As we already have seen and will see in much more detail in the following chapters, in order to be successful in becoming regular exercisers, your patients will need to do a good deal of mental work before they start the physical activity. At the same time, if you are going to be successful in providing the exercise prescription in the way that will be most effective in helping your patients to achieve their goals, you will want to do some mental work as well. You will need to do a modest amount of it just to get going, more if you decide to get into the subject more deeply. Some of you will have already done that mental work. But many of you will not have. This chapter is about the thought processes you can engage in that will help you as you proceed down the road to organizing your practice and the way you practice to most effectively deliver the exercise prescription. We will start with some fairly simple approaches and proceed to some more complex ones.

One way of thinking about organizing both the way you work with individual patients and the way you manage your practice is to use what is called the “Five As Framework: Assess, Advise, Agree, Assist, Arrange follow-up” (1). You can use it in a step-wise fashion with patients, going along the pathway one step at a time. If you decide to undertake a reformulation of your practice, you can also use it comprehensively, as a planning model for doing so.

With patients in the first step, the Assessment process, you review both patient knowledge and present behavior(s). Hopefully, you will obtain some information about your patient’s attitudes, beliefs, preferences, and feelings about the prospects of becoming a regular exerciser. Assessment can be carried out in a number of ways that we will discuss in more detail in Chapter 3, including use of pre-visit health risk appraisal instruments, questionnaires, and interactive computer-based systems.

Enabling you to effectively Advise your patients to accept the exercise prescription and implement it for themselves, in their own lives, is of course one of the central foci of this book. Advice is most effective when it is personalized and relates to your patient’s particular situation. Agreement by the patient to engage in the process is the first step that they need to take in order to get on the pathway of exercising regularly. As noted, actively Assisting the patient to engage in the activity is a role that clinicians have in implementing few other prescriptions. In this case, because of the ongoing nature of the behavior change process that is at the center of becoming a regular exerciser, it is necessary for the clinician to be proactive. Your ongoing help is essential if your patients are going to build up their confidence in their own ability to actually effect the necessary behavior change(s).

Arrange here refers to arrangements that your patient will be making, from scheduling, to choosing the type(s) of regular exercise they are going to engage in, to finding locations, acquiring equipment, learning new sport(s) if applicable, and so on and so forth. It also refers to arrangements that you will be making, that is, if this is a new function for your practice or if you will be considerably expanding your focus on it, and to arranging to engage in long-term follow-up with your patients.

As part of what can help you to become effective, we turn to a consideration of creating, being part of, and using the physician-fitness professional team, as developed by the American College of Sports Medicine itself. The ACSM recognizes, trains, and certifies a broad range of Fitness Professionals. In addition to them, there are numerous other recognized health professionals, described briefly in the following paragraphs, dealing with regular exercise and regular exercisers, present or potential. The list includes: the physical therapist, the occupational therapist, the athletic trainer, the chiropractor, the sports psychologist, the health educator, the nutritionist, the addiction counselor, the social worker, and the certified athletic trainer.

In dealing with one or another aspect of regular exercise for one patient or another, clinicians making referrals to other clinicians obviously have a wide range of potential colleagues to choose from. The choice for referral, when made, should reflect the needs of the particular patient in question. All of these healthcare professionals can be part of the regular-exercise-promoting team. In some locales certain of them may sit under one roof. Or they may form a “virtual team,” working in different locations but working together and communicating regularly about individual patients, the interventions they are using, and new developments they come across.

The ACSM’s Guidelines for Exercise Testing and Prescription, now in its 8th edition (GETP8), provides a more in-depth, detailed approach to screening patients, exercise testing protocols, and exercise prescription. This text is highly recommended to exercise professionals and the interested clinician. The balance of this section of this chapter is drawn from the text of the Report of the Guidelines for Exercise Testing and Prescription, 8th edition, Appendix D (2).

The first ACSM clinical certification was initiated over 30 years ago in conjunction with the publication of the first edition of the GETP. That era was marked by, first, the rapid development of exercise programs for patients with stable coronary artery disease (CAD). ACSM sought a means to disseminate accurate information on this healthcare initiative through the expression of consensus from its members in basic science, clinical practice, and education. Thus, these early clinical certifications were viewed as an aid to the establishment of safe and scientifically based exercise services within the framework of cardiac rehabilitation practice as it was then understood.

The ongoing development of the health/fitness certifications in the 1980s reflected ACSM’s intent to increase the availability of qualified professionals to provide scientifically sound advice and supervision regarding appropriate physical activities for health maintenance in the apparently healthy adult population. Since 1975, more than 35,000 certificates have been awarded in the several ACSM certification categories. With this consistent growth, ACSM has taken steps to ensure that its competency-based certifications will continue to be regarded as the premier set of programs in the exercise field.

The principal Fitness Professionals recognized by ACSM are as follows. All should be considered when a Physician-Fitness Professional team is being developed. If they are ACSM-certified, one can be assured that their education will have been based upon a common body of Knowledge, Skills, and Attitudes (KSAs), with the appropriate specializations for each of the professions.

The ACSM Certified Personal Trainer^SM is a fitness professional involved in developing and implementing an individualized approach to exercise leadership in healthy populations and/or those individuals with medical clearance to exercise. Using a variety of teaching techniques, the ACSM Certified Personal Trainer^SM is proficient in leading and demonstrating safe and effective methods of exercise by applying the fundamental principles of exercise science. The ACSM Certified Personal Trainer^SM is familiar with forms of exercise used to improve, maintain, and/or optimize health-related components of physical fitness and performance. The ACSM Certified Personal Trainer^SM is proficient in writing appropriate exercise recommendations, leading and demonstrating safe and effective methods of exercise, and motivating individuals to begin and to continue with their healthy behaviors.

The ACSM Health/Fitness Instructor^® (HFI) is a health and fitness professional holding a degree qualified for career pursuits in the university, corporate,
commercial, hospital, and community settings. The HFI has knowledge and skills in management, administration, training, and supervising entry-level personnel. The HFI is skilled in conducting risk stratification, conducting physical fitness assessments and interpreting results, constructing appropriate exercise prescriptions and motivating apparently healthy individuals and individuals with medically-controlled diseases to adopt and maintain healthy lifestyle behaviors

The ACSM Exercise Specialist^® (ES) is a healthcare professional certified by ACSM to deliver a variety of exercise assessment, training, rehabilitation, risk factor identification, and lifestyle management services to individuals with or at risk for cardiovascular, pulmonary, and metabolic disease(s). These services are typically delivered in cardiovascular/pulmonary rehabilitation programs, physicians’ offices, or medical fitness centers. The ACSM Exercise Specialist^® is also competent to provide exercise-related consulting for research, public health, and other clinical and non-clinical services and programs.

The ACSM Registered Clinical Exercise Physiologist^® (RCEP) is an allied health professional who works in the application of physical activity and behavioral interventions for those clinical conditions where they have been shown to provide therapeutic and/or functional benefit. Persons for whom RCEP services are appropriate may include, but are not limited to, those individuals with cardiovascular, pulmonary, metabolic, orthopedic, musculoskeletal, neuromuscular, neoplastic, immunologic, or hematologic disease. The RCEP provides primary and secondary prevention strategies designed to improve fitness and health in populations ranging from children to older adults. The RCEP performs exercise screening, exercise and fitness testing, exercise prescription, exercise and physical activity counseling, exercise supervision, exercise and health education/promotion, and measurement and evaluation of exercise- and physical activity-related outcome measures. The RCEP works individually or as part of an interdisciplinary team in a clinical, community, or public health setting. The practice and supervision of the RCEP is guided by published professional guidelines, standards, and applicable state and federal regulations.

Certification at a given level requires the candidate to have a knowledge and skills base commensurate with that specific level of certification. In addition, the HFI level of certification incorporates the KSAs associated with the ACSM Certified Personal Trainer^SM

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