CHaPTeR6. REGULAR EXERCISE 153 in the decision-making process. The primary need is for the clinician to spend time with patients communicating about regular exercise, recognizing bstacles to success, and equipping patients with the tools to overcome them Risk Assessment The clinician should assess patient before recommending a regular exercise program. Some will need a full medical examination(see subsequent text). Many otherwise healthy patients will not. According to the USPSTF, neither a resting electrocardiogram nor an exercise stress test provides information helpful in reducing the risk of an adverse outcome from regular exercise among asymptomatic persons. Although the USPSTF does not endorse them, these tests may be clinically indicated for men older than 40 years with two or more risk factors for coronary artery disease other than sedentary lifestyle. Coronary artery disease risk factors include elevated serum cholesterol, history of cigarette smoking, hypertension, diabetes,or a family history of early-onset coronary artery disease Furthermore, the clinician should conduct a thorough clinical evaluation of patients for whom regular exercise presents a definite risk, before advising these patients to start exercising. These high-risk patients may have a history of one or more of the following diseases or conditions Previous myocardial infarction Exertional chest pain or pressure, or severe shortness of breath Pulmonary disease, especially chronic obstructive pulmonary disease Bone, joint or other musculoskeletal diseases or other limitations These conditions are not necessarily contraindications to regular exercise but each patient's risk must be assessed on an individual basis Patients for whom regular exercise presents a possible risk may have a history of one or more of the following di Iscascs or co Hypertension Cigarette smoking Elevated serum cholesterol Prescription medication used on a regular basis Abuse of drugs or alcohol Any other chronic illness, such as diabetes Family history of heart disease Overweight in excess of 20 lb Current sedentary lifestyle Regular exercise is very useful in the management of a number of these diseases and conditions (3). For example, regular physical activity has been shown to reduce the rate of progression of diabetes by more than 50%(11) In fact, regular exercise may be a pivotal force in changing the natural
154SECT|oN‖· WHAT TO DO W| TH THE|NF○RMAT|ON history of a number of disease processes and possibly even obviate the need for therapeutic interventions. As mentioned earlier, the presence of these diseases may well bccomc a motivational factor in convincing a nonexerciscr to get started. Regular exercise in high-risk patients is beyond the scope of this chapter. However, it is important to stress that in initiating exercise such patients must follow a slow, gradual, and careful regimen with close medical supervision COUNSELING Getting Started GOAL SETTING In most cases, the first subject to discuss with patients is goal setting: why is the patient thinking about regular exercise? It may be because the clinician suggested it, but virtually no one becomes and remains a regular exerciser simply because they are told to do so. To succeed, the patient must mobilize internal motivation. What goals does the patient want to achieve, and why? Specifically, does the patient want to become fit, lose weight, look better and feel better, reduce future risk of various diseases and conditions, or join a friend or family member in a race? In both starting and staying with a regular exercise program, it is very helpful if patients have a good grasp of just why they are doing it in the first place. The same list can be used in the process of motivational interviewing with patients who are not yet prepared to make health-promoting lifestyle changes. Chapter 5 provides additional information about motivational interviewing and also discusses the"stages of change""delineated in Prochaska's Transtheoretical Model: precontemplation, contemplation, Preparation, action, and maintenance(see pages 132-133). For patients currently in the precontemplation or contemplation stages of change, addressing the questions mentioned earlier may be helpful to patients in advancing to the next stage REALISM The clinician should counsel patients to set realistic goals and define success for themselves. a good formulation of this concept is to explore your limits and recognize your limitations. " Consider the example of endurance versus speed After some reasonable period of training, say 3-4 months, most people can improve endurance, but they may not be able to improve their speed. Speed is the product of speed-specific training plus natural ability. Many people will be able to train fairly easily for endurance, because for most people endurance is not simply the product of natural ability. On the other hand, because natural ability is such an important element in speed, many exercisers will not be able to improve their speed no matter how hard they try. Clinicians should stress