CNews21.3.pp4:ACSM template 9/8/11 9:24 AM Page 1 … lores.pdf · Contribute To ACSM’s Certified News and Earn Valuable Benefitspage 6 page 5 page 16 CNews21.3.pp4:ACSM template

NEWSJ U L Y – S E P T E M B E R , 2 0 1 1 • V O L U M E 2 1 : I S S U E 3

SurvivingCancer:PhysicalRealities

page 3

Building Muscle: SignalsInduced by Exercise,Nutrition, and Supplements

page 3

Continuing EducationSelf-Tests on page 15

Strength Training: Instructional StrategiesAnd Teaching Techniques page 8

Integrating the Exercise is Medicine®

Initiative into the Role of the ClinicalExercise Professional page 10

The Clinical Exercise Physiologist (CEP) as aCertified Diabetes Educator® (CDE®) page 12

Contribute To ACSM’s Certif ied Newsand Earn Valuable Benefits page 6

SurvivingCancer:PhysicalRealities

page 5

Building Muscle: SignalsInduced by Exercise,Nutrition, and Supplements

page 3

Strength Training: Instructional StrategiesAnd Teaching Techniques page 8


Initiative into the Role of the ClinicalExercise Professional page 10

The Clinical Exercise Physiologist (CEP) as aCertified Diabetes Educator® (CDE®) page 12

Contribute To ACSM’s Certif ied Newsand Earn Valuable Benefits page 16

CNews21.3.pp4:ACSM template 9/8/11 9:24 AM Page 1

The Profession (continued on page 11)

2 ACSM’S CERTIFIED NEWS • JULY—SEPTEMBER 2011 • VOLUME 21: ISSUE 3

ACSM’S CERTIFIED NEWS

July–September 2011 • VOLUME 21, ISSUE 3

In this Issue

Building Muscle: Signals Induced by Exercise,

Nutrition, and Supplements ................................. 3

Surviving Cancer: Physical Realities........................ 5

Coaching News........................................................... 7

Strength Training: Instructional Strategies

And Teaching Techniques ..................................... 8


Initiative

into the Role of the Clinical Exercise

Professional ............................................................10

The Clinical Exercise Physiologist (CEP) as a

Certified Diabetes Educator®

(CDE®

) ....................12

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

Contribute To ACSM’s Certified News

and Earn Valuable Benefits ................................. 16

Co-Editors

Peter Magyari, Ph.D.

Peter Ronai, M.S., FACSM

Committee on Certification

and Registry Boards Chair

Deborah Riebe, Ph.D., FACSM

CCRB Publications Subcommittee Chair

Paul Sorace, M.S.

ACSM National Center Certified News Staff

National Director of Certification

and Registry Programs

Richard Cotton

Assistant Director of Certification

Traci Sue Rush

Publications Manager

David Brewer

Editorial Services Department

Lori Tish

Angela Chastain

Editorial Board

Chris Berger, Ph.D., CSCS

Clinton Brawner, M.S., FACSM

Ted Dreisinger, Ph.D., FACSM

Avery Faigenbaum, Ed.D., FACSM

Riggs Klika, Ph.D., FACSM

Tom LaFontaine, Ed.D., FACSM

Thomas Mahady, M.S.

Paul Sorace, M.S.

Maria Urso, Ph.D.

David Verrill, M.S.

Stella Volpe, Ph.D., FACSM

Jan Wallace, Ph.D.

For More Certification Resources Contact the

ACSM Certification Resource Center:

1-800-486-5643

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ACSM’s Certified News (ISSN# 1056-9677) is published

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Committee on Certification and Registry Boards (CCRB). All

issues are published electronically and in print. The articles

published in ACSM’s Certified News have been carefully

reviewed, but have not been submitted for consideration as, and

therefore are not, official pronouncements, policies,

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ACSM’s Certified News is not necessarily the position of the

American College of Sports Medicine or the Committee on

Certification and Registry Boards. The purpose of this

publication is to provide continuing education materials to the

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individuals about activities of ACSM and their profession.

Information presented here is not intended to be information

supplemental to the ACSM’s Guidelines for Exercise Testing and

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© 2011 American College of Sports Medicine.

ISSN # 1056-9677

THE CES, THE RCEP,AND THE PROFESSIONOF CLINICAL EXERCISE

PHYSIOLOGY

Clinton A. Brawner, M.S., RCEP, FACSMAs of January 2011, ACSM offers two certifications for the clinical exercise professional: the ACSM

Certified Clinical Exercise SpecialistSM (CES) and the ACSM Registered Clinical Exercise Physiologist®

(RCEP). To qualify to sit for the CES or RCEP exams, individuals must have a minimum of a bache-lor’s degree or a graduate degree, respectively, in exercise science/physiology. These two examsassess competency in similar domains (e.g., exercise testing, exercise prescription, and exercise train-ing). The CES exam includes content in cardiovascular disease, pulmonary disease, and diabetes, whilethe RCEP includes these content areas plus other metabolic disorders, as well as orthopedic, neuro-muscular, oncologic, immunologic, and hematologic disorders. These similarities have created someconfusion among academia regarding which exam aspiring professionals with a master’s degree shouldattempt. In addition, health care providers and institutions may feel they are left to “sort out” the dif-ferences in competencies assessed between these certifications and how they fit into their clinical pro-grams. Should a Cardiology Unit hire a CES or an RCEP to administer maximal exercise tests? Doessomeone with an RCEP deserve a higher salary than someone with a CES?

The RCEP exam was launched in 2000. Attaining the RCEP credential was intended to be one ofthree criteria to become a “Registered Clinical Exercise Physiologist.” The other criteria were a grad-uate degree in exercise science/physiology and preceptor-supervised clinical experience. The“Registry” was the culmination of a decade of work by dedicated clinical exercise physiologists (CEPs)with the goal of a national registry of CEPs. The purpose was to advance the profession of CEPs byrecognizing their competency in traditional clinical exercise domains, such as clinical exercise testingand cardiopulmonary rehabilitation, as well as other content areas in which exercise had been shownto provide therapeutic benefit. They did this by defining a scope of practice, promoting ethical stan-dards, and defining minimal academic standards.

In contrast, long before the RCEP certification was offered, the CES certification was availableto individuals with a bachelor’s degree in a variety of health-related disciplines (e.g., nursing); it wasnot limited to graduates of exercise science/physiology programs as it is today. In addition, therewere no accredited exercise science/physiology programs like there are today. In summary, therewere no national standards to define the clinical exercise professional separate from other alliedhealth professionals.

For a profession to be recognized as unique it must have the following elements: (a) a body ofknowledge, (b) a standardized academic curriculum, (c) an accredited credentialing exam, and (d) anorganization whose purpose includes advocacy of that profession. Each of these elements are now inplace for the clinical exercise professional and include ACSM’s Guidelines for Exercise Testing andPrescription, academic program accreditation through the Commission on Accreditation of AlliedHealth and Education Programs (CAAHEP), credentialing exams (i.e., CES and RCEP) accredited bythe National Commission for Certifying Agencies (NCCA), and a professional organization in theClinical Exercise Physiology Association (CEPA).

Although there are more than 35 years of history behind the CES certification, anecdotal evi-dence suggests that the penetration of certified exercise professionals in health care has been slow.For example, among cardiopulmonary exercise testing laboratories in the United States, approximate-ly 25% are staffed by clinical exercise professionals. In addition, where these professionals areemployed, the CES or RCEP certification is recognized (e.g., described in a job description or definessalary) in less than half of these institutions (based on observations by author of nearly 100 institu-tions in the United States).

In the United States there have been state-level legislative activities advancing the licensure of CEPswith a licensure law enacted in Louisiana in 1996 and three states with bills in process today(Massachusetts, North Carolina, and Utah). In each of these states a licensure candidate must have


In the last two issues of ACSM’s Certif ied News,12, 13 we exploredthe basics of gene expression and protein synthesis as a foundation forskeletal muscle hypertrophy. We also discussed the impact of an individ-ual’s genetic make-up on changes in skeletal muscle size and strength.The purpose of this final commentary in the series is to understand howexercise, nutrition, and supplements can manipulate gene expression.

In the previous commentary, we referred to deoxyribonucleic acid(DNA) sequences of humans as hardware to emphasize their funda-mental role in dictating phenotypical (or physical) properties. Theterm hardware was used since these are physical traits that cannotbe changed with exercise, diet, or supplements. One aspect of hard-ware that was discussed in depth was the effects of single nucleotidepolymorphisms (SNPs) and their genetic influence on gains in skeletalmuscle size and strength. In this commentary, we will focus on howindividuals can use exercise, nutrition, and supplements to manipulatethe activity of genes that increase protein synthesis and musclegrowth through stimuli that alter the rate and magnitude of DNAtranscription to messenger Ribonucleic Acid (mRNA). These factorscan be referred to as software since they can be changed with vari-ous interventions, environmental influences, and stimuli. This articlewill identify ways to manipulate software (gene expression) throughexercise, nutrition, and supplements. It should be emphasized thatSNP and molecular pathway data certainly are not independent, inthat DNA sequence information (SNPs) can affect pathway activitiesin a number of ways. While most studies conducted to date have notcombined genetic variation and pathway data, current research meth-ods are integrating data across multiple levels including both “beneaththe skin” (i.e., DNA, RNA, protein activity, etc.) and “above the skin”(i.e., environmental) factors.

Skeletal muscle adapts readily to changes in the environment, mostnotably through exercise training and diet interventions. Exercise train-ing can affect strength via changes in both neuromuscular efficiency andmuscle size, while diet modulates strength primarily via regulation ofmuscle size. Diet and exercise training routines are modified or manip-ulated in order to optimize strength gains and can be augmented by theuse of ergogenic aids, including nutritional supplements and pharmaco-logical interventions. The following sections will briefly outline how skele-tal muscle software is affected by these factors.

Exercise Training

Exercise training can include various types of activities that have dif-ferent effects on skeletal muscle characteristics such as strength andpower. Endurance-type training, such as running, cycling, or long-distance swimming, evokes primarily metabolic changes within muscle,increasing endurance and aerobic capacity but not significantly affect-ing strength. The lack of strength gain with endurance exercise stemsfrom the preferential activation during exercise of less fatigable Type Imuscle fibers, which undergo no or little hypertrophy with endurancetraining due to the relatively low loads placed on muscle. This is due

to the preferential recruitment of slow-twitch motor units during low-intensity aerobic-type exercise. However, as intensity increases, higher-threshold fast-twitch motor units are recruited. These concepts areimportant to understand. If high power output and muscle hypertro-phy is the objective of the training program, interventions involvingresistance-type exercise that generates high mechanical strain and therecruitment of high-threshold fast-twitch motor units (in addition tolow-threshold slow twitch motor units) are essential.

The functional link between strength training and muscle sizegains can be explained at the cellular level by understanding theeffects of loading on the balance of protein breakdown and synthesis.The balance of skeletal muscle protein synthesis versus protein degra-dation dictates muscle size gains. Research has shown that proteinsynthesis and breakdown increase with resistance training, butincreases in translation initiation and subsequent protein synthesisgreatly outpace protein breakdown, producing net gains in proteinaccretion. The duration of increased protein synthesis followingresistance exercise has been a topic of significant investigation.Researchers have attempted to identify periods when skeletal musclemay be more resistant to additional gains in protein synthesis (e.g.,repeating a bout of exercise in a previously exercised muscle), as wellas to understand optimal timing for nutrient delivery.3 Resistanceexercise is documented to cause a rapid increase in protein synthesiswithin 1 to 2 hours of a single bout, and this increased rate of synthe-sis persists for 24 to 48 h, depending on the resistance training vari-ables applied and the individuals training status.1, 9

Regulation of translation initiation in response to hypertrophy-inducing stimuli such as loading is a complex process, controlledthrough the activation of stimulus sensing proteins, signal transduc-tion proteins, and effector proteins. The Figure is a simplified illustra-tion of how these pathways respond to resistance exercise. Stimulussensing proteins transmit information regarding the external environ-ment to the intracellular domain and include insulin-like growth factor-1 (IGF-I)/Mechano-growth factor (MGF) (mechano-sensors),myostatin (inhibitor of muscle growth), and AMP-activated proteinkinase AMPK (energy-sensor). Activation of these proteins modulatesskeletal muscle growth. Signal transduction proteins include proteinkinases and transcription factors that enter the nucleus upon activa-tion, binding to respective genes. The forkhead family of transcriptionfactors (FKHR) is an example of one transcription factor regulatingskeletal muscle size. This is a complex system and several upstreamprotein kinases act upon FKHR, and multiple signal transduction pro-teins are affected by its activity. Activation of the stimulus sensing pro-teins phosphorylates (P) the Akt/mTOR pathway and increases skele-tal muscle protein synthesis through activation of signal transductionproteins which activate effector proteins and translation initiation.2

In the case of endurance-type exercise, signaling mechanisms relat-ed to metabolic adaptations, such as the activation of AMPK predom-inate, limiting gains in skeletal muscle size. This is due to the role of

BUILDING MUSCLE:SIGNALS INDUCED BY EXERCISE,NUTRITION, AND SUPPLEMENTS

By Maria L. Urso, Ph.D.

WELLNESS ARTICLE

ACSM’S CERTIFIED NEWS • JULY—SEPTEMBER 2011 • VOLUME 21: ISSUE 3 3


AMPK in monitoring the energy status of the cell, such that AMPKactivity is modulated by changes in ADP/ATP ratio. For example,when energy status in the cell is low (ADP>ATP), AMPK is activated,subsequently reducing skeletal muscle protein synthesis by inhibitingAKT/ mTOR signaling and downstream signal transduction.

Nutrition

The first article in this series emphasized the concept that skeletalmuscle hypertrophy is dependent on an increase in the machineryresponsible for protein translation (e.g., ribosomes) and that insuffi-cient dietary protein decreases translation initiation. Translation initi-ation is the first step in protein synthesis; thus, deficiencies in transla-tion initiation due to inadequate protein intake interfere with skeletalmuscle adaptation. Despite potential increases in processed mRNAdue to other stimuli (e.g., resistance training), the mRNA is not effi-ciently translated into peptides by ribosomes, subsequently reducingsize gains.9

Significant breakthroughs have been made in the past decade inunderstanding how nutrition and diet affect skeletal muscle strengthand hypertrophy at the cellular level. These breakthroughs haveenabled scientists to identify the acute effects of feeding on key pro-tein signaling pathways in skeletal muscle. Specifically, this work hasdemonstrated that protein intake, when combined with resistanceexercise, has a measurable effect on downstream regulatory factorsin the AKT/mTOR pathway, resulting in increased protein synthesisas compared to resistance training alone. Others have explored thetiming of protein intake in reference to a bout of resistance exerciseto identify when protein should be ingested to increase activity ofprotein synthesis pathways.8 Recent work suggests that there is a syn-ergistic effect of the timing and composition of meals with resistanceexercise on the overall rate of protein synthesis and subsequent gainsin muscle strength and size.8

Essential amino acid cocktails with a high concentration of leucine,administered immediately pre- and/or post-exercise, have shown thegreatest benefits in up regulating signaling pathways responsible fortranslation initiation and protein synthesis.4 The beneficial effects ofessential amino acid intake also have been shown to be augmented

when administered prior to exercise and when combined with carbo-hydrate ingestion.4, 6 In addition to increased activity of theAKT/mTOR pathway, nutritional interventions have been shown toalter levels of myosin heavy chain (MHC) and the negative regulator ofmuscle growth, myostatin.

Ergogenic Aids

Ergogenic aids that have purported anabolic or growth promotingeffects on skeletal muscle range from pharmacological aids (i.e., ana-bolic steroids) to over the counter supplements like creatine mono-hydrate. While substantial research has been completed to character-ize the performance-promoting effects of various ergogenic aids,these data are equivocal and very few of these studies examine dataat the molecular level. Understanding how specific ergogenic aidsimpact cell signaling events is important in prescribing safe and effec-tive use of various supplements. However, due to the lack of bio-chemical data from research studies investigating the impact ofergogenic aids on skeletal muscle, this commentary will only brieflyreview supplements with biochemical data to support their role inincreasing skeletal muscle strength and size. These include anabolicagents (purported to promote adaptations in strength and size); cre-atine monohydrate (theorized to activate protein synthesis path-ways), and antioxidants (marketed to protect cellular integrity).

Use of anabolic agents enhances skeletal muscle hypertrophybeyond normal limits via increased transcription of DNA for myofib-rillar proteins, accelerated activation of satellite cells, and subsequentsynthesis of nuclear and contractile proteins.7 In humans, the use ofanabolic androgenic steroids has been widespread in sport, despitesignificant warning of lethal side-effects and possible elimination dueto anti-doping regulations. Anabolic agents that have been used incombination with resistance exercise to promote hypertrophyinclude growth hormone, testosterone-like hormones, IGF-I, and B2adrenoceptor agonists (B2 Agonists). Increases in muscle size havebeen achieved with the use of each of these agents, and in somecases, without the added intervention of resistance training, typicallyin pathological conditions with the intent to attenuate the atrophyprocess15.

In most cases, the mechanisms driving supplement-induced hyper-trophy are unique to the supplement used, based on the physiologi-cal effects of each supplement. The most recent evidence has provid-ed mechanistic studies examining not only alterations in phenotype(e.g., physical characteristics), but alterations in the expression ofgenes regulating protein synthetic and degradative pathways. Thiswork has confirmed the efficacy at both the systems and molecularlevel of anabolic agents including, testosterone enanthate,Oxandrolone, recombinant human growth hormone (rhGH), insulin,and nandrolone decanoate. Common transcription factors affectedby their use include myostatin, IGF-I, MGF, and components of theAKT/mTOR pathway (Figure).

In regards to creatine supplementation, a more pronounced mus-cle hypertrophy has been documented in individuals simultaneouslyparticipating in resistance training.5 There is significant evidence thatsatellite cell activation and proliferation is induced with creatine inges-tion,14 and this is the mechanism behind the anabolic effects observedwith creatine supplementation. This conclusion is supported byincreases in mRNA for IGF-I and markers of satellite cell activation.11

Building Muscle (continued on page 11)


Figure. Signaling Mechanisms Mediating the AnabolicResponse. First, sensor proteins such as AKT and mTORsense the stimulus (e.g., mechanical stretch), inducingthe activation of signal transduction proteins (e.g.,protein kinases that phosphorylate (P) other proteins),and finally the activation (or inhibition) of effectorproteins which include, transcription factors,translational regulators, and regulatory proteins.


Editor’s note: This article was previously published in theClinical Exercise Physiology Association (CEPA) Spring 2011Newsletter (Vol. 4, Issue 2). After consulting with the editors ofthe CEPA Newsletter, ACSM’s Certified News has agreed to acceptthis article for publication in an ef fort to reach a broader spec-trum of Certif ied Exercise Professionals. CEPA is a member ofACSM’s af f iliate societies. www.cepa-acsm.org.

Cardiorespiratory (CR) fitness is one of the most important indica-tors of health and longevity in humans. CR fitness refers to the body’sability to transport oxygen from the air to the body’s cells in order toproduce energy for a multitude of processes (e.g., muscle contractionand immune system function, among others). The integrity of the car-diopulmonary system, as well as the circulatory system, dictates howwell oxygen can be transported and utilized in the body. Following can-cer therapies, such as surgery, chemotherapy and/or radiation treat-ment, CR fitness will be significantly reduced.

Notably, reduction of CR fitness primarily follows the decline in phys-ical activity for most cancer patients. Please read a more detailed reviewof this outcome by Courneya and Friedenreich.3 Furthermore, cancersurvivors typically reduce physical activity as a result of a myriad of com-peting distractions, including: doctor’s visits, infusion therapy, radiationtherapy, coping with family, work, and/or financial stressors. Frankly,remaining active during cancer treatment is a very low priority for mostcancer survivors.

In addition to reduced CR fitness, radiation and chemotherapy treat-ments may alter normal heart function (e.g., contractility, perfusion,stroke volume, among others) and affect systemic circulation such thatblood flow is diminished throughout the body. This may cause cancersurvivors to lose the ability to efficiently and economically process oxy-gen, especially in skeletal muscle. As a result, a cancer survivor’s fitnesslevel is typically lower than pre-diagnosis. Additionally, these adversechanges may alter substrate utilization and adjust energy productionsuch that the anaerobic system becomes more active during and imme-diately after treatments (this remains to be determined).10 Therefore, inour cancer rehabilitation center, one of the primary objectives is toreturn CR fitness to pre-cancer levels post therapy and in many cases,increase it beyond pre-cancer diagnosis. In other words, by promoting ahigh fitness level and even improving on it after debilitating therapies andabrupt or adverse changes in lifestyle, a cancer survivor may decreasethe chance of reoccurrence while rapidly improving their activities ofdaily living. Why?

To underscore this last point, the American College of SportsMedicine (ACSM) convened a number of experts from the field of exer-cise science and cancer rehabilitation who reviewed the current statusof what is known about physical activity and cancer survivorship. Werecommend you review the researchers’ observations by visiting the fol-l o w i n g w e b l i n k : ( h t t p : / / j o u r n a l s . l w w. c o m / a c s m -msse/Fulltext/2010/07000/American_College_of_Sports_Medicine_Roundtable_on.23.aspx).7

From the panel’s extensive review, it is clear that cancer survivors whoadopt an active lifestyle can have beneficial effects on the following areas:

Benefits of Exercise for the Cancer Survivor:• Improved physical function/physical fitness• Improved aerobic fitness • Increased muscular strength • Improved flexibility • Improved/maintained ideal body size (weight, BMI, body composi-

tion, muscle mass) • Increased bone health• Help with lymphedema-related outcomes• Increased quality of life • Increased energy level or vigor/vitality • Decreased cancer related fatigue • Improved sleep patterns• Decreased depression • Decreased anxiety • Improved physiological outcomes (e.g., hemoglobin, blood lipids,

IGF pathway hormones, oxidative stress, inflammation, or immuneparameters; includes PSA for prostate cancer)

• Decreased symptoms/adverse effects (including pain).5

CLINICAL FEATURE


SURVIVING CANCER: PHYSICAL REALITIESBY RIGGS J. KLIKA, PH.D., FACSM AND SCOTT N. DRUM, PH.D., FACSM


Benefits of exercise for the cancer survivor also include decreasingthe risk of developing cardiovascular disease by lowering body fat, LDL-cholesterol, triglycerides, blood pressure, risk of developing diabetesmellitus and being diagnosed with a secondary cancer, and increasingHDL-cholesterol. These benefits are essentially the standards we seewith any physical activity intervention. However, there is emerging epi-demiological evidence indicating that remaining physically active duringand after treatment may decrease the risk of cancer reoccurrence6, asalluded to earlier. This is an important point and bears repeating: Beingphysically active may prevent the risk of cancer reoccurrence for can-cer survivors.

Exercise Guidelines for Cancer Survivors

The ACSM guidelines for cancer survivors include meeting the follow-ing criteria ≥ 150 minutes per week of aerobic exercise at a moderate-to-vigorous level or ≥ 75 minutes per week of aerobic exercise at a vig-orous intensity with specific exercise programming adaptations basedon the disease and treatment-related adverse effect.7 These generalguidelines are meant to be a starting point for the cancer patient whohas completed treatment. While exercise is encouraged during treat-ment, the number of variables affecting each individual’s health and capa-bilities is so vast that general guidelines have not been issued and remaina pertinent focus of many studies.

Moving from the guidelines

to practical application

Both during and post-cancer treatment, exercise programs and limita-tions can be complex and it is suggested that as a health professionalworking with cancer survivors that you have a minimal certification as acancer exercise fitness trainer. Currently ACSM/American CancerSociety offers this type of certification (ACSM/ACS Certified ExerciseTrainer). In our experience, it is critical that you or the individual work-ing directly with the cancer survivor have an understanding of the med-ical diagnosis(es), staging, pharmacology associated with acute andchronic treatment of cancer, surgical treatments, and the associated sideeffects of the treatment options. Additionally, you are strongly encour-aged to confer with the client’s oncology team directly to gain a minimalunderstanding of medical terminology, which is critical to your evolutionas a certified cancer exercise fitness trainer.

As ancillary health care providers in cancer management, you willneed to assist the oncology team during the rehabilitation phase. At ourcenter, we monitor hematologic abnormalities (e.g., low platelets,hematocrit and hemoglobin levels, neutrophil counts), musculoskeletaldisorders (e.g., recent bone, back or neck pain; unusual muscular weak-ness; extreme fatigue; severe cachexia [muscle mass loss]), gastrointesti-nal disorders (e.g., severe nausea, vomiting and diarrhea, dehydration,poor nutrition), cardiovascular disorders (e.g., chest pain, elevated rest-ing heart rates, elevated blood pressure [both systolic and diastolic],irregular heartbeats, lymphedema), pulmonary disorders (e.g., severedifficulty breathing, coughing/wheezing), and neurological disorders(e.g., decline in cognitive status, dizziness/lightheadedness, disorienta-tion, blurred vision, increased postural instability). Each one of theseconditions warrants further investigation or referral back to the primarycare physician and possible modification of the exercise plan. If you donot have prior clinical experience or fail to fully understand the previouslist, you should not be working with cancer survivors. Instead, consider

referring the cancer survivor to an experienced colleague and seek spe-cialized training/certification, such as mentioned prior.

At our center, we review blood work on a regular basis and conductinterviews (typically immediately before an exercise session) about thepotential health problems indicated above. As a rule, we use three con-secutive bloods test and monitor red and white blood cell counts (RBCand WBC, respectively). If RBC/WBC counts are improving or stable(but all within normal limits), we continue with the exercise plan. IfRBC/WBC numbers are trending poorly albeit within normal limits (i.e.,anemia and/or neutropenia) we consult with the client and typicallydecrease INTENSITY or VOLUME (duration or frequency) of exercisefor 3 to 5 days before resuming with the original plan.

SAFETY: For most cancer patients and survivors, exercise is safe.4 Ifthe cancer survivor is suffering from serious adverse side effects of treat-ment or is a stage IV patient, we recommend consulting the client’soncology team before starting any exercise program. While it is difficultto broach, there are cancer patients/survivors for whom the addedstress of exercise may exacerbate physical decline and therefore be con-traindicated. For those individuals, we suggest a discussion with theclient, family and/or significant others and the medical team about whyexercise should be limited.

If concerned about lymphedema, consider that Kathryn Schmitz,Ph.D., FACSM, a lead author on the ACSM/ACS exercise guidelines, leda recent study that found careful weight training can protect againstlymphedema.8 Our work generally has found that exercise does notexacerbate lymphedema when the cancer survivor is monitored close-ly. There are excellent resources available to the cancer rehabilitationspecialist regarding lymphedema and lymphedema control athttp://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/Patient/page1.

HOW MUCH: Meeting the ACSM recommendations for cancer sur-vivors is relatively simple; increase physical activity to at least 150 min-utes of exercise per week (i.e., five sessions/week x 30 min-utes/session). This may be as simple as prescribing walking 30 minutesper day, five days a week. This should be considered the minimum levelyou need to set as a goal for your post-cancer treatment rehabilitationexercise program. We suggest you start with a walking program andperhaps progress to a variety of other modalities (e.g., jogging, running,cycling, swimming, alpine and/or Nordic skiing) as your client’s fitnessand health level dictates. Additionally, encourage a cancer survivor tochoose what best fits their long term goals and interests.

HOW HARD: The current guidelines suggest moderate-to-vigorousintensity for 150 minutes per week. While moderate-to-vigorous inten-sity is defined specifically in the ACSM guidelines as 40% to 85% of max-imal oxygen uptake reserve or heart rate reserve, it is not uniform fromindividual to individual. This is where the certified exercise physiologistis valuable. At our center, all cancer survivors complete a cardiopul-monary stress test (on a cycle ergometer or treadmill) with lactate test-ing in order to provide precise measures of their initial fitness level. Thishelps us establish individualized intensity guidelines for aerobic exerciseprogramming. Although, cardiopulmonary exercise testing may not beavailable to you, our philosophy is that an initial assessment of the can-cer survivor’s health status should be an integral part of all rehabilitationprograms.9 If you are unable to conduct an initial, advanced exerciseassessment yourself or by a trained professional, there are alternativemethods available, such as a timed one mile walk test on a local track,

Surviving Cancer (continued on page 14)



Let’s start with

the raw data

In the 1990s, Losada and his assistantspainstakingly coded every single statement,moment by moment in chronological order,made in videotaped meetings of 60 teams in alarge international corporation who werecrafting business missions and strategic plans.The coding tracked three dimensions, whichLosada predicted would be vital and interde-pendent, building on each other in either anupward or downward spiral:1. Was a statement positive or negative?2. Was a statement self-focused or other-

focused?3. Was a statement based on inquiry or

advocacy?Independently, Losada also identified

whether these groups were high, medium, orlow performers based upon a number of criti-cal success factors.

The Butterfly – a nonlinear

dynamic system

Losada validated a set of mathematicalequations to capture the relationship amongthe three dimensions and calculated a new vari-able called connectivity, which measured howmuch each group member influenced thebehavior of others (mutual influence) and howattuned and responsive group members wereto each other. Losada ran the raw datathrough his mathematical model and voila, thebutterfly graphs (Figure) came to life. Whenmutual influence reaches a critical level, a but-terfly appears and grows.

Then Losada’s breakthrough came, inspiredby Fredrickson’s work on demonstrating theevolutionary role of positive emotions. Usingalgebra he translated the connectivity tipping

point into a positivity ratio or tipping point of2.9 to 1. A tipping point that leads to flourish-ing rather than languishing of groups is above apositivity ratio of 2.9 positive emotions toevery negative emotion.

In the Figure, the first butterfly with the talland wide wings is the data plotting of the highperformance groups. The vertical axis of theleft graph represents the level of positive emo-tions and you see that the high performancegroups have high positivity ratios. Also on theleft graph, the left half of the horizontal axis isa rating of open inquiry, while the right half is arating of advocacy. The highperforming groups’ butterflyhas a wide wing span repre-senting an outward focus anda broad and balanced rangeof inquiry and advocacy. Forthe exercise professional, thiswould represent creating anenvironment in which clientsare encouraged to be cre-ative, open-minded and sup-portive of one another if in agroup setting.

The mixed performancegroups are represented bythe second butterfly, lowerpositivity levels (below the tip-ping point), a narrower rangeof inquiry and advocacy, alongwith a more restrictive emo-tional space and less connec-tivity. For the exercise profes-sional, this would representcreating an environment inwhich there is little emotionalconnection with and betweenclients.

The small, white structures

represent the languishing of low performancegroups. No butterfly here, not even a littleone. They are stuck in a cocoon of restrictive,distrustful, and cynical self-absorbed advocacyfrom the start, losing behavioral flexibility alltogether. For the exercise professional, thiswould represent creating an environment inwhich the agenda of the exercise expert takespriority of the needs of the client or group.

Here are some of Losada’s discoveriesabout groups that also can be applied to theexercise professional in relationship with aclient or group:

REPRINTED FROM (2) USED WITH PERMISSION.

Coaching News (continued on page 9)


COACHING NEWS:GROUP & INDIVIDUAL FLOURISHING —BUTTERFLIES & COCOONS

By Margaret Moore (Coach Meg), M.B.A.ONE OF THE BRILLIANT ADVANCES IN THE APPLICATION OF POSITIVE PSYCHOLOGY TO HUMAN FLOURISHING RELATES TO GROUP

PERFORMANCE AND IS A CONCEPT WHICH EMERGED FROM A DYNAMIC COLLABORATION BETWEEN TWO SCIENTISTS, MARCIAL

LOSADA AND BARBARA FREDRICKSON. THIS WORK WAS SUMMARIZED IN THEIR 2005 PAPER: POSITIVE AFFECT AND THE COMPLEX

DYNAMICS OF HUMAN FLOURISHING. LOSADA HAS MADE AN INARGUABLE CASE FOR THE PIVOTAL ROLE OF POSITIVE EMOTIONS IN

SUCCESSFUL GROUP PERFORMANCE CONCEPTS, WHICH CAN BE APPLIED TO GROUP EXERCISE SETTINGS IN SUPPORT OF BOTH

INDIVIDUAL AND GROUP FLOURISHING.

Orange is high-performing,

green is medium, and blue

is low-performing.


BY WAYNE L. WESTCOTT, Ph.D.

In a survey published more than 20 years ago, adults enrolled in formal exercise programs throughoutNew England reported that knowledge of physical fitness and effective teaching skills were the twoinstructor characteristics most valued by the exercise participants.11 In fact, it has been demonstrated thatexercise instructors who model these and related instructional abilities have a greater influence on theirclients’ behavior.9 The purpose of this column is to address some of the key instructor characteristics andteaching strategies that should enable personal trainers to better educate and motivate their clients as high-status role models.

STRENGTH TRAINING:

HEALTH & FITNESS COLUMN

High-Status Role Models

Personal trainers long have been perceived as exercise role mod-els by their clients. However, based on various personal and profes-sional behaviors, one’s role model influence may range from low tohigh. Fitness instructors who are most respected and emulated bytheir program participants are referred to as high-status role models.In particular, four key attributes associated with high-status role mod-els have been identified: knowledge, similarity, nurturance, and rein-forcement.6 Personal trainers who develop these characteristicsshould be more effective exercise role models who elicit more com-petent and confident exercise performance in their clients.7,8

Knowledge: The most important characteristic of high status person-al trainers is their knowledge base in the field of exercise science.However, a key aspect of knowledgeable instructors is the ability to pres-ent the information that they have learned through their college course-work, professional certifications, and specialized training in a relevantand practical manner. For greatest impact, it is essential for fitnessinstructors to impart information clearly, concisely, and progressively,without overwhelming clients with too much material at a time.

Similarity: Research indicates that people place greater confidence inrole models who seem to be similar to themselves in some manner.6

Although there are many ways in which fitness professionals and exer-cise participants may share common interests and experiences, one areawhere instructor similarity may be most appreciated is a sincere interestin the client’s personal progress. Personal trainers should make attentionto each client’s training program and outcomes a high priority.

Nurturance: When the instructor is perceived as knowledgeable andsimilar, most clients then welcome a more nurturing professional rela-tionship. This tends to resemble a coach-athlete relationship that has ahigh-degree of trust and cooperation as both parties desire the best pos-sible training experience and fitness results for the exercise participant.6

Reinforcement: Positive reinforcement is a powerful motivator.Instructors who provide appropriate affirmation for desirable exer-cise behavior typically have a higher role model status. To be mosteffective, positive reinforcement should be presented in a sincere andspecific manner. That is, reinforcing comments should contain rele-vant content that clearly tells clients what they are doing correctly.

For example, saying “Good set of chest presses Nancy; you per-formed every repetition through a full movement range” is more like-ly to encourage her to use this technique in future sessions than sim-ply saying “Good job, Nancy.”

In summary, influential exercise instructors are typically perceivedas high-status role models. Attaining this desirable level of respectappears to be enhanced by the role model characteristics of knowl-edge, similarity, nurturance, and reinforcement.

Teaching Guidelines

Baechle and Westcott5 have presented 10 suggestions for person-al trainers with respect to teaching techniques and instructionalstrategies.

1. Clear Training Objectives: Begin each exercise session byexplaining the training objective and what you would like your clientto accomplish during the workout.

2. Concise Instruction with Precise Demonstration: Brief per-formance explanations coupled with excellent exercise demonstra-tions appears to be a highly effective means for eliciting the desiredbehavior.9

3. Attentive Supervision: Previously inactive individuals tend to lackconfidence in their physical abilities, and typically appreciate instructorswho are fully focused on them as they perform their exercises.

4. Appropriate Assistance: To ensure correct exercise execution,it is frequently necessary for personal trainers to manually assist theirclients with the activity performance, such as giving and taking dumb-bells, spotting barbell lifts, and guiding proper resistance trainingmovement patterns.

5. One Task at a Time: Rather than projecting a series of per-formance requirements, it is advisable to present one directive at atime to increase the probability that your client will successfully com-plete each specific task.

6. Gradual Progression: In the field of resistance exercise, itappears especially important to progress in a gradual and systematicmanner, with relatively small increments in training intensity (e.g.,loads) and volume (e.g., repetitions and sets).

7. Positive Reinforcement: Positive comments are always appreci-ated by exercise participants, particularly new clients who are less

INSTRUCTIONAL STRATEGIESAND TEACHING TECHNIQUES



confident about their physical performance.8. Specific Feedback: Positive reinforcement is more meaningful

when it is coupled with specific information feedback that increasesits value by becoming both an educational and motivational tool.

9. Careful Questioning: Because some participants may not vol-unteer information that could be useful for their program design, askrelevant questions to ascertain how they are responding to theirexercise experiences.

10. Pre- and Post-Exercise Dialogue: It is advisable to commenceand conclude each exercise session with a couple minutes of person-al communication with your clients to share relevant training informa-tion and to gain perspective on their training program perceptions.

Benefits of Purposeful Instruction

Several studies have shown that well-designed strength trainingprograms produce desirable psychological outcomes as well as physi-ological improvements.1,2,3 These beneficial changes include physicalself-concept, as well as feeling states of total mood disturbance, posi-tive engagement, revitalization, tranquility, and physical exhaustion.One study4 clearly demonstrated that how we teach our exerciseclients definitely influences emotional and self-concept changes thatare associated with strength training program participation. It istherefore recommended that personal trainers examine their teach-ing techniques and instructional strategies to fur-ther enhance their clients’ exercise experiencesphysiologically and psychologically.

About the Author

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

and conducts fitness research at Quincy College in

Quincy, MA.

References

1. Annesi J, Westcott W. Relationship of feeling states after exercise

and total mood disturbance over 10 weeks in formerly sedentary

women. Perceptual and Motor Skills. 2004;99: 107-115.

2. Annesi J, Westcott W. Relations of physical self-concept and mus-

cular strength with resistance exercise induced feeling state scores

in older women. Perceptual and Motor Skills. 2007;104: 183-190.

3. Annesi J, Westcott W, Gann S. Preliminary evaluation of a 10-

week resistance and cardiovascular exercise protocol on physiologi-

cal and psychological measures for a sample of older women.

Perceptual and Motor Skills. 2004;98: 163-170.

4. Annesi J, Westcott W, La Rosa Loud R, Powers L. Effects of associa-

tion and dissociation formats on resistance exercise induced emo-

tion change and physical self-concept in older women. Journal of

Mental Health and Aging. 2004;10(2): 87-97.

5. Baechle T, Westcott W. Fitness Professional’s Guide to Strength

Training Older Adults, (2nd Ed). Champaign, Il: Human Kinetics,

2010. p. 28-32.

6. Brofenbrenner U. Two Worlds of Childhood: U.S. and U.S.S.R.

New York, Russell Sage Foundation, 1970.

7. Rushall B, Siedentop D. The Development and Control of Behavior

in Sport and Physical Education. Philadelphia, PA: Lea and Febriger,

1972.

8. Siedentop D. Developing Teaching Skills in Physical Education.

Boston, MA: Houghton-Mifflin, 1976.

9. Westcott W. Effects of teacher modeling on children’s peer

encouragement behavior. Research Quarterly for Exercise and

Sport. 1980;51 (3): 585-587.

10. Westcott W. Four ways for fitness instructors to become good

role models. Perspective. 1988;14(6): 36-37.

11. Westcott W. Role-model instructors. Fitness Management.

1991;7(4): 48-50.

1. Start by creating a positive and appreciative dynamic. Begin each ses-sion by asking about client successes, best experiences, and newhopes. This positive start builds the positive emotions needed toaddress challenges later.

2. Allow yourself to open and broaden. Be aware of your limiting bias-es and assumptions about client stereotypes. Be curious about what’snew – what can you learn from each client and their experiences?

3. Get out of the way of your personal need to control outcomes.Invite your client to explore her/his own motivation and agenda forchange.

4. Keep the ratio of positive and negative topics above 3:1. Make surethat 75% of your time together is focused on positive topics, askingpositive questions, providing affirmations, exploring strengths, newpossibilities, or success stories, and 25% is focused on more negativetopics such as challenges and concerns.

5. Be attentive to and build on the contributions and synergy of every-one’s strengths. Learn about your clients strengths and explore howto leverage those strengths for greater success. One excellent toolfor identifying strengths is the Values in Action Character StrengthsSurvey (www.viacharacter.org).

6. Balance authentic, open-minded inquiry and exploration with advo-cacy of what you believe is the best approach. Your expertise is valu-able but your client may learn more from self-awareness and insightthat emerges from your carefully chosen questions and reflections.

7. Grow perspectives to something bigger than self. Support clients inidentifying how their individual changes will help them make a largercontribution, which they value personally, to their friends, family, col-leagues, and the world.

8. Allow the system to be chaotic in the moment in order to flourishand easily absorb bumps and blows over time. Bring a belief in yourclient’s resilience to bumps on his or her path and in your workingrelationship. Engage the client in learning from every outcome, evenwhen a goal is not met, by viewing every experience as a win/learnopportunity rather than a win/lose situation.

Watch and enjoy how the butterfly combines beauty and subtlety tocreate an unexpectedly wonderful impact on your individual clients andgroups.

About the Author

Margaret Moore/Coach Meg, M.B.A., is the

founder and CEO of Wellcoaches Corporation, a

strategic partner of ACSM, widely recognized as

setting a gold standard for professional coaches in

healthcare and wellness. She is co-director at the

Institute of Coaching, at McLean Hospital/

Harvard Medical School and co-directs the annual

Harvard Medical School Coaching in Medicine &

Leadership Conference. She co-authored the ACSM-endorsed Lippincott,

Williams & Wilkins Coaching Psychology Manual, the first coaching

textbook in healthcare.

Reference

1. Losada M, Fredrickson B. Positive Affect and the Complex Dynamics of

Human Flourishing, American Psychologist: 2005; 60(7): 678–686.

2. Losada M, Heaphy M. The Role of Positivity and Connectivity in the

Performance of Business Teams: A Nonlinear Dynamic, American

Behavioral Scientist: 2004; 47(6): 740-765.

Coaching News (continued from page 7)




INTEGRATING THE EXERCISE IS MEDICINE® INITIATIVE INTOTHE ROLE OF THE CLINICAL EXERCISE PROFESSIONAL

CLINICAL COLUMN

BY JONATHAN K. EHRMAN, Ph.D., CES, FACSMIn 2007 the Exercise is Medicine® (EIM®) initiative began with a stat-

ed goal of “Calling on all health care providers to assess and review everypatient’s physical activity program at every visit.” Since this time EIM®

has morphed into an international initiative with global partners and theWorld Congress on Exercise is Medicine® held in conjunction withACSM’s Annual Meeting. Given this quick growth and strong focus onphysicians providing regular physical activity counseling several clinicalexercise professionals have asked where they might fit in and use EIM®.

While the EIM® message is appropriate and the right thing to do, afocus on physical activity and exercise during an office visit is often timesdifficult to fit into a 10 or 15 minute appointment. A recent report inthe New England Journal of Medicine1 described the daily workload of pri-mary care physicians while seeing patients during which much of theirtime is spent diagnosing, treating, ordering tests, and filling out forms.On average, each physician in this office-based practice saw 18.1 patientsper day. For an 8 hour day this level of demand allowed 26.5 minutesper patient appointment. However, these physicians have additionaldemands responding to more than 43 phone calls and lab results review-ing 14 consultation reports, 11 imaging reports, 16 emails, and 12 pre-scription refills each day; thus leaving much less time, likely in the rangeof 10 to 15 minutes, to see each patient. The authors of this study con-cluded that a radical change in the primary care physician (PCP) officepractice is needed.

Given the magnitude of work performed each day by the averagePCP one might question if it is reasonable for a physician to providemeaningful physical activity and exercise training information to apatient. Maybe not. However, this may provide a tremendous oppor-tunity for the clinical exercise professional to insert himself or herself asa resource for a physician. Most physicians will realize their shortcom-ings from either a time or a knowledge aspect. And with the amount ofpatients with chronic diseases such as arthritis, diabetes, high blood pres-sure, asthma and others (see Figure), that are seen by the typical PCP,they may recognize that some of their patients may need specialized

assistance when designing and beginning an exercise program. This issimilar to sending a patient with heart or lung disease to a cardiac or pul-monary rehabilitation program with staff specialized in working withthese types of patients. Given this, many physicians may be more thanwilling to partner with an energetic and knowledgeable clinical exerciseprofessional to fill the gaps of both a lack of time and a lack of knowl-edge and skill. But how might this be accomplished?

Someone once told me that EIM® is an opportunity for the clinical exer-cise professional to become similar to a pharmaceutical “rep” with respectto interacting with physicians and selling their products. Setting up meet-ings with physicians and their staff could be an effective method to pro-mote yourself and your ACSM certification. Getting a physician to under-stand that you have the skills to work directly with patients in developingand implementing an exercise program would provide a physician with areliable resource to send their patient to for learning and implementing anexercise training program. But how might you go about this task?

The EIM® Web site (www.exerciseismedicine.org) provides a varietyof information aimed directly at the health and fitness professional.2 Theclinical exercise professional certainly fits this description. And a portionof the information is aimed at marketing oneself to other health careprofessionals to fill the void almost certainly left by physician exercisetraining counseling. These documents include “How to work with healthcare providers” and a marketing document titled “Exercise is Medicine®

Health and Fitness Professionals’ Action Guide.” This latter documentprovides practical information and forms to use when approaching physi-cians about potentially sending their patients to you or your program forexercise training. The former document also provides constructiveinformation about marketing to physicians.

In closing, EIM® is an excellent initiative for the entrepreneurial clinicalexercise professional. While there is no doubt a great need for physi-cians to seriously discuss and encourage their patients to exercise, theability of each physician to informatively speak on this topic is limited.And certainly physicians seldom have time to practically implement exer-cise training or to follow up regularly with the patient regarding exercise.The clinical exercise professional is suited expertly for this type of workand with a little initiative and salesmanship should and can provide all theexercise needs for the patients of a busy group of physicians.

About the Author

Jonathan K. Ehrman, Ph.D., CES, FACSM, is the

associate program director of Preventive

Cardiology at Henry Ford Hospital, Detroit MI. He

also is the Director of the hospital’s Clinical

Weight Management Program. He served on

ACSM’s Committee of Certification and Registry

Board (CCRB) from 2000 to 2010 and was chair of

the Clinical Exercise Specialist Committee. He also is the senior editor of

the sixth edition of ACSM’s Resource Manual for Guidelines for

Exercise Testing and Prescription and is the umbrella editor for the next

editions (2013 release date) of the ACSM certification texts.

References

1. Baron RJ. What’s keeping us so busy in primary care? A snapshot from

one practice. NEJM 2010; 362 (17):1632-1636.

2. Exercise is Medicine®

[Internet]. Indianapolis (IN): Exercise is Medicine®

;

[cited 2011 Jul 26]. Available from: www.exerciseismedicine.org.

Figure: Proportions of clinical conditions typically addressed by primary care

physicians

Source: CDC/NCHS, National Ambulatory Medical Care Service, and

National Hospital Ambulatory Medical Care Survey.


Satellite cells contribute to skeletal muscle repair, regeneration, andhypertrophy.

Supplements receiving much attention in the first half of thisdecade are the antioxidants. While the intent of antioxidant supple-mentation was not to increase muscle size, per se, but rather toincrease skeletal muscle resistance to oxidative stress and possiblyenhance adaptation, data demonstrating a positive effect of antioxi-dant supplementation have been equivocal. In fact, recent work ana-lyzing the expression of genes related to the oxidant defense systemin skeletal muscle has shown that antioxidant supplementation actual-ly may impede gene expression that modulates adaptation toendurance exercise.10

To summarize, resistance-type exercise that induces a significantload on the muscle is most important in activating protein synthesispathways. Nutritional interventions with a combination of protein(containing the essential amino acid leucine) and carbohydrate havebeen shown to augment the traditional response to resistance train-ing. Finally, the only safe and effective supplement on the market thathas shown benefit at both the performance and cellular level is crea-tine monohydrate. Nonetheless, as discussed in these three commen-taries, skeletal muscle growth is polygenic (resulting from the input ofmany genes) and results from a complex set of underlying genetic andenvironmental modifiers. Scientists in this field should be commend-ed for their aggressive approach in providing data to assist in ourunderstanding of the genetics underlying athletic performance as wellas the environmental modifiers and how they influence cell signaling.However, this field is still in its infancy and there are significant areasof research that have yet to be explored. Until then, the only safe andeffective mode of inducing skeletal muscle growth through manipula-tion of cellular signaling is proper exercise and nutrition.

Disclaimer: The opinions or assertions contained herein are theprivate views of the author and are not to be construed as official oras reflecting the views of the Army or the Department of Defense.

About the Author

Maria L. Urso, Ph.D., is a principal investigator in the

Military Performance Division at the United States

Army Research Institute of Environmental Medicine

(USARIEM) in Natick, MA. Dr. Urso also serves as an

associate editor for the NSCA’s Journal of Strength

and Conditioning Research.

References

1. Baar K, Nader G, Bodine S. Resistance exercise, muscle load-

ing/unloading and the control of muscle mass. Essays Biochem.

2006;42:61-74.

2. Bodine SC, Stitt TN, Gonzalez M, et al. Akt/mTOR pathway is a cru-

cial regulator of skeletal muscle hypertrophy and can prevent muscle

atrophy in vivo. Nat Cell Biol. 2001;3:1014-1019.

3. Cribb PJ, Hayes A. Effects of supplement timing and resistance exer-

cise on skeletal muscle hypertrophy. Med Sci Sports Exerc. 38:1918-

1925, 2006.

4. Dreyer HC, Drummond MJ, Pennings B, et al. Leucine-enriched essen-

tial amino acid and carbohydrate ingestion following resistance

exercise enhances mTOR signaling and protein synthesis in human

muscle. Am J Physiol Endocrinol Metab. 2008;294:E392-400.

5. Hespel P, Derave W. Ergogenic effects of creatine in sports and reha-

bilitation. Subcell Biochem. 2007;46:245-259.

6. Ivy JL, Ding Z, Hwang H, Cialdella-Kam LC, Morrison PJ. Post exercise

carbohydrate-protein supplementation: phosphorylation of muscle

proteins involved in glycogen synthesis and protein translation.

Amino Acids. 2008;35:89-97.

7. Kadi F, Eriksson A, Holmner S, Thornell LE. Effects of anabolic

steroids on the muscle cells of strength-trained athletes. Med Sci

Sports Exerc. 1999;31:1528-1534.

8. Miller BF. Human muscle protein synthesis after physical activity and

feeding. Exerc Sport Sci Rev. 2007;35:50-55.

9. Nader GA, Hornberger TA, Esser KA. Translational control: implica-

tions for skeletal muscle hypertrophy. Clin Orthop Relat Res.

2002;S178-187.

10. Ristow M, Zarse K, Oberbach A, et al. Antioxidants prevent health-

promoting effects of physical exercise in humans. Proc Natl Acad

Sci U S A. 2009;106:8665-8670.

11. Safdar A, Yardley NJ, Snow R, Melov S, Tarnopolsky MA. Global and

targeted gene expression and protein content in skeletal muscle of

young men following short-term creatine monohydrate supplementa-

tion. Physiol Genomics. 2008;32:219-228.

12. Urso ML. Building Muscle: How Important is the “Nature” Part of

the Nature Vs. Nurture Equation? ACSM’s Certified News.

2011;21:5-7.

13. Urso ML. Building Muscle: Understanding the Building Blocks

known as Genes. ACSM’s Certified News. 2011;21:4-6.

14. Willoughby DS, Rosene JM. Effects of oral creatine and resistance

training on myogenic regulatory factor expression. Med Sci Sports

Exerc. 2003;35:923-929.

15. Wolfe R, Ferrando A, Sheffield-Moore M, Urban R. Testosterone

and muscle protein metabolism. Mayo Clin Proc. 2000;75

Suppl:S55-59; discussion S59-60.

SELF-TEST ANSWER KEY FOR PAGE 15

————————————————————— QUESTION —————————————————————

12345

TEST 1BBABD

TEST 2EDECC

TEST 3DABDD


earned the CES or RCEP certification and, with the exception of a tem-porary qualification period that permits a bachelor’s degree (e.g., grand-fathering clause), a graduate degree in exercise science/physiology.

As of June 2011, there are 3,596 individuals who hold the CES cre-dential and 853 with the RCEP. In 2010, 229 individuals earned the CESand 38 the RCEP. Efforts are needed by more academicians to get theirprograms accredited and to encourage their students who plan to workin clinical exercise physiology to take the CES exam (bachelor’s pre-pared) or the RCEP exam (graduate degree). In addition, efforts areneeded by many to promote the unique knowledge and skills of individ-uals who hold the CES or RCEP certification and the roles they fill inhealth care. These efforts fall on ACSM, CEPA, academia, and every cer-tified professional.

Concerning the latter, as certified professionals working in healthcare, we have many opportunities to advance our profession throughour interactions with colleagues, our patients, the public, the media, andadministrators and human resource professionals where we areemployed. We all play an important role in the advancement of the pro-fession. Towards this end, I encourage you to present yourself as a cer-tified exercise specialist/physiologist (e.g., email signatures, one-on-oneintroductions), maintain your certification, be a member of CEPA, andencourage and counsel young professionals as to the importance ofbecoming certified. Together we will help to solidify the profession ofclinical exercise physiology.

The Profession (continued from page 2)

Building Muscle (continued from page 4)


WELLNESS ARTICLE

THE CLINICAL EXERCISEPHYSIOLOGIST (CEP) AS A CERTIFIEDDIABETES EDUCATOR® (CDE®)

By Cathy Mullooly, M.S., RCEP, CDE


ABSTRACT: The Certif ied Diabetes Educator® (CDE®) credentialwas f irst of fered in 1986. This mastery credential quicklybecame recognized as the “gold standard” for diabetes educa-tors. It is managed by the National Certif ication Board forDiabetes Educators (NCBDE), which oversees the eligibilityrequirements, as well as the examination application process andexamination administration. Exercise professionals who meetthe eligibility criteria also are potential candidates for the CDE®

credential.

Diabetes has reached epidemic proportions around the globe.The rapidly increasing prevalence and the escalating personal andfinancial costs associated with diabetes are frequently in the head-lines. Additionally, the medical guidelines to diagnose, treat, and pre-vent the ravages of the disease are under constant scrutiny and revi-sion. The January–March, 2011 edition of ACSM’s Certif ied News con-tained an excellent overview of the expanding role of Clinical ExercisePhysiologists (CEPs) in providing exercise counseling to people withtype 2 diabetes. For CEPs who have people with diabetes in theirclinical care, the CDE® credential can provide another level of profes-sional creditability and recognition as an effective member of the dia-betes care team.

A unique feature of CDE® certification is that it is a multi-disciplinarycredential. Eligible health care disciplines are those that possess anddemonstrate the expertise to provide components of Diabetes Self-Management Education (DSME). However, if you have a peer who isone of the 17,000+ CDEs®, it is likely that they are either a RegisteredNurse or a Registered Dietitian as these disciplines make up the major-ity of CDEs®. Historically, it has been the rare exercise physiologistwho has sought out and successfully obtained the CDE® credential.This probably is due to one of three reasons: 1) confusion surround-ing the professional qualifications, 2) the impression that the compo-nents of DSME are outside of the CEP scope of practice, and 3) limit-ed opportunities to function as a member of the diabetes care team.

Professional qualifications

NCBDE has offered a professional pathway for CEPs to sit for theCDE® examination from the beginning. This pathway has undergoneseveral changes over time as the CEP profession matured and as theAmerican College of Sports Medicine (ACSM) changed its own clini-cal certifications requirements. Initially, the first CEP candidates were

required to have a master’s degree in an exercise science field and toprovide transcripts of their degree program to satisfy the CDE® dis-cipline requirements. When the ACSM Registered Clinical ExercisePhysiologist® (RCEP®) credential was created by ACSM, it was quick-ly adopted by NCBDE in 2005 as satisfying the discipline require-ment. However, the candidate still was required to possess a mas-ter’s degree in an exercise science program.

In 2010, NCBDE announced changes to the CEP discipline require-ments that went into effect as of January 2011. CEPs who possesseither an active ACSM Clinical Exercise Specialist® (CES), or RCEPcertification satisfy the professional eligibility requirements. This elim-inates the past requirement for the RCEP candidate to be master’sprepared. This change also recognizes the CES as a qualifying creden-tial for the first time. These changes will simplify the applicationprocess and allow a greater number of eligible CEPs to join theirmulti-disciplinary peers in achieving this credential. As CEPs, weshould be proud of the advances made over the last decade and theprofessional recognition this progress has realized.

Scope of Practice

The CDE® credential d o e s n o t expand the scope of practice forany successful candidate. A nurse, dietitian, pharmacist, or otherhealth care professional still is governed by the laws and regulationsthat their licensure provides them or by a job description and func-tions established by an employer. The CDE®, as a mastery credential,demonstrates that the professional has clinical experience and is pro-ficient in a specific body of knowledge. For diabetes educators, thisbody of knowledge is DSME. DSME includes physical activity as partof the body of knowledge. As an example, physical activity is high-lighted as one of the healthy patient behaviors within the AmericanAssociation of Diabetes Educators (AADE7) education programofferings.1

NCBDE’s definition of DSME is adapted from the NationalStandards for Diabetes Self-Management Education which is publishedby the American Diabetes Association.2 The following information istaken from the NCBDE Web site3:

“DSME involves the person with pre-diabetes or diabetes and/orthe caregivers and the educator(s) and is defined as the ongoingprocess of facilitating the knowledge, skill, and ability necessary forself-care. It is a component of a comprehensive plan of diabetes care.The process incorporates the needs, goals, and life experiences of the


person with pre-diabetes or diabetes and is guided by evidence-basedstandards. The overall objectives of DSME are to support informeddecision-making, self-care behaviors, problem-solving and active col-laboration with the health care team and to improve clinical out-comes, health status, and quality of life.”

The process includes:1. An individual assessment and education plan developed collabo-

ratively by the individual and educator(s) to direct the selectionof appropriate educational interventions and self-managementsupport strategies.

2. Educational interventions directed toward helping the individualachieve self-management goals.

3. Periodic evaluations to determine the attainment of educationalobjectives or need for additional interventions and futurereassessments.

4. A personalized follow-up plan developed collaboratively by theindividual and educator(s) for ongoing self-management support.

5. Documentation in the education record of the assessment andeducation plan and the intervention and outcomes.

In addition, program development and administration provided insupport of the diabetes patient education program are consideredpart of the DSME process.”

As you read through the description of DSME, it is easy to recognizea framework similar to what CEPs currently provide in clinical settings.If the clinical program also serves a large portion of people with dia-betes, it may already incorporate many of the components of DSME.However, it is import to distinguish that the CDE® credential isdesigned and intended solely for health care professionals who have adefined role as a diabetes educator. Someone who performs occasion-al or partial diabetes related functions in the course of their work rou-tine does not meet this definition. For example, many clinically super-vised exercise programs will have people with diabetes perform andrecord their blood glucose values at the beginning and end of the work-out session. If that is the extent of the process, it would not qualify asDSME. However, a CEP with a defined role as a diabetes educatorwould evaluate the glucose reading for risk of hypoglycemia or hyper-glycemia during exertion, discuss a plan with the person with diabetesto prevent these acute complications from interfering with the exerciseactivity, re-assess the plan as needed, and document these actions aspart of participating in the program.

Diabetes Care team

Another component of the eligibility requirements for initial certifica-tion is accruing professional practice experience. Before applying for theexamination, both of the following requirements must be met3:

1. Minimum of two (2) years to the day of professional practiceexperience in the discipline under which the individual is apply-ing for certification.

2. Minimum of 1,000 hours of DSME experience accrued up tofour (4) years prior to submission of an application. However,a minimum of 40% of those hours (400 hours) must beaccrued in the most recent year preceding application.

CEPs are not the only clinicians that experience limited opportuni-ties to practice as part of a diabetes care team. To meet that need,NCBDE, the American Association of Diabetes Educators, and the

American Diabetes Association have created the Diabetes EducatorMentorship Program.3 This program was developed in order to pro-mote careers that will lead to a CDE® designation. Also, with agreater number of multi-disciplinary CDEs®, access to DSME canimprove for people and families of people with diabetes.

The Diabetes Educator Mentorship Program began in January2011. It partners experienced CDEs® with health care professionalsinterested in gaining the experience needed in providing DSME.Qualifying volunteer hours accrued under this program will assist pro-fessionals with meeting the current practice requirement for CDE®

certification. While this program will prove useful for many diabeteseducators, participation is not a mandatory requirement.

Professional Development

The final component to meet the eligibility requirements is one ofcontinuing education. The candidate must collect a minimum of 15clock hours from an approved provider. The list of NCBDE approvedproviders does include ACSM. These clock hours need to be applica-ble to diabetes and obtained within the two (2) years prior to apply-ing for certification.

Summary

This overview was intended to raise awareness and to clarify therequirements for CEPs interested in pursuing the CDE® credential.As stated throughout this article, changes can occur at any time tothe process, available resources, or eligibility requirements.Candidates need to follow and adhere to the requirements for theyear they are applying to sit for the CDE® exam. NCBDE continual-ly posts all of the information and updates to the CDE® process socandidates can prepare and plan as needed. You can review thesedetails, search for mentors in your area or use the NCBDE contactinformation found on its Web site.3

ABOUT THE AUTHOR

Cathy Mullooly, MS, RCEP, CDE is a diabetes

medical liaison with Novo Nordisk, Inc. Much of

her clinical career was spent at the Joslin Diabetes

Center in Boston, MA in the Exercise Physiology

Department. She has contributed to many articles,

chapters, and presentations on the subject of

diabetes and exercise. She also served on many

multidisciplinary diabetes boards as the clinical

exercise physiology professional. Currently she is

working with the Clinical Exercise Physiology

Association as the diabetes liaison and is a member of the Credentials

Committee for the National Certification Board of Diabetes Educators.

References

1. AADE Position Statement: AADE7 Self-Care Behaviors. Diabetes Educ,

2008; 34(3), 445 -449.

2. National Standards for Diabetes Self-Management Education,

American Diabetes Association Clinical Practice Recommendations.

Diabetes Care, Vol. 33, Supplement 1, January, 2010.

3. National Certification Board for Diabetes Educators. Web site

[Internet]. Arlington Heights (IL): NCBDE; [cited 2011 July 27].

Available from www.ncbde.org



to determine where your client ranks with regards to fitness and appro-priate general intensity guidelines.

WHAT TYPE OF EXERCISE? Aerobic exercise is emphasized heav-ily in our programs. Why? Circulating oxygenated blood is the bestmethod we have to help the body heal itself.2 The benefits of empha-sizing an aerobic based cancer rehabilitation program are: increased car-diorespiratory fitness, augmented immune system function, increasedRBC/WBC production, and possibly augmented circulation throughoutthe body to aid in removing cytotoxic agents.7

Because cancer treatments also affect bone mineral density and over-all muscle mass integrity, we prescribe a strength training component formost of our clients during exercise sessions.11 Our strength training pro-grams are based on three pillars of body function: posture, mobility, andstability.5 For instance, a woman who has undergone chemotherapy,radiation treatment, and surgery for breast cancer, requires comprehen-sive strength training to improve posture (i.e., neutral spine position),upper body range of motion (or mobility) on both sides, stability in theshoulder girdle, and muscular strength and endurance (possibly to helphold a child for a prolonged period of time). Because most of our clientsare 50+ years, promoting improved posture, greater mobility of the hipsand upper body musculature, and spinal stability with neuromuscular re-education, we see stellar results in overall enhanced movement patterns.These improved movement patterns allow the older adult to exerciseand move/walk safely while avoiding falls and potential future orthope-dic complications. It also allows our clients to engage safely in other aer-obic activities.

Last, we highly suggest exercising with a partner. Why? Researchersbelieve that exercising together may increase exercise compliance whileimproving physical function and mental well-being.1 At our center, nutri-tion advice and mental health counseling also are an integral part of therehabilitation phase of cancer interventions.

In summary, the evidence is rather convincing that exercise should bea critical component of all cancer rehabilitation programs. The guidelinesfor cancer rehabilitation programs are defined clearly in the ACSMroundtable guidelines for cancer survivors.7 These guidelines should beseen as the minimum level of physical activity needed for the cancer sur-vivor with alterations made for each individual based on their unique can-cer history, current health status, and/or undulating energy levels if cur-rently undergoing cancer treatment. Ideally, we encourage cancer sur-vivors to engage in five days of aerobic activity per week for 30 minutesper session at moderate-to-vigorous levels. These levels should be estab-lished by a trained exercise professional who critically understands thedistinctive health needs/fluctuations of a cancer survivor. Additionally,most cancer survivors will benefit from a twice-a-week strength trainingprogram designed to increase posture, mobility, and stability. Even if this

prescription appears rather aggressive, we havefound the diagnosis of cancer, while startling, isoften a life altering opportunity for individuals tostart and continue working towards health andlongevity.

About the Author

Riggs Klika, Ph.D., FACSM is director of the Cancer

Survivor Center. He is a clinical exercise physiolo-

gist and cancer rehabilitation specialist.

Scott Drum, Ph.D., FACSM is associate professor at

Western State College of Colorado in Gunnison,

CO in the Department of Recreation and Exercise &

Sport Science.

References

1. Bennett JA, Winters-Stone K. Motivating older adults to exercise: What

works? Age Ageing. 2011;40(2):148-9.

2. Bitterman, H. Bench-to-bedside review: Oxygen as a drug. Critical Care

2009;13:205-213.

3. Courneya KS, Friedenreich CM. Physical activity and cancer: An intro-

duction. Recent Results Cancer Res. 2011;186:1-10.

4. Jones LW, Eves ND, Peterson BL, et al. Safety and feasibility of aerobic

training on cardiopulmonary function and quality of life in postsurgi-

cal nonsmall cell lung cancer patients: a pilot study.

Cancer.2008;113(12):3430-9.

5. McGill S. Core Training: Evidence translating to better performance

and injury prevention. Strength Cond J: 2010; 32(3): 33-46

6. Pekmezi DW, Demark-Wahnefried W. Updated evidence in support of diet

and exercise interventions in cancer survivors. Acta Oncol.2011;

50(2):167-78.

7. Schmitz KH, Courneya KS, Matthews C, et al. American College of

Sports Medicine Roundtable on Exercise Guidelines for Cancer

Survivors. Med Sci Sports Exerc. 2010;42:1409-1426.

8. Schmitz KH, Ahmed RL, Troxel AB, et al. Weight lifting for women at risk

for breast cancer-related lymphedema: A randomized trial

JAMA.2010;304(24):2699-705.

9. Schneider CM, CA Dennehy, SD Carter. Exercise and Cancer Recovery.

Human Kinetics, Champaign, IL, 2003.

10. Tosti KP, Hackney AC, Battaglini CL, Evans ES, Groff D. Exercise in

patients with breast cancer and healthy controls: energy substrate oxida-

tion and blood lactate responses. Integr Cancer Ther. 2011;10(1):6-15.

11. Winters-Stone KM, Schwartz A, Nail LM. A review of exercise interven-

tions to improve bone health in adult cancer survivors. J Cancer Surviv.

2010;4(3):187-201.

Surviving Cancer (continued from page 6)



ACSM’s Certified NewsISSN # 1056-9677401 West Michigan StreetIndianapolis, IN 46202-3233 USA

NONPROFIT ORGU.S. POSTAGE

PAIDIndianapolis, IN

Permit No. 6580

Readers of the American College of Sports Medicine’s (ACSM)Certif ied News can make significant contributions for students andexercise professionals while earning valuable benefits.

The purpose of ACSM’s Certif ied News is to provide continuingeducation material to the certified exercise and health professional andinform these individuals about activities of ACSM and their profession.All materials submitted to and subsequently published in ACSM’sCertif ied News have been carefully reviewed by an editorial boardcomprised of content experts from a number of disciplines from withinthe exercise sciences. Articles appearing in ACSM’s Certif ied Newsinclude health and wellness, clinical, wellness features, clinical features,and a number of ongoing columns. ACSM’s Certif ied News readersreceive helpful information, which they can immediately apply in theirpractice as exercise professionals. They also can earn up to four (4) con-tinuing education credits (CECs) per quarterly issue by taking and pass-ing continuing education quizzes appearing in each issue of ACSM’sCertif ied News. This is particularly important for those who holdACSM certifications in either the health and fitness or clinical tracks.

Authors can earn 10 CECs per article appearing in ACSM’sCertif ied News. Professionals who teach in academic institutions canprovide mentorship to their students by co-authoring articles with themin ACSM’s Certif ied News. Students can develop good professionalwriting skills while sharing useful information with other exercise profes-sionals. Those interested in submitting articles to ACSM’s Certif ied

News should contact Traci Rush in ACSM’s Certification Department([email protected]) to request the Instructions for Authors.

Rewards For Service

The editorial staff of ACSM’s Certif ied News recruits contentexperts to serve as reviewers on the editorial board. Terms are for atwo (2) year commitment. Members of the editorial board help enhancethe quality of all articles and their value to readers of ACSM’s Certif iedNews. They can receive “service points” toward earning recognition asa Fellow of the American College of Sports Medicine.

Professionals can earn ACSM Fellowship service points by contribut-ing to ACSM’s Certif ied News in the following ways:

• Publishing one or more articles in ACSM’s Certif ied News: 1ACSM Service Point

• Serving a full, two-year term on the Editorial Board: 2 ACSMService Points

• Serving a full, two-year term as a co-editor of ACSM’s Certif iedNews: 2 ACSM Service Points

Those professionals interested in serving on the editorial boardshould contact the co-editors, Peter Ronai ([email protected])and Peter Magyari ([email protected]).

By Peter Ronai, M.S., FACSM, RCEP, CES, PD, CSCS-D

CONTRIBUTE TO ACSM'S CERTIFIED NEWS AND EARN VALUABLE BENEFITS


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