Starting an Exercise Program: How Your Doctor Can Help

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Presented by: Paul Wang, MD
Director, Stanford Cardiac Arrhythmia Service

Nawal Atwan, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
October 21, 2010

Lecture Overview:

  • Many heart conditions often have no symptoms, so it is important to screen young athletes before they start a sport or activity.
  • Screening should include a health history and a complete physical, which may include an electrocardiogram.
  • People over 40 who have symptoms of chest pain or shortness of breath should have a stress test before starting a new sport.
  • Mix up your routine to include exercises for cardiovascular health, weight training for strengthening muscles, and stretches for flexibility and balance.
  • Start with a plan and steadily increase your goals to measure improvement.

Most people know the many benefits of exercise. Including workouts into your routine has shown to increase longevity, reduce the risk of heart attack and stroke, improve cholesterol levels, lower blood pressure, prevent diabetes, and make you feel better. It helps with weight loss, strengthens bones, and enhances cognitive function-all concerns that affect the quality of life as we age.

Screen for Heart Conditions The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest. Sudden cardiac arrest-when the heart ceases to beat without any warning-is one of the largest heart health problems in the United States. The heart’s electrical system goes awry, making it unable to pump blood to the rest of the body.

The chance of successful resuscitation drops 10 percent every minute, said Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory, who spoke about cardiovascular evaluation and screening at a presentation sponsored by the Stanford Health Library.

There are more adults with congenital heart defects than ever before, due in large part from improved surgeries. According to the 36th Bethesda Conference, which establishes guidelines for people with cardiac disorders, most congenital heart disease patients have a reduced ability to exercise. Experts are still debating how much exercise is appropriate and whether teens with a heart condition should be allowed to participate in sports.

Many heart conditions often have no symptoms, so it is especially important to screen young athletes before they start to participate in a sport or activity. In athletes younger than age 40, the most common underlying cause of heart problems is known as hypertrophic cardiomyopathy. This rare genetic disease causes the heart muscle (myocardium) to become abnormally thick, making it harder for the heart to pump blood.

The condition tends to manifest in the late teens, and the risk remains an ongoing concern, said Dr. Wang.

“If you’ve had an arrhythmia once, or have a condition that could lead to arrhythmia, the likelihood is higher that you can suffer from cardiac arrest,” he said. “The recommendations are that you should be excluded from most competitive sports.”

There are other conditions that young people should be screened for before taking on a strenuous sport, including anomalous coronary artery, a rare condition that can be detected by an angiogram. These youths should also be restricted in their athletic activities, said Dr. Wang.

In older athletes, the most common cause of problems is coronary artery disease-the buildup of plaque inside the blood vessels. Other conditions of concern include myocarditis, an inflammation of the heart wall, and Marfan syndrome, a disease that weakens the walls of the aorta.

Dr. Wang recommends that all young people see their doctor for a complete physical that includes a health history. An electrocardiogram may be helpful in some cases, but experts are still discussing its benefits. Athletes over 40 who have possible symptoms of heart disease such as chest pain or shortness of breath, and sedentary people with risk factors for heart disease should have a stress test before starting a new regimen. These tests can provide clues to help your physician uncover underlying disease.

“Screening athletes is an important aspect of safety,” he said. “Then follow-up is essential.”

Before You Start to Exercise Nawal Atwan, MD, provided more detail about the benefits of exercise and how to start a healthy regimen. She recommended working out at least 30 minutes five times a week and mixing activities for cardiovascular health, strengthening muscles, and stretching.

She suggested that you start with a plan and steadily increase your goals to measure improvement. Use a pedometer for inspiration, and be realistic about what you can and can’t do. Start with lower goals and then build up the intensity and frequency, she said.

Dr. Atwan suggested a visit to the doctor before starting a new exercise or to assess risk. The physical should assess your blood pressure, heart rate, cholesterol, body mass index (BMI), percentage of body fat, gait, balance, and hand grip. Your doctor may recommend an electrocardiogram or a stress test to measure your heart capacity.

Talk to your physician if you have joint pain or how to prevent developing joint problems. If you have arthritis, you may benefit from a low-impact activity like swimming or water aerobics, which studies have shown can decrease pain, she said. All participants should be sure to stretch as a warm-up and cool-down, holding each position for at least 30 seconds.

“There are lots of excuses to not exercise: no time, no motivation, it’s boring, it hurts. But it’s a matter of getting out there and doing something,” Dr. Atwan said. “Exercise is the cheapest drug around-you can get the same benefits as some medications and without any side effects.”

About the Speakers
Paul Wang, MD, is a professor of medicine (cardiology) and director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory. He received his medical education at the College of Physicians & Surgeons at Columbia University in New York, did his internship at New York Presbyterian Medical Center, and did his fellowship at Brigham and Women’s Hospital at Harvard Medical School.

Nawal Atwan, MD, is a clinical instructor of medicine (internal medicine) who specializes in women’s health, athletic health, and chronic disease management. She received her MD from Harvard Medical School and did her residency at Stanford. She joined Stanford in 2009. She is Board Certified by the American Board of Internal Medicine.

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WebMD: Starting an Exercise Program

Prenatal Genetic Screening and Diagnosis

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Presented by: Jane Cheuh, MD
Director, Prenatal Diagnosis and Therapy
Stanford University Medical Center
March 21, 2013

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Prenatal screening, including ultrasounds and blood tests, gives pregnant women an important heads-up on possible birth defects and allow women to make decisions about their pregnancy.  The most common test is for Down syndrome (trisomy 21), a condition in which an extra chromosome causes delays in the child’s mental and physical development. It affects about 1 in every 800 babies born in the United States.

Down syndrome and other chromosomal abnormalities are tested by chorionic villus sampling (CVS), which is done when the pregnancy is at 10 to 14 weeks. CVS involves taking a small sample of cells through the cervix. The main advantage of CVS is that it can be done earlier than an amniocentesis, which is generally done between 15 and 20 weeks.

Twenty years ago, the procedure was associated with a very small risk of miscarriage (1 percent) compared to amniocentesis (.5 percent), although the risk today is minimal when performed by an experienced physician, said Jane Chueh, MD, a clinical professor of maternal fetal medicine who practices at Stanford Hospital and at Packard Children’s Hospital. Dr. Chueh spoke at a presentation sponsored by the Stanford Hospital Health Library.

Prenatal screening should be done by women over age 35, since the risk of a chromosomal anomaly tends to be higher in older mothers. However since most mothers are under age 35, the majority of Down syndrome cases occur in younger women, so she advocates that all women should be screened early in their pregnancy.

“Age is only one factor,” she said. “Age 35 is an arbitrary number and is no longer the threshold for screening.”

Dr. Chueh said the average risk of Down syndrome for women age 35 is 1 in 380,, which is considered moderate. In comparison, the risk is 1 in 11 (high) in women age 49 or older; and is 1 in 667 (low risk) in 20-year-old women. First and second trimester screening tests are available through the state of California State. If the results show high risk, the state will pay for subsequent diagnostic testing

First Trimester Tests
Several tests are offered during the first trimester. A prenatal test called a nuchal fold scan, or NT, uses ultrasound to measure the space in the tissue at the back of the developing fetus’ neck. A fetus with an abnormality tends to accumulate more fluid at the back of the neck during the first trimester, causing the space to be larger than average. The NT scan must be done between 11.5 and 14 weeks of pregnancy. The result is combined with concurrent tests for PAPP-A (pregnancy-associated plasma protein A and free beta hCG.

“Increased NT is associated with chromosomal abnormalities, cardiac problems, and other fetal anomalies,” Dr. Chueh said. “But timing is important. Being off by even one day can throw it off, and if it’s done too early we may need to redraw blood or re-measure another day”

“Screening is not the same as a diagnosis. It’s important to realize that there are certain algorithms for these tests that consider detection rates and the chance of a false positive. Testing positive means there is a possibility of Down, but the test is not definitive,” she said.

Second Trimester Tests
Second trimester screenings, which are generally integrated with the first series of tests,  include a quad marker screen, a blood test for increased risk of Down syndrome and neural tube defects such as spina bifida. The quad screen is done between 15 and 20 weeks of pregnancy and can detect about 80 percent of fetuses affected by Down syndrome.

Ultrasounds may also detect soft markers which, while not necessarily an anomaly, may increase the statistical chances of chromosomal abnormalities. These markers include an enlarged nuchal fold, echogenic bowel, and short humerus or femur bones. Often these markers have no real impact on risk if the patient has a low risk to begin with, said Dr. Chueh, and may soon become obsolete with the advent of cell free DNA screening on maternal blood.

The Future of Screenings
While current diagnostic tests such as amniocentesis and CVS are reliable and readily available, they are invasive and carry a slight risk of miscarriage. The goal, said Dr. Chueh, is to identify a technique for noninvasive and accurate diagnosis.

That goal is closer, thanks to a new finding that assesses fetal DNA circulating in the mother’s blood. Minute amounts of free-floating DNA (CfDNA) from fragments of the placenta appear to increase with gestational age and completely disappear 48 hours after birth. Physicians are able to look at the DNA sequences of certain chromosomes and match them up to determine if the fetus is normal. If the counts run less or more than normal, there is a possibility of an  anomaly. Several companies now offer cfDNA tests.

The advantages to this approach over traditional screening tests are numerous, said Dr. Chueh, including a shorter wait time for results, a single blood draw, and an earlier window of opportunity for screening. Integrated first and second trimester screening results are available after six weeks and have a 90 percent detection rate; cfDNA tests have a 99.4 percent detection rate and take one to two weeks. They are also automated, which make them more consistent and less time-consuming.

There is a downside, however, she added. These tests are still new and are more expensive than standard tests, which are covered by the state. They test for only a few conditions and have a higher failure rate in which the tests are not able to get a result.

“The success of cell free DNA has opened up renewed interest in noninvasive prenatal diagnosis. The next step is finding intact fetal cells in maternal blood with no invasive procedure to the pregnancy,” Dr. Chueh says. “We are looking for strategies that are faster, cheaper, and more comprehensive than current screening tests, but more studies are needed.”

About the Speaker
Dr. Chueh is a clinical professor of obstetrics and gynecology and the director of Prenatal Diagnosis and Therapy in the Division of Maternal Fetal Medicine. She received her MD from the University of California, San Diego, did her internship and residency at University of Washington Medical Center, and did a fellowship at University of California, San Francisco. She is Board Certified in Maternal and Fetal Medicine and in Obstetrics and Gynecology by the American Board of Obstetrics and Gynecology.

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Non-Pharmalogic Treatment of Pain

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Presented by: Ravi Prasad, PhD
Clinical Associate Professor of Anesthesia
February 27, 2014

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The pain that comes from hitting a finger with a hammer or touching a hot stove serves an important purpose, warning our bodies to respond to danger. But for more than 100 million adult Americans, the pain never seems to go away.

Chronic pain affects more Americans than diabetes, heart disease, and cancer combined. It is one of the largest causes of disability in the United States, costing greater than $500 billion each year in lost productivity and health care treatment.

“The purpose of pain is to act as a warning system to protect the body from harm,” said Ravi Prasad, PhD, the assistant chief of the Division of Pain Medicine, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “It alerts you to react in order to avoid damage. The problem is, that is not true of all kinds of pain.”

Different Categories
There are two types of pain. Acute pain has a specific cause that can usually be resolved by following a protocol, such as taking medication or undergoing a procedure.  The pain is a direct reflection of harm. For example, a fall can lead to a fractured ankle that can be put in a cast, treated short-term with mild painkillers, and/or strengthened with physical therapy.

Chronic pain, on the other hand, does not always have a specific or identifiable origin, and the brain continues to send out pain messages even though there is no longer a stimulus for danger. “It’s a like a false alarm to the body. The pain is real, but it is not a sign of active harm. There’s no imminent threat and yet it persists with no fixed endpoint,” he said. “Many people suffer for months or even years without any evidence of ongoing physical damage.”

For most people, life is filled with multitudes of activities and interests, from family to work to hobbies. For people suffering from chronic pain, that one aspect of life starts to take over everything else and becomes the central focus.

Facets of Treatment
“Acute pain and chronic pain are two different beasts. Using acute modalities to treat chronic pain is a disservice to the patient: It can lead to false hope and disappointment when standard approaches don’t deliver results,” Dr. Prasad said. “Chronic pain needs to be perceived and treated like other chronic conditions, using similar paradigms to optimize the condition.”

Treatment for chronic conditions like diabetes, high blood pressure, or asthma involve both behavior and lifestyle modification, and patients need to incorporate all recommendations.

“It’s a matter of balance— you can’t just pick and choose the things you like or think might work. Stress and emotions have a powerful effect on chronic pain as well, so it’s not just a matter of diet or exercise or movement. Treatment involves a multifaceted approach to improve quality of life,” he said.

The first step is medical optimization, a careful analysis by a medical specialist to make sure the condition is indeed chronic and not caused by an undiagnosed disease. Options can include surgical treatment or injection therapies, or the physician also may use pharmacologic interventions by prescribing the most appropriate medication(s) at the most appropriate level. In conjunction, they usually incorporate physical reconditioning with physical therapists to offset the tendency to minimize using the painful area or to overcompensate by favoring other parts.

Like other chronic conditions, behavior and lifestyle modification are fully integrated into treatment as well. These non-pharmacologic strategies include psychological and behavior-based therapies that incorporate the mind-body connection, such as biofeedback, breathing and relaxation training, and cognitive behavioral therapy.

Mind and Body
Pain is a complicated process that involves an intricate interplay of chemicals and signals in the body’s sympathetic and parasympathetic nervous system. The process serves as an on-off switch, a feedback system of excitation and inhibition—“the “fight or flight” response. When the sympathetic nervous system activates, it raises blood pressure, heart rate, and muscle tension. The parasympathetic system brings these functions back to normal.

Because pain’s effect on the brain affects the same regions associated with basic emotions, feelings like stress or anxiety can amplify the suffering.

“Stress and pain are intrinsically connected, “said Dr. Prasad. “The nervous system’s reaction to stressors is directly involved with physiological changes. The body doesn’t discriminate between physical and emotional stressors: The physiological response pathway is the same, whether we are responding to a threatening dog or an argument with a spouse. It creates a vicious cycle.”

The challenge with chronic pain, he added, is how to break the cycle since the pain itself cannot be alleviated. One of the most successful strategies is the application of breathing exercises, focusing in deep and slow inhalations and exhalations. Deep breathing activates the parasympathetic nervous system, cueing the brain to slow things down after a stressful event. But the process requires some mental discipline and concentration for it to work.

“It’s not just a psychological trick,” he said. “It’s a physiological response. It’s also a distraction since it helps to refocus your attention away from the pain. The pain still exists, but you’re giving your body a reprieve to stop the feedback system.”

He also emphasized the benefit of cognitive restructuring to learn how to reinterpret the situation and override one’s automatic reaction to a stimulus. Thoughts control emotional, physical, and behavioral responses, so changing perspective can have a powerful impact on outcomes. The process is not easy, he warned, since automatic responses tend to develop over a lifetime, and habits are hard to break.

Studies show that cognitive restructuring helps to reduce perception of pain as well as levels of anxiety and depression, he said, and shows an improved sense of control since its users are better able to recognize their triggers for pain episodes.

“It’s not as simple as, ‘Think positive,’ but there are ways to break the cycle by targeting your thoughts and asking some fundamental questions about their usefulness. Ask, ‘Is this helpful?’ or ‘Is this accurate?’ It can eventually lead to a different set of automatic thoughts,” he said. “The pain is still there but it may reduce the loop of activation.”

About the Speaker
Ravi Prasad, PhD, is a clinical associate professor of anesthesiology, perioperative, and pain medicine, assistant chief of the Division of Pain Medicine, and director of the Stanford Comprehensive Interdisciplinary Pain Program. He received his PhD from Texas Tech University and completed his internship at Salt Lake City Veterans Affairs Medical Center in Utah and his fellowship at Kaiser Permanente in San Francisco.

About the Stanford Pain Management Center
The Stanford Pain Management Center is an integrated, comprehensive program that treats more than 12,000 patients a year.. A team of anesthesiologists, physiatrists, neurologists, psychologists, nurses, and physical therapists assess each patient’s type and degree of pain, and develop personalized treatment plans. The Center is one of only a few institutions in the country that have received consecutive Center of Excellence awards from the American Pain Society.

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A Practical, Holistic Approach to Stress & Wellness in a High Pressure World

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Presented by: Nadia E. Haddad, MD, MS
Clinical Instructor, Psychiatry and Behavioral Sciences
April 14, 2016

Stress is an undeniable aspect of modern life. Though everyone experiences and responds to stress in an individual way, stress is defined as physical and psychological pressure that causes a disturbance in your body’s natural equilibrium. It’s actually an important short-term adaptive response for meeting natural threats: The stress response prepares the body to fight or flight, a protective mechanism that could save your life.

But the daily trials and tribulations of managing a career, making ends meet, or taking care of a family can cause our bodies to activate the same physical reaction, turning on that fight-or-flight response indefinitely. The effects can damage your health if you don’t find a way to address the root cause or learn to manage your stress.

“Stress in itself is not a bad thing—but how you manage it is key.” said Nadia Haddad, MD, MS, L.Ac, a clinical instructor of psychiatry and behavioral sciences, who spoke at a presentation sponsored by the Stanford Health Library. “There is a message encoded in our stress, and to manage it we need to understand the message and respond.”

Dr. Haddad specializes in integrating modern science with Chinese medicine’s holistic approach to health and well-being. She looks at the relationship between the mind and body in a field known as integrative medicine, which combines conventional and complementary approaches to address the biological, psychological, social, and spiritual aspects of health and illness.

Ongoing Stress
Dr. Haddad emphasized that, in the short term, some stress can help you meet daily challenges, keep you motivated, and enhance learning. But she sees a glorification of stress in modern society, with people boasting about how many hours they put in at work or how little sleep they need. “The current mentality is, if you’re not stressed, you’re not working hard enough,” she said. “There’s also a regular bleed of work into daily life as email, text and cellular phones give us easy access even when out of the office.”

The result is chronic tiredness, an overactive mind, and poor sleep, which in turn leads to decreased work performance. People often overcompensate with caffeine or energy drinks to address their tiredness, medications to fall asleep, or stimulants for focus.

“Many of us have a control mentality, as in, ‘my body and mind should do what I want them to when I want them to, and willpower and self-medication are my tools.’ But ignoring stress is not the same as controlling it,” she said.

Maintaining Balance
The body has a set point to function efficiently, a natural balance of pH, oxygen, carbon dioxide, temperature and other physical mechanisms that work in conjunction with complex factors like sleep, activity, diet, and social interactions. Together, all biological systems work in conjunction to regulate this homeostasis and maintain physiologic rhythm. Stress applies pressure to this programmed equilibrium and can hamper virtually every aspect of health, from contributing to heart disease to causing weight gain. Stress has also been associated with the development of certain types of cancer.

Dr. Haddad recommends developing an awareness of your body’s messages to learn how to regulate its balance. An important internal rhythm is based on your circadian clock, a biological timekeeper that synchronizes chemicals, hormones, body temperature, and sleep patterns. This biological clock induces “larks” to go to bed early and wake earlier in the morning, and “owls” to stay awake later into the night, often with difficulty waking up.

Studies show an increased mortality risk for those reporting less than seven hours of sleep per night. Most of society is based on a lark schedule, which creates a long-term mismatch for owls’ sleep cycles. This mismatch can affect alertness and performance, and chronic sleep deprivation can cause obesity, depression, high blood pressure, stroke, and heart attack.

Management Tactics
She suggests that you try to establish a regular wake-up time that fits your circadian clock and maintain a regular sleep schedule all week. If sleep is problematic, avoid the vicious cycle of taking stimulants like caffeine, which can affect sleep no matter how early in the day you drink it: Studies have shown that caffeine in the morning can affect sleep the following night. You might consider switching to a less-potent stimulant like tea, and avoid alcohol, which disrupts sleep patterns. Some people respond to melatonin, which helps to shift the natural sleep cycle (she recommends 3-5 milligrams taken an hour before bedtime). Exposure to early morning light can also help adjust the body’s circadian rhythm.

Another important body rhythm is controlled by eating, which maintains metabolism and energy. Dr. Haddad recommends eating a wide variety of nutrients, avoiding processed foods, and increasing your intake of foods rich in omega-3, such as flax seeds, and fatty fish (sardines, mackerel, salmon). Incorporate physical activity and exercise that you enjoy into your daily routine, and take classes to expose yourself to new ways to move your body.

She also suggests you build in some downtime to relax and enjoy being in the present, such as breathing exercises, stretching exercises, yoga, or meditation. Attune yourself to external rhythms through music and dance, which can alter your brain waves, lower blood pressure, and improve immune function. Stress also can come from interpersonal friction, so seek meaningful connections with people you enjoy.

Fine-Tune Your Rhythm
People who have trouble identifying their emotions may benefit from short-term psychotherapy, though it’s important to find a professional you can relate to. Acupuncture is designed to support both balance and rhythm, and can improve sleep patterns, reduce inflammation, and diminish perceptions of pain. Massage with moderate pressure has also shown to reduce the effects of stress.

To make positive, permanent changes, choose two small, measureable steps for one week, such as reducing coffee or meditating for 10 minutes a day. Become aware of your circadian rhythm and modify your sleep accordingly.

“We have important internal cues that help us navigate the world.” Haddad said. “The key to reducing stress is to get to know yourself to help support your body’s internal rhythms. Handling stress better means handling our bodies better as well.”

About the Speaker
Nadia E. Haddad, MD, MS, is a clinical instructor of psychiatry and behavioral sciences, who specializes in merging traditional science with Chinese medicine. She received her MS in Oriental Medicine from Dongguk Royal University in Los Angeles, her MD from the University of Colorado School of Medicine, and she completed her residency at Stanford, where she joined the faculty in 2015. She is board certified in psychiatry by the American Board of Psychiatry & Neurology.

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