Starting an Exercise Program

Aerobic exercise refers to exercise that requires more than the usual amount of oxygen to reach the muscles, thus the heart and lungs are forced to work harder. Running, biking, swimming, skating, and using aerobic exercise machines (such as treadmill, stair-climbing, and elliptical training machines) are activities that people do to experience aerobic exercise. Aerobic exercise tends to expend many calories, improves heart function, and decreases slightly the risk of death due to heart disease. However, it is less effective than strength training at building strength and muscle mass. Too much weight-bearing aerobic exercise (such as running or using a treadmill machine) causes excessive wear on the joints and surrounding tissues, thus contributing to the development of osteoarthritis.

For aerobic exercise to benefit the heart, exercise intensity should be increased until the heart rate is within about 60 to 85% of the maximum rate the body can sustain. This maximum rate can be estimated using a formula. But people should temporarily stop increasing the intensity of exercise if they have trouble breathing or maintaining controlled rhythmic breathing.

The target heart rate is only an estimate. Overweight or deconditioned people reach their target heart rate more quickly and with less effort. Athletic people reach their target heart rate more slowly. Conditioned athletes may exceed the target heart rate, because such targets are based on people of average fitness. People taking medications that slow heart rate (such as beta-blockers or calcium channel blockers) may not reach their target heart rate despite intense exercise. These people should discuss with their doctor what target heart rate is desirable.

A typical recommendation is to do 30 minutes of aerobic exercise at sufficient intensity about 2 to 3 times per week, with 5-minute warm-up (gradual increase to peak intensity) and 5-minute cool-down (gradual decrease in intensity) periods. However, the 30-minute length of time is arbitrary. Certain people can safely achieve maximum aerobic conditioning by doing as little as 10 to 15 minutes of activity per session 2 to 3 times per week if interval cycling is used.

In interval cycling (also called high intensity interval training or HIIT), moderate aerobic exercise is alternated with intense exertion. For example, about 90 seconds of moderate activity (60 to 80% of maximum heart rate) is alternated with 20 to 30 seconds of all-out effort, such as sprinting (85 to 95% of maximum heart rate or as hard as the person can exercise while maintaining correct exercise form). Proper technique should be maintained to avoid injury during intense exertion. Sometimes aerobic exercise can be done while strength training (for example, if little time is taken to rest between doing strength training exercises).

Exercise is one of most effective ways to improve overall health and health of the heart and lungs. However, people who do regular, prolonged and intense endurance exercise may be at slightly increased risk of developing atrial fibrillation, particularly people younger than age 55.

Different aerobic exercises work different muscle groups. For example, running works primarily the lower leg muscles. Landing on the heels and rising on the toes exerts the greatest force on the ankle. Riding a bicycle works primarily the upper leg muscles because pedaling works the front thigh muscles (quadriceps) and hips. Rowing and swimming work the upper body and the back predominantly. These exercises can be alternated each workout to avoid injury and work different muscle groups.

Strength training (also called resistance training) involves forceful muscular contraction against resistance, usually using free or machine weights or sometimes body weight (such as when a person does push-ups or abdominal crunches). Some people may use elastic bands rather than weights when they begin a strength training program.

Depending on how it is done, strength training may be somewhat less beneficial for cardiovascular fitness than aerobic exercise. However, sustained, high-intensity strength training can be as beneficial for cardiovascular fitness as aerobic exercise. The main goals of strength training are to develop the following in muscle:

• Strength

• Size

• Endurance

• Flexibility

In the long run, increased muscle mass helps a person become leaner and lose body fat because muscle uses more calories, even at rest, than do other types of tissues, particularly fat. More muscle mass also means more functional ability into later years, which helps people remain independent as they age. In older adults, particularly those who are frail, such as those living in nursing homes, increased muscle mass improves recovery from critical illness by improving mobility and providing the body with protein stores that are needed for recovery (see Exercise in Older Adults).

Strengthening muscles around an injury (for example, thigh muscles with an injured knee) decreases pain. Thus, a strength training program may help in injury rehabilitation. This approach should be supervised by a rehabilitation physical therapist.

Individual exercises are designed to strengthen particular muscles or muscle groups. Usually, larger muscle groups are exercised first, then smaller ones. Usually a person starts with the legs, then exercises the upper back, chest, shoulders, and then the arms. Maximum benefit is obtained by exercising at a high workload, but not necessarily to failure. Failure is defined as the point at which it is impossible to do another repetition while using the correct technique.

Traditionally, particular exercises are done in sets. Each set includes 8 to 12 repetitions of the exercise, done continuously (that is, no rest, or joint “locking,” between repetitions). The amount of weight used is the maximum that allows the person to do 8 to 12 repetitions in a relatively slow and controlled manner, without heaving, throwing, or lowering the weight too quickly. If the first set is done with high, steady tension, each subsequent set provides progressively less value. Three is generally the maximum recommended number of sets for most strength training exercises.

Tension time is another way to determine recommended muscle workload besides simply counting the amount and number of times a weight is lifted. Tension time refers to the total duration of lifting and lowering the weight in one set. Tension time should be briefer if the goal is moderate exercise and building strength than if the goal is more muscular endurance than strength (for example, during rehabilitation from injury). Tension time—rather than number of repetitions—is a better gauge of recommended muscle workload, whether exercising for strength, increases in muscle mass, or endurance.

To continue to increase strength and muscle mass, once the recommended tension time is achieved with good technique, weight should be increased to the maximum at which the person can maintain or be challenged again with the same tension time. Recommended tension time is ideally 40 to 60 seconds per set for the upper body and, because the lower body has greater endurance, about 60 to 90 seconds for the lower body. If the goal is muscular endurance, tension time is usually about 90 to 120 seconds. Strength athletes, such as power lifters, respond better and favor briefer tension times of 10 to 30 seconds because the concurrently heavier loads stimulate superior strength increases, although with less muscle growth and increases in endurance. However, the average person should avoid such heavy training because heavier loads also increase tissue strain and thus the risk of injury.

Frequency of exercise is a critical factor. Muscles start to break down when exercised heavily more often than every other day. The day after an adequate workout, bleeding and microscopic tears are present in muscle fibers, which is probably why muscles feel sore. This soreness (also called an alarm reaction) is one sign that muscles are being stimulated to repair themselves and grow to adapt to a higher state of function. Exercisers should allow about 48 hours for muscles to recover after exercise. After very vigorous exercise, a muscle group may take several days to heal completely and thus become stronger. Hence, in strength training, it is usually best to alternate the muscle groups being exercised. One ideal schedule, for example, alternates exercise for the upper body on one day with exercise for the lower body on the next, with each muscle trained no more than twice per week. The more intense and the more exercise done for a muscle, the less often it should be worked. People who train with a very high level of intensity of effort likely should not train each muscle any more than once a week to allow for proper recovery.

Injury rehabilitation may not aim for development of large muscles initially, although better muscle function and strength strongly correlate with reduced pain. Exercising with less weight but increased number of repetitions can increase strength and endurance, provide some aerobic exercise (particularly if rests between sets are less than 60 seconds), and increase blood flow to the area, which accelerates healing. This approach may be tolerated better than exercising muscles with too much weight and fewer repetitions, which requires a high degree of motivation. Exercise form must be strictly maintained because incorrect form risks aggravating the injury. People who are undergoing rehabilitation may limit exercise because of discomfort or pain. Occasionally these people also may be inexperienced with exercise and may not know how much effort they are capable of. Once the injured person's confidence and function increase (and often pain decreases), intensity of effort and workloads should increase in order to optimize results.

In circuit weight training, the large muscles of the legs, hips, back, and chest are exercised followed by the smaller muscles of the shoulders, arms, abdomen, and neck. Some people prefer to train legs last because they require so much energy and are so fatiguing to work. Circuit weight training of only 15 to 20 minutes (with 30 seconds or less of rest between exercises/sets) potentially can benefit the cardiovascular system more than jogging or using aerobic exercise machines for the same amount of time. The workout is often more intense, and heart rate can increase even more as a result. However, resting for longer periods between certain exercise sets might help recovery of muscle energy stores between sets, resulting in better effort in subsequent sets and thus more muscle strength gains.

Safe technique is of paramount importance. Jerking or dropping weights can cause injury due to sudden starts and stops. People should move smoothly and continuously while exercising, striving for proper body mechanics (chest high, shoulders square and back, stomach pulled in tight, avoiding locking the joints). Controlled breathing prevents light-headedness and fainting, which can occur when forcefully exhaling or bearing down. Specifically, people should exhale while lifting a weight and inhale while lowering a weight. If a movement is slow, such as lowering a weight for 5 seconds or longer, people may need to breathe in and out more than once, but breathing still should be coordinated so that a final breath is taken just before the lifting phase and released when lifting begins.

Blood pressure increases during resistance training, particularly when the large muscles of the lower body are worked and when gripping very hard with the hands (as when doing the leg press exercise while gripping the machine's handles). However, blood pressure returns to normal quickly after exercise. This temporary increase in blood pressure is minimal when the breathing technique is correct, no matter how hard a person may exert. Most people who intend to lift weights benefit from initial supervision that includes instruction on how to set the weights and seat levels, how to maintain proper technique, and how to breathe during exercises. Having a professional trainer observe as the person exercises is usually most helpful, so that improper techniques can be identified and corrected.

Stretching reduces stiffness of muscles and tendons and thereby improves flexibility. Flexibility is important for comfortable performance of everyday physical activities. Although stretching itself does not strengthen muscles, it can increase the area over which the muscle contracts, which allows muscle force to be exerted more effectively and with less risk of injury. Stretching may help people jump higher, lift heavier weights, run faster, and throw farther.

Specific flexibility exercises involve slowly and steadily stretching groups of muscles without jerking, bouncing, or causing excess pain (minor discomfort is normal when stretching current limits of a joint, but pain should never be severe or intolerable). To achieve maximal flexibility, a stretch should be held for 20 to 60 seconds. A stretch can be held longer than 60 seconds, but doing so has not been proven to further increase flexibility. Stretches are usually repeated 2 to 3 times, each time stretching further than before if possible. These exercises can be done before or after other forms of training or as a program in itself, as occurs in yoga and Pilates sessions.

Although stretching before exercise enhances mental preparedness, there is no conclusive evidence that stretching decreases risk of injury. General warming-up (for example, with low-intensity simulation of the exercise to be done, jogging on the spot, calisthenics, or other light activities that increase core temperature) appears to be more effective than stretching for facilitating safe exercise and feeling loose and limber. Stretching after exercise is preferred because tissues stretch more effectively when warmed. Stretching also can be done between exercises, but stretching between exercises can decrease strength during exercise, thus resulting in the need to decrease the weight or number of repetitions during strength training.

Balance training aims to challenge the center of gravity by exercising in unstable environments, such as standing on one leg or using balance boards. Basic strength training improves balance because it increases muscle size and strength around the joints, improving balance indirectly because the joints are more stable.