Basic principles

Assessment of present levels of activity;

The UK General Practice Physical Activity Questionnaire (GPPAQ)¹ can be used to categorize patients into recommended levels of activity.

A brief assessment using just 3 questions, ‘The Scot-PASQ’.² is increasingly used as a quick motivational screening tool to help raise the issue of physical activity and deliver advice.

In the past week, on how many days have you been physically active for a total of 30 minutes or more?
If four days or less, have you been physically active for at least two and a half hours (150 minutes) over the course of the past week?
Are you interested in being more physically active?

Read the brief guidance on how to use the tool by downloading it here

Four important aspects of exercise;

Cardiovascular fitness
Muscular strength
Endurance
Flexibility

Many of the health benefits of exercise come from improved cardiovascular fitness using aerobic exercise. However, muscle strengthand resistance exercises also benefit bone formation, glucose metabolism, hypertension and maintenance of weight.

Muscle strength and endurance are also essential to maintain mobility and prevention of falls, which increases in importance as we grow older. Flexibility is often overlooked, but is also important as it reduces the possibility of injury, stiffness and an inability to perform simple tasks like turning around to enable you to park your car.

There are some simple basic principles that can be used in ‘prescribing exercise’, which if patients can grasp, will promote more enjoyment and increase motivation, cutting through some of their beliefs/fears of pain or difficulty.

Warm up and Cool down

It is desirable that individuals include a warm up and cool down as part of their activity. This may be the same activity performed at a lower intensity. For example, walking at a slow pace for your warm up and cool down, with a moderate intensity walk for 30 minutes as the main activity.

Apply the FITT principle.

Frequency - How many times a week for an activity?
Intensity ---- How hard to exert?
Time --------- How long in minutes?
Type --------- Which type of activity agreed with the patient?

The current UK physical activity guidelines are for moderate intensity activity on 5 or more days a week. For individuals who have led a sedentary lifestyle this may be difficult to establish initially. Here, the advice may be to exercise aerobically three times a week, allowing a day or two in between exercise days. However, once this is established individuals should be encouraged to increase the frequency to 5 or more days.

Frequency is the most important aspect to establish as without a routine pattern it will not become a lifestyle change. Motivation is what gets you started but habit is what keeps you going.

Newcomers to exercise may need to start at low intensity but need to be aware that the evidence for health change is mostly from moderate exercise, so if walking they won’t improve their cardiovascular fitness with a gentle stroll for 30 minutes. If walking, aim to increase the number of minutes of walk before increasing the intensity (by walking faster or uphill).

Time or how long to exercise, should be established but should not include any warm up or cool down. Present guidelines have recently changed and people can be advised that bouts of physical activity of 10 min or more accumulated throughout the day are as effective as longer sessions.

There are many activities that can be started and it is most important to find a type of exercise that the individual finds enjoyable, convenient, affordable and achievable. Walking, cycling and swimming are three of the commonest and known to virtually everyone, but there are many more. Dancing, yoga, Pilates and Tai Chi are also very popular and help prevent falls and encourage core strength.

Definitions of moderate and vigorous intensity:

Moderate intensity physical activity causes adults to feel warmer, breathe harder and the heart beats faster with the example of brisk walking being the easiest to recognize.
Vigorous intensity physical activity causes adults to get warm quickly, breathe much harder, perspire and find it difficult to maintain a conversation

Monitoring

Some people find it helpful to monitor their progress and use this to motivate themselves.

Ways of monitoring progress:

Keep an exercise diary – cheap and easy to record your progress, success, feelings and to identify barriers to exercise
Pedometers – cheap and easy to use, but not always reliable³
Accelerometers – more reliable and can be linked to a computer program for monitoring
Walk4life – the walking web based site which is free to join; it uses ordinance survey maps and routes and has a ‘track your progress’ page to monitor your own fitness

How many steps is enough? Differing advice is often given over how many steps is good for our health, with perhaps 10,000 steps a day as the commonest quoted.^{4, 5, 6} Yet, adult physical activity guidelines advise at least 30 minutes of moderate intensity activity per day and this translates to only 3000 - 4000 steps, ^7,8 To fit with public health guidelines these should be:^9,10

Of moderate intensity (i.e. over 100 steps/minute)⁷
Accumulated in at least 10 minute bouts
Taken over and above some minimal level of physical activity (i.e., number of daily steps) below which individuals may be classified as sedentary

As the pedometer or accelerometer will also detect also a low intensity levels of steps, it is these small daily movements that are added to the total step count, but they are unlikely to contribute much to health benefits. It is therefore suggested that, total steps of less than 5000 steps/day, may reflect a level of sedentary activity which is associated with a higher prevalence of obesity.^{9, 11}However, adding 3000-4000/day moderate intensity steps to this, then equates with a hierarchy level of 7500-9999 steps/day (somewhat active) which may be more useful for monitoring or motivation purposes.⁹

< 5000 steps/day – sedentary
5000 – 7499 steps/day – low active
7500 - 9999 steps/day – somewhat active
> 10000 -12.499 steps/day – active
> 12,500 – steps/day – highly active

In summary, every step may be counted, but greater emphasis still needs to be placed on ‘healthy’ moderate intensity steps.

The above advice is partly taken from Bandolier.¹² Further advice on ‘Starting to Exercise’ available from their fuller version here, and the Swedish guidance on activity.¹³