Exercise has the most evidence to support that it is efficacious - over any supplement Benefits Physiological Heart is a more

efficient pump CRP lowers Health 30% risk reduction in the incidence of HA's and strokes. One of the only ways that we have as doctors to increase mitochondrial mass One of the strongest ways to activate the NRF2 gene response. This response deals with the activation of the bodies own antioxidant system. Antioxidant supplements do not work for many things....they are not efficacious, can be turned into pro-oxidants and often are not effective. The activation of the NRF2 gene is one of the only ways. With activation there is an increase in the GSSH production. EXERCISE IS ONE OF THE BEST WAYS TO DO THIS! Aerobic exercise decreases all cause mortality - having more than 6 hrs of sleep on a regular basis also decreases all cause mortality. Having less than or equal to 6 hrs of sleep on a regular basis increases all cause mortality. If we take a person who is exercising regularly and then remove them from exercise they can a whole cascade of events that can lead to dysfunction in their bodies. Hormonally Increase insulin sensitivity Increase the lean body-to-fat ratio - we want to increase the body muscle mass and decrease the fat content. Aerobic exercise combined with strength training can decrease fat and increase muscle. We want more muscle because it burns more calories, possibly store less toxins, and as we age past the age of 30 we loss muscle (age-related sarcopenia). EXERCISE IS THE ONE THING THAT CAN HELP TO DECREASE AGE_RELATED SARCOPENIA. This is the replacement of muscle fibers with fat. Organ Improve cardiac contractility, decrease elevated blood pressure - when the heart is work more efficently there resting heart rate will decrease as it works more efficiently. This is correlated with increased life span. Improve brain function by decreasing stress and with BDNGF. Exercising

can benefit the brain and improve it functioning. Over the long term it can decrease our risk of dementia. BDNGF Brain Dervied Nerve Growth Factor, is a hormone need for improving synaptic connections. It also can improve brain functioning due to improving sleep. Whole-body Stress management, endorphin release, enhancement of sleep (growth hormone, adrenal function, and immune function), detoxification ***Who are the best clinicians in the world? They actively ask themselves questions while they are with patients. WIll the patient benefit from a whole-body or a regional intervention? It is not a bad idea to have a list of wholebody interventions that will help all patients. Mind/Attitude Improve self-esteem, reprogram a feeling of wellness, start an attitude of taking responsibility for one's health by linking success with exercise to improvements in other aspects of health I can do it (transfer of effect to other aspects of health) I can get better We are not fixing patients, we want them involved in the process. "I can't get better" OR "you can't get me better" ***CO-COUNSELING*** Dr. Musnick feels this is the most influential technique class he has ever taken Is there any attitude or mind-body issue going on with this patient that is affecting their ability to get better? Poor Compliance We need to educate patients about optimal exercise programs, the specifics of an exercise prescription, and the benefits. We also need to educate about monitoring progress and compliance. Excerise Prescription In order to prescribe exercise, it is important to: Understand the benefits of a exercise intervention Memorize the guidelines Take an exercise history Prescribe the exercise with an exercise calendar and .... ..... Can decrease the risk of developing cancers especailly colon and breast cancer by 30% (including colon, breast, pancreas, lung)....this is ris k reduction. The

documentation is the strongest for colon and breast and is the best for colon cancer. Sleep: Exercise improves sleep especially in cases of insomnia secondary to restless legs, onset insomnia.... Decreases stress and anxiety STRESS MAKES PAIN WORSE, CAN LEAD TO INSOMNIA Exercise improves mood: helps depression and anxiety - as much as an antidepressant drugs Pain: decreases the pain of .... Improves mental sharpness... ... Weight: Helps a person to lose weight and manage weight. Article in NEWSWEEK - Exercise does not help weight management, people tend to eat more... instruct patients to eat 30 g of protein follow strength training. This helps us to retain muscle. May improve ATP production and energy metabolism by increasing structural mitochondiral area in muscles. THINK ABOUT THIS WITH FATIGUE. As we age our mitochondria shrink and we lose mitochondrial size. The 2 most common causes of fatigue as mitochondrial dysfunction and adrenal issues. Next is depression. If they have chronic fatigue we don't want to get them exercising, because they do not have enough energy. Aerobic exercise may not People are not ready to introduce more exercise until: Do you have enough energy to get through your daily life? Do feel okay walking to your car? Do you have more energy than when you first started seeing me? Consistency is important! We want people doing exercise over long periods of time to get benefits. As an intervention this is a long-term project that can have these benefits if it is done consistently. Note that more energy .... 2008 Physical Activity Guidelines for Americans ***MEMORIZE*** Guidelines for Exercise Prescription: Duration Good: 150 min/wk - moderate or 75 min/wk - vigorous or combination Better 300 min/wk - moderate or 150 min/wk - vigorous or combination and 2x/wk - Strength training 3x/wk will help to build muscle, 2x/wk will help to support muscle. 3x/wk is better than 2x/wk Intensity

Intensity can be correlated with heart rate response or rating of percieved exertion (1-10 or 1-20). Max HR = 220 - age Moderate - 50-70% Max Ht rate Vigorous - 70-85% Max Ht rate People on beta blockers or calcium channel drugs will not be able to exercise in their calculated heart rate ranges because these drugs block heart rate conduction. RECOMMEND THAT PEOPLE GET A HR MONITOR WATCH Write this recommendation in for them Remind them to have someone show them what button to push...people will often buy these and not know how to use them. As a general rule of thumb we want everyone to do moderate exercise because it is much less risky. NOTE: for patients older than 40 and for anyone not very fit recommend starting with moderate intesity exercise. For men over 40 and women over 45 need to do a complete history and cardiac screening before allowing them to do vigorous exercise. 12 Lead EKG Stress Test Stress Test with Echo - does not show false positive (vs. EKG does in women) Doing both of these can decrease false negatives. We need to recommend and document this in the charts to help cover ourselves if something does happen. Interval Training Interval training is bouts of exercise at 85%-95% of max HR for 20 seconds to 2 minutes. It is beneficial for weight loss, stress management, decreasing CRP, and raising HDL. It is very beneficial for high-level athletes or weekend warriors who have to do spurts of high intensity. Intensity should not be so high as to lead to significant dyspnea or any chest pain. Don't suggest interval training unless they have done at least 10 weeks of vigorous exercise and have been screened for cardiac and orthopedic risks of vigorous aerobic exercise. NOT for anyone with foot, ankle, knee, or SI issue. Or anyone with a Hx of angina. Interval training needs 48 hrs between training intervals for muscle recovery. Best prescription is for a baseline of high moderate intensity or low vigorous intensity for a 3-5 min warm up and then with 30 second-1.5 minute intervals with at least 90

seconds of rest in a 20-30 minute workout. Do not do this on consecutive days and not more than 3 a week. They need to stop if they have any chest pain or muscular pain. We should start with 3 intervals and gradually work-up to 6-9 intervals. ***Recommend that people get pissed off at something when they are doing interval training. Frequency: Goal: at least 3 sesion per week. Ideal if 506 sessions especially for moderate intensity or for stress management Start with 203 sessions per week and add 1 per week until up to 4-6 sessions per week. Duration: Start with 10-15 minutes and then add 1-2 minutes per session until up to 30-40 minutes or 45-60 minutes (weight loss) ***GET SPECIFIC WITH PATIENTS. HELP THEM SCHEDULE...when are they going to exercise and what time of the day are they going to exercise. We want to encourage people to do different things, especially if they are overweight, as it will both decrease boredom and decrease the chance of injury.