1
INTRODUCTION
e purpose of this chapter is to provide current information on the benefi ts
and risks of physical activity (PA) and/or exercise. For clarifi cation purposes, key
terms used throughout the Guidelines related to PA and fi tness are defi ned in this
chapter. Additional information specifi c to a disease, disability, or health condi-
tion are explained within the context of the chapter in which they are discussed
in the Guidelines . PA continues to take on an increasingly important role in the
prevention and treatment of multiple chronic diseases, health conditions, and
their associated risk factors. erefore, Chapter 1 focuses on the public health per-
spective that forms the basis for the current PA recommendations ( 5 , 26 , 34 , 70 , 93 ).
Chapter 1 concludes with recommendations for reducing the incidence and
severity of exercise-related complications for primary and secondary prevention
programs.
PHYSICAL ACTIVITY AND FITNESS TERMINOLOGY
PA and exercise are o en used interchangeably, but these terms are not synon-
ymous. PA is defi ned as any bodily movement produced by the contraction of
skeletal muscles that results in a substantial increase in caloric requirements over
resting energy expenditure ( 14 , 78 ). Exercise is a type of PA consisting of planned,
structured, and repetitive bodily movement done to improve and/or maintain one
or more components of physical fi tness ( 14 ). Physical fi tness has been defi ned in
several ways, but the generally accepted defi nition is the ability to carry out daily
tasks with vigor and alertness, without undue fatigue, and with ample energy to
enjoy leisure-time pursuits and meet unforeseen emergencies ( 76 ). Physical fi tness
is composed of various elements that can be further grouped into health-related
and skill-related components which are defi ned in Box 1.1 .
In addition to defi ning PA, exercise, and physical fi tness, it is important to
clearly defi ne the wide range of intensities associated with PA (see Table 6.1 ).
Methods for quantifying the relative intensity of PA include specifying a percentage
1
CHAPTER
Benefits and Risks
Associated with
Physical Activity
ACSM-GETP10e_Ch01.indd 1ACSM-GETP10e_Ch01.indd 1 11/16/16 2:39 AM11/16/16 2:39 AM
2
Guidelines for Exercise Testing • www.acsm.org
of oxygen uptake reserve (V
·
O
2
R), heart rate reserve (HRR), oxygen consumption
(V
·
O
2
), heart rate (HR), or metabolic equivalents (METs) (see Box 6.2 ). Each of
these methods for describing the intensity of PA has strengths and limitations.
Although determining the most appropriate method is le to the exercise profes-
sional, Chapter 6 provides the methodology and guidelines for selecting a suitable
method.
METs are a useful, convenient, and standardized way to describe the absolute
intensity of a variety of physical activities. Light intensity PA is defi ned as requir-
ing 2.0–2.9 METs, moderate as 3.0–5.9 METs, and vigorous as ⱖ6.0 METs ( 26 ).
Table 1.1 g i v e s s p e c i fi c examples of activities in METs for each of the intensity
ranges. A complete list of physical activities and their associated estimates of en-
ergy expenditure can be found elsewhere ( 2 ).
Maximal aerobic capacity usually declines with age ( 26 ). For this reason, when
older and younger individuals work at the same MET level, the relative exercise in-
tensity ( e.g. , %V
·
O
2max
) will usually be diff erent (see Chapter 6 ). In other words, the
older individual will be working at a greater relative percentage of maximal oxygen
consumption (V
·
O
2max
) than their younger counterparts. Nonetheless, physically
active older adults may have aerobic capacities comparable to or greater than those
of physically inactive younger adults.
Box 1.1
Health-Related and Skill-Related Components of
Physical Fitness
Health-Related Physical Fitness Components
■
Cardiorespiratory endurance: the ability of the circulatory and respiratory
system to supply oxygen during sustained physical activity
■
Body composition: the relative amounts of muscle, fat, bone, and other vital
parts of the body
■
Muscular strength: the ability of muscle to exert force
■
Muscular endurance: the ability of muscle to continue to perform without
fatigue
■
Flexibility: the range of motion available at a joint
Skill-Related Physical Fitness Components
■
Agility: the ability to change the position of the body in space with speed and
accuracy
■
Coordination: the ability to use the senses, such as sight and hearing, together
with body parts in performing tasks smoothly and accurately
■
Balance: the maintenance of equilibrium while stationary or moving
■
Power: the ability or rate at which one can perform work
■
Reaction time: the time elapsed between stimulation and the beginning of the
reaction to it
■
Speed: the ability to perform a movement within a short period of time
Adapted from ( 96 ). Available from http://www.fitness.gov/digest_mar2000.htm
ACSM-GETP10e_Ch01.indd 2ACSM-GETP10e_Ch01.indd 2 11/3/16 1:38 AM11/3/16 1:38 AM
3
Chapter 1 Benefi ts and Risks Associated with Physical Activity
TABLE 1.1
Very Light/Light
(⬍3.0 METs)
Moderate
(3.0–5.9 METs) Vigorous (ⱖ6.0 METs)
Walking
Walking slowly around home,
store, or offi ce ⫽ 2.0
a
Household and occupation
Standing performing light
work, such as making bed,
washing dishes, ironing,
preparing food, or store
clerk ⫽ 2.0–2.5
Leisure time and sports
Arts and crafts, playing
cards ⫽ 1.5
Billiards ⫽ 2.5
Boating — power ⫽ 2.5
Croquet ⫽ 2.5
Darts ⫽ 2.5
Fishing — sitting ⫽ 2.5
Playing most musical instru-
ments ⫽ 2.0–2.5
Walking
Walking 3.0 mi ⴢ h
⫺1
⫽ 3.0
a
Walking at very brisk pace (4
mi ⴢ h
⫺1
) ⫽ 5.0
a
Household and occupation
Cleaning, heavy — washing
windows, car, clean
garage ⫽ 3.0
Sweeping fl oors or carpet,
vacuuming, mopping ⫽
3.0–3.5
Carpentry — general ⫽ 3.6
Carrying and stacking
wood ⫽ 5.5
Mowing lawn — walk power
mower ⫽ 5.5
Leisure time and sports
Badminton — recreational
⫽ 4.5
Basketball — shooting
around ⫽ 4.5
Dancing — ballroom slow ⫽
3.0; ballroom fast ⫽ 4.5
Fishing from riverbank and
walking ⫽ 4.0
Golf — walking, pulling
clubs ⫽ 4.3
Sailing boat, wind
surfi ng ⫽ 3.0
Table tennis ⫽ 4.0
Tennis doubles ⫽ 5.0
Volleyball — noncompetitive
⫽ 3.0–4.0
Walking, jogging, and running
Walking at very, very brisk
pace (4.5 mi ⴢ h
⫺1
) ⫽ 6.3
a
Walking/hiking at moderate
pace and grade with no or
light pack (⬍10 lb) ⫽ 7.0
Hiking at steep grades and
pack 10–42 lb ⫽ 7.5–9.0
Jogging at 5 mi ⴢ h
⫺1
⫽ 8.0
a
Jogging at 6 mi ⴢ h
⫺1
⫽ 10.0
a
Running at 7 mi ⴢ h
⫺1
⫽ 11.5
a
Household and occupation
Shoveling sand, coal,
etc. ⫽ 7.0
Carrying heavy loads, such
as bricks ⫽ 7.5
Heavy farming, such as
bailing hay ⫽ 8.0
Shoveling, digging
ditches ⫽ 8.5
Leisure time and sports
Bicycling on fl at — light effort
(10–12 mi ⴢ h
⫺1
) ⫽ 6.0
Basketball game ⫽ 8.0
Bicycling on fl at — moderate
effort (12–14 mi ⴢ h
⫺1
) ⫽
8.0; fast (14–16 mi ⴢ h
⫺1
)
⫽ 10.0
Skiing cross-country — slow
(2.5 mi ⴢ h
⫺1
) ⫽ 7.0; fast
(5.0–7.9 mi ⴢ h
⫺1
) ⫽ 9.0
Soccer — casual ⫽ 7.0;
competitive ⫽ 10.0
Swimming leisurely ⫽ 6.0
b
;
swimming — moderate/
hard ⫽ 8.0–11.0
b
Tennis singles ⫽ 8.0
Volleyball — competitive at
gym or beach ⫽ 8.0
Metabolic Equivalents (METs) Values of Common Physical
Activities Classified as Light, Moderate, or Vigorous Intensity
a
On fl at, hard surface.
b
MET values can vary substantially from individual to individual during swimming as a result of differ-
ent strokes and skill levels.
Adapted from ( 2 ).
ACSM-GETP10e_Ch01.indd 3ACSM-GETP10e_Ch01.indd 3 11/3/16 1:38 AM11/3/16 1:38 AM
4
Guidelines for Exercise Testing • www.acsm.org
PUBLIC HEALTH PERSPECTIVE FOR CURRENT
RECOMMENDATIONS
Over 20 yr ago, the American College of Sports Medicine (ACSM) in conjunc-
tion with the Centers for Disease Control and Prevention (CDC) ( 73 ), the U.S.
Surgeon General ( 93 ), and the National Institutes of Health ( 75 ) issued landmark
publications on PA and health. An important goal of these reports was to clarify
for exercise professionals and the public the amount and intensity of PA needed to
improve health, lower susceptibility to disease (morbidity), and decrease premature
mortality ( 73 , 75 , 93 ). In addition, these reports documented the dose-response re-
lationship between PA and health ( i.e. , some activity is better than none, and more
activity, up to a point, is better than less).
In 1995, the CDC and ACSM recommended that “every U.S. adult should
accumulate 30 min or more of moderate PA on most, preferably all, days of the
week” ( 73 ). e intent of this statement was to increase public awareness of the
importance of the health-related benefi ts of moderate intensity PA. As a result of
an increasing awareness of the adverse health eff ects of physical inactivity and
because of some confusion and misinterpretation of the original PA recom-
mendations, the ACSM and American Heart Association (AHA) issued updated
recommendations for PA and health in 2007 ( Box 1.2 ) ( 34 ).
More recently, the federal government convened an expert panel, the 2008
Physical Activity Guidelines Advisory Committee, to review the scientifi c ev-
idence on PA and health published since the 1996 U.S. Surgeon General’s
Report ( 76 ). is committee found compelling evidence regarding the benefi ts of
PA for health as well as the presence of a dose-response relationship for many dis-
eases and health conditions. Two important conclusions from the Physical Activity
Box 1.2
The ACSM-AHA Primary Physical Activity (PA)
Recommendations (
33 )
■
All healthy adults aged 18–65 yr should participate in moderate intensity aer-
obic PA for a minimum of 30 min on 5 d ⴢ wk
⫺1
or vigorous intensity aerobic
activity for a minimum of 20 min on 3 d ⴢ wk
⫺1
.
■
Combinations of moderate and vigorous intensity exercise can be performed to
meet this recommendation.
■
Moderate intensity aerobic activity can be accumulated to total the 30 min
minimum by performing bouts each lasting ⱖ10 min.
■
Every adult should perform activities that maintain or increase muscular
strength and endurance for a minimum of 2 d ⴢ wk
⫺1
.
■
Because of the dose-response relationship between PA and health, individuals
who wish to further improve their fitness, reduce their risk for chronic diseases
and disabilities, and/or prevent unhealthy weight gain may benefit by exceed-
ing the minimum recommended amounts of PA.
ACSM, American College of Sports Medicine; AHA, American Heart Association.
ACSM-GETP10e_Ch01.indd 4ACSM-GETP10e_Ch01.indd 4 11/3/16 1:38 AM11/3/16 1:38 AM
5
Chapter 1 Benefi ts and Risks Associated with Physical Activity
Guidelines Advisory Committee Report that infl uenced the development of the PA
recommendations are the following:
■
Important health benefi ts can be obtained by performing a moderate amount of
PA on most, if not all, days of the week.
■
Additional health benefi ts result from greater amounts of PA. Individuals who
maintain a regular program of PA that is longer in duration, of greater intensity, or
both are likely to derive greater benefi t than those who engage in lesser amounts.
Similar recommendations have been made in the 2008 federal PA guidelines
( http://www.health.gov/PAguidelines ) ( 93 ) based on the 2008 Physical Activity
Guidelines Advisory Committee Report ( 76 ) ( Box 1.3 ) .
Since the release of the U.S. Surgeon General’s Report in 1996 ( 93 ), several reports
have advocated PA levels above the minimum CDC-ACSM PA recommendations
( 22 , 26 , 80 , 92 ). ese guidelines and recommendations primarily refer to the volume
of PA required to prevent weight gain and/or obesity and should not be viewed as
contradictory. In other words, PA that is suffi cient to reduce the risk of developing
chronic diseases and delaying mortality may be insuffi cient to prevent or reverse
weight gain and/or obesity given the typical American lifestyle. PA beyond the min-
imum recommendations combined with proper nutrition is likely needed in many
individuals to manage and/or prevent weight gain and obesity ( 22 , 42 ).
Several large-scale epidemiology studies have been performed that docu-
ment the dose-response relationship between PA and cardiovascular disease
(CVD) and premature mortality ( 52 , 57 , 72 , 79 , 88 , 107 ). Williams ( 104 ) performed
a meta-analysis of 23 sex-specifi c cohorts reporting varying levels of PA or cardio-
respiratory fi tness (CRF) representing 1,325,004 individual-years of follow-up and
showed a dose-response relationship between PA or CRF and the risks of coronary
artery disease (CAD) and CVD ( Figure 1.1 ). It is clear that greater amounts of PA
or increased CRF levels provide additional health benefi ts. Table 1.2 provides the
Box 1.3
The Primary Physical Activity Recommendations
from the 2008 Physical Activity Guidelines Advisory
Committee Report (
93 )
■
All Americans should participate in an amount of energy expenditure equivalent
to 150 min ⴢ wk
⫺1
of moderate intensity aerobic activity, 75 min ⴢ wk
⫺1
of
vigorous intensity aerobic activity, or a combination of both that generates
energy equivalency to either regimen for substantial health benefits.
■
These guidelines further specify a dose-response relationship, indicating addi-
tional health benefits are obtained with 300 min ⴢ wk
⫺1
or more of moderate inten-
sity aerobic activity, 150 min ⴢ wk
⫺1
or more of vigorous intensity aerobic activity,
or an equivalent combination of moderate and vigorous intensity aerobic activity.
■
Adults should do muscle strengthening activities that are moderate or high
intensity and involve all major muscle groups in ⱖ2 d ⴢ wk
⫺1
because these
activities provide additional health benefits.
ACSM-GETP10e_Ch01.indd 5ACSM-GETP10e_Ch01.indd 5 11/3/16 1:38 AM11/3/16 1:38 AM
6
Guidelines for Exercise Testing • www.acsm.org
strength of evidence for the dose-response relationships among PA and numerous
health outcomes.
e ACSM and AHA have also released two publications examining the
relationship between PA and public health in older adults ( 5 , 70 ). In general, these
publications off ered some recommendations that are similar to the updated guide-
lines for adults ( 26,34 ), but the recommended intensity of aerobic activity refl ected
in these guidelines is related to the older adult’s CRF level. In addition, age-specifi c
recommendations are made concerning the importance of fl exibility, neuromotor,
and muscle strengthening activities. e 2008 Physical Activity Guidelines for Amer-
icans made age-specifi c recommendations targeted at adults (18–64 yr) and older
adults (ⱖ65 yr) as well as children and adolescents (6–17 yr) ( http://www.health.gov/
PAguidelines ) ( 93 ) that are similar to recommendations by the ACSM and AHA.
Despite the well-known health benefi ts, physical inactivity is a global pandemic
that has been identifi ed as one of the four leading contributors to premature mortal-
ity ( 30 , 50 ). Globally, 31.1% of adults are physically inactive ( 30 ). In the United States,
51.6% of adults meet aerobic activity guidelines, 29.3% meet muscle strengthening
guidelines, and 20.6% meet both the aerobic and muscle strengthening guidelines ( 15 ).
SEDENTARY BEHAVIOR AND HEALTH
Prolonged periods of sitting or sedentary behavior are associated with deleterious
health consequences (see Chapter 6 ) ( 35 , 36 , 44 , 47 ) independent of PA levels ( 8 , 51 ,
63 , 82 ). is is concerning from a public health perspective because population-based
studies have demonstrated that more than 50% of an average person’s waking day in-
volves activities associated with prolonged sitting such as television viewing and com-
puter use ( 62 ). A recent meta-analysis demonstrated that a er statistical adjustment
Physical
activity
Physical
fitness
Percentage
Relative risk
1
0.8
0.6
0.4
0.2
0 25 50 75 100
Figure 1.1 Estimated dose-response curve for the relative risk of atherosclerotic cardio-
vascular disease by sample percentages of fi tness and physical activity. Studies weighted
by individual-years of experience. Used with permission from ( 104 ).
ACSM-GETP10e_Ch01.indd 6ACSM-GETP10e_Ch01.indd 6 11/3/16 1:38 AM11/3/16 1:38 AM
7
Chapter 1 Benefi ts and Risks Associated with Physical Activity
for PA, sedentary time was independently associated with a greater risk for all-cause
mortality, CVD incidence or mortality, cancer incidence or mortality (breast, colon,
colorectal, endometrial, and epithelial ovarian), and Type 2 diabetes mellitus (T2DM)
in adults ( 8 ). However, sedentary time was associated with a 30% lower relative risk
for all-cause mortality among those with high levels of PA as compared with those
with low levels of PA, suggesting that the adverse outcomes associated with sedentary
time decrease in magnitude among persons who are more physically active ( 8 ).
HEALTH BENEFITS OF REGULAR PHYSICAL ACTIVITY
AND EXERCISE
Evidence to support the inverse relationship between regular PA and/or exercise
and premature mortality, CVD/CAD, hypertension, stroke, osteoporosis, T2DM,
TABLE 1.2
Evidence for Dose-Response Relationship between Physical
Activity and Health Outcome
Variable
Evidence for a Dose-
Response Relationship
Strength of
Evidence
a
All-cause mortality Yes Strong
Cardiorespiratory health Yes Strong
Metabolic health Yes Moderate
Energy balance:
Weight maintenance Insuffi cient data Weak
Weight loss Yes Strong
Weight maintenance following
weight loss
Yes Moderate
Abdominal obesity Yes Moderate
Musculoskeletal health:
Bone Yes Moderate
Joint Yes Strong
Muscular Yes Strong
Functional health Yes Moderate
Colon and breast cancers Yes Moderate
Mental health:
Depression and distress Yes Moderate
Well-being:
Anxiety, cognitive health, and sleep Insuffi cient data Weak
a
Strength of the evidence was classifi ed as follows:
“Strong” — Strong, consistent across studies and populations
“Moderate” — Moderate or reasonable, reasonably consistent
“Weak” — Weak or limited, inconsistent across studies and populations
Adapted from ( 76 ).
ACSM-GETP10e_Ch01.indd 7ACSM-GETP10e_Ch01.indd 7 10/5/17 4:47 AM10/5/17 4:47 AM
8
Guidelines for Exercise Testing • www.acsm.org
metabolic syndrome (Metsyn), obesity, 13 cancers (breast, bladder, rectal, head
and neck, colon, myeloma, myeloid leukemia, endometrial, gastric cardia, kid-
ney, lung, liver, esophageal adenocarcinoma), depression, functional health, falls,
and cognitive function continues to accumulate ( 26 , 67 , 76 ). For many of these
diseases and health conditions, there is also strong evidence of a dose-response
relationship with PA (see Table 1.2 ). is evidence has resulted from clinical
intervention studies as well as large-scale, population-based, observational studies
( 26 , 34 , 37 , 45 , 54 , 69 , 94 , 100 , 103 ).
Several large-scale epidemiology studies have clearly documented a dose-
response relationship between PA and risk of CVD and premature mortality in
men and women and in ethnically diverse participants ( 52 , 57 , 69 , 71 , 76 , 88 , 107 ). It
is also important to note that aerobic capacity ( i.e. , CRF) has an inverse relation-
ship with risk of premature death from all causes and specifi cally from CVD, and
higher levels of CRF are associated with higher levels of habitual PA, which in turn
are associated with many health benefi ts ( 10 , 11 , 26 , 49 , 84 , 99 , 103 ). Box 1.4 s u m m a -
rizes the benefi ts of regular PA and/or exercise.
HEALTH BENEFITS OF IMPROVING MUSCULAR FITNESS
e health benefi ts of enhancing muscular fi tness ( i.e. , the functional parameters
of muscle strength, endurance, and power) are well established ( 26 , 93 , 102 ). Higher
levels of muscular strength are associated with a signifi cantly better cardiometabolic
risk factor profi le, lower risk of all-cause mortality, fewer CVD events, lower risk of
developing physical function limitations, and lower risk for nonfatal disease ( 26 ).
ere is an impressive array of changes in health-related biomarkers that can be
derived from regular participation in resistance training including improvements
in body composition, blood glucose levels, insulin sensitivity, and blood pressure
in individuals with mild or moderate hypertension ( 17 , 26 , 74 ). Recent evidence
suggests that resistance training is as eff ective as aerobic training in the manage-
ment and treatment of T2DM ( 106 ) and in improving the blood lipid profi les
of individuals who are overweight/obese ( 83 ). Resistance training positively af-
fects walking distance and velocity in those with peripheral artery disease (PAD)
( 6 , 106 ). Further health benefi ts attributed to resistance training were confi rmed by
a recent meta-analysis of published reports which revealed that regimens featuring
mild-to-moderate intensity isometric muscle actions were more eff ective in reduc-
ing blood pressure in both normotensive and hypertensive people than aerobic
training or dynamic resistance training ( 13 ). Accordingly, resistance training may
be eff ective for preventing and treating the dangerous constellation of conditions
referred to as Metsyn ( 26 ) (see Chapter 10 ).
Exercise that enhances muscle strength and mass also increases bone mass
( i.e. , bone mineral density and content) and bone strength of the specifi c bones
stressed and may serve as a valuable measure to prevent, slow, or reverse the loss of
bone mass in individuals with osteoporosis ( 5 , 26 , 93 ) (see Chapter 11 ). Resistance
training can reduce pain and disability in individuals with osteoarthritis ( 26 , 65 )
and has been shown to be eff ective in the treatment of chronic back pain ( 57 , 97 ).
ACSM-GETP10e_Ch01.indd 8ACSM-GETP10e_Ch01.indd 8 11/3/16 1:38 AM11/3/16 1:38 AM
9
Chapter 1 Benefi ts and Risks Associated with Physical Activity
Box 1.4
Benefits of Regular Physical Activity and/or Exercise
Improvement in Cardiovascular and Respiratory Function
■
Increased maximal oxygen uptake resulting from both central and peripheral
adaptations
■
Decreased minute ventilation at a given absolute submaximal intensity
■
Decreased myocardial oxygen cost for a given absolute submaximal intensity
■
Decreased heart rate and blood pressure at a given submaximal intensity
■
Increased capillary density in skeletal muscle
■
Increased exercise threshold for the accumulation of lactate in the blood
■
Increased exercise threshold for the onset of disease signs or symptoms
( e.g. , angina pectoris, ischemic ST-segment depression, claudication)
Reduction in Cardiovascular Disease Risk Factors
■
Reduced resting systolic/diastolic pressure
■
Increased serum high-density lipoprotein cholesterol and decreased serum
triglycerides
■
Reduced total body fat, reduced intra-abdominal fat
■
Reduced insulin needs, improved glucose tolerance
■
Reduced blood platelet adhesiveness and aggregation
■
Reduced inflammation
Decreased Morbidity and Mortality
■
Primary prevention ( i.e. , interventions to prevent the initial occurrence)
■
Higher activity and/or fitness levels are associated with lower death rates from CAD
■
Higher activity and/or fitness levels are associated with lower incidence rates
for CVD, CAD, stroke, Type 2 diabetes mellitus, metabolic syndrome, osteo-
porotic fractures, cancer of the colon and breast, and gallbladder disease
■
Secondary prevention ( i.e. , interventions after a cardiac event to prevent another)
■
Based on meta-analyses ( i.e. , pooled data across studies), cardiovascular
and all-cause mortality are reduced in patients with post-myocardial infarc-
tion (MI) who participate in cardiac rehabilitation exercise training, especially
as a component of multifactorial risk factor reduction (Note: randomized
controlled trials of cardiac rehabilitation exercise training involving patients
with post-MI do not support a reduction in the rate of nonfatal reinfarction).
Other Benefits
■
Decreased anxiety and depression
■
Improved cognitive function
■
Enhanced physical function and independent living in older individuals
■
Enhanced feelings of well-being
■
Enhanced performance of work, recreational, and sport activities
■
Reduced risk of falls and injuries from falls in older individuals
■
Prevention or mitigation of functional limitations in older adults
■
Effective therapy for many chronic diseases in older adults
CAD, coronary artery disease; CVD, cardiovascular disease.
Adapted from ( 45 , 70 , 94 ).
ACSM-GETP10e_Ch01.indd 9ACSM-GETP10e_Ch01.indd 9 11/3/16 1:38 AM11/3/16 1:38 AM
10
Guidelines for Exercise Testing • www.acsm.org
Preliminary work suggests that resistance exercise may prevent and improve
depression and anxiety, increase vigor, and reduce fatigue ( 26 , 86 ).
RISKS ASSOCIATED WITH PHYSICAL
ACTIVITY AND EXERCISE
Although the benefi ts of regular PA are well established, participation in exercise is
associated with an increased risk for musculoskeletal injury (MSI) and cardiovas-
cular complications ( 26 ). MSI is the most common exercise-related complication
and is o en associated with exercise intensity, the nature of the activity, preexisting
conditions, and musculoskeletal anomalies. Adverse cardiovascular events such as
sudden cardiac death (SCD) and acute myocardial infarction (AMI) are usually
associated with vigorous intensity exercise ( 3 , 66 , 93 ). SCD and AMI are much less
common than MSI but may lead to long-term morbidity and mortality ( 4 ).
Exercise-Related Musculoskeletal Injury
Participation in exercise and PA increases the risk of MSI ( 68 , 76 ). e intensity
and type of exercise may be the most important factors related to the incidence
of injury ( 26 ). Walking and moderate intensity physical activities are associated
with a very low risk of MSI, whereas jogging, running, and competitive sports
are associated with an increased risk of injury ( 26 , 39 , 40 ). e risk of MSI is
higher in activities where there is direct contact between participants or with
the ground ( e.g. , football, wrestling) versus activities where the contact between
participants or with the ground is minimal or nonexistent ( i.e ., baseball, running,
walking) ( 38 , 76 ). In 2012, over 6 million Americans received medical attention for
sport-related injuries, with the highest rates found in children between the ages of
12 and 17 yr (91.34 injury episodes per 1,000 population) and children younger
than the age of 12 yr (20.03 injury episodes per 1,000 population) ( 1 ). e most
common anatomical sites for MSI are the lower extremities with higher rates in the
knees followed by the foot and ankle ( 39 , 40 ).
e literature on injury consequences of PA participation o en focuses on
men from nonrepresentative populations ( e.g. , military personnel, athletes) ( 43 ).
A prospective study of community-dwelling women found that meeting the
national guidelines of ⱖ150 min ⴢ wk
⫺1
of moderate-to-vigorous intensity PA
resulted in a modest increase in PA-related MSI compared to women not meeting
the PA guidelines ( 68 ). However, the risk for developing MSI is inversely related to
physical fi tness level ( 76 ). For any given dose of PA, individuals who are physically
inactive are more likely to experience MSI when compared to their more active
counterparts ( 76 ).
Commonly used methods to reduce MSI ( e.g. , stretching, warm-up, cool-down,
and gradual progression of exercise intensity and volume) may be helpful in some
situations; however, there is a lack of controlled studies confi rming the eff ective-
ness of these methods ( 26 ). A comprehensive list of strategies that may prevent
MSI can be found elsewhere ( 12 , 28 ).
ACSM-GETP10e_Ch01.indd 10ACSM-GETP10e_Ch01.indd 10 11/3/16 1:38 AM11/3/16 1:38 AM
11
Chapter 1 Benefi ts and Risks Associated with Physical Activity
SUDDEN CARDIAC DEATH AMONG YOUNG INDIVIDUALS
e cardiovascular causes of exercise-related sudden death in young athletes are
shown in Table 1.3 ( 4 ). It is clear from these data that the most common causes of
SCD in young individuals are congenital and hereditary abnormalities including
TABLE 1.3
Cardiovascular Causes of Exercise-Related Sudden Death in
Young Athletes
a
Van Camp et al.
(n ⫽ 100)
b
(95)
Maron et al.
(n ⫽ 134) (60)
Corrado et al.
(n ⫽ 55)
c
(18)
Hypertrophic CM 51 36 1
Probable hypertrophic CM 5 10 0
Coronary anomalies 18 23 9
Valvular and subvalvular
aortic stenosis
8 4 0
Possible myocarditis 7 3 5
Dilated and nonspecifi c
CM
7 3 1
Atherosclerotic CVD 3 2 10
Aortic dissection/rupture 2 5 1
Arrhythmogenic right
ventricular CM
1 3 11
Myocardial scarring 0 3 0
Mitral valve prolapse 1 2 6
Other congenital
abnormalities
0 1.5 0
Long QT syndrome 0 0.5 0
Wolff-Parkinson-White
syndrome
1 0 1
Cardiac conduction
disease
0 0 3
Cardiac sarcoidosis 0 0.5 0
Coronary artery aneurysm 1 0 0
Normal heart at necropsy 7 2 1
Pulmonary
thromboembolism
0 0 1
a
Ages ranged from 13 to 24 yr ( 95 ), 12 to 40 yr ( 60 ), and 12 to 35 yr ( 18 ). References ( 95 ) and ( 60 )
used the same database and include many of the same athletes. All ( 95 ), 90% ( 60 ), and 89% ( 18 )
had symptom onset during or within an hour of training or competition.
b
Total exceeds 100% because several athletes had multiple abnormalities.
c
Includes some athletes whose deaths were not associated with recent exertion. Includes aberrant
artery origin and course, tunneled arteries, and other abnormalities.
CM, cardiomyopathy; CVD, cardiovascular disease.
Used with permission from ( 4 ).
ACSM-GETP10e_Ch01.indd 11ACSM-GETP10e_Ch01.indd 11 11/3/16 1:38 AM11/3/16 1:38 AM
12
Guidelines for Exercise Testing • www.acsm.org
hypertrophic cardiomyopathy, coronary artery abnormalities, and aortic stenosis.
e absolute annual risk of exercise-related death among high school and college
athletes is 1 per 133,000 men and 769,000 women ( 95 ). It should be noted that these
rates, although low, include all sports-related nontraumatic deaths. Of the 136 total
identifi able causes of death, 100 were caused by CVD. A more recent estimate places
the annual incidence of cardiovascular deaths among young competitive athletes in
the United States as 1 death per 185,000 men and 1.5 million women. ( 58 ). Some
experts, however, believe the incidence of exercise-related sudden death in young
sports participants is higher, ranging between 1 per 40,000 and 1 per 80,000 athletes
per year ( 32 ). Furthermore, death rates seem to be higher in African American male
athletes and basketball players ( 32 , 59 ). Experts debate on why estimates of the in-
cidence of exercise-related sudden deaths vary among studies. ese variances are
likely due to diff erences in (a) the populations studied, (b) estimation of the number
of sport participants, and (c) subject and/or incident case assignment. In an eff ort
to reduce the risk of SCD incidence in young individuals, well-recognized organi-
zations such as the International Olympic Committee and AHA have endorsed the
practice of preparticipation cardiovascular screening ( 19 , 53 , 61 ). e recent position
stand by the American Medical Society for Sports Medicine presents the latest evi-
dence based research on cardiovascular preparticipation screening in athletes ( 23 ).
EXERCISE-RELATED CARDIAC EVENTS IN ADULTS
In general, exercise does not provoke cardiovascular events in healthy individu-
als with normal cardiovascular systems. e risk of SCD and AMI is very low in
apparently healthy individuals performing moderate intensity PA ( 76 , 101 ). ere
is an acute and transient increase in the risk of SCD and AMI in individuals per-
forming vigorous intensity exercise, particularly in sedentary men and women
with diagnosed or occult CVD ( 3 , 4 , 29 , 66 , 85 , 90 , 105 ). However, this risk decreases
with increasing volumes of regular exercise ( 89 ). Chapter 2 includes an exercise
preparticipation health screening algorithm to help identify individuals who may
be at risk for exercise-related cardiovascular events.
It is well established that the transient risks of SCD and AMI are substan-
tially higher during acute vigorous physical exertion as compared with rest
( 29 , 66 , 85 , 91 , 105 ). A recent meta-analysis reported a fi vefold increased risk of SCD
and 3.5-fold increased risk of AMI during or shortly a er vigorous intensity PA ( 20 ).
e risk of SCD or AMI is higher in middle-aged and older adults than in younger
individuals due to the higher prevalence of CVD in the older population. e rates
of SCD and AMI are disproportionately higher in the most sedentary individu-
als when they perform unaccustomed or infrequent exercise ( 4 ). For example, the
Onset Study ( 65 ) showed that the risk of AMI during or immediately following vig-
orous intensity exercise was 50 times higher for the habitually sedentary compared
to individuals who exercised vigorously for 1-h sessions ⱖ5 d ⴢ wk
⫺1
( Figure 1.2 ) .
Although the relative risks of SCD and AMI are higher during sudden vig-
orous physical exertion versus rest, the absolute risk of these events is very low.
ACSM-GETP10e_Ch01.indd 12ACSM-GETP10e_Ch01.indd 12 11/3/16 1:38 AM11/3/16 1:38 AM
13
Chapter 1 Benefi ts and Risks Associated with Physical Activity
Prospective evidence from the Physicians’ Health Study and Nurses’ Health
Study suggests that SCD occurs every 1.5 million episodes of vigorous physical
exertion in men ( 3 ) and every 36.5 million h of moderate-to-vigorous exertion
in women ( 101 ). Retrospective analyses also support the rarity of these events.
ompson et al. ( 90 ) reported 1 death per 396,000 h of jogging. An analysis
of exercise-related cardiovascular events among participants at YMCA sports
centers found 1 death per 2,897,057 person-hours, although exercise intensity
was not documented ( 55 ). Kim et al. ( 46 ) studied over 10 million marathon and
half-marathon runners and identifi ed an overall cardiac arrest incidence rate
of 1 per 184,000 runners and an SCD incidence rate of 1 per 256,000 runners,
which translates to 0.20 cardiac arrests and 0.14 SCDs per 100,000 estimated
runner-hours.
Although the risk is extremely low, vigorous intensity exercise has a small but
measurable acute risk of CVD complications; therefore, mitigating this risk in sus-
ceptible individuals is important (see Chapter 2 ). e exact mechanism of SCD
during vigorous intensity exercise with asymptomatic adults is not completely
understood. However, evidence exists that the increased frequency of cardiac con-
traction and excursion of the coronary arteries produces bending and fl exing of
the coronary arteries may be the underlying cause. is response may cause crack-
ing of the atherosclerotic plaque with resulting platelet aggregation and possible
acute thrombosis and has been documented angiographically in individuals with
exercise-induced cardiac events ( 9 , 16 , 31 ).
Figure 1.2 The relationship between habitual frequency of vigorous physical activity and
the relative risk of acute myocardial infarction (AMI). Used with permission from ( 24 ).
*
*
*
*
Baseline
risk
Habitual frequency of vigorous physical activity
Relative risk of AMI
0 1-2 3-4 5+
(Days/Week)
200
100
50
30
10
8
4
2
1
0.5
0
Active subject
Sedentary subject
*
Vigorous exercise bout
ACSM-GETP10e_Ch01.indd 13ACSM-GETP10e_Ch01.indd 13 11/3/16 1:38 AM11/3/16 1:38 AM
14
Guidelines for Exercise Testing • www.acsm.org
TABLE 1.4
Cardiac Complications during Exercise Testing
a
Reference Year Site
No. of
Tests MI VF Death Hospitalization Comment
Rochmis and
Blackburn
(78)
1971 73 U.S.
centers
170,000 NA NA 1 3 34% of tests
were symptom
limited; 50%
of deaths in
8 h; 50% over
the next 4 d
Irving et al.
(41)
1977 15 Seattle
facilities
10,700 NA 4.67 0 NR
McHenry
(64)
1977 Hospital 12,000 0 0 0 0
Atterhög
et al. (7)
1979 20 Swedish
centers
50,000 0.8 0.8 0.4 5.2
Stuart and
Ellestad
(87)
1980 1,375 U.S.
centers
518,448 3.58 4.78 0.5 NR VF includes
other dysrhyth-
mias requiring
treatment.
Gibbons
et al. (27)
1989 Cooper
Clinic
71,914 0.56 0.29 0 NR Only 4% of men
and 2% of
women had
CVD.
Knight et al.
(48)
1995 Geisinger
Cardiology
Service
28,133 1.42 1.77 0 NR 25% were
inpatient tests
supervised by
non-MDs.
a
Events are per 10,000 tests.
CVD, cardiovascular disease; MD, medical doctor; MI, myocardial infarction; NA, not applicable; NR, not reported; VF, ventricular
fi brillation.
EXERCISE TESTING AND THE RISK OF CARDIAC EVENTS
As with vigorous intensity exercise, the risk of cardiac events during exercise test-
ing varies directly with the prevalence of diagnosed or occult CVD in the study
population. Several studies have documented these risks during exercise testing
( 7 , 27 , 41 , 48 , 64 , 78 , 87 ). Table 1.4 summarizes the risks of various cardiac events in-
cluding AMI, ventricular brillation, hospitalization, and death. ese data indi-
cate in a mixed population the risk of exercise testing is low with approximately
six cardiac events per 10,000 tests. One of these studies includes data for which the
exercise testing was supervised by nonphysicians ( 48 ). In addition, the majority
of these studies used symptom-limited maximal exercise tests. erefore, it would
be expected that the risk of submaximal testing in a similar population would
be lower.
ACSM-GETP10e_Ch01.indd 14ACSM-GETP10e_Ch01.indd 14 10/5/17 4:47 AM10/5/17 4:47 AM
15
Chapter 1 Benefi ts and Risks Associated with Physical Activity
RISKS OF CARDIAC EVENTS DURING
CARDIAC REHABILITATION
e highest risk of cardiovascular events occurs in those individuals with di-
agnosed CAD. In one survey, there was one nonfatal complication per 34,673 h
and one fatal cardiovascular complication per 116,402 h of cardiac rehabilita-
tion ( 33 ). Other studies have found a lower rate: one cardiac arrest per 116,906
patient-hours, one AMI per 219,970 patient-hours, one fatality per 752,365 pa-
tient-hours, and one major complication per 81,670 patient-hours ( 21 , 25 , 96 , 98 ).
ese studies are presented in Table 1.5 ( 4 ). A more recent study demonstrated an
even lower rate of cardiovascular complications during cardiac rehabilitation with
one cardiac arrest per 169,344 patient-hours, no AMI per 338,638 patient-hours,
and one fatality per 338,638 patient-hours ( 81 ). Although these complication rates
are low, it should be noted that patients were screened and exercised in medically
supervised settings equipped to handle cardiac emergencies. e mortality rate
appears to be six times higher when patients exercised in facilities without the
ability to successfully manage cardiac arrest ( 4 , 21 , 25 , 96 , 98 ). Interestingly, how-
ever, a review of home-based cardiac rehabilitation programs found no increase in
cardiovascular complications versus formal center-based exercise programs ( 100 ).
PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS
Because of the low incidence of cardiac events related to vigorous intensity exercise,
it is very diffi cult to test the eff ectiveness of strategies to reduce the occurrence of
TABLE 1.5
Summary of Contemporary Exercise-Based Cardiac Rehabilitation
Program Complication Rates
Investigator Year
Patient
Exercise
Hours
Cardiac
Arrest
Myocardial
Infarction
Fatal
Events
Major
Complications
a
Van Camp and
Peterson (96)
1980–1984 2,351,916 1/111,996
b
1/293,990 1/783,972 1/81,101
Digenio et al. (21) 1982–1988 480,000 1/120,000
c
1/160,000 1/120,000
Vongvanich et al.
(98)
1986–1995 268,503 1/89,501
d
1/268,503
d
0/268,503 1/67,126
Franklin et al. (25) 1982–1998 292,254 1/146,127
d
1/97,418
d
0/292,254 1/58,451
Average 1/116,906 1/219,970 1/752,365 1/81,670
a
Myocardial infarction and cardiac arrest.
b
Fatal 14%.
c
Fatal 75%.
d
Fatal 0%.
Used with permission from ( 4 ).
ACSM-GETP10e_Ch01.indd 15ACSM-GETP10e_Ch01.indd 15 11/3/16 1:38 AM11/3/16 1:38 AM
16
Guidelines for Exercise Testing • www.acsm.org
these events. According to a recent statement by the ACSM and AHA ( 4 ), “Physi-
cians should not overestimate the risks of exercise because the benefi ts of habitual
physical activity substantially outweigh the risks.” is report also recommends sev-
eral strategies to reduce these cardiac events during vigorous intensity exercise ( 4 ):
■
Health care professionals should know the pathologic conditions associated
with exercise-related events so that physically active children and adults can be
appropriately evaluated.
■
Physically active individuals should know the nature of cardiac prodromal
symptoms ( e.g. , excessive, unusual fatigue and pain in the chest and/or upper
back) and seek prompt medical care if such symptoms develop (see Table 2.1 ).
■
High school and college athletes should undergo preparticipation screening by
qualifi ed professionals.
■
Athletes with known cardiac conditions or a family history should be evaluated
prior to competition using established guidelines.
■
Health care facilities should ensure their staff is trained in managing cardiac
emergencies and have a specifi ed plan and appropriate resuscitation equipment
(see Appendix B ).
■
Physically active individuals should modify their exercise program in response
to variations in their exercise capacity, habitual activity level, and the environ-
ment (see Chapters 6 and 8 ) .
Although strategies for reducing the number of cardiovascular events during
vigorous intensity exercise have not been systematically studied, it is incumbent
on the exercise professional to take reasonable precautions when working with
individuals who wish to become more physically active/fi t and/or increase their
PA/fi tness levels. ese precautions are particularly true when the exercise pro-
gram will be of vigorous intensity. Although many sedentary individuals can safely
begin a light-to-moderate intensity exercise program, all individuals should par-
ticipate in the exercise preparticipation screening process to determine the need
for medical clearance (see Chapter 2 ).
Exercise professionals who supervise exercise and fi tness programs should
have current training in basic and/or advanced cardiac life support and emer-
gency procedures. ese emergency procedures should be reviewed and practiced
at regular intervals (see Appendix B ). Finally, individuals should be educated on
the signs and symptoms of CVD and should be referred to a physician for further
evaluation should these symptoms occur.
ONLINE RESOURCES
American College of Sports Medicine Position Stand on the Quantity and
Quality of Exercise:
http://www.acsm.org
2008 Physical Activity Guidelines for Americans:
http://www.health.gov/PAguidelines
ACSM-GETP10e_Ch01.indd 16ACSM-GETP10e_Ch01.indd 16 11/3/16 1:38 AM11/3/16 1:38 AM
17
Chapter 1 Benefi ts and Risks Associated with Physical Activity
REFERENCES
1 . A d a m s P F , K i r z i n g e r W K , M a r t i n e z M . S u m m a r y h e a l t h s t a t i s t i c s f o r t h e U . S . p o p u l a t i o n :
National Health Interview Survey, 2012 . Vital Health Stat . 2013 ; 10 ( 259 ): 1 – 95 .
2 . A i n s w o r t h B E , H a s k e l l W L , W h i t t M C , e t a l . C o m p e n d i u m o f p h y s i c a l a c t i v i t i e s : a n u p d a t e o f
activity codes and MET intensities . Med Sci Sports Exerc . 2000 ; 32 ( Suppl 9 ): S498 – 504 .
3 . A l b e r t C M , M i t t l e m a n M A , C h a e C U , L e e I M , H e n n e k e n s C H , M a n s o n J E . T r i g g e r i n g o f s u dden
death from cardiac causes by vigorous exertion . N Engl J Med . 2000 ; 343 ( 19 ): 1355 – 61 .
4. American College of Sports Medicine , American Heart Association . Exercise and acute cardio-
vascular events: placing the risks into perspective . Med Sci Sports Exerc . 2007 ; 39 ( 5 ): 886 – 97 .
5. American College of Sports Medicine , Chodzko-Zajko WJ , Proctor DN , et al. American College
of Sports Medicine Position Stand . Exercise and physical activity for older adults . Med Sci Sports
Exerc . 2009 ; 41 ( 7 ): 1510 – 30 .
6 . A s k e w C D , P a r m e n t e r B , L e i c h t A S , W a l k e r P J , G o l l e d g e J . E x e r c i s e & S p o r t s S c i e n c e A u s t r a lia
(ESSA) position statement on exercise prescription for patients with peripheral arterial disease
and intermittent claudication . J Sci Med Sport . 2014 ; 17 ( 6 ): 623 – 9 .
7 . A t t e r h ö g J H , J o n s s o n B , S a m u e l s s o n R . E x e r c i s e t e s t i n g : a p r o s p e c t i v e s t u d y o f c o m p l i c a t i o n
rates . Am Heart J . 1979 ; 98 ( 5 ): 572 – 9 .
8. Biswas A , Oh PI , Faulkner GE , et al. Sedentary time and its association with risk for disease
incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis . Ann
Intern Med . 2015 ; 162 ( 2 ): 123 – 32 .
9. Black A , Black MM , Gensini G . Exertion and acute coronary artery injury . Angiology .
1975 ; 26 ( 11 ): 759 – 83 .
10. Blair SN , Kohl HW III , Barlow CE , Paff e n b a r g e r R S J r , G i b b o n s L W , M a c e r a C A . C h a n g e s i n
physical fi tness and all-cause mortality . A prospective study of healthy and unhealthy men .
JAMA . 1995 ; 273 ( 14 ): 1093 – 8 .
11. Blair SN , Kohl HW III , Paff e n b a r g e r R S J r , C l a r k D G , C o o p e r K H , G i b b o n s L W . P h y s i c a l fi tness
and all-cause mortality . A prospective study of healthy men and women . JAMA . 1989 ; 262 ( 17 ):
2395 – 401 .
1 2 . B u l l o c k S H , J o n e s B H , G i l c h r i s t J , M a r s h a l l S W . P r e v e n t i o n o f p h y s i c a l t r a i n i n g - r e l a t e d i n j u r i e s
recommendations for the military and other active populations based on expedited systematic
reviews . Am J Prev Med . 2010 ; 38 : S156 – 181 .
1 3 . C a r l s o n D J , D i e b e r g G , H e s s N C , M i l l a r P J , S m a r t N A . I s o m e t r i c e x e r c i s e t r a i n i n g f o r b l o o d pres-
sure management: a systematic review and meta-analysis . Mayo Clin Proc . 2014 ; 89 ( 3 ): 327 – 34 .
14. Caspersen CJ , Powell KE , Christenson GM . Physical activity, exercise, and physical fi tness: defi -
nitions and distinctions for health-related research . Public Health Rep . 1985 ; 100 ( 2 ): 126 – 31 .
15. Centers for Disease Control and Prevention . Adult participation in aerobic and muscle-strengthening
activities — United States, 2011 . MMWR Morb Mortal Wkly Rep . 2013 ; 62 ( 17 ): 326 – 30 .
1 6 . C i a m p r i c o t t i R , D e c k e r s J W , T a v e r n e R , e l G a m a l M , R e l i k - v a n W e l y L , P o o l J . C h a r a c teristics of
conditioned and sedentary men with acute coronary syndromes . Am J Cardiol . 1994 ; 73 ( 4 ): 219 – 22 .
1 7 . C o l b e r g S R , S i g a l R J , F e r n h a l l B , et al. Exercise and type 2 diabetes: the American College of
Sports Medicine and the American Diabetes Association: joint position statement . Diabetes Care .
2010 ; 33 ( 12 ): e147 – 67 .
1 8 . C o r r a d o D , B a s s o C , R i z z o l i G , S c h i a v o n M , iene G . Does sports activity enhance the risk of
sudden death in adolescents and young adults? J Am Coll Cardiol . 2003 ; 42 ( 11 ): 1959 – 63 .
19. Corrado D , Pelliccia A , Bjørnstad HH , et al. Cardiovascular pre-participation screening of young
competitive athletes for prevention of sudden death: proposal for a common European protocol .
Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac
Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial
Diseases of the European Society of Cardiology . Eur Heart J . 2005 ; 26 ( 5 ): 516 – 24 .
2 0 . D a h a b r e h I J , P a u l u s J . A s s o c i a t i o n o f e p i s o d i c p h y s i c a l a n d s e x u a l a c t i v i t y w i t h t r i g g e r i n g o f a c u t e
cardiac events: systematic review and meta-analysis . JAMA . 2011 ; 305 ( 12 ): 1225 – 33 .
2 1 . D i g e n i o A G , S i m J G , D o w d e s w e l l R J , M o r r i s R . E x e r c i s e - r e l a t e d c a r d i a c a r r e s t i n c a r d i a c r e h a b i l -
itation . e Johannesburg experience . S Afr Med J . 1991 ; 79 ( 4 ): 188 – 91 .
ACSM-GETP10e_Ch01.indd 17ACSM-GETP10e_Ch01.indd 17 11/3/16 1:38 AM11/3/16 1:38 AM
18
Guidelines for Exercise Testing • www.acsm.org
22. Donnelly JE , Blair SN , Jakicic JM , et al. American College of Sports Medicine Position Stand .
Appropriate physical activity intervention strategies for weight loss and prevention of weight
regain for adults . Med Sci Sports Exerc . 2009 ; 41 ( 2 ): 459 – 71 .
23. Drezner JA , O’Connor FG , Harmon KG , et al. AMSSM position statement on cardiovascular
preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and
future directions . Curr Sports Med Rep . 2016 ; 15 ( 5 ): 359 – 75 .
24. Franklin BA . Preventing exercise-related cardiovascular events: is a medical examination more
urgent for physical activity or inactivity? Circulation . 2014 ; 129 ( 10 ): 1081 – 4 .
2 5 . F r a n k l i n B A , B o n z h e i m K , G o r d o n S , T i m m i s G C . S a f e t y o f m e d i c a l l y s u p e r v i s e d o u t p a t i e n t
cardiac rehabilitation exercise therapy: a 16-year follow-up . Chest . 1998 ; 114 ( 3 ): 902 – 6 .
2 6 . G a r b e r C E , B l i s s m e r B , D e s c h e n e s M R , e t a l . A m e r i c a n C o l l e g e o f S p o r t s M e d i c i n e p o s i t i o n
stand . e quantity and quality of exercise for developing and maintaining cardiorespiratory,
musculoskeletal, and neuromotor fi tness in apparently healthy adults: guidance for prescribing
exercise . Med Sci Sports Exerc . 2011 ; 43 ( 7 ): 1334 – 559 .
2 7 . G i b b o n s L , B l a i r S N , K o h l H W , C o o p e r K . e safety of maximal exercise testing . Circulation .
1989 ; 80 ( 4 ): 846 – 52 .
2 8 . G i l c h r i s t J , J o n e s B H , S l e e t D A , K i m s e y C . E x e r c i s e - r e l a t e d i n j u r i e s a m o n g w o m e n : s t r a t e g i e s f o r
prevention from civilian and military studies . MMWR Recomm Rep . 2000 ; 49 ( RR-2 ): 15 – 33 .
2 9 . G i r i S , ompson PD , Kiernan FJ , et al. Clinical and angiographic characteristics of exertion-
related acute myocardial infarction . JAMA . 1999 ; 282 ( 18 ): 1731 – 6 .
3 0 . H a l l a l P C , A n d e r s e n L B , B u l l F C , e t a l . G l o b a l p h y s i c a l a c t i v i t y l e v e l s : s u r v e i l l a n c e p r o g r e s s ,
pitfalls, and prospects . Lancet . 2012 ; 380 ( 9838 ): 247 – 57 .
3 1 . H a m m o u d e h A J , H a J . Coronary-plaque rupture in acute coronary syndromes triggered by
snow shoveling . N Engl J Med . 1996 ; 335 ( 26 ): 2001 .
32. Harmon KG , Drezner JA , Wilson MG , Sharma S . Incidence of sudden cardiac death in athletes: a
state-of-the-art review . Heart . 2014 ; 100 ( 16 ): 1227 – 34 .
33. Haskell WL . Cardiovascular complications during exercise training of cardiac patients . Circula-
tion . 1978 ; 57 ( 5 ): 920 – 4 .
34. Haskell WL , Lee IM , Pate RR , et al. Physical activity and public health: updated recommendation
for adults from the American College of Sports Medicine and the American Heart Association .
Med Sci Sports Exerc . 2007 ; 39 ( 8 ): 1423 – 34 .
3 5 . H e a l y G N , D u n s t a n D W , S a l m o n J , e t a l . B r e a k s i n s e d e n t a r y t i m e : b e n e fi cial associations with
metabolic risk . Diabetes Care . 2008 ; 31 ( 4 ): 661 – 6 .
3 6 . H e a l y G N , M a t t h e w s C E , D u n s t a n D W , W i n k l e r E A , O w e n N . S e d e n t a r y t i m e a n d c a r d i o -
metabolic biomarkers in US adults: NHANES 2003-06 . Eur Heart J . 2011 ; 32 ( 5 ): 590 – 7 .
37. Hollingworth M , Harper A , Hamer M . Dose–response associations between cycling activity
and risk of hypertension in regular cyclists: the UK Cycling for Health Study . J Hum Hypertens .
2015 ; 29 ( 4 ): 219 – 23 .
38. Hootman JM , Dick R , Agel J . Epidemiology of collegiate injuries for 15 sports: summary and
recommendations for injury prevention initiatives . J Athl Train . 2007 ; 42 ( 2 ): 311 – 9 .
3 9 . H o o t m a n J M , M a c e r a C A , A i n s w o r t h B E , A d d y C L , M a r t i n M , B l a i r S N . E p i d e m i o l o g y o f
musculoskeletal injuries among sedentary and physically active adults . Med Sci Sports Exerc .
2002 ; 34 ( 5 ): 838 – 44 .
4 0 . H o o t m a n J M , M a c e r a C A , A i n s w o r t h B E , M a r t i n M , A d d y C L , B l a i r S N . A s s o c i a t i o n a m o n g phys-
ical activity level, cardiorespiratory fi tness, and risk of musculoskeletal injury . Am J Epidemiol .
2001 ; 154 ( 3 ): 251 – 8 .
4 1 . I r v i n g J B , B r u c e R A , D e R o u e n T A . V a r i a t i o n s i n a n d s i g n i fi cance of systolic pressure during
maximal exercise (treadmill) testing . Am J Cardiol . 1977 ; 39 ( 6 ): 841 – 8 .
42. Jensen MD , Ryan DH , Apovian CM , et al. 2013 AHA/ACC/TOS guideline for the management
of overweight and obesity in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines and e Obesity Society . J Am Coll Cardiol .
2014 ; 63 ( 25 ): 2985 – 3023 .
43. Kaplan RM , Hermann AK , Morrison JT , DeFina LF , Morrow JR Jr . Costs associated with wom-
en’s physical activity musculoskeletal injuries: the women’s injury study . J Phys Act Health .
2014 ; 11 ( 6 ): 1149 – 55 .
ACSM-GETP10e_Ch01.indd 18ACSM-GETP10e_Ch01.indd 18 11/3/16 1:38 AM11/3/16 1:38 AM
19
Chapter 1 Benefi ts and Risks Associated with Physical Activity
44. Katzmarzyk PT , Church TS , Craig CL , Bouchard C . Sitting time and mortality from all causes,
cardiovascular disease, and cancer . Med Sci Sports Exerc . 2009 ; 41 ( 5 ): 998 – 1005 .
4 5 . K e s a n i e m i Y K , D a n f o r t h E J r , J e n s e n M D , K o p e l m a n P G , L e f è b v r e P , R e e d e r B A . D o s e - r e sponse
issues concerning physical activity and health: an evidence-based symposium . Med Sci Sports
Exerc . 2001 ; 33 ( Suppl 6 ): S351 – 8 .
46. Kim JH , Malhotra R , Chiampas G , et al. Cardiac arrest during long-distance running races .
N Engl J Med . 2012 ; 366 ( 2 ): 130 – 40 .
4 7 . K i m Y , W i l k e n s L R , P a r k S Y , G o o d m a n M T , M o n r o e K R , K o l o n e l L N . A s s o c i a t i o n b e t w e e n
various sedentary behaviours and all-cause, cardiovascular disease and cancer mortality: the
Multiethnic Cohort Study . Int J Epidemiol . 2013 ; 42 ( 4 ): 1040 – 56 .
4 8 . K n i g h t J A , L a u b a c h C A J r , B u t c h e r R J , M e n a p a c e F J . S u p e r v i s i o n o f c l i n i c a l e x e r c i s e t e s t i n g b y
exercise physiologists . Am J Cardiol . 1995 ; 75 ( 5 ): 390 – 1 .
4 9 . K o d a m a S , S a i t o K , T a n a k a S , e t a l . C a r d i o r e s p i r a t o r y fi tness as a quantitative predictor of all-
cause mortality and cardiovascular events in healthy men and women: a meta-analysis . JAMA .
2009 ; 301 ( 19 ): 2024 – 35 .
50. Kohl HW III , Craig CL , Lambert EV , et al. e pandemic of physical inactivity: global action for
public health . Lancet . 2012 ; 380 ( 9838 ): 294 – 305 .
51. Koster A , Caserotti P , Patel KV , et al. Association of sedentary time with mortality independent of
moderate to vigorous physical activity . PLoS One . 2012 ; 7 ( 6 ): e37696 .
5 2 . L e e I M , R e x r o d e K M , C o o k N R , M a n s o n J E , B u r i n g J E . P h y s i c a l a c t i v i t y a n d c o r o n a r y h e a r t
disease in women: is “no pain, no gain” passe? JAMA . 2001 ; 285 ( 11 ): 1447 – 54 .
5 3 . L j u n g q v i s t A , J e n o u r e P , E n g e b r e t s e n L , e t a l . e International Olympic Committee (IOC) con-
sensus statement on periodic health evaluation of elite athletes, March 2009 . Br J Sports Med .
2009 ; 43 ( 9 ): 631 – 43 .
54. Loprinzi PD , Lee H , Cardinal BJ . Dose response association between physical activity and biolog-
ical, demographic, and perceptions of health variables . Obes Facts . 2013 ; 6 ( 4 ): 380 – 92 .
55. Malinow M , McGarry D , Kuehl K . Is exercise testing indicated for asymptomatic active people?
J Cardiac Rehab . 1984 ; 4 : 376 – 9 .
56. Manniche C , Lundberg E , Christensen I , Bentzen L , Hesselsøe G . Intensive dynamic back
exercises for chronic low back pain: a clinical trial . Pain . 1997 ; 47 ( 1 ): 53 – 63 .
57. Manson JE , Greenland P , LaCroix AZ , et al. Walking compared with vigorous exercise for the
prevention of cardiovascular events in women . N Engl J Med . 2002 ; 347 ( 10 ): 716 – 25 .
58. Maron BJ , Doerer JJ , Haas TS , Tierney DM , Mueller FO . Sudden deaths in young competi-
tive athletes: analysis of 1866 deaths in the United States, 1980-2006 . Circulation . 2009 ; 119 ( 8 ):
1085 – 92 .
59. Maron BJ , Haas TS , Murphy CJ , Ahluwalia A , Rutten-Ramos S . Incidence and causes of sudden
death in U.S. college athletes . J Am Coll Cardiol . 2014 ; 63 ( 16 ): 1636 – 43 .
60. Maron BJ , Shirani J , Poliac LC , Mathenge R , Roberts WC , Mueller FO . Sudden death in young com-
petitive athletes . Clinical, demographic, and pathological profi les . JAMA . 1996 ; 276 ( 3 ): 199 – 204 .
6 1 . M a r o n B J , ompson PD , Ackerman MJ , et al. Recommendations and considerations related to
preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update:
a scientifi c statement from the American Heart Association Council on Nutrition, Physical Activ-
ity, and Metabolism: endorsed by the American College of Cardiology Foundation . Circulation .
2007 ; 115 ( 12 ): 1643 – 455 .
62. Matthews CE , Chen KY , Freedson PS , et al. Amount of time spent in sedentary behaviors in the
United States, 2003–2004 . Am J Epidemiol . 2008 ; 167 ( 7 ): 875 – 81 .
6 3 . M a t t h e w s C E , G e o r g e S M , M o o r e S C , e t a l . A m o u n t o f t i m e s p e n t i n s e d e n t a r y b e h a v i o r s a n d
cause-specifi c mortality in US adults . Am J Clin Nutr . 2012 ; 95 ( 2 ): 437 – 45 .
64. McHenry PL . Risks of graded exercise testing . Am J Cardiol . 1977 ; 39 ( 6 ): 935 – 7 .
65. Messier SP . Obesity and osteoarthritis: disease genesis and nonpharmacologic weight manage-
ment . Med Clin North Am . 2009 ; 93 ( 1 ): 145 – 159 .
6 6 . M i t t l e m a n M A , M a c l u r e M , T o fl e r G H , S h e r w o o d J B , G o l d b e r g R J , M u l l e r J E . T r i g g e r i n g o f
acute myocardial infarction by heavy physical exertion . Protection against triggering by regu-
lar exertion. Determinants of Myocardial Infarction Onset Study Investigators . N Engl J Med .
1993 ; 329 ( 23 ): 1677 – 83 .
ACSM-GETP10e_Ch01.indd 19ACSM-GETP10e_Ch01.indd 19 11/3/16 1:38 AM11/3/16 1:38 AM
20
Guidelines for Exercise Testing • www.acsm.org
67. Moore SC , Lee I , Weiderpass E , et al. Association of leisure-time physical activity with risk of
26 types of cancer in 1.44 million adults . JAMA Intern Med . 2016 ; 176 ( 6 ): 816 – 25 . doi:10.1001
/jamainternmed.2016.1548
6 8 . M o r r o w J R J r , D e F i n a L F , L e o n a r d D , T r u d e l l e - J a c k s o n E , C u s t o d i o M A . M e e t i n g p h y s i c a l
activity guidelines and musculoskeletal injury: the WIN study . Med Sci Sports Exerc . 2012 ; 44 ( 10 ):
1986 – 92 .
69. Naci H , Ioannidis J . Comparative eff ectiveness of exercise and drug interventions on mortality
outcomes: metaepidemiological study . BMJ . 2013 ; 347 : f5577 .
70. Nelson ME , Rejeski WJ , Blair SN , et al. Physical activity and public health in older adults: recom-
mendation from the American College of Sports Medicine and the American Heart Association .
Med Sci Sports Exerc . 2007 ; 39 ( 8 ): 1435 – 45 .
7 1 . P a ff e n b a r g e r R S J r , H y d e R T , W i n g A L , L e e I M , J u n g D L , K a m p e r t J B . e association of changes
in physical-activity level and other lifestyle characteristics with mortality among men . N Engl J
Med . 1993 ; 328 ( 8 ): 538 – 45 .
7 2 . P a ff enbarger RS Jr , Lee IM . Smoking, physical activity, and active life expectancy . Clin J Sport Med .
1999 ; 9 ( 4 ): 244 .
7 3 . P a t e R R , P r a t t M , B l a i r S N , e t a l . P h y s i c a l a c t i v i t y a n d p u b l i c h e a l t h . A r e c o m m e n d a t i o n f r o m
the Centers for Disease Control and Prevention and the American College of Sports Medicine .
JAMA . 1995 ; 273 ( 5 ): 402 – 7 .
7 4 . P e s c a t e l l o L S , F r a n k l i n B A , F a g a r d R , e t a l . A m e r i c a n C o l l e g e o f S p o r t s M e d i c i n e p o s i t i o n s t a n d .
Exercise and hypertension . Med Sci Sports Exerc . 2004 ; 36 ( 3 ): 533 – 53 .
75. Physical activity and cardiovascular health . NIH Consensus Development Panel on Physical
Activity and Cardiovascular Health . JAMA . 1996 ; 276 ( 3 ): 241 – 6 .
76. Physical Activity Guidelines Advisory Committee . Physical Activity Guidelines Advisory Commit-
tee Report, 2008 [Internet] . Washington (DC) : U.S. Department of Health and Human Services ;
2008 [updated Sep 24]. 683 p. Available from: http://www.health.gov/paguidelines/Report/pdf
/CommitteeReport.pdf
77. President’s Council on Physical Fitness and Sports . Defi nitions — Health, Fitness, and Physical
Activity [Internet]. Washington (DC) : President’s Council on Physical Fitness and Sports ; 2000
[cited 2016 Jun 6]. Available from: http://purl.access.gpo.gov/GPO/LPS21074
78. Rochmis P , Blackburn H . Exercise tests . A survey of procedures, safety, and litigation experience
in approximately 170,000 tests . JAMA . 1971 ; 217 ( 8 ): 1061 – 6 .
7 9 . R o c k h i l l B , W i l l e t t W C , M a n s o n J E , e t a l . P h y s i c a l a c t i v i t y a n d m o r t a l i t y : a p r o s p e c t i v e s t u d y
among women . Am J Public Health . 2001 ; 91 ( 4 ): 578 – 83.
80. Saris WH , Blair SN , van Baak MA , et al. How much physical activity is enough to prevent
unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement .
Obes Rev . 2003 ; 4 ( 2 ): 101 – 14 .
81. Scheinowitz M , Harpaz D . Safety of cardiac rehabilitation in a medically supervised, community-
based program . Cardiology . 2005 ; 103 ( 3 ): 113 – 7 .
82. Schmid D , Ricci C , Leitzmann MF . Associations of objectively assessed physical activ-
ity and sedentary time with all-cause mortality in US adults: the NHANES study . PLoS One .
2015 ; 10 ( 3 ): e0119591 .
8 3 . S c h w i n g s h a c k l L , M i s s b a c h B , D i a s S , K ö n i g J , H o ff m a n n G . I m p a c t o f d i ff erent training modal-
ities on glycaemic control and blood lipids in patients with type 2 diabetes: a systematic review
and network meta-analysis . Diabetologia . 2014 ; 57 ( 9 ): 1789 – 97 .
8 4 . S e s s o H D , P a ff enbarger RS Jr , Lee IM . Physical activity and coronary heart disease in men: the
Harvard Alumni Health Study . Circulation . 2000 ; 102 ( 9 ): 975 – 80 .
8 5 . S i s c o v i c k D S , W e i s s N S , F l e t c h e r R H , L a s k y T . e incidence of primary cardiac arrest during
vigorous exercise . N Engl J Med . 1984 ; 311 ( 14 ): 874 – 7 .
8 6 . S t r i c k l a n d J C , S m i t h M . e anxiolytic eff ects of resistance exercise . Front Psychol . 2014 ; 5 : 753 .
8 7 . S t u a r t R J J r , E l l e s t a d M H . N a t i onal survey of exercise stress testing facilities . Chest .
1980 ; 77 ( 1 ): 94 – 7 .
8 8 . T a n a s e s c u M , L e i t z m a n n M F , R i m m E B , W i l l e t t W C , S t a m p f e r M J , H u F B . E x e r c i s e t y p e a nd
intensity in relation to coronary heart disease in men . JAMA . 2002 ; 288 ( 16 ): 1994 – 2000 .
ACSM-GETP10e_Ch01.indd 20ACSM-GETP10e_Ch01.indd 20 11/3/16 1:38 AM11/3/16 1:38 AM
21
Chapter 1 Benefi ts and Risks Associated with Physical Activity
8 9 . o m p s o n P D , F r a n k l i n B A , B a l a d y G J , e t a l . E x e r c i s e a n d a c u t e c a r d i o v a s c u l a r e v e n t s p l a c i n g
the risks into perspective: a scientifi c statement from the American Heart Association Council
on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology . Circu-
lation . 2007 ; 115 ( 17 ): 2358 – 68 .
9 0 . o m p s o n P D , F u n k E J , C a r l e t o n R A , S t u r n e r W Q . I n c i d e n c e o f d e a t h d u r i n g j o g g i n g i n R h o d e
Island from 1975 through 1980 . JAMA . 1982 ; 247 ( 18 ): 2535 – 8 .
9 1 . o m p s o n P D , S t e r n M P , W i l l i a m s P , D u n c a n K , H a s k e l l W L , W o o d P D . D e a t h d u r i n g j o g g i n g
or running . A study of 18 cases . JAMA . 1979 ; 242 ( 12 ): 1265 – 7 .
92. U.S. Department of Agriculture, U.S. Department of Health and Human Services . Dietary
Guidelines for Americans, 2010 . 7th ed . Washington (DC) : U.S. Government Printing Offi ce ;
2010 . 112 p.
93. U.S. Department of Health and Human Services . 2008 Physical Activity Guidelines for Amer-
icans [Internet]. Washington (DC) : U.S. Department of Health and Human Services ; 2008
[cited 2016 Jun 6]. Available from: http://health.gov/paguidelines/pdf/paguide.pdf
94. U.S. Department of Health and Human Services . Physical Activity and Health: A Report of the
Surgeon General . Atlanta (GA) : U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Pre-
vention and Health Promotion ; 1996 . 278 p.
9 5 . V a n C a m p S P , B l o o r C M , M u e l l e r F O , C a n t u R C , O l s o n H G . N o n t r a u m a t i c s p o r t s d e a t h i n h i g h
school and college athletes . Med Sci Sports Exerc . 1995 ; 27 ( 5 ): 641 – 7 .
9 6 . V a n C a m p S P , P e t e r s o n R A . C a r d i o v a s c u l a r c o m p l i c a t i o n s o f o u t p a t i e n t c a r d i a c r e h a b i l i t a t i o n
programs . JAMA . 1986 ; 256 ( 9 ): 1160 – 3 .
9 7 . V i n c e n t H K , G e o r g e S Z , S e a y A N , V i n c e n t K R , H u r l e y R W . R e s i s t a n c e e x e r c i s e , d i s a b i l i t y , and
pain catastrophizing in obese adults with back pain . Med Sci Sports Exerc . 2014 ; 46 ( 9 ): 1693 – 701 .
98. Vongvanich P , Paul-Labrador MJ , Merz CN . Safety of medically supervised exercise in a cardiac
rehabilitation center . Am J Cardiol . 1996 ; 77 ( 15 ): 1383 – 5 .
9 9 . W a n g C Y , H a s k e l l W L , F a r r e l l S W , e t a l . C a r d i o r e s p i r a t o r y fi tness levels among US adults
20-49 years of age: fi ndings from the 1999-2004 National Health and Nutrition Examination
Survey . Am J Epidemiol . 2010 ; 171 ( 4 ): 426 – 35 .
100. Wenger NK , Froelicher ES , Smith LK , et al. Cardiac rehabilitation as secondary prevention .
Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute .
Clin Pract Guidel Quick Ref Guide Clin . 1995 ;( 17 ): 1 – 23 .
101. Whang W , Manson JE , Hu FB , et al. Physical exertion, exercise, and sudden cardiac death in
women . JAMA . 2006 ; 295 ( 12 ): 1399 – 403 .
102. Williams MA , Haskell WL , Ades PA , et al. Resistance exercise in individuals with and without
cardiovascular disease: 2007 update: a scientifi c statement from the American Heart Associa-
tion Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabo-
lism . Circulation . 2007 ; 116 ( 5 ): 572 – 84 .
103. Williams PT . Dose-response relationship of physical activity to premature and total all-cause
and cardiovascular disease mortality in walkers . PLoS One . 2013 ; 8 ( 11 ): e78777 .
104. Williams PT . Physical fi tness and activity as separate heart disease risk factors: a meta-analysis .
Med Sci Sports Exerc . 2001 ; 33 ( 5 ): 754 – 61 .
105. Willich SN , Lewis M , Löwel H , Arntz HR , Schubert F , Schröder R . Physical exertion as a trig-
ger of acute myocardial infarction . Triggers and Mechanisms of Myocardial Infarction Study
Group . N Engl J Med . 1993 ; 329 ( 23 ): 1684 – 90 .
106. Yang Z , Scott CA , Mao C , Tang J , Farmer AJ . Resistance exercise versus aerobic exercise for
type 2 diabetes: a systematic review and meta-analysis . Sports Med . 2014 ; 44 ( 4 ): 487 – 99 .
107. Yu S , Yarnell JW , Sweetnam PM , Murray L . What level of physical activity protects against
premature cardiovascular death? e Caerphilly study . Heart . 2003 ; 89 ( 5 ): 502 – 6 .
ACSM-GETP10e_Ch01.indd 21ACSM-GETP10e_Ch01.indd 21 11/3/16 1:38 AM11/3/16 1:38 AM
