GIORGIO GALANTI LAURA STEFANI Scuola di Specializzazione di Medicina dello Sport

1. “VALUTAZIONE FUNZIONALE E PRESCRIZIONE DELL’ESERCIZIO FISICO IN SOGGETTI PORTATORI DI PATOLOGIE CRONICHE” Montecatini 10 Dicembre 2012 AMSE Prescrizione dell’esercizio fisico nei soggetti affetti da patologie croniche: una nuova frontiera per la Medicina dello Sport GIORGIO GALANTI LAURA STEFANI Scuola di Specializzazione di Medicina dello Sport Agenzia di Medicina dello Sport E dell’Esercizio

2. Perché l’esercizio?

3. Piramide delle età nel 2050 60-85 anni Europa 60-85 anni Italia

4. Theoretical relation between musculoskeletal fitness and independent living across a person’s lifespan Thresold for dependence

5. The normalage-associateddecline in cardiovascular performance CMAJ • March 14, 2006; 174(6)

6. The normalage-associateddecline in cardiovascular performance Ath NAth J ApplPhysiol 82:1508-1516, 1997

8. Cosa sappiamo riguardo all’esercizio • Necessario per lo stato di salute • Riduce i rischi per molte malattie • Favorisce la salute ed una buona indipendenza nell’età avanzata • Componente chiave nella gestione di malattie croniche

9. Relationship between exercise capacity, expressed as METs, and 1-yr total health care costs in the year following the treadmill test.

10. WHO

11. Definitions of concepts used in the recommended levels of physical activity • Type of physical activity (What type). The mode of participation in physical activity. The type of physical activity can take many forms: aerobic, strength, flexibility, balance. • Duration (For how long). The length of time in which an activity or exercise is performed. Duration is generally expressed in minutes. • Frequency (How often). The number of times an exercise or activity is performed. Frequency is generally expressed in sessions, episodes, or bouts per week. • Intensity (How hard a person works to do the activity). Intensity refers to the rate at which the activity is being performed or the magnitude of the effort required to perform an activity or exercise.

12. Volume (How much in total). Aerobic exercise exposures can be characterized by an interaction between bout intensity, frequency, duration, and longevity of the programme. The product of these characteristics can be thought of as volume. • Moderate-intensity physical activity. On an absolute scale, moderate intensity refers to activity that is performed at 3.0–5.9 times the intensity of rest. On a scale relative to an individual’s personal capacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10. • Vigorous-intensity physical activity. On an absolute scale, vigorous intensity refers to activity that is performed at 6.0 or more times the intensity of rest for adults and typically 7.0 or more times for children and youth. On a scale relative to an individual’s personal capacity, vigorousintensity physical activity is usually a 7 or 8 on a scale of 0–10. • Aerobic activity. Aerobic activity, also called endurance activity, improves cardiorespiratory fitness. Examples of aerobic activity include: brisk walking, running, bicycling, jumping rope, and swimming. Moderate-intensity physical activity. On an absolute scale, moderate intensity refers to activity that is performed at 3.0–5.9 times the intensity of rest. On a scale relative to an individual’spersonalcapacity, moderate-intensity physical activity is usually a 5 or 6 on a scale of 0–10.

13. Scala di Percezione della Fatica

14. Public HealthSignificanceOf Physical Activity • It is estimated currently that of every 10 deaths, 6 are attributable to NCDs • Physical inactivity is estimated as being the principal cause for approximately 21–25% of breast and colon cancer burden, 27% of diabetes and approximately 30% of ischaemic heart disease burden In addition, NCDs now account for nearly half of the overall global burden of disease.

15. LeadingRiskFactor for Global Mortality (%)

16. Global Recommendations on Physical Activity for Health • Cardiorespiratory health (coronary heart disease, cardiovascular , stroke and hypertension) • Metabolic health (diabetes and obesity) • Musculoskeletal health (bone health, osteoporosis) • Cancer(breast and colon cancer) • Functional health and prevention of falls • Depression

17. Healthy adults aged 18-65 years • These guidelines are relevant to all healthy adults aged 18–64 years unless specific medical conditions indicate to the contrary. • Pregnant, postpartum women and persons with cardiac events may need to take extra precautions and seek medical advice before striving to achieve the recommended levels of physical activity for this age group. • Inactive adults or adults with disease limitations will have added health benefits if moving from the category of “no activity” to “some levels” of activity.

18. Adults aged 65 years and above should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorousintensityactivity. • Aerobic activity should be performed in bouts of at least 10 minutes duration. • For additional health benefits, adults aged 65 years and above should increase their moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous intensity aerobic physical activity per week, or an equivalent combination of moderate-and vigorous-intensityactivity. • Adults of this age group, with poor mobility, should perform physical activity to enhance balance and prevent falls on 3 or more days per week. • Muscle-strengthening activities should be done involving major muscle groups, on 2 or more days a week. • When adults of this age group cannot do the recommended amounts of physical activity due to health conditions, they should be as physically active as their abilities and conditions allow. Healthy adults aged65 years and above

19. For adults of this age group, physical activity includes recreational or leisure-time physical activity, transportation (e.g walking or cycling), occupational (i.e. work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities. In order to improve cardiorespiratory and muscular fitness, bone health and reduce the risk of NCDs and depression the following are recommended: • Adults aged 18–64 should do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week or an equivalent combination of moderate- and vigorous-intensity activity. • Aerobic activity should be performed in bouts of at least 10 minutes duration. • For additional health benefits, adults should increase their moderate-intensity aerobic physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity aerobic physical activity per week, or an equivalent combination of moderate- and vigorous-intensity activity. • Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

20. Overall, across all the age groups, the benefits of implementing the above recommendations, and of being physically active, outweigh the harms. • At the recommended level of 150 minutes per week of moderateintensityactivity, musculoskeletal injury rates appear to be uncommon. • In a population-based approach, in order to decrease the risks of musculoskeletal injuries, it would be appropriate to encourage a moderate start with gradual progress to higher levels of physical activity. AMSE

21. No strategies have been adequately studied to evaluate their ability to reduce exercise-related acute cardiovascular events. • Maintaining physical fitness through regular physical activity may help to reduce events because a disproportionate number of events occur in least physically active subjects performing unaccustomed physical activity. • Other strategies, such as screening patients before participation in exercise, excluding high-risk patients from certain activities, promptly evaluating possible prodromal symptoms, training fitness personnel for emergencies, and encouraging patients to avoid high-risk activities, appear prudent but have not been systematically evaluated.

22. Physiological alterations accompanying acute exercise and recovery and their possible sequelae.

23. The focus of the Global Recommendations on Physical Activity for Health is primary prevention of NCDs through physical activity at population level • the primary target audience for these Recommendations are policy-makers at national level.

24. Global Recommendations on Physical Activity for Health • Cardiorespiratory health (coronary heart disease, cardiovascular , stroke and hypertension) • Metabolic health (diabetes and obesity) • Musculoskeletal health (bone health, osteoporosis) • Cancer(breast and colon cancer) • Functional health and prevention of falls • Depression

25. But,exercise…..

26. Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons.

27. Relative risk of MI associated with vigorous exertion (>6METs) according to habitual frequency of vigorous exertion.

28. "The paradox of physicalexercise" • Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons. • Exercise-associated acute cardiacevents generally occur in individuals with structural cardiac disease. Hereditary or congenital cardiovascular abnormalities are predominantly responsible for cardiac events among young individuals, whereas atherosclerotic disease is primarily responsible for these events in adults. Herz 2006;31:553-8

31. Risposta cardiovascolare all’esecizio acuto

32. Fase preparatoria iniziale Stimolazione adrenergica Vasocostrizione distrettuale • Fase intermedia metabolicaFattori locali Stimolazione adrenergica

33. FactorsAffectingNeural Control of CardiovascularFunction

34. 25% Radius 63% Area Vasoconstriction (Acute Exercise) No Ischemia AMSE Exercise,Vasoconstrictionand Coronary Flow in normal

35. 25% Radius 63% Area Vasoconstriction (Acute Exercise) No Ischemia 17% Radius 96% Area Ischemia Exercise,Vasoconstrictionand Coronary Flow

36. 1% 4% 5% 4% Rest 3-5 Lmin Exercise 25-30 Lmin Distribution of Flow at rest and during Acute Exercise

37. Exercise and Blood Pressure in normal and hypertensive subjects Peak P.A. Watts

38. Chronic Cardiac Adaptation to Exercise • Morphological • Myocardial • Vascular • Functional • Neural AMSE

39. Dynamic and static exertion Dynamic or isotonicactivity:physicalexertioncharacterized by rhytmic,repetitivemovements of large musclegroups Isometric or staticactivity:physicalexertioncharacterized by sustainedmusclecontractionagainst a fixedload or resistance with non change in length of the involvedmusclegroup or joint motion

41. Evidence regular physical activity contributes to the primary and secondary prevention of several chronic diseases and is associated with a reduced risk of premature death. There appears to be a graded linear relation between the volume of physical activity and health status, such that the most physically active people are at the lowest risk. However, the greatest improvements in health status are seen when people who are least fit become physically active. EvidenceBased Sport Medicine D.MacAuley,T.B Best 2006

42. Global Recommendations On Physical Activity For Health Recovery • Cardiorespiratory health (coronary heart disease, cardiovascular , stroke and hypertension) • Metabolic health (diabetes and obesity) • Musculoskeletal health (bone health, osteoporosis) • Cancer(breast and colon cancer) • Functional health and prevention of falls • Depression

43. L’esercizio nella prevenzione delle malattie • Malattiecoronariche / Ictus • Obesità e Diabete di tipo 2 • Demenza • Depressione • Alcuni tumori • Osteoporosi

44. Review article Kujala UM Evidence of the effects of exercise therapy in the treatment of chronic disease. Br J Sports Med 2009; 43: 550-555. Sponsored by:

45. Exercise is medicine ‘the benefits of regular physical activity on health, longevity and wellbeing easily surpass the effectiveness of any drugs or other medical treatment.’ Sir Liam Donaldson

46. ‘‘In a word, allparts of the body whichwere made for active use, ifmoderatelyused and exercisedat the labor to whichthey are habituated, becomehealthy, increase in bulk, and bear theirage well, butwhennotused, and whenleftwithoutexercise, theybecomediseased, theirgrowthisarrested, and theysoonbecomeold.’’ HyppocratesMedicine’sview of exercisedidnot progress much in the subsequenttwomillenia, and exercisewasprimarilyviewedas an activity for healthypeople, butnot for the chronically ill. The use of exerciseas a medical treatment is an oldconcept, but onethatdidnot start gainingacceptanceuntil the 20th century. Today, exercisescientists are exploring the limits of exerciseas a therapy—of exerciseas a medicine. Br J Sports Med 2004;38:6–7.

47. The first recordedanecdote of exerciseas a treatment for heartdiseaseisthought to be from William Heberden,whowrote of a man with angina pectoris in 1772: ‘‘I knew of onewho set himself the task of sawingwoodforhalf an hour everyday, and wasnearlycured’’.Ironically, Heberdendidnotknowthat angina pectoris is a cardiacdisorder.‘‘ Physicians of the 1800s wereinterested in the role of exercise in maintenance of health, but the modernnotion of exerciseas a medicaltreatmentisthought to haveoriginated with R TaitMcKenzie. McKenzieperceivedexerciseas a technique to rehabilitatepeople with disablinginjuries’’ William Osler, in the 1909 edition of The principles and practice of medicine, wrotethat bed rest and bathsatspaslikeBadNauheimwere the optimal treatment for heartdisease. In 1939, Paul Dudley White, the first cardiology professor at Harvard Medical School, co-authored a manuscriptshowingcardiacdilatationthroughaneurysmformationaftermyocardialinfarction, and thiswasusedas an argumentagainstexerciseaftermyocardialinfarction. By 1958, Dr White hadchangedhisviews and coauthored a textbook on cardiacrehabilitation in whichlowlevelexercisewaspromoted.Then in 1968, the concept of bed restwasfinally put to rest by the landmarkpaper of BengtSaltin et al. In 60 years, physicianshadlearnedthatexercisewasuseful in rehabilitation of people with bothmusculoskeletalinjuries and cardiovasculardisease. ‘‘Ourcurrentunderstanding of exerciseprescriptionislimited for mostchronicdiseases’’

48. Il concetto di “esercizio fisico come terapia”, nato in America già dal secolo scorso, si identifica con la pratica regolare e costante di questo, opportunamente stabilito e dosato come “intensità, frequenza e durata”, all’interno di un atto medico diagnostico – terapeutico complesso del quale la Medicina dello Sport, come disciplina internistica, ha la piena ed esclusiva competenza. • La prescrizione dell’esercizio quindi ha effetti positivi sulla salute attraverso azioni specifiche sui meccanismi della malattia stessa , che rappresenta, a differenza dell’Attività Fisica Adattata, un atto sanitario con finalità terapeutiche.

49. L’esercizio nella curadelle malattie • Osteoartrite • artriteReumatoide • Spondiliteanchilopoietica • Fibromialgia • Malattiacoronarica • Ipertensione • Ictus • Obesità & Diabete di tipo 2 • Asma • BPCO • Malattia di Parkinson • SclerosiMultipla • Cancro del Seno e dell’Intestino • Depressione

50. Physicalactivity/exerciseastheraphy:Mechanisms of Action Body fat Visceralfat Liverfat Physical fitness (aerobic fitness and muscularstrength) Posittivechanges in skeletalmusclestructurefunction and metabolism Insulinsensityvity Parasympathetictone Peripheralresistance Heartstructure And function Inflammation Glicemic control in insulinresistance Electricalstability of the heart Blood pressure HDL2 Cholest Risks of type 2 of Diabete Mell Plateletagggregation Risk of life threateningarithmias Atherosclerosis Risks of ischemicstroke Neurotropic effects Risks of Dementia Risks of myocardialinfarction Risk of disability Risk of death BrithMed Sport J 43 2009