Heart Health & Brain Health Go Hand-in-Hand

According to the Center of Disease Control and Prevention, heart disease accounts for one of every four deaths in the United States. Many of the causes of heart disease are well-known, including hypertension, hyperlipidemia, diabetes and obesity. Fortunately, there are also well-known lifestyle and behavior changes that can drastically reduce the risk of heart disease and include: smoking cessation, eating a healthy diet and exercising.

Despite the multitude of data showing that lifestyle behaviors can reduce the risk of heart disease and improve cardiovascular health, the Framingham Offspring Study recently reported that the percentage of people with ideal cardiovascular health (using the American Heart Association’s definition of Ideal Cardiovascular Health) has declined over the past 20 years.

Even in the absence of heart disease, the increasing percentage of Americans with less than ideal cardiovascular health translates to greater risk of heart disease and increased all-cause mortality. Because the heart and cardiovascular system are vital factors in overall health, other organ systems will be affected by less-than-ideal cardiovascular health. Importantly, adults having an ideal cardiovascular health score during the middle-aged years had a lower risk of cognitive decline and dementia. In addition, large-scale epidemiological studies have continued to show a strong correlation between cardiovascular health and brain health.

What is the link between cardiovascular health and brain health?

It is possible that heart disease and Alzheimer’s disease or dementia have common risk factors and that is why there are correlations between these conditions. However, the brain requires a large amount of blood flow, which needs to be precisely controlled to maintain optimal neuronal function. If a patient has a problem with the function of the heart or blood vessels, this could prevent adequate blood flow supply to the brain and eventually affect brain function and cognition. We know that patients with congestive heart failure have higher incidence of dementia. In heart failure patients, a reduced capacity of the left ventricle to pump blood (i.e. ejection fraction) is associated with poor cognitive test scores.

The function of the large vessels supplying blood flow to the brain are also important to overall brain health. A paper published almost 70 years ago first reported that patients with carotid occlusion (due to atherosclerosis) eventually progressed to dementia. This early case study was the first to suggest that mild hypoperfusion of the brain, due to large vessel stenosis, could lead to dementia.

Dysfunction in the heart (or pump) or the large blood vessels (or conduits) is associated with reduced cognitive function, but the small blood vessels in the brain that control the blood supply to neurons may also contribute to the link between cardiovascular health and brain health. This hypothesis was first proposed decades ago, based on evidence of disrupted microvessel structure in the brains of Alzheimer’s disease patients. Disruption in the microvessels can lead to hypoperfusion, disrupt the blood-brain-barrier or reduce the ability of the brain to utilize glucose. Collectively, an interruption at any segment of the blood delivery system (heart, large and small blood vessels) could impair the ability of the brain to function optimally.

physical activity recommendationsNow, for the good news: Because of the link between heart health and brain health, we know that lifestyle behaviors (like exercise!) can reduce the risk of developing heart disease AND developing cognitive decline. Older adults who are more physically active have better brain health compared with sedentary counterparts, suggesting a protective effect of exercise. And although more research is necessary to determine how exercise may promote healthy brain aging and what might be the optimal training program, using what we know about what works for heart health and following ACSM’s guidelines for physical activity is a great place to start. Remember to take care of our heart so that our heart can take care of our brain.

By: Jill Barnes, Ph.D., FACSM, is an Assistant Professor at the University of Wisconsin-Madison in the Department of Kinesiology and has an affiliate faculty appointment in the Division of Geriatrics and Gerontology in the School of Medicine and Public Health.

Related Article: Heart disease and brain health: Looking at the links

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What To Know About Victor Oladipo’s Quad Injury

Indiana Pacers guard Victor Oladipo suffered a torn quadriceps tendon in his right knee and will miss the remainder of the NBA season, the team announced Thursday. Surgery will be required to repair the tendon.

Dr. Adam Yanke, a sports medicine orthopedic surgeon from Midwest Orthopaedics at Rush, and head team physician for the Windy City Bulls answers three questions about the injury and expected recovery.


Q: What exactly is a ruptured quadriceps tendon?

A: The quadriceps tendon attaches the entire quad muscle to the kneecap or the patella and allows you to straighten your leg. This tendon can commonly have inflammation in it that causes pain but it can occasionally also rupture. This injury is more common in individuals over 50 years of age but can happen in younger, athletic patients as well. Typically this happens from the tendon being overloaded but can also be due to some underlying tendon disease that weakens the tissue before injury.

Q: How do you repair a torn quadriceps tendon?

A: There are multiple ways to fix a quadriceps tendon tear with regards to specific surgical technique. Regardless of the specifics, they all involve an open approach to directly visualize the tendon. Once you can see the tear directly sutures are placed through the tendon and they are either brought through drill tunnels or anchors in the patella to perform the repair. Typically the soft tissue adjacent to the tendon called the retinaculum is also torn and this requires repair as well.

Q: What is the rehab and recovery process?

A: The recovery after quadriceps tendon repair typically involves a period of immobilization in a brace for 4-6 weeks. After this time, we work aggressively on range of motion try to eliminate any stiffness. There is always a balance between healing and motion and it is important to have both be successful for return to play. Some patients do get back to full activity without pain or restrictions, however there is a subset that still have discomfort in that area or have issues with building up muscle strength. In general its a successful procedure with good outcomes but can take up to 6 months for complete recovery.


Dr. Adam Yanke’s clinical interests include advanced arthroscopy, shoulderImage replacement, and a special focus on patellofemoral dysfunction and cartilage restoration. Dr. Yanke is a team physician for the Chicago Bulls, Windy City Bulls, Chicago White Sox and DePaul Blue Demons.

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Concussions in Cheerleaders: Symptoms and Treatment

By Tara Hackney, PT, DPT, OCS, KTTP for Athletico Physical Therapy

Cheerleaders are commonly seen on the sidelines of school and professional sporting events, but the sport is no longer reserved for the sidelines. Cheerleaders have their own competitions where they are in the spotlight. Competitive cheerleading participation is on the rise with teams ranging in age from 5 years old through college.

All-Star cheerleading is the name used to refer to cheer groups created for competition and not associated with any school or team. Competitive cheerleading is divided into groups according to age and each group has different levels according to experience. Cheerleaders perform tumbling, stunting and pyramids as part of their routines. As with any sport, injuries can occur.

Did you know that the most common injury in competitive cheerleading is concussions? The overall injury rate in cheerleading is low; however of those injuries, concussions account for 31.1 percent.1 You may be thinking this high rate of concussions would be from cheerleaders falling and landing on their heads. However, the cheerleading position that suffers the most concussions are the bases, the athletes who support the flyers in the air by holding them up and catching them. This position is at risk for concussions as a flyer may fall on top of them, or from a foot or elbow hitting them in the head as the flyer comes down from a stunt. In fact, it is more likely in cheerleading for a concussion to occur after contact with another athlete than with contact with the floor.

Concussion Symptoms

Any one or more of the following signs and symptoms may indicate a head injury:

  • Headache
  • Nausea or vomiting
  • Dizziness
  • Coordination or balance issues
  • Blurred or double vision
  • Light and noise sensitivity
  • Feelings of sluggishness
  • Memory or concentration problems
  • Altered sleep patterns

Signs observed by coaches or other team members that may indicate a concussion has occurred:

  • Stunned or confused appearance
  • Forgets arm motions or cheers
  • Confused about formations in routines
  • Unsure of surroundings
  • Moves clumsily
  • Loss of consciousness (long or short)
  • Personality or behavior changes
  • Forgets events right before or after a blow to the head

If a head injury or concussion is suspected, the athlete should not return to play prior to 24 hours after the initial incident and should be cleared by a physician prior to returning to sport.

Concussion Management

Concussion management is evolving through research. There is strong evidence to support an active approach to rehabilitation of concussions. Physical therapy is one way to help manage the symptoms following a concussion. Physical therapy can include management of neck pain and headaches, balance exercises, progression of exercise tolerance and cardiovascular activities, and vision training. Ideally, an athlete will complete a graded exposure program that starts with symptom limited activity, progress through light aerobic activity, and transition to sport-specific incremental intensity training. Finally, the athlete will be cleared to practice prior to being cleared to compete.

Speed of recovery after concussion is individualistic for each athlete and may be affected by severity of trauma, area of the brain injured, age, gender, past medical history, and previous history of concussions.

Please visit our Concussion Page to learn more about our services.

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Exercise for the Prevention and Treatment of Hypertension – Implications and Application

3 Key Points:

  • Regular aerobic exercise results in reductions in blood pressure of 5-7 mmHg among individuals with hypertension and these reductions translate to a reduced risk of CVD of 20-30%.
  • Emerging research suggests that dynamic resistance exercise may also serve as an efficacious strategy to lower blood pressure to levels similar to aerobic exercise.
  • Special consideration should be given to signs/symptoms or presence of disease, concomitant drug therapy, and other comorbidities in order to optimize CVD risk reduction and improve overall health. The goal of preparticipation screening should be to risk classify individuals at risk for an adverse or life threatening response to exercise while decreasing barriers to physical activity participation.

Cardiovascular disease (CVD) is the leading cause of death in the United States (U.S.) and accounts for 1 out of every 3 deaths in U.S. adults. High blood pressure (BP) or hypertension is the most common, costly, but modifiable major risk factor for the development of CVD and premature mortality, affecting nearly half (46%) of U.S. adult population (PMID: 30700139).

Hypertension is the most common, costly, and modifiable CVD risk factor.

In 2017, The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released new guidelines, which now define ‘hypertension’ as:

  • having a resting systolic BP (top number) of 130 mmHg or greater
  • having a resting diastolic BP (bottom number) of 80 mmHg or greater
  • taking antihypertensive medication
  • being told by a physician or health professional on at least two occasions that one has high BP
  • or any combination of these criteria

Blood Pressure Guidelines Zaleski

The ACSM recommends that individuals with hypertension engage in moderate intensity, aerobic exercise 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

Participation in regular exercise is a key modifiable determinant of hypertension and is recognized as a cornerstone therapy for the primary prevention, treatment, and control of high BP. On average, regular aerobic exercise lowers resting systolic BP 5-7 mmHg, while resistance exercise lowers resting systolic BP 2-3 mmHg among individuals with hypertension. These BP reductions follow the “law of initial values” such that individuals with higher baseline BP values experience even greater reductions in BP from exercise training. In other words, exercise works best in those who can stand to benefit the most.

BP reductions of this magnitude lower overall CVD risk by 20-30%. For these reasons all major public health organizations universally recommend aerobic exercise for the primary prevention and treatment of hypertension. Similar to a drug prescription, individuals can be “prescribed” an exercise prescription for the prevention, treatment, and control of high BP following the FITT principle:

Frequency: How often?

Intensity: How hard?

Time: How long?

Type: What kind?

Specifically, the ACSM recommends the following exercise prescription for individuals with hypertension:

Frequency:

For aerobic exercise, 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

The frequency of aerobic exercise is slightly greater than those with normal BP (i.e., 3-5 d/wk). In fact, individuals with hypertension are encouraged to engage in greater frequencies of aerobic exercise than those with normal BP because we know that a single bout of aerobic exercise results in immediate reductions in BP of 5-7 mmHg, that persist for up to 24 hr (i.e., postexercise hypotension). For this reason, individuals with hypertension are encouraged to exercise on most days of the week in order to benefit from the acute effects of aerobic exercise on BP.

Intensity:

Moderate [i.e., 40-<60% VO2R or 11-14 on a scale of 6 (no exertion) to 20 (maximal exertion) level of physical exertion or an intensity that causes noticeable increases in heart rate and breathing] for aerobic exercise; moderate to vigorous (60-80% 1RM) for resistance; and stretch to the point of feeling tightness or slight discomfort for flexibility.

New and emerging evidence suggest that the magnitude of the BP reductions that result from aerobic exercise occur as a direct function of intensity, such that the more vigorous the intensity, the greater the resultant BP reductions (PMID: 26423529). Individuals who are willing and able may consider progressing to more vigorous intensities, however, the risk-to-benefit ratio has not yet been established.

Time:

For aerobic exercise, a minimum of 30 min or up to 60 min/d for continuous or accumulated aerobic exercise. If intermittent, begin with a minimum of 10 min bouts.

New and emerging research has shown that short bouts of exercise (3-10 min) interspersed throughout the day may elicit BP reductions similar in magnitude to one continuous bout of exercise and may be a viable antihypertensive lifestyle strategy for individuals with limited time.

Type:

For aerobic exercise, emphasis should be placed on prolonged, rhythmic activities using large muscle groups such as walking, cycling, or swimming. Resistance training may supplement aerobic training and should consist of 2-4 sets of 8-12 repetitions for each of the major muscle groups. For flexibility, hold each muscle 10-30 s for 2-4 repetitions per muscle group. Balance training (neuromotor) exercise training is also recommended in individuals at high risk for fall (i.e., older adults) and is likely to benefit younger adults as well.

Blood pressure reductions appear to occur in a dose-response manner such that greater volumes of exercise elicit greater reductions in blood pressure. Progression to the Ex Rx should be gradual, avoiding large increases in any of the FITT components of the Ex Rx, especially intensity for most individuals with hypertension.

A recent meta-analysis demonstrated dynamic resistance exercise training to result in BP reductions similar in magnitude to aerobic exercise training (PMID: 27680663). These results suggest that the antihypertensive benefits of resistance exercise training may have been largely underestimated and warrant reappraisal in the near future. Note that, inhaling and breath-holding while engaging in the actual lifting of a weight (i.e., Valsalva maneuver) can result in extremely high BP responses, dizziness, and even fainting and should be avoided during resistance training.

Practical Applications

Accurate BP assessment is critical for a) the initial diagnosis of hypertension and b) to establish a baseline BP to properly evaluate the influence of lifestyle intervention strategies across time. Proper patient positioning and preparation are critical for ensuring accuracy of BP values. Caffeine, exercise, and smoking should be avoided at least 24 hr before BP assessment. Prior to the first reading, the patient should be:

  • seated quietly and not talking for at least 5 min prior to or during the measurements
  • legs uncrossed and flat on the floor
  • bladder empty
  • back supported upright
  • arm supported at heart level
  • with an appropriate sized cuff

American Heart Association standards state that BP should be measured three times in each arm, separated by at least 1 min, and averaged. This is particularly important given that the first reading is often the highest reading. Preferably, the same exercise professional should measure BP on the same patient and using the same BP monitoring device. Approximately ~25% of patients experience “white-coat hypertension” such that BP readings obtained in the presence of a healthcare provider appear elevated, however, home or ambulatory BP values are within normal ranges. Patients with suspected white-coat hypertension may be referred to their healthcare provider for proper evaluation.

Appropriate preparticipation health screening should be implemented to identify at-risk individuals who may require medical clearance before they begin an exercise program (PMID: 2647375). Although exercise is safe for most individuals, there is a small risk of cardiovascular complications in certain susceptible individuals, particularly among sedentary adults with known or underlying CVD who perform vigorous-intensity exercise they do not usually engage in. The ACSM preparticipation guidelines emphasize the public health message that exercise is important for all individuals and largely triages individuals on the basis of current physical activity levels, desired exercise intensity, and the presence of known or underlying CVD, metabolic, and/or renal disease.

As such, individuals with hypertension cleared to exercise (by the preparticipation algorithm or healthcare provider) should be encouraged to progress gradually, avoiding large increases in any of the components of the FITT. Progression should begin by increasing exercise duration over the first 4-6 wk, followed by an increase in frequency and intensity to achieve the recommended volume of 150 min/wk or 700-2000 kcal/wk over the next 4-8 mo. Progression may be individualized based on tolerance and preference in a conservative manner.

Lifestyle modifications, such as regular aerobic exercise, are fundamental for the prevention, treatment, and control of hypertension. When lifestyle interventions are not effective in achieving treatment BP goals, antihypertensive therapy may be required to optimize CVD risk reduction. Whenever possible, an interdisciplinary, collaborative approach involving the patient, healthcare provider(s), and exercise professional will largely improve lifestyle and pharmaceutical adherence, translating to greater BP control and overall health, which is the ultimate goal in the treatment of hypertension.


Author: Amanda Zaleski, PhD is an American Heart Association Postdoctoral Fellow in Amanda Zaleski PhDthe Department of Kinesiology at the University of Connecticut. She is also a Project Manager and Evidence-Based Credentialed Analyst for the forthcoming ACSM Hypertension Position Stand Update and Co-Chair of the Communications Committee for New England ACSM.


Recommended Reading: New Blood Pressure Guidelines, Preparticipation Screening

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