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ACSMS CERTIFIED

NEWS

J A N UA RY MA RC H, 2 010 VOLU M E 2 0 ; I S S U E 1

Agility Training

For the General Population

page 5
Prescribing Exercise in

Cardiac
Rehabilitation
Without an Exercise Test

page 7

Exercise
Recommendations
for the Frail

Population

page 3

Making Sense
of the Exercise

Prescription

page 13

Effects of Strength
Training on

Resting Energy
Expenditure

page 10

Continuing Education
Self-Tests
page 15
ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

ACSMS CERTIFIED NEWS


JANUARY-MARCH 2010 VOLUME 20, ISSUE 1

In this Issue
Exercise Recommendations for the
Frail Population...................................................... 3
Agility Training For the General Population ......... 5
Prescribing Exercise in Cardiac
Rehabilitation Without an Exercise Test ............. 7
Coaching News........................................................... 9
Effects of Strength Training
on Resting Energy Expenditure.............................10
Making Sense of the Exercise Prescription..............13
Self-Tests ........................................................................15
Co-Editors
Paul Sorace, M.S., James R. Churilla, Ph.D., M.P.H.
Committee on Certification
and Registry Boards Chair
Madeline Bayles, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Jan Wallace, Ph.D., FACSM

National Center Newsletter Staff


National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Professional Education Coordinator
Shaina Loveless
Publications Manager
David Brewer

Editorial Board
Chris Berger, Ph.D.
Brian Coyne, M.Ed.
Yuri Feito, M.S., M.P.H.
Tom LaFontaine, Ph.D., FACSM
Peter Magyari, Ph.D.
Jacalyn McComb, Ph.D., FACSM
Peter Ronai, M.S.
Larry Verity, Ph.D., FACSM
Stella Volpe, Ph.D., FACSM
Jan Wallace, Ph.D., FACSM

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ACSMs Certified News (ISSN# 1056-9677) is published
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American College of Sports Medicine or the Committee on
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certified exercise and health professional and to inform these
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A HEALTHY SET OF
CHANGES FOR YOU
James R. Churilla, Ph.D., M.P.H.
Paul Sorace, M.S.
Co-Editors

To continue to provide ACSM


certified professionals with
important and timely information, ACSM s Certif ied News
has undergone some changes
starting in 2010.
We would like to highlight these changes which include:
More pages: Each issue of Certified News will now have 16 pages.
Color-glossy pages. To make the publication more visually appealing, Certified
News has a new look, which includes color headshots of all authors. Speaking of
authors, ACSM certified professionals are encouraged to submit articles to
Certified News. Author guidelines can be obtained by emailing ACSM at
trush@acsm.org
Features, Wellness, and Columns: Each issue of Certified News will have one
health & fitness feature article, one clinical feature article, two wellness articles, a
health & fitness column and a clinical column. Wayne Westcott, Ph.D., is the inaugural health & fitness columnist. We are very excited to have Dr. Westcott fill this
role! We are also very excited to announce that our inaugural clinical columnist
will be Jonathan K. Ehrman, Ph.D. We look forward to kicking off our clinical column by the third issue of 2010. Each issue of Certified News will continue to provide 4 CECs.
Editorial Board: An editorial review board was added to Certified News in 2009
to further increase the quality of all articles published in Certified News.
We feel these changes will enhance the publication and offer relevant and timely topics for any
and all ACSM certified professionals. We look forward to continue providing you with evidencebased information and continuing education.

ACSM National Center


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2010 American College of Sports Medicine.
ISSN # 1056-9677

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

HEALTH & FITNESS FEATURE

Exercise Recommendations for the

Frail Population
FRAILTY

IS A CONDITION SEEN

PARTICULARLY IN THE ELDERLY AND

BY PAUL SORACE, M.S., RCEP, CSCS*D,


HACKENSACK UNIVERSITY MEDICAL
CENTER, HACKENSACK, NJ

IS CHARACTERIZED BY WEAKNESS, FATIGUE,

FUNCTIONAL IMPAIRMENT AND A VARIETY OF DISEASES AND/OR DISABILITIES.


It causes a deterioration of a persons physiological functions,
increases the risk of loss of independence and even death. Frailty can
be challenging to diagnose, although it has been defined (see Table 1).
There are a number of contributing factors for frailty. Older adults
are often at risk for becoming frail due to aging, physical disuse and
chronic diseases.2 Obesity is also a potential contributing factor to
frailty.6 Table 2 lists some of the common diseases and disabilities that
can lead to frailty.

Exercise Effects on Frailty


Regular exercise can have a number of benefits in older, frail persons.1,2,6 These include:
Improved muscular strength and endurance
Increased aerobic capacity
Enhanced joint flexibility
Improved balance and coordination
Improved psychological well-being
Weight loss (if needed)
Management of chronic diseases/disabilities
These potential benefits can result in enhanced functional abilities,
maintained or increased independent living and possibly reversing the
condition of frailty. Weight loss and regular exercise/physical activity
have been shown to reduce the effects of frailty in obese older

Table 1. Defining Criteria for Frailty


The person must have at least three of the following:
Unintentional weight loss (10 lbs. in past year)
A feeling of exhaustion
Weakness (measured by grip strength)
A slow walking speed (defined as the slowest 20% of the
population studied to walk 15 feet)
Low physical activity
Adapted from reference 5.

2,5

adults.6 Exercise can slow the process of frailty and may even prevent
it from developing.

Exercise Recommendations
Due to a variety of health conditions that may be present in this
population, obtaining medical clearance prior to initiating an exercise
program is prudent. Exercise testing should be performed whenever
possible to determine what the persons abilities are prior to beginning an exercise program. Additionally, baseline testing will provide
the necessary information for developing an exercise prescription.
Some of the exercise tests that can be done include a 6-minute walk
to estimate cardiorespiratory fitness, a handgrip dynamometer to
measure upper body strength and a sit and reach test to measure
flexibility.2 Resting heart rate, resting blood pressure and body composition also should be measured. If a medical condition such as
hypertension or diabetes is present, monitoring blood pressure or
blood glucose levels pre- and post-exercise should be performed.
Increasing the functional abilities of the individual should be kept
in mind when developing the exercise program. Depending on the
individual, different modes of exercise should be considered. Walking
is the most common aerobic activity in older adults.1 Large muscle
groups and weight bearing aerobic exercises should be emphasized
whenever possible. Non-weight bearing aerobic activities (e.g.,
cycling, swimmimg) should be used when weight bearing exercises
are too strenuous. Aerobic training should be performed 3 to 5 or
more days per week.1,2 However, this may not always be possible and
a lesser frequency might be all the individual can tolerate during the
early stages of an exercise program. The certified personal trainer or
health/fitness specialist should encourage increased daily physical
activity (e.g., climbing stairs, short walks) to improve aerobic conditioning and functional abilities.
Flexibility training (e.g., static stretching) for frail persons is important to increase joint range of motion, which can increase ease of
movement with daily activities. Yoga is a form of exercise that is suitable for many frail persons. DiBenedetto and colleagues4 suggest that
yoga can improve hip extension, stride length and pelvic tilt in the eld-

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

point of mild tension; all major muscle groups; 15 to 60 seconds


in duration.
Properly supervised resistance training 2 to 3 days per week
(nonconsecutive days); use modes (e.g., free weight, machines,
elastic bands) that are suitable for the individual; 8 to 10 exercises for the major muscle groups; 1 to 3 sets per exercise; 10
to 15 repetitions.
Other activities such as yoga, Tai Chi and functional exercises
can be performed on a daily or near-daily frequency, based on
the abilities of the individual.
Note: Recommendations may need to be modified depending on
the individual. These recommendations are based on references.1,2

Table 2. Chronic Diseases and Disabilities that


Contribute to Frailty
Hypertension

Diabetes

Coronary Artery Disease

Cancer

Peripheral Artery Disease

Anemia

Asthma; Chronic
Obstructive Pulmonary
Disease (COPD)

Parkinsons Disease
Alzheimers Disease

Arthritis
Osteoporosis
Adapted from reference 2.

Summary
erly population. Yoga as a lifestyle intervention has been shown to
assist in improving cardiovascular disease risk factors (e.g., blood
lipids, blood glucose).3 Also, yoga can improve balance and coordination to help promote fall prevention.
Sarcopenia (muscle loss) is very common in older adults and contributes to a loss of functional abilities. This emphasizes the importance of resistance training for this population. Resistance training
increases muscle mass, muscular strength, power and endurance.
Maintained or increased muscular strength can enhance functional
abilities in older, frail individuals.2
All major muscle groups and multi-joint exercises should be
emphasized. Modes of resistance training include resistance bands,
free weights, resistance machines, medicine balls and calisthenics.
Resistance training should be performed two to three times per
week.1,2 The resistance training program should start at a low level
(e.g., with little or no resistance/weight) in those who are very
deconditioned. However, the resistance training program should be
gradually progressed, as tolerated. Muscle hypertrophy (accompanied by increases in strength) occurs at all ages as a result of regular
resistance training. Gradual progression to heavier weights (i.e., more
resistance) in the properly risk stratified individual is just as important in older populations as it is in their younger counterparts.
Functional training can improve body awareness and balance,
increase neuromuscular coordination, flexibility, ambulation and
lower body strength.2 This is important for frail individuals, particularly in reducing the risk of falls. Examples include a chair sit and stand,
one-foot stand, balance board walking and activity-specific exercises
(e.g., carrying objects). Other activities such as obstacle courses can
enhance reaction time and coordination.
Tai Chi, a form of martial arts that enhances balance and body
awareness through slow, graceful and precise body movements, has
been shown to reduce the risk of falling by approximately 47.5% in
frail older adults.7 Like yoga, Tai Chi is an activity that many frail individuals can perform at their own pace.
Some general exercise recommendations include:
Properly supervised aerobic exercise 3 to 5 or more days per
week; exercise heart rate should not be the focus; use a 5 to 8
on a 1 to 10 rating of perceived exertion scale to measure moderate to vigorous exertion; accumulate 20 to 60 minutes; large
muscle group activities (e.g., walking, cycling, swimming).
Flexibility training 3 to 7 days per week; static stretching to a

Frailty is a medical condition that is linked to chronic health


problems, disability, reduced functional capacity and loss of independence. Many of the effects of frailty can be improved by participation in a comprehensive exercise program. The certified health
and fitness professional must consider the overall health and functional abilities of the individual when designing an exercise program. The benefits of exercise can contribute to a healthier and
more independent lifestyle for frail persons.

About the Author


Paul Sorace, M.S., RCEP, CSCS*D, is a clinical
exercise physiologist for The Cardiac Prevention
and Rehabilitation Program at Hackensack
University Medical Center in Hackensack, NJ.
Paul also is a member of the ACSM Publications
Subcommittee and ACSMs Health & Fitness
Summit & Exposition Program Committee. He is
co-editor for ACSMs Certified News and an
editorial board member for ACSMs Health & Fitness Journal.

References
1. American College of Sports Medicine. ACSMs Guidelines for
Exercise Testing and Prescription, 8th ed. Thompson WR, Gordon
NF, Pescatello LS, editors. Baltimore, MD: Lippincott Williams &
Wilkins, 2009:190-194.
2. American College of Sports Medicine. ACSMs Exercise
Management for Persons with Chronic Diseases and Disabilities,
2nd ed. Durstine JL, Moore GE, editors. Champaign, IL: Human
Kinetics 2003:157-163.
3. Bijlani RL, Vempati RP, Yadav RK, et al. A brief but comprehensive
lifestyle education program based on yoga reduces risk factors
for cardiovascular disease and diabetes mellitus. J Altern
Complement Med. 2005;11:267-74.
4. DiBenedetto M, Innes KE, Taylor AG, et al. Effect of a gentle
Iyengar yoga program on gait in the elderly: an exploratory study.
Arch Phys Med Rehabil. 2005;86:1830-7.
5. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci.
2001;56:M146-56.
6. Villareal DT, Banks M, Sinacore DR, Siener C, Klein S. Effect of
weight loss and exercise on frailty in obese older adults. Clin J
Sport Med. 2006;166:860-6.
7. Wolf SL, OGrady M, Easley KA, Guo Y, Kressing RW, Kutner M.
The influence of intense Tai Chi training on physical performance
and hemodynamic outcomes in transitionally frail, older adults. J
Gerontol A Biol Sci Med Sci. 2006;61:184-9.

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

WELLNESS ARTICLE

AGILITY TRAINING
For the General Population
BY: JAY DAWES, M.S., CSCS, FNSCA, ACSM-HFS
In most sports, an athlete must be able to accelerate,
decelerate and change directions rapidly with good body
control in order to perform well and reduce their risk of
injury. For this reason, agility drills are commonly utilized by
athletes to enhance their on-field performance. However,
these same types of drills can easily be incorporated into
training programs for the general fitness population in
order to improve performance in recreational and daily
activities and help them respond faster in emergency situations. In this article, a few suggestions for implementing
these drills into a comprehensive training program for the
non-athlete will be discussed.
Safety
Prior to beginning any agility training, it is important to make certain the client can safely participate in this type of activity. Clients
with orthopedic limitations that affect their ability to balance either
statically or dynamically, and those that lack the strength or ability
to maintain proper position should refrain from this type of training
until they have adequately developed their performance levels. Table
1 lists individual characteristics that would preclude participation in
agility training. It also is recommended that before these individuals
participate in agility training for the first time, they have at least 2 to
3 months of consistent resistance training experience.

Drill Selection
When selecting drills, an emphasis should be placed on improving
fundamental movement skills. These skills include locomotor, nonlocomotor, manipulative, and movement/body awareness skills
(Table 2).These movements are required in all activities in varying
amounts, and should
be performed at a
Table 1:Those Who Should
wide array of speeds,
Not Participate in Agility
Training
amplitudes, and
forces based on the
Very old and frail
specific population.
Severe neuromuscular disorders
(e.g., stroke, Parkinsons
For ins tance, the
disease)
s a m e m ove m e n t s
Pregnancy
being produced by an
Morbidly obesity
athlete in a game or

practice situation versus a non-athlete playing with their children or


crossing a busy street may require similar intensity and mobility
demands. While certain skills are necessary, balance, explosiveness
and speed (in both situations), the degree of skill and the magnitude
of movement may be different for these movement abilities. Thus,
when used as in conjunction with a comprehensive resistance training program this form of training may better prepare individuals for
the demands of their daily lives, allowing them to perform activities
with greater skill and efficiency. Furthermore, training drills that help
individuals develop generalized motor programs aid in the development of greater proprioceptive capabilities.4 This provides the client
with a reference point to evaluate their own movement behaviors in
the future and a greater capacity to detect errors in performance
and correct them via augmented musculoskeletal feedback.4,5
In general terms, agility drills can be classified as closed or
opened.2 Closed drills are preprogrammed drills, performed in a predictable and unchanging environment.2,3,5 Initially, closed drills, with
minimal force production requirements, such as most agility ladder
drills or cone drills, should be performed, progressing to more complex drills later, such as those that are non-programmed, or open.
An individual attempting to mirror the actions of another individual
or drills that require a person to respond to an auditory cue before
selecting a specific movement pattern. The focus of closed drills is
primarily on proper movement mechanics, proper body position and
simple changes of direction. Clients should be encouraged to perform drills only at speeds that allow proper execution of the targeted movements. Once the technique has been mastered, the client
may then increase their speed of movement.

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

Additionally, the client will develop certain perceptual and decision


making skills that cannot be learned as effectively during closed training drills. Table 3 shows some examples of closed, semi-programmed, and open agility drills.

Table 2: Fundamental Movement Skills


Locomotor
Walking
Running
Skipping
Hopping
Sliding
Chasing
Fleeing
Dodging
Galloping
Rolling

NonLocomotor

Movement
Manipulative Awareness

Twisting
Turning
Balancing
Jumping
Landing
Stretching
Pushing
Pulling

Throwing
Catching
Kicking
Punting
Dribbling
Striking
Volleying

Spatial
Awareness
Kinesthetic
Awareness

Modifications

Table 3: Examples of Agility Drills


CLOSED AGILITY DRILLS
EXAMPLES

SEMI-PROGRAMMED/OPEN
AGILITY DRILLS EXAMPLES

Forward Run: Start diagonally


behind one cone. When ready,
sprint forward to the second
cone. Upon reaching the second cone, come to a complete
stop in an athletic position,
immediately turn and accelerate in the opposite direction.
Sprint past the first cone.

Ball drops: While performing


the forward/run, randomly
drop a tennis or racquet ball
When the ball is dropped the
client should immediately
sprint toward the ball and
catch it before it bounces
twice.

Backpedal: The client will start


diagonally behind the first
cone with their back turned
toward both cones. When
ready, backpedal to the second cone. Upon reaching the
second cone, immediately turn
and backpedal to the first
cone. The focus of this drill
should be on keeping the hips
low and maintaining the athletic position.

Forward/Run-Backpedal
with auditory cue: The client
should begin this drill by running forward to the second
cone, and upon reaching the
second cone decelerate the
body and backpedal to the
first cone. Periodically the
trainer will provide an auditory cue by blowing a whistle to
signal the client to immediately stop where they are and
change directions.

Lateral Shuffle: The client


should begin by facing the
first cone. When ready, shuffle
to the second cone while
keeping the hips low, keeping
the hips, shoulders and torso
parallel to the cones. Upon
reaching the second cone,
immediately shuffle back to
the first cone.

Mirror Drill: Begin with the


trainer facing the client in the
center of the cones. On the go
command the client must
mimic the trainers
movements.

Note: For all drills featured in this table two cones


should be placed approximately 6 to 10 feet apart.

Following technique mastery, the exercise professional may now


consider the implementation of open drills to the clients agility program. This can be easily done by adding some form of sensory stimuli (visual, auditory or kinesthetic) to a traditional closed training
drill. For instance, tossing a client a ball to catch or requiring them
to perform various biomotor skills based on the trainers command.2
These advanced drill progressions require the client to adapt their
newly learned skills based on a novel situation, similar to real life,
rather than simply performing a preprogrammed pattern or drill.

When integrating agilities into a client training program it is


important to modify each specific drill based on the clients current
skills and abilities. As previously stated, most non-athletes will not be
required to make high intensity cutting movements with large amplitudes of movements at maximal speeds. Therefore, when designing
an agility-training program for the general fitness client, maximum
effort and speed of movement is not necessarily the focus of training. Rather it should be performing the appropriate movement patterns through the desired ranges of motion in a safe and effective
manner. Since these individuals may not be athletes, agility training
programs should be modified by starting and progressing more slowly. Furthermore, adjusting the mobility and flexibility demands of a
drill also allows clients to work at their own level versus trying to
accomplish the movement patterns expected of elite athletes.

Conclusion
Agility training can provide fun and variety to a traditional training program aimed at improving health and fitness. Enhanced agility
also may help improve performance in basic activities of daily living,
and even assist in the prevention of some types of injuries, especially falls. However, it is important to remember that for individuals in
the general fitness population appropriate modifications to accommodate their current levels of health and skill related fitness must be
made to promote safety. It is recommended that agility drills be progressed slowly with an emphasis on technique mastery, before progressing the speed of movements and adding complex variations,
such as open, or non-programmed agility training.

About the Author


Jay Dawes, M.S., CSCS, FNSCA, ACSM-HFS, is
the director of education for the National
Strength and Conditioning Association located
on Colorado Springs, CO. He is also an adjunct
faculty member of the School of Nursing and
Health Sciences at the University of Colorado in
Colorado Springs, as well as a Ph.D. student at
Oklahoma State University.

References
1. Dawes J, Mooney C. 101 Conditioning Games and Drills for
Athletes. Monterey, CA: Monterey Bay Press. 2006:9.
2. Dawes J. ONE-ON-ONE: Creating Open Agility Drills. Strength &
Conditioning Journal. 2008;30: 54-55.
3. Dawes J. Learning to React. Professional Strength & Conditioning.
2008;9:25-27.
4. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral
Emphasis, 4th ed. Champaign, IL: Human Kinetics, 2005:91-101, 280285, 401-431
5. Young W, Farrow D. A Review of Agility: Practical Applications for
Strength and Conditioning. Strength & Conditioning Journal.
2006;28:24-29

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

CLINICAL FEATURE

PRESCRIBING EXERCISE IN

CARDIAC
REHABILITATION
WITHOUT AN EXERCISE TEST
It is not uncommon for patients to begin
phase II cardiac rehabilitation without a
recent exercise test. According to a survey
by Andreuzzi et al.,2 60% of programs do
not require an exercise test prior to program entry. However, there are few evidence-based recommendations for establishing a target heart rate (HR) in patients
with heart disease in the absence of an exercise test. ACSMs Guidelines for Exercise
Testing and Prescription, 8th edition1 improves
on prior editions by providing some guidance for these situations (see Table 9.1, p.
214). These guidelines will be refined as
more evidence-based data become available.
This article will discuss challenges faced by
the exercise physiologist when prescribing
exercise without an exercise test.

PRE-PROGRAM
EXERCISE TEST

BY CLINTON A. BRAWNER, M.S., RCEP, FACSM


A CONTRIBUTION FROM THE CLINICAL
EXERCISE PHYSIOLOGY ASSOCIATION (CEPA)

Although the American College of Cardiology and


the American Heart Association recommend a pre-program, symptom-limited exercise test in all patients in which cardiac rehabilitation is indicated,9 the necessity has been questioned. McConnell et
al.12 concluded that patients completing 12 weeks of cardiac rehabilitation can be safely progressed and demonstrate similar improvements in
caloric expenditure, independent of whether they have a pre-program
exercise test. It should be kept in mind, however, that an exercise test
provides more than just data for an exercise prescription. Following a
cardiac event or procedure, an exercise test also provides information
on residual ischemia, risk stratification, and functional capacity.11 If implemented before and after an exercise training program, changes in functional capacity can be quantified which can be useful for program outcomes and patient motivation.

REST PLUS 20
When an exercise test is not available, clinicians will typically set a target HR based on the patients resting HR plus 20 beats per minute
(bpm; rest plus 20), or they will guide exercise based solely on ratings
of perceived exertion (RPE). Establishing a target HR using rest plus 20
was originally intended to be a temporary recommendation following
hospital discharge until the patient had a symptom-limited exercise test
in conjunction with an outpatient cardiac rehabilitation program. In
some programs it is viewed as a safe and conservative initial training
intensity in the absence of an exercise test. Practical experience, however, suggests that some patients may not undergo an exercise test

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

while in cardiac rehabilitation. Some of these patients will have had a


pharmacologic stress test that was ordered by a physician for clinical purposes. The absence of exercise test data presents a challenge when
defining the exercise intensity for an individual patient.
Joo et al.10 reported that, on average, rest plus 20 corresponded to
42% of VO2 reserve among patients entering a phase II cardiac rehabilitation program. Brawner et al.4 reported the relative percent HR
reserve associated with rest plus 20 in patients with ischemic heart disease (Table 1). Although rest plus 20 appears to be a good fit for
some, it may result in suboptimal training intensity in many.

Table 1. Exercise intensity based on resting HR


plus 20 bpm and corresponding HR reserve in
patients with heart disease.
Beta-Blockade
Therapy
(n= 50)
% HR reserve
45%
% patients below 50% HR reserve 80%
% patients above 80% HR reserve
4%

No
Beta-Blockade
Therapy
(n= 46)
31%
91%
0%

HR= heart rate; bpm= beats per min.


Adapted from reference 4.

In the HF-ACTION trial (Heart Failure: A Controlled Trial


Investigating Outcomes of Exercise TraiNing), we learned that various
rest plus 20 procedures were being used across exercise centers. It was
not uncommon for centers to recalculate this each day. Neither ACSM
nor the American Association for Cardiovascular and Pulmonary
Rehabilitation (AACVPR) provide specific procedures on the calculation
and use of rest plus 20.
In light of this, the following is presented as a framework to establish
program procedures for the use of rest plus 20 when an entry exercise
test is not available. First, identify a baseline resting HR in an upright position (seated or standing) after two minutes of quiet rest on three separate days. In addition to its use in establishing a target HR, it also will provide a useful baseline resting HR to help identify patients during subsequent exercise sessions who may not have taken, or had a change in,
their beta blockade. Patients are then provided a target HR range
based on their resting HR plus 15 to 25 bpm. This provides patients a
10 beat range that they can use consistently.

RATINGS OF PERCEIVED EXERTION


Per ACSMs recommendations, a target HR range based on rest plus
20 can be gradually titrated to higher intensities based on RPE, signs,
and symptoms.1 Although RPE scales are frequently cited as valid tools
to guide exercise intensity, specifics on how to implement them are
rarely outlined. In addition, discordance exists between RPE and target
HR during exercise in many patients.13 However, in healthy adults, the
validity of RPE has been shown to improve when feedback on their
intensity (e.g., too high or too low) is provided during three initial training sessions.8 Caution should be used when depending solely on RPE.
Another perceived exertion-related tool that may be useful is the
talk test. This is the highest exercise intensity at which the person feels
they can talk comfortably. The talk test has been shown to be a good
estimate of the exercise intensity associated with the ventilatory-derived

anaerobic threshold7 and the ischemic threshold.6 When patients with


heart disease were asked to exercise on a track at the fastest pace that
still allowed them to talk comfortably, 59% chose a pace that was within 50-85% of HR reserve; 14% chose a pace above this range and 27%
were below.5 Similar to RPE, the talk test results in inter-individual variability; however, if a patient feels they cannot talk comfortably, they are
likely exercising too hard.

A CASE STUDY
The following case study illustrates the challenges of depending solely on RPE. A 55-year-old male with heart failure was referred to cardiac
rehabilitation. Based on an exercise test, his peak HR was 115 bpm and
the target HR range based on 60-70% HR reserve was set at 89 to 102
bpm. During the first few exercise sessions he exercised at a HR of 105
bpm and a RPE of 10 (Borg 6 to 20 scale). Because of the low RPE, the
exercise staff decided to forgo using HR and guide exercise solely by
RPE. He then began to exercise at a HR of 115 bpm and a RPE of 14.
Following these exercise bouts he reported extreme fatigue and subsequently missed several visits. When he returned to exercise he was
instructed to keep his HR within his previously defined target range and
he tolerated exercise much better without complaints of excessive, postexercise fatigue. This individual did not interpret his RPE well. Optimally,
exercise staff would have looked for reasons the target HR range and
RPE were discordant (e.g., patient not taking medications, change in
beta blockade). If none were identified, then the importance of the prescribed target HR range should have been emphasized and the patient
educated on the RPE that corresponds with this range. Alternative subjective methods, such as the talk test, also may have been useful.

EXERCISE TESTS VS.


PHARMACOLOGICAL TESTS
It is not uncommon for patients in phase II or maintenance-type cardiac rehabilitation programs to undergo pharmacological stress tests
(e.g., dobutamine, adenosine) instead of a symptom-limited exercise test.
A common question that arises is, can information from these tests be
used to develop an exercise prescription? ACSM provides options for
this situation;1 however, this information does not address all possible
circumstances.
A symptom-limited exercise test assesses ischemia by increasing
myocardial oxygen demand through increases in HR and myocardial contractility. Ischemia occurs when myocardial blood supply cannot match
the myocardial demand for oxygen. An exercise test also is used to
assess functional capacity (e.g., peak VO2, peak watts). Functional capacity is the focus of the exercise intensity prescription with a typical goal
of 50-85% of functional capacity (i.e., VO2 reserve). Because of the linear relationship between HR and VO2 (or watts), HR serves as a useful
surrogate or estimate of a target work rate.
On the other hand, dobutamine stress tests assess ischemia without
exercise by increasing myocardial oxygen demand through medicationinduced increases in HR and myocardial contractility. However, they do
not assess functional capacity. No studies have shown a useful relationship between HR responses observed during dobutamine and exercise
tests. For these reasons the usefulness of this information is limited. If a
dobutamine test is positive for ischemia, the rate-pressure product (HR
systolic blood pressure) at the ischemic threshold could be used to
Cardiac Rehabilitation (continued on page 12)

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

COACHING NEWS: CURIOSITY


AT THE FRONTIER OF COACHING
HEALTH AND WELL-BEING
By BJ Richstone, Psy.D., CPC; and Margaret Moore (Coach Meg), MBA
In a recent study, more than 2,000 older
adults aged 60 to 86 were evaluated to determine who was more likely to be alive at the
conclusion of the study. In the group that
achieved greater longevity, one factor was significantly more important than any other.9 Are
you curious as to what that factor was?
Knowing about this factor also may help you
enjoy a long life.
In his new book, Curious? Todd Kashdan,
professor of psychology at George Mason
University, reveals that the all-important ingredient to longevity in this study was curiosity.
He points out: Those who were more curious
at the beginning of the study were more likely
to be alive at the end of the study, even after
taking into account age, whether they smoked,
the presence of cancer or cardiovascular disease, and all the rest of the usual markers.2
While he acknowledges that declining curiosity
may be a sign of declining health and neurological illness, Kashdan believes that there are
promising signs that enhancing curiosity
reduces the risk for these diseases and even
the potential to reverse some of the natural
degeneration that occurs.2
According to Kashdan, curiosity has a powerful effect on well-being and thriving.It is
incumbent upon coaches to understand precisely what it is, its benefits for psychological
and physical health, and how to best facilitate
curiosity in our clients.

What is Curiosity?
Curiosity has received more than a century
of psychological study and many definitions
have been offered over the years. What all definitions have in common, however, is that
curiosity is (1) a motivational state; (2)
approach-oriented and; (3) associated with
exploration. A good working definition of
curiosity, offered by Kasdan, is: The recognition, pursuit, and intense desire to explore

novel, challenging, and uncertain events.4

We are Wired to Be Curious


Psychologists who subscribe to the intrinsic
motivation tradition believe that interest or
curiosity arises from the operation of evidencebased primal needs, such as competence,
autonomy, and relatedness.1,8 Scientists also
have focused on physiological explanations by
studying curiosity patterns in the brain. They
have discovered that the chemical dopamine is
released from the striatum in the brain at a
greater rate when a person pushes beyond the
boundaries of the known, facing challenges,
novelty, and uncertainty. There is also a greater
release of dopamine when there is personal
importance or meaning in the novel situation.
This surge of dopamine prepares us to capitalize on these experiences by focusing our attention on the present, mobilizing our energy
resources, and initiating approach movements.7

What purpose does curiosity serve?


Curiosity motivates us to be receptive to
the happenings of the present moment, to be
immersed in, explore, and investigate our surroundings. In the process, curiosity stretches
our knowledge and skills, enabling us to meet
new people and learn new things. In the long
term, curiosity builds competence.

Curiosity leads to well-being


In cross-sectional studies, researchers who
measured levels of curiosity consistently
report a greater level of psychological wellbeing.5,6,10 Regarding physical health, as was previously mentioned, older adults with greater
curiosity have been found to live longer over a
5-year period.9
Kashdan admits that the mechanisms linking curiosity to physical health, illness and mortality are not yet fully understood. He offers
several intriguing explanations for why highly

curious people may live longer, such as the


process of neurogenesis stemming from continued novel and intellectual pursuits, a nondefensive willingness to try unfamiliar yet science-based health strategies, or the psychological benefits of evaluating stressors as challenges being guided by exploration as opposed
to avoidance.2 He suggests that an examination of cognitive, behavioral, social, and biological levels of analysis will lead to promising
avenues of when and how curiosity leads to
desirable outcomes.2

In Coaching
Perhaps most important for coaching,
curiosity promotes new ways of thinking and
acting. Perspective change is the bread and butter of coaching. Kashdan writes, People who
feel curious challenge their views of self, others,
and the world with an inevitable stretching of
information, knowledge and skills.4 Coaches
know that this is an important route to meaningful change.
Curiosity also helps in goal fulfillment.
Kashdan and Steger (2007)3 studied people
over the course of 21 days and found that people who were highly curious were more likely
to persist in attaining their goals, even in the
face of obstacles, and were also more likely to
express gratitude to their benefactors. This led
to higher levels of perceived meaning and
purpose.
Curiosity also can help our clients build neurological connections as they explore new
experiences and seek out new information.
Finally, according to Kashdan, curiosity
leads to more efficient decision-making and
helps us grow in our ability to see the relationships among disparate ideas, leading to more
creativity.

Conclusion
It is not surprising that curiosity and achieving our best life have been found to be linked.
Coaching News (continued on page 11)

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

HEALTH & FITNESS COLUMN

EFFECTS OF STRENGTH TRAINING ON

RESTING ENERGY
EXPENDITURE
BY WAYNE L. WESTCOTT, Ph.D.
Although a Gallup poll6 found that 52% of American adults are
attempting to reduce their body weight through dieting, approximately
one-third of our population is overweight and another one-third is
obese. Contrary to the August 17, 2009 cover story in Time magazine,
dieting alone is not a productive means for attaining permanent weight
loss.
A comprehensive research review titled,
Medicares search for effective obesity interventions:
Diets are not the answer stated that dieters who
manage to sustain a weight loss are the rare exception,
rather than the rule. Dieters who gain back more
weight than they lost may very well be the norm
(page 230).4
If diets dont work what does? Most of us would
agree that regular aerobic activity is an appropriate
recommendation for increasing energy expenditure,
and indeed it is. However, during the past two
decades, there has been considerable interest in the
role of resistance exercise for enhanced fat loss due to
its positive impact on resting energy expenditure.
In 1994, two landmark studies were published
regarding the effects of standard strength training on
resting metabolic rate in older adults. Campbell et al.1
at Tufts University conducted a carefully controlled
study in which subjects ate measured meals and performed no physical training except for three sets of
four resistance exercises, three days each week. After
12 weeks on this basic strength training program, the
participants increased their lean weight by about three
pounds and their resting metabolic rate by about 7%.
This represented approximately 100 additional calories burned at rest on a daily basis.
That same year, Pratley and associates5 conducted
a similar study with senior men. The research subjects
performed relatively brief strength training sessions
(one set of 14 resistance exercises) three days each

10

week for 16 weeks. At the conclusion of the strength


training program, the participants increased their lean
weight by 3.5 pounds and their resting metabolic rate
by about 8%. This represented approximately 120
additional calories burned at rest on a daily basis.
A few years later, Hunter and colleagues3 at the
University of Alabama at Birmingham conducted a
longer-term study on strength training and resting
energy expenditure. The senior subjects performed
two sets of 11 resistance exercises, three days a week
for 26 weeks. After six months of training, the program participants increased their lean weight by 4.5
pounds and their resting metabolic rate by about 7%.
This represented approximately 100 additional calories burned at rest on a daily basis.
While it appears that regular resistance exercise
results in a higher resting metabolism, it is less clear
what mechanisms are responsible for this increase.
Although one factor may be the additional lean weight
(much of which is water), this most likely accounts for
a relatively small percentage of the rise in resting metabolic rate. So what is the best explanation for the 7 to
8% elevation in resting energy expenditure experienced by the subjects in these strength training studies? A recent study conducted at Wayne State
University suggests muscle repair and remodeling
processes that follow a physically demanding strength
training session may be largely responsible for the resting metabolic increase.
In 2008, Hackney and associates2 administered a

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

single session of resistance exercise to eight untrained and eight


trained individuals, all of whom performed eight sets of six repetitions for each of eight standard exercises. The untrained participants
experienced a consistent 9% elevation in resting energy expenditure
at 24 hours, 48 hours, and 72 hours after their strength training session. The trained participants resting energy expenditure was 4%
above normal 24 hours post-workout, 10% above normal 48 hours
post-workout, and 8% above normal 72 hours post-workout. The
trained exercisers averaged an 8% elevation in resting energy expenditure for three days following their strength training session.
Based on these findings, it would appear that the increased resting metabolic rate associated with resistance exercise has less to do
with additional lean weight and more to do with energy requirements for remodeling muscle tissue that has experienced traininginduced microtrauma. Assuming that one performs strength exercise
every two or three days, resting energy expenditure may remain elevated throughout the training program due to ongoing muscle microtrauma and tissue remodeling processes. If this is the case, the 7 to
8% increase in resting metabolic rate measured at the completion of
the 12-week, 14-week, and 26-week strength training programs presented above most likely began after the initial exercise session and
continued throughout the study duration.
If regular resistance exercise can induce a 7% increase in resting
energy expenditure, trainees with a resting metabolic rate of 1500
calories per day would use an extra 100 calories a day or
(potentially) an additional 36,000 calories per year. Other things
equal, this could possibly result in a 10-pound fat loss over the course
of one year. Unlike dieting alone which leads to lean weight loss and
metabolic decrease, strength training results in lean weight gain and
metabolic increase. It would therefore seem that strength exercise
may offer a more sensible and successful means than dieting alone for
attaining and maintaining desirable bodyweight and body
composition.

About the Author


Wayne L. Westcott, Ph.D., teaches exercise science
and directs the fitness research programs at
Quincy College, in Quincy, MA.

References
1. Campbell WW, Crim MC, Young VR, Evans WJ.
Increased energy requirements and changes in
body composition with resistance training in
older adults. Am J Clin Nutr. 1994;60:167-175.
2. Hackney KJ, Engels HJ, Gretebeck RJ. Resting energy expenditure and
delayed-onset muscle soreness after full-body resistance training
with an eccentric concentration. J Strength Cond Res.
2008;22:1602-1609.
3. Hunter GR, Wetzstein CJ, Fields DA, et al. Resistance training
increases total energy expenditure and free-living physical activity in
older adults. J Appl Physiol. 2000;89:977-984.
4. Mann TA, Tomiyama J, Westlin E, et al. Medicares search for effective obesity treatments: Diets are not the answer. Am Psychol.
2007;62:220-233.
5. Pratley R, Nicklas B, Rubin M, et al. Strength training increases
resting metabolic rate and norepinephrine levels in healthy 50 to 65
year old men. J Appl Physiol. 1994;76:133-137.
6. Research Alert. Gallup poll of American adults on diets. 17(6): 1-3,
1999.

Coaching News (continued from page 9)


Imagine life without curiosity. It would be a grim, boring existence.
Our mission as coaches should be three-fold. First, we should be
curious about curiosity, encouraging research in our field. Second, we
should model curiosity for our clients in our powerful questions, active
listening, and perceptive reflections. Third, we should facilitate curiosity,
helping clients develop and use their curiosity to enhance their lives and
their health, so that they can live longer, more fulfilling lives.

About the Authors


BJ Richstone, Psy.D., CPC is a Harvard-trained clinical psychologist
and Certified Professional Coach. She has a Doctorate in Ministry
and is a published spiritual author. She has appeared nationally on
radio and television.
Margaret Moore (Coach Meg), MBA, is the
founder & CEO of Wellcoaches Corporation, a
strategic partner of ACSM, widely recognized as
setting a gold standard for professional coaches
in healthcare. She is co-director, Institute of
Coaching, at McLean Hospital/ Harvard Medical
School. She co-authored the ACSM-endorsed
Lippincott, Williams & Wilkins Coaching
Psychology Manual, the first coaching textbook
in healthcare. (www.wellcoaches.com www.instituteofcoaching.org
www.coachmeg.com coachmeg@wellcoaches.com)

References
1. Deci EL. The relation of interest to the motivation of behavior: A selfdetermination theory perspective. In: Renninger KA, Hidi S, Krapp A,
editors. The Role of Interest in Learning and Development. Hillsdale,
NJ: Lawrence Erlbaum, 1992.
2. Kashdan T. Curious? New York: HarperCollins, 2009.
3. Kashdan TB, Steger MF. Curiosity and pathways to well-being and
meaning in life: Traits, states, and everyday behaviors. Motiv Emot.
2007;31:159-173.
4. Kashdan TB, Silvia PJ. Curiosity and interest: The benefits of thriving
on novelty and challenge. In: Snyder CR, Lopez SJ, editors. Oxford
Handbook of Positive Psychology, 2nd edition. New York: Oxford
University Press, 2009.
5. Naylor FD. A state-trait curiosity inventory. Aust Psychol. 1981;16:172183.
6. Park N, Peterson C, Seligman MEP. Strengths of character and wellbeing. J Soc Clin Psychol. 2004;23:603-619.
7. Pecina S. Opiod reward liking and wanting in the nucleus accumbens. Physiol Behav. 2008;94:675-680.
8. Ryan RM, Deci EL. Self-determination theory and the facilitation of
intrinsic motivation, social development, and well-being. Am Psychol.
2000;55:68-78.
9. Swan GE, Carmelli D. Curiosity and mortality in aging adults: A 5year follow-up of the Western Collaborative Group Study. Psychol
Aging. 1996;11:449-453.
10. Vitterso J. Flow versus life satisfaction: A projective use of cartoons to
illustrate the difference between the evaluation approach and the
intrinsic motivation approach to subjective quality of life. J Happiness
Stud. 2003;4:141-167.

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

11

Cardiac Rehabilitation (continued from page 8)


limit exercise intensity. To do this, the clinician would monitor HR and
blood pressure during a few exercise sessions to identify the highest
work rate at which the patient remains below the rate-pressure product associated with the ischemic threshold identified during the dobutamine test. The resultant target HR range would then be set at 10 to 15
beats below this corresponding HR. Although this recommendation is
based on sound physiologic principles, it should be noted that the validity of this method has not been studied.
Vasodilator stress tests (e.g., adenosine, persantine) depend on medication-induced coronary artery vasodilatation and assess ischemia by
altering blood supply through the concept of coronary steal. During
this test, normal coronary arteries dilate to a greater extent than arteries with atherosclerosis and steal blood supply. Some testing laboratories include low levels of steady rate exercise during the test, but this
should not be mistaken for exercise test data. Since these tests do not
increase myocardial oxygen demand (HR and blood pressure response
are flat) and do not assess functional capacity, they provide little, if any,
useful information for the exercise prescription.
Finally, when a pharmacological stress test is negative, ACSMs current recommendations state If good HR increase: 70 to 85% HRmax.
It is not clear if this is referring to the highest HR observed during the
test or a predicted maximum HR. As was discussed above, the HR
response during pharmacological testing is not reflective of the HR
response that would be observed during an exercise test and is not useful for the exercise prescription. In addition, maximum HR predicted
from equations, such as 220-age, is not a useful tool in older patients,
patients with cardiovascular disease, and those on beta blockade therapy.3 The mechanisms underlying the variability associated with predicted
maximum HR are not clear, but may be due variations in genetics, autonomic function, and beta receptor activity.
In conclusion, defining exercise intensity without a recent exercise
test can be challenging. Further research to validate methods in these
situations is needed. In this absence, sound physiological principles
should guide clinical decisions. Towards this end, the knowledge, experience, and skills of the clinical exercise physiologist are important and
contribute to the art of exercise prescription.

4. Brawner CA, Ehrman JK, Keteyian SJ. Identifying a target heart rate
in patients with ischemic heart disease without an exercise stress
test. Med Sci Sports Exerc. 2005;37 (5 suppl): S226.
5. Brawner CA, Vanzant MA, Ehrman JK, et al. Guiding exercise using
the talk test among patients with coronary artery disease. J
Cardiopulm Rehabil. 2006;26:72-75.
6. Cannon C, Foster C, Porcari JP, Skemp-Arlt KM, Fater DCW, Backes
R. Prescribing exercise using the talk test: avoidance of exertional
ischemia. Am J Sports Med. 2004;6:52-56.
7. Dehart-Beverly M, Foster C, Porcari JP, Fater DCW, Mikat RP.
Relationship between the talk test and ventilatory threshold. Clin
Exerc Physiol. 2000;2:34-38.
8. Dishman RK. Prescribing exercise intensity for healthy adults using
perceived exertion. Med Sci Sports Exerc. 1994;26(9):1087-1094.
9. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline
update for exercise testing: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on Exercise Testing). Available from:
http://www.americanheart.org/downloadable/heart/10322790136
58exercise.pdf.
10. Joo KC, Brubaker PH, MacDougall A, Saikin AM, Ross JH, Whaley
MH. Exercise prescription using resting heart rate plus 20 or perceived exertion in cardiac rehabilitation. J Cardiopulm Rehabil.
2004;24:178-186.
11. Kraus WE. Utility of graded exercise testing in the cardiac rehabilitation setting. In: Kraus WE, Keteyian SJ, editors. Contemporary
Cardiology: Cardiac Rehabilitation. Totowa, NJ: Humana Press,
2007:103-110.
12. McConnell TR, Klinger TA, Gardner JK, Laubach CA, Herman CE,
Hauck CA. Cardiac rehabilitation without exercise tests for postmyocardial infarction and post-bypass surgery patients. J Cardiopulm
Rehabil. 1998;18:458-463.
13. Whaley MH, Brubaker PH, Kaminsky LA, Miller CR. Validity of rating of perceived exertion during graded exercise testing in apparently healthy adults and cardiac patients. J Cardiopulm Rehabil.
1997;17:261-267.

ABOUT THE AUTHOR


Clinton A. Brawner, M.S., RCEP, FACSM, is a
clinical exercise physiologist at Henry Ford
Hospital, Detroit, MI where he provides consultation and oversight on cardiopulmonary exercise
testing for sponsors of multi site clinical trials.
He is the chair of ACSMs RCEP practice board and
a member-at-large on the executive committee of the Clinical Exercise
Physiology Association (CEPA; www.cepa-acsm.org).

REFERENCES
1. American College of Sports Medicine. ACSMs Guidelines for
Exercise Testing and Prescription, 8th edition. Thompson WR,
Gordon NF, Pescatello LS, editors. Baltimore, MD: Lippincott
Williams & Wilkins, 2009:214-219.
2. Andreuzzi RA, Franklin BA, Gordon NF, Haskell WL. National survey of exercise practices in outpatient cardiac rehabilitation programs. Med Sci Sports Exerc. 2004;34 (suppl 5), S181.
3. Brawner CA, Ehrman JK, Schairer JR, Cao JJ, Keteyian SJ.
Predicting maximum heart rate among patients with coronary heart
disease receiving beta-adrenergic blockade therapy. Am Heart J.
2004;148: 910-914.

12

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

WELLNESS ARTICLE

MAKING SENSE OF THE

EXERCISE
PRESCRIPTION
Effective exercise prescription
requires that an exercise professional
be able to translate scientific principles
and theory into language and ideas
that are easy for a client to understand
and apply. In addition, an understanding of some of the theories of behavior
change may help the practitioner to
tailor the exercise prescription to each
clients individual needs.
The first step in developing an exercise prescription is to
determine the clients goals. Goals must be realistic, measurable,
and achievable. By applying behavioral change theory, such as
the theory of self-efficacy3 and the readiness for change model,8
the exercise professional involves the client in the goal-setting
process. Asking about a clients self-efficacy (self-confidence) to
make lifestyle changes regarding exercise, determining the barriers to exercise that may be encountered, and helping the individual make a plan to address those barriers, increases ownership in the exercise plan and may help the client adhere to the
program.2,3,6
When the goals have been determined, apply the FITT principle2 to address those goals. The FITT principle stands for
Frequency, Intensity, Time (duration), and Type (mode) of exercise; it provides a simple way to outline the components of any exercise
prescription. Whether a client wants to improve cardiorespiratory fitness or gain muscular endurance, whether he/she wants to lose weight,
recover from heart surgery, or train for the Olympics, the exercise professional can use the acronym FITT to delineate an appropriate exercise prescription.
The first three components must actually be considered together as
the total volume of physical activity will have an impact on the
health/fitness benefits achieved.5 When frequency (F) of exercise is
increased, it may be prudent to cut down on the intensity (I) or the time
(T) spent exercising. Alternatively, when intensity (I) is low, a person may
need to exercise for a longer duration (T) to reach their specific goals.
Considering the fourth component, type (T) of exercise, the principle of
specificity of training9 informs us that the mode of activity needed for
cardiorespiratory benefits is aerobic; resistance training exercises will be

BY SHERRY BARKLEY, Ph.D., CES, RCEP


AUGUSTANA COLLEGE, SIOUX FALLS, SD
necessary for improvements in muscular fitness; and stretching exercises are needed for improving flexibility. For each aspect of overall fitness,
there are many activities to choose from, some requiring little to no skill,
others requiring high levels of fitness.2,6 Encourage the client to choose
an appropriate mode (or modes) of exercise based on their goals, access
to facilities and equipment, current health status, physical ability, and personal preference.
For health benefits, recent guidelines specify that healthy adults
between the ages of 18 and 65 years should participate in at least 30
minutes of moderate-intensity aerobic activities on five days per week,
or 20 minutes of vigorous aerobic activity on three days of the week, or
some combination of moderate- and vigorous-intensity aerobic activity.5
Moderate- and vigorous-intensity activities are described as equivalents
to a brisk walk or jog respectively, and by the persons heart rate and
breathing response to exercise. The guidelines also specify that the 30

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

13

interrupted for any extended time needs to be reminded that is important to re-start slowly and not expect to pick up where one left off.
In summary, while the client does not need to understand all the scientific principles of exercise, the exercise professional must be aware of
all of these guidelines to help each individual determine an appropriate
prescription that will make SENSE and FITT their unique needs.

About the Author


Sherry Barkley, Ph.D., CES, RCEP is an assistant professor and chair of the HPER Department at
Augustana College in Sioux Falls, SD. She is a pastpresident of the NACSM and a current member of
the CCRB Publications Subcommittee. Sherry has
many years of clinical experience and has prescribed
exercise for healthy adults, expectant mothers, and
participants in weight management programs as well
as for patients with cardiac, pulmonary, renal and
neuromuscular diseases.

References:
1. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical
activities: An update of activity codes and MET intensities. Med Sci
Sports Exerc. 2000;32(suppl.):S498-S516.
2. American College of Sports Medicine. ACSMs Guidelines for Exercise
Testing and Prescription, 8th ed. Thompson WR, Gordon NF, Pescatello
LS, editors. Baltimore, MD: Lippincott Williams & Wilkins, 2009.
3. Bandura A. Social foundations of thought and action, a social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1994.
4. Borg GAV. Borgs perceived exertion and pain scales. Champaign, IL:
Human Kinetics, 1998.
5. Haskell WL, Lee I-M, Pate RR, et al. Physical activity and public health:
Updated recommendation for adults from the American College of
Sports Medicine and the American Heart Association. Med Sci Sports
Exerc. 2007;39:1423-1434.
6. Heyward VH. Advanced Fitness Testing and Exercise Prescription, 5th ed.
Champaign, IL: Human Kinetics, 2006.
7. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public
health in older adults: Recommendations from the American College of
Sports Medicine and the American Heart Association. Med Sci Sports
Exerc. 2007;39:1435-1445.
8. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and
stages of change. In: Glanz K, Rimer BK, Lewis FM, Eds. Health behavior
and health education, theory research and practice. San Francisco:
John Wiley & Sons, 2002.
9. Wilmore JH, Costill DL, Kenney WL. Physiology of Sport and Exercise,
4th ed. Champaign, IL: Human Kinetics, 2008.

SELF-TEST ANSWER KEY FOR PAGE 15


QUESTION
1
2
3
B
A
C
C
A
B
B
B
A
C
D
B

4
D
C
D
D

5
A
D
D
B

14

TEST #1:
TEST #2:
TEST #3:
TEST #4:

minutes of moderate-intensity activity may be accumulated in 10-minute


bouts if necessary. Moreover, this group also is encouraged to include
two non-consecutive days of activity which promote improvements in
muscular fitness/strength. A separate document was presented to clarify the recommendations for adults over the age of 65, and for those
aged 50 to 64 years with various health limitations.7
For cardiorespiratory fitness, a minimum threshold of frequency,
intensity and duration of aerobic exercise must be attained before benefits are achieved, although the appropriate dose of exercise can vary
from one individual to the next. In general, the recommended frequency is three to five days/week, intensity may vary from 40% to 85% of
ones VO2 reserve (VO2R), and duration may be from 20 to over 60
minutes.2,9 In some cases, the volume of exercise is specified by calories
(kcals) expended in a week.2 Clients also may need to be reminded that
while exercise is good, more is not always better; an excessive amount
of exercise can increase the risk of an overuse injury.2
Intensity is the component of the exercise prescription that usually
needs most clarification. Some clients feel that exercise is a no pain, no
gain experience, and it is up to the exercise professional to dissuade
that line of thinking. Intensity can be prescribed in terms of heart rate
(HR), aerobic capacity (VO2), metabolic equivalents (METs), or perceived exertion (RPE). These are well-described in the eighth edition of
the ACSM Guidelines for Exercise Testing and Prescription.2 Using HR
as a gauge of intensity is very helpful if the client can accurately find
his/her pulse or has access to a HR monitor and he/she is not taking
any medications that impact HR. Intensity prescriptions using percentage of VO2R or METs may be helpful if they can be translated into specific activities1 or to more precise workout levels on a specific piece of
equipment. However, unless the client has participated in a maximumeffort graded exercise test, any prescription using HR, VO2R, or MET
level is only an estimate. Conversely, if the client can be made to understand how to use the RPE scale appropriately, someone who exercises
at a level of fairly light to somewhat hard or hard is usually exercising at an appropriate HR, VO2R or MET level.2,4 It is up to the exercise
professional to determine which explanation of exercise intensity will be
most helpful to each individual client.
The acronym SENSE (Start Exercise Nice and Slow Everytime) can
be used to explain that every exercise training session should include a
warm-up period along with the conditioning phase, stretching, and cooldown activities. In addition, the client whose exercise routine has been

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

JANUARY-MARCH 2010 Continuing Education Self-Tests


Credits provided by the American College of Sports Medicine CEC Offering Expires March 31, 2011
SELF-TEST #1 (1 CEC):The following questions
4. According to the author, prior to engaging in
were taken from Exercise Recommendations for the agility training clients should have approximately
Frail Population published in this issue on page 3.
___ to ___ months of consistent resistance training
experience.
1. Which of the following is NOT a defining criteria
a. 1-2
b. 2-3
for frailty?
c. 3-4
d. 4-6
a. Feeling of exhaustion
5.According to this article, agility training may be
b. Depression
beneficial to the general population for:
c. Low physical activity
a. improving proprioceptive capabilities.
d. Slow walking speed
b. injury prevention.
2. Obesity is a potential contributing factor to frailty.
c. the development of motor programs.
a. True
b. False.
d. all of the above.
3. Sarcopenia can most effectively be countered
with:
a. aerobic training.
b. flexibility training.
c. resistance training.
d. yoga and Tai Chi.
4. Resistance training for frail persons should be
performed using ___ repetitions per set.
a. 6-10
b. 8-12
c. 6-12
d. 10-15
5. _______ is the most common aerobic activity in
older adults.
a. Walking
b. Cycling
c. Swimming
d. Rowing
SELF-TEST #2 (1 CEC): The following questions
were taken from Agility Training for the General
Population published in this issue on page 5.
1. ________ drills are preprogrammed drills,
performed in a predictable and unchanging
environment.
a. Open
b. Semi-open
c. Closed
d. Skill

3.Drills that are partially preprogrammed and


partially random are classified as________ drills.
a. Open
b. Semi-programmed
c. Closed
d. Skill

ACSMS

CERTIFIED
NEWS

SELF-TEST #4 (1 CEC): The following questions


were taken from Making Sense of the Exercise
Prescription published in this issue on page 13.

SELF-TEST #3 (1 CEC): The following questions


1. The behavioral change theory that address selfwere taken from Prescribing Exercise in Cardiac
confidence to exercise is:
Rehabilitation Without an Exercise Test published in
a. the self-esteem theory.
this issue on page 7.
b. the stages of change model.
1. ACSMs Guidelines for Exercise Testing and
c. the self-efficacy theory.
Prescription, 8th edition does not address the
d. the theory of self-reliance.
determination of target heart rate in patients with
2. For a client who has not performed a maximal
heart disease in the absence of an exercise test.
exercise test, the most accurate marker of exercise
a. True
b. False.
intensity may be:
2. According to the article, which of the following is
NOT a typical reason to conduct a symptom-limited
exercise test in patients with heart disease entering
cardiac rehabilitation:
a. identify residual ischemia
b. assess breathing reserve
c. risk stratification
d. quantify functional capacity
3. According to the article, what is the anticipated
percent of heart rate reserve when exercise
intensity is established using rest plus 20 in patients
with heart disease?
a. <50%
b. 50-60%
c. 60-70%
d. 70-80%

2. Agility training should not be performed


by_______________.
a. those who are pregnant
b. those who are overweight
c. those with more than 4 to 6 months of
resistance training experience
d. all of the above

5. According to the article, a vasodilator stress test


(e.g., adenosine):
a. is useful for establishing an exercise target
heart rate range.
b. is useful for establishing an exercise target
heart rate range if exercise is included.
c. is useful for establishing an exercise intensity
based on perceived exertion.
d. is not useful for establishing an exercise target
heart rate range.

4. Per ACSM's Guidelines for Exercise Testing and


Prescription, 8th edition, which of the following is
NOT suggested as a guide to titrate exercise
intensity?
a. rating of perceived exertion
b. signs
c. symptoms
d. resting heart rate

a. heart rate.
c. MET level.

b. VO2.
d. Rate of Perceived
Exertion (RPE).

3. When prescribing moderate-intensity exercise for


health benefits, the recommended duration and
frequency of exercise is:
a. 20 minutes, 2 times per week.
b. 30 minutes, 5 times per week.
c. 40 minutes, 4 times per week.
d. 60 minutes, 5 times per week.
4. The acronym SENSE can be used to help remind a
client to include start slowly:
a. during an individual exercise session.
b. when beginning an exercise program.
c. when re-starting an exercise program after a
period of inactivity.
d. All of the above.
5. A thorough explanation of all of the scientific
principles behind an exercise prescription will help a
client adhere to an exercise program.
a. True
b. False.

To receive credit, circle the best answer for each question, check your answers against the answer key on page 14,
and mail entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine,
Dept 6022, Carol Stream, IL 60122-6022
ACSM Member (PLEASE MARK BELOW)
Please Allow 4-6 weeks for processing of CECs
[ ] Yes-$15
TOTAL $_________________
ACSM USE:
[ ] No- $20
($25 fee for returned checks)
666919
ID # __________________ (Please provide your ACSM ID number)

PLEASE PRINT OR TYPE REQUESTED INFORMATION


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JANUARY-MARCH 2010 Issue EXPIRATION DATE: 03/31/11 SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED Federal Tax ID number 23-6390952

Tip: Frequent self-test participants can find their ACSM ID number located on any ACSM CEC verification letter.

ACSMS CERTIFIED NEWS JANUARY-MARCH 2010 VOLUME 20:1

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