Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults

Guidance for Prescribing Exercise

Carol Ewing Garber, Ph.D., FACSM, (Chair); Bryan Blissmer, Ph.D.; Michael R. Deschenes, Ph.D., FACSM; Barry A. Franklin, Ph.D., FACSM; Michael J. Lamonte, Ph.D., FACSM; I-Min Lee, M.D., Sc.D., FACSM; David C. Nieman, Ph.D., FACSM; David P. Swain, Ph.D., FACSM.

Disclosures

Med Sci Sports Exerc. 2011;43(7):1334-1359.

What Are the Benefits of Neuromotor Exercise Training?

Neuromotor exercise training, sometimes called functional fitness training, incorporates motor skills such as balance, coordination, gait, and agility, and proprioceptive training. Multifaceted physical activities such as tai ji (tai chi), qigong, and yoga involve varying combinations of neuromotor exercise, resistance exercise, and flexibility exercise. Neuromotor exercise training is beneficial as part of a comprehensive exercise program for older persons, especially to improve balance, agility, muscle strength, and reduce the risk of falls.^{[38,181,194,224,264,350,369]} Tai ji, the most widely studied neuromotor activity, and exercises incorporating balance and agility can be effective in improving balance, agility, motor control, proprioception, and quality of life.^{[69,74,131,132,181,205,222,223,230,363,375,378]} Agility and balance training may reduce the risk of falling and fear of falling^{[194,226,227]} and probably reduce the number of falls, although more definitive evidence is needed to confirm this finding.^{[153,227,228,230,236,264,404]}

Few studies have evaluated the benefits of neuromotor exercise training in younger adults. The only English-language study of tai ji in middle-aged adults reported improvements in balance.^[363] Limited evidence suggests that exercises involving balance and agility may reduce anterior cruciate injury^[165,350] and reduce recurrent ankle injury in men and women athletes.^[174] Definitive recommendations as to whether neuromotor exercise is beneficial in young and middle-aged adults cannot be made owing to a paucity of data, although there may be benefit, especially if participating in physical activities requiring agility, balance, and other motor skills. More data are needed in all age groups to elucidate the specific health-related changes resulting from such training and to determine the effectiveness of various exercise types and doses (i.e., frequency, duration, and intensity) and training programs.

What Quality and Quantity of Neuromotor Exercise Are Needed?

The frequency and duration of neuromotor exercise training to accrue health and fitness benefits are uncertain because there is variability in the quality of available studies, the types, duration, and frequency of neuromotor exercise used; there is inconsistent length of the training programs, and no standardized outcome measures have been used.^{[138,264,404]} Further confounding the interpretation of the results, many studies have combined resistance, cardiorespiratory, and/or flexibility training with neuromotor exercise.^[138,404] Development of some degree of proficiency in activities, such as balance training and tai ji, may also be important with respect to achieving improvements in physical function and in outcomes such as falls.^[404] Studies that have resulted in improvements have mostly used training frequencies of ≥2–3 d·wk⁻¹ with exercise sessions of ≥20–30 min in duration, for a total of ≥60 min of neuromotor exercise per week; however, more research is needed before any definitive recommendations can be made. There is no available evidence concerning the number of repetitions of exercises needed, the intensity of the exercise, or optimal methods for progression.

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

Table evidence categories: A, randomized controlled trials (rich body of data); B, randomized controlled (limited body of data); C, nonrandomized trials, observational studies; D, panel consensus judgment. From the National Heart Lung and Blood Institute (263).

Table 2. Evidence statements and summary of recommendations for the individualized exercise prescription.
	Evidence-Based Recommendation	Evidence Category
Cardiorespiratory ("aerobic") exercise
Frequency	≥ 5d·wk⁻¹ of moderate exercise, or ≥3 d·wk⁻¹ of vigorous exercise, or a combination of moderate and vigorous exercise on ≥3–5 d·wk⁻¹ is recommended.	A
Intensity	Moderate and/or vigorous intensity is recommended for most adults.	A
	Light- to moderate-intensity exercise may be beneficial in deconditioned persons	B
Time	30–60 min·d⁻¹ (150 min·wk⁻¹) of purposeful moderate exercise, or 20–60 min min·d ⁻¹ (75 min·wk⁻¹ of vigorous exercise, or a combination of moderate and vigorous exercise per day is recommended for most adults.	A
	<20 min·d⁻¹ (<150 min·wk⁻¹) of exercise can be beneficial, especially in previously sedentary persons.	B
Type	Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature is recommended.	A
Volume	A target volume of ≥ 500–1000 MET·min·wk⁻¹ is recommended.	C
	Increasing pedometer step counts by ≥2000 steps per day to reach a daily step count ≥7000 steps per day is beneficial.	B
	Exercising below these volumes may still be beneficial for persons unable or unwilling to reach this amount of exercise	C
Pattern	Exercise may be performed in one (continuous) session per day or in multiple sessions of ≥10 min to accumulate the desired duration and volume of exercise per day.	A
	Exercise bouts of <10 min may yield favorable adaptations in very deconditioned individuals.	B
	Interval training can be effective in adults.	B
Progression	A gradual progression of exercise volume by adjusting exercise duration, frequency, and/or intensity is reasonable until the desired exercise goal (maintenance) is attained.	B
	This approach may enhance adherence and reduce risks of musculoskeletal injury and adverse CHD events.	D
Resistance exercise
Frequency	Each major muscle group should be trained on 2–3 d·⁻¹	A
Intensity	60%–70% of the 1RM (moderate to hard intensity) for novice to intermediate exercisers to improve strength.	A
	≥80% of the 1RM (hard to very hard intensity) for experienced strength trainers to improve strength.	A
	40%–50% of the 1RM (very light to light intensity) for older persons beginning exercise to improve strength	A
	40%–50% of the 1RM (very light to light intensity) may be beneficial for improving strength in sedentary persons beginning a resistance training program	D
	<50% of the 1RM (light to moderate intensity) to improve muscular endurance.	A
	20%–50% of the 1RM in older adults to improve power.	B
Time	No specific duration of training has been identified for effectiveness.
Type	Resistance exercises involving each major muscle group are recommended.	A
	A variety of exercise equipment and/or body weight can be used to perform these exercises	A
Repetitions	8–12 repetitions is recommended to improve strength and power in most adults.	A
	10–15 repetitions is effective in improving strength in middle aged and older persons starting exercise	A
	15–20 repetitions are recommended to improve muscular endurance	A
Sets	Two to four sets are the recommended for most adults to improve strength and power.
	A single set of resistance exercise can be effective especially among older and novice exercisers.	A
	≤2 sets are effective in improving muscular endurance	A
Pattern	Rest intervals of 2–3 min between each set of repetitions are effective.	B
	A rest of ≥48 h between sessions for any single muscle group is recommended	A
Progression	A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.	A
Flexibility exercise
Frequency	≥2–3 d·wk⁻¹ is effective in improving joint range of motion, with the greatest gains occurring with daily exercise.	B
Intensity	Stretch to the point of feeling tightness or slight discomfort.	C
Time	Holding a static stretch for 10–30 s is recommended for most adults.	C
	In older persons, holding a stretch for 30–60 s may confer greater benefit	C
	For PNF stretching, a 3- to 6-s contraction at 20%–75% maximum voluntary contraction followed by a 10- to 30-s assisted stretch is desirable.	B
Type	A series of flexibility exercises for each of the major muscle–tendon units is recommended.	B
	Static flexibility (active or passive), dynamic flexibility, ballistic flexibility, and PNF are each effective	B
Volume	A reasonable target is to perform 60 s of total stretching time for each flexibility exercise.	B
Pattern	Repetition of each flexibility exercise two to four times is recommended-
	Flexibility exercise is most effective when the muscle is warmed through light to moderate aerobic activity or passively through external methods such as moist heat packs or hot baths	A
Progression	Methods for optimal progression are unknown.
Neuromotor exercise training
Frequency	≥2–3 d·wk⁻¹ is recommended.	B
Intensity	An effective intensity of neuromotor exercise has not been determined.
Time	≥20–30 min ·d⁻¹ may be needed.	B
Type	Exercises involving motor skills (e.g., balance, agility, coordination, and gait), proprioceptive exercise training, and multifaceted activities (e.g., tai ji and yoga) are recommended for older persons to improve and maintain physical function and reduce falls in those at risk for falling.	B
	The effectiveness of neuromuscular exercise training in younger and middle-aged persons has not been established, but there is probable benefit.	D
Volume	The optimal volume (e.g., number of repetitions, intensity) is not known.
Pattern	The optimal pattern of performing neuromotor exercise is not known.
Progression	Methods for optimal progression are not known.

Table evidence categories: A, randomized controlled trials (rich body of data); B, randomized controlled trials (limited body of data); C, nonrandomized trials, observational studies; D, panel consensus judgment. From the National Heart Lung and Blood Institute (263).

Table 3. Evidence categories.
Evidence Category	Sources of Evidence	Definition
A	Randomized controlled trials (RCT; rich body of data)	Evidence is from end points of well-designed RCT (or trials that depart only minimally from randomization) that provide a consistent pattern of findings in the population for which the recommendation is made. Category A therefore requires substantial numbers of studies involving substantial numbers of participants.
B	Randomized controlled trials (limited body of data)	Evidence is from end points of intervention studies that include only a limited number of RCT, post hoc or subgroup analysis of RCT, or meta-analysis of RCT. In general, Category B pertains when few randomized trials exist, they are small in size, and the trial results are somewhat inconsistent, or the trials were undertaken in a population that differs from the target population of the recommendation.
C	Nonrandomized trials, observational studies	Evidence is from outcomes of uncontrolled or nonrandomized trials or from observational studies.
D	Panel consensus judgment	Expert judgment is based on the panel's synthesis of evidence from experimental research described in the literature and/or derived from the consensus of panel members based on clinical experience or knowledge that does not meet the above-listed criteria. This category is used only in cases where the provision of some guidance was deemed valuable but an adequately compelling clinical literature addressing the subject of the recommendation was deemed insufficient to justify placement in one of the other categories (A through C).

Evidence categories reprinted with permission from the National Heart Lung and Blood Institute (263).

Table 4. Definition of key terms.
Active commuting	Traveling to or from work or school by a means involving physical activity, such as walking, riding a bicycle (324).
Biomarkers	A specific biochemical indicator of a biological process, event, or condition (i.e., disease, aging, etc.) (251).
Cardiometabolic	Factors associated with increased risk of CVD and metabolic abnormalities including obesity, insulin resistance, glucose intolerance, and type 2 diabetes mellitus.
Physical activity	"Any bodily movement produced by skeletal muscles that results in energy expenditure" (64) above resting (basal) levels (371). Physical activity broadly encompasses exercise, sports, and physical activities done as part of daily living, occupation, leisure, and active transportation.
Exercise	"Physical activity that is planned, structured, and repetitive and [that] has as a final or intermediate objective the improvement or maintenance of physical fitness" (64).
Physical fitness	" The ability to carry out daily tasks with vigor and alertness, without undue fatigue and with ample energy to enjoy [leisure] pursuits and to meet unforeseen emergencies" (64). Physical fitness is operationalized as "[a set of] measurable health and skill-related attributes" that include cardiorespiratory fitness, muscular strength and endurance, body composition and flexibility, balance, agility, reaction time and power (1985).
Physical function	The capacity of an individual to carry out the physical activities of daily living. Physical function reflects motor function and control, physical fitness, and habitual physical activity (54,176) and is an independent predictor of functional independence (130), disability (126), morbidity, and mortality (125).
Energy expenditure	The total amount of energy (gross) expended during exercise, including the resting energy expenditure (resting energy expenditure + exercise energy expenditure). Energy expenditure may be articulated in METs, kilocalories or kilojoules (342).
MET	An index of energy expenditure. " [A MET is] the ratio of the rate of energy expended during an activity to the rate of energy expended at rest… [One] MET is the rate of energy expenditure while sitting at rest…by convention, [1 MET is equal to] an oxygen uptake of 3.5 [mL·kg⁻¹·min⁻¹]" (370).
MET-minutes	An index of energy expenditure that quantifies the total amount of physical activity performed in a standardized manner across individuals and types of activities (370). Calculated as the product of the number of METs associated with one or more physical activities and the number of minutes the activities were performed (i.e., METs × minutes). Usually standardized per week or per day. Example: jogging (at ~7 METs) for 30 min on 3 d·wk⁻¹1: 7 METs × 30 min × three times per week = 630 MET·min·wk⁻¹.
Sedentary behavior	Activity that involves little or no movement or physical activity, having an energy expenditure of about 1–1.5 METs. Examples are sitting, watching television, playing video games, and using a computer (276).

Table 5. Classification of exercise intensity: relative and absolute exercise intensity for cardiorespiratory endurance and resistance exercise.
Intensity	Cardiorespiratory Endurance Exercise											Resistance Exercise
	Relative Intensity				Intensity (%VO_2max) Relative to Maximal Exercise Capacity in METs			Absolute Intensity		Absolute Intensity (MET) by Age		Relative Intensity
	%HRR or %VO₂R	%HR_max	%VO_2max	Perceived Exertion (Rating on 6–20 RPE Scale)	20 METs % VO_2max	10 METs % VO_2max	5 METs %VO_2max	METs	Young (20–39 yr)	Middle-aged (40–64 yr)	Older (≥65 yr)	% 1RM
Very light	<30	<57	<37	<Very light (RPE < 9)	<34	<37	<44	<2	<2.4	<2.0	<1.6	<30
Light	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 somewhat hard (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 very hard (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–maximal to maximal	≥90	≥96	≥91	≥Very hard (RPE ≥ 18)	≥91	≥91	≥92	≥8.8	≥10.2	≥8.5	≥6.8	≥85

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).
HR_max, maximal HR; %HR_max, percent of maximal HR; HRR, HR reserve; VO_2max, maximal oxygen uptake; %VO_2max, percent of maximal oxygen uptake; VO₂R, oxygen uptake reserve; RPE, ratings of perceived exertion (48).

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Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults

Guidance for Prescribing Exercise

What Are the Benefits of Neuromotor Exercise Training?

What Quality and Quantity of Neuromotor Exercise Are Needed?

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