Professional Documents
Culture Documents
“Exercise Prescription”
Jim Chesnutt, M.D.
OHSU Sports Medicine
Medical Director
OHSU march wellness & fitness center
The Problem of Inactivity
Nearly half of U.S. adults do not meet the recommendations for aerobic
physical activity
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Nearly one-third (30 percent) report doing less than 10 minutes of moderate-
to-vigorous physical activity per week.
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Exercise is Medicine!
Exercise is Medicine™
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To make physical activity and exercise a standard part of
a global disease prevention and treatment medical
paradigm.
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GOAL: Exercise is Medicine will be a sustainable global initiative
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• Recommendations
• Benefits
• Contraindication
• Dose, frequency, duration
• The FITT Principle
• OHSU Medical Exercise Program
Physical Activity Recommendations
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• 1995 CDC/ ACSM- first recommendations
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• 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.
Physical Activity Recommendations
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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
ACSM & AHA 2007, HHS 2008,ACSM 2011
HHS,AHA,ACSM 2018, WHO 2020
Physical Activity Recommendations
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Healthy Adults age 18-64
• Aerobic Physical Activity
⚫ Moderate intensity: 150 minutes/wk, OR
⚫ Vigorous intensity: 75 minutes/wk (or a combo)
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HHS 2018
2018
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So do we meet the guidelines?
CDC Behavioral Risk Factor Surveillance System (BRFSS) assessed
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participation in aerobic physical and muscle-strengthening activities
among adults in the US 2008-2018
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increase physical activity.
• 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.
Indications for Exercise
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• Longevity
• Quality of Life
• Socialization
• Weight control
• Disease prevention
• Disease management
• Covid risk: 2-2.5 risk hosp/death if inactive
And others…
Death Prevention:
Attributable Deaths (%) from various
health conditions
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Aerobics Center Longitudinal Study (ACLS), Cooper Institute
•40,842 men; 12,943 women. BLAIR et al.
Strong Evidence of Benefit from
Physical Activity for…
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• Lower risk of: • Prevention of wt gain
⚫ Early death( >50%) • Wt loss w/dieting
⚫ Heart disease
• Improved CardioRsp &
⚫ Stroke
muscular fitness
⚫ Type 2 diabetes
• Prevention of falls
⚫ High blood pressure
• Reduced depression
⚫ Dyslipidemia
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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.
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• Wt maintenance after loss
• Lower risk of hip fx
• Increased bone density
• Improved sleep quality
• Lower risk lung and endometrial Ca
Contraindications for Exercise
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• Acute cardiac event happening now/recent
• Uncontrolled arrhythmia causing sxs
• Severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolism
• Acute myocarditis
• Dissecting aneurysm
Screening needed before participating
in gym or vigorous exercise
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The 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.
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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
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• 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?
A Plan to Move More
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• 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
• If we had a pill that conferred all
the benefits of exercise, physicians
would prescribe it to every patient.
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Our health care system would find
a way to make sure that every
patient had access to this “wonder
drug.”
Physicians and their Patients
• 47% of primary care physicians include an
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exercise history as part of their initial
examination (self report)
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• Physically active physicians are more likely to
discuss exercise with their patients
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The Physical Activity(PA) Vital Sign
1. assess the current PA level of your patient
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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
Rx Exercise: Be “FITT”
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Frequency
Intensity
Time (duration)
Type
Frequency
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• 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
Dose-response Curve for Exercise
most improvement is getting off the couch
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Intensity
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• Moderate Exercise
⚫ Equivalent of
BRISK WALK
⚫ Noticeably
accelerates HR
⚫ Able to walk & talk
but not sing
⚫ “talk test”
⚫ RPE 4-6 out of 10
Exercise Intensity:
Relative Perceived Exertion( RPE)
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Use 1-10 Scale
Examples of Moderate Intensity
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• Brisk walking
• Household cleaning: vacuum, mop, wipe
• Mowing lawn
• Shooting hoops
• Recreational badminton
• Ballroom dance
• Golf & pulling clubs
• Leisurely sports
• Leisurely biking, swimming
Intensity
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• Vigorous Exercise
⚫ Equivalent of running
⚫ Fail “talk test”
⚫ Vigorousactivity counts
2x as much as moderate:
75 min vs 150 min/ wk
Examples of Vigorous Intensity
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• Running
• Shoveling
• Heavy farming
• Competitive sports
• Cross country skiing
• Intense biking, swimming
Time (Duration)
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• Accumulate 30
minutes a day
⚫ Add all minutes
• More is better!
• 150-300 min/ week
• Or 75 min of vigorous
activity
Type
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Aerobic Activity -AND-
Muscle Strengthening
Muscular Strengthening
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• 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
The Exercise Prescription:
Be “FITT”
⚫ Frequency: 5 days a week (or more)
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⚫ 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)
Strategies to improve adoption
and adherence to prescribed
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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
Behavioral Readiness- Transtheoretical Model of
Behavior Change can help focus counseling.
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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.
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• 60 minutes or more of physical activity
every day
⚫ Mostly moderate or vigorous
⚫ Vigorous activity at least 3 days/wk
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• 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
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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
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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.
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EPIC After Visit Summary
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Exercise is Medicine!
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.
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FITT Exercise Prescription
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!
Exercise is Medicine!
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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.
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• 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)
Finally….
Start/ continue to be an Exercising Example
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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
Exercise Guidelines Key References
Exercise is Medicne Website & Fact Sheet www.exerciseismedicine.org
https://exerciseismedicine.org/wp-content/uploads/2021/02/EIM-Fact-Sheet.pdf
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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
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