Patient professional reference
Healthcare professionals may be involved in giving advice to people about physical training. Such advice may be given to healthy individuals, patients with a variety of medical conditions or even professional athletes. Appropriate levels of physical activity are important for good health and should be promoted by healthcare professionals.
Advice on exercise and physical training is best tailored to the individual. The advice will vary according to the individual's current state of health, their fitness, available resources and the aims and motivation of the individual.
Physical training may be started for a variety of reasons. It may be initiated by the individual or promoted by healthcare professionals in the course of comprehensive medical care.
Whatever the reason for discussing physical training, it is helpful to ask the individual some basic questions before embarking on a more detailed assessment and setting realistic targets.
- What is the motivation?
- Exploration of motivating factors should allow for encouragement and positive reinforcement. For example:
- What are the associated aims and objectives? What is the individual trying to achieve?
- There may be a very specific target (for example, running a marathon, or achieving specific weight loss).
- There may be more general aims (for example, looking and feeling better, reducing risk factors for disease).
- Clarification of this will help to understand the motivation and enhance this where appropriate with additional information, ideas and supporting evidence of benefit.
- Exploration of motivating factors should allow for encouragement and positive reinforcement. For example:
- What is their current state of health and fitness? For example:
- What is their past and present exercise routine?
- What is the current weight and body mass index (BMI)?
- Have they got any health problems? This may require a detailed history if the individual is not known to the doctor.
- What forms of exercise and training are preferred, possible and appropriate? For example:
- Does the chosen form of exercise suit the aims and state of health?
- Common options include:
- Gym membership.
- Personal trainer.
- Home training programme.
- Group activities (for example, keep fit clubs).
- Specific sporting activities.
- Use of community facilities (for example, leisure centres, swimming pools, etc.).
- Integration of training with other physical activities (for example, work, commuting and activities of daily living).
Even if an individual is healthy and highly motivated to train or exercise there may still be a role for medical advice. Excessive exercise or a training routine which is having an adverse effect on health, fitness or the achievement of objectives may need advice and modification (for example, in anorexia nervosa). Motivation may need modification but often encouragement and reinforcement are all that is required.
It is much more common outside professional sport to have to help, understand and improve the individual's motivation. It is also more likely that general health (rather than sports injuries) will be important to consider when giving advice on physical training and motivating people to take up exercise.
The reasons why individuals may be motivated to take up physical training are many and include:
- Specific targets or ambitions (for example, running a marathon, raising money for charity, weight loss, etc.).
- Participation in recreational or professional sport.
- Social and psychological benefits.
- Achievement of entry standards for certain careers, such as the armed forces, police or fire service.
- More general benefits (for example, general wellbeing, looking better, confidence, quality of life, etc.).
- Reduction of risk factors for disease (particularly when there is a family history).
- Management of disease.
Reinforcement of motivation
- Improved cardiovascular and respiratory reserve.
- Weight control.
- Reduction in blood pressure and the risk of hypertension.
- Improvements in blood lipids.
- Reduction in cardiovascular risk.
- Reduction in risk of type 2 diabetes.
- Benefits to mental health (including relief of stress and aggression).
- Reduction in the risk of osteoporosis (certain forms of exercise).
- Enhancement of smoking cessation.
- Reduction of falls and fractures in the elderly (improved balance).
- It may prevent, or slow, development of dementia.
Assessment of health and fitness
It is possible to do very extensive and detailed assessments of both health and fitness. Whether health and fitness are assessed in advance of physical training will depend on why training is being undertaken and on the person undertaking the training. Clearly, very often physical training is done without any formal medical consultation and with minimal medical history (for example, gym questionnaires, etc.). It is often done purely for insurance purposes.
The assessment may need to be detailed where specific activities or training are to be undertaken. However, it is usually sufficient to advise on known medical history without conducting exhaustive examinations or investigations. Consideration should be given to risk factors for disease and any existing diseases when giving medical advice on fitness. For medicolegal reasons, care should be taken in the wording of any endorsements of fitness for exercise or exercise programmes.
It is usually appropriate to make an assessment of health and fitness prior to exercise:
- When given as part of even general health promotion by the patient's GP.
- When given because of specific diseases or disease risk factors.
- For activities which carry specific risks to health or have specific contra-indications.
- When required by insurance companies or other interested third parties (for example, sports clubs, gyms, sporting associations, etc.).
Medical conditions and training
See also separate articles Heart Disease and Exercise and Diabetes Diet and Exercise.
Medical conditions are rarely a total bar to exercise but they may often impose limitations or require modification of training programmes. Others involved in helping, encouraging, coaching or teaching people with medical conditions may be made aware if appropriate to help support the individual concerned and to maintain a safe environment for all. Careful individual assessment is required. Common examples include:
- Asthma is common and affects children and adults. Asthma action plans or care plans should incorporate advice on exercise. Asthma may influence the choice of activity. It can be more troublesome in sports which involve running. It is less troublesome in cycling and least troublesome in swimming.
- Good control should be demonstrated. Improvements in control of asthma may be required when symptoms limit performance.
- As mentioned in the separate article Drugs and Sport, beta agonists are subject to regulation but this is relevant only for professional athletes subject to drug testing. Clearly, then a doctor will certify that medication is necessary and used by inhaler for asthma.
- Angina pectoris and intermittent claudication:
- Cardiac rehabilitation is essential for those recovering after myocardial infarction. It involves advice and graduated physical training programs.
- Pain should not be ignored. Exercise may be beneficial and enable the person to extend the time before the pain of angina or claudication demands cessation.
- Exercise should be unhurried and attempts to increase the distance should not be too ambitious.
- Glyceryl trinitrate (GTN) may be used before exercise.
- Betablockers may extend the duration of exercise in angina (although, generally, they are an impediment because they slow the heart rate response to exercise).
- Other heart disease:
- Exercise metabolises glucose and increases tissue sensitivity to insulin. This is important with vigorous exercise in those on insulin.
- When vigorous exercise is anticipated, the diabetic should reduce insulin and increase carbohydrate 20 minutes before exercise. Control can be complex when training is intensive but, as witnessed by prominent diabetic athletes, success at a high level can still be achieved.
- 'Fast glucose' should be available for symptomatic hypoglycaemia.
- It is also important to remember that rehydration after sport should not be alcoholic, as alcohol depresses blood glucose.
- As a general rule, arthritis benefits from exercise, although goals should be realistic.
- The notable exception is an acute inflammatory arthritis that needs rest.
- There is some evidence that mild depression in young people may benefit from an exercise programme but the evidence is not very strong.
- Exercise and physical training are important for obese patients to improve weight loss and are an essential part of a return to health and fitness.
- Caution is required because obesity is also a risk factor for other diseases, including heart disease, hypertension, diabetes and arthritis.
Methods in physical training
Methods to optimise physical performance and improve physical training have advanced in recent years. Some of this has arisen from the demands of sports which are increasingly the province of professional athletes and commercial demands. Physical training may involve:
- Stamina or endurance.
- Speed or rapid movements.
- Co-ordination and proprioceptive skills.
- Activity or sport-specific skills.
Physical training programmes
These can be tailored to suit motivation, aims, fitness, health and preference for equipment and methods of training. Familiarity with any equipment is important. Personal trainers will devise a physical training programme around such considerations.
Frequency of training
Training should be neither too frequent or infrequent. Muscles need recovery time. The physiology of exercise dictates that care should be taken to devise programmes which are appropriate. Generally, variety in the type of exercise taken is beneficial and avoids, for example, overuse or the development of imbalances in posture from asymmetric or unbalanced strengthening. This is particularly important in adolescents when muscle growth is very rapid.
Expensive equipment is not required. Comfort is essential.
Trainers should give adequate support and have good cushioning. They should be correctly fitted. Feet swell a little on exercise and so trainers may need to be slightly large when tried on cold. A pair of sports socks gives extra protection and absorbs sweat.
For some people, loss of weight will be the prime objective of physical training. For others it will be a secondary but important gain. Indeed trying to lose weight without exercise is extremely difficult. Exercise is more than burning extra calories during training. Nevertheless, diet must not be forgotten and alcohol is also a potent source of 'empty' calories.
Insulin is strongly anti-lipolytic whilst catecholamines facilitate lipolysis. This means that it is a potent force in preventing the breakdown of fat. Exercise suppresses insulin secretion and so facilitates the metabolism of fat. It is said that it takes 20 to 30 minutes of exercise before 'fat burning' starts. However, it is affected by many factors, including intensity of exercise and relationship to food intake. Type 2 diabetics have high resting levels of insulin but lipolysis will occur in them at higher levels of insulin. Hence, type 2 diabetics can successfully exercise and burn fat.
The rate at which fat is metabolised is dependent upon the rate of exercise. Exercise is often measured by the percent of maximal heart rate that is achieved as this is much easier to measure than percent of VO2 maximum (the maximum amount of oxygen in millilitres one can use in one minute per kilogram of bodyweight). If a person exercises at a rate of about 80% of maximum heart rate, most of the energy is provided by carbohydrate whilst only a minority is derived from fat. This can be calculated by the ratio of oxygen consumed to carbon dioxide produced, provided that the subject is not exercising at an anaerobic level. At 60% of maximal heart rate, the ratio is reversed and most energy comes from fat rather than carbohydrate. If maximum heart rate in beats per minute is 220 - age in years, calculation will show that 80% of maximum is not exceptionally onerous whilst 60% of maximum is a very leisurely pace.
Longer periods of less intense exercise are likely to be better for weight loss. Some people discount the concept of 'the fat burning zone'. More intense exercise may burn a lower percentage of fat but a higher total amount of fat. There are other variables such as an enhanced ability to metabolise fat with physical training.
With exercise, the early weight loss is not sustained (weight may even rise as fat is replaced by muscle). Vigorous exercise is followed by about 36 hours of a higher basal metabolic rate that is not seen after lower levels of exercise. The basal metabolism of muscle is rather higher than the fat that it replaces.
Muscle strengthening exercises are part of physical training and can involve use of weights.
- Individuals may use weights to maintain physical appearance.
- Strength training is important for many sports.
- It can prevent injury and is part of rehabilitation after injury. It can prevent recurrence of injury - for example, after injury to knees, shoulders and backs.
- Strength training as part of general physical fitness enhances the metabolism of fat.
There are certain rules or guidelines for weight training:
- Always warm up on cardiovascular equipment before moving on to weights.
- An exercise programme for one set of muscles (agonists) should be accompanied by a programme for the opposing set of muscles (antagonists). For example, biceps and triceps, quadriceps and hamstrings.
- Do not try to lift excessive weights or injury will result and set back training.
- As a general rule, using heavy weights that can be lifted just once before needing to rest is a less effective method of training than having less iron on the bar but doing more repetitions. This may not be true for power-lifting but it applies for most weight training. Repetitions should start at 8 to 10, working up to 12 before increasing weights progressively at subsequent sessions.
- Weight training sessions should not take place on consecutive days. Muscle building sessions should be at least 48 hours apart, although it is possible to do upper body work on one day and lower body work the following day.
Fitness training involves work on stamina and endurance. It comes in various forms and the profile of fitness required in different activities is varied. For example:
- Running 400 metres requires the ability to drive on and maintain anaerobic exercise whilst blood lactate levels are very high.
- Long-distance running is more aerobic, although a fast finish may involve an anaerobic flourish.
- Field sports, such as football, rugby and hockey, involve sprinting mixed irregularly with slower running at intervals over a long period of time. They require the ability to exercise anaerobically but with a rapid recovery time.
All this may be simulated in the gym or outdoors. Runners need both speed and stamina and so a 400 metres runner may train over 300 metres for speed and 500 metres for stamina. Even a 100 metres runner may train over 80 and 120 metres. Field sport athletes who need rapid recovery may train with activities which simulate match demands. In the 1970s there was a vogue for very high mileage training and distance runners may have trained by running 50 to 80 miles a week. This is no longer recommended. It leads to exhaustion and overuse injury.
The person who just wants to 'get fit' may start with some distance training, then insert some brief anaerobic training and finally aim for rapid recovery training. However, many people will be content to function at a much lower level.
Nutrition and hydration
Advances in nutritional medicine, the demands of professional sport and the increasing engagement of individuals with a healthier lifestyle have all helped dissemination of knowledge about healthy diets.
Diet is an important component of training. If weight loss is an aim, consumption, especially in the evening, should be reduced. In extreme exercise, taking in adequate calories can be a problem. Competitors in the Tour de France may be using 9,000 calories a day, and taking in that level of energy can be problematic.
People who aim to build a great deal of muscle eat a considerable amount of protein to do so. Protein is essential to build muscle. However, there is a tendency to eat vastly more protein than can be used to build muscle and even lean meat is quite high in fat.
Just a few decades ago steak and chips would be served at Twickenham to international rugby teams about to compete. Such a high-fat diet before exercise is ill-advised. Fat delays gastric emptying. Nowadays most teams and athletes have pasta before exercise. If a top level football team is competing with a kick-off at 3 pm, they will have a largely carbohydrate lunch at about 11.30 am.
A more scientific approach towards diet is one of the many reasons for improved standards in modern sport.
Nutrition includes adequate hydration. Even a fairly moderate level of dehydration has a significant effect on performance and this is an aspect that is now much better understood.
Further reading and references
Poirier P, Despres JP; Exercise in weight management of obesity. Cardiol Clin. 2001 Aug
Warburton DE, Nicol CW, Bredin SS; Health benefits of physical activity: the evidence. CMAJ. 2006 Mar 14
Penedo FJ, Dahn JR; Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry. 2005 Mar
Daniel JZ, Cropley M, Fife-Schaw C; The effect of exercise in reducing desire to smoke and cigarette withdrawal symptoms is not caused by distraction. Addiction. 2006 Aug
Kramer A, Erickson KI, Colcombe SJ; Exercise, Cognition and the Aging Brain. J Appl Physiol. 2006 Jun 15
Richter EA, Galbo H; Diabetes, insulin and exercise. Sports Med. 1986 Jul-Aug
Larun L, Nordheim L, Ekeland E, et al; Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006 Jul 19
Hales CN, Luzio JP, Siddle K; Hormonal control of adipose-tissue lipolysis. Biochem Soc Symp. 1978
Simonsen L, Henriksen O, Enevoldsen LH, et al; The effect of exercise on regional adipose tissue and splanchnic lipid metabolism in overweight type 2 diabetic subjects. Diabetologia. 2004 Apr
Achten J, Jeukendrup AE; Optimizing fat oxidation through exercise and diet. Nutrition. 2004 Jul-Aug
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