Guidelines for Exercise Prescription at the Office

Joseph Ihm, MD Assistant Professor

Rehabilitation Institute of Chicago Northwestern University Feinberg School

of Medicine

Disclosures

Nothing to disclose

Topics to be discussed !  Does a physician’s health

matter? !  Does counseling matter? !  How active are we? !  Screening prior to exercise !  Guidelines for fitness and

health !  Ways to communicate with

patients about activity, health and fitness

Physician habits and counselling What we do and know affects our patients !  23-42% familiar with ACSM guidelines (Williford, 1992;

Costello 2012) !  96% felt it was responsibility but only 28% felt confident

in their skills to prescribe exercise (Rogers, 2002) !  If exercises more likely to counsel patients (Rogers, 2005;

Abramson, 2000 (OR 4.55-5.72)) !  If healthy more likely to counsel (Wells, 1984) !  If trying to improve exercise habits more likely to counsel

(Frank, 2000) !  70% more likely to comply if physician active (Harsha,

1996) !  More likely to comply if well dressed or well groomed

(Harsha, 1996)

Does counseling matter? !  Number who counsel

is increasing (Barnes, 2012)

!  After 3-5 minutes of counseling moved from contemplator to active (Calfas, 1996)

!  Improved fitness levels (JAMA, 2001)

How many are active?

!  48% meet 2008 Physical Activity Guidelines (activity and resistance training)

!  2010 – 64.5% active !  2010 – 24.5% inactive CDC website

Screening prior to starting exercise MAJOR SIGNS OR SYMPTOMS SUGGESTIVE OF CARDIOVASCULAR, PULMONARY, OR METABOLIC DISEASE !  Pain, discomfort (or other anginal equivalent) in the

chest, neck, jaw, arms, or other areas that may result from ischemia

!  Shortness of breath at rest or with mild exertion !  Dizziness or syncope !  Orthopnea or paroxysmal nocturnal dyspnea !  Unusual fatigue or shortness of breath with usual

activities !  Ankle edema !  Palpitations or tachycardia !  Intermittent claudication !  Known heart murmur

Screening prior to starting exercise Cardiovascular risk factors ! Age ! Family history ! Cigarette smoking ! Sedentary lifestyle ! Obesity ! Hypertension ! Dyslipidemia ! Prediabetes

ACSM risk stratification for CVD

!  Low risk -- asymptomatic with < 2 risk factors

!  Moderate risk -- asymptomatic with >1 risk factor

!  High risk -- individuals with known cardiovascular, pulmonary, or metabolic disease, or one or more sign or symptom

and circumstances, the health status of the patient, and the training and experi-ence of the laboratory staff. Physicians responsible for supervising exercise test-ing should meet or exceed the minimal competencies for supervision and inter-pretation of results as established by the AHA (21). In all situations in whichexercise testing is performed, site personnel should at least be certified at a level

32 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

RiskStratification

Low Risk Moderate RiskAsymptomatic Asymptomatic

≤1 Risk Factors ≥ 2 Risk Factors

High RiskSymptomatic, orknown cardiac,pulmonary, or

metabolic disease

Medical Exam & GXTbefore exercise?

Mod Ex - Not NecVig Ex - Not Nec

Medical Exam & GXTbefore exercise?

Mod Ex - Not NecVig Ex - Rec

Medical Exam & GXTbefore exercise?

Mod Ex - RecVig Ex - Rec

MD Supervision of Exercise Test?

Submax - Not NecMax - Not Nec

MD Supervision of Exercise Test?

Submax - Not NecMax - Rec

MD Supervision of Exercise Test?

Submax - RecMax - Rec

Mod Ex:

Vig Ex:

Not Nec:

Rec:

Moderate intensity exercise; 40-60% of VO2max; 3-6 METs; “an intensitywell within the individual’s capacity, one which can be comfortablysustained for a prolonged period of time (~45 minutes)”

Vigorous intensity exercise; > 60% of VO2max; > 6 METs; “exercise intenseenough to represent a substantial cardiorespiratory challenge”

Not Necessary; reflects the notion that a medical examination, exercisetest, and physician supervision of exercise testing would not be essentialin the preparticipation screening, however, they should not be viewed asinappropriate

Recommended; when MD supervision of exercise testing is“Recommended,” the MD shold be in close proximity and readily availableshould there be an emergent need

•

•

FIGURE 2.4. Exercise Testing and Testing Supervision Recommendations Based on RiskStratification.

LWBK119-3920G_CH02_18-40.qxd 10/20/08 11:25 AM Page 32 Aptara Inc.

and circumstances, the health status of the patient, and the training and experi-ence of the laboratory staff. Physicians responsible for supervising exercise test-ing should meet or exceed the minimal competencies for supervision and inter-pretation of results as established by the AHA (21). In all situations in whichexercise testing is performed, site personnel should at least be certified at a level

32 GUIDELINES FOR EXERCISE TESTING • www.acsm.org

RiskStratification

Low Risk Moderate RiskAsymptomatic Asymptomatic

≤1 Risk Factors ≥ 2 Risk Factors

High RiskSymptomatic, orknown cardiac,pulmonary, or

metabolic disease

Medical Exam & GXTbefore exercise?

Mod Ex - Not NecVig Ex - Not Nec

Medical Exam & GXTbefore exercise?

Mod Ex - Not NecVig Ex - Rec

Medical Exam & GXTbefore exercise?

Mod Ex - RecVig Ex - Rec

MD Supervision of Exercise Test?

Submax - Not NecMax - Not Nec

MD Supervision of Exercise Test?

Submax - Not NecMax - Rec

MD Supervision of Exercise Test?

Submax - RecMax - Rec

Mod Ex:

Vig Ex:

Not Nec:

Rec:

Moderate intensity exercise; 40-60% of VO2max; 3-6 METs; “an intensitywell within the individual’s capacity, one which can be comfortablysustained for a prolonged period of time (~45 minutes)”

Vigorous intensity exercise; > 60% of VO2max; > 6 METs; “exercise intenseenough to represent a substantial cardiorespiratory challenge”

Not Necessary; reflects the notion that a medical examination, exercisetest, and physician supervision of exercise testing would not be essentialin the preparticipation screening, however, they should not be viewed asinappropriate

Recommended; when MD supervision of exercise testing is“Recommended,” the MD shold be in close proximity and readily availableshould there be an emergent need

•

•

FIGURE 2.4. Exercise Testing and Testing Supervision Recommendations Based on RiskStratification.

LWBK119-3920G_CH02_18-40.qxd 10/20/08 11:25 AM Page 32 Aptara Inc.

8th Edition, 2009

9th Edition, 2013

Differentiate activity and exercise !  Activity

! Any bodily movement produced by skeletal muscles that results in increased energy expenditure

! May not change fitness level greatly !  Exercise

!  Planned, structured and repetitive activity !  Should improve or maintain fitness

Recommendations for Adults !  150 minutes per week mod

intensity !  75 minutes per week of

vigorous intensity !  Combinations of mod and

vigorous can be done !  If exceeded then greater

fitness and health benefits

-2008 Physical Activities Guidelines for Americans -Haskell, et al. Med Sci Sport and Exercise, 2007

Copyright @ 200 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.7

The health benefits of various combinations of moderate-and vigorous-intensity activity have not been sufficientlyexamined in observational studies nor investigated usingrandomized controlled trials. However, based on healthoutcome data from observational studies and an extensivedatabase on the energy costs of various activities, thefollowing approach is recommended for determining whatcombinations of moderate- and vigorous-intensity activitiesmeet the dose recommendation.

A shorthand method for estimating energy expenditureduring physical activity is the MET or metabolic equivalent(1). One MET represents an individual’s energy expenditurewhile sitting quietly. An adult walking at 3 mph on a flat,hard surface is expending about 3.3 METs and whilejogging/running on a similar surface at 5 mph (12 min permile pace) is expending approximately 8 METs (see Table 2for the MET values of selected activities). Thus, if aman or women walked at 3 mph (moderate-intensity) for30 min they would accumulate 99 METImin of activity(3.3 MET ! 30 min = 99 METImin), but if they joggedat 5 mph for 20 min they would accumulate 160 METImin(8 MET ! 20 min = 160 METImin). So, if a man or womenwas to meet the minimum moderate intensity recommenda-tion by walking for 30 min at 3 mph on 5 days of the week,they would accumulate about 495 METImin (99 ! 5), or tomeet the minimum vigorous-intensity recommendation byjogging at 5 mph for 20 min on 3 days they would accumu-

late about 480 METImin (160 ! 3). Also, they could meetthe recommendation by walking at 3.0 mph for 30 min on2 days (3.3 MET ! 60 min = 198 METImin) and thenjogging at 5 mph for 20 min on 2 other days (8 MET !40 min = 320 METImin) for a total during the week ofabout 518 METImin (320 + 198).

Using METs as an indicator of activity intensity allowsgenerally healthy adults to accumulate credit for thevarious moderate or vigorous intensity activities theyperform during the week. When combining moderate andvigorous intensity activity to meet the current recommen-dation, the minimum goal should be in the range of 450 to750 METIminIwkj1. These values are based on the METrange of 3 to 6 for moderate-intensity activity and150 minIwkj1 (3 ! 150 = 450 and 5 ! 150 = 750).Individuals should start at the lower end of this rangewhen beginning an activity program and progress towardsthe higher end as they become more fit. Listed in Table 2are the MET values for a variety of physical activities thatare of light, moderate or vigorous intensity. For acomprehensive listing of MET values see tabulation byAinsworth and colleagues (1) or the following Web site:http://prevention.sph.sc.edu/tools/compendium.htm. It isrecognized that actual MET values can vary from personto person depending on a variety of factors (e.g., how theyperform the activity, skill level, body composition), but thevalues provided in the compendium are sufficiently accurate

TABLE 2. MET equivalents of common physical activities classified as light, moderate or vigorous intensity.

Light G3.0 METs Moderate 3.0 – 6.0 METs Vigorous 96.0 METs

Walking Walking Walking, jogging & runningWalking slowly around home,store or office = 2.0*

Walking 3.0 mph = 3.3* Walking at very very brisk pace (4.5 mph) = 6.3*

Walking at very brisk pace (4 mph) = 5.0* Walking/hiking at moderate pace and grade with no orlight pack (G10 lb) = 7.0

Hiking at steep grades and pack 10–42 lb = 7.5–9.0Jogging at 5 mph = 8.0*Jogging at 6 mph = 10.0*Running at 7 mph = 11.5*

Household & occupationSitting — using computer work at desk usinglight hand tools = 1.5

Cleaning — heavy: washing windows, car,clean garage = 3.0

Shoveling sand, coal, etc. = 7.0

Standing performing light work such asmaking bed, washing dishes, ironing,preparing food or store clerk = 2.0–2.5

Sweeping floors or carpet, vacuuming,mopping = 3.0–3.5

Carrying heavy loads such as bricks = 7.5

Carpentry — general = 3.6 Heavy farming such as bailing hay = 8.0Carrying & stacking wood = 5.5 Shoveling, digging ditches = 8.5Mowing lawn — walk power mower = 5.5

Leisure time & sportsArts & crafts, playing cards = 1.5 Badminton — recreational = 4.5 Basketball game = 8.0Billiards = 2.5 Basketball — shooting around = 4.5 Bicycling — on flat: moderate effort (12–14 mph) = 8.0;

fast (14–16 mph) = 10Boating — power = 2.5 Bicycling — on flat: light effort (10–12 mph) = 6.0 Skiing cross country — slow (2.5 mph = 7.0;

fast (5.0–7.9 mph) = 9.0Croquet = 2.5 Dancing — ballroom slow = 3.0;

ballroom fast = 4.5Soccer — casual = 7.0; competitive = 10.0

Darts = 2.5 Fishing from river bank & walking = 4.0 Swimming — moderate/hard = 8–11†Fishing — sitting = 2.5 Golf — walking pulling clubs = 4.3 Tennis singles = 8.0Playing most musical instruments = 2.0–2.5 Sailing boat, wind surfing = 3.0 Volleyball — competitive at gym or beach = 8.0

Swimming leisurely = 6.0†Table tennis = 4.0Tennis doubles = 5.0Volleyball — noncompetitive = 3.0–4.0

Ainsworth, et al. 2000 (1). * On flat, hard surface. † MET values can vary substantially from person to person during swimming as a result of different strokes and skill levels.

http://www.acsm-msse.org1428 Official Journal of the American College of Sports Medicine

SPEC

IALCO

MMUNICAT

IONS

Haskell, 2007

ACSM Position Stand, 2011

fixedexercise

volumes

onfitness

andbiom

arkersof

dis-ease.

Chu

rchet

al.(76)

evaluatedthe

effectof

varyingex-

ercisevolum

esat

afixed

intensity(50%

V̇O2max )

insedentary,

overweight,

orobese

postm

enopausal

wom

enrandom

izedto

exercisevo

lumes

of50%

,10

0%,or

150%

ofthe

recommended

weekly

energyexpenditure

(4,8,

and12

kcalIkgj1Iw

kj1,respectively;

orapproxim

ately330,

840,and

1000kcalIw

kj1,

respectively).A

dose–responseeffect

acrossthe

threevolum

eswas

observed,and

modest

im-

provements

incardiorespiratory

fitness(4%

–8%)occurred

at6months

atexercisetraining

volumesas

lowas

one-halfoftherecom

mended

weekly

volume.Aprelim

inaryreport

suggeststhatinitialleveloffitness

may

affectthetraining

responsestoa

setvolum

eof

exercise(18),

butmore

definitiveevidence

isneeded

beforethe

resultsof

thesestudies

canbe

generalizedto

personsof

higherfitness

levels.

HOW

AREEXERCISEIN

TENSITYAND

VOLUMEESTIM

ATED?

Most

epidemiologic

andmany

laboratorystudies

provid-ing

evidenceof

thebeneficial

effectsof

exercisehave

clas-sified

intensityaccording

tothe

absoluteenergy

demands

ofthe

physicalactivity

(323).Measured

orestim

atedmeasures

ofabsolute

exerciseintensity

includecaloric

expenditure(kcalIm

inj1),absolute

oxygenuptake

(mLIminj1or

LIminj1),

andMETs.These

absolutemeasures

canresult

inmisclassi-

ficationof

exerciseintensity

(e.g.,moderate,

vigorous)be-

causethey

donot

considerindividual

factorssuch

asbody

weight,

sex,and

fitnesslevel

(4,58,173).Measurem

ent—and

consequentlymisclassification—

erroris

greaterwhen

usingestim

atedrather

thandirectly

measured

absoluteenergy

ex-penditure,

andunder

free-livingcom

paredwith

laboratoryconditions

(4,58,173).For

example,

anolder

personworking

at6METsmay

beexercising

atavigorous

tomaxim

alin-

tensity,while

ayounger

personworking

atthe

sameabsolute

intensitywill

beexercising

moderately

(173).Therefore,

forindividual

exerciseprescription,

arelative

measure

ofinten-

sity(i.e.,

theenergy

costof

theactivity

relativeto

theindi-

vidual’smaxim

alcapacity)ismore

appropriate,especiallyfor

olderand

deconditionedpersons

(173,264).There

areseveral

commonly

usedmethods

ofestim

atingrelative

exerciseintensity

duringcardiorespiratory

exercise:V̇O2 R

,HRR,percent

ofthe

maxim

umHR

(%HRmax ),

%V̇O2max ,

and%METmax .

Each

ofthese

methods

forpre-

scribingexercise

intensityhas

beenshow

nto

resultin

improvem

entsin

cardiorespiratoryfitness

when

usedfor

exerciseprescription,

thencecan

berecom

mend

edwhen

prescribingexercise

foran

individual(12).

Table

5show

sthe

approximate

classificationof

exerciseintensity

usingrelative

andabsolute

methods

commonly

usedin

practice.

No

studieshave

compared

allof

themethod

sof

measurem

entof

exerciseintensity

simulta-

neously;therefore,

itcannot

beassum

edthat

onemethod

ofdeterm

iningexercise

intensityis

necessarilyequivalent

tothat

derivedusing

anothermethod.

Itis

prudentto

keepin

TABLE 5. Classification of exercise intensity: relative and absolute exercise intensity for cardiorespiratory endurance and resistance exercise.

Cardiorespiratory Endurance Exercise Resistance Exercise

Relative IntensityIntensity (%V̇O2max)) Relative to

Maximal Exercise Capacity in METsAbsoluteIntensity

Absolute Intensity(MET) by Age Relative Intensity

Intensity%HRR or%V̇O2R %HRmax %V̇O2max

Perceived Exertion(Rating on 6–20 RPE Scale)

20 METs%V̇O2max

10 METs%V̇O2max

5 METs%V̇O2max METs

Young(20–39 yr)

Middle-aged(40–64 yr) Older (Q65 yr) % 1RM

Very light G30 G57 G37 GVery light (RPE G 9) G34 G37 G44 G2 G2.4 G2.0 G1.6 G30Light 30–39 57–63 37–45 Very light–fairly light

(RPE 9–11)34–42 37–45 44–51 2.0–2.9 2.4–4.7 2.0–3.9 1.6–3.1 30–49

Moderate 40–59 64–76 46–63 Fairly light to somewhathard (RPE 12–13)

43–61 46–63 52–67 3.0 to 5.9 4.8–7.1 4.0–5.9 3.2–4.7 50–69

Vigorous 60–89 77–95 64–90 Somewhat hard to veryhard (RPE 14–17)

62–90 64–90 68–91 6.0–8.7 7.2–10.1 6.0–8.4 4.8–6.7 70–84

Near–maximalto maximal

Q90 Q96 Q91 QVery hard (RPE Q 18) Q91 Q91 Q92 Q8.8 Q10.2 Q8.5 Q6.8 Q85

Table adapted from the American College of Sports Medicine (14), Howley (173), Swain and Franklin (344), Swain and Leutholtz (346), Swain et al. (347), and the US Department of Health and Human Services (370).HRmax, maximal HR; %HRmax, percent of maximal HR; HRR, HR reserve; V̇O2max, maximal oxygen uptake; %V̇O2max, percent of maximal oxygen uptake; V̇O2R, oxygen uptake reserve; RPE, ratings of perceived exertion (48).

QUANTITYANDQUALIT

YOFEXERCISE

Med

icine&Science

inSports

&Exercise

d1341

SPECIALCOMMUNICATIONS

Copyright ©

2011 by the Am

erican College of S

ports Medicine. U

nauthorized reproduction of this article is prohibited.

fixedexercise

volumes

onfitness

andbiom

arkersof

dis-ease.

Church

etal.

(76)evaluated

theeffect

ofvarying

ex-ercise

volumes

ata

fixedintensity

(50%V̇O2max )

insedentary,

overweight,

orobese

postmenopau

salwom

enrandom

izedto

exercisevolum

esof

50%,100%

,or

150%of

therecom

mended

weekly

energyexpenditure

(4,8,

and12

kcalIkgj1Iw

kj1,respectively;

orapproxim

ately330,

840,and

1000kcalIw

kj1,

respectively).A

dose–responseeffect

acrossthe

threevolum

eswas

observed,and

modest

im-

provements

incardiorespiratory

fitness(4%

–8%)occurred

at6months

atexercisetraining

volumesas

lowas

one-halfoftherecom

mended

weekly

volume.Aprelim

inaryreport

suggeststhatinitialleveloffitness

may

affectthetraining

responsestoa

setvolum

eof

exercise(18),

butmore

definitiveevidence

isneeded

beforethe

resultsof

thesestudies

canbe

generalizedto

personsof

higherfitness

levels.

HOW

AREEXERCISEIN

TENSITYAND

VOLUMEESTIM

ATED?

Most

epidemiologic

andmany

laboratorystudies

provid-ing

evidenceof

thebeneficial

effectsof

exercisehave

clas-sified

intensityaccording

tothe

absoluteenergy

demands

ofthe

physicalactivity

(323).Measured

orestim

atedmeasures

ofabsolute

exerciseintensity

includecaloric

expenditure(kcalIm

inj1),absolute

oxygenuptake

(mLIminj1or

LIminj1),

andMETs.These

absolutemeasures

canresult

inmisclassi-

ficationof

exerciseintensity

(e.g.,moderate,

vigorous)be-

causethey

donot

considerindividual

factorssuch

asbody

weight,

sex,and

fitnesslevel

(4,58,173).Measurem

ent—and

consequentlymisclassification—

erroris

greaterwhen

usingestim

atedrather

thandirectly

measured

absoluteenergy

ex-penditure,

andunder

free-livingcom

paredwith

laboratoryconditions

(4,58,173).For

example,

anolder

personworking

at6METsmay

beexercising

atavigorous

tomaxim

alin-

tensity,while

ayounger

personworking

atthe

sameabsolute

intensitywill

beexercising

moderately

(173).Therefore,

forindividual

exerciseprescription,

arelative

measure

ofinten-

sity(i.e.,

theenergy

costof

theactivity

relativeto

theindi-

vidual’smaxim

alcapacity)ismore

appropriate,especiallyfor

olderand

deconditionedpersons

(173,264).There

areseveral

commonly

usedmethods

ofestim

atingrelative

exerciseintensity

duringcardiorespiratory

exercise:V̇O2 R

,HRR,percent

ofthe

maxim

umHR

(%HRmax ),

%V̇O2max ,

and%METmax .

Each

ofthese

methods

forpre-

scribingexercise

intensityhas

beenshow

nto

resultin

improvem

entsin

cardiorespiratoryfitness

when

usedfor

exerciseprescription,

thencecan

berecom

mend

edwhen

prescribingexercise

foran

individual(12).

Table

5show

sthe

approximate

classificationof

exerciseintensity

usingrelative

andabsolute

methods

commonly

usedin

practice.No

studieshave

compared

allof

themethod

sof

measurem

entof

exerciseintensity

simulta-

neously;therefore,

itcannot

beassum

edthat

onemethod

ofdeterm

iningexercise

intensityis

necessarilyequivalent

tothat

derivedusing

anothermethod.

Itis

prudentto

keepin

TABLE 5. Classification of exercise intensity: relative and absolute exercise intensity for cardiorespiratory endurance and resistance exercise.

Cardiorespiratory Endurance Exercise Resistance Exercise

Relative IntensityIntensity (%V̇O2max)) Relative to

Maximal Exercise Capacity in METsAbsoluteIntensity

Absolute Intensity(MET) by Age Relative Intensity

Intensity%HRR or%V̇O2R %HRmax %V̇O2max

Perceived Exertion(Rating on 6–20 RPE Scale)

20 METs%V̇O2max

10 METs%V̇O2max

5 METs%V̇O2max METs

Young(20–39 yr)

Middle-aged(40–64 yr) Older (Q65 yr) % 1RM

Very light G30 G57 G37 GVery light (RPE G 9) G34 G37 G44 G2 G2.4 G2.0 G1.6 G30Light 30–39 57–63 37–45 Very light–fairly light

(RPE 9–11)34–42 37–45 44–51 2.0–2.9 2.4–4.7 2.0–3.9 1.6–3.1 30–49

Moderate 40–59 64–76 46–63 Fairly light to somewhathard (RPE 12–13)

43–61 46–63 52–67 3.0 to 5.9 4.8–7.1 4.0–5.9 3.2–4.7 50–69

Vigorous 60–89 77–95 64–90 Somewhat hard to veryhard (RPE 14–17)

62–90 64–90 68–91 6.0–8.7 7.2–10.1 6.0–8.4 4.8–6.7 70–84

Near–maximalto maximal

Q90 Q96 Q91 QVery hard (RPE Q 18) Q91 Q91 Q92 Q8.8 Q10.2 Q8.5 Q6.8 Q85

Table adapted from the American College of Sports Medicine (14), Howley (173), Swain and Franklin (344), Swain and Leutholtz (346), Swain et al. (347), and the US Department of Health and Human Services (370).HRmax, maximal HR; %HRmax, percent of maximal HR; HRR, HR reserve; V̇O2max, maximal oxygen uptake; %V̇O2max, percent of maximal oxygen uptake; V̇O2R, oxygen uptake reserve; RPE, ratings of perceived exertion (48).

QUANTITYANDQUALIT

YOFEXERCISE

Med

icine&Science

inSports

&Exercise

d1341

SPECIALCOMMUNICATIONS

Copyright ©

2011 by the Am

erican College of S

ports Medicine. U

nauthorized reproduction of this article is prohibited.

Increase aerobic fitness !  60-70% of max heart rate

!  30y/o – 114-133 bpm !  50y/o – 102-119 bpm

!  20-30 minutes at 70% or 45-60 minutes at 60%

!  3+ days per week !  Higher the intensity the

greater the improvement !  If more fit then more

calories per workout

Measuring intensity !  Borg rated perceived exertion scale !  Talk test (Quinn, 2009) !  Counting Talk Test (Loose, 2012) !  Heart rate (by palpation or monitor) !  Pedometer – steps/min and recommended time

Resistance training !  Most or all muscle

groups (8-10 exercises) !  2 or more days per week !  1-3 sets per exercise !  65-75% of 1 rep max !  10-15 reps per set !  Screen for orthopedic

and cardiac conditions !  Variable motivation and

tolerance

Flexibility !  Two or three days each

week !  Hold for 10-30 seconds to

the point of tightness !  Accumulate 60 seconds

per stretch !  Static, dynamic, ballistic

and PNF !  Most effective when the

muscle is warm

From ACSM website

Discussing activity with patients !  Assess current activity level !  Discuss ways to increase

activity !  Provide options for

increasing fitness level !  Do not accept “I walk

everywhere” or “My house has a lot of stairs” as confirming adequate activity

!  Try to impress consequences of inadequate activity

Conclusions !  Encourage patients to be active !  Use other resources for patients

!  Exercise is Medicine website ! www.health.gov/paguidelines/guidelines/ ! www.cdc.gov/physicalactivity/everyone/

guidelines/index.html