Exercise Prescription

According to the International Conference on Frailty and Sarcopenia Research (ICFSR) expert consensus, prescription of physical activity and structured exercise should be based on the intended outcome (primary prevention, improvement in fitness or functional status, or disease treatment) and should be individualised, adjusted and controlled like any other medical treatment. ^[1] Practical prescription guidance structures the dose according to the principles of frequency, intensity, time (duration), type, volume and progression, as in current recommendations for patients with chronic heart failure. ^[2] The American College of Sports Medicine position stand on older adults states that exercise prescription should ideally include aerobic exercise, muscle strengthening exercises and flexibility exercises. ^[3] The 2026 American College of Cardiology scientific statement on exercise prescriptions covers aerobic, resistance, balance and flexibility training and concludes that exercise should be prescribed as a core component of cardiovascular prevention and disease management. ^[4] Exercise is Medicine was established in 2007 by the American College of Sports Medicine to educate physicians and other health care providers about exercise and to bridge the gap between health care and health fitness. ^[5] High-quality exercise prescription is described as an iterative, progressive process that integrates individual biopsychosocial patient factors into actionable and specific parameters, although no shared language or systematic process yet exists to explain prescription reasoning in musculoskeletal care. ^[6]

Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, and these changes are substantially attenuated in the presence of adequate exercise and physical activity. ^[1] Like other therapeutic agents, exercise shows a dose-response effect and can be individualised through different modalities, volumes and intensities, but unlike most drugs it is often directed at several physiological systems simultaneously. ^[1] In a dose-response meta-analysis of large prospective cohorts, differences in risk were greatest between 0 and 8.75 marginal MET-hours per week of non-occupational physical activity (equivalent to the recommended 150 min/week of moderate-to-vigorous aerobic physical activity), smaller up to 17.5 mMET-hours/week, and small and uncertain beyond that level. ^[7] The 2026 ACC scientific statement emphasises that the greatest absolute benefits occur when inactive individuals begin moving, with additional benefits accruing at higher volumes and intensity within appropriate clinical limits. ^[4] Training effects are largely modality-specific: in a Cochrane review of stroke survivors, physical effects tended to be intervention-specific, and cardiorespiratory training increased VO2 peak by 3.40 mL/kg/min.

Using individual level data from accelerometry studies (n=36 383), a harmonised meta-analysis found that any physical activity regardless of intensity was associated with lower mortality in a non-linear dose-response, with hazard ratios of 0.48 in the second quarter and 0.27 in the most active quarter compared with the least active. ^[11] At 8.75 mMET-hours/week of non-occupational physical activity, relative risks were 0.69 for all-cause mortality, 0.71 for cardiovascular disease mortality and 0.85 for cancer mortality, and achieving this level in all insufficiently active individuals would have averted an estimated 15.7% of premature deaths. ^[7] An umbrella review of meta-analyses found suggestive (not convincing) evidence linking aerobic plus resistance training with lower all-cause mortality (equivalent hazard ratio 0.60) and concluded that combined training most effectively reduces all-cause and cardiovascular mortality. ^[12] In a meta-analysis of 15 international cohorts, mortality risk fell progressively with more daily steps up to 6000-8000 steps per day in adults aged 60 years and older and up to 8000-10 000 steps per day in younger adults. ^[13]

The ICFSR consensus notes that exercise can be an alternative to pharmacological treatment in some conditions such as depression, and may play a primary role where no effective drug therapy exists, such as sarcopenia or dementia. ^[1] The 2026 ACC statement considers exercise testing useful to assess safety, guide intensity, establish baseline fitness and monitor responses, while recognising that routine preparticipation testing is not required for most asymptomatic individuals. ^[4] In heart failure, prescription must account for medications, implantable devices, exercise-induced ischemia and frailty. ^[2] The Exercise and Sports Science Australia position statement holds that multimodal, moderate to high intensity exercise is appropriate for most people with cancer, but that no single prescription or total weekly dosage is evidence-based for all cancer patients. ^[17]