Canadian Journal of Cardiology - (2016) 1e9
Review
Practical Approaches to Prescribing Physical Activity and
Monitoring Exercise Intensity
Jennifer L. Reed, PhD, MEd, CS, and Andrew L. Pipe, CM, MD
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
ABSTRACT
Regular physical activity helps to prevent heart disease, and reduces
the risk of first or subsequent cardiovascular events. It is recom-
mended that Canadian adults accumulate at least 150 minutes of
moderate- to vigorous-intensity aerobic exercise per week, in bouts of
10 minutes or more, and perform muscle- and bone-strengthening
activities at least 2 days per week. Individual exercise prescriptions
can be developed using the frequency, intensity, time, and type prin-
ciples. Increasing evidence suggests that high-intensity interval training
is efficacious for a broad spectrum of heart health outcomes. Several
practical approaches to prescribing and monitoring exercise intensity
exist including: heart rate monitoring, the Borg rating of perceived
exertion scale, the Talk Test, and, motion sensors. The Borg rating of
perceived exertion scale matches a numerical value to an individual’s
perception of effort, and can also be used to estimate heart rate. The
Talk Test, the level at which simple conversation is possible, can be
used to monitor desired levels of moderate- to vigorous-intensity
exercise. Motion sensors can provide users with practical and useful
exercise training information to aid in meeting current exercise rec-
ommendations. These approaches can be used by the public, exercise
scientists, and clinicians to easily and effectively guide physical activity
in a variety of settings.
Heart disease remains one of the leading causes of death in
Canada. More than 1.3 million Canadians are living with
heart disease, and 9 in 10 have at least 1 modifiable risk
factor.1 There is irrefutable evidence that regular physical
activity contributes to the prevention of heart disease,
lowering the risk of first or subsequent cardiovascular
Received for publication August 13, 2015. Accepted December 16, 2015.
Corresponding author: Dr Jennifer L. Reed, University of Ottawa Heart
Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada. Tel.: þ1-613-
761-5284; fax: þ1-613-761-5238.
E-mail: jreed@ottawaheart.ca
See page 7 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2015.12.024
0828-282X/
2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.


RESUM

E

physique re
L’activite
gulière aide à pre
venir les maladies du cœur et

duit le risque d’e
re
ve

nements cardiovasculaires initiaux ou
subse
quents. On recommande aux adultes canadiens d’accumuler au
moins 150 minutes d’activite
physique ae
robie d’intensite
mode
re
e à
vigoureuse par semaine, par pe
riodes de 10 minutes ou plus, et de
pratiquer des activite
s de renforcement musculaire et osseux au moins
2 fois par semaine. Les prescriptions individuelles d’exercices peuvent
être e
labore

es sur la base des principes de fre
quence, d’intensite
, de
dure
e et de type. Les donne
es probantes de plus en plus nombreuses
suggèrent que l’entraînement par intervalles à haute intensite
est
efficace pour un large e
ventail de re
sultats en matière de sante

cardiaque. Il existe plusieurs approches pratiques en matière de
prescription et de surveillance de l’intensite
de l’exercice, dont la sur-
veillance de la fre
quence cardiaque, la notation sur l’e
chelle de
perception de l’effort de Borg, le test de la parole et les capteurs de
mouvement. La notation sur l’e
chelle de perception de Borg corres-
pond à une valeur nume
rique de la perception individuelle de l’effort,
qui peut e
galement être utilise
pour estimer la fre
quence cardiaque.

de tenir une conversation
Le test de la parole, c’est-à-dire la possibilite
simple, peut être utilise
pour atteindre les niveaux vise
s d’activite


physique d’intensite
mode
re
e à vigoureuse. Les capteurs de mouve-
ment peuvent fournir aux utilisateurs des informations pratiques et
utiles sur l’entraînement à l’effort pour les aider à se conformer aux
recommandations actuelles en matière d’activite
physique. Ces
approches peuvent être utilise
es par le public, et par les scientifiques
et les cliniciens de l’activite
physique pour guider facilement et effi-
cacement l’activite
physique dans des cadres varie
s.
events.2,3 The Canadian Society for Exercise Physiology
(CSEP) recommends that adults aged 18-64 years accumulate
at least 150 minutes of moderate- to vigorous-intensity aer-
obic exercise per week, in bouts of 10 minutes or more.4
Muscle- and bone-strengthening activities using major mus-
cle groups are also advised on at least 2 days per week.4
Adherence to CSEP guidelines increases the likelihood that
improvements in health and fitness will be achieved.2,5,6 It is
important that physical activity, ordinarily a fundamental
element of human behaviour, be viewed from a practical
perspective. There is a danger that we can ‘overmedicalize’
this important health behaviour and in so doing, intimidate,
complicate, or otherwise deter adoption of simple, healthy
patterns of activity.
2 Canadian Journal of Cardiology
Individual exercise prescriptions can be developed using
the frequency, intensity, time, and type (FITT) principles.7
The most difficult of these principles to prescribe is
intensity, particularly when exercise testing with ergo-
spirometry, the gold standard for determining peak aerobic
power (VO_ 2peak), is not available. Peak aerobic exercise testing
is often impractical because of the cost, expertise, and tech-
nological resources required. Several alternative and practical
approaches to prescribing and monitoring exercise intensity
exist, including heart rate monitoring, Borg rating of
perceived exertion (RPE) scale,8 Talk Test,9 and motion
sensors. These methods are used by the general population,
exercise physiologists and therapists, and clinicians, but are
not without limitations. In this article we examine the role of
regular exercise in reducing modifiable risk factors, current
exercise training recommendations for Canadian adults,
including new approaches such as high-intensity interval
training (HIIT), and practical tools for prescribing and
monitoring exercise intensity.
Risk Factors for Heart Disease
There are several nonmodifiable and modifiable risk factors
for heart disease. Nonmodifiable risk factors include age, sex,
family history, ethnicity, and history of stroke or transient
ischemic attack. Modifiable risk factors include a sedentary
lifestyle (not participating in at least 30 minutes of moderate-
intensity exercise on at least 3 days of the week for at least 3
months), sedentary behaviour, inadequate consumption of
fruits and vegetables, being overweight and obese, high blood
pressure, high cholesterol, diabetes, stress, depression, and
smoking.1,7,10,11 Most Canadians (90%) aged 20 years and
older have at least 1 modifiable risk factor for heart disease, with
many having more than 1 risk factor (Fig. 1).1 The risk of heart
disease increases as the number of risk factors increases.
Figure 1. Percentage of the Canadian population aged 20 years and
older who reported  1 modifiable risk factors for heart disease, ac-
cording to age group. ª All Rights Reserved. Tracking Heart Disease
and Stroke in Canada, 2009. Chronic Disease Surveillance Division,
Centre for Chronic Disease Prevention and Control, Public Health
Agency of Canada, using data from Canadian Community Health Sur-
vey (Statistics Canada). Adapted and reproduced with permission from
the Minister of Health, 2015.1
Volume - 2016
The Role of Exercise in Reducing Risk Factors
for Heart Disease
Despite the overwhelming evidence supporting regular
exercise in the prevention of heart disease, few (15%) Cana-
dian adults accumulate the recommended 150 minutes of
moderate- to vigorous-intensity aerobic exercise per week, in
bouts of 10 minutes or more.12 It is estimated that in the
United States, 23% of adults participate in strengthening
activities at least 2 times per week.13 Estimates for Canada do
not currently exist but are likely similar. Substantial evidence
supports the role of moderate- to vigorous-intensity aerobic
exercise in reducing the modifiable risk factors for heart dis-
ease, including being overweight and obese, hypertension,
dyslipidemia, diabetes, stress, and depression. Reducing these
risk factors before a first cardiovascular event could prevent or
postpone 33% of all cardiovascular-related deaths.14 Unlike
drugs, which are typically specific for single modifiable risk
factors (eg, antihypertensives, lipid-lowering agents, antidia-
betics), exercise exerts favourable effects on all risk factors
simultaneously. In Table 1 the health benefits associated with
regular exercise are summarized.15 The role of physical activity
in addressing specific risk factors for heart disease is addressed
in more detail below.
Physical activity and overweight and obesity
More than 39% of Canadian men and 27% of Canadian
women are overweight (body mass index, 25.0-29.9 kg/m2),
and more than 20% of Canadian adults are obese (body mass
index,  30.0 kg/m2).16 Changes in weight are affected by the
amount of energy expended vs the amount of calories
consumed.17 If energy expenditure remains low, but caloric
consumption is in excess, weight gain will occur. Strong
evidence suggests that regular aerobic exercise can attenuate
Table 1. Health benefits associated with regular exercise
Adults and older adults
Strong evidence
 Lower risk of early death
 Lower risk of coronary artery disease
 Lower risk of stroke
 Lower risk of high blood pressure
 Lower risk of adverse blood lipid profile
 Lower risk of type 2 diabetes
 Lower risk of metabolic syndrome
 Lower risk of colon cancer
 Lower risk of breast cancer
 Prevention of weight gain
 Weight loss, particularly when combined with reduced calorie intake
 Improved cardiorespiratory and muscular fitness
 Prevention of falls
 Reduced depression
 Better cognitive function (for older adults)
Moderate to strong evidence
 Better functional health (for older adults)
 Reduced abdominal obesity
Moderate evidence
 Lower risk of hip fracture
 Lower risk of lung cancer
 Lower risk of endometrial cancer
 Weight maintenance after weight loss
 Increased bone density
 Improved sleep quality
Reproduced from U.S. Department of Health and Human Services.15
Reed and Pipe
Physical Activity and Monitoring Exercise Intensity
weight gain in those at risk for overweight and obesity, and is
capable of assisting with some degree of weight loss (approx-
imately 2 kg).18 It is important to note, however, that
substantial weight loss is unlikely without accompanying
caloric restriction.19 Between 150 and 300 minutes of mod-
erate- to vigorous-intensity aerobic exercise per week is advised
for the prevention of weight gain and maintenance of weight
loss.18 Clinical trials of exercise training that report no weight
loss or modest weight loss (<5 kgs) still show numerous
health benefits for overweight and obese adults at risk of heart
disease; they include, but are not limited to, improved fitness,
endothelial function, lipoprotein particle size, and high-
density lipoprotein (HDL) and glucose control.19
Physical activity and hypertension
It is estimated that 17.7% (5.3 million) of Canadians aged
12 years and older have hypertension,20 defined as the
chronically increased resting arterial blood pressure > 140
mm Hg systolic and/or 90 mm Hg diastolic. Strong evidence
from a recent meta-analysis of randomized controlled trials of
exercise training in persons without cardiovascular or other
diseases (5223 participants: 3401 exercise training partici-
pants and 1822 sedentary controls) suggests that systolic
blood pressure is reduced after endurance (3.5 mm Hg),
dynamic resistance (1.8 mm Hg), and isometric resistance
(10.9 mm Hg) training.21 Diastolic blood pressure is
reduced after endurance (2.5 mm Hg), dynamic resistance
(3.2 mm Hg), isometric resistance (6.2 mm Hg), and
combined (2.2 mm Hg) training.21 The greatest reductions
in blood pressure occur in response to moderate- to high-
intensity aerobic exercise.21
Physical activity and dyslipidemia
Many Canadian adults report having high total cholesterol
(>19%;  5.2 mmol/L), high low-density lipoprotein
(>12%;  3.5 mmol/L), and low HDL (>22%;  1.0
mmol/L in men and  1.3 mmol/L in women).22 Regular
exercise leads to favourable antiatherogenic modifications of
lipid metabolism. A recent meta-analysis of randomized
controlled trials identified that moderate- to vigorous-intensity
exercise training (aerobic, resistance, and/or combined)
significantly reduced triglyceride levels (0.30 mmol/L), and
increased HDL (þ0.13 mmol/L) and apolipoprotein A1
Table 2. Exercise frequency, intensity, time, and type recommendations for adults7
Frequency Intensity
At least 5 days per week _ 2
Moderate (40 to < 60% HRR or VO
reserve)
At least 3 days per week _ 2
Vigorous (60 to < 90% HRR or VO
reserve)
Each major muscle group 40%-50% 1 RM (very light to light
2-3 days per week intensity) for sedentary individuals
beginning to exercise
60%-70% 1 RM (moderate to
vigorous intensity) for novice to
intermediate exercisers
 80% 1 RM (vigorous to very
vigorous intensity) for experienced
strength trainers
HRR, heart rate reserve; RM, repetition maximum; VO _ 2, oxygen uptake.
3
(þ0.23 mmol/L) levels compared with controls.23 Aerobic
exercise also reduces low-density lipoprotein and total
cholesterol levels.24 The mechanisms by which these modifi-
cations occur might be attributed to reduced insulinemia;
increased somatotrope (growth hormone), cortisol and cate-
cholamine; increased lipoprotein lipase activity; increased
lecithin-cholesterol-acetyltransferase enzyme activity; and,
reduced hepatic triglyceride lipase activity.24
Physical activity and diabetes
More than 8% of Canadian adults are living with type 1
or type 2 diabetes mellitus (T2DM).25 Exercise training
significantly reduces fasting insulin concentrations (1.03
mIU/mL),23 homeostatic model assessment-insulin resistance
(0.30),23 and glycated hemoglobin A1c (0.28%)
compared with controls.23 Observations from the Health
Benefits of Aerobic and Resistance Training in Individuals
with Type 2 Diabetes (HART-D) and Diabetes Aerobic and
Resistance Exercise (DARE) trials suggest that an exercise
training program composed of moderate-intensity aerobic
exercise and resistance training promotes greater changes in
hemoglobin A1c compared with aerobic exercise or resistance
training alone in adults with T2DM.26,27 Modifications in
glucose tolerance and insulin sensitivity are associated with
exercise training volume, and glucose uptake increases more
markedly in trained than in untrained muscles.28 Although
exercise training has been shown to improve blood glucose
and insulin concentrations, it might not reduce the risk or
rate of future cardiac events in those with T2DM. Findings
from the Action for Health in Diabetes (Look AHEAD) trial
showed that an intensive lifestyle intervention involving ex-
ercise and dietary modification to induce a mean weight loss
of 7% or more did not reduce the rate of cardiovascular
events in overweight or obese adults with T2DM.29
Aerobic Exercise and Resistance Training
Recommendations
The CSEP recommends that adults aged 18-64 years
accumulate at least 150 minutes of moderate- to vigorous-
intensity aerobic exercise per week, in bouts of 10 minutes
or more.4 Examples of moderate- to vigorous-intensity aerobic
exercise include brisk walking, jogging, climbing, lifting
Time Type
30-60 minutes per day (at least 150 Continuous exercise using major
minutes per week) in bouts of 10 muscle groups
minutes or more
20-60 minutes per day (at least 75 Continuous exercise using major
minutes per week) in bouts of 10 muscle groups
minutes or more
No specified duration. 2-4 sets with Resistance training
8-12 repetitions per set with a rest
interval of 2-3 minutes between sets
4 Canadian Journal of Cardiology
heavier loads, shoveling snow, swimming, and competitive
sports. Muscle- and bone-enhancing activities using major
muscle groups at least 2 days per week are also advised. In
Table 2 the specific FITT recommendations for aerobic
exercise and resistance training are identified.7 These recom-
mendations are generally appropriate for young to middle-
aged adults at risk of heart disease. Special considerations
should be given for children and adolescents, older adults,
pregnant women, and specific clinical populations (eg, those
with heart disease, arthritis, cancer, renal disease, osteoporosis,
or those at high risk for coronary artery disease, with long-
standing diabetes, high Framingham score, and significant
family history).7
HIIT
HIIT is a form of exercise in which individuals alternate
periods of short, intense, nonoxidative exercise with less intense
recovery periods. It has been defined as either repeated short
(eg, < 45 seconds) to long (eg, 2-4 minutes) bouts of rather
high (ie, > 75% VO _ 2peak, > 80% maximal heart rate
[HRmax])-intensity exercise, or short (eg, 10 seconds,
repeated sprint sequences) or long (eg, > 30-45 seconds, sprint
interval session) all-out sprints, interspersed with recovery pe-
riods.30 HIIT has traditionally been used to train athletes
requiring high levels of oxidative and nonoxidative fitness (eg,
track and team sport athletes), but in the past decade,
increasing evidence has shown its efficacy in achieving a broad
spectrum of heart health outcomes in those with heart disease.
In a recent review, Kessler et al.31 reported that HIIT improved
insulin sensitivity, HDL levels, and blood pressure in healthy
populations and in those with established cardiovascular and
metabolic disease.31 Weston et al.32 published a systematic
review and meta-analysis (10 studies, 273 patients) showing the
superiority of HIIT compared with moderate-intensity,
continuous exercise among patients with cardiometabolic dis-
ease in improving VO _ 2peak (þ3.0 mL/kg/min),32 blood pres-
sure (8/5 mm Hg),33 HDL (þ0.1 to þ0.15 mmol/L),34,35
triglycerides (0.4 mmol/L),35 and fasting glucose levels
(0.7 to 0.9 mmol/L).34,35
There are, however, conflicting opinions in the literature as
to the effectiveness and safety of HIIT for population-level
exercise training options.36 It has been argued that those
who need to exercise the most will choose the ‘hard’ option of
HIIT, and for those who do there will be poor adherence and
high attrition, such that effectiveness will be low.36 Such
criticisms have largely been directed at sprint-interval training
(ie, Wingate-based HIIT), one of many permutations of
HIIT. It has also been argued that HIIT might be psycho-
logically aversive leading to dropout or a marked reduction in
exercise intensity over time during self-regulated exercise
training bouts.36 HIIT appears to be safe for the rehabilitation
(class 1 recommendation) of patients with coronary artery
disease and heart failure.37-39 Because few (15%) Canadians
are meeting the recommended 150 minutes of moderate- to
vigorous-intensity aerobic exercise per week, it is appropriate
to consider alternative, effective exercise training options.
Such an approach might be particularly appropriate for those
with a history of sport or significant exercise activity in the
past who are dismissive of simple, low-level activity recom-
mendations (eg, walking daily). The following practical FITT
Volume - 2016
Table 3. FITT approach to HIIT7,40
Frequency. Most days of the week; a day of rest between training sessions is
recommended to avoid injuries or overtraining if the sessions incorporate
resistance training.
Intensity. High-intensity (64%-100% VO _ 2max; 76%-100% HRmax; 60%-
100% HRR or VO _ 2R; 14-20 RPE;  6 MET) exercise. Begin with
moderate, followed by moderate to high, then progress to high-intensity
exercise.
Time intervals. Work to rest intervals of 20-60 seconds. Begin with a 30-
second bout of moderate-intensity exercise, followed by a 2-minute
recovery period of lower intensity activity. As fitness improves, decrease the
duration of the recovery period until it eventually matches that of the
exercise bout. Time sessions: 15-30 minutes per training session.
Type. Aerobic activities that use large muscle groups (eg, swimming, outdoor
running, running on the spot, cycling, spinning, rowing, elliptical,
skipping). Avoid activities that require balance and coordination.
Examples: alternating running and walking between telephone poles or
alternating sprint and recovery freestyle laps in a swimming pool.
FITT, frequency, intensity, time, type; HIIT, high-intensity interval
training; HRR, heart rate reserve; HRmax, maximal heart rate; MET, meta-
_ 2max, maximal
bolic equivalent of task; RPE, rating of perceived exertion; VO
_ 2R, oxygen uptake reserve.
aerobic power; VO
recommendations (Table 3) might help to encourage in-
dividuals to participate in and sustain this form of exercise. It
must be emphasized that progression to high-intensity levels
of exercise is not necessary for the benefits of this form of
regular physical activity to be achieved.
Practical Approaches to Prescribing and
Monitoring Exercise Intensity
Exercise training standardized according to an absolute
_ 2: 1.2 L/min; workload: 150 W; heart
external workload (ie, VO
rate: 150 beats per minute) might produce large differences in
cardiometabolic stress between individuals. It is more common
to “individualize” exercise prescriptions. Individual exercise
prescriptions are developed using the FITT principles.7 The
most difficult of these principles to prescribe is intensity. The
traditional approach when prescribing relative exercise intensity
has been to use a percentage of maximal aerobic power
_ 2max) or HRmax, and the literature continues to favour these
(VO
methods.41 Exercise testing with ergospirometry is the gold
standard for determining VO _ 2max. However, maximal exercise
testing is impractical for exercise prescription at the population
level. Alternative and practical methods for prescribing and
monitoring relative exercise intensity are available and
frequently used (Table 4).7,9,42 Depending on the method used,
varying exercise intensities can be derived and therefore
prescribed (Supplemental Fig. S1).
One of the difficulties in getting sedentary individuals to
engage in effective exercise training is the lack of specific
recommendations, unlike the ones that are provided for pre-
scription medications. All too often the concepts of exercise
intensity are poorly explained, and ineffective prescriptions are
provided. At one extreme is general exercise training in which
an individual is told to take the stairs or walk. Such activities
will certainly not cause any harm, but are relatively inadequate
for improving cardiovascular fitness and decreasing one’s risk
for heart disease unless practiced for at least 2 or more hours
per week.2,43 There is strong evidence from experimental trials
that regular moderate- to vigorous-intensity exercise is critical
for reducing one’s risk of heart disease.2,6 Heeding advice to
Reed and Pipe 5
Physical Activity and Monitoring Exercise Intensity

_ 2, heart rate, rating of perceived exertion, Talk Test, and metabolic equivalent methods7,9,42
Table 4. Exercise intensity ranges calculated using VO
% HRR RPE scale
Intensity _ 2max
% VO % HRmax _ 2R
or % VO (6-20) Talk test MET level Activity
Light 37 to < 45 57 to < 64 30 to < 40 9-11 Comfortable conversation <3 Walking, very slow (2 mph)
possible
Moderate 46 to < 64 64 to < 76 40 to < 60 12-13 Comfortable conversation 3 to < 6 Walking the dog
possible
Vigorous 64 to < 91 76 to < 96 60 to < 90 14-17 Comfortable conversation 6 to < 8.8 Jogging, basketball game, tennis
not likely possible singles, swimming laps moderate
or light effort
Near maximal  91  96  90  18 Comfortable conversation not  8.8 Running fast (6 mph, 10 min/mile)
or maximal possible
_ 2, oxygen uptake; VO
HR, heart rate; HRR, heart rate reserve; MET, metabolic equivalent of task; RPE, rating of perceived exertion; VO _ 2R, oxygen uptake
reserve.

take the stairs or walk might serve to ease the transition from a
sedentary lifestyle to one of regular moderate- to vigorous-
intensity exercise. It is important to recognize that for the
most of the population the adoption of low to moderate levels
of exercise on a near daily basis might be appropriate and
realistic. At the other extreme are recommendations suited for
athletic individuals such as HIIT for improving VO _ 2peak.
HIIT might be dangerous with respect to musculoskeletal
injuries for sedentary individuals, especially those who are
obese and/or have no previous exercise training experience. To
ensure that individuals are working at the recommended
exercise intensity, one must be able to quantify and/or qualify
their efforts. Several practical tools are available and are
frequently used for such purposes.
Practical Tools for Prescribing and Monitoring
Exercise Intensity
Heart rate monitoring
There is a linear relation between heart rate and VO _ 2
during exercise, particularly between heart rates of 110-150
beats per minute (moderate- to vigorous-intensity).44 The cost
of heart rate monitors range between $50 and $500,
depending on the available features (eg, calorie counter, GPS
receiver, accelerometer, calendar); they are lightweight and are
user-friendly, making them appropriate, cost aside, for wide-
scale use. Many pieces of aerobic exercise equipment also
contain heart rate monitors. Prescribing exercise intensity
according to a percentage of a person’s HRmax has been, and
remains, a commonly used method by many health and fitness
professionals. Maximal exercise tests, which might be used to
determine HRmax, are often impractical because of the cost,
expertise, and technological resources required. If such testing
is not feasible, HRmax can be estimated using standardized
equations. Several commonly used equations for estimating
HRmax are shown in Table 5.45-48 (When estimating HRmax
the use of b-blocker medications must be considered; specif-
ically, 30 beats per minute should be subtracted from an
estimated HRmax.49) It is preferable to prescribe exercise
intensity on the basis of a percentage of a person’s heart rate
reserve (HRR) rather than a percentage of his or her HRmax.
HRR takes into account maximal and resting heart rates, and
is calculated as: % HRR ¼ (((HRmax  HR at rest)  %
intensity) þ HR at rest).7 Measured HRmax or age-estimated
HRmax equations (adjusted for b-blocker use as appropriate),
if needed, can be used to compute % HRR.49 As shown in
Supplemental Figure S1, relative exercise intensity might
differ depending on whether it is calculated using a percentage
of HRmax or HRR. For examples of how to apply this equa-
tion, see Supplemental Box S1.
Using heart rate to prescribe and monitor exercise intensity
is not without limitations. Heart rate is influenced by
cardiovascular conditions (ie, arrhythmias), high ambient
temperature, emotional stress, high humidity, caffeine, med-
ications (ie, b-blockers), dehydration, posture, size of the
muscle mass involved in exercise, fatigue, and illness.44,50
Further, heart rate monitoring is limited because small
changes in heart rate can reflect large differences in work-
load.51 Many can experience difficulty in assessing their own
heart rate. Despite these limitations, heart rate monitoring
remains a valid, reliable, and practical means of prescribing
and monitoring exercise intensity.
Borg RPE
The Borg RPE scale is self-reported; it is an easily imple-
mented and validated approach to assessing exercise intensity,
and a practical means of prescribing and monitoring exercise.
It matches an individual’s perception of effort on a scale of 6
to 20.8 The scale begins with “no exertion at all,” (RPE ¼ 6),
and ends with “very, very hard,” (RPE ¼ 20). The scale can
also be used to estimate heart rate; multiplying the Borg score

Table 5. Commonly used equations for estimating HRmax

Reference Equation Population used to derive equation
Fox et al.45 HRmax ¼ 220  age Small group of men and women
Astrand46 HRmax ¼ 216.6  (0.84  age) Men and women aged 4-34 years
Tanaka et al.47 HRmax ¼ 208  (0.7  age) Healthy men and women
Gellish et al.48 HRmax ¼ 207  (0.7  age) Men and women participants in an adult fitness program with
a broad range of age and fitness levels
HRmax, maximal heart rate.
6 Canadian Journal of Cardiology
by 10 gives an approximate heart rate for a particular level of
exercise. The modified Borg Category-Ratio 10 scale is used to
assess localized muscle, breathing, or pain sensations, which
are characteristic of resistance training exercise.52 For this tool
to be used it is necessary that an individual can see the
scaleda significant limitation for those who wish to exercise
outdoors!53 Some investigators have questioned the use of the
Borg RPE scale in monitoring or prescribing exercise
intensity.54-57 They note, in particular, that familiarity with
training and specific exercise activities and testing strategies,
sex, education, and even the use of diuretics can alter Borg
ratings of exertion.54-57
Talk Test
The Talk Test is a practical, validated and inexpensive tool
for guiding exercise intensity.9 Exercising at or above the
ventilatory or lactate threshold does not permit comfortable,
conversational speech (or singing) and can identify the
‘boundary’ between moderate- and vigorous-intensity exercise.
An inability to carry on a simple conversation while exercising
serves to indicate that the exerciser is now engaged in
vigorous-intensity activity. It is known that ventilation in-
creases in direct proportion to exercise intensity up to
50%-75% of VO _ 2max; at this pointdthe ventilatory thresh-
olddventilation increases exponentially.58 At around this
point blood lactate levels increasedthe lactate thresholddas a
result of greater production and/or reduced clearance of
lactate. Lactic acid combines with sodium bicarbonate ulti-
mately producing carbon dioxide; an increased level of carbon
dioxide stimulates increased respiration to allow excess carbon
dioxide to be exhaled.58 As exercise intensity increases, the
resulting accelerated rate of respiration makes comfortable
speech difficult; during more vigorous activity (>85%
_ 2max) ventilation increases significantly and comfortable
VO
speech is impossible. It follows that when comfortable speech
is possible exercise intensity is below the lactate and ventila-
tory threshold.59 Therein lies the elegant simplicity of the
“Talk Test”!
Published research has shown the Talk Test to be a useful
surrogate of the ventilatory and/or lactate threshold in compet-
itive athletes,60 healthy active adults,61-63 and patients with heart
disease64; comfortable speech is possible when exercise intensity
is below the ventilatory threshold, and comfortable speech is not
possible when exercise intensity exceeds the ventilatory
threshold.60,61,62,64 In these studies, the exercise intensity asso-
ciated with comfortable speech falls consistently within the
CSEP exercise training guidelines for moderate- to vigorous-
intensity aerobic exercise.4,60-64 The Talk Test is not practical
for HIIT because of the shorter duration (1 minute) and
greater intensity of the exercise bouts.
Motion Sensors
Motion sensors such as pedometers and accelerometers are
small, noninvasive, and provide an objective record of move-
ment for varying periods of time. Pedometers are devices that
count the number of steps accumulated throughout a day. In
Table 6 a graduated step index is provided.65 It has been
recommended that individuals walk at least 10,000 steps per
day. Some pedometers also measure average speed, total dis-
tance, and caloric expenditure. A threshold value of 100 steps
Volume - 2016
Table 6. Graduated step index65
Steps per day Lifestyle classification
< 5000 Sedentary lifestyle
5000-7499 Low active
7500-9999 Somewhat active
 10,000 Active
> 12,500 Highly active
per minute has been used to define moderate-intensity aerobic
exercise.66,67 A general consensus exists that accumulating at
least 15,000 steps per day equates to 150 minutes of moder-
ate- to vigorous-intensity aerobic exercise per week.68 It has
been suggested that individuals accumulate at least 15,000
steps per week in moderate- to vigorous-intensity exercise (eg,
3000 steps per day in moderate- to vigorous-intensity exercise
most days of the week).68 Accelerometers provide a contin-
uous measure of the frequency and amplitude of movement
along one or multiple axes to generate a “count” with larger
counts indicative of higher intensities of exercise. Cut points
to differentiate exercise intensities (ie, light, moderate,
vigorous) have been established using healthy adult pop-
ulations,69,70 and one has been recently proposed as appro-
priate for those with coronary artery disease.71 Sasaki et al.70
suggested cut points of 2690 and 6167 counts per minute
for moderate- and high-intensity exercise, respectively, using
the ActiGraph in young adults.70 Others have identified cut
points of 3208 and 8565 counts per minute for moderate- and
vigorous-intensity exercise using vector magnitudes from the
ActiGraph GT3X in middle-aged adults.72 Many commer-
cially available and consumer-oriented accelerometers use
these established cut points or a proprietary signal processing
algorithm (eg, Tractivity)73 to provide users with daily and/or
weekly steps or time spent engaging in low-, moderate-, and
vigorous-intensity exercise. These devices might assist in-
dividuals in meeting current exercise training recommenda-
tions. Recent publications have compared the features and
validity of many consumer-level motion sensors.74-76
New Technologies
Advances in technology in many areas of research are
occurring rapidly. The health and fitness industry is no
exception. It is foreseeable that new technologies (ie, global
positioning systems, smart watches, e-technologies) will pro-
vide additional means of assessing the quantity and quality of
exercise required for optimal health benefits and the reduction
of cardiovascular risk. The cost of such devices will, in all
likelihood, continue to decrease.
A Simple, Initial Exercise Prescription
A simple goal for sedentary individuals is to walk briskly for
30 minutes daily. A gradual approach should be taken
beginning with walking 10 minutes daily 5 days per week and
slowly building to 30 minutes daily at least 5 days per week.
Resistance training should then be added to develop and
preserve muscular fitness. Alternatively, individuals could
perform HIIT on a stationary bicycle for 10 minutes daily 2-3
days per weekdgradually building to 30 minutes daily at least
3 days per week. Individuals should pedal against a
Reed and Pipe
Physical Activity and Monitoring Exercise Intensity
challenging resistance in interval training blocks of 20-60
seconds of work with 20-60 seconds of active recovery. This
HIIT approach could be applied to the use of an elliptical
trainer or, jogging and cycling outdoors. Heart rate moni-
toring or the Talk Test can be used to ensure individuals are
working at a moderate- to vigorous-intensity. Motion sensors
(eg, pedometers, accelerometers) could also be used to ensure
individuals are accumulating 150 minutes of moderate- to
vigorous-intensity exercise. Fundamentally, the challenge for
most clinicians is to stimulate the adoption of near-daily,
enjoyable, physical activity. For most individuals in our
population this might involve walking the dogdeven if you
don’t have onedfor 30 minutes or more most days of the
week. For those with more ambitious goals, monitoring the
intensity of exercise can be achieved using any of the
approaches described. As important for physical activity to be
effective in modifying risk factors, it must be “fun, feasible,
and forever”dcareful questioning of physical activity prefer-
ences (fun), a discussion of strategies to include activity into
daily routines (feasibility), and the importance of sustaining
physical activity behaviours (forever)dmight be among the
most important considerations in influencing such behaviour
change.
Conclusions
There are several validated, practical, and inexpensive
methods for prescribing and monitoring exercise intensity,
including heart rate monitoring, the Borg RPE, the Talk Test,
and motion sensors. The Borg RPE scale matches a numerical
value to how hard one perceives they are working, and can be
used to estimate heart rate for a particular level of exercise.
The Talk Test, a simple conversation with a friend, can be
used to achieve desired exercise intensities (moderate- to
vigorous-intensity). Advances in device technology have
leddand will likely continuedto the development of so-
phisticated wearable motion sensors that provide users with
practical and useful information to potentially aid in meeting
current exercise training recommendations. Although not
without limitations, these simple, straightforward approaches
permit exercise to be easily and effectively guided in a variety
of health promotion and clinical settings.
Disclosures
The authors have no conflicts of interest to disclose.
References
1. Public Health Agency of Canada. Tracking Heart Disease and Stroke in
Canada. Ottawa: Public Health Agency of Canada, 2009.
2. Warburton DE, Charlesworth S, Ivey A, et al. A systematic review of the
evidence for Canada’s Physical Activity Guidelines for Adults. Int J Behav
Nutr Phys Act 2010;7:1-220.
3. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical
activity: the evidence. CMAJ 2006;174:801-9.
4. Canadian Society for Exercise Physiology. Canadian Physical Activity
Guidelines for adults 18-64 years 2011. Available at: http://www.csep.ca/
en/guidelines/read-the-guidelines. Accessed February 6, 2016.
7
5. Tremblay MS, Warburton DE, Janssen I, et al. New Canadian physical
activity guidelines. Appl Physiol Nutr Metab 2011;36:36-46. 7-58.
6. Warburton DE, Katzmarzyk PT, Rhodes RE, et al. Evidence-informed
physical activity guidelines for Canadian adults. Can J Public Health
2007;98(suppl 2):S16-68.
7. American College of Sports Medicine. ACSM’s Guidelines for Exercise
Testing and Prescription. 9th Ed. Baltimore, MD: Lippincott Williams
& Wilkins, 2014.
8. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL:
Human Kinetics, 1998.
9. Reed JL, Pipe AL. The Talk Test: a useful tool for prescribing and
monitoring exercise intensity. Curr Opin Cardiol 2014;29:475-80.
10. Khawaja IS, Westermeyer JJ, Gajwani P, et al. Depression and coronary
artery disease: the association, mechanisms, and therapeutic implications.
Psychiatry (Edgmont) 2009;6:38-51.
11. Biswas A, Oh PI, Faulkner GE, et al. Sedentary time and its association
with risk for disease incidence, mortality, and hospitalization in adults: a
systematic review and meta-analysis. Ann Intern Med 2015;162:123-32.
12. Colley RC, Garriguet D, Janssen I, et al. Physical activity of Canadian
adults: accelerometer results from the 2007 to 2009 Canadian Health
Measures Survey. Health Rep 2011;22:7-14.
13. Centers for Disease Control and Prevention. QuickStats: Percentage of
Adults Aged 18 Years Who Engaged in Leisure-Time Strengthening
Activities at Least Twice a Week, by Race/Ethnicity and Sex e National
Health Interview Survey 2009.
14. Kottke TE, Faith DA, Jordan CO, et al. The comparative effectiveness of
heart disease prevention and treatment strategies. Am J Prev Med
2009;36:82-8.
15. U.S. Department of Health and Human Services. 2008 Physical Activity
Guidelines for Americans. ODPHP Publication No U0036. 2008:1-76.
16. Statistics Canada. Overweight and obese adults (self-reported), 2014.
Health Fact Sheet no. 82-625-X. Available at: http://www.statcan.gc.ca/
pub/82-625-x/2015001/article/14185-eng.htm. Accessed February 7,
2016.
17. Reed JL, Chaput JP, Tremblay A, et al. The maintenance of energy
balance is compromised after weight loss. Can J Diabetes 2013;37:121-7.
18. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports
Medicine Position Stand. Appropriate physical activity intervention
strategies for weight loss and prevention of weight regain for adults. Med
Sci Sports Exerc 2009;41:459-71.
19. Swift DL, Johannsen NM, Lavie CJ, et al. The role of exercise and
physical activity in weight loss and maintenance. Prog Cardiovasc Dis
2014;56:441-7.
20. Statistics Canada. High blood pressure, 2014. Health Fact Sheet no. 82-
625-X. Available at: http://www.statcan.gc.ca/pub/82-625-x/2015001/
article/14184-eng.htm. Accessed February 7, 2016.
21. Cornelissen VA, Smart NA. Exercise training for blood pressure: a sys-
tematic review and meta-analysis. J Am Heart Assoc 2013;2:e004473.
22. Statistics Canada. Cholesterol levels of Canadians, 2009-2011. Health
Fact Sheet no 82-625-X. Available at: http://www.statcan.gc.ca/pub/82-
625-x/2012001/article/11732-eng.htm. Accessed February 7, 2016.
23. Lin X, Zhang X, Guo J, et al. Effects of exercise training on cardiore-
spiratory fitness and biomarkers of cardiometabolic health: a systematic
review and meta-analysis of randomized controlled trials. J Am Heart
Assoc 2015;4.
8 Canadian Journal of Cardiology
24. Giada F, Biffi A, Agostoni P, et al. Exercise prescription for the pre-
vention and treatment of cardiovascular diseases: part I. J Cardiovasc Med
(Hagerstown) 2008;9:529-44.
25. Public Health Agency of Canada. Diabetes in Canada: Facts and Figures
From a Public Health Perspective. Ottawa: Public Health Agency of
Canada, 2011.
26. Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance
training on hemoglobin A1c levels in patients with type 2 diabetes: a
randomized controlled trial. JAMA 2010;304:2253-62.
27. Sigal RJ, Kenny GP, Boule NG, et al. Effects of aerobic training, resis-
tance training, or both on glycemic control in type 2 diabetes: a ran-
domized trial. Ann Intern Med 2007;147:357-69.
28. Boule NG, Haddad E, Kenny GP, et al. Effects of exercise on glycemic
control and body mass in type 2 diabetes mellitus: a meta-analysis of
controlled clinical trials. JAMA 2001;286:1218-27.
29. Look AR, Wing RR, Bolin P, et al. Cardiovascular effects of intensive
lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145-54.
30. Buchheit M, Laursen PB. High-intensity interval training, solutions to
the programming puzzle: Part I: cardiopulmonary emphasis. Sports Med
2013;43:313-38.
31. Kessler HS, Sisson SB, Short KR. The potential for high-intensity in-
terval training to reduce cardiometabolic disease risk. Sports Med
2012;42:489-509.
32. Weston KS, Wisloff U, Coombes JS. High-intensity interval training in
patients with lifestyle-induced cardiometabolic disease: a systematic
review and meta-analysis. Br J Sports Med 2014;48:1227-34.
33. Molmen HE, Wisloff U, Aamot IL, et al. Aerobic interval training
compensates age related decline in cardiac function. Scand Cardiovasc J
2012;46:163-71.
34. Tjonna AE, Lee SJ, Rognmo O, et al. Aerobic interval training versus
continuous moderate exercise as a treatment for the metabolic syndrome:
a pilot study. Circulation 2008;118:346-54.
35. Wisloff U, Stoylen A, Loennechen JP, et al. Superior cardiovascular effect
of aerobic interval training versus moderate continuous training in heart
failure patients: a randomized study. Circulation 2007;115:3086-94.
36. Biddle SJ, Batterham AM. High-intensity interval exercise training for
public health: a big HIT or shall we HIT it on the head? Int J Behav Nutr
Phys Act 2015;12:95.
37. Rognmo O, Moholdt T, Bakken H, et al. Cardiovascular risk of high-
versus moderate-intensity aerobic exercise in coronary heart disease
patients. Circulation 2012;126:1436-40.
38. Guiraud T, Nigam A, Gremeaux V, et al. High-intensity interval training
in cardiac rehabilitation. Sports Med 2012;42:587-605.
39. Meyer P, Gayda M, Juneau M, et al. High-intensity aerobic interval
exercise in chronic heart failure. Curr Heart Fail Rep 2013;10:130-8.
40. Pollock ML, Franklin BA, Balady GJ, et al. AHA Science Advisory.
Resistance exercise in individuals with and without cardiovascular disease:
benefits, rationale, safety, and prescription: an advisory from the Com-
mittee on Exercise, Rehabilitation, and Prevention, Council on Clinical
Cardiology, American Heart Association; Position paper endorsed by the
American College of Sports Medicine. Circulation 2000;101:828-33.
41. Mann T, Lamberts RP, Lambert MI. Methods of prescribing relative
exercise intensity: physiological and practical considerations. Sports Med
2013;43:613-25.
Volume - 2016
42. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical
activities: an update of activity codes and MET intensities. Med Sci
Sports Exerc 2000;32:S498-504.
43. Warburton DE, Nicol CW, Bredin SS. Prescribing exercise as preventive
therapy. CMAJ 2006;174:961-74.
44. Freedson PS, Miller K. Objective monitoring of physical activity using
motion sensors and heart rate. Res Q Exerc Sport 2000;71:S21-9.
45. Fox SM 3rd, Naughton JP, Haskell WL. Physical activity and the pre-
vention of coronary heart disease. Ann Clin Res 1971;3:404-32.
46. Astrand P. Experimental studies of physical working capacity in relation
in sex and age. Copenhagan, Denmark: Musksgaard, 1952:171.
47. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate
revisited. J Am Coll Cardiol 2001;37:153-6.
48. Gellish RL, Goslin BR, Olson RE, et al. Longitudinal modeling of the
relationship between age and maximal heart rate. Med Sci Sports Exerc
2007;39:822-9.
49. Association of Chartered Physiotherapists in Cardiac Rehabiliation.
ACPIRC Standards: Standards for Physical Activity and Exercise in
the Cardiovascular Population. 3rd Ed. Association of Chartered Phys-
iotherapists in Cardiac Rehabiliation, 2015. Available at: http://acpicr.
com/sites/default/files/ACPICR%20Standards%202015.pdf. Accessed
February 7, 2016.
50. Ainslie P, Reilly T, Westerterp K. Estimating human energy expenditure:
a review of techniques with particular reference to doubly labelled water.
Sports Med 2003;33:683-98.
51. Zanettini R, Centeleghe P, Ratti F, et al. Training prescription in patients
on beta-blockers: percentage peak exercise methods or self-regulation?
Eur J Prev Cardiol 2012;19:205-12.
52. Borg G, Borg E. The Borg CR Scales Folder. Methods for Measuring
Intensity of Experience. Hasselby, Sweden: Stockholm University, 2010.
53. Abadie BR. Effect of viewing the RPE scale on the ability to make ratings
of perceived exertion. Percept Mot Skills 1996;83:317-8.
54. Joo KC, Brubaker PH, MacDougall A, et al. Exercise prescription using
resting heart rate plus 20 or perceived exertion in cardiac rehabilitation.
J Cardiopulm Rehabil 2004;24:178-84 [quiz: 85-6].
55. Magal M, Zoeller RF. A pilot study comparing physiological responses of
phase III cardiac patients to recumbent and upright exercise using the
RPE scale. Percept Mot Skills 2005;100:357-61.
56. Gondoni LA, Nibbio F, Caetani G, et al. What are we measuring?
Considerations on subjective ratings of perceived exertion in obese
patients for exercise prescription in cardiac rehabilitation programs. Int
J Cardiol 2010;140:236-8.
57. Buckley JP, Sim J, Eston RG. Reproducibility of ratings of perceived
exertion soon after myocardial infarction: responses in the stress-testing
clinic and the rehabilitation gymnasium. Ergonomics 2009;52:421-7.
58. Powers SK, Howley ET. Exercise Physiology: Theory and Application to
Fitness and Performance. 8th Ed. New York, NY: McGraw Hill, 2012.
59. Meckel Y, Rotstein A, Inbar O. The effects of speech production on
physiologic responses during submaximal exercise. Med Sci Sports Exerc
2002;34:1337-43.
60. Rodriguez-Marroyo JA, Villa JG, Garcia-Lopez J, et al. Relationship
between the talk test and ventilatory thresholds in well-trained cyclists.
J Strength Cond Res 2013;27:1942-9.
61. Persinger R, Foster C, Gibson M, et al. Consistency of the talk test for
exercise prescription. Med Sci Sports Exerc 2004;36:1632-6.
Reed and Pipe
Physical Activity and Monitoring Exercise Intensity
62. Foster C, Porcari JP, Anderson J, et al. The talk test as a marker of
exercise training intensity. J Cardiopulm Rehabil Prev 2008;28:24-30
[quiz: 1-2].
63. Quinn TJ, Coons BA. The Talk Test and its relationship with the
ventilatory and lactate thresholds. J Sports Sci 2011;29:1175-82.
64. Voelker SA, Foster C, Porcari JP, et al. Relationship between the talk test
and ventilatory threshold in cardiac patients. Clin Exerc Physiol 2002;4:
120-3.
65. Tudor-Locke C, Bassett DR Jr. How many steps/day are enough? Pre-
liminary pedometer indices for public health. Sports Med 2004;34:1-8.
66. Tudor-Locke C, Sisson SB, Collova T, et al. Pedometer-determined step
count guidelines for classifying walking intensity in a young ostensibly
healthy population. Can J Appl Physiol 2005;30:666-76.
67. Marshall SJ, Levy SS, Tudor-Locke CE, et al. Translating physical
activity recommendations into a pedometer-based step goal: 3000 steps
in 30 minutes. Am J Prev Med 2009;36:410-5.
68. Tudor-Locke C, Craig CL, Brown WJ, et al. How many steps/day are
enough? For adults. Int J Behav Nutr Phys Act 2011;8:79.
69. Freedson PS, Melanson E, Sirard J. Calibration of the Computer Science
and Applications, Inc. accelerometer. Med Sci Sports Exerc 1998;30:
777-81.
70. Sasaki JE, John D, Freedson PS. Validation and comparison of Acti-
Graph activity monitors. J Sci Med Sport 2011;14:411-6.
9
71. Prince SA, Reed JL, Mark AE, et al. A comparison of accelerometer cut-
points among individuals with coronary artery disease. PLoS One
2015;10:e0137759.
72. Santos-Lozano A, Santin-Medeiros F, Cardon G, et al. Actigraph GT3X:
validation and determination of physical activity intensity cut points. Int
J Sports Med 2013;34:975-82.
73. Warburton DE, Jeklin A, Bredin S, et al. The validity of the Tractivity
motion sensor during walking. Health & Fitness Journal of Canada
2013;6:114-22.
74. Ferguson T, Rowlands AV, Olds T, et al. The validity of consumer-level,
activity monitors in healthy adults worn in free-living conditions: a cross-
sectional study. Int J Behav Nutr Phys Act 2015;12:42.
75. Lee JM, Kim Y, Welk GJ. Validity of consumer-based physical activity
monitors. Med Sci Sports Exerc 2014;46:1840-8.
76. Evenson KR, Goto MM, Furberg RD. Systematic review of the validity
and reliability of consumer-wearable activity trackers. Int J Behav Nutr
Phys Act 2015;12:159.
Supplementary Material
To access the supplementary material accompanying this
article, visit the online version of the Canadian Journal of
Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10.
1016/j.cjca.2015.12.024.