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Changes in perceived exertion

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Changes in perceived exertion Powered By Docstoc
					 Effective Physical Activity
for Cardiovascular Disease
         Prevention
    Jeremy Pomeroy MS, RCEP
          Past Experience
• Physical activity programs in Gila River
  – Diabetes secondary and tertiary
    prevention
  – Diabetes primary prevention
  – Medical fitness programs
   Gila River Physical Activity
            Programs
• Hospital-based at a medical fitness
  center
  – Facility with specialized equipment and
    staff to provide safe and effective physical
    activity programs to individuals with a
    variety of medical conditions
• Community-based
  – Trained CHRs met with participants at
    locations throughout the community
    • Including homes
   Gila River Physical Activity
            Programs
• Goals
  – Increase / maintain quality of life
    • Reduce incidence of diabetes
    • Reduce incidence of diabetes complications
    • Increase / maintain physical function
   Gila River Physical Activity
            Programs
• Outcomes
 – Primary prevention
   • participants with NGT and IGT lost significant
     amounts of weight
   Gila River Physical Activity
            Programs
• Outcomes
 – Primary prevention
   • participants with NGT and IGT lost significant
     amounts of weight
 – Secondary prevention
   • Average HbA1c reduction was 2.1%
      – Baseline 8.6%, follow up 6.5%
      – >95% of long-term participants maintain HbA1c
        ≤7.0%
       Glycemic control for individuals with type 2
   diabetes participating in GRHCC’s physical activity
                        programs
        9.5
          9
        8.5
          8
        7.5
HbA1c




          7
        6.5                                                 Intervention HbA1c
          6
        5.5
          5
        4.5
          4
                 e




                                     12



                                              15



                                                       18
                      3



                             6
                 in
              el
         as
        B




                      Time (months of participation)
Glycemic control and body mass for individuals with type 2
    diabetes participating in GRHCC’s physical activity
                         programs

         9                                            44
        8.5                                           43
                                                      42
         8
                                                      41
        7.5                                           40
         7
HbA1c




                                                      39




                                                           BMI
        6.5                                           38
                                                                 Intervention HbA1c
          6                                           37
                                                      36         Intervention BMI
        5.5
                                                      35
         5
                                                      34
        4.5                                           33
         4                                            32
                    3


                            6


                                   12


                                          15


                                                 18
               e
               in
            el
         as
        B




                    Time (months of participation)
   Gila River Physical Activity
            Programs
• Outcomes
 – Diabetes related complications
    • 1 new complication for long term participants
 – Quality of life
    • Dramatic increases for nearly all participants
   Gila River Physical Activity
            Programs
• Average exercise frequency, intensity,
  and type
  – Individuals with diabetes exercised on
    average for 45 min/wk at low-moderate
    intensity using a combination of
    cardiorespiratory exercise and resistance
    exercise
         Process
Define the goal, design the plan
 to achieve the goal, evaluate,
            modify
           Define the goal
• Increase energy expenditure?
  – Any activity above resting
  – Cumulative effect
• Increase fitness?
  – Fitness is a physiologic adaptation to
    stress
  – Requires moderate intensity and moderate
    frequency
           Define the Goal
• Weight loss?
  – Individuals can use physical activity to
    achieve weight loss without any changes
    in fitness
• Reduce diabetes-related risk factors?
  – Improvements in HbA1c have been shown
    at levels of physical activity that are not
    sufficient to improve fitness or promote
    weight loss
 Glycemic control and body mass for individuals with
  type 2 diabetes participating in GRHCC’s physical
                  activity programs

         9                                            44
        8.5                                           43
                                                      42
         8
                                                      41
        7.5                                           40
         7
HbA1c




                                                      39




                                                           BMI
        6.5                                           38
                                                                 Intervention HbA1c
          6                                           37
                                                      36         Intervention BMI
        5.5
                                                      35
         5
                                                      34
        4.5                                           33
         4                                            32
                    3


                            6


                                   12


                                          15


                                                 18
               e
               in
            el
         as
        B




                    Time (months of participation)
Process
Design the plan
         Exercise and Risk
• Cardiovascular events
  – Largely related to intensity
    • As intensity increases so does risk
                  Intensity Curve
           20
           18
           16
           14
     RPE




                                                      RPE
           12
           10
           8
           6
                10min 20min 30min 40min 50min 60min
                               Time


• As time increases so does relative intensity
  even at the same absolute intensity
           Upper limit for safety
      20
      18
      16
      14
RPE




                                                 RPE
      12
      10
      8
      6
           10min 20min 30min 40min 50min 60min
                          Time
      Conservative upper limit for
                safety
      20
      18
      16
      14
RPE




                                                 RPE
      12
      10
      8
      6
           10min 20min 30min 40min 50min 60min
                          Time
         Exercise and Risk
• Cardiovascular events
  – Largely related to intensity
    • As intensity increases so does risk
• Other adverse events
  – Dehydration
  – Falls
  – Blisters / ulcers
  – Overuse injuries
             Minimize risk
• Participants with peripheral neuropathy
  – Don’t recommend walking long distances
    for exercise
    • +30 min
  – Instruct in appropriate foot care
• Participants with osteoarthritis
  – Pain free range of motion
  – If OA is in knees instruct in low weight
    bearing activities
             Minimize risk
• ESRD / HTN
  – Avoid activities that greatly increase blood
    pressure
    • Heavy weight lifting
    • High intensity cardiorespiratory exercise
  – Do encourage resistance exercise
    • Low weight moderate repetition
    • Maintain lean tissue
   Process
Facilitate utilization
       Change Theories
• Transtheoretical Model
• Health Belief Model
• Self Determination Theory
    Transtheoretical Model
             Stage of Change Theory

• 5 Stages
  – Precontemplation
  – Contemplation
  – Preparation
  – Action
  – Maintenance
     Transtheoretical Model
• Role in promoting health behavior
  – Target education to participant’s stage of
    change
    • Attempts to increase awareness appropriate
      for individuals in precontemplation stage
    • Strategies to reduce environmental barriers
      appropriate for individuals in action stage
  – Also useful for designing interventions to
    target subsets of a population
       Health Belief Model
• Perceived susceptibility
• Perceived seriousness
• Perceived benefits of adopting new
  behavior
• Barriers to adopting behavior
• Cues to action
    Successfully adopting new
           behaviors
• Desire to change behavior
• Belief that new behavior will result in
  desired outcome
• Belief that new behavior can be
  accomplished
  Self-Determination Theory
• Focus is on extent that behavior is
  adopted volitionally
  – Classifies motivation as ranging on a
    continuum from lack of motivation
    (amotivation) to intrinsic motivation
   Self-Determination Continuum
Behavior     Non self-determined                                 Self-determined




Motivation   Amotivation                   Extrinsic                      Intrinsic




Regulatory   Non-          External Introjected Identified Integrated     Intrinsic
Styles       Regulation

Regulatory   Lack of       Compliance                   Congruence
Processes    Control                                                    Enjoyment
   Self-Determination Continuum
Behavior     Non self-determined                                 Self-determined




Motivation   Amotivation                   Extrinsic                      Intrinsic




Regulatory   Non-          External Introjected Identified Integrated     Intrinsic
Styles       Regulation

Regulatory   Lack of       Compliance                   Congruence
Processes    Control                                                    Enjoyment
   Self-Determination Continuum
Behavior     Non self-determined                                 Self-determined




Motivation   Amotivation                   Extrinsic                      Intrinsic




Regulatory   Non-          External Introjected Identified Integrated     Intrinsic
Styles       Regulation

Regulatory   Lack of       Compliance                   Congruence
Processes    Control                                                    Enjoyment
Promoting Integrated Regulation

• Recognize the participant as a
  physically active person
• Link the behavior to the desired
  outcomes
  – Feeling good because of exercise
     Increasing the chance of
             success
• Provide a full spectrum of social
  support
  – Emotional support (concern)
  – Esteem support (encouragement)
  – Informational support (education)
  – Network support (sense of belonging)
Reducing psychological barriers

• Empowerment
  – Focus on helping the client to understand
    their own power to create self-change
• Self-efficacy
  – People estimate the chance of future
    success on past performance so make
    sure initial experiences are successful
     Increasing the chance of
             success
• Acknowledge barriers
  – Show empathy
  – Don’t start off by offering advice to
    overcome barrier
    • If it was that easy the client probably would
      have thought of it
    • Work with the client to teach the skills to
      overcome barriers
    Maximize effectiveness
• Resistance training
  – Muscle weakness often the most
    significant limitation to functional capacity
  – Can be done a variety of ways in a variety
    of settings
    • Machines
    • Resistive bands / tubing
    • Body weight
     Maximize effectiveness
• Encourage lifestyle activity
  – Parking at the far end of the lot
  – Walking instead of driving
  – Gardening
• Every bit helps and focus on that
  instead of “not enough”
       Equivalence of lifestyle physical activity versus
                   programmed exercise
                               Treatment
                                 Phase        Maintenance Phase
                      0
Weight Change (kg)




                                                Diet + programmed activity
                      -2
                                                Diet + lifestyle activity
                      -4

                      -6
                                                                                 P=0.06
                      -8

                     -10
                           0      8    16     28    36      44    52        60   68
                                            Time (months)
Andersen et al. JAMA 1999;281:335.
   Gila River Physical Activity
            Programs
• Average exercise frequency, intensity,
  and type
  – Individuals with diabetes exercised on
    average for 45 min/wk at low-moderate
    intensity using a combination of
    cardiorespiratory exercise and resistance
    exercise
             Resources
• American College of Sports Medicine
  – www.acsm.org
• American Heart Association
  – www.americanheart.org
• North American Society for the Study
  of Obesity
  – www.obesityonline.org
Thank you for participating



   Jeremy Pomeroy MS, RCEP
       jeremyp@grhc.org

				
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posted:8/18/2012
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