key: cord-0015581-j6uiv4pl authors: Lucini, Daniela; Pagani, Massimo title: Exercise Prescription to Foster Health and Well-Being: A Behavioral Approach to Transform Barriers into Opportunities date: 2021-01-22 journal: Int J Environ Res Public Health DOI: 10.3390/ijerph18030968 sha: 2ef5f0e05b5a2cb9bce0e2da652421037854a852 doc_id: 15581 cord_uid: j6uiv4pl The current literature contains multiple examples of exercise interventions to foster health and to prevent/treat many chronic non-communicable diseases; stress and functional syndromes. On the other hand, sedentariness is increasing and to transform a sedentary subject into a regular exerciser is not only very difficult but considered by some unrealistic in current clinical practice. Ideally a physical activity intervention may be considered actually efficacious when it outgrows the research setting and becomes embedded in a system, ensuring maintenance and sustainability of its health benefits. Physicians need specific skills to improve patients’ exercise habits. These range from traditional clinical competencies, to technical competencies to correctly prescribe exercise, to competencies in behavioral medicine to motivate the subject. From a behavioral and medical point of view, an exercise prescription may be considered correct only if the subject actually performs the prescribed exercise and this results in an improvement of physiological mechanisms such as endocrine, immunological and autonomic controls. Here we describe a model of intervention intended to nurture exercise prescription in everyday clinical setting. It aims to a tailored prescription, starts from the subject’s assessment, continues defining clinical goals/possible limitations and ends when the subject is performing exercise obtaining results. Prevention and treatment of chronic non-communicable diseases (CNCD) represent one of the major goals and challenges of governments and medical institutions worldwide. Interventions aiming to improve lifestyles play a pivotal role in this scenario since ancient times when Hippocrates (5th century BC) wrote: "if we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health" [1] . This statement underlies not only the importance of nutrition and exercise, but almost the importance to titrate their "dose", as if they were a medicine. Eons of interest and scientific research eventually followed through, and the role of regular physical activity in influencing health grew of importance so much as to be proffered as a possible therapy [2] at the end of nineties, being subsequently considered itself an official treatment ten years later when the scientific community launched the slogan "exercise is medicine" [3] , and being considered today a sustainable tool both for individual health and community [4] and a real tool to foster health and well-being in the general population and not only in patients affected by chronic diseases [5] . The importance to address lifestyle in the prevention and management of CNCD is also corroborated by the observation that social environments strongly influence individual behavioral choices henceforth affecting health [6] . The link between social ties and behavior is well-known and it may be crucial both in worsening health (for instance, network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity Sport and exercise are sometimes used to indicate the same concept, risking confusion. In fact these terms have different meanings (see Table 1 ). From a clinical point of view their main difference may perhaps be summarized with the following sentence: the goal of sport is competition while the goal of exercise is health. Consequently the goal of sports medicine may be considered to help the athlete to prevent and to manage injuries, to maintain health avoiding any problem, and to increase performance. The goal of exercise medicine may be considered, instead, to utilize physical exercise as a tool to foster health and wellbeing, to prevent and manage most chronic non communicable diseases in any subject independently of her/his fitness level. Sport medicine physicians generally work with athletes used to the ontology, benefits/problems and practical issues of exercise, willing (and usually fit) to perform exercise even at high intensity. Conversely Exercise medicine physicians usually approach subjects who actually do not exercise, and who need an exercise prescription tailored on their own characteristics, needs and clinical goals [24] . The beneficial effects of exercise may be increased by addressing also other components of lifestyle, in particular nutrition, stop smoking and stress management. This approach is typical of lifestyle medicine [61] , which consists in the therapeutic use of evidence-based lifestyle interventions to treat and prevent lifestyle related diseases in a clinical setting, empowering individuals with the knowledge/skills to make effective behavior changes. There is a great debate [62] [63] [64] on who is the professional entitled to practice exercise medicine (in particular exercise prescription) [62] [63] [64] [65] and this debate becomes even more heated when considering the different education training of professionals who may have a Conventional medical expertise is needed to adequately assess subjects/patients, to know medical implications of the disease to prevent/treat and of its eventual pharmacological treatment, to tailor exercise and nutrition prescriptions to subjects'/patients' needs and characteristics, to reveal possible contraindications for some modalities/intensities of exercise. • Psychological expertise is needed to motivate and help patients to change behavior and/or to manage possible psychological issues resulting from a major disease (if present) [70] . • Technical expertise is needed in order to prescribe exercise, nutrition or for smoking cessation programs, to educate subjects/patients and to help them overcome practical barriers. To acquire all these competencies may be more important than simply belonging to a specific profession or medical specialization. To include lifestyle medicine in undergraduate medical curricula [67] [68] [69] 71] or in other health professionals' curricula, would be welcomed in order to implement efficacious lifestyle change programs. This improvement in medical training would help to overcome an important limitation often encountered in clinical practice: the limitation of the physician's role to subject/patient assessment and or to pharmacological/surgical management of the disease. On the contrary physician's role should include the ability to prescribe exercise and to reveal clinical issues (for instance the presence of contraindications to some exercise modality or the need to consider the effects of some pharmacological treatment) mandatory to an efficacious and safe tailored, inclusive, prescription of exercise programs. Other exercise professionals (exercise physiologists, physiotherapists) have an important specific role, especially the one of following up the subject/patient over time, adjusting the program, designing new protocols, etc. This approach may contribute to eradicate interprofessional barriers constructed as a result of historical professional hierarchies and tensions [65] , hence opening a new opportunity to implement exercise medicine [65] . Despite the benefits of physical activity are well documented, physical inactivity is rapidly becoming a major global concern and now this issue is described as pandemic, with health, economic, environmental and social consequences [50, 51, 72, 73] . As previously reported, any lifestyle intervention considering physical activity must consider two parallel lines of intervention. The first one aims to reduce sedentariness (to take advantage of any opportunity during day life to perform physical activity, such as avoiding elevators, preferring stairs, etc), and the second one aims to introduce into daily life a structured exercise program [28] . The scientific literature contains many examples of physical activity interventions: some of which are efficacious and may represent a model to scale up [14, 74, 75] . Other ones resulted uncapable to produceany significant change [14, 15, 76, 77] . The programs that appeared to be most effective, are characterized by multifactorial interventions and are designed for individuals or groups according to specific characteristics and needs [14, 16, 17, 78, 79] , often including computer/technology-based strategies [14, 16] . Sim-ple counseling about healthy behavior, in particular exercise, yields limited or no results [14, 15, 76, 77] , while success requires the implementation of specific action plans in partnership with subjects/patients and intentional follow-up [4, 67, 74, 75] . Ideally a physical activity intervention may be considered actually efficacious when it outgrows the research setting and becomes embedded in a delivery system, ensuring maintenance and sustainability of its health benefits [4, 75] . Approaches based on the combination of careful patient assessment, tailored prescription of healthy nutrition, exercise and smoking cessation plans, cognitive behavioral strategies (CBS), have been shown to be most effective [4, 14, 17, 18] . These approaches (see also our previous paper [4] ) require multidisciplinary expertise to be included in the program. This is often guaranteed by the involvement of several different healthcare professionals (specialists, general practitioners, psychologists, dieticians, exercise physiologists) which are required to work in truly collaborative and goal oriented teams in order to get positive results [14, 18, 74, 75] . On the contrary, simple referral to other healthcare professionals without joint responsibility often results in a time consuming, expensive and rather ineffective approach [14, 15, 76] . Notably this strategy is frequently presented in clinical contexts outside research programs, representing paradoxically a barrier to a successful result. Other important barriers reported by patients regarding the financial burden and time investment [80, 81] , i.e., conditions woefully characterizing intensive lifestyle modification programs (multiple encounters with different experts, educational sessions, assisted training sessions, etc, that are not always covered by social security system or insurance). These elements should be minimized as much as possible in order to design realistic and efficacious programs. The possibility to have a physician trained in Life Style Medicine, as hypothesized in many papers [67] [68] [69] 71] , capable of entirely manage the patient's pathway forward a new behavior, may help to overcome some of these barriers [4] . Obviously the possibility to add other different healthcare professionals will improve the quality of the program when economic and organizational barriers are not present. WHO defines empowerment as "a process through which people gain greater control over decisions and actions affecting their health and should be seen as both an individual and a community process. Empowerment in health care generally refers to the process that allows an individual or a community to gain the knowledge, skills, and attitude needed to make choices about their care" [82] . The key components of empowerment are: (1) understanding by the patient of his/her role; (2) acquisition by patients of sufficient knowledge to be able to engage with their healthcare provider; (3) patient skills and (s4) the presence of a facilitating environment. Translating these concepts into exercise medicine means to employ behavioral medicine tools (see Table 2 ) in order to help the subject/patient to understand the important link between his/her health issue and exercise, showing the real benefits associated to become physically active following prescription tailored on his/her needs, characteristics and preferences, hence defining a new ecology. Behavioral medicine may be defined as "the interdisciplinary field concerned with the development and integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation" [83]. Table 3 ) Motivational interviewing is an example of a methodology using a combination of behavior change techniques to help pragmatically people to change behavior [84] . It is a directive, client-centered method for enhancing intrinsic motivation by exploring and resolving ambivalence and barriers to behavior change considering lecturing or confrontation as unhelpful [85] . The main principles of motivational interviewing are: express empathy (through reflective listening); develop discrepancy (between the individual's goals and their current behavior), avoid argumentation and roll with resistance (acknowledge and explore the individual's resistance to change, rather than opposing it) [86, 87] . Another approach commonly known as 'nudging', primarily drawn from behavioral economics, has attracted interest in these years. It aspires to 'nudge' people's choices, not by taking off the less healthy ones, but by making the healthier option easier [88] . Table 3 . Main psychological theories and models of behaviour change. Considers that an individual's belief that he/she has the capabilities to produce an effect or reach a certain goal is a major determinant of behavioral change. Transtheoretical Model [89] (also referred to as the 'Stages of Change' model) Suggests to tailor the intervention to individual stage of change: precontemplation (the subject is unaware of the problem and he/she is not even considering changing), contemplation (the subject is aware of the problem and he/she is ambivalent about changing), preparation (the subject intends to take action and is prepared to experiment with small changes), action (the subject takes definitive action to change), maintenance and relapse prevention (the subject works to sustain the behavior change over the long term). Motivation may be considered as a strategy to help the subject/patient to transform his/her desires about health improvement into realistic goals, furnishing all the required resources in order to be proactive. Tailored prescription of exercise programs is strongly recommended in all exercise guidelines [3, 20, 48] and requires the clear definition of modality, intensity, frequency, duration and progression of exercise in order to reach the set clinical goals considering also individual characteristics, limitations and preferences. A correct tailored exercise prescription requires a specific focus on the single patient/subject more than on a specific disease/condition. Obviously some specific clinical conditions require, sometimes, particular protocols; in addition, a correct tailored exercise prescription needs to consider, for a single patient, all the coexisting conditions and possible contraindications. The process which drives to a tailored prescription starts from the subject's assessment, continues defining clinical goals and possible limitation ( Figure 1 ) and ends when the subject is performing exercise. A correct assessment of subjects' clinical conditions and lifestyles is of paramount importance in order to define clinical goals and to exclude any contraindication to some exercise modality/intensity or possible development of complications, moreover it may furnish important parameters, for instance maximal and basal heart rate, necessary to a correct exercise prescription. The need for formal medical screening (in order to verify the clearance to perform exercise and minimize possible health related problems) depends on the age, clinical condition, cardiac risk factor and the intensity of exercise [20, 48, 93] . Healthy adults who desire to perform low-moderate intensity walking program or equivalent exercise do not need a formal medical screening when the intention is to exclude possible cardiovascular events [20, 48, 93] , but it is welcomed particularly when the intention is to tailor exercise prescription and to set specific clinical goal/s in order to reach specific benefits. In this case it may be useful to consider personal and parenteral history, standard medical examination (anthropometric and hemodynamic data), medical tests (for instance a cardiopulmonary stress test or a simple stress test in order to define training heart rate [20, 30, 48, 93] depending on patients' conditions, risk and intensity of physical activity). Moreover subjects who desire to perform a resistance training program should be carefully screened for both cardiovascular limitations and preexisting orthopedic and musculoskeletal problems [93] . Ad hoc questionnaire may be used in order to define lifestyle, with particular focus on physical activity, nutrition, perception of stress, substance abuse, alcohol consumption, smoke and sleep [94] . Specifically regarding the assessment of daily physical activity, it is particularly important to define for every modality of performed physical activity the intensity an duration which may permit (referring to validated tables [95] ) to calculate (with reasonable accuracy) the total activity dose expressed in Metabolic equivalents (METs) of aerobic physical activity performed in a given period (one day or one week). Physical activity may also be quantified using objective methods like wearable devices (pedometer, accelerometers [94] ). These techniques may be useful also to monitor improvement of physical activity level or to help motivate adherence to the prescribed program. Correct subject's assessment is also an essential starting point of Cognitive Behavioral Strategies (CBS) applied in medical setting (see Table 2 ). In fact, every patient needs to know his/her health status and to realize how physical training could improve it. It will be a physician's responsibility/skill to drive the subject/patient from the general concept of "exercise is good for health" toward the full understanding of real individual benefits which he may derive from becoming physically active, following the exercise prescription tailored also on the assessment of results. It consists in the definition of the clinical goals that patients need to reach and considers both subjects' initial requests (for instance to lose weight) and physician's considerations derived from subjects' assessment (for instance to loose fat mass and to improve muscular mass). Goal setting will determine the correct exercise prescription. For instance the optimal exercise dose defined from international guidelines is clearly aimed to promote and maintain health [18, 20, 28, 48, 96] . If the goal were different, for instance to manage back pain, the prescription should be different! In the specific example the exercise modality needs to consider flexibility exercise, to relax back muscles, and strength exercise to improve muscular mass and quality. Different clinical goals require different modality and/or intensity of exercise. Figure 2 shows the exercise modalities needed to reach the main clinical goals. Addressing possible contraindications revealed by clinical assessment may become a further goal to reach. For instance the presence of lumbar bulging disks in an overweight subject may represent a contraindication to high impact exercise, such as running or brisk walking on treadmill, and suggests the need of specific exercise modality to manage/prevent lumbar pain. In this case swimming might be a best endurance choice and flexibility/strength exercise at low-moderate intensity involving lumbar/abdominal muscle would be also welcomed. To discuss with the subject how his/her assessments and clinical condition shape goals definition and subsequently tailor exercise prescription, is of paramount importance in order to foster his/her proactive role. The subject needs to realize the possible real benefits that he/she will obtain and the practical and psychological resources that are required. International Guidelines define the optimal dose of exercise to obtain health benefit [19, 20, 28, 48, 93] : in order to promote and maintain health, all healthy adults aged 18 to 65 years need moderate-intensity aerobic physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. Combination of moderate-and vigorous-intensity activity can be performed to meet this recommendation [19, 20, 28, 48, 93] . In addition, every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of two days each week [19, 20, 28, 48, 93, 97] . Even low doses (a daily average of 15 min of moderate intensity) [23] of exercise may be associated to health benefit when comparing to sedentary individual. On the other hand, because of the dose-response relation between aerobic physical activity and health, to exceed the minimum recommended amount of physical activity will result in a further improvement of personal fitness, reduction in risk for chronic disease and disabilities [20, 28, 48, 93, 98] . Very high dose of exercise (generally characterized by anaerobic metabolism) were not associated to health benefits [98, 99] . This concept is well pointed out in the most recent World Health Organization 2020 guidelines [28] , which prefer to indicate a target range of 150-300 min of moderate-intensity and 75-150 min of vigorous-intensity physical activity (instead of simply achieve at least 150 min of moderate-intensity or 75 min of vigorous-intensity activity per week). This change recognizes that there is a range of physical activity which grants the maximal risk reductions for health outcomes associated with physical activity and going beyond this range does not further reduce the risk of major outcomes. Recommendation for older subjects [19, 28] are very similar to those for adults, although some differences particularly related to intensity levels and the set goals need to be considered. Moreover, multicomponent physical activity, which emphasizes functional balance and strength training to enhance functional capacity and prevent falls, are recommended [28] . Children and adolescent require a higher exercise dose corresponding to at least an average of 60 min/day of moderate to vigorous intensity physical activity [28] , including muscle-strengthening and bone loading activities, performed at least 3 days a week [19, 100] . Children before scholar age should spend at least 180 min in a variety of physical activities at any intensity including moderate-to vigorous-intensity physical activity (of which at least 60 min for children older than 3-4 years), spread throughout the day [101] . Tailored prescription of exercise programs is strongly recommended in all exercise guidelines [3, 19, 20, 48, 93, 102] and requires the clear definition of modality, intensity, frequency, duration and progression of exercise. The concept of exercise dose or volume refers to the combination of intensity, duration and intensity. • Endurance activity entails rhythmic motion of large muscle groups in aerobic activities (walking, jogging, swimming, etc.) [93] . Aerobic activity is physical exercise that depends primarily on the aerobic energy-generating process [60] , it may be of low to high intensity depending on subject's fitness level (i.e., exercise capacity). Endurance aerobic activities are primarily prescribed in order to improve cardiorespiratory fitness, to reduce cardio-metabolic-oncologic risk, to reduce fat mass, to improve wellness and to maintain health [3, 19, 20, 48, 93] . Resistance or strength exercise involves activities that use low-or moderate-repetition movements against resistance [93] , it is primarily prescribed in order to increases strength and muscle mass and physical independence. Conventional strength exercises typically consist of lifting heavier weights with longer rest periods (a greater anaerobic component), whereas circuit training consists of lifting lighter weights with shorter rest periods between exercises, introducing a greater aerobic component to the workout [97] . • Flexibility and muscle stretching exercises are focused on improving joint range of motion (flexibility), and on decreasing muscle tension [103] , they are primarily prescribed in order to relieve muscle pain associated to muscle tension, to improve joint range and to prevent injuries. • Balance exercise are aimed to improve the ability to maintain the body's center of gravity within its base of support and it is primarily prescribed in order to reduce the risk of falls and injury [104] . • Endurance aerobic exercise: (see Table 4 ) Ideally, to define the intensity of an aerobic endurance exercise, a cardiopulmonary exercise test (CPX) would be required in order to establish cardiorespiratory fitness (VO 2max ) and subsequently define the exercise intensity as percent of it. From a practical point of view, the exercise intensity is usually indicated by training heart rate, based on the approximate linear relationship between the increase of O 2 consumption and the increase of heart rate (HR). Training heart rate may be calculated employing the heart rate reserve (HRR) formula (see Table 4 ) starting from resting heart rate and actual maximal heart rate measured by conventional maximal (not submaximal!) exercise stress test. If it is not possible to perform even this test, the usage of predefined tables to estimate the training HR might be useful, but this easier approach cannot be considered a tailored exercise intensity prescription (it is only a best guess!) and must not be used in case of patients under pharmacological chronotropic therapies (such as beta blockers) or in subjects particularly deconditioned [105] . Another solution, particularly when it is useless/impossible to perform a maximal exercise stress test (for instance in the initial phase of a training program of a sedentary/deconditioned subject who might be unable to reach maximal cardiovascular response, because of low exercise capacity) empirical methods may be considered, as general physical activity promotion tools (Table 4 ). In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Empirical tools muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. movement: the more elevated is the weight and the less is the speed of movem and/or then the number of repetitions that the subject may sustain. A lower repetit range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). 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To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . 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Using weight loads that perm facilitate improvements in muscular strength a strength intensity one-repetition maximum (1RM of weight that a person can possibly lift for one maximum amount of force that can be generated i erally employed [20, 97] . 1RM can either be calcula or indirectly using submaximal estimation [108] . I pabilities, the use of multiple repetitions, usually may be considered (5RM represents the maximum formed 5 times [20] ). This technique helps to avoi difficult to perform and possibly dangerous in risk [20, 97] . 1RM can or indirectly using submaximal es pabilities, the use of multiple rep may be considered (5RM represen formed 5 times [20] ). This techniq difficult to perform and possibly Examples not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise w not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated int sity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It pends from many factors, such as the resistance (generally represented by a wei to lift) that the muscle must win, the speed of movement and number of repetitio Usually, there is an inverse association between the weight to lift and the speed movement: the more elevated is the weight and the less is the speed of movem and/or then the number of repetitions that the subject may sustain. A lower repetit range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. the benefits will increase performing exercise at higher intensities as long as they rem aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particula cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise w not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated int sity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It pends from many factors, such as the resistance (generally represented by a wei to lift) that the muscle must win, the speed of movement and number of repetitio Usually, there is an inverse association between the weight to lift and the speed movement: the more elevated is the weight and the less is the speed of movem and/or then the number of repetitions that the subject may sustain. A lower repetit range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. beginning of intervention programs or in deconditioned patients [23] . On the other ha the benefits will increase performing exercise at higher intensities as long as they rem aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particula cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise w not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated int sity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It pends from many factors, such as the resistance (generally represented by a wei to lift) that the muscle must win, the speed of movement and number of repetitio Usually, there is an inverse association between the weight to lift and the speed movement: the more elevated is the weight and the less is the speed of movem and/or then the number of repetitions that the subject may sustain. A lower repetit range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. cise intensity is generally required; even lower intensity may be useful particularly in beginning of intervention programs or in deconditioned patients [23] . On the other ha the benefits will increase performing exercise at higher intensities as long as they rem aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particula cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise w not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated int sity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It pends from many factors, such as the resistance (generally represented by a wei to lift) that the muscle must win, the speed of movement and number of repetitio Usually, there is an inverse association between the weight to lift and the speed movement: the more elevated is the weight and the less is the speed of movem and/or then the number of repetitions that the subject may sustain. A lower repetit range with a heavier weight (anaerobic) may better optimize muscular strength a power, whereas a higher repetition range with a lighter weight may better enhan muscular endurance. Using weight loads that permit 8 to 15 repetitions will genera facilitate improvements in muscular strength and endurance [97] . To calcul strength intensity one-repetition maximum (1RM) (which is the maximum amou of weight that a person can possibly lift for one repetition, considered also as maximum amount of force that can be generated in one maximal contraction) is g erally employed [20, 97] . 1RM can either be calculated directly using maximal test or indirectly using submaximal estimation [108] . In order to better meet patients' pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weig may be considered (5RM represents the maximum amount of weight that can be p formed 5 times [20] ). This technique helps to avoid maximal exercise which may difficult to perform and possibly dangerous in risk populations. cardiac and musculoskeletal risk) [20, 35] and at very high dose, endu not be performed using a prevalent aerobic metabolic pathways [20,1 sity of exercise may be even associated to an increased mortality [99,1 • Strength exercise: to define the intensity of strength exercise is q pends from many factors, such as the resistance (generally repre to lift) that the muscle must win, the speed of movement and nu Usually, there is an inverse association between the weight to li movement: the more elevated is the weight and the less is the s and/or then the number of repetitions that the subject may sustain range with a heavier weight (anaerobic) may better optimize mu power, whereas a higher repetition range with a lighter weight muscular endurance. Using weight loads that permit 8 to 15 repet facilitate improvements in muscular strength and endurance strength intensity one-repetition maximum (1RM) (which is the of weight that a person can possibly lift for one repetition, con maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . In order to bette pabilities, the use of multiple repetitions, usually five (5RM) usin may be considered (5RM represents the maximum amount of wei formed 5 times [20] ). This technique helps to avoid maximal exe difficult to perform and possibly dangerous in risk populations. [20, 35] and at very high dose, endu not be performed using a prevalent aerobic metabolic pathways [20,1 sity of exercise may be even associated to an increased mortality [99,1 • Strength exercise: to define the intensity of strength exercise is q pends from many factors, such as the resistance (generally repre to lift) that the muscle must win, the speed of movement and nu Usually, there is an inverse association between the weight to li movement: the more elevated is the weight and the less is the s and/or then the number of repetitions that the subject may sustain range with a heavier weight (anaerobic) may better optimize mu power, whereas a higher repetition range with a lighter weight muscular endurance. Using weight loads that permit 8 to 15 repet facilitate improvements in muscular strength and endurance strength intensity one-repetition maximum (1RM) (which is the of weight that a person can possibly lift for one repetition, con maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . In order to bette pabilities, the use of multiple repetitions, usually five (5RM) usin may be considered (5RM represents the maximum amount of wei formed 5 times [20] ). This technique helps to avoid maximal exe difficult to perform and possibly dangerous in risk populations. [35, 106] . Increasing the exercise intensity means also to increa cardiac and musculoskeletal risk) [20, 35] and at very high dose, endu not be performed using a prevalent aerobic metabolic pathways [20,1 sity of exercise may be even associated to an increased mortality [99,1 • Strength exercise: to define the intensity of strength exercise is q pends from many factors, such as the resistance (generally repre to lift) that the muscle must win, the speed of movement and nu Usually, there is an inverse association between the weight to li movement: the more elevated is the weight and the less is the s and/or then the number of repetitions that the subject may sustain range with a heavier weight (anaerobic) may better optimize mu power, whereas a higher repetition range with a lighter weight muscular endurance. Using weight loads that permit 8 to 15 repet facilitate improvements in muscular strength and endurance strength intensity one-repetition maximum (1RM) (which is the of weight that a person can possibly lift for one repetition, con maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . In order to bette pabilities, the use of multiple repetitions, usually five (5RM) usin may be considered (5RM represents the maximum amount of wei formed 5 times [20] ). This technique helps to avoid maximal exe difficult to perform and possibly dangerous in risk populations. the benefits will increase performing exercise at higher intensities as l aerobic [35, 106] . Increasing the exercise intensity means also to increa cardiac and musculoskeletal risk) [20, 35] and at very high dose, endu not be performed using a prevalent aerobic metabolic pathways [20,1 sity of exercise may be even associated to an increased mortality [99,1 • Strength exercise: to define the intensity of strength exercise is q pends from many factors, such as the resistance (generally repre to lift) that the muscle must win, the speed of movement and nu Usually, there is an inverse association between the weight to li movement: the more elevated is the weight and the less is the s and/or then the number of repetitions that the subject may sustain range with a heavier weight (anaerobic) may better optimize mu power, whereas a higher repetition range with a lighter weight muscular endurance. Using weight loads that permit 8 to 15 repet facilitate improvements in muscular strength and endurance strength intensity one-repetition maximum (1RM) (which is the of weight that a person can possibly lift for one repetition, con maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . In order to bette pabilities, the use of multiple repetitions, usually five (5RM) usin may be considered (5RM represents the maximum amount of wei formed 5 times [20] ). This technique helps to avoid maximal exe difficult to perform and possibly dangerous in risk populations. cise intensity is generally required; even lower intensity may be usefu beginning of intervention programs or in deconditioned patients [23] . the benefits will increase performing exercise at higher intensities as l aerobic [35, 106] . Increasing the exercise intensity means also to increa cardiac and musculoskeletal risk) [20, 35] and at very high dose, endu not be performed using a prevalent aerobic metabolic pathways [20,1 sity of exercise may be even associated to an increased mortality [99,1 • Strength exercise: to define the intensity of strength exercise is q pends from many factors, such as the resistance (generally repre to lift) that the muscle must win, the speed of movement and nu Usually, there is an inverse association between the weight to li movement: the more elevated is the weight and the less is the s and/or then the number of repetitions that the subject may sustain range with a heavier weight (anaerobic) may better optimize mu power, whereas a higher repetition range with a lighter weight muscular endurance. Using weight loads that permit 8 to 15 repet facilitate improvements in muscular strength and endurance strength intensity one-repetition maximum (1RM) (which is the of weight that a person can possibly lift for one repetition, con maximum amount of force that can be generated in one maximal erally employed [20, 97] . 1RM can either be calculated directly usi or indirectly using submaximal estimation [108] . In order to bette pabilities, the use of multiple repetitions, usually five (5RM) usin may be considered (5RM represents the maximum amount of wei formed 5 times [20] ). This technique helps to avoid maximal exe difficult to perform and possibly dangerous in risk populations. sity of exercise may be even associated to an increased • Strength exercise: to define the intensity of streng pends from many factors, such as the resistance ( to lift) that the muscle must win, the speed of mov Usually, there is an inverse association between t movement: the more elevated is the weight and and/or then the number of repetitions that the subj range with a heavier weight (anaerobic) may bette power, whereas a higher repetition range with a l muscular endurance. Using weight loads that perm facilitate improvements in muscular strength a strength intensity one-repetition maximum (1RM of weight that a person can possibly lift for one maximum amount of force that can be generated i erally employed [20, 97] . 1RM can either be calcula or indirectly using submaximal estimation [108] . I pabilities, the use of multiple repetitions, usually may be considered (5RM represents the maximum formed 5 times [20] ). This technique helps to avoi difficult to perform and possibly dangerous in risk aerobic [35, 106] . Increasing the exercise intensity mean cardiac and musculoskeletal risk) [20, 35] and at very h not be performed using a prevalent aerobic metabolic sity of exercise may be even associated to an increased • Strength exercise: to define the intensity of streng pends from many factors, such as the resistance ( to lift) that the muscle must win, the speed of mov Usually, there is an inverse association between t movement: the more elevated is the weight and and/or then the number of repetitions that the subj range with a heavier weight (anaerobic) may bette power, whereas a higher repetition range with a l muscular endurance. Using weight loads that perm facilitate improvements in muscular strength a strength intensity one-repetition maximum (1RM of weight that a person can possibly lift for one maximum amount of force that can be generated i erally employed [20, 97] . 1RM can either be calcula or indirectly using submaximal estimation [108] . I pabilities, the use of multiple repetitions, usually may be considered (5RM represents the maximum formed 5 times [20] ). This technique helps to avoi difficult to perform and possibly dangerous in risk [18, 20, 62, 93, 109, 110] . VO 2 max = maximal aerobic capacity; HRR = Heart rate reserve = Maximal heart rate -resting HR; METs indicates metabolic equivalents. 1 MET = 3.5 mL O2 kg −1 min −1 . * % Heart rate reserve (HRR) = calculate HRR target by (HRR × %value) + resting HR; RPE, rating of perceived exertion (20 value Borg score); ** Sedentary behavior is defined as any walking behavior which is characterized by an energy expenditure ≤ 1.5 Mets. *** Adapted from refs [105] , using training zones related to aerobic and anaerobic thresholds. Low-intensity exercise is below the aerobic threshold; moderate is above the aerobic threshold but not reaching the anaerobic zone; high intensity is close to the anaerobic zone; and very intense exercise is above the anaerobic threshold. The duration of exercise will also largely influence this division in intensity [20] . This parameter is particularly important for endurance exercise and the session length required to improve health is of 30 min every day if the intensity is moderate. In unfit subjects who cannot exercise for 30 min consecutively, even shorter duration at moderate intensity may grant some benefits when compared with individuals who were inactive [23] particularly if the shorter period is repeated during the day. Recent guidelines [28] underline that physical activity of any bout duration is associated with improved health outcomes. Longer periods may be required to reach particular goals: for instance to loose fat mass 60 min/day of endurance moderate exercise is required [96] . • Endurance aerobic exercise needs to be performed ideally every day, at least 5 days/week, particularly if the intensity of exercise is light or moderate. Subjects who are fit and can exercise at aerobic vigorous intensity may also exercise 3 days/week [16, 18, 20, 93, 109] . On the other hand when the goal is to improve metabolic control in diabetic and obese patients a high frequency is welcomed [48, 111] . • Strength exercise requires to exercise the same muscular group two-three, days/week, non-consecutive days in order to permit muscular recovery [48, 97] . To drive the subject toward the planned exercise dose in order to reach the established goal [48, 93, 102, 112] . This is a particularly important point in order to foster subject's compliance. Progression consists in modulating intensity, frequency and duration of exercise considering subject's training level, preference and personal characteristic. For instance, for an obese, unfit patient 30 min of endurance aerobic moderate exercise performed every day may be a very difficult goal to reach. Starting with a less demanding protocol, and subsequently improving it, could be a better solution. The prescription of a tailored exercise program should be accompanied by a reduction of sedentary behavior (to benefit of any occasion during regular daily chores, or working time, to perform physical activity) [50, 51, 57] . Replacing sedentary time with any intensity of physical activity (including light intensity) may grant health benefits [28] . The reduction of sedentariness often represents the first step particularly in unfit subjects unwilling to perform structured exercise or unfit patients with an elevated cardiometabolic risk. In these subjects the prescription of a structured exercise program may represents a second step. From a medical and behavioral point of view, an exercise prescription may be considered correct only if the subject actually performs the prescribed exercise and this latter one is capable to improve physiological mechanisms such as endocrine, immunological and autonomic controls. Execution of exercise may occur in different places (home, fitness centers, outdoor, indoor, etc) considering subjects' preferences/need. The presence of a health professional, such as exercise physiologist or physiotherapist, capable to transform into concrete actions the prescribed program, will tremendously improve the program and the results [65] . Table 5 depicts the main actions that may be performed during a first encounter or follow up visit with the subject/patient in order to prescribe an exercise program. Considering that exercise is only one component of a lifestyle intervention, to address also the others components, in particular nutrition, may be of pivotal importance in order to reach the defined clinical goal/s [61] . This action may be taken during the first encounter or in follow up visits, considering time constraint and subject's/patient's characteristics and preferences Table 5 . Description of first and follow up visits (see also our previous paper [4] ). [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. pabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Setting of specific individual goals muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Education about physical activity and tailored exercise prescription movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Help the patient to discover and define practical strategies to reduce sedentariness during his/her normal daily activities pends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. sity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. racing or any all-out activity (eg Elicit in the patient the desire to adhere to the tailored exercise prescription taking into account medical guidelines, personal clinical needs and patient's preferences not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Welcome beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . • Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. In order to get significant benefits from endurance aerobic exercise a moderate exercise intensity is generally required; even lower intensity may be useful particularly in the beginning of intervention programs or in deconditioned patients [23] . On the other hand, the benefits will increase performing exercise at higher intensities as long as they remain aerobic [35, 106] . Increasing the exercise intensity means also to increase risk (particularly cardiac and musculoskeletal risk) [20, 35] and at very high dose, endurance exercise will not be performed using a prevalent aerobic metabolic pathways [20, 107] . Elevated intensity of exercise may be even associated to an increased mortality [99, 106] . Strength exercise: to define the intensity of strength exercise is quite difficult. It depends from many factors, such as the resistance (generally represented by a weight to lift) that the muscle must win, the speed of movement and number of repetitions. Usually, there is an inverse association between the weight to lift and the speed of movement: the more elevated is the weight and the less is the speed of movement and/or then the number of repetitions that the subject may sustain. A lower repetition range with a heavier weight (anaerobic) may better optimize muscular strength and power, whereas a higher repetition range with a lighter weight may better enhance muscular endurance. Using weight loads that permit 8 to 15 repetitions will generally facilitate improvements in muscular strength and endurance [97] . To calculate strength intensity one-repetition maximum (1RM) (which is the maximum amount of weight that a person can possibly lift for one repetition, considered also as the maximum amount of force that can be generated in one maximal contraction) is generally employed [20, 97] . 1RM can either be calculated directly using maximal testing or indirectly using submaximal estimation [108] . In order to better meet patients' capabilities, the use of multiple repetitions, usually five (5RM) using a lighter weight, may be considered (5RM represents the maximum amount of weight that can be performed 5 times [20] ). This technique helps to avoid maximal exercise which may be difficult to perform and possibly dangerous in risk populations. Make the patient aware that he/she is regaining control on his/her life and wellbeings Exercise represents a preventive/therapeutical tool in many clinical conditions ranging from cardiometabolic disease to cancer. Being this Review part of a Special Issue entitled "Sport-Exercise and Stress: A Winning Combination" we consider meaningful to underline the role of exercise in the management of stress and conditions, such as functional syndrome, where stress may play an important role. The definitions of stress are many, particularly considering the various interplay between psychological, physiological, behavioral or social aspects [113] [114] [115] . In a previous paper [25] we proposed the following definition in the full awareness that it might be improved "stress may be considered as the psychological, behavioral and physiological (or pathophysiological) consequence of the interaction between a subject and a stressor; considering as "stressor" everything (acute or chronic) present in the environment or in the subject's mind that could be perceived as important, dangerous or potentially capable to modify, both negatively or positively, the subject's life". Stress per se [116] is a physiological response [114] to re-establish homeostasis through regulatory systems (hypothalamicpituitary-adrenocortical, autonomic nervous system and immunity) [25, [117] [118] [119] [120] modulated by subjective perception of the stressor, individual (genetic, biological, psychological) differences and behavior [120] . The negative nature of stress manifests itself when bodily (somatic symptoms/diseases [115, 119, [121] [122] [123] ) or psychosocial effects appear. These negative consequences sometimes are more determined by individual characteristics, as the personal way of perceiving the stressor and behavior [25, 120] (coping strategy), then by the initial stressor. Sometimes, they may even worsen the clinical picture becoming themselves new stressors [25, 124] (for instance the fear to be ill) and may even worsen the risk of occurrence of chronic non communicable diseases (assumption of unhealthy lifestyles). Moreover, subjects may, again unconsciously, change decision making strategies [25, 125, 126] , change social behavior, isolating themselves, incrementing litigation in the family or on the job, etc, reducing their work and social performance thus further deteriorating their quality of life. The mechanisms which link chronic stressful conditions to health are complex and modulated by genetic predisposition [25, 114, 119] , being both direct (involving bodily control systems) and indirect (favoring unhealthy life styles). From a clinical point of view [25] , chronic stressful conditions may play a role in the development/worsening of other diseases and in determining somatic symptoms not explained by the presence of "traditional" disease. These conditions are now defined as functional syndromes [123] . In fact, a somatic symptom may not always have an organic cause, but it might arise in consequence of an increased awareness of physiological changes associated with a stressor or disease/injury or physiological process, or variants of normal physiology. Individual experience and/or biological characteristics [25, 123, 124] may facilitate the occurrence of specific symptoms. Moreover the behavior assumed by the patient just to reduce the symptoms, may instead increase them in the long term, for instance to completely stop physical activity to reduce lower back pain [25] . From a clinical management point of view, stress and functional syndromes require a multidimensional approach which considers physiological, psychological and behavioral factors contributing to the genesis of symptoms [25, [119] [120] [121] [122] 124, 127, 128] . A correct assessment in order to exclude other possible diseases and reach a clear diagnosis is, however, essential before starting treatment [129] ; traditional tests and examinations are crucial to define the nature of reported symptoms and new diagnostic tools [25, 129] , as autonomic nervous system assessment, may furnish help in order to discover peculiar alterations present in patients who lament "unexplained" somatic symptoms and to monitor the effects of treatments [25, [130] [131] [132] . Several studies show that Functional syndromes and stress conditions are actually characterized by an impaired cardiac autonomic control [130] [131] [132] [133] [134] . The recent multidimensional approaches to manage stress [25, 110, 119, 133, 135] and other functional syndromes [25, 124, 136] consider the following tools: A plausible explanation of symptoms, based on a correct diagnosis and available evidence, is offered by references [121, 122] to provide a clear summary of the effects of predisposing (like preexisting diseases or genetic background), precipitating (like psychosocial stressors or infections [137, 138] and perpetuating (like unhealthy lifestyle modifications or erroneous patient's interpretation of personal condition) factors. The use of modern, simple diagnostic techniques capable of revealing autonomic nervous systems alterations may represent a useful tool [25] to explain that a symptom may be present even in absence of a traditional organic damage, being generated by a functional impairment [130, 131] . This approach can be the starting point for translating a therapeutic rationale in concrete actions that also need patient's active role such as lifestyle modification. Antidepressants and anxiolytics are the more frequently prescribed drugs even if their usefulness is controversial [124, 139] . Other drugs aimed at peripheral physiological processes [128] , for instance muscle tension, inflammation, bowel function [140] could be useful, in specific patients lamenting specific symptoms. On the other hand psychological treatments, in particular cognitive behavioral therapy and relaxation techniques [121, 124, 128, 130, 131, [139] [140] [141] [142] [143] [144] proved to be efficacious. The assumption of an unhealthy behavior (improper coping strategy) may be a consequence of chronic stressful conditions (for instance lack of time for exercise) or an attempt to minimize symptoms and individual impairment in some functional syndromes (for instance to rest as much as possible in presence of muscular pain and or fatigue). A cornerstone of the treatment is to counterbalance these unhealthy behaviors. In this context, a particularly important role is played by physical activity [9] [10] [11] 145, 146] . Exercise may improve brain function, primarily cognition and executive control processes [146] . It may also reduce symptoms of anxiety and depression and it may improve stress system dysregulation [145] . Exercise, particularly aerobic activity [147] , plays an important role in the management of unexplained somatic symptoms, chronic fatigue and fibromyalgia [119, 121, 124, 136] ; recent data [148] show also a role of strength exercise in the management of anxiety. The mechanisms underlying these beneficial effects are multifarious; of main importance may be the role of exercise in modulating all the control systems (immunological, hormonal and autonomic nervous system [4, [37] [38] [39] 41, 43, 44, 46] ) implied in the genesis of stress. Moreover the possibility to prove to the patient that he/she could modify his/her behavior (for instance to become physically active) may be a powerful tool to improve self-efficacy and self-esteem, mandatory skills in order to eventually take actions in order to manage the cause of stress and the stressful situation. Patient can realize that he/she can assume a proactive role, can regain the control on own life, can find the resources to take actions and change. In order to manage stress and somatic symptoms, exercise must be correctly prescribed and tailored to patient's characteristics and preferences [20, 24, 48, 102] . Patients lamenting fatigue, muscular pain or other symptoms generally dislike performing physical activity and believe that it may be useless, if not even dangerous to their peculiar condition. Incorrect exercise prescription might strengthen these incorrect beliefs. A correct exercise protocol should include the establishment of a baseline followed by a planned increase in duration of low intensity physical activity, followed by gradual increases in intensity leading to moderate loads of aerobic exercise. Modification in nutrition styles, smoke, sleep hygiene, are other lifestyle components which need to be taken into account, considering obviously patient's characteristics and clinical condition. The role of exercise to foster wellbeing, to support healthy ageing, to prevent and manage many chronic non communicable diseases and stress conditions, is nowadays undoubted. On the other hand to modify lifestyle introducing exercise into daily life is very difficult. To move from "what" to "how" [149] , may be a keystone to realize exercise medicine. Physician's competence to foster a patient's behavioral change is important as much as technical skills to prescribe exercise. While this concept may seem self-evident, it is anything but established in current practice. To include lifestyle medicine (considering all the required competencies) in undergraduate medical curricula [67] [68] [69] 71, 150] or in other health professionals' curricula, would be welcome in order to implement efficacious lifestyle change programs. The practical model proposed in this paper might represent a possible example to pioneer exercise medicine [62] [63] [64] [65] [66] as a component of everyday medical practice. Furthermore the importance that the physician could be a model (being or becoming a regular exerciser) for the patient needs to be underlined [112, [151] [152] [153] . Exercise prescription: What does it mean for primary care? 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