Exercise: Too much or too little

[anon44]

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I think that in body building, one exercises to the point of injury of
muscle fibers and the body's repair leads to bigger better muscles.

When does this become a negative, with injury to the muscle producing
fibrosis rather than hypertrophy? Body building techniques work to
some extent in older patients, but they maintain strength rather than
getting bulging biceps.

For skeletal muscle, too much exercise may not be that serious, but
what about heart patients? Exercising to reach a target heart rate
may be further injuring an already damaged heart. Do too little exercise
and nothing happens.

 

[Danae00]

I think that in body building, one exercises to the point of injury of
muscle fibers and the body's repair leads to bigger better muscles.

When does this become a negative, with injury to the muscle producing
fibrosis rather than hypertrophy? Body building techniques work to
some extent in older patients, but they maintain strength rather than
getting bulging biceps.

For skeletal muscle, too much exercise may not be that serious, but
what about heart patients? Exercising to reach a target heart rate
may be further injuring an already damaged heart. Do too little exercise
and nothing happens.

I don't have much time to respond right now, but I did want to point out that there is a world of difference between body building and resistance training in general. The goal of body building is to achieve a specific physical appearance often determined by what wins competitions. The aim is not to get optimal health, strength, power, or functional gains. I just wanted to point that out because that might change the question you are trying to ask! While they do exist, very few elderly individuals are into "body building".

With heart patients I think HR is a poor guide to go by. Many will be on medications that will impact heart rate (beta blockers) it's an unreliable guide. Using a RPE scale (ie. the BORG) would be a better bet IMO.

That said, I personally think some PTs are too gentle on heart patients. As long as our clients are stable and not having an acute heart incident they should be working hard on improving their cardio! A few months ago I recall reading some articles showing that high intensity aerobic interval training in patients with heart problems show more improvements compared to continuous moderate aerobic activity. I don't recall the parameters off the top of my head (what types of heart problems, etc), but I think a literature search on this topic will surprise you.

 

[anon44]

That said, I personally think some PTs are too gentle on heart patients. As
long as our clients are stable and not having an acute heart incident they
should be working hard on improving their cardio! A few months ago I recall
reading some articles showing that high intensity aerobic interval training in
patients with heart problems show more improvements compared to
continuous moderate aerobic activity. I don't recall the parameters off the
top of my head (what types of heart problems, etc), but I think a literature
search on this topic will surprise you.

Thanks for your info. Good point about body building's different goal than
rehab exercises.

My questions relate to the fact that most exercise, even conditioning and
rehab require vigorous activity to have a positive effect. Is there a line
where too much exercise causes damage?


In the heart, ignoring the acute ischemic symptoms and infarction, could
vigorous exercise go beyond the beneficial actions and cause a more
chronic muscle damage with subsequent fibrosis? In a damaged heart,
that already has significant fibrosis, would exercising to the point of
improvement also risk causing a more subtle chronic damage?

Post infarction, most patient are put at rest initially. Exercise comes later,
immediate exercise would be damaging. I'm asking if there's a point where
exercise becomes counter-productive even after the acute stage of
cardiac damage.

In congestive heart failure, cardio programs seem to relieve symptoms but
show no improvement for outcome or mortality. Could exercise be causing
damage at the cellular level that manifests it self in the 5 year survival?

 

[Danae00]

First I am prefacing this by saying that I am not an expert by any means. I'm a student. So this is all my opinion and it should not be used for any medical purposes! 😛

Of course you can exercise too much. You can overdo anything in life. You will see patients who have overuse injuries like compression fractures and tendinopathies. If you see serious athletes in your practice you likely will see some clients who have various stages of overtraining syndrome. Athletes in particular can be hard to rehab. How do you convince an athlete to cut way back on their training less than a month before their big competition? 😕

But for the most part with your typical rehab patient I would say exercising too much is not a major concern as long as you are good at educating your patient. When you prescribe exercises make sure you let them know to stick to the parameters you give them, and that 50 reps is not "5x better" than the 10 reps you recommended. Letting them know what they should feel and what they shouldn't feel afterwards is also important. Slight soreness the next day is normal, a lot of pain with increased inflammation is not.

With heart patients I still stick to my belief that we rest patients with heart conditions far too much. Some newer research is showing that prolonged rest after a heart attack rest is actually not the best route. For example, this study concludes: "Exercise training has beneficial effects on LV remodeling in clinically stable post-MI patients with greatest benefits occurring when training starts earlier following MI (from one week) and lasts longer than 3 months." Here is one of the articles I was thinking of when I previously referred to aerobic HIIT being beneficial to heart patients (stable postinfarction heart failure).

That said, of course cardiac patients can overdo it too. As physios we have to be able to monitor our patients and know how to keep them within a safe exertion level as well as be able to recognize the signs of symptoms of an acute cardiac situation. But for long term "cellular" effects? Until I see a study showing that outcome measures are improved with lower exercise intensities then I am not buying it. We need to stop coddling our heart patients!

My two cents 🙂

 

[anon44]

Of course you can exercise too much. You can overdo anything in life....

That's the question. Is the regularly prescribed exercise too much? The
current results of treatment for heart failure are lackluster at best, if not
pathetic. 20% mortality in the first year and 50% in 5 years.

But for the most part with your typical rehab patient I would say exercising
too much is not a major concern as long as you are good at educating your patient....

I'm questioning whether enough is know to educate the patient correctly.
The guidelines don't rely on fine data to determine how much exercise.
Patients would seems to exercise to some point before they drop. Not very
scientific.

The study you refer to http://www.trialsjournal.com/content/12/1/92
writes that exercise begins after 1 week. And then exercise improves
symptoms, not clinical outcome or survival. So, is exercising really helping?
Only so far as running up a flight of stairs without huffing and puffing. Not
for staying alive. Maybe the heart needs to rest for 6 months for survival
and then exercise to reduce symptoms.

That said, of course cardiac patients can overdo it too. As physios we have to be
able to monitor our patients and know how to keep them within a safe exertion
level as well as be able to recognize the signs of symptoms of an acute cardiac
situation. But for long term "cellular" effects? Until I see a study showing that
outcome measures are improved with lower exercise intensities then I am not
buying it. We need to stop coddling our heart patients!

There are irreversible metabolic changes in the skeletal muscles after heart
failure that I don't think are evaluated or considered in exercise
programs. Most exercise programs look at gross physical symptoms, again
it's "work'em until just before they drop."

I'm sure that too little exercise leads to problems and too much leads to
problems. Just that I'm not sure the proper level is determined correctly. If
exercise helps, it should reduce mortality. Measuring reduction in symptoms
is not the correct measure. If patients aren't living longer, maybe the
exercise plan is hurting them?

Digitalis is a similar case. Made people feel better but didn't help them live
longer. And added too many potential risks to justify routine use.

 

[fozzy40]

Thanks for your info. Good point about body building's different goal than
rehab exercises.

My questions relate to the fact that most exercise, even conditioning and
rehab require vigorous activity to have a positive effect. Is there a line
where too much exercise causes damage?


In the heart, ignoring the acute ischemic symptoms and infarction, could
vigorous exercise go beyond the beneficial actions and cause a more
chronic muscle damage with subsequent fibrosis? In a damaged heart,
that already has significant fibrosis, would exercising to the point of
improvement also risk causing a more subtle chronic damage?

Post infarction, most patient are put at rest initially. Exercise comes later,
immediate exercise would be damaging. I'm asking if there's a point where
exercise becomes counter-productive even after the acute stage of
cardiac damage.

In congestive heart failure, cardio programs seem to relieve symptoms but
show no improvement for outcome or mortality. Could exercise be causing
damage at the cellular level that manifests it self in the 5 year survival?

It's a great question that you are asking. I don't have a study to cite off of the top of my head but I suspect that the answer to your question is that anything is possible but highly unlikely. The problem with CHF is that these patients have poor/abnormal cardiac function, organ perfusion, metabolic activity at the cellular level PLUS symptoms with usual activity. Exercise has been clearly shown to improve symptoms with usual activity, improve exercise tolerance, and positively effect left ventricular remodeling and cardiac output. If anything, exercise is keeping the people included in the metanalysis alive. Despite our best therapeutic interventions, those who exercise have a 5 year survival. The effect of exercise is seen when you compare them to those who do not or unable to exercise. I'm sure their life expectancy is much shorter.

The fact of the matter is that the effects of CHF are not completely reversible and that is what contributes to the mortality rate. Lets not also the other co-morbidities (diabetes, hypertension, sleep apnea, re-infarction) that often accompany CHF and also affect survival.

In terms of outcomes, the other one to measure is quality of life.

In short, I don't think that exercise is adding gas to the fire but smoldering it.

 

[anon44]

...If anything, exercise is keeping the people
included in the metanalysis alive. Despite our best therapeutic
interventions, those who exercise have a 5 year survival. The effect of
exercise is seen when you compare them to those who do not or unable to
exercise. I'm sure their life expectancy is much shorter....

I can understand your enthusiasm for exercise, but it's not justifiable.
Exercise DOES NOT reduce mortality from CHF, it only reduces symptoms.

"Exercise and Heart Failure: A Statement From the American Heart
Association Committee on Exercise, Rehabilitation, and Prevention"
Circulation. 2003;107:1210-1225

"To date, no large-scale, randomized trials that evaluate the
long-term clinical efficacy or patient survival rates of exercise
training in HF have been reported.... Furthermore, published
trials have predated the increasing and current use of
ß-blockers in HF.

"These promising preliminary results should stimulate a wider
clinical application of exercise training in patients with stable HF.
The results of this trial, however, cannot be considered proof of
a mortality reduction because it was not powered to show
survival differences."
​

And more:

Exercise won't help patients with heart failure.
Disappointing study found that working out didn't
improve survival rates.
​

http://www.msnbc.msn.com/id/2766766.../t/exercise-wont-help-patients-heart-failure/
​

My view of medicine is more despairing than yours. I'm looking at studies
and statistics of the results rather than anecdotal reports and the
picture isn't so great.

There are lots of things that sound wonderful but just aren't true. Like
we have good treatments for cancers. Truth is that we are losing the war
on cancer, but most doctors won't say it and most people don't want
to hear about it.


Why We're Losing The War On Cancer
http://www.newsweek.com/2008/09/05/we-fought-cancer-and-cancer-won.html

We Fought Cancer…And Cancer Won.
http://money.cnn.com/magazines/fortune/fortune_archive/2004/03/22/365076/index.htm

So, I'm skeptical about determining amount of exercise, since benefits are
"window dressing", that is quality of life, when we really want to make a
difference between life and death, and that isn't happening.

 

[Danae00]

So, I'm skeptical about determining amount of exercise, since benefits are
"window dressing", that is quality of life, when we really want to make a
difference between life and death, and that isn't happening.

And this is where we are going to have to disagree. In my (limited) clinical experience quality of life was far more important to my patients than mortality.

When you ask a patient to list their goals for rehab they don't typically respond with "to live 10 more years". Rather they will say things like "I want to be able to play golf again" or even just "I want to be able to live at home".

 

[anon44]

And this is where we are going to have to
disagree.

OK.

My own feeling is that people chose life. And that's why I think
so many people seek cures and treatments that are unproven when
standard treatments don't work.

 

[fozzy40]

I can understand your enthusiasm for exercise, but it's not justifiable.
Exercise DOES NOT reduce mortality from CHF, it only reduces symptoms.

"Exercise and Heart Failure: A Statement From the American Heart
Association Committee on Exercise, Rehabilitation, and Prevention"
Circulation. 2003;107:1210-1225

"To date, no large-scale, randomized trials that evaluate the
long-term clinical efficacy or patient survival rates of exercise
training in HF have been reported.... Furthermore, published
trials have predated the increasing and current use of
ß-blockers in HF.

"These promising preliminary results should stimulate a wider
clinical application of exercise training in patients with stable HF.
The results of this trial, however, cannot be considered proof of
a mortality reduction because it was not powered to show
survival differences."
​

And more:

Exercise won't help patients with heart failure.
Disappointing study found that working out didn't
improve survival rates.
​

http://www.msnbc.msn.com/id/2766766.../t/exercise-wont-help-patients-heart-failure/
​

My view of medicine is more despairing than yours. I'm looking at studies
and statistics of the results rather than anecdotal reports and the
picture isn't so great.

There are lots of things that sound wonderful but just aren't true. Like
we have good treatments for cancers. Truth is that we are losing the war
on cancer, but most doctors won't say it and most people don't want
to hear about it.


Why We're Losing The War On Cancer
http://www.newsweek.com/2008/09/05/we-fought-cancer-and-cancer-won.html

We Fought Cancer…And Cancer Won.
http://money.cnn.com/magazines/fortune/fortune_archive/2004/03/22/365076/index.htm

So, I'm skeptical about determining amount of exercise, since benefits are
"window dressing", that is quality of life, when we really want to make a
difference between life and death, and that isn't happening.

Thank you for the citations. What they tell me is that there are some inherent methodology flaws which implies that you have to be careful about how you interpret the data. Based on these studies, would I advise my patient not to exercise? Absolutely not.

The 2nd study that you cited also brings up a big problem with some of our exercise studies: compliance. ~50% were not doing the treatment (exercise) 3 months into study. This is obviously going to make a difference in the outcome. Why were they not exercising is the big question. Were their symptoms not well controlled? Did they have problems with accessing an exercise facility? Did they have another acute medical event?

 

[fozzy40]

And this is where we are going to have to disagree. In my (limited) clinical experience quality of life was far more important to my patients than mortality.

When you ask a patient to list their goals for rehab they don't typically respond with "to live 10 more years". Rather they will say things like "I want to be able to play golf again" or even just "I want to be able to live at home".

I completely agree. Quality of life is the biggest factor without question. As a medical provider, improving the quality of life is probably the biggest factor we can have an influence on. There is a big difference between being "alive" and "living."

 

[markelmarcel]

Great convo! Just wanted to throw in my 2 cents about a side comment...

With heart patients I think HR is a poor guide to go by. Many will be on medications that will impact heart rate (beta blockers) it's an unreliable guide. Using a RPE scale (ie. the BORG) would be a better bet IMO.

HR is a poor guide to go by in general, for anyone, with exercising. It's much more efficient to go by power output vs effort... HRs are so subjective it is a very shaky (and weak) baseline to go off of.