Q: For an exercise prescription to be effective, advancement or progression is recommended. What factors should be considered when addressing progression of an exercise program?
A: Progression is an important part of an effective exercise program. To highlight the various aspects to consider when developing an exercise training plan, the American College of Sports Medicine (ACSM) uses the FITT-VP principle of exercise prescription (1,2). The FITT-VP principle includes the following: Frequency (how often is exercise done each week), Intensity (how hard is the exercise), Time (how long is the exercise duration), Type (what is the mode of exercise), Volume (what is the total amount of exercise), and Progression (how is the program advanced).
FITT-VP is applied to each component of a complete exercise program, including aerobic, resistance, flexibility, and neuromotor exercise training. Within this frame of reference, an exercise prescription should be individualized with consideration for health status (including clinical conditions), physical ability, age, training responses, and individual goals (1). For example, a training program for a 25-year-old competitive marathoner obviously will differ from a 65-year-old patient participating in a cardiac rehabilitation program. Even in an apparent homogeneous group, progression should be individualized to match personal goals as well as differing responses to the exercise stimulus. Thus, ACSM recommendations are presented in a way that supports customization to match the individual participant with ranges and options for frequency, intensity, time, and type of activity. See Box 1 for a brief summary of recommendations for adults (for more complete information on the FITT-VP for each exercise component, see the ACSM Position Stand at http://journals.lww.com/acsm-msse/Abstract/2011/07000/Quantity_and_Quality_of_Exercise_for_Developing.26.aspx (2)).
BOX 1. Exercise recommendations for adults
Recommendations for the components of a complete exercise program include the following (note – deconditioned or sedentary individuals may benefit from activity levels below those listed; additional recommendations are available for youth as well as older adults (1)):
- AEROBIC EXECISE: At least 5 days/week of moderate intensity activity or at least 3 days/week of vigorous activity, or a combination of moderate and vigorous on at least 3 to 5 days/week; 30 to 60 minutes/day for moderate activity and 20 to 60 minutes/day for vigorous activity; includes exercises using major muscle groups in a continuous, rhythmic manner.
- RESISTANCE EXERCISE: Train each major muscle group 2 to 3 days per week; for strength development 60% to 70% of one repetition max (1-RM) for novice to intermediate exercisers and higher levels (80% or greater) for more experienced strength exercisers, for muscular endurance development 50% 1-RM or lower; includes exercises for each major muscle group.
- FLEXIBILITY EXERCISE: At least 2 to 3 days/week (daily is most effective); stretch to point of feeling tightness or slight discomfort; includes exercises (static, dynamic, ballistic, or proprioception neuromuscular facilitation) for each of the major muscle-tendon units.
- NEUROMOTOR EXERCISE: At least 2 to 3 days/week; consider at least 20 to 30 minutes; activities depend on the individual with recommendations for fall reduction including exercises involving balance, agility, coordination, gait, proprioception, and other multifaceted activities such as Tai Chi and yoga.
RECOMMENDATIONS FOR PROGRESSION
Progression takes into account the exercise volume (which reflects FITT factors) over time. General progression recommendations by ACSM for each of these areas are described in Box 2 (1). Given the current lack of research on optimal progression for flexibility and neuromotor exercise training, the focus of this article is on aerobic and resistance exercise for general health and fitness.
Box 2. Exercise prescription progression
ACSM’s Guidelines for Exercise Testing and Prescription, 10th edition, includes information on the principle of progression as follows:
- AEROBIC EXERCISE: Program advancement can occur by adjusting frequency, intensity, and/or time, thus progressing the overall exercise volume. Care should be taken to enhance adherence also while reducing risks of injury or cardiac events; the recommendation of “start low and go slow” reflects this objective.
- RESISTANCE EXERCISE: Program advancement can occur by adjusting resistance, repetitions, and/or frequency.
- FLEXIBLITY EXERCISE: Methods to achieve optimal progression are not known.
- NEUROMOTOR EXERCISE: Methods to achieve optimal progression are not known.
The ACSM Position Stand “Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise” includes evidence-based recommendations related to exercise prescription (for information on the evidence categories, see Box 3) (2). When applying these criteria, the ACSM Position Stand suggests evidence at a level B for this recommendation on aerobic exercise 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.” With regard to the impact of implementing this type of progression for aerobic exercise, evidence at a level D is noted for adherence and risk reduction: “This approach may enhance adherence and reduce risk of musculoskeletal injury and adverse CHD [coronary heart disease] events.” For resistance training exercise, evidence is at a level A for the following recommendation: “A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.”
Box 3. Evidence categories
Evidence is presented in categories based on the amount and type of research on which recommendations will be based:
- “A” – this level of evidence includes many studies including many participants; the study endpoints provide a pattern of findings that is consistent. The sources of the evidence are randomized control studies (i.e., assignment to treatment vs. nontreatment or control group is done by chance rather than by researcher or participant selection).
- “B” – this includes a fewer number of studies, smaller participant number, or where results are from a study focusing on a different population. These sources of evidence are randomized control studies, but the number is limited.
- “C” – this includes evidence based on nonrandomized studies (i.e., participants were not assigned to groups by chance) or observational studies (i.e., examining status rather than providing an intervention or treatment).
- “D” – this includes evidence from an expert panel; this is used when there is insufficient evidence for assignment of one of the other levels of evidence (A, B, or C).
Reviewing these recommendations, along with level of evidence, is helpful in visualizing a framework within which progression can be developed. Although resistance training recommendations are based on the highest level of evidence, the recommendation itself reflects the opportunity to individualize a resistance training program by means of increasing resistance, repetition number, and/or training frequency. Opportunity to create a personalized aerobic conditioning program also is provided through manipulation of duration, frequency, and/or intensity. ACSM Guidelines points out “Progression may consist of increasing any of the components of the FITT principle…as tolerated by the individual.” If a person is not tolerating the progression, disproportionate fatigue or soreness may be evidenced, suggesting a need to decrease the exercise volume. When an exercise training program volume is excessive, overtraining can result (for insights on overtraining, see “Finding the Balance Between Overload and Recovery” in the January/February 2016 issue of ACSM’s Health & Fitness Journal®) (4).
Many variables can be manipulated within an exercise program. The role of the exercise professional is to develop individualized plans, with the aforementioned considerations in mind. Tables 1 and 2 contain sample programs that reflect progression over a number of months (5). No rigid timeframe is given, but rather an individual can advance based on personal comfort and response to the training stimulus (5). Within the aerobic sample program (Table 1), the intensity during the initial weeks is light to moderate and the progression is focused on increasing duration. The intensity is then increased later in the program. In a similar fashion, the sample resistance training progression begins with a limited number of exercises and sets, with potential consideration of 10 to 15 repetitions for those starting exercise. Within the initial phase of a resistance training program, a major goal is learning correct form and technique (5). With time in the program, individuals will increase the total number of exercises as well as sets, with the option of advancing from whole body training sessions where all major muscular groups are training in one session to split body sessions where specific muscle groups are trained on separate days (2). Typically, 8 to 12 repetitions are recommended to improve strength and power in most adults (1).
BENEFITS OF PROGRESSION
Although exercise promotes health on many fronts (e.g., decreasing risk of chronic disease such as coronary heart disease), issues related to musculoskeletal injury can derail exercise plans. Injury seems to be related more closely to the type of exercise and intensity rather than to the volume (2). For example, walking, or other moderate-intensity exercise, has a low risk of injury compared to running or higher intensity competitive sports (2). In addition, new exercise demands may result in soreness and injury (2). This underscores the need to carefully advance an exercise program, especially for beginners, to avoid these concerns and dropout.
To realize health and fitness benefits, adherence to exercise and advancement (or potentially maintenance) is desired. The statement “some is good, more is better” has been used to simplify the dose-response connection between activity and health (2). Researchers continue to examine this relationship because factors such as initial activity levels and what health outcomes are of interest potentially impact that relationship (2). Finding the optimal level of training results in improvements in fitness while avoiding discouragement or overtraining.
Progression for aerobic exercise includes adjustments to frequency, intensity, and time (duration) of activity and for resistance exercise includes greater resistance, repetitions per set, or frequency. Advancement or progression should be gradual to allow for adaptations to the increased training volume, with the potential to lower the risk of injury and to promote adherence to the exercise program. The rate and manner in which a program is advanced should be individualized based on personal characteristics (e.g., health status, age, physical ability), responses to training, and personal goals.
1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription
, 10th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2017, 472 p.
2. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine Position Stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc
3. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Obesity in Adults (US). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report
. Available at: National Heart, Lung, and Blood Institute Web site [Internet]. Rockville (MD): National Institutes of Health, National Heart, Lung, and Blood Institute; [cited 2017 November 13]. Available from: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf
4. Bushman BA. Finding the balance between overload and recovery. ACSMs Health Fit J
5. American College of Sports Medicine. ACSM’s Complete Guide to Fitness & Health
, 2nd ed. Champaign (IL): Human Kinetics; 2017. 436 p.