The Exercise Prescription

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I prescribe exercise all the time to my patients.  The word “prescribe” may seem odd, but it is important.  Before starting on an exercise program, you should meet with your health care provider , to weigh risks and benefits and to help design a fitness program that is safe, with reasonable goals.  Therefore, just as a health care provider weighs the risks and benefits of any other type of treatment, exercise can be viewed as a “prescription.”  However, as so many active people know, fitness is also a lifestyle.  This article is intended as a guide to help you get started with a fitness program first as a prescription, then, most importantly, as a lifestyle. Please review any large changes in your lifestyle, such as starting an exercise program, with your health care provider FIRST!

A Position Stand from The American College of Sports Medicine was recently published and it contains a wealth of information for both health care providers and patients.  In this manuscript, experts reviewed the evidence supporting the prescription of exercise, and then gave evidence-based advice on how to “write” the prescription.

Table 1, below, was adapted from this manuscript.  There are a couple main points to highlight. First of all, evidence is very clear that engaging in regular exercise AND reducing sedentary behavior is vital for the health of adults.  In fact, sustained sedentary activity, like watching television, driving a vehicle, or sitting at a desk, can reduce the benefits of regular exercise, even if the benchmarks of exercise, discussed below, are reached.  The other main point has to do with medical evaluation before initiating an exercise program.  While the Table, below, expresses some flexibility about obtaining such an evaluation, please see my previous article on this subject which discusses my position that, in the interest of safety, planning, and support, anyone planning to start a fitness program, along with those engaged in regular exercise, should consult their health care providers.

TABLE 1. Summary of the general evidence relevant to the exercise prescription.
Evidence Statement – Evidence Category
Engaging in regular exercise and reducing sedentary behavior is vital for the health of adults. A
Training-induced adaptations are reversed to varying degrees over time upon cessation of a program of regular exercise. A
There is considerable variability in individual responses to a standard dose of exercise. A
Cardiorespiratory and resistance exercise training is recommended to improve physical fitness and health. A
Flexibility exercises improve and maintain and joint range of movement. A
Neuromotor exercises and multifaceted activities (such as tai ji and yoga) can improve or maintain physical function, and reduce falls in older persons at risk for falling. B
Neuromotor exercises may benefit middle aged and younger adults. D
Theory-based exercise interventions can be effective in improving adoption and short-term adherence to exercise. B
Moderate-intensity exercise and exercise that is enjoyable can enhance the affective responses to exercise, and may improve exercise adherence. B
Supervision by an experienced health and fitness professional and enhance exercise adherence. C
Exercise is associated with an increased risk of musculoskeletal injury and adverse coronary heart disease (CHD) events. B
The benefits of exercise far outweigh the risks in most adults. C
Warm-up, cool down, flexibility exercise, and gradual progression of exercise volume and intensity may reduce the risk of cardiovascular disease (CVD) events and musculoskeletal injury during exercise. C
Consultation with a physician and diagnostic exercise testing for CHD may reduce risks of exercise if medically indicated, but are not recommended on a routine basis. C
Consultation with a well-trained fitness professional may reduce risks in novice exercisers and in persons with chronic diseases and conditions. D
Preexercise screening Screening for and educating about the forewarning signs or symptoms of CVD events may reduce the risks of serious untoward events. C
Table evidence categories: A, randomized controlled trials (rich body of data); B, randomized controlled (limited body of data); C, nonrandomized trials, observational studies; D, panel consensus judgment. From the National Heart Lung and Blood Institute.


Table 2, below, was also adapted from the Position Stand (sections about resistance, flexibility, and neuromuscular training were edited out for the purposes of this article).  This table is especially useful because it gives goal levels of exercise as well as some useful information for people who may just be starting out.  Goal levels of exercise include 5 or more days per week (of at least 150 minutes per week) of moderate exercise or 3 or more days per week (totaling at least 75 minutes per week) of vigorous exercise.  This exercise should be regular and purposeful (a benchmark I use is breaking a sweat).  For users of Fitbits and other activity monitors, a goal is at least 7000 steps per day.  However, the expert panel also clearly stated that lower levels of exercise are still beneficial.  Furthermore: “A gradual progression of exercise volume by adjusting exercise duration, frequency, and/or intensity is reasonable until the desired exercise goal (maintenance) is attained.”  It is dangerous and unwise to try to progress quickly from being inactive to exercising 150 or more minutes per week.  Since, as stated clearly in Table 2, exercise of less volume or intensity can still give important benefits, a good approach to starting a fitness program is to start with a fairly light level of exercise and, then, gradually and carefully build.  The determination of the initial intensity of an exercise program is another area in which a health care provider can be very helpful.

TABLE 2. Evidence statements and summary of recommendations for the individualized exercise prescription.
Evidence-Based Recommendation. Evidence Category
Aerobic Exercise
5+ d/wk of moderate exercise, or 3+ d/wk of vigorous exercise, or a combination of moderate and vigorous exercise on 3-5 or more d/wk is recommended. A
Moderate and/or vigorous intensity is recommended for most adults. A
Light- to moderate-intensity exercise may be beneficial in deconditioned persons. B
30–60 min/d (at least 150 min/wk) of purposeful moderate exercise, or 20–60 min/d (at least 75 min/wk) of vigorous exercise, or a combination of moderate and vigorous exercise per day is recommended for most adults. A
<20 min/d (<150 min/wk) of exercise can be beneficial, especially in previously sedentary persons. B
Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature is recommended. A
A target volume of at least 500–1000 MET/min/wk is recommended. C
Increasing pedometer step counts by at least 2000 steps per day to reach a daily step count of at least 7000 steps per day is beneficial. B
Exercising below these volumes may still be beneficial for persons unable or unwilling to reach this amount of exercise. C
Exercise may be performed in one (continuous) session per day or in multiple sessions of at least 10 min to accumulate the desired duration and volume of exercise per day. A
Exercise bouts of <10 min may yield favorable adaptations in very deconditioned individuals. B
Interval training can be effective in adults. B
A gradual progression of exercise volume by adjusting exercise duration, frequency, and/or intensity is reasonable until the desired exercise goal (maintenance) is attained. B
This approach of gradual progression may enhance adherence and reduce risks of musculoskeletal injury and adverse CHD events. D
Table evidence categories: A, randomized controlled trials (rich body of data); B, randomized controlled trials (limited body of data); C, nonrandomized trials, observational studies; D, panel consensus judgment.
From the National Heart Lung and Blood Institute.

Once you have seen your health care provider, come up with goals and a plan of how to achieve them, how do you follow through?  I think for most people this is the hardest part. From my experience, here are some do’s and don’t’s:

Do:

  • Pick an activity or set of activities that is fun and SUSTAINABLE.  It really won’t help you to do an activity for a few weeks, get bored or frustrated, and quit.  You are trying to achieve a lifestyle change and these kinds of changes are long-term.
  • Try a variety of activities, at first, to learn what you like.
  • Get a book, watch videos online, or learn from friends about how to do your chosen activity well.  It will be much more fun if you do it right.
  • Be confident that you BELONG in the gym or on the bike path.
  • Find a good group of like-minded people.  These people can be your neighbors and friends, a local club, or an online group.  I have been highly impressed with the very supportive Facebook groups: Fitbit Rules!! and the Red Tennis Shoe Group.
  • Consider signing up for a goal event, such as a 5K run or a charity walk.  The “reality” of a date on a calendar is motivating for a lot of people.
  • Smile and have fun!

Don’t:

  • Buy a gym membership on January 1st if you are not POSITIVE you will use it throughout the year.  Get a trial membership and try different things until you find out what is good for you.
  • Buy expensive gear until you learn what activities you really like.  Think sustainability!
  • Quit.  Your goal may take months or years.  Actually, if you are approaching fitness correctly, you will continue to set and reach new goals.

It is hard to go from inactivity to fitness.  But you will never regret it!

Reference:

Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand.  Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-1359.

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