Exercise Prescription

Introduction
The patient is a 42-year-old man who
comes to the office for an annual
check-up.

Current History
The patient is a lawyer and reports that he has
had a stressful year at work due to lay offs at
his firm.
In the past few months, he noticed the onset
of intermittent low back pain, which is mild-tomoderate at times.
The patient complains that since he turned 40
his body seems to be going down hill with
more general aches and pains.
He does not feel as energetic as he used to
feel.

Past Medical History

Medial epicondylitis, which flares
up during golf tournaments and is
managed conservatively with ice and
Non-steroidal anti-inflammatory
drugs (NSAIDS)

Social History
The patient has a 20 pack-per-year
history of cigarette smoking and quit
when he was 35.
He drinks 2-3 beers on weekend
nights.
He is married and has four children
(ages 10, 8, 6, and 2).
He plays golf twice a week in
spring, summer, and fall. He rides a
golf cart.

Family History
He has two brothers. One brother is
48 years old and has adult onset
diabetes. The other brother is 46 and
healthy.
His father died of colon cancer at age
55.
His mother suffered an MI at age 62.

Review of systems
He denies chest pain, neck pain, jaw
pain, shortness of breath at rest or
with mild exertion, dizziness
symcope, orthopnea, paroxysmal
nocturnal dyspnea, palpitations,
tachycardia, leg pain, or unusual
fatigue or shortness of breath with
usual activities.

Physical Examination
Heart Rate: 74 beats per minute
Blood Pressure: 135/87 mm Hg
RR: 12
Weight: 196 pounds
Height: 5'10"
BMI: 28.1
Abdominal Girth: 38 inches
The general exam and neurological exam were within normal limits with special attention to:
Neck: No carotid bruits appreciated bilaterally. Carotid pulses 2+ bilaterally. No jugular venous distention. No masses. No
thyromegaly appreciated.
Lungs: Clear to auscultation, no wheezing or crackles bilaterally
Cardiac: Regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: No hepatosplenomegaly. No ascites.
Extremities: No swelling or edema, pulses were 2+ bilaterally, no swelling but slight tenderness over the medial epicondyle on
left.
Back: Decreased range of motion on forward flexion and extension. No tenderness to palpation over the lower back. Negative
straight leg raise bilaterally.

Labs

The patient calculates his BMI from a reference chart on the exam room
wall. (Click here for a link to a Child and Teen BMI Calculator). He expresses
concern to you that he falls in the over-weight category. To calculate a
patients BMI you can use the website from the National Heart Lung and
Blood Institute.
After checking in with the patient about his level of physical activity, you
ask him how he feels about his exercise program or lack thereof. The
patient says he does not have an exercise regimen because his work is so
busy that he does not have time. He also admits to feeling heavy and not
liking how he has let himself go. He wants to exercise so that he can lose
weight and feel more comfortable in his clothes.

 Question 1: Before making any exercise recommendations, you

determine the patients level of risk for participating in an
exercise program. Given his history of the present illness, past
medical history, family history, physical exam, and review of
systems, into which category would you place this patient?
a. High risk because of his family history (with a mother suffering
an MI at age 62), his weight, his cholesterol, and his sedentary behavior.
b. Low risk because he is younger than 45 years old, has a normal
exam, and he does not have known cardiovascular, pulmonary or
metabolic disease and he is not experiencing any symptoms of
cardiovascular or pulmonary disease.
c. Moderate risk because he does not have known cardiovascular,
pulmonary, or metabolic disease, nor does he have any major signs or
symptoms suggestive of these diseases, but he does meet the threshold
for two coronary artery disease risk factors.
d. It is not possible to place this patient into an exercise risk
stratification category due to lack of information.

 Correct Choices:
c.Moderate risk because he does not have known cardiovascular,
pulmonary, or metabolic disease, nor does he have any major signs or
symptoms suggestive of these diseases, but he does meet the threshold
for two coronary artery disease risk factors.This answer is correct.
According to the American College of Sports Medicine, in order to be
considered moderate risk, a patient needs to be a man 45 years or older
or a woman 55 years or an individual who meets the threshold for two or
more risk factors for coronary artery disease (1). As this patient is 42
years old, his age does not play a role in placing him in the moderate risk
category. However, he does have two coronary artery disease risk factors:
1) His family history with his mother experiencing an MI at age 62
2) His sedentary lifestyle with no regular exercise program
These two risk factors place this patient in the moderate risk category.

Incorrect Choices:
a.High risk because of his family history (with a mother
suffering an MI at age 62), his weight, his cholesterol,
and his sedentary behavior.The authors disagree.

According to the American College of Sports Medicines

risk (ACSM) stratification categories, in order to be
considered high risk, a patient needs to have one or
more signs and symptoms suggestive of cardiovascular,
pulmonary, or metabolic disease or they need to have
known cardiovascular, pulmonary or metabolic disease
(1). The patients history, physical exam and lab results
do not place him in the high risk category.

 b.Low risk because he is younger than 45 years old, has a normal exam,
and he does not have known cardiovascular, pulmonary or metabolic
disease and he is not experiencing any symptoms of cardiovascular or
pulmonary disease. The authors disagree.
According to the ACSMs risk stratification categories, in order to be
considered low risk, a patient needs to be a man less than 45 years old or
a woman less than 55 years old who is asymptomatic and meets no more
than one risk factor for coronary artery disease (1). This patient has a
positive family history (with a mother having an MI at 62), and a
sedentary lifestyle defined by the ACSM as, "Persons not participating in
a regular exercise program or not meeting the minimal physical activity
recommendations."(American College of Sports Medicine. ACSMs
guidelines for exercise testing and prescription. 7th Edition. Philadelphia:
Lippincott, Williams and Wilkins; 2006. Page 22.). With these two
coronary artery disease risk factors, the patient can not be placed in the
low risk category.

 d.It is not possible to place this patient into an

exercise risk stratification category due to lack of
information. The authors disagree.
The American College of Sports Medicine has
created a user friendly method of placing patients
into risk categories using information you can
obtain from your knowledge of the past medical
history or during a routine office visit (1). There is
enough information provided in this case thus far
to allow the patient to be placed in one of the
three ACSM risk categories (low, moderate, or
high).

ACSMs risk stratification

system
The ACSMs risk stratification system can be found in multiple sources such as the
ACSMs Guidelines for Exercise Testing and Prescription (1). The system is straightforward
and easy to use. It is meant to serve as a general guideline for physicians to use when
assessing the patients risk with exercise.
The system hinges on three main questions:
1) Does the patient have any known cardiovascular, pulmonary, or metabolic
disease?
2) Does the patient have major signs or symptoms suggestive of
cardiovascular, pulmonary or metabolic disease?
3) How many coronary artery disease risk factors does the patients have?
Question one is important because if the answer is "yes," the patient is immediately
placed into the high-risk category. By "cardiovascular disease," the American College of
Sports Medicine is referring to cardiac, peripheral vascular, cerebrovascular disease.
Pulmonary disease includes chronic obstructive pulmonary disease, asthma, interstitial
lung disease, or cystic fibrosis. Metabolic disease includes diabetes (Type 1 and Type 2),
thyroid disorders, renal disease, and liver disease.

Question two is the next question to ask. If the answer is

"yes," the patient is placed into the high-risk category, just as
with question one. The signs and symptoms suggestive of
cardiovascular, pulmonary, or metabolic disease include:

1) Pain, discomfort (or other anginal equivalent) in the chest,

neck, jaw, arms, or other areas that may result from cardiac
ischemia
2) Shortness of breath at rest or with mild exertion
3) Dizziness or syncope
4) Orthopnea or paroxysmal nocturnal dyspnea
5) Ankle edema
6) Palpitations or tachycardia
7) Intermittent claudication
8) Known heart murmur
9) Unusual fatigue or shortness of breath with usual activities.
If the patient has one or more of these signs and symptoms,
he or she is in the high-risk category.

 Question three helps sort out the moderate and low-risk categories. Depending on how many coronary
artery risk factors the patients has, the patient will be placed in the moderate or low-risk category. The
coronary artery disease risk factors for the ACSM risk stratification system include family history, cigarette
smoking, hypertension, dyslipidemia, impaired fasting glucose, obesity, and sedentary lifestyle. The
specifics of each risk factor can be found in the ACSMs Guidelines for Exercise Testing and Prescription (1).
For family history, the patient needs to have a first degree relative who suffered a myocardial infarction
before the age of 55 if the relative is a man, and before the age of 65, if the relative is a woman. Cigarette
smoking counts as a risk factor if the patient is currently smoking or if he or she quit less than six months
ago. For hypertension, the cut-off numbers used by the ACSM are systolic 140 mm Hg and diastolic 90 mm
Hg. For dyslipidemia, LDL>130 mg-dL, HDL < 40 mg-dL, or total cholesterol > 200 mg-dL. For impaired
fasting glucose, the cut-off is greater or equal to 100 mg-dL. Obesity is defined as BMI > 30 is greater or
equal to 100 mg-dL. Obesity is defined as BMI > 30 or waist girth > 102 cm (40 inches) for men and >88
cm (35 inches) for women. A sedentary lifestyle is defined by the ACSM as not participating in a regular
exercise program or not meeting the minimal physical activity recommendations. If the patients HDL is
>60mg-dl, this is considered a "negative" risk factor to be subtracted from the total of positive risk factors.
If a patient has two or more of these coronary artery disease risk factors, he or she is in the moderate-risk
category. If a patient has no more than one coronoary artery risk factor, he can be considered for
placement in the low-risk category. However, age also plays a factor in risk stratification. A patient can be
in the low-risk category only if he is less than 45 years old or she is less than 55 years old. If a man is 45,
he is automatically considered moderate risk. If a woman is 55 years old, she is automatically considered
moderate risk.

Question 2 Given the patients family history and sedentary

lifestyle, he is considered in the moderate risk category for
exercise according to the ACSM risk stratification system. With
that knowledge what level of intensity physical activity is
appropriate to prescribe to this patient?

a.I would not prescribe any physical activity until the

patient underwent exercise stress testing.
b.I would prescribe low, moderate, or vigorous intensity
physical activity to the patient since he does not have
any signs or symptoms of cardiac disease.
c.I would ask the patient what level of intensity he felt
he could handle while performing physical activity.
d.I would prescribe low or moderate intensity physical
activity given that he is sedentary and in the moderate
risk category.
e.I would not indicate an intensity level for the physical
activity I prescribe because I do not have enough
information.

 Correct Choices:
d.I would prescribe low or moderate intensity physical activity given
that he is sedentary and in the moderate risk category.The answer is
correct.
For patients in the moderate risk category, the ACSM recommends
prescribing low or moderate intensity exercise without the need for
an exercise test (1). However, an exercise test is recommended for
the moderate risk patient before he or she participates in a vigorous
intensity level exercise program. Given the fact that this patient is
currently not participating in any exercise program, starting at a low
intensity level will help him to feel some success early on in his
training. Small successes with exercise lead to improved confidence
and when patients feel good about exercising they are more likely to
continue. A general recommendation when initiating an exercise
program for a sedentary patient is to "start low and go slow."

 Incorrect Choices:
a.I would not prescribe any physical activity until the patient
underwent exercise stress testing.The authors disagree.

If this patient fell into the high risk category, the ACSM would
recommend an exercise test prior to prescribing any exercise
program (low, moderate or vigorous intensity) (1). If a patient
falls in the moderate risk category, medical examination and
exercise testing are only recommended prior to starting a
vigorous intensity physical activity program (1). For the moderate
risk category patients, they can initiate a low or moderate level
physical activity program without undergoing an exercise stress
test (1). Selecting either low or moderate intensity will depend on
the patients current fitness level, current exercise program, and
prior experience with physical activity.

 b.I would prescribe low, moderate, or vigorous intensity physical

activity to the patient since he does not have any signs or symptoms
of cardiac disease.The authors disagree.
The American College of Sports Medicine recommends that a patient
in the moderate risk category undergoes exercise testing prior to
engaging in vigorous intensity physical activity (1). Studies have
shown that one of the greatest risks for an acute cardiac event is in
the sedentary patient who suddenly participates in vigorous intensity
physical activity (2). As this patient is sedentary, starting him at a
vigorous intensity level could be dangerous. Additionally, you want to
introduce physical activity to the patient in a way that will promote
self confidence and mastery, not in a way that will create
disappointment and defeat. By starting at a low intensity, you are
more likely to help him to avoid injuries and to experience small
successes which will keep him feeling good and exercising.

 c.I would ask the patient what level of intensity he felt he could
handle while performing physical activity.The authors disagree.
Although it is a good idea to consult your patient about his exercise
regimen, (especially what type of exercise he wants to do), allowing
him to dictate the intensity is not recommended. The main reason for
this is that the patient might feel invigorated and motivated to start
exercising at a vigorous intensity. If the patient is starting from a
sedentary baseline, then vigorous intensity exercise poses the threat
of an acute cardiac event. Studies have shown that the greatest risk
for a cardiac event is in the sedentary patient who suddenly
participates in vigorous intensity physical activity (2). For a patient in
the moderate risk category, low to moderate level intensity exercise
can be prescribed without an exercise test (1). When deciding which
intensity to select between low and moderate, you will need to factor
in current fitness level and previous experience with physical activity.

 e.I would not indicate an intensity level for the physical activity I
prescribe because I do not have enough information.The authors disagree.
According to the ACSM, taking a careful history with a review of systems
focusing specifically on cardiovascular, pulmonary, and systems focusing
specifically on cardiovascular, pulmonary, and metabolic diseases in
addition to performing a careful physical exam looking for signs of these
diseases will provide enough information for a physician to place the
patient in an exercise risk category. Given that risk category, the ACSM
has made recommendations for the intensity level of prescribed physical
activity for the patient. There is enough information here to prescribe an
intensity level. A low or moderate intensity level is usually a safe place to
start for those patients in the moderate to low risk category. However, if
you have all this information but you are still not comfortable prescribing
exercise, then you should not. You could consider consulting an exercise
specialist, a cardiologist, a pulmonologist, or an endocrinologist depending
on the problem that is causing you to feel uncomfortable.

ACSM guidelines
There are general guidelines for exercise prescription provided by the American
College of Sports Medicine (1). As with many areas of medicine, exercise prescription
is not black and white. Each patient needs to be evaluated individually and treated
specifically. The ACSM recommendations are meant to help guide physicians in
prescribing exercise. However, each physician needs to use his or her own judgment
when utilizing those guidelines.
The ACSM guidelines for medical clearance prior to exercise are as follows:
1) Patients in the low risk category do not need further medical clearance or an
exercise test before participating in a low, moderate, or vigorous intensity exercise
regimen.
2) Patients in the moderate risk category do not need further medical clearance or an
exercise test before participating in low or moderate intensity exercise, but they do
need it for vigorous intensity exercise.
3) Patients in the high risk category do need further medical clearance and most
likely an exercise test before participating in any exercise program.

Question 3
Now, that you know the patient is in the moderate risk
category for exercise and that he can safely initiate a low to
moderate intensity exercise program, what would be the most
useful initial recommendations to make regarding exercise?
a.Recommend that he start jogging three days a week for
thirty minutes at a moderate intensity level. b.Recommend
that he walk the golf course twice a week when he plays golf
instead of riding in the golf cart. c.He told you that he had a
stressful year at work, and he is not obese, so there is no need
to mention exercise at this visit.d.Tell the patient about your
exercise program and share with him how much it has helped
you.

 Correct Choices:
b.Recommend that he walk the golf course twice a week
when he plays golf instead of riding in the golf cart. The
answer is correct.
Since this patient stated that he played golf twice a week,
we recommend working with this interest. The patient also
admitted to using a golf cart. With this information, there is
a simple modification that could create significant
opportunities for cardiovascular exercise. Prescribing
walking the golf course, instead of using the cart every
time he plays golf, is a great place to start. The key is to
work with the patients interest and make small
modifications.

 Incorrect Choices:
a.Recommend that he start jogging three days a week for
thirty minutes at a moderate intensity level. The authors
disagree.
Although this may be a useful recommendation for some
individuals, it is an unrealistic initial goal for this patient,
who currently rides a golf cart when engaging in his only
form of exercise. This answer recommends too much, too
fast. Small steps with an exercise program lead to success
from improved confidence from achieving the initial goal
and beneficial effects of the limited exercise program. The
important point here is to start slowly to increase the
chance of success and to decrease the risk of injury.

 c.He told you that he had a stressful year at

work, and he is not obese, so there is no need
to mention exercise at this visit.The authors
disagree.
Exercise should be discussed at every visit. In
fact, for this patient, exercise will help him
manage and reduce his stress. Regular exercise
such as walking has been shown to reduce
depression and anxiety in patients with chronic
disease as well as in healthy individuals.

 d.Tell the patient about your exercise program and share with him how much it has helped
you.The authors disagree.
Although this is not an inappropriate answer, it is not the best answer to this question. Patients are
positively affected by images of their physician exercising. If you have pictures of yourself finishing
a running race or playing tennis or if you have certificates from athletic activities displaying these
in your office can be a less intrusive way of sharing your exercise. After viewing these items in the
office, the patient may bring it upon herself to ask you about these items, which can serve as the
introduction to a discussion of an exercise prescription for that patient.
Personalizing the exercise recommendation does seem to help. There is a study that evaluated the
impact of a general/generic video demonstrating the benefits of exercise compared to listening to
the personal account of the physicians exercise experience and adding the physicians experience
was more powerful (3).
However, you need to address the patients situation and make specific recommendations to him.
If you feel comfortable, you could discuss your exercise regimen and the benefits of it in addition
to making specific recommendations to the patient. To do this, you would need to have your own
exercise regimen which is highly recommended for your own health as a physician.
It has been demonstrated that physicians who exercise themselves are more likely to counsel their
patients on exercise (4).

Physical activity is a vital sign

Physical activity should be another vital sign. Just as blood
pressure, heart rate, and weight are checked at every
visit, physical activity level should be discussed during
every visit as well. Checking in with patients about their
physical activity level will help reinforce its importance.
To impress upon the patient the importance of exercise,
you tell him about the most current exercise
recommendations from the US Department of Health and
Human Services which were released in October, 2008.
You mention that this is the minimal activity goal for all
adults.

Question 4

What are the most current physical activity

recommendations issued by the US Department
of Health and Human Services in October, 2008?
a.Exercise for 20 minutes at a moderate intensity
two days a week.b.Accumulate a total of 60
minutes of exercise during the
week.c.Accumulate a total of 150 minutes of
moderate intensity physical activity over the
course of one week.d.Exercise for as long as you
can for as many days of the week as possible.

 Correct Choices:
c.Accumulate a total of 150 minutes of moderate intensity physical activity over
the course of one week.The answer is correct.

In October 2008, the US Department of Health and Human Services released

physical activity guidelines for adults (5). After two years of reviewing the 6,800
journal articles on exercise, the committee came up with the following
recommendations for American Adults:
150 minutes of moderate intensity physical activity per week
OR
75 minutes of vigorous physical activity per week (in bouts of at least 10
minutes)
For more extensive health benefits:
300 minutes per week of moderate intensity physical activity
OR
150 minutes per week vigorous physical activity
http://www.health.gov/PAguidelines (accessed November 2008)

 Incorrect Choices:
a.Exercise for 20 minutes at a moderate intensity two days a
week.The authors disagree.
If your patient is pressed for time and she is physically fit, she may
exercise at a vigorous intensity for 20 minutes three days per
week, but this does not meet the minimum recommendations for
weekly physical activity.
b.Accumulate a total of 60 minutes of exercise during the week.The
authors disagree.
Although this may be an interim step and is better than no exercise,
it is not the actual recommendation. Studies have demonstrated that
150 minutes of moderate intensity physical activity or 75 minutes of
vigorous intensity physical activity accumulated over the week is
associated with general health benefits.

 d.Exercise for as long as you can for as many days of the week as
possible.The authors disagree.
Although this is not bad advice, it is too vague. Recommending
exercise is most effective if it is specific and attainable. The
Department of Health and Human Services, the American College of
Sports Medicine, and the American Heart Association have developed
specific recommendations involving frequency, duration, and
intensity of physical activity in order to help give people a guideline
and a goal for which to strive when initiating physical activity.
There are updated recommendations for physical activity from the US
Department of Health and Human Services (5). These
recommendations build on the earlier ones from the Surgeon
General, the American Heart Association and the American College of
Sports Medicine.

Surgeons call to action

In the 1996 Surgeon General's Report on
Physical Activity and Health, he
recommended:
"All people over the age of 2 years should
accumulate at least 30 minutes of endurancetype physical activity, of at least moderate
intensity, on most--preferabley all-- days of the
week." (6) Click here to access the full report (
http://www.cdc.gov/nccdphp/sgr/prerep.htm).

The ACSM/AHA recommendations from 2007 are more specific:

"Primary Recommendation To promote and maintain health, all healthy
adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical
activity for a minimum of 30 min on five days each week or vigorous-intensity
aerobic physical activity for a minimum of 20 min on three days each week. [I
(A)] Combinations of moderate- and vigorous-intensity activity can be performed
to meet this recommendation. [IIa (B)] For example, a person can meet the
recommendation by walking briskly for 30 min twice during the week and then
jogging for 20 min on two other days. Moderate-intensity aerobic activity, which
is generally equivalent to a brisk walk and noticeably accelerates the heart rate,
can be accumulated toward the 30-min minimum by performing bouts each
lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by
jogging, and causes rapid breathing and a substantial increase in heart rate. In
addition, every adult should perform activities that maintain or increase
muscular strength and endurance a minimum of two days each week. [IIa (A)]
Because of the dose-response relation between physical activity and health,
persons who wish to further improve their personal fitness, reduce their risk for
chronic diseases and disabilities or prevent unhealthy weight gain may benefit
by exceeding the minimum recommended amounts of physical activity." (7)

The US Department of Health and Human Services

Physical Activity Guidelines for Americans 2008 (5).
150 minutes of moderate intensity physical activity per week
OR
75 minutes of vigorous physical activity(in bouts of at least 10 minutes)
For more extensive health benefits:
300 minutes of moderate intensity physical activity
OR
150 min vigorous physical activity per week
There are also specific recommendations for elderly, children, pregnant women, people
with chronic medical conditions, and adults with disabilities. Click here to see the full
report (http://www.health.gov/paguidelines/).
These new guidelines allow for more flexibility in the scheduling of physical activity. For
example, a busy physically fit, healthy physician might be able to meet these
recommendations by exercising at a vigorous intensity for forty minutes twice a week or
a less fit busy physician could meet these recommendations by exercising at a moderate
intensity for forty five minutes twice a week plus an hour once a week. These
recommendations also make it clear that more extensive health benefits can be obtained
with more exercise with 300 minutes of moderate intensity exercise being the goal.

Definitions of exercise terms

The correct answer to question number 2 used the term physical activity.
Physical Activity refers to any bodily movement performed by the skeletal
muscles that results in energy expenditure (8). Exercise is a subset of physical
activity that refers to structured repetitive bodily movement performed with
the intention of increasing ones level of physical fitness (8,9).

Before reviewing the process of writing an exercise prescription, it is important

to understand different definitions of basic exercise terms:

Table 01 Sources: American Family Physician-Volume 71, Issue 3

(August 2006). Exercise and the Older Patients: Prescribing Guidelines
page 2. American College of Sports Medicine. Guidelines for exercise
testing and prescription. 5th edition. Philadelphia: Lea and Febiger;

Exercise Prescription
Exercise prescriptions are guidelines for patients to use in order to initiate,
maintain or increase their overall physical activity. For some patients the physical
activity might be jogging for a half an hour each session while for others it might
be gardening for fifteen minutes each session. The exercise prescription might
involve life style exercise such a using the stairs to get to a third floor office. The
main point is that an exercise prescription does not have to be for jogging,
attending an exercise class or using the stationary bicycle which are aerobic
exercises that many people associate with structured exercise. The goal of
increasing physical activity, no matter what type of activity, is to increase
physical fitness and accrue general health benefits.

Actually writing the recommendations down on a prescription pad serves many

purposes. First, it gives the prescription more significance and emphasizes the
fact that "exercise is medicine." It gives the patient a piece of paper to take
home which will remind him or her of the recommendation. If there is confusion
or a question regarding the recommendation, the patient can consult his or her
prescription and will not have to rely on his or her memory. The prescription can
be posted on the refrigerator or another place that is easily seen and frequently
used.

FITT

1. Frequency
The ultimate goal for general health
benefits is to engage in physical
activity 5-7 days of the week or
most, if not all, days of the week.
However, if a patient has never
exercised before, it is reasonable to
start with 2 days a week and move
up from there.

2. Intensity
The patient can determine the intensity of the
exercise he is performing by measuring and
by self-monitoring his own level of perceived
exertion.
For a healthy individual on no medications,
maximum heart rate can be calculated by the
simple equation 220-age=maximal heart rate.
Click here to see the American Heart
Association's table of maximum heart rates.
You can use the maximum heart rate to
determine a target heart rate.

The target heart rate will vary depending

on the desired level of intensity.

 It is important that the physician reviews how to calculate heart rate and where to find a pulse.
Since the radial pulse is superficial at the wrist and often easily detected, it is a good one for many
patients to use. The carotid pulse is also a reasonable option. Make sure to emphasize that the
patient should not occlude both carotid arteries at one time. A picture of the carotid pulse or radial
pulse measurement could be given to the patient.
The heart rate method of gauging intensity of exercise is not recommended for older patients and
those taking medications such as beta-blockers, which affect heart rate. The Borg Scale is most
often used in cardiac rehabilitation facilities and hospital based programs. This scale ranges from
6-20 with 6 indicating "no exertion at all and 20 indicating "maximal exertion." Moderate intensity
is somewhere in the 12-14 range with 13 meaning "Somewhat hard. It still feels OK to continue."
Click to access the full Borg scale.
Most people use an internal monitoring system to evaluate their level of exertion. They factor in
the amount they are sweating, their respiratory rate, their heart rate, and their muscle fatigue. A
simple suggestion to help patients reach a moderate intensity of exercise is to recommend that
the patients exercise so that they can talk but not sing. If patients can sing while they are
exercising, then they have reached a low level of intensity.
When prescribing intensity, consider the patients current level of physical activity and current
level of fitness.

3. Time
The initial goal for general health benefits is to accumulate 150
minutes of moderate intensity exercise per week. This could be
30 minutes for 5 days a week, 60 minutes for two days and 30
minutes on a third day, or any variation that accommodates the
patients work and life schedule. It is recommended that each
exercise sessions be at least 10 minutes in duration.
Accumulating minutes during different exercise or physical
activity sessions in the course of one day is acceptable
especially when first starting an exercise program. The initial
exercise prescription for a sedentary patient might recommend
accumulating 10 minutes of physical activity in one day. As the
patient experiences success with this goal, he could do a
morning 10 minute session and add an afternoon 10 minute
session. This will vary based on the patient's fitness level, time
availability, and motivation.

 The type of exercise needs to be patientspecific. Writing a prescription tailored to the

individuals interests and experience.
Compliance with the exercise prescription is
more likely if the type of exercise is one that
the patient enjoys and one that he or she can
successfully accomplish. Ask the patients
questions about his or her past involvement
with exercise and sports (in childhood, college
and after college). Ask, "What is your favorite
type of exercise?" Use that as a starting point.

There are many different types of exercises

from which to choose. For example:

There are many different lifestyle

exercises from which to choose.

Written Example

Question 5
Regular exercise has multiple benefits.
Which of the following statements best describes the benefits of exercise?

a. There is scientific evidence that suggests an inverse dose

response
relationship between physical activity and colon
cancer.
b. Regular exercise can increase the number of capillaries in
your muscle.
c. Regular exercise can increase your insulin sensitivity.
d. All of the above

 Correct Choices:
d.All of the aboveThis answer is
correct.
Exercise has all of these benefits and
more.

 Incorrect Choices:
a.There is scientific evidence that suggests an inverse dose response
relationship between physical activity and colon cancer.The authors disagree.
This is a true statement, but it is not the best answer.
There is evidence in the medical literature that suggests that higher physical
activity levels are associated with lower incidence rates of colon cancer. It is
Category C evidence meaning that it is from outcomes of uncontrolled or nonrandomized trials or observational studies (10).
b.Regular exercise can increase the number of capillaries in your muscle.The
authors disagree. This is a true statement, but it is not the best answer.
After engaging in a routine exercise program, the number of capillaries in
muscle may increase, depending on the intensity and frequency of the
program. With more capillaries, the muscle can more easily extract oxygen
from the blood supply. The extra capillaries allow greater uptake of free fatty
acids from the blood supply which in turn creates increased fat oxidation (11).

 c.Regular exercise can increase your insulin

sensitivity.The authors disagree. This is a true
statement, but it is not the best answer.
While exercising, the body uses glucose for energy.
Over time, after regular exercise, the body can
become more sensitive to insulin. However,
exercise can also cause diabetics to have an
extremely low glucose. Thus, in the case of
diabetics one needs to take special precautions
and make specific recommendations about the
timing of insulin treatment in relation to exercise.

Benefits of Exercise
Health care providers have a unique opportunity to tailor the message about the benefits of
exercise to patients based on their medical and family histories.
This patient has pre-hypertension, a family history of heart disease, a family history of diabetes, is
over-weight, and has a stressful job. All of these problems are helped by exercise. He also
complains of intermittent back pain, which could be directly related to his weight and will be
helped by regular cardiovascular exercise, stretching, and back strengthening.
You discuss the patients risk factors for cardiovascular disease pointing out his BMI of 28, which
means he is overweight; his blood pressure of 135/87, which is considered pre-hypertension; and
his family history of coronary artery disease with his mother suffering a Myocardial Infarction (MI)
at 62 years of age. According to the ACSM and the American Heart Association, his sedentary
behavior is considered a modifiable risk factor for coronary vascular disease. Counseling your
patient on exercise will provide specific actions that can improve these conditions.
Following these same risk factors over time can be instructive to the patient and physician. It can
also help patients adhere to the exercise prescription. For example, track the patients weight and
abdominal girth each visit. Make a chart of his blood pressure and heart rate. After a few months
re-check his cholesterol and show him the results. Objective feedback can be a powerful motivator.
You then mention the benefits of exercise to the patient, highlighting those that directly affect the
patient (11).

Health Benefits of regular physical activity are well documented

(1,5,8,10-13, x1). They can be organized in terms of systems.

Organ System Benefits of Exercise

The Case Continues

Guidelines for exercise testing and prescription,
they wrote and if large numbers (of sedentary
individuals) adopt a more active way of life, the
public health will be enhanced (14).
In 1992, the AHA recognized a sedentary lifestyle as
a primary controllable risk factor for cardiac disease.
In fact, the risks of a sedentary lifestyle are many,
including reduced functional capacity, osteoporosis,
obesity, anxiety, depression, hypertension, type 2
diabetes, cardiovascular disease, thromboembolic
stroke, colon cancer, and breast cancer (10).

The patient takes his prescription for

exercise, which reads:

Question 6
The patient has his written exercise prescription in his
hand. He has left the office.

Which of the options below would most effectively help

the patient adhere to this new exercise prescription?
a.A telephone call from your office staff asking about
how the exercise plan is going
b.An E-mail contact from a nurse in your office
inquiring about compliance with exercise prescription
c.A postcard asking about the exercise program
d.All of the above

 Correct Choices:
d.All of the aboveThe answer is correct.
Any follow up with regards to the exercise prescription is
beneficial to the patient. What you want to avoid is giving the
prescription and then saying, "OK. Good luck with that. Ill see
you at your next annual visit in one year." The patients need to
feel accountable for the exercise prescription and following up
is important. The follow up can take a variety of forms: email,
phone call, post card, or letter. You, a nurse or an office staff
can do the follow up. The main point is to remind the patient of
the exercise prescription and make it clear to him that it is
important enough that someone from the office called about it.
Holding the patient accountable for the exercise prescription is
almost as important as writing it.

 Incorrect Choices:
a.A telephone call from your office staff asking about how the exercise plan is
goingThis is only partially correct.

This is an excellent recommendation to help improve a patients chance of

adherence to an exercise regimen. A phone call to follow up on an exercise
prescription 2-4 weeks after the appointment may increase patient compliance.
b.An E-mail contact from a nurse in your office inquiring about compliance
with exercise prescriptionThis is only partially correct.
This is an excellent recommendation to help improve a patients chance of
adherence to an exercise regimen. While sending an e-mail might seem like
nagging, this simple act may improve patient compliance. The patient is
reminded of the exercise prescription and is aware that someone else
remembers it as well. The patient whom received an e-mail or a phone call
asking about the exercise prescription, may then assume that the physician
who wrote the prescription or someone in the physicians office will be
inquiring about exercise at the next visit.

 c.A postcard asking about the

exercise programThis is only partially
correct.
This is an excellent recommendation
to help improve a patients chance of
adherence to an exercise regimen.
Sending a postcard is a gentle
reminder that is not intrusive, yet it
may be effective in encouraging

Question 7
A month later the patient calls in response to your e-mail and reports
that he is enjoying walking the golf course and no longer drives a golf
cart. He says he is feeling great and would like to ramp up his exercise
regimen, but he is not sure how. What is the best advice to give the
patient at this point?
a."Keep with the same program because you are doing fine. Keep up
the good work.
b."You have been doing a great job with walking. Lets try jogging.
Start jogging three times a week for thirty minutes each session.
c."You have made great progress with your physical activity level.
Keep up the good work. In addition to the walking twice a week, add
two more days of low intensity physical activity for thirty minutes
each session. What other type of activity would you like to do?
d."Since you have been doing so well, you are ready to handle your
exercise regimen yourself. Congratulations."

 Correct Choices:
c."You have made great progress with your physical activity level. Keep
up the good work. In addition to the walking twice a week, add two more
days of low intensity physical activity for thirty minutes each session.
What other type of activity would you like to do?"The answer is correct.
According to the US Department of Health and Human Services 2008
physical activity guidelines, this patient needs to increase the frequency of
his exercise sessions and accumlate more minutes of exercise each week.
It is best to find out what type of exercise the patient enjoys. If walking the
golf course has been enjoyable, perhaps walking around the neighborhood
with his significant other for 30 minutes would also be exercise he would
also enjoy and perform regularly. If these suggestions are not acceptable,
then suggest other types of exercise such as swimming or riding a
stationary bicycle. There are known benefits of cross-training and this
might be a reasonable time to discuss them with the patient. Cross
training allows the person exercising to use and strengthen other muscles.

 Incorrect Choices:
a."Keep with the same program because you are doing fine. Keep up the good
work."The authors disagree.
It is human nature to want to raise the goal once one has been met. Success is
motivating. This patients self-efficacy for making changes has gone up because he
reached his small, attainable goal. It is best to honor that improvement and raise the
goal by changing his exercise prescription. Of note, he is still below the US
Department of Health and Human Services 2008 minimum recommendations. Thus,
there is room to improve encouragement such as "Keep up the good work" is helpful
in any situation where the praise is warranted.
b."You have been doing a great job with walking. Lets try jogging. Start jogging
three times a week for thirty minutes each session."The authors disagree.
This is too much, too fast. It is important to talk to the patient and get his input as to
which exercises he finds enjoyable. The patient is most likely to be compliant if he
has had a role in creating the prescription and if it is something acceptable to him. He
feels successful after reaching his initial goal. The physician needs to consider the
next goal carefully and try to make it attainable to continue the cycle of success.

 d."Since you have been doing so well, you are ready to handle your
exercise regimen yourself. Congratulations." The authors disagree.
It is good for patients to be a part of the exercise prescription, and
ultimately they are responsible for their own behavior. However, initiating
an exercise program is a difficult task, especially for the sedentary patient.
In fact, the sedentary patient needs guidance and continued support from
the physician. The physician needs to play a major role. This type of
behavior change requires team work. It would be good for the patient to
suggest the type of exercise that he wants to do. The patient might want to
increase his frequency from 2 days a week to 7 days a week, and this is
where the physician needs to help guide the patient. A sudden large
increase in frequency, such as from twice a week to seven times a week, is
hard to attain and could be a set up for injury or failure. In this case, the
physician might suggest that the patient add two more exercise sessions to
his exercise regimen and then reassess again in several weeks. There is a
greater chance of success if the physician and the patient work side by side
while trying to make physical activity a regular routine.

Proposed schedule
It is important to work closely with the patient who is initiating
an exercise program. How the program progresses depends on
the patient. When making recommendations to increase the
level of physical activity make sure that the patient is ready for
the next step and can succeed in meeting the new goal.
Changing behavior takes time, it is important to make physical
activity an enjoyable and rewarding experience in order to
increase the chances that the patient will continue the program.
The general recommendations for progression of an exercise
regimen are to first increase the frequency, then the duration
and finally the intensity. Here is a proposed schedule for
gradually ramping up the aerobic exercise program of a
sedentary, healthy individual:

Table 02
Stein, Joel, M.D., Julie Silver, M.D., and Elizabeth Pegg Frates, M.D.
Foreword by Robert J. Wityk, M.D.. Life After Stroke: The Guide to
Recovering Your Health and Preventing Another Stroke . pp. 269. Table 167. 2006 The Johns Hopkins University Press. Reprinted with permission
of The Johns Hopkins University Press.

History of Present Illness

Three months after the initial visit, the patient
returns for a follow up visit.
The patient reports that he feels more energetic.
He says he feels "younger." He has been doing
more walking throughout the day and taking the
stairs at work instead of the elevator. He went out
and bought new pants because some of his old
ones were too big now and did not fit right
anymore. Work is still stressful, but he feels he is
handling the stress better now.

Physical Exam
Heart Rate: 70 beats per minute
Blood Pressure: 130/80 mm Hg
RR: 12
Weight: 191 pounds
BMI: 27.4
Abdominal Girth: 37 inches

Labs
Cholesterol: 175

LDL: 120
HDL: 55
Triglycerides: 150
Glucose: 95
He feels so good, and he wants to tell his wife to follow the same
regimen. She is overweight and sedentary. The patient says that
he is worried about his wife because she also has high blood
pressure. The patient is convinced that his wife should exercise.

Question 8
He asks you if she should just use his original exercise
prescription and start from there. The most appropriate
response to this question is:
a.Almost everyone can start with that same prescription, and
she can too.
b.You recommend that she walk for an hour two days a week
at a moderate intensity such that she can talk but not sing.
c.Getting her on an exercise program will in fact help your
patient adhere to his exercise program. Thus, you write out a
prescription for her, recommending that she join her husband
walking 45 minutes twice a week.
d.You recommend that she make an appointment with her
own physician to discuss her own personal exercise
prescription.

 Correct Choices:
d.You recommend that she make an appointment with her
own physician to discuss her own personal exercise
prescription.The answer is correct.
The wife should make an appointment to see her own
primary care physician. The husband states that she has
high blood pressure, but we do not know how high. She
needs to have her blood pressure checked before starting
any exercise regimen. If she has cardiac conditions, she
may require the input of a cardiologist. It is important that
the physician, who is writing the exercise prescription for a
patient, knows the patients full medical history and is
currently taking care of that patient.

 Incorrect Choices:
a.Almost everyone can start with that same prescription, and
she can too.The authors disagree.
An exercise prescription is not one size fits all. In this case, you
do not have enough information to write an exercise
prescription. The wifes own physician who knows her medical
history should be the one to write out an exercise prescription
for her. Her physician will go through the same process that
you did for your patient: risk stratification, determine
appropriate intensity, discuss different types of exercise that
might be motivating for the patient and realistic, and work with
the patients schedule. His wife may have an absolute
contraindication to exercise. Without knowing her medical
history, you can not write an appropriate exercise prescription.

 b.You recommend that she walk for an hour two days a week at a moderate
intensity such that she can talk but not sing.The authors disagree.
Physical activity recommendations need to be individualized. His wifes exercise
prescription needs to take into consideration her current activity level and her
interests. Perhaps she is bored by walking or perhaps she has severe osteoarthritis of
the knee that is exacerbated by walking. Maybe she prefers swimming.
c.Getting her on an exercise program will in fact help your patient adhere to his
exercise program. Thus, you write out a prescription for her, recommending that she
join her husband walking 45 minutes twice a week. The authors disagree.
A patients spouse is an important factor in exercise compliance. Your life partner can
directly affect how much you exercise. Encouraging his wife to make an appointment
with her own physician is the best intervention that you could make at this time for
the wife and for your patient. If the wife starts exercising, there is a better chance
that your patient will continue exercising. Since the wife is not one of your patients
and you do not know her medical history, her current blood pressure, her interests, or
her current activity level, you should not write an exercise prescription for her.

The Case Continues

You inform the patient that his wifes physician is
the one that should be responsible for making
exercise recommendations and writing out an
exercise prescription. You emphasize that his
wife needs a full medical history and exam prior
to receiving an exercise prescription. If a patient
is not well enough to perform an exercise test,
he or she is not well enough to participate in a
structured exercise program. There are absolute
contraindications to exercise testing which we
can generalize to contraindications to exercising.

Question 9
Which of the conditions listed below
are absolute contraindications for
exercise testing?
a.History of congestive heart failure
b.Mild tri-compartmental arthritis of
the knee
c.Chronic low back pain
d.Acute systemic infection with
associated fever, swollen lymph
glands and body aches

 Correct Choices:
d.Acute systemic infection with
associated fever, swollen lymph glands
and body achesThe answer is correct.
Acute infection is an absolute
contraindication to exercise testing. It is
important to diagnose and treat an acute
infection prior to exercise testing and
starting or resuming an exercise program.

 Incorrect Choices:
a.History of congestive heart failureThe authors disagree.
There are a number of cardiac contraindications to exercise stress testing that
can be applied to general exercise. Uncontrolled symptomatic heart failure is
an absolute contraindication to exercise stress testing but a history of
congestive heart failure that is now compensated and not symptomatic is not
an absolute contraindication. With cardiac patients, it makes sense to have a
cardiologist evaluate them for exercise prior to prescribing a specific regimen.
b.Mild tri-compartmental arthritis of the kneeThe authors disagree.
Chronic musculoskeletal disorders that are exacerbated by exercise are a
relative contraindication to exercise testing. In mild tri-compartmental arthritis
of the knee, quadriceps strengthening helps relieve the pain from arthritis.
Mild tri-compartmental arthritis of the knee could be considered a relative
contraindication to exercise but only if the exercise exacerbates the arthritis.
c.Chronic low back pain. The authors disagree.
Chronic low back pain patients can benefit from 1) aerobic exercise, 2)
stretching exercises, and 3) back, abdominal, and hip strengthening
exercises(15).

Guidelines for stress testing

The American College of Cardiology and the
American Heart Association have developed
guidelines for exercise stress testing and they cite
several contraindications
to exercise testing in their 2002 ACC/ AHA
Guideline Update for Exercise Testing
(16). Click here to access the original article. The
ACSM has also documented contraindications
based on this article (1). If patients are
experiencing any of the below signs
or symptoms, they should not exercise (1,16).

Absolute Contraindications

Relative Contraindications

Summary
1) Exercise prescriptions are guidelines for patients to use in order to
initiate, maintain or increase their overall physical activity.
2) An exercise prescription has four main parts:
Frequency
Intensity
Time
Type
The mnemonic FITT is used.
3) US Department of Health and Human Services physical activity
guidelines are:
150 minutes of moderate intensity physical activity per week
OR
75 minutes of vigorous physical activity(in bouts of at least 10 minutes)
For more extensive health benefits:
300 minutes of moderate intensity physical activity
OR
150 min vigorous physical activity per week

 4) Exercise has multiple benefits on many different systems including cardiovascular,

body composition, metabolism, psychological well being, muscle strength and
functional capacity.
5) There are some patients for whom exercise is contra-indicated. Patients should not
exercise if they are suffering from the following:
Acute symptomatic congestive heart failure
Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands
Acute myocarditis or pericarditis
Recent myocardial infarction (within two days)
Recent significant change in the resting ECG that suggests ischemia or other acute
cardiac event.
Acute pulmonary embolus or pulmonary infarction
Severe symptomatic aortic stenosis
Suspected or known dissecting aneurysm
Uncontrolled cardiac dysrhythmia that compromises cardiac function
Unstable angina
6) You can help your patients increase their physical activity by writing out a specific
exercise prescription and following up with them via phone call, email or post card
from your office to check in on the new program.

References
1. American College of Sports Medicine. ACSMs guidelines for exercise testing and prescription. 7th Edition. Philadelphia: Lippincott,
Williams and Wilkins; 2006.
2. AHA Scientific Statement. Exercise and Acute Cardiovascular Events. Circulation 2007; 115: 2358-2368.
3. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med
2000;9:287-90.
4. Abramson S, Stein J, Schaufele M, Frates E, Rogan S.
Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin J Sport Med 2000;10:40-8.
5. US Health and Human Services 2008 Physical Activity Guidelines for Americans. Be Active Healthy and Happy.
www.health.gov/paguidelines (accessed November 5, 2008)
6. Physical Activity and Health: A Report from the Surgeon General. http://www.cdc.gov/nccdphp/sgr/pdf/prerep.pdf (accessed December
31, 2008)
7. Haskell WL, Lee I-M, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A.
Physical activity and public health. Updated recommendation for adults from the American College of Sports Medicine and the American Hear
t Association.
Circulation 2007;116:1081-93.
8. American College of Sports Medicine. The ACSMs resource manual for guidelines for exercise testing and prescription. 5th ed.
Philadelphia: Lippincott Williams and Wilkins; 2006.
9. McDermott AY, Mernitz H. Exercise and the Older Patients: Prescribing Guidelines. American Family Physician; 2006:71: Issue 3.
10. Kesaniemi YK, Danforth E Jr, Jensen MD, et al.
Dose response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exerc 2001; 33:S351-8.
11. American College of Sports Medicine, ACSMs Advanced Exercise and Physiology. Lippincott, Williams and Wilkins; 2006.
12. Cress ME, Buchner DM, Prohaska T, Rimmer J, Brown M, Macera C, DePietro L, Chodzko-Zajko W.
Physical activity programs and behavior counseling in older adult populations. Med Sci Sports Exerc 2004;36:1997-2003.
13. American College of Sports Medicine. ACSMs Health Related Physical Fitness Assessment Manual, Second Edition. Philadelphia:
Lippincott Williams and Wilkins; 2008.

2013 references
x1. Alberti KGMM, Eckel RH, Grundy SM, et al.
Harmonizing the Metabolic Syndrome, A Joint In
terim Statement of the International Diabetes
Federation Task Force on Epidemiology and Prev
ention; National Heart, Lung, and Blood Instit
ute; American Heart Association; World Heart F
ederation; International Atherosclerosis Socie
ty; and International Association for the Stud
.y Circulation.
of Obesity 2009;120:1640-1645
x2. Angevaren M, Aufdemkampe G, Verhaar
HJ, Aleman A, Vanhees L.
Physical activity and enhanced fitness to impr