant Professor in the Department of Family Practice at the University of British Columbia, and an investigator at the Centre for Hip Health & Mobility in Vancouver, Canada. Her research interests include investigating older adults’ physical activity and sedentary behaviour patterns and the influence on mobility. More recently, she expanded her focus to include the role of the built and social environments on older adults’ community participation.

References:

1. Troiano RP, Berrigan D, Dodd KW, et al. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40(1):181-8 doi: 10.1249/mss.0b013e31815a51b3[published Online First: Epub Date]|.

2. Ashe MC, Miller WC, Eng JJ, et al. Older adults, chronic disease and leisure-time physical activity. Gerontology 2009;55(1):64-72 doi: 10.1159/000141518[published Online First: Epub Date]|.

3. Matthews CE, Chen KY, Freedson PS, et al. Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am J Epidemiol 2008;167(7):875-81 doi: kwm390 [pii] 10.1093/aje/kwm390[published Online First: Epub Date]|.

4. Willis BL, Gao A, Leonard D, et al. Midlife fitness and the development of chronic conditions in later life. Arch Intern Med 2012;172(17):1333-40 doi: 10.1001/archinternmed.2012.3400[published Online First: Epub Date]|.

5. Stein J. Stay moving, not still. Exercise slows aging and makes us feel better. Los Angeles Times. Los Angeles, 2009.

6. Hamilton MT, Hamilton DG, Zderic TW. Exercise physiology versus inactivity physiology: an essential concept for understanding lipoprotein lipase regulation. Exerc Sport Sci Rev 2004;32(4):161-6 doi: 00003677-200410000-00007 [pii][published Online First: Epub Date]|.

7. Owen N, Bauman A, Brown W. Too much sitting: a novel and important predictor of chronic disease risk? BJSM 2009;43(2):81-3 doi: bjsm.2008.055269 [pii] 10.1136/bjsm.2008.055269[published Online First: Epub Date]|.

8. Proper KI, Singh AS, van Mechelen W, et al. Sedentary behaviors and health outcomes among adults: a systematic review of prospective studies. Am J Prev Med 2011;40(2):174-82 doi: 10.1016/j.amepre.2010.10.015[published Online First: Epub Date]|.

9. Sedentary Behaviour Research Network. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab 2012;37(3):540-2 doi: 10.1139/h2012-024[published Online First: Epub Date]|.

10. Gardiner PA, Eakin EG, Healy GN, et al. Feasibility of reducing older adults’ sedentary time. Am J Prev Med 2011;41(2):174-7 doi: 10.1016/j.amepre.2011.03.020[published Online First: Epub Date]|.

11. Robinson TN. Stealth interventions for obesity prevention and control: motivating behavior change. In: Dube L, Bechara A, Dagher A, et al., eds. Obesity Prevention: The Role of Brain and Society on Individual Behavior. New York, NY: Elsevier, 2010.

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Exercise training in children with asthma: avoid or encourage? ~ Maartje Willeboordse, MSc

A large amount of parents of children with exercise-related asthmatic complaints have doubts about the beneficial effects of exercise in asthmatic children. Approximately forty to ninety percent of children with asthma suffer from exercise-related shortness of breath.

Photo by "The owner". Used with permission. All rights reserved. Source: flickr

Photo by “The owner”. Used with permission. All rights reserved. Source: flickr

Despite asthma medication which can prevent exercise-induced bronchoconstriction (EIB), exercise-related symptoms often lead to avoidance of exercise. Conversely, exercise can improve physical fitness and it is often thought that exercise is beneficial for your lung function. A significant need exists for a complete overview of the effects of exercise training in this patient group.

Published online in the BJSM, a recent systematic review detected 29 studies which investigated the effects of exercise programs in children with asthma compared to asthmatic children who did not receive exercise programs. Despite the moderate quality of the studies, several conclusions can be made regarding important asthma outcomes.

Although it is common among asthma patients to think that exercise can improve their ‘lung function’, researchers hardly found any evidence for improvement in lung function parameters by training. On the other hand, EIB could slightly be improved by training. These exercise-related symptoms are thought to be caused by the increased volume of inhaled dry and cold air during training, which can cause airway bronchoconstriction and obstruction via several pathways.

Researchers measured the degree of EIB as the decrease in lung function after a submaximal exercise test such as cycling on an ergometer. The decrease in lung function after an exercise test was slightly smaller in children which completed an exercise training program, which implies that regular exercise training could be beneficial for exercise-related asthma symptoms.

A limited amount of studies also measured asthma-related outcome measures such as quality of life, school absenteeism, and symptom scores. Although evidence is scarce, most of the asthma-related outcomes were improved after training. In addition, asthmatic children were able to improve their cardiorespiratory fitness to the same extent as non-asthmatic children.

Most improvements of cardiorespiratory fitness were seen in studies with an exercise program with a minimum duration of three months, with at least two 60-minute training sessions per week, and a training intensity set at the personalised ventilatory threshold (which correspondents to approximately 80 percent of maximum heart rate).

It can be concluded that, if asthmatic children consequently use their prescribed medication, exercise training has overall beneficial effects in asthmatic children. Physical exercise can be considered safe and therefore should be recommended in children with asthma.

For more information  on how to manage asthma and other respiratory problems turn to chapter 50, Respiratory symptoms during exercise, in Clinical Sports Medicine.

Maartje Willeboordse is a PhD student at the Paediatric Pulmonology Department of the Academic Hospital in Maastricht. She studied the biology of human performance and her research focuses on the relationship between paediatric asthma and obesity and the role of lifestyle factors such as weight reduction and exercise.

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