The American College of Sports Medicine recently released the ninth edition of ACSM’s Guidelines for Exercise Testing and Prescription. References to the Guidelines are ubiquitous in evidence-based fitness articles and textbooks, including the ACE manuals. While ACE certainly recommends that all certified fitness professionals review this important document themselves, this article highlights the essential take-home points that may impact your day-to-day practice.

Pre-participation Health-screening Recommendations

The most pertinent updates are in the area of pre-participation health screening, a topic that often causes confusion among both new and experienced fitness professionals. The new pre-participation health-screening recommendations reduce the emphasis on the need for medical evaluation prior to initiating a progressive exercise regimen in healthy, asymptomatic individuals. ACSM also emphasizes the identification of clients or class participants with known disease, because these individuals are at the greatest risk for an exercise-related cardiac event. 

Recommendations for a Medical Examination Prior to Initiating Physical Activity

Individuals at moderate risk with two or more cardiovascular disease (CVD) risk factors should be encouraged to consult with their physicians prior to initiating a vigorous-intensity physical-activity program. The atherosclerotic CVD risk-factor thresholds are outlined in Table 2.2 on page 27 of the new ACSM Guidelines. This table, which also appears in each of the ACE manuals, remains unchanged from the previous edition and is an essential tool for all fitness professionals. While medical evaluation is taking place, the majority of these people can begin light- to moderate-intensity physical-activity programs such as walking without consulting a physician. In the previous edition, there was no discussion of what these individuals could do in the interim. 

Why the change? Moderate-risk clients who are referred to their physicians prior to beginning an exercise program may easily feel discouraged by the idea of having to fulfill this requirement, and they may never return to the fitness facility. Instead, you can have your moderate-risk clients immediately get started on a walking program (likely the most appropriate starting point anyway), and also recommend they visit a doctor. Once clearance is given, you can safely progress the intensity of each client’s program in accordance with the doctor’s recommendations.

Recommendations for Exercise Testing Prior to Initiating Physical Activity

Routine exercise testing before initiating a vigorous-intensity physical-activity program is recommended only for individuals at high risk of exercise-related complications, including those with unstable or new or possible symptoms of CVD, diabetes mellitus in combination with one or more of several complicating factors, end-stage renal disease or symptomatic or diagnosed pulmonary disease (refer to Table 2.3 on page 32 of the new ACSM Guidelines). This is an important change, as the previous edition was more restrictive in recommending testing for moderate-risk individuals as well. Exercise testing is also warranted whenever the health/fitness or clinical exercise professional has concerns about an individual’s CVD risk, requires additional information to design an exercise program, or when the exercise participant has concerns about starting an exercise program of any intensity without such testing.

This is another example where ACSM has removed a barrier to participation in an active lifestyle for moderate-risk individuals.

The figure that outlines the exercise testing and testing supervision recommendations has been modified in this new edition of the ACSM Guidelines and appears as Figure 2.4 on page 28. In the previous edition, the medical exam and graded exercise test were considered a single element of the screening process, but they have been separated in the new edition. The biggest change comes in the column covering moderate-risk individuals. While a medical exam is still recommended before the commencement of exercise, exercise testing is no longer required. In addition, doctor supervision is not necessary during either a maximal or submaximal exercise test, while in the previous edition doctor supervision was recommended for maximal exercise testing. This reflects ACSM’s focus on removing unnecessary obstacles before adopting a physically active lifestyle.

There are multiple considerations that prompted the changes in the screening process. The risk of a cardiovascular event is increased during vigorous-intensity exercise relative to rest, but the absolute risk of a cardiac event is low in healthy individuals. Recommending a medical examination and/or stress test as part of the pre-participation health-screening process for all people at moderate-to-high risk prior to initiating a light- to moderate-intensity exercise program implied that being physically active confers greater risk than a sedentary lifestyle. In fact, the cardiovascular health benefits of regular exercise far outweigh the risks of exercise for the general population.

Other Noteworthy Additions


All fitness professionals are familiar with the FITT acronym—frequency, intensity, time, and type. The new Guidelines add VP to the mix, indicating volume (the product of frequency, intensity and time) and either pattern (multiple bouts of 10 minutes or more each day, or one continuous session) or progression (a gradual progression of exercise volume achieved by adjusting any or all of the three components of volume). Very deconditioned clients may yield benefits from exercise bouts lasting less than 10 minutes, but the plan should always be to adjust volume until the ultimate goal—long-term exercise maintenance—is attained. A gradual progression also may enhance adherence and reduce the risk of musculoskeletal injury and adverse cardiac events.

Special Populations

The number of special populations has been increased, as more information related to exercise testing, programming and special considerations of these populations became available since the publication of the eighth edition. These newly included populations are individuals with low-back pain, cerebrovascular disease or stroke, fibromyalgia, intellectual disability and Down syndrome, multiple sclerosis, Parkinson’s disease, and multiple chronic diseases and health conditions, as well as those who have had bariatric surgery.

Chapter 11: Behavioral Theories and Strategies for Promoting Exercise

This all-new chapter covers exercise prescription, theoretical foundations for understanding exercise behavior, theoretical strategies and approaches to change, behavior and adherence, and special populations. As stated in the introduction to the chapter, “The purpose of this chapter is to provide health/fitness, public health, clinical exercise, and health care professionals a basic understanding of how to assist individuals to adopt and adhere to the exercise prescription recommendations that are made in the Guidelines” (p. 355).