Strategies for Promoting Physical Activity in Clinical Practice Robert Sallis, Barry Franklin, Liz Joy, Robert Ross, David Sabgir, James Stone PII: DOI: Reference:

S0033-0620(14)00165-0 doi: 10.1016/j.pcad.2014.10.003 YPCAD 626

To appear in:

Progress in Cardiovascular Diseases

Please cite this article as: Sallis Robert, Franklin Barry, Joy Liz, Ross Robert, Sabgir David, Stone James, Strategies for Promoting Physical Activity in Clinical Practice, Progress in Cardiovascular Diseases (2014), doi: 10.1016/j.pcad.2014.10.003

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Strategies for Promoting Physical Activity in Clinical Practice Authors: Robert Sallis1, Barry Franklin2, Liz Joy3, Robert Ross4, David Sabgir5 and James Stone6 Department of Family Medicine, Kaiser Permanente Medical Center, Fontana, CA,

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Cardiac Rehabilitation and Exercise Laboratories, Beaumont Health Center, Preventive Cardiology, Royal Oak, MI Intermountain Healthcare, Salt Lake City, UT

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School of Kinesiology and Health Studies, Queen's University, Kingston, Ontario, Canada

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Mount Carmel Clinical Cardiovascular Specialists, Westerville, Ohio

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University of Calgary, TotalCardiology of Calgary, and Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada Address for Correspondence

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Dr Robert Sallis, Department of Family Medicine Kaiser Permanente Medical Center, 9961 Sierra Avenue, Fontana, CA, 92336, USA; [email protected]

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Abbreviations ACSM – American College of Sports Medicine

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AMA – American medical association

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AMI – Acute myocardial infarction BMI – Body mass index

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CHD – Coronary heart disease CRF – Cardiorespiratory fitness

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CV - Cardiovascular

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CVD – Cardiovascular disease

CVMRI- Cardiovascular magnetic resonance imaging

EHR – Electronic health record

EVS – Exercise vital sign

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EIM – Exercise is medicine

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EBW! – Every body walk

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HCS – Healthcare system or systems

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LWM CPM - Lifestyle and Weight Management Care Process Model METs – Metabolic equivalents NCD – Non-communicable disease PA – Physical Activity PAVS - Physical Activity Vital Sign PCP – Primary care provider SCD – Sudden cardiac death T2D – Type 2 diabetes U.S. – United States WHO – World Health Organization

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WWAD – Walk with a Doc

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Abstract

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The time has come for healthcare systems to take an active role in the promotion of physical activity (PA). The connection between PA and health has been clearly established and exercise

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should be viewed as a cost effective medication that is universally prescribed as a first line

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treatment for virtually every chronic disease. While there are potential risks associated with exercise, these can be minimized with a proper approach and are far outweighed by the benefits.

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Key to promoting PA in the clinical setting is the use of a PA Vital Sign in which every patient’s exercise habits are assessed and recorded in their medical record. Those not meeting the

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recommended 150 minutes per week of moderate intensity PA should be encouraged to increase their PA levels with a proper exercise prescription. We can improve compliance by assessing

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our patient’s barriers to being more active and employing new and evolving technology like

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accelerometers and smart phones applications, along with various websites and programs that

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have proven efficacy.

Key Words: Lifestyle; Health and Wellness; Exercise; Physical Inactivity

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Introduction

Years of observation and research have proven the harmful health effects of a sedentary

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lifestyle. At the same time, it is clear that exercise is a powerful medicine for the primary and

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secondary prevention of virtually every chronic disease, for largely mitigating the harmful effects of obesity and for reducing premature mortality. It has been shown that there is a linear

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relationship between ones physical activity (PA) habits and health status. Individuals who maintain an active and fit way of life are generally healthier and live longer. In contrast, those

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who are sedentary and unfit tend to suffer prematurely from chronic disease and die at a younger age.

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Regardless of whether you study men or women, different ethnic groups, or different age

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ranges (from pediatric to middle age to geriatric patients), those who are active and fit live longer

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and healthier lives. For this reason, all healthcare systems and practitioners should take an active role in promoting PA in the clinical setting. Based on the strength of existing evidence, it is clear that regular PA should be the first line medicine used for both the treatment and prevention of chronic disease. In fact, one is hard pressed to find any disease today that is not helped in some fashion by engaging in regular PA. For this reason, the issue of promoting PA in the clinical setting is not just a primary care issue, but rather should extend to all specialties and branches of the healthcare system (HCS) . Certainly any practitioner involved in the treatment and prevention of cardiovascular diseases (CVDs) should be fully committed to getting their patients more active. The purpose of this article is to review current strategies for promoting PA in the clinical setting and within HCS.

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The Health Benefits of PA The connection between PA and health

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Seminal observations from Jeremiah Morris in 1954 on PA and coronary heart disease

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(CHD) laid the groundwork for recognizing PA as a major determinant of health [1, 2]. It is now readily apparent that the adoption of PA consistent with consensus guidelines provides benefit

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across a wide range of health outcomes. There is also overwhelming evidence to suggest that

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engaging in PA well below the current guidelines also provides substantive health benefit [3-5]. Increasing PA is associated with an improvement in cardiorespiratory fitness (CRF), where CRF

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is a well-established objective measure of one’s health as it relates to disease risk [6]. Increases in PA and improvements in CRF are clearly associated with reduced risk of developing CVD,

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type-2 diabetes (T2D) and all-cause mortality [7, 8]. This reduced risk is observed across all

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weight categories, from normal-weight to overweight and obese individuals [9]. Based on this evidence, the World Health Organization (WHO) recently recognized physical inactivity as the

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fourth leading risk factor of global morbidity and premature mortality [5, 10].

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Fortunately, the economic burden associated with treating non-communicable diseases (NCDs) that occur as a result of inactivity can be substantially reduced by incorporating PA into daily life [11]. However, though numerous trials confirm that cognitive behavioural strategies employed in clinical settings are associated with adoption of PA in most adults [12-14], regardless of age and gender[15, 16], the challenge in developed societies is to sustain PA over the long-term. Incorporating PA into routine daily life in today’s technologically advanced society remains one of the most important challenges to population health. Accordingly, a focus of primary prevention should be on methods for incorporating PA into everyday life for the purposes of reducing NCD risk and improving overall health and wellbeing.

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Inactivity as a public health problem According to the United Nations High Level Meeting on NCDs, diseases that place the

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greatest burden on global health are CHD, breast and colon cancer and T2D, all of which are

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related to physical inactivity [1, 17]. In a recent analysis by Lee et al, approximately 6-10% of NCDs worldwide are caused by physical inactivity [1]. The authors also reported that physical

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inactivity leads to 9% of total premature mortality. However, the most startling discovery from

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this group was that physical inactivity is as detrimental a risk factor as smoking and obesity. This carries considerable weight in Canada and the United States (U.S.), where inactivity is more

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prevalent than all other modifiable risk factors [4, 11]. In 1995, the American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention stated that adults are

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encouraged to get 30 minutes of moderate intensity PA every day in order to optimize health

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benefits. Recently, the ACSM has adjusted these recommendations, recognizing that 30 minutes of moderate-intensity aerobic PA is interchangeable with 20 minutes of vigorous intensity

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aerobic PA. They further stated that one’s daily exercise can be affectively accumulated in 10

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minutes or longer or shorter accumulating bouts[3]. These new guidelines facilitate the incorporation of PA into daily life by acknowledging the health benefit achieved from accumulated brief bouts of daily exercise. In other words, individuals should be informed that 30 minutes of moderate-intensity PA on most days of the week is a target, and not a threshold required for achieving health benefits when increasing PA. Indeed, all forms of PA, be it structured (e.g., exercise performed in a special facility) or unstructured (e.g., activities of daily living) are associated with meaningful health benefits. As the challenges of incorporating prescribed, structured PA are very real for many adults, integrating PA into one’s daily routine

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may likely be the most effective method of reducing physical inactivity and improving overall quality of life and health.

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Cost vs. benefits compared to drugs

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Inactivity has a substantive and growing impact on healthcare costs worldwide. In 2000, a meta-analysis by Katzmarzyk et al calculated that the total attributable cost of physical

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inactivity represents just over 25% of the cost of treating CVD, T2D, and colon and breast cancer

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in Canada [18]. Similarly, Wang et al, reported that in the U.S., inactivity contributed to 22.5% of CVD-related medical expenses [19]. These diseases cost approximately $2.1 billion in Canada

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and $24.3 billion in the U.S. [11, 18], while estimates from Switzerland have shown similar statistics, where direct healthcare costs due to physical inactivity were estimated at 1.58 billion

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Swiss Francs ($1.65 billion U.S.) [11]. Furthermore, these calculations did not include the

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indirect costs of physical inactivity, which include lost productivity in the workplace and the

facilities [18].

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development of illnesses such as anxiety, depression and premature admission into geriatric care

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Fortunately, moderate increases in PA can significantly reduce these costs. A 10% reduction in physical inactivity in Canada would yield a health care savings of approximately $150 million per year, where a similar percentile estimate was found for health care costs in the U.S. [18]. Furthermore, a meta-analysis has shown that brief counselling is a cost effective method to increase leisure time and structured PA for diverse patient groups [20]. Exercise in combination with statin treatment has also been shown to be highly effective at lowering mortality risk in individuals with and without CVD [21, 22]. From 2000 to 2005, statin use in the U.S. nearly doubled and expenditures rose from $7.7 billion to $19.7 billion. Similar findings have been shown in England where from 2001 to 2011 statin use increased five-

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fold with expenditures increasing to 544 million Pounds ($869 million U.S.) [22]. Thus, combining regular exercise with moderate statin use may be a more cost-effective method for

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risk reduction. Currently HCS are shifting from treatment of illness to health promotion with a

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focus on modifiable risk factors [11]. As CHD is the leading cause of mortality worldwide, a key element of prevention is focusing on the risk factors associated with the disease [23]. These risk

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factors, such as physical inactivity, smoking, and poor diet, can be substantively reduced through

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population-based strategies to make healthful behaviours a societal norm [24]. Promoting

on healthcare systems worldwide. Obesity vs. inactivity

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exercise as medicine is a crucial first step in reducing the overall burden of CVD-related illness

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The focus of health care practitioners on the use of regular PA as a treatment strategy for

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obesity has distracted many from the polyvalent benefits associated with regular PA. Though obesity is an established risk factor, physical inactivity and obesity carry similar risk and both are

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comparable risk factors to smoking [1, 25]. Numerous reports have shown that the adoption of

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PA and improved CRF reduces CVD risk regardless of bodyweight [26-30]. Likewise, various treatises have been written on the relationship between PA and obesity. From there a consensus has emerged on two major observations: 1) physically active individuals are at lower risk for allcause mortality than physically inactive individuals regardless of body mass index (BMI); and 2) overweight or obese individuals who are active have as low and often lower risk of morbidity and mortality than normal-weight sedentary individuals [25, 28, 30]. Though the risks associated with obesity per se should not be overlooked, the importance of adopting PA as a strategy for improving overall health is of paramount importance and should be encouraged independent of age, gender or race regardless of BMI.

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The Risks of PA Although numerous epidemiologic studies suggest that structured exercise, increased

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lifestyle PA, or moderate-to-high levels of CRF may protect against the development of

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cardiovascular disease CVD and other chronic diseases, exertion-related CVD events, including acute myocardial infarction (AMI), sudden cardiac death (SCD), and stroke, as well as various

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musculoskeletal complications, have been reported in the medical literature and the lay press

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[31-33]. This section reviews the pathophysiological basis for exercise-related untoward events, with specific reference to AMI and SCD, cardiotoxic effects of extreme exercise, orthopedic

regular exercise outweigh the risks.

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overuse injuries, prophylactic strategies to reduce the risk of PA, and whether the CV benefits of

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Exercise-related AMI and/or SCD

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By augmenting the rate-pressure product and simultaneously shortening diastole and coronary perfusion time, exercise may provoke myocardial ischemia and threatening ventricular

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arrhythmias in adults (> 40 years) with known or occult atherosclerotic CVD. The transient

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oxygen deficiency at the subendocardial level may be exacerbated by abrupt cessation of exercise and decreased venous return. Moreover, the associated shear forces secondary to the heightened cardiac demands, coupled with induced spasm in diseased coronary artery segments and/or platelet aggregation, may increase the likelihood of plaque rupture, coronary thrombosis, and AMI [32]. In contrast, inherited structural CV abnormalities, most notably, hypertrophic cardiomyopathy, are the major causes of SCD in younger athletes [34]. Although CV events can be triggered by vigorous-to-high intensity PA, it appears that the relative risk of AMI and SCD decreases with increasing frequencies of regular strenuous exercise, and vice versa [33,35,36]. Accordingly, the estimated relative risk of exercise-related

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CV events is inversely related to the individual’s habitual frequency of PA (bouts/week), and in some cases may increase greater than 100 fold [36,37]. A profile of the individual who may be

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“at risk” for exercise-related CV complications is listed in Table 1 [33, 38].

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Cardiotoxicity from Extreme Exercise

High-volume, high-intensity endurance exercise has been reported to have adverse CV

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effects, including a postexercise rise in selected cardiac biomarkers and evidence of transient

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myocardial dysfunction using echocardiographic studies or CV magnetic resonance imaging (CVMRI). Using CVMRI, Trivax et al. [39] reported that marathon running was associated with

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decreased right ventricular ejection fraction and abnormal increases in cardiac troponin I and Btype natriuretic peptide – possible harbingers of adverse long-term CV sequelae, including

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fibrosis. Indeed, newer tissue characterization techniques such as delayed gadolinium

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enhancement on CVMRI have been used to describe diverse patterns of myocardial fibrosis in highly trained veteran endurance athletes [40]. Collectively, these studies suggest that regular

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exercise overdosing may at least in some individuals create a substrate for threatening cardiac

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arrhythmias, including atrial fibrillation and ventricular tachycardia [41]. Orthopedic Overuse Injuries Orthopedic overuse injuries represent the most common risk of vigorous PA, including plantar fasciitis, Achilles tendonitis, shin splints, and patellofemoral syndrome. Sports and recreational injuries account for approximately 2.1 million hospital visits each year, with men experiencing a two-to-threefold greater number of injuries than women [31]. Inordinate physical demands, particularly during the initial weeks of an exercise program, often result in muscle soreness, orthopedic injury, and attrition. Excessive frequency (≥ 5 days/week) and/or duration (≥ 45 minutes/session) of training offer the novice exerciser little

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additional gain in CRF, whereas the incidence of orthopedic injury increases disproportionately [42]. Similarly, very-hard training intensities (≥ 90% heart rate reserve) provide only modest

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Prophylactic Strategies to Reduce the Risk of Activity

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added improvement in CRF, and are associated with an injury rate of ~ 50% [43].

Recommendations to reduce the likelihood of musculoskeletal and CV complications during

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exercise include [31, 32]: 1) Counsel previously sedentary patients to avoid unaccustomed,

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vigorous physical exertion and high risk activities [racquet sports, water or cross-country skiing, highly competitive sports (e.g., basketball)], deer hunting, snow shoveling; 2) Advocate

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appropriate warm-up and cool-down procedures; 3) Promote education of warning signs/symptoms (e.g., chest pain or pressure, lightheadedness, heart palpitations/arrhythmias); 4)

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Emphasize strict adherence to prescribed training heart rates and perceived exertion levels (e.g.,

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“fairly light” to “somewhat hard”); and 5) Reduce the intensity of exercise under hyperthermic conditions [44] and at altitudes of >1500 meters until acclimatized.

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When previously sedentary individuals initiate an exercise program, it is best to begin

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with a light-to-moderate intensity [e.g., 2 to 3 metabolic equivalents (METs)], and gradually increase the intensity of exertion over time (e.g., to 3 to 5 METs) on most, and preferably all days of the week. Such recommendations appear prudent since these intensities are below the vigorous physical activity (≥ 6 METs) that is commonly associated with the triggering of CVD events [33]. This “progressive transitional phase” will help to minimize the risk of orthopedic injury as well as allow sedentary individuals to improve their CRF without going through a period during which each bout of vigorous exercise is associated with large spikes in relative CV risk. Finally, for patients with signs/symptoms of myocardial ischemia, which can be highly

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arrhythmogenic [45], the target heart rate for endurance exercise should be set safely below (≥ 10 bpm) the ischemic electrocardiographic or angina threshold [46].

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Risk versus Benefit Analysis

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To put the risk-to-benefit ratio of exercise into perspective, it is important to recognize that the absolute risk associated with each bout of exercise is extremely low. The relative risk is

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directly related to the presence of CVD and/or symptoms and inversely related to the habitual

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level of PA, and the long-term cardioprotective effect of regular PA, which is substantial. Using data from the Onset study [35], during or soon after an acute bout of unaccustomed vigorous

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physical exertion, the relative risk of AMI for the habitually sedentary person may increase > 100-fold (Figure 1) [47]. On the other hand, the risk of AMI during a bout of strenuous PA for

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an individual who regularly participates in vigorous 1-hour exercise sessions ≥ 5 days/week is

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only increased by approximately two-fold (35). Because regular exercise has been reported to reduce the baseline or overall risk of CV events by up to 50% (48, 49), the habitually active

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individual’s relative risk would be significantly lower both during vigorous exercise and over the

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remaining 23 hours of the day, highlighting the clear net benefit of regular PA. Exercise Assessment and Prescription As previously noted, there is incontrovertible evidence that a physically active lifestyle reduces the likelihood of developing chronic disease and premature mortality, and improves quality of life. Previous reports and clinical guidelines have recommended that physicians advise their patients to engage in regular PA to promote health and prevent disease [50-55]. However, the overall impact of health care based interventions on PA levels has been limited [56-58]. More recently, advances in technology, such as electronic health records (EHR), and payment reform efforts aimed at lowering health care expenditures, including population health management

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strategies, have made PA assessment and promotion both easier to perform and more aligned with financial incentives [59, 60].

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The PA Vital Sign

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Several large HCS have integrated a PA or exercise vital sign (EVS) into their EHRs. Kaiser Permanente’s Exercise Vital Sign has been in their Epic EHR since 2010 (Figure 2).

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Likewise, Intermountain Healthcare, integrated its Physical Activity Vital Sign (PAVS) into their

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HELP2 EHR 2013 [61] (Figure 3), and has integrated the PAVS into their new EHR iCentra, which will be implemented in late 2014. These PA assessment tools are utilized at the point of

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care in ambulatory visits. Adult patients are asked 2-3 questions about their current PA level, typically by a medical assistant, at the start of the clinic visit. This information is recorded in the

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EHR for interpretation by the physician.

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Investigators at Kaiser Permanente found the EVS to have good face and discriminate validity compared with national surveys of PA [61]. Likewise, they found that the EVS was well

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accepted by clinical providers and patients, resulting in more exercise-related activities such as

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physician counseling, and referrals for exercise, nutrition and weight loss counseling [63]. The Exercise Prescription The PAVS is the first step in the exercise prescription. Without an understanding of current PA levels, it is difficult to advise patients on how to optimize their exercise habits. The 2008 PA Guidelines for Americans recommend that adults should achieve at least 150 minutes per week of moderate intensity (e.g., brisk walking) PA, or 75 minutes per week of vigorous PA (e.g., jogging), in addition to strength training for major muscle groups 2 times per week [52]. Although the current versions of Kaiser Permanente’s EVS and Intermountain Healthcare’s

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PAVS only assess aerobic PA, it is important to discuss strength training and flexibility as important components of the exercise prescription.

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A major challenge to PA promotion in the healthcare setting is time, specifically the

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competing demands in a typical 15-20 minute office visit. However, the brevity of the Physical EVS or other similar approaches, along with the implementation of team-based care, helps to

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“bring” PA assessment and prescription into the office setting. Each person on the health care

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team plays an important role in promoting PA. The medical assistant asks questions related to PA habits and records the answers in the EHR. The physician interprets the EVS/PAVS, and

Providing PA advice in the exam room

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advises the patient to start, increase or maintain his or her PA.

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Time permitting, the physician can delve deeper into the patient’s readiness for change as

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it relates to PA, and use evidence based behavior change principles to guide patients toward a more physically active lifestyle. Intermountain Healthcare developed an integrated behavioral

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approach to PA promotion as part of its Lifestyle and Weight Management Care Process Model

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(LWM CPM) [64]. The LWM CPM provides guidance to physicians and their care team on why and how to address PA (along with healthy eating, adequate sleep, stress management and weight loss) with adult patients (Figure 4). Patients with limiting musculoskeletal conditions may also benefit from further evaluation by a physical therapist, who in turn can prescribe therapeutic exercises aimed at resolving or minimizing associated symptoms that occur during or as a result of PA. Likewise, patients wishing to change their dietary intake may benefit from consultation with a registered dietitian, a service now mandated for coverage by commercial insurance payers through the Affordable Care Act [65].

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If physicians, physical therapists, dietitians and other health professionals all consistently assess and promote PA, as a routine component of every clinical encounter, it is likely that we

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would start to see changes in patient self-reported PA. There is some evidence that the more

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often a provider discusses PA with their patient, the more likely that person is to both recall such advice and to engage in regular PA [66]

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Integrating PA into daily life

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Because we have largely engineered PA out of our day-to- day lives, declining trends in activity patterns is understandable. Between remote controllers for the television, moving

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sidewalks in airports, escalators and elevators, email and instant messaging, we hardly have to move at all both at home and at work. As such, the exercise prescription is not only about getting

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30 minutes of moderate intensity PA on most days of the week, but also increasing opportunities

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for movement throughout the day, and reducing time spent sitting. Workplace strategies like standing desks and walking desks can reduce sitting time. Encouraging people to get up and out

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of their office chair every 30-60 minutes, and walk for 2-4 minutes can be beneficial [67]. Other

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strategies aimed at environmental changes like stairway prompts [68], walking and standing meetings [52], and access to fitness facilities and or showers have been shown to facilitate workplace PA levels.

While most adults spend the majority of their waking hours at work Monday thru Friday, evenings and weekends provide an opportunity to be active. Encouraging individuals to seek active recreation with family and friends as an alternative to surfing the Internet or watching television is part of the adjunctive exercise prescription. A 10-minute walk on Monday may evolve into a 20-minute walk by the end of the week. A dog is a terrific walking partner, as are friends, neighbors, and family members. Because after work time is often limited for working

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parents with dinner preparation and homework, mornings may be better for many. If walking is not an option, does the patient have access to a television, DVD player, or computer that

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supports the use of exercise videos? There are videos for almost anyone’s age, gender, interests,

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and CRF level. Be creative, and work with the patient to develop SMART (specific, measureable, attainable, relevant, and time bound) PA goals.

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Connecting PA with HCS

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This is where connecting efforts to promote PA in the HCS with the expertise of colleagues in health and fitness can be the most valuable. The ACSM, and more recently,

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Exercise Is Medicine (EIM), certifies health and fitness professionals to work with individuals in achieving health and fitness goals; EIM in its “call to action” urges “health care providers and

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fitness professionals to integrate exercise assessment and prescription into every patient and

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client interaction.”

Currently, EIM certifies health and fitness professionals at 3 levels, based on varied

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conditions that a potential client may have. A Level 1 provider can work with low or moderate

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risk patients who are exercising independently. A Level 2 provider can work with low, moderate or high-risk individuals cleared by their physician for independent exercise. A Level 3 provider can work with low, moderate or high-risk individuals who require clinical monitoring. Health and fitness professionals certified by EIM also receive training on communicating with physicians, thereby facilitating information exchange between health care providers and fitness professionals in a fashion similar to other healthcare professionals [69]. Given the importance of PA in maintaining health and preventing disease, efforts to integrate health and fitness professionals into the healthcare arena should be pursued. Their

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training in health promotion, exercise physiology, and behavior change make them ideally suited to help the patient “fill” their exercise prescription.

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Adult patients see their primary care provider (PCPs) on average 1.6 times per calendar

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year [70]. These visits present an opportunity for physicians to assess and counsel patients on the importance of PA in promoting health, while both preventing and managing chronic disease.

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Despite past research suggesting that the efforts of PCPs may have limited impact [58], recent

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innovations such as the EVS or PAVS, team-based care, and efforts of programs such as EIM, should serve to improve the effectiveness of health care in promoting PA to patients.

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Program Success Stories EIM initiative

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The stated goal of the EIM initiative is "to make PA assessment and exercise prescription

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a standard part of the disease prevention and treatment paradigm for all patients".11 This initiative was started by the ACSM, in conjunction with the American Medical Association

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(AMA), with a National Launch in Washington DC, in November of 2007. The national launch

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was attended by then U.S. Acting Surgeon General Dr. Steve Galson, along with the Directors of the President’s Council on Physical Fitness and Sports and the California Governor's Council on Physical Fitness and Sports. In May 2008 the first world Congress on EIM was held in conjunction with the ACSM Annual Meeting to announce the global launch of this program. This was an opportunity to bring together like-minded professionals from around the world to discuss current issues and share successes toward the goal of establishing PA assessment and exercise prescription as a standard of care. Subsequently, EIM has spread to over 40 countries, including seven regional centers around the world which include North America, Latin America, Europe, China, Asia, Africa and

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Australia. It has been interesting to note the worldwide acceptance of the basic tenets of EIM, including assessing PA as a vital sign. Most countries around the world have now established PA

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guidelines which are essentially the same. It is encouraging to have a major public health

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problem in which there is a worldwide consensus on the proper treatment. Walk With Your Doc

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Walk with a Doc (WWAD) is a free physician-led, year-round walking program that

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began in 2005 and operates in communities across the U.S. and abroad. It is hosted by local volunteer physicians in public spaces, and everyone is welcome; WWAD’s mission is to

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encourage healthy PA in people of all ages, and reverse the consequences of a sedentary lifestyle, which will improve the health and well-being of all who participate. Beyond the basics,

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each community follows a simple WWAD template to build its own walk; whether they meet

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once a week or once a month (minimum once a month), the walks can be done in the mountains or on a beach, in the city, at a park or in a mall. Each program starts with a volunteer physician

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introducing a popular health topic for brief discussion. Conversation migrates into the walk, all

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the way back to the meeting point, where walkers can have their blood pressure checked, get water, fresh fruit, healthy snacks or coffee. Many WWAD programs also offer pedometers. Participants have been surveyed and results show that since starting WWAD: 1) 91% feel more educated (participants also receive weekly newsletter); 2) >75% feel they are getting significantly more exercise; 3) >70% feel more empowered to take part in their own healthcare; and 4) overall >98% enjoy the concept of pairing physicians and community members outside of the traditional medical setting. Every Body Walk!

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Every Body Walk! (EBW!) was started as a public awareness project in January of 2011, aimed at initiating a national conversation about the health benefits of walking. Recognizing that

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more than 70 percent of all adults in the U.S. lead sedentary lifestyles that significantly impact

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the overall health of our country, the aim of the EBW! campaign has been to inform Americans about the importance of walking.

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The EBW! campaign was the brainchild of the former Kaiser Chairman and CEO,

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George Halvorson. Though powered by Kaiser Permanente, this is an unbranded campaign that celebrates the power of walking to improve health. At the heart of the campaign is an online

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educational campaign aimed at getting Americans up and moving. A walking hub, www.everybodywalk.org, contains news and resources on walking, health information, walking

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maps, how to find walking groups, a personal pledge form to start walking as well as a place to

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share stories about individual experiences with walking. This website has over 1.3 million views to date.

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A centerpiece of the website is a series of short video vignettes featuring average

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Americans and motivational stories about how walking has changed their lives and lifestyles. The videos on www.everybodywalk.org have been viewed over 300,000 times and are intended to be shared with family, friends, neighbors, colleagues and anybody else. New videos are added to the site on a regular basis. A highlight of the project was a 30-minute documentary on the health benefits of walking, called the Walking Revolution (http://vimeo.com/65986201), which is accessible online and has been viewed over 95,000 times. Other highlights of the campaign include a cell phone app (http://everybodywalk.org/app/ ) to track walking that has been downloaded 175,000 times. The cast of the West Wing Television show volunteered to do a public service announcement

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(https://www.youtube.com/watch?v=PEdHhZcmEoM) for EBW! that has been seen over 834,000 times. And the campaign spawned a television show on local Public Television affiliate

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KCET called City Walk (http://www.kcet.org/shows/citywalk/). This show has proved to be

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immensely popular with over 2.5 million views. All of this speaks to the power of walking and its growing acceptance by the public as being important to health.

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Motivating Exercise in the Physician Office or Clinical Environment

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The physician office or clinic environment provides both unique challenges and unique opportunities when counseling patients regarding exercise therapy and their personal motivation

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to exercise [71]. Potentially the greatest challenge is that, unlike acute care environments where significantly symptomatic patients understand the need to immediately do something to relieve

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symptoms and reduce risk, in stable outpatient populations and in the absence of symptoms, the

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motivation to change health behavior is often less pressing. In other words, when we understand that the risk of something bad happening to us is very likely to occur immediately, we are more

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than willing to make the appropriate decisions to eliminate or minimize that risk.

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Conversely, when patients do not have an urgent sense of risk and the effort required to minimize that risk is substantial, human behavior dictates that most of us decide not to expend the effort to minimize or eliminate what we perceive as a minimal risk. Thus, one of the critical elements in motivating individuals to improve their adherence to exercise prescriptions in the outpatient environment is to help them realize that their perception of minimal risk, based on an absence of symptoms, is not substantiated by the scientific literature. The overwhelming majority of patients with documented CHD will die from it. Helping patients understand this, and helping them understand that those with the best adherence to exercise prescriptions and the greatest functional capacities have the lowest incidence of recurrent CVD events, is an essential element

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in the exercise motivation process. However, although this principle is easy to articulate, it’s reconciliation with the realities of human behavior in office practice is challenging to say the

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least.

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Think realistically. The clinical reality for most in patient care disciplines is that our patients are mostly sedentary and have been that way for their entire adult lives. The expectation

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that they will suddenly become someone who performs 30 minutes of exercise on most days of

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the week is simply unrealistic. If we set this as the minimum standard for our patients, a great many of them will fail. On the other hand, if we work with our patients to explore what they are

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willing to do, then we are working with what we have rather than lamenting over what we do not have. We need to understand our patient’s intrinsic motivation for improving adherence to

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exercise interventions and PA as well as understanding or developing any sources of external

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motivation. Ultimately, the key to motivating patients to exercise is to help them understand why exercise will benefit them. If they understand why exercise will benefit them, then most patients

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will find the means to do it.

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Play realistically. If our patients are willing to do some exercise, then we need to help them understand which forms of exercise and PA they are likely to be adherent to. In this situation, like most coaching situations in life and sports, we need to play to our patients’ strengths. We need to understand which forms of exercise or PA they are likely to adhere to. Persons with significant arthritis below the waist are unlikely to be fans of high-impact type activities. On the other hand, they may be persuaded to become involved in exercise activities that involve the use of nonimpact exercise equipment or aquasize. This may be done by asking patients directly or having them fill out a survey with a wide range of choices, affording them the opportunity to reflect on each of the available choices in a more casual environment.

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Manage realistically. Finally, in motivating patients to improve their adherence to exercise therapies, we need to help them access and manage their exercise and PA; you can only

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manage what you measure. As health care professionals, each of us needs to encourage our

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patients to keep track of their adherence to exercise and track their daily PA. This can be done on paper, or increasingly, with a myriad of digital devices and smart phone applications. In addition,

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each and every health care professional involved with helping patients manage chronic disease

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conditions which may benefit from increased adherence to exercise therapies and PA, must be aware that our patients often ask what we do. If we do not adhere to exercise therapies, then they

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may be less likely to. If we are going to talk the talk, then we must consistently walk the walk (see WWAD). When our patients observe us adhering to longevity enhancing health behaviors,

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they are much more likely to do the same.

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Technology for Promoting PA in Patients Because increasing PA can have such dramatic positive health benefits [72, 73], it is

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therefore something all health care professionals should strive to achieve in their patients. The

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public, in general, still holds health care professionals in high regard [74]. This, in turn, provides a platform from which care providers can advocate for the importance of PA. Today, these health care professionals have motivational techniques and technology at their disposal not available even a few years ago. While the use of pedometers began in Japan in the 1960’s, the increased accessibility of pedometers and now accelerometers is a relatively new phenomenon. In addition to pedometers, there has been a rapid expansion of smartphones. These smartphones have many free or low cost wellness related applications. These have brought with them an expanding interest in taking care of one’s own health through technology [75]. Social media also has the potential to serve as a strong motivation tool to increase our PA as a population [76].

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With so many new interventions at our disposal, now seems like an ideal time for health practitioners to act. Many physicians are incorporating these tools into motivating their patients

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to either become physically active or help maintain a level of PA that will contribute to a healthy

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lifestyle.

It has been proven repeatedly that wearing a pedometer/accelerometer has health benefits

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[77]. In general, these devices provide an affordable and easily accessible technology that is

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simple to employ, low-literacy friendly, and immediately understandable to users [78]. They also offer up a component of internal and external competition. They give us a constant reminder to

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the importance of regular activity, many calculate calories burned, and some of the newer devices are being worn on the wrist. Modern day accelerometers come from a host of

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capabilities, from tracking arm movement to sleep patterns. Moreover, health care professional’s

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recommending/providing pedometers to their patients can be an effective strategy for increasing PA [77]. Other research has shown that the exercise advice a doctor gives to his or her patients

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might be more effective if a pedometer were part of the prescription [78].

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More than half the people in the U.S. own smartphones [79] and many are turning to these devices to track their health. Smartphone applications today can monitor heart rate as well as measure speed, distance, and elevation by employing GPS. They can keep track of progress (both personal and friends’), send encouraging comments and reminders, and share how many calories are burned. They allow you to map your course and find courses that others have used [80]. Studies are underway to evaluate the efficacy of smartphone based interventions in primary care [81]. Smartphone activity is significant, and studies show that social media is even more prevalent with two-thirds of Americans using social media sites [82]. Many are incorporating social media sites into their PA plans. These sites are utilized for multiple reasons; many are

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akin to community bulletin boards that announce and promote local events such as walking groups or gatherings of cyclists for a ride. Some use these sites to share their accomplishments

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with their friends and followers. This can instill a sense of pride in those who post and provide

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motivation for those looking to get started. In summary, there are many new opportunities available for today’s health care provider to promote PA to their patients using new technology.

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Conclusion

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It is clear that physical inactivity is the major public health problem of our time. While obesity is most often publicized, its adverse effects on health are largely mitigated by engaging

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in regular PA. Inactivity is among the strongest risk factors for chronic disease and early mortality and therefore patients’ activity levels should be assessed at every visit using an

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EVS/PAVS. The recommended amount of 150 minutes per week of moderate PA (like a brisk

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walk) should be prescribed to all patients, but especially those who have or are at risk for chronic diseases. Physicians have an ethical (and perhaps medical-legal) obligation to inform patients of

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the dangers of inactivity and to provide a safe and effective exercise prescription. They should

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not underestimate their power to promote PA to their patients in the clinical setting. However, physicians cannot do it alone. Everyone on the health care team, from the front desk receptionist to the medical assistant, nursing staff, dietitians, physical therapists, etc, need to be on the same page and actively promote regular PA as a key to improved health outcomes. Extending our reach outside the office through partnerships and collaborations with health and fitness professionals, community-based, and web-based PA promotion programs has proven beneficial. Likewise the expanded use of technology to track activity can help support the achievement of step goals. Ultimately to succeed, we need to leverage all the tools in our toolbox

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and continue to investigate and add new tools in our efforts to help our patients, our families and

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our communities move more.

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80. Jeffrey W. Lockhart, Gary M. Weiss. The Benefits of Personalized Smartphone-Based Activity Recognition Models. http://www.cis.fordham.edu/wisdm/SIAM-2014-final-v3.pdf

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82. Social Networking Fact Sheet. http://www.pewinternet.org/fact-sheets/social-networkingfact-sheet/ Accessed September 28, 2014

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Table 1 – Characteristics Associated with Exercise-Related Cardiac Events* Clinical Status

Rest or unstable angina pectoris

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Serious dysrhythmias at rest

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Impaired left ventricular function (ejection fraction < 35%)

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Multiple myocardial infarctions

High-grade left anterior descending lesions and/or significant (≥ 75% occlusion) multivessel

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atherosclerosis on angiography

Exercise Training Participation

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Low serum potassium

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Disregard for appropriate warm-up and cool-down

Consistently exceeds prescribed training heart rate (i.e. intensity violators)

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Infrequent exerciser Exercise Test Data

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Low and high exercise tolerance (≤ 4 METs or ≥ 10 METs)

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Chronotropic impairment off drugs (< 120 beats/min) Inotropic impairment (exertional hypotension with increasing workloads) Myocardial ischemia (angina and/or ST depression ≥ 0.2 mV) Malignant cardiac dysrhythmias (especially in patients with impaired left ventricular function) Other Cigarette smoker Male gender Obese Hyperlipidemic *Adapted from references # 3 and 8.

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Figure 1: Relative risk of AMI during vigorous physical exertion (≥ 6 METs) according to habitual frequency (days/week) of vigorous physical activity. Baseline or overall risk for the active subject is approximately half that of their sedentary counterpart, 0.5 and 1.0, respectively. (From Franklin BA. Circulation 129:1081-1084, 2014. Used with permission).

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Figure 2: Kaiser Permanente Exercise Vital Sign

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Figure 3: Intermountain Healthcare Physical Activity Vital Sign

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Figure 4: Intermountain Healthcare: Lifestyle and Weight Management Care Process Model