Who could and should give exercise prescription: Physicians, exercise and health scientists, fitness trainers, or ChatGPT?

Highlights

• •There has been a hot debate on who could and should give exercise prescriptions.
• •While physicians, exercise and health scientists, and fitness trainers each have their role in prescribing exercise, an integrated and interdisciplinary team approach is recommended.
• •ChatGPT showed great potential to become a smart, interdisciplinary, yet independent, assistant to provide accurate and individualized exercise prescriptions for both general and professional use in the very near future.

Benefits of exercise for personal health, as well as preventing and treating chronic diseases, have been well documented during the past several decades.¹ Exercise prescription is a specialized field that involves assessing an individual's health status, fitness level, and specific goals to create a tailored exercise program based often on the FITT-VP principle:

• Frequency: How often exercise should be performed (e.g., 5 times per week)

• Intensity: The intensity at which the exercise should be performed (e.g., 75% of maximum heart rate)

• Time: How long each exercise should last (e.g., 15 min)

• Type: The type of exercise that should be performed (e.g., walking, cycling, swimming, weightlifting)

• Volume: Total amount of exercise, usually taking into account the total amount of aerobic training or sets and reps for strength (resistance) training

• Progression: How to safely increase frequency, intensity, time, and/or volume to improve or maintain performance and health

Other information of an exercise prescription may also include guidance on injury prevention, key steps of an exercise routine, such as warm-up, conditioning, and cooling down, and how to rest and recover, and so on.

While the guidelines of physical activity (PA) and exercise for the general public2, 3 or specific medical conditions, such as diabetes⁴ and cancer,⁵ have been developed, who could and should prescribe exercises—physicians, exercise sciences scientists, or fitness trainers—has been a frequent and hotly debated topic.⁶ The pros and cons of physicians, exercise sciences scientists, or fitness trainers as the prescribers of exercise that arose from these debates, are summarized in Table 1.

Table 1.

Pros and cons of physicians, exercise and health scientists, or fitness trainers as the exercise prescribers.

Profession	Related Degrees	Pros	Cons
Physicians	MD	They have been trained to deal with persons with medical conditions; therefore, they are most qualified to give prescriptions to patients or persons with special needs	They were not trained in exercise prescription and many do not exercise regularly themselves
Exercise and health scientists	PhD (Dr.)	They are most knowledgeable about the relationships that exist between exercise dose and health outcomes; they were the primary contributors to the formulation and development of exercise prescription	They are typically not trained in dealing with specific medical conditions and they typically have little clinical experience working with specific patient populations
Fitness trainers	MS, BS, or HSD	They are the ones who most often work directly with people	Many of them do not have adequate training in the field of exercise science. They typically work with healthy clients

Abbreviations: BS = bachelor of science; HSD = high school diploma; MD = doctor of medicine; MS = master of science; PhD = doctor of philosophy.

Rather than jumping into the debate itself, a quick review of the major historical events or developments, and the corresponding game changer(s) related to exercise prescription, may shine light on the debate. Below are a few selected historical events, presented in chronological order, that influenced the debates on who should prescribe exercise.

• 1953: The London Bus Study by the British epidemiologist Jeremy N. Morris is recognized as the earliest and most influential study on the relationship between PA and health. Compared with drivers who basically sit still, Morris et al.⁷ found that conductors went up and down about 600 “stairs” every day, which resulted in a heart attack rate of the “active” conductors that was half of that of the “sedentary” drivers. This study was published in The Lancet in 1953⁷ and started the field of PA epidemiology.

• 1968–1989–2016: In 1968, Kenneth H. Cooper, MD, the father of aerobics and a pioneer in preventive medicine, published his famous book “Aerobics”,⁸ and “invented” the 12-min run to predict maximum oxygen consumption.⁹ In 1970, Cooper founded the Cooper Clinic and Cooper Aerobics Research Center in Dallas, TX, USA. At the Cooper Clinic, in addition to the usual medical examination, each patient undergoes testing of aerobic capacity and other physical fitness markers. The world's largest fitness and health database and tracking study emerged from Cooper's work, which was first called “Aerobics Center Longitudinal Study” and later changed to “Cooper Center Longitudinal Study”. Dr. Steven N. Blair used epidemiological methods to analyze Cooper Center Longitudinal Study data and found that if a person's aerobic capacity is good, then the person's risk of death from various diseases could be reduced by 58%! Dr. Blair and others published this landmark research result in the Journal of the American Medical Association in 1989,¹⁰ laying a new foundation for understanding the effects of exercise on health. In 2016, the American Heart Association published an article in Circulation listing aerobic capacity as a “Clinical Vital Sign” and the first author of that article is Dr. Robert Ross.¹¹

• 1975–2022: In 1975, the American College of Sports Medicine (ACSM) published its first edition of the Guidelines for Graded Exercise Testing and Exercise Prescription,¹² which was later renamed to the ACSM's Guidelines for Exercise Testing and Prescription (hereinafter referred to as the “ACSM's Guidelines”). In 2022, ACSM's Guidelines were upgraded to its 11th edition,¹³ and after nearly half a century of careful craftsmanship, ACSM's Guidelines have evolved into the exercise prescription “Bibles” in the global fitness and health community. Interestingly, except for Neil F. Gordon, MD, and Paul D. Thompson, MD, as the associate editors of the 8th and 9th editions of ACSM's Guidelines, respectively, all other editorial chairs, co-chairs, senior editors, and associate editors received their PhD degrees in exercise science and health related fields (see Page vi of the 11th edition of ACSM's Guidelines for details).¹³

• 1993–2024: The metabolic equivalent (MET) of PA or exercise is a multiple of the approximate energy expenditure at rest, equivalent to 3.5 mL O₂/kg (body weight) per minute, which is a measure of exercise intensity. To unify the scoring of commonly used PA questionnaires at the time, a team led by Dr. Barbara E. Ainsworth published the first edition of the “Compendium of Physical Activity” in 1993,¹⁴ which included 19 major activity categories and a total of 477 activities or sports and their estimated equivalent MET values. The second edition published in 2000,¹⁵ included 21 major activity categories with a total of 605 activities or sports and their equivalent MET values. The third edition in 2011,¹⁶ still contained 21 main activity categories, but the activities and sports had increased to 822 items, which provided a great reference for evaluating the interchangeability of physical activities in terms of equivalent METs. Finally, the 4th edition has been completed and has been published in the first issue of 2024 of the Journal of Sport and Health Science.¹⁷ The main activity categories in this newest edition have been increased to 22, including 1119 activities and sports, and their equivalent MET values.

• 1994: If exercise is regarded as a “medicine” for health, the direct dose–response relationship between exercise and health outcomes must be understood. Dr. William Haskell expounded on exercise dose–response in 1994,¹⁸ setting the stage for a scientific and complete framework for research in this field. His elaborations include the following key points: The application of “exercise medicine” should be studied and approved according to the same standards as approved medicine, including the following: (a) Effectiveness: Can a specific exercise bring special health benefits? (b) Dose: What dose (intensity × time × frequency) is effective? What dose is safe for a specific group of people and patients? (c) Applicability: Can the therapeutic effect be applied to most people? (d) Mechanism of action: What physiological changes bring about the therapeutic effect? These principles are still relevant when studying exercise prescription today.

• 1996: Physical Activity and Health: A Report by the Surgeon General¹⁹ was published in 1996, which is a historical milestone recognizing the positive role of PA in public health. Led by Dr. Steven N. Blair, nearly 100 experts participated in the formulation and writing of this report. In this report, it was stated for the first time that 150 min of moderate-intensity PA per week can achieve significant health benefits, and this statement set a new foundation for exercise prescription.

• 1996–1999–2000: Measuring PA accurately is essential when determining the dose–response relationship between exercise and health outcomes. Because measuring PA using questionnaires is easily affected by people's subjectivity, researchers began to actively explore other, more objective, methods including pedometers, accelerators, heart rate belts or exercise watches in the 1990s. Dr. Henry J. Montoye and others published the book Measuring Physical Activity and Energy Expenditure in 1996,²⁰ which was an early and detailed elaboration of research and practice in exercise and health. In October 1999, the Measurement and Evaluation Council of The American Alliance for Health, Physical Education, Recreation and Dance held a forum with the theme of PA assessment at the Cooper Institute to discuss the status and future direction of measurement and evaluation of PA. The conference papers were published in a supplement of Research Quarterly for Exercise and Sport (Vol. 71, Suppl. 2, 2000) in 2000. Some of the papers were published in the book titled Physical Activity Assessments for Health-related Research²¹ in 2002 and Dr. Gregory J. Welk served as the editor of the book.

• 2007: In view of the positive role of exercise in preventing and treating diseases, but the lack of exercise prescription by physicians in their clinical practice, ACSM and the American Medical Association jointly launched the Exercise is Medicine® (https://www.exerciseismedicine.org/) program in 2007, to allow medical staff to measure patients’ PA participation, to determine if the patients’ amount of exercise meets the PA guidelines, and to provide medical advice on how to achieve the PA recommendations outlined in the guidelines. Robert Sallis, MD, made major contributions to the advancement of this program.²²

• 2008 and 2018: The U.S. Department of Health and Human Services published Physical Activity Guidelines for Americans in 2008,² which was based on summarizing the findings of decades of scientific research and it provided specific guidance as to the benefits, needs, and sports injury protection of children, adolescents, adults, and the elderly. These guidelines were updated in 2018.³ The 2 teams developing these guidelines were comprised of a majority of exercise science and health scientists, joined by a small number of MDs.

Reviewing the events that had a primary impact in the field of exercise prescription, it seems that scholars in the exercise and health science areas made the most significant contributions in the formulation and development of exercise prescriptions. This assertion seems to hold true also when reviewing the development of exercise prescriptions for specific medical conditions: for example, Dr. Barry A. Franklin's leadership role in cardiac rehabilitation,23, 24 Dr. Sheri R. Colberg in exercise and diabetes,4, 25 and Dr. Robert U. Newton in exercise and cancer.26, 27 Does this mean that exercise science and health scientists (with PhDs) are more qualified to prescribe exercise? Not really! Because most exercise science and health scientists are not adequately trained in clinical exercise physiology and rehabilitation, and are not in a position to prescribe exercise for patients suffering from complicated and complex medical conditions, possibly also receiving a mixture of drugs and other medical interventions that may affect exercise prescriptions. As a result, it has been recognized that an integrated, interdisciplinary team, including physicians, clinical exercise physiology, physical therapy/occupational therapy, and certified fitness trainers, is needed for prescribing and implementing exercise in clinical settings.⁶ Yet, the current medical/health care/exercise science structures make such an integration difficult, even impossible. Novel approaches and restructuring of the health care system may be required to overcome the current barriers.

Fortunately, the advent of a new generation of artificial intelligence, especially OpenAI/ChatGPT lunched in November 2022, may provide a powerful approach to help overcome current barriers. ChatGPT is an expert think tank that allows users to enter demand prompts to receive images, texts, or videos created by artificial intelligence. The biggest advantage of ChatGPT is in its “interdisciplinary” capacity, which is the exact capacity and strength required to overcome the lack of integration between medical/health care systems and the exercise science fields.

By checking if ChatGPT can indeed be used to develop integrated and thoughtful exercise prescriptions, we made 2 tests. In the first test, we used a case (Case Study III) on Page 39 of ACSM's Guidelines, 11th edition,¹³ to determine whether the results given by ChatGPT (4.0) are consistent with the answers provided in the ACSM's Guidelines.

In Table 2, we provide the prompt entered and the responses given by ChatGPT (4.0). The recommendation “it's essential to have medical clearance” by ChatGPT is the same as that listed in the ACSM's Guidelines, but with more explanations as to “why” and the resources used in providing the response.

Table 2.

The prompt entered, and the responses provided by ChatGPT (4.0).

Prompts entered:

Need help! We have a 60-year-old women who is beginning a professionally-led walking program. Two years ago, she had a drug-eluting stent placed in her left anterior descending coronary artery, after a routine exercise stress test revealed significant ST-segment depression. She completed a brief cardiac rehabilitation program in the 2 months following the procedure but has been inactive since. She reports no signs or symptoms and takes a cholesterol-lowering statin and antiplatelet medications as directed by her cardiologist. Is it necessary for her to have a medical clearance before we let her start the program?

ChatGPT (4.0)’s response (Note that, interestingly, ChatGPT used “I” when replying):

I did a quick search and here's what I found.

For the 60-year-old woman who had a drug-eluting stent placed in her left anterior descending coronary artery and is now looking to start a professionally led walking program, it is indeed advisable to obtain medical clearance before she begins the program. Exercise is generally recommended after angioplasty and stenting, but individual recommendations can vary based on the patient's specific health condition, the complexity of the procedure, and recovery progress. It's usually recommended to wait at least 3 to 5 days post-procedure before starting cardiac rehabilitation and low-intensity exercise. The specific timeline and intensity of exercise should be determined by a healthcare professional, often in the context of a cardiac rehabilitation program.

Cardiac rehabilitation is a supervised program that includes exercise training, emotional support, and education about heart-healthy lifestyle changes. It is often recommended after heart procedures like stenting to improve overall health, reduce the risk of future heart problems, and enhance the quality of life. Since each individual's health status and response to the procedure can vary, the safety and appropriateness of exercise post-stent procedure must be evaluated by a cardiologist or healthcare provider. They consider factors such as health history, current health conditions, and the success of the procedure before giving exercise recommendations.

Given her history and the fact that she has been inactive since completing her brief cardiac rehabilitation program, it is crucial to have a medical assessment to ensure that the walking program is safe for her and to determine the right intensity and duration of exercise. The healthcare provider may conduct an exercise stress test to assess how her heart responds to physical activity. It's also important to ease into the exercise program, starting with lower intensity activities and gradually increasing as recommended by healthcare professionals.

In summary, while exercise is beneficial post-stent, it's essential to have medical clearance and guidance to ensure safe and effective participation in the walking program.

Sources (with links): Livestrong, Carda Health, and Mayo Clinic

In the second test, we asked ChatGPT to provide aerobic and strength training prescriptions for persons with Parkinson's disease, and we compared the answers by ChatGPT with the recommendations provided by ACSM's Guidelines, Page 419.¹³

The prompt entered and the response provided by ChatGPT (4.0) are summarized in Table 3. Again, besides providing the same recommendations as those given in ACSM's Guidelines, ChatGPT also provided information on the prescription for “Balance, Agility, Multitasking and Stretching”, as well as for “Safety Precautions” and “Motivation and Cognitive Challenges”.

Table 3.

Prompts entered and response provided by ChatGPT (4.0) on exercise prescriptions related to persons with Parkinson's disease.

Prompts entered:

We are also designing an exercise intervention program for persons with Parkinson's disease. What frequency, intensity, time and type should we follow for both aerobic and resistance exercises?

ChatGPT (4.0)’s responses:

I did a quick search and here's what I discovered.

Designing an exercise intervention program for individuals with Parkinson's disease requires attention to specific guidelines regarding the frequency, intensity, time, and type of both aerobic and resistance exercises. Based on the recommendations from the Parkinson's Foundation and the American College of Sports Medicine, here are the guidelines:

1. Aerobic activity

○ Frequency: It is recommended to engage in aerobic activities 3 days a week

○ Intensity: The intensity should be moderate or vigorous

○ Time: Each session should last for at least 30 min, consisting of continuous or intermittent movement

○ Type: Suitable aerobic activities can include walking, cycling, swimming, or any other form of cardio that elevates the heart rate

2. Strength training

○ Frequency: Strength training exercises should be done 2–3 times a week on non-consecutive days

○ Intensity: Focus on resistance, speed, or power exercises

○ Time: Each session should be at least 30 min

○ Type: Major muscle groups should be targeted, and exercises can include the use of resistance bands, bodyweight exercises, or light weights

3. Balance, agility, and multitasking

○ Frequency: These exercises should be incorporated 2–3 days per week, with daily integration if possible

○ Intensity and time: Should be adjusted based on individual capabilities and the progression of the disease

○ Type: Activities may include tai chi, yoga, or specific balance and coordination exercises

4. Stretching

○ Frequency: Stretching should be done 2–3 days per week, with daily stretching being most effective

○ Intensity and time: Gentle and sustained stretching, focusing on major muscle groups

○ Type: Include stretches for flexibility and mobility, such as calf stretches, hamstring stretches, and arm stretches

Safety Precautions

• Medical clearance: Individuals should have a full functional evaluation by a physical therapist specializing in Parkinson's and exercise during their on periods when their medication is most effective

• Monitoring: Due to risks like orthostatic hypotension and increased fall risk, exercises may need to be modified. It is important to monitor the individual's response to exercise and adjust the program as needed

Motivation and cognitive challenges

• Non-motor symptoms: Exercise professionals should be aware of non-motor symptoms like apathy, depression, and fatigue that might affect motivation and participation in the exercise program

Overall, these guidelines aim to provide safe and effective exercise programs for individuals with Parkinson's disease, with a focus on improving quality of life and managing symptoms. Exercise professionals play a vital role in developing and supervising these programs

For more detailed information and resources, you can visit the Parkinson's Foundation and the American College of Sports Medicine

In summary, while physicians, exercise and health scientists, and fitness trainers each have their role in prescribing exercise, an integrated and interdisciplinary team approach that provides exercise prescriptions is recommended. The current cross-professional barriers make such an integration difficult, if not impossible. Fortunately, the advance of AI, especially the launch of ChatGPT, may help overcome current barriers and may become a smart, interdisciplinary, yet independent, assistant to provide accurate and individualized exercise prescriptions for both general and professional use in the very near future.

Authors’ contributions

WZ generated the idea of the article and completed the first draft; the other authors provided comments and suggestions on the draft and were ranked based on their contributions. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.

Competing interests

The authors declare that they have no competing interests.