Author(s): Colleen Jacobs, DO, Molly Litten Smith, MD, Ryan Floresca, MD, Donald Kasitinon, MD, Kim Barker, MD
Originally published: October 22, 2013 Last updated: November 20, 2025
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Overview and Description

Exercise is one of the most underutilized treatment options in modern American healthcare which places an emphasis on medications and procedures. The benefits of exercise have been researched and documented by many groups and agencies over the past three decades. The American College of Sports Medicine (ACSM),1 U.S. Centers for Disease Control and Prevention,2 the U.S. Surgeon General, and the National Institutes of Health have issued landmark publications on physical activity and health.1,2 An exercise program that includes aerobic, resistance, flexibility, and neuromotor training is indispensable to improve and maintain physical fitness and health.

Exercise has been shown to

  • Benefit cardiovascular and respiratory function
  • Reduce cardiovascular and respiratory disease progression
  • Decrease morbidity and mortality
  • Decrease anxiety and depression2
  • Reduce pain2
  • Improve cognitive function
  • Enhance physical function and independent living in older individuals
  • Enhance feelings of well-being
  • Reduce neuropathic symptoms for various peripheral neuropathies
  • Reduce risk of falls in older individuals
  • Prevent or mitigate functional limitations in older adults
  • Enhance performance of work, recreational, and sport activities2

Exercise and physical activity are often overlooked as therapeutic treatment options. Additionally, prescribing exercise may be challenging as many patients are looking for an “easy fix.” A high-quality therapeutic exercise prescription should be Individualized and multi-faceted

  • Mindful of patient safety
  • Integrated with behavioral support

When appropriately utilized, exercise can be an effective long-term treatment for many conditions. The therapeutic effects of exercise may arise through both direct and indirect mechanisms. For example, direct benefits include the correction of muscle imbalances, while indirect benefits include the promotion of weight loss with subsequent cardiovascular improvements and the reduction of osteoarthritic pain.

The U.S. Department of Health and Human Services published Physical Activity Guidelines in 1996 and more recently in 2018.

Adult recommendations

  • At least 150 minutes a week of moderate-intensity aerobic activity, or
  • 75 minutes a week of vigorous-intensity aerobic activity, or
  • An equivalent combination of the two ACSM definitions on intensity levels:
  • Moderate intensity: 3 to 5.9 metabolic equivalents (METs), 45-63% VO2 max, or 64-91% of maximum heart rate
  • Vigorous intensity as greater than 6.0 METs, 64-91% VO2 max, or 77-93% of maximum heart rate (please also refer to Table 1).2 

Children and adolescent recommendations

  • Encouraged to perform 60 minutes or more of physical activity daily, including aerobic, muscle-strengthening and bone-strengthening activities.2

While these recommendations provide a general target for much of the population, many people need additional directions. Considerations for creating an exercise program for patients can include

  • Individual goals and interests
  • Age
  • Ability level
  • Pain (which can serve as a barrier and may lead to non-compliance)5
  • Comorbidities; especially relating to cardiovascular, pulmonary, and metabolic health5

The evidence in favor of regular physical activity outweighs any inherent risk for adverse events.6 Patients should be counseled on appropriate advancement or potential reduction of their exercise program. The person performing the exercise should be focused on maintaining proper form and what that feels like physically. Insistence on perfecting technique will allow the person to challenge him or herself while increasing strength and endurance gains, with less risk of pain or injury. Lastly, a home exercise program should prepare the patient for his or her normal activities, fitness needs/goals, occupation, sport, or recreational activities. Many well-intended practitioners prescribe exercises that are appropriate and fit the suggestions above, but do not assist the patient in returning to their desired job or activity. Other exercises can potentially put the area to be treated under too much strain, such as using resistance bands or weights to “strengthen” a still painful rotator cuff injury.

Exercise Prescription Framework

  • FITT or FITT-VP (recommended by ACSM)
    • Frequency
    • Intensity
    • Time
    • Type
    • Volume
    • Progression

Utilizing these methodologies parallels writing a traditional medication prescription. Each component of the prescription provides a patient with specific information to incorporate aerobic, resistance, flexibility, and neuromotor exercise training into a fitness program.2

Greenman’s idea of exercise discusses restoring length, strength and control of muscle function as the process of treating muscular imbalances. A successful exercise program restores nervous system control of muscle function as much as possible. To achieve this, he prescribes the following sequence

  • Sensory motor balance training
  • Stretching of short, tight, hypertonic muscle to symmetry
  • Strengthening of inhibited weak muscles
  • Restoration of symmetrical movement patterns
  • Aerobic conditioning5

Yet another method of exercise prescription, outlined by McGill, takes on a five-stage progression of training:

  • Stage 1 involves detection and remedy of incorrect motor patterns
  • Stage 2 establishes stability of joints throughout the whole body via exercise and education, with a focus on spine stability
  • Stage 3 develops endurance and applying prior skills to daily activities
  • Stages 4 and 5 are for athletes and includes training strength, speed, power, and agility

Additional consideration towards stages or progressions of the exercise can be made from the foundation laid by the initial prescribed regimen.  Progression of exercise allows the body to adapt to the stresses of it, from a musculoskeletal level. When exercise is progressed too quickly, patients are at an increased risk of injury. A patient must also understand how to recognize the difference between signs of exercise stress, such as increased heart rate and muscle soreness, and symptoms of overexertion or injury.5 If a patient cannot perform the exercise due to pain, muscle tension or fatigue, various tools should be made available to the patient, such as medications – or other modalities such as massage therapy, TENS, manual therapy, etc. to facilitate the exercises.4  Informing the patient that these symptoms generally improve after the first few days of starting or increasing a program can be helpful.  Regular reassessment and adaptation of the exercise prescription may be needed depending on both patient response and tolerance.

Table 1 Exercise Intensity

Adapted from ACSM 2018 guidelines2

 METs%HRmax%VO2max
Low1.6-2.950-63<45
Moderate3.0-5.964-7645-63
Vigorous≥6.077-9364-91

Relevance to Clinical Practice

Despite recommendations and guidelines, many people possess a variety of reasons why they do not exercise. Patients will note lack of time, lack of motivation, finances, and poor ability to maintain adherence. Therefore, it is crucial to take these aspects into account when formulating an exercise prescription in order to increase compliance.2 There are tools available to measure a person’s readiness to increase their exercise. The Physical Activity Readiness Questionnaire (PAR-Q) is a self-guided, seven question tool that can be used as a screening instrument. Using models like the Transtheoretical Stages of Change to identify the patient’s stage (e.g., precontemplation, contemplation) and applying motivational interviewing messages accordingly can help with exploring barriers and discussing benefits for those not yet ready to act.5 Finding activities that the person will enjoy also helps improve compliance with exercise.5 In the table below, potential barriers to patient participation in exercise are outlined with the corresponding potential solutions to these barriers.

Potential barriers to exercise participationPotential solutions to barriers
Time (particularly prevalent among working adults, individuals with chronic conditions, and those with family or caregiving responsibilities)High-intensity interval training (HIIT), which is episodic, short bursts of high intensity exercise (lowest VO2 max should be 65% and the highest should be maximal possible effort) have protocols as short as 10–30 minutes per session. Doing this 2–3 times per week has demonstrated significant health benefits despite the shorter durations in active exercise.2

Home-based exercise programs that can be performed at home or at the office during a lunch break are especially useful to avoid additional travel time limiting adherence.
Pain (either pre-morbid or new onset due to premature exercise progression)Addressing medical conditions or accommodating them by finding an alternative exercise can significantly improve their level of exercise adherence. For instance, a person with knee osteoarthritis who experiences limitations with running or walking may do well with swimming or water aerobics in which the buoyancy of the water decreases load on the joints.

Using multimodal pain control with shared decision making can help with premorbid chronic pain control that might affect a patient’s confidence in the ability to perform exercise without pain. Providing stretching techniques and alternative options such as acupuncture and massage can be helpful as well.
DeconditioningThe ACSM uses walking at 3-4 mph as an example of moderate-intensity exercise.4 However, for people who are physically deconditioned, morbidly obese, or with various other physical impairments, walking at 3-4 mph may actually be considered vigorous exercise. These individuals can be taught to use tools such as heart rate or perceived exertion indices (e.g., Borg Perceived Exertion Scale) to monitor their activity. They can also be taught how to slowly increase the activity, starting with duration, frequency, or intensity. They should be taught not to increase all three at once. A personal trainer or physical therapist who can provide additional instruction through close and frequent communication can help ensure compliance and safety.
MotivationStart by assessing readiness for change. Use models like the Transtheoretical Stages of Change to identify the patient’s stage (e.g., precontemplation, contemplation) and match counseling messages accordingly, such as exploring barriers and discussing benefits for those not yet ready to act.

Encourage patients to set achievable goals, self-monitor their activity, and receive feedback on progress to foster self-regulation and motivation.

Facilitate a strong therapeutic alliance to boost motivation and accountability.

Help patients fit activity into their routines and consider wearable devices or apps for feedback and motivation. Finding activities that the person will enjoy doing also helps improve compliance.5 For example, a person who enjoys socializing with others has more success when enrolled in group classes or participating in team sports rather than working out alone.
FinancesHaving a gym membership, owning home exercise equipment, or access to transportation can certainly be barriers to many patients. Providing a list of free online videos, body weight exercises, outdoor walking program, or referring patients to free or low-cost exercise programs, public spaces, and nonprofit organizations (e.g., YMCA) can help overcome financial barriers with assistance from social work and case management if needed.

Cutting Edge/Unique Concepts/Emerging Issues

While the majority of the recommendations for exercise are targeted at the generally healthy adult or youth population, evidence suggests that specified exercise therapy prescriptions are beneficial for patient populations with certain co-morbidities. Guidelines and recommendations are available for chronic diseases such as diabetes, obesity, arthritis, peripheral arterial disease, COPD, coronary artery disease, multiple sclerosis, and cancer. Some of these diseases along with other specific conditions will be discussed below.

Cardiovascular diseases

The benefits of physical activity on cardiorespiratory health are extensively well-documented.2 Heart disease risk can be dramatically decreased with exercise.

Regular aerobic exercise

  • Decreases arterial stiffness
  • Reduces blood pressure
  • Increases HDL
  • Decreases LDL
  • Decreases resting heart rate.

Exercise is known to decrease all-cause mortality in those with coronary artery disease.2 But what is often overlooked are the benefits of the addition of resistance training to aerobic exercise. Resistance training and increasing skeletal muscle mass have similar effects as aerobic exercise and can complement the effects to further reverse disease and improve cardiovascular health.6 Historically, several studies identified concerns that resistance training alone may increase arterial stiffness, however, recent studies have shown a combination of aerobic exercise and resistance training can reduce arterial stiffness in adults with hypertension.6

Stroke

The American Heart Association and American Stroke Association both provide comprehensive guidelines for stroke survivors while newer studies provide more focused recommendations related to cardiac rehab and more.

AHA/ASA guidelines7

  • Across all stages of recovery, recommend
    • Low to moderate-intensity aerobic activity
    • Muscle strengthening activity
    • Reduction of sedentary behavior

Cardiac Rehabilitation Principles8

  • Cardiac rehabilitation and aerobic exercise
    • Improve cardiovascular performance
    • Improve functional outcomes
    • Reduce readmissions
  • HIIT within cardiac rehabilitation framework can enhance walking capacity compared to moderate exercise

Multiple sclerosis and neuromuscular diseases

For people with multiple sclerosis (MS) and neuromuscular diseases (NMD), different forms of exercise can be a vital treatment modality to alleviate symptoms associated with these conditions.

  • For people with MS, aerobic and resistance exercises both improve fatigue and improve quality of life9
  • Additionally in people with MS, walking endurance improved with9
    • Aerobic exercise
    • Resistance exercise
    • High intensity training
    • Pilates
  • For NMD patients, light to moderate intensity aerobic exercise10
    • Improves mobility
    • Improves self-care
    • Improves social participation
    • Can slow disease progression

Cancer

The ACSM published guidelines for physical activity in cancer survivors updated in 2019 with general recommendations. They instruct to avoid inactivity, and to continue exercise as soon and as often as possible. Generally they recommend aerobic and/or resistance training 2-3x per week for 30-60 minutes with strong evidence this improves11

  • Cancer related fatigue
  • Health quality of life
  • Physical function
  • Anxiety/depression

Additionally, more recent research has provided details into the benefits of exercise for specific types of cancer listed below.

Cancer Type/ConditionBenefits of Exercise
Breast Cancer Colorectal CancerReduces risk of recurrence and mortality11
Improves the following:12 Fatigue, Sleep quality, Psychological well being, Physical function, Quality of life
Lung CancerImproves cognitive function, Improves quality of life, Enhances physical function, Reduces dyspnea12
General Cancer PopulationReduces adverse events, Modulates body composition and biomarkers (IGF-1, CRP), Enhances overall quality of life12

Pregnancy

The traditional advice to rest during pregnancy has changed, with current advice recommending a more active pregnancy.13 Regular exercise during pregnancy promotes overall wellness and may reduce hypertensive disorders of pregnancy and gestational diabetes.14 The American College of Obstetricians and Gynecologists recommends an exercise program of moderate-intensity exercise for at least 20-30 minutes per day on most or all days of the week for women with medical obstetric complications being monitored closely by their obstetrician.14

Dementia/cognitive impairment

In recent years, there has been excitement about exercise’s effect on cognition and potentially decreasing a person’s risk of dementia. One study out of Catalonia showed that participants who completed physical activity greater than or equal to 150 minutes of moderate to vigorous exercise per week had lower beta-amyloid accumulation and greater cortical thickness in areas of the brain associated with memory.15 Additionally, there continues to be new research analyzing the impact in people who have been diagnosed with dementia/cognitive impairment. A 2025 meta-analysis of older adults with cognitive impairment revealed multi component exercise including aerobic, resistance, and balance training over 3-6 months performed at least 3 times per week resulted in significantly improved memory and executive function. With long-term exercise, there can be improvement in executive functioning including the ability to plan and organize, attention, processing, and emotional control.16

COVID-19

Long COVID syndrome (LCS) has become readily apparent in patients previously infected with COVID. LCS is defined as symptoms lasting more than 12 weeks post COVID infection with the most common symptoms being breathlessness and fatigue. There is still no clear guideline for exercise rehabilitation in patients with LCS but more research has been conducted since it’s initial discovery showing exercise benefits in people suffering from LCS. More recent research found that tailored physical activity programs can significantly reduce dyspnea, anxiety while improving muscle strength, quality of life, and perceived fatigue in individuals with LCS.17

App-based exercise

The widespread availability of smartphones and tablets has increased the potential applicability of app-based exercise programs. The use of digital health applications has become more popular in recent years due to their widespread availability, convenience, and ability to reach people in any location. One of the challenges regarding the use of these applications remains sustaining long-term adherence and engagement of patients. A 2025 systematic review of mobile fitness applications found that the factors that lead to sustained engagement included personalization, social support, usability, and feedback mechanisms. More large-scale randomized-controlled trials are needed to fully determine the most feasible and effective method of utilizing app-based programs.18

Other

Use of performance enhancing substances has become quite controversial. This is sometimes referred to as “doping.” Doping refers to the use of prohibited performance-enhancing drugs, hormones and growth factors, or methods (e.g., gene doping, blood doping, etc.) specifically used to enhance athletic performance beyond normal physiologic levels and not for the purposes of treating a legitimate medical condition.20 Our role as physicians should be to direct our patients away from these substances and provide education on the harmful effects that can arise from their use.

Low-intensity resistance training combined with blood flow restriction (BFR) is gaining favor as an alternative means to increase muscular strength and hypertrophy. External pressure is applied to the area of interest and maintains arterial inflow while occluding venous outflow to the area. A recent meta-analysis of 20 studies shows that BFR in combination with resistance training achieves similar muscle strength and thickness when compared to high intensity resistance training.19 BFR resistance exercise may be performed 2 to 3 times weekly for the same muscles utilizing 50-80% of arterial occlusion pressure, but higher frequencies may be implemented depending on individual training status and goals. Along with closely monitoring “time under occlusion,” it is also important to release pressure between sets to allow for adequate reperfusion. Potential safety issues of BFR include muscle necrosis and thrombus formation. Participants must be monitored closely by a qualified provider.19

Gaps in Knowledge/Evidence Base

Most exercise research has focused on outcomes for healthy adults, leaving significant gaps in the optimal exercise regimens for patients with chronic diseases, physical disabilities, or older adults. While current guidelines are available for the volume, intensity, and frequency of exercise for healthy individuals, additional research is needed to determine what guidelines would be beneficial for other specific populations. Further investigation into these disease processes will better emphasize the preventative and curative effects of exercise. Additionally, longitudinal studies to investigate how exercise impacts a person over a lifetime will also be helpful in further defining its role in maintaining overall health. Other directions include research and guidelines for those with physical disabilities, both congenital and acquired. The focus on acquired disability and aging will become more important in our nation as the American population becomes older and faces new health challenges. Additionally, accessibility to exercise at home with a personal trainer will continue to expand with growing comfort in telehealth and virtual communication platforms. Research is lacking on the effectiveness and accessibility of home-based and telehealth exercise interventions. As research and literature become more robust over time, it will likely become even more evident that therapeutic exercise, when used in conjunction with medications and procedures, will lead to improved outcomes in our patients.

References

  1. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402-407.
  2. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020-20
  3. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal Science and Medicine in Sport. 2011; 14(1):4-9.
  4. McGill SM. Low Back Disorders, Evidence-Based Prevention and Rehabilitation. 2nd ed., Champaign, IL: Human Kinetics; 2007:168.
  5. Buchner D. “Physical Activity.” IN: Goldman L, Schafer A Goldman’s Cecil Medicine. 24th ed. Vol 2. Saunders. 2016. 56-58.
  6. Paluch AE, Boyer WR, Franklin BA, et al. Resistance Exercise Training in Individuals With and Without Cardiovascular Disease: 2023 Update: A Scientific Statement From the American Heart Association. Circulation. 2024;149(3):e217-e231. doi:10.1161/CIR.0000000000001189
  7. Billinger S, Arena R, Bernhardt J, et al. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; A Journal of Cerebral Circulation. 2014;45(8):2532-2553.
  8. Cuccurullo SJ, Fleming TK, Petrosyan H, Hanley DF, Raghavan P. Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health. Front Cardiovasc Med. 2024 May 2;11:1376616. doi: 10.3389/fcvm.2024.1376616. PMID: 38756753; PMCID: PMC11096558
  9. Li D, He X, et al. Effects of exercise in people with MS: systematic review/meta-analysis of RCTs. Front Public Health. 2024;12:1387658
  10. Silva SF, de Magalhães HL, de Deus FA, et al. Rehabilitation interventions targeting the activity and participation of patients with neuromuscular diseases: what do we know? A systematic review. Arq Neuropsiquiatr. 2024;82(2):s00441779295. doi:10.1055/s-0044-1779295.
  11. Eickmeyer s, et al. The role and efficacy of exercise in persons with cancer. PMR. 2012;4(11):874-81.
  12. Zhu, Ma, H., He, A., Li, Y., He, C., & Xia, Y. Exercise in cancer prevention and anticancer therapy: Efficacy, molecular mechanisms and clinical information. Cancer Letters. 2022; 544. https://doi.org/10.1016/j.canlet.2022.215814.
  13. Barakat R and Perales M. Resistance Exercise in Pregnancy and Outcome. Clinical Obstetrics and Gynecology. 2016;59(3):591-599.
  14. Gregg VH and Ferguson JE. Exercise in Pregnancy. Clin Sports Med. 2017;36(4):741-752.
  15. Muniesa-I-Torregrosa G, Arenaza-Urquijo EM, Sala-Llonch R, et al. Physical activity and Alzheimer’s disease biomarkers in middle-aged adults: a 4-year longitudinal cohort study. Alzheimers Dement. 2025;21(3):612-624. doi:10.1002/alz.14567
  16. Wang Y, Li X, Chen H, et al. Effects of multi-component exercise on cognitive function in older adults with cognitive impairment: a systematic review and meta-analysis. Front Aging Neurosci. 2025;17:1551877. doi:10.3389/fnagi.2025.1551877
  17. Sirotiak T, Shelley BM, Wurz H, et al. Associations between physical activity and long COVID symptom burden: a systematic review. Front Psychol. 2024;15:1498900. doi:10.3389/fpsyg.2024.1498900
  18. Berglind D, Yacaman-Mendez D, Lavebratt C, Forsell Y. The Effect of Smartphone Apps Versus Supervised Exercise on Physical Activity, Cardiorespiratory Fitness, and Body Composition Among Individuals With Mild-to-Moderate Mobility Disability: Randomized Controlled Trial. JMIR Mhealth Uhealth. 2020;8(2):e14615. Published 2020 Feb 4. doi:10.2196/14615.
  19. Ma F, He J, Wang Y. Blood flow restriction combined with resistance training on muscle strength and thickness improvement in young adults: a systematic review, meta-analysis, and meta-regression. Front Physiol. 2024;15:1379605. doi:10.3389/fphys.2024.1379605.
  20. Finoff JT, Chimes GP, Murray TH. Performance enhancing drugs: point/counterpoint. PM&R. 2010;2(4):285-293.

Original Version of the Topic

Adam P. Cugalj, DO. Exercise prescription and basic principles of therapeutic exercise. 10/22/2013.

Previous Revision(s) of the Topic

Kim Barker, MD. Austin Johnson, DO. Exercise prescription and basic principles of therapeutic exercise. 3/23/2017

Kim Barker, MD. Donald Kasitinon, MD. Exercise prescription and basic principles of therapeutic exercise. 10/5/2019

Alison Ho, DO, Kim Dan Do Barker, MD and Donald Kasitinon, MD. Exercise Prescription and Basic Principles of Therapeutic Exercise. 11/30/2022

Author Disclosure

Colleen Jacobs, DO
Nothing to Disclose

Molly Litten Smith, MD
Nothing to Disclose

Ryan Floresca, MD
Nothing to Disclose

Donald Kasitinon, MD
Nothing to Disclose

Kim Barker, MD
Nothing to Disclose