“Exercise Prescription”

Jim Chesnutt, M.D.

OHSU Sports Medicine

Medical Director

OHSU march wellness & fitness center

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The Problem of InactivityNearly half of U.S. adults do not meet the recommendations for aerobic

physical activity

Nearly one-third (30 percent) report doing less than 10 minutes of moderate-

to-vigorous physical activity per week.

Estimates suggest that many individuals spend almost 8 hours a day in

sedentary behaviors,

24 percent of adults engage in no leisure-time physical activity at all.

Physical inactivity causes 9 percent of premature mortality, or more than 5.3

million of the 57 million deaths that occurred worldwide in 2008.5

Globally, physical inactivity costs health care systems 54 billion dollars,

productivity losses of 14 billion, and 13.4 million disability-adjusted life years.

www.exerciseismedicine.org

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What is the single best thing we can do for our health?

Exercise is Medicine!

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Exercise is Medicine™

To make physical activity and exercise a standard part of a global disease prevention and treatment medical paradigm.

For physical activity to be considered by all health care providers as a vital sign in every patient visit, and that patients are effectively counseled and referred as to their physical activity and health needs, thus leading to overall improvement in the public's health and long-term reduction in health care cost.

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GOAL: Exercise is Medicine will be a sustainable global initiative

1.Creates broad awareness that exercise is indeed medicine.

2.Makes "level of physical activity" a standard vital sign question in each patient visit.

3.Helps physicians and other health care providers to become consistently effective in

counseling and referring patients as to their physical activity needs.

4.Leads to policy changes in public and private sectors that support physical activity

counseling and referrals in clinical settings.

5.Produces an expectation among the public and patients that their health care providers

should and will ask about and prescribe exercise.

6.Appropriately encourages physicians and other health care providers to be physically

active themselves.

Exercise is Medicine™

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• Recommendations

• Benefits

• Contraindication

• Dose, frequency, duration

• The FITT Principle

• OHSU Medical Exercise Program

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Physical Activity Recommendations

• 1995 CDC/ ACSM- first recommendations

• 1996 Report of the Surgeon General:

• Physical Activity and Health.

U.S. Dept of Health and Human Services

These were the first public policy and position

statements to address physical activity and health.

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Physical Activity Recommendations

2007 ACSM/ AHA

• Physical activity and public health: updated

recommendation for adults from the American

College of Sports Medicine and the American

Heart Association.

• Haskell WL, Lee IM, Pate RR, et al. Med Sci Sports

Exerc. 2007;39(8):1423-34.

2008 Physical Activity Guidelines for Americans.

US Dept of Health and Human Services.

http://www.health.gov/paguidelines.

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Physical Activity Recommendations

ACSM- 2011 Position Statement

• Quantity and Quality of Exercise for

Developing and Maintaining

Cardiorespiratory, Musculoskeletal, and

Neuromotor Fitness in Apparently Healthy

Adults: Guidance for Prescribing Exercise

Medicine & Science in Sports & Exercise:

July 2011 - Volume 43 - Issue 7 - pp 1334-1359

http://journals.lww.com/acsm-

msse/Fulltext/2011/07000/Quantity_and_Quality_of_Exercis

e_for_Developing.26.aspx

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ACSM & AHA 2007, HHS 2008,ACSM 2011

HHS,AHA,ACSM 2018, WHO 2020

Physical Activity Recommendations

Healthy Adults age 18-64

• Aerobic Physical Activity

⚫ Moderate intensity: 150 minutes/wk, OR

⚫ Vigorous intensity: 75 minutes/wk (or a combo)

⚫ Can accumulate 10 min minutes( now every

minute), preferably spread throughout week

• Muscle Strengthening Activity

⚫ 2 or more days/week

⚫ 8-10 exercises

⚫ 10-15 reps (one set)

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Newest Physical Activity Guidelines 2018-2020

HHS 2018OHSU

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2018

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So do we meet the guidelines?

CDC Behavioral Risk Factor Surveillance System (BRFSS) assessed

participation in aerobic physical and muscle-strengthening activities

among adults in the US 2008-2018

• 20.8% of adult respondents met both aerobic and muscle-

strengthening guidelines ( 24.0 by 2018)

⚫ 51.6% of U.S. adults met the aerobic activity ( 54.2 by 2018)

⚫ 24.2% met the muscle-strengthening guideline. ( 27.6- 2018)

• Adult Participation in Aerobic and Muscle-Strengthening Physical Activities -

United States, 2011 MMWR, May 3, 2013/62(17); 326-330

• Trends in Meeting the 2008 Physical Activity Guidelines, 2008—2018

• https://www.cdc.gov/physicalactivity/downloads/trends-in-the-prevalence-of-

physical-activity-508.pdf

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Prevalence of Self-Reported Physical Inactivity* Among

US Adults by State and Territory, BRFSS, 2015–2018

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Policy and Environmental Indicators• The policy and environmental indicators reflect 3 overarching strategies to

increase physical activity.

• 1. Create or enhance access to safe places for physical activity;

• 2. Enhance physical education and physical activity in schools / child care

• 3. Support street-scale and community-scale design policy.

• Each strategy is supported by The CDC Guide to Strategies for Increasing Physical

Activity in the Community, The Guide for Community Preventive Services, and

The National Physical Activity Plan.

• These 3 strategies can be supported at the state level as well as at the local level in

communities across the state. States may choose to focus on improving some or all

of the indicators based on their capacity, partnerships, and resources.

• Centers for Disease Control and Prevention. State Indicator Report on Physical

Activity, 2014. Atlanta, GA: U.S. Department of Health and Human Services, 2014.

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Indications for Exercise

• Longevity

• Quality of Life

• Socialization

• Weight control

• Disease prevention

• Disease management

• Covid risk: 2-2.5 risk hosp/death if inactive

And others…

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Death Prevention:Attributable Deaths (%) from various

health conditions

Aerobics Center Longitudinal Study (ACLS), Cooper Institute

•40,842 men; 12,943 women. BLAIR et al.

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Strong Evidence of Benefit from

Physical Activity for…

• Lower risk of:

⚫ Early death( >50%)

⚫ Heart disease

⚫ Stroke

⚫ Type 2 diabetes

⚫ High blood pressure

⚫ Dyslipidemia

⚫ Metabolic syndrome

⚫ Colon and breast Ca

• Prevention of wt gain

• Wt loss w/dieting

• Improved CardioRsp &

muscular fitness

• Prevention of falls

• Reduced depression

• Better cognitive

fxn(youth and adults)

and less dementia (older)

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Exercise and CA risk reduction• Can reduce mortality and the risk of recurrent breast cancer by

approximately 50%.• Physical activity and survival after breast cancer diagnosis. Holmes MD et al. JAMA 2005; 293:2479

• A Prospective Study of Cardiorespiratory Fitness and Breast Cancer Mortality Peel JB, Sui X, Adams SA,

Hébert JR, Hardin JW, Blair SN. Med Sci Sports Exerc. 2009 Apr;41(4):742-8.

• Can lower the risk of colon cancer by over 60%.

• Physical activity and colon cancer: confounding or interaction? Medicine & Science in Sports &

Exercise: June 2002 - Volume 34 - Issue 6 - pp 913-919

• Can reduce the risk of developing of Alzheimer’s disease by

approximately 40%. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and

older. Larsen EB et al. Annals of Internal Medicine 2006; 144:73-81

Also lower incidence of bladder, endometrium,

esophagus, kidney, stomach and lung cancers

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Moderate evidence for…

• Wt maintenance after loss

• Lower risk of hip fx

• Increased bone density

• Improved sleep quality

• Lower risk lung and endometrial CaOHSU

Contraindications for Exercise

• Acute cardiac event happening now/recent

• Uncontrolled arrhythmia causing sxs

• Severe aortic stenosis

• Uncontrolled heart failure

• Acute pulmonary embolism

• Acute myocarditis

• Dissecting aneurysm

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Screening needed before participating

in gym or vigorous exerciseThe ACSM Pre participation Health Screening:

1) a determination of current

exercise habits;

2) the identification of established cardiovascular,

metabolic, and renal diseases; and

3) the delineation of signs and/or symptoms at rest or during

physical exertion, suggesting underlying CVD.

BUT, only current symptoms of CVD limit immediate

participation . Otherwise can exercise at low level exercise if

currently exercising while waiting for further evaluation.

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Side effects of exercise

• Mild to Moderate risk of Musculoskeletal

injury- 10 % walkers, 40% runners

⚫ Increases with duration & intensity

• RARE cardiac events

⚫ FAR outweighed by benefits to heart!

• 25-60% decrease in CVD and all cause

mortality in exercisers

See: Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s

recommendations for exercise preparticipation health screening. Med Sci

Sports Exerc. 2015;47(11):2473–9.

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Joint related pains limiting exercise

• What are some the the joint pains that you

have?

• What are the concerns you have about your

joints?

• What joint/ muscle issues keep you from

exercising or being as active as you want?

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A Plan to Move More

• Identify objective problem to address

• Find specific impairments

• Focus plan around specific impairments

• Incorporate regular daily aerobic exercises

• Losing even a little wt can significantly

improve joint symptoms

• Add in weight lifting or resistance training

as this can improve wt loss and health

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• If we had a pill that conferred all

the benefits of exercise, physicians

would prescribe it to every patient.

Our health care system would find

a way to make sure that every

patient had access to this “wonder

drug.”OHSU

Physicians and their Patients• 47% of primary care physicians include an

exercise history as part of their initial examination (self report)

• Only 13% of patients report physicians giving advice about exercise

• Exercise status is rarely a vital sign in chart

• Docs don’t feel effective at exercise promotion- best to connect into community exercise resources: gyms, trainers

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Physicians and their Patients

• Physically active physicians are more likely to discuss exercise with their patients

• 40% of US primary care doctors and 36% of US medical students did not meet federal physical activity guidelines.

• Physically inactive doctors provide less credible role models for the adoption of healthy behaviors.

• Physical activity habits of doctors and medical students influence their counseling practices. Lobelo F, Duperly J, Frank E. Br J Sports Med. 2009 Feb;43(2):89-92.

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How to Write an

Exercise Prescription

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The Physical Activity(PA) Vital Sign

1. assess the current PA level of your patient

2. provide brief advice and/or write an exercise prescription

3. refer your patient to physical activity resources: programs,

places,gyms, professionals, or self-directed resources.

Add two simple questions to the health history form and electronic

health record to determine if the patient is meeting the PA

guidelines:

1. On average, how many days/week do you engage in moderate

to vigorous PA (like brisk walking)? _____ days

2. On average, how many minutes do you engage in PA at this level?

_____ minutes

Total Activity (days/week x minutes/day) = ____ minutes/week

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Rx Exercise: Be “FITT”

Frequency

Intensity

Time (duration)

Type

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Frequency

• 5 days a week

• More is even better!⚫Dose-response curve!

⚫Getting off the couch makes the most benefit

⚫Avoiding excessive inactivity also a goal

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Dose-response Curve for Exercisemost improvement is getting off the couch

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Intensity

• Moderate Exercise

⚫Equivalent of BRISK WALK

⚫Noticeably accelerates HR

⚫Able to walk & talk but not sing

⚫ “talk test”

⚫RPE 4-6 out of 10

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Exercise Intensity:

Relative Perceived Exertion( RPE)

Use 1-10 Scale

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Examples of Moderate Intensity

• Brisk walking

• Household cleaning: vacuum, mop, wipe

• Mowing lawn

• Shooting hoops

• Recreational badminton

• Ballroom dance

• Golf & pulling clubs

• Leisurely sports

• Leisurely biking, swimming

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Intensity

• Vigorous Exercise

⚫Equivalent of running

⚫Fail “talk test”

⚫RPE 7-10 out of 10

⚫Vigorous activity counts

2x as much as moderate:

75 min vs 150 min/ wk

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Examples of Vigorous Intensity

• Running

• Shoveling

• Heavy farming

• Competitive sports

• Cross country skiing

• Intense biking, swimming

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Time (Duration)

• Accumulate 30

minutes a day⚫ Add all minutes

• More is better!

• 150-300 min/ week

• Or 75 min of vigorous

activity

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TypeAerobic Activity -AND-

Muscle StrengtheningOHSU

Muscular Strengthening

• Exercise large muscle groups

• 10-15 reps; should fatigue by last rep

• Rest 2-3 minutes between exercises

• 1 set good, 2 sets better

• Rest day in between

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The Exercise Prescription:

Be “FITT”⚫Frequency: 5 days a week (or more)

⚫ Intensity: moderate intensity,⚫ 5-6 on 10 scale. 60% of max HR ( 220-age)

⚫Time: 30 minutes aerobics (all minutes add up)

⚫150 min moderate/wk

⚫75 min vigorous/wk

⚫Type: ⚫Aerobic activity

⚫Muscular strengthening activity (at least 2 x wk)

⚫Flexibility activity (in elderly/sick)

⚫Balance training (if fall risky)

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Strategies to improve adoption

and adherence to prescribed

exercise programs- ACSM

• Behaviorally based exercise interventions

• Use of behavior change strategies

• Involve an experienced fitness instructor

• Choose pleasant and enjoyable exercises

• Exercise in the morning- scheduled time

• Exercise with friends - accountability

• Wearable monitors help starting exercise only

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Behavioral Readiness- Transtheoretical Model of

Behavior Change can help focus counseling.

For individuals in precontemplation (no intention to become

more physically active), discussing the health benefits of regular

PA; exploring doubts, misconceptions, and myths about PA; and

addressing barriers and facilitators for increased PA will be more

appropriate than providing a specific PA prescription now.

For individuals in contemplation and preparation (thinking about

becoming physically active and have made small changes but not

sustained yet to meet guidelines), a written PA prescription using

the FITT principle (recommended frequency, intensity, time, and

type of PA) with or without a referral to a trusted exercise

professional/program constitutes an appropriate step.

CirculationVol 137, Issue 18, 1 May 2018

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What about Children/Adolescents?

• 60 minutes or more of physical activity

every day

⚫ Mostly moderate or vigorous

⚫ Vigorous activity at least 3 days/wk

• Strength building exercise

• 3 days/wk

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What about Older Adults >65,

or those with chronic diseases?

• Aerobic exercise: same

• Strength exercise: same

• Slightly lighter weights

• Flexibility exercise 2 days/wk, 10 min

• Balance training to decr risk for falls, 3x/wk

Nelson ME et al. Physical activity and public health in older adults:

Recommendation from the ACSM and the AHA.

Med Sci Sports Exer 2007;39(8):1435.

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OHSU Medical Exercise Program

Medical Exercise Program includes: Nearly 1000 patients a year

• Enrollment with intake based on current physical capabilities

• march wellness & fitness center membership

• Personal training session

• Supervised group fitness classes (march ahead)

• Motivational education classes: MEP Essentials, Orthopedic Joint, Nutrition, and Disease Specific*

• Email check in and encourage journaling diet, exercise, and emotion on FitDay

• Outtake and next step plan with results sent to referring clinician

The medical exercise consultant supervises all aspects of participant's program.

*Diabetes (in partnership with Harold Schnitzer Diabetes Health Center)

*Cardiovascular Risk Reduction

*Weight Reduction & Bariatrics (in partnership with Bariatrics clinic)

*Cancer

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MEP Referral & Cost

EPIC

Enter “Consult to medical exercise program” in the order entry window.

Enter any special instructions.

Use the DOT phrase “.medicalexerciseprogram” in the after visit

summary to give instructions to patients on how to access the program.

• Can also use .march or .exercise or .fitness

3 month program: $400

OHSU Patients receive 50% discount: $198

About $65/ month

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EPIC After Visit Summary

Exercise is Medicine!

Exercise is a key component of a complete healthcare plan.

Current guidelines recommend that you exercise at least 5 days a week for an

average of 30 minutes a day or 150 minutes a week of moderate exercise.

We realize that most Americans do not meet these goals so we would like to

help you!

We have provided you some tools below to help you achieve these fitness goals.

1. The FITT Exercise Prescription

2. OHSU Medical Exercise Program

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EPIC After Visit Summary

F Frequency 5 or more days a week

I Intensity Moderate exercise means you can walk and talk but not sing.

T Type Activities like gardening, yard work or climbing stairs is as good as walking, running or cycling.

T Timing Even 10 minutes of exercise multiple times a day can add up to give results!

FITT Exercise Prescription

Exercise is Medicine!

Exercise is shown to improve your health as good as most medicines! Make a

commitment with yourself to start exercising regularly today! Schedule

exercise on your calendar like other important meetings to assure it fits into

your busy day. You will feel better, healthier and reduce your risk of disease.

If you need help or don’t know where to start, OHSU has developed a

successful program to get you moving.

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EPIC After Visit Summary

OHSU Medical Exercise Program ( MEP)

On the recommendation of your health care team, you have an opportunity to improve

your fitness by participating in the OHSU Medical Exercise Program. We will assess

your current health status, health & wellness goals, and establish an exercise prescription

and action plan.

The program and your success focus on these essential pieces:

Individual & group exercise

Three appointments with an exercise specialist

Motivational education classes

Program Overview

If you want more information, please schedule an appointment to review the program.

In person: OHSU Center for Health and Healing

Phone: 503.418.6272

Email: wallacea@ohsu.edu

Not in the area? Ask about the Medical Exercise 2GO Program.

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Take Home Pearls

• Exercise is the best “medicine” around

• Assess physical activity in ALL patients- PA VITAL SIGN

• Only RARE patients need cards/stress test before exercise

• Restrict pts only with symptomatic CV/pulm/ metabolic dz

• The Prescription is: Be “FITT”

⚫ Frequency: 5 days a week (or more)

⚫ Intensity: moderate intensity, 3-6 on 10 scale

⚫ Time: 30 minutes aerobics ( accumulate all day)⚫ Or 75 min of vigorous activity

⚫ Type: ⚫ Aerobic activity

⚫ Muscular strengthening activity- 2 days a week

⚫ Flexibility activity (in elderly/sick)

⚫ Balance training ( in elderly to reduce fall risk)

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Finally….Start/ continue to be an Exercising Example

for your friends, family and patients!

EXERCISE IS MEDICINE!Jim Chesnutt MD Sports Medicine, Chesnutt@ohsu.edu 503-494-1950

Medical Director, OHSU March Wellness and Fitness Center

https://www.ohsu.edu/march-wellness/programs-services

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Exercise Guidelines Key ReferencesExercise is Medicne Website & Fact Sheet www.exerciseismedicine.org

https://exerciseismedicine.org/wp-content/uploads/2021/02/EIM-Fact-Sheet.pdf

Thompson PD, Baggish AL, Franklin B, Jaworski C, Riebe D. ACSM expert

consensus statement for screening, staffing and emergency policies to prevent

cardiovascular events at health fitness facilities. Curr Sports Med Reports.

2020;19(6):223–31.

U.S. Department of Health and Human Services. Physical Activity Guidelines for

Americans. 2nd ed. 2018. Available from: https://health.gov/sites/default/files/2019-

09/Physical_Activity_Guidelines_2nd_edition.pdf

2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity

Guidelines Advisory Committee Scientific Report. Washington (DC): U.S.

Department of Health and Human Services; 2018. Available from:

https://health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf

For references related to the effectiveness of various clinical implementation strategies, see the

citation list from the 2018 Scientific Statement from the American Heart Association:

https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000000559

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