Prescribing Exercise For Adults - UpToDate

Prescribing exercise for adults - UpToDate 19/09/18 09.
08
Authors: Barry A Franklin, PhD, Robert E Sallis, MD, FAAFP, FACSM, Francis G O'Connor, MD, MPH, FACSM
Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2018. | This topic last updated: Aug 22, 2018.
INTRODUCTION — Regular exercise has been shown to have wide ranging health benefits. There is
evidence to suggest a sedentary lifestyle may be an even stronger predictor of mortality than such
established risk factors as smoking, hypertension, and diabetes [1]. Numerous epidemiologic studies show
that unfit individuals are two to three times more likely to die during follow-up compared with their more fit
counterparts, regardless of their risk profile, body habitus, or the presence of cardiovascular disease.
Perhaps Per-Olof Åstrand, MD summed it up best when he said: "As a general rule, moderate activity is less
harmful than inactivity…A medical evaluation is more urgent for those who plan to remain inactive than for
those who intend to get into good physical shape." Because physical inactivity is a modifiable risk factor,
clinicians should routinely assess and prescribe structured exercise and increased lifestyle activity to all
patients.
In this topic, we discuss exercise terminology, clinical assessment for exercise readiness, prescribing and
supporting regular aerobic exercise, and mitigating the risks of exercise. The general benefits and risks of
exercise and the role of exercise for patients with cardiovascular and other significant comorbidities are
reviewed separately. (See "The benefits and risks of exercise" and "Exercise and fitness in the prevention of
atherosclerotic cardiovascular disease" and "Cardiac rehabilitation programs" and "Effects of exercise in
adults with diabetes mellitus" and "Exercise in the treatment and prevention of hypertension".)
TERMINOLOGY AND COMMON TYPES OF EXERCISE
Exercise terminology
● Physical activity is any sustained body movement that increases energy expenditure, such as
walking, jogging, dancing, gardening, swimming, heavy physical labor, etc [2].
● Exercise is a subcategory of physical activity that is planned, purposeful, and repeated on a regular
basis, in order to improve or maintain health and fitness [2,3]. Exercises may be divided into four major
types, although these may overlap. They include:
• Aerobic or endurance exercises designed to increase cardiovascular and respiratory fitness, such
as walking or running
• Strength (or resistance) exercises designed to increase muscular strength, such as weight lifting or
body weight resistance exercises (eg, pull up, push up, squat)
• Balance exercises designed to improve balance and proprioception, and to prevent falls, such as
heel-toe walking or Tai Chi.
• Mobility (or flexibility) exercises intended to maintain or improve range of motion around a joint or
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Prescribing exercise for adults - UpToDate 19/09/18 09.08
lengthen a muscle, such as stretching or yoga
● Physical fitness is a set of somatic attributes brought about by engaging in regular activity that allows
one to perform vigorous tasks without undue fatigue. The general attributes of fitness can be split into
two categories, those related to health and those related to skill (athletic performance) [2].
The health-related components of fitness include:
• Cardiovascular endurance – Relates to the body's ability to supply fuel and eliminate waste during
moderate-to-high intensity exercise via the cardiovascular and respiratory systems
• Muscular strength – Relates to the body's ability to exert force against external resistance
• Muscular endurance – Relates to the body's ability to exert force repeatedly within a limited period
or continuously
• Mobility – Relates to maintaining a healthy range of motion around key joints, particularly the hips
and shoulders
• Body composition – Relates to the relative amounts of body fat, muscle, bone, and other tissues
The skill-related components of fitness include:
• Agility – The ability to change direction with speed and precision
• Balance – The ability to maintain physical equilibrium when stationary and during movement
• Coordination – The ability to use ones senses (vision, hearing, touch) to perform motor tasks
smoothly and accurately
• Power – The ability to perform work rapidly
• Reaction time – The ability to react rapidly to a stimulus
Characteristics of exercise — The United States Physical Activity Guidelines recommend that adults
engage in at least 150 minutes of activity per week of moderate or greater intensity. The FITT mnemonic
can be used to summarize the components of an exercise prescription [4]:
● F for Frequency – Refers to the number of days per week in which a person is physically active and
should be five or more days on average
● I for Intensity – Refers to how hard an activity should be performed with regard to an individual's
perceived level of effort and should be moderate to vigorous intensity on average depending on
individual health and fitness goals
● T for Time – Refers to how long an activity is undertaken during a session and should be 30 minutes or
more on average
● T for Type – Refers to the specific kind of activity that should be done (walking is often recommended to
previously sedentary beginning exercisers); however, most any activity that works major muscle groups
and requires comparable energy expenditure is acceptable (cycling, swimming, dancing, gardening,
etc)
Application and sample prescriptions of the FITT mnemonic are provided below. (See 'Components of an
exercise program' below and 'Writing the aerobic exercise prescription' below and 'Advancing aerobic
exercise' below.)
Determining exercise intensity — Intensity is an important factor in developing cardiovascular

performance and fitness. Athletes know that to improve performance some training must be performed at
high intensity. However, significant health benefits can be achieved with more moderate intensity exercise.
Exercise intensity is commonly described using one of the parameters outlined below; the physiology of
exercise is discussed in greater detail separately [5] (see "Exercise physiology"):
● Training heart rate (THR) is based on the linear relationship between heart rate (HR) and oxygen
consumption (VO2). The THR can be calculated using the HR reserve (HRR) or the Karvonen Method,
where the THR equals a given percentage of HRR added to the resting HR (RHR).
● Metabolic equivalent (METs) system estimates exercise intensity by comparing the VO2 during an
activity to VO2 at rest. At rest, VO2 is approximately 3.5 mL per kg body weight per minute, which
equals 1 MET. An activity rated as 2 METs would require twice the oxygen consumption as occurs at
rest. Tables are available that compare the MET requirements at rest with the requirements of various
recreational and sports activities (table 1).
● Rates of perceived exertion (RPE) are scales based on an individual's perception of how hard they are
working. The most commonly used is the Borg Scale, which rates the intensity of activity between 6 and
20 (table 2). Moderate exercise correlates with an RPE of 12 to 13 (somewhat hard), while vigorous
exercise correlates with an RPE of 14 to 16 (hard). By adding a zero to the rating on the Borg RPE
scale, one can estimate the corresponding HR in healthy young adults when performing activity at that
perceived intensity. Thus, moderate exercise would correlate with a HR between 120 and 130 beats per
minute. Although this appears simplistic, numerous studies have demonstrated the accuracy of this
method [5].
● Non-exercise activity thermogenesis (NEAT) refers to a person's daily physical activity that is not
structured exercise [6].
Exercise intensity for aerobic activity may be categorized as follows [5]:
● Light – HRR/VO2 30 to 40 percent; 2 to 3 METs; RPE 9 to 11
● Moderate – HRR/VO2 40 to 60 percent; 4 to 6 METs; RPE 12 to 13
● Vigorous – HRR/VO2 60 to 90 percent; 8 to 12 METs; RPE 14 to 17
● Near Maximal – HRR/VO2 >90 percent; 14 to 20 METs; RPE 18 to 20
For strength training, intensities are determined using a percentage of the maximum weight a person can lift
for a single repetition of a given exercise. That weight is called the one repetition maximum (1-RM). As an
example, if a person can press 110 pounds (50 kg) overhead just once (1-RM), then 55 pounds (25 kg)
would be 50 percent of their 1-RM.
Using this approach, intensities for strength training can be categorized as follows [7]:
● Light ‒ 40 to 50 percent of 1-RM
● Moderate ‒ >50 percent to <70 percent of 1-RM
● Vigorous ‒ ≥70 percent to <80 percent of 1-RM
● Near maximal ‒ ≥80 percent of 1-RM
Before prescribing strength exercise, the clinician or coach should explain how to determine a 1-RM for
each exercise. Several online calculators are available to assist the patient in calculating a 1-RM; actually
lifting the maximal weight is typically unnecessary and potentially harmful. What follows is one method that
may be used:
● Warm up for 10 minutes then select weight light enough for >10 repetitions;
● Perform 12 to 15 repetitions, then rest 2 minutes;
● Increase weight 5 to 10 percent, perform 10 to 12 repetitions, then rest 3 minutes.
● Increase weight 5 to 10 percent, perform 6 to 8 repetitions then rest for 3 minutes.
● Increase weight 5 to 10 percent, perform 5 repetitions – should be close to 5-RM;
● Multiply 5-RM weight by 1.15 to get 1-RM.
Common types of exercise
● Standard endurance training – Examples include distance running, cycling, swimming, and hiking
● Traditional strength training – Examples include weight lifting, Olympic style weight lifting, and
resistance equipment (eg, leg press machine (picture 1), elastic resistance bands (picture 2).
● High intensity interval training (HIIT) – HIIT involves intermittent, usually regularly timed bouts of high-
intensity activity incorporated into a sustained aerobic workout. (See 'High intensity interval training:
Which patients are best suited?' below.)
● Dynamic flexibility training – Examples include yoga (picture 3), Pilates, Tai Chi (movie 1), Zumba, and
similar types of activity that focus on improving mobility and muscular endurance. (See "Overview of
yoga".)
● Mixed strength and aerobic training – Sometimes called "circuit training," this approach is incorporated
into such activities as BodyPump, CrossFit, "boot camps," and some “aerobics” classes. Many such
programs include resistance training of all major muscle groups, while using short recovery periods and
continual activity to work the aerobic system.
● Functional fitness training – A form of exercise that involves training the body for the activities
performed in daily life. Functional fitness exercises use various muscles in the upper and lower body at
the same time, emphasizing core stability.
Some jobs (eg, construction work) often make sufficient aerobic and musculoskeletal demands to provide a
training effect, which should be factored into any exercise prescription (table 3).
BENEFITS AND RISKS ASSOCIATED WITH EXERCISE — The benefits and risks associated with
exercise are reviewed in detail separately. (See "The benefits and risks of exercise", section on 'Benefits of
exercise' and "The benefits and risks of exercise", section on 'Risks of exercise'.)
ASSESSMENT OF INDIVIDUAL PATIENT ACTIVITY — One of the key determinants of health for an adult
is the number of minutes spent being physically active each week. Numerous studies and guidelines
suggest that regular exercise is perhaps the single most important intervention to prevent and manage
chronic disease [2]. The United States Physical Activity Guidelines recommend that adults (18 years and
older) perform at least 150 minutes per week of moderate intensity exercise (like a brisk walk). Guidelines
for Canada and the European Union parallel those of the United States. Australian guidelines are similar
and offer specific suggestions for activity for different ages of life. All published guidelines encourage the
accumulation of 150 minutes of moderate intensity activity or more each week [8-11].
Primary care clinicians should ask every patient about their exercise habits at each visit. This can be done
using a physical activity vital sign (PAVS, or exercise vital sign). Clinicians should do their utmost to ensure
that all patients exercise regularly, and should provide an exercise prescription as needed [12]. (See
'Prescribing an exercise program' below.)
Physical activity vital sign (PAVS) — PAVS is designed to assess whether a patient is meeting published
recommendations for performing at least 150 minutes per week of moderate or greater intensity exercise.
PAVS can be assessed by a medical assistant as they settle the patient in the examination room and obtain
standard vital signs. At several large United States health care organizations, the PAVS assessment is
performed by asking the following questions [13]:
● On average, how many days each week do you engage in moderate or greater physical activity (like a
brisk walk)?
● On the days you exercise, on average, how many minutes do you engage in this physical activity?
Based on the patient's responses, total exercise time is calculated in minutes per week of moderate or
greater physical activity. This number can be displayed in the patient's chart adjacent to the traditional vital
signs. The patient's body mass index (BMI), smoking history, and other important information relevant to the
patient's capacity for and risks associated with exercise are also recorded.
PAVS allows the clinician to assess a patient's exercise habits quickly and offer either brief advice or a more
detailed exercise prescription. At a minimum, providers are asked to offer each patient feedback, saying
either:
● "Good job! I see you are meeting the PA guidelines of 150 minutes per week of moderate exercise.
Keep it up!"
Or if not meeting guidelines, offer advice, such as:
● "Today I noticed your blood pressure (or blood sugar or cholesterol, etc) is elevated, and you report you
are not doing any exercise. Before I put you on medication (or increase your current medication), why
don't you try doing brisk walking for 30 minutes on five or more days each week (along with proper diet
modifications) and have you follow up to see how that improves your reading?"
ASSESSMENT OF PATIENT WILLINGNESS TO BEGIN EXERCISING — The Transtheoretical Model (or

Stages of Change Model) describes six stages for any major change in behavior:
● Pre-contemplation – Patient is not thinking about making lifestyle changes
● Contemplation – Patient is considering but is not yet ready to change
● Determination – Patient has taken some behavioral steps and intends to take action in the next 30 days
● Action – Patient begins to demonstrate the new behavior consistently for <6 months
● Maintenance – Patient has consistently performed the new behavior for ≥6 months
● Relapse – Patient returns to former [unhealthy] lifestyle habits
A patient's current stage should be determined before a clinician counsels them about a specific behavior
change (eg, becoming more physically active) to help ensure their counsel is appropriate. While a pre-
contemplator may need help changing their understanding, the contemplator may need help assessing the
pros and cons of changing a behavior. Exploring alternative action plans, providing specific instructions
(step-by-step guides), offering positive personal feedback, and halting recidivism may be needed for
patients in the determination, action, maintenance, and relapse stages, respectively.
Topics devoted to the Transtheoretical Stages of Change model and its implementation are found
separately. The discussion below focuses on its application for exercise. (See "Motivational interviewing for
substance use disorders", section on 'Theoretical foundation' and "Brief intervention for unhealthy alcohol
and other drug use: Goals and components".)
● Facilitating behavior change – The likelihood that a patient will change a longstanding unhealthy
behavior is governed by a myriad of socioeconomic, attitudinal, and cultural factors, including their
expectation of the benefits, costs, and consequences of that behavior [14]. Common barriers to making
lasting behavioral changes (eg, following an exercise program) include suboptimal social support,
social isolation, financial difficulties, and a lack of free time. Strategizing with the patient to identify
realistic options to overcome these barriers, real or perceived, is integral to changing unhealthy
behaviors.
The "Five A’s" approach (Ask, Advise, Assess, Assist, and Arrange) has been reported to produce
significant improvements in a variety of health behaviors, including physical activity. Use of the Five A's
for smoking cessation is discussed separately. (See "Overview of smoking cessation management in
adults", section on 'The "5A's" Approach'.)
More clinicians now perform the first two A's, that is, ask about the risky behavior and advise behavior
change. However, it is the less frequently performed A's (assess, assist, arrange) that require more
time and specific counseling skills to implement, and that have the greatest impact on healthful
behavior change [15]. The core of effective counseling is a patient-centered approach, helping the
patient to create and implement an "action plan" to reach their self-stated goals [16]. This approach
grows out of the patient's answers to carefully worded questions posed by the clinician.
● Motivational interviewing – Motivational interviewing is a form of talk therapy used by the clinician
during patient encounters to encourage behavioral change [17]. To achieve such change, the clinician
must convey understanding, acceptance, and sincere interest in the patient.
The first step is to identify the patient's readiness to change their behavior. Unhealthy lifestyle practices
should be discussed in a sympathetic manner, as the clinician helps the patient to understand the
factors that contribute to these behaviors.
The next step in getting the patient to understand and accept the need for change is to assist them in
identifying and overcoming obstacles. Questions to help them accomplish this task may include:
• What activity would you most like to do if you start exercising?
• Are there any barriers to starting this exercise, and how could they most easily be overcome?
• Could you commit to exercising for a total of 30 minutes per day, three times per week, prior to our
next visit?
Next, the clinician should help the patient overcome inertia and become independent and self-
motivating, emphasizing that time is an ally to successful lifestyle modification. Finally, patients should
be counseled on handling resistance and dealing with recidivism.
● The PACE program: A model to emulate? – The PACE Program (Patient-centered Assessment and
Counseling for Exercise) is a comprehensive approach to physical activity counseling [18]. This
approach draws heavily on the "stages of change" model, which suggests that individuals change their
behavior in stages, and uses tailored recommendations for each stage [19].
The PACE program was developed to overcome common barriers to physician counseling for physical
activity, using brief counseling sessions (2 to 5 minutes) during a conventional physical examination.
The results of controlled trials suggest that the PACE approach can be incorporated effectively into
clinical encounters intended to motivate previously sedentary adults to become more physically active
[20]. Guidance for how to implement the program can be found in the following reference [21].
MEDICAL ASSESSMENT AND CLEARANCE FOR EXERCISE — "Do no harm" remains a cardinal tenet
of medicine. Following on this maxim, a number of medical organizations, including the American Heart
Association (AHA), American College of Cardiology, and American College of Sports Medicine (ACSM)
have emphasized preparticipation screening examinations to identify "at risk" individuals who should seek
more detailed medical evaluation prior to beginning an exercise regimen. Such medical evaluation may
include a history and physical examination, exercise stress testing, or more extensive diagnostic testing.
The approach to screening is summarized in the following algorithm (algorithm 1).
Currently, little evidence supports the role of screening examinations or diagnostic testing in reducing the
risk of exercise-related cardiovascular events [22-25]. In addition, there is a lack of consensus among
organizations about the extent of the medical evaluation needed for screening [2]. In part, this stems from
the many variables to be considered, such as patient age, intensity of the exercise to be performed, prior
training history, and whether the patient has known cardiovascular, metabolic, or renal disease [26]. Despite
this, many patients will seek advice from their medical providers before engaging in an exercise program.
The clinician needs to be aware of current guidelines for identifying high risk individuals who may require a
more thorough evaluation before beginning an exercise program, as well as what advice to give low risk
individuals.
Patients who do not need preparticipation screening — The 2008 Physical Activity Guidelines for
Americans promulgated by the US Department of Health and Human Services (HHS) state: "People without
diagnosed chronic conditions (such as diabetes mellitus, heart disease, or osteoarthritis) and who do not
have symptoms (such as chest pain or pressure, dizziness, or joint pain) do not need to consult a health
care provider about physical activity" [4,27]. While we concur with this approach, many patients will seek
advice regardless; this represents a great opportunity for the clinician to educate patients and promote
regular exercise.
ACSM recommendations for pre-exercise screening — The ACSM has published recommendations
describing which patients warrant a screening evaluation before starting an exercise program based on four
major categories for assessment [23]:
● The individual's current level of physical activity
● The presence of known cardiovascular, metabolic, or renal disease, or symptoms or signs suggestive of
such disease
● The desired or anticipated exercise intensity
● The potential hazards of unaccustomed, high-intensity physical activity
We agree with the ACSM recommendations, which can be succinctly summarized as follows:
● For a patient who is asymptomatic and already physically active, with or without known
cardiovascular, metabolic, or renal disease (CMRD), medical clearance is not necessary for moderate
intensity exercise. Individuals without known disease or symptoms may progress to vigorous exercise
using an appropriate approach (as outlined in separate ACSM guidelines [2]), whereas asymptomatic
individuals with CMRD may progress to vigorous activity after medical clearance.
● Any patient who was previously physically active and asymptomatic, but who becomes symptomatic
during exercise should immediately discontinue such activity and seek medical evaluation before
resuming physical activity.
● For a patient who is inactive, asymptomatic, and without known CMRD, medical clearance for light-
to-moderate intensity exercise is not necessary. Such individuals may progress, over time, to vigorous
exercise (as outlined in separate ACSM guidelines [2]), provided they remain asymptomatic.
● For inactive, asymptomatic patients with known CMRD, medical clearance is recommended for
light-to-moderate exercise. For inactive patients with any symptoms or signs that suggest CMRD,
medical clearance is recommended before participating in light-to-moderate exercise with progression.
The approach described in the ACSM guidelines is also summarized in the following algorithm (algorithm 1).
The ACSM guidelines forego age cutoffs, risk factor profiles, and the use of low, moderate, and high-risk
classifications. The term "medical clearance" is used, rather than specific recommendations for performing a
formal medical examination or exercise testing, as the authors felt that such evaluations should be left to the
clinician's discretion. In addition, patients with pulmonary disease are no longer automatically referred for
medical clearance because pulmonary disease does not necessarily confer greater risk of nonfatal and fatal
cardiovascular complications during exercise [23].
Medical evaluation for those who require screening or seek guidance prior to beginning an exercise
program — The screening of recreational and competitive adult and adolescent athletes to identify those at
increased risk of sudden cardiac death is reviewed in detail separately. A brief discussion of the medical
evaluation of patients beginning an exercise program is provided here (algorithm 1). (See "Screening to
prevent sudden cardiac death in athletes".)
There are several means by which recreational athletes and those beginning an exercise program with
heretofore unknown structural cardiovascular abnormalities or atherosclerotic cardiovascular disease
(placing them at risk of sudden cardiac death during strenuous exercise) may be identified. These include:
● Comprehensive evaluation by a primary care physician or specialist (eg, clinical cardiologist)
● Systematic screening of those whose families have a genetic predisposition to premature

cardiovascular disease
● Incidental findings on clinical examination or an imaging study, detected during evaluation for another
medical problem
● Systematic population screening, with or without concomitant diagnostic testing
● Symptomatology (eg, chest pain or pressure, unusual shortness of breath, palpitations or abrupt
tachycardia, syncope) at rest or during strenuous activity
While most patients do not need clearance prior to starting a regular exercise program, those with
concerning symptoms, findings identified through one of the methods listed above, or other concerns should
be evaluated, starting with an appropriate history and physical examination. (See 'ACSM recommendations
for pre-exercise screening' above.)
If the patient responds in the positive to any of the following questions, a more thorough evaluation for
possible cardiac disease is needed:
● Any history of chest pain, particularly during exertion?
● Any history of feeling dizzy or faint or passing out during exertion?
● Any history of palpitations or excessive shortness of breath during exertion?
● Any history of paroxysmal nocturnal dyspnea or orthopnea?
● Any prior medical condition that has caused symptoms with exertion?
A more thorough evaluation for possible cardiac disease is needed if any of the following findings are noted
on examination:
● Significant elevation in blood pressure or pulse (see "Hypertension in athletes" and "Exercise in the
treatment and prevention of hypertension")
● New cardiac murmur (systolic above grade 2/6 or any diastolic) or arrhythmia
● Significant ankle edema (2+ or greater)
● Other concerning findings consistent with cardiac disease (eg, bilateral crackles)
Based on the results of the history and physical examination, the clinician may decide to pursue further
testing, possibly including a stress electrocardiogram, echocardiogram, or other studies. (See "Selecting the
optimal cardiac stress test", section on 'Indications for stress testing'.)
Musculoskeletal dysfunction from injury or chronic disease can present significant obstacles to exercise.
Patients with new musculoskeletal complaints or known chronic conditions should be evaluated and
managed as necessary. Appropriate modifications to a standard exercise program may be needed for such
patients. Multiple UpToDate topics address the workup of patients with musculoskeletal complaints and
issues around exercise in patients with chronic conditions. A sample of such topics include the following:
(see "Approach to the adult with unspecified knee pain" and "Approach to the adult with knee pain likely of
musculoskeletal origin" and "Evaluation of the adult with hip pain" and "Approach to hip and groin pain in the
athlete and active adult" and "Management of knee osteoarthritis", section on 'Exercise' and
"Nonpharmacologic therapies and preventive measures for patients with rheumatoid arthritis", section on
'Exercise').
Determining functional capacity using the history — In many cases, a patient's functional capacity can
be estimated based on their clinical history. A patient who uses a walker or seldom leaves their single-level
home because of symptoms has poor functional capacity, while a patient who walks approximately 3.5 miles
(5.5 km) in one hour several times per week, or regularly plays singles tennis, has an above average to high
functional capacity.
In select patients, simple surveys, such as the Duke Activity Status Index, can be used to obtain a valid and
reliable estimate of the patient's functional capacity (expressed in METs) [28]. (See 'Terminology and
common types of exercise' above.)
Others have shown that cardiorespiratory fitness can be estimated accurately from readily-available
demographic and clinical data, including gender, age, body mass index, resting heart rate, and self-reported
physical activity [29].
The authors prefer to use two simple questions to estimate a patient's functional capacity [30]:
● Can you walk approximately 10 minutes at a 2.5 to 3 miles per hour (4 to 5 km per hour) pace
(approximately 3.0 to 3.5 METs) without experiencing limiting symptoms (eg, shortness of breath)?
● Can you climb two standard flights of stairs without stopping because of limiting symptoms?
An affirmative answer to either question suggests the patient's functional capacity is adequate (ie, able to
perform activities ≥5 METs), which typically places the patient in a lower risk cohort. Conversely, clear
negative responses to both questions generally confirm that a patients has reduced exercise tolerance or
poor functional capacity.
Functional screening of mobility and strength — A variety of screening tests have been proposed to
identify individuals who are predisposed to injury, whether from sports, occupational labor, or exercise. The
Functional Movement Screen (FMS) is one of the most widely used and consists of seven individual tests
used to assess injury risk. Despite widespread use, the strength of association between FMS composite
scores and subsequent injury does not support its use as an injury prediction tool [31,32].
Screening exercise testing — Screening for cardiac disease and the appropriate use and performance of
exercise testing is reviewed in detail separately. The role of such testing in patients beginning an exercise
program is discussed briefly below. (See "Screening for coronary heart disease" and "Exercise ECG testing:
Performing the test and interpreting the ECG results" and "Selecting the optimal cardiac stress test".)
The United States Preventive Services Task Force has concluded that screening exercise testing has no
value in low-risk asymptomatic adults, and found insufficient evidence for or against exercise testing in the
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preparticipation assessment for structured exercise in subjects at higher risk [33]. The AHA echoes these
conclusions, emphasizing the absence of data from randomized controlled trials about the value of exercise
testing to screen individuals at potential risk during exercise [24]. The authors of a systematic review of the
benefits and risk of structured exercise in persons over 75 years of age have argued that mandatory
preparticipation exercise testing, in addition to being expensive and of unproven benefit, could deter many
older persons from exercising and cause more harm than good [23].
Limitations of exercise testing — While not needed for most adults beginning an exercise program,
exercise testing can be helpful for assessing a range of potential cardiovascular disorders in patients at risk.
Suitable candidates for exercise testing prior to beginning a vigorous exercise program (ie, activities
involving ≥60 percent VO2 reserve or >6 METs) include individuals with known or suspected coronary heart
disease (eg, symptomatic, history of diabetes) [2,34]. However, as most acute coronary syndromes that
occur in previously asymptomatic subjects are due to vulnerable plaque disruption, it is impractical to use
exercise testing to prevent acute cardiovascular events at rest or during exercise in asymptomatic subjects
[22]. Other patients who may benefit from such testing prior to beginning an exercise program include those
whom the clinician suspects may be ignoring symptoms or not giving an accurate history, patients with
atypical chest pain at rest or during exertion, and those who complain of palpitations [35].
PRESCRIBING AN EXERCISE PROGRAM
Components of an exercise program — Ideally, an exercise program should include exercises that
improve aerobic fitness, strength, and mobility [2]. Some programs and individual exercises allow two or
more of these components to be developed simultaneously.
● Aerobic exercise is a general term, often referred to as endurance training, and includes any activity
that develops cardiovascular and pulmonary fitness. It is an important component of an exercise
prescription with an abundance of evidence supporting its benefits for health [36-38].
● Strength exercises provide important health benefits beyond aerobic activity. Also referred to as
resistance training, strength training can be performed using bodyweight resistance (eg, push-ups
(picture 4)), free weights (eg, barbell squats (picture 5)), or other tools (eg, machines (picture 1),
resistance bands (picture 2)) that place loads on muscles forcing them to work harder. The best
programs emphasize multijoint exercises such as the squat, deadlift, and press that involve all the
major muscle groups, working them through a full, functional range of motion. Strength training is
typically done two or three days per week. (See "Strength training for health in adults: Terminology,
principles, benefits, and risks".)
● Mobility exercises are important for maintaining functional capacity. Particularly among older adults,
mobility is important for performing activities of daily living and avoiding falls. The goal of mobility work
is to maintain a healthy range-of-motion, particularly at the shoulders, hips, and thoracic spine.
However, separate mobility exercises are not needed for all individuals, particularly those who regularly
engage in activities that involve full motion at the major joints. Time spent performing isolated flexibility
exercises is not counted towards the weekly goal of 150 minutes of exercise.
If stretching exercises are performed to increase muscle flexibility, it is usually best to do so after
aerobic or strength workouts when muscles are warm. Studies of stretching have failed to demonstrate
benefits in the form of reduced injury rates or improved functional status, but many people feel better
when following a stretching regimen. Stretching is best done using slow and steady movements, rather
than bouncing (so-called ballistic stretching). Functional movement activities, such as yoga (picture 3),
Pilates, and Tai Chi (movie 1), improve flexibility, balance, and mobility. (See "Overview of yoga".)
● Warm up/cool down. In addition to the elements described above, moderate and vigorous exercise is
best preceded by a warm up and followed by a cool-down period. A warm up usually involves doing the
planned exercise at a lower intensity and speed, and allows the body to prepare for more vigorous
activity. A cool down is done to aid recovery and following vigorous exercise can prevent exercise-
associated collapse. (See "Exertional heat illness in adolescents and adults: Management and
prevention", section on 'Heat syncope and exercise associated collapse' and "Preparation and
management of mass participation endurance sporting events", section on 'Exercise-associated
postural hypotension'.)
Writing the aerobic exercise prescription — A typical exercise prescription can be created using the FITT
mnemonic:
● F – Frequency: Number of days per week (ideally three or more)
● I – Intensity: Moderate or greater
● T – Time: Number of minutes per session (ideally 30 minutes or longer)
● T – Type: Activities that involve major muscle groups
Important aspects of each component of the exercise prescription are discussed here, and an example of a
prescription for a beginning exerciser is provided (table 4). Additional sample exercise prescriptions are
provided below. (See 'Helping patients advance their exercise program' below.)
● Frequency – Abundant evidence suggests that spreading the total weekly time for aerobic exercise
across three or more days produces consistent health benefits and decreases the risk of injury [2].
Whenever possible, we recommend exercising three or more days per week. However, if this is not
feasible, exercising for the same total period over two days (75 minutes each day), or possibly even
one day (150 minutes), may provide equivalent health benefits. However, the risk of injury, particularly
from overuse, is likely increased.
Epidemiologic, observational, and randomized controlled trials have examined the impact of exercise
frequency, either per day or per week, as a function of health-fitness outcomes. As an example, in one
trial subjects who were randomly assigned to one of three groups that ran the same total distance, but
in one, two, or three sessions daily, demonstrated comparable improvements in cardiovascular
endurance [39]. In another trial, 56 obese women were randomly assigned to either repeated short
exercise bouts (n = 28), or one continuous bout (n = 28), and followed for 20 weeks [40]. Each group
exercised five days per week. Although both groups made comparable improvements in functional
capacity, the repeated short-bout exercise group demonstrated better adherence and a greater average
weight loss, 8.9±5.3 kg versus 6.4±4.5 kg.
● Intensity – Increasing the intensity of aerobic exercise can produce similar benefits in a shorter period.
As an example, 15 minutes of jogging appears to confer the same health benefit as 30 minutes of
moderate intensity walking.
In addition to the methods described above, the "talk test" is a simple way to gauge exercise intensity
[41]. During moderate intensity exercise, a person is too winded to sing, but not so winded they cannot
talk. During vigorous exercise, a person has difficulty maintaining a conversation. (See 'Determining
exercise intensity' above.)
● Time – The time required for aerobic exercise each week depends on both frequency and intensity.
Benefit can be accrued in many ways, and a flexible approach is encouraged. Bouts of exercise can be
performed in 30 to 60-minute blocks, or accumulated throughout the day in 5 to 10-minute periods.
(See 'Compliance with a basic aerobic exercise program' below and 'Strategies for incorporating
exercise into the workday' below.)
The 2008 Physical Activity Guidelines [36] recommend the equivalent of 150 minutes per week of
moderate intensity physical activity for health. However, these guidelines and other seminal studies
[37,42] support the assertion that some physical activity is better than none. Earlier studies reported
that three 10-minute bouts of exercise performed throughout the day provide similar health benefits to a
single continuous 30-minute bout of moderate exercise [2,43,44], and subsequent studies suggest that
even shorter periods of light-to-moderate physical activity, accrued over time, can produce
cardiovascular, metabolic health, and even survival benefits [45-47]. In a prospective observational
study involving over 400,000 subjects, researchers found that 10-minute bouts of daily moderate
activity were associated with nearly a 10 percent reduction in all-cause mortality. Collectively, these
data support the hypothesis that, when it comes to exercise, every minute counts.
While more than 150 minutes per week of moderate intensity exercise may provide some additional
health benefit, returns on the investment diminish as the time spent increases. As an example, in the
large observational described above, the maximum mortality reduction associated with regular,
vigorous physical activity approached 45 percent, and appeared to plateau between 40 and 50 minutes
of daily exercise. For the typical adult seeking to improve their general health, it is unlikely that much is
gained by exercising for longer than 100 minutes per day [42]. In fact, excessive vigorous exercise can
be harmful [48].
● Type – A wide range of activities can be used to achieve exercise goals. Walking is often considered
the default activity for a beginning aerobic exercise prescription because it is simple, requires no
equipment, and is easily measured by time, distance, or step count. Walking for 30 minutes generally
correlates with ambulating approximately 4000 steps or 2 miles (3.2 km). Guidelines suggest a
reasonable total daily step count goal for adults is 7000 to 10,000 [49].
Regular walking is highly beneficial for most inactive, unfit subjects. In a large prospective observational
study, subjects who walked just 15 minutes a day or 90 minutes per week had a 14 percent reduction in
mortality over an average follow-up of 8.1 years compared with their inactive counterparts [42].
Although walking may be easiest for beginning exercisers, any comparable activity performed at a
moderate pace and for the same total duration provides similar health benefits to brisk walking.
Activities such as bicycling, water aerobics, doubles tennis, ballroom dancing, or gardening can be
done to satisfy weekly exercise goals.
Once regular exercise has been made a habit, patients may be encouraged to incorporate more
vigorous forms of activity into their program. (See 'Helping patients advance their exercise program'
below.)
Writing the strength training exercise prescription — The benefits of a strength training program to
function and health have been clearly established [2]. As humans age, we undergo a progressive decline in
both lean muscle mass and bone density. A well-designed resistance training program can help retard such
losses and improve strength, function, and quality-of-life, while reducing the risk for many chronic diseases
and premature death. The benefits of strength training are reviewed separately. (See "Strength training for
health in adults: Terminology, principles, benefits, and risks".)
A resistance training program is usually done at least two days per week and should include exercises that
work all the major muscle groups. When lifting weights, it is important to maintain proper technique and to
move through a full, functional range of motion. The implementation of strength training programs is
discussed separately.
Compliance with a basic aerobic exercise program — As with taking prescription medications, getting
patients to comply with an aerobic exercise prescription can be challenging. Often the major barrier is the
lack of time due to competing work and family responsibilities. When patients say they cannot find time to
exercise, the authors often advise the following:
● Use a workday walking routine – To start the day, park your car further away from your place of work
and walk 10 minutes to your worksite. At lunchtime, walk 5 minutes away from work and 5 minutes
back before eating your lunch. At the end of the day, take that same 10-minute route to walk back to
your car. You will now have completed your recommended daily exercise.
● Exercise on weekends – If you simply cannot exercise during the week, do it on the weekends. Taking
75-minute walks on Saturday and on Sunday appears to provide similar health benefits to doing the
same total amount of walking during the week [2]. However, it is prudent to build up to the 75-minute
walks gradually in order to avoid overuse injuries of the lower extremities and other problems (eg,
friction blisters). Perhaps start with 30-minute walks and each successive weekend add five minutes to
each walk until you reach 75 minutes.
● Increase workout intensity – You get the same benefit in half the time by performing vigorous as
opposed to moderate intensity exercise. As an example, if you jog for 25 minutes three days each
week, you reap the same benefits as walking for 30 minutes five days each week.
● Find a partner – Find someone to exercise with or join a group exercise program. This makes
exercising more social and fun, and increases the likelihood that you will continue. Joining a group of
like-minded exercisers (such as a walking group or tennis circle) or a gym can provide necessary
encouragement and support. However, such a strategy may be more costly and limit your exercise
options. Adopting a dog helps some people exercise more regularly [50].
● Exercise at home – For some, a home exercise program is just what they need to comply with an
exercise prescription. When time is short, being able to use a home exercise bicycle or treadmill without
driving to the gym is a great solution. However, quality equipment can be expensive and oftentimes the
initial enthusiasm for home equipment fades and exercise declines.
● Use a DVD or Internet-based fitness program ‒ Another approach to helping patients perform
regular aerobic exercise is using a DVD or internet fitness program. Such programs range from yoga to
aerobics to resistance exercise circuit training. However, participants should be sure the program
selected is appropriate for their fitness level and goals, and is well designed with proper instruction
about exercise technique. The following table identifies a number of resources that are available as
smartphone applications that may assist in promoting exercise (table 5).
● Join a gym or work with a fitness professional ‒ Joining a local gym or working with a qualified
fitness coach can be extremely helpful for some who are struggling to adhere to an exercise program.
Several professional associations, including the ACSM, offer instruction and proficiency standards and
competency certification. A knowledgeable coach can help you create an exercise regimen that best fits
your functional status and goals, while providing guidance on proper technique to help you avoid injury.
A gym or health club can not only provide a safe and inviting place to exercise, it can also provide
opportunities for socialization that make exercising more enjoyable, leading to enhanced adherence.
STRATEGIES FOR INCORPORATING EXERCISE INTO THE WORKDAY — For many individuals, finding
time to exercise during the workday can be challenging. We advocate a flexible approach and suggest using
whatever methods are best suited to individual constraints and most effective for incorporating exercise as
part of a daily routine.
Moderate-to-vigorous intensity physical activity (MVPA), which corresponds to any activity ≥3 METs, has
been consistently shown to reduce the health risks associated with chronic diseases and the risk of
developing them [38]. Other reports suggest that replacing sedentary time with even brief periods of light
physical activity (approximately 2 minutes per hour) may confer a survival benefit [47]. Accordingly, frequent
bouts of light to moderate activity can improve health, especially if the total energy expenditure is
comparable to shorter periods of more strenuous physical exertion [51]. Thus, the desk-bound worker who
jogs 30 minutes, three days per week, may not derive any greater exercise benefits than the worker who
does frequent bouts of light to moderate physical activity throughout the day.
Encourage the use of measurement tools ‒ Health professionals can promote physical activity to their
patients by encouraging them to use pedometers, accelerometers, and smartphone-based health and
wellness applications [38,52]. According to one systematic review, pedometers are associated with
significant decreases in body mass index and blood pressure [53]. In addition, pedometer users increase
their physical activity by an average of nearly 25 steps per day compared with their control counterparts.
Incorporate more activity into the regular workday ‒ A number of workplace strategies can be used to
increase activity throughout the workday, including the following [54-57]:
● Encourage workers to park their car farther from the workplace and walk.
● Use standing or walking desks to reduce sitting time, which is associated with increased morbidity and
mortality. (See "The benefits and risks of exercise", section on 'Physical inactivity and health'.)
● Encourage workers to leave their desk regularly (eg, every 30 to 60 minutes).
● Replace e-mails or phone calls with personal visits.
● Hold standing or walking meetings, instead of sitting.
● Use signs and wall or floor prompts to encourage activity. One clever cafeteria exit sign reads: “How
often should you exercise? Only on the days you eat" [57].
● Provide access to fitness facilities.
HELPING PATIENTS ADVANCE THEIR EXERCISE PROGRAM
Advancing aerobic exercise — Progressive overload is the fundamental principle for advancing exercise.
This strategy involves systematically increasing the stress (eg, exercise intensity) placed on the body once it
adapts, thereby allowing for continual improvement. By following this principle, the patient can advance their
exercise through three basic stages [58]:
● Initial conditioning stage – This stage should begin gradually at an intensity of about 40 percent of the
patient’s maximal heart rate (approximated as 220 minus patient's age), and gradually progressing to
around 70 percent of the maximal heart rate (HR). Exercise is done three days per week and sessions
last 12 to 20 minutes. This stage occurs over a four to five-week period.
● Improvement stage – This stage follows the initial conditioning stage and typically lasts four to five
months. This stage involves gradual increases in intensity, up to 60 to 85 percent of the maximal HR,
and in duration, up to three to five sessions per week. Duration should be increased gradually, until the
goal of 30 to 45 minutes per session is achieved, before intensity is raised.
● Maintenance stage – This stage begins after about six months of training and involves exercising three
to five times per week at a target HR of 50 to 85 percent of maximum, with a duration of 30 to 45
minutes per session. The goal here is to maintain one's fitness level and functional capacity at the
desired level.
Keep in mind that a person's risk of injury while exercising is directly related to the gap between their usual
level of activity and a new, higher level of activity. The size of this gap refers to one's relative overload, and
this should be advanced gradually and in small increments to avoid injury. Older and less fit adults are more
prone to injury, and therefore, increases in their exercise activity should be made even more gradually.
Sample exercise prescriptions for patients of different fitness levels can be found in the following tables:
● FITT prescription for non-sedentary beginning exerciser (table 6)
● FITT prescription for intermediate exerciser with running (table 7)
● FITT prescription for intermediate exerciser without running (table 8)
As beginning exercisers become more fit, it is helpful to begin incorporating basic strength and mobility
exercises into their workouts. The following figures show how to perform the exercises included in the
prescriptions above (picture 6 and picture 7).
More challenging versions of selected exercises are shown in the following pictures:
● Squat (picture 8)
● Lunge (movie 2)
● Push-up (picture 4)
● Core stability (picture 9)
High intensity interval training: Which patients are best suited? — High intensity interval training (HIIT)
involves intermittent, usually regularly timed bouts of high intensity activity alternating with brief, often timed
periods of low intensity activity or rest. Numerous studies have compared the effectiveness of moderate-
intensity continuous exercise training (MICT) with HIIT for improving aerobic capacity and other measures of
cardiovascular function in healthy adults and in patients with coronary artery disease (CAD), including those
with post-infarction heart failure being optimally medically managed.
In studies of healthy adults, HIIT regimens have been shown to induce greater increases in
cardiorespiratory fitness than MICT, especially when the total work performed during training is comparable
[59-61]. Thus, for young, healthy asymptomatic individuals, including military personnel, seeking to improve
cardiorespiratory fitness rapidly, HIIT may be a more effective approach.
While HIIT may be an effective approach to exercise for patients with known or suspected CAD, additional
long-term studies assessing safety, compliance, and morbidity and mortality are required before this
approach can be widely recommended for such patients [62]. Exercise for patients with heart disease is
discussed in detail separately. Below, we discuss some studies of HIIT in heart disease patients. (See
"Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease" and "Cardiac
rehabilitation programs" and "Cardiac rehabilitation in patients with heart failure" and "Cardiac rehabilitation
in older adults".)
In several randomized controlled studies involving patients with cardiovascular disease, including heart
failure, HIIT was found to be superior to MICT in improving cardiorespiratory fitness, physical work capacity,
distance covered during a 6-minute walk distance test, and indices of vascular function [1,63-66]. As an
example, investigators randomly assigned 27 patients with stable post-infarction heart failure and impaired
left ventricular ejection fraction to either MICT (goal to maintain 70 percent of peak heart rate) or HIIT (goal
to achieve 95 percent peak heart rate during work intervals) three times per week for 12 weeks, or to a
control group (ie, usual care) [66]. The HIIT group achieved significantly greater improvements in
cardiorespiratory fitness (46 versus 14 percent), left ventricular remodeling, and brachial artery flow-
mediated dilation (endothelial function) than the MICT group.
A meta-analyses of 10 studies, including 472 patients with CAD, found that HIIT was associated with more
pronounced gains in cardiorespiratory fitness than MICT; however, MICT was associated with greater
reductions in resting heart rate and body weight [67]. In contrast, some investigations have reported that
HIIT is not superior to other forms of endurance training for exercise-based cardiac rehabilitation [68,69].
BASIC NUTRITIONAL GUIDANCE — The contribution of nutrition to health is well established; sound
nutrition provides the fuel for all exercise and the building blocks for recovery following exercise [70]. The
patient embarking on an exercise program should consume a diet rich in vegetables and fruits, lean forms of
protein, and healthy fats, while avoiding refined grains (eg, white bread, white rice, refined and sweetened
cereals). The basics of nutrition for health and weight loss are reviewed separately. (See "Healthy diet in
adults" and "Obesity in adults: Dietary therapy".)
For clinicians dealing with competitive athletes, detailed nutritional guidance is provided in the following
reference [70]. Hydration and nutrient timing are important concepts that the clinician advising recreational
or competitive athletes should understand. These concepts are discussed below.
Hydration considerations — Water is an essential nutrient for all who exercise. Endurance exercise on
average causes one to sweat about 1 L of water per hour, while losing 1 g of sodium per hour and burning
80 g of carbohydrate per hour. However, there is wide variation among individuals depending on their age,
body type, exercise intensity, and environmental conditions (eg, humidity) [70]. Guidance from the National
Athletic Trainers Association about hydration in physically active adults can be found in the following
reference [71].
In general, water needs are best gauged by thirst, especially for light sweaters doing light to moderate
exercise. Those performing strenuous exercise or exercising for long durations (>1 hour) should determine
their rehydration needs based on their sweat rate. The sweat rate can be estimated by weighing oneself
nude before and after a 60-minute bout of exercise done at a typical intensity and under typical
environmental conditions of heat and humidity. The sweat rate is the difference between the pre- and post-
exercise weight.
Based on the sweat rate estimation, an exerciser should try to replace each 0.5 kg (1.1 lb) of weight lost
with 500 mL (17 ounces) of fluid each hour during and after exercise. Of note, this approach underestimates
fluid needs for exercise performed at higher intensity or during hotter or more humid conditions than those of
the test. Knowing one's sweat rate can help prevent both under and over-drinking during exercise, and help
optimize performance. If a sweat rate cannot be determined, a reasonable strategy is to let thirst guide
hydration.
Endurance athletes involved in prolonged bouts of exercise who ingest excessive volumes of free water
relative to their sweat losses are at risk of developing acute hyponatremia. Strategies for preventing and
managing exercise-associated hyponatremia are discussed separately. (See "Exercise-associated
hyponatremia".)
Nutrient timing — Training goals are realized more efficiently when appropriate nutritional strategies are
implemented before, during, and after training. "Nutrient timing" is the term coined by Drs. John Ivy and
Robert Portman to suggest that "when food is consumed" is as important as "what food is consumed" [72].
The three phases of nutrient timing include: during exercise; period immediately after exercise (ie, recovery);
and, interval between exercise sessions (ie, maintenance and growth).
According to the International Society of Sports Nutrition (ISSN) guidelines, the timing of energy intake and
the ratio of certain ingested macronutrients (eg, carbohydrate and protein) may enhance recovery and
tissue repair, augment muscle protein synthesis, and improve mood following high-volume or intense
exercise [73]. Providers who interact with competitive athletes are directed to the ISSN position stand for
detailed reference and guidance [73]. Salient guidance from the ISSN position statement for general adult
exercisers includes the following:
● Endogenous glycogen stores are depleted most by high volume exercise. These stores are maximized
by consuming a high-carbohydrate diet (8 to 12 g of carbohydrate/kg bodyweight per day).
Carbohydrates should take the form of fruits and whole grains; refined grain products (eg, white bread,
white rice, refined and sweetened cereals) should be avoided.
● Extended (>60 minutes) bouts of high intensity (>70 percent VO2max) aerobic exercise pose
challenges for fuel supply and fluid regulation. The exerciser should consume approximately 30 to 60 g
of carbohydrate each hour during intense aerobic exercise that extends beyond 70 minutes. Ideally, this
takes the form of a 6 to 8 percent carbohydrate-electrolyte solution (175 to 350 mL, or 6 to 12 fluid
ounces) every 10 to 15 minutes.
Particularly when carbohydrate delivery is inadequate, consuming some protein along with the
carbohydrate may help increase performance, ameliorate muscle damage, promote euglycemia, and
facilitate glycogen re-synthesis.
● During a standard strength training workout (eg, three to six sets of 8 to 12 repetitions performing
exercises targeting all major muscle groups), consuming adequate carbohydrate has been shown to
promote euglycemia and higher glycogen stores. In addition, consuming carbohydrate solely or in
combination with protein during resistance exercise increases muscle glycogen stores, ameliorates
muscle damage, and improves training adaptations. Nutrition for adults participating in resistance
training programs is reviewed separately.
● Meeting the total daily intake of protein, preferably with evenly spaced protein feedings (approximately
every three to four hours during the day), is important for exercising individuals. Consuming high-quality
protein within two hours of exercising stimulates muscle protein synthesis and aids recovery. Adults
who exercise regularly, particularly those performing resistance exercises, should try to consume 2 g of
lean protein/kg bodyweight daily.
STRATEGIES TO REDUCE RISK DURING EXERCISE
Contraindications to exercise — Common reasons not to exercise include acute illness or injury. In such
circumstances, it is often best to rest and recover before engaging in vigorous exercise, although in many
circumstances patients can perform light activity to maintain some level of fitness. Following significant
musculoskeletal injury, a complete functional recovery is important before returning to full sport in order to
avoid reinjury. (See "Upper respiratory tract infections: Considerations in adolescent and adult athletes".)
Exacerbations or acute flares of chronic illnesses can restrict exercise. In some cases, alternative forms of
exercise that do not exacerbate the acute condition may be used. As an example, a patient experiencing an
acute flare of osteoarthritis may be able to swim or perform water aerobics. Societies for several chronic
illnesses have established criteria to guide safe participation. Links to topics addressing exercise in patients
with specific diseases are provided below.
Guidance for patients with significant chronic disease or other conditions — Many patients with
chronic disease can reap significant benefits through regular participation in appropriately designed exercise
programs. The role of exercise in adult patients with chronic disease and a range of other conditions is
discussed separately.
● Cardiovascular disease (see "Exercise and fitness in the prevention of atherosclerotic cardiovascular
disease" and "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart
disease" and "Cardiac rehabilitation programs" and "Cardiac rehabilitation in patients with heart failure"
and "Cardiac rehabilitation in older adults")
● Dyslipidemia (see "Effects of exercise on lipoproteins and hemostatic factors" and "Statin muscle-
related adverse events", section on 'Exercise')
● Diabetes mellitus (see "Effects of exercise in adults with diabetes mellitus")
● Hypertension (see "Exercise in the treatment and prevention of hypertension")
● Kidney disease (see "Physical activity in patients with chronic kidney disease (including end-stage renal
disease and renal transplantation)")
● Arthritis (see "Comorbidities that impact management of osteoarthritis", section on 'Cardiovascular
disease')
● Pulmonary disease (see "Pulmonary rehabilitation")
● Cancer (see "The roles of diet, physical activity, and body weight in cancer survivors")
● Obesity (see "Obesity in adults: Role of physical activity and exercise")
● Pregnancy and exercise (see "Exercise during pregnancy and the postpartum period")
● Aging and exercise (see "Physical activity and exercise in older adults")
Common safeguards — The benefits of exercise far out-weigh the small associated risks. The benefits and
risks associated with exercise are reviewed separately. (See "The benefits and risks of exercise".)
Many exercise-associated risks can be mitigated by following common sense practices. Most important is to
encourage patients to "listen" to their body and how it is responding to exercise. The intensity and duration
of exercise should be decreased when a person is not feeling well. In general, exercise should be avoided
when a patient is severely ill, especially in the presence of fever, productive cough, significant vomiting or
diarrhea, or severe pain.
Other important safeguards include exercising with a partner when possible and wearing a medic alert
bracelet if a person has a significant medical issue (eg, diabetes, epilepsy, significant allergic reactions) that
could affect treatment should something untoward occur.
Emphasize the importance of warm up and cool down — There is a sound physiologic basis for
recommending calisthenics and a gradual cardiorespiratory warm up prior to the endurance or stimulus
phase of an exercise session. A proper warm up stretches postural muscles and helps to increase blood
flow and the metabolic rate. In addition, it may reduce the potential for ischemic ST-segment depression and
ventricular arrhythmias that can be triggered by sudden strenuous exertion [74]. A warm up may reduce the
susceptibility to musculoskeletal injury by increasing connective tissue extensibility and increasing joint
mobility.
Our empiric experience suggests that the preferred warm up for any aerobic activity is that activity,
performed at a lower intensity (eg, brisk walking before slow jogging over a 5 to 10-minute period). At the
conclusion of the warm up, the heart rate should fall within 10 beats per minute of the lower limit for the
endurance or stimulus phase.
For strength training, an appropriate warm up involves performing the same exercise starting with lower
resistance (eg, less weight) and gradually increasing it. And for activities that involve complex movements,
particularly explosive and unpredictable ones (as with many sports), a warm up should incorporate the full
range of movements to be used, with a gradual increase in intensity. (See "Anterior cruciate ligament (ACL)
injury prevention" and "Throwing injuries of the upper extremity: Treatment, follow-up care, and prevention",
section on 'Exercise and throwing programs for treatment and injury prevention'.)
A 5 to 10-minute postexercise cool-down period involving slow jogging or walking or cycling permits
appropriate circulatory adjustments and a more gradual return of the heart rate and blood pressure to near
resting values. A proper cool down enhances venous return, thereby reducing the potential for post exercise
hypotension, and possible collapse, and combats the potential, deleterious effects of the post-exercise rise
in plasma catecholamines [75].
Increase exercise intensity gradually — It is always best to begin a new exercise routine at a low
intensity, performing fewer repetitions or for a shorter duration. Gradually, exercise volume and intensity
may be increased as tolerated. A knowledgeable fitness professional or coach can provide instruction about
proper programming and progression of an exercise routine.
Patients with little or no experience exercising in particular should be instructed to begin with small amounts
of low-intensity exercise, and to build gradually. As an example, a sedentary 55 year old woman might begin
by walking on a level surface at a pace of 1.5 to 5 km per hour (ie, 1 to 3 miles per hour [mph], or
approximately 1.7 to 3 metabolic equivalents [METs]). Gradually, over a few weeks, the intensity can be
raised, such as by increasing the pace to 5 to 6.5 km per hour (ie, 3 to 4 mph, or approximately 3 to 5
METs). Such gradual increases in intensity may continue for as long as the patient remains asymptomatic.
Such an approach helps to minimize the risk of any orthopedic injury while enabling individuals to improve
their cardiorespiratory fitness.
This approach is particularly important for the least active adults, who represent a "high risk" cohort (bottom
20 percent in physical activity). If such patients engage in unaccustomed, vigorous-to-near maximal physical
activity, there is a large associated relative risk of an acute cardiovascular event [22,23]. (See "The benefits
and risks of exercise", section on 'Risks of exercise'.)
Emphasize perceived exertion and prescribed training heart rates — As a general guideline, exercise
can be monitored by using the rate of perceived exertion (6 to 20 category scale (table 2)) [76], which, like
heart rate, can be used to prescribe and modulate exercise intensity. Exercise rated as 11 ("fairly light") to
13 ("somewhat hard") generally corresponds to the upper limit of recommended exercise intensities during
the first six to eight weeks of training. As a patient’s fitness gradually increases, ratings of 13 to 15 ("hard")
may be appropriate, provided the exerciser remains asymptomatic. The anaerobic or ventilatory threshold
generally occurs within this range. Thus, most physically active persons who remain symptom-free can rely
on perceived exertion, rather than heart rate, to regulate their exercise intensity.
Exercisers who experience exertion-related symptoms (eg, chest pain or pressure, unusual shortness of
breath, palpitations) should immediately cease training and seek medical clearance before resuming
exercise.
Educate patients about medical danger signs — A number of observational studies report that
competitive and recreational athletes who experience nonfatal or fatal cardiovascular complications during
or soon after exercise often had prodromal symptoms (eg, chest pain or pressure, unusual shortness of
breath, lightheadedness, palpitations, a drop in exercise capacity) in the days or weeks before their cardiac
event [77-80]. These symptoms were often ignored. Consequently, it is important for clinicians to review with
exercising patients, particularly those who are new to exercise or have risk factors for coronary heart
disease (CHD), symptoms that suggest such disease and the importance of seeking prompt medical
evaluation should such symptoms develop. (See "Initial evaluation and management of suspected acute
coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on
'Clinical presentation' and "Angina pectoris: Chest pain caused by myocardial ischemia", section on 'Clinical
features'.)
Account for environmental conditions — Exercising in extreme environmental conditions poses potential
health risks. Hot and humid environments increase the risk for exertional heat illness (EHI). Adults who have
not acclimated to such conditions should exercise with less intensity and for shorter periods, and should
stop should they develop lightheadedness or any other concerning symptom. EHI, including steps for
prevention, is reviewed in detail separately. (See "Exertional heat illness in adolescents and adults:
Management and prevention" and "Exertional heat illness in adolescents and adults: Epidemiology,
thermoregulation, risk factors, and diagnosis".)
Exercising in cold weather poses general risks, such as frostbite, and particular risks for patients with CHD.
A cold weather face mask or a scarf worn around the mouth may help to reduce such problems [81,82]. It
bears emphasis that temperature alone is not the best index of cold stress, and wind-chill should be
accounted for when exercising outdoors. Some general preventative measures for exercising safely
outdoors are provided separately. (See "Frostbite", section on 'Prevention'.)
At high altitude, oxygen availability decreases, leading to increased cardiorespiratory and hemodynamic
responses to any given work load. Individuals ascending above 1500 m should refrain from vigorous
exercise until they have acclimatized. (See "High altitude illness: Physiology, risk factors, and general
prevention".)
Prophylactic use of cardioprotective medications prior to exercise — Although there are no definitive
data indicating that cardioprotective medications prevent acute cardiovascular events due to intense
physical exertion, some researchers have suggested that patients at risk may benefit from taking particular
medications shortly before strenuous exercise, thereby reducing the potential pathophysiologic
consequences of the exercise trigger [83]. We believe that the evidence pertaining to the prophylactic use of
cardioprotective medications prior to exercise is too limited to make general recommendations, and that any
decision to use such strategies requires careful assessment of the individual patient and a detailed
discussion of potential risks and benefits.
Short-acting beta-blockers and aspirin are the two medications most often considered for prophylaxis
against cardiac events during strenuous exercise. Presumably, beta-blockers reduce the rate-pressure
shear forces and associated cardiac demands during vigorous physical exertion, whereas aspirin likely
inhibits epinephrine-induced platelet aggregation [84-88]. Beta-blockers appear to show the most promise
for cardioprotection during physical stress [84,85]. Studies of aspirin are more limited [86-88].
SURVEILLANCE OF THE ADULT EXERCISER — The primary care clinician plays an important role in
monitoring the new exerciser moving from a sedentary to a more active lifestyle, and the more advanced
exerciser, particularly those engaged in prolonged endurance sports (eg, marathons) or other extreme
exercise activities. Evidence to guide such surveillance is scant; what follows are the authors' suggestions.
A table summarizing our approach to primary care surveillance of exercisers follows (table 9).
Attrition rates among sedentary individuals embarking on a new exercise program are high, with one source
citing adherence rates of less than 50 percent [89]. According to a small observational study, poor exercise
adherence was associated with overly optimistic expectations among inexperienced exercisers, which led to
disappointment [90]. Interventions to help ensure realistic expectations among participants may increase
successful completion of exercise programs. One such strategy is to remind patients of the considerable
health benefits gained from even small increases in physical activity.
Most beginning exercisers are thought to face their greatest challenges in maintaining their exercise
regimen during the initial conditioning stage (first 5 to 10 weeks), and so it makes sense for primary care
clinicians to intervene during this time. Interventions can include phone calls from office staff or the clinician
to encourage adherence. In addition, as dropout rates are highest during this early period of exercise, we
suggest making a scheduled office visit to reinforce the new behavior and to help overcome any obstacles
to exercising.
Extreme exercisers pose a different set of challenges for the clinician. Little evidence is available to inform
how to approach surveillance of the extreme endurance exerciser. In a review of this subject, one team of
researchers suggests that extreme exercise not be discouraged but recommends annual surveillance of
these athletes [91]. We believe that the management of extreme athletes should be individualized. An
annual cardiovascular assessment, including an electrocardiogram, seems to us a reasonable approach.
Clinicians should be aware of the potential risks associated with extreme endurance exercise and provide
appropriate counsel to patients contemplating such activity. Emerging literature suggests that excessive
endurance exercise may be harmful:
● The Copenhagen City Heart Study reported a U-shaped relationship between mortality and duration of
exercise among joggers [92]. Runners who exercised over four hours per week had slightly higher
hazard ratios (0.86) compared to those who exercised between 2.5 and 4 hours per week (0.79).
● The Harvard Alumni Study reported slightly increased mortality rates among individuals who exercised
most intensely compared to those engaged in more moderate levels of physical activity [93].
● Several studies have found that those who engage in high volume endurance exercise have a higher
risk for developing atrial fibrillation [94].
However, research in this area is limited, and while exercise is clearly beneficial to health outcomes, the
dose–response relationship between exercise and health remains incompletely understood [95].
Because individuals involved in high-volume, high-intensity training regimens or competitions are not
immune to structural cardiovascular abnormalities or atherosclerotic cardiovascular disease, and because
extreme exercise is more likely to trigger acute cardiac events in such participants, preparticipation and
serial screening aimed at identifying athletes at risk of exertion-related sudden cardiac arrest or progression
of cardiovascular disease appears warranted. Most individuals who sustain an exercise-related cardiac
arrest have risk factors or a history of cardiovascular disease or have experienced symptoms prior to the
arrest. Therefore, it is important for clinicians to counsel their patients about warning signs of cardiac
disease [96]. The issues surrounding the screening of such athletes is reviewed in detail separately. (See
"Screening to prevent sudden cardiac death in athletes".)
SUMMARY AND RECOMMENDATIONS
● Regular exercise has wide ranging health benefits. Exercise types include endurance exercise to
improve cardiovascular and respiratory fitness, resistance exercise to improve strength, exercises to
improve balance and proprioception, mobility exercise, and combinations of these. The different types
and facets of exercise and physical activity are reviewed in the text, while more detailed discussions of
the benefits and risks of exercise are provided separately. (See 'Terminology and common types of
exercise' above and "The benefits and risks of exercise".)
● One key determinant of cardiovascular health for an adult is the number of minutes spent being
physically active each week. All published guidelines encourage the accumulation of 150 minutes of
moderate intensity activity or more each week. Assessment of a patient's physical activity and of a
sedentary patient's willingness to embark upon an exercise program are reviewed above. (See
'Assessment of individual patient activity' above and 'Assessment of patient willingness to begin
exercising' above.)
● Patients without diagnosed chronic disease (eg, heart disease, diabetes, kidney disease) or concerning
symptoms (eg, chest discomfort, dyspnea at rest, dizziness) generally do not require a health screen
prior to beginning a suitable exercise program. Patients with significant cardiovascular, metabolic, or
kidney disease, those who develop concerning symptoms at rest or during activity, and some others
should be evaluated by their primary care clinician prior to embarking on an exercise program.
Screening of patients is reviewed in the text. (See 'Medical assessment and clearance for exercise'
above.)
● Ideally, an exercise program should include exercises that improve aerobic fitness, strength, and
mobility. A typical exercise prescription can be created using the FITT mnemonic:
• F – Frequency: Number of days each week
• I – Intensity: Low, moderate, or greater
• T – Time: Minutes per session for endurance exercise
• T – Type: Endurance, strength, mobility, or some combination
Sample prescriptions for beginning and intermediate exercisers using this mnemonic are provided
(table 4 and table 6 and table 7 and table 8). The exercises included in these prescriptions are found in
the following figures (picture 6 and picture 7). Strategies for incorporating more exercise into the
workday, and for reducing the risks associated with exercise, are reviewed in the text. (See 'Prescribing
an exercise program' above and 'Strategies for incorporating exercise into the workday' above and
'Strategies to reduce risk during exercise' above.)
● Evidence to guide primary care surveillance of the adult exerciser is scant. A table summarizing our
approach to surveillance is provided (table 9). Attrition rates among sedentary individuals embarking on
a new exercise program are high, particularly during the initial conditioning stage (first 5 to 10 weeks).
Interventions during this period, such as phone calls from office staff or clinicians encourage patients,
can reduce attrition. We suggest making a scheduled office visit during this period to reinforce the new
behavior and to help overcome any obstacles to exercising. (See 'Surveillance of the adult exerciser'
above.)
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TERMINOLOGY AND COMMON TYPES OF EXERCISE

lengthen a muscle, such as stretching or yoga

The health-related components of fitness include:

The skill-related components of fitness include:

• Agility – The ability to change direction with speed and precision

• Power – The ability to perform work rapidly

• Reaction time – The ability to react rapidly to a stimulus

Determining exercise intensity — Intensity is an important factor in developing cardiovascular

Exercise intensity for aerobic activity may be categorized as follows [5]:

● Light – HRR/VO2 30 to 40 percent; 2 to 3 METs; RPE 9 to 11

● Moderate – HRR/VO2 40 to 60 percent; 4 to 6 METs; RPE 12 to 13

● Vigorous – HRR/VO2 60 to 90 percent; 8 to 12 METs; RPE 14 to 17

● Near Maximal – HRR/VO2 >90 percent; 14 to 20 METs; RPE 18 to 20

● Light ‒ 40 to 50 percent of 1-RM

● Moderate ‒ >50 percent to <70 percent of 1-RM

● Vigorous ‒ ≥70 percent to <80 percent of 1-RM

● Near maximal ‒ ≥80 percent of 1-RM

● Perform 12 to 15 repetitions, then rest 2 minutes;

● Increase weight 5 to 10 percent, perform 10 to 12 repetitions, then rest 3 minutes.

● Increase weight 5 to 10 percent, perform 6 to 8 repetitions then rest for 3 minutes.

● Increase weight 5 to 10 percent, perform 5 repetitions – should be close to 5-RM;

● Multiply 5-RM weight by 1.15 to get 1-RM.

Common types of exercise

Or if not meeting guidelines, offer advice, such as:

ASSESSMENT OF PATIENT WILLINGNESS TO BEGIN EXERCISING — The Transtheoretical Model (or

● Pre-contemplation – Patient is not thinking about making lifestyle changes

● Contemplation – Patient is considering but is not yet ready to change

● Relapse – Patient returns to former [unhealthy] lifestyle habits

• What activity would you most like to do if you start exercising?

● The individual's current level of physical activity

● The desired or anticipated exercise intensity

● The potential hazards of unaccustomed, high-intensity physical activity

● Comprehensive evaluation by a primary care physician or specialist (eg, clinical cardiologist)

● Systematic screening of those whose families have a genetic predisposition to premature

● Systematic population screening, with or without concomitant diagnostic testing

● Any history of chest pain, particularly during exertion?

● Any history of feeling dizzy or faint or passing out during exertion?

● Any history of palpitations or excessive shortness of breath during exertion?

● Any history of paroxysmal nocturnal dyspnea or orthopnea?

● Significant ankle edema (2+ or greater)

PRESCRIBING AN EXERCISE PROGRAM

● F – Frequency: Number of days per week (ideally three or more)

● I – Intensity: Moderate or greater

● T – Time: Number of minutes per session (ideally 30 minutes or longer)

● T – Type: Activities that involve major muscle groups

● Encourage workers to leave their desk regularly (eg, every 30 to 60 minutes).

● Replace e-mails or phone calls with personal visits.

● Hold standing or walking meetings, instead of sitting.

● Provide access to fitness facilities.

HELPING PATIENTS ADVANCE THEIR EXERCISE PROGRAM

● FITT prescription for non-sedentary beginning exerciser (table 6)

● FITT prescription for intermediate exerciser with running (table 7)

● FITT prescription for intermediate exerciser without running (table 8)

● Core stability (picture 9)

facilitate glycogen re-synthesis.

STRATEGIES TO REDUCE RISK DURING EXERCISE

● Diabetes mellitus (see "Effects of exercise in adults with diabetes mellitus")

● Hypertension (see "Exercise in the treatment and prevention of hypertension")

● Arthritis (see "Comorbidities that impact management of osteoarthritis", section on 'Cardiovascular

● Pulmonary disease (see "Pulmonary rehabilitation")

● Obesity (see "Obesity in adults: Role of physical activity and exercise")