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The scope of practice for the personal trainer

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PERSONAL TRAINING QUARTERLY

PTQ VOLUME
VOLUME1 1
ISSUE
ISSUE41
ABOUT THIS PUBLICATION PERSONAL TRAINING QUARTERLY
Personal Training Quarterly (PTQ)
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PTQ 1.4 | NSCA.COM
TABLE OF CONTENTS
THE SCOPE OF PRACTICE FOR
04 PERSONAL TRAINERS
JUSTIN KOMPF, CSCS, NSCA-CPT, NICK TUMMINELLO,
AND SPENCER NADOLSKY, MD

EXERCISE BEFORE AND AFTER

10 BARIATRIC SURGERY
CINDY KUGLER, MS, CSCS, CSPS

SMALL GROUP TRAINING UTILIZING CIRCUITS

16 CHAT WILLIAMS, MS, CSCS,*D, CSPS,
NSCA-CPT,*D, FNSCA

HIGH HORMONE CONDITIONS FOR HYPERTROPHY

20 WITH RESISTANCE TRAINING: A BELIEF—NOT
EVIDENCE-BASED PRACTICE IN STRENGTH
AND CONDITIONING
STUART PHILLIPS, PHD, CSCS, FACSM, FACN, ROBERT
MORTON, CSCS, AND CHRIS MCGLORY, PHD

HOW SAFE ARE SUPPLEMENTS?

24 DEBRA WEIN, MS, RD, LDN, NSCA-CPT,*D, AND
JENNA AMOS, RD

THE SHARED ADAPTATIONS OF THE TRAINING AND

26 REHABILITATION PROCESSES
CHARLIE WEINGROFF, DPT, ATC, CSCS

GETTING THE MOST OUT OF A CERTIFICATION IN

30 PERSONAL TRAINING
ROBERT LINKUL, MS, CSCS,*D, NSCA-CPT,*D

PTQ
PTQ1.41.1| |NSCA.COM
NSCA.COM
FEATURE ARTICLE
THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS
JUSTIN KOMPF, CSCS, NSCA-CPT, NICK TUMMINELLO, AND SPENCER NADOLSKY, MD
T
he personal trainer can play a vital role in the overall health
and well-being in each of their clients. The purpose of this
article is to define the role of the personal trainer. This
article will also explore the extent of their scope and will identify
when a referral to a healthcare provider would be appropriate.
Out of the major, recognized certifying bodies, the American
College of Sports Medicine (ACSM) and the National Strength and
Conditioning Association (NSCA) are the only two organizations
that have attempted to delineate the specific job description of
the personal trainer.
According to the ACSM (1):
The ACSM Certified Personal Trainer (CPT) works with
apparently healthy individuals and those with health
challenges who are able to exercise independently to enhance
quality of life, improve health-related physical fitness,
performance, manage health risk, and promote lasting health
behavior change. The CPT conducts basic pre-participation
health screening assessments, submaximal aerobic exercise
tests, and muscular strength/endurance, flexibility, and
body composition tests. The CPT facilitates motivation and
adherence as well as develops and administers programs
designed to enhance muscular strength/endurance, flexibility,
cardiorespiratory fitness, body composition, and/or any of the
motor skill related components of physical fitness (i.e., balance,
coordination, power, agility, speed, and reaction time).
4 PTQ 1.4 | NSCA.COM
Likewise, according to the NSCA (13):
Personal trainers are health/fitness professionals who, using an
individualized approach, assess, motivate, educate, and train
clients regarding their health and fitness needs. They design
safe and effective exercise programs, provide the guidance to
help clients achieve their personal health/fitness goals, and
respond appropriately in emergency situations. Recognizing
their own area of expertise, personal trainers refer clients to
other healthcare professionals when appropriate.
Personal trainers should fulfill a specific role within the healthcare
system and as a healthcare provider. Trainers should have a strong
knowledge base in kinesiology, psychology, injury prevention,
nutrition, and knowledge of simple medical screening tests.
Because of this, they may share certain roles with other healthcare
providers such as dietitians, physical therapists, doctors, and
psychologists.
Before divulging into the scope of the practice, it is necessary
for personal trainers to identify two major components of their
profession; research and practical experience, more specifically
the application of research to practice. In a review by English et
al., the author defines evidence-based training for strength and
conditioning professionals as a systematic approach to the training
of athletes and clients based on the current best evidence from
peer-reviewed and professional reasoning (6). Evidence-based
practice is a five step systematic process. The five steps are to
develop a question, find evidence, evaluate the evidence, integrate
the evidence into practice, and reevaluate the evidence.
The question should be defined precisely; the authors provide
the acronym “PICOT,” which stands for population, intervention,
comparison, outcome, and time (6). The question that trainers
ask should contain all of these components. For example, is a
resistance training program (intervention) of pull-ups or
chin-ups (comparison) a better biceps muscle builder (outcome)
in healthy college-aged males (population) over the course of
12 weeks (time)?
Evidence can be obtained through a variety of sources. Some
sources personal trainers should consider using include academic
search engines as well as websites like the National Strength and
Conditioning Association website (www.nsca.com). Professional
experience can also be counted as anecdotal evidence although
it is not as strong as a form of evidence as peer-reviewed studies.
The ability to evaluate evidence and weigh it against other
evidence is an important skill for the success of a personal trainer.
The Journal of Bone and Joint Surgery introduced a system for
ranking levels of evidence. The levels of evidence in order from
lowest to highest are: expert opinion; case series (no control
group); case-control study, retrospective cohort study, and
systematic review of level-III studies; prospective cohort study,
poor quality randomized controlled trial, systematic review of level
II studies, and nonhomogeneous level I studies; and randomized
controlled trial and systematic review of level I randomized
controlled trials (19).
If the evidence presented is strong, then a training modality
should be integrated into practice. For example, it has been proven
that Olympic-style lifting improves explosive power (3,18). If a
personal trainer is working with an athlete that requires explosive
power, then they should consider integrating some Olympic-style
weightlifting. If the evidence is weak or inconsistent, then perhaps
time would be better spent on other training practices (6).
Being able to evaluate research means keeping an open mind,
as the evidence-based personal trainer will change their practice
when new and better evidence demands are presented. Once the
personal training field as a whole understands how to evaluate
evidence, the scope of practice may expand; however, for now,
personal trainers should focus specifically on exercise screening
and prescription. Personal trainers can also hold some ground
in injury management, psychology, and nutrition. Given the
appropriate educational background, personal trainers may
also play a role in working with populations with specific
medical impairments.
EXERCISE ASSESSMENT AND PRESCRIPTION
Personal trainers provide resistance training exercise prescription
which may improve cardiovascular function, reduce the risk
of coronary heart disease and noninsulin dependent diabetes,
prevent osteoporosis, reduce the risk of colon cancer, enhance
weight loss while preserving muscle mass, improve dynamic
stability, and maintain functional capacity and psychological
well-being (17). The personal trainer should have an established
screening protocol including a physical activity readiness
questionnaire as well as a movement screen, which should be
conducted before resistance training.
PTQ 1.4 | NSCA.COM
The Physical Activity Readiness Questionnaire (PAR-Q) is a
screening test designed to determine an individual’s risks in
participating in physical activity (7). The PAR-Q allows the
personal trainer to identify clients with cardiovascular disease
or risk factors for disease. If a client is identified as “at risk” they
should be referred to a medical professional who will provide a
medical evaluation before beginning an exercise program (11).
While there are a variety of movement screens available to the
personal trainer, they all provide similar outcomes and offer
insight as to which exercises can be performed in a safe and
non-painful way.
Personal trainers should be able to take the information from their
screening process to create an exercise program for each client
based on their current physical capabilities. Effective strength
training programs include multi-joint movements which have been
grouped in a variety of different ways. For example, Kritz et al.
states that there are seven fundamental patterns: squat, lunge,
upper body push, upper body pull, bend, twist, and single-leg
patterns (9). If a trainer screens a client and discovers that they
are new to exercise and possess limited hip mobility, the personal
trainer may want to prescribe a kettlebell hinge exercise rather
than a conventional deadlift for the bend category of movement.
The inability to apply the screening results to an exercise program
could lead to frustration and/or injury.
A personal trainer should also be competent in coaching and
teaching a variety of exercises. Trainers should be able to coach
a basic hinge and bodyweight squat to their clients. In that, the
job of the personal trainer is to find the safest and most effective
means of helping clients achieve their performance and/or
physical goals (e.g., become stronger, bigger, leaner, and faster).
The job of the personal trainer is to help their client achieve these
goals while working around any aches, pains, or limitations.
THE PERSONAL TRAINER’S ROLE WITH
INJURED CLIENTS
In regards to the specific job description of the physical therapist,
according to the Maine Physical Therapy Practice Act (16):
The practice of physical therapy includes the evaluation,
treatment, and instruction of human beings to detect, assess,
prevent, correct, alleviate, and limit physical disability, bodily
malfunction, and pain from injury, disease, and any other
bodily condition; the administration, interpretation, and
evaluation of tests and measurements of bodily functions and
structures for the purpose of treatment planning; the planning,
administration, evaluation, and modification of treatment and
instruction; and the use of physical agents and procedures,
activities, and devices for preventive and therapeutic purposes;
and the provision of consultative, educational, and other
advisory services for the purpose of reducing the incidence
and severity of physical disability, bodily malfunction, and pain.
5
THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS
Additionally, the Florida State Physical Therapy Practice Act
describes what a physical therapy assessment entails (14):
Physical therapy assessment means observational,
verbal, or manual determinations of the function of
the musculoskeletal or neuromuscular system relative
to physical therapy, including, but not limited to, range
of motion of a joint, motor power, postural attitudes,
biomechanical function, locomotion, or functional abilities,
for the purpose of making recommendations for treatment.
Based on these above job descriptions provided by the certifying
bodies in each profession, it is clear and obvious that the
assessments of muscle imbalances, compensations, movement
impairments, and other orthopedic issues and the attempt to
correct these issues using specific exercise interventions, is the
job of the physical therapist and/or orthopedic specialist, not of
the personal trainer. Physical therapists and orthopedic specialists
work specifically to fix what is broken or severely injured, whereas
personal trainers and coaches work to enhance what is not broken.
Put simply, training consists of assessing what they currently have
and using general exercise to improve on what they currently
have while working around what is broken or severely injured. On
the other hand, treatment, which is in the realm of the physical
therapist and/or orthopedic specialist, is the diagnosing of what is
broken and using specific corrective measures to fix it in order to
bring the clients back to what they previously had. When it comes
to performing the exercises provided in a way that best fits the
client, there are two simple criteria:
1. Comfort: Movement is pain-free, feels natural, and works
within the client’s current physiology
2. Control: The client can demonstrate the movement
technique and body positioning as provided in each
exercise description (e.g., when squatting, the client
displays good knee and spinal alignment throughout, along
with smooth, deliberate movement)
It is important to keep in mind that “comfort” does not mean the
sensation associated with muscle fatigue or “feeling the burn.”
Discomfort refers to aches and pains that exist outside the gym
or flare up when the client performs certain movements. To allow
for comfort and control, personal trainers may have to modify (i.e.,
shorten) the range of motion or adjust the hand or foot placement
of a particular exercise to best fit the client’s current ability and
anatomy.
THE PERSONAL TRAINER’S ROLE IN PSYCHOLOGY
AND NUTRITION COUNSELING
The personal training profession has a solid base not just in
exercise, but in nutrition as well (2). However, a personal trainer is
not qualified like a Registered Dietitian (RD), who can write meal
plans for clients. Nutrition is related to psychology in that most
clients have a fair and very general understanding of what they
need to do to improve their eating habits. The real question, and
the one personal trainers can help with, is why do they not take
the steps to become healthy? Personal trainers should be able
6 PTQ 1.4 | NSCA.COM
to disseminate information on nutrition, serve as counselors to
behavior change, and act as a motivator for health change. This
can all be done without writing a specific meal plan for a client.
Trainers can implement an effective change protocol to be used
to hasten behavior change. Chip and Dan Heath, the authors of
the book “Switch: How to Change Things When Change is Hard,”
identify two factors that can be modified to help people change
(8). The authors talk about the environment which includes the
person’s network and the path to change, discussing how small
changes are more lasting than big changes. For example, one
longitudinal study showed that if a close, same-sex friend became
obese, that person has a 71% risk of becoming obese as well (4).
Changing environmental habits linked to eating can also help a
client lose weight. Successful behavioral modification interventions
have worked by limiting the place overweight people eat to one
location, which may prevent binge eating or random snacking
(15). The book also explains how to direct the client analytically
and how to get them on board for long-term goals emotionally
(8). Some initial questions a personal trainer may ask a client
could include (8):
1. How ready are you to change on a scale of 1-10?
2. How important is it for you to change on a scale of 1-10?
3. How confident are you that you can change on a scale of
1-10?
4. Of your five closest friends, spouses, partners, and siblings,
how many of them place a strong emphasis on healthy
living?
5. Name the people that do and your relationship with them.
6. Are there any people that are close to you that you feel
negatively affect your health goals? If so, who are these
people and what is your relationship to them?
THE PERSONAL TRAINER’S ROLE IN MEDICAL CARE
Practicing medicine is not within the scope of practice for the
personal trainer. However, there are certain conditions that could
be easily screened by a personal trainer especially if a client does
not spend much time with their physician or even go to their
physician regularly. Personal trainers push a healthy all-around
lifestyle, which includes diet, exercise, and even sleep. As the
obesity epidemic continues, so do the comorbid conditions that
accompany it, including osteoarthritis, diabetes, hypertension, and
obstructive sleep apnea (OSA) (10). Even through physician visits
are typically short, hypertension and diabetes can be easily and
regularly screened.
Osteoarthritis is a very common complaint that a patient will see a
doctor for due to pain. OSA, on the other hand, may be missed in
a quick doctor visit. While a personal trainer cannot diagnose OSA,
it would benefit the client if the personal trainer could recognize
the signs of OSA, so that it might not go unnoticed. Personal
trainers could ask questions from validated questionnaires to
 NSCA.com
NSCA.com

know when to refer to a doctor. One such questionnaire, the STOP Figure 1 provides some basic examples of scenarios that a personal
questionnaire, is an easy way to assess if a client is at risk of trainer may encounter to help decipher whether it is within the
having OSA (5): scope of practice or not. It is important for all personal trainers to
be familiar with local bylaws on scope of practice, as they may be
1. Snoring: Do you snore loudly? (louder than talking or different depending on where the personal trainer lives. Personal
heard through closed doors) Y/N trainers play a vital role in the general health and well-being of
their clients, but it is important for the personal trainer to clearly
2. Tired: Do you often feel tired, fatigued, or sleepy during
understand the extent of their influence to avoid legal implications
the day? Y/N
and potential injuries to their clients.
3. Observed: Has anyone observed you stop breathing during
your sleep? Y/N

4. Pressure: Do you have or are being treated for high blood

pressure? Y/N

5. Body mass index (BMI): Is your BMI greater than 35 kg/

m2?

6. Age: Are you over the age of 50?

7. Neck circumference: Is your neck circumference greater

than 40 cm?

8. Gender: Is your gender male?

High risk for OSA = 3 or more questions answered “yes”

Low risk for OSA = less than 3 questions answered “yes”

FIGURE 1. BASIC EXAMPLES OF A PERSONAL TRAINER’S SCOPE OF PRACTICE (11,12)

INJURED CLIENTS NUTRITION AND PSYCHOLOGY MEDICINE

Chronic low back pain and local Facilitation of habit change

Practicing medicine is not
Within the Scope of Practice within the scope of practice;
Dissemination of
Pain comes and goes however, trainers may have
nutrition knowledge
knowledge of screens to use
Minor acute pain to make appropriate referrals
Motivational interviewing and
abetment of change talk

Unmanageable pain PAR-Q indicates potential

Eating disorder
with movement cardiovascular disease

When a Referral is Necessary Unable to complete activities

Metabolic disease
of daily living
Positive screen for OSA
Client has been following or other conditions
Radiating low back pain
healthy habit changes but
is not losing weight

PTQ 1.4 | NSCA.COM 7

THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS
REFERENCES
1. American College of Sports Medicine. ACSM Certified Personal
Trainer job task analysis. ACSM.org. 2010. Retrieved 2014 from
http://certification.acsm.org/files/file/JTA%20CPT%20FINAL%20
2012.pdf.
2. Carter, L. The personal trainer: A perspective. Strength and
Conditioning Journal 23(1): 14-17, 2001.
3. Channell, BT, and Barfield, JP. Effect of Olympic and
traditional resistance training on vertical jump performance
improvement in high school boys. The Journal of Strength and
Conditioning Research 22(5): 1522-1527, 2008.
4. Christakis, NA, and Fowler, JH. The spread of obesity in large
social network over 32 years. N Engl J Med 357(4): 370-379, 2007.
5. Chung, F, Yegneswaran, B, Liao, P, Chung, SA, Vairavanathan,
S, Islam, S, Khajehdehi, A, and Shapiro, CM. STOP questionnaire:
A tool to screen patients with obstructive sleep apnea.
Anesthesiology 108: 812-821, 2008.
6. English, KL, Amonette, WE, Graham, M, and Spiering, B. What
is “evidence-based” strength and conditioning? Strength and
Conditioning Journal 34(3): 19-24, 2012.
7. Evetovich, TK, and Hinnerichs, KR. Client consultation and
health appraisal. In: Coburn, JW, and Malek, MH (Eds.), NSCA’s
Essentials of Personal Training. (2nd ed.) Champaign, IL: Human
Kinetics; 147-200, 2012.
8. Heath, C, and Heath, D. Switch: How to Change Things When
Change Is Hard. New York, NY: Broadway; 2010.
9. Kritz, M, Cronin, J, and Hume, P. Screening the upper body
push and pull patterns using bodyweight exercises. Strength and
Conditioning Journal 32(3): 72-82, 2010.
10. Kushner, R. Roadmaps for Clinical Practice: Case Studies in
Disease Prevention and Health Promotion-A Primer for Physicians;
Communication and Counseling Strategies. Chicago, IL: American
Medical Association; 2003.
11. McNeely, E. Prescreening for the personal trainer. Strength
and Conditioning Journal 30(5): 68-69, 2008.
12. Mikla, T, and Linkul, R. Drawing the line: The CPT’s scope of
practice. National Strength and Conditioning Association National
Conference, July 2012.
13. National Strength and Conditioning Association. NSCA
Certified Personal Trainer (NSCA-CPT). NSCA.com. Retrieved 2014
from http://www.nsca.com/Certification/CPT/.
14. Official Internet Site of the Florida Legislature: Online
Sunshine. The 2014 Florida statutes. 2014. Retrieved 2014
from http://www.leg.state.fl.us/statutes/index.cfm?App_
mode=Display_Statute&Search_String=&URL=0400-0499/0486/
Sections/0486.021.html.
15. Penick, SB, Lilion, R, Fox, S, and Stunkard, AJ. Behavior
modification in treatment of obesity. J Behav Med 33: 49-56, 1971.
8 PTQ 1.4 | NSCA.COM
16. Public Laws: 123rd Legislature First Regular Session. Section
N-2 32 MRSA 3111-A: Scope of practice. Retrieved 2014 from
http://www.mainelegislature.org/ros/LOM/lom123rd/PUBLIC402_
ptN.asp.
17. Ratamess, NA, Alvar, BA, Evetoch, TK, Housch, TJ, Kibler, WB,
Kraemer, WJ, and Triplett TN. Progression models in resistance
training for healthy adults. Med Sci Sports Exerc 41: 687-708, 2009.
18. Suchomel, TJ, Wright, GA, Kernozek, TW, and Kline, DE.
Kinetic comparison of the power development between power
clean variations. The Journal of Strength and Conditioning
Research 28(2): 350-360, 2014.
19. Wright, JG, Swiontkowski, MF, and Heckman, JD. Introducing
levels of evidence to the journal. J Bone Joint Surg Am 85(1): 1-3,
2003.
ABOUT THE AUTHOR
Justin Kompf is the Head Strength and Conditioning Coach at
the State University of New York at Cortland. He is a Certified
Strength and Conditioning Specialist® (CSCS®) and a Certified
Personal Trainer® (NSCA-CPT®) through the National Strength and
Conditioning Association (NSCA).
Nick Tumminello is the owner of Performance University, which
provides practical fitness education for fitness professionals
worldwide, and is the author of the book “Strength Training
for Fat Loss.” Tumminello has worked with a variety of clients
from National Football League (NFL) athletes to professional
bodybuilders and figure models to exercise enthusiasts. He also
served as a conditioning coach for the Ground Control Mixed
Martial Arts (MMA) Fight Team and is a fitness expert for Reebok.
Tumminello has produced 15 DVDs, is a regular contributor to
several major fitness magazines and websites, and writes a very
popular blog at PerformanceU.net.
Spencer Nadolsky is a licensed practicing family medicine resident
physician. After a successful athletic career at the University of
North Carolina at Chapel Hill, Nadolsky enrolled in medical school
at the Virginia College of Osteopathic Medicine with aspirations to
change the world of medicine by pushing lifestyle changes before
drugs (when possible). Proper lifting, eating, laughter, and sleeping
are medications he advocates.
 NSCA.com

PTQ 1.4 | NSCA.COM 9

FEATURE ARTICLE
EXERCISE BEFORE AND AFTER BARIATRIC SURGERY
CINDY KUGLER, MS, CSCS, CSPS
A
s reports from the Centers for Disease Control and
Prevention indicate, obesity continues to remain high and
is associated with high morbidity and mortality rates (3).
The increase in obesity results in a higher volume of bariatric
surgeries being performed (10). This increases the likelihood that
exercise professionals working in various settings will encounter
patients who are pre- or post-bariatric surgery. This article will
address exercise-related issues and programming needs specific
to the bariatric surgical client.
TYPES OF SURGERY
Bariatric surgery falls into two main categories, restrictive
procedures and malabsorptive procedures. Both of these
types can be done either laparoscopically or with an open,
larger incision. Restrictive procedures include gastric band
and sleeve gastrectomy. These procedures decrease the size
of the stomach reservoir so as to limit food intake.
Malabsorptive procedures include biliopancreatic diversion,
in which a portion of the stomach is removed and a part of
the small bowel is bypassed; thus, causing weight loss by
decreased absorption of food. The Roux-en-Y gastric bypass
procedure is another malabsorptive procedure which also
includes a restrictive component.
PRE-SURGICAL ASSESSMENT
Due to the possible complications and risks of surgery, a
multidisciplinary pre-operative assessment is done to determine
appropriate surgical candidates (11,13). The patient should have a
10 PTQ 1.4 | NSCA.COM
comprehensive medical, physical, and psychological assessment.
See Table 1 for pre-screening criteria examples.
The primary exercise objectives pre-surgery are to assess the
client’s ability to follow the lifestyle change necessary for long-
term success and to decrease the surgical risks by increasing
cardiorespiratory fitness (3,16). After surgery, not only is exercise
essential for long-term weight loss, it has also been shown to be
critical in reducing health risks (5).
PRE-SURGICAL TESTING
Exercise testing is beneficial to assist in exercise prescription
(initial and ongoing), monitoring progress and giving feedback
to the client, trainer, and physician. Initial testing should be done
pre-surgery and repeated at regular intervals—a minimum of every
three months post-surgery is recommended. Prior to testing and
exercise, medical clearance from the patient’s surgeon or primary
physician should be obtained (1). Ideally, yet rarely available,
having results of a physician-supervised stress test to assist in
program design and risk assessment would be beneficial (7).
Additional beneficial tests include (8,17):
• Circumference measurements
• Body composition (using dual-energy x-ray absorptiometry
[DEXA] or body fat assessment)
• 6-min walk test
• Sit and reach (modified if indicated)
 • Grip dynamometer
• Modified push-up (wall if indicated)
• Metabolic testing (indirect calorimetry to determine resting
metabolic rate)
PRE-SURGICAL EXERCISE
Physical activity recommendations should take into account
musculoskeletal issues, activity tolerance, along with personal
preferences. Adherence will decrease if the program is not
practical, easily accomplished, and able to be integrated into an
individual’s lifestyle. A gradual progression of aerobic exercise
based on tolerance, as well as resistance training and flexibility
training is recommended. In order to meet the pre-surgical
exercise goals of predicting long-term success via lifestyle change
and decreasing surgical risks, exercise should begin 8 – 12 weeks
prior to surgery. Those with weight bearing limitations should
focus on low-impact exercise such as recumbent bicycles, chair
exercise, and water exercise. With water exercise, finding an
environment the client will feel comfortable in will be important.
Utilizing assistive devices such as canes, grocery carts, or walking
sticks along with any needed supportive devices such as braces/
sleeves, orthotics, or abdominal binders may assist in successful
ambulation. The overall goal is to establish a consistent routine
of cardiovascular exercise 3 – 5 times per week at low levels.
Often this population begins with very low exercise tolerance.
Many will need to start at 5 – 10 min of exercise and progress to
30 min. This may include intermittent bouts working towards the
recommended 150 min per week (16).
Resistance training should include one set of 12 – 15 repetitions 2 –
3 times per week utilizing bands, tubing, and/or bodyweight with
8 – 10 exercises for a total body workout. Important in exercise
selection is to include exercises for the abdominal musculature.
This will assist in post-surgical movement and recovery. Exercises
may need to be designed to be performed primarily in a sitting
position, with limited standing positions as tolerated. See Table 2
for a sample resistance training program.
POST-SURGICAL EXERCISE PRESCRIPTION
Quality of life can be greatly improved after successful bariatric
surgery (5). Exercise is one of the key tools for achieving weight
loss and preventing weight gain post-surgery (14). Resistance
exercise may also help by preventing muscle loss associated with
rapid weight loss, increasing bone strength, and decreasing the
chance of osteoporosis (8,9).
Immediate post-surgical exercise may also reduce the risk of
blood clots and other post-operative complications. In addition,
it can help patients tolerate their post-operative diet, assist in
alleviating nausea, and aid in getting the digestive system moving
again. Post-bariatric surgery exercise is consistent with guidelines
prescribed for obese clients (15).
CARDIORESPIRATORY EXERCISE
Initial in-hospital exercise through two weeks post-surgery should
consist of low-level exercise such as walking, seated marching,
chair boxing, or stationary recumbent bicycling as tolerated
(usually 5 – 10 min sessions) 3 – 4 times per day. Increasing
duration slowly to 20 – 30 min, using multiple bouts is acceptable
to assist in progress.
PTQ 1.4 | NSCA.COM
During the next 2 – 4 weeks post-surgery, additional modalities
can be added along with water exercise if the incision has healed
fully. Continue progression toward 30 – 40 min sessions for 5 – 6
times per week. After one month, progress toward 40 – 60 min for
5 – 6 times per week. The initial goal should be to obtain 150 total
min per week with a longer term goal of 300 total min per week
(15). Intermittent, interval, and circuit training exercise protocols
can be useful in aiding this progression. A typical progression is
presented in Table 3.
RESISTANCE EXERCISE
Prior to starting post-surgery resistance training, clearance
from the surgeon is required to ensure the abdominal muscles
have healed fully. Abdominal exercises are important to include,
but should wait until either 3 – 6 months post-surgery or upon
obtaining surgeon’s clearance. The length of healing time before
beginning abdominal exercises is dependent on whether the
surgery was done laparoscopically or open. Clearance for general
resistance training can typically be obtained in about 4 – 8 weeks
post-surgery. Due to a bariatric client’s initial size, they usually do
not fit comfortably in selectorized equipment; therefore, the use
of bands, tubing, free weights, and bodyweight exercises may be
more suitable alternatives (17). Guidelines for resistance training
follow those recommended for obese clients (15). A typical
resistance training progression is presented in Table 4.
Providing variety and time efficient workouts may assist the
client’s progress and in keeping the client’s interest levels high.
One method through which this can be accomplished is to
create a circuit training program incorporating biking for
approximately 5 min or treadmill walking with 30 s intervals
of resistance training stations.
FLEXIBILITY EXERCISE
As recommended for joint mobility, stretching is indicated for a
well-rounded fitness program. Light stretching can be done after
the initial warm-up. To increase flexibility, stretch post-exercise
after muscles are warm. Flexibility exercises should be done 2 – 3
times per week, 3 – 4 repetitions per muscle group and static
stretches should be held 15 – 60 s (15).
POPULATION-SPECIFIC CONSIDERATIONS
Several special concerns may affect exercise programming,
including exercise selection, intensity, and instruction. Special
considerations include psychological/emotional status,
comorbidities, size and deconditioning, skin issues, and post-
surgical concerns (6,8,15,17). See Table 5 for special consideration
and recommendations.
Studies have shown that modern society has little respect for
morbidly obese individuals (19). Stigmatization may lead to a
limited number of friends and social involvement, along with
depression (3). Organizations and personal trainers working with
the obese should identify if they have any weight bias and include
sensitivity training. Sensitivity training should include knowledge
on the complex etiology of obesity, compassion and empathy
training, and environmental awareness and adaptation needed
to create an atmosphere of acceptance (9). It can often be
helpful if an organization or personal trainer can refer a client
to a qualified individual within their professional network for
appropriate assistance.
11
EXERCISE BEFORE AND AFTER BARIATRIC SURGERY

CONCLUSION 12. McMahon, M, Sarr, M, Clark, M, Gall, M, Knoetgen III, J, Service,

Bariatric surgery is not the “easy way out” or a cosmetic F, Laskowski, E, and Hurley, D. Clinical management after bariatric
procedure. It creates a forced lifestyle change, which can be surgery: Value of a multidisciplinary approach. Mayo Clinic
lifesaving in some cases. Bariatric surgery is one tool to assist Proceedings 81(10 suppl): s34-s45, 2006.
in weight loss for those that meet the requirements. For long- 13. Owens, C, Abbas, Y, Ackroyd, R, Barron, N, and Khan, M.
term success, healthy eating habits, stress management, social Perioperative optimization of patients undergoing bariatric
support, regular exercise, and increased daily activity are essential. surgery. Journal of Obesity 81(10 suppl): s25-s33, 2012.
Personal trainers play a critical role in helping clients to adopt the
14. Richardson, W, Plaisance, A, Periou, L, Buquoi, J, and Tillery, D.
lifestyle that is needed for both recovery and long-term success
Long-term management of patients after weight loss surgery. The
by addressing proper exercise protocols and providing appropriate
Ochsner Journal 9: 154-159, 2009.
recommendations. As personal trainers, working with bariatric
clients can be challenging, yet also very rewarding. 15. Smith, D, and Fiddler, R. In: NSCA’s Essential of Personal
Training (2nd ed.) Champaign, IL: Human Kinetics; 489-505, 2012.
REFERENCES
16. Sorace, P, and LaFontaine, T. Lifestyle intervention: A priority
1. Abbott, A. Personal training – litigation insulation. ACSM’s
for long-term success in bariatric patients. ACSM’s Health and
Health and Fitness Journal 15(5): 40-44, 2011.
Fitness Journal 11(6): 19-25, 2007.
2. Barbalho-Moulim, C, Miguel, G, Forti, E, Campos, F, and Costa,
17. Sorace, P, and LaFontaine, T. Personal training post-bariatric
D. Effects of preoperative inspiratory muscle training in obese
surgery patients: Exercise recommendations. Strength and
women undergoing open bariatric surgery: Respiratory muscle
Conditioning Journal 32(3): 101-104, 2010.
strength, lung volumes, and diaphragmatic excursion. Clinics
66(10): 1721-1727, 2011. 18. Tessier, A, Zavorsky, G, Jun Kim, D, Carli, F, Christou, N, and
Mayo, N. Understanding the determinants of weight-related quality
3. Bond, D, Evans, R, DeMaria, E, Wolfe, L, Meador, J, Kellum,
of life among bariatric surgery candidates. Journal of Obesity Epub
J, Maher, J, and Warren, B. Physical activity and quality of life
Jan 12, 2012.
improvements before obesity surgery. Am J Health Behav 30(4):
422-434, 2006. 19. Vartanian, L, and Novak, S. Internalized societal attitudes
moderate the impact of weight stigma on avoidance of exercise.
4. Brzozowska, M, Sainsbury, A, Eisman, J, Baldock, P, and
Obesity 19(4): 757-762, 2011.
Center, J. Bariatric surgery, bone loss, obesity, and possible
mechanisms. Obesity Reviews 14: 52-67, 2013. 20. Wollner, S, Adair, J, Jones, D, and Blackburn, G. Preoperative
progressive resistance training exercise for bariatric surgery
5. Chapman, N, Hill, K, Taylor, S, Hassanal, M, Straker, L, and
patients. Bariatric Times 7(5): 11-13, 2010.
Hamdorf, J. Patterns of physical activity and sedentary behavior
after bariatric surgery: An observational study. Surg Obes Relat Dis
10(3): 524-530, 2014. ABOUT THE AUTHOR
6. Cheifetz, O, Lucy, S, Overend, T, and Crowe, J. The effect of Cindy Kugler is currently employed by the Bryan Health System in
abdominal support on functional outcomes in patients following Lincoln, NE. She has worked as an exercise specialist for cardiac/
major abdominal surgery: A randomized controlled trial. pulmonary rehabilitation, a department manager, and is currently
Physiotherapy Canada 62: 242-253, 2010. the LifePoint Clinical Liaison. She has assisted with lifestyle
modification for those with chronic disease and worksite health
7. deJong, A. Cardiopulmonary exercise testing in assessing the
promotion for her organization and others. She obtained her Master
risk of bariatric surgery, implications for allied health professionals.
of Science degree in Exercise Physiology from the University of
ACSM’s Health and Fitness Journal 12(4): 38-40, 2008.
Nebraska Omaha and is currently the Chair of the National Strength
8. Drew, K. Exercise and bariatric surgery. ACSM’s Certified News and Conditioning Association (NSCA) Certified Special Populations
22(3): 11-15, 2012. Specialist® (CSPS®) certification committee.
9. Kushner, R. Roadmaps for Clinical Practice: Case Studies in
Disease Prevention and Health Promotion-A Primer for Physicians;
Communication and Counseling Strategies. Chicago, IL: American
Medical Association; 2003.
10. Manchester, S, and Roye, G. Bariatric surgery, an overview for
dietetics professionals. Nutrition Today 46(6): 264-273, 2011.
11. McCullough, P, Gallagher, M, deJong, A, Sandberg, K, Trivax,
J, Alexander, D, Kasturi, G, Jafri, S, Krause, K, Chengelis, D, Moy,
J, and Franklin, B. Cardiorespiratory fitness and short-term
complications after bariatric surgery. Chest 130: 517-525, 2006.

12 PTQ 1.4 | NSCA.COM

 NSCA.com

TABLE 1. SCREENING POTENTIAL SURGICAL CANDIDATES (10)

• Adults
• Body mass index (BMI) ≥ 40 kg/m2 with no comorbidities
• BMI ≥ 35 kg/m2 with obesity-associated comorbidities
• Weight loss history
• Failure of previous nonsurgical attempts at weight reduction, including nonprofessional programs
• Commitment
• Expectation that patient will adhere to post-operative care

§ Follow-up visits with physician and team members

§ Recommended medical management, including the use of dietary supplements
§ Instructions regarding any recommended procedures or tests
• Exclusions

§ Reversible endocrine or other disorders that can cause obesity

§ Current drug or alcohol abuse
§ Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes
required with bariatric surgery
§ Caution must be used when language or literacy issues are present
§ Severe food allergies or intolerances must be addressed before surgery

TABLE 2. SAMPLE PRE-SURGERY RESISTANCE TRAINING PROGRAM

Wall push-ups Bodyweight
Biceps curls Tubing or dumbbell
Upper body
Triceps push-downs/kick backs Tubing or dumbbell
Shoulder presses/raises Tubing or dumbbell
Seated rows Tubing
Chair squats Bodyweight
Lower body
Calf raises Bodyweight
Leg presses Tubing
Seated crunches Tubing
Abdominals
Standing core twists Tubing or dumbbell

PTQ 1.4 | NSCA.COM 13

EXERCISE BEFORE AND AFTER BARIATRIC SURGERY

TABLE 3. POST-SURGERY CARDIORESPIRATORY EXERCISE PROGRESSION

TIME POST-SURGERY FREQUENCY DURATION
As tolerated; 5 – 10 min per bout
Weeks 0 – 2 3 – 4 x/day
Increase daily activities
20 – 30 min; in minimum of
10 min increments, if needed
Weeks 2 – 4 5 – 6 x/week
Focus on increasing duration
(increase by 2 – 3 min every 2 – 3 days)
40 – 60 min
Weeks 4+ 5 – 6 x/week
Increase intensity and utilize intervals

TABLE 4. POST-SURGERY RESISTANCE TRAINING PROGRESSION

TIME POST-CLEARANCE SETS/REPETITIONS FREQUENCY MUSCLE GROUPS
Weeks 1 – 4 8 – 10 exercises; all major muscle groups
1 set/12 – 15 reps 2x/week*
(4 – 8 weeks post-surgery) No abdominal exercises
8 – 10 exercises; all major muscle groups
Weeks 4 – 8 2 sets**/12 – 15 reps 2 – 3x/week*
Abdominal exercises, if clearance is given
8 – 10 exercises minimum;
all major muscle groups
Weeks 8+ 3 sets**/8 – 12 reps 2 – 3x/week*
Add more functional, postural, balance,
and abdominal exercises
* Allow 48 hours between sessions
** Approximately 1-min rest intervals

14 PTQ 1.4 | NSCA.COM

 NSCA.com

TABLE 5. SPECIAL CONSIDERATIONS (3,6,8,9,12,16,19)

CATEGORY CONCERNS RECOMMENDATIONS
Stigma Sensitivity training
Decreased self-esteem Establish excellent rapport
Psychological/
Depression Refer to physician or counselor
Emotional Status
Empathy and listening skills
Embarrassment
Give home exercise and equipment options
Refer to physician
Obstructive sleep apnea/fatigue
Timing of exercise session with rest
Choice of appropriate exercise modality
(e.g., water, non-weight bearing, etc.)
Common
Orthopedic/pain (e.g., knees, Use of supportive devices (e.g., orthotics, braces/sleeves, etc.)
Comorbidities
back, hips, and feet) Use of thick large mats
Refer to physician for pain control and treatment
Instruction in use of rest, ice, and compression
Diabetes mellitus Utilize appropriate guidelines for checking blood glucose and exercise
Utilize intermittent exercise and/or interval protocols; utilize dyspnea
Shortness of breath
scale with exercise
Panniculus interference Abdominal binder and supportive clothing
Utilize ratings of perceived exertion scale with exercise, intermittent,
Exercise fatigue and/or interval protocols
Size/Deconditioning Chairs available for rest
Awareness of environmental needs such as use of chairs without arms,
ability to get up and down off the floor, alternatives to machines they do
Self-consciousness
not fit into, and an exercise area that is more private
Give home exercise and equipment options
Overheating Cooler environment, fans, wicking clothing, and cooling towel
Chafing, yeast, and fungus Use of commercial products according to individual preference
Skin Issues
Excess skin Use of tighter, supportive, wicking clothing
Awareness of changing balance and having support when including
Post-Surgical Changing body size/mass
balance exercises
Timing of exercise with meal or snack
Low energy due to
Utilizing lower intensities and/or intervals
low calorie diet
Refer to dietitian for nutrient and caloric recommendations
Consume a minimum of 64 oz of water per day in 1 oz increments
Continuous sipping before, during, and after exercise
Dehydration
Take water breaks
Concerns Refer to dietitian as needed
May sabotage their new lifestyle
Changing relationships with food,
Need support, encouragement, and empathy
family, and friends
Refer to physician and/or counselor as needed
Include resistance training and weight bearing exercises
Bone loss and osteoporosis Encourage compliance with prescribed supplements
Refer to physician and/or dietitian as needed

PTQ 1.4 | NSCA.COM 15

SMALL GROUP TRAINING UTILIZING CIRCUITS
CHAT WILLIAMS, MS, CSCS,*D, CSPS, NSCA-CPT,*D, FNSCA
I
am often asked the following questions by students and other
individuals who are starting a profession in personal training:
“What could be changed?” “What could be done differently?”
“What population should I work with?” “Is there a specific area
of focus to study?” My answer always discusses the benefits of
incorporating small group training into their training protocols. I
have witnessed many fads and fitness trends over the last 18 years
and the one concept that seems to be growing steadily is personal
training in a small group setting. How is small group training
defined? Here are some differences associated with other types of
training in the strength and conditioning industry.
Personal Training: In the traditional sense, personal training is
performed in a one-on-one setting and typically ranges from 30 –
60 min.
Semiprivate: Personal trainer will work with 2 – 3 individuals
during the same session for 30 – 60 min.
Small Group: Personal trainer will develop a training program for
4 – 10 individuals at the same time.
All of these training methods have benefits associated with
them; it will depend on the individual’s personal goals, schedule
availability, fitness level, and comfort level training with other
people. Here are some potential benefits to consider with small
group training.
FINANCIAL INVESTMENT
One of the first questions during the initial inquiries about
personal training is “How much does it cost per session?” Many
times, individuals may not be able to hire a personal trainer due
to a limited budget. For example, a one-on-one session may cost
50 dollars an hour, but in a small group setting a lower rate of 15
dollars per hour may be more realistic. Plus, the total revenue per
hour increases for the personal trainer. Using the same example
with a small group of eight people, the personal trainer will
generate about 120 dollars an hour as opposed to 50 dollars an
hour. The small group concept can be a “win-win” for both parties
as it generates more revenue and time efficiency for the personal
trainer and breaks down the cost barrier for the client.
16 PTQ 1.4 | NSCA.COM
SUPPORT AND MOTIVATION
Being part of a group instantly develops a support network
for the individuals. This could be family, friends, or coworkers.
Working out with like-minded individuals creates the
competiveness that may push them to a higher level, while
recognizing their own individual fitness strengths. Motivating,
encouraging, and driving one another during workouts develops
a positive environment and camaraderie amongst the group.
Plus, there is accountability that each person must have in a
group setting. The people in the group are typically supportive
in a positive manner and have a tendency to “call out” those who
are missing sessions. People in the group count on individuals to
show up, especially when partner-based training and circuit-type
training are a part of the overall program design.
ADHERENCE, FUN, AND GROUP STRUCTURE
Teamwork, group motivation, and encouragement must also be
supported by the personal trainer to create fun and challenging
workouts. Exercise adherence can be difficult for any individual
participating in a fitness program, but it is especially crucial for a
beginner. A more dynamic program may lead to higher adherence
rates for the individual and the group. Groups can be categorized
by assigned, mixed, and team (e.g., coworkers) depending on
fitness levels and schedule availability. Beginners and individuals
that need programs with a little less intensity can be assigned to
the same group. Individuals with prior fitness experience can be
assigned to a mixed group where the personal trainer can modify
the training within the sessions to meet some of their specific
goals. Team groups can develop their own goals as a group and
individually. For example, they may want to lose a specific amount
of weight as an organization. All three of these groups can set
goals as a group and as individuals every 8 – 12 weeks to maintain
success and motivation.
DEFINITIONS, RESEARCH, AND PROGRAM DESIGN
Circuits, supersets, compound sets, and complex sets are great
ways to keep workouts fast-paced, fun, challenging, and energetic.
Circuits typically utilize 10 – 15 exercises and can either be grouped
together as one big circuit or grouped together focusing on upper
body, lower body, or core. To incorporate greater challenges with
a circuit, programming may include supersets, compound sets,
and complex sets. A superset consists of two exercises involving
opposing muscle or action of the muscles (e.g., pairing bench
press with lat pull-down). A compound set involves two exercises
utilizing the same muscle group or action of the muscle (e.g.,
pairing single-arm dumbbell row and bodyweight inverted row).
A complex set combines a power movement with a strength
movement (e.g., pairing countermovement vertical jump and
squat) and usually flow from one movement to the next in terms
of the finishing position (3). The frequency, intensity, rest intervals,
volume, and exercise selection will depend on the overall objective
of the group (2).
REFERENCES
1. Alcaraz, P, Perez-Gomez, J, Chavarrias, M, Blazavich, A.
Similarity in adaptations to high-resistance training vs. traditional
strength training in resistance trained men. Journal of Strength and
Conditioning Research 25(9): 2519-2527, 2011.
2. Waller, M, Miller, J, and Hannon, J. Resistance circuit training:
It’s application for the adult population. Strength and Conditioning
Journal 33(1): 16-22, 2011.
3. Williams, C. Complex set variations: Improving strength and
power. Personal Training Quarterly 1(3): 20-25, 2014.

Circuit training has been shown to improve multiple fitness

components including time to lactate threshold and increased
endurance (2). Increased maximal oxygen consumption (VO2max),
functional capacity, improved pulmonary ventilation, reduced
body fat, and overall improved body composition are some of
the improvements that may be elicited when incorporating circuit
training where lighter loads are lifted with minimal rest (1). In one
study where heavier loads of six repetition maximum (6RM) were
used comparing traditional strength training to heavy resistance
circuits in resistance trained males showed similar strength and
muscle mass improvements to traditional strength training (1).
Other findings included similar improvements in power, reductions
in body fat, and an increased performance on the 20-meter
shuttle run (1).
ABOUT THE AUTHOR
Chat Williams is the Supervisor for Norman Regional Health Club.
He is a past member of the National Strength and Conditioning
Association (NSCA) Board of Directors, NSCA State Director
Committee Chair, Midwest Regional Coordinator, and State Director
of Oklahoma (2004 State Director of the Year). He also served on
the NSCA Personal Trainers Special Interest Group (SIG) Executive
Council. He is the author of multiple training DVDs. He also runs his
own company, Oklahoma Strength and Conditioning Productions,
which offers personal training services, sports performance
for youth, metabolic testing, and educational conferences and
seminars for strength and conditioning professionals.

PROGRAM EXAMPLES
Here are a couple of examples including different types of circuits
that can be incorporated into the training program design. Each
workout should begin with a warm-up and end with a cool-down
and/or stretching.

10 STATION CIRCUIT (TABLE 1)

This circuit includes 10 different exercises targeting the full body.
This may be useful for a beginner training program that has
10 participants. Each individual can rotate through three times
completing 10 – 15 repetitions for each exercise. Rest between
each exercise should be approximately 30 s or just enough time to
move to the next exercise.

3 MINI-CIRCUITS (TABLE 2)
This circuit includes three mini-circuits which all contain
four exercises. These mini-circuits will include supersets,
compound sets, and complex sets. This full body workout is
not recommended for beginners as it contains intermediate
level exercises.

PTQ 1.4 | NSCA.COM 17

SMALL GROUP TRAINING UTILIZING CIRCUITS

TABLE 1. 10 STATION CIRCUIT SAMPLE

MOVEMENT AREA TARGETED SET/REPETITIONS

Bench presses Upper body 3/10

Leg presses Lower body 3/10

Single-arm dumbbell rows Upper body 3/10

Seated leg curls Lower body 3/10

Stability ball abs

Core 3/15
(modify for group ability)

Seated overhead presses Upper body 3/10

Cable cross posterior deltoids

Upper body 3/10
(modify for group ability)

Calf raises Upper body 3/10

Dumbbell curls Upper body 3/10

Triceps extensions Upper body 3/10

TABLE 2. 3 MINI-CIRCUITS SAMPLE

Circuit 1

EXERCISE TYPE SETS/REPETITIONS

Box jumps Complex set 3/5
Leg presses Complex set 3/10
Leg extensions Superset 3/10
Leg curls Superset 3/10

Circuit 2

EXERCISE TYPE SETS/REPETITIONS

Seated chest presses Compound set 3/10
Push-ups Compound set 3/10
Lat pull-downs Compound set 3/10
Pull-ups Compound set 3/10

Circuit 3

EXERCISE TYPE SETS/REPETITIONS

Hanging leg raises Compound set 3/12
Crunches Compound set 3/15
Straight-bar curls Superset 3/10
Overhead triceps extensions Superset 3/10

18 PTQ 1.4 | NSCA.COM

 NSCA.com

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FEATURE ARTICLE
HIGH HORMONE CONDITIONS FOR HYPERTROPHY
WITH RESISTANCE TRAINING: A BELIEF—NOT
EVIDENCE-BASED PRACTICE IN STRENGTH
AND CONDITIONING
STUART PHILLIPS, PHD, CSCS, FACSM, FACN, ROBERT MORTON, CSCS, AND CHRIS MCGLORY, PHD
T
he ability to maintain or increase skeletal muscle mass
(hypertrophy) has clear advantages in the athletic setting.
An increase in the cross-sectional area (CSA) of skeletal
muscle fibers ultimately occurs when the net rate of muscle
protein synthesis (MPS) exceeds that of muscle protein breakdown
(MPB) (16). Both resistance exercise and protein ingestion
stimulate a significant increase in the rates of MPS over and above
rates of MPB and, when combined, are synergistic in their effects.
Hence, frequent resistance exercise and protein consumption
support increases in MPS and may induce skeletal muscle
remodelling and hypertrophy (2).
Despite the wealth of information pertaining to the impact
of resistance exercise and protein consumption on MPS,
the exact cellular and molecular mechanisms that underpin
resistance exercise-induced changes in MPS remain unclear.
Many hypotheses have been proposed but some are with little
supporting evidence and empirical data. One such hypothesis
is that higher elevated concentrations of exercise-induced
systemic “anabolic” hormones are needed for attaining optimal
hypertrophy with resistance training (RT); a thesis termed the
“hormone hypothesis.” The hormone hypothesis seems compelling
based on the well-documented knowledge that resistance
exercise is followed by a transient (approximately 30 min)
systemic elevation of hormones, some of which are “anabolic”
(12,26). Notably there are increases in free and protein-bound
forms of testosterone (T), growth hormone (GH), and insulin-like
growth factor-1 (IGF-1). While there is indisputable evidence to
show that exogenous supraphysiological doses of testosterone
20 PTQ 1.4 | NSCA.COM
augments muscle hypertrophy and strength, there is not
convincing data for GH or for IGF-1 (1,3,10,18). The link between
the transient increase in concentration of these hormones and
hypertrophy has been explicitly examined in primary research
papers (1,13,21,24,25,26,27,28,29). However, the aim of this article
is to address the following questions: 1) is the transient post-
exercise hormonal response playing a role in skeletal muscle
hypertrophy? If so, then 2) should hormonal changes influence RT
program design and periodization aimed at maximizing muscle
hypertrophy? If the answer to the first question is no, then the
second question is moot.
It has been known for some time that GH secretion increases
bone and muscle mass in growing animals and children (8,14,15).
It is undeniable that exogenous supraphysiological GH stimulates
collagen protein synthesis, but the notion that supraphysiological
GH administration directly increases skeletal muscle mass is
without direct support (3,24). A plausible argument is that the
exogenous GH-mediated increase in connective tissue would
allow for more loading, but such a thesis awaits experimental
confirmation. Alternatively, increases in GH may exert an indirect
anabolic influence via IGF-1, which is synthesized by the liver.
Often recognized for its relation with GH, IGF-1 is also transiently
elevated post-exercise (28,29). The GH/IGF-1 axis is involved with
muscle growth during adolescence where, like T and GH, levels
of IGF-1 reach their peak (6). The assertion that IGF-1 is anabolic
comes from selective rodent data in which the IGF-1 receptor
in skeletal muscle was knocked out and the rates of MPS, in
response to 50 “repetitions” in rats (standing on their hind legs),
was reduced (4). In contrast, removal of the IGF-1 receptor from
skeletal muscle in mice did nothing to attenuate load-induced
skeletal muscle hypertrophy (21). However, it is important to
acknowledge that rodents exhibit marked differences in rates
of protein turnover as compared to humans. Moreover, insulin
is known to stimulate the phosphorylation (and presumably
activation) of the IGF-1 receptor, resistance exercise does not (9).
Given that insulin plays only a permissive role in the regulation of
human MPS, these data suggest that IGF-1 exerts a minimal, if any,
impact on resistance exercise-induced increases in MPS (7). In fact,
one year of IGF-1 administration was shown to have no noticeable
impact on bone or body composition in older women (10).
An often-used, but categorically incorrect, argument in support of
the hormone hypothesis is the marked potency of T when given
as an exogenous anabolic agent (1). There are, however, critically
important differences between pharmacological doses (or
pharmacological suppression) of T and the comparatively minor
and fleeting increases in post-exercise T. For example, when young
men are administered 600 mg weekly for 10 weeks, bringing total
T concentrations from approximately 500 ng/dl (nanograms per
deciliter) to 3,000 ng/dl, there is an increase in both muscle mass
and strength (1). We also know that when T is pharmacologically
supressed to one tenth of normal levels, the training response is
attenuated (13). Studies administering T to hypogonadal elderly
men (60 or more years old) found increased muscle protein
anabolism (5). The exercise-induced increases in T concentration,
which are no greater than the daily diurnal fluctuation of the
hormone, are simply not comparable in magnitude (usually
1/10th to 1/100th of the pharmacologic dose) or duration
(approximately 30 min versus constant elevation dependent on
dosing in pharmacologic models) to what is seen with exogenous
supplementation (20).
An interesting finding for the hormonal hypothesis is that, despite
the lower acute increases in T post-resistance exercise, females
demonstrate the same relative hypertrophic response to resistance
exercise (11). A common misconception is that the relative
hypertrophic response to RT is lower in women compared to men.
For example, despite a 45-fold lower exercise-induced T response
in women, (compared to men), women achieve similar relative
MPS post-exercise (26). Hubal et al. also found that women, who
had roughly about one tenth of the resting T levels as men, had
the same relative hypertrophic response (11). If the post-exercise T
response were a determinant of MPS and subsequent hypertrophy,
then women would have a lower relative hypertrophic and MPS
response, but that is not the case. This important consideration is
frequently overlooked when evaluating the hormone hypothesis.
In another study, hypertrophy and strength gains of limbs
were examined within the same individual under two different
hormonal environments (28). Twelve young men trained each
of their elbow flexors every 72 hr with one arm being grouped
into a low hormonal (LH) environment and the other into a high
hormonal (HH) environment for the duration of the study. Despite
15 weeks of RT with limbs in a LH or HH environment, there
were no differences between groups in muscle CSA or strength
following training (28). It was concluded that muscle hypertrophy
and strength with RT in young men was unaffected by exposure
to exercise-induced elevations in GH, IGF-1, or T (Figure 1) (28).
In general, these studies provide evidence that exercise-induced
hypertrophic adaptation in skeletal muscle occurs independently
of exercise-induced endogenous anabolic hormone concentrations
(25,28). Nonetheless, the lack of bona fide RT trial data to support
the hormone hypothesis has not prevented the propagation of
dogmatic beliefs that are not evidence-based recommendations
for “effective” RT leading to hypertrophy.
In summary, it appears as if there is little evidence to support
the assertion that transient post-exercise increases in hormones
are causative in normal RT-stimulated hypertrophy. If how one
responds to RT is not hormonally driven, then what drives it?
One theory is that hypertrophy is facilitated via local muscle-
mediated mechanisms that are intrinsic to the skeletal muscle
(24). Instead, the post-exercise increase in hormones is a generic
stress response seen after many forms of high-intensity exercise,
many of which do not lead to hypertrophy (i.e., middle distance
running) (23). Thus, in failing to establish a direct causal,
or even associative, link between post-exercise hormonal
concentrations directly calls into question their measurement
as a driver of any kind of decision making or planning of RT
programs or periodization of training. It is recommended that the
attainment of RT-induced hypertrophy based on measurement
of systemic hormone concentrations is a belief, and not an
evidence-based practice.

In contrast to the belief that the post-exercise hormonal response

is an important mediator of hypertrophy, published studies have
yielded little mechanistic support or valid clinical data to uphold
this proposition. In fact, in most studies that have investigated
whether the repeated increase in systemic “anabolic” hormones
promote hypertrophy, it seems as though none have provided any
unequivocal support for this assertion. In a large cohort (n = 56) of
young men, associations were examined between acute increases
in T, GH, and IGF-1 with lean body mass, fiber CSA, and leg press
strength following a 12-week RT protocol (25). The exercise-
induced hormonal response was not correlated with gains in lean
body mass, fiber CSA, or strength (25).

PTQ 1.4 | NSCA.COM 21

HIGH HORMONE CONDITIONS FOR HYPERTROPHY WITH RESISTANCE
TRAINING: A BELIEF—NOT EVIDENCE-BASED PRACTICE IN STRENGTH
AND CONDITIONING
REFERENCES
1. Bhasin, S, Storer, T, Berman, N, Callegari, C, Clevenger, B,
Phillips, J, Bunnell, T, Tricker, R, Shirazi, A, and Casaburi, R. The
effects of supraphysiologic doses of testosterone on muscle size
and strength in normal men. The New England Journal of Medicine
335(1): 1-7, 1996.
2. Burd, N, Tang, J, Moore, D, and Phillips, S. Exercise training
and protein metabolism: Influences of contraction, protein intake,
and sex-based differences. Journal of Applied Physiology 106:
1609-1701, 2009.
3. Doessing, S, Heinemeier, K, Holm, L, Mackey, A, Schjerling, P,
Rennie, M, Smith, K, Reitelseder, S, Kapplegaard, A, Rasmussen,
M, Flyvbjerg, A, and Kjaer, M. Growth hormone stimulates the
collagen synthesis in human tendon and skeletal muscle without
affecting myofibrillar protein synthesis. Journal of Physiology
588(2): 341–351, 2010.
4. Fedele, M, Lang, C, and Farrell, P. Immunization against
IGF-1 prevents increases in protein synthesis in diabetic rats after
resistance exercise. American Journal of Physiology, Endocrinology
and Metabolism 280: E877-E885, 2001.
5. Ferrando, A, Sheffield-Moore, M, Yeckel, C, Gilkison, C, Jiang,
J, Achasoa, A, Lieberman, S, Tipton, K, Wolfe, R, and Urban,
R. Testosterone administration to older men improves muscle
function: Molecular and physiological mechanisms. American
Journal of Physiology 282(3): E601-607, 2002.
6. Goldspink, G, Wessner, B, Tschan, H, and Bachl, N. Growth
factors, muscle function and doping. Endocrine and Metabolism
Clinics 39(1): 169-181, 2010.
7. Greenhaff, P, Karagounis, L, Peirce, N, Simpson, E, Hazell, M,
Layfield, R, Wackerhage, H, Smith, K, Atherton, P, Selby, A, and
Rennie, M. Disassociation between the effects of amino acids
and insulin on signaling, ubiquitin ligases, and protein turnover in
human muscle. American Journal of Physiology - Endocrinology
and Metabolism 295(3): E595-604, 2008.
8. Gregory, J, Greene, S, Jung, R, Scrimgeour, C, and Rennie,
M. Changes in body composition and energy expenditure after
six weeks’ growth hormone treatment. Archives of Disease in
Childhood 66: 598–602, 1991.
9. Hamilton, D, Philip, A, MacKenzie, M, and Baar, K. A limited
role for PI(3,4,5)P3 regulation in controlling skeletal muscle mass in
response to resistance exercise. PLOS One 5(7): e11624, 2010.
10. Hoffman, A, Marcus, R, Lee, S, Matthias, D, Yesavage, J,
Friedman, L, Holloway, L, Pollack, M, Grillo, J, Moynihan, S,
Butterfield, G, and Friedlander, A. One year of insulin-like growth
factor 1 treatment does not affect bone density, body composition,
or psychological measures in postmenopausal women. Journal of
Clinical Endocrinology and Metabolism 86(4): 1496-1503, 2001.
11. Hubal, M, Gordish-Dressman, H, Thompson, P, Price, T,
Hoffman, E, Angelopoulos, T, Gordon, P, Moynga, N, Pescatello, L,
Visich, P, Zoeller, R, Seip, R, and Clarkson, P. Variability in muscle
size and strength gain after unilateral resistance training. Medicine
and Science in Sport and Exercise 37(6): 964-972, 2005.
22 PTQ 1.4 | NSCA.COM
12. Kraemer, W, and Ratamess, N. Hormonal responses and
adaptations to resistance exercise and training. Sports Medicine
35: 339-361, 2005.
13. Kvorning, T, Anderson, M, Brixen, K, and Madsen, K.
Suppression of endogenous testosterone production attenuates
the response to strength training: A randomized, placebo-
controlled, and blinded intervention study. American Journal of
Physiology, Endocrinology and Metabolism 291(6): 1325-1332,
2006.
14. Lissett, C, and Shalet, S. Effects of growth hormone on bone
and muscle. Growth Hormone and IGF Research 10: S95-101, 2000.
15. Pell, J, and Bates P. The nutritional regulation of growth
hormone action. Nutrition Research Reviews 3: 163-92, 1990.
16. Phillips, S. Protein requirements and supplementation in
strength sports. Nutrition 20(7-8): 689-695, 2004.
17. Pritzlaff, C, Wideman, L, Weltman, J, Abbott, R, Gutgesell, M,
Hartman, M, Veldhuis, J, and Weltman, A. Impact of acute exercise
intensity on pulsatile growth hormone release in men. Journal of
Applied Physiology 87: 498-504, 1999.
18. Rennie, M. Claims for the anabolic effects of growth hormone:
A case of the Emperor’s new clothes? British Journal of Sports
Medicine 37: 100-105, 2003.
19. Rosen, C. Growth hormone and again. Endocrine 12: 197-201,
2000.
20. Schroeder, E, Villanueva, M, West, D, and Phillips, S. Are
acute post-resistance exercise increases in testosterone, growth
hormone, and IGF-1 necessary to stimulate skeletal muscle
anabolism and hypertrophy? Medicine and Science in Sport and
Exercise 45(11): 2044-2051, 2013.
21. Spangenburg, E, Le Roith, D, Ward C, and Bodine, S. A
functional insulin-like growth factor receptor is not necessary
for load-induced skeletal muscle hypertrophy. The Journal of
Physiology 586: 283-291, 2008.
22. Staron, R, Karapond, D, Kraemer, W, Fry, A, Gordon, S, Falkel,
J, Hagerman, F, and Hikida, R. Skeletal muscle adaptations during
early phase of heavy-resistance training in men and women.
Journal of Applied Physiology 76(3): 1247-1255, 1994.
23. Vuorimaa, T, Ahotupa, M, Hakkinen, K, and Vasankari, T.
Different hormonal response to continuous and intermittent
exercise in middle-distance and marathon runners. Scandinavian
Journal of Medicine and Science in Sports 18(5): 565-572, 2008.
24. West, D, and Phillips, S. Anabolic processes in human
skeletal muscle: Restoring the identities of growth hormone and
testosterone. The Physician and Sportsmedicine 38(3): 97-104,
2010.
25. West, D, and Phillips, S. Associations of exercise-induced
hormone profiles and gains in strength and hypertrophy in a
large cohort after weight training. European Journal of Applied
Physiology 112: 2693-2702, 2012.
 NSCA.com

26. West, D, Burd, N, Churchward-Venne, T, Camera, D, Mitchell,

C, Baker, S, Hawley, J, Coffey, V, and Phillips, S. Sex-based
comparisons of myofibrillar protein synthesis after resistance
exercise in the fed state. Journal of Applied Physiology 112(11):
1805-1813, 2012.
27. West, D, Burd, N, Staples, A, and Phillips, S. Human exercise-
mediated skeletal muscle hypertrophy is an intrinsic process. The
International Journal of Biochemistry and Cell Biology 42: 1371-
1375, 2010.
28. West, D, Burd, N, Tang, J, Moore, D, Staples, A, Holwerda,
A, Baker, S, and Phillips, S. Elevations in ostensibly anabolic
hormones with resistance exercise enhance neither training-
induced muscle hypertrophy nor strength of the elbow flexors.
Journal of Applied Physiology 108(1): 60-67, 2010.
29. West, D, Kujbida, G, Moore, D, Atherton, P, Burd, N,
Padzik, J, De Lisio, M, Tang, J, Parise, G, Rennie, M, Baker, S,
and Phillips, S. Resistance exercise-induced increases in putative
anabolic hormones do not enhance muscle protein synthesis or
intracellular signalling in young men. The Journal of Physiology
587: 5239-5247, 2009.
ABOUT THE AUTHOR
Stuart Phillips is a Fellow of the American College of Sports
Medicine (FACSM) and the American College of Nutrition
(FACN). He is a professor at McMaster University in the
Kinesiology Department and is also an Associate Member of
the School of Medicine at McMaster. Phillips’ research is focused
on the interaction between skeletal muscle contraction and
nutritional support in the regulation of muscle mass. He has
more than 200 published papers and has delivered more than
120 public presentations.
Robert Morton is a graduate student working with Dr. Stuart Phillips
at McMaster University. He is a personal trainer, rugby player, and
strength and conditioning coach possessing a strong passion for
the application of science in sport. Having interned with Hockey
Canada, the University of Louisville, the Ontario Soccer Association,
the Hamilton Bulldogs of the American Hockey League (AHL), and
McMaster University Athletics, Morton hopes to work within high-
level sport organizations. His goal is to be an industry-leader in
sport science and to bridge the gap between science and sport.

Chris McGlory is a Postdoctoral Research Fellow and a graduate of

Liverpool John Moores University (where he attained his Master of
Science degree) and the University of Stirling (where he completed
his PhD). He competed in high-level rugby until injury forced a
premature exit from the game. McGlory is very interested in the
link between muscle contraction and mechanisms leading to
hypertrophy in human skeletal muscle.

FIGURE 1. HIGH AND LOW HORMONE CONDITIONS ON HYPERTROPHY, AGGREGATE EXPOSURE, AND STRENGTH

Panel A: Hypertrophy of the biceps brachii after a 15-week RT program under high hormone (HH) or low hormone (LH) conditions.

Panel B: Aggregate exposure (mean area under the curve [AUC] post-exercise before and after training) for free testosterone (fT).

Panel C: Mean increase in maximal elbow flexor strength – one repetition maximum (1RM); values are means ± standard error of
the mean.

Figures redrawn with data from West et al. with permission (28).

PTQ 1.4 | NSCA.COM 23

HOW SAFE ARE SUPPLEMENTS?
DEBRA WEIN, MS, RD, LDN, NSCA-CPT,*D, AND JENNA AMOS, RD
S
upplement use in the United States has been steadily
increasing over the last several decades. Consumers spent
almost 34 billion dollars on herbal and dietary supplements
in 2007 alone, which was an increase of almost seven billion
dollars, or 25%, since 1997 (4). As of 2010, approximately half of
all adults in the United States reported taking an herbal dietary
supplement (HDS) (4). These adults generally care about their
health; they cite health maintenance and improvement as two of
the main reasons for beginning a regimen of HDS (1). Interestingly,
of the almost 50% of adult consumers who report taking HDS,
less than half of those do so because of a healthcare provider’s
recommendation (1). This may be related to consumers commonly
perceiving supplements as generally safe (4).
While consumers may perceive supplements as safe, the
regulatory standards set forth by the Dietary Supplement Health
and Education Act of 1994 require less evidence of safety than
medications require (3). The act allows the sale of HDS without
prior approval of their efficacy or safety by the Federal Drug
Administration (FDA) or other regulatory bodies (5). Consumers’
increasing use of supplements coupled with the industry’s lax
standards has triggered research to investigate possible negative
side effects of supplement use.
Previous research by Navarro et al. attempted to quantify negative
outcomes, specifically hepatotoxicity (chemical induced liver
damage) and associated liver transplant or death, related to HDS
and medication use (4). The study recruited individuals from eight
United States Drug Induced Liver Injury Network referral centers
between 2004 and 2013. The researchers grouped the 839 patients
who met inclusion criteria into three categories: liver injury caused
by bodybuilding supplements, non-bodybuilding supplements, and
medications. The study showed that 130 patients (15.5%) had liver
injury related to HDS. The study’s results mirrored the national
trend of increasing supplement use as liver injury from HDS
increased from 7% at the beginning of the study to 20% at the end
of the study. In addition, participants with liver injury from HDS
took a total of 217 different products. It is worth noting that 42
of these products had unidentifiable ingredients and 21 products
contained more than 20 ingredients.
24 PTQ 1.4 | NSCA.COM
In the same study, patients with liver injury resulting from
bodybuilding and non-bodybuilding HDS were younger than those
with liver injury resulting from medications (5). Patients with liver
injury from HDS had a significantly higher proportion of severe
cases, including those that required liver transplant or resulted
in death (4). This is interesting considering that comorbidities
such as diabetes and heart disease were more common among
the medication associated liver injury group. A total of 13 patients
in the non-bodybuilding HDS-related liver injury group died or
received a liver transplant while no patients in the bodybuilding
HDS-related liver injury group died or required a transplant.
However, patients with liver injury related to bodybuilding HDS
experienced increased latency (time between the start of the
supplement and the onset of injury) and prolonged jaundice
compared to the other two groups (4).
Previous case studies and research findings support the possible
association between hepatotoxicity and supplement intake.
Timcheh-Hariri et al. investigated case studies of individuals
who had taken three specific supplements (6). The study
concluded possible causality between the supplement use and the
hepatotoxicity in the otherwise healthy individuals. Interestingly,
liver injury resolved in all cases within one month of stopping
supplement intake.
Another study by Martin et al. found that 48 military personnel
who required evacuation from a military facility had drug-
induced liver injury. Of those 48, 12 military personnel (25%) were
associated with a pre-workout supplement (2).
Consumers and healthcare providers should remain aware that
the supplement industry has fairly loose regulation, rendering
supplement use risky at times. Studies have shown the harm and
dangers that certain supplements can cause to otherwise healthy
individuals. This suggests a need for more research on the topic to
understand the potential problems better. Ultimately, a consumer
should always discuss the use of HDS with a physician, pharmacist,
or Registered Dietitian (RD) for important information on dosing
and possible drug interactions prior to implementation.
REFERENCES
1. Bailey RL, Gahche JJ, Miller PE, Thomas PR, and Dwyer JT. ABOUT THE AUTHOR
Why U.S. adults use dietary supplements. JAMA Intern Med 173(5): Debra Wein is a recognized expert on health and wellness and
355-61, 2013. designed award-winning programs for both individuals and
2. Martin, DJ, Partridge, BJ, and Shields, W. Hepatotoxicity corporations around the United States. She is the President and
associated with the dietary supplement N.O.-XPLODE. Ann Intern Founder of Wellness Workdays, Inc., (www.wellnessworkdays.com)
Med 159(7): 503-504, 2013. a leading provider of worksite wellness programs. In addition, she
is the President and Founder of the partner company, Sensible
3. National Institutes of Health Office of Dietary Supplements.
Nutrition, Inc. (www.sensiblenutrition.com), a consulting firm of
Dietary Supplement Health and Education Act of 1994. Public Law
registered dietitians and personal trainers, established in 1994, that
103-417: 103rd Congress. 1994. Retrieved 2014 from http://ods.
provides nutrition and wellness services to individuals. She has
od.nih.gov/About/DSHEA_Wording.aspx.
nearly 20 years of experience working in the health and wellness
4. Navarro, VJ, Barnhart, H, Bonkovsky, HL, Davern, T, Fontana, industry. Her sport nutrition handouts and free weekly email
RJ, Grant, L, et al. Liver injury from herbals dietary supplements newsletters are available online at www.sensiblenutrition.com.
in the U.S. Drug-Induced Liver Injury Network. Hepatology 60(4):
1399-1408, 2014. Jenna Amos is a Registered Dietitian (RD). She is a graduate
of Boston University’s undergraduate dietetics program
5. Stickel F, Kessebohm K, Weimann R, and Seitz HK. Review of
and of Virginia Commonwealth University Health System’s
liver injury associated with dietary supplements. Liver Int 31(5):
dietetic internship.
595-605, 2011.
6. Timcheh-Hariri A, Balali-Mood M, Aryan E, Sadeghi M,
and Riahi-Zanjani B. Toxic hepatitis in a group of 20 male
bodybuilders taking dietary supplements. Food Chem Toxicol
50(10): 3826-3832, 2012.

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PTQ 1.4 | NSCA.COM 25

FEATURE ARTICLE
THE SHARED ADAPTATIONS OF THE TRAINING AND
REHABILITATION PROCESSES
CHARLIE WEINGROFF, DPT, ATC, CSCS
R
ehabilitation and performance enhancement training are
often classified and taught as two distinct processes. In the
best-case scenario, the rehabilitation and performance staff
work together closely to manage the athlete through the stages
of recovery. These situations utilize common communication
methods to create an easy transition for an individual that is
no longer in need of rehabilitation and may be in need of more
advanced performance training for optimal recovery (17). Despite
what may appear to be useful teamwork leading to a return to
sport and performance training, this sometimes is not the case.
In reality, this process is on a continuum that encompasses the
same laws of neurological and physiological principles (7,17).
Understanding these principles may allow for even further overlap
of the rehab and performance training processes leading to
potentially quicker results.
In the sports rehabilitation and performance field, often “worlds
collide” based on semantics and definitions. Many practitioners
have a vision of what the rehab and training processes looks
like (16). As a common denominator, both processes are about
changing the body. Changes in the body’s performance, whether
it is movement skills or performance measures can usually be
tracked to a common response of adaptation to stress (7). This
is known as specific adaptation to imposed demands, or the
SAID Principle.
When the intent is to change the perception of pain or change
motor control, the focus is neurological or neuromuscular,
respectively. If the intent is to change or improve measures of
flexibility, speed, power, and/or endurance, the focus of the
26 PTQ 1.4 | NSCA.COM
stressor is often neurophysiological or neuroendocrine. Regardless
of the goal of the stressor or the designation of the professional,
the body is stressed and required to adapt. Viewing the
adaptation process through this lens may begin to bring the basic
processes of rehab and training much closer together.
When viewed through the rehabilitation process, the suggestion
is that the body is broken or has negatively adapted to some
form of stress (21). The body is injured, and the goal is to restore
it to normal levels. This negative stress may be in the form of an
ill-advised therapy plan, repetitive motions, overuse syndromes
from daily life or fitness activities, or trauma. The stress can be in
many different forms, but if the adaptation is not desirable, the
individual will often seek medical intervention (7). If the body has
responded negatively to stress, one answer to injury prevention
is resistance to stress (1,6,8). Some key bodily adaptations can
yield resiliency to overloading, overtraining, and certain levels of
trauma. Performance training may help improve this resiliency and
progress toward injury prevention, if applied properly. Although
rarely applied, sometimes it could be beneficial to expedite the
rehabilitation process via concurrent application of performance
training using movements and exercises that do not exploit the
injury or pain (8). These performance training processes manage
qualities of the body that are already at normal or above normal
levels and aim to create adaptations that are above normal. If
the training process intends to restore or improve qualities of the
body based on general and specific applications of stress, there
would potentially be less discord and improved outcomes in
both processes with professionals of both ends of the spectrum
working off the same premises and goals.
Proper stress application is the common thread between
rehabilitation and performance training processes, and there is
a lot of scientific research behind each field of study. Matching
the correct practitioner to the appropriate stage of the training
process is less science-based and more philosophical. Changing
semantics may help make this process easier. If there is injury,
it may be acceptable to say that there has been failure of the
body to adapt appropriately at some level (10,15). The failure
may be anywhere from a local tissue failure to a general injury
or an inability to train or compete. Failure from the performance
training process is likely an indicator that the individual’s physical
adaptations are not at a high enough level to be successful in
competitions of the sport (19,20).
There are four potential areas of failure where sport coaches,
performance coaches, and healthcare professionals can all be
legitimate entry points with the common goal of performance
training. The first area for potential injury is the equipment. The
equipment being used in sports may be out of date in terms of
technology, inappropriately sized, or poorly chosen for the type of
surface or weather (14).
The second area of concern is one of technical skills. Oftentimes
the best technical approach to athletics is one that emphasizes
positions of the body that are possible injury mechanisms (4).
Other times, simply poorly practiced technique may limit power or
cause injury (11). In these areas, the sport coach may be the best
individual to modulate the stressors that may potentially lead to
injury or limitations in output.
The third area of potential failure can be termed “biological
power.” It is conventional to suggest that limitations in power,
endurance, speed, or mental focus are targets to improve
performance. However, as the upper thresholds of these qualities
are reached or exceeded, it is very reasonable that individuals may
need to resort to poor execution or higher threshold techniques
that may create joint wear (1,6,13). While operating under lactic-
generating conditions, and given poor conditioning for the
selected sport, the body becomes more susceptible to injury,
particularly if acute or prolonged rest is not provided (2).
Operating under lactic-generating conditions, and given poor
conditioning for the selected sport, the body becomes far more
susceptible to injury, particularly if acute or prolonged rest is
not provided (2). Any limitations in capacities listed above
may lead to compensatory strategies as well as function under
unfavorable allostasis for performance or injury. Identifying the
ideal joint positions, tonic and phasic muscle function of the
sport, allostatic recovery, and the most efficient work capacity are
all key management strategies that the healthcare provider and
performance coach can apply (4,8,11,13).
Power can be developed, and this falls under the performance
coach. Carryover to sport is paramount during training as much as
it is important to select volumes and intensities that complement
the current status and development of the individual. There is a
lot of leeway in training the general population with this in mind;
however, training at intensities that far exceed the individual’s
current capabilities is a potentially dangerous process. Choosing
movements that do not degrade technical proficiency due to lactic
energy supply may take a program away from personal preference
PTQ 1.4 | NSCA.COM
or ideal sport specificity. In general, movement selection may
be less important, but carryover efficiency is more important in
training competitive athletes (10,13).
While the performance coach may be too aggressive and cause
injury via overtraining, the check and balance to this process,
for example, may come from the healthcare provider training in
manual therapy or other recovery methods that may expedite
acute levels of recovery (3,12). No neurological recovery technique
can outrun poorly managed physiological training approaches, but
in a well-crafted team-based approach, injury may be limited, and
performance may be enhanced if executed properly. This is where
some rehabilitation techniques are also doubling as recovery
techniques (3,12). Using the stress application thought process,
injury can be viewed as the recovery process that has gone awry
so that there may be pain or compensatory movement strategies,
such as autogenic inhibition or tone (21).
While the third area of potential injury is traditionally governed
by the performance coach, the fourth has more to do with the
rehabilitation professional; this area is movement. Simply, when
all other categories are exhausted and do not manage the failure
of injury or performance, the assumption is that the body simply
cannot get into the positions, mechanically or neurologically, to
absorb, and adapt to stress appropriately (19). This may require
the development of the physiological qualities required to
compete, or it may require the neurological acquisition of new
motor skills best suited for training or the sport.
There are many ways to screen or assess for movement
competency and the corrective methods to fix what is found
are countless. Techniques that span joint mobility, soft tissue
extensibility, and neurological tone are managed by the
rehabilitation professional (18,20). These techniques set up the
motor acquisition process via applying unique stressors to up-
regulate proprioception. And it is this proprioception that allows
for repetition in the desired form and patterns of training and
practicing sport-specific skills (15).
Although there is gray area surrounding this topic, it is grounded
in the scientific approach of creating desired adaptations via
unique and guided applications of stress. There is a recognition
that neurological adaptations can be fleeting but exploited where
available to develop physiological adaptations. Keen levels of
evaluation of movement, biological power, technical skills, and
equipment can reveal the best entry point for rehabilitation and
performance professionals to work together.
27
THE SHARED ADAPTATIONS OF THE TRAINING AND
REHABILITATION PROCESSES
REFERENCES
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Head and neck injuries in college football: An eight-year analysis.
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3. Bang, M, and Deyle, G. Comparison of supervised exercise
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Sports Physical Therapy 30(3): 126-137, 2000.
4. Chu, Y, Sell, T, and Lephart, S. The relationship between
biomechanical variables and driving performance during the golf
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Therapy 87(6): 641-653, 2007.
6. Ekstrand, J, Gillquist, J, Moller, M, Oberg, B, and Liljedahl, S.
Incidence of soccer injuries and their relation to training and team
success. The American Journal of Sports Medicine 11(2): 63-67,
1983.
7. Finger, M, Cieza, A, Stoll, J, Stucki, G, and Huber, E.
Identification of intervention categories for physical therapy, based
on the international classification of functioning, disability and
health: A Delphi exercise. Physical Therapy 86(9): 1203-1220, 2006.
8. Gabbett, T, and Domrow, N. Relationships between training
load, injury, and fitness in sub-elite collision sport athletes. Journal
of Sports Sciences 25(13): 1507-1519, 2007.
9. George, SZ, Bialosky, JE, and Fritz, JM. Physical therapist
management of a patient with acute low-back pain and elevated
fear avoidance beliefs. Phys Ther 84(6): 538-549, 2004.
10. Hodges, PW, and Moseley, GL. Pain and motor control of
the lumbopelvic region: Effect and possible mechanisms. J
Electromyogr Kinesiol 13(4): 361-70, 2003.
11. Hume, P, Keogh, J, and Reid, D. The role of biomechanics in
maximizing distance and accuracy of golf shots. Sports Medicine
35(5): 429-449, 2005.
12. Jull, G, Trott, P, Potter, H, Zito, G, Niere, K, Shirley, D,
Emberson, J, Marschner, I, and Richardson, C. A randomized
controlled trial of exercise and manipulative therapy for
cervicogenic headache. Spine 27(17): 1835-1843, 2002.
13. Liederbach, M, and Compagno, J. Psychological aspects of
fatigue-related injuries in dancers. The Journal of Dance Medicine
and Science 5(4): 116-120, 2001.
14. Marshall, S, Waller, A, Dick, R, Pugh, C, Loomis, D, and
Chalmers, D. An ecologic study of protective equipment and injury
in two contact sports. International Journal of Epidemiology 31(3):
587-592, 2001.
28 PTQ 1.4 | NSCA.COM
15. O’Sullivan P. Diagnosis and classification of chronic
low-back pain disorders: Maladaptive movement and motor
control impairments as underlying mechanism. Man Ther 10(4):
242-55, 2005.
16. Philosophical Statement on the Definition of Physical Therapy
(HOD 06–83–03–05). In: House of Delegates Policies. Alexandria,
VA: American Physical Therapy Association; 1983.
17. Rose, SJ. Diagnosis: Defining the term Phys Therapy 69(2):
162-163, 1989.
18. Sahrmann, S. Diagnosis and Treatment of Movement
Impairment Syndromes. (1st ed.) St Louis, MO: Mosby, Inc.; 2001.
19. Sahrmann, S. Diagnosis by the physical therapist—A
prerequisite for treatment. Journal of the American Physical
Therapy Association 68(11): 1703-1706, 1988.
20. Scheets, P, Sahrmann, S, and Norton, B. Use of movement
system diagnoses in the management of patients with
neuromuscular conditions: A multiple-patient case report.
Phys Ther 87(6): 654-669, 2007.
21. Simons, DG, and Mense, S. Understanding and measurement
of muscle tone as related to clinical muscle pain. Pain 75(1):
1-17, 1998.
ABOUT THE AUTHOR
Charlie Weingroff is a Doctor of Physical Therapy, Certified Athletic
Trainer (ATC), and Certified Strength and Conditioning Specialist®
(CSCS®). He spends his time training and rehabbing athletes and
clients at Drive495 in New York City, NY and Fit For Life in Marlboro,
NJ. He is also an internationally renowned speaker for his own
seminar series “Training = Rehab, Rehab = Training,” M-F Athletic,
and other various conferences and outlets. Weingroff is the Director
of Physical Performance and the Head Strength and Conditioning
Coach for the Canadian Men’s National Basketball Team. He also
holds a similar position as Director of Performance for the Roddick-
Grunberg School of Tennis in Ft. Worth, Texas. Positions he has
formally held include Head Strength and Conditioning Coach for
the Philadelphia 76ers in the National Basketball Association (NBA)
and Lead Physical Therapist for the United States Marine Corps
Special Operations Command.
NSCA.com
GETTING THE MOST OUT OF A CERTIFICATION IN
PERSONAL TRAINING
ROBERT LINKUL, MS, CSCS,*D, NSCA-CPT,*D
T
he hours that you spent studying and preparing for your
certified personal trainer (CPT) certification exam paid off.
You are now officially ready to join the work force and bare
the “CPT” credentials after your name. These initials indicate to the
client that you are an educated professional that can help them
achieve their fitness goals. They also indicate to other trainers that
you belong among the ranks, but it does not stop there. You can
get a lot more out of your certification if you set your standards
high and implement these important steps.
KEEP IT CURRENT
It is unfortunate to think that after all the hours spent to earn
a certification that a trainer would let his or her certification expire,
but many do. The reasons vary, maybe it is a financial issue or
maybe they feel they no longer need it because the standards
that they have set for themselves are not high enough. The
basic demands of the strength and conditioning industry
recommend that a trainer keep up-to-date with first aid
and cardiopulmonary resuscitation (CPR) qualifications, as
well as maintain a current certification. These are general
recommendations, not requirements; the industry does not
officially require a trainer to have a certification, and there is
no governing body or entity to uphold a high standard for
trainers. The only standards are the ones that each individual sets
for themselves and it all starts with keeping that hard earned
certification(s) current and up-to-date, in which the length can
vary between organizations and certifications.
The best way to keep a certification current is by obtaining
continuing education. Earning continued education units (CEUs)
is a mandatory requirement for keeping up most certifications.
Conferences, clinics, seminars, webinars, self-studies, home
studies, quizzes, book chapters, book reviews, journal articles,
journal reviews, secondary certifications, and specialized
certifications make up the more popular ways to earn CEUs. The
material presented for CEUs in this day and age is exceptional.
Research in the strength and conditioning industry is at an all-time
high and the information that is coming from these studies has
proven to be very beneficial for clients, if implemented correctly
by their trainer. Adhering to a high standard and keeping
30 PTQ 1.4 | NSCA.COM
certifications current may allow the trainer to be showcased in
a very professional manor and prove to be a valuable asset to
the client.
SHOWCASING VALUE
Oftentimes, one of the first things a potential client does prior to
contacting a trainer is research their name on the Internet. The
client wants to be assured that they are making the right decision
by selecting the individual that has the proper education and
experience to help them with their specific needs. Knowing how
important this information is to the client, it is even more reason to
showcase everything that a trainer has to offer.
The trainer’s name, title, and credentials should appear the same
way anywhere it is displayed. Business cards, information on the
website, content on promotional flyers, and biographies hanging
on the wall in the gym should be updated regularly with the most
recent information, education, experience, credentials, and areas
of expertise. The trainer should take advantage of any chance to
inform the client; for example, they could do this by explaining
what certain certifications emphasize. Professional branding is a
further step that can be taken to showcase a personal trainer’s
value over the competition.
EDUCATING CLIENTELE
It is the trainer’s job to educate clients about fitness. It is also the
trainer’s job to educate clients on how to select the right trainer
to work with in the first place. One of the best ways to do this is
by producing materials that explain what the credentials mean.
Explain to clients the requirements that must be met in order to
maintain those credentials and the number of hours spent earning
CEUs. Another great way to showcase this is to write reviews
about conferences or workshops attended and to post pictures at
these educational events on the Internet for all to see.
If possible, a trainer could allow one day a week in which they
wear clothing (e.g., polo shirts, t-shirts, sweatshirts, etc.) of the
certifying organization that shows affiliation or certification. You
want clients to recognize these organizations and credentials, and
to affiliate them with success, education, and professionalism.
It is recommended that a trainer make the certifying agency
and credentials a common topic in the facility. Additionally, the
trainer could put up posters, membership stickers, upcoming REFERENCES
clinic or conference information, and anything else that will show 1. Clayton, N. The key to career growth. PFP Magazine.
a professional affiliation with a reputable organization. Not only July-August: 10, 2013.
can the trainer improve the quality of the product this way, but
2. Douglas, S. Making the most of your NSCA certification –
could also help to build a reputation for being an educated fitness
interview with the 2012 Personal Trainer of the Year. NSCA Career
professional as well.
Development Website. 2012. Retrieved 2014 from http://www.nsca.
The product provided to the client and the trainer’s reputation are com/Membership/Career-Services/Making-the-Most/.
two products that go hand-in-hand. Providing a quality product 3. Douglas, S. Boost marketability: Leverage your continuing
to each client will grow a reputation for being an elite trainer, and education. PFP Magazine November-December: 10, 2013.
a high-quality reputation in the industry is a better self-marketing
4. Pettitti, C. Wellness coaching certification: A new frontier for
tool then any promotional campaign. Building a quality reputation
personal trainers in health care. Strength and Conditioning Journal.
will earn more business without having to resort to sales pitches
35(5): 63-65, 2013.
or extreme discounts because the client will have already heard of
the trainer and his or her successes. Ultimately, this may lead to
clients seeking out the best trainers for assistance and when that ABOUT THE AUTHOR
happens, a trainer who adheres to high standards can reap the Robert Linkul is the National Strength and Conditioning
rewards of this hard work. Associations (NSCA) 2012 Personal Trainer of the Year and is a
volunteer with the NSCA as their Southwest Regional Coordinator
The client wants to work with the best and the brightest trainer
and committee chairman for the Personal Trainers Special Interest
they can find. All a trainer needs to do is promote himself or
Group (SIG). Linkul has written for a number of fitness publications
herself as that person. A trainer should hold himself or herself to
including Personal Fitness Professional, Healthy Living Magazine,
a high standard and keep first aid, CPR, and certification(s)
OnFitness Magazine, and the NSCA’s Performance Training Journal
current. A trainer should keep attending conferences and taking
(PTJ). Linkul is an international continued education presenter
advantage of CEU opportunities. In addition, it is important to
within the fitness industry and a career development instructor for
showcase value by placing an emphasis on elite certification and
the National Institute of Personal Training (NPTI).
the organization that hosts it. By doing all these things, a trainer
can effectively showcase value to the client and effectively get the
most of a certification.

NSCA’s Certified Personal Trainer (NSCA-CPT) Enhanced

Online Study Course
Master the essentials of personal training
Developed by the NSCA and Human Kinetics, this enhanced online study course
offers a practical and efficient method of studying for the NSCA-CPT exam,
including more than 120 interactive learning activities and real-world applications.
An end-of-course exam mimics the scope and difficulty of the actual certification
exam. Current NSCA-certified professionals can also earn CEUs by completing
this course.
National Strength and Conditioning Association
Enhanced online course with NSCA’s Essentials of Personal Training,
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NSCA 1.5 • Eligible for recertification with distinction
† Also available as an e-book. If you already own the book, you may purchase the course without the book.

Corresponding Text
NSCA’s Essentials of Personal Training, Second Edition
National Strength and Conditioning Association
Jared W. Coburn, PhD, and Moh H. Malek, PhD, Editors
©2012 • Hardback, e-book • 696 pp
ISBN 978-0-7360-8415-4 • $96.00

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PTQ 1.4 | NSCA.COM 31
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