Exercise

Dr. Aidah Abu Elsoud Alkaissi

An-Najh National University

Faculty of Nursing

Faculty of Graduate Studies1

Objectives• Explain the physical activity and fittness goals of healthy

people 2000 and the progress made toward these goals• Describe how physical activity positively influences

physical and psychological health• Identify the benefits of physical activity throughout the

aging process• Describe the prescriptions for and benefits of daily physical

activity, aerobic exrecise, and resistance training• Discuss how exercise can be combined with mindfulness to

facilitate body awareness and self inquiry (a search for knowledge)

• Explain the intervention to promote exercise adherence and compliance 2

Introduction• People who exerise regularly, or those who naturally

include physical activity in their daily routine, feel better mentally and physically, improve their health profile and safeguard their functional independence as they go through the aging process

• A holistic approach to physical activity involves exercise for cardiorespiratory health, endurance (the power to withstand hardship or stress) exercise for musculoskeletal health ( strength, flexibility, and bone density) and body awareness

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Introduction

• Body awareness and mindfulness during exercise facilitate self-inquiry (a search for knowledge) and self acceptance, helping to relieve psychological stress and preventing physical injury

• Regular physical activity is an essential modality in the treatment of chronic disease, which sets up the potential for benefit in all aspects of biopsychosocial and spiritual model of health

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Healthy people 2010• A sedentary lifestyle:• Machines to do the work and provide transportation• Increased computer time at work and home• Decrease financial resources in schools, college and

communities for physical activity instruction, playgrouds, parks and recreation facilities and after school sports programs and staff

• Decreased outdoor activity resulting from fear of crime in neighborhoods

• Children spending increased time watching television and playing video games

• An active life style improves health and lowers mortality rates for people of all fitness levels 5

Revised Physical Activity Goals• A sedentary life place the individual at risk for

becoming a hypokinetic (Lack of physical activity) statistic (A view of inventory information that looks at several systems rather than one at a time), whereas regular physical activity is associated with a wide variety of physical and mental health benefits

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Examples

• The prevention and management of CHD• Hypertension• Noninsulin-dependent diabetes mellitus• Colon cancer• Osteoporosis• Obesity• Anxiety• depression

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• Regular physical activity may also be linked to a reduction in back injuries

• Activity that promotes fittnes, builds muscle strength, endurance and flexibility and expends calories may protect against injury, chronic disease and disability

• Regular physical activity can help maintain functional independence and improve the quality of life throughout the aging process

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Coronary Heart Disease

• Until recently, physical activity was not considered one of the most powerful risk factors

• Hypertension, smoking, obesity and hyperlipidemia were considered to have greater influence

• However, at any level or combination of risk factors, individuald who are sedentary are at an even greater risk

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Coronary Heart Disease• Blaire (1989) suggest a significant inverse (reversed

(turned backward ) relationship between physical fittness and CHD risk, higher level of fittness are associated with lower CHD risk

• A sedentary lifestyle is now recognized as a major risk factor in the development of CHD

• The relative risk of CHD associated with physical inactivity is comparable to the risk observed for hyperlipidemia, HTN, and cigarette smoking

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• A large study on 25,000 men suggests that even in the presence of other CHD risk factors, moderate to high levels of cardiorespiratory fitness provides protection from CHD mortality

• All of these studies reveal the value of exercise in the primary prevention of CHD

• Exercise also plays a role in secondary preventions (recurrence)

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• Increased physical activity appears to benefit individuals with CVD, including MI, angina pectoris, CHF, their status after coronary artery bypass surgery and percutaneous transluminal coronary angioplasty or stent

• Benefit include reduction in cardiovascular mortality rates, reduction of symptoms, improvement in exercise toleranc and functional capacity and improvement in psychological well being and quality of life

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• The consensus is that regular dynamic physical activity plays a role in both the primary and secondary prevention of CHD

• Evidence suggests that regular moderate to vigorous leisure time or occupational physical activities may protect against CHD

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• Current litterature demonstrates that the risk of CHD decreases as physical activity increases and that a plausible relationship between the decreased risk and a number of potential physiological and metabolic mechanisms exist:

– Increasing high-density lipoprotein (HDL) cholesterol– Decreasing serum triglyceride levels– Decreasing high blood pressure– Improving glucose tolerance and insulin sensitivity

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– Decreasing obesity, altering distribution of body fat

– Decreasing the sensitivity of the myocardium to the effects of catecholamines, therby decreasing the risk of ventricular arrythmias

– Enhancing fibrinolysis and altering platelet function

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High Density Lipoprotein and Serum Triglyceride Levels

• Increase in HDL lower the total cholesterol HDL ratio, thereby reducing CHD risk

• Exercise has a potent lowering effect on levels of plasma TRG that is evident within hours after a bout of exercise

• Exercise training incerases lipoprotein lipase activity, an enzyme that removes cholesterol and fatty acid from the blood

• TRG levels are lower and HDL levels are higher in physical active people compared with the sedentary population

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• A dose response relationship between amounts of physical activitiy and HDL levels appears to exist, with endurance trained athletes having 20-30% compared with sedentary

• Regular repeated bouts of activity are needed for long term benefits

• Change in lipid profiles are most significant with moderate exercise over a prolonged period (1 year)

• At best, exercise appears to involve a commitment to regular, moderately intense physical activity over an extended period- a lifetime commitment to an active lifestyle

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Hypertension• In one study, habitual activity and physical fittness may

reduce the risk of developing HTN

• People who do not engage in vigorous sports play or who were at low levels of fittness were at 35% to 52% greater risk for developing HTN

• Mechanism may involve attenuation ( Reduction of signal strength during transmission) of sympathetic nervous system activity

• This attenuation results in the dilation of peripheral blood vessels, which decreases systemic vascular resistance

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• Decreasing SNS activity may have a beneficial effect on the insulin resistance that is often observed in hypertensive people

• Reduction in circulating insulin levels decrease the potential for insulin-mediated sodium reabsorption by the kidneys and increased blood pressure

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Hyperinsulinemia and glucose intolerance

• This account for the following types of diabetes:• Diabetes Mellitus(DM) which encompasses a group of

metabolic disorder that have in common an increase in blood sugar levels and associated metabolic dysfunction

• Insulin dependent diabetes mellitus (IDDM) which involves elevated blood glucose levels that are a result of a deficiency of circulating insulin cause by distruction of the pancreatic beta cell

• NIDDM, which involves elevated blood glucose levels from insulin resistance (decreased insulin sensitivity)-largely in skeletal muscles-or impaired insulin secretion. 90% of persons with diabetes have NIDDM

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• Exercise training is associated directly with improved insulin sensitivity

• Prospective cohort studies demonstrate that physical activity is related to a reduced incidence of NIDDM

• Dose response has been noted, each 500 kcal of additional leisure time physical activity per week was associated with a 6% reduction in the risk of developing NIDDM

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• During physical activity, contracting skeletal muscles work with insulin to enhance glucose up take into the cells

• Insulin resistance impedes (To retard or obstruct the progress) glucose mobilization into cells

• Increasing plasma glucose level and setting the potential for developing NIDDM

• Insulin resistance in skeletal muscles may be the primary defect, the development of disease appears to be related to elevated insulin levels, a result of the body´s response to the need to mobilize glucose into the cells

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• This syndrome often involves elevated TRG and HTN, which contribute to potential disease

• Exercise increases insulin sensitivity, improves the inherent effect of endogenous insulin, decreases obesity and plays a role in lowering TRG and HTN

• Therefore it is recommended in the treatment of NIDDM

• With diet, wt control and exercise, preventing or decreasing the need for oral antiglucolytic agents and insulin is possible while maintaining normal blood glucose levels

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• Physical activity may be most beneficial in preventing the progression of NIDDM during the earlier stages of the disease process, before insulin therapy is required

• Low fittness men are 7.4 times more likely to die from their diabetes and twice as likely to die from CHD

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Fibrinolysis and platelet aggregability

• The relationship among physical activity, fibrinolysis and platelet aggregability suggests that regular physical activity decreases the risk of acute cardiovacular thrombosis

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Obesity• Overweight and obese are major contributors to many

preventable causes of death

• For men obesity is closely related to CVD, respiratory disease, NIDDM, musculoskeletal dysfunction, various cancers, emotional stress, and all cause mortality

• Obesity is generally defined as an excess of adipose tissue, corresponding to a weight that is equel to or greater than 120% to 125% of the ideal body weight

• Fat mass (body fat percentage) is most important in determining the ideal body weight

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• The recommended body fat levels for men and women are approximately 15% to 16% for men and 23% to 24% for women

• An increase in fat mass and the development of obesity occur when energy intake exceeds total daily energy expenditure for a prolonged period

• Decreased physical activity may be both a cause and a consequence of weight gain over a lifetime

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The positive influence that physical activity has on body weight and obesity

• Promote a negative energy balance (burns calories)

• Increase metabolic rate for an extended period after the activity

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• Increase metabolic efficiency for burning calories by increasing lean body mass (The mass of the body minus the fat (storage lipid).

• There are a number of methods for determining the lean body mass. Some of these methods require specialized equipment such as underwater weighing (hydrostatic weighing), and DEXA (dual-energy X-ray absorptiometry).

• Other methods for determining the lean body mass are simple such as skin calipers and bioelectric impedance analysis (BIA).

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The positive influence that physical activity has on body weight and obesity

• Helps counteract the dicrease in metabolic rate associate with low-calories diets by preserving lean body mass

• Is a good alternative to eating when eating is a response to stress rather than to hunger

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• The treatment of obesity involves a comprehensive program of nutrition management, behavior modification, and physical activity or exercise

• The key to normalizing body fatness in long-term adherence and permanent lifestyle changes, not from dieting or short-term exercise trials

• The combination of increased physical activity and nutrition management appear to be more effective for long term weight regulation compared with either exercise or dieting alone

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• The effectiveness of phyical activity is related to the frequency and duration of each activity session and the longevity of the activity program

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Recommended thresholds for exercise include

• A program of low-impact aerobic exercise, increase in daily activities and resistance training

• Afrequency of 5-7 times a week

• A length of 40-60 minutes a day or 20-30 minutes twice daily

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• Fat in men is stored primarily in the upper body or upper abdominal region

• Fat in women is primarily stored in the lower half of the abdomen, the hips, and the thighs

• Adipose tissue metabolism tends to be different in various regions

• The fat metabolizm response to exercise appears to be less in the femoral gluteal region compared with the upper body abdominal region

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• Femoral gluteal adipose tissue serves as an important source of energy during lactation

• Women may not lose fat as easily as do men in response to exercise because genetic differences are related to where and how fat is stored and metabolized

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Aging• The biological changes attributed to aging closely resemble

the effects of physical inactivity

• The list for both aging and inactivity includes an increase in body fat and a decrease in aerobic capacity, muscle mass, metabolic rate, stregth and flexibility, bone mass, sexual function, mental performance, immune function and sleep quality

• The popular theory that exercise increases the quality of life is based on the rationale that regular exercise maintain function during the aging process

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• Physical activity has been shown to be associated with reductions in age-related morbidity, improvemrnts in functional capacity and preservation of independence

• 1-2 year increased life expectancy for physically active men compared with physically inactive men

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Use it or lose it

• Functional aerobic capacity reflects oxygen delivery and use, which normally decreases with age

• Aerobic fitness is important for every one

• It helps to lower the risk of CHD and all cause mortality, it enhances the ability to maintain independence in daily activities and it improves the overall quality of life

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• The health of the musculoskeletal system depend on movement and activity

• Bone is a dynamic tissue constantly changing and adapting to the stress to which it is subjected

• Bone strength is dependent on stresses applied by muscular and weight bearing activity (mechanical stress during active movement)

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• Exercise enhances bone mineralization and helps prevent bone loss overtime

• To say healthy, joints must do what they are designed to do-move and bear weight

• The health of the cartilage covering the joint surfaces is vital for maintaining proper joint function

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• The only way the cartilage can receive nourishment is through the manufacture and distribution of synovial fluid, which delivers nutrients, removes waste products, and lubricates joint surfaces

• Movement is vital for creating this environment of blood and lymph in and out of joint structures and the adjacent (Lying nearby) soft tissues

• Without the stress of weight bearing activity, normal bone and cartilage metabolism and repair become dysfunctional resulting in injury and disease

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Osteoporosis• It is characterized by decreased bone mass and structural

weaknes of bone tissue, leading to bone fragility and increased risk of fractures

• Women are more susceptible than men because they tend to have lower peak bone mass, suffer bone mass loss at an accelerated rate as estrogen level decline and have a longer lifespan than men

• Some loss of bone occurs naturally after age 30, but the severity of this of this process in increased with reduced levels of calcium, estrogen, and physical activity

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• In addition to the importance of optomizing physiological intake of calcium, vitaminD therapy, and maintaining normal menstrual cycles for maximizing peak bone mass, physical activity plays a significant role in developing bone mass during childhood and adolescence and in maintaining skeletal mass into adulthood

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• Teegarden et al 1996, Young women aged 18-31 asserts that previous levels of physical activity correlate positively with bone mineral measures

• Physical activity increases the potential for increased peak bone mass and provides for a stronger skeletal foundation throughout aging

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• Row et al (1987) state that the reduction in bone density that are normally seen with aging may be preventable or at least modifiable by regular exercise, reduced smoking and an adequate intake of calcium

• Estrogen replacement therapy may be considered in osteoporosis prevention because the positive effect of physical activity on bone may depend on the presence of estrogen

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• Maintenance of bone mass may be related to the intensity of the physical activity and the degree to which the activity stresses the bone

• Weight bearing actions that stress the skeleton (walking, stair climbing, aerobic dance) have a positive effect on bone density

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• Resistance training may be more effective than aerobic exercise in its effects on bone mass

• Resistnce training improve muscle mass, strength, and balance, all of which decrease the risk of falls in older adults

• Whereas in younger women, the goal would be to increase bone density

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Arthritis• The process of arthritis upset the balance of joint health

• Rheumatoid arthritis and osteoarthritis have different causes and attack different parts of the joint, impaired joint function is the result

• Cartilage is worn a way and irregularities occur in the bone ends

• As normal movement is altered, proper joint alignment fails, normal ROM is decreased, and with the imbalance of altered muscle activity, disfigurement and dysfunction occur

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• There is an onging progression in arthritis that cannot be healed by exercise, physical activity nevertheless helps to restore health to synovium and cartilage, improve strength and flexibility, decrease joint vulnerability and delay the onset of dysfunction

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• Competitive athlets who participate in activities involving the excessive use of specific joints have an increased risk of developing OA especially when the joint has been injured

• Joint injurry is strong risk factor for the developmet of OA

• One of the cheif goal of exercise and physical activity for the individual with arthritis is to counter the effects of inactivity

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• Researchers have concluded that regular exercise cannot improve or cure arthritis, exercise has quality of life benefits for people with arthritis:

• Improvement in joint function and ROM

• Increase in muscular strength and aerobic fittness that enhance daily activities of living

• Improvement in psychological state

• Decrease in loss of bone mass

• Decrease in the risk of chronic disease

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• Exercise programs based on individual needs and interests should emphasize exercises to develop joint ROM and flexibility(daily) and should also include strengthening ( 2-3 times per week), aerobic exercise (30-45 min most days of the week) and recreational activities that are enjoyable

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Low back pain

• Most causes, poor posture, weak muscles, poor body mechanics, sedentary lifestyle

• Exercise can have a positive influence on decreasing back pain

• Cady et al 1985 report that back injuries decrease with increasing levels of fittnes and that an employee fitness program can result in a 25% decline in workers compensation costs

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Low back pain

• The spinal column is made up of a series of vertebrae stacked one on another, forming natural curves that allow the bony column to function with the resiliency (Ability of a fabric to return to its original shape after compressing, bending or other deformation) of a spring

• The invertebral disks help with mobility and shock absorption

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• The health of the bony vertebrae and the cartilaginous disks depends on movement

• The cartilage gets its nutrients from the compression of bearing weight and this same weight-bearing activity stimulates vertebral bone integrity

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Low back pain

• Compression fractures of the vertebrae are often the result of osteoporosis

• Increases in vertebral bone mass have been noted in women after menopause as the result of an exercise program

• Muscles are involved in the support and function of the spinal column

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• Maintaining the proper curves (anterior and posterior convexities) of lordosis in the cervical and lumbar vertebrae and kyphosis in the thoracic vertebrae is vital for sustaining the spring and shock absorption qualities of the spine

• The lumber curve is especially influenced by 3 sets of muscles that are attached to the pelvis and the lumbar vertebrae

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Low back pain

• By altering the tilt of the pelvis, these muscles can increase (iliopsoas muscle) or decrease (abdominal and hamstring muscles) the lumbar curve

• In addition, the deep muscles of the back (paraspinal muscles) work in controlled synergistic and antagonistic fashion to control spinal planes of motion, thet are also influential in supporting the spinal curves in posture

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• Weakness, overstretching, or tightening of any of these muscles can negatively affect posture and increase wear and tear on the back

• The result can be back pain from muscle strain, altered joint function and abnormal force on the intervertebral disks

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What is the Illiopsoas muscle?

• The iliopsoas muscle is a very strong muscle that lifts the knee up. It starts at the lower back and inserts into the thigh bone (femur). This muscle can become inflamed if you over do the situps especially with a weight behind your neck, or do lots of up hill running.

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The Iliopsoas muscle

                             

              

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The Iliopsoas muscle

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hamstring muscles

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Low back pain

• The goal of exercise programs for individuals with low back pain is to prevent debilitation as a result of inactivity and to improve endurance, strength, and flexibility allowing for a return to usual functional activities

• Exercise recommendations and progression of activity are highly individualized based on origin, duration, and severity of pain

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• Strengthening exercises for trunk and extrimity musculature are useful in persons with chronic, but not acute-low back pain

• Aerobic conditioning such a walking, swimming, and stationary bicycling is recommended to maintain endurance and prevent debilitation from inactivity

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Low back pain

• Advanced age, osteoporosis, arthritis, and low back pain are not reasons to exclude exercise from anyone´s lifestyle

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Immune Function

• Establishing the relationship between exercise and immunes function has a fairly long history of study

• Renewed interest has grown out of the human immunodeficiency virus (HIV) epidemic

• Several studies demonstrate that persons with impaired immune function can exercise safely without risk to their health status and can enhance their physiological and psychological well being with regular exercise

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Immune Function

• Changes in immune markers, such as CD4 and CD8 cell counts and the number and activity of natural killer cells, indicate that moderate exercise may help bolster (to support) an impaired immune system

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• CD4 cells: Type of T cell involved in protecting against viral, fungal, and protozoal infections. These cells normally orchestrate the immune response, signaling other cells in the immune system to perform their special functions. Also known as T helper cells.

• CD8 T cell - T cell with CD8 receptor that recognizes antigens on the surface of a virus-infected cell and binds to the infected cell and kill it

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Immune Function

• Evidence suggests that regular exercises do not get sick as often as do less active people

• Moderate exercise may decrease the risk of URTI below that of a sedentary individual, but high-intensity exercise may raise the risk above average

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Immune Function

• Ultramarathoners and high intensity marathoners have a significantly higher incidence of URTI symptoms compared with control subjects

• Immune system changes that apparently related to the intensity of exercise have been identified

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Immune Function

• Moderate endurance exercise stimulates the neuroendocrine system which causes changes in the function and numbers of various immune system cells such as the natural killer, CD4 and CD8 cells as mentioned

• Natural killer cells play a major role in the host-rejection of both tumours and virally infected cells.

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Immune Function• Evidence indicates that moderate exercise is associated

with a prolonged improvement in the killing capacity of neutrophils (one of the most efficient phagocytes)

• Several immune marker changes suggest increased risk for high intensity exercise, including low level of salivary immunoglobulin (antibodies) , low serum complement levels, low lymphocyte count, depressed NK cell activity, low helper and suppressor T-cell ratio and decreased neutrophil phagocytic capacity

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Immune Function• Changes in immune cell counts and activity may be

related to hormonal immunoregulation

• Moderate exercise increases the release of immunostimulatory hormones, such as growth hormone and endogenous opiates (beta endorphin and methionine-enkephalin)

• The increase in beta-endorphins with exercise seems to have a positive effect on NK cell activity

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Immune Function

• Intense exercise is associated with increases in catecholamine and corticosteroid (cortisol) levels, which have immunosuppressive characteristics

• High intensity exercise is associated with muscle cell damage and inflammation

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Immune Function

• The immune system is involved in tissue repair

• Rest is recommended after vigorous exercise to allow the body to recover and moderate exercise may be the better choice for enhancing health and well being

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Immune Function• Large-scale epidemiological studies report a reduced

incidence of cancer in physically active groups

• Research on occupational and leisure time activity strongly suggests that physical activity has a protective effect against the risk of developing colon cancer

• Data from the nurses health study indicate that women who are more physically active in adulthood hav a lower risk of breast cancer compared with those who are less physically active

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Immune Function

• Researchers argue that lifetime physical activity is the critical variable affecting breast cancer risk

• A large prospective study of over 12,000 men suggests that cardiorespiratory fitness and higher levels of physical activity may protect against the development of prostate cancer

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Immune Function

• NK cells and microphages are involved in the first-line defense against the development and spread of malignancies

• Exercise can help increase NK cell cytotoxicity, change the influx (the process of flowing in) of macrophage into tissue, and promote the release of cytokines with antitumor properties

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• In helping to prevent colon cancer, exercise increases intestinal motility by altering local prostaglandin synthesis and decreases gastrointestinal transit time thereby decreasing length of contact between colon mucosa and potential carcinogens

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Mental Health• People who exercise regularly generally state that they feel better,

have increased self-esteem and have a more positive outlook on life

• Not only do they feel better physically, but they also feel better mentally

• Epidemiological research with both men and women suggests that physical activity may be associated with reduced symptoms of depression and anxiety and improvements in positive affect and general sense of well being

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Mental Health

• A canadian survey suggests that higher levels of daily energy expenditure are associated with a more positive mood compared with lower levels of expenditure

• An inverse relationship exists between physical activity and symptoms of depression in people aged 25 years and older

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Mental Health

• Folkinset et al (1976) found that after 12 weeks of exercise, the exercise group showed significant improvement in all levels of cardiovascular fitness and decreases in anxiety and depression

• In aerobic exercise studies, the exercise groups experienced reductions in anxiety, tension, depression and fatigue and an increase in vigor and clear mindedness

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Mental Health

• Brown et al (1995) determined that exercise combined with a cognitive activity (low intensity walking with relaxation response, or modified Tai Chi) appears to be more effective in improving mood states compared with exercise alone

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Mental Health• Blumenthal et al (1980) concluded that basically

healthy, well adjusted people who exercise can increase their sense of well being more than healthy people who do not exercise

• Even when no change is observed in objective mental health measures with older people in relatively good physical and mental health, they report feelings of improved physical, psychological and social well being after regular physical activity

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Mental Health• Kobassa (1985) has perfomed extensive work on

stress-illness relationship• Exercise is considered one of the moderating

variables (resistance resources) in addition to hardiness and social support- that affects the relationship.

• Hardiness (defined in terms of commitment, control, and challenge) is believed to be the most effective buffer against the effects of stress, exercise is associated with lower overall scores in people under stress

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Mental Health

• Exercise not only increase regular participants´ feelings about coping with stress but enhances their overall feeling of well being

• Physical activity and exercise should be encouraged in an attempt to maximize their associated benefits of enhanced sense of personal acheivement

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How much exercise is enough• Regular physical activity or exercise can help people feel

better, look better, and perform better

• People should be reminded that many of their daily physical activities are actually forms of exercise

• Individuals should also be encouraged to include more formal exercise training in their overall activities to promote optimal cardiorespiratory fitness and significantly improve muscle strength and endurance

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Aerobic Exercise• The benefits of aerobic exercise are cumulative, therefore

frequency of 3-5 times a week is recommended, every other day is a good frame of reference

• The benefits of exercising more than 5 times a week are outweighed by the risk of injury especially with higher impact activities

• When more frequet exercising is a goal, cross training is recommended

• Cross training means performing different types of exercise on different days of the week or performing different types of exercise within one exercise session

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Aerobic Exercise• The benefits of cross training include a

decreased risk of musculoskeletal injury, an increased potential for total body conditioning and improved long term compliance because variety decreases boredom and eliminates the exercise barrier of limited choices

• Intensity is defined by the objective measure of heart rate and the subjective measure of perceived exertion

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Aerobic Exercise

• The increase in heart rate during exercise has a strong linear relationship with exercise intensity and aerobic capacity

• Resting heart rate is the HR measured at rest

• Maximal heart rate is the HR measured at the highest workload tolerated during exercise

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Aerobic Exercise

• Maximal heart rate decreases with age

• Formulas for determining appropriate exercise HRs have been developed that take resting heart rate and maximal heart rate into consideration

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Aerobic Exercise

• The goal to acheive a conditioning effect and to burn a significant number of calories, but the individual must also enjoy the activity enough to be willing to continue exercising on a regular basis

• Perceptions of exertion and the relationship to HR are influenced by both physiological and pychological factors (aches, cramps, pain, fatigue, shortness of breath, anxiety, depression, and introversion or extrversion)

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Aerobic Exercise

• The borg scale for rating perceived exertion is a psychophysical category for the subjective rating of sensations associated with the intensity of physical work

• The scale uses ratings based on the individual´s overall feeling of exertion and physical fatigue

• These rating correspond well with metabolic responses to exercise, such as HR and oxygen consumption

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Aerobic Exercise

• Subjective parameters include being slightly short of breath, but not out of breath, able to talk without difficulty, but unable to sing a song easily, being pleasantly fatigued, but not exhausted and having mild musculoskeletal discomfort , but not pain

• Walking, cycling, rowing, swimming, water walking or other water aerobics activities

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Warm-up and cool-down periods• Should be a regular part of the exercise session

• The warm up period lasts 5-10 minutes and may include light stretching, or performance of the chosen aerobic activity at a low intensity

• This approach prepares both the musculoskeletal and cardiorespiratory systems for the transition from rest to exercise by increasing blood flow, respiration and body temperature and improving muscle flexibility

• The warm up period decreases the risks of injury and potential heart irregularities

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Warm-up and cool-down periods

• Individuals should be encouraged to develop a warm up practice that involves listening to the body and paying attention to physical and mental cues which increases awareness of muscle tightness and the general energy level and helps in making exercise goals for that particular session

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The cool-down period• Follows the endurance phase and usually lasts 5-10

minutes• This phase allows the body to readjust gradually

from the demands of exercise back to baseline• Stretching and slow, rhythmical movement helps

to increase muscle elasticity, prevent blood pooling and potential hypotension and removal of lactic acid

• The result is the prevention of injury, light headedness, fatigue, and muscle soreness

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The cool-down period

• Cool-down provides a wonderful opportunity to combine movement with relaxation skills, enhancing mind-body awareness

• Yoga is an excellent form of exercise to use during warm up and cool down period

• The word yoga means union or established in being, which implies a mind-body connection

• Yoga is mindful stretching106

The cool-down period

• The mind is quite and awarness is focused on feeling the body as it moves

• Movement into and out of yoga postures (called asanas) provide the necessary stimulation of weight-bearing activity to help keep bones strong, provides the movement to increase joint ROM and stretches and tones muscles

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Flexibility• Is a basic component of physical fitness

• Warm-up and cool-dawn periods provide the opportunity to work on stretching muscles and increasing joint ROM

• A safe stretch is one that is gentle and relaxing, a little discomfort may be felt as the muscle stretches, but the discomfort should never reach the point of pain

• Stretching mindfully, as in yoga, will ensure a safe stretch • Holding the position for 10-20 seconds and repeating the stretch

3-5 times will encourage optimal flexibility108

Resistance training

• Increases muscle strength and endurance, increase muscle mass, improves metabolic efficiency, maintain or increases bone density, prevents limitations in performance of every day tasks, decreases the effort required to perform these tasks and decreases the potential for injury during physical activity

• On the average, after their early 20s, people lost about half a pound of muscle every year through lack of use

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Resistance training

• This reduction in muscle mass is largely responsible for a decrease in resting metabolic rate, which may translate into weight gain

• Resistance training is recommended for the general population because it has a positive effect on many of the degenerative problems associated with the aging process

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Resistance training• Every individual should try to perform activities

throughout the day that stimulate muscle strength and endurance

• Activities that involve lifting, carrying, or performing repetitive movement against a resistance (shoveling (A tool with a handle and a broad scoop or blade for digging and moving material, such as dirt or snow), or baking bread) help preserve lean body mass (The mass of the body minus the fat (storage lipid).

• If these types of activities are not performed on a regular basis, then the guidelines for resistance training are suggested

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Resistance training

• The purpose of weight training from a health perspective is:

• To develop toned (Normal firmness of a tissue or an organ) , healthy muscles that provide the strength to do daily activities without risk of injury

• To stimulate healthy bone

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Exercise the Spirit: Relaxation Response

• Exercise should not be considered merely a physical regimen with objective outcomes (calories burned and repititions completed)

• Exercise is a process of challenging the body and the mind to gain a sens of well being and a feeling of accomplishment, an opportunity to learn about who we really are

• The body mirrors the mind and soul and is much more accessible than either

• Listening to the body, is hearing from your whole self113

Exercise the spirit: relaxation response

• Success in embracing (To take up willingly or eagerly) a physically active lifestyle may involve a change in focus from the mechanics of exercise to an appreciation for how it feels and what it means to move

• Physical activity can be time spent in meditation that fuels both the body and the spirit

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Exercise the spirit: relaxation response

• The relaxation response (RR) is an inborn (conforming with or constituting a norm or standard or level or type or social) set of phyiological changes that offset those of the fight-or-flight (stress) response

• RR results in a letting go of physical, emotional and mental tension

• Some techniques used diaphragmatic breathing, meditation, imagery, mindfulness, yoga stretching and repetitive exercise

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Exercise the spirit: relaxation response

• Successful elicitation (To arrive at (a truth, for example) by logic) of the RR involves two basic componenets:

• 1. A repetitive focus (the breath, a mantra (A commonly repeated word or phrase) , the cadence (The measure or beat of movement, as in dancing) or rhythm of physical activity

• 2. A judgmental attitude (about everyday thoughts and the quality of performance)

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Exercise the spirit: relaxation response

• Exercise characretistics:– Be pleasant and enjoyable

– Be noncompetitive, compitition implies judgment about the self and others

– Be predictable

– Be repetitive and rhythmical

– Facilitate abdominal breathing. It provides focus awarness

– Continue for 20-30 minutes at a comfortable intensity on most days of the week. This continuity restores a sense of serenity (the absence of mental stress or anxiety)

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Exercise the spirit: relaxation response

• For example: yoga, Tai-Chi, aerobic• Bicycling, swimming (it has rhythmical and repetitive

form)• Mantars can be used to create a positive mind-set and to

focus the mind in the present moment as the experience unfolds

• Resistance training takes on new meaning when coordinated with the breath

• Focusing on the muscles and how it feels to move through the ROM enhances the knowledge of what feels good and what does not, providing feedback on accepting physical challenge 118

Exercise the spirit: relaxation response

• When exercise integrates mind and body , it stops being something that has to be done and instead becomes something desired

• Being mindful during physical activity and exercising in the moment increases awareness

• With awareness comes choice in the possibilities of self care

• Exercise for fitness of the spirit, walk for the soul and just let the body do the work

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Monitoring the inner and outer environment

• When a person is not feeling well, the exercise effort should be decreased or stopped until the individual is feeling better

• With an infection, a cold, or influenza, the body is under stress and overexertion will only increase that stress and possibly lengthen the healing time

• The level of activity should be adjusted to accommodate how the individual feels, slowly progressing to normal workout levels until strength and energy return

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Monitoring the inner and outer environment

• This philosophy also holds true for chronic diseases such as arthritis and HIV

• During an acute exacerbation, activity should be limited to necessary activities of daily living, but on a regular basis, staying active is important, adjusting activity levels as tolerated

• Exercise can be a useful tool in coping with disease• Inactivity for 3-5 months results in the loss of all

benefits gained and resumption of exercise involves starting over

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Monitoring the inner and outer environment

• Being a ware of the external exercise environment is also important, extremes of heat and cold affect performance as the body adjusts to different temperatures and wind conditions

• Air temp and humidity affect muscle flexibility and the ability to perspire and regulate body temp

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• Changing the time of day for exercise (early morning or later evening are better choices for humid days)

• Adjusting fluid intake and varying the length of warm up and cool down periods will improve tolerance for environmental conditions and enhance exercise safety

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Fluid News• Proper hydration is an important component of a good

fitness program• Extra fluid is needed to support physiological homeostasis

during exercise especially during hot weather• Drinking a cup of water 15-30 minutes before exercise is

recommemded• If the weather is hot of the indoor exercise area is very

warm then 5-12 ounces of fluid should be taken in every 15-20 min during exercise

• Fitness water is new on the market and is a good fluid replacement during exercise periods

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Fluid News

• For exercise routines lasting longer than 1 hour, a sports drink with carbohydrates and electrolytes enhances performance and is recommended

• This type of liquid provides muscles with energy and hels delay fatigue while meeting fluid needs

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• Sports drinks containing a 4% to 6% carbohydrate concentration are designed to replace carbohydrates at the proper rate during exercise

• They also contain sodium, which promotes fluid retention, enhances flavor and protect against hyponatremia which can occur wiyh lengthy exercise csessions

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What to wear• Appropriate foot gear (To become adjusted so as to fit)

and clothing can enhance comfort and decrease the risk of injury during exercise

• Foot Gear: a good all-around shoe with proper support can be adequate for general physical activity, different types of exercise that the feet be supported indifferent ways

• Jogging shoes should be worn for jogging, walking shoes for walking 127

What to wear

• For jogging having the shoe best suited to accommodate a particular foot structure is important

• A normal foot does best in stability shoes with moderate control features

• A flat (floppy) foot does best with motion control that reduces pronation (To turn or rotate )

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• A high-arched (rigid) foot is best supported by cushioned shoes with plenty of flexibility to encourage foot mobility

• Any foot or general orthopedic problems that have required medical attention in the past should be discussed with an appropriate health care provider before beginning exercise

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Dress for Success

• Cotton T-shirts may be comfortable, but they are not the best choice for exercise

• Cotton is great for soaking up sweat, but it also retains the moisture, making the wearer sticky and irritated in hot weather and cold and damp in cooler weather

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• In warm or hot weather, lightweight, breathable gear made from high-tech fabric is prefered because it wicks (A piece of material that conveys liquid by capillary action) moisture away from the skin to the outer surface of the fabric where it can evaporate quickly, helping the inside surface stay dry

• In cold weather, 2,3 layers of light clothing that can be removed as the body warms and replaced if the body cools off is recommended

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Dress for Success• The inner layer should be lightweight, synthetic material

that wicks moisture to the outside to prevent chiling, in extremely cold weather, a middle layer is often necessary to provide additional insulation (a material that reduces or prevents the transmission of heat or sound or electricity)

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• The outer layer should be a loose-fitting protective shell to shield against cold, wind, rain, or snow while allowing perspiration to evaporate

• Wearing a hat helps keep the rest of the body warm, which preserves heat that would be lost through the top of the head and can instead be circulated around the body

• For helping to keep the hands and feet warm, wearing a hat is beneficial

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Dress for Success• To further protect the hands, mittens, old socks, or gloves

should be worn• Mittens keep the hands warmer than gloves with the

shared warmth of the fingers• Gloves are good for milder days• Socks that provide warmth but wick moisture away from

the skin, are best for keeping feet comfortable• For hats and hand and footwear, high tech fabrics that are

lightweight and breathable are a better choice than cotton or wool

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Special consideration• People with CHD and/or diabetes are 2 groups of people

with social exercise needs• Limitation in the ability to exercise are related to the

severity of the disease and the signs and symptoms of intolerance

• For persons with CHD and DM safety with starting a new exercise program requires supervision and guidance from knowledgeable health care providers

• Before starting these individuals should have a medical evaluation, including an exercise tolerance test to determine functional capacity and severity of disease

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Coronary heart disease• Exercise plays a strong role in rehabilitation after a cardiac

event such as MI, CABG, PTCA and stent, and angina• Increased physical activity appears to benefit individuals

from each of these groups• Benefits include the following :

– Reduction in cardiovascular mortality

– Reduction of symptoms improvement of exercise tolerance and functional capacity

– I ncrease in the confidence and ability to carry out usual ADLs

– I mprovemrent in psychological well being and quality of life

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Coronary heart disease• People with CHD demonstrate a reduction in Vo2

(upptaking oxygen) max and the ability to do submaximal levels of work

• With exercise training, the increase in Vo2 max in patients with CHD averages approximately 20% after 3 months

• This improvement in conditioning is the result of both central (cardiac) and peripheral /muscular) changes

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• Some of the most signifucant improvements in exercise tolerance have been noted in patients with angina

• With a decrease in submaximal HR and/or a decrease in SBP resulting from conditioning, myocardial oxygen demand is decreased and patients are able to do a greater amount of work before reaching their anginal threshold

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Coronary heart disease• This boots is reflected in an observed increase in rate

pressure product (RPP) (HRxSBP) at the anginal threshold (The place or point of beginning)

• An increase in functional capacity allows for progression of exercise tolerance and capacity with daily activities and leisure or vocational activities

• Exercise plays a significant role in improving negative affective states and may help decrease the onset and recurrence of coronary events and symptoms

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Coronary heart disease

• Resistance training has not been commonly recommended for patients with CHD, the belief was that lifting weights resulted in a disproportionate rise in blood pressure, increased the myocardial oxygen demand and increased risk of angina

• Current belief suggests that strength training can keep the heart healthy by helping to control body weight, reduce cholesterol, and control blood sugar

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Coronary heart disease• People who are the most deconditioned may need to

exercise at lower intensities, for short durations and more frequently throughout the day

• Emphasis is placed on development of each person´s self-monitoring skills for activity tolerance

• To continue with safe, progressive exercise on their own, individual need to develop the ability to monitor pulse rate, and signs and symptoms of intolerance

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Diabetes

• Exercises has long been regarded as part of the triad (A group of three) in the treatment of diabetes in conjunction with diet and medication (insulin or oral medication)

• In early 1900s it was determined that exercise lowers the blood glucose concentration of people with diabetes

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• After the introduction of insulin, studies revealed that exercise can potentiate the hypoglycemic effect of injected insulin

• More recently findings suggest that in idividuals who are in poor control (excessive blood glucose level) exercise may induce a further increase in blood glucose levels, resulting in ketoses (A pathological increase in the production of ketone bodies)

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Diabetes

• On the average, people with diabetes have a lower MHR, acheive a lower cardiac output at maximal exercise, and have a higher blood pressure during exercise, resulting in lower maximal oxygen consumption

• These individuals can improve their exercise capacity with training and can experience the benefits related to overall fitness and cardiorespiratory training similar to the benefit gained by people without diabetes

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Diabetes• The overall goals should be to teach individuals to

incorporate activity into their daily life, pursue (To carry on) an exercise progrm if they wish, and develop strategies to avoid the complications of exsercise

• In addition to diet and weight loss, regular physical activity is an important modality in the prevention and treatment of NIDDM

• People with NIDDM should monitor their blood glucose levels and determine their responses to exercise

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Diabetes• With exercise , insulin secretion decreases slightly

and the concentration of the counter (To or toward an opposite) regulatory hormones increaes

• This increase stimulates hepatic glucose production, which balances the increased use of glucose by the working muscles, maintaining normoglycemia

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Diabetes• Microvacular changes overtime cause people with diabetes to

be at risk for developing and should be screened for the presence of retinopathy, nephtopathy, cardiovascular diease and peripheral and autonomic neuropathies, all of which present increased risks with exercise

• To prevent rupture of fragile eye vessels in retinopathy, jarring (characterized by rough motion) activities and activities that cause a significant rise in blood pressure should be avoided

• Vital signs should be monitored and person watched closely for signs of autonomic neuropathy (hypotension)

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Diabetes• Individuals with peripheral neuropathy are at risk for decreased

sensation and neuropathic joints

• Trauma and high impact activity to the involved extrimities should be avoided

• Each person with diabetes should be evaluated and given individual exercise recommendations, the goals of an exercise program are universal:

• 1. Maintain or improve cardiovascular fitness to prevent or menimized long-term cardiovacular complications

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Diabetes• 2.Improve flexibility that is impaired as muscle

collagen becomes glycosylated• 3. Improve muscle strength, which may deteriorate

as a result of neuropathy• 4. Allow people with IDDM to safely participate in

and enjoy physical activities or sports• Assist with weight control for people with NIDDM• Allow people with diabetes to experience and gain

the same benefit and enjoyment from regular exercise as do people without diabetes

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Building a rhythm of physical activity

• The following generalities are true:• Men are more active than are women• Physical activity decline with age• Ethnic minorities are less active than are White Americans• Higher education and income are associated with more

leisure time activity• People who are obese are usually less active compared

with their leaner (Not fleshy or fat; thin) counterpart

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Adherence and Compliance

• Physiological, behavioral, and psychoogical variable all influence the decision to be physically active

• Core desire defines the purpose behind putting the effort into developing and maintaining an active lifestyle, it is what to motivate the individual to exercise

• People should be encouraged to spend some quite time meditating on why being physically fit is important to them

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Adherence and Compliance• Physical ctivity is more likely to be intiated and

maintained if the individual:– Perceive a net benefit– Chooses an enjoyable activity– Feels competent doing the activity– Feels confident in overcoming barriers that may interfer

with the activity– Feels safe doing the activity– Can easily access the activity on a regular basis

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Adherence and Compliance

– Perceive no significant negative financial or social cost

– Experiences minimal musculoskeletal discomfort– Is able to address competing time demands– Is readily able to fit the activity into the daily schedule

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Adherence and Compliance• Educating the public about physical activity helps to

provide guidelines for safe and effective exercise, to reinforce potential benefits, and to alleviate misperceptions that may interfere with the decision to change behavior

• Confididence in the ability to be physically active and the confidence that overcoming barriers produces positive benefits that are related to personal goals (self efficacy) is strongly related to participation and compliance

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• Exercise self-efficacy is increased when people perform exercise successfully, receive positive feedback about success, view exercise role models and learn more about the relationships among exercise, health, and body awareness

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Adherence and Compliance

• Enjoyment is another strong predictor of compliance and is often associated with low-to moderate intensity activities versus high intensity activities, it is also related to increased comfort and decreased incidence of injury

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Creating a climate that supports exercises

• Exercie and fitness need to be social norms

• A climate that supports and encourages physical activity should be fostered

• Other people and organizations in the individual´s social environment can influence the adoption and maintenance

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Health care professionals• People are more likely to increase physical activity if

counseled to do so by clinicians• Clinicians should inquire (ask) about exercise habits,

communicate the benefit of increased activity, assist the person in initiating activity and provide adequate follow up

• Challenging perceived individual barriers to exercise and offering alternative viewpoints can help create new exercise paradigms (pattern or model)

• Clinicians should also serve as role models by demonstrating enthusiasm for being physical active

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Health care professionals

• The decision to change may come gradually• After the person has made the commitiment to

change, the action phase lasts about 6 months• Continued follow up throughout the action

phase into maintenance is valuable in helping the individual stay committed until the termination phase is reached and the behavior is secure

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Family and friends

• Social support can be a valuable resource for behavioral change

• Significant others or friends can serve a buddies (A partner) , providing a source of companionship and motivation

• These people can offer to share daily responsibilities to free up time for exercise

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• Parents can support their children´activity by having family outing (a journey taken for pleasure) and providing transportation, and encouragement, joining a fittness club or an exercise group at work provides various forms of stimulation and socialization which increase the potential for new friendships grounded in an appreciation for the rewards of exercise

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Work sites

• In revewing progress towards healthy people 2000 goals, fittnes opportunities at the work site are one of the few bright spots

• Employers can provide space for fitness facilities or offer payroll deductions (The drawing of a conclusion by reasoning) for affiliated (To become closely connected or associated) health facilities

• Companies can make time and programs available to encourage people to be active during work hours

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• Motivational signs can be placed strategically around the facility that encourage stairs climbing and walking or bicycling to work

• Secured areas for bikes and shower facilities encourage people to take advantage of building exercise into their work related schedule

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Schools

• Strategies must be developed to facilitate increased activitiy in children because it is clear that children are becoming less active and more obese

• Schools are providing less opportunity and poorer quality time for physical ctivity during school hours

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Schools• All schools should provide oppotunities for

physical activity that:– Are appropriate and enjoyable for children of all skill

levels and are not limited to competitive sport or physical education classes

– Appeal (To be attractive or interesting) to girls and boys to children from diverse background

– Are offered on a daily basis– Can serve a a foundation for activities throughout life– Schools can also serve as a resource for the

community

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Communities

• Community government agencies, local health agencies, schools and places of workship have the potential to provide activity resources to the population at large

• Churches seem to have been particularly successful in reaching ethnic minoritues and elderly adults

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• Govenmet agencies must respond to reports by health agencies and establish public policies that support the importance of physical activity for the general population

• Individuals should make a personal commitment to be physically active but that commitment needs to be supported by a social and political environment that values this type of lifestyle choice

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