ACSM’S CERTIFIED NEWS - ACSM Certification | … to the ACSM’s Guidelines for Exercise Testing and Prescription or the established positions of ACSM.ACSM’s Certified News is

ACSM’S CERTIFIED NEWS • JANUARY-MARCH 2010 • VOLUME 20:1 1

NEWSACSM’S CERTIFIED

Continuing EducationSelf-Tests page 15

Agility TrainingFor the General Population

page 5

JANUARY – MARCH, 2010 • VOLUME 20; ISSUE 1

Prescribing Exercise in

CardiacRehabilitation

Without an Exercise Testpage 7

ExerciseRecommendationsfor the FrailPopulationpage 3

Making Senseof the ExercisePrescriptionpage 13

Effects of StrengthTraining on

Resting EnergyExpenditure

page 10

Effects of StrengthTraining on

Resting EnergyExpenditure

page 10

2 ACSM’S CERTIFIED NEWS • JANUARY-MARCH 2010 • VOLUME 20:1

ACSM’S CERTIFIED NEWS

JANUARY-MARCH 2010 • VOLUME 20, ISSUE 1

In this Issue

Exercise Recommendations for the

Frail Population...................................................... 3

Agility Training For the General Population ......... 5

Prescribing Exercise in Cardiac

Rehabilitation Without an Exercise Test ............. 7

Coaching News........................................................... 9

Effects of Strength Training

on Resting Energy Expenditure.............................10

Making Sense of the Exercise Prescription..............13

Self-Tests ........................................................................15

Co-Editors

Paul Sorace, M.S., James R. Churilla, Ph.D., M.P.H.

Committee on Certification

and Registry Boards Chair

Madeline Bayles, Ph.D., FACSM

CCRB Publications Subcommittee Chair

Jan Wallace, Ph.D., FACSM

National Center Newsletter Staff

National Director of Certification

and Registry Programs

Richard Cotton

Assistant Director of Certification

Traci Sue Rush

Professional Education Coordinator

Shaina Loveless

Publications Manager

David Brewer

Editorial Board

Chris Berger, Ph.D.

Brian Coyne, M.Ed.

Yuri Feito, M.S., M.P.H.

Tom LaFontaine, Ph.D., FACSM

Peter Magyari, Ph.D.

Jacalyn McComb, Ph.D., FACSM

Peter Ronai, M.S.

Larry Verity, Ph.D., FACSM

Stella Volpe, Ph.D., FACSM

Jan Wallace, Ph.D., FACSM

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A HEALTHY SET OFCHANGES FOR YOU

James R. Churilla, Ph.D., M.P.H.Paul Sorace, M.S.

Co-Editors

To continue to provide ACSMcertified professionals withimportant and timely informa-tion, ACSM ’s Certif ied Newshas undergone some changesstarting in 2010.

We would like to highlight these changes which include:• More pages: Each issue of Certif ied News will now have 16 pages.• Color-glossy pages. To make the publication more visually appealing, Certif ied

News has a new look, which includes color headshots of all authors. Speaking ofauthors, ACSM certified professionals are encouraged to submit articles toCertif ied News. Author guidelines can be obtained by emailing ACSM [email protected]

• Features, Wellness, and Columns: Each issue of Certif ied News will have onehealth & fitness feature article, one clinical feature article, two wellness articles, ahealth & fitness column and a clinical column. Wayne Westcott, Ph.D., is the inau-gural health & fitness columnist. We are very excited to have Dr. Westcott fill thisrole! We are also very excited to announce that our inaugural clinical columnistwill be Jonathan K. Ehrman, Ph.D. We look forward to kicking off our clinical col-umn by the third issue of 2010. Each issue of Certif ied News will continue to pro-vide 4 CECs.

• Editorial Board: An editorial review board was added to Certif ied News in 2009to further increase the quality of all articles published in Certif ied News.

We feel these changes will enhance the publication and offer relevant and timely topics for anyand all ACSM certified professionals. We look forward to continue providing you with evidence-based information and continuing education.


It causes a deterioration of a person’s physiological functions,increases the risk of loss of independence and even death. Frailty canbe challenging to diagnose, although it has been defined (see Table 1).

There are a number of contributing factors for frailty. Older adultsare often at risk for becoming frail due to aging, physical disuse andchronic diseases.2 Obesity is also a potential contributing factor tofrailty.6 Table 2 lists some of the common diseases and disabilities thatcan lead to frailty.

Exercise Effects on Frailty

Regular exercise can have a number of benefits in older, frail per-sons.1,2,6 These include:

• Improved muscular strength and endurance• Increased aerobic capacity • Enhanced joint flexibility• Improved balance and coordination • Improved psychological well-being • Weight loss (if needed)• Management of chronic diseases/disabilities

These potential benefits can result in enhanced functional abilities,maintained or increased independent living and possibly reversing thecondition of frailty. Weight loss and regular exercise/physical activityhave been shown to reduce the effects of frailty in obese older

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

Exercise Recommendations

Due to a variety of health conditions that may be present in thispopulation, obtaining medical clearance prior to initiating an exerciseprogram is prudent. Exercise testing should be performed wheneverpossible to determine what the person’s abilities are prior to begin-ning an exercise program. Additionally, baseline testing will providethe necessary information for developing an exercise prescription.Some of the exercise tests that can be done include a 6-minute walkto estimate cardiorespiratory fitness, a handgrip dynamometer tomeasure upper body strength and a sit and reach test to measureflexibility.2 Resting heart rate, resting blood pressure and body com-position also should be measured. If a medical condition such ashypertension or diabetes is present, monitoring blood pressure orblood glucose levels pre- and post-exercise should be performed.

Increasing the functional abilities of the individual should be keptin mind when developing the exercise program. Depending on theindividual, different modes of exercise should be considered. Walkingis the most common aerobic activity in older adults.1 Large musclegroups and weight bearing aerobic exercises should be emphasizedwhenever possible. Non-weight bearing aerobic activities (e.g.,cycling, swimmimg) should be used when weight bearing exercisesare too strenuous. Aerobic training should be performed 3 to 5 ormore days per week.1,2 However, this may not always be possible anda lesser frequency might be all the individual can tolerate during theearly stages of an exercise program. The certified personal trainer orhealth/fitness specialist should encourage increased daily physicalactivity (e.g., climbing stairs, short walks) to improve aerobic condi-tioning and functional abilities.

Flexibility training (e.g., static stretching) for frail persons is impor-tant to increase joint range of motion, which can increase ease ofmovement with daily activities. Yoga is a form of exercise that is suit-able for many frail persons. DiBenedetto and colleagues4 suggest thatyoga can improve hip extension, stride length and pelvic tilt in the eld-

FRAILTY IS A CONDITION SEEN

PARTICULARLY IN THE ELDERLY AND

IS CHARACTERIZED BY WEAKNESS, FATIGUE,FUNCTIONAL IMPAIRMENT AND A VARIETY OF DISEASES AND/OR DISABILITIES.2,5

HEALTH & FITNESS FEATURE

Exercise Recommendations for the

Frail PopulationBY PAUL SORACE, M.S., RCEP, CSCS*D,

HACKENSACK UNIVERSITY MEDICALCENTER, HACKENSACK, NJ

Table 1. Defining Criteria for Frailty

The person must have at least three of the following:

• Unintentional weight loss (10 lbs. in past year)

• A feeling of exhaustion

• Weakness (measured by grip strength)

• A slow walking speed (defined as the slowest 20% of thepopulation studied to walk 15 feet)

• Low physical activity

Adapted from reference 5.


erly population. Yoga as a lifestyle intervention has been shown toassist in improving cardiovascular disease risk factors (e.g., bloodlipids, blood glucose).3 Also, yoga can improve balance and coordina-tion to help promote fall prevention.

Sarcopenia (muscle loss) is very common in older adults and con-tributes to a loss of functional abilities. This emphasizes the impor-tance of resistance training for this population. Resistance trainingincreases muscle mass, muscular strength, power and endurance.Maintained or increased muscular strength can enhance functionalabilities in older, frail individuals.2

All major muscle groups and multi-joint exercises should beemphasized. Modes of resistance training include resistance bands,free weights, resistance machines, medicine balls and calisthenics.Resistance training should be performed two to three times perweek.1,2 The resistance training program should start at a low level(e.g., with little or no resistance/weight) in those who are verydeconditioned. However, the resistance training program should begradually progressed, as tolerated. Muscle hypertrophy (accompa-nied by increases in strength) occurs at all ages as a result of regularresistance training. Gradual progression to heavier weights (i.e., moreresistance) in the properly risk stratified individual is just as impor-tant in older populations as it is in their younger counterparts.

Functional training can improve body awareness and balance,increase neuromuscular coordination, flexibility, ambulation andlower body strength.2 This is important for frail individuals, particular-ly in reducing the risk of falls. Examples include a chair sit and stand,one-foot stand, balance board walking and activity-specific exercises(e.g., carrying objects). Other activities such as obstacle courses canenhance reaction time and coordination.

Tai Chi, a form of martial arts that enhances balance and bodyawareness through slow, graceful and precise body movements, hasbeen shown to reduce the risk of falling by approximately 47.5% infrail older adults.7 Like yoga, Tai Chi is an activity that many frail indi-viduals can perform at their own pace.

Some general exercise recommendations include:• Properly supervised aerobic exercise 3 to 5 or more days per

week; exercise heart rate should not be the focus; use a 5 to 8on a 1 to 10 rating of perceived exertion scale to measure mod-erate to vigorous exertion; accumulate 20 to 60 minutes; largemuscle group activities (e.g., walking, cycling, swimming).

• Flexibility training 3 to 7 days per week; static stretching to a

point of mild tension; all major muscle groups; 15 to 60 secondsin duration.

• Properly supervised resistance training 2 to 3 days per week(nonconsecutive days); use modes (e.g., free weight, machines,elastic bands) that are suitable for the individual; 8 to 10 exer-cises for the major muscle groups; 1 to 3 sets per exercise; 10to 15 repetitions.

• Other activities such as yoga, Tai Chi and functional exercisescan be performed on a daily or near-daily frequency, based onthe abilities of the individual.

Note: Recommendations may need to be modified depending onthe individual. These recommendations are based on references.1,2

Summary

Frailty is a medical condition that is linked to chronic healthproblems, disability, reduced functional capacity and loss of inde-pendence. Many of the effects of frailty can be improved by partic-ipation in a comprehensive exercise program. The certified healthand fitness professional must consider the overall health and func-tional abilities of the individual when designing an exercise pro-gram. The benefits of exercise can contribute to a healthier andmore independent lifestyle for frail persons.

About the Author

Paul Sorace, M.S., RCEP, CSCS*D, is a clinical

exercise physiologist for The Cardiac Prevention

and Rehabilitation Program at Hackensack

University Medical Center in Hackensack, NJ.

Paul also is a member of the ACSM Publications

Subcommittee and ACSM’s Health & Fitness

Summit & Exposition Program Committee. He is

co-editor for ACSM’s Certified News and an

editorial board member for ACSM’s Health & Fitness Journal®

.

References

1. American College of Sports Medicine. ACSM’s Guidelines for

Exercise Testing and Prescription, 8th ed. Thompson WR, Gordon

NF, Pescatello LS, editors. Baltimore, MD: Lippincott Williams &

Wilkins, 2009:190-194.

2. American College of Sports Medicine. ACSM’s Exercise

Management for Persons with Chronic Diseases and Disabilities,

2nd ed. Durstine JL, Moore GE, editors. Champaign, IL: Human

Kinetics 2003:157-163.

3. Bijlani RL, Vempati RP, Yadav RK, et al. A brief but comprehensive

lifestyle education program based on yoga reduces risk factors

for cardiovascular disease and diabetes mellitus. J Altern

Complement Med. 2005;11:267-74.

4. DiBenedetto M, Innes KE, Taylor AG, et al. Effect of a gentle

Iyengar yoga program on gait in the elderly: an exploratory study.

Arch Phys Med Rehabil. 2005;86:1830-7.

5. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evi-

dence for a phenotype. J Gerontol A Biol Sci Med Sci.

2001;56:M146-56.

6. Villareal DT, Banks M, Sinacore DR, Siener C, Klein S. Effect of

weight loss and exercise on frailty in obese older adults. Clin J

Sport Med. 2006;166:860-6.

7. Wolf SL, O’Grady M, Easley KA, Guo Y, Kressing RW, Kutner M.

The influence of intense Tai Chi training on physical performance

and hemodynamic outcomes in transitionally frail, older adults. J

Gerontol A Biol Sci Med Sci. 2006;61:184-9.

Table 2. Chronic Diseases and Disabilities thatContribute to Frailty

Adapted from reference 2.

• Hypertension

• Coronary Artery Disease

• Peripheral Artery Disease

• Asthma; ChronicObstructive PulmonaryDisease (COPD)

• Arthritis

• Osteoporosis

• Diabetes

• Cancer

• Anemia

• Parkinson’s Disease

• Alzheimer’s Disease


Safety

Prior to beginning any agility training, it is important to make cer-tain the client can safely participate in this type of activity. Clientswith orthopedic limitations that affect their ability to balance eitherstatically or dynamically, and those that lack the strength or abilityto maintain proper position should refrain from this type of traininguntil they have adequately developed their performance levels. Table1 lists individual characteristics that would preclude participation inagility training. It also is recommended that before these individualsparticipate in agility training for the first time, they have at least 2 to3 months of consistent resistance training experience.

Drill Selection

When selecting drills, an emphasis should be placed on improvingfundamental movement skills. These skills include locomotor, non-locomotor, manipulative, and movement/body awareness skills(Table 2).These movements are required in all activities in varying

amounts, and shouldbe performed at awide array of speeds,a m p l i t u d e s , a n dforces based on thespecif ic population.For ins tance, thesame movementsbeing produced by anathlete in a game or

practice situation versus a non-athlete playing with their children orcrossing a busy street may require similar intensity and mobilitydemands. While certain skills are necessary, balance, explosivenessand speed (in both situations), the degree of skill and the magnitudeof movement may be different for these movement abilities. Thus,when used as in conjunction with a comprehensive resistance train-ing program this form of training may better prepare individuals forthe demands of their daily lives, allowing them to perform activitieswith greater skill and efficiency. Furthermore, training drills that helpindividuals develop generalized motor programs aid in the develop-ment of greater proprioceptive capabilities.4 This provides the clientwith a reference point to evaluate their own movement behaviors inthe future and a greater capacity to detect errors in performanceand correct them via augmented musculoskeletal feedback.4,5

In general terms, agility drills can be classified as closed oropened.2 Closed drills are preprogrammed drills, performed in a pre-dictable and unchanging environment.2,3,5 Initially, closed drills, withminimal force production requirements, such as most agility ladderdrills or cone drills, should be performed, progressing to more com-plex drills later, such as those that are non-programmed, or open.An individual attempting to mirror the actions of another individualor drills that require a person to respond to an auditory cue beforeselecting a specific movement pattern. The focus of closed drills isprimarily on proper movement mechanics, proper body position andsimple changes of direction. Clients should be encouraged to per-form drills only at speeds that allow proper execution of the target-ed movements. Once the technique has been mastered, the clientmay then increase their speed of movement.

In most sports, an athlete must be able to accelerate,decelerate and change directions rapidly with good bodycontrol in order to perform well and reduce their risk ofinjury. For this reason, agility drills are commonly utilized byathletes to enhance their on-field performance. However,these same types of drills can easily be incorporated intotraining programs for the general fitness population inorder to improve performance in recreational and dailyactivities and help them respond faster in emergency situa-tions. In this article, a few suggestions for implementingthese drills into a comprehensive training program for thenon-athlete will be discussed.

AGILITY TRAININGFor the General PopulationBY: JAY DAWES, M.S., CSCS, FNSCA, ACSM-HFS

Table 1:Those Who ShouldNot Participate in AgilityTraining

• Very old and frail• Severe neuromuscular disorders

(e.g., stroke, Parkinson’s disease)

• Pregnancy• Morbidly obesity

WELLNESS ARTICLE


Following technique mastery, the exercise professional may nowconsider the implementation of open drills to the client’s agility pro-gram. This can be easily done by adding some form of sensory stim-uli (visual, auditory or kinesthetic) to a traditional closed trainingdrill. For instance, tossing a client a ball to catch or requiring themto perform various biomotor skills based on the trainer’s command.2

These advanced drill progressions require the client to adapt theirnewly learned skills based on a novel situation, similar to real life,rather than simply performing a preprogrammed pattern or drill.

Additionally, the client will develop certain perceptual and decisionmaking skills that cannot be learned as effectively during closed train-ing drills. Table 3 shows some examples of closed, semi-pro-grammed, and open agility drills.

Modifications

When integrating agilities into a client training program it isimportant to modify each specific drill based on the clients’ currentskills and abilities. As previously stated, most non-athletes will not berequired to make high intensity cutting movements with large ampli-tudes of movements at maximal speeds. Therefore, when designingan agility-training program for the general fitness client, maximumeffort and speed of movement is not necessarily the focus of train-ing. Rather it should be performing the appropriate movement pat-terns through the desired ranges of motion in a safe and effectivemanner. Since these individuals may not be athletes, agility trainingprograms should be modified by starting and progressing more slow-ly. Furthermore, adjusting the mobility and flexibility demands of adrill also allows clients to work at their own level versus trying toaccomplish the movement patterns expected of elite athletes.

Conclusion

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

About the Author

Jay Dawes, M.S., CSCS, FNSCA, ACSM-HFS, is

the director of education for the National

Strength and Conditioning Association located

on Colorado Springs, CO. He is also an adjunct

faculty member of the School of Nursing and

Health Sciences at the University of Colorado in

Colorado Springs, as well as a Ph.D. student at

Oklahoma State University.

References

1. Dawes J, Mooney C. 101 Conditioning Games and Drills for

Athletes. Monterey, CA: Monterey Bay Press. 2006:9.

2. Dawes J. ONE-ON-ONE: Creating Open Agility Drills. Strength &

Conditioning Journal. 2008;30: 54-55.

3. Dawes J. Learning to React. Professional Strength & Conditioning.

2008;9:25-27.

4. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral

Emphasis, 4th ed. Champaign, IL: Human Kinetics, 2005:91-101, 280-

285, 401-431

5. Young W, Farrow D. A Review of Agility: Practical Applications for

Strength and Conditioning. Strength & Conditioning Journal.

2006;28:24-29

Table 3: Examples of Agility Drills

Table 2: Fundamental Movement Skills

LocomotorWalkingRunningSkippingHopping Sliding ChasingFleeingDodgingGallopingRolling

Non-LocomotorTwistingTurningBalancingJumpingLandingStretchingPushingPulling

ManipulativeThrowingCatchingKickingPuntingDribblingStrikingVolleying

MovementAwarenessSpatialAwarenessKinestheticAwareness

CLOSED AGILITY DRILLSEXAMPLES

Forward Run: Start diagonallybehind one cone. When ready,sprint forward to the secondcone. Upon reaching the sec-ond cone, come to a completestop in an athletic position,immediately turn and acceler-ate in the opposite direction.Sprint past the first cone.

Backpedal: The client will startdiagonally behind the firstcone with their back turnedtoward both cones. Whenready, backpedal to the sec-ond cone. Upon reaching thesecond cone, immediately turnand backpedal to the firstcone. The focus of this drillshould be on keeping the hipslow and maintaining the ath-letic position.

Lateral Shuffle: The clientshould begin by facing thefirst cone. When ready, shuffleto the second cone whilekeeping the hips low, keepingthe hips, shoulders and torsoparallel to the cones. Uponreaching the second cone,immediately shuffle back tothe first cone.

SEMI-PROGRAMMED/OPENAGILITY DRILLS EXAMPLES

Ball drops: While performingthe forward/run, randomlydrop a tennis or racquet ballWhen the ball is dropped theclient should immediatelysprint toward the ball andcatch it before it bouncestwice.

Forward/Run-Backpedalwith auditory cue: The clientshould begin this drill by run-ning forward to the secondcone, and upon reaching thesecond cone decelerate thebody and backpedal to thefirst cone. Periodically thetrainer will provide an audito-ry cue by blowing a whistle tosignal the client to immediate-ly stop where they are andchange directions.

Mirror Drill: Begin with thetrainer facing the client in thecenter of the cones. On the gocommand the client mustm i m i c t h e t r a i n e r ’ s movements.

Note: For all drills featured in this table two conesshould be placed approximately 6 to 10 feet apart.


It is not uncommon for patients to beginphase II cardiac rehabilitation without arecent exercise test. According to a surveyby Andreuzzi et al.,2 60% of programs donot require an exercise test prior to pro-gram entry. However, there are few evi-dence-based recommendations for estab-lishing a target heart rate (HR) in patientswith heart disease in the absence of an exer-cise test. ACSM’s Guidelines for ExerciseTesting and Prescription, 8th edition1 improveson prior editions by providing some guid-ance for these situations (see Table 9.1, p.214). These guidelines will be refined asmore evidence-based data become available.This article will discuss challenges faced bythe exercise physiologist when prescribingexercise without an exercise test.

PRE-PROGRAM

EXERCISE TEST

Although the American College of Cardiology andthe American Heart Association recommend a pre-pro-gram, symptom-limited exercise test in all patients in which cardiac reha-bilitation is indicated,9 the necessity has been questioned. McConnell etal.12 concluded that patients completing 12 weeks of cardiac rehabilita-tion can be safely progressed and demonstrate similar improvements incaloric expenditure, independent of whether they have a pre-programexercise test. It should be kept in mind, however, that an exercise testprovides more than just data for an exercise prescription. Following acardiac event or procedure, an exercise test also provides informationon residual ischemia, risk stratification, and functional capacity.11 If imple-mented before and after an exercise training program, changes in func-tional capacity can be quantified which can be useful for program out-comes and patient motivation.

REST PLUS 20

When an exercise test is not available, clinicians will typically set a tar-get HR based on the patient’s resting HR plus 20 beats per minute(bpm; “rest plus 20”), or they will guide exercise based solely on ratingsof perceived exertion (RPE). Establishing a target HR using rest plus 20was originally intended to be a temporary recommendation followinghospital discharge until the patient had a symptom-limited exercise testin conjunction with an outpatient cardiac rehabilitation program. Insome programs it is viewed as a safe and conservative initial trainingintensity in the absence of an exercise test. Practical experience, how -ever, suggests that some patients may not undergo an exercise test

CARDIACREHABILITATION

WITHOUT AN EXERCISE TEST

BY CLINTON A. BRAWNER, M.S., RCEP, FACSM A CONTRIBUTION FROM THE CLINICAL

EXERCISE PHYSIOLOGY ASSOCIATION (CEPA)

PRESCRIBING EXERCISE INCLINICAL FEATURE


while in cardiac rehabilitation. Some of these patients will have had apharmacologic stress test that was ordered by a physician for clinical pur-poses. The absence of exercise test data presents a challenge whendefining the exercise intensity for an individual patient.

Joo et al.10 reported that, on average, rest plus 20 corresponded to42% of VO2 reserve among patients entering a phase II cardiac rehabili-tation program. Brawner et al.4 reported the relative percent HRreserve associated with rest plus 20 in patients with ischemic heart dis-ease (Table 1). Although rest plus 20 appears to be a “good fit” forsome, it may result in suboptimal training intensity in many.

In the HF-ACTION trial (Heart Failure: A Controlled TrialInvestigating Outcomes of Exercise TraiNing), we learned that variousrest plus 20 procedures were being used across exercise centers. It wasnot uncommon for centers to recalculate this each day. Neither ACSMnor the American Association for Cardiovascular and PulmonaryRehabilitation (AACVPR) provide specific procedures on the calculationand use of rest plus 20.

In light of this, the following is presented as a framework to establishprogram procedures for the use of rest plus 20 when an entry exercisetest is not available. First, identify a baseline resting HR in an upright posi-tion (seated or standing) after two minutes of quiet rest on three sepa-rate days. In addition to its use in establishing a target HR, it also will pro-vide a useful baseline resting HR to help identify patients during subse-quent exercise sessions who may not have taken, or had a change in,their beta blockade. Patients are then provided a “target HR range”based on their resting HR plus 15 to 25 bpm. This provides patients a10 beat range that they can use consistently.

RATINGS OF PERCEIVED EXERTION

Per ACSM’s recommendations, a target HR range based on rest plus20 can be gradually titrated to higher intensities based on RPE, signs,and symptoms.1 Although RPE scales are frequently cited as valid toolsto guide exercise intensity, specifics on how to implement them arerarely outlined. In addition, discordance exists between RPE and targetHR during exercise in many patients.13 However, in healthy adults, thevalidity of RPE has been shown to improve when feedback on theirintensity (e.g., too high or too low) is provided during three initial train-ing sessions.8 Caution should be used when depending solely on RPE.

Another perceived exertion-related tool that may be useful is thetalk test. This is the highest exercise intensity at which the person feelsthey can talk comfortably. The talk test has been shown to be a goodestimate of the exercise intensity associated with the ventilatory-derived

anaerobic threshold7 and the ischemic threshold.6 When patients withheart disease were asked to exercise on a track at the fastest pace thatstill allowed them to talk comfortably, 59% chose a pace that was with-in 50-85% of HR reserve; 14% chose a pace above this range and 27%were below.5 Similar to RPE, the talk test results in inter-individual vari-ability; however, if a patient feels they cannot talk comfortably, they arelikely exercising too hard.

A CASE STUDY

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

EXERCISE TESTS VS.

PHARMACOLOGICAL TESTS

It is not uncommon for patients in phase II or maintenance-type car-diac rehabilitation programs to undergo pharmacological stress tests(e.g., dobutamine, adenosine) instead of a symptom-limited exercise test.A common question that arises is, can information from these tests beused to develop an exercise prescription? ACSM provides options forthis situation;1 however, this information does not address all possible circumstances.

A symptom-limited exercise test assesses ischemia by increasingmyocardial oxygen demand through increases in HR and myocardial con-tractility. Ischemia occurs when myocardial blood supply cannot matchthe myocardial demand for oxygen. An exercise test also is used toassess functional capacity (e.g., peak VO2, peak watts). Functional capac-ity is the focus of the exercise intensity prescription with a typical goalof 50-85% of functional capacity (i.e., VO2 reserve). Because of the lin-ear relationship between HR and VO2 (or watts), HR serves as a usefulsurrogate or estimate of a target work rate.

On the other hand, dobutamine stress tests assess ischemia withoutexercise by increasing myocardial oxygen demand through medication-induced increases in HR and myocardial contractility. However, they donot assess functional capacity. No studies have shown a useful relation-ship between HR responses observed during dobutamine and exercisetests. For these reasons the usefulness of this information is limited. If adobutamine test is positive for ischemia, the rate-pressure product (HR× systolic blood pressure) at the ischemic threshold could be used to

Cardiac Rehabilitation (continued on page 12)

Table 1. Exercise intensity based on resting HRplus 20 bpm and corresponding HR reserve inpatients with heart disease.

NoBeta-Blockade Beta-Blockade

Therapy Therapy(n= 50) (n= 46)

% HR reserve 45% 31%% patients below 50% HR reserve 80% 91%% patients above 80% HR reserve 4% 0%

HR= heart rate; bpm= beats per min.Adapted from reference 4.


In a recent study, more than 2,000 olderadults aged 60 to 86 were evaluated to deter-mine who was more likely to be alive at theconclusion of the study. In the group thatachieved greater longevity, one factor was sig-nificantly more important than any other.9 Areyou curious as to what that factor was?Knowing about this factor also may help youenjoy a long life.

In his new book, Curious? Todd Kashdan,professor of psychology at George MasonUniversity, reveals that the all-important ingre-dient to longevity in this study was curiosity.He points out: “Those who were more curiousat the beginning of the study were more likelyto be alive at the end of the study, even aftertaking into account age, whether they smoked,the presence of cancer or cardiovascular dis-ease, and all the rest of the usual markers.”2

While he acknowledges that declining curiositymay be a sign of declining health and neurolog-ical illness, Kashdan believes that “there arepromising signs that enhancing curiosityreduces the risk for these diseases and eventhe potential to reverse some of the naturaldegeneration that occurs.”2

According to Kashdan, curiosity has a pow-erful effect on well-being and thriving.It isincumbent upon coaches to understand pre-cisely what it is, its benefits for psychologicaland physical health, and how to best facilitatecuriosity in our clients.

What is Curiosity?

Curiosity has received more than a centuryof psychological study and many definitionshave been offered over the years. What all def-initions have in common, however, is thatcuriosity is (1) a motivational state; (2)approach-oriented and; (3) associated withexploration. A good working definition ofcuriosity, offered by Kasdan, is: “The recogni-tion, pursuit, and intense desire to explore

novel, challenging, and uncertain events.”4

We are Wired to Be Curious

Psychologists who subscribe to the intrinsicmotivation tradition believe that interest orcuriosity arises from the operation of evidence-based primal needs, such as competence,autonomy, and relatedness.1,8 Scientists alsohave focused on physiological explanations bystudying curiosity patterns in the brain. Theyhave discovered that the chemical dopamine isreleased from the striatum in the brain at agreater rate when a person pushes beyond theboundaries of the known, facing challenges,novelty, and uncertainty. There is also a greaterrelease of dopamine when there is personalimportance or meaning in the novel situation.This surge of dopamine prepares us to capital-ize on these experiences by focusing our atten-tion on the present, mobilizing our energyresources, and initiating approach movements.7

What purpose does curiosity serve?

Curiosity motivates us to be receptive tothe happenings of the present moment, to beimmersed in, explore, and investigate our sur-roundings. In the process, curiosity stretchesour knowledge and skills, enabling us to meetnew people and learn new things. In the longterm, curiosity builds competence.

Curiosity leads to well-being

In cross-sectional studies, researchers whomeasured levels of curiosity consistentlyreport a greater level of psychological well-being.5,6,10 Regarding physical health, as was pre-viously mentioned, older adults with greatercuriosity have been found to live longer over a5-year period.9

Kashdan admits that the mechanisms link-ing curiosity to physical health, illness and mor-tality are not yet fully understood. He offersseveral intriguing explanations for why highly

curious people may live longer, such as “theprocess of neurogenesis stemming from con-tinued novel and intellectual pursuits, a non-defensive willingness to try unfamiliar yet sci-ence-based health strategies, or the psycholog-ical benefits of evaluating stressors as chal-lenges being guided by exploration as opposedto avoidance.”2 He suggests that “an examina-tion of cognitive, behavioral, social, and biolog-ical levels of analysis will lead to promisingavenues of when and how curiosity leads todesirable outcomes.”2

In Coaching

Perhaps most important for coaching,curiosity promotes new ways of thinking andacting. Perspective change is the bread and but-ter of coaching. Kashdan writes, “People whofeel curious challenge their views of self, others,and the world with an inevitable stretching ofinformation, knowledge and skills.”4 Coachesknow that this is an important route to mean-ingful change.

Curiosity also helps in goal fulfillment.Kashdan and Steger (2007)3 studied peopleover the course of 21 days and found that peo-ple who were highly curious were more likelyto persist in attaining their goals, even in theface of obstacles, and were also more likely toexpress gratitude to their benefactors. This ledto higher levels of perceived meaning and purpose.

Curiosity also can help our clients build neu-rological connections as they explore newexperiences and seek out new information.

Finally, according to Kashdan, curiosityleads to more efficient decision-making andhelps us grow in our ability to see the relation-ships among disparate ideas, leading to morecreativity.

Conclusion

It is not surprising that curiosity and achiev-ing our best life have been found to be linked.

By BJ Richstone, Psy.D., CPC; and Margaret Moore (Coach Meg), MBA

COACHING NEWS: CURIOSITY—AT THE FRONTIER OF COACHINGHEALTH AND WELL-BEING

Coaching News (continued on page 11)


A comprehensive research review titled,“Medicare’s search for effective obesity interventions:Diets are not the answer” stated that dieters whomanage to sustain a weight loss are the rare exception,rather than the rule. Dieters who gain back moreweight than they lost may very well be the norm…”(page 230).4

If diets don’t work what does? Most of us wouldagree that regular aerobic activity is an appropriaterecommendation for increasing energy expenditure,and indeed it is. However, during the past twodecades, there has been considerable interest in therole of resistance exercise for enhanced fat loss due toits positive impact on resting energy expenditure.

In 1994, two landmark studies were publishedregarding the effects of standard strength training onresting metabolic rate in older adults. Campbell et al.1

at Tufts University conducted a carefully controlledstudy in which subjects ate measured meals and per-formed no physical training except for three sets offour resistance exercises, three days each week. After12 weeks on this basic strength training program, theparticipants increased their lean weight by about threepounds and their resting metabolic rate by about 7%.This represented approximately 100 additional calo-ries burned at rest on a daily basis.

That same year, Pratley and associates5 conducteda similar study with senior men. The research subjectsperformed relatively brief strength training sessions(one set of 14 resistance exercises) three days each

week for 16 weeks. At the conclusion of the strengthtraining program, the participants increased their leanweight by 3.5 pounds and their resting metabolic rateby about 8%. This represented approximately 120additional calories burned at rest on a daily basis.

A few years later, Hunter and colleagues3 at theUniversity of Alabama at Birmingham conducted alonger-term study on strength training and restingenergy expenditure. The senior subjects performedtwo sets of 11 resistance exercises, three days a weekfor 26 weeks. After six months of training, the pro-gram participants increased their lean weight by 4.5pounds and their resting metabolic rate by about 7%.This represented approximately 100 additional calo-ries burned at rest on a daily basis.

While it appears that regular resistance exerciseresults in a higher resting metabolism, it is less clearwhat mechanisms are responsible for this increase.Although one factor may be the additional lean weight(much of which is water), this most likely accounts fora relatively small percentage of the rise in resting meta-bolic rate. So what is the best explanation for the 7 to8% elevation in resting energy expenditure experi-enced by the subjects in these strength training stud-ies? A recent study conducted at Wayne StateUniversity suggests muscle repair and remodelingprocesses that follow a physically demanding strengthtraining session may be largely responsible for the rest-ing metabolic increase.

In 2008, Hackney and associates2 administered a

BY WAYNE L. WESTCOTT, Ph.D.

Although a Gallup poll6 found that 52% of American adults areattempting to reduce their body weight through dieting, approximatelyone-third of our population is overweight and another one-third isobese. Contrary to the August 17, 2009 cover story in Time magazine,dieting alone is not a productive means for attaining permanent weightloss.

RESTING ENERGYEXPENDITURE

EFFECTS OF STRENGTH TRAINING ON

HEALTH & FITNESS COLUMN


single session of resistance exercise to eight untrained and eighttrained individuals, all of whom performed eight sets of six repeti-tions for each of eight standard exercises. The untrained participantsexperienced a consistent 9% elevation in resting energy expenditureat 24 hours, 48 hours, and 72 hours after their strength training ses-sion. The trained participants’ resting energy expenditure was 4%above normal 24 hours post-workout, 10% above normal 48 hourspost-workout, and 8% above normal 72 hours post-workout. Thetrained exercisers averaged an 8% elevation in resting energy expen-diture for three days following their strength training session.

Based on these findings, it would appear that the increased rest-ing metabolic rate associated with resistance exercise has less to dowith additional lean weight and more to do with energy require-ments for remodeling muscle tissue that has experienced training-induced microtrauma. Assuming that one performs strength exerciseevery two or three days, resting energy expenditure may remain ele-vated throughout the training program due to ongoing muscle micro-trauma and tissue remodeling processes. If this is the case, the 7 to8% increase in resting metabolic rate measured at the completion ofthe 12-week, 14-week, and 26-week strength training programs pre-sented above most likely began after the initial exercise session andcontinued throughout the study duration.

If regular resistance exercise can induce a 7% increase in restingenergy expenditure, trainees with a resting metabolic rate of 1500calories per day would use an extra 100 calories a day or (potentially) an additional 36,000 calories per year. Other thingsequal, this could possibly result in a 10-pound fat loss over the courseof one year. Unlike dieting alone which leads to lean weight loss andmetabolic decrease, strength training results in lean weight gain andmetabolic increase. It would therefore seem that strength exercisemay offer a more sensible and successful means than dieting alone forattaining and maintaining desirable bodyweight and body composition.

About the Author

Wayne L. Westcott, Ph.D., teaches exercise science

and directs the fitness research programs at

Quincy College, in Quincy, MA.

References

1. Campbell WW, Crim MC, Young VR, Evans WJ.

Increased energy requirements and changes in

body composition with resistance training in

older adults. Am J Clin Nutr. 1994;60:167-175.

2. Hackney KJ, Engels HJ, Gretebeck RJ. Resting energy expenditure and

delayed-onset muscle soreness after full-body resistance training

with an eccentric concentration. J Strength Cond Res.

2008;22:1602-1609.

3. Hunter GR, Wetzstein CJ, Fields DA, et al. Resistance training

increases total energy expenditure and free-living physical activity in

older adults. J Appl Physiol. 2000;89:977-984.

4. Mann TA, Tomiyama J, Westlin E, et al. Medicare’s search for effec-

tive obesity treatments: Diets are not the answer. Am Psychol.

2007;62:220-233.

5. Pratley R, Nicklas B, Rubin M, et al. Strength training increases

resting metabolic rate and norepinephrine levels in healthy 50 to 65

year old men. J Appl Physiol. 1994;76:133-137.

6. Research Alert. Gallup poll of American adults on diets. 17(6): 1-3,

1999.

Imagine life without curiosity. It would be a grim, boring existence.Our mission as coaches should be three-fold. First, we should be

curious about curiosity, encouraging research in our field. Second, weshould model curiosity for our clients in our powerful questions, activelistening, and perceptive reflections. Third, we should facilitate curiosity,helping clients develop and use their curiosity to enhance their lives andtheir health, so that they can live longer, more fulfilling lives.

About the Authors

BJ Richstone, Psy.D., CPC is a Harvard-trained clinical psychologist

and Certified Professional Coach. She has a Doctorate in Ministry

and is a published spiritual author. She has appeared nationally on

radio and television.

Margaret Moore (Coach Meg), MBA, is the

founder & CEO of Wellcoaches Corporation, a

strategic partner of ACSM, widely recognized as

setting a gold standard for professional coaches

in healthcare. She is co-director, Institute of

Coaching, at McLean Hospital/ Harvard Medical

School. She co-authored the ACSM-endorsed

Lippincott, Williams & Wilkins Coaching

Psychology Manual, the first coaching textbook

in healthcare. (www.wellcoaches.com• www.instituteofcoaching.org

• www.coachmeg.com • [email protected])

References

1. Deci EL. The relation of interest to the motivation of behavior: A self-

determination theory perspective. In: Renninger KA, Hidi S, Krapp A,

editors. The Role of Interest in Learning and Development. Hillsdale,

NJ: Lawrence Erlbaum, 1992.

2. Kashdan T. Curious? New York: HarperCollins, 2009.

3. Kashdan TB, Steger MF. Curiosity and pathways to well-being and

meaning in life: Traits, states, and everyday behaviors. Motiv Emot.

2007;31:159-173.

4. Kashdan TB, Silvia PJ. Curiosity and interest: The benefits of thriving

on novelty and challenge. In: Snyder CR, Lopez SJ, editors. Oxford

Handbook of Positive Psychology, 2nd edition. New York: Oxford

University Press, 2009.

5. Naylor FD. A state-trait curiosity inventory. Aust Psychol. 1981;16:172-

183.

6. Park N, Peterson C, Seligman MEP. Strengths of character and well-

being. J Soc Clin Psychol. 2004;23:603-619.

7. Pecina S. Opiod reward ‘liking’ and ‘wanting’ in the nucleus accum-

bens. Physiol Behav. 2008;94:675-680.

8. Ryan RM, Deci EL. Self-determination theory and the facilitation of

intrinsic motivation, social development, and well-being. Am Psychol.

2000;55:68-78.

9. Swan GE, Carmelli D. Curiosity and mortality in aging adults: A 5-

year follow-up of the Western Collaborative Group Study. Psychol

Aging. 1996;11:449-453.

10. Vitterso J. Flow versus life satisfaction: A projective use of cartoons to

illustrate the difference between the evaluation approach and the

intrinsic motivation approach to subjective quality of life. J Happiness

Stud. 2003;4:141-167.

Coaching News (continued from page 9)


limit exercise intensity. To do this, the clinician would monitor HR andblood pressure during a few exercise sessions to identify the highestwork rate at which the patient remains below the rate-pressure prod-uct associated with the ischemic threshold identified during the dobuta-mine test. The resultant target HR range would then be set at 10 to 15beats below this corresponding HR. Although this recommendation isbased on sound physiologic principles, it should be noted that the valid-ity of this method has not been studied.

Vasodilator stress tests (e.g., adenosine, persantine) depend on med-ication-induced coronary artery vasodilatation and assess ischemia byaltering blood supply through the concept of “coronary steal.” Duringthis test, normal coronary arteries dilate to a greater extent than arter-ies with atherosclerosis and “steal” blood supply. Some testing laborato-ries include low levels of steady rate exercise during the test, but thisshould not be mistaken for exercise test data. Since these tests do notincrease myocardial oxygen demand (HR and blood pressure responseare flat) and do not assess functional capacity, they provide little, if any,useful information for the exercise prescription.

Finally, when a pharmacological stress test is negative, ACSM’s cur-rent recommendations state “If good HR increase: 70 to 85% HRmax.”It is not clear if this is referring to the highest HR observed during thetest or a predicted maximum HR. As was discussed above, the HRresponse during pharmacological testing is not reflective of the HRresponse that would be observed during an exercise test and is not use-ful for the exercise prescription. In addition, maximum HR predictedfrom equations, such as 220-age, is not a useful tool in older patients,patients with cardiovascular disease, and those on beta blockade thera-py.3 The mechanisms underlying the variability associated with predictedmaximum HR are not clear, but may be due variations in genetics, auto-nomic function, and beta receptor activity.

In conclusion, defining exercise intensity without a recent exercisetest can be challenging. Further research to validate methods in thesesituations is needed. In this absence, sound physiological principlesshould guide clinical decisions. Towards this end, the knowledge, experi-ence, and skills of the clinical exercise physiologist are important andcontribute to the “art” of exercise prescription.

ABOUT THE AUTHOR

Clinton A. Brawner, M.S., RCEP, FACSM, is a

clinical exercise physiologist at Henry Ford

Hospital, Detroit, MI where he provides consulta-

tion and oversight on cardiopulmonary exercise

testing for sponsors of multi site clinical trials.

He is the chair of ACSM’s RCEP practice board and

a member-at-large on the executive committee of the Clinical Exercise

Physiology Association (CEPA; www.cepa-acsm.org).

REFERENCES

1. American College of Sports Medicine. ACSM’s Guidelines for

Exercise Testing and Prescription, 8th edition. Thompson WR,

Gordon NF, Pescatello LS, editors. Baltimore, MD: Lippincott

Williams & Wilkins, 2009:214-219.

2. Andreuzzi RA, Franklin BA, Gordon NF, Haskell WL. National sur-

vey of exercise practices in outpatient cardiac rehabilitation pro-

grams. Med Sci Sports Exerc. 2004;34 (suppl 5), S181.

3. Brawner CA, Ehrman JK, Schairer JR, Cao JJ, Keteyian SJ.

Predicting maximum heart rate among patients with coronary heart

disease receiving beta-adrenergic blockade therapy. Am Heart J.

2004;148: 910-914.

4. Brawner CA, Ehrman JK, Keteyian SJ. Identifying a target heart rate

in patients with ischemic heart disease without an exercise stress

test. Med Sci Sports Exerc. 2005;37 (5 suppl): S226.

5. Brawner CA, Vanzant MA, Ehrman JK, et al. Guiding exercise using

the talk test among patients with coronary artery disease. J

Cardiopulm Rehabil. 2006;26:72-75.

6. Cannon C, Foster C, Porcari JP, Skemp-Arlt KM, Fater DCW, Backes

R. Prescribing exercise using the talk test: avoidance of exertional

ischemia. Am J Sports Med. 2004;6:52-56.

7. Dehart-Beverly M, Foster C, Porcari JP, Fater DCW, Mikat RP.

Relationship between the talk test and ventilatory threshold. Clin

Exerc Physiol. 2000;2:34-38.

8. Dishman RK. Prescribing exercise intensity for healthy adults using

perceived exertion. Med Sci Sports Exerc. 1994;26(9):1087-1094.

9. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline

update for exercise testing: a report of the American College of

Cardiology/American Heart Association Task Force on Practice

Guidelines (Committee on Exercise Testing). Available from:

http://www.americanheart.org/downloadable/heart/10322790136

58exercise.pdf.

10. Joo KC, Brubaker PH, MacDougall A, Saikin AM, Ross JH, Whaley

MH. Exercise prescription using resting heart rate plus 20 or per-

ceived exertion in cardiac rehabilitation. J Cardiopulm Rehabil.

2004;24:178-186.

11. Kraus WE. Utility of graded exercise testing in the cardiac rehabilita-

tion setting. In: Kraus WE, Keteyian SJ, editors. Contemporary

Cardiology: Cardiac Rehabilitation. Totowa, NJ: Humana Press,

2007:103-110.

12. McConnell TR, Klinger TA, Gardner JK, Laubach CA, Herman CE,

Hauck CA. Cardiac rehabilitation without exercise tests for post-

myocardial infarction and post-bypass surgery patients. J Cardiopulm

Rehabil. 1998;18:458-463.

13. Whaley MH, Brubaker PH, Kaminsky LA, Miller CR. Validity of rat-

ing of perceived exertion during graded exercise testing in apparent-

ly healthy adults and cardiac patients. J Cardiopulm Rehabil.

1997;17:261-267.

Cardiac Rehabilitation (continued from page 8)

The first step in developing an exercise prescription is todetermine the client’s goals. Goals must be realistic, measurable,and achievable. By applying behavioral change theory, such asthe theory of self-efficacy3 and the readiness for change model,8

the exercise professional involves the client in the goal-settingprocess. Asking about a client’s self-efficacy (self-confidence) tomake lifestyle changes regarding exercise, determining the barri-ers to exercise that may be encountered, and helping the indi-vidual make a plan to address those barriers, increases owner-ship in the exercise plan and may help the client adhere to theprogram.2,3,6

When the goals have been determined, apply the FITT prin-ciple2 to address those goals. The FITT principle stands forFrequency, Intensity, Time (duration), and Type (mode) of exer-cise; it provides a simple way to outline the components of any exerciseprescription. Whether a client wants to improve cardiorespiratory fit-ness or gain muscular endurance, whether he/she wants to lose weight,recover from heart surgery, or train for the Olympics, the exercise pro-fessional can use the acronym “FITT” to delineate an appropriate exer-cise prescription.

The first three components must actually be considered together asthe total volume of physical activity will have an impact on thehealth/fitness benefits achieved.5 When frequency (F) of exercise isincreased, it may be prudent to cut down on the intensity (I) or the time(T) spent exercising. Alternatively, when intensity (I) is low, a person mayneed to exercise for a longer duration (T) to reach their specific goals.Considering the fourth component, type (T) of exercise, the principle ofspecificity of training9 informs us that the mode of activity needed forcardiorespiratory benefits is aerobic; resistance training exercises will be

necessary for improvements in muscular fitness; and stretching exercis-es are needed for improving flexibility. For each aspect of overall fitness,there are many activities to choose from, some requiring little to no skill,others requiring high levels of fitness.2,6 Encourage the client to choosean appropriate mode (or modes) of exercise based on their goals, accessto facilities and equipment, current health status, physical ability, and per-sonal preference.

For health benefits, recent guidelines specify that healthy adultsbetween the ages of 18 and 65 years should participate in at least 30minutes of moderate-intensity aerobic activities on five days per week,or 20 minutes of vigorous aerobic activity on three days of the week, orsome combination of moderate- and vigorous-intensity aerobic activity.5

Moderate- and vigorous-intensity activities are described as equivalentsto a brisk walk or jog respectively, and by the person’s heart rate andbreathing response to exercise. The guidelines also specify that the 30


Effective exercise prescriptionrequires that an exercise professionalbe able to translate scientific principlesand theory into language and ideasthat are easy for a client to understandand apply. In addition, an understand-ing of some of the theories of behaviorchange may help the practitioner totailor the exercise prescription to eachclient’s individual needs.

EXERCISEPRESCRIPTION

BY SHERRY BARKLEY, Ph.D., CES, RCEPAUGUSTANA COLLEGE, SIOUX FALLS, SD

MAKING SENSE OF THEWELLNESS ARTICLE


minutes of moderate-intensity activity may be accumulated in 10-minutebouts if necessary. Moreover, this group also is encouraged to includetwo non-consecutive days of activity which promote improvements inmuscular fitness/strength. A separate document was presented to clar-ify the recommendations for adults over the age of 65, and for thoseaged 50 to 64 years with various health limitations.7

For cardiorespiratory fitness, a minimum threshold of frequency,intensity and duration of aerobic exercise must be attained before ben-efits are achieved, although the appropriate dose of exercise can varyfrom one individual to the next. In general, the recommended frequen-cy is three to five days/week, intensity may vary from 40% to 85% ofone’s VO2 reserve (VO2R), and duration may be from 20 to over 60minutes.2,9 In some cases, the volume of exercise is specified by calories(kcals) expended in a week.2 Clients also may need to be reminded thatwhile exercise is good, more is not always better; an excessive amountof exercise can increase the risk of an overuse injury.2

Intensity is the component of the exercise prescription that usuallyneeds most clarification. Some clients feel that exercise is a “no pain, nogain” experience, and it is up to the exercise professional to dissuadethat line of thinking. Intensity can be prescribed in terms of heart rate(HR), aerobic capacity (VO2), metabolic equivalents (METs), or per-ceived exertion (RPE). These are well-described in the eighth edition ofthe ACSM Guidelines for Exercise Testing and Prescription.2 Using HRas a gauge of intensity is very helpful if the client can accurately findhis/her pulse or has access to a HR monitor and he/she is not takingany medications that impact HR. Intensity prescriptions using percent-age of VO2R or METs may be helpful if they can be translated into spe-cific activities1 or to more precise workout levels on a specific piece ofequipment. However, unless the client has participated in a maximum-effort graded exercise test, any prescription using HR, VO2R, or METlevel is only an estimate. Conversely, if the client can be made to under-stand how to use the RPE scale appropriately, someone who exercisesat a level of “fairly light” to “somewhat hard” or “hard” is usually exercis-ing at an appropriate HR, VO2R or MET level.2,4 It is up to the exerciseprofessional to determine which explanation of exercise intensity will bemost helpful to each individual client.

The acronym SENSE (Start Exercise Nice and Slow… Everytime) canbe used to explain that every exercise training session should include awarm-up period along with the conditioning phase, stretching, and cool-down activities. In addition, the client whose exercise routine has been

interrupted for any extended time needs to be reminded that is impor-tant to re-start slowly and not expect to pick up where one left off.

In summary, while the client does not need to understand all the sci-entific principles of exercise, the exercise professional must be aware ofall of these guidelines to help each individual determine an appropriateprescription that will make “SENSE” and “FITT” their unique needs.

About the Author

Sherry Barkley, Ph.D., CES, RCEP is an assistant pro-

fessor and chair of the HPER Department at

Augustana College in Sioux Falls, SD. She is a past-

president of the NACSM and a current member of

the CCRB Publications Subcommittee. Sherry has

many years of clinical experience and has prescribed

exercise for healthy adults, expectant mothers, and

participants in weight management programs as well

as for patients with cardiac, pulmonary, renal and

neuromuscular diseases.

References:

1. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical

activities: An update of activity codes and MET intensities. Med Sci

Sports Exerc. 2000;32(suppl.):S498-S516.

2. American College of Sports Medicine. ACSM’s Guidelines for Exercise

Testing and Prescription, 8th ed. Thompson WR, Gordon NF, Pescatello

LS, editors. Baltimore, MD: Lippincott Williams & Wilkins, 2009.

3. Bandura A. Social foundations of thought and action, a social cogni-

tive theory. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1994.

4. Borg GAV. Borg’s perceived exertion and pain scales. Champaign, IL:

Human Kinetics, 1998.

5. Haskell WL, Lee I-M, Pate RR, et al. Physical activity and public health:

Updated recommendation for adults from the American College of

Sports Medicine and the American Heart Association. Med Sci Sports

Exerc. 2007;39:1423-1434.

6. Heyward VH. Advanced Fitness Testing and Exercise Prescription, 5th ed.

Champaign, IL: Human Kinetics, 2006.

7. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public

health in older adults: Recommendations from the American College of

Sports Medicine and the American Heart Association. Med Sci Sports

Exerc. 2007;39:1435-1445.

8. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and

stages of change. In: Glanz K, Rimer BK, Lewis FM, Eds. Health behavior

and health education, theory research and practice. San Francisco:

John Wiley & Sons, 2002.

9. Wilmore JH, Costill DL, Kenney WL. Physiology of Sport and Exercise,

4th ed. Champaign, IL: Human Kinetics, 2008.

SELF-TEST ANSWER KEY FOR PAGE 15

————— QUESTION ——————

12345

TEST #1:BACDA

TEST #2:CABCD

TEST #3:BBADD

TEST #4:CDBDB


SELF-TEST #1 (1 CEC):The following questionswere taken from “Exercise Recommendations for theFrail Population” published in this issue on page 3.

1. Which of the following is NOT a defining criteriafor frailty?

a. Feeling of exhaustionb. Depression c. Low physical activityd. Slow walking speed

2. Obesity is a potential contributing factor to frailty. a. True b. False.

3. Sarcopenia can most effectively be counteredwith:

a. aerobic training.b. flexibility training.c. resistance training.d. yoga and Tai Chi.

4. Resistance training for frail persons should beperformed using ___ repetitions per set.

a. 6-10 b. 8-12c. 6-12 d. 10-15

5. _______ is the most common aerobic activity inolder adults.

a. Walking b. Cyclingc. Swimming d. Rowing

SELF-TEST #2 (1 CEC): The following questionswere taken from “Agility Training for the GeneralPopulation” published in this issue on page 5.

1. ________ drills are preprogrammed drills,performed in a predictable and unchangingenvironment.

a. Open b. Semi-openc. Closed d. Skill

2. Agility training should not be performedby_______________.

a. those who are pregnantb. those who are overweightc. those with more than 4 to 6 months of

resistance training experienced. all of the above

3.Drills that are partially preprogrammed andpartially random are classified as________ drills.

a. Open b. Semi-programmedc. Closed d. Skill

4. According to the author, prior to engaging inagility training clients should have approximately___ to ___ months of consistent resistance trainingexperience.

a. 1-2 b. 2-3c. 3-4 d. 4-6

5.According to this article, agility training may bebeneficial to the general population for:

a. improving proprioceptive capabilities.b. injury prevention.c. the development of motor programs.d. all of the above.

SELF-TEST #3 (1 CEC): The following questionswere taken from “Prescribing Exercise in CardiacRehabilitation Without an Exercise Test” published inthis issue on page 7.

1. ACSM’s Guidelines for Exercise Testing andPrescription, 8th edition does not address thedetermination of target heart rate in patients withheart disease in the absence of an exercise test.

a. True b. False.

2. According to the article, which of the following isNOT a typical reason to conduct a symptom-limitedexercise test in patients with heart disease enteringcardiac rehabilitation:

a. identify residual ischemiab. assess breathing reservec. risk stratificationd. quantify functional capacity

3. According to the article, what is the anticipatedpercent of heart rate reserve when exerciseintensity is established using rest plus 20 in patientswith heart disease?

a. <50% b. 50-60%c. 60-70% d. 70-80%

4. Per ACSM's Guidelines for Exercise Testing andPrescription, 8th edition, which of the following isNOT suggested as a guide to titrate exerciseintensity?

a. rating of perceived exertionb. signsc. symptomsd. resting heart rate

5. According to the article, a vasodilator stress test(e.g., adenosine):

a. is useful for establishing an exercise targetheart rate range.

b. is useful for establishing an exercise targetheart rate range if exercise is included.

c. is useful for establishing an exercise intensitybased on perceived exertion.

d. is not useful for establishing an exercise targetheart rate range.

SELF-TEST #4 (1 CEC): The following questionswere taken from “Making Sense of the ExercisePrescription” published in this issue on page 13.

1. The behavioral change theory that address self-confidence to exercise is:

a. the self-esteem theory.b. the stages of change model.c. the self-efficacy theory.d. the theory of self-reliance.

2. For a client who has not performed a maximalexercise test, the most accurate marker of exerciseintensity may be:

a. heart rate. b. VO2.c. MET level. d. Rate of Perceived

Exertion (RPE).

3. When prescribing moderate-intensity exercise forhealth benefits, the recommended duration andfrequency of exercise is:

a. 20 minutes, 2 times per week.b. 30 minutes, 5 times per week.c. 40 minutes, 4 times per week.d. 60 minutes, 5 times per week.

4. The acronym SENSE can be used to help remind aclient to include start slowly:

a. during an individual exercise session.b. when beginning an exercise program.c. when re-starting an exercise program after aperiod of inactivity.d. All of the above.

5. A thorough explanation of all of the scientificprinciples behind an exercise prescription will help aclient adhere to an exercise program.

a. True b. False.

JANUARY-MARCH 2010 Continuing Education Self-TestsCredits provided by the American College of Sports Medicine • CEC Offering Expires March 31, 2011

To receive credit, circle the best answer for each question, check your answers against the answer key on page 14,and mail entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine, Dept 6022, Carol Stream, IL 60122-6022

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

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