Exercise Intervention Intervention in Healthcare

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Exercise Intervention in Healthcare (English English)) Sport’s role as a treatment tool applied to Healthcare

Ezequiel R. Rodríguez Rey, M.D. C.S. Ma. Ángeles López Gómez Leganés, Madrid

Panama Olympic Committee FIE Medical Commission

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Gro Harlem Brundtland, World Health Organization Director General 2002: «The recent WHO initiative considering physical activity as an integral part of its program to fight the burden on world morbidity of non-infectious diseases has special relevance, as it is rising in the delevoped as well as in the underdeveloped world. This initiative represents a new challenge, as well as at the same time, an extraordinary opportunity for the Sports world as a whole and for Sports for all in particular. In order to fight the rise of non-infectious diseases, the WHO compells to focus more on physical activity. All people, groups, Healthcare professionals, teachers and urban planners must grant it full priority. In turn, chronic disease ailments and long-term Healthcare costs will be reduced.».

Healthcare Tools  Epidemiology  Basic Science Research  Clinical Research (medical-surgical)  Technological Research and Innovation  Public Health Research  Healthcare Management Research  Drug and Pharmacological Research  Clinical Applications  Protocol Reviews  Preventive Medicine (Health Education;) ERRR2015

Preventive Medicine 

A basic task in Primary Care is the “continued education” of the patient. The better informed and educated our patients are, - the better knowledge of Health and Healthcare they will enjoy. - the better use it will make of available resources. - the better habits they will have. - improvement of the measurable population Health parameters. - transferral of the concept of “shared responsibility in Healthcare”:

“Health, as a plant, will bear flowers and fruit, if it is sewn, cared for, fertilized, pruned and irrigated”.

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Prevention Levels 



 



The WHO defines 3 levels of prevention as goals: Primary, Secondary and Tertiary Prevention, which suppose different techniques and targets, when considering as standard the combination of Health-illness, according to the aimed individual’s, group’s or community’s health status. – Primary prevention: avoids the illness itself (vaccinations, elimination and control of enviromental risks, health education, etc.). Prevents the illness or harm to healthy individuals. – Secondary prevention: directed towards detecting disease in early stages in which establishing appropiate measures may hinder its progression. – Tertiary prevention: includes all measures directed towards treatment and rehabilitation of an illness to slow its progression and thus the occurrence of or the deterioration of complications an impairment, trying to improve the patient’s quality of life. On occassions we speak of quaternary prevention when having to deal with relapses. ERRR2015

Social Habits and Factors which favor Chronic Illnesses of Health Relevance            

Overingestion /Malnutrition Sedentarism Work stress Sleep disorders Alcohol Drug abuse Enviromental pollution Climate change Economic instability Life expectancy Expectations placed in Medicine Health Management models ERRR2015

The Role of Sport in Society

¿Which functions does Sport have to meet?  Healthcare  Physical Exercise  Leisure acivity  Physical Education  Individual global education  Competitive sport  Professional or high-Competition sport  ¿What do we do? ¿Why do we do it? ¿How do we do it? We are EDUCATORS.

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Physical activity activity// Sport  Basic physical activity  Regular exercise  Regular sport / Leisure  Competitive Sport  High-level or professional Sport

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Initial Premises  General State policy: establishing priorities and the role of Healthcare in society,

planning, goals, budget, quality control.  Healthcare and established social status: relevance, knowledge and potential.  Sport and established social status: relevance, knowledge and potential.  Material means: State, Public Administrations, Citizens’ Associations, sport

associations – Sport venues and urban development.  Human Resources: qualified and motivated Healthcare and Sports personnel.  Planning and Coordination: Goals, Methodology, Timetable, Quality Control.  Exposure: media, social networks, citizens’ initiatives.  Social mass: to motivate each citizen to take over and participate in his/ her own

Healthcare.

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Identifying Goals Goals,, Conceptual Tools and Methodology Methodology,, Role of Medical Services aiding Population

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Social--Healthcare Coordination Social Political Direction Strategic Policy Design Design,, Budgets,, Budgets Promotion and Advertising

Healthcare Direction Strategic Policy Design Design,, Planning,, Planning Promotion and Advertising

Primary Care Care,, Specialized Care Technical Personnel Technical Planning Planning,, Coaches

Health Control, Health Education Program Design and Supervision

Patients,, Population Patients Health Education Education,, Partaking in Healthcare ERRR2015

Systems experiencing a positive modification through Exercise            

Cardiovascular Respiratory Digestive tract Metabolic--Endocrinologic Metabolic Neurologic Musculoskeletal Syst Syst.. Inmunologic Dermatologic Mental Health – Drug Abuse Adaptation disorders Sexual Health Social Skills ERRR2015

Healthcare Team – Patients Coordination Therapeutic Start Identification of health problems

Clinical record and collection of parameters Communication of results

Medical tests Design of individual exercise program Periodic controls of partial goals Annual program control

Explaining the whys and hows of the program Periodic communication of results to foster adherence Shared review of goals, “quality control”

End of programed cycle

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Chronic Illnesses Illnesses,, Frequent Pathology

          

Obesity Hypertension Cardiovascular disease Diabetes mellitus Asthma / CPOD Dyslipemias Digestive tract malfunction Arthromyalgies Depressive Sd. Sleep disorders Psycological stress ERRR2015

Conceptual Frame of Exercise as a Health Tool

 Exercise Adaptation  Cardiovascular and Respiratory Physiology  Digestive tract and Metabolism Physiology  Musculoskeletal physiology and Neurophysiology  Treatments and Rehabilitation  Sports Psychology (Motivation, Coordination)  Collective Education

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Exercise Physiology I First Law of Thermodynamics “Energy is whether created nor destroyed, but merely transformed.” Energy contained in foods is not immediately converted into heat, but is more conserved as chemical energy and then transformed into mechanical energy through the musculoskeletal system, being only then transformed into heat.

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Exercise Physiology II Biologic Work in Humans Mechanical work: - muscle fiber contraction turns chemical energy into mechanical energy. - Contractile elements in the nucleus pull at the chromosomes to initiate cellular division. - Cilliary elements in diverse parts of the body: respiratory tract, cochlea, etc. Chemical Work: - carried out by all acells and tissues for their growth and homeostasis. Biosynthesis. Transport work: not required in passive processes (diffusion) - Active transport: from one area to another against a dilutional gradient (renal tubuli, cellular membranes, etc.)

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Exercise Physiology III Energy Transmission in the Human Body Foods (Carbohydrates, Fats and Proteins) transfer their Energy (E) in a gradual manner through complex enzyme-controlled reactions. This allows for greater efficiency in energy transfer. - Approximately 40% of the potentially contained E in food is transferred into the ATP compound (Adenosin triphosphate). When the terminal link is broken, E is liberated to fuel all types of biologic work. “Molecular unit of currency ”. - Creatine phosphate (CP) interacts with ADP (Adenosine biphosphate) to form ATP, thus becoming the reserve from which to rebuild ATP. - Oxidative phophorylation is the process through which E is transferred in the form of phosphate links. Thus, ADP and Creatine are continuously recycled into ATP and CP. - Cellular oxidation takes place in the mitochondria and supposes electron transfer from H+ to the molecular O2. This means the liberation of E and the transfer of chemical E to build high-energy phosphate compounds. - In the aerobic resynthesis of ATP, the main function of O2 is to be the final electron acceptor in the respiratory chain and to combine with H+ to form H2O. ERRR2015

Exercise Physiology IV Energy Liberation of Food - Glycolysis: 2 ATP molecules are built in the cellular cytoplasm in the anaerobic process of phosforylation at the substrate level. - At the second stage of Carbohydrate (CH) metabolism in the mitochondrial complex, pyruvate is converted into en Acetyl-CoA, which is then processed through the Krebs Cycle. The through glucose-metabolism liberated Hydrogens are oxydated through the respiratory chain pathway and the generated E is linked to the phosphorylation. - In striated muscle, CH metabolization produces 36 ATP molecules. - When the H+ atoms are metabolized at the same rate they are produced, a stable stage (“steady state”) is reached. During intense exercise, an excess of H+ atoms is produced, which is combined with pyruvate to form Lactic acid. - Fatty acids metabolism is directly associated to O2-consumption, so their reactions are aerobic. - Proteins are also a source of E. After removing N from the aminoacid molecule (deamination), the remaining carbon skeleton can enter the Krebs Cycle to produce ATP through the aerobic pathway. - A certain level of CH metabolization is required to process fats in a continued manner: “fats are burned in a CH flame”. ERRR2015

Exercise Physiology V Energy Transfer during Exercise - The prevailing ATP-producing pathway is different according to each performed exercise (type and duration) .

;;;...... Different

;..fuels ERRR2015

Exercise Physiology VI Energy Transfer during Exercise - The prevailing ATP-producing pathway is different according to each performed exercise (type and duration) . - Intense Exercise: (short and quick sprints, weights) E is drawn from the intramuscular ATP and CP reseves (immediate E system). - If exercise lasts 1-2 min., E is generated from anaerobic glycolitic reactions (short term system). - If exercise lasts > several minutes, the aerobic system will prevail and O2 consumption becomes an important factor (long-term E system). - Human beings have different types ofe muscle fibers, each with its own metabolic and contractile qualities: * Slow-contracting fibers, low glycolisis and high oxidation. * Rapid-contracting fibers, high glycolisis and low oxidation. * Rapid-contracting fibers with mixed metabolism. - Understanding the energetic exercise spectrum, specifically directed work can be precisely honed to the chosen clinical target and energy system. ERRR2015

Exercise Physiology VII Energy Transfer during Exercise - A stable phase (“steady state”) of O2-consumption means a balance between muscular energy expenditure and aerobic ATP resynthesis. The difference between O2 needs and O2 consumption is called oxygen debt. - The maximal aerobic capacity for ATP resynthesis is measured quantitatively as maximum O2 consumption/ uptake or max VO2. It is one of the important indicators for the individual exercise capacity. - After exercise, O2 consumption is kept high above the resting level. This recovery O2 uptake reflects the metabolic characteristics of the performed work, as well as the physiologic changes it brings about. - Moderate exercise carried out during this recovery phase (active recovery) facilitates the whole process, as opposed to more passive measures. This reflects in the majority of cases as an earlier lactate metabolization.

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“¿Do we want to be healthy or look the like?” like?”

 ¿What importance does Health have in my life?  ¿What do we strive for?  ¿What means are at our reach?  ¿How are we to achieve this?  ¿In which period of time do we plan to do it?  ¿Are we willing to work towards this goal?

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Shared responsibility of the patient in his/ his/her state of health and motivation to actively participate in its maintenance and improvement:: improvement

“SELF--IMPROVEMENT IS POSSIBLE” “SELF

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Obesity   







One of the great epidemics of developed societies, it keeps a close relationship with sedentary habits, stress and excessive- /malnutrition. BMI > 30 Kg/m2 . It prevails among urban populations, but affects all age groups, inadequate balance between activity/ caloric intake. “Miracle diets” should be avoided. Improvement of the weight/ waist perimeter in the periodic follow-up of exercise in all age groups, adjusting training loads to each: aerobic exercise, low intensity, prolongued duration (>45 min.). Installing exercise habits must be gradual, but methodic; initially 3-4 sessions/ week,15-20 min., progressing up to 45-60 min. It is the most difficult part: overcoming resilience. Improvement with this system of adaptation to newhabits, without overexertion, with cardiac and pulmonary capacity progression, of fatty acids mobilization as fuel, minimizing injuries due to overweight. The improvement must be registered to help motivate this group of patients. Distrust “miracle methods”. ERRR2015

Hypertension

 Another of the great apidemics, it bears a close relationship with stress and     

excessive fat dietary intake. It affects young adults and a growing group beginning with the 4th decade of life onwards. Improvement of systolic and diastolic values, adequating training loads: aerobic exercise, low-medium intensity, medium-prolongued duration (>45 min.). The establishment of an exercise habit must also be gradual, but methodic; initially 3-4 sessions/ week,15-20 min., progressing up to 45-60 min. Improvement of the cardiovascular system withthis program of adaptation to the new habit, without overexertion, with progression of cardiac capacity. The improvement must be recorded (Ambulatory blood pressure monitoring, ABPM), thus helping motivate this group of patients.

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Cardiovascular Disease I  Improvement of cardiac output in the healthy heart, of the Ventricular Ejection

Fraction (VEF), of the miocardic vascularization and of coronary collaterals (aerobic exercise, aerobic/ anaerobic, low, medium and high-intensity).  Improvement of the exercise adaptation in all age groups, adjusting training (aerobic exercise, aerobic/ anaerobic, low, medium and high-intensity).  Symptomatic Congestive Heart Failure (CHF): improvement of prognosis and evolution with resistance exercise; weight reduction; increase in vagal tone, decrease in sympathetic activation, improves muscle strength, vasodilatative capacity, corrects endothelial dysfunction and decreases oxidative stress. Metaanalysis: decrease in mortality, as well as in number of hospital admissions. Class IIa recommendation, C Level of Evidence.  Stable CHF: regular exercise contributes to the improvement of all stable chronic patients. There is no evidence that itshould be limited to any subgroup of patients (ethiology, NYHA grade, LV ejection fraction, medication). Work programs can be carried out at home or in wards. Class I recommendation, B Level of Evidence. ERRR2015

Cardiovascular Disease II

 Weight reduction (BMI