From the Editor appy holidays! I sincerely hope all is well with you and yours. This issue marks the end of my term as Editor-in-Chief of ACSM’s Health & Fitness JournalA. It has been a great pleasure serving you in this role and meeting so many great people along the way. I want to say a special ‘‘thank you’’ to several people I worked closely with for the past 7 years. First, Lori Tish our managing editor. We started on this path together, and Lori has been a special person to work with. She always was welcoming, accommodating, and supportive to our authors, our associate editors, and me. Lori, I will miss working with you; thank you for everything. Next, our Associate Editor/Associate Editor-in-Chief, Dixie Thompson, Ph.D., FACSM, who also is stepping down. I had the pleasure of working with Dixie on the faculty at the University of Tennessee and in our roles with the Journal. She covered for me when I had knee surgery more than 5 years ago and was the author of one of the most popular columns in the Journal, Fitness Focus. Dixie, thank you for doing such a great job and in volunteering to serve when you had much on your plate. I want to thank Larry Golding, Ph.D., FACSM, for getting the Journal started and handing it over to me in good shape. I also would like to recognize and thank D. Mark Robertson and Kerry O’Rourke who served as ACSM’s director of publishing at the beginning and end of my service as editor-in-chief, respectively. Their support was greatly appreciated. I want to thank all of the Associate Editors who were part of the Journal during my term. It was a great pleasure working with you, and I was impressed by your ability to write interesting and easy-to-read columns issue after issue. A special thank you to Madeline Bayles, Ph.D., FACSM, who is rotating off as the author of the ACSM Certification column, and a special welcome to Deb Riebe, Ph.D., FACSM, who is taking on that role. Lastly, the quality of the feature articles depends on authors who have something to say and take the time to say it well, and reviewers who provide helpful feedback to make the feature even better. Thanks to you all for making the Journal what it is. Lastly, I want to welcome our new Editor-in-Chief, Steven J. Keteyian, Ph.D., FACSM. Steven already has been active in his role as editor-in-chief as we made the transition from me to him over the past several months. I know Steven will do a great job with the Journal, and I wish him the very best in the years ahead. We have three interesting feature articles in this issue. We begin with our annual installment of ‘‘Worldwide Survey of Fitness Trends for 2012’’ by Walter R. Thompson, Ph.D., FACSM. This article is based on the annual ACSM’s Health & Fitness Journal A worldwide survey of health and fitness professionals. This year’s survey supports some previous trends and reveals two interesting new trends. This article is the most cited article of the Journal and is picked up by news organizations around the world. Needless to say V a must read. Most readers are probably familiar with the hormonal responses to prolonged aerobic exercise that help maintain blood glucose levels; fewer are familiar with the hormonal responses to resistance training. Our second feature, ‘‘An Exercise Professional’s Guide to Acute Hormonal Changes from Resistance Exercise’’ by Jeremy C. Fransen, M.S., and Len Kravitz, Ph.D., provides Our Associate Editors have done their usual excellent job in an overview of hormone function, describes the providingconcise,well-writtencolumnsondiversetopics.Enjoy. acute hormonal responses to resistance exercise, • Fitness Focus: And in Summary...... and describes ways to optimize training to enhance • Wouldn’t You Like To Know: My husband (36 years old) was recently diagnosed with type 1 diabetes. How is this different from these responses. Much of this information is new, type 2 diabetes? Is this diagnosis typical for someone of his age? and I am sure we will see more on this topic in the Does he need to go on a special restricted diet? We exercise together years ahead. This is an important paper for students and wonder what he should include in his workouts? This diagnosis has been rather overwhelming for us as a couple, but we want to and professionals alike. develop a plan to manage his disease and optimize his health. Our final paper, ‘‘The Use of Vibration Ex• On the Floor: Aging Successfully: Doing the Right Thing at ercise in Clinical Populations’’ by Rita Toma´s, the Right Time V Ages 26 to 65, Part 2 M.D.; Vinson Lee, M.S.; and Scott Going, Ph.D., • ACSM Certification: Advancing the Exercise Science Profession provides insights into a less well-known type of • Clinical Applications: Maximal Aerobic Power: An Important exercise. Vibration exercise, which has gained Clinical and Research Measurement • Medical Report: Nonsteroidal Anti-Inflammatory Drugs: in popularity in the athletic training and fitness General Risks of Prophylactic, Acute, and Long-Term Use settings, may be an efficacious alternative form • Take Ten: 10 Health/Medical Problems No One Wants to of exercise for patients with neurological and Receive as a Holiday Gift musculoskeletal conditions. This article gives an overview of vibration exercise, discusses the rationale underlying its use in clinical populations, and provides an analysis of the literature Edward T. Howley, Ph.D., FACSM in terms of whether it works as advertised. I am sure you will enjoy it. Editor-in-Chief
H
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MISSION
STATEMENT The mission of ACSM’s Health & Fitness JournalÒ is to provide credible, readable, and applicable information about research in sports medicine and exercise science, and about health and fitness-related practices. The Journal strives to help health and fitness practitioners improve their knowledge and experience through reports and recommendations from experts, CEC offerings, opportunities to question the experts, listings of job openings, and more. Letters to the editor are welcome. Letters may be submitted through Editorial Manager (EM) (www.editorialmanager.com/fit). If you are new to EM, click ‘‘Register’’ and follow prompts to create a username and password. Log into the system as an author using your username and password. From the author menu, select ‘‘Submit New Manuscript,’’ then ‘‘Letter to the Editor-in-Chief.’’ Follow the prompts through to submission. Please make letters brief (no more than 300 words); they may be edited for reasons of clarity or space. Letters may appear in print or on the Journal’s Web site (www.acsm-healthfitness.org). Authors may submit original articles for possible publication in the Journal. Visit www.acsm-healthfitness.org and click on ‘‘For Authors’’ for submission instructions.
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News Briefs ELECTRIC BIKES AS A NEW ACTIVE TRANSPORTATION MODALITY TO PROMOTE HEALTH study published in the November 2011 issue of Medicine & Science in Sports & ExerciseÒ, the official journal of the American College of Sports Medicine (ACSM), examined whether using electrically assisted bicycles (EABs) in a hilly city allowed sedentary subjects to commute comfortably and provide healthenhancing benefits. Sedentary subjects, 18 in all, performed four different trips at a self-selected pace: walking 1.7 km uphill, biking 5.1 km with regular bike or 5.1 km with EAB at two different power assistance settings (EABhigh
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and EABstd). Time to complete each course, ˙ O2max, and HRmax were measured. V The study showed that EAB is a comfortable and ecological transportation modality, helping sedentary people commute to work and meet physical activity guidelines.
FOLLOW ACSM JOURNALS ON FACEBOOK TO STAY INFORMED ACSM’s journals (ACSM’s Health & Fitness JournalÒ, Current Sports Medicine Reports, Exercise and Sport Sciences Reviews, and Medicine & Science in Sports & ExerciseÒ) now have a page on Facebook. Following ACSM journals on Facebook is a great way to stay in touch with the journals and the latest research. You will receive up-
dates on new articles, most popular articles, published ahead of print articles, and more. ‘‘Like’’ us on Facebook today at www.facebook.com/acsmjournals.
MAKE PLANS NOW TO ATTEND ACSM’S 2012 HEALTH & FITNESS SUMMIT You will not want to miss ACSM’s Health & Fitness Summit & Exposition from March 27 to 30, 2012, in Las Vegas, NV. Begin making plans now to attend. Check out www.acsmsummit.org for valuable information and travel tips. This conference is for all professionals and students with a background in any health and fitness setting who want to inspire the life and well-being of others. You won’t want to miss this event! DON’T MISS ACSM’S PHYSICAL ACTIVITY, COGNITIVE FUNCTION, AND ACADEMIC ACHIEVEMENT CONFERENCE Join ACSM November 17 to 18, 2011, as renowned researchers and educators share evidence-based knowledge supporting the connection between physical activity, brain function, and academic achievement. Attendees will learn how to implement policy changes and programming to impact students today and tomorrow, hear from dynamic keynote speakers, explore symposia and scientific abstracts, network with national experts and policymakers, participate in a town hall discussion, and earn 13.75 ACSM CECs. The conference will be held at the Capital Hilton, 1001 16th St. NW, Washington, DC. For more information, please email
[email protected], or visit www.acsm.org/academicachievement. ACSM SELF-TESTS GO PAPERLESS! In the coming months, look for ACSM to go green and transfer all self-tests to an online learning system. Earning CECs has never been easier! Watch for more detailed news coming soon.
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News Briefs MEDICAL FITNESS ASSOCIATION LAUNCHES NEW WEB SITE
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he new Medical Fitness Association (MFA) Web site went live on July 17 to positive reviews. The continually revising interactive site features a growing bank of rich, relevant content including articles, free member Webinars that will archive, and discussion and group forums and allows you to construct a personal and professional profile there. The site includes full automation and online commerce opportunities as well. MFA Executive Director and founder of Operation FitKids, Ken Germano, stated, ‘‘as a service provider building memorable member experiences, we have taken one step forward in doing just that. We always seek to know and learn what our members are thinking in regard to the fully integrated, outcomes and accountability based delivery of medical fitness and now, they have a new and easier way to achieve this on a 365, 24/7 basis.’’
MEDICAL FITNESS WEEK WINNERS ANNOUNCED
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n April 2011, MFA successfully produced its seventh annual Medical Fitness Week. The goal of this initiative is to promote and increase physical activity opportunities for all age groups starting at children through older adults inside our nation_s schools and outside through medical fitness facilities into our communities underscoring the importance of the medical fitness difference. During this international event, medical fitness facilities, schools, and commu-
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nities are invited to offer programming that focuses on teaching students and families the behaviors they need to develop toward healthy lifestyles and well-being. Facilities can participate in a number of ways including health fairs, educational seminars, demonstrations, open houses, local school activities, and senior citizen participation. Many facilities choose to participate by entering in the ‘‘Steppin’ OutI for a Lifetime’’ National Walking Challenge:70,000 Steps in 7 Days. The ‘‘Steppin’ OutI for a Lifetime’’ National Walking Challenge: 70,000 Steps in 7 Days encourages local communities to get up and move by striving for 70,000 steps in 7 days from each participant. Centers can use this event as a fundraiser and donate all monies raised to local programs and scholarship funds in the fight against obesity or other healthrelated issues. The challenge involves wearing a pedometer and tracking how many steps a day a person is achieving. The community who achieves the most steps in the 7 days receives national recognition through press releases, the MFA Web site, and the 2011 Annual Conference in Orlando where we invite and hope to see you all. Beach Cities Health District members in California recorded the highest amount of total steps, whereas the Vanderbilt Dayani Center for Health and Wellness Center in Tennessee finished with the highest average steps per person. The 5,556 Beach City participants walked a total of 317,151,149 steps. Vanderbilt Dayani members averaged 123,627 steps during the 7-day challenge.
STEPPING OUT WINNERS Total Steps 1. Beach Cities Health District, CA 2. Providence Health & Services, OR 3. Community Hospital Fitness Pointe, IN 4. Galter Life Center, IL 5. Wilfred R. Cameron Center, PA 6. The Center for Health Improvement, KS 7. East Texas Medical CenterYOlympic Center, TX 8. Saint Francis Medical Center, Fitness Plus, MO 9. Trover Fitness Formula, KY 10. The Fitness Center at Highpoint Regional, NC
Average Steps Per Person 1. Vanderbilt Dayani Center for Health and Wellness, TN 2. North Mississippi Medical Center, Wellness Center, MS 3. Owensboro Medical Health Center, KY 4. East Texas Medical CenterYOlympic Center, TX 5. Aspirus, WI 6. Galter Life Center, IL 7. Water_s Edge Health and Wellness Center, OR 8. Florida Hospital, FL 9. The Fitness Center at Highpoint Regional, NC 10. Davis-Monthan AFB Fitness Center, AZ Congratulations to all of the Medical Fitness Centers and the more than 14,000 participants of the MFA 2011 Steppin_ Out Challenge.
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Fitness Focus Copy-and-Share by Dixie L. Thompson, Ph.D., FACSM
And in SummaryII Brought to you by the American College of Sports Medicine www.acsm.org
S
ince 2005, I have been entrusted with writing the Fitness Focus column. It has been a privilege to share some of my thoughts about fitness. My thanks to Editor-in-Chief Ed Howley, Ph.D., FACSM, for his guidance; to Managing Editor Lori Tish for keeping us all on schedule; and to you, the readers, for your support. Several themes have emerged through these columns, so in my last column, I am presenting what I consider some of the most important factors in maintaining good fitness for a lifetime. Keep it fun. There are many ways to stay fit, so choose those that fit your lifestyle and preferences. Exercise can be and should be enjoyable. Find those activities that make you want to do them. If you enjoy the solitude of a solo run, make sure at least some of your workouts give you that opportunity. If a morning exercise class is just the thing to get you up, moving, and motivated, then find one in your area. There are limitless ways to stay fit, so find what works for you. Mix it up. To have a well-rounded fitness program, it is important that cardiovascular endurance, musculoskeletal fitness, and flexibility have a place in your routine. Build each of these into your weekly workouts. Commonly, people are more attracted to one particular aspect of their fitness: maybe they like strength training but not aerobic training, or they like to run but hate to
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stretch. Paying attention to all aspects of your fitness over the course of your lifetime will pay many dividends in terms of your overall health and wellness. Find support. All of us need encouragement and this can come from many different types of sources. Workout partners, a hiking club, exercise class, or an Internet support group are just a few examples of ways that people can get support for their active lifestyles. Seek out individuals in your life who can give you encouragement when it is difficult for you to pursue a fitness program and who can help celebrate your successes. Your life will be enriched by these relationships. Remind yourself why you do it. People exercise for all types of reasons: to lose weight, for competition, to fight disease, to relieve stress, or for the sheer enjoyment of it. Keep in mind why you are exercising and link it with your short- and long-term goals. You may choose to keep a journal of your goals and accomplishments. The reasons you exercise will shift over time, and by remaining cognizant of your reasons for exercise, you are more likely to stick with it. Be persistent. Regardless of who you are, there are times when keeping your focus on fitness becomes difficult. Job changes, family difficulties, and illness are common challenges that can cause us to lose our fitness focus. When those times come, fitness may take a temporary backseat to other priorities, but getting back to your fitness routine can be an important way to deal with these challenges. When challenges come, some people find it daunting to reestablish their active lifestyles, so they slip into a sedentary pattern. If you find yourself facing that challenge, look back to the tips above, remind yourself that no one is perfect (so do not judge yourself too harshly), and recommit yourself to being fit. The multitude of physical, mental, and emotional benefits that come from being active will make you glad that you did. Dixie L. Thompson, Ph.D., FACSM, is the director of the Center for Physical Activity and Health and professor and department head for the Department of Kinesiology, Recreation, and Sport Studies at the University of Tennessee, Knoxville.
B 2011 by the American College of Sports Medicine. Reprint permission is granted to subscribers of ACSM’s Health & Fitness Journal A.
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Wouldn’t You Like to Know by Barbara Bushman, Ph.D., FACSM
Q:
My husband (36 years old) was recently diagnosed with type 1 diabetes. How is this different from type 2 diabetes? Is this diagnosis typical for someone of his age? Does he need to go on a special restricted diet?
We exercise together and wonder what he should include in his workouts? This diagnosis has been rather overwhelming for us as a couple, but we want to develop a plan to manage his disease and optimize his health.
A:
Diabetes is a disease characterized by elevated blood glucose. According to the 2011 National Diabetes Fact Sheet, 25.8 million children and adults have diabetes in the United States, and in 2010 alone, there were 1.9 million new cases of diabetes (8). Although these numbers indicate the prevalence, your questions show how very personal each case is for individuals and families. You already have identified two important lifestyle factors to help manage diabetes V diet and exercise.
TYPE 1 VERSUS TYPE 2 DIABETES With regard to your first question, although types 1 and 2 diabetes both result in higher than normal blood glucose levels, the cause of each differs (3). Type 1 diabetes results when the insulin-producing beta cells in the pancreas are destroyed by the body. The trigger for this autoimmune response is still poorly defined (3). Insulin is required to help transport glucose from the blood into the cells of the body, so when the beta cells are unable to produce insulin, the glucose levels become elevated in the blood. Type 2 diabetes begins with insulin resistance, meaning the cells cannot properly use the insulin released by the pancreas (3). When cells are resistant to the action of insulin, glucose remains in the blood, thus resulting in elevated levels. Over time, the body_s ability to produce insulin also can VOL. 15/ NO. 6
decrease, contributing to high blood glucose (referred to as hyperglycemia). Risk factors associated with types 1 and 2 diabetes are found in Table 1. Type 2 diabetes is much more common than type 1 diabetes, about 90% to 95% of cases compared with about 5%, respectively (3). Type 2 diabetes is mainly found in adults (explaining the formerly used designation of adult-onset diabetes) but also can be found in youth V rare in those younger than 10 years (0.4 new cases per 100,000 annually), but somewhat greater rates have been identified in youth age 10 to 19 years (8.5 new cases per 100,000) (8). Most, but not all, individuals with type 2 are obese or have a higher percentage of fat in the abdominal region (3). Type 1 diabetes is diagnosed more typically in youth (formerly called juvenile diabetes) but, as you have experienced, also can be found in adults. Although the
onset of type 1 diabetes often occurs early in life, half of new diagnoses are in those older than 20 years (9). People in their late 30s and early 40s also have a relatively high prevalence, although the onset often is not as abrupt as found in youth; this slow-onset
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Wouldn’t You Like to Know TABLE 1: Risk Factors Associated with Types 1 and 2 Diabetes (8) Type 1
Type 2
Autoimmune
Older age
Genetic
Obesity
Environmental
Family history of diabetes History of gestational diabetes Impaired glucose metabolism Physical inactivity Race/ethnicity
adult form is referred to as latent autoimmune diabetes of the adult (9).
NUTRITION FOCUS Although weight loss often is a major focus for individuals with type 2 diabetes, good nutrition is important for everyone. Diabetes results from a breakdown in the link between carbohydrates consumed and the body_s ability to use carbohydrate for energy. Given the focus on carbohydrate (glucose), you might anticipate that a highly restrictive diet would be necessary. Low-carbohydrate diets (G130 g per day) actually are not recommended as a means to manage diabetes (5). Consider the following recommendations for management of diabetes (5): •
Include carbohydrate from fruits, vegetables, whole grains, legumes, and lowfat milk.
•
Consume a variety of fiber-containing foods.
•
Monitor carbohydrates (e.g., carb counting, exchanges, experienced-based estimation).
•
Limit saturated fat to less than 7% of the total calories, minimize intake of trans-fats, and limit dietary cholesterol (G200 mg per day).
•
Consume two or more servings of fish each week.
• Follow typical recommendations to consume 15% to 20% of total calories from protein. Working with an endocrinologist, diabetes educator, and/or dietician will be important to individualize how to balance insulin therapy along with dietary and physical activity patterns. Each person is different and must learn to adapt to daily changes in how the body responds to activity, food consumed, and other situations like illness and stress. Two general ways to approach diet are the plate method and carb counting. The plate method of meal planning encourages consuming foods in appropriate amounts by dividing your plate in half and then one side in half again (Figure 1); foods include nonstarchy vegetables, starch and bread, and meat or other protein in addition to a dairy item and fruit. This method helps to keep portions in check while also providing a balance of carbohydrates, fats, and proteins (6).
Figure 1. Plate method of meal planning. Adapted, with permission, from B. Bushman (ed.), 2011, ACSM’s Complete Guide to Fitness & Health (Champaign, IL: Human Kinetics) p. 285.
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Situations in which a Cardiac Stress Test is Recommended before Exercising (2) • Previously sedentary and older than 35 years • Sedentary (any age) with diabetes for more than 10 years • Type 1 diabetes for more than 15 years (note V for type 2 diabetes, more than 10 years) • Major risk factor for heart disease (e.g., smoking, high cholesterol) • Have peripheral vascular disease, kidney disease, heart or blood vessel disease, or nervous system disease • Chest pain or discomfort with physical activity
Another commonly used method is to count grams of carbohydrate. Although carbohydrates can be in the form of starches, sugars, or fiber, the first two have the greatest impact on blood glucose levels. Although your diabetes care provider can provide specific targets, a typical starting point is about 45 to 60 g of carbohydrate per meal (6). Keeping carbohydrate intake consistent with regard to time and amount is helpful for anyone with fixed daily insulin (5). If using rapid-acting insulin or an insulin pump, then insulin doses can be adjusted depending on the content of the meal or snack. The nutritional plan for individuals with diabetes reflects healthy eating patterns, rather than an oppressive, restrictive diet. Many resources are available to help manage the nutritional aspect of diabetes. The American Diabetes Association has a calorie and carbohydrate counting tool called MyFoodAdvisor (see www.diabetes. org/food-and-fitness). Also, the U.S. Department of Agriculture provides the nutrient content of a wide variety of foods at www.ars.usda.gov (then enter
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TABLE 2: General Exercise Recommendations for Individuals with Type 1 Diabetes (1,2) Frequency (sessions per week)
Component
Intensity
Time (minutes per day)
Type
Aerobic exercise
3 to 7
50% to 80% heart rate reserve; 12 to 16 RPE*
20 to 60 minutes per session at moderate intensity
Large muscle group activities (e.g., walking, jogging, cycling, water aerobic exercises)
Resistance training
2 to 3
60% to 80% one-repetition max, low to moderate; 14 to 16 RPE*
Time needed to complete 2 to 3 sets per exercise for 8 to 12 exercises
All the major muscle groups in upper and lower body
Flexibility
2 to 3
Stretch to range of motion tightness
Time needed to complete 15- to 30-second stretches with 2 to 4 repetitions
Body wide with 4 to 5 exercises for both upper and lower body
*RPE using the 6 to 20 scale. RPE indicates rate of perceived exertion.
Nutrient Data Laboratory into the search box).
EXERCISE AND DIABETES Exercise can help improve blood glucose levels as well as provide many benefits related to cardiovascular health, weight management, blood pressure, and cholesterol. Including exercise on a regular basis is particularly important as the effect on blood glucose control will be lost within days (10). Because of the relationship between diabetes and heart disease, there are situations in which having a cardiac stress test are warranted (see Box), and there may be other concerns, such as retinopathy, nephropathy, or neuropathy, that may need to be addressed with your diabetes care provider (4). Assuming appropriate medical clearance is in place, exercise should include a warm-up, conditioning phase, and then a cooldown. Both cardiorespiratory (aerobic) exercise and resistance training are recommended, along with stretching to maintain flexibility (1,2). A general summary of exercise recommendations for individuals with type 1 diabetes is given in Table 2. A consistent exercise plan along with balanced food consumption and insulin doses will help to maintain appropriate blood glucose levels, not too low or too high. Exercise helps to move glucose into the cells. This is beneficial but also may result in blood glucose dropping too low (hypoglycemia), especially when combined VOL. 15/ NO. 6
with insulin. Some hints to help avoid hypoglycemia are as follows (2): •
Be consistent with carbohydrate intake related to the timing of your meals and exercise.
•
Do not exercise at the time of peak insulin action.
•
Maintain a regular time of day for your exercise.
•
Monitor your blood glucose before and after exercise, and if a longer exercise session, even during V typically, the goal is to keep blood glucose between 100 and 250 mg/dL to help avoid both hypoglycemia as well as hyperglycemia.
The effects of exercise can affect blood glucose for up to 12 hours or more, so spe-
cial care should be taken to check glucose levels if exercising later in the day (to avoid hypoglycemia during sleep). Having an extra snack may be necessary; such snacks should include both carbohydrate (15 g) and protein (7 to 8 g) (7). When glucose levels are not under control, the liver_s production of glucose increases, potentially resulting in higher blood glucose levels during exercise (7). Although moderate-intensity exercise may reduce blood glucose by helping increase glucose transport into the cells, high blood glucose levels can occur after intense exercise (10). Thus, hyperglycemia before exercise may require exercise to be delayed or the intensity decreased to avoid ketoacidosis (reflecting fat use and the resulting production
Figure 2. Decision-making flow chart for exercise for those with type 1 diabetes. Reprinted with permission from B. Bushman (ed.), 2011, ACSM’s Complete Guide to Fitness & Health (Champaign, IL: Human Kinetics), p. 292. ACSM’s HEALTH & FITNESS JOURNALA
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Wouldn’t You Like to Know of ketones), which is a serious medical condition (10). Blood glucose levels should be monitored before any exercise session. See Figure 2 for a decision-making flow chart. If glucose levels are too low, some carbohydrate should be consumed before exercising. If glucose levels are high, then it will become important to reflect on how you are feeling and to check for ketones in the urine (done with a simple at-home test kit). Work with your diabetes care provider to develop your individualized plan of action regarding adjustments in food consumption and insulin doses when planning for exercise. Some other factors to consider, specific for individuals with diabetes are as follows (4): •
Wear polyester or cotton-polyester blend socks to prevent blisters.
•
Keep feet dry to minimize trauma to the feet.
•
Wear proper footwear for the activity.
Maintain proper hydration (dehydration can affect blood glucose levels). Wearing a diabetes identification bracelet or shoe tag is highly recommended. In cases of hypoglycemia, individuals can become confused and even lose consciousness. Thus, it is important for others to be informed, so they can take action if needed. •
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CONCLUSION Although your husband_s diagnosis of diabetes was a shock, you are right on track with a focus on including physical activity and nutrition as tools in managing the disease, as well as in promoting overall health. Each day will present new challenges, but monitoring blood glucose and continuing to work with your diabetes care provider will result in good health now and into the future.
References 1. American College of Sports Medicine. ACSM_s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 380 p. 2. American College of Sports Medicine. ACSM_s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 868 p. 3. American Diabetes Association. Position statement: diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33: S62Y9. 4. American Diabetes Association. Position statement: physical activity/exercise and diabetes. Diabetes Care. 2004;27:S58Y62. 5. American Diabetes Association. Position statement: nutrition recommendations and interventions for diabetes. Diabetes Care. 2007;30:S48Y65. 6. American Diabetes Association Web site [Internet]. Alexandria VA: American Diabetes Association [cited 2011 May 10]. Available from: www.diabetes.org/food-and-fitness. 7. Beaser R, Horton E, Mullooly C. Physical activity for fitness. In: Beaser RS, editor.
Joslin_s Diabetic Deskbook, 2nd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2007. p. 127Y152. 8. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. 9. Khardori R, Bessen HA, Hussain AN, Schraga ED, Vincent MT. Type 1 diabetes mellitus. Medscape Reference. [Internet]. May 12, 2011 [cited 2011 May 20]. Available from http://emedicine.medscape.com/article/ 117739-overview#a0156. 10. Steppal J, Horton E. Exercise in patients with diabetes mellitus. In: Kahn CR, Weir GC, King GL, et al. editors. Joslin_s Diabetes Mellitus. Philadelphia (PA): Lippincott Williams & Wilkins; 2005. p. 649Y57.
Barbara Bushman, Ph.D., FACSM is a professor at Missouri State University. She holds four ACSM certifications: Program Director, Clinical Exercise Specialist, Health Fitness Specialist, and Personal Trainer. Dr. Bushman has authored papers related to menopause, factors influencing exercise participation, and deep water run training; she authored ACSM’s Action Plan for Menopause (Human Kinetics, 2005), edited ACSM’s Complete Guide to Fitness & Health (Human Kinetics, 2011) and promotes health/fitness at www.Facebook.com/FitnessID.
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WORLDWIDE SURVEY OF FITNESS TRENDS FOR 2012 by Walter R. Thompson, Ph.D., FACSM
LEARNING OBJECTIVES From this article, the reader should understand the following concepts: • The difference between a fad and a trend • Worldwide trends in the commercial, corporate, clinical (including medical fitness), and community health and fitness industry • Expert opinions about identified fitness trends for 2012
Key words: Commercial, Clinical, Corporate, Community, Expert Opinions, Future Programs
INTRODUCTION
N
ow in its sixth consecutive year, the 2012 ACSM Worldwide Survey of Fitness Trends embraced previous trends and also reinforced the deletion of what had seemed to be strong trends for 2 to 3 years but now have dropped off the list for the second year in a row relegating them to the growing bucket of fitness crazes, rages, and fads. Arguably, there are growing concerns about the still sluggish economy and how people choose to spend their hardearned income. The results of this annual survey will help the health and fitness industry make some very important investment decisions when planning for the future. Those business decisions should be based upon emerging trends and not the latest exercise innovation peddled by late night television infomercials or the hottest celebrity endorsing a product. As in the past five ACSM fitness trends surveys, respondents had to first make the important distinction between a ‘‘fad’’ and a ‘‘trend.’’ Many (if not all) surveys of this type rarely make a distinction, but because this is a survey of trends and not fads, it is important to define each. A trend has
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been described as ‘‘a general development or change in a situation or in the way that people are behaving’’ (http://dictionary.cambridge.org). It would be totally expected then to see the same trends appearing for multiple years in a ‘‘trends survey.’’ The definition of trend, after all, includes the phrase ‘‘general development’’ as opposed to ‘‘a fashion that is taken up with great enthusiasm for a brief period,’’ which is the definition of a fad (http://dictionary.reference.com). For the last 6 years, the editors of ACSM’s Health & Fitness JournalÒ have developed and widely disseminated electronic surveys to thousands of professionals to determine trends in the health and fitness industry that might help to guide programming efforts for 2012 and, perhaps, into the next decade. The first survey (1), conducted in 2006 (for predictions in 2007), was the initial effort to develop a systematic way to predict the future of the health and fitness industry, and surveys have been done each year since (2Y5). These annual surveys of health and fitness trends in the commercial (for-profit), clinical (including medical fitness), community (not-forprofit), and corporate sectors of the industry confirmed some trends revealed in previous surveys. Some of the trends first identified for 2007 have moved up and stayed in the top 10 since the original survey was published, whereas some new trends seem to be emerging for 2012, and others have disappeared out of the top 20. Future surveys will either confirm these new trends or fall short of making an impact on the health and fitness industry and drop out of the survey as did the stability ball, Pilates, and balance training in 2011; this was confirmed for 2012 as none of these appeared in the top 20. Dropping out of the survey may indicate that what was perceived to be a trend in the industry was actually a fad. Others ACSM’s HEALTH & FITNESS JOURNALA
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Fitness Trends for 2012 (ZUMBAÒ and outdoor activities) appear in the top 20 for the first time. Future surveys will either confirm or reject that these are emerging trends. This survey made no attempt to evaluate equipment, gym apparatus, tools, or other exercise devices that may suddenly appear at clubs or recreation centers or during late-night infomercials often seen during the winter holidays or the week before and a few weeks into the New Year. The survey has been designed to reconfirm, confirm, or even introduce new trends (not fads) that have been sustained by having a proven impact on the industry according to the international respondents. Using this framework, it is understandable that some of the trends revealed in earlier surveys would appear again (and perhaps for several years as is the case for several of the top 10 trends). It is as important for the health and fitness industry to pay close attention to not only those trends appearing for the first time but also those that do not appear this year or have been replaced on the list by other trends (e.g., Pilates and stability ball). The ACSM annual worldwide survey of health and fitness trends should not be confused with estimating the potential impact of a piece of new equipment or some emerging exercise device on the bottom line in for-profit clubs. That type of information is left to the reader to determine if it fits into their business model and how best to use it. The health and fitness industry should consider taking this information and applying it to its own settings, which may include commercial health clubs (for-profit), community settings (not-for-profit), corporate wellness programs, and medical fitness centers (clinical programs). The benefit to commercial health clubs (those that are for-profit) is the establishment (or perhaps justification) of new markets resulting in a potential for increased and sustainable revenue. Community-based programs should use the results to continue to justify an investment in their unique market by providing protracted programs serving families and youth. Corporate wellness programs and medical fitness centers may find these results useful through an increased service to their members and patients. There were 37 possible trends in the 2012 survey (six more than for 2011). The top 25 trends from previous years were included in the survey as were some emerging trends identified by the editors of ACSM’s Health & Fitness JournalÒ. To create a balance, the editors represent all four sectors of the health and fitness industry (corporate, clinical, community, and commercial) as well as members of academia. In the survey, potential trends were first identified, and then, short explanations were written to offer the respondent a few details without inconveniencing them with too much reading, analysis, or interpretation. The survey was designed to be completed in less than 15 minutes. As an incentive to complete the survey, the editors made available several ACSM books published by Wolters Kluwer/Lippincott Williams & Wilkins and Human Kinetics and a $100 American Express gift card. See a list of winners in ACSM’s Newsbriefs on page 2 of this issue. These incentives helped to increase participation in the survey.
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As in all of the previous ACSM worldwide fitness trends surveys, the 37 potential items were constructed using a Likerttype scale ranging from a low score of 1 (least likely to be a trend) to a high score of 10 (most likely to be a trend). After each scoring opportunity, space was allowed for the respondent to add comments (these proved to be very helpful in the identification of emerging trends appearing in this year’s survey). At the conclusion of the survey, additional space was left for the respondent to add comments or to add potential fitness trends left off the list to be considered for future surveys. This year’s survey also included some valuable demographic information that will help to guide the construction of subsequent surveys. The next step was to send the survey electronically to a defined list of health and fitness professionals. Using Survey Monkey (www.surveymonkey.com), the online survey was sent to 18,474 health fitness professionals. This list included all currently certified ACSM Certified Personal TrainersSM, ACSM Health/Fitness InstructorsÒ (presently known as ACSM Certified Health Fitness SpecialistsSM), ACSM Exercise SpecialistsÒ (now ACSM Certified Clinical Exercise SpecialistsSM), ACSM Registered Clinical Exercise PhysiologistsÒ, ACSM Health/Fitness DirectorsÒ, ACSM Program DirectorsSM, ACSM Alliance members, ACSM’s Health & Fitness JournalÒ nonmember subscribers, ACSM’s Health & Fitness JournalÒ Editorial Board, and ACSM’s Health & Fitness JournalÒ Associate Editors. Of these, 283 were returned for bad addresses, 49 opted out, leaving 18,474 possible participants. After the 3-week window of opportunity had been completed, 2,620 responses were received, which represents an excellent return rate of 14% (401 more than last year and an increase of 1,143 in the last 2 years). Responses were received from just about every continent including Asia, Europe, Australia, Africa, North America, and South America (some specific countries represented included The United States, Australia, Canada, China, France, Germany, Japan, India, Italy, and Russia). Demographics of the survey respondents included 66.1% female and 33.9% male respondents with a wide variability in ages (Figure). The first step in the analysis was to collate all of the responses and then rank-order them from highest (most popular trend) to lowest (least popular trend). Only the top 20 for 2012 are described in this report. After rank-ordering the responses, we asked four internationally recognized experts representing all sectors in the health and fitness industry to comment on the findings. Their analysis and commentary are included at the end of this report. Table 1 provides the top 10 results of the 5 previous surveys (1Y5). The same top six trends identified in 2008, 2009, and 2010 appeared as top six trends for 2011 and now for 2012, just in a different order with educated, certified, and experienced fitness professional maintaining the no. 1 spot, fitness programs for older adults holding on at no. 3 and strength training landing at no. 2. Therefore, the 2012 survey (Table 2) reinforces those findings of previous years, which was expected when tracking
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Figure. Age (years) of survey respondents.
trends and not fads. Dropping out of the top 20 trends for 2012 were outcomes measurements (no. 13 in 2011) and clinical integration/medical fitness (appearing for the first time in 2011 at no. 18). Staying out of the top 20 was balance training, Pilates, and stability ball (or Swiss Ball). These three potential trends had shown remarkable strength in past years. Pilates was no. 9 on the list as recent as 2010 and appeared also as no. 7 in 2008 and 2009. Although Pilates had all of the characteristics of a trend in the industry, it may now be thought of as a fad (as supported by this current trend analysis). Appearing for the first
time in the top 20 trends for 2012 were ZUMBAÒ and other dance workouts (no. 9) and outdoor activities (no. 14). Clinical integration/medical fitness (no. 18 in 2011) and outcomes measurements (no. 13 in 2011) dropped out of the top 20 for 2012. 1. Educated, Certified, and Experienced Fitness Professionals. Holding on to the no. 1 spot for the last 5 years, this is a trend that continues with education and certification programs that are fully accredited by national third-party accrediting organizations for health/fitness and clinical professionals. There
TABLE 1: Top 10 Worldwide Fitness Trends for 2007, 2008, 2009, 2010, and 2011 2007
2008
2009
2010
2011
1. Children and obesity
1. Educated and experienced fitness professionals
1. Educated and experienced fitness professionals
1. Educated and experienced fitness professionals
1. Educated and experienced fitness professionals
2. Special fitness programs for older adults
2. Children and obesity
2. Children and obesity
2. Strength training
2. Fitness programs for older adults
3. Educated and experienced fitness professionals
3. Personal training
3. Personal training
3. Children and obesity
3. Strength training
4. Functional fitness
4. Strength training
4. Strength training
4. Personal training
4. Children and obesity
5. Core training
5. Core training
5. Core training
5. Core training
5. Personal training
6. Strength training
6. Special fitness programs for older adults
6. Special fitness programs for older adults
6. Special fitness programs for older adults
6. Core training
7. Personal training
7. Pilates
7. Pilates
7. Functional fitness
7. Exercise and weight loss
8. Mind/Body exercise
8. Functional fitness
8. Stability ball
8. Sport-specific training
8. Boot camp
9. Exercise and weight loss
9. Stability ball
9. Sport-specific training
9. Pilates
9. Functional fitness
10. Outcome measurements VOL. 15/ NO. 6
10. Yoga
10. Balance training
10. Group personal training
10. Physician referrals
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Fitness Trends for 2012 TABLE 2: Top 20 Worldwide Fitness Trends for 2012* 2012 1. Educated, certified and experienced fitness professionals 2. Strength training 3. Fitness programs for older adults 4. Exercise and weight loss 5. Children and obesity 6. Personal training 7. Core training 8. Group personal training 9. ZUMBA and other dance workouts* 10. Functional fitness 11. Yoga 12. Comprehensive health promotion programming at the worksite 13. Boot camp 14. Outdoor activities* 15. Reaching new markets 16. Spinning (indoor cycling) 17. Sport-specific training 18. Worker incentive programs 19. Wellness coaching 20. Physician referrals *Indicates a top 20 position new for 2012.
seems to be exponential growth of educational programs at community colleges and undergraduate programs and graduate programs at colleges and universities, which have become accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) through the Committee on Accreditation for the Exercise Sciences and more certification programs accredited by the National Commission for Certifying Agencies (NCCA). According to the U.S. Department of Labor Bureau of Labor Statistics (BLS), ‘‘Ijobs for fitness workers are expected to increase much faster than the average for all occupations [through 2018]’’ (http://www.bls.gov/oco/ocos296.htm, cited on July 25, 2011). They go on to say ‘‘Those with formal training or experience will have the best chances to get a job.’’ The BLS defines ‘‘much faster than average’’ (their highest rating) as an increase of 20% or more. The BLS estimated that in 2008 there were approximately 261,100 employed fitness trainers and projects that by 2018 that number will increase to 337,900 (a difference of 76,800 workers, a 29% increase in the work force in just 10 years). It has become abundantly clear in this still sluggish economy that as the market for fitness professionals becomes even more crowded and more competitive, some degree of regulation either from within the industry or
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from external sources (i.e., government) seems to be growing as a number of states and the District of Columbia consider legislation to regulate personal trainers just as it does physicians, lawyers, and pharmacists. Commission on Accreditation of Allied Health Education Programs and NCCA are both third-party accrediting agencies V CAAHEP for academic programs and NCCA for certification programs. Because of their independence, neither organization is directly influenced by the health and fitness industry. In 2007, CAAHEP added a Personal Fitness Trainer accreditation for certificate (1 year) and associate (2 years) degree programs. Accreditation for the academic training of the Personal Fitness Trainer joins academic program accreditation for Exercise Science (baccalaureate) and Exercise Physiology (graduate programs in either applied exercise physiology or clinical exercise physiology). Collaboration also has started within the fitness industry to address the issue of standardized facility practices. Coordinated by NSF International (www.nsf.org), this collaboration (known as the NSF Joint Committee on Health Fitness Facilities Standards) brings various sectors of the industry and the public together to resolve the issues of facility standards (i.e., the characteristics of a health fitness facility). Look for these standards to be adopted by the joint committee within the year with a voluntary certification program to follow. 2. Strength Training. Strength training moved from no. 6 on the list in 2007 to no. 4 in 2008 and remained in that position in 2009. For 2010, strength training moved up to the no. 2 position on the list and, in 2011, dropped slightly to no. 3. This is a trend for both men and women to incorporate strength training into their exercise routines. For many years, and for a good number of health clubs (both for-profit and not-for-profit), a central theme remainsVstrength training. Historically, there are many clients who train exclusively using weights, and there are still those who lift weights for body building. However, today, there
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are many other individuals (both men and women, young and old) whose main focus is on using weight training to simply increase or maintain strength. Most health and fitness professionals today incorporate some form of strength training into a comprehensive exercise routine for both apparently healthy clients and for patients with controlled disease. It is common for cardiac rehabilitation, pulmonary rehabilitation, or metabolic disease management programs to include some form of weight training in the exercise prescription. Strength training is popular in commercial, community, clinical, and corporate health and fitness facilities for men, women, and in many cases, children. 3. Fitness Programs for Older Adults. Jumping from no. 6 in 2010, fitness programs for older adults was no. 2 in the 2011 survey and now remains strong at no. 3. As the baby boom generation ages into retirement, and because they may have more discretionary money than their younger counterparts, fitness clubs may capitalize on this exponentially growing market. Falling from no. 2 in 2007 to no. 6 in 2008, 2009, and 2010 and then rebounding to no. 2 in 2011, fitness programs for older adults remain a strong trend for 2012. Falling to no. 6 between 2007 and 2008 was a bit of a surprise, considering all the discussion about the baby boom generation rapidly approaching retirement age. However, this trend continues to be strong, making the top 10 in each year of the survey. It is assumed that in retirement, people typically have greater discretionary money but have a tendency to spend it more wisely and have more time to engage in an exercise VOL. 15/ NO. 6
program. Health and fitness professionals should take advantage of this growing population of retired persons by providing age-appropriate exercise programs. The more active older adult can enjoy golf and even an inspired game of pickle ball. The highly active older adult (the athletic old) also can be targeted by commercial and community-based organizations to participate in more rigorous exercise programs including strength training. Even the frail elderly can improve their ability to perform activities of daily living when provided the appropriate quality and quantity of exercise. Health and fitness professionals would be wise to develop and sustain fitness programs for people of retirement age. 4. Exercise and Weight Loss. For many years, exercise professionals have been trying to infuse a regular exercise program into the caloric restriction diets of many popular weight loss programs. Most well-publicized diet programs incorporate exercise program into their daily routine of providing meals to their clients. Exercise and weight loss is a trend toward incorporating all weight loss programs with a sensible exercise program. This has been a growing trend since the survey began. In 2009, exercise and weight loss was ranked no. 18, moving to no. 12 in 2010 and no. 7 in 2011, and now sits in the no. 4 spot. It seems as though people who are in the business of providing weight loss programs will incorporate regular exercise and caloric restriction for weight control. There also is increasing amounts of evidence that shows exercise is essential in weight loss maintenance.
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Fitness Trends for 2012
5. Children and Obesity. The problem with childhood and adolescent obesity continues to be a major health issue. As school systems face the reality of cutting programs, such as physical education and recess, to spend more time preparing for standardized testing in this challenging economy, this is a trend toward more programs and a potential new market for commercial and community-based organizations. Although slipping slightly to no. 4 for 2011 and no. 5 for 2012, for the sixth year, childhood obesity programming is a trend in the health and fitness industry. Health and fitness practitioners and industry leaders see the problem of childhood obesity and its associated comorbidities as an opportunity to positively influence a health issue that not only impacts the health care industry today but also has an even greater effect on the health of these children as they mature into adults. The health and fitness industry has recognized this problem and are beginning to mobilize with new programs aimed specifically at children. Corporate and clinical programs also may see this as an opportunity to develop specialized physical activity programs for children of their staff and clients. 6. Personal Training. Many of the undergraduate majors in kinesiology cited in an American Kinesiotherapy Association report (6) will turn to the personal training industry as their vocational choice. The growing number of undergraduate students seems to suggest that some students are being prepared for graduate school, but as the report cited, graduate programs seem to be reducing in size for economic and other reasons. Therefore, the students who do not go on to graduate school are finding employment in the health and fitness industry, many of them personal trainers. As more professional personal trainers are educated and become
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certified, they are more accessible to more people in all sectors of the health/fitness industry. Personal training has been in the top 10 of this survey for the past 6 years and top 5 for the past 5 years. Recently, much attention has been paid to the education and certification of personal trainers. In a number of states (California, New Jersey, Massachusetts, Georgia, and several others), legislation has been introduced to license personal trainers, none of which has yet passed. Although there are some minor variations of personal training (e.g., small groups as opposed to one-on-one), respondents to this survey believe that personal trainers are here to stay and will continue to be an important part of the professional staff of health and fitness centers. 7. Core Training. This trend stresses strength and conditioning of the stabilizing muscles of the abdomen, thorax, and back. Core training continues to use stability balls, BOSU balls, wobble boards, and foam rollers among other pieces of equipment. Although some have speculated that core training just a few years ago was a ‘‘fad,’’ it seems to have stood the test of time as it appears at no. 7 on our trends list for 2012. Core training typically includes the muscles of the hips, lower back, and abdomen, all of which provide support for the spine and thorax. Exercising the core muscles may enable the client or patient to improve the overall stability of the trunk and transfer that to the extremities, enabling the individual to meet the demands of activities of daily living and for the performance of various sports that require strength, speed, and agility. 8. Group Personal Training. Falling to no. 14 for 2011 from the top 10 in 2010 but rebounding to the no. 8 spot in 2012 is group personal training. This trend allows the personal trainer to still provide the personal service clients expect but now in a small group of 2 to 4, offering potentially deep discounts to each member of the group. In 2007, group personal training was no. 19 on the list. In 2008, it rose slightly to no. 15 but dropped again in 2009 to no. 19 and to no. 10 in 2010. In these still arguably challenging economic times when personal income may be decreasing, personal trainers must be more creative in the way they package personal training sessions. Training two or three people at the same time in a small group seems to make good economic sense for both the trainer and the client. 9. ZUMBAÒ and Other Dance Workouts. ZUMBAÒ requires energy and enthusiasm from the instructor and the participants, which combines Latin rhythms with interval-type exercise and resistance training. ZUMBAÒ and other dance workouts first appeared on the list of potential trends in 2010 and ranked no. 31 of 37 potential trends; in 2011, it was ranked no. 24 of a possible 31 choices. In 2012, it jumped to the top 10. Clearly, the popularity of ZUMBAÒ is growing with this rapid escalation in popularity. Future surveys will determine if this is a trend or a fad. 10. Functional Fitness. Rounding out the top 10 for 2012 is functional fitness. Functional fitness is defined as using strength
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training to improve balance, coordination, force, power, and endurance to improve someone’s ability to perform activities of daily living. The exercise programs reflect actual activities someone might do as a function of their daily living. Functional fitness first appeared on the survey in the no. 4 position in 2007 but fell to no. 8 in 2008 and no. 11 in 2009. It reappeared in the top 10 in 2010 at no. 7 and in 2011 at no. 9. Some survey respondents thought that there may be a relationship between functional fitness and fitness programs for older adults. Many exercise programs for the older age group are composed of functional fitness activities. 11. Yoga. Yoga has taken on a variety of forms within the past couple of years (such as Power Yoga, Yogalates, and other forms including Yoga done in hot and humid environments). Some of these forms are known as Iyengar Yoga, Ashtanga, Bikram Yoga (the hot and humid one), Vinyasa Yoga, Kripalu Yoga, Anuara Yoga, Kundalini Yoga, and Sivananda Yoga. Instructional tapes and books are abundant, as are the growing numbers of certifications for the many Yoga formats. Yoga appeared in the top 10 in this survey in 2008 and seems to be making a comeback in 2010 (no. 14) and 2011 surveys (no. 11). 12. Comprehensive Health Promotion Programming at the Worksite. Worksite health promotion programs jumped from no. 20 in 2010 to no. 12 for 2011 after first appearing in the 2009 survey at no. 12. This is a trend for a range of programs and services provided to improve the health of workers and incorporates systems to evaluate their impact on health, health care costs, and worker productivity. Some of these programs are housed within the company or corporation building or on their campus. Other programs may contract with independent commercial or community-based programs. Within the context of pending health care reform in the United States, health promotion programs may take on additional importance in the future. 13. Boot Camp. After first appearing in the 2008 survey at no. 26, Boot Camp was no. 23 in 2009, no. 16 in 2010, and no. 8 in 2011 but fell to no. 13 in 2012. Boot Camp is a high-intensity, structured activity patterned after military style training. Boot Camp includes cardiovascular, strength, endurance, and flexibility drills and usually involves both indoor and outdoor exercises typically led by an instructor who means business. Boot Camps also can combine sports-type drills and calisthenics. Because of its climb in the survey rankings in just 2 years with a slight decrease in the trend analysis this year, it will be interesting to see if Boot Camp programs continue as a trend in the fitness industry. 14. Outdoor Activities. This is a trend for health and fitness professionals to offer more outdoor activities to their clients. In 2010, outdoor activities ranked no. 25 in the annual survey, and in 2011, it ranked no. 27. Perhaps the best reason as to why there seems to be a trending up for outdoor activities came from VOL. 15/ NO. 6
a respondent who wrote ‘‘The best things about outdoor activities are that you don’t get bored, you spend precious time with family and friends, you give your mind a rest and put most of your energy into the physical aspect of your body and best of all, you don’t even realize that you are exercising.’’ 15. Reaching New Markets. This is a trend that identifies new markets in all aspects of the health/fitness industry. With an estimated 80% of Americans not having a regular exercise program or a place to exercise, commercial, clinical, corporate, and community programs will reach out to tap into this huge market. Reaching new markets appeared in the top 20 in previous years of this survey but dropped out in 2010. In 2011, it reappeared as no. 19, moving up to no. 15 for 2012. As with some of the other trends already discussed, health fitness professionals and their employers may be searching for new ways to deliver their services to the majority of people who are still not engaged in their programs. 16. Spinning (Indoor Cycling). Staying in the top 20 for 2012 is indoor cycling or spinning. As an instructor explains the terrain and provides the motivation, this group fitness program has been described as pedaling outdoors without temperature, humidity, or other environmental changes. The pedal tension on the stationary bike can be varied to simulate riding uphill or through valleys. Upbeat background music motivates people through this relatively high-intensity workout. Spinning classes have been reported to be one of the most popular group exercise programs in the commercial sector. 17. Sport-specific Training. Falling from a top 10 spot (no. 8) in 2010, sport-specific training dropped to no. 16 for 2011 and no. 17 for 2012. This trend incorporates sport-specific training for sports such as baseball and tennis, designed especially for young athletes. For example, a high school athlete might join a commercial or community-based fitness organization to help develop skills during the off-season and to increase strength and endurance specific to that sport. Breaking into the top 10 for the first time in the survey in 2009 (no. 9), sport-specific training jumped from no. 13 in 2008 after falling from no. 11 in 2007. This is an interesting trend for the health/fitness industry to watch over the next few years because of the fall to no. 17 for 2012 from its relative popularity in 2010. Sportspecific training could possibly attract a new market to commercial and community clubs as well as offer a different kind of service that could lead to increased revenues. 18. Worker Incentive Programs. Appearing for the first time in the survey top 20 in 2011 are worker incentive programs. This is a trend toward creating incentive programs to stimulate positive healthy behavior change as part of employer-based health promotion programming and health care benefits. This trend might represent a resurgence of corporate health promotion programs as a potential result of rising health care costs experienced by both small and large companies and corporations. It also may be ACSM’s HEALTH & FITNESS JOURNALA
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Fitness Trends for 2012 a response to recent health care reform legislation in the United States. Worker incentive programs also may be associated with the trend to provide worksite health promotion programs (no. 12 on the 2011 and 2012 surveys) in an attempt to reduce health care costs. 19. Wellness Coaching. Falling from no. 13 in 2010 but remaining in the top 20 for 2011 and 2012 is wellness coaching. This is a trend that incorporates behavioral change science into health promotion and disease prevention programs. Wellness coaching often uses a one-on-one approach similar to a personal trainer with the coach providing support, guidance, and encouragement. The wellness coach focuses on the client’s values, needs, vision, and goals. It seems as though wellness coaching and its principled techniques of behavior change are being adopted by not only personal trainers but also health care providers. 20. Physician Referrals. Jumping from no. 17 in 2010 and rounding out the top 10 for 2011 was physician referrals, a program associated with ACSM’s Exercise is MedicineÒ initiative. In the 2012 survey, physician referrals fell to no. 20. This is a trend toward an emergent emphasis being placed on partnerships with the medical community, resulting in seamless referrals to a health and fitness facility and health fitness professionals. Physician referrals to fitness professionals first appeared in the top 20 in the 2010 survey and will find, it seems, additional traction because of ACSM’s Exercise is MedicineÒ initiative and health care reform measures being considered around the world. All four sectors of the health and fitness industry can take advantage of the renewed interest of physicians and the health care insurance industry to add exercise to the daily regimen of their patients.
variable diameter of between 55 and 85 cm (22 to 34 inches), allowing for a wide range of activities to be performed. The stability ball also is known by other names, including exercise ball, gym ball, Pilates ball, Swiss ball, sports ball, fit or fitness ball, therapy ball, yoga ball, balance ball, or body ball. The stability ball was a surprise in the top 10 for 2008 and 2009 but fell to no. 18 for 2010, no. 26 in 2011, and no. 27 in 2012. This type of exercise did not make the top 20 in 2007, giving some indication that the use of the stability ball alone may have been a 3-year fad and not a trend at all, as suggested in the 2010 survey (4). The continued interest of the health fitness industry with specialized exercise programs for the older adult has triggered balance training as a possible trend in past surveys. Activities that promote balance include Tai Chi, yoga, and Pilates as well as exercise balls, wobble boards, BOSU balls, and foam rollers. In 2007, balance training was not in the top 20 in the trends survey. It first emerged at no. 14 in 2008 and gained strength in 2009 in the no. 10 position. In 2010, balance training not only fell out of the top 10 fitness trends but went to nos. 19 and 21 for 2011 and no. 24 for 2012. A growing segment of the commercial health club industry is unmonitored fitness facilities (as evidenced by the sales of franchises in many parts of the world). However, what seems to be a growing trend in the industry is not supported by this survey. Superficial monitoring is typically only during ‘‘normal work hours,’’ but members can access the facility at any time by using a special keypad that unlocks the door to the facility. Respondents to this survey placed this trend nearly last (no. 32) on the potential list of 37 trends. Clearly, health fitness professionals do not believe that this trend will continue, regardless of the business model and its apparent success in the commercial marketplace.
WHAT’S OUT FOR 2012?
SUMMARY
It is always interesting to see what fell out of the top 20 list on this survey for the next year and what seems to be supported by this year’s survey. Particularly surprising, but supported by the 2012 survey, was the fall of Pilates from no. 9 in 2010 (and a top 10 trend for the previous 3 years) to being not even in the top 20 for 2011 and no. 26 in 2012. Pilates is a form of exercise that targets the core of the body (i.e., the abdomen, back, and hips) while using the entire body during a training session. It also increases flexibility and improves posture. The exercises are typically done lying down on a mat and involve a series of controlled movements of the arms and legs that strengthen the abdominal muscles, hips, and back. Pilates first appeared in the top 10 on the survey in 2008 and remained strong through 2010 but disappeared from the top 20 for 2011. The 2012 survey suggests that perhaps Pilates was a fad and not a trend after all. Also falling out of the top 20 for 2011and supported by the 2012 survey was the use of the stability ball and balance training. A stability ball is a round object constructed of rubber with a
As in the previous six ACSM worldwide surveys, some trends were embraced again (e.g., educated and certified health fitness professionals), whereas others fell out of the top 20, and still, others were not supported at all (unsupervised and unmonitored fitness facilities). Trends have been defined as a general development that takes some time and then stays for a period (usually described as a behavior change), whereas a fad comes and goes. In the top 10 fitness trends for 2012, eight have been on the list in previous years. Falling out of the top 20 for 2011 and for 2012 includes balance training, Pilates, and the use of the stability ball. Pilates dropped the furthest in the last 2 years as it was listed as no. 9 in the 2010 survey and no. 7 in 2008 and 2009. It appears from this survey that Pilates may not have been a trend at all but may be considered a fad in the health fitness industry. ACSM’s Exercise is MedicineÒ initiative continues to be strong in the survey as physician referrals continues to appear in the top 20 in the survey but is a concern as clinical integration dropped out of the top 20 for 2012.
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INTERNATIONAL EXPERTS COMMENT ON 2012 TRENDS Josie Gardiner, American Council on Exercise Instructor of the Year 2005, IDEA Instructor of the Year 2002. After 40 years in the fitness industry and turning 65 this month, I am looking at fitness trends from a different prospective than many of my younger fitness professionals have. I have seen many fads come and go. It seems as if we are going full circle back to the 1960s. Baby boomers are turning 65 for the first time, and we are seeing the physical effects of all the high impact, killer, and extreme programs that have been popular. I believe we will see a rise in a combination of rehab and strength training focusing on the joints (ankle, knee, hip, shoulder, wrist, and elbow). Balance training will again be integrated into all forms of programs to help avoid falls. Core training that emphasizes spinal stability and utilizes equipment such as stability balls, Pilates circles, Bender balls to engage the core and work the weakest links. Small group personal training is on the rise especially with the uncertain stock markets. Many of these trainings are taking place in private homes and condominiums with gyms rather than in the health club setting. Personal training specific to the older adult is on the rise. The problem seems to be the fact that there is a shortage of older or younger certified personal trainers with the knowledge and understanding of how to develop a safe and effective program for the older adult. The challenge is finding a trainer who can decide how to select exercises where the risk does not outweigh the benefits! ZUMBAÒ is still the hottest dance exercise program worldwide. This is because the company is committed to their ZUMBAÒ Instructor Network by providing continuing educational materials on a monthly basis. They also are expanding their programs to fit the needs of all populations as well as bringing fun back into fitness. Definitely, programs to get our obese of all ages moving will soon be mandatory. Lastly, I believe that we will see a rise in medically based programming for all special populations like cancer, breast cancer, Parkinson’s disease, multiple sclerosis, and autism. It is an exciting time, and there is a great need for instructors and trainers to become more educated in all areas of fitness to make a difference in this world. Deborah Riebe, Ph.D., FACSM, Chair, Department of Kinesiology, University of Rhode Island; Chair, ACSM Committee for Certification and Registry Boards. The most impressive result of the 2012 fitness trends is the consistent importance placed upon the educational levels and experience of health fitness professionals. As the health and fitness industry matures, the expectation of having highly qualified professionals continues to grow. ACSM has kept up with this trend by introducing changes in the eligibility criteria for some certifications (e.g., candidates for ACSM’s Certified Health Fitness SpecialistSM VOL. 15/ NO. 6
certification must now have a bachelor’s degree from an exercisebased program) and maintaining highly respected clinical and health fitness certifications. The new job task analyses that will soon replace the current KSAs (knowledge, skills and abilities) have a greater emphasis on resistance training (no. 2) and behavior change. Although not specifically cited, behavior change is an important component in many of the top 20 trends including weight loss, personal training, worksite health promotion, worker incentive programs, and wellness coaching. I believe that exercise professionals will continue to integrate behavior change techniques into fitness and wellness programs to promote motivation and adherence to healthier lifestyles. Finally, the Exercise is MedicineÒ program has potential to facilitate relationships between physicians and qualified exercise professionals. Although the results of the survey show physician referrals decreasing in importance, this remains a viable method for exercise professionals to increase their reach and attract new business. Fred Hoffman, M.Ed., Paris, France, International Education Development Director, BatukaÒ, IDEA Fitness Instructor of the Year 2007, member of the program committee for the ACSM Health & Fitness Summit (www.fredhoffman.com). One of the most encouraging findings from the survey is that fitness professionals continue to recognize the need for quality educational programs and nationally accredited certifications. Regardless if this is driven by industry peer pressure or demands from an increasingly informed consumer base, the trend is welcome and encourages recognition of fitness professionals and their contributions to the general public’s overall health and wellbeing. I believe strength training and fitness programs for older adults continue to rank among the top five trends because of two factors: a changing demographic, and an increased awareness and understanding of the role strength training and regular exercise play in maintaining general health for all populations. Because many Baby Boomers and aging adults have been exercising for years, the findings remain consistent. I am not surprised that ZUMBAÒ and dance-based workouts have moved rapidly into position no. 9. Current pop culture greatly contributed to this rise by indirectly encouraging the unfit to ‘‘get up and move’’ with reality TV shows such as ‘‘Dancing with the Stars’’ and ‘‘So You Think You Can Dance.’’ ZUMBAÒ and similar formats, such as Batuka and Flirty Girl FitnessÒ, offer noncompetitive, accessible, fun activities driven by upbeat, motivating music. Because dance is not commonly viewed as exercise, these formats are reaching a new market demographic (trend no. 15). Lastly, that no. 4 (exercise and weight loss) and no. 5 (children and obesity) remain high on the list alludes to the unfortunate fact that our industry still has a great deal of work to do combating global obesity. I am encouraged though that because they remain high on the ‘‘to do’’ list, more initiatives will be taken to address these issues. ACSM’s HEALTH & FITNESS JOURNALA
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Fitness Trends for 2012 Olivia Affuso, Ph.D., Associate Professor, Department of Epidemiology, Associate Scientist in the Nutrition Obesity Research Center, and Associate Scientist in the Center for Exercise Medicine, University of Alabama-Birmingham, Birmingham, Alabama. As a physical activity epidemiologist, it is quite interesting to see the continued increase in strength training (no. 2) that may have been influenced by the 2008 Physical Activity Guidelines for Americans, which recommends two or more days a week of ‘‘muscle-building’’ activities for adults. In addition, this trend also may have been affected by fitness-based TV programming that shows nonathletes reaching their health and fitness goals by incorporating strength training into their exercise routines. What exactly is responsible for the continued growth in the strength training trend is unknown. However, trained and experienced fitness professionals have an opportunity to gain new clientele desiring to incorporate muscle-building activities into their exercise regimens. In contrast, one worrisome trend is the continued decline in focus on children and obesity (no. 5). Although the Continuous National Health and Nutrition Examination Survey reports an apparent plateau in childhood obesity prevalence, it is clear that children still are not sufficiently active and continue to be at risk for chronic diseases such as type 2 diabetes. Interestingly, it is possible that the new trend of outdoor activities (no. 14) may translate into more activity for the children of clients who participate in this type of fitness training as time spent outdoors is one of the strongest predictors of physical activity among children. Lastly, it is not surprising to see ZUMBAÒ and other dance workouts (no. 9) emerging in the top 10 trends for 2012. Dancebased workouts overcome barriers to fitness training such as gym access and inclement weather.
References 1. Thompson WR. Worldwide survey reveals fitness trends for 2007. ACSM Health Fit J. 2006;10(6):8Y14. 2. Thompson WR. Worldwide survey reveals fitness trends for 2008. ACSM Health Fit J. 2007;11(6):7Y13. 3. Thompson WR. Worldwide survey reveals fitness trends for 2009. ACSM Health Fit J. 2008;12(6):7Y14. 4. Thompson WR. Worldwide survey reveals fitness trends for 2010. ACSM Health Fit J. 2009;13(6):9Y16. 5. Thompson WR. Worldwide survey reveals fitness trends for 2011. ACSM Health Fit J. 2010;14(6):8Y17. 6. Quickly Growing Major, Inside Higher Education [Internet]. 2010 [cited 2010 Aug 13]. Available from: http://www.insidehighered.com/ news/2010/08/11/kinesiology.
Walter R. Thompson, Ph.D., FACSM, is a regents professor of Exercise Science in the Department of Kinesiology and Health (College of Education) at Georgia State University where he has a second academic appointment in the Division of Nutrition (Byrdine F. Lewis School of Nursing and Health Professions) where he also serves as the executive director of the After-School All-Stars Atlanta. He has lectured on health promotion and fitness topics in 24 countries on 5 continents. He has served on the ACSM Board of Trustees and was twice elected a member of its Administrative Council. He is a past chairman of the ACSM Committee on Certification and Registry Boards and the CAAHEP Committee on Accreditation for the Exercise Sciences, and he currently is serving as the chairman of the ACSM Publications Committee, Chairman of the ACSM American Fitness IndexTM Advisory Board and Chairman of the NSF International Joint Committee on Health Fitness Facilities Standards.
Acknowledgments The author thanks Editor-in-Chief Ed Howley, Ph.D., FACSM, for considering this project important enough to include in the year-end edition of ACSM’s Health & Fitness JournalÒ. The author also thanks the ACSM’s Health & Fitness JournalÒ editorial team, especially those who contributed to the original survey in 2006, Paul Couzelis, Ph.D.; John Jakicic, Ph.D., FACSM; Nico Pronk, Ph.D., FACSM; Mike Spezzano, M.S.; Neal Pire, M.A., FACSM; Jim Peterson, Ph.D., FACSM; Melinda Manore, Ph.D., R.D., FACSM; Cary Wing, Ed.D.; Reed Humphrey, Ph.D., P.T., FACSM; and Steve Tharrett, M.S., for their very important input into the construction of the original and subsequent surveys. Finally, the author is indebted to the ACSM staff that supported this study by assisting in the construction, formatting, and delivery of it to thousands of fitness professionals around the world. In particular, the author recognizes the important contributions of Dick Cotton, Traci Rush, and especially Lori Tish who has worked tirelessly on this survey since it started in 2006.
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CONDENSED VERSION AND BOTTOM LINE The 2012 worldwide survey of fitness trends is now in its sixth year. It assists the health and fitness industry in making critical programming and business decisions. The results are applicable to all four sectors of the health fitness industry V commercial, clinical, corporate, and community fitness programs. Although no one can accurately predict the future because of the continued uncertain economy all over the world, this survey helps to track trends in the field that will assist owners, operators, program directors, and personal trainers make important business decisions.
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AN EXERCISE PROFESSIONAL’S GUIDE TO ACUTE HORMONAL CHANGES FROM RESISTANCE EXERCISE by Jeremy C. Fransen, M.S. and Len Kravitz, Ph.D.
LEARNING OBJECTIVE • To gain a broad understanding of the acute hormonal responses to resistance exercise training.
Key words: Endocrine System, Program Variables, Muscle Hypertrophy, Sex Differences, Overtraining
INTRODUCTION
A
ccording to a recent Gallup poll, approximately 15% of Americans engage in weight training three or more days per week (14). The improvement in muscular strength and hypertrophy gained from resistance training is due to acute and chronic elevations in circulating blood hormone concentrations (12). The endocrine (i.e., meaning hormone secreting) system is a system of glands that discharge hormones that regulate body functions. Understanding the function of the endocrine system and the hormonal changes during resistance training is meaningful for all exercise professionals. It also is relevant to recognize that the U.S. Department of Health and Human Services recommends all active adults complete at least one set of 8 to 12 repetitions of each exercise for the major muscles of the body and that two or three sets may be more effective (15). The acute hormonal responses to resistance exercise discussed in this article help to explain the muscular fitness responses observed in clients who weight train on a regular basis.
hormones into the circulatory system. Hormones are chemical messengers that allow the transmission of messages from one part of the body to another. Hormones are released in small concentrations and regulate physiological and metabolic function, such as protein synthesis. They affect the human body in several ways, including the regulation of growth, development, reproduction, and the body’s ability to handle physical and mental stress. Hormonal action can last from seconds to hours. The ability for the target tissue to respond to a hormone depends on the presence of specific receptors in or on the tissue. Once bound, the hormone can influence cellular metabolism (i.e., reactions). Hormones are classified by their chemical structures as amines, peptides (proteins), and steroids (see Figure for more on hormones).
HORMONES 101 The role of the endocrine system is to maintain the body’s homeostasis through the release of VOL. 15/ NO. 6
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differs from chronic changes (i.e., long-term; weeks to months) in resting hormone concentrations and long-term changes in the acute hormonal response to a single bout of resistance exercise. The following is a review of the key hormones and their acute response to resistance exercise.
Catecholamines
Figure. Some key endocrine glands and hormones of the body.
THE IMPORTANCE OF HORMONES DURING RESISTANCE TRAINING Resistance exercise stimulates acute hormonal responses and subsequent physical adaptation (i.e., muscle growth). The appropriate resistance exercise prescription combined with manipulation of the acute program variables ensures an optimal hormonal response. Acute program variables, such as training frequency, exercise selection and sequence, intensity (% of one repetition maximum [1 RM]), volume (sets repetitions), rest intervals, and repetition speed are important factors in the hormonal response to resistance exercise (12). In general, there seems to be a minimal threshold of intensity and volume (i.e., 50% to 60% 1 RM; less than three sets) to elicit the desired hormonal response. Program design that includes progressive overload, variation, and specificity will ensure adequate adaptations of the neuromuscular system by increasing motor unit recruitment and allowing greater hormone release. Besides the exercise training stimulus, other uncontrollable factors, such as genetic predisposition, age, and sex, can play a role in the endocrine responses and adaptations to resistance training. Finally, controllable factors, such as fitness level, nutritional intake, training experience, interactions with other exercise modalities, and diurnal variations, can influence the acute and chronic hormonal responses to resistance exercise (12).
The acute response to resistance training involves increases in concentrations of epinephrine, norepinephrine, and dopamine, referred to as catecholamines. Catecholamines are important for increasing muscle force production and improving energy availability. There also is evidence that catecholamines may improve the functions of other hormones such as testosterone and growth hormone (GH) (5,10). The increase in blood concentrations of catecholamines may be dependent on the amount of muscle mass stimulated, the volume of exercise performed, and the rest interval between sets (5,6,10). An acute bout of resistance exercise training can increase plasma levels of both epinephrine and norepinephrine. Epinephrine increases both glycogenolysis (breakdown of glycogen) in the muscle and lipolysis (breakdown of fat) in adipose tissue (6). Physically demanding exercise increases caloric expenditure while stimulating a greater release of epinephrine and norepinephrine. Research has confirmed an increase fat mobilization during resistance training, which is stimulated through the release of epinephrine (5). Although evidence suggests that only a small portion of the total fatty acids may actually be oxidized, the increased lipolysis during resistance exercise may contribute to the success of training programs aimed at body fat reduction (6). For clients interested in losing body fat, resistance training programs using high volume (4 to 6 sets per exercise) and short rest between sets (G1 minute) can elicit a larger catecholamine response. Systematic variation and progressive overload may be critical in maintaining the acute training-induced elevations of epinephrine and norepinephrine (10,12).
Growth Hormone Growth hormone is a protein-based peptide (an amino acid combined to a carboxyl molecule) hormone secreted from the
ACUTE HORMONE RESPONSE TO RESISTANCE EXERCISE Most of the research regarding hormonal response to resistance exercise has focused on acute changes that occur during resistance training or immediately after exercise (usually 0 to 48 hours). This
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Cortisol
anterior pituitary gland that exists in different forms (called isoforms) in the blood; they are important in the growth of all body systems. Resistance exercise has been shown to increase concentrations of GH up to 30 minutes after exercise in both men and women (3,12). The magnitude of the GH response seems to be dependent on exercise selection, intensity, volume, training status, and most importantly, rest intervals between sets. Multijoint exercises that recruit a large amount of muscle mass using concentric (muscle shortening) muscle actions produce larger increases in GH compared with single-joint exercises focusing on eccentric (muscle lengthening) muscle actions. Total work during a resistance training session is important, with multiple-set protocols eliciting a greater GH response than single-set protocols. Resistance training protocols with high total work and short rest intervals between sets tend to produce substantial GH responses (16). Goto et al. (8) showed that a single high repetition set of knee extension exercise with 50% of 1 RM at the end of an entire strength training protocol (five sets of knee extension using 90% of 1 RM) elicits a significantly higher GH response compared with a traditional strength training workout without the high repetition set. Finally, greater acute elevation in the GH response is found in trained individuals who are stronger and able to perform a large volume of exercise (2).
Insulin-like Growth Factors Insulin-like growth factors (IGFs) are small polypeptide (molecule made up of a string of amino acids) hormones secreted by the liver. IGFs are secreted in response to an increase in GH. IGFs increase protein synthesis and enhance muscle hypertrophy in response to resistance exercise. The most extensively studied IGF is IGF-1. The acute response of IGF-1 to resistance exercise remains elusive. Most studies have shown no change in IGF-1 during or immediately after resistance exercise, whereas a few other studies have shown acute elevations during or immediately after exercise (12). For a client wishing to gain maximal muscle mass, workouts consisting of large muscle groups, multiple sets, moderate intensity, and short rest periods between sets will produce the largest increases in IGF-1. VOL. 15/ NO. 6
Cortisol is a steroid hormone that is released in response to an increase in adrenocorticotropic hormone (ACTH; corticotropin), a pituitary hormone that stimulates cortisol release from the adrenal cortex (of the adrenal gland, which is on top of the kidneys). Cortisol has catabolic effects on skeletal muscle, adipose tissue, and the liver. It stimulates lipolysis (breakdown of fat) in adipose cells and increases protein degradation and decreases protein synthesis in muscle cells. Resistance exercise can cause acute elevations in ACTH and subsequently cortisol with the response being similar in both men and women. Training programs designed to increase muscle hypertrophy that include a high volume, moderate to high intensity, and short rest periods between sets significantly increase the cortisol response, whereas power/strength training programs with low volume, high intensity, and long rest periods between sets produce minimal change in the acute cortisol response (9). Excessive cortisol release may be a result of overtraining (see Side Bar 2).
Testosterone Testosterone is a steroid hormone that is primarily secreted by the testes in male subjects and the ovaries in female subjects. Smaller amounts of testosterone are secreted by the
SEX DIFFERENCES IN ACUTE HORMONAL RESPONSE TO RESISTANCE EXERCISE A vast majority of research examining the acute hormonal response to resistance exercise traditionally has been conducted on men. Hakkinen and Pakarinen (9) studied the acute hormonal responses to heavy resistance exercise in young, middle-aged, and elderly men and women. The mean concentrations of both testosterone and cortisol remained unchanged for all female groups. In contrast, there were significant increases in testosterone and cortisol for both young and middle-aged men, whereas elderly men showed no change at all. Although there was no increase in testosterone concentrations in women, other research has shown up to a 25% increase in free testosterone in young women after acute resistance exercise (9,12). GH concentrations increased in young and middle-aged men and women, with no changes seen in elderly men and women (9). The research seems to support that there is an increase in GH in younger women and men after an acute bout of resistance exercise (9,12). It should be emphasized that the influence of sex on hormonal responses is difficult to directly compare because of other variables including baseline hormone levels, age, training experience, and the different types of training protocols (i.e., exercises, sets, reps, and rest periods between sets) used by researchers.
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HORMONAL RESPONSE TO OVERTRAINING Hormonal adaptations to resistance training can take place during periods of overtraining. Overtraining occurs when excessive volume and/or intensity causes long-term decreases in exercise performance. Overtraining resulting from large increases in training volume (Q3 additional sets per exercise) has been shown to reduce total and free testosterone levels and increase resting concentrations of epinephrine and norepinephrine. In addition, the normal elevation in total testosterone after resistance training is lowered. Conversely, intensity-related overtraining (i.e., heavy weights) does not seem to alter resting hormone concentrations, thus indicating a difference in response compared with volume-related overtraining. There also have been studies showing reductions in IGF-1 during a planned short-term increase in training volume and intensity, called overreaching, but concentrations have shown to return to normal levels when the overreaching phase was complete (11). Combining strength training with cardiovascular endurance training has been shown to limit maximal strength and power development while enhancing endurance capacity in elite endurance athletes (1,11). Bell et al. (4) found no changes in resting concentrations (i.e., after 48 to 72 hours of no training) of testosterone or GH after 12 weeks of combined strength and endurance training in men. However, women experienced significant increases in urinary cortisol, suggesting that concurrent resistance and endurance training may result in an elevated catabolic state and subsequent overtraining in women compared with men (4). Leading researchers on hormones and resistance exercise from the University of Connecticut, William J. Kraemer, Ph.D., FACSM, and colleagues (11), had subjects perform resistance training 4 days per week along with 4 days of endurance training and found significant increases in exercise-induced cortisol concentrations. These results suggest that concurrent strength and endurance training may lead to overtraining, resulting in a catabolic hormonal environment. Therefore, the take home message is that training volume, not intensity, seems to significantly alter hormone concentrations during overtraining.
adrenal glands in both sexes, with adrenal secretion playing a significant role in resistance exercise-induced raises in some women. Testosterone produces both anabolic (tissue building) and androgenic (secondary sexual characteristics) effects in the body. Anabolic effects include increasing musculoskeletal mass and strength. Resistance exercise produces an acute increase in total testosterone concentrations in men (3), whereas the results in young
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women have been equivocal, with some showing no change and other research showing elevations (9). Acute serum total testosterone responses after resistance training are influenced by several factors, including exercise selection, intensity and volume, training experience, caloric intake, and protein/carbohydrate supplementation (12,16). Exercises that use a large amount of muscle mass, such as the Olympic lifts (e.g., clean and jerk; snatch), squats, and dead lift, produce larger elevations when compared with single-joint exercises using a smaller muscle mass. Highvolume, moderate-intensity training sessions with short rest intervals (i.e., 3 to 4 sets of 10 to 20 repetitions at 50% to 70% of 1 RM, 2-minute rest periods) have been shown to produce greater testosterone increases than traditional strength training protocols that use high-load, multi-set training sessions with long (3-minute) rest intervals between sets (9,10).
Estrogen Estrogens are steroid hormones that are synthesized and secreted by the ovaries and adrenal glands in women. Men also produce estrogen through a conversion process known as aromatization. Estrogens perform various bodily functions including the slowing of bone and muscle loss during aging. Research has shown differences in the rate of muscle decrement during aging between men and women, and this difference may be due to changes in sex hormones (13). Whereas lower testosterone levels in men contribute to the decline in muscle strength, the relationship between estrogen levels in women to muscle strength loss is less understood.
FROM HORMONES TO MUSCLE GROWTH When muscles undergo the challenges of progressive overload from resistance training bouts, there is trauma to the muscle fibers. This disruption to muscle fibers activates special satellite cells, which are located on the outside of the muscle fibers. Through a cascade of biological steps, the satellite cells help to repair and build the muscle fibers that have been stimulated through the resistance training workout. The increase in size of the muscle cells that follows from repeated progressive overload training is referred to as hypertrophy. The hormones discussed in this article help to serve a primary role as growth factors for muscles that have been trained. These growth factors have been shown to affect muscle growth by regulating satellite cell activity. Therefore, it is interesting to note that, although resistance training elicits an increased release of several hormones into the blood, the only muscles of the body that will respond and adapt to these hormones are the muscles that have been weight trained. It is always beneficial to share this information with clients, so they realize the importance of training all of their major muscle groups.
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TABLE: Resistance Training Components to Maximize Acute Hormonal Response Hormone
Resistance Training Protocol (Load/Sets/Rest Periods)
Catecholamines*
Intense exercise with short rest intervals between sets, high volume, systematic variation, progressive overload
GH
Mulit-joint exercises, concentric muscle actions, multiple-set protocols, short rest intervals between sets, chronic training
IGF-1
Large muscle groups, multi-joint exercises, multiple sets, moderate intensity, short rest intervals between sets
Testosterone
Large muscle groups, multi-joint exercises, high volume, moderate intensity, short rest intervals between sets
Estrogen
Light to moderate exercise, hypocaloric state
Cortisol
Prolonged exercise, high volume, moderate to high intensity, short rest intervals between sets, concurrent resistance and endurance training
(65% to 90% of 1 RM, 4 to 6 sets, 3 to 12 repetitions, 30- to 90-second rest period)
(50% to 75% 1 RM, 4 to 10 sets, 8 to 20 repetitions, 1- to 2-minute rest period)
(60% to 80% 1 RM, 3 to 5 sets, 1- to 2-minute rest period)
(60% to 80% 1 RM, 4 to 10 sets, 6 to 15 repetitions, 1- to 2-minute rest period)
(Unknown)
(65% to 75% 1 RM, 4 to 8 sets, 8 to 15 repetitions, 30-to 90-second rest period) *Catecholamines are epinephrine and norepinephrine.
Studies show an accelerated loss of muscle and strength immediately after menopause. Estrogen may play a protective role in muscle strength and quality through the actions of the estrogen receptor (ER). Dieli-Conwright et al. (7) found greater enhancements of ER activity after a single eccentric exercise bout in postmenopausal women using hormone replacement therapy, compared with controls. This suggests that estrogen plays an important role in the development of muscle after resistance exercise. Fitness professionals should recognize the varying roles estrogen plays in the female body and understand that muscle mass and strength gains may be influenced by menopause and/or if the client is taking estrogen replacement medication.
SUMMARY Resistance exercise elicits an impressive response in various hormone concentrations of the body that are central for muscle growth and repair (Table). This acute hormonal response seems to be influenced by the exercise stimulus (i.e., intensity, volume, muscle mass involved, rest intervals, frequency). It is hoped, from this brief review of acute hormonal responses of resistance exercise, that exercise professionals will be able to better explain, describe, and communicate to their clients and students how the development of muscle strength and endurance occurs.
References 1. Aagaard P, Anderson JL. Effects of strength training on endurance capacity in top-level endurance athletes. Scand J Med Sci Sports. 2010; 20(Suppl. 2):39Y47. VOL. 15/ NO. 6
2. Ahtianen JP, Pakarinen A, Alen M, et al. Muscle hypertrophy, hormonal adaptations and strength development during strength training in strength-trained and untrained men. Eur J Appl Physiol. 2003;89: 555Y63. 3. Ahtianen JP, Pakarinen A, Kraemer WJ, et al. Acute hormonal and neuromuscular responses and recovery to forced vs maximum repetitions multiple resistance exercises. Int J Sports Med. 2003;24: 410Y8. 4. Bell GJ, Syrotuik D, Martin TP, et al. Effect of concurrent strength and endurance training on skeletal muscle properties and hormone concentrations in humans. Eur J Appl Physiol. 2000;81:418Y27. 5. Chatzinikolaou A, Fatouros I, Anatoli P. Adipose tissue lipolysis is upregulated in lean and obese men during acute resistance exercise. Diabetes Care. 2008;31:1397Y9. 6. De Glisezinski I, Larruoy D, Bajzova M, et al. Epinephrine but not norepinephrine is a determinant of exercise-induced lipid mobilization in human subcutaneous adipose tissue. J Physiol Published online before print May 5, 2009, doi: 10.1113/jphysiol.2009.168906. 7. Dieli-Conwright CM, Spektor TM, Rice JC, Sattler FR, Schroeder ER. Hormone replacement therapy and messenger RNA expression of estrogen receptor coregulators after exercise in postmenopausal women. Med Sci Sports Exerc. 2010;42(3):422Y9. 8. Goto K, Sato K, Takamatsu K. A single set of low intensity resistance exercise immediately following high intensity resistance exercise stimulates growth hormone secretion in men. J Sports Med Phys Fitness. 2003;43:243Y9. 9. Hakkinen K, Pakarinen A. Acute hormonal responses to heavy resistance exercise in men and women at different ages. Int J Sports Med. 1995; 16:507Y13. 10. Kraemer WJ, Noble BJ, Clark MJ, et al. Physiologic responses to heavy-resistance exercise with very short rest periods. Int J Sports Med. 1987;8:247Y52. 11. Kraemer WJ, Patton JF, Gordon SE, et al. Compatibility of high-intensity strength and endurance training on hormonal and skeletal muscle adaptations. J Appl Physiol. 1995;78:976Y89. 12. Kraemer WJ, Ratamess NA. Hormonal responses and adaptations to resistance exercise and training. Sports Med. 2005;35(4):339Y61. ACSM’s HEALTH & FITNESS JOURNALA
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13. Lowe DA, Balgalvis KA, Greising SM. Mechanisms behind estrogen’s beneficial effect on muscle strength in females. Sport Sci Rev. 2010; 38(2):61Y7. 14. Saad, L. Few Americans meet exercise targets. Gallup [Internet]. 2008. Available from: Gallop.com: http://www.gallup.com/poll/103492/ few-americans-meet-exercise-targets.aspx#1. Accessed September 23, 2011. 15. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. ODPHP Publication No. U0036, October, 2008 [cited 2011 January 20]. Available from: http://www. health.gov/paguidelines/guidelines/chapter4.aspx. 16. Williams AG, Ismail AN, Sharma A, et al. Effects of resistance exercise volume and nutritional supplementation on anabolic and catabolic hormones. Eur J Appl Physiol. 2002;86:315Y21.
Jeremy C. Fransen, M.S., is a Visiting Instructor in the Department of Kinesiology and Nutrition at the University of Illinois at Chicago. His current research focuses on examining the effectiveness of creatine supplementation on high-energy phosphate kinetics using 31P MRS during exercise and recovery after limb immobilization.
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Len Kravitz, Ph.D., is an associate professor of Exercise Science in the Department of Health, Exercise, and Sports Sciences at the University of New Mexico. His current research focuses on energy expenditure, exercise interventions for obesity management, and exercise program evaluation.
CONDENSED VERSION AND BOTTOM LINE Hormones play a significant role in the body’s response to resistance exercise. Muscle mass, strength, and body composition are influenced by the hormonal responses after resistance exercise. Manipulating acute program variables, such as volume, intensity, rest between sets, exercise selection, the muscle mass involved, and workout duration, can impact acute hormonal responses associated with resistance exercise.
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THE USE OF VIBRATION EXERCISE IN CLINICAL POPULATIONS by Rita Toma´s, M.D.; Vinson Lee, M.S.; and Scott Going, Ph.D.
LEARNING OBJECTIVES • Describe whole body vibration exercise. • Understand the rationale for the use of vibration exercise. • Understand current evidence in support of vibration exercise in clinical populations. • Understand the basic guidelines for prescription of vibration exercise.
Key words: Whole Body Vibration, Training, Rehabilitation, Neurological Disorders, Osteoporosis
tional effects on muscle strength and jump performance’’ (26) to ‘‘greater strength improvement compared with conventional resistance training’’ (23). Methodological problems, common to almost every study, hinder internal validity and the variability among protocol limit comparisons. Recently, there has been growing interest in the use of vibration in clinical populations to improve health and functional capacity, moving beyond the focus on elite athletes and strength. Clinical trials have been developed in patients with neurological, musculoskeletal, and metabolic diseases and outcomes other than strength (e.g., balance, proprioception, pain, body composition, quality of life, and disease severity) have been studied.
WHAT IS VIBRATION EXERCISE?
P
erforming exercise on a vibrating platform has gained popularity over the past decade among athletes. The potential therapeutic benefit of vibration also has been studied recently in clinical populations, although its clinical use began much earlier, in the 1940s, with the use of a special bed that delivered mechanical vibration to prevent bone loss in immobilized subjects (43). Further development was undertaken more than 30 years later in Eastern Europe, with ‘‘biomechanical stimulation’’ being used with Russian cosmonauts to prevent muscle atrophy and osteopenia while in space. At about the same time, localized vibration was applied in gymnasts to enhance strength and flexibility (17). Subsequently, the physiological effects of recreational whole body vibration (WBV) were studied, and efficacy trials were conducted to assess its influence on muscular strength. Despite its history, the mechanisms underlying vibratory exercise and its advantages over regular exercise remain unclear. Recent reviews offer contradictory conclusions, suggesting ‘‘no or only minor addi-
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Vibration training relies upon application of a mechanical oscillation to the body using a vibrating platform. This vibration is usually delivered with Photo courtesy of The University of Arizona.
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Figure. Types of whole body vibration platforms.
the person standing, although special devices have been used when the person is unable to stand, such as a standing frame or a chair. In the standing position, the vibratory wave propagates from the feet to the legs, thighs, and upward to the trunk and head. Subjects can perform voluntary muscle contractions (e.g., squats) throughout the exposure. Commonly, the platforms have handle bars for safety or support and a display screen to indicate machine settings. Vertical platforms, which oscillate synchronously up and down, are used, as are side-alternating platforms, which oscillate on the left and right side of a fulcrum (Figure). To a lesser extent, horizontal and random vibration platforms also are used. With side-alternating platforms, it is important to know that the amplitude of platform displacement changes with foot position. For example, there is an increased displacement when the feet are further apart from fulcrum. Other components of a vibration exercise prescription are listed in Table 1 according to recent guidelines (21,27). Chronic exposure to vibration has been studied only in the occupational setting. Some negative side effects have been identified, including spinal degeneration, vestibular disturbances, and vascular and neurological conditions (34). Guidelines have been published to limit the exposure to industrial WBV, but intermittent exposure while exercising on a platform has not been addressed (16). Although WBV uses frequencies and amplitudes lower than occupation vibration, a recent study (1) estimated that the vibration dose in typical vibration training
regimens (10 minutes a day at 30 Hz, 4-mm displacement) exceed the recommendations (16). They also concluded that vertical vibration, a fully upright position, and full-squat exercises were potentially harmful and that knee flexion of 26 to 30 degrees should be encouraged to minimize head vibration (1). Exercises that involve lying or sitting on the platform (e.g., doing push-ups) should be avoided. In addition, recent work showed that amplitudes above 0.5 mm can lead to unpredictable high peak accelerations and may pose a risk to fragile bone and cartilage (19). The most common reported side effects are transient itching and tingling (feet, legs, and nose), skin redness (legs), and muscle soreness. Incorrect exercise technique also could result in headache, motion sickness (if too much vibration is transmitted to the head), and anterior knee pain (if squatting is involved). However, no serious adverse effects were reported in recent reviews that included clinical populations (24,35). Before starting a vibration exercise program, the participant should be screened for possible contraindications. Exclusion criteria used in clinical trials are likely good standards to follow (8,24). A nonexhaustive list is provided in Table 2.
HOW VIBRATION EXERCISE WORKS Vibration massage and application of local vibration on the muscles have been used extensively in rehabilitation. Vibration massage has documented circulatory effects, whereas applying a vibrating stimulus to a muscle belly has been shown to facilitate motor responses, even under pathological circumstances. This reflex muscle contraction is known as the tonic vibration reflex (12). Although it was studied with localized vibration rather than WBV, and with higher frequencies than those usually used in
TABLE 1: Characterization of Vibration Exercise Type of vibration
Vertical (synchronous), side-alternating, random, horizontal
Frequency
Number of cycles (oscillations) per second (6 to 45 Hz)
Peak-to-peak displacement
Extent of the vibration, displacement of the platform from the lowest to the highest point (1 to 14 mm)
Magnitude
Vertical acceleration imposed to the body, usually measured in multiple of Earth’s gravity (9.81 m/s2) (up to 15g)
Protocol
Single or multiple application of the stimulus Acute exposure or chronic exposure (more than one point in time)
Duration
Exposure to vibration per application (15 seconds to 10 minutes)
Type of exercises
Standing only or exercise Static or dynamic exercises Lower body: squats (two legged or single legged), lunges, calf raises Upper body: push-ups, body plank, triceps dips Joint angles of limb (e.g., full squat, half squat) and precise foot position should be predefined (e.g., wide or narrow stance) Rest periods between exercises (10 to 60 seconds) Number of repetitions per exercise (1 to 3 repetitions)
Frequency
Number of sessions a week (1 to 7 days)
Additional loads
Vest with weights, dumbbells
Footwear
Barefoot, socks, or tennis shoes
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TABLE 2: Contraindications for the Use of Vibration Training Conditions Musculoskeletal
Hip or knee endoprosthesis Osteosynthesis with metal implant in lower body Acute vertebral disk herniation Recent fracture Acute soft tissue injury Joint inflammation Osteoporosis with vertebral fracture
Cardiovascular
Recent myocardial infarction Pacemaker Artificial heart valves Uncontrolled hypertension Venous thrombosis Aortic aneurysm
Neurological
Epilepsy Migraine Peripheral neuropathy Impaired cognition that precludes exercise training Deep brain and/or spinal cord stimulation
Other
Pregnancy Acute limb edema Impaired skin integrity Tumors or metastases Recent surgery Bladder and/or bowel Incontinence
The improvement of flexibility after stretching while on a vibrating platform can be attributed to diverse causes, namely, heatrelated facilitation, circulatory factors, and increased pain threshold (17,29). While on the platform at lower frequencies (up to 12 Hz), one experiences rapid cyclic transition between concentric and eccentric contractions, underlying attempts to maintain balance, and dampen the vibration. The mechanical oscillation provides valuable sensory information to cutaneous and joint receptors, and the vestibular system, likely improving proprioception (25). Hormonal responses to WBV exercise have been identified but not consistently replicated. Some studies reported acute increases of growth hormone, insulin-like growth factors, and testosterone that could corroborate the anabolic effect of vibration training on muscle and bone (6,9,20). Little is known about the cumulative effects of WBV exercise, whether ‘‘more is better’’ or whether there is a plateau after which no further benefit is seen. In most studies, follow-up assessments occurred soon after the end of the intervention, so the long-term safety and duration of benefits still have to be established for this type of training regimen. Whole body vibration exercise has the potential to positively influence motor response, strength, proprioception, bone quality, and pain control, which could benefit millions of patients by leading to an overall improvement in quality of life.
NEUROLOGICAL CONDITIONS Whole body vibration exercise has been studied in patients with different central nervous system disorders such as Parkinson’s disease, stroke, multiple sclerosis, cerebral palsy, and spinal cord injury. A recent review of seven trials concluded that ‘‘there was weak to moderate evidence for positive effects on postural control, mobility, motor function and strength after a single application of WBV’’ (44).
vibration exercise, it is thought to be one of the primary mechanisms to explain the increased neuromuscular activation during and following vibration. There are several ways vibration may potentiate muscular contraction. Together with enhancing the stretch reflex, vibration also stimulates somatosensory areas of the cortex, which can facilitate subsequent voluntary movements (7). Increased muscle temperature, due to better perfusion and dampening of mechanical vibration, also may have a positive effect on force generation (29). Theoretically, with more powerful muscle contractions (during the WBV exercise), the conditioning stimulus would be stronger than conventional resistance training. Exercise done on a vibrating platform may influence the skeleton in at least two ways. First, it may potentiate muscle contractions that are known to be important osteogenic stimuli. Second, vibration transmitted by the platform is perceived as a strainactivating mechanism that promotes bone formation, ultimately leading to an increase in bone mineral density (BMD) (29). Vibration also has been shown to influence pain perception, possibly by a ‘‘gate-control theory’’Ymediated effect, similar to transcutaneous electric nerve stimulation (22,29). VOL. 15/ NO. 6
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No conclusion could be made about long-term treatment as longterm studies are scarce. In Parkinson’s disease patients, five acute bouts of 60 seconds of WBV (6 Hz, 6 mm peak-to-peak displacement, random vibration platform) resulted in reduced tremor, rigidity (38), and body sway (15), but no differences in knee proprioception (14). A protocol with 12 sessions over 5 weeks (five bouts of 1 minute at 6 Hz, 26 mm of peak-to-peak displacement, side-alternating platform) failed to show differences in gait, balance, hand dexterity, and disease severity between intervention and control groups (5), whereas a more intense program, with two daily sessions of 15 minutes for 3 weeks (25 Hz, 14 to 28 mm of peak-to-peak displacement, side-alternating platform) had similar effects on equilibrium and gait compared with conventional physiotherapy with a balance board (11). In a 4-week crossover study, multiple sclerosis patients performed 10 exercises for 30 seconds on the platform (40 to 50 Hz, 4mm of peak-to-peak displacement, vertical oscillating platform) after a ‘‘massage’’/warm-up period. No differences were detected between exercise with or without vibration for disease severity, spasticity, and functional measures (33). In respect to acute exposure, five 1-minute bouts, (2 to 4.4 Hz, 6 mm of peakto-peak displacement, random vibration platform) improved ‘‘timed-get-up-and-go’’ test performance and reduced body sway (32). Positive acute effects on postural control also were shown in stroke patients, with four 45-second periods of exposure (30 Hz, 6 mm of peak-to-peak displacement, side-alternating platform) (39). A transient increase in knee extension strength was shown with a similar protocol (six bouts of 1 minute at 20 Hz, 5 mm of peak-to-peak displacement), showing the capability of WBV to influence the motor response of affected limbs (36). A longer regimen of 6 weeks with subacute patients (four bouts of 45 seconds, 5 days a week, at 30 Hz, 6 mm of peak-to-peak displacement, side-alternating platform) failed to show any additional recovery in terms of balance or activities of daily living (40). In adult cerebral palsy patients, an 8-week WBV regimen (3 days a week, 3 to 8 bouts of 30 to 110 seconds at 25 to 40 Hz, vertical oscillating platform) was as good as leg press for improving quadriceps strength without negative effects on spasticity (2). A 6-month study (10 minutes a day, 5 days a week at 90 Hz, 0.1 mm of peak-to-peak displacement) of disabled children with cerebral palsy or muscular dystrophy reported a significant increase in tibial BMD, despite poor compliance. However, no significant benefit was found for spinal BMD (42).
MUSCULOSKELETAL CONDITIONS Whole body vibration exercise has been studied in different joint and musculoskeletal conditions including low back pain, knee osteoarthritis, total knee arthroplasty, fibromyalgia, chronic fatigue syndrome, anterior cruciate ligament/reconstructed knee, low BMD, and osteogenesis imperfecta. Although occupational vibration has been associated with disk degeneration and low back pain (34), WBV decreased low back pain in patients with chronic back
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pain and osteoporosis, perhaps by better spinal proprioception and trunk muscle conditioning induced by vibration. An additional reason for the pain relief may be the analgesic effect of mechanical oscillations via a ‘‘gate-control theory.’’ One intervention, a 3-month study of vibration exercise versus traditional resistance training (4 to 7 minutes, 1 to 2 times a week at 18 Hz, 12 mm of peak-to-peak displacement, side-alternating platform) used supplementary weight on the shoulders or upper arm while on the platform (30). The protocol involved standing with different foot positions, slow amplitude squatting, and slow movements of the hips and waist such as bending sideways, tilting back and forward, and left and right trunk torsions. Both types of training increased lumbar extension torque and reduced pain sensation. Improved proprioception after 1 month of whole body vibration training also has been documented in patients recovering from an anterior cruciate ligament reconstruction (25). The vibration exercise group (4 to 16 minutes, 3 days a week at 30 to 60 Hz, 5 to 10 mm of peak-to-peak displacement, vertical oscillating platform) did a variety of static and dynamic exercises such as mini-squats, single leg mini-squat, lunges, and toe standing. Results were significantly better than conventional rehabilitation, consisting of lower body strengthening and tilt/wobble board training. Vibration training has been used in fibromyalgia and chronic fatigue syndrome patients with promising results. A 6-week randomized controlled trial (4.5 to 18 minutes, 2 times a week at 30 Hz, 4 mm of peak-to-peak displacement, vertical oscillating platform) reported less pain and fatigue with WBV training, whereas with exercise alone, there was no amelioration. The protocol consisted of static and dynamic squats, unilateral squats, and
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approach the values elicited by traditional aerobic exercise. Although perceived exertion may be high and fatigue can occur in just a few minutes, the conditioning stimulus may be insufficient to load the cardiovascular system (8).
calf raises after 90 minutes of traditional exercise (4). The addition of WBV exercise to a conventional exercise protocol resulted in additional benefits on disease symptoms. WBV may be a promising modality to enhance bone density and lessen postmenopausal bone loss (28,35,37). Among subjects with low BMD, with diagnosed osteoporosis (18,31) or osteopenia (13), vibration has shown promising results. In patients not using osteoporosis medication, regular WBV exposure at 30 Hz over six (10 minutes, 5 times a week at 30 Hz, 10 mm of peak-to-peak displacement) and 12 months (10 minutes daily, at 30 Hz, 0.05 mm of peak-to-peak displacement, vertical oscillating platform) led to increases in femoral and spinal BMD (13,31). However, in a 12-month study with patients on alendronate, a biphosphonate drug that increases bone mass, there was no additional benefit of 4 minutes of exposure to vertical whole body vibration (12 Hz, once per week, 1.4 to 8.2 mm peak-to-peak displacement, side-alternating platform) (18). In populations known to have increased risk of bone loss (postmenopausal women, disabled patients), there are conflicting results, with some studies reporting benefits in femoral cortical bone, whereas others failed to show benefits (28,35,37).
IMPLICATIONS FOR PRACTICE There have been aggressive marketing campaigns advocating for WBV platforms. The cost of a device can range from $200 (home units) up to $12,500 for a fitness/clinical facility unit. The money spent purchasing this device is not currently reimbursed because there is no prototype that is approved by the U.S. Food and Drug Administration as a medical device. When purchasing a device, one should look for a certified machine, with peer-reviewed published data. Preferably, acceleration, frequency, and amplitude of the prototype should have been confirmed by an independent party. Not all devices allow manipulation of the frequency or peak-to-peak displacement; rather, they are limited to pre-defined ‘‘programs,’’ and the characteristics of the vibration being delivered are not well described. A machine that delivers more acceleration is not necessarily better, as too much acceleration can be detrimental. The lowest effective dose should be used. Practitioners should choose published exercise protocols and vibration settings for their patients/clients, with proven safety and efficacy rather than accept those recommended by vendors, which might not have strong scientific rationale. Some examples of protocols are given in Table 3 (3,4,15,41). The selection of participants should follow rigorous criteria (Table 2), and when working with clinical populations, one should seek medical clearance before participation. When initiating a training regimen, the fitness professional should advise the client to wear shoes with thin hard soles to avoid
MEDICAL CONDITIONS Vibration exercise may be an alternative form of exercise for people who cannot or will not undertake other types of physical activity because of their medical conditions. WBV exercise has been shown to acutely increase oxygen consumption in healthy young and older people and overweight/obese patients, although this increase may not be enough to induce cardiovascular training or weight loss (8,10). Even with the use of additional weight and at higher frequency and amplitude, the oxygen uptake does not
TABLE 3: Guidelines for Vibration Exercise Prescription Clinical Populations Parkinson’s Disease (15) Goal
Improve motor symptoms
Type of vibration
Random
Parameters
6 Hz, 6 mm of peak-to-peak displacement
Duration
1 minutes 5, with 1-minute rest between bouts
Exercises
Frequency VOL. 15/ NO. 6
Simple standing
As needed to control symptoms
Fibromyalgia (4) Pain and fatigue control
Frail Adults (3)
Osteopenia (41)
Improve balance
Increase BMD
Vertical (synchronous)
Side-alternating
Vertical (synchronous)
30 Hz, 4 mm of peak-to-peak displacement
5 to 12 Hz, 5 mm of peak-to-peak displacement
35 to 40 Hz, 1.7 to 2.5 mm of peak-to-peak displacement
30 seconds each exercise, up to 6 repetitions
5 to 30 seconds each exercise, 3 repetitions
Up to 30 minutes each session
3 minutes recovery between repetitions
3 minutes recovery between repetitions
Static squat
Simple standing without using the handrails
Squat
Dynamic squat
Body weight shifts from one leg to the other
Deep squat
Calf raises
Slight foot lift and hold
Wide stance squat
Body weight shifts from one leg to the other
One-legged squat
Lunge
Twice a week
Thrice a week
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too much dampening of the vibration by the footwear during the exercise session. The first few sessions should be of shorter duration at a lower frequency and peak-to-peak displacement to ensure that the client can tolerate WBV. Duration of an exercise should not exceed 20 to 30 seconds initially with plenty of time for recovery (this principle may not apply when simple standing is being performed). As with any type of exercise, the progression should consider the client’s tolerance and clinical status, being mindful of any preexisting conditions and contraindications. Increases in intensity can be achieved by increasing the frequency, amplitude, duration, and number of repetitions of the exercise and decreasing recovery time. Correct foot placement is very important. Feet should be placed symmetrically on the platform, with toes pointed slightly outward. Some exercises can be performed with a single leg (squats, calf raises). The handrail should be used to enhance safety; however, some balance exercises may not be useful if performed while holding it. During all exercises, a locked knees position should be avoided to limit transmission of the vibration to the trunk and head. The provider should look for the more common side effects, such as transient itching and skin redness, muscle soreness, headache, mild knee pain, and forefoot pain, and monitor them closely. In weighing the potential benefits and the known risks, WBV exercise in clinical populations may be useful when other forms of exercise are not feasible (time constraints, lack of motivation for conventional programs, limited human resources, not able to do weight-bearing impact exercise).
SUMMARY There is no current consensus on the efficacy of vibration exercise, but there have been some very promising results. The potential to improve lower body muscle power, bone strength, proprioception, balance, and pain warrants further investigation. Studies with extended duration and follow-up periods are needed to better define long-term benefits and risk. This novel type of exercise has been well tolerated by people with chronic conditions and even perceived by some patients as pleasant and easy. This training could be an alternative for people who otherwise would not be able to perform conventional exercise or just want to diversify their training. Using published protocols when prescribing WBV (e.g., volume, exercises, and device settings) should minimize unwanted side effects and increase the likelihood of effectiveness.
References
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1. Abercromby AF, Amonette WE, Layne CS, McFarlin BK, Hinman MR, Paloski WH. Vibration exposure and biodynamic responses during whole-body vibration training. Med Sci Sports Exerc. 2007;39(10):1794Y800.
22. Lundeberg T, Abrahamsson P, Bondesson L, Haker E. Effect of vibratory stimulation on experimental and clinical pain. Scand J Rehabil Med. 1988;20(4):149Y59.
2. Ahlborg L, Andersson C, Julin P. Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy. J Rehabil Med. 2006; 38(5):302Y8.
23. Marin PJ, Rhea MR. Effects of vibration training on muscle strength: a meta-analysis. J Strength Cond Res. 2010;24(2):548Y56.
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24. Merriman H, Jackson K. The effects of whole-body vibration training in aging adults: a systematic review. J Geriatr Phys Ther. 2009;32(3):134Y45.
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25. Moezy A, Olyaei G, Hadian M, Razi M, Faghihzadeh S. A comparative study of whole body vibration training and conventional training on knee proprioception and postural stability after anterior cruciate ligament reconstruction. Br J Sports Med. 2008;42(5):373Y8.
Recommended Readings
26. Nordlund MM, Thorstensson A. Strength training effects of whole-body vibration? Scand J Med Sci Sports. 2007;17(1):12Y7.
Rittweger J. Vibration as an exercise modality: how it may work, and what its potential might be. Eur J Appl Physiol. 2010;108(5):877Y904.
27. Rauch F, Sievanen H, Boonen S, et al. Reporting whole-body vibration intervention studies: recommendations of the International Society of Musculoskeletal and Neuronal Interactions. J Musculoskelet Neuronal Interact. 2010;10(3):193Y8.
Slatkovska L, Alibhai SM, Beyene J, Cheung AM. Effect of whole-body vibration on BMD: a systematic review and meta-analysis. Osteoporos Int. 2010;21(12):1968Y80.
Albasini A, Krause M, Rembitzki I. Using Whole Body Vibration in Physical Therapy and Sports. 1st ed. London (UK): Churchill Livingstone; 2010.
28. Rehn B, Nilsson P, Norgren M. Effects of whole-body vibration exercise on human bone density V systematic review. Phys Ther Rev. 2008;13(6):427Y33.
Wunderer K, Schabrun SM, Chipchase LS. The effect of whole body vibration in common neurological conditions V a systematic review. Phys Ther Rev. 2008;13(6):434Y42.
29. Rittweger J. Vibration as an exercise modality: how it may work, and what its potential might be. Eur J Appl Physiol. 2010;108(5):877Y904.
Disclosure: Dr. Toma´s is a recipient of a Fulbright Visiting Researcher Scholarship (2009Y2010).
30. Rittweger J, Just K, Kautzsch K, Reeg P, Felsenberg D. Treatment of chronic lower back pain with lumbar extension and whole-body vibration exercise: a randomized controlled trial. Spine (Phila Pa 1976). 2002;27(17):1829Y34. 31. Ruan XY, Jin FY, Liu YL, Peng ZL, Sun YG. Effects of vibration therapy on bone mineral density in postmenopausal women with osteoporosis. Chin Med J (Engl). 2008;121(13):1155Y8. 32. Schuhfried O, Mittermaier C, Jovanovic T, Pieber K, Paternostro-Sluga T. Effects of whole-body vibration in patients with multiple sclerosis: a pilot study. Clin Rehabil. 2005;19(8):834Y42. 33. Schyns F, Paul L, Finlay K, Ferguson C, Noble E. Vibration therapy in multiple sclerosis: a pilot study exploring its effects on tone, muscle force, sensation and functional performance. Clin Rehabil. 2009;23(9):771Y81. 34. Seidel H. Selected health risks caused by long-term, whole-body vibration. Am J Ind Med. 1993;23(4):589Y604. 35. Slatkovska L, Alibhai SM, Beyene J, Cheung AM. Effect of whole-body vibration on BMD: a systematic review and meta-analysis. Osteoporos Int. 2010;21(12):1968Y80. 36. Tihanyi TK, Horvath M, Fazekas G, Hortobagyi T, Tihanyi J. One session of whole body vibration increases voluntary muscle strength transiently in patients with stroke. Clin Rehabil. 2007;21(9):782Y93. 37. Totosy de Zepetnek JO, Giangregorio LM, Craven BC. Whole-body vibration as potential intervention for people with low bone mineral density and osteoporosis: a review. J Rehabil Res Dev. 2009;46(4):529Y42. 38. Turbanski S, Haas CT, Schmidtbleicher D, Friedrich A, Duisberg P. Effects of random whole-body vibration on postural control in Parkinson’s disease. Res Sports Med. 2005;13(3):243Y56. 39. van Nes IJ, Geurts AC, Hendricks HT, Duysens J. Short-term effects of whole-body vibration on postural control in unilateral chronic stroke patients: preliminary evidence. Am J Phys Med Rehabil. 2004;83(11):867Y73. 40. van Nes IJ, Latour H, Schils F, Meijer R, van Kuijk A, Geurts AC. Long-term effects of 6-week whole-body vibration on balance recovery and activities of daily living in the postacute phase of stroke: a randomized, controlled trial. Stroke. 2006;37(9):2331Y5. 41. Verschueren SM, Roelants M, Delecluse C, Swinnen S, Vanderschueren D, Boonen S. Effect of 6-month whole body vibration training on hip density, muscle strength, and postural control in postmenopausal women: a randomized controlled pilot study. J Bone Miner Res. 2004;19(3):352Y9. 42. Ward K, Alsop C, Caulton J, Rubin C, Adams J, Mughal Z. Low magnitude mechanical loading is osteogenic in children with disabling conditions. J Bone Miner Res. 2004;19(3):360Y9. 43. Whedon GD, Deitrick JE, Shorr E. Modification of the effects of immobilization upon metabolic and physiologic functions of normal men by the use of an oscillating bed. Am J Med. 1949;6(6):684Y711. 44. Wunderer K, Schabrun SM, Chipchase LS. The effect of whole body vibration in common neurological conditions V a systematic review. Phys Ther Rev. 2008;13(6):434Y42. VOL. 15/ NO. 6
Rita Toma´s, M.D., is a physician specializing in physical medicine and rehabilitation in Lisbon, Portugal, and a Fulbright Visiting Researcher at The University of Arizona. Her research focuses on the effects of exercise on bone, muscle, and physical function.
Vinson Lee, M.S., is a research specialist in the Department of Physiology at The University of Arizona. His research interests are in physical activity, sarcopenia, obesity, and diabetes. Scott Going, Ph.D., is a professor in the Departments of Nutritional Sciences and Physiological Sciences and is the director of the Center for Physical Activity and Nutrition at The University of Arizona. His research interests include development of methods and models for body composition assessment; changes in body composition during growth and development in children and aging in older adults; and the effects of exercise and diet on bone, soft tissue composition, functional capacity, and health.
CONDENSED VERSION AND BOTTOM LINE Vibration exercise is a type of exercise that has recently gained in popularity and may benefit clinical populations. There have been trials with patients with neurological and musculoskeletal disorders that showed improvements in muscle power, bone strength, proprioception, balance, and pain. Although these results are promising, caution is warranted because of its injurious potential. The use of this type of training should follow published guidelines that have been shown to be safe and efficacious.
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CLINICAL INTEGRATION AS A SUBVERSIVE ACTIVITY by Don L. Jones, Ph.D., ACSM-CPT
LEARNING OBJECTIVE • This article will provide the reader with insights to improve clinical integration efforts between wellness and fitness centers and physicians as well as clinicians.
Key words: Clinical Integration Associates, Affordable Care Act, HydroWorx, ‘‘Wounded Warriors,’’ Social Media, Exercise is MedicineÒ
T
here has been a lot of good dialogue and publications over the last few years regarding the need to establish relationships with the medical community to enhance physician referrals to medical wellness centers (1,4,5,8). In addition, articles have been published on sound practices to help secure physical therapy referrals (5,8). The purpose of this dialogue is to offer a different approach that has helped centers achieve more referrals V not only from physicians but from the clinical centers within the hospital. It should be noted that, for the first time Clinical Integration and Medical Fitness made the Top Twenty (no. 18) for Worldwide Fitness Trends for 2011. In addition, Physician Referrals landed in the Top Ten for the first time. Educated and Experienced Fitness Professionals remained at no. 1 (7). The above is very encouraging and gives rise to the need to seize the moment and look for new and different ways to enhance clinical referrals from all sources.
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The approach we took at Florida Hospital Celebration Health was a little bit radical at the time in that we actually sat in on weekly meetings with the different clinical departments to offer our input into how we felt exercise could improve the patient care outcome V hence, the title, Clinical Integration as a Subversive Activity. You might be asking how we were able to gain that type of access to patient care V at least I hope you are. That will be covered in this article. Suffice it to say for now that a different approach is needed to augment the Exercise is MedicineÒ initiative so that we, as exercise physiologists, can gain the respect of the physicians, physical therapists, and other clinicians, so they will feel comfortable and confident that their patients are being released to experts in the field. It seems as though most medical fitness centers have gained access to physical therapy and cardiac rehabilitation patients as more and more hospitals and clinicians see the benefits of moving their patients through the continuum of care. In addition, managed care has reduced the number of physical therapy visits. The options for continuing self-care are either prescribing a Photo courtesy of Tri-City Wellness Center.
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home care program or referring their patient to a trainer at a local fitness center. With the continuing push for credentialed personal trainers and specialists, clinicians have more options for referrals than ever before. Medical fitness centers have much more to gain now provided they are encouraging their employees to get appropriate training and certifications that have undergone third-party accreditation, such as the National Commission for Certifying Agencies. There is something for everyone depending on your area of interest and specialty. The medical community recognizes the value of these credentials and will take notice of those centers with credentialed staff. As Amanda Harris, M.Ed., vice president of fitness and wellness for ACAC Fitness & Wellness Centers points out, ‘‘the marketing image of your facility has a lot to do with whether a physician will consider referring a diabetic, hypertensive, overweight, or otherwise challenging patient to your facility’’ (1). Part of that marketing image is your Web site, Facebook page, blog, email blasts, and any other marketing materials that showcase the credentials of your staff. Social media is a new way to gain acceptance in the medical community, provided it is done with taste and offers education and information (blogging) to members and nonmembers. Another part of that marketing image is your own internal campaign within your local hospital. Dr. Harris and Doug Ribley, M.S., director of Wellness and Administrative Services at Akron General Health and Wellness Center have previously addressed physician referrals and rehabilitative referrals, respectively (1,5). In addressing the issue of physician referrals, Dr. Harris emphasizes the need to reach out to medical professionals and build relationships with them. One way to do this is to create a Medical Advisory Board: ‘‘Having a strong advisory board can bolster your facility’s professional image and build credibility among area hospitals, physicians, and patients’’ (1). With regard to rehabilitation referrals, Ribley states that the key ‘‘is to develop a keen understanding and respect between those staff members who will be sharing space and exhibit wide ranging degrees, credentials, licenses, and expertise’’ (5). This mutual understanding and respect will aid the rehabilitation patient and/or fitness center client so that he or she will be referred to the appropriate professional. Everybody wins. Wendy A. Williamson, Ph.D., of Williamson Fitness Consulting, published an article on ‘‘Medical Exercise Positioning V A Business Tool Kit’’ (8) wherein she pointed out that ‘‘positioning exercise professionals to service medical conditions is gaining more attention.’’ I would agree and add that because of the attention, fitness professionals need to be more assertive in how we introduce ourselves to the medical community V physicians and clinicians. Although I agree in principal with such initiatives as Medical VOL. 15/ NO. 6
Advisory Boards and professional certifications, I feel we need to get more involved with the medical community. As a case in point, Edward Phillips, M.D., director of Outpatient Medical Service, Spaulding Rehabilitation Hospital, was asked by Brad A. Roy, Ph.D., FACSM, FACHE, and the then president of the Medical Fitness Association, ‘‘Are physicians comfortable referring patients to health/fitness clubs?’’ Dr. Phillips responded, ‘‘No, health clubs are not yet perceived to be part of the continuum of clinical care’’ (4). When Dr. Phillips was asked what would convince them V physicians V to do so (refer patients to health/fitness clubs), Dr. Phillips referred to the need for the following: •
third-party accreditation
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medical fitness facility certification
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appropriate educational training and professional certification for exercise professionals
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demonstrated positive health outcomes for patients
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communication with physicians on the progress of their patients
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educational programs at health clubs or at the local hospital
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joining the Exercise is MedicineÒ initiative
This is a time of unprecedented opportunity. We now need to seize the moment and go with the momentum. At the recent Medical Fitness Institute held at Vanderbilt University (June 22 to 25, 2011), I discussed clinical integration initiatives with Jay Groves, Ed.D, MMHC, administrative director for Vanderbilt’s Dayani Center for Health and Wellness (J. Groves, personal communication, June 2011). Dr. Groves summarized three key questions that physicians V and I would add that this applies to other clinicians as well V want to know from health and fitness centers: • What can you do for my patient? •
What are you doing with my patient?
What are the results of your actions? We need to send back a simple, clear message to the provider, physician, and/or clinician: ‘‘Your patient completed X program by doing Y, and this was the result’’ V a very simple but very powerful statement (J. Groves, personal communication, June 2011). Dr. Groves goes on to say, ‘‘From my experience, it has not always been intuitive to our clinicians how their patients will specifically benefit from our services. In addition, in our zeal, we (medical fitness professionals) often promote our core services and modalities as if they will improve if not cure every symptom or condition that our patients and members present with. As a result, we stand the potential to lose our credibility, audience, and potential referral sourcesIthe key here is to be specific in a practical and informative way. Anticipating or responding to simple what, where, and when questions can be of great value when communicating with a clinician.’’ •
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Clinical Integration Dr. Groves gives this specific example to use when communicating with clinicians: ‘‘As a part of our Phase III Cardiac Rehabilitation program, your patient will be working with us 2 to 3 times/week. While here they will be completing 25 to 30 minutes of moderate treadmill walking to improve their stamina and endurance, strength training with their arms to become more functional and independent at home and spending 5 to 10 minutes in a breathing and meditation exercise to help them relax’’ (J. Groves, personal communication, June 2011). Sharon M. Slowik, M.D., recently observed, ‘‘As the supervising physician at Tri-City Wellness Center’s Cardiac Rehabilitation program, I have witnessed patient’s becoming accountable for their health. Patients reduced medication use and report improved well-being after the program (cardiac rehabilitation). Concentrated risk factor modification during a time when a patient is most motivated to make lifestyle changes has been a critical role for a rehabilitation team, and the fitness professional plays an important part of that team whether it is cardiac rehabilitation, bariatric surgery patients, diabetes programs, total joint replacement, oncology, stroke, peripheral vascular diseases, the list is endless’’ (S. Slowik, personal communication, May 2011). Besides the previously reviewed articles on physician referrals (1) and rehabilitation referrals (5), the strategy may assist in gaining access to the other patients: bariatric, oncology, adhesions, stroke, and joint replacement patients just to name a few. While serving as the executive director of The Fitness Centre & Day Spa at Florida Hospital Celebration Health, we founded the CIA V no, not that one V the Clinical Integration Associates. This group of individuals was composed of personal trainers and fitness professionals with a multi-varied level of interests and skill sets. For example, one of our personal trainers worked almost exclusively with bariatric patients. He developed a program for preparing and transitioning bariatric patients. Another trainer worked almost exclusively with oncology and stroke patients. What we decided to do, with the invaluable help of our vice president, Vickie White, was to ‘‘infiltrate’’ the various departments within the hospital, attend their bimonthly patient update meetings, present current literature reviews and research pertaining to their patients, and essentially ‘‘win the hearts and minds’’ of the physicians and clinicians. We wanted them to view our staff as the experts in the field. The only way to do this was to go ‘‘undercover.’’ To my knowledge, this type of integration is seldom tried or even allowed V hence the reference to the terms subversive activity and undercover. It is vitally important to have an administrator lend support for such an initiative. The time has now come where this is more and more likely to happen V provided we are ready with the research and can present it in a cogent fashion to clinicians. As mentioned earlier, clinical integration/medical fitness is now in the Top 20 as a Worldwide Fitness Trend, whereas Edu-
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cated and Experienced Fitness Professionals remains no. 1. Let’s roll up our sleeves and show Fem what we’ve got. It’s time to get involved at the departmental level. To build the necessary intelligence before we went bounding off to department meetings, we held weekly CIA meetings wherein each staff member was responsible for presenting two current articles about their specialty from respected journals. This enabled the staff to fully acquaint themselves with the literature, gain confidence in their presentation skills, and share knowledge with other professionals. It was almost like being back in college again V without the worry of a grade. The standard ‘‘Lunch Fn Learn,’’ although often treated as a cliche´, also was a valuable tool for our staff to introduce concepts to hospital clinicians in a comfortable environment. We take the lead. We are seen as the experts in our field. Here at Tri-City Wellness Center in Carlsbad, CA, where I am now the Wellness Center Manager, we call these Lunch Fn Learn programs ‘‘Active Education.’’ Whatever you call them, at the very least provide them and ‘‘be the ball’’ V put your wellness staff front and center as the experts in the field. Showcase your staff’s talents. People V including physicians and clinicians V do take notice. Holding workshops also builds cache with other clinicians. We held a Functional Movement Screen workshop at Celebration Health that was attended by two of the hospital’s physical therapists and the wife of a leading golf professional. Again, we were seen as the leaders, not the followers V and therefore, as experts in our field. One of the most valuable ways to win the hearts and minds of clinicians is to present outcomes data. An excellent article by Paul Sorace, M.S., RCEP, CSCS, a clinical exercise physiologist for The Cardiac Prevention & Rehabilitation Program, and Tom LaFontaine, Ph.D., RCEP, FACSM, CSCS, NSCA-CPT of PREVENT Consulting Services, LLC, cites the ‘‘benefits of lifestyle intervention on overweight, stages 1 and 2 obesity, and associated risk factors and comorbidities’’ (6). This is ‘‘just what the doctor ordered’’ V positive outcome measures for their patients. Of vital importance to note is that Mr. Sorace and Dr. LaFontaine point out, ‘‘The health and fitness professional’s role is not diminished with bariatric surgery but rather amplified.’’ This is true with almost all medical conditions V the fitness professional’s role is amplified. There is ample evidence of the benefits of exercise in the literature. As fitness professionals, we need to be competent in reviewing it, putting it in context for our respective specialties, and presenting it in a cogent fashion to clinicians and physicians. Amanda Harris points to the need to be a good community partner (1). She cites examples of partnering with the American Heart Association, Arthritis Foundation, and the American Diabetes Association just to name a few. There are a number of other opportunities to win hearts and minds and build cache with the medical community. Think
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Photo courtesy of Tri-City Wellness Center.
mild difficulty or discomfort’’ (A. Siebert, personal communication, May 2011). When we first started working with the ‘‘Wounded Warriors’’ project and the soldiers from Camp Pendleton, there were only three participants and one personal trainer. Now, we have up to 15 soldiers and 3 personal trainers. These veterans have all commented on how much these sessions have improved their morale V in addition to their level of fitness. This is just another way your club can be a good community partner and provide essential services for a deserving group of people who otherwise may not have this type of outlet.
SUMMARY
of your local Reservists, National Guard members, and their families V think of International Health, Racquet & Sportsclub Association’s (IHRSA’s) new ‘‘Joining Forces Network.’’ See www.ihrsa.org for details on how your club can provide a valuable service to your community and be seen as the expert in the field. The ‘‘Wounded Warrior Project,’’ www.woundedwarriorproject.org, offers another service opportunity. ‘‘More than 40,000 service members have been injured in the current conflicts’’ and are in need of care (9). Many have already experienced the benefits of exercise. A recent article in USA Today reviewed the recent Warrior Games in Colorado Springs, CO, and how different the approach is now with injured soldiers. Col. Barbara Springer, a former chief of physical therapy services at Walter Reed Army Medical Center in Washington pointed out, ‘‘We used to try to set limits (on what they can do), because we didn’t want people to get discouraged. We don’t do that anymore’’ (3). At Tri-City Wellness Center, we are fortunate enough to have a HydroWorx pool in our facility. We use this pool not only for physical therapy patients but also for personal training sessions and now for the ‘‘Wounded Warriors’’ program. The HydroWorx pool is essentially an underwater treadmill 8 10 ft with jets that can be increased or decreased to move the water. In addition, there are underwater cameras, so a staff member can remain on the top level and view the client/patient’s gait from above. Our personal trainers volunteer their time every Friday morning to work with up to 15 injured combat veterans from Camp Pendleton. As one soldier stated, it was ‘‘by far the best overall 50 minute workout/therapeutic session I have experienced. Since my injury in 2006, I have not been able to run, but while submerged mid to upper torso I was able to open my stride, bound, and align my right foot in a toe/heel step all with no or VOL. 15/ NO. 6
To truly capture the hearts and minds of physicians and clinicians and to seize on the Worldwide Trends of 2011, we, as fitness professionals, need to do the following: • We must be aggressively friendly V community service offers many chances to meet individuals and offer assistance. •
Divide and conquer V infiltrate the clinical departments and help them help their patients.
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Find a champion for our cause V preferably a VP or hospital administrator.
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‘‘Publish or perish’’ V provide outcomes data for our physicians and clinicians.
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Get certified V the options are numerous.
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Host workshops at your site V help educate your staff and other clinicians.
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Grand rounds V offer to present outcomes data.
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Lunch Fn Learns V ‘‘active education’’ V whatever you call them, provide them V weekly.
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Work with physicians and clinicians V help them help their Photo courtesy of Tri-City Wellness Center.
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Clinical Integration Photo courtesy of Tri-City Wellness Center.
to help their patients with their transition and truly establish a continuum of care once and for all.
References 1. Harris A. Is your facility linked to the health-care community? ACSM’s Health & Fitness Journal. 11(6):26Y8, November/December 2007. 2. Kufahl P. Prescription for fitness. Club Industry. 28Y37, June 2011. 3. Michaelis V. Sports help wounded vets heal. USA Today, May 25, 2011. 4. Phillips EM, Roy BA. Exercise is MedicineTM: partnering with physicians. ACSM Health Fitness J. 2009;13(6):28Y30. 5. Ribley D. Integrating rehabilitation services and medical fitness: what are you waiting for? ACSM Health Fitness J. 2006;10(3):27Y8. 6. Sorace P, LaFontaine T. Lifestyle intervention: a priority for long-term success in bariatric patients. ACSM’s Health Fitness J. 2007;11(6):19Y25. 7. Thompson W. Worldwide survey of fitness trends for 2011. ACSM’s Health Fitness J. 2010;14(6):8Y17. 8. Williamson W. Medical exercise positioning: a business tool kit. ACSM’s Health Fitness J. 2010;14(1):30Y3.
patients get better and communicate what you are doing along with the results. Speak their language V know the literature inside and out V become the Rosetta Stone of the fitness language. A recent article in Club Industry, June 2011, points to the trend of increasing medical fitness center operations despite the recession (2). The Affordable Care Act may very well be responsible for driving this growth. As Doug Ribley points out, ‘‘It (Affordable Care Act) will compel more health care organizations to assume the risks of their communityIkeeping people in the community around each hospital out of the health system by keeping them healthy is the solution to the whole health care cost crisis’’ (2). As fitness professionals, we must be prepared now more than ever to work with physicians and clinicians. We cannot wait for patients to come to us. We cannot wait for referrals. We have to infiltrate the various clinical departments. We have to be the experts on exercise. We have to publish our results. We have to set the bar higher. We can seize the moment and drive initiatives such as ACSM’s Exercise is MedicineÒ, IHRSA’s Joining Forces Network, and the Wounded Warrior Project. It’s an exciting time to be a fitness professional. The barriers to entry into the clinical world are now coming down. According to the ACSM’s Health & Fitness JournalÒ; we’re now in the Top Twenty Worldwide (Clinical Integration and Medical Fitness)! It’s time to get to work and expand on our fields of expertise V and show the clinicians and physicians that we are willing and able •
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9. Wounded Warrior Project Web site [Internet]. Available from: http://www.woundedwarriorproject.org. Accessed September 23, 2011.
Don L. Jones, Ph.D., ACSM-CPT, is the wellness center manager for Tri-City Wellness Center in Carlsbad, CA. He earned his Ph.D. from The Florida State University in 1985. His career in the medical fitness industry spans more than 25 years. Dr. Jones serves on the Editorial Board of ACSM’s Health & Fitness JournalÒ. Additionally, he is ACSM Certified Personal TrainerSM certified.
CONDENSED VERSION AND BOTTOM LINE Clinical integration is a strategic imperative for medical wellness centers. It is one of the key initiatives that set these centers apart from their competitors. Today, more and more wellness center members are coming via direct referrals from cardiac rehabilitation and physical therapy departments. The Exercise is MedicineÒ initiative is expected to improve physician referrals as well. This article describes additional ways to augment the above approaches and involve other hospital clinical departments such as oncology, bariatrics, joint replacement, diabetes, and stroke to provide a true continuum of care.
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On the Floor by Mary E. Sanders, Ph.D., FACSM, RCEP and Quang Nguyen, D.O. Endocrinology, CTPC
Aging Successfully Doing the Right Thing at the Right Time V Ages 26 to 65, Part 2
I
n the previous column (July/August 2011), we looked at Bwindows of opportunity[ from infancy to 34 years, when taking the right action may lead to a preventive health foundation for successful aging. This column provides some additional insights about other time-sensitive periods, from age 26 to 65 years. Quang Nguyen, D.O., zeros in on complex and controversial women_s health issues for this period to help clarify our understanding. By knowing these critical periods, health and fitness professionals can help clients shape a preventive health care plan for successful aging with well-timed education, referrals, or interventions.
TIME TO PAY ATTENTION: VISION Ages, 35 for High Risk 39, 40 to 54, 55 to 64, and 65 Windows of Vision Everyone is at risk for glaucoma. There are no known ways to prevent it, but blindness or significant vision loss from glaucoma can be prevented if the disease is recognized in early stages. It is the leading cause of blindness among African Americans. You are six times more likely to get glaucoma if you are older than 60 years. Timely diagnosis and appropriate treatment are critical (15).
Leadership Strategies for Health and Fitness Professionals •
Ask clients about preventive checks. Remind clients to follow up with their health care providers using the guidelines below: ) For high risk individuals (African descent, people with diabetes, people with a family history of glaucoma), every 2 years after age 35 years ) Before age 40 years, every 2 to 4 years ) From 40 to 54 years, every 1 to 3 years ) 55 to 64 years, every 1 to 2 years ) After age 65 years, every 6 to 12 months
•
Teach clients to avoid injury by including protective eyewear when engaged in sports activities, indoor/outdoor, or during home improvement projects.
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For clients at risk, moderate exercise three or more times per week can help reduce intraocular pressure (IOP) and prevent damage to the optic nerve. Yoga can help, but headstands or shoulder stands should be avoided as these may increase IOP.
TIME TO PAY ATTENTION: FINANCIAL AND ECONOMIC SECURITY 20 to 65 Years Independence allows people to make choices about their lives. Adequate resources reduce stress and allow people to choose safe situations, access transportation for social and health care purposes, modify a home to accommodate mobility changes, purchase food, and participate in physical activity. In 2000, the per capita lifetime expenditure was $316,600, a third higher for women ($361,200) than men ($268,700), because of women_s longer life expectancy. Nearly one third of lifetime expenditure is incurred during middle age and nearly half during the senior years. With the rapid aging of the population, there is an increased urgency to build understanding and to address the interaction between aging and health care spending. It_s recommended that individuals learn how to manage finances and build for Photo courtesy of WaterFit.
Be Alert to Times of Change Changes in vision, and eyewear, especially the transition from Bover the counter readers[ to prescription lenses, especially bifocal lenses, require new skills and time for adjustment. Balance and mobility may be affected during periods of adjustment. VOL. 15/ NO. 6
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On the Floor Photo courtesy of WaterFit.
retirement, especially during earning periods in life (1).
Leadership Strategies for Health and Fitness Professionals •
Encourage clients, friends, and family to take steps for economic responsibility and refer to qualified professionals for assistance.
TIME TO PAY ATTENTION: MUSCLE UP 20 to 50 Years Maintaining muscle function is vital to functional independence. Muscle mass and force reach their peak between the second and fourth decades of life (2). Sarcopenia is defined as the loss of skeletal muscle mass and function with aging. These changes lead to decreased physical functioning and physical activity, increased frailty, fall risks, fractures, and ultimately, loss of independent living. According to Waters et al. (18): • The rate of muscle loss is estimated to be 1% to 2% annually after age 50 years in concert with strength declines of 1.5% per year that accelerate to 3% annually after age 60 years. •
These losses result in a decrease in total muscle area of about 40% between 20 and 60 years of age. These losses are even higher in sedentary individuals and twice as high in men compared with women.
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The prevalence of sarcopenia in the United States and parts of Europe has been reported to be 5% to 13% in people aged 60 to 70 years and 11% to 50% in those older than 80 years. In the United States, 53% of men and 43% of women older than 80 years are sarcopenic. Older adults with body mass index (BMI) lower than 18, who have both low muscle mass and fat mass, have an increased prevalence of function and mobility limitation and disability. Older obese adults and adults with BMIs higher than 30 have an increased prevalence of functional limitation and disability. The sarcopenic obese body composition (low muscle mass-high fat) have been associated with poor physical functioning, disability, falls, and metabolic syndrome and may be a better predictor of functional ability compared with muscle mass alone. Maximal oxygen consumption decreases with age, along with the loss of muscle mass. This leads to a lower work capacity and most likely contributes to the loss of function during aging.
Leadership Strategies for Health and Fitness Professionals •
Encourage physical activity starting at age 20 years to slow muscle functional loss.
•
Assess body weight and composition to identify risks of sarcopenic obesity. Refer to a dietician for nutrition counseling.
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Leisure time physical activity may play an important role in general health but does not prevent the aging-related loss of muscle mass or the increase in fat mass. Encourage participation and teach clients the skills to perform safe yet more vigorous activity when appropriate. Water exercise for example can be performed at high intensity without high risk of injury.
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Instruct clients on how to include higher levels of physical activity, power, and resistance training.
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The aging-related decline in muscle power is more rapid than strength and should be addressed as part of a physical activity program throughout adulthood.
The Second Time to Pay Attention: Bone Health (50 years) The second most critical time to pay attention to bone health is around menopause, during which time the loss of estrogen causes a more rapid loss of bone. As much as 20% or more of bone density can be lost in the 5 to 7 years after menopause (9). The greater the bone density one has before menopause, the lower the chance of developing osteoporosis. Photo courtesy of WaterFit.
Education session, 2010 International Conference of Community-Based Promotion for Senior Citizens, Hong-Dao Foundation, Taichung, Taiwan.
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Photo courtesy of WaterFit.
Performing weight-bearing exercise and assuring adequate calcium is consumed is important to increase peak bone mass and slow the loss of bone during menopause. Reports indicate that exercise in combination with 1,000 mg/day of calcium is more effective in bone preservation and response than calcium supplementation alone (10). In general, the recommended daily calcium and vitamin D intake for women aged 50 years or older is at least 1,200 mg/day (16) and 800 to 1,000 IU/day, respectively (5). Supplementation with both forms can reduce fracture risks (5). Data on hormone replacement therapy (HRT) for bone preservation during perimenopausal or menopausal periods are conflicting and controversial. Although its effect on bone health is unquestioned (13), there is evidence that HRT can increase the risk of breast cancer, strokes, heart attacks, blood clots, and cognitive decline (9,13). The timing of HRT use (within or beyond 5 years of menopause) and/or the components of hormonal replacement (estrogen alone vs. estrogen and progesterone) VOL. 15/ NO. 6
plays a key role in the development of adverse outcomes (2,13). One study reported that the risk of breast cancer is greatest among users who started HRT (estrogen-progestin) before or soon after menopause, (2) whereas another study reported a lower risk of invasive breast cancer and coronary heart disease and a marginally lower risk of mortality in postmenopausal women with hysterectomies who initiated estrogenonly therapy soon after menopause (4,6). Because of these controversies, it is recommended that women be encouraged to work with their health care providers, look at other pharmacological options first before taking HRT, and determine if HRT is necessary. If HRT is deemed to be the best course, the lowest possible dose for the shortest period should be used (9).
TIME TO PAY ATTENTION: WINDOWS OF OPPORTUNITY FOR WOMEN Late 30s, 40 to 45, and 50 years The relationship between estrogen therapy and cognitive changes in women has been widely debated. Many animal studies have suggested that estrogen has neuroprotective properties through mechanisms such as the following: 1. improvement of cerebral blood flow and glucose metabolism (7)
risk of cognitive impairment or dementia in women who underwent oophorectomy (surgical removal of an ovary or ovaries) before menopause (12). The impairment is worst with oophorectomy at a younger age or with a longer length of estrogen deficiency. Interestingly, patients who were offered estrogen therapy after the oophorectomy and maintained therapy past 50 years of age did not experience an increased risk of cognitive impairment (12). In contrast to the previous findings, a Women_s Health Institute (WHI) study recently identified an increased risk of dementia among women who initiated estrogen alone or in combination with progestin at ages 65 to 79 years (14). One explanation for the discordant result could be because the WHI groups were much older and had already had degenerative lesions that were not reversible with late estrogen intervention. This theory is supported by the current recommendation of The European Menopause and Andropause Society: women who undergo bilateral oophorectomy before the onset of natural menopause or who have premature natural menopause should be considered for estrogen therapy and continued until the average age of natural Photo courtesy of WaterFit.
2. reduction of "-amyloid plaques (3) 3. prevention of mitochondrial damage (8) The abrupt cessation of estrogen in a woman_s life span can have a significant effect on cognitive impairment. Investigators from the Mayo Clinic, Rochester, MN, recently have demonstrated an almost doubled long-term
Old and young in Taiwan spend time together under the shade of the bamboo trees. It’s a great time to share insights into living and aging well. ACSM’s HEALTH & FITNESS JOURNALA
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On the Floor menopause (approximately occurring at age 51 years) (11,17).
Leadership Strategies for Health and Fitness Professionals •
Draw attention to these periods in your client_s life and encourage them to initiate discussions with health care providers to address strategies for healthy transitions.
Running on Time: Education, Referral, Partnerships, and Guidance Well-timed actions may provide investment opportunities that lead to higher long-term quality of life. Health and fitness professionals may find this framework useful when developing programs for clients. Partnering with other health care providers, and working as a team member within the context of the Exercise is MedicineA initiative, trainers may be in a position to shape preventive programs across a client_s life span. Much more investigation is needed, but I think it_s worth the time now to focus on important issues that may affect the future. Maybe someone will develop an app that alerts us to healthy actions performed in the nick of time.
Blending Generations For many, this information comes too late to optimize opportunities, but by building awareness across generations, we can reach those who can benefit the most. This fall, we_ll again be presenting an educational workshop for elders in Taiwan. This year we_ll teach older adults about potentially critical times across the life span where action can make a difference. Senior organizations, such as the Hong-Dao Foundation in Taichung, Taiwan, with members educated in this topic, can then serve as advocates for preventive health strategies within their family and community. Armed with education, the elders have a role to keep younger generations on track for making well-timed decisions. Health and fitness professionals may consider offering this type of education for senior
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groups who enjoy helping young generations take charge of aging well.
References 1. Alemayehu B, Warner KE. The lifetime distribution of health care costs. Health Serv Res. 2004;39(3):627Y42. 2. Beral V, Reeves G, Bull D, et al. Breast cancer risk in relation to the interval between menopause and starting hormone therapy. J Natl Cancer Inst. 2011;103:296Y305. 3. Huang J, Guan H, Booze RM, et al. Estrogen regulates neprilysin activity in rat brain. Neurosci Lett. 2004;367:85Y7. 4. Jungheim ES, Colditz GA. Short-term use of unopposed estrogen: a balance of inferred risks and benefits. JAMA. 2011;305:1354. 5. Kumar J, Muntner P, Kaskel FJ, et al. Prevalence and associations of 25-OH Vit D deficiency in US children: NHANES 2001Y2004. Pediatrics. 2009;124:362Y70. 6. LaCroix AZ, Chlebowski RT, Manson JE, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial. JAMA. 2011;305:1305Y14. 7. McEwen BS, Alves SE. Estrogen actions in the central nervous system. Endocrinol Rev. 1999;20:279Y307. 8. Morrison JH, Brinton RD, Schmidt PJ, et al. Estrogen, menopause, and the aging brain: how basic neuroscience can inform hormone therapy in women. J Neurosci. 2006;26:10332Y48. 9. National Osteoporosis Foundation [Internet]. 2011 [cited 2011 Jun 6] Available from: http://www.nof.org/aboutosteoporosis/ whatwomencando/menopause. 10. Prince R, Devine A, Dick I, et al. The effects of calcium supplementation (milk powder or tablets) and exercise on bone density in postmenopausal women. J Bone Miner Res. 1995;10:1068Y75. 11. Rocca WA, Grossardt BR, Shuster LT. Oophorectomy, menopause, estrogen treatment, and cognitive aging: clinical evidence for a window of opportunity. Brain Res. 2011; 1379:188Y98. 12. Rocco WA, Bower JH, Maraganore DM, et al. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007;69:1074Y83. 13. Rossouw J, Anderson G, Prentice R, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002; 288:321Y33. 14. Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of
dementia and mild cognitive impairment in post-menopausal women: the Women_s Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003;289: 2651Y62. 15. Stamper RL. What can I do to prevent glaucoma? [Internet]. 2011 [cited 2011 Jan 25]. Available from: http:// www.glaucoma.org. 16. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Calcium. In: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington (DC): The National Academies Press; 1997. p.73. 17. Vujovic S, Brincat M, Erel T, et al. EMAS position statement: managing women with premature ovarian failure. Maturitas. 2010;67:91Y3. 18. Waters DL, Baumgartner RN, Garry PJ, Vellas B. Advantages of dietary, exercise related, and therapeutic interventions to prevent an treat sarcopenia in adult patients: an update. Clin Interv Aging. 2010;5:259Y70.
Mary E. Sanders, Ph.D., FACSM, RCEP, is an associate professor in the School of Medicine and adjunct professor in the School of Public Health, University of Nevada, Reno. She is an associate editor of ACSM_s Health & Fitness JournalA, editor of the YMCA Water Fitness for Health training manual, and the 1997 IDEA Instructor of the Year. Dr. Sanders is ACSM Exercise SpecialistA certified and ACSM Registered Clinical Exercise Physiologist A certified. Dr. Sanders’ Web site is www.waterfit.com.
Quang Nguyen, D.O. Endocrinology, CTPC, practices Endocrinology at Carson Tahoe Physician Clinics, Carson City, NV, is an assistant clinical professor of Medicine at the University of Nevada, School of Medicine in Reno, and adjunct associate professor Endocrinology & Internal Medicine at Touro University in Nevada.
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ACSM Certification by Deborah Riebe, Ph.D., FACSM
Advancing the Exercise Science Profession
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n 2008, the Committee on Certification and Registry Boards (CCRB) developed a 5-year strategic plan for the American College of Sports Medicine_s (ACSM) credentials. During this process, it was acknowledged that, although ACSM credentials historically have been recognized as the gold standard, there are hundreds of other organizations in existence that credential thousands of exercise professionals. The requirements necessary to become certified vary widely among these organizations. In some cases, the requirements to become a certified exercise professional require little education or experience, and virtually everyone qualifies as a certification candidate. Because ACSM is committed to excellence, the CCRB identified, as one of its strategic plan goals, to advance the profession of the exercise professional. The Australian Council of Professions defines a profession as a disciplined group of individuals who adhere to ethical standards and uphold themselves to, and are accepted by, the public as possessing special knowledge and skills in a widely recognized body of learning derived from research, education, and training at a high level, and who are prepared to exercise this knowledge and these skills in the interest of others. We are part of a relatively young profession. In 1975, ACSM was the first organization to define minimal proficiencies for a clinical exercise professional and published the first edition of the Guidelines for Graded Exercise Testing and Prescription. As an organization, we have taken steps to respond to the growth and changes in our field. For example, our clinical certifications were initially concerned with only cardiovascular, pulmonary, and metabolic diseases. The Registered Clinical Exercise Physiologist
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(RCEP) certification was added in (June 2000) to address many other clinical populations (e.g., cancer, Parkinson’s disease) as new research demonstrated the positive effects of exercise on various disease processes. In response to this evolving profession, new certifications have been added, whereas others have been refined or eliminated. To truly establish exercise physiology/ science as a profession, members of the CCRB have determined that four factors must be in place: • established academic guidelines for colleges and universities interested in offering exercise physiology/science programs •
the existence of a professional organization that services its members and advocates to others on their behalf
•
the existence of a unique body of knowledge
an examination that can be taken by only those students who graduate from an accredited program in exercise physiology/science ACSM has achieved many benchmarks in professionalizing our field. One of the most important steps was the decision for ACSM to participate in the Committee on Accreditation for the Exercise Sciences (CoAES). This organization established academic standards under the auspices of the Commission on Accreditation of Allied Health Education Programs, a wellrespected accreditation agency. The CCRB has continued to make strides toward advancing the profession of both the clinical and health fitness exercise professionals since setting this as a formal strategic goal 3 years ago. Below are some of the recent achievements: Academic Standards. In 2011, the eligibility requirements for the Health Fitness Specialist (HFS) and the Clinical •
Exercise Specialist (CES) certifications were changed so that certification candidates must now hold a bachelor_s degree in Kinesiology, Exercise Science, or an exercise-based program. Previously, an individual taking the HFS or CES examination needed a degree in a health-related field, which allowed individuals without formal training in exercise physiology/science to qualify for the examination. Because our field is based on a unique body of knowledge, certification is now available only to true exercise professionals. This academic preparation was deemed necessary based on the required knowledge and skills of those currently working as HFSs and CESs. In making this change, the CCRB tookmany thingsinto consideration, including professionalizing the field as we move toward the future. Advocacy. Several states have proposed legislation to require licensure for personal trainers. The CCRB and ACSM have been monitoring this process, as some of the proposed bills are not in the best interest of the exercise profession. We are in the process of developing a health fitness advocacy kit that can be used proactively or as an alternative to existing proposals. The CCRB also is working with the Clinical Exercise Physiology Association to develop a blueprint for licensure legislation for clinical exercise professions. Body of Knowledge. In collaboration with Human Kinetics and Lippincott Williams & Wilkins, the CCRB continues to publish new editions of flagship books (e.g., ACSM_s Guidelines for Exercise Testing and Prescription) and publish new books in the latest areas of study. Writing teams are working on a variety of new resources including ACSM_s Resources for the Group Exercise Instructor, ACSM_s Resources for the Health Fitness ACSM’s HEALTH & FITNESS JOURNALA
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ACSM Certification Specialist, ACSM_s Guide to Exercise and Cancer Survivorship, and ACSM_s Behavioral Aspects of Exercise. These publications will become available in 2011, 2012, or 2013. We continue to collaborate with other national organizations to create specialty certifications to provide the latest information for exercise professionals who work in very specific aspects of our profession. These include the Certified Cancer Exercise Trainer in collaboration with the American Cancer Society, the Certified Inclusive Fitness Trainer in collaboration with the National Center of Physical Activity and Disability, and the Physical Activity in Public Health specialist in collaboration with the National Society of Physical Activity Practitioners in Public Health. National Examination. A long-term goal of the CCRB is to require that certifi-
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cation candidates for HFS, CES, and RCEP graduate from a CoAES-accredited program. As a first step, the CES eligibility criteria now differentiates the amount of clinical experience needed before the examination between colleges and universities whose curriculums are accredited by CoAES and programs that are not accredited. Candidates who attend a nonCoAES accredited curriculum must have an additional 100 hours of clinical experience before being eligible to take the CES examination. ACSM has established a University Partnership and will work closely with this network to promote accreditation and support the programs that prepare future exercise professionals. The CCRB will continue to identify strategies that will advance the career of the exercise professional. The college leadership and the professional volunteers
that make up the CCRB are qualified and willing to tackle the important issues that our profession will face in the months and years to come.
Deborah Riebe, Ph.D., FACSM, is a professor and chair of the Department of Kinesiology at the University of Rhode Island. Dr. Riebe is a past president of the New England Chapter of ACSM and is the current chair of ACSM_s Committee on Certification and Registry Boards. Her research focuses on promoting physical activity in special populations, with an emphasis on obesity and aging.
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Clinical Applications by Adam deJong, M.A., FACSM
Maximal Aerobic Power An Important Clinical and Research Measurement
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aximal aerobic power describes the functional capacity of the cardiorespiratory system and is defined as the maximum rate at which oxygen can be used during a specified period, usually during intense exercise. It is a function both of cardiorespiratory performance and the maximum ability to remove and use oxygen from the blood. The higher the measured cardiorespiratory fitness level, the more oxygen has been transported to and used by exercising muscles, resulting in a higher level of exercise intensity that is able to be achieved. Because regular physical activity is required to maintain cardiovascular health and improve athletic performance, its measurement continues to be a focus in the health and clinical setting. Because of its underlying value as a health indicator across a variety of clinical populations, maximal aerobic power often is used as a primary or secondary end point in many research trials (10). This article will discuss the measurement of maximal aerobic power and the use of this measurement in various clinical settings, particularly as it relates to cardiovascular disease.
FACTORS AFFECTING MAXIMAL AEROBIC POWER Maximal aerobic power has been shown to provide important prognostic and diagnostic information in a variety of patient populations. It provides the foundation for many clinical and research applications and can be measured directly or estimated from physiological responses to submaximal or maximal exercise tests. Direct measurement of maximal aerobic power often is expressed as maximal oxygen consump˙ O2max), which is the product of cartion (V VOL. 15/ NO. 6
diac output and arteriovenous oxygen (AV O2) difference and defines the ability of an individual to perform aerobic work. Maximal aerobic power also can be expressed in metabolic equivalents (METs) to allow for intersubject comparison relative to body weight because one MET approximates 3.5 mL O2/kg body weight per minute (10). Maximal aerobic power can be affected by age, conditioning status, the presence of disease, or medication regimen. Typi˙ O2max in men is 10% cally, the average V to 20% greater than that in women, related largely to a greater muscle mass, higher hemoglobin concentration, and greater stroke volume (10). Regular endurance exercise has been associated with an increase in ˙ O2max of 10% to 30%, because of enV hanced AV O2 difference and increased maximal stroke volume, which can help attenuate the reduction in aerobic capacity that occurs over time, often declining by 8% to10% per decade in nonathletic subjects (9). These declines often are the result of a decrease in maximal heart rate and AV O2 difference (9). Because few activities of daily living require maximal effort, tests done to ˙ O2max measure V often includes measurement of the ventilatory threshold (VT). VT is a submaximal value that is identified as the point during which ventilation increases exponentially relative to the increase in oxygen consump-
tion. The VT is linked to the rising lactic acid level in the blood, which is, in turn, related to an increased recruitment of fast twitch muscle fibers, higher levels of epinephrine and a decreased rate of removal of lactate by the liver. The increased lactic acid accumulation, and subsequent conversion to lactate, results in increased carbon dioxide production and an increased ventilatory response to the exercise (21). The VT usually occurs between 47% and 64% ˙ O2max in most healthy individuals of V but occurs at a higher percentage in trained endurance athletes (5,13). Additional variables measured during cardiopulmonary exercise testing are presented in the Table. Direct measurement of VO2 is the most accurate and reliable method for determining maximal aerobic power, yet it can prove very difficult to find outside traditional exercise physiology laboratories. Expensive and sophisticated equipment, along with highly trained staff, is required for testing. In addition, many patients are unable or unwilling to exercise to a truly maximal VO2. In such instances, maximal
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Clinical Applications TABLE: Key Variables Measured During Cardiopulmonary Exercise Testing • Peak oxygen consumption (peak VO2) V peak capacity of an individual’s body to transport and use oxygen during incremental exercise. • Ventilatory threshold (VT) V the point during which ventilation increases exponentially relative to the increase in oxygen consumption. • Pulmonary ventilation (VE) V the amount of air moved in and out of the lungs per minute. • Carbon dioxide production (VCO2) V by-product of cellular metabolism. • Respiratory exchange ratio (RER) V ratio of carbon dioxide production to oxygen consumption (VCO2/VO2). • VE/VCO2 slope V The abnormal ventilatory response to exercise as identified by an increased slope of ventilation versus carbon dioxide production related to an incremental workload. • Oxygen uptake efficiency slope (OUES) V derived from the relation between oxygen uptake (VO2 [milliliters per minute]) and minute ventilation (VE [liters per minute]) during incremental exercise. • Oxygen pulse V the amount of oxygen extracted from the blood by active tissues per beat of the heart.
aerobic power may need to be estimated using regression equations derived from submaximal or maximal exercise protocols. Although it is important to note that direct measures of VO2 are more reproducible and are used to minimize the standard deviation of the measurement, regression equations can provide reasonable estimations of aerobic capacity from steady state exercise protocols. However, care must be taken to eliminate variables that could alter the accuracy of the regression equations. In addition to traditional testing measures, a timed walking test (6- or 12minute walk test) can be used to estimate maximal aerobic power and assess the risk for cardiopulmonary morbidity and mortality in various patient populations (8,15). These tests possess administration benefits over maximal exercise tests, are well tolerated in many clinical populations, and have demonstrated significant correlation with maximal oxygen consumption tests (11,14). Although both methods provide advantages in safety and ease of use, the potential for error in estimating functional capacity should be recognized in a clinical setting. When evaluating maximal aerobic power, protocol selection is very important to ensure accurate outcomes are achieved. In the United States, testing is typically completed using a motorized treadmill or cycle ergometer, although treadmill is the
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preferred mode because of greater familiarity. Arm ergometer testing is typically avoided as a testing modality because of an inability to achieve and maintain high work rates as a result of a smaller muscle mass being used. Avoidance of protocols that involve large work rate increments is recommended, instead focusing on protocols that allow for smaller MET increments per stage (i.e., Balke and Ware (1) or Naughton et al. (20) protocols). Regardless of the protocol selected, the test should be tailored to each patient to yield fatigue-limited exercise duration of approximately 10 minutes (19).
AEROBIC CAPACITY MEASUREMENT IN PATIENTS WITH CARDIOVASCULAR DISEASE Decreased maximal aerobic power, as a measure of cardiorespiratory fitness, is associated with increased cardiovascular disease and all-cause mortality (7). Low cardiorespiratory fitness increases the relative risk of death to a similar level as tobacco abuse, hypertension, and/or diabetes (2,16). Maximal aerobic power also has significant prognostic capabilities in patients with known or suspected cardiovascular disease. In particular, when using the standard Bruce protocol during graded exercise testing, a maximal aerobic power exceeding 14 METs was associated with a reduced probability for severe cor-
onary artery disease and an improved 4year survival rate when compared with those with less than a 5 MET maximal aerobic power (18). Additionally, in coronary artery disease patients undergoing preoperative evaluations before noncardiac surgery, the ability to achieve a high exercise workload was consistent with a low postoperative cardiac risk, regardless of associated symptoms or ST-segment changes (6). In patients entering cardiac rehabilitation, maximal aerobic power measurements provide the necessary information for developing an appropriate exercise prescription and for evaluating the results of an exercise training regimen. In patients with chronic heart failure, estimates of maximal aerobic power are less reliable than the direct measurement of gas exchange (3). Thus, in this patient population, cardiopulmonary gas exchange measurements have become standard for the assessment of maximal aerobic power. In particular, measurements of peak VO2 and VT are highly reproducible and recommended for this patient population (4). Markedly impaired exercise tolerance places the heart failure patient in a highrisk category for a poor outcome. For instance, a peak VO2 of less than 10 to 12 mL O2/kg body weight per minute identifies a poor 1-year prognosis, whereas a peak VO2 of greater than 14 mL O2/kg body weight per minute demonstrate a more favorable outcome (17). Evaluation of peak VO2 also can be beneficial in patients with other cardiovascular diseases. In those with valvular or congenital heart disease, measuring maximal aerobic power can assist in identifying candidates in need of early surgical intervention (12). Additionally, using maximal aerobic power measurements in those with peripheral arterial disease can assist in the development of an exercise prescription and evaluate the overall response to exercise training (10).
OPPORTUNITIES FOR THE CLINICAL EXERCISE PROFESSIONAL Data support the use of maximal aerobic power in clinical populations, particularly
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in those with cardiovascular disease, to help guide treatment and evaluate interventions. Exercise professionals, particularly those with clinical backgrounds, are uniquely qualified to assist with research and testing in this area. These individuals can play a significant role in the coordination of oxygen consumption testing to ensure protocol optimization and data collection. Although directly measured VO2 is primarily used in patients with cardiovascular disease and in athletes, the use of estimated ˙ O2max is a regular part of fitness evaluaV tions. Thus, clinical exercise professionals who are adept at exercise testing, including in the measurement of VO2, can play an important role in the use and interpretation of these important clinical measures.
References 1. Balke B, Ware RW. An experimental study of physical fitness of Air Force personnel. US Armed Forces Med J. 1959;10:675Y88. 2. Blair SN, Kohl HW 3rd, Barlow CE, et al. Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA. 1995;273: 1093Y8. 3. Cohen-Solal A, Chabernaud JM, Gourgon R. Comparison of oxygen uptake during bicycle exercise in patients with chronic heart failure and in normal subjects. J Am Coll Cardiol. 1990;16:80Y5. 4. Cohen-Solal A, Zannad F, Kayanakis JG, et al. Multicentre study of the determination of peak oxygen uptake and ventilatory threshold during bicycle exercise in chronic heart failure: comparison of graphical methods, interobserver variability and influence of the exercise protocol: the VO2 French Study Group. Eur Heart J. 1991;12:1055Y63.
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5. Davis JA, Vodak P, Wilmore JH, et al. Anaerobic threshold and maximal aerobic power for three modes of exercise. J Appl Physiol. 1976;41:544Y50. 6. Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evalutation for Noncardiac Surgery). J Am Coll Cardiol. 1996;27:910Y48. 7. Ekelund LG, Haskell WL, Johnson JL, et al. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. N Engl J Med. 1988;319:1379Y84. 8. Enright P. The six-minute walk test. Respir Care. 2003;48:783Y5. 9. Fleg JL, Lakatta EG. Role of muscle loss in ˙ O2max. J the age-associated reduction in V Appl Physiol. 1988;65:1147Y51. 10. Fleg JL, Pina IL, Balady GJ, et al. Assessment of functional capacity in clinical and research applications: An Advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation. 2000;102: 1591Y7. 11. Gayda M, Temfemo A, Choquet D, Ahmaidi S. Cardiorespiratory requirements and reproducibility of the six-minute walk test in elderly patients with coronary artery disease. Arch Phys Med Rehabil. 2004;85: 1538Y43. 12. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997;30:260Y311. 13. Jones AM, Carter H. The effect of endurance training on parameters of aerobic fitness. Sports Med. 2000;29:373Y86. 14. Kervio G, Carre F, Ville N. Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med Sci Sports Exerc. 2003; 35:169Y74.
15. Lankin JL, Bundy S, Marron H, et al. Using a treadmill for the 6-minute walk test. J Cardiopulm Rehabil Prev. 2007;27:407Y10. 16. Laukkanen JA, Lakka TA, Rauramaa R, et al. Cardiovascular fitness as a predictor of mortality in men. Arch Intern Med. 2001; 161:825Y31. 17. Mancini DM, Eisen H, Kussmaul W, et al. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation. 1991;83:778Y86. 18. McNeer JF, Margolis JR, Lee KI, et al. The role of the exercise test in the evaluation of patients for ischemic heart disease. Circulation. 1978;57:64Y70. 19. Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol. 1991;17:1334Y42. 20. Naughton J, Balke B, Nagle F. Refinements in method of evaluation and physical conditioning before and after myocardial infarction. Am J Cardiol. 1964;14:837Y43. 21. Wasserman K, Beaver WL, Whipp BJ. Gas exchange theory and the lactic acidosis (anaerobic) threshold. Circulation. 1990; 81(suppl):II-14Y30.
Adam deJong, M.A., FACSM, is the cardiology manager at Wi l l i a m B e a u m o n t Hospital in Royal Oak, MI, and is a faculty lecturer in the School of Health Sciences at Oakland University in Rochester, MI. He earned his Bachelor of Applied Arts and Master of Arts degrees in Exercise Science from Central Michigan University. He currently serves as chair of the ACSM International Certification and Professional Education committees.
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Medical Report by Heather Gillespie, M.D., M.P.H.
Nonsteroidal Anti-Inflammatory Drugs General Risks of Prophylactic, Acute, and Long-Term Use
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onsteroidal anti-inflammatory drugs (NSAIDs) are used extensively in medicine for the treatment of pain, inflammation, and fever. NSAIDs use is prevalent in athletes and nonathletes and products are available in over the counter (OTC) as well as prescription form. NSAIDs are among the most widely prescribed therapeutic agents because of their effectiveness in treating pain and inflammation, but they also have side effects on various organ systems that should be taken into account when considering their use, especially in certain populations. There are many formulations of NSAIDs available, including both ‘‘selective’’ and ‘‘nonselective’’ types. The selectivity of the NSAIDs refers to the relative inhibition of the cyclooxygenase (COX) enzymes, with nonselective NSAIDs inhibiting both COX-1 and COX-2 enzymes and selective NSAIDs targeting the COX-2 enzyme, primarily. When tissues are damaged, such as in musculoskeletal injuries, cells secrete prostaglandins, which lead to inflammation. NSAIDs exert their anti-inflammatory effect by decreasing prostaglandin production and therefore decreasing inflammation. NSAIDs are able to decrease prostaglandin production by blocking an enzyme called cyclooxygenase. Unfortunately, COX does more than just block prostaglandin synthesis in response to tissue injury. As mentioned previously, there are two major types of COX, COX-1 and COX-2, and each plays a different role in the body. COX-1 is involved in the regulation of hemostasis (process leading to stopping bleeding), the integrity of the gastrointestinal (GI) and renal tracts, platelet
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function, and macrophage differentiation (4). Although NSAIDs are effective in inhibiting COX-1 and reducing inflammation, the adverse effects of NSAIDs are primarily related to the inhibition of these other important functions of COX-1. COX-2 plays a larger role in inflammation; therefore, selective NSAIDs that inhibit COX-2 may result in fewer side effects than nonselective NSAIDs. That said, all NSAIDs have some effect on both COX-1 and COX-2, and none is absolutely selective for COX-2, so there are similar side effects with all NSAIDs (4). Damage to the upper GI tract was one of the first recognized clinical side effects of NSAID use and continues to cause significant morbidity and mortality. As stated previously, prostaglandins provide a gastroprotective effect, and the use of NSAIDs decreases the production of these prostaglandins; this puts the athlete or patient at risk for GI bleeding. Statistics from a study in the 1990s in the United States found that there were 32,000 hospitalizations and 3,200 deaths annually from NSAID-related GI bleeding. The risk of bleeding is directly related to patient age and comorbidities, and the risk of serious bleeding from chronic NSAID use ranges from 1 in 2,100 for adults younger than 45 years to 1 in 110 for adults older than 75 years (5). In chronic NSIAD use, adding a proton pump inhibitor (that
reduces acid production in the stomach) or using a selective NSAID has been shown to help decrease the risk of GI bleeding, but there is still a risk (4). In addition to GI effects, prostaglandins also play a role in the cardiovascular system. By decreasing prostaglandin production with NSAID use, there has been an associated increased risk of cardiac disease and complications (4). This again is more prevalent in those with underlying pathology and disease but must be factored in with any patient or athlete, especially those who use NSAIDs chronically. NSAIDs may be associated with slower bone healing and increased risk of nonunion, but there continues to be significant debate in the literature regarding the strength of this evidence. The reason for this is that most conclusions are based on animal models and moderate-quality observational studies in humans (1). That being said, there has been an association shown between exposure to NSAIDs and increased nonunion risk in patients with long bone fractures, and animal models ACSM Photo\Lori Tish.
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have shown an association between NSAID use and risk of bony nonunion (2,3,6). Although additional research is still needed, based on the available data and combined with the multiple potential medical problems associated with NSAID use, many physicians use caution in the use of NSAIDs in acute bone fractures. Another potential side effect of NSAIDs is in the renal system (kidneys). NSAIDs have been found to affect kidney function and cause acute renal failure (7). Risk of kidney damage with NSAID use is increased in those with preexisting kidney damage as well as in situations in which plasma volume is reduced. NSAIDs use also has been found to be a risk factor in the development of hyponatremia in long distance endurance events. In athletes who often are in a state of dehydration in training or competition, potential volume depletion and the effect of NSAID use on kidney function becomes very relevant. NSAIDs are not only used to treat established injuries, but with the extensive availability of these medications, many athletes have taken on the potentially detrimental practice of using NSAIDs prophylactically before competition, during practice, or events (8). This prophylactic use carries inherent risks. By masking pain, and potentially ‘‘pushing through’’ an injury, there may be an increased risk of the athlete worsening an injury that the sensation of pain would normally limit. Additionally, there is a suggestion that COX-2 and prostaglandins are important in the body’s synthesis of collagen, an important soft tissue component (8). If the COX-2 system is inhibited,
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there may be a decreased adaptation and response of the body to mechanical stress, and this may potentially delay tissue repair in both bone, ligament, and muscle/tendon injuries (8). With the above risks and side effects in mind, it is generally recommended to consider alternatives to NSAIDs in any athlete but especially those high-risk populations with underlying comorbidities. If NSAIDs are chosen as the treatment of choice, the recommendation would be to use the minimal dose for a minimal duration as short-term use might limit side effects. The use of gastroprotective agents, such as proton pump inhibitors, in those at increased risk of GI side effects also should be considered (4). In summary, NSAIDs are highly effective for reducing pain, inflammation, and fever. Widely used in our population, in both OTC and prescription forms, we must keep in mind the significant potential side effects of NSAIDs including the risk of GI bleeding, acute renal failure, cardiovascular effects, and potential delayed bone healing when deciding to use or prescribe both selective and nonselective NSAIDs. As always, a patient/athlete-centered approach, balancing the risks, benefits, and alternatives, should be considered when recommending and selecting NSAIDs for use in pain and antiinflammatory management situations.
References 1. Dodwell ER, Latorre JG, Parisini E, et al. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87:193Y202. 2. Gerstenfeld LC, Al-Ghawas M, Alkhiary YM, et al. Selective and nonselective
cyclooxygenase-2 inhibitors and experimental fracture-healing. J Bone Joint Surg Am. 2007;89:114Y25. 3. Ho ML, Chang JK, Wang GJ. Antiinflammatory drug effects on bone repair and remodeling in rabbits. Clin Orthop Relat Res. 1995;313:270Y8. 4. Jones R, Rubin G, Berenbaum F, Scheiman J. Gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs. Am J Med. 2008;121:464Y74. 5. Risser A, Donovan D, Heintzman J, Page T. NSAID prescribing precautions. Am Fam Physician. 2009;80(12):1371Y8. 6. Simon AM, O’Connor JP. Dose and time-dependent effects of cyclooxygenase-2 inhibition on fracture-healing. J Bone Joint Surg Am. 2007;89:500Y11. 7. Ulinski T, Guiqonis V, Dunan O, Bensman A. Acute renal failure after treatment with non-steroidal anti-inflammatory drugs. Eur J Pediatr. 2004;163:148Y50. 8. Warden SJ. Prophylactic misuse and recommended use of non-steroidal anti-inflammatory drugs by athletes. Br J Sports Med. 2009;43(8):548Y9.
Heather Gillespie, M.D., M.P.H., is an assistant professor in the Division of Sports Medicine at the University of California-Los Angeles (UCLA). She serves as one of the varsity athlete team physicians at UCLA. Dr. Gillespie runs a pediatric sports medicine clinic in downtown Los Angeles and additionally has an active musculoskeletal practice for children and adults of all ages in Santa Monica, CA. A former collegiate swimmer and water polo player, Dr. Gillespie enjoys an active lifestyle training, competing in triathlons, and the southern California weather.
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Continuing Education Self-Test Credits Provided by the American College of Sports Medicine
NOVEMBER/DECEMBER 2011 | EXPIRATION DATE DECEMBER 31, 2012 | SELF-TEST #1: 2 CECs | SELF-TEST #2: 2 CECs
To participate in this program, you must read the designated feature articles carefully, answer the test questions, obtain a passing grade (a minimum score of 60%), and complete the credit evaluation form. After answering the questions, turn to the bottom of the Table of Contents to score your exam. To receive credit verification, fill out and sign the form on page 50, confirming that you have read the materials and obtained a minimum passing score. Select the best answer for each of the following by placing an ‘‘x’’ in one box for each question.
CEC Self-Test 1
An Exercise Professional’s Guide to Acute Hormonal Changes from Resistance Exercise page 19 by Jeremy C. Fransen, M.S., and Len Kravitz, Ph.D. 1. Which of the following is true regarding hormone secretion? r A. Hormones are usually secreted in large concentrations. r B. Hormones are secreted in a continuous manner. r C. Hormones are secreted in small concentrations. r D. Hormones are secreted at random by the gland or organ.
2. What does endocrine mean? r A. Efflux of a fluid r B. Hormone secreting r C. Influx of a fluid
4. Which of the following acute training variables increases the growth hormone response to resistance exercise? r A. High set protocols r B. Eccentric muscle actions r C. Single-joint exercise r D. Large rest intervals between sets 5. Which of the following hormones has primarily catabolic functions by stimulating lypolysis in adipose tissue and decreasing protein synthesis in muscle cells? r A. Testosterone r B. Growth hormone r C. Cortisol r D. Insulin-like growth factors 6. Acute testosterone increases following resistance training are consistent with which of the following training sessions? r A. Low-set, low-load
r D. Cellular absorption of a fluid
r B. High-intensity, long rest intervals between sets r C. Single-joint exercises
3. Which hormone increases glycogenolysis (i.e., the breakdown of glycogen) in the muscle? r A. Growth hormone
r D. High-volume, moderate-intensity, short rest intervals between sets
r B. Norepinephrine r C. Estrogen r D. Epinephrine
48
7. Estrogen may play a protective role in muscle strength via the actions of ________. r A. aromatization
r B. estrogen receptors r C. menopause r D. ovaries
8. Which of the following has the largest influence on hormone concentrations during overtraining? r A. Training volume r B. Training intensity r C. Training time-of-day r D. Sleep
9. Which of the following hormone increases in a similar manner for younger men and women after an acute bout of resistance exercise? r A. Testosterone r B. Insulin-like growth factors r C. Estrogen r D. Growth hormone
10. ________ is a polypeptide hormone that is secreted by the liver in response to GH stimulation. r A. Epinephrine r B. Testosterone r C. Cortisol r D. Insulin-like growth factor
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CEC Self-Test 2
The Use of Vibration Exercise in Clinical Populations page 25 by Rita Toma´s, M.D.; Vinson Lee, M.S., and Scott Going, Ph.D. 1. Types of whole body vibration platform include: r A. vertical and rotational displacement. r B. electromagnetic and infrared. r C. intermittent and continuous. r D. rotational and pivotal displacement. 2. Negative effects of chronic exposure to vibration in the occupational setting include: r A. spinal degeneration. r B. vestibular disturbances. r C. peripheral neuropathy. r D. All of the above 3. Which of the following is a common side effect of whole-body vibration exercise? r A. Low back pain r B. Nausea r C. Transient itching r D. Insomnia 4. Which of the following is not a contraindication to the use of whole-body vibration? r A. Peripheral neuropathy
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r B. Migraine r C. Low bone mineral density r D. Osteosynthesis in the lower body
r B. Increase the amplitude of displacement r C. Lower body muscle contraction r D. Static standing with complete knee extension
5. Potential benefits of whole-body vibration include: r A. pain relief. r B. increased muscle strength. r C. slowed bone loss. r D. All of the above
6. Which of the following mechanisms may explain the acute increase of strength after a short bout of vibration? r A. Increase of serum testosterone r B. Tonic vibration reflex r C. Gate-control theory r D. Mecanotransduction
7. Which type of exercise is recommended while on a whole body vibration platform? r A. Dynamic half squats r B. Push-ups r C. Static standing with complete knee extension r D. Triceps dips
8. Which of the following decreases the magnitude of the vibration transmitted to the upper body? r A. Being on the platform barefoot
9. Which is true about vibration in an industrial setting versus a whole body vibration platform? r A. The frequency is higher but at a smaller amplitude on a vibration platform compared with the industrial setting. r B. The frequency is lower but at a greater amplitude on a vibration platform compared with the industrial setting. r C. The frequency is higher and at a greater amplitude in an industrial setting. r D. The frequency is lower and at a lower amplitude on a vibration platform.
10. When choosing a whole body vibration platform, look for: r A. a certified machine. r B. one with peer-reviewed published results. r C. published confirmation of its acceleration, frequency, and amplitude. r D. All of the above
(Answers can be found at the bottom of the Table of Contents.)
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Continuing Education Self-Test
To receive credit, mail this page with check or money order payable in U.S. dollars in the amount of $15 (ACSM and ACSM Alliance members) or $20 (nonmembers).
Mail CEC tests to: American College of Sports Medicine Department 6022 Carol Stream, IL 60122-6022
(A $25 fee will be assessed on all returned checks.) Fed ID#23-6390952 Test Expires: December 31, 2012.
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Brought to you by the AMERICAN COLLEGE OF SPORTS MEDICINE w w w . a c s m . o r g
Educational Opportunities: Meetings and Providers
ACSM ACSM OPPORTUNITIES Date
Event
Location
Contact
November 3–4, 2011
New England ACSM Regional Chapter Annual Meeting
Providence, RI
For more information, visit www.neacsm.org
November 4–5, 2011
Mid-Atlantic ACSM Regional Chapter Annual Meeting
Harrisburg, PA
For more information, visit www.marcacsm.org
February 9–11, 2012
Southeast ACSM Regional Chapter Annual Meeting
Jacksonville, FL
For more information, visit www.seacsm.org
March 1–2, 2012
Texas ACSM Regional Chapter Annual Meeting
Austin, TX
For more information, visit www.tacsm.org
March 27–30, 2012
ACSM’s Health & Fitness Summit & Exposition
Las Vegas, NV
For more information, visit www.acsmsummit.org
March 30–31, 2012
Northwest ACSM Regional Chapter Annual Meeting
Coeur d’Alene, Idaho For more information, visit www.acsmnorthwest.org A
May 29–June 2, 2012 ACSM’s Annual Meeting & World Congress on Exercise is Medicine
San Francisco, CA
For more information, visit www.acsmannualmeeting.org
ACSM CERTIFICATION WORKSHOPS Various dates and locations
Credits
ACSM Certified Group Exercise Instructor
SM
webinars
9.0 ACSM CECs
A
ACSM Certified Personal Trainer Workshops ACSM Certified Health Fitness Specialist
SM
ACSM Certified Clinical Exercise Specialist
20.75 ACSM CECs
Events
SM
Workshop: 16.0 ACSM CECs/Webinar: 9.0 ACSM CECs
Events
Workshop: 13.25 CECs/Webinar: 9.0 ACSM CECs
A
ACSM Registered Clinical Exercise Physiologist Workshops ACSM/NCPAD Certified Inclusive Fitness Trainer ACSM/ACS Certified Cancer Exercise Trainer
SM
SM
15.0 ACSM CECs
Webinar Series
Webinar series
9.0 ACSM CECs 9.0 ACSM CECs
ACSM Weight Management for the Fitness Professional 1-day CEC Course
7.0 ACSM CECs
ACSM Business Management for Fitness Professionals 1-day CEC Course
7.0 ACSM CECs
For more information or to register for any of the ACSM certification workshops, contact ACSM’s Certification Resource Center by phone: 1Y800Y486Y5643, Email:
[email protected], or Web site: www.acsm.org/register.
ACSM APPROVED PROVIDERS AND OPPORTUNITIES Apply to Become an ACSM Approved Provider! ACSM approved providers are reviewed and approved entities that can offer ACSM continuing education credits for any program, meeting, conference, workshop, or home-study opportunity for a 3-year period. This new program has replaced the endorsement application process that only reviewed and approved meetings offered by organizations annually. For more information or to apply to become an ACSM-approved provider, visit www.acsm.org. The following are ACSM Approved Providers American Council on Exercise Art and Science of Health Promotion Conference Athletes’ Performance Athletic Business Publications B2C Fitness LLC Bryan LGH Medical Center CEPA Center for Health and Fitness Continuing Education Club Industry Contemporary Forums Cooper Institute Cross Country Education Department of Health & Physical Education-University of Alabama Huntsville
VOL. 15/ NO. 6
www.acefitness.org www.healthpromotionconference.org www.athletesperformance.com www.athleticbusinessconference.com No Web site www.bryanlgh.org www.acsm-cepa.org www.center4healthandfitness.com www.clubindustryshow.com www.cforums.com www.cooperinstitute.org www.crosscountryeducation.com www.uah.edu/hpe
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ACSM EDUCATIONAL OPPORTUNITIES ACSM APPROVED PROVIDERS & OPPORTUNITIES (continued) Desert Southwest Fitness Diabetes Training Camp Discover Strength Personal Fitness Center Educational Fitness Solutions, Inc. Egg Nutrition Center Elements in Motion European Institute of Fitness Exercise Etc. Exercise Science Academy Fitness Education Network Fitness Learning Systems Focus Personal Training Institute Gatorade Sports Science Institute G. Schweitzer Massage Therapist Corp. Geisinger Health System Gray Institute Healthways HP Career.Net HPI Health Profile Institute, Inc. Human Kinetics IDEA Innovative Wellness Education International Association for Worksite Health Promotion International Council on Active Aging International Society of Sports Nutrition Japan Fitness Association Medical Fitness Association Motivate to Train Muscle Gaines National Center on Physical Activity and Disability National Intramural-Recreational Sports Association National Society for Physical Activity Practitioners in Public Health National Wellness Institute, Inc. New England Health, Racquet & Sports Club Association New Territories West Cluster Rehabilitation Center Nutrition Dimension Onlife Health, Inc. PALS for Life Post Rehabilitative Solutions, Inc. Real Balance Global Wellness Services LLC Real Ryder International Road Runners Club of America Rose Center for Health & Sport Science/Rose Hospital Sports Cardiovascular, and Wellness Nutrition Sports Nutrition Workshop Sports Science Insights, LLC St. John Hospital St. Louis Association of Cardiovascular and Pulmonary Rehabilitation St. Vincent Bariatric Center for Excellence Technogym The National Association of Health and Fitness (NAHF) Totally Coached TRIFEST events Under ArmourYCombine 360 Utah Council for Worksite Health Promotion Wellcoaches Wellness Council of the Midlands Women’s Health Foundation Yoga Tune Up Z-Health Performance Solutions
52
www.dswfitness.com www.diabetestrainingcamp.com www.discoverstrength.com www.efslibrary.net www.eggnutritioncenter.org www.elementsinmotion.org www.eifitness.com www.exerciseetc.com www.esaindiaonline.com www.fitnessednet.com www.fitnesslearningsystems.com www.FocusNYC.com www.gssiweb.com www.anatomyonlineeducation.com www.geisinger.org www.grayinstitute.com www.silversneakers.com www.HPCareer.net www.healthprofileinstitute.com www.hkeducationcenter.com www.ideafit.com www.innovativewellnessed.com www.acsm-iawhp.org www.icaa.cc www.sportsnutritionsociety.org www.jafanet.jp www.medicalfitness.org www.bootcampalliance.com No Web site www.ncpad.org www.nirsa.org www.nspapph.org www.nationalwellness.org www.nehrsa.org No Web site www.NutritionDimension.com www.onlifehealth.com No Web site No Web site www.realbalance.com www.realryder.com www.rrca.org/ www.rosechss.com www.scandpg.org www.sportsnutritionworkshop.com www.sportsscienceinsights.com www.stjohn.org No Web site www.stvincent.org/ourservices/bariatrics www.technogym.com www.physicalfitness.org www.totallycoached.com www.trifest.com www.imgacademies.com www.health.utah.gov/worksitewellness www.wellcoach.com www.wellnesscouncil.org www.womenshealthfoundation.org www.yogatuneup.com www.zhealth.net
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Events Calendar Wellcoaches Workshop A Medical Fitness Association Partner DATE/TIME: November 29, 2011, 9 a.m. to 5 p.m. LOCATION: Orange County Convention Center, Orlando, FL CONTACT: Web site: www.wellcoaches.com
20th Medical Fitness Association Medical Fitness and Health Care Conference In Conjunction with the Athletic Business Conference & Expo Register Today! DATE/TIME: November 30 to December 3, 2011 LOCATION: Orange County Convention Center, Orlando, FL CONTACT: Web site: www.medicalfitness.org
Brought to you by the
Medical Fitness Association www.medicalfitness.org
Educational Teleconference Orthopedica in Young Adults DATE/TIME: April 19, 2012, 2 p.m. (Eastern) CONTACT:
[email protected] CREDIT: CECs available.
Educational Teleconference Generating Revenue Through Personal Training and Personal Training Programming DATE/TIME: May 17, 2012, 2 p.m. (Eastern) PRESENTER: Kathy Kelly DeBlasio, M.A., ATC CONTACT:
[email protected] CREDIT: CECs available.
Educational Teleconference Creating Winning Special Events That Will Capture New Members DATE/TIME: February 16, 2012, 2 p.m. (Eastern) PRESENTER: Belinda Wiggins CONTACT:
[email protected] CREDIT: CECs available.
ABOUT THE MEDICAL FITNESS ASSOCIATION The Medical Fitness Association, a nonprofit organization founded in 1991, is the only organization dedicated to comprehensive care as the prescription for better health. The Medical Fitness Association serves facilities and professionals who are committed to promoting the benefits of health and fitness programs on lifestyle-related disease and making medical fitness programs and services available within their community. As a professional membership association, The Medical Fitness Association provides industry standards, educational programs, benchmarks, professional development, and networking opportunities to its members. To learn more about the Medical Fitness Association, please visit www.medicalfitness.org, or contact Ken Germano, executive director, at 804Y897Y5701 or
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53
Take Ten
Brought to you by the
American College of Sports Medicine www.acsm.org
by James A. Peterson, Ph.D., FACSM
Health/Medical Problems No One Wants to Receive as a Holiday Gift Hypertrichosis. Abnormal hair density and length.
6.
Gingivitis. Inflammation of the gums. An early stage
Hyperhydrosis. Overactive sweat glands. Although almost
7.
all people sweat, when, where, and how much can vary from person to person. Unfortunately, excessive perspiring can lead, in some instances, to an abnormal change in body odor. More often than not, certain steps can be undertaken to help prevent such an unwanted assault on the public_s olfactory senses, including bathing regularly, wearing clean clothes, using antiperspirants, and avoiding foods with strong odors (e.g., garlic, onions).
8.
burping are natural human conditions. It is normal, for example, for a person to Brelease air[ 6 to 20 times a day, an action that occasionally can be embarrassing or annoying. Individuals who want to reduce the number of times that they belch or burp can help themselves in that regard by watching what they eat or drink. Bromhidrosis. Foot odor. The stench that sometimes
9.
Halitosis. Bad breath. The extent of the unpleasant odors
5.
experiencing pain when urinating may be felt either right at the point the urine leaves the body or inside the body (behind the pubic bone or in the bladder or prostate). More often than not, painful urination is caused by a urinary tract infection (particularly in women) or by urethritis and certain conditions of the prostate (in men). The form of treatment for this problem depends on what is causing the pain. Paronychia. Nail infection. The most common symp-
affects human feet is typically the result of sweat and bacteria that are trapped inside of enclosed toe shoes. As such, a host of steps can help prevent the occurrence of foot odor, including washing the feet regularly, wearing shoes made from breathable material, wearing socks that fit and are made of 100% cotton and changing them regularly, and using foot powders. that accompany the breath of some individuals tends to vary, depending on the source or the underlying cause of the bad breath. Although a chronic cause of bad breath is poor oral hygiene, a number of other factors also can lead to this loathsome condition, including periodontal gum disease, postnasal drip, and dry mouth. Among the activities that can help prevent halitosis are better oral hygiene (brushing, flossing, and mouthwash), avoiding certain foods, and targeted dental treatments.
of a more serious form of gum disease (periodontitis), gingivitis is characterized by red and swollen gums that often bleed when the teeth are being brushed. If left untreated, this condition can lead to gum infection and, in more serious cases, tooth loss. The primary cause of gingivitis is poor oral hygiene. Dysuria. Painful urination. A fairly common problem,
Eructation. Belching or burping. In reality, belching and
3. 4.
Individuals of different ethnic backgrounds, ages, and sex often exhibit substantial differences in hair growth patterns on their bodies. What is normal for one person may be considered abnormal for another. On the other hand, the existence of excessive body hair can be both embarrassing and troubling for individuals who believe it disfigures their appearance.
10.
toms of this problem are swelling, redness, the accumulation of pus under the skin (i.e., an abscess has formed), and tenderness and pain upon touching. As a rule, a paronychia is caused either by bacteria entering the skin around a nail that has been damaged by trauma or by fungus. Furuncle. A skin infection involving an entire hair follicle and adjacent skin tissue, also known as a boil. Starting in a hair follicle or oil gland, a boil initially entails the skin turning red in the area of the infection. Subsequently, it may feel somewhat like a cyst or a water-filled lump. As a rule, self-care treatment of boils involves applying a warm compress to them and then soaking them in warm water. When the boil starts to drain, it should be washed with an antibacterial soap. If the boil doesn_t heal, a physician should be consulted.
James A. Peterson, Ph.D., FACSM, is a freelance writer and consultant in sports medicine. From 1990 until 1995, Dr. Peterson was director of sports medicine with StairMaster. Until that time, he was professor of physical education at the United States Military Academy. C 2011 by the American College of Sports Medicine. Reprint permission is granted to subscribers of ACSM’s Health & Fitness Journal A.
54
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(cut, copy, and distribute to students, clients, patients)
1. 2.
Borborygmi. Tummy sounds. Like it or not, almost everyone_s stomach will growl or gurgle on occasion, some more often than others, some more loudly than others. As a rule, such noises are caused by the human digestive process in which food is propelled through the digestive system via a series of muscular and intestinal contractions. On the other hand, this generally unwanted symphony of belly sounds can occur at anytime V whether the stomach is full.
Index 2011 Author Index
Geithner, C.A., (15:3, p.19)
Pate, R.R., (15:1, p.7)
Gillespie, H., (15:6, p.46)
Patton, R.W., (15:3, p.15)
Glazer, J., (15:4, p.47)
Perez, K.S., (15:3, p.8)
Glynn, J., (15:5, p.45)
Abbott, A.A., (15:3, p.38), (15:5, p.40)
Peterson, J.A., (15:1, p.50), (15:2, p.56), (15:3, p.54), (15:4, p.58), (15:5, p.57), (15:6, p.56)
Going, S.B., (15:5, p.8), (15:6, p.25)
Abildson, C.G., (15:5, p.21)
Golesh, A., (15:4, p.35)
Pronk, N.P., (15:1, p.13), (15:1, p.41), (15:3, p.43), (15:5, p.48)
Bailey, S.P., (15:1, p.20)
Greenleaf, C., (15:3, p.15)
Reed, B.L., (15:3, p.29)
Henning, N., (15:3, p.29)
Reeves, J., (15:5, p.8)
Bauman, A., (15:5, p.21) Bayles, M.P., (15:2, p.40), (15:4, p.42) Benson, G.A., (15:1, p.13) Bond, D.S., (15:2, p.8) Bourque, W., (15:3, p.41)
Hill, J.O., (15:2, p.8) Holbrook, K., (15:1 p.38) Houtkooper, L., (15:5, p.8)
Reger-Nash, B., (15:5, p.21) Riddick, V., (15:4, p.35) Riebe, D.A., (15:6, p.41) Roy, B., (15:2, p.26)
Bracko, M.R., (15:1, p.30), (15:3, p.34), (15:5, p.35)
Howley, E.T., (15:1, p.1), (15:2, p.1), (15:3, p.1), (15:4, p.1), (15:5, p.1), (15:6, p.1)
Bushman, B.A., (15:5, p.5), (15:6, p.5)
Jackson, A., (15:3, p.15)
Saunders, R.P., (15:1, p.7)
Byrd, N., (15:1, p.26)
Jones, D.L., (15:6, p.32)
Scharpf, J.A., (15:3, p.19)
Cecil, B., (15:3, p.29)
Katz, A.S., (15:1, p.13)
Schlicht, J., (15:2, p.31)
Cheng, N., (15:5, p.45)
Kennedy-Armbruster, C., (15:4, p.18)
Shook, R.P., (15:4, p.5)
Craig, C.L., (15:5, p.21)
Kolovou, T.A., (15:4, p.24)
Smith, B.J., (15:5, p.21)
Cress, M.E., (15:2, p.20)
Kravitz, L., (15:6, p.19)
Thomas, J.G., (15:2, p.8)
deJong, A., (15:2, p.43), (15:4, p.44), (15:6, p.43)
Lee, V., (15:6, p.25)
Thompson, D.L., (15:1, p.4), (15:2, p.5), (15:3, p.4), (15:4, p.4), (15:5, p.4), (15:6, p.4)
Delistraty, J., (15:3, p.19)
Lewis, R.D., (15:2, p.20)
Dowda, M., (15:1, p.7)
Leyden, K.M., (15:5, p.21)
Eickhoff-Shemek, J.M., (15:1 p.34)
Marquette, D., (15:4, p.18)
Farrell, V.A., (15:5, p.8)
Marr, T.J., (15:1, p.13)
Volpe, S.L., (15:1 p.32), (15:3, p.36), (15:5, p.37)
Fink, B., (15:4, p.35)
McGuire, A., (15:3, p.15)
Wadsworth, L.T., (15:2, p.46)
Flatt, W., (15:2, p.20)
Milliken, L.A., (15:2, p.13)
Warren, B.A., (15:4, p.29)
Fransen, J.C., (15:6, p.19)
Nadal, M.A., (15:5, p.28)
Whiteley, J.A., (15:2, p.13)
Gallagher, J., (15:2, p.26)
Nieman, D.C., (15:1, p.5), (15:2, p.6)
Williams, A., (15:4, p.18)
Gallo, P.M., (15:4, p.8)
O’Neill, J.R., (15:1, p.7)
Williams, M.H., (15:5, p.17)
Garber, C.E., (15:3, p.8), (15:4, p.8)
Olsen, K.D., (15:4, p.29)
Wing, R.R., (15:2, p.8)
2011 Subject Index
aerobic exercise: for fitness in children, (15:3, p. 35); improves overall bone mineral density (BMD) in elderly people, (15:2, p. 23); for people with type 1 and type 2 diabetes, (15:2, p. 5)
MedicineA, (15:3, p. 2); certifications; examination 2011, (15:2, p. 40Y42); in human health behavior change, (15:4, p. 42Y43); Certified Personal Trainer (CPT), (15:2, p. 40Y41); Clinical Exercise SpecialistSM (CES), (15:2, p. 41); common communication errors, (15:2, p. 56); Complete Guide to Fitness & Health, (15:4, p. 2); events calendar, (15:1, p. 47Y48), (15:2, p. 52Y53), (15:3, p. 49Y50), (15:4, p. 53Y54), (15:5, p. 54Y55), (15:6, p. 51Y52); Health Fitness SpecialistSM (HFS), (15:2, p. 41); Health & Fitness Summit & Exposition, 2011, (15:1, p. 2), (15:2, p. 2); Health & Fitness Summit & Exposition, 2012, (15:4, p. 2), (15:5, p. 2), (15:6, p. 2); journals on Facebook, (15:6, p. 2); Lawrence A. Golding student health/fitness scholarship winners, 2011, (15:2, p. 3); legal articles published by, (15:1, p. 36); legal aspects of, (15:1, p. 34Y37); physical activity, cognitive function, and academic achievement conference, (15:6, p. 2); registration for health and fitness summit exposition, (15:2, p. 2); Registered Clinical Exercise PhysiologistTM (RCEP), (15:2, p. 41Y42); salary survey results by Clinical Exercise Physiology Association, (15:2, p. 2); training guidelines for muscular conditioning by, (15:2, p. 33Y39); transfer all self-tests to online learning system, (15:6, p. 2); on Twitter, (15:4, p. 2); VISTA Conference to promote cross-disciplinary professional interaction in paralympic sport, (15:2, p. 2)
A abdominal fat: increase in, during menopause, (15:3, p. 9Y10) active transport: interpersonal barriers to, (15:1, p. 8) activities of daily living (ADL): three ways of muscle contraction during, (15:2, p. 34)
after school program: to improve children’s knowledge, attitudes, and behaviors regarding nutrition, gardening and physical activity, (15:4, p. 35Y36) aging: and bone health, (15:2, p. 23Y24), (15:4, p. 39); and financial/economic security, (15:6, p. 37Y38); and hearing, (15:4, p. 40); muscle mass and function with, (15:6, p. 38Y39); and obesity, (15:2, p. 21), (15:4, p. 37Y39); potential role of health and fitness professionals in, (15:4, p. 37); and smoking, (15:4, p. 39Y40); successfully from age 26 to 65 years, (15:6, p. 37Y40); successfully in first quarter of life, (15:4, p. 37Y40); and vision, (15:4, p. 40), (15:6, p. 37); for women, (15:6, p. 39Y40)
activity management: of chronic fatigue syndrome, (15:1, p. 24)
Alzheimer’s disease: physical activity improves cognitive function in elders with, (15:1, p. 5Y6)
acupuncture, (15:2, p. 46Y48)
amenorrhea, (15:3, p. 4)
acute hormonal responses: to resistance training, (15:6, p. 19Y23)
American College of Sports Medicine (ACSM): 2011 Annual Meeting and World Congress on Exercise is
Sanders, M.E., (15:2, p.33), (15:4, p.37), (15:6, p.37)
Thompson, W.R., (15:6, p.9) Toma´s, R., (15:6, p.25) VanWormer, J.J., (15:1, p.13)
ACSM’s HEALTH & FITNESS JOURNALA
1
Index 2011 Subject Index (continued)
core training: and throwing velocity, (15:5, p. 35) corporate fitness: evolution of, (15:3, p. 41Y42); future environment for, (15:3, p. 42); health and wellness programs in 1980s, (15:3, p. 41); worksite fitness centers in 2000, (15:3, p. 42); worksite wellness programs in 1990s, (15:3, p. 41Y42)
D A (continued) athletes: glycemic index and performance of, (15:1, p. 32Y33); loss of bone mineral density in, (15:3, p. 4); low-energy availability in female, (15:3, p. 4); menstrual cycle dysfunction in, (15:3, p. 4) athletic heart: vs. hyperthropic cardiomyopathy, (15:4, p. 44Y45) autism spectrum disorder (ASD), (15:3, p. 54)
B barefoot running, (15:5, p. 35) behavioral client-centered approach to weight loss, (15:2, p. 13Y14) biomechanics: of inclined treadmill walking in obese adults, (15:4, p. 2) blood pressure: yoga in reducing, (15:1, p. 4)
daily activities level: monitoring use of pedometers, (15:4, p. 4) diabetes: benefits of exercise, (15:2, p. 5); exercise and, (15:6, p. 7Y8); long-term weight management in individuals with, (15:1, p. 15Y18); nutritional focus on management of, (15:6, p. 6Y7); type 1 vs. type 2 diabetes, (15:6, p. 5Y6) 2010 Dietary Guidelines for Americans: and dietary approaches to stop hypertension (DASH) diet, (15:5, p. 37); goals of, (15:5, p. 37); and Mediterranean diet, (15:5, p. 37Y38); nutritional updates in, (15:5, p. 5Y7); providing nutritional information, (15:5, p. 37Y39); for public, (15:5, p. 37); U.S. Department of Agriculture (USDA), (15:5, p. 37Y39)
F fad: difference between trend and, (15:6, p. 9Y18) female athlete triad: definition of, (15:3, p. 4); loss of bone mineral density, (15:3, p. 4); low-energy availability of, (15:3, p. 4); menstrual cycle dysfunction due to, (15:3, p. 4) financial benchmark: membership attrition or retention, (15:1, p. 27); membership growth rate, (15:1, p. 27); nondues revenue, (15:1, p. 28); productivity measure per hour, (15:1, p. 27Y28); revenue growth rate, (15:1, p. 27); revenue per membership, (15:1, p. 27); revenue per square foot, (15:1, p. 27); Southeastern Hospital Health and Fitness Alliance (SEHFA), (15:1, p. 26Y29) fitness: some of the important factors in maintaining, (15:6, p. 4); trends for 2012, (15:6, p. 9Y18) fitness equipment: considerations for selection of, (15:3, p. 17Y18); sex differences in use of, (15:3, p. 15Y18); use of cardiovascular equipment data, (15:3, p. 16); use of strength equipment data, (15:3, p. 16Y17) fitness facility orientation: legal aspects of, (15:3, p. 38Y40)
dietary intake: of public school vs. home school children, (15:1, p. 30)
fitness industry: facility orientation classes in, (15:3, p. 38Y40); legal aspects of, (15:3, p. 38Y40)
dietary supplement: quercetin as, (15:5, p. 17Y20)
fitness professionals/educators: teaching business practices to, (15:4, p. 18Y23); working together with fitness equipment manufacturers innovatively, (15:4, p. 18Y23)
dog walking, (15:3, p. 36Y37)
body mass index (BMI): effects and tilt angle on activity monitor output, (15:3, p. 2)
editorials, (15:1, p. 1), (15:2, p. 1), (15:3, p. 1), (15:4, p. 1), (15:5, p. 1), (15:6, p. 1)
flavonoids: on exercise-induced inflammation, (15:2, p. 7); influence on exercise performance, (15:2, p. 7); protection from stress of hard workout, (15:2, p. 6Y7); subgroups and food sources of, (15:2, p. 6)
bone health: associated with aging, (15:2, p. 23Y24)
electric bikes: as a new active transportation modality to promote health, (15:6, p. 2)
flexibility exercises: for muscular conditioning, (15:2, p. 33Y39); for postmenopausal women, (15:3, p. 12)
bone mineral density (BMD): loss of, in athletes with female athlete triad, (15:3, p. 4); reduction in, during menopause, (15:3, p. 10) brain: exercise improves function of, (15:1, p. 5Y6)
E
employee wellness: five best practices for, (15:1, p. 38Y40); future evolution of, (15:5, p. 45Y47); at Mayo Clinic, (15:4, p. 29Y34) energetics: of inclined treadmill walking in obese adults, (15:4, p. 2)
C cardiopulmonary exercise (CPX) testing: current and emerging clinical applications of, (15:2, p. 44); gas exchange physiology in, (15:2, p. 43); opportunities for clinical exercise professional in, (15:2, p. 44Y45); reasons for underuse of, (15:2, p. 43); variables and clinical indications of, (15:2, p. 43Y44) cardiopulmonary gas exchange, (15:2, p. 44), p. 43 cardiovascular disease: risk of, during menopause, (15:3, p. 10) cardiovascular fitness: equipment use for, (15:3, p. 16) certified personal trainer (CPT), (15:2, p. 40Y41) chronic fatigue syndrome (CFS): activity management of, (15:1, p. 24); Centers for Disease Control and Prevention (CDC) report on, (15:1, p. 20Y21); diagnostic criteria for, (15:1, p. 21); exercise training for treatment of, (15:1, p. 20Y24); typical treatments, (15:1, p. 21Y22) circuit training: in body weight reduction, (15:1, p. 31) Clinical Exercise SpecialistSM (CES), (15:2, p. 41) cognitive behavioral therapy: for chronic fatigue syndrome, (15:1, p. 21) cognitive function: physical activity in elders improves, (15:1, p. 5Y6) communication model: role of listener in, (15:4, p. 24Y28) community-level physical activity campaign: five phases of effective, (15:5, p. 21Y27) continuing education (CEC) self-test, (15:1, p. 44Y46), (15:2, p. 49Y51), (15:3, p. 46Y48), (15:4, p. 50Y52), (15:5, p. 51Y53), (15:6, p. 48Y50)
energy expenditure: effects of vigorous cycling bout on postexercise, (15:5, p. 2) exercise: See also physical activity; acute hormonal responses to resistance exercise training, (15:6, p. 19Y23); barefoot running, (15:5, p. 35); benefits to quality of life and mental health during menopause, (15:3, p. 10); before breakfast, (15:5, p. 35Y36); circuit training, (15:1, p. 31); core training and throwing velocity, (15:5, p. 35); and diabetes, (15:2, p 5), (15:6, p. 7Y8); effects of vigorous cycling bout on postexercise energy expenditure, (15:5, p. 2); energetics and biomechanics of inclined treadmill walking in obese adults, (15:4, p. 2); evidence for prevention of weight gain through, (15:3, p. 36); improved brain function during, (15:1, p. 5Y6); induced muscle injury during mountain walking, trekking poles reduce, (15:1, p. 2); influence of flavonoids on performance of, (15:2, p. 7); influence on menopausal symptoms, (15:3, p. 11); interval training for heart disease patients, (15:5, p. 35); maximal aerobic power measurement and use of this measurement in clinical settings, (15:6, p. 43Y45); muscular and flexibility training, (15:2, p. 33Y39); open vs. closed kinetic chain leg, (15:1, p. 30Y31); personal training and litigation insulation, (15:5, p. 40Y44); practical strength training for adults with disabilities, (15:2, p. 31Y32); quercetin supplement and recovery from intense, (15:5, p. 17Y20); shoulder lift, (15:2, p. 35); shoulder overhead press, (15:2, p. 36); sports bra design for, (15:1, p. 30); traditional vs. HIIT, (15:3, p. 34); treatment for chronic fatigue syndrome, (15:1, p. 20Y24); and type 2 diabetes, (15:1, p. 2); use of vibration exercise in clinical populations, (15:6, p. 25Y30); ways to motivate people to, (15:3, p. 36) Exercise is MedicineA: 2011 Annual Meeting and World Congress on, (15:3, p. 2); Web site for, (15:3, p. 2)
G gardening: children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36) glycemic index: and athletic performance, (15:1, p. 32Y33); factors affecting, (15:1, p. 32); low, medium, and high foods, (15:1, p. 32); measurement of, (15:1, p. 32)
H hatha yoga, (15:1, p. 4) health and fitness industry: worldwide trends in the commercial, corporate, clinical, and community, (15:6, p. 9Y18) health and fitness profession: fight against quackery in, (15:4, p. 5Y7) health care: integrating health and, (15:4, p. 29Y34) health care executives: eating right program for, (15:3, p. 30); HealthPark fitness program for, (15:3, p. 29Y33); physical activity for, (15:3, p. 30); wellness education for, (15:3, p. 29) health/fitness professionals: academic training programs for, (15:3, p. 19Y28); comparisons of two programs for educating and training, (15:3, p. 21); development and implementation of experiential learning programs in, (15:3, p. 22Y26); health care reform during tight money markets, (15:5, p 28Y34); implementation of education and training in, (15:3, p. 22Y26); to provide exercise counseling for Parkinson’s disease, (15:4, p. 8Y15); ten ways health/fitness professionals can continue to learn, (15:5, p. 58); ways to establish a track record for being truthful, (15:4, p. 58); working together with fitness equipment manufacturers innovatively, (15:4, p. 18Y23) Health Fitness SpecialistSM (HFS), (15:2, p. 41) health/medical problems, (15:6, p. 56)
exercise science profession: CCRB to identify strategies in advancing the career of, (15:6, p. 46Y47)
health-related New Year’s resolutions, (15:1, p. 52)
exercise testing: for cardiovascular and pulmonary disorders, (15:2, p. 43Y45)
heatstroke: symptoms, cause, diagnosis and treatment of, (15:4, p. 47Y49)
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Index 2011 Subject Index (continued) H (continued) high-intensity interval training (HIIT): for cardiorespiratory fitness, (15:3, p. 34); effectiveness of, (15:3, p. 34); vs. traditional exercise, (15:3, p. 34) home exercise, (15:5, p. 4) hyperthropic cardiomyopathy: vs. athletic heart, (15:4, p. 44Y45)
I interactive learning model: components necessary to build an, (15:4, p. 18Y23) interval training: for heart disease patients, (15:5, p. 35)
K kinetic chain exercises: open vs. closed, (15:1, p. 30Y31)
L 2011 Lawrence A. Golding Student Scholarship Winners, (15:2, p. 3) leg exercises: open vs. closed kinetic chain, (15:1, p. 30Y31) listening response: in day-to-day communication situations, (15:4, p. 24Y28)
M maximal aerobic power: associated with increased cardiovascular disease and all-cause mortality, (15:6, p. 44); in clinical populations, (15:6, p. 44Y45); factors affecting, (15:6, p. 43Y44) Mayo Clinic: integrating health and health care at, (15:4, p. 29Y34) Medical Fitness Association (MFA): 3-day program by, (15:1, p. 3); DiNubile and Peeke Headline MFA Annual Conference, (15:4, p. 3); events calendar, (15:1, p. 49), (15:2, p. 54), (15:3, p. 51), (15:4, p. 55), (15:5, p. 56), (15:6, p. 53); facility certification for medical fitness industry, (15:4, p. 3); history of, (15:2, p. 27Y28); launch of new Web site, (15:6, p. 3); Medical Fitness Week, 2011, winners, (15:2, p. 4), (15:6, p. 3); new executive director of, (15:3, p. 3); origin of, (15:2, p. 26); presidents of, (15:2, p. 28); 2010 professional recognition awards, (15:1, p. 3), (15:2, p. 4); program innovation award winners, (15:2, p. 4); purpose of, (15:2, p. 28); regional Rising Star Awards program by, (15:1, p. 3); significant events, (15:2, p. 29); Stepping Out winners, (15:6, p. 3); 20th Anniversary Annual MFA conference, 2011, (15:5, p. 3); 20th anniversary celebration of, (15:2, p. 26Y30); 17th Annual Conference, 2011, (15:3, p. 3); registration, (15:4, p. 3); 17th Annual Medical Fitness and Health Care Conference, (15:2, p. 4); Third Annual Medical Fitness Institute, (15:1, p. 3), (15:2, p. 4), (15:3, p. 3); Web site of, (15:1, p. 3) medical fitness centers: clinical integration efforts between physicians/clinicians and, (15:6, p. 32Y36); difference from other commercial and institutional counterparts, (15:2, p. 28Y29); financial benchmarks of, (15:1, p. 26Y29); health care reform during tight money markets, (15:5, p. 28Y34); membership attrition or retention, (15:1, p. 27); membership growth rate, (15:1, p. 27); nondues revenue, (15:1, p. 28); origin of, (15:2, p. 26); percent people costs, (15:1, p. 27); productivity measure, (15:1, p. 27Y28); revenue growth rate, (15:1, p. 27); revenue per square foot, measurement of, (15:1, p. 27) Medical Fitness Institute (MFI), (15:1, p. 3)
menopausal transition (MT): common signs and symptoms associated with, (15:3, p. 8Y13); exercise prescription for, (15:3, p. 8Y13); exercise program design considerations, (15:3, p. 11Y12); group exercise settings for women during, (15:3, p. 12); health effects of, (15:3, p. 9Y10); influence of exercise on, (15:3, p. 11) menopause: ACSM’s Action Plan for, (15:3, p. 12); benefits of exercise on quality of life and mental health during, (15:3, p. 10); benefits of flexibility exercise during, (15:3, p. 12); benefits of neuromotor exercise during, (15:3, p. 12); cardiorespiratory exercise during, (15:3, p. 11Y12); definition related to, (15:3, p. 8Y9); exercise prescription for women at the age of, (15:3, p. 8Y13); increase in abdominal fat during, (15:3, p. 9Y10); reduction in bone mineral density during, (15:3, p. 10); resistance exercise during, (15:3, p. 12); risk of cardiovascular disease at the time of, (15:3, p. 10); social factors affecting, (15:3, p. 10Y11); symptoms associated with, (15:3, p. 9); weight gain during, (15:3, p. 9)
contribute to heart disease in women, (15:3, p. 10); institutional factors as barriers to, (15:1, p. 8); intrapersonal and interpersonal barriers to active transport, (15:1, p. 8); and nutritional practices to combat the rising prevalence of childhood obesity, (15:5, p. 8Y15); overcoming barriers to, (15:1, p. 7Y11); oxygen uptake during, (15:2, p. 43); physical environment for, (15:1, p. 8); practical strength training for adults with disabilities, (15:2, p. 31Y32); of public school vs. home school children, (15:1, p. 30); QOL in women at menopause, (15:3, p. 10); strategies to assess needs, plan, implement, and evaluate physical activity campaign in their community, (15:5, p. 21Y27); structured and free-time, (15:1, p. 8Y11) physical education: barriers to school-based physical activity, (15:1, p. 9Y11) Project Matrix: assignment and outcomes of, (15:4, p. 18Y23) psychological well-being: yoga increases, (15:1, p. 4)
menstrual cycle dysfunction: in female athletes, (15:3, p. 4) muscle injury: during mountain walking, trekking poles reduce exercise induced, (15:1, p. 2) muscle training and flexibility exercise, (15:2, p. 33Y39) musculoskeletal fitness: yoga improves, (15:1, p. 4)
N National Weight Control Registry (NWCR): weight loss methods in, (15:2, p. 9Y10); weight maintenance methods in, (15:2, p. 10Y11) neuromotor exercise: for women at the age of menopause, (15:3, p. 12) nonsteroidal anti-inflammatory drugs: general risks of prophylactic, acute, and long-term use of, (15:6, p. 46Y47) nutrient density: important for weight loss, (15:5, p. 6Y7) nutrition: children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36); and physical activity practices to combat the rising prevalence of childhood obesity, (15:5, p. 8Y15); updates in 2010 Dietary Guidelines for Americans, (15:5, p. 5Y7); 2010 USDA Dietary Guidelines for Americans provides nutritional information, (15:5, p. 37Y39)
O obesity, (15:2, p. 13); energetics and biomechanics of inclined treadmill walking in adults, (15:4, p. 2); nutrition and physical activity to combat the rising prevalence in childhood, (15:5, p. 8Y15) oligomenorrhea, (15:3, p. 4)
P paralympic sport, VISTA Conference on, (15:2, p. 2) Parkinson’s disease: cardiorespiratory exercise training for, (15:4, p. 11Y12); diagnosis of, (15:4, p. 9); flexibility exercise training for, (15:4, p. 13); general considerations for exercise training in persons with, (15:4, p. 10Y11); neuromotor exercise/functional fitness training for, (15:4, p. 13Y15); outcomes of exercise training in, (15:4, p. 15); physical activity and exercise for, (15:4, p. 9Y10); resistance training for, (15:4, p. 12Y13); symptoms, (15:4, p. 8Y9); treatment of, (15:4, p. 9) pedometers: daily activities level monitoring using, (15:4, p. 4) personal training: litigation insulation against, (15:5, p. 40Y44) physical activity. see also exercise; active video games for improving the, (15:3, p. 34Y35); barriers to school-based, (15:1, p. 9Y11); barriers to utilitarian, (15:1, p. 8); CEC self-test, (15:1, p. 44); children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36); dog walking for improved, (15:3, p. 36Y37); in elders improves cognitive function, (15:1, p. 5Y6); electric bikes as a new active transportation modality to promote health, (15:6, p. 2); guidelines for Americans, (15:1, p. 7Y8); guidelines for health enhancing, (15:1, p. 41Y42); improved cognitive performance during, (15:1, p. 5Y6); improves the risk factors that
Q quackery: fight against, (15:4, p. 5Y7) quality of life: of chronic fatigue syndrome after excersice, (15:1, p. 23); by physical activity in women at menopause, (15:3, p. 10) quercetin: and performance enhancement, (15:5, p. 18Y19); and recovery from intense exercise, (15:5, p. 18); as sports supplement, (15:5, p. 17Y20)
R recognitions: Lawrence A. Golding Scholarship award, (15:2, p. 3), (15:5, p. 2); Rising Star Awards winners, (15:1, p. 3), (15:5, p. 3) Registered Clinical Exercise PhysiologistTM (RCEP), (15:2, p. 41Y42) resistance training exercise: acute hormonal responses to, (15:6, p. 19Y23); for elderly people, (15:2, p. 22); during menopause, (15:3, p. 12); motivation for, (15:3, p. 34) respiratory exchange ratio (RER), (15:2, p. 43Y44)
S sedentary behavior: breaks and metabolic biomarkers, (15:1, p. 42); health hazards of, (15:1, p. 41); ideas for reducing sitting time among employees, (15:1, p. 42Y43); and workplace productivity, (15:1, p. 42) sports nutrition: glycemic index and athletic performance, (15:1, p. 32Y33) sports supplement. see quercetin stages of reproductive aging (STRAW), (15:3, p. 9) strength training: for adults with disabilities, (15:2, p. 31Y32); for elderly people, (15:2, p. 22) student health/fitness scholarship winners, 2011, (15:2, p. 3)
T telephone-based coaching: on body mass index (BMI), (15:1, p. 13); health-coaching topics for weight loss surgery, (15:1, p. 15); HLHW bariatric surgery support program, (15:1, p. 18); program design, (15:1, p. 14); on total caloric intake, (15:1, p. 13); for weight loss surgery, (15:1, p. 13Y18) trekking poles: reduces exercise induced muscle injury during mountain walking, (15:1, p. 2) trend: difference between fad and, (15:6, p. 9Y18) type 2 diabetes: exercise and, (15:1, p. 2), (15:2, p. 5)
V ventilatory threshold (VT), (15:2, p. 43) vibration exercise: characterization of, (15:6, p. 26); in clinical populations, (15:6, p. 25Y30); contraindications for,
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Index 2011 Subject Index (continued) V (continued) (15:6, p. 27); guidelines for, (15:6, p. 29); how vibration exercise works, (15:6, p. 26Y27); implications for practice, (15:6, p. 29Y30); and medical conditions, (15:6, p. 29); study in different joint and musculoskeletal conditions, (15:6, p. 28Y29); study in patients with central nervous system disorders, (15:6, p. 27Y28) VISTA conference, (15:2, p. 2)
W weight loss: behavioral client-centered approach to, (15:2, p. 13Y14); behavioral strategies, (15:2, p. 17Y18); brainstorming worksheet, (15:2, p. 16); decisional balance sheet, (15:2, p. 16); directive vs. client-centered approach to, (15:2, p. 14); individual vs. family-friendly behavioral strategies for, (15:2, p. 17); motivations for, (15:2, p. 9); role of family in, (15:2, p. 13Y18) weight loss maintenance: characteristics of, (15:2, p. 9); habits of weight loss maintainers, (15:2, p. 10); weight loss methods in NWCR, (15:2, p. 9Y11) weight loss surgery: bariatric surgery, (15:1, p. 13Y14); biliopancreatic diversion, (15:1, p. 13); enrollment and participant characteristics, (15:1, p. 16); impact on patients with diabetes, (15:1, p. 17); in individuals with diabetes mellitus, (15:1, p. 15Y16); malabsorptive procedures, (15:1, p. 13); practice-based program evaluation for, (15:1, p. 13Y18); Roux-en-Y gastric bypass, (15:1, p. 13);
telephone-based support for, (15:1, p. 13Y18); three types of, (15:1, p. 13) whole body vibration. See vibration exercise worksite health promotion: company policy on; classification of, (15:3, p. 43); corporate smoke-free policy, (15:3, p. 44Y45); design of, (15:3, p. 45); for employee health and wellness, (15:3, p. 43Y44); need for, (15:3, p. 44), p. 43; health hazards of too much sitting, (15:1, p. 41); physically active work breaks, (15:1, p. 42); prolonged sitting and workplace productivity, (15:1, p. 42); reducing sitting time among employees, (15:1, p. 42Y43); WHO healthy workplace model to protect and promote workplace health, (15:5, p. 48Y50)
Y yoga: body positions in, (15:1, p. 4); hatha yoga, (15:1, p. 4); improved flexibility by, (15:1, p. 4); improves mental state, (15:1, p. 4); improves musculoskeletal fitness, (15:1, p. 4); origin of, (15:1, p. 4); reducing blood pressure by, (15:1, p. 4)
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Index 2011 Author Index
Geithner, C.A., (15:3, p.19)
Pate, R.R., (15:1, p.7)
Gillespie, H., (15:6, p.46)
Patton, R.W., (15:3, p.15)
Glazer, J., (15:4, p.47)
Perez, K.S., (15:3, p.8)
Glynn, J., (15:5, p.45)
Abbott, A.A., (15:3, p.38), (15:5, p.40)
Peterson, J.A., (15:1, p.50), (15:2, p.56), (15:3, p.54), (15:4, p.58), (15:5, p.57), (15:6, p.56)
Going, S.B., (15:5, p.8), (15:6, p.25)
Abildson, C.G., (15:5, p.21)
Golesh, A., (15:4, p.35)
Pronk, N.P., (15:1, p.13), (15:1, p.41), (15:3, p.43), (15:5, p.48)
Bailey, S.P., (15:1, p.20)
Greenleaf, C., (15:3, p.15)
Reed, B.L., (15:3, p.29)
Henning, N., (15:3, p.29)
Reeves, J., (15:5, p.8)
Bauman, A., (15:5, p.21) Bayles, M.P., (15:2, p.40), (15:4, p.42) Benson, G.A., (15:1, p.13) Bond, D.S., (15:2, p.8) Bourque, W., (15:3, p.41)
Hill, J.O., (15:2, p.8) Holbrook, K., (15:1 p.38) Houtkooper, L., (15:5, p.8)
Reger-Nash, B., (15:5, p.21) Riddick, V., (15:4, p.35) Riebe, D.A., (15:6, p.41) Roy, B., (15:2, p.26)
Bracko, M.R., (15:1, p.30), (15:3, p.34), (15:5, p.35)
Howley, E.T., (15:1, p.1), (15:2, p.1), (15:3, p.1), (15:4, p.1), (15:5, p.1), (15:6, p.1)
Bushman, B.A., (15:5, p.5), (15:6, p.5)
Jackson, A., (15:3, p.15)
Saunders, R.P., (15:1, p.7)
Byrd, N., (15:1, p.26)
Jones, D.L., (15:6, p.32)
Scharpf, J.A., (15:3, p.19)
Cecil, B., (15:3, p.29)
Katz, A.S., (15:1, p.13)
Schlicht, J., (15:2, p.31)
Cheng, N., (15:5, p.45)
Kennedy-Armbruster, C., (15:4, p.18)
Shook, R.P., (15:4, p.5)
Craig, C.L., (15:5, p.21)
Kolovou, T.A., (15:4, p.24)
Smith, B.J., (15:5, p.21)
Cress, M.E., (15:2, p.20)
Kravitz, L., (15:6, p.19)
Thomas, J.G., (15:2, p.8)
deJong, A., (15:2, p.43), (15:4, p.44), (15:6, p.43)
Lee, V., (15:6, p.25)
Thompson, D.L., (15:1, p.4), (15:2, p.5), (15:3, p.4), (15:4, p.4), (15:5, p.4), (15:6, p.4)
Delistraty, J., (15:3, p.19)
Lewis, R.D., (15:2, p.20)
Dowda, M., (15:1, p.7)
Leyden, K.M., (15:5, p.21)
Eickhoff-Shemek, J.M., (15:1 p.34)
Marquette, D., (15:4, p.18)
Farrell, V.A., (15:5, p.8)
Marr, T.J., (15:1, p.13)
Volpe, S.L., (15:1 p.32), (15:3, p.36), (15:5, p.37)
Fink, B., (15:4, p.35)
McGuire, A., (15:3, p.15)
Wadsworth, L.T., (15:2, p.46)
Flatt, W., (15:2, p.20)
Milliken, L.A., (15:2, p.13)
Warren, B.A., (15:4, p.29)
Fransen, J.C., (15:6, p.19)
Nadal, M.A., (15:5, p.28)
Whiteley, J.A., (15:2, p.13)
Gallagher, J., (15:2, p.26)
Nieman, D.C., (15:1, p.5), (15:2, p.6)
Williams, A., (15:4, p.18)
Gallo, P.M., (15:4, p.8)
O’Neill, J.R., (15:1, p.7)
Williams, M.H., (15:5, p.17)
Garber, C.E., (15:3, p.8), (15:4, p.8)
Olsen, K.D., (15:4, p.29)
Wing, R.R., (15:2, p.8)
2011 Subject Index
aerobic exercise: for fitness in children, (15:3, p. 35); improves overall bone mineral density (BMD) in elderly people, (15:2, p. 23); for people with type 1 and type 2 diabetes, (15:2, p. 5)
MedicineA, (15:3, p. 2); certifications; examination 2011, (15:2, p. 40Y42); in human health behavior change, (15:4, p. 42Y43); Certified Personal Trainer (CPT), (15:2, p. 40Y41); Clinical Exercise SpecialistSM (CES), (15:2, p. 41); common communication errors, (15:2, p. 56); Complete Guide to Fitness & Health, (15:4, p. 2); events calendar, (15:1, p. 47Y48), (15:2, p. 52Y53), (15:3, p. 49Y50), (15:4, p. 53Y54), (15:5, p. 54Y55), (15:6, p. 51Y52); Health Fitness SpecialistSM (HFS), (15:2, p. 41); Health & Fitness Summit & Exposition, 2011, (15:1, p. 2), (15:2, p. 2); Health & Fitness Summit & Exposition, 2012, (15:4, p. 2), (15:5, p. 2), (15:6, p. 2); journals on Facebook, (15:6, p. 2); Lawrence A. Golding student health/fitness scholarship winners, 2011, (15:2, p. 3); legal articles published by, (15:1, p. 36); legal aspects of, (15:1, p. 34Y37); physical activity, cognitive function, and academic achievement conference, (15:6, p. 2); registration for health and fitness summit exposition, (15:2, p. 2); Registered Clinical Exercise PhysiologistTM (RCEP), (15:2, p. 41Y42); salary survey results by Clinical Exercise Physiology Association, (15:2, p. 2); training guidelines for muscular conditioning by, (15:2, p. 33Y39); transfer all self-tests to online learning system, (15:6, p. 2); on Twitter, (15:4, p. 2); VISTA Conference to promote cross-disciplinary professional interaction in paralympic sport, (15:2, p. 2)
A abdominal fat: increase in, during menopause, (15:3, p. 9Y10) active transport: interpersonal barriers to, (15:1, p. 8) activities of daily living (ADL): three ways of muscle contraction during, (15:2, p. 34)
after school program: to improve children’s knowledge, attitudes, and behaviors regarding nutrition, gardening and physical activity, (15:4, p. 35Y36) aging: and bone health, (15:2, p. 23Y24), (15:4, p. 39); and financial/economic security, (15:6, p. 37Y38); and hearing, (15:4, p. 40); muscle mass and function with, (15:6, p. 38Y39); and obesity, (15:2, p. 21), (15:4, p. 37Y39); potential role of health and fitness professionals in, (15:4, p. 37); and smoking, (15:4, p. 39Y40); successfully from age 26 to 65 years, (15:6, p. 37Y40); successfully in first quarter of life, (15:4, p. 37Y40); and vision, (15:4, p. 40), (15:6, p. 37); for women, (15:6, p. 39Y40)
activity management: of chronic fatigue syndrome, (15:1, p. 24)
Alzheimer’s disease: physical activity improves cognitive function in elders with, (15:1, p. 5Y6)
acupuncture, (15:2, p. 46Y48)
amenorrhea, (15:3, p. 4)
acute hormonal responses: to resistance training, (15:6, p. 19Y23)
American College of Sports Medicine (ACSM): 2011 Annual Meeting and World Congress on Exercise is
Sanders, M.E., (15:2, p.33), (15:4, p.37), (15:6, p.37)
Thompson, W.R., (15:6, p.9) Toma´s, R., (15:6, p.25) VanWormer, J.J., (15:1, p.13)
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Index 2011 Subject Index (continued)
core training: and throwing velocity, (15:5, p. 35) corporate fitness: evolution of, (15:3, p. 41Y42); future environment for, (15:3, p. 42); health and wellness programs in 1980s, (15:3, p. 41); worksite fitness centers in 2000, (15:3, p. 42); worksite wellness programs in 1990s, (15:3, p. 41Y42)
D A (continued) athletes: glycemic index and performance of, (15:1, p. 32Y33); loss of bone mineral density in, (15:3, p. 4); low-energy availability in female, (15:3, p. 4); menstrual cycle dysfunction in, (15:3, p. 4) athletic heart: vs. hyperthropic cardiomyopathy, (15:4, p. 44Y45) autism spectrum disorder (ASD), (15:3, p. 54)
B barefoot running, (15:5, p. 35) behavioral client-centered approach to weight loss, (15:2, p. 13Y14) biomechanics: of inclined treadmill walking in obese adults, (15:4, p. 2) blood pressure: yoga in reducing, (15:1, p. 4)
daily activities level: monitoring use of pedometers, (15:4, p. 4) diabetes: benefits of exercise, (15:2, p. 5); exercise and, (15:6, p. 7Y8); long-term weight management in individuals with, (15:1, p. 15Y18); nutritional focus on management of, (15:6, p. 6Y7); type 1 vs. type 2 diabetes, (15:6, p. 5Y6) 2010 Dietary Guidelines for Americans: and dietary approaches to stop hypertension (DASH) diet, (15:5, p. 37); goals of, (15:5, p. 37); and Mediterranean diet, (15:5, p. 37Y38); nutritional updates in, (15:5, p. 5Y7); providing nutritional information, (15:5, p. 37Y39); for public, (15:5, p. 37); U.S. Department of Agriculture (USDA), (15:5, p. 37Y39)
F fad: difference between trend and, (15:6, p. 9Y18) female athlete triad: definition of, (15:3, p. 4); loss of bone mineral density, (15:3, p. 4); low-energy availability of, (15:3, p. 4); menstrual cycle dysfunction due to, (15:3, p. 4) financial benchmark: membership attrition or retention, (15:1, p. 27); membership growth rate, (15:1, p. 27); nondues revenue, (15:1, p. 28); productivity measure per hour, (15:1, p. 27Y28); revenue growth rate, (15:1, p. 27); revenue per membership, (15:1, p. 27); revenue per square foot, (15:1, p. 27); Southeastern Hospital Health and Fitness Alliance (SEHFA), (15:1, p. 26Y29) fitness: some of the important factors in maintaining, (15:6, p. 4); trends for 2012, (15:6, p. 9Y18) fitness equipment: considerations for selection of, (15:3, p. 17Y18); sex differences in use of, (15:3, p. 15Y18); use of cardiovascular equipment data, (15:3, p. 16); use of strength equipment data, (15:3, p. 16Y17) fitness facility orientation: legal aspects of, (15:3, p. 38Y40)
dietary intake: of public school vs. home school children, (15:1, p. 30)
fitness industry: facility orientation classes in, (15:3, p. 38Y40); legal aspects of, (15:3, p. 38Y40)
dietary supplement: quercetin as, (15:5, p. 17Y20)
fitness professionals/educators: teaching business practices to, (15:4, p. 18Y23); working together with fitness equipment manufacturers innovatively, (15:4, p. 18Y23)
dog walking, (15:3, p. 36Y37)
body mass index (BMI): effects and tilt angle on activity monitor output, (15:3, p. 2)
editorials, (15:1, p. 1), (15:2, p. 1), (15:3, p. 1), (15:4, p. 1), (15:5, p. 1), (15:6, p. 1)
flavonoids: on exercise-induced inflammation, (15:2, p. 7); influence on exercise performance, (15:2, p. 7); protection from stress of hard workout, (15:2, p. 6Y7); subgroups and food sources of, (15:2, p. 6)
bone health: associated with aging, (15:2, p. 23Y24)
electric bikes: as a new active transportation modality to promote health, (15:6, p. 2)
flexibility exercises: for muscular conditioning, (15:2, p. 33Y39); for postmenopausal women, (15:3, p. 12)
bone mineral density (BMD): loss of, in athletes with female athlete triad, (15:3, p. 4); reduction in, during menopause, (15:3, p. 10) brain: exercise improves function of, (15:1, p. 5Y6)
E
employee wellness: five best practices for, (15:1, p. 38Y40); future evolution of, (15:5, p. 45Y47); at Mayo Clinic, (15:4, p. 29Y34) energetics: of inclined treadmill walking in obese adults, (15:4, p. 2)
C cardiopulmonary exercise (CPX) testing: current and emerging clinical applications of, (15:2, p. 44); gas exchange physiology in, (15:2, p. 43); opportunities for clinical exercise professional in, (15:2, p. 44Y45); reasons for underuse of, (15:2, p. 43); variables and clinical indications of, (15:2, p. 43Y44) cardiopulmonary gas exchange, (15:2, p. 44), p. 43 cardiovascular disease: risk of, during menopause, (15:3, p. 10) cardiovascular fitness: equipment use for, (15:3, p. 16) certified personal trainer (CPT), (15:2, p. 40Y41) chronic fatigue syndrome (CFS): activity management of, (15:1, p. 24); Centers for Disease Control and Prevention (CDC) report on, (15:1, p. 20Y21); diagnostic criteria for, (15:1, p. 21); exercise training for treatment of, (15:1, p. 20Y24); typical treatments, (15:1, p. 21Y22) circuit training: in body weight reduction, (15:1, p. 31) Clinical Exercise SpecialistSM (CES), (15:2, p. 41) cognitive behavioral therapy: for chronic fatigue syndrome, (15:1, p. 21) cognitive function: physical activity in elders improves, (15:1, p. 5Y6) communication model: role of listener in, (15:4, p. 24Y28) community-level physical activity campaign: five phases of effective, (15:5, p. 21Y27) continuing education (CEC) self-test, (15:1, p. 44Y46), (15:2, p. 49Y51), (15:3, p. 46Y48), (15:4, p. 50Y52), (15:5, p. 51Y53), (15:6, p. 48Y50)
energy expenditure: effects of vigorous cycling bout on postexercise, (15:5, p. 2) exercise: See also physical activity; acute hormonal responses to resistance exercise training, (15:6, p. 19Y23); barefoot running, (15:5, p. 35); benefits to quality of life and mental health during menopause, (15:3, p. 10); before breakfast, (15:5, p. 35Y36); circuit training, (15:1, p. 31); core training and throwing velocity, (15:5, p. 35); and diabetes, (15:2, p 5), (15:6, p. 7Y8); effects of vigorous cycling bout on postexercise energy expenditure, (15:5, p. 2); energetics and biomechanics of inclined treadmill walking in obese adults, (15:4, p. 2); evidence for prevention of weight gain through, (15:3, p. 36); improved brain function during, (15:1, p. 5Y6); induced muscle injury during mountain walking, trekking poles reduce, (15:1, p. 2); influence of flavonoids on performance of, (15:2, p. 7); influence on menopausal symptoms, (15:3, p. 11); interval training for heart disease patients, (15:5, p. 35); maximal aerobic power measurement and use of this measurement in clinical settings, (15:6, p. 43Y45); muscular and flexibility training, (15:2, p. 33Y39); open vs. closed kinetic chain leg, (15:1, p. 30Y31); personal training and litigation insulation, (15:5, p. 40Y44); practical strength training for adults with disabilities, (15:2, p. 31Y32); quercetin supplement and recovery from intense, (15:5, p. 17Y20); shoulder lift, (15:2, p. 35); shoulder overhead press, (15:2, p. 36); sports bra design for, (15:1, p. 30); traditional vs. HIIT, (15:3, p. 34); treatment for chronic fatigue syndrome, (15:1, p. 20Y24); and type 2 diabetes, (15:1, p. 2); use of vibration exercise in clinical populations, (15:6, p. 25Y30); ways to motivate people to, (15:3, p. 36) Exercise is MedicineA: 2011 Annual Meeting and World Congress on, (15:3, p. 2); Web site for, (15:3, p. 2)
G gardening: children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36) glycemic index: and athletic performance, (15:1, p. 32Y33); factors affecting, (15:1, p. 32); low, medium, and high foods, (15:1, p. 32); measurement of, (15:1, p. 32)
H hatha yoga, (15:1, p. 4) health and fitness industry: worldwide trends in the commercial, corporate, clinical, and community, (15:6, p. 9Y18) health and fitness profession: fight against quackery in, (15:4, p. 5Y7) health care: integrating health and, (15:4, p. 29Y34) health care executives: eating right program for, (15:3, p. 30); HealthPark fitness program for, (15:3, p. 29Y33); physical activity for, (15:3, p. 30); wellness education for, (15:3, p. 29) health/fitness professionals: academic training programs for, (15:3, p. 19Y28); comparisons of two programs for educating and training, (15:3, p. 21); development and implementation of experiential learning programs in, (15:3, p. 22Y26); health care reform during tight money markets, (15:5, p 28Y34); implementation of education and training in, (15:3, p. 22Y26); to provide exercise counseling for Parkinson’s disease, (15:4, p. 8Y15); ten ways health/fitness professionals can continue to learn, (15:5, p. 58); ways to establish a track record for being truthful, (15:4, p. 58); working together with fitness equipment manufacturers innovatively, (15:4, p. 18Y23) Health Fitness SpecialistSM (HFS), (15:2, p. 41) health/medical problems, (15:6, p. 56)
exercise science profession: CCRB to identify strategies in advancing the career of, (15:6, p. 46Y47)
health-related New Year’s resolutions, (15:1, p. 52)
exercise testing: for cardiovascular and pulmonary disorders, (15:2, p. 43Y45)
heatstroke: symptoms, cause, diagnosis and treatment of, (15:4, p. 47Y49)
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Index 2011 Subject Index (continued) H (continued) high-intensity interval training (HIIT): for cardiorespiratory fitness, (15:3, p. 34); effectiveness of, (15:3, p. 34); vs. traditional exercise, (15:3, p. 34) home exercise, (15:5, p. 4) hyperthropic cardiomyopathy: vs. athletic heart, (15:4, p. 44Y45)
I interactive learning model: components necessary to build an, (15:4, p. 18Y23) interval training: for heart disease patients, (15:5, p. 35)
K kinetic chain exercises: open vs. closed, (15:1, p. 30Y31)
L 2011 Lawrence A. Golding Student Scholarship Winners, (15:2, p. 3) leg exercises: open vs. closed kinetic chain, (15:1, p. 30Y31) listening response: in day-to-day communication situations, (15:4, p. 24Y28)
M maximal aerobic power: associated with increased cardiovascular disease and all-cause mortality, (15:6, p. 44); in clinical populations, (15:6, p. 44Y45); factors affecting, (15:6, p. 43Y44) Mayo Clinic: integrating health and health care at, (15:4, p. 29Y34) Medical Fitness Association (MFA): 3-day program by, (15:1, p. 3); DiNubile and Peeke Headline MFA Annual Conference, (15:4, p. 3); events calendar, (15:1, p. 49), (15:2, p. 54), (15:3, p. 51), (15:4, p. 55), (15:5, p. 56), (15:6, p. 53); facility certification for medical fitness industry, (15:4, p. 3); history of, (15:2, p. 27Y28); launch of new Web site, (15:6, p. 3); Medical Fitness Week, 2011, winners, (15:2, p. 4), (15:6, p. 3); new executive director of, (15:3, p. 3); origin of, (15:2, p. 26); presidents of, (15:2, p. 28); 2010 professional recognition awards, (15:1, p. 3), (15:2, p. 4); program innovation award winners, (15:2, p. 4); purpose of, (15:2, p. 28); regional Rising Star Awards program by, (15:1, p. 3); significant events, (15:2, p. 29); Stepping Out winners, (15:6, p. 3); 20th Anniversary Annual MFA conference, 2011, (15:5, p. 3); 20th anniversary celebration of, (15:2, p. 26Y30); 17th Annual Conference, 2011, (15:3, p. 3); registration, (15:4, p. 3); 17th Annual Medical Fitness and Health Care Conference, (15:2, p. 4); Third Annual Medical Fitness Institute, (15:1, p. 3), (15:2, p. 4), (15:3, p. 3); Web site of, (15:1, p. 3) medical fitness centers: clinical integration efforts between physicians/clinicians and, (15:6, p. 32Y36); difference from other commercial and institutional counterparts, (15:2, p. 28Y29); financial benchmarks of, (15:1, p. 26Y29); health care reform during tight money markets, (15:5, p. 28Y34); membership attrition or retention, (15:1, p. 27); membership growth rate, (15:1, p. 27); nondues revenue, (15:1, p. 28); origin of, (15:2, p. 26); percent people costs, (15:1, p. 27); productivity measure, (15:1, p. 27Y28); revenue growth rate, (15:1, p. 27); revenue per square foot, measurement of, (15:1, p. 27) Medical Fitness Institute (MFI), (15:1, p. 3)
menopausal transition (MT): common signs and symptoms associated with, (15:3, p. 8Y13); exercise prescription for, (15:3, p. 8Y13); exercise program design considerations, (15:3, p. 11Y12); group exercise settings for women during, (15:3, p. 12); health effects of, (15:3, p. 9Y10); influence of exercise on, (15:3, p. 11) menopause: ACSM’s Action Plan for, (15:3, p. 12); benefits of exercise on quality of life and mental health during, (15:3, p. 10); benefits of flexibility exercise during, (15:3, p. 12); benefits of neuromotor exercise during, (15:3, p. 12); cardiorespiratory exercise during, (15:3, p. 11Y12); definition related to, (15:3, p. 8Y9); exercise prescription for women at the age of, (15:3, p. 8Y13); increase in abdominal fat during, (15:3, p. 9Y10); reduction in bone mineral density during, (15:3, p. 10); resistance exercise during, (15:3, p. 12); risk of cardiovascular disease at the time of, (15:3, p. 10); social factors affecting, (15:3, p. 10Y11); symptoms associated with, (15:3, p. 9); weight gain during, (15:3, p. 9)
contribute to heart disease in women, (15:3, p. 10); institutional factors as barriers to, (15:1, p. 8); intrapersonal and interpersonal barriers to active transport, (15:1, p. 8); and nutritional practices to combat the rising prevalence of childhood obesity, (15:5, p. 8Y15); overcoming barriers to, (15:1, p. 7Y11); oxygen uptake during, (15:2, p. 43); physical environment for, (15:1, p. 8); practical strength training for adults with disabilities, (15:2, p. 31Y32); of public school vs. home school children, (15:1, p. 30); QOL in women at menopause, (15:3, p. 10); strategies to assess needs, plan, implement, and evaluate physical activity campaign in their community, (15:5, p. 21Y27); structured and free-time, (15:1, p. 8Y11) physical education: barriers to school-based physical activity, (15:1, p. 9Y11) Project Matrix: assignment and outcomes of, (15:4, p. 18Y23) psychological well-being: yoga increases, (15:1, p. 4)
menstrual cycle dysfunction: in female athletes, (15:3, p. 4) muscle injury: during mountain walking, trekking poles reduce exercise induced, (15:1, p. 2) muscle training and flexibility exercise, (15:2, p. 33Y39) musculoskeletal fitness: yoga improves, (15:1, p. 4)
N National Weight Control Registry (NWCR): weight loss methods in, (15:2, p. 9Y10); weight maintenance methods in, (15:2, p. 10Y11) neuromotor exercise: for women at the age of menopause, (15:3, p. 12) nonsteroidal anti-inflammatory drugs: general risks of prophylactic, acute, and long-term use of, (15:6, p. 46Y47) nutrient density: important for weight loss, (15:5, p. 6Y7) nutrition: children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36); and physical activity practices to combat the rising prevalence of childhood obesity, (15:5, p. 8Y15); updates in 2010 Dietary Guidelines for Americans, (15:5, p. 5Y7); 2010 USDA Dietary Guidelines for Americans provides nutritional information, (15:5, p. 37Y39)
O obesity, (15:2, p. 13); energetics and biomechanics of inclined treadmill walking in adults, (15:4, p. 2); nutrition and physical activity to combat the rising prevalence in childhood, (15:5, p. 8Y15) oligomenorrhea, (15:3, p. 4)
P paralympic sport, VISTA Conference on, (15:2, p. 2) Parkinson’s disease: cardiorespiratory exercise training for, (15:4, p. 11Y12); diagnosis of, (15:4, p. 9); flexibility exercise training for, (15:4, p. 13); general considerations for exercise training in persons with, (15:4, p. 10Y11); neuromotor exercise/functional fitness training for, (15:4, p. 13Y15); outcomes of exercise training in, (15:4, p. 15); physical activity and exercise for, (15:4, p. 9Y10); resistance training for, (15:4, p. 12Y13); symptoms, (15:4, p. 8Y9); treatment of, (15:4, p. 9) pedometers: daily activities level monitoring using, (15:4, p. 4) personal training: litigation insulation against, (15:5, p. 40Y44) physical activity. see also exercise; active video games for improving the, (15:3, p. 34Y35); barriers to school-based, (15:1, p. 9Y11); barriers to utilitarian, (15:1, p. 8); CEC self-test, (15:1, p. 44); children’s knowledge, attitudes, and behaviors regarding, (15:4, p. 35Y36); dog walking for improved, (15:3, p. 36Y37); in elders improves cognitive function, (15:1, p. 5Y6); electric bikes as a new active transportation modality to promote health, (15:6, p. 2); guidelines for Americans, (15:1, p. 7Y8); guidelines for health enhancing, (15:1, p. 41Y42); improved cognitive performance during, (15:1, p. 5Y6); improves the risk factors that
Q quackery: fight against, (15:4, p. 5Y7) quality of life: of chronic fatigue syndrome after excersice, (15:1, p. 23); by physical activity in women at menopause, (15:3, p. 10) quercetin: and performance enhancement, (15:5, p. 18Y19); and recovery from intense exercise, (15:5, p. 18); as sports supplement, (15:5, p. 17Y20)
R recognitions: Lawrence A. Golding Scholarship award, (15:2, p. 3), (15:5, p. 2); Rising Star Awards winners, (15:1, p. 3), (15:5, p. 3) Registered Clinical Exercise PhysiologistTM (RCEP), (15:2, p. 41Y42) resistance training exercise: acute hormonal responses to, (15:6, p. 19Y23); for elderly people, (15:2, p. 22); during menopause, (15:3, p. 12); motivation for, (15:3, p. 34) respiratory exchange ratio (RER), (15:2, p. 43Y44)
S sedentary behavior: breaks and metabolic biomarkers, (15:1, p. 42); health hazards of, (15:1, p. 41); ideas for reducing sitting time among employees, (15:1, p. 42Y43); and workplace productivity, (15:1, p. 42) sports nutrition: glycemic index and athletic performance, (15:1, p. 32Y33) sports supplement. see quercetin stages of reproductive aging (STRAW), (15:3, p. 9) strength training: for adults with disabilities, (15:2, p. 31Y32); for elderly people, (15:2, p. 22) student health/fitness scholarship winners, 2011, (15:2, p. 3)
T telephone-based coaching: on body mass index (BMI), (15:1, p. 13); health-coaching topics for weight loss surgery, (15:1, p. 15); HLHW bariatric surgery support program, (15:1, p. 18); program design, (15:1, p. 14); on total caloric intake, (15:1, p. 13); for weight loss surgery, (15:1, p. 13Y18) trekking poles: reduces exercise induced muscle injury during mountain walking, (15:1, p. 2) trend: difference between fad and, (15:6, p. 9Y18) type 2 diabetes: exercise and, (15:1, p. 2), (15:2, p. 5)
V ventilatory threshold (VT), (15:2, p. 43) vibration exercise: characterization of, (15:6, p. 26); in clinical populations, (15:6, p. 25Y30); contraindications for,
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Index 2011 Subject Index (continued) V (continued) (15:6, p. 27); guidelines for, (15:6, p. 29); how vibration exercise works, (15:6, p. 26Y27); implications for practice, (15:6, p. 29Y30); and medical conditions, (15:6, p. 29); study in different joint and musculoskeletal conditions, (15:6, p. 28Y29); study in patients with central nervous system disorders, (15:6, p. 27Y28) VISTA conference, (15:2, p. 2)
W weight loss: behavioral client-centered approach to, (15:2, p. 13Y14); behavioral strategies, (15:2, p. 17Y18); brainstorming worksheet, (15:2, p. 16); decisional balance sheet, (15:2, p. 16); directive vs. client-centered approach to, (15:2, p. 14); individual vs. family-friendly behavioral strategies for, (15:2, p. 17); motivations for, (15:2, p. 9); role of family in, (15:2, p. 13Y18) weight loss maintenance: characteristics of, (15:2, p. 9); habits of weight loss maintainers, (15:2, p. 10); weight loss methods in NWCR, (15:2, p. 9Y11) weight loss surgery: bariatric surgery, (15:1, p. 13Y14); biliopancreatic diversion, (15:1, p. 13); enrollment and participant characteristics, (15:1, p. 16); impact on patients with diabetes, (15:1, p. 17); in individuals with diabetes mellitus, (15:1, p. 15Y16); malabsorptive procedures, (15:1, p. 13); practice-based program evaluation for, (15:1, p. 13Y18); Roux-en-Y gastric bypass, (15:1, p. 13);
telephone-based support for, (15:1, p. 13Y18); three types of, (15:1, p. 13) whole body vibration. See vibration exercise worksite health promotion: company policy on; classification of, (15:3, p. 43); corporate smoke-free policy, (15:3, p. 44Y45); design of, (15:3, p. 45); for employee health and wellness, (15:3, p. 43Y44); need for, (15:3, p. 44), p. 43; health hazards of too much sitting, (15:1, p. 41); physically active work breaks, (15:1, p. 42); prolonged sitting and workplace productivity, (15:1, p. 42); reducing sitting time among employees, (15:1, p. 42Y43); WHO healthy workplace model to protect and promote workplace health, (15:5, p. 48Y50)
Y yoga: body positions in, (15:1, p. 4); hatha yoga, (15:1, p. 4); improved flexibility by, (15:1, p. 4); improves mental state, (15:1, p. 4); improves musculoskeletal fitness, (15:1, p. 4); origin of, (15:1, p. 4); reducing blood pressure by, (15:1, p. 4)
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