Prescrizione dell’esercizio fisico nei soggetti affetti da patologie

croniche: una nuova frontiera per la Medicina dello

Sport GIORGIO GALANTI LAURA STEFANI

SCUOLA DI SPECIALIZZAZIONE DI MEDICINA DELLO SPORT AGENZIA DI MEDICINA DELLO SPORT E DELL’ESERCIZIO

“VALUTAZIONE FUNZIONALE E PRESCRIZIONE DELL’ESERCIZIOFISICO IN SOGGETTI PORTATORI DI PATOLOGIE CRONICHE”

Montecatini 10 Dicembre 2012

PERCHÉ L’ESERCIZIO?

PIRAMIDE DELLE ETÀ NEL 2050

Italia

Europa60-85 anni

60-85 anni

THEORETICAL RELATION BETWEEN MUSCULOSKELETAL FITNESS AND INDEPENDENT LIVING ACROSS A PERSON’S

LIFESPAN

Thresold for dependence

THE NORMAL AGE-ASSOCIATED DECLINE IN CARDIOVASCULAR

PERFORMANCE

CMAJ • March 14, 2006; 174(6)

THE NORMAL AGE-ASSOCIATED

DECLINE IN CARDIOVASCULAR PERFORMANCE

J Appl Physiol 82:1508-1516, 1997

Ath

NAth

Cosa sappiamo riguardo all’esercizio

Necessario per lo stato di saluteRiduce i rischi per molte malattieFavorisce la salute ed una buona

indipendenza nell’età avanzata Componente chiave nella gestione di

malattie croniche

RELATIONSHIP BETWEEN EXERCISE CAPACITY, EXPRESSED AS METS, AND 1-YR TOTAL HEALTH

CARE COSTS IN THE YEAR FOLLOWING THE TREADMILL TEST.

WHO

DEFINITIONS OF CONCEPTS USED IN THE RECOMMENDED LEVELS OF

PHYSICAL ACTIVITY• TYPE OF PHYSICAL ACTIVITY (WHAT TYPE). THE

MODE OF PARTICIPATION IN PHYSICAL ACTIVITY. THE TYPE OF PHYSICAL ACTIVITY CAN TAKE MANY FORMS: AEROBIC, STRENGTH, FLEXIBILITY, BALANCE.

• DURATION (FOR HOW LONG). THE LENGTH OF TIME IN WHICH AN ACTIVITY OR EXERCISE IS PERFORMED. DURATION IS GENERALLY EXPRESSED IN MINUTES.

• FREQUENCY (HOW OFTEN). THE NUMBER OF TIMES AN EXERCISE OR ACTIVITY IS PERFORMED. FREQUENCY IS GENERALLY EXPRESSED IN SESSIONS, EPISODES, OR BOUTS PER WEEK.

• INTENSITY (HOW HARD A PERSON WORKS TO DO THE ACTIVITY). INTENSITY REFERS TO THE RATE AT WHICH THE ACTIVITY IS BEING PERFORMED OR THE MAGNITUDE OF THE EFFORT REQUIRED TO PERFORM AN ACTIVITY OR EXERCISE.

• VOLUME (HOW MUCH IN TOTAL). AEROBIC EXERCISE EXPOSURES CAN BE CHARACTERIZED BY AN INTERACTION BETWEEN BOUT INTENSITY, FREQUENCY, DURATION, AND LONGEVITY OF THE PROGRAMME. THE PRODUCT OF THESE CHARACTERISTICS CAN BE THOUGHT OF AS VOLUME.

• MODERATE-INTENSITY PHYSICAL ACTIVITY. ON AN ABSOLUTE SCALE, MODERATE INTENSITY REFERS TO ACTIVITY THAT IS PERFORMED AT 3.0–5.9 TIMES THE INTENSITY OF REST. ON A SCALE RELATIVE TO AN INDIVIDUAL’S PERSONAL CAPACITY, MODERATE-INTENSITY PHYSICAL ACTIVITY IS USUALLY A 5 OR 6 ON A SCALE OF 0–10.

• VIGOROUS-INTENSITY PHYSICAL ACTIVITY. ON AN ABSOLUTE SCALE, VIGOROUS INTENSITY REFERS TO ACTIVITY THAT IS PERFORMED AT 6.0 OR MORE TIMES THE INTENSITY OF REST FOR ADULTS AND TYPICALLY 7.0 OR MORE TIMES FOR CHILDREN AND YOUTH. ON A SCALE RELATIVE TO AN INDIVIDUAL’S PERSONAL CAPACITY, VIGOROUSI NTENSITY PHYSICAL ACTIVITY IS USUALLY A 7 OR 8 ON A SCALE OF 0–10.

• AEROBIC ACTIVITY. AEROBIC ACTIVITY, ALSO CALLED ENDURANCE ACTIVITY, IMPROVES CARDIORESPIRATORY FITNESS. EXAMPLES OF AEROBIC ACTIVITY INCLUDE: BRISK WALKING, RUNNING, BICYCLING, JUMPING ROPE, AND SWIMMING.

MODERATE-INTENSITY PHYSICAL ACTIVITY. ON AN ABSOLUTE SCALE, MODERATE INTENSITY REFERS TO ACTIVITY THAT IS PERFORMED AT 3.0–5.9 TIMES THE INTENSITY OF REST. ON A SCALE RELATIVE TO AN INDIVIDUAL’SPERSONAL CAPACITY, MODERATE-INTENSITY PHYSICAL ACTIVITY IS USUALLY A 5 OR 6 ON A SCALE OF 0–10.

SCALA DI PERCEZIONE DELLA FATICA

PUBLIC HEALTH SIGNIFICANCE

OF PHYSICAL ACTIVITY IT IS ESTIMATED CURRENTLY THAT OF

EVERY 10 DEATHS, 6 ARE ATTRIBUTABLE TO NCDS

PHYSICAL INACTIVITY IS ESTIMATED AS BEING THE PRINCIPAL CAUSE FOR APPROXIMATELY 21–25% OF BREAST AND COLON CANCER BURDEN, 27% OF DIABETES AND APPROXIMATELY 30% OF ISCHAEMIC HEART DISEASE BURDEN IN ADDITION, NCDS NOW ACCOUNT FOR NEARLY HALF OF THE OVERALL GLOBAL BURDEN OF DISEASE.

LEADING RISK FACTOR FOR GLOBAL

MORTALITY (%)

HBP Tobacco HBG Obesity Inactivity0

2

4

6

8

10

12

14

Serie 1

GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY FOR HEALTH CARDIORESPIRATORY HEALTH (CORONARY

HEART DISEASE, CARDIOVASCULAR , STROKE AND HYPERTENSION)

METABOLIC HEALTH (DIABETES AND OBESITY)

MUSCULOSKELETAL HEALTH (BONE HEALTH, OSTEOPOROSIS)

CANCER (BREAST AND COLON CANCER)FUNCTIONAL HEALTH AND PREVENTION OF

FALLSDEPRESSION

THESE GUIDELINES ARE RELEVANT TO ALL HEALTHY ADULTS AGED 18–64 YEARS UNLESS SPECIFIC MEDICAL CONDITIONS INDICATE TO THE CONTRARY.

PREGNANT, POSTPARTUM WOMEN AND PERSONS WITH CARDIAC EVENTS MAY NEED TO TAKE EXTRA PRECAUTIONS AND SEEK MEDICAL ADVICE BEFORE STRIVING TO ACHIEVE THE RECOMMENDED LEVELS OF PHYSICAL ACTIVITY FOR THIS AGE GROUP.

INACTIVE ADULTS OR ADULTS WITH DISEASE LIMITATIONS WILL HAVE ADDED HEALTH BENEFITS IF MOVING FROM THE CATEGORY OF “NO ACTIVITY” TO “SOME LEVELS” OF ACTIVITY.

HEALTHY ADULTS AGED 18-65

YEARS

ADULTS AGED 65 YEARS AND ABOVE SHOULD DO AT LEAST 150 MINUTES OF MODERATE-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR DO AT LEAST 75 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUSINTENSITY ACTIVITY.

AEROBIC ACTIVITY SHOULD BE PERFORMED IN BOUTS OF AT LEAST 10 MINUTES DURATION.

FOR ADDITIONAL HEALTH BENEFITS, ADULTS AGED 65 YEARS AND ABOVE SHOULD INCREASE THEIR MODERATE INTENSITY AEROBIC PHYSICAL ACTIVITY TO 300 MINUTES PER WEEK, OR ENGAGE IN 150 MINUTES OF VIGOROUS INTENSITY AEROBIC PHYSICAL ACTIVITY PER WEEK, OR AN EQUIVALENT COMBINATION OF MODERATE-AND VIGOROUS-INTENSITY ACTIVITY.

ADULTS OF THIS AGE GROUP, WITH POOR MOBILITY, SHOULD PERFORM PHYSICAL ACTIVITY TO ENHANCE BALANCE AND PREVENT FALLS ON 3 OR MORE DAYS PER WEEK.

MUSCLE-STRENGTHENING ACTIVITIES SHOULD BE DONE INVOLVING MAJOR MUSCLE GROUPS, ON 2 OR MORE DAYS A WEEK.

WHEN ADULTS OF THIS AGE GROUP CANNOT DO THE RECOMMENDED AMOUNTS OF PHYSICAL ACTIVITY DUE TO HEALTH CONDITIONS, THEY SHOULD BE AS PHYSICALLY ACTIVE AS THEIR ABILITIES AND CONDITIONS ALLOW.

HEALTHY ADULTS AGED65 YEARS

AND ABOVE

FOR ADULTS OF THIS AGE GROUP, PHYSICAL ACTIVITY INCLUDES RECREATIONAL OR LEISURE-TIME PHYSICAL ACTIVITY, TRANSPORTATION (E.G WALKING OR CYCLING), OCCUPATIONAL (I.E. WORK), HOUSEHOLD CHORES, PLAY, GAMES, SPORTS OR PLANNED EXERCISE, IN THE CONTEXT OF DAILY, FAMILY, AND COMMUNITY ACTIVITIES. IN ORDER TO IMPROVE CARDIORESPIRATORY AND MUSCULAR FITNESS, BONE HEALTH AND REDUCE THE RISK OF NCDS AND DEPRESSION THE FOLLOWING ARE RECOMMENDED:

1. ADULTS AGED 18–64 SHOULD DO AT LEAST 150 MINUTES OF MODERATE-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR DO AT LEAST 75 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY THROUGHOUT THE WEEK OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUS-INTENSITY ACTIVITY.

2. AEROBIC ACTIVITY SHOULD BE PERFORMED IN BOUTS OF AT LEAST 10 MINUTES DURATION.

3. FOR ADDITIONAL HEALTH BENEFITS, ADULTS SHOULD INCREASE THEIR MODERATE-INTENSITY AEROBIC PHYSICAL ACTIVITY TO 300 MINUTES PER WEEK, OR ENGAGE IN 150 MINUTES OF VIGOROUS-INTENSITY AEROBIC PHYSICAL ACTIVITY PER WEEK, OR AN EQUIVALENT COMBINATION OF MODERATE- AND VIGOROUS-INTENSITY ACTIVITY.

4. MUSCLE-STRENGTHENING ACTIVITIES SHOULD BE DONE INVOLVING MAJOR MUSCLE GROUPS ON 2 OR MORE DAYS A WEEK.

OVERALL, ACROSS ALL THE AGE GROUPS, THE BENEFITS OF IMPLEMENTING THE ABOVE RECOMMENDATIONS, AND OF BEING PHYSICALLY ACTIVE, OUTWEIGH THE HARMS.

AT THE RECOMMENDED LEVEL OF 150 MINUTES PER WEEK OF MODERATEINTENSITY ACTIVITY, MUSCULOSKELETAL INJURY RATES APPEAR TO BE UNCOMMON.

IN A POPULATION-BASED APPROACH, IN ORDER TO DECREASE THE RISKS OF MUSCULOSKELETAL INJURIES, IT WOULD BE APPROPRIATE TO ENCOURAGE A MODERATE START WITH GRADUAL PROGRESS TO HIGHER LEVELS OF PHYSICAL ACTIVITY.

AMSE

NO STRATEGIES HAVE BEEN ADEQUATELY STUDIED TO EVALUATE THEIR ABILITY TO REDUCE EXERCISE-RELATED ACUTE CARDIOVASCULAR EVENTS.

MAINTAINING PHYSICAL FITNESS THROUGH REGULAR PHYSICAL ACTIVITY MAY HELP TO REDUCE EVENTS BECAUSE A DISPROPORTIONATE NUMBER OF EVENTS OCCUR IN LEAST PHYSICALLY ACTIVE SUBJECTS PERFORMING UNACCUSTOMED PHYSICAL ACTIVITY.

OTHER STRATEGIES, SUCH AS SCREENING PATIENTS BEFORE PARTICIPATION IN EXERCISE, EXCLUDING HIGH-RISK PATIENTS FROM CERTAIN ACTIVITIES, PROMPTLY EVALUATING POSSIBLE PRODROMAL SYMPTOMS, TRAINING FITNESS PERSONNEL FOR EMERGENCIES, AND ENCOURAGING PATIENTS TO AVOID HIGH-RISK ACTIVITIES, APPEAR PRUDENT BUT HAVE NOT BEEN SYSTEMATICALLY EVALUATED.

Physiological alterations accompanying acute exercise and recovery and their possible

sequelae.

THE FOCUS OF THE GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY FOR HEALTH IS PRIMARY PREVENTION OF NCDS THROUGH PHYSICAL ACTIVITY AT POPULATION LEVEL

THE PRIMARY TARGET AUDIENCE FOR THESE RECOMMENDATIONS ARE POLICY-MAKERS AT NATIONAL LEVEL.

GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY FOR HEALTH CARDIORESPIRATORY HEALTH (CORONARY

HEART DISEASE, CARDIOVASCULAR , STROKE AND HYPERTENSION)

METABOLIC HEALTH (DIABETES AND OBESITY)

MUSCULOSKELETAL HEALTH (BONE HEALTH, OSTEOPOROSIS)

CANCER (BREAST AND COLON CANCER)FUNCTIONAL HEALTH AND PREVENTION OF

FALLSDEPRESSION

But,exercise…..

HABITUAL PHYSICAL ACTIVITY REDUCES CORONARY HEART DISEASE EVENTS, BUT VIGOROUS ACTIVITY CAN ALSO ACUTELY AND TRANSIENTLY INCREASE THE RISK OF SUDDEN CARDIAC DEATH AND ACUTE MYOCARDIAL INFARCTION IN SUSCEPTIBLE PERSONS.

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

"The paradox of physical exercise"

Herz 2006;31:553-8

HABITUAL PHYSICAL ACTIVITY REDUCES CORONARY HEART DISEASE EVENTS, BUT VIGOROUS ACTIVITY CAN ALSO ACUTELY AND TRANSIENTLY INCREASE THE RISK OF SUDDEN CARDIAC DEATH AND ACUTE MYOCARDIAL INFARCTION IN SUSCEPTIBLE PERSONS.

EXERCISE-ASSOCIATED ACUTE CARDIAC EVENTS GENERALLY OCCUR IN INDIVIDUALS WITH STRUCTURAL CARDIAC DISEASE. HEREDITARY OR CONGENITAL CARDIOVASCULAR ABNORMALITIES ARE PREDOMINANTLY RESPONSIBLE FOR CARDIAC EVENTS AMONG YOUNG INDIVIDUALS, WHEREAS ATHEROSCLEROTIC DISEASE IS PRIMARILY RESPONSIBLE FOR THESE EVENTS IN ADULTS.

RISPOSTA CARDIOVASCOLARE ALL’ESECIZIO ACUTO

1.Fase preparatoria iniziale Stimolazione adrenergica Vasocostrizione distrettuale

2.Fase intermedia metabolica Fattori locali Stimolazione adrenergica

Factors Affecting Neural Control

of Cardiovascular Function

Exercise,Vasoconstriction and Coronary Flow in normal

AMSE

Exercise,Vasoconstriction and Coronary Flow

20%

4%

6%

27%

22%

14%

7%

MuscleHeartSkinBrainOtherLiverKidneys

Muscle84%

4%1%4%

5%

Rest3-5 Lmin

Exercise25-30 Lmin

Distribution of Flow at rest and during Acute Exercise

6080

100120140160180200220240260

0 100 150 230 rec rec

NormotHypertnormothyp

Exercise and Blood Pressure in normal and hypertensive

subjects

Watts

P.A.Peak

Chronic Cardiac Adaptation to Exercise

Morphological• Myocardial

• Vascular

Functional• Neural

AMSE

Dynamic and static exertion

Dynamic or isotonic activity: physical exertion characterized by rhytmic,repetitive movements of large muscle groups

Isometric or static activity: physical exertion characterized by sustained muscle contraction against a fixed load or resistance with non change in length of the involved muscle group or joint motion

EVIDENCE REGULAR PHYSICAL ACTIVITY

CONTRIBUTES TO THE PRIMARY AND SECONDARY PREVENTION OF SEVERAL CHRONIC DISEASES AND IS ASSOCIATED WITH A REDUCED RISK OF PREMATURE DEATH.

THERE APPEARS TO BE A GRADED LINEAR RELATION BETWEEN THE VOLUME OF PHYSICAL ACTIVITY AND HEALTH STATUS, SUCH THAT THE MOST PHYSICALLY ACTIVE PEOPLE ARE AT THE LOWEST RISK.

HOWEVER, THE GREATEST IMPROVEMENTS IN HEALTH STATUS ARE SEEN WHEN PEOPLE WHO ARE LEAST FIT BECOME PHYSICALLY ACTIVE.

Evidence Based Sport Medicine D.MacAuley,T.B Best 2006

GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY FOR HEALTH

RECOVERY CARDIORESPIRATORY HEALTH (CORONARY

HEART DISEASE, CARDIOVASCULAR , STROKE AND HYPERTENSION)

METABOLIC HEALTH (DIABETES AND OBESITY)

MUSCULOSKELETAL HEALTH (BONE HEALTH, OSTEOPOROSIS)

CANCER (BREAST AND COLON CANCER)FUNCTIONAL HEALTH AND PREVENTION OF

FALLSDEPRESSION

L’ESERCIZIO NELLA PREVENZIONE

DELLE MALATTIE MALATTIE CORONARICHE /

ICTUSOBESITÀ E DIABETE DI TIPO 2 DEMENZADEPRESSIONEALCUNI TUMORIOSTEOPOROSI

Review article

KUJALA UM

EVIDENCE OF THE EFFECTS OF EXERCISE THERAPY IN THE TREATMENT OF CHRONIC DISEASE.

BR J SPORTS MED 2009; 43: 550-555. Sponsored by:

EXERCISE IS MEDICINE

‘THE BENEFITS OF REGULAR PHYSICAL ACTIVITY ON HEALTH, LONGEVITY AND WELLBEING EASILY SURPASS THE EFFECTIVENESS OF ANY DRUGS OR OTHER MEDICAL TREATMENT.’SIR LIAM DONALDSON

‘‘In a word, all parts of the body which were made foractive use, if moderately used and exercised at the labor to which theyare habituated, become healthy, increase in bulk, and bear their agewell, but when not used, and when left without exercise, they become diseased, their growth is arrested, and they soon become old.’’Hyppocrates Medicine’s view of exercise did not progress much in thesubsequent two millenia, and exercise was primarily viewed as an activity for healthy people, but not for the chronically ill. The use of exercise as a medical treatment is an old concept, butone that did not start gaining acceptance until the 20th century.Today, exercise scientists are exploring the limits of exercise as a therapy—of exercise as a medicine.

Br J Sports Med 2004;38:6–7.

The first recorded anecdote of exercise as a treatment for heart disease is thought to be from William Heberden,who wrote of a man with angina pectoris in 1772: ‘‘I knew of one who set himself the task of sawing wood forhalf an hour every day, and was nearly cured’’.Ironically, Heberden did not know that angina pectoris is a cardiac disorder.‘‘

Physicians of the 1800s were interested in the role of exercise in maintenance of health, but the modern notion of exercise as a medical treatmentis thought to have originated with R Tait McKenzie. McKenzie perceived exercise as a technique to rehabilitate people with disabling injuries’’

William Osler, in the 1909 edition of The principles and practice of medicine, wrote that bed rest and baths at spas like Bad Nauheim were the optimal treatment for heart disease.

In 1939, Paul Dudley White, the first cardiology professor at Harvard Medical School, co-authored a manuscript showing cardiac dilatation through aneurysm formation after myocardial infarction, and this was used as an argument against exercise after myocardial infarction.

By 1958, Dr White had changed his views and coauthored a textbook on cardiac rehabilitation in which low level exercise was promoted.Then in 1968, the concept of bed rest was finally put to rest by the landmark paper of Bengt Saltin et al. In 60 years, physicians had learned that exercise was useful in rehabilitation of people with both musculoskeletal injuries and cardiovascular disease.

‘‘Our current understanding of exercise prescription is limited for most chronic diseases’’

Il concetto di “esercizio fisico come terapia”, nato in America già dal secolo scorso, si identifica con la pratica regolare e costante di questo, opportunamente stabilito e dosato come “intensità, frequenza e durata”, all’interno di un atto medico diagnostico – terapeutico complesso del quale la Medicina dello Sport, come disciplina internistica, ha la piena ed esclusiva competenza.

La prescrizione dell’esercizio quindi ha effetti positivi sulla salute attraverso azioni specifiche sui meccanismi della malattia stessa , che rappresenta, a differenza dell’Attività Fisica Adattata, un atto sanitario con finalità terapeutiche.

L’ESERCIZIO NELLA CURADELLE MALATTIE

OSTEOARTRITE ARTRITE

REUMATOIDE SPONDILITE

ANCHILOPOIETICA FIBROMIALGIA MALATTIA

CORONARICA IPERTENSIONE ICTUS

OBESITÀ & DIABETE DI TIPO 2

ASMA BPCO MALATTIA DI

PARKINSON SCLEROSI MULTIPLA CANCRO DEL SENO E

DELL’INTESTINO DEPRESSIONE

Posittive changes in skeletal muscle structure function

and metabolism

Physical fitness (aerobic fitness and muscular strength)

Heart structureAnd function

Glicemic control in insulin resistance

Risk of life threatening arithmias

Risks ofDementia

Risks of myocardial infarction

Risks of type 2 of Diabete Mell

Risks of ischemic stroke

Electrical stability of the heart

Parasympathetic tone Peripheral resistance

Inflammation

Blood pressure

Platelet agggregation

Risk of disability

Risk of death

Atherosclerosis

HDL2 Cholest

Neurotropiceffects

Body fatVisceral fatLiver fat

Insulin sensityvity

Brith Med Sport J 43 2009

Physical activity/exercise as theraphy:Mechanisms of Action

EXERCISE COMPARED WITH DRUGS OR SURGERY IN IN NCD

EXERCISE BENEFIT DRUGS OR SURGERY BEN

CARDIAC DISEASE 40% RISK REDUCTION 24% RISK RED WITH STATINS

STABLE CORONARY ARTERIESDISEASE

80% SURVIVAL AT 12 MONTHS

70% AT 12 MONTHS WITH PTCA

TYPE 2 DIABETE 58% REDUCTION 38% RED WITH METPHORM

HIP FRACTURE 55% INCIDENCE REDUCTION

38% RISK REDUCTION WITH RISEDRONSTE

BREAST CANCER 40% RISK REDUCTION 38% INCIDENCE AND RISK REDUCTION WITH TAMOXIF

RECURRENT BREAST CANCER

54% REDUCTION OF MORTALITY

59% REDUCTION OF MORTALITY WITH TAMOXF

MAJOR DEPRESSION EXERCISE EFFECTIVE AS SERTRALINE(60,4% REMISSION)BUT WITH REDUCED RELAPSE OF 30%

SERTRALINE EFFECTIVE AS EXERCISE(65,4% REMISSION)BUT WITH INCREASED RELAPSE OF 50%

Lancet vol 280 Jul 2012

Exercise interventions on health-related quality of life forcancer survivors (Review)Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, Gotay CC, Snyder CCocrhane lib 2012 n 8

Exercise or exercise and diet for preventing type 2 diabetesmellitus (Review)Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roqué i Figuls M, Richter B, Mauricio DThe Cochrane Library 2008, Issue 3

Exercise interventions on health-related quality of life forcancer survivors (Review)Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, Gotay CC, Snyder CCocrhane lib 2012 n 8

Exercise for the management of cancer-related fatigue inadults (Review)Cramp F, Byron-Daniel JCocrhane library 2012 n 11

GENERICALLY SPEAKING, ANY EXERCISE PRESCRIPTION RESEMBLES A DRUG PRESCRIPTION:EXERCISE A, TAKEN N TIMES DAILY, FOR X DURATION OF WEEKS/MONTHS/YEARS.

THE EXERCISE TYPE AND DOSE ARE CHOSEN BY THE

PERSON’S INDIVIDUAL NEEDS, GOALS, AND ABILITY LEVEL;THE FREQUENCY AND INTENSITY OF EACH SESSION ARE CHOSEN BY THE PERSON’S INTRINSIC ENDURANCE AND ABILITY TO RECOVER; THE PROGRESSION AND DURATION OF THE PROGRAMME IS DETERMINED BY THE PERSON’S INTERMEDIATE AND LONG TERM GOALS.

ADVERSE EFFECTS ARE RELATED TO THE TYPE OF EXERCISE-FOR EXAMPLE, DELAYED ONSET MUSCLE SORENESS-AND THE SPECIFIC CHRONIC DISEASE-FOR EXAMPLE, CHEST PAIN IN ANGINA PECTORIS, JOINT PAIN IN ARTHRITIS, FATIGUE IN FIBROMYALGIA.

EXERCISE/DRUG

La medicina dello sport è ad una svolta: dalla

valutazione dei soggetti che possono far sport,gli

idonei; alla valutazione dei soggetti che devono fare sport all’interno di un piano terapeutico,i pazienti.

AMS