II Five points to consider when addressing exercise
III Practical examples
--Submitted by Elsbeth Vaino, Head trainer, Custom Strength
"Exercise is medicine" is an expression that a trainer friend of mine likes to use. I completely agree. But like medicine, it's very important to know what to prescribe. Prescribing too much medicine, or the wrong medicine can be dangerous. The same is true with exercise.
This can create a challenge for those in health promotion, because there is a need to get people moving more as our society faces an ever-growing obesity epidemic. What and how much exercise should you recommend as someone with a mandate to improve the health of those around you without a sound understanding of exercise physiology and biomechanics?
I have the good fortune to work as a strength and conditioning specialist in both a gym and a sports therapy clinic environment. This is aided by my background in engineering, which means I take a very analytical approach to training clients. I basically look at each client's body as a machine. I assess them to see what parts work well, and what parts need extra maintenance. I also have a sound understanding of general maintenance requirements for the body as a whole. Through my experience assessing and training clients, and the knowledge I have picked up from reading the works of, networking with, and attending courses by, great trainers and manual therapists, I have developed some expertise in exercise prescription. My hope is that I can share some critical points about how to prescribe exercise to help you provide better, and safer exercise guidance as part of your work in health promotion.
II Five points to consider when addressing exercise
There are five crucial elements of exercise that one should consider when providing exercise guidance:
1. "No pain, no gain" is an expression we have all heard, but is absolutely not appropriate for most people in most situations. In fact, a more appropriate saying would be "Pain? No gain!" Two things tend to happen when people exercise through the pain: they get injured and stop exercising, or they feel sore for days and stop exercising. The most effective exercise is the exercise that people will continue to do.
2. "Does it hurt?" is a question everyone should ask about the exercise they are doing. This sounds like a repeat of the first point, and in a way it is. It is just that important. But this is a slightly different point. If an exercise hurts someone, it is either not an appropriate exercise for that person in that situation, or it is an exercise that is not being performed properly. If you want to help people to develop life-long healthy exercise habits, it is very important that they hear this message. If someone is performing an exercise and it hurts, they should stop that exercise. Period. Now does this mean they should stop exercising entirely? No! They should either try something else, or they should try an easier version. One of the great things about exercise, is that there is always a way to make it a bit easier.
What if they cannot find any exercise that they can do without pain? Then it is time to bring in a professional. If they are in pain with regular activities, then they should go to a doctor or manual therapist (athletic therapist, chiropractor, massage therapist, osteopath or physical therapist). If they are only in pain with exercise, then they can either turn to a manual therapist or to a qualified personal trainer.
3. "Training is like farming; it takes time." This is an expression I learned from Michael Boyle, who is a Boston-based strength coach, and a leader in the training industry. Put another way, training is a careful and methodical process that will yield great results in due time. There are quick fixes out there, but they tend to have poor yields. The great news is that, like farming, exercise results in some improvements very quickly. Farmers will see plants start to pop through the earth within a fairly short time, just as those who exercise will see small changes in their body, or in how well they move. Further along these lines, more is not always better. Fertilizer is an important part of successful farming. But too much fertilizer will kill the crop. The same is true of exercise. Too much exercise, or the wrong exercise too soon, will cause damage; but the right amount will help the body to flourish. In both farming and exercise, the end goal takes time, and can only be achieved through patience and persistence. In both cases, it is definitely worth the wait.
4. Strength training is a better option than aerobic exercise for fat loss. This may be the first critical point that appears controversial, as many health promotion messages talk almost exclusively about aerobic exercise. In fact the Canadian Society of Exercise Professionals (CSEP) New Physical Activity Guidelines state: "To achieve health benefits, adults aged 18 – 64 years should accumulate at least 150 minutes of moderate- to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more.”  There is no mention of strength training, even though the evidence is quite significant that strength training is more effective for fat loss.  So why the focus on aerobic exercise? I do not know for certain, but I suspect for two reasons: because aerobic exercise is easier to prescribe, and because the CSEP guidelines are for overall health, not just for fat loss. While strength training is also great for overall health, aerobic training may have a bit of an edge there. But please consider strength training in your messaging alongside aerobic exercise. The muscle it builds increases a person's resting metabolic rate (RMR), meaning they will burn more calories even when they are not working out. And of course, that muscle also helps reduce the risk of osteoporosis and improves coordination, which is important in fall prevention for seniors.
5. You should be in shape to run; you should not run to get in shape. This may also come across as controversial. Running is a popular activity among people of all shapes, sizes and abilities, but is it a good way to get in shape? Running burns a lot of calories and requires minimal equipment, which is part of the reason it is so popular. But running also puts a lot of stress on the joints – the ground contact force as well as the vertical force on the hip joint in running is twice as high as it is in walking. [3,4] Loading of the joint is not necessarily a bad thing, and in fact weight bearing is important for bone mineral density. But for people who are obese, the forces on the joint while running can be very hard on the joints. [3,4] Running is best done by people who weigh less and ideally, who have built strong muscles to support the joints through this repetitive loading.  I often tell my runner clients that they should think of running as their sport, and that like other athletes, they must train for their sport.
III Practical examples
A great exercise example of progression and proper selection is the squat. The squat is an excellent exercise for a healthy person who has good ankle, hip, and thoracic spine mobility. It allows for great leg and core strength development, with little risk of injury if done well. But if mobility is lacking in any of those joints, perhaps from spending too much time at a computer, or from an arthritic hip, or a previous ankle injury, the exercise can cause compensations that will lead to injury. Should the squat be avoided then, just in case? Actually, no. That may seem like an appropriate response, but squatting is a fundamental movement pattern that we rely on every time we sit down and stand up again. So what should we do for the person who is not able to squat well? There are several options:
- They can start with less range of motion. Instead of squatting down to the point where their thighs are parallel with the ground, they can squat to a stool and gradually work down.
- Or they can hold onto something as they squat to take some weight off. As they get stronger, they can reduce how much they hold.
- They can try a slightly different exercise such as a split squat (static lunge). This exercise has a similar effect, but requires less hip mobility to do it well. It can be a great option for those with arthritic hips.
Another example is in the pushup. Pushups are not only great for the chest and arm muscles, but also for developing core strength. In order to do a pushup well, a person needs to have strength in these three areas. The best way to start is to do pushups from an incline. I often get clients to do pushups with their hands on the counter in their kitchen. If that is still too challenging, then they can try against a wall. As they get better, they can move to a lower and lower incline. In this way, they can experience the benefits of exercise, without the risk of injury or the feeling of failure that could come with trying to do actual pushups if they are not strong enough.
One last example is in regards to aerobic exercise. Whether it is walking, swimming, cycling, inline skating, or running, there are always options if one exercise is too challenging or is painful. The first progression to consider is to start with less. If walking for 30 minutes causes excessive fatigue or joint pain, then consider walking for only 20 minutes. Or they could try 15 minutes, take a break, and then try 15 more. The options are endless for regressing exercise to a level where individuals can do them safely, with a feeling that they are succeeding at every step instead of failing. But sometimes, it takes a bit of thought, planning and creativity.
One way to summarize the messages above, is that everyone should exercise to their ability, and let their ability, and their body dictate the pace. If pain is present, try to make some changes, and if pain persists, bring in a professional to help. If someone is unable to do an exercise, don't give up! Instead, try to find a way to make it easier and then work your way up from there. The beautiful thing about exercise, is that if you do it well, you will improve over time.
 Refer to http://elsbethvaino.com/2011/01/on-canadas-new-exercise-guideline/ for more information
 Relationship between vertical ground reaction force and speed during walking, slow jogging, and running. Available at http://www.sciencedirect.com/science/article/pii/0268003395000682
 An analysis of hip joint loading during walking, running, and skiing. Available at
 Refer to http://elsbethvaino.com/2010/01/am-i-fit-enough-to-play/ for more information.