Exercise is Therapy, Prevention, and Treatment: An Exercise Physiologist's Perspective
Tommy Boone, PhD, MPH, FASEP, EPC
Professor and Chair
Director, Exercise Physiology Laboratories
The College of St. Scholastica
Duluth, MN 55811
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Introduction
There is little
doubt that exercise has a positive influence on health. C. Everett
Koop (1) echoed what my father new and his father new
(and that dates back to about 1875) -- "Exercise is Medicine". Everyone
who engages in regular exercise knows that there are health benefits.
Most of us have known for years that if you do not use it, you lose it.
Regular exercise (and even physical activity) is medicine. Exercise
is physical activity. Therefore, exercise is medicine. Since
exercise physiologists are professionals who study exercise via physiology,
they must be professionally speaking exercise-based medical professionals.
This view is not new, but it is not inherently understood or accepted.
Many members
of the healthcare profession know that physiology of exercise is a scientific
area of study. What is not completely appreciated is that exercise
is medicine! Yet, as just described, exercise and, therefore, exercise
physiology is an exercise-based medicine founded on scientific research
that improves personal health. Exercise physiology can also improve
fitness, athletics, and important dimensions of a variety of illnesses,
including but not limited to, depression, obesity, diabetes mellitus, coronary
artery disease, coronary heart disease, peripheral artery disease, blood
lipids, hypertension, mental health, depression, osteoarthritis, and osteoporosis.
One of the
biggest mistakes in exercise physiology is the attempt to view the emerging
profession solely from the perspective of helping athletes run faster or
jump higher. While important, exercise physiology is also concerned
with resolving healthcare problems. Exercise physiologists are among
the few professions with an extensive research background that is interlaced
with the immense benefits of regular exercise and physical activity.
They have grown into their own academic curriculum after decades of maturing
through separation from physical education (now called kinesiology or exercise
science).
Exercise
Physiology is a Healthcare Profession
As exercise
physiologists, we need a vision of what the future can be. We need
to allow our minds to imagine possibilities beyond what we have come to
accept. Most urgently, we need professors throughout our colleges
and universities who are willing to encourage students to think beyond
the tunnel vision of a singular clinical realm of work (such as cardiac
rehabilitation). To best serve the public sector, exercise physiologists
cannot be controlled by the idea that exercise physiology is clinical exercise
physiology. This is absolute mis-information. It is also too
narrow in its view of the emerging exercise physiology profession.
Technical advances and new thinking have created new job related opportunities.
But, until the traditional professions come to understand who we are and
what we do, the professionalization of exercise physiology will take considerable
time.
Interestingly,
other professions are also becoming attuned to the benefits of exercise.
Physicians, in particular, are promoting regular exercise as a means to
reducing healthcare costs, absenteeism, productivity, and morale (2).
They, too, understand that a sedentary lifestyle is statistically associated
with an increased risk of cardiovascular disease, diabetes mellitus, osteoporosis,
and certain cancers (3). Exercise physiologists
have been teaching for decades that physical fitness delays disability.
They have written books after books about the benefits of exercise.
Now, it seems that exercise is everybody’s business other than the emerging
professionals who have been the true pioneers in the field for years.
Why physicians, physical therapists, nurses, and others now believe they
somehow own the body of knowledge generated by exercise physiologists is
not hard to figure out. What is hard to except, however, is that
exercise physiologists ought to be mentioned in the same breath when other
professionals talk about exercise as medicine.
Clearly, exercise
helps to reduce healthcare and insurance costs, reduce absenteeism, and
improve job performance. And, it is equally clear that the medical
community has not been the front runners in such thinking. Exercise
physiologists have intuitively understood that exercise is medicine.
Of course it is only one form of treatment of conditions that appear to
be related to the American lifestyle. Because of this view, exercise
physiologists have promoted an active lifestyle that includes healthful
exercise habits. They have done so by promoting health and wellness
programs, by developing corporate fitness programs, and by working with
other professional groups in sharing and presenting research findings on
exercise guidelines, cardiovascular conditioning, resistance training,
and range of motion.
It will take
time, but time well-spent in educating the public sector (including the
medical profession) that exercise physiologists have made an enormous impact
on generating the foundational research about the benefits of regular exercise.
Exercise physiologists not only teach about the health problems resulting
from obesity, but they are part of only a few professions that actually
teach, measure, analyze, and publish data about body mass index (BMI).
They argue, as others do, that physical inactivity and level of fatness
are strongly related to television watching. It is common knowledge
that most exercise physiologists teach that losing weight and keeping it
off is most successfully done when exercising on a regular basis.
This is an important point since exercise physiology is the only profession
(or emerging profession) with the word “exercise” in its professional title.
This should lead physicians and others to use exercise physiologists in
assessing a baseline body-composition, the incorporation of exercise in
losing weight and gaining leanness, and improving body image and self-esteem
through regular exercise. Physicians ought to incorporate the exercise
physiology profession in their practice, particularly the assessment of
overweight and the design of exercise programs to help individuals live
more healthfully. And, in particular, exercise physiology can be
(and is in certain areas of the United States) a cornerstone in the multidisciplinary
approach to managing, if not, preventing juvenile obesity.
On possible
reason for the lack of clear association between physicians and exercise
physiologists is that the latter have not had their own professional organization
to market the profession. Fortunately, there is now evidence that
the structure provided by the American Society of Exercise Physiologists
(ASEP) has systematically encouraged the hiring of exercise physiologists
within and outside of the traditional medical settings. The efficacy
of the ASEP approach has also been shown in several universities applying
for accreditation under the guidelines established by exercise physiologists
for the enhancement of the exercise physiology profession. With newly
aligned academic curricula, exercise physiologists will emphasize with
greater vigor the importance of exercise in lowering plasma glucose levels,
improving insulin sensitivity and glycemic control, and other exercise
induced improvements in blood pressure and lipid levels.
Exercise
Physiology, Cardiac Rehabilitation, and Concerns
Physical activity
is not a new field of laboratory research; rather it has always been the
backbone of improving health and fitness. Exercise physiologists
understand that regular exercise lowers heart rate and systolic blood pressure
and, thus improves the work of the heart (4). They
understand that thre are other benefits such as increased muscle strength
and maximal working capacity. Additionally, much of the research
(and especially the exercise-based benefits from cardiac rehabilitation)
have been published by exercise physiologists, who also have documented
increased levels of high-density lipoproteins, decreased levels of low-density
lipoproteins and homocysteine.
The benefit
of exercise for heart disease patients is obvious, yet it is continues
to be underused. Think for a moment: Even after 30 years
of cardiac rehabilitation in the United States, the medical profession
continues to demonstrate a miserable referral percentage of about 15% of
the eligible coronary artery disease (CAD) patients. Equally as confusing
is the apparent lack of the medical community’s commitment to exercise
rehabilitation beyond an exercise rehabilitation of 3 months. It
is impossible to expect a 20- or 30-year period of disease development
to be adequately addressed in 3 months. Cardiac rehabilitation, as
originally conceived by academic exercise physiologists, was designed in
much the same way as adult fitness programs had flourished as part of academic
settings. Had cardiac rehabilitation matured within the university
settings, under the direction of exercise physiologists, it would not be
a treatment administered primarily by nurses.
Shortened hospitalization
for myocardial infarction patients is not the reason cardiac rehabilitation
ended up as an adjunct to the hospital’s list of ways to make money.
This is also true for cost-containment, that is, the question of fees for
service within the academic setting did not exit the programs from the
institutions. Hospital administrators’ vision for increased revenue
and exercise physiologist’s lack of vision encouraged the shift from academic
settings to hospitals. As a result, the cardiac rehabilitation research
by exercise physiologists, that helped their graduate students, failed
to mature or to allow a continuity of critical reflection. This particular
point will someday be recognized as the “straw that broke the backs of
exercise physiologists who understood that their original work was medicine
in motion”.
Aside from
the critical elements of failing to uplift the emerging profession of exercise
physiology, those who did work in academics continued to teach cardiac
rehabilitation courses. Their work has been especially important
in spreading the “good news” of exercise rehabilitation. Much of
their work stems from research that supports cardiac rehabilitation, both
psychologically and physiologically. Exercise physiologists have
also researched the role of various dietary and pharmacological treatments
in conjunction with exercise rehabilitation in the modification of serum
lipids. They have researched and published important components of
exercise prescription and the role of beta-blockers in rehabilitation and
the effects on the patients’ cardiovascular response during exercise.
Exercise physiology
is the profession that brought maximum oxygen consumption to the forefront
in science. They have measured and reported on just about everything
possible to understand the role of training, genetics, and/or nutritional
aids in the enhancement of maximum exercise. They were among the
first to publish physiological research on patients in cardiac rehabilitation
programs. In the early 1970s not very many medical doctors or anyone
understood whether it was possible to exercise myocardial infarction patients.
For certain, no one really understood the degree to which the patient’s
oxygen consumption would change during incremental exercise and following
training. Much work still needs to be done but, unfortunately, since
most cardiac rehabilitation programs are no longer associated with university
graduate programs, relative little physiological research will prevail.
This does not mean that research is not being done; rather that the impetus
that had been realized decades ago is no longer reality. Today, there
are only few academic institutions in the United States that continue outpatient
cardiac rehabilitation as part of the graduate program experience.
The most obvious
findings by exercise physiologists from 30 years of research in cardiac
rehabilitation are three-fold:
1.
Patients with CAD can exercise and benefit from rehabilitation with significant
reductions in exercise heart rate, thus allowing the heart to function
at a higher exercise load without the need for an increase in oxygen.
2. Cardiac
rehabilitation patients begin to understand that they have the opportunity
through exercise to increase their psychological states of mind; and
3. Exercise
rehabilitation, however important from a structural and physiological perspective
given the “power of the training factor”, the disease remains!
Exercise physiologists
understand that the “disease” is not corrected by exercise rehabilitation,
which is a major shift in thinking from the medical community and others
(especially the die-hard “prevention personalities”). They also know
that statistically significant (and clinically significant) findings cannot
be realized after just 3 months of training. Skeletal muscle increases
in capillary density, changes in mitochondrial size and function, and increase
in muscle strength and endurance are strongly related to a stressor response
of high intensity training. Heart patients should not be (and usually
cannot be) trained at high intensity. There is a difference in the
training of heart patients and those who plan to run a marathon.
Regular exercise ought to be about low to moderate heart rate intensity
across decades of commitment.
Exercise physiologists
also understand that cardiac rehabilitation is not going to increase coronary
collateral flow in CAD patients or decrease the severity of stenotic lesions.
This does not mean, however, that exercise physiologists do not believe
in the positive aspects of exercise. They have come to agree, although
admittedly without a lot of discussion, that exercise rehabilitation does
not reduce the incidence of repeated cardiac events in CAD patients.
In actuality, this is not the point of exercise rehabilitation. Life
is much too complex to argue that exercise is the correction for everything
that is negative in the American lifestyle. If (and this is a big
question) exercise training decreases the incidence of ventricular fibrillation
during ischemia, it certainly would seem to encourage the use of exercise
as part of the treatment for myocardial infarction patients. The
problem, however, is the scientific data does not support the notion that
exercise training significantly decrease ventricular arrhythmias, improve
left ventricular ejection fraction, or collateral circulation (4).
Whether patients
in cardiac rehabilitation programs have fewer hospital admissions is not
the question. Rather, the question should be, from the exercise physiologists’
point of view, since they have been primarily responsible for creating
cardiac rehabilitation programs: Why would the medical community
be interested in the likelihood of shorter stays and saved dollars?
There is no reason to think that the medical community is interested since
their view of medicine appears to be driven by something other than cost-containment.
Assuming this point is true, the rationale for the use of exercise as therapy
for coronary artery disease is meaningless without participating cardiologists.
Perhaps, it is because exercise training of myocardial infarction patients
does little to improve left ventricular ejection fraction, serious ventricular
arrhythmias, or collateral circulation (5). If
so, medical doctors ought to realize that considerable benefit is derived
from the decreased rate-pressure and associated myocardial oxygen demands
at any given submaximal workload. There are also data showing that
exercise improves coronary artery endothelial function in CAD patients
(6). Then, why is the exercise prescription for
the primary or secondary prevention of cardiovascular disease so little
regarded by medical doctors and, in particular, by cardiologists since,
when according to Franklin and Sanders (7) “…prescribed
exercise is the same as prescribing medication”?
Exercise
Physiologists as Leaders in Exercise Research
For over 40
years exercise physiologists have worked in their laboratories and in outpatient
based exercise programs to demonstrate the benefits of exercise training
and early ambulation. Their research has been published throughout
the scientific community and, in particular, at the annual meetings of
the American College of Sports Medicine (ACSM). They have helped
the world understand the importance of multiple risk factors in the primary
and secondary prevention of CAD, and that exercise is only one among many
factors that need modification. The point being, exercise physiologists
have taught the importance of lifestyle changes for many decades beginning,
in particular, with the development of adult fitness testing and exercise
programs in the late 1960s. The pioneers were not only concerned
with evaluating the cardiorespiratory system (with regards to maximum oxygen
consumption), but understood all too well the benefit of exercise.
They suspected and subsequently published research that exercise increased
a sense of well-being and self-confidence, reduced depression, and other
significant lifestyle changes (such as cessation of cigarette smoking and
weight reduction).
As “authors”
of the phrase “exercise prescription” more so than any other professional
group, exercise physiologists were among the first to study and publish
work on the type, duration, and intensity of exercise. With published
guidelines established by exercise physiologists as members of ACSM (8),
other professional organizations (such as the American College of Cardiology
(9) and the American Association of Cardiovascular and
Pulmonary Rehabilitation (10) did the same. The
science behind the today’s popular phrase, consult your doctor prior to
beginning an exercise program, was created in a large way by physical educators
as exercise physiologists. The phrase ought to be rewritten to “consult
your exercise physiologists prior to beginning an exercise program”.
It is not that difficult to understand that if an individual is experiencing
extra heartbeats or skipped beats or feels dizzy, he/she should stop exercising
and, then, consult the medical doctor. Similarly, there is logically
little reason for an individual to exercise with chest pain. If that
were the case, consult the medical doctor. There is always the possibility
of underlying issues that need attention to exercise safely. Sudden
coronary death and acute myocardial infarction among healthy adults usually
result from artherosclerotic plaque rupture with acute thrombosis (11).
Summary
Exercise physiologists
teach Exercise Physiology! They teach the benefits of exercise, and
the “how to” exercise safely. Their work extends beyond “therapy,
treatment, and prevention”, but what they have done in each of the three
areas ought to be recognized and appreciated. The medical community
and members from other professional groups that have a part to play in
the healthcare of the public sector ought to acknowledge the role exercise
physiologists have played in shaping lifestyle thinking within the United
States, if not world wide.
References
1.
US Public Health Service. (1992). Healthy People 2000: Public Health Service
Action. Washington, DC: Department of Health and Human Services.
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DiNubile, N.A. & Sherman, C. (1999). Exercise and the Bottom Line.
The Physician and Sportsmedicine. Vol 27, No 2. [Retrieved February
25, 2002 from the World Wide Web] http://www.physsportsmed.com/issues/1999/02_99/dinubile.htm
3.
US Department of Health and Human Services. (1996). Physical Activity and
Health: A Report of the Surgeon General. Atlanta, DHHS: Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention
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4.
Hagberg, J.M. Stefanick, M.L., Williams, P.T., et. al. (1995). Does exercise
training play a role in the treatment of essential hypertension?
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No. 96-0672.
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7.
Franklin, B.A. & Sanders, W. (2000). Reducing the risk of heart disease
and stroke. The Physician and Sportsmedicine. [Retrieved February 26, 2002
from the World Wide Web] http://www.physsportsmed.com/issues/2000/10_00/franklin.htm
8.
American College of Sports Medicine. (1995). Guidelines for Exercise Testing
and Prescription. 5th ed. Baltimore, MD: Williams & Wilkins.
9.
Parmley, W.W. (1986). Position report on cardiac rehabilitation: Recommendations
of the American College of Cardiology. Journal of American College of Cardiology.
7:451-453.
10.
American Association of Cardiovascular and Pulmonary Rehabilitation. (1991).
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11.
Davies, M.J. & Thomas, A.C. (1985). Plaque fissuring: The cause of
acute myocardial infarction, sudden ischaemic death, and crescendo angina.
British Heart Journal. 53:363-373.