The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

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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

Various theories have been proposed to explain increases in muscle extensibility observed after intermittent stretching. Most of these theories advocate a mechanical increase in length of the stretched muscle. More recently, a sensory theory has been proposed suggesting instead that increases in muscle extensibility are due to a modification of sensation only. Studies that evaluated the biomechanical effect of stretching showed that muscle length does increase during stretch application due to the viscoelastic properties of muscle. However, this length increase is transient, its magnitude and duration being dependent upon the duration and type of stretching applied. Most of these studies suggest that increases in muscle extensibility observed after a single stretching session and after short-term (3- to 8-week) stretching programs are due to modified sensation. The biomechanical effects of long-term (>8 weeks) and chronic stretching programs have not yet been evaluated. The purposes of this article are to review each of these proposed theories and to discuss the implications for research and clinical practice.

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Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation?

The pathophysiology of multiple sclerosis (MS) is characterised by fatigue, motor weakness, spasticity, poor balance, heat sensitivity and mental depression. Also, MS symptoms may lead to physical inactivity associated with the development of secondary diseases. Persons with MS are thus challenged by their disability when attempting to pursue an active lifestyle compatible with health-related fitness. Although exercise prescription is gaining favour as a therapeutic strategy to minimise the loss of functional capacity in chronic diseases, it remains under-utilised as an intervention strategy in the MS population. However, a growing number of studies indicate that exercise in patients with mild-to-moderate MS provides similar fitness and psychological benefits as it does in healthy controls. We reviewed numerous studies describing the responses of selected MS patients to acute and chronic exercise compared with healthy controls. All training studies reported positive outcomes that outweighed potential adverse effects of the exercise intervention. Based on our review, this article highlights the role of exercise prescription in the multidisciplinary approach to MS disease management for improving and maintaining functional capacity. Despite the often unpredictable clinical course of MS, exercise programmes designed to increase cardiorespiratory fitness, muscle strength and mobility provide benefits that enhance lifestyle activity and quality of life while reducing risk of secondary disorders. Recommendations for the evaluation of cardiorespiratory fitness, muscle performance and flexibility are presented as well as basic guidelines for individualised exercise testing and training in MS. Special considerations for exercise, including medical management concerns, programme modifications and supervision, in the MS population are discussed.

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Exercise and Multiple Sclerosis

Strength and flexibility are common components of exercise programmes; however, it is not clear how best to include both of these elements in a single training programme. It is common practice among athletes, coaches and recreational exercisers to perform a stretching routine before a strength training session. Stretching exercises are regularly recommended, even in many textbooks, with the claimed purpose of preventing injury and muscle soreness, or even enhancing performance. However, as highlighted in recent review articles, this recommendation lacks scientific evidence. Thus, the purpose of the present review is to determine the acute and chronic effects of stretching on strength performance, together with the underlying mechanisms. Although most studies have found acute decreases in strength following stretching, and that such decreases seem to be more prominent the longer the stretching protocol, the number of exercises and sets, and the duration of each set have, in general, exceeded the ranges normally recommended in the literature. Consequently, the duration of the stimuli were excessively long compared with common practice, thus making evident the need for further studies. In addition, when recommending flexibility exercises, one should consider other underlying issues, such as the safety of the participants, possible increases in injury risks and the unnecessary time expenditure. Many mechanisms underlying stretching exercises still demand investigation so that links between the observed effects, their causes and the consequences may be constructed.

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The effects of stretching on strength performance.

Stretching is a common activity used by athletes, older adults, rehabilitation patients, and anyone participating in a fitness program. While the benefits of stretching are known, controversy remains about the best type of stretching for a particular goal or outcome. The purpose of this clinical commentary is to discuss the current concepts of muscle stretching interventions and summarize the evidence related to stretching as used in both exercise and rehabilitation.

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Current concepts in muscle stretching for exercise and rehabilitation

Background and Purpose. Stretching protocols for elderly people (≥65 years of age) have not been studied to determine the effectiveness of increasing range of motion (ROM). The purpose of this study was to determine which of 3 durations of stretches would produce and maintain the greatest gains in knee extension ROM with the femur held at 90 degrees of hip flexion in a group of elderly individuals. Subjects. Sixty-two subjects (mean age=84.7 years, SD=5.6, range= 65–97) with tight hamstring muscles (defined as the inability to extend the knee to less than 20° of knee flexion) participated. Subjects were recruited from a retirement housing complex and were independent in activities of daily living. Methods. Subjects were randomly assigned to 1 of 4 groups and completed a physical activity questionnaire. The subjects in group 1 (n=13, mean age=85.1 years, SD=6.4, range=70–97), a control group, performed no stretching. The randomly selected right or left limb of subjects in group 2 (n=17, mean age=85.5 years, SD=4.5, range=80–93), group 3 (n=15, mean age=85.2 years, SD=6.5, range=65–92), and group 4 (n=17, mean age=83.2 years, SD=4.6, range=68–90) was stretched 5 times per week for 6 weeks for 15, 30, and 60 seconds, respectively. Range of motion was measured once a week for 10 weeks to determine the treatment and residual effects. Data were analyzed using a growth curve model. Results. A 60-second stretch produced a greater rate of gains in ROM (60-second stretch=2.4° per week, 30-second stretch=1.3° per week, 15-second stretch=0.6° per week), which persisted longer than the gains in any other group (group 4 still had 5.4° more ROM 4 weeks after treatment than at pretest as compared with 0.7° and 0.8° for groups 2 and 3, respectively). Discussion and Conclusion. Longer hold times during stretching of the hamstring muscles resulted in a greater rate of gains in ROM and a more sustained increase in ROM in elderly subjects. These results may differ from those of studies performed with younger populations because of age-related physiologic changes.

The Effect of Duration of Stretching of the Hamstring Muscle Group for Increasing Range of Motion in People Aged 65 Years or Older

This study examined the effect of the Ornish Program for Reversing Heart Disease and cardiac rehabilitation (CR) on psychosocial risk factors and quality of life in patients with confirmed coronary artery disease. Participants had previously undergone a revascularization procedure. The 84 patients self-selected to participate in the Ornish Program for Reversing Heart Disease (n = 507 28), CR (n = 28), or a control group (n = 28). Twelve psychosocial risk factors and quality of life variables were collected from all three groups at baseline, 3 months, and 6 months. At 3 and 6 months, Ornish group participants demonstrated significant improvements in all 12 outcome measures. The rehabilitation group improved in 7 of the 12, and the control group showed significant improvements in 6 of the variables. Intensive lifestyle modification programs significantly affect psychosocial risk factors and quality of life.

Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life.

In an effort to make intensive lifestyle modification programs more accessible to patients with cardiovascular disease, the Ornish Program was offered at eight independent medical centers located across the United States. The purpose of this study was to determine if one of these independent sites was able to replicate outcomes produced by the original Ornish Program. Fifty program participants from six different cohorts provided baseline, 3- and 12-month data consisting of blood lipids, body fat, blood pressure, anginal pain, quality of life, stress, depression, social support, and hostility. A pooled analysis showed significant reductions in almost all physiological and psychosocial variables with most reductions persisting for at least 12 months. These findings suggest that cardiovascular disease patients who choose to participate in an independent, intensive lifestyle modification program can experience significant improvements in both physiological and psychosocial cardiovascular disease risk factors.

Gill W. Fellingham

Papers

The Effect of Duration of Stretching of the Hamstring Muscle Group for Increasing Range of Motion in People Aged 65 Years or Older

Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life.

The influence of an intense cardiovascular disease risk factor modification program.