Physical Activity and Exercise Prescription
Original Editor - Karen Wilson
Physical activity prescription is an under-utilised tool for improving community health. In the right dose, physical activity can help to prevent, treat, and manage a range of chronic health conditions that increasingly impact the quality of life and physical function of individuals on a global scale.
Safe and effective exercise prescription requires careful consideration for the target individual's health status, baseline fitness, goals and preferences. Several national and international organisations provide clinicians and allied health professionals with guidelines for how to screen, assess, and, when appropriate, prescribe exercise for the benefit of their patients/clients.
Before starting a physical activity program, the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend screening to identify cardiovascular risk factors. Screenings help mitigate the risk for adverse responses to exercise, as even moderate physical activity can trigger cardiac events in individuals who are largely sedentary.
With this in mind, two instruments are recommended to facilitate the risk screening process for fitness professionals. The most commonly used questionnaire is the PAR-Q, followed by the Fitness Facility Pre-participation Screening Questionnaire. The PAR-Q is a brief 7 item questionnaire that uses a yes/no answer format to identify personal risk factors. In comparison, the Fitness Facility Pre-participation Screening Questionnaire is slightly longer and captures more detailed information about cardiovascular symptoms.
Screening results in stratifying prospective participants into 3 levels of risk: low, moderate, and high. Low risk individuals are men younger than 45 and women younger than 55 with no more than one cardiovascular risk factor. Moderate risk stratification pertains to men over 45 and women over 55 with 2 or more risk factors. The highest risk category includes any individual with known cardiovascular, pulmonary or metabolic disease or who demonstrates signs or symptoms of cardiovascular disease. Signs and symptoms that automatically lead to high risk stratification include:
- Pain, discomfort in the chest, neck, jaw, arms, or other areas that may be due to ischaemia.
- Shortness of breath at rest or with mild exertion.
- Orthopnaea or paroxysmal nocturnal dyspnea.
- Ankle oedema.
- Palpitations or tachycardia.
- Intermittent claudication.
- Unusual fatigue or shortness of breath with usual activities.
- Known heart murmur.
From this information, a decision about the need for medical clearance/consultation can be made prior to further testing. Below is a summary of medical clearance and testing recommendations based on the risk level of the individual and the intensity of exercise in which he or she wishes to participate.
|Risk Profile||Medical Clearance/Consultation||Exercise Testing Conditions|
|Low-risk individuals & vigorous exercise||Not necessary||Submaximal or maximal testing; no physician present, emergency procedures in place|
|Moderate-risk individuals & moderate exercise||Not necessary||Submaximal or maximal testing; no physician present, emergency procedures in place|
|Moderate-risk individuals & vigorous exercise||Recommended||Physician supervision recommended for maximal exercise testing|
|High-risk individuals & moderate to vigorous exercise||Recommended||Physician supervision recommended for submaximal or maximal exercise testing|
Assessment of Exercise Capacity
Multiple protocols for measuring baseline exercise capacity exist. For aerobic capacity, exercise testing falls into 2 categories: maximal and sub-maximal testing. Maximal testing is reserved for assessing the capacity of individuals who participate in vigorous exercise. Sub-maximal testing is adequate for individuals who will only participate in moderate or low-intensity exercise. Information about specific protocols for sub-maximal testing has assembled by Noonan & Dean.
Exercise prescription is based on 5 principles: type, duration, frequency, intensity, and volume. Type refers to mode of exercise training, with the main forms being aerobic (i.e. endurance training), resistance (i.e. strength training), flexibility, and balance. The length and number of exercise sessions performed within a given time frame, are described by duration and frequency, respectively. Intensity is defined as the level of effort being exerted by the participant and can be measured in a variety of ways. Common measures of aerobic intensity include the following:
- Borg Rating of Perceived Exertion Scale (RPE)
- Target heart rate: Percent of maximum heart rate (HR max) or Karvonen Formula/Heart Rate Reserve (HRR)
- Metabolic Equivalents (METS)
- Maximum oxygen consumption (VO2 max)
Each measure has guidelines for what parameters denote vigorous, moderate, and low intensity exercise. The following table offers a comparison of intensity across multiple measurement methods.
|Measurement||Low Intensity||Moderate Intensity||Vigorous Intensity|
|Borg RPE scale (0-10)||< 5||5-6||≥ 7|
|HR max||50- 63%||64- 76%||77-93%|
|METS||< 3||3-6||> 6|
With moderate intensity the patient will have a faster heart beat, feel warmer, and breath harder. An example is brisk walking.
With vigorous intensity the patient will get warm quickly, perspire, breath much harder, and will struggle to maintain a conversation. 
The final principle of exercise prescription is volume. Volume is a sum of the intensity, frequency, duration, and longevity of a physical activity program.
Recommendations regarding frequency, time, and intensity have been established for each type of exercise training.
|Aerobic (Endurance)||5 days/week||Moderate||30 minutes (for 150 minutes per week)||Vigorous walking, jogging, swimming, hiking, cycling|
|Resistance (Strength)||2-3 days/week||60-70% of 1 rep max (novice), 40-50% of 1 rep max (sedentary person, older adult)||8-12 repetitions, 2-4 sets with 2-3 minutes rest in between||Free weights, bodyweight exercise, calisthenics|
|Flexibility||2-3 days/week||Until feeling of tightness.||Hold 10-30 seconds, 2-4 times to accumulate 60 seconds per stretch||Ballistic, static, dynamic, proprioceptive neuromuscular facilitation|
|Balance||2-3 days/week||Has not been determined.||20-30 minutes||Tai Chi, Yoga|
The way in which these recommendations are applied depends on multiple factors. In developing a program prescription, health professionals must consider fitness level, fitness goals, exercise preferences, equipment availability, and other personal factors that may impact participation. For example, if a patient or client is starting at a low level of fitness, an initial program may include low to moderate intensity, aerobic exercise that the individual enjoys and fits his or her time schedule to encourage adherence. In addition, the patient or client may have to work up to meeting the recommended 150 minutes per week.
Apply the FITT principle when prescribing exercise:
- How many times a week for an activity?
- For sedentary individuals, start with 2-3 days/week of aerobic exercise and build up to 5 days/week. Help pt to establish an exercise routine.
- How hard to exert?
- Someone new to exercise should start at a low intensity, but health changes occur at a moderate exercise intensity
- Which type of activity agreed with the patient?
- Should be enjoyable, affordable, and achievable
- How long in minutes
- This does not include the warm up or cool down.
- 10 min bouts of exercise can be accumulated throughout the day
- If walking is the exercise - first increase the time before increasing the intensity (walking uphill/at a quicker pace)
Progression is way in which frequency, intensity, and duration of an exercise program are increased. Advancement of an exercise program should be incremental to encourage participant adherence and avoid injury. Recommendations for progressing aerobic exercise include increasing the duration of sessions 5 to 10 minutes every 1-2 weeks for the first 4-6 weeks. Frequency and intensity can be progressed as tolerated. Overall volume should be monitored for adverse effects decreased if necessary.
In the case of resistance exercise, increasing repetitions is favoured before increasing load. Once the maximum repetitions for a target range have been achieved, load can be increased by approximately 5% so that no more than the lower limit of repetitions can be performed.
Implications for Physical Therapist Practice
As experts in exercise across the life span, physical therapists stand to play an important role in promoting, prescribing and managing exercise programs. A randomized control trial suggests home-based exercise and nutrition strategies have a positive outcome on the frailty score and physical performance in the pre-frail or frail older adults. In addition to being a tool to remediate impairments, activity limitations, and participation restrictions, exercise prescription should also be used to improve the fitness and well being of patients and clients.
- Khan KM, Weller R, Blair SN. Prescribing exercise in primary care: ten practical steps on how to do it. British Medical Journal. 2011;343(d4141):806.
- World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization Press, 2009
- Balady GJ, Chaitman B, Driscoll D, Foster C, Froelicher E, Gordon N, Pate R, Rippe J, Bazzarre T. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Circulation. 1998 Jun 9;97(22):2283-93.
- American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2014.
- Noonan V, Dean E. Submaximal exercise testing: clinical application and interpretation. Physical therapy. 2000 Aug 1;80(8):782-807.
- Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington (DC); US Department of Health and Human Services; 2008.
- U.S. Department of Health and Human Services (1996). Physical Activity and Health: A Report of the Surgeon General. Atlanta GA. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.
- Motivate2Move. Exercise Medicine for Students.
- Center for Health Protection. Exercise Prescription Doctor's Handbook. Hong Kong: Department of Health; 2012
- Hsieh TJ, Su SC, Chen CW, Kang YW, Hu MH, Hsu LL, Wu SY, Chen L, Chang HY, Chuang SY, Pan WH. Individualized home-based exercise and nutrition interventions improve frailty in older adults: a randomized controlled trial. International Journal of Behavioral Nutrition and Physical Activity. 2019 Dec 1;16(1):119.