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NEWS
J U LY
–
S E P T E M B E R
,
2 011
•
VO LU M E
21 :
I S S U E
3
Building Muscle: Signals
Induced by Exercise,
Nutrition, and Supplements
page 3
Surviving
Cancer:
Physical
Realities
page 53
Strength Training: Instructional Strategies
And Teaching Techniques page 8
Integrating the Exercise is Medicine®
Initiative into the Role of the Clinical
Exercise Professional page 10
The Clinical Exercise Physiologist (CEP) as a
Certified Diabetes Educator® (CDE®) page 12
Contribute To ACSM’s Certif ied News
and Earn Valuable Benefits page 16
6
Continuing Education
Self-Tests on page 15
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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
Integrating the Exercise is Medicine® 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
Information for Subscribers
Correspondence Regarding Editorial Content
Should be Addressed to:
Certification & Registry Department
E-mail: [email protected]
Tel.: (317) 637-9200, ext. 115
For back issues and author guidelines visit:
www.acsm.org/certifiednews
Change of Address or Membership Inquiries:
Membership and Chapter Services
Tel.: (317) 637-9200, ext. 139 or ext. 136.
ACSM’s Certified News (ISSN# 1056-9677) is published
quarterly by the American College of Sports Medicine
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,
statements, or opinions of ACSM. Information published in
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
certified exercise and health professional and to inform these
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
Prescription or the established positions of ACSM. ACSM’s
Certified News is copyrighted by the American College of
Sports Medicine. No portion(s) of the work(s) may be
reproduced without written consent from the Publisher.
Permission to reproduce copies of articles for noncommercial
use may be obtained from the Rights and Permissions editor.
ACSM National Center
401 West Michigan St., Indianapolis, IN 46202-3233.
Tel.: (317) 637-9200 • Fax: (317) 634-7817
© 2011 American College of Sports Medicine.
ISSN # 1056-9677
Page 2
THE CES, THE RCEP,
AND THE PROFESSION
OF CLINICAL EXERCISE
PHYSIOLOGY
Clinton A. Brawner, M.S., RCEP, FACSM
As 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 bachelor’s degree or a graduate degree, respectively, in exercise science/physiology. These two exams
assess competency in similar domains (e.g., exercise testing, exercise prescription, and exercise training). The CES exam includes content in cardiovascular disease, pulmonary disease, and diabetes, while
the RCEP includes these content areas plus other metabolic disorders, as well as orthopedic, neuromuscular, oncologic, immunologic, and hematologic disorders. These similarities have created some
confusion among academia regarding which exam aspiring professionals with a master’s degree should
attempt. In addition, health care providers and institutions may feel they are left to “sort out” the differences in competencies assessed between these certifications and how they fit into their clinical programs. Should a Cardiology Unit hire a CES or an RCEP to administer maximal exercise tests? Does
someone 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 of
three criteria to become a “Registered Clinical Exercise Physiologist.” The other criteria were a graduate 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 by
recognizing their competency in traditional clinical exercise domains, such as clinical exercise testing
and cardiopulmonary rehabilitation, as well as other content areas in which exercise had been shown
to provide therapeutic benefit. They did this by defining a scope of practice, promoting ethical standards, and defining minimal academic standards.
In contrast, long before the RCEP certification was offered, the CES certification was available
to individuals with a bachelor’s degree in a variety of health-related disciplines (e.g., nursing); it was
not limited to graduates of exercise science/physiology programs as it is today. In addition, there
were no accredited exercise science/physiology programs like there are today. In summary, there
were no national standards to define the clinical exercise professional separate from other allied
health professionals.
For a profession to be recognized as unique it must have the following elements: (a) a body of
knowledge, (b) a standardized academic curriculum, (c) an accredited credentialing exam, and (d) an
organization whose purpose includes advocacy of that profession. Each of these elements are now in
place for the clinical exercise professional and include ACSM’s Guidelines for Exercise Testing and
Prescription, academic program accreditation through the Commission on Accreditation of Allied
Health and Education Programs (CAAHEP), credentialing exams (i.e., CES and RCEP) accredited by
the National Commission for Certifying Agencies (NCCA), and a professional organization in the
Clinical Exercise Physiology Association (CEPA).
Although there are more than 35 years of history behind the CES certification, anecdotal evidence 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, approximately 25% are staffed by clinical exercise professionals. In addition, where these professionals are
employed, the CES or RCEP certification is recognized (e.g., described in a job description or defines
salary) in less than half of these institutions (based on observations by author of nearly 100 institutions in the United States).
In the United States there have been state-level legislative activities advancing the licensure of CEPs
with 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
The Profession (continued on page 11)
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WELLNESS ARTICLE
BUILDING MUSCLE:
SIGNALS INDUCED BY EXERCISE,
NUTRITION, AND SUPPLEMENTS
By Maria L. Urso, Ph.D.
In the last two issues of ACSM’s Certif ied News , 12, 13 we explored
the basics of gene expression and protein synthesis as a foundation for
skeletal muscle hypertrophy. We also discussed the impact of an individual’s genetic make-up on changes in skeletal muscle size and strength.
The purpose of this final commentary in the series is to understand how
exercise, 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 fundamental role in dictating phenotypical (or physical) properties. The
term hardware was used since these are physical traits that cannot
be changed with exercise, diet, or supplements. One aspect of hardware that was discussed in depth was the effects of single nucleotide
polymorphisms (SNPs) and their genetic influence on gains in skeletal
muscle size and strength. In this commentary, we will focus on how
individuals can use exercise, nutrition, and supplements to manipulate
the activity of genes that increase protein synthesis and muscle
growth through stimuli that alter the rate and magnitude of DNA
transcription to messenger Ribonucleic Acid (mRNA). These factors
can be referred to as software since they can be changed with various interventions, environmental influences, and stimuli. This article
will identify ways to manipulate software (gene expression) through
exercise, nutrition, and supplements. It should be emphasized that
SNP and molecular pathway data certainly are not independent, in
that DNA sequence information (SNPs) can affect pathway activities
in a number of ways. While most studies conducted to date have not
combined genetic variation and pathway data, current research methods are integrating data across multiple levels including both “beneath
the 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, most
notably through exercise training and diet interventions. Exercise training can affect strength via changes in both neuromuscular efficiency and
muscle size, while diet modulates strength primarily via regulation of
muscle size. Diet and exercise training routines are modified or manipulated in order to optimize strength gains and can be augmented by the
use of ergogenic aids, including nutritional supplements and pharmacological interventions. The following sections will briefly outline how skeletal muscle software is affected by these factors.
Exercise Training
Exercise training can include various types of activities that have different effects on skeletal muscle characteristics such as strength and
power. Endurance-type training, such as running, cycling, or longdistance swimming, evokes primarily metabolic changes within muscle,
increasing endurance and aerobic capacity but not significantly affecting strength. The lack of strength gain with endurance exercise stems
from the preferential activation during exercise of less fatigable Type I
muscle fibers, which undergo no or little hypertrophy with endurance
training due to the relatively low loads placed on muscle. This is due
to the preferential recruitment of slow-twitch motor units during lowintensity aerobic-type exercise. However, as intensity increases, higherthreshold fast-twitch motor units are recruited. These concepts are
important to understand. If high power output and muscle hypertrophy is the objective of the training program, interventions involving
resistance-type exercise that generates high mechanical strain and the
recruitment of high-threshold fast-twitch motor units (in addition to
low-threshold slow twitch motor units) are essential.
The functional link between strength training and muscle size
gains can be explained at the cellular level by understanding the
effects of loading on the balance of protein breakdown and synthesis.
The balance of skeletal muscle protein synthesis versus protein degradation dictates muscle size gains. Research has shown that protein
synthesis and breakdown increase with resistance training, but
increases in translation initiation and subsequent protein synthesis
greatly outpace protein breakdown, producing net gains in protein
accretion. The duration of increased protein synthesis following
resistance exercise has been a topic of significant investigation.
Researchers have attempted to identify periods when skeletal muscle
may be more resistant to additional gains in protein synthesis (e.g.,
repeating a bout of exercise in a previously exercised muscle), as well
as to understand optimal timing for nutrient delivery.3 Resistance
exercise is documented to cause a rapid increase in protein synthesis
within 1 to 2 hours of a single bout, and this increased rate of synthesis persists for 24 to 48 h, depending on the resistance training variables applied and the individuals training status.1, 9
Regulation of translation initiation in response to hypertrophyinducing stimuli such as loading is a complex process, controlled
through the activation of stimulus sensing proteins, signal transduction proteins, and effector proteins. The Figure is a simplified illustration of how these pathways respond to resistance exercise. Stimulus
sensing proteins transmit information regarding the external environment 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 protein
kinase AMPK (energy-sensor). Activation of these proteins modulates
skeletal muscle growth. Signal transduction proteins include protein
kinases and transcription factors that enter the nucleus upon activation, binding to respective genes. The forkhead family of transcription
factors (FKHR) is an example of one transcription factor regulating
skeletal muscle size. This is a complex system and several upstream
protein kinases act upon FKHR, and multiple signal transduction proteins are affected by its activity. Activation of the stimulus sensing proteins phosphorylates (P) the Akt/mTOR pathway and increases skeletal muscle protein synthesis through activation of signal transduction
proteins which activate effector proteins and translation initiation.2
In the case of endurance-type exercise, signaling mechanisms related to metabolic adaptations, such as the activation of AMPK predominate, limiting gains in skeletal muscle size. This is due to the role of
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Figure. Signaling Mechanisms Mediating the Anabolic
Response. First, sensor proteins such as AKT and mTOR
sense the stimulus (e.g., mechanical stretch), inducing
the activation of signal transduction proteins (e.g.,
protein kinases that phosphorylate (P) other proteins),
and finally the activation (or inhibition) of effector
proteins which include, transcription factors,
translational regulators, and regulatory proteins.
AMPK in monitoring the energy status of the cell, such that AMPK
activity 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 inhibiting
AKT/ mTOR signaling and downstream signal transduction.
Nutrition
The first article in this series emphasized the concept that skeletal
muscle hypertrophy is dependent on an increase in the machinery
responsible for protein translation (e.g., ribosomes) and that insufficient dietary protein decreases translation initiation. Translation initiation is the first step in protein synthesis; thus, deficiencies in translation initiation due to inadequate protein intake interfere with skeletal
muscle adaptation. Despite potential increases in processed mRNA
due to other stimuli (e.g., resistance training), the mRNA is not efficiently translated into peptides by ribosomes, subsequently reducing
size gains.9
Significant breakthroughs have been made in the past decade in
understanding how nutrition and diet affect skeletal muscle strength
and hypertrophy at the cellular level. These breakthroughs have
enabled scientists to identify the acute effects of feeding on key protein signaling pathways in skeletal muscle. Specifically, this work has
demonstrated that protein intake, when combined with resistance
exercise, has a measurable effect on downstream regulatory factors
in the AKT/mTOR pathway, resulting in increased protein synthesis
as compared to resistance training alone. Others have explored the
timing of protein intake in reference to a bout of resistance exercise
to identify when protein should be ingested to increase activity of
protein synthesis pathways.8 Recent work suggests that there is a synergistic effect of the timing and composition of meals with resistance
exercise on the overall rate of protein synthesis and subsequent gains
in muscle strength and size.8
Essential amino acid cocktails with a high concentration of leucine,
administered immediately pre- and/or post-exercise, have shown the
greatest benefits in up regulating signaling pathways responsible for
translation initiation and protein synthesis.4 The beneficial effects of
essential amino acid intake also have been shown to be augmented
4
when administered prior to exercise and when combined with carbohydrate ingestion.4, 6 In addition to increased activity of the
AKT/mTOR pathway, nutritional interventions have been shown to
alter levels of myosin heavy chain (MHC) and the negative regulator of
muscle growth, myostatin.
Ergogenic Aids
Ergogenic aids that have purported anabolic or growth promoting
effects on skeletal muscle range from pharmacological aids (i.e., anabolic steroids) to over the counter supplements like creatine monohydrate. While substantial research has been completed to characterize the performance-promoting effects of various ergogenic aids,
these data are equivocal and very few of these studies examine data
at the molecular level. Understanding how specific ergogenic aids
impact cell signaling events is important in prescribing safe and effective use of various supplements. However, due to the lack of biochemical data from research studies investigating the impact of
ergogenic aids on skeletal muscle, this commentary will only briefly
review supplements with biochemical data to support their role in
increasing skeletal muscle strength and size. These include anabolic
agents (purported to promote adaptations in strength and size); creatine monohydrate (theorized to activate protein synthesis pathways), and antioxidants (marketed to protect cellular integrity).
Use of anabolic agents enhances skeletal muscle hypertrophy
beyond normal limits via increased transcription of DNA for myofibrillar proteins, accelerated activation of satellite cells, and subsequent
synthesis of nuclear and contractile proteins.7 In humans, the use of
anabolic androgenic steroids has been widespread in sport, despite
significant warning of lethal side-effects and possible elimination due
to anti-doping regulations. Anabolic agents that have been used in
combination with resistance exercise to promote hypertrophy
include growth hormone, testosterone-like hormones, IGF-I, and B2
adrenoceptor agonists (B2 Agonists). Increases in muscle size have
been achieved with the use of each of these agents, and in some
cases, without the added intervention of resistance training, typically
in pathological conditions with the intent to attenuate the atrophy
process15.
In most cases, the mechanisms driving supplement-induced hypertrophy are unique to the supplement used, based on the physiological effects of each supplement. The most recent evidence has provided mechanistic studies examining not only alterations in phenotype
(e.g., physical characteristics), but alterations in the expression of
genes regulating protein synthetic and degradative pathways. This
work has confirmed the efficacy at both the systems and molecular
level of anabolic agents including, testosterone enanthate,
Oxandrolone, recombinant human growth hormone (rhGH), insulin,
and nandrolone decanoate. Common transcription factors affected
by their use include myostatin, IGF-I, MGF, and components of the
AKT/mTOR pathway (Figure).
In regards to creatine supplementation, a more pronounced muscle hypertrophy has been documented in individuals simultaneously
participating in resistance training.5 There is significant evidence that
satellite cell activation and proliferation is induced with creatine ingestion,14 and this is the mechanism behind the anabolic effects observed
with creatine supplementation. This conclusion is supported by
increases in mRNA for IGF-I and markers of satellite cell activation.11
Building Muscle (continued on page 11)
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CLINICAL FEATURE
SURVIVING CANCER: PHYSICAL REALITIES
BY RIGGS J. KLIKA, PH.D., FACSM AND SCOTT N. DRUM, PH.D., FACSM
Editor’s note: This article was previously published in the
Clinical Exercise Physiology Association (CEPA) Spring 2011
Newsletter (Vol. 4, Issue 2). After consulting with the editors of
the CEPA Newsletter, ACSM’s Certified News has agreed to accept
this article for publication in an ef fort to reach a broader spectrum of Certif ied Exercise Professionals. CEPA is a member of
ACSM’s af f iliate societies. www.cepa-acsm.org.
Cardiorespiratory (CR) fitness is one of the most important indicators of health and longevity in humans. CR fitness refers to the body’s
ability to transport oxygen from the air to the body’s cells in order to
produce energy for a multitude of processes (e.g., muscle contraction
and immune system function, among others). The integrity of the cardiopulmonary system, as well as the circulatory system, dictates how
well oxygen can be transported and utilized in the body. Following cancer therapies, such as surgery, chemotherapy and/or radiation treatment, CR fitness will be significantly reduced.
Notably, reduction of CR fitness primarily follows the decline in physical activity for most cancer patients. Please read a more detailed review
of this outcome by Courneya and Friedenreich.3 Furthermore, cancer
survivors typically reduce physical activity as a result of a myriad of competing distractions, including: doctor’s visits, infusion therapy, radiation
therapy, coping with family, work, and/or financial stressors. Frankly,
remaining active during cancer treatment is a very low priority for most
cancer survivors.
In addition to reduced CR fitness, radiation and chemotherapy treatments may alter normal heart function (e.g., contractility, perfusion,
stroke volume, among others) and affect systemic circulation such that
blood flow is diminished throughout the body. This may cause cancer
survivors to lose the ability to efficiently and economically process oxygen, especially in skeletal muscle. As a result, a cancer survivor’s fitness
level is typically lower than pre-diagnosis. Additionally, these adverse
changes may alter substrate utilization and adjust energy production
such that the anaerobic system becomes more active during and immediately after treatments (this remains to be determined).10 Therefore, in
our cancer rehabilitation center, one of the primary objectives is to
return CR fitness to pre-cancer levels post therapy and in many cases,
increase it beyond pre-cancer diagnosis. In other words, by promoting a
high fitness level and even improving on it after debilitating therapies and
abrupt or adverse changes in lifestyle, a cancer survivor may decrease
the chance of reoccurrence while rapidly improving their activities of
daily living. Why?
To underscore this last point, the American College of Sports
Medicine (ACSM) convened a number of experts from the field of exercise science and cancer rehabilitation who reviewed the current status
of what is known about physical activity and cancer survivorship. We
recommend you review the researchers’ observations by visiting the foll ow i n g we 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 who
adopt 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 composition, 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 immune
parameters; includes PSA for prostate cancer)
• Decreased symptoms/adverse effects (including pain).5
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Benefits of exercise for the cancer survivor also include decreasing
the risk of developing cardiovascular disease by lowering body fat, LDLcholesterol, triglycerides, blood pressure, risk of developing diabetes
mellitus and being diagnosed with a secondary cancer, and increasing
HDL-cholesterol. These benefits are essentially the standards we see
with any physical activity intervention. However, there is emerging epidemiological evidence indicating that remaining physically active during
and after treatment may decrease the risk of cancer reoccurrence6, as
alluded to earlier. This is an important point and bears repeating: Being
physically active may prevent the risk of cancer reoccurrence for cancer survivors.
Exercise Guidelines for Cancer Survivors
The ACSM guidelines for cancer survivors include meeting the following criteria ≥ 150 minutes per week of aerobic exercise at a moderateto-vigorous level or ≥ 75 minutes per week of aerobic exercise at a vigorous intensity with specific exercise programming adaptations based
on the disease and treatment-related adverse effect.7 These general
guidelines are meant to be a starting point for the cancer patient who
has completed treatment. While exercise is encouraged during treatment, the number of variables affecting each individual’s health and capabilities is so vast that general guidelines have not been issued and remain
a pertinent focus of many studies.
Moving from the guidelines
to practical application
Both during and post-cancer treatment, exercise programs and limitations can be complex and it is suggested that as a health professional
working with cancer survivors that you have a minimal certification as a
cancer exercise fitness trainer. Currently ACSM/American Cancer
Society offers this type of certification (ACSM/ACS Certified Exercise
Trainer). In our experience, it is critical that you or the individual working directly with the cancer survivor have an understanding of the medical diagnosis(es), staging, pharmacology associated with acute and
chronic treatment of cancer, surgical treatments, and the associated side
effects of the treatment options. Additionally, you are strongly encouraged to confer with the client’s oncology team directly to gain a minimal
understanding of medical terminology, which is critical to your evolution
as a certified cancer exercise fitness trainer.
As ancillary health care providers in cancer management, you will
need to assist the oncology team during the rehabilitation phase. At our
center, we monitor hematologic abnormalities (e.g., low platelets,
hematocrit and hemoglobin levels, neutrophil counts), musculoskeletal
disorders (e.g., recent bone, back or neck pain; unusual muscular weakness; extreme fatigue; severe cachexia [muscle mass loss]), gastrointestinal disorders (e.g., severe nausea, vomiting and diarrhea, dehydration,
poor nutrition), cardiovascular disorders (e.g., chest pain, elevated resting heart rates, elevated blood pressure [both systolic and diastolic],
irregular heartbeats, lymphedema), pulmonary disorders (e.g., severe
difficulty breathing, coughing/wheezing), and neurological disorders
(e.g., decline in cognitive status, dizziness/lightheadedness, disorientation, blurred vision, increased postural instability). Each one of these
conditions warrants further investigation or referral back to the primary
care physician and possible modification of the exercise plan. If you do
not have prior clinical experience or fail to fully understand the previous
list, you should not be working with cancer survivors. Instead, consider
referring the cancer survivor to an experienced colleague and seek specialized training/certification, such as mentioned prior.
At our center, we review blood work on a regular basis and conduct
interviews (typically immediately before an exercise session) about the
potential health problems indicated above. As a rule, we use three consecutive bloods test and monitor red and white blood cell counts (RBC
and WBC, respectively). If RBC/WBC counts are improving or stable
(but all within normal limits), we continue with the exercise plan. If
RBC/WBC numbers are trending poorly albeit within normal limits (i.e.,
anemia and/or neutropenia) we consult with the client and typically
decrease INTENSITY or VOLUME (duration or frequency) of exercise
for 3 to 5 days before resuming with the original plan.
SAFETY: For most cancer patients and survivors, exercise is safe.4 If
the cancer survivor is suffering from serious adverse side effects of treatment or is a stage IV patient, we recommend consulting the client’s
oncology team before starting any exercise program. While it is difficult
to broach, there are cancer patients/survivors for whom the added
stress of exercise may exacerbate physical decline and therefore be contraindicated. For those individuals, we suggest a discussion with the
client, family and/or significant others and the medical team about why
exercise should be limited.
If concerned about lymphedema, consider that Kathryn Schmitz,
Ph.D., FACSM, a lead author on the ACSM/ACS exercise guidelines, led
a recent study that found careful weight training can protect against
lymphedema.8 Our work generally has found that exercise does not
exacerbate lymphedema when the cancer survivor is monitored closely. There are excellent resources available to the cancer rehabilitation
specialist regarding lymphedema and lymphedema control at
http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphede
ma/Patient/page1.
HOW MUCH: Meeting the ACSM recommendations for cancer survivors is relatively simple; increase physical activity to at least 150 minutes of exercise per week (i.e., five sessions/week x 30 minutes/session). This may be as simple as prescribing walking 30 minutes
per day, five days a week. This should be considered the minimum level
you need to set as a goal for your post-cancer treatment rehabilitation
exercise program. We suggest you start with a walking program and
perhaps progress to a variety of other modalities (e.g., jogging, running,
cycling, swimming, alpine and/or Nordic skiing) as your client’s fitness
and health level dictates. Additionally, encourage a cancer survivor to
choose what best fits their long term goals and interests.
HOW HARD: The current guidelines suggest moderate-to-vigorous
intensity for 150 minutes per week. While moderate-to-vigorous intensity is defined specifically in the ACSM guidelines as 40% to 85% of maximal oxygen uptake reserve or heart rate reserve, it is not uniform from
individual to individual. This is where the certified exercise physiologist
is valuable. At our center, all cancer survivors complete a cardiopulmonary stress test (on a cycle ergometer or treadmill) with lactate testing in order to provide precise measures of their initial fitness level. This
helps us establish individualized intensity guidelines for aerobic exercise
programming. Although, cardiopulmonary exercise testing may not be
available to you, our philosophy is that an initial assessment of the cancer survivor’s health status should be an integral part of all rehabilitation
programs.9 If you are unable to conduct an initial, advanced exercise
assessment yourself or by a trained professional, there are alternative
methods available, such as a timed one mile walk test on a local track,
Surviving Cancer (continued on page 14)
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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 COM PLEX
DYNAM ICS OF HUM AN 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.
Let’s start with
the raw data
In the 1990s, Losada and his assistants
painstakingly coded every single statement,
moment by moment in chronological order,
made in videotaped meetings of 60 teams in a
large international corporation who were
crafting business missions and strategic plans.
The coding tracked three dimensions, which
Losada predicted would be vital and interdependent, building on each other in either an
upward or downward spiral:
1. Was a statement positive or negative?
2. Was a statement self-focused or otherfocused?
3. Was a statement based on inquiry or
advocacy?
Independently, Losada also identified
whether these groups were high, medium, or
low performers based upon a number of critical success factors.
The Butterfly – a nonlinear
dynamic system
Losada validated a set of mathematical
equations to capture the relationship among
the three dimensions and calculated a new variable called connectivity, which measured how
much each group member influenced the
behavior of others (mutual influence) and how
attuned and responsive group members were
to each other. Losada ran the raw data
through his mathematical model and voila, the
butterfly graphs (Figure) came to life. When
mutual influence reaches a critical level, a butterfly appears and grows.
Then Losada’s breakthrough came, inspired
by Fredrickson’s work on demonstrating the
evolutionary role of positive emotions. Using
algebra he translated the connectivity tipping
point into a positivity ratio or tipping point of represent the languishing of low performance
2.9 to 1. A tipping point that leads to flourish- groups. No butterfly here, not even a little
ing rather than languishing of groups is above a one. They are stuck in a cocoon of restrictive,
positivity ratio of 2.9 positive emotions to distrustful, and cynical self-absorbed advocacy
from the start, losing behavioral flexibility all
every negative emotion.
In the Figure, the first butterfly with the tall together. For the exercise professional, this
and wide wings is the data plotting of the high would represent creating an environment in
performance groups. The vertical axis of the which the agenda of the exercise expert takes
left graph represents the level of positive emo- priority of the needs of the client or group.
Here are some of Losada’s discoveries
tions and you see that the high performance
groups have high positivity ratios. Also on the about groups that also can be applied to the
left graph, the left half of the horizontal axis is exercise professional in relationship with a
a rating of open inquiry, while the right half is a client or group:
rating of advocacy. The high
performing groups’ butterfly
has a wide wing span representing an outward focus and
a broad and balanced range
of inquiry and advocacy. For
the exercise professional, this
would represent creating an
environment in which clients
are encouraged to be creative, open-minded and supportive of one another if in a
group setting.
The mixed performance
groups are represented by
the second butterfly, lower
positivity levels (below the tipping point), a narrower range
of inquiry and advocacy, along
Orange is high-performing,
with a more restrictive emotional space and less connecgreen is medium, and blue
tivity. For the exercise professional, this would represent
is low-performing.
creating an environment in
which there is little emotional
connection with and between
REPRINTED FROM (2) USED WITH PERMISSION.
clients.
Coaching News (continued on page 9)
The small, white structures
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HEALTH & FITNESS COLUMN
STRENGTH TRAINING:
INSTRUCTIONAL STRATEGIES
AND TEACHING TECHNIQUES
BY WAYNE L. WESTCOTT, Ph.D.
In a survey published more than 20 years ago, adults enrolled in formal exercise programs throughout
New England reported that knowledge of physical fitness and effective teaching skills were the two
instructor characteristics most valued by the exercise participants.11 In fact, it has been demonstrated that
exercise instructors who model these and related instructional abilities have a greater influence on their
clients’ behavior.9 The purpose of this column is to address some of the key instructor characteristics and
teaching strategies that should enable personal trainers to better educate and motivate their clients as highstatus role models.
High-Status Role Models
Personal trainers long have been perceived as exercise role models by their clients. However, based on various personal and professional behaviors, one’s role model influence may range from low to
high. Fitness instructors who are most respected and emulated by
their program participants are referred to as high-status role models.
In particular, four key attributes associated with high-status role models have been identified: knowledge, similarity, nurturance, and reinforcement.6 Personal trainers who develop these characteristics
should be more effective exercise role models who elicit more competent and confident exercise performance in their clients.7,8
Knowledge: The most important characteristic of high status personal trainers is their knowledge base in the field of exercise science.
However, a key aspect of knowledgeable instructors is the ability to present the information that they have learned through their college coursework, professional certifications, and specialized training in a relevant
and practical manner. For greatest impact, it is essential for fitness
instructors 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 in
role models who seem to be similar to themselves in some manner.6
Although there are many ways in which fitness professionals and exercise participants may share common interests and experiences, one area
where instructor similarity may be most appreciated is a sincere interest
in the client’s personal progress. Personal trainers should make attention
to each client’s training program and outcomes a high priority.
Nurturance: When the instructor is perceived as knowledgeable and
similar, most clients then welcome a more nurturing professional relationship. This tends to resemble a coach-athlete relationship that has a
high-degree of trust and cooperation as both parties desire the best possible training experience and fitness results for the exercise participant.6
Reinforcement: Positive reinforcement is a powerful motivator.
Instructors who provide appropriate affirmation for desirable exercise behavior typically have a higher role model status. To be most
effective, positive reinforcement should be presented in a sincere and
specific manner. That is, reinforcing comments should contain relevant content that clearly tells clients what they are doing correctly.
8
For example, saying “Good set of chest presses Nancy; you performed every repetition through a full movement range” is more likely to encourage her to use this technique in future sessions than simply saying “Good job, Nancy.”
In summary, influential exercise instructors are typically perceived
as high-status role models. Attaining this desirable level of respect
appears to be enhanced by the role model characteristics of knowledge, similarity, nurturance, and reinforcement.
Teaching Guidelines
Baechle and Westcott5 have presented 10 suggestions for personal trainers with respect to teaching techniques and instructional
strategies.
1. Clear Training Objectives: Begin each exercise session by
explaining the training objective and what you would like your client
to accomplish during the workout.
2. Concise Instruction with Precise Demonstration: Brief performance explanations coupled with excellent exercise demonstrations appears to be a highly effective means for eliciting the desired
behavior.9
3. Attentive Supervision: Previously inactive individuals tend to lack
confidence in their physical abilities, and typically appreciate instructors
who 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 their
clients with the activity performance, such as giving and taking dumbbells, spotting barbell lifts, and guiding proper resistance training
movement patterns.
5. One Task at a Time: Rather than projecting a series of performance requirements, it is advisable to present one directive at a
time to increase the probability that your client will successfully complete each specific task.
6. Gradual Progression: In the field of resistance exercise, it
appears especially important to progress in a gradual and systematic
manner, with relatively small increments in training intensity (e.g.,
loads) and volume (e.g., repetitions and sets).
7. Positive Reinforcement: Positive comments are always appreciated by exercise participants, particularly new clients who are less
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confident about their physical performance.
8. Specific Feedback: Positive reinforcement is more meaningful
when it is coupled with specific information feedback that increases
its value by becoming both an educational and motivational tool.
9. Careful Questioning: Because some participants may not volunteer information that could be useful for their program design, ask
relevant questions to ascertain how they are responding to their
exercise experiences.
10. Pre- and Post-Exercise Dialogue: It is advisable to commence
and conclude each exercise session with a couple minutes of personal communication with your clients to share relevant training information and to gain perspective on their training program perceptions.
Benefits of Purposeful Instruction
Several studies have shown that well-designed strength training
programs produce desirable psychological outcomes as well as physiological improvements.1,2,3 These beneficial changes include physical
self-concept, as well as feeling states of total mood disturbance, positive engagement, revitalization, tranquility, and physical exhaustion.
One study4 clearly demonstrated that how we teach our exercise
clients definitely influences emotional and self-concept changes that
are associated with strength training program participation. It is
therefore recommended that personal trainers examine their teaching techniques and instructional strategies to further enhance their clients’ exercise experiences
physiologically 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 muscular 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 10week resistance and cardiovascular exercise protocol on physiological 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 association and dissociation formats on resistance exercise induced emotion 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.
Coaching News (continued from page 7)
1. Start by creating a positive and appreciative dynamic. Begin each session by asking about client successes, best experiences, and new
hopes. This positive start builds the positive emotions needed to
address challenges later.
2. Allow yourself to open and broaden. Be aware of your limiting biases and assumptions about client stereotypes. Be curious about what’s
new – 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 for
change.
4. Keep the ratio of positive and negative topics above 3:1. Make sure
that 75% of your time together is focused on positive topics, asking
positive questions, providing affirmations, exploring strengths, new
possibilities, or success stories, and 25% is focused on more negative
topics such as challenges and concerns.
5. Be attentive to and build on the contributions and synergy of everyone’s strengths. Learn about your clients strengths and explore how
to leverage those strengths for greater success. One excellent tool
for identifying strengths is the Values in Action Character Strengths
Survey (www.viacharacter.org).
6. Balance authentic, open-minded inquiry and exploration with advocacy of what you believe is the best approach. Your expertise is valuable but your client may learn more from self-awareness and insight
that emerges from your carefully chosen questions and reflections.
7. Grow perspectives to something bigger than self. Support clients in
identifying how their individual changes will help them make a larger
contribution, which they value personally, to their friends, family, colleagues, and the world.
8. Allow the system to be chaotic in the moment in order to flourish
and easily absorb bumps and blows over time. Bring a belief in your
client’s resilience to bumps on his or her path and in your working
relationship. Engage the client in learning from every outcome, even
when a goal is not met, by viewing every experience as a win/learn
opportunity rather than a win/lose situation.
Watch and enjoy how the butterfly combines beauty and subtlety to
create an unexpectedly wonderful impact on your individual clients and
groups.
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.
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CLINICAL COLUMN
INTEGRATING THE EXERCISE IS MEDICINE® INITIATIVE INTO
THE ROLE OF THE CLINICAL EXERCISE PROFESSIONAL
BY JONATHAN K. EHRMAN, Ph.D., CES, FACSM
®
®
In 2007 the Exercise is Medicine (EIM ) initiative began with a stated goal of “Calling on all health care providers to assess and review every
patient’s physical activity program at every visit.” Since this time EIM®
has morphed into an international initiative with global partners and the
World Congress on Exercise is Medicine® held in conjunction with
ACSM’s Annual Meeting. Given this quick growth and strong focus on
physicians providing regular physical activity counseling several clinical
exercise professionals have asked where they might fit in and use EIM®.
While the EIM® message is appropriate and the right thing to do, a
focus on physical activity and exercise during an office visit is often times
difficult to fit into a 10 or 15 minute appointment. A recent report in
the New England Journal of Medicine1 described the daily workload of primary care physicians while seeing patients during which much of their
time is spent diagnosing, treating, ordering tests, and filling out forms.
On average, each physician in this office-based practice saw 18.1 patients
per day. For an 8 hour day this level of demand allowed 26.5 minutes
per patient appointment. However, these physicians have additional
demands responding to more than 43 phone calls and lab results reviewing 14 consultation reports, 11 imaging reports, 16 emails, and 12 prescription refills each day; thus leaving much less time, likely in the range
of 10 to 15 minutes, to see each patient. The authors of this study concluded that a radical change in the primary care physician (PCP) office
practice is needed.
Given the magnitude of work performed each day by the average
PCP one might question if it is reasonable for a physician to provide
meaningful physical activity and exercise training information to a
patient. Maybe not. However, this may provide a tremendous opportunity for the clinical exercise professional to insert himself or herself as
a resource for a physician. Most physicians will realize their shortcomings from either a time or a knowledge aspect. And with the amount of
patients with chronic diseases such as arthritis, diabetes, high blood pressure, asthma and others (see Figure), that are seen by the typical PCP,
they may recognize that some of their patients may need specialized
Figure: Proportions of clinical conditions typically addressed by primary care
physicians
assistance when designing and beginning an exercise program. This is
similar to sending a patient with heart or lung disease to a cardiac or pulmonary rehabilitation program with staff specialized in working with
these types of patients. Given this, many physicians may be more than
willing to partner with an energetic and knowledgeable clinical exercise
professional to fill the gaps of both a lack of time and a lack of knowledge and skill. But how might this be accomplished?
Someone once told me that EIM® is an opportunity for the clinical exercise professional to become similar to a pharmaceutical “rep” with respect
to interacting with physicians and selling their products. Setting up meetings with physicians and their staff could be an effective method to promote yourself and your ACSM certification. Getting a physician to understand that you have the skills to work directly with patients in developing
and implementing an exercise program would provide a physician with a
reliable resource to send their patient to for learning and implementing an
exercise training program. But how might you go about this task?
The EIM® Web site (www.exerciseismedicine.org) provides a variety
of information aimed directly at the health and fitness professional.2 The
clinical exercise professional certainly fits this description. And a portion
of the information is aimed at marketing oneself to other health care
professionals to fill the void almost certainly left by physician exercise
training counseling. These documents include “How to work with health
care providers” and a marketing document titled “Exercise is Medicine®
Health and Fitness Professionals’ Action Guide.” This latter document
provides practical information and forms to use when approaching physicians about potentially sending their patients to you or your program for
exercise training. The former document also provides constructive
information about marketing to physicians.
In closing, EIM® is an excellent initiative for the entrepreneurial clinical
exercise professional. While there is no doubt a great need for physicians to seriously discuss and encourage their patients to exercise, the
ability of each physician to informatively speak on this topic is limited.
And certainly physicians seldom have time to practically implement exercise training or to follow up regularly with the patient regarding exercise.
The clinical exercise professional is suited expertly for this type of work
and with a little initiative and salesmanship should and can provide all the
exercise 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
Source: CDC/NCHS, National Ambulatory Medical Care Service, and
National Hospital Ambulatory Medical Care Survey.
10
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.
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B
B
TEST 1
2
1
B
E
A
3
D
C
B
4
D
C
D
5
————————————————————— QUESTION —————————————————————
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References
1. Baar K, Nader G, Bodine S. Resistance exercise, muscle loading/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 crucial 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 exercise on skeletal muscle hypertrophy. Med Sci Sports Exerc. 38:19181925, 2006.
4. Dreyer HC, Drummond MJ, Pennings B, et al. Leucine-enriched essential 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 rehabilitation. 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.
earned the CES or RCEP certification and, with the exception of a temporary qualification period that permits a bachelor’s degree (e.g., grandfathering clause), a graduate degree in exercise science/physiology.
As of June 2011, there are 3,596 individuals who hold the CES credential and 853 with the RCEP. In 2010, 229 individuals earned the CES
and 38 the RCEP. Efforts are needed by more academicians to get their
programs accredited and to encourage their students who plan to work
in clinical exercise physiology to take the CES exam (bachelor’s prepared) or the RCEP exam (graduate degree). In addition, efforts are
needed by many to promote the unique knowledge and skills of individuals who hold the CES or RCEP certification and the roles they fill in
health care. These efforts fall on ACSM, CEPA, academia, and every certified professional.
Concerning the latter, as certified professionals working in health
care, we have many opportunities to advance our profession through
our interactions with colleagues, our patients, the public, the media, and
administrators and human resource professionals where we are
employed. We all play an important role in the advancement of the profession. Towards this end, I encourage you to present yourself as a certified exercise specialist/physiologist (e.g., email signatures, one-on-one
introductions), maintain your certification, be a member of CEPA, and
encourage and counsel young professionals as to the importance of
becoming certified. Together we will help to solidify the profession of
clinical exercise physiology.
A
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.
The Profession (continued from page 2)
D
Satellite cells contribute to skeletal muscle repair, regeneration, and
hypertrophy.
Supplements receiving much attention in the first half of this
decade are the antioxidants. While the intent of antioxidant supplementation was not to increase muscle size, per se, but rather to
increase skeletal muscle resistance to oxidative stress and possibly
enhance adaptation, data demonstrating a positive effect of antioxidant supplementation have been equivocal. In fact, recent work analyzing the expression of genes related to the oxidant defense system
in skeletal muscle has shown that antioxidant supplementation actually may impede gene expression that modulates adaptation to
endurance exercise.10
To summarize, resistance-type exercise that induces a significant
load on the muscle is most important in activating protein synthesis
pathways. Nutritional interventions with a combination of protein
(containing the essential amino acid leucine) and carbohydrate have
been shown to augment the traditional response to resistance training. Finally, the only safe and effective supplement on the market that
has shown benefit at both the performance and cellular level is creatine monohydrate. Nonetheless, as discussed in these three commentaries, skeletal muscle growth is polygenic (resulting from the input of
many genes) and results from a complex set of underlying genetic and
environmental modifiers. Scientists in this field should be commended for their aggressive approach in providing data to assist in our
understanding of the genetics underlying athletic performance as well
as the environmental modifiers and how they influence cell signaling.
However, this field is still in its infancy and there are significant areas
of research that have yet to be explored. Until then, the only safe and
effective mode of inducing skeletal muscle growth through manipulation of cellular signaling is proper exercise and nutrition.
Disclaimer: The opinions or assertions contained herein are the
private views of the author and are not to be construed as official or
as reflecting the views of the Army or the Department of Defense.
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: implications for skeletal muscle hypertrophy. Clin Orthop Relat Res.
2002;S178-187.
10. Ristow M, Zarse K, Oberbach A, et al. Antioxidants prevent healthpromoting 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 supplementation. 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.
E
Building Muscle (continued from page 4)
D
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WELLNESS ARTICLE
THE CLINICAL EXERCISE
PHYSIOLOGIST (CEP) AS A CERTIFIED
DIABETES EDUCATOR® (CDE®)
By Cathy Mullooly, M.S., RCEP, CDE
ABSTRACT: The Certif ied Diabetes Educator® (CDE ®) credential
was f irst of fered in 1986. This mastery credential quickly
became recognized as the “gold standard” for diabetes educators. It is managed by the National Certif ication Board for
Diabetes Educators (NCBDE), which oversees the eligibility
requirements, as well as the examination application process and
examination administration. Exercise professionals who meet
the 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 and
financial costs associated with diabetes are frequently in the headlines. Additionally, the medical guidelines to diagnose, treat, and prevent the ravages of the disease are under constant scrutiny and revision. The January–March, 2011 edition of ACSM’s Certified News contained an excellent overview of the expanding role of Clinical Exercise
Physiologists (CEPs) in providing exercise counseling to people with
type 2 diabetes. For CEPs who have people with diabetes in their
clinical care, the CDE® credential can provide another level of professional creditability and recognition as an effective member of the diabetes care team.
A unique feature of CDE® certification is that it is a multi-disciplinary
credential. Eligible health care disciplines are those that possess and
demonstrate the expertise to provide components of Diabetes SelfManagement Education (DSME). However, if you have a peer who is
one of the 17,000+ CDEs®, it is likely that they are either a Registered
Nurse or a Registered Dietitian as these disciplines make up the majority of CDEs®. Historically, it has been the rare exercise physiologist
who has sought out and successfully obtained the CDE® credential.
This probably is due to one of three reasons: 1) confusion surrounding the professional qualifications, 2) the impression that the components of DSME are outside of the CEP scope of practice, and 3) limited opportunities to function as a member of the diabetes care team.
Professional qualifications
NCBDE has offered a professional pathway for CEPs to sit for the
CDE® examination from the beginning. This pathway has undergone
several changes over time as the CEP profession matured and as the
American College of Sports Medicine (ACSM) changed its own clinical certifications requirements. Initially, the first CEP candidates were
12
required to have a master’s degree in an exercise science field and to
provide transcripts of their degree program to satisfy the CDE® discipline requirements. When the ACSM Registered Clinical Exercise
Physiologist® (RCEP®) credential was created by ACSM, it was quickly adopted by NCBDE in 2005 as satisfying the discipline requirement. However, the candidate still was required to possess a master’s degree in an exercise science program.
In 2010, NCBDE announced changes to the CEP discipline requirements that went into effect as of January 2011. CEPs who possess
either an active ACSM Clinical Exercise Specialist® (CES), or RCEP
certification satisfy the professional eligibility requirements. This eliminates the past requirement for the RCEP candidate to be master’s
prepared. This change also recognizes the CES as a qualifying credential for the first time. These changes will simplify the application
process and allow a greater number of eligible CEPs to join their
multi-disciplinary peers in achieving this credential. As CEPs, we
should be proud of the advances made over the last decade and the
professional recognition this progress has realized.
Scope of Practice
®
The CDE credential d o e s n o t expand the scope of practice for
any successful candidate. A nurse, dietitian, pharmacist, or other
health care professional still is governed by the laws and regulations
that their licensure provides them or by a job description and functions established by an employer. The CDE®, as a mastery credential,
demonstrates that the professional has clinical experience and is proficient in a specific body of knowledge. For diabetes educators, this
body of knowledge is DSME. DSME includes physical activity as part
of the body of knowledge. As an example, physical activity is highlighted as one of the healthy patient behaviors within the American
Association of Diabetes Educators (AADE7) education program
offerings.1
NCBDE’s definition of DSME is adapted from the National
Standards for Diabetes Self-Management Education which is published
by the American Diabetes Association.2 The following information is
taken from the NCBDE Web site3:
“DSME involves the person with pre-diabetes or diabetes and/or
the caregivers and the educator(s) and is defined as the ongoing
process of facilitating the knowledge, skill, and ability necessary for
self-care. It is a component of a comprehensive plan of diabetes care.
The process incorporates the needs, goals, and life experiences of the
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person with pre-diabetes or diabetes and is guided by evidence-based
standards. The overall objectives of DSME are to support informed
decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.”
The process includes:
1. An individual assessment and education plan developed collaboratively by the individual and educator(s) to direct the selection
of appropriate educational interventions and self-management
support strategies.
2. Educational interventions directed toward helping the individual
achieve self-management goals.
3. Periodic evaluations to determine the attainment of educational
objectives or need for additional interventions and future
reassessments.
4. A personalized follow-up plan developed collaboratively by the
individual and educator(s) for ongoing self-management support.
5. Documentation in the education record of the assessment and
education plan and the intervention and outcomes.
In addition, program development and administration provided in
support of the diabetes patient education program are considered
part of the DSME process.”
As you read through the description of DSME, it is easy to recognize
a framework similar to what CEPs currently provide in clinical settings.
If the clinical program also serves a large portion of people with diabetes, it may already incorporate many of the components of DSME.
However, it is import to distinguish that the CDE® credential is
designed and intended solely for health care professionals who have a
defined role as a diabetes educator. Someone who performs occasional or partial diabetes related functions in the course of their work routine does not meet this definition. For example, many clinically supervised exercise programs will have people with diabetes perform and
record their blood glucose values at the beginning and end of the workout session. If that is the extent of the process, it would not qualify as
DSME. However, a CEP with a defined role as a diabetes educator
would evaluate the glucose reading for risk of hypoglycemia or hyperglycemia during exertion, discuss a plan with the person with diabetes
to prevent these acute complications from interfering with the exercise
activity, re-assess the plan as needed, and document these actions as
part of participating in the program.
Diabetes Care team
Another component of the eligibility requirements for initial certification is accruing professional practice experience. Before applying for the
examination, both of the following requirements must be met3:
1. Minimum of two (2) years to the day of professional practice
experience in the discipline under which the individual is applying for certification.
2. Minimum of 1,000 hours of DSME experience accrued up to
four (4) years prior to submission of an application. However,
a minimum of 40% of those hours (400 hours) must be
accrued in the most recent year preceding application.
CEPs are not the only clinicians that experience limited opportunities 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 Educator
Mentorship Program.3 This program was developed in order to promote careers that will lead to a CDE® designation. Also, with a
greater number of multi-disciplinary CDEs®, access to DSME can
improve for people and families of people with diabetes.
The Diabetes Educator Mentorship Program began in January
2011. It partners experienced CDEs® with health care professionals
interested in gaining the experience needed in providing DSME.
Qualifying volunteer hours accrued under this program will assist professionals with meeting the current practice requirement for CDE®
certification. While this program will prove useful for many diabetes
educators, participation is not a mandatory requirement.
Professional Development
The final component to meet the eligibility requirements is one of
continuing education. The candidate must collect a minimum of 15
clock hours from an approved provider. The list of NCBDE approved
providers does include ACSM. These clock hours need to be applicable to diabetes and obtained within the two (2) years prior to applying for certification.
Summary
This overview was intended to raise awareness and to clarify the
requirements for CEPs interested in pursuing the CDE® credential.
As stated throughout this article, changes can occur at any time to
the process, available resources, or eligibility requirements.
Candidates need to follow and adhere to the requirements for the
year they are applying to sit for the CDE® exam. NCBDE continually posts all of the information and updates to the CDE® process so
candidates can prepare and plan as needed. You can review these
details, search for mentors in your area or use the NCBDE contact
information 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
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Surviving Cancer (continued from page 6)
to determine where your client ranks with regards to fitness and appropriate general intensity guidelines.
WHAT TYPE OF EXERCISE? Aerobic exercise is emphasized heavily in our programs. Why? Circulating oxygenated blood is the best
method we have to help the body heal itself.2 The benefits of emphasizing an aerobic based cancer rehabilitation program are: increased cardiorespiratory fitness, augmented immune system function, increased
RBC/WBC production, and possibly augmented circulation throughout
the body to aid in removing cytotoxic agents.7
Because cancer treatments also affect bone mineral density and overall muscle mass integrity, we prescribe a strength training component for
most of our clients during exercise sessions.11 Our strength training programs are based on three pillars of body function: posture, mobility, and
stability.5 For instance, a woman who has undergone chemotherapy,
radiation treatment, and surgery for breast cancer, requires comprehensive strength training to improve posture (i.e., neutral spine position),
upper body range of motion (or mobility) on both sides, stability in the
shoulder girdle, and muscular strength and endurance (possibly to help
hold a child for a prolonged period of time). Because most of our clients
are 50+ years, promoting improved posture, greater mobility of the hips
and upper body musculature, and spinal stability with neuromuscular reeducation, we see stellar results in overall enhanced movement patterns.
These improved movement patterns allow the older adult to exercise
and move/walk safely while avoiding falls and potential future orthopedic complications. It also allows our clients to engage safely in other aerobic activities.
Last, we highly suggest exercising with a partner. Why? Researchers
believe that exercising together may increase exercise compliance while
improving physical function and mental well-being.1 At our center, nutrition advice and mental health counseling also are an integral part of the
rehabilitation phase of cancer interventions.
In summary, the evidence is rather convincing that exercise should be
a critical component of all cancer rehabilitation programs. The guidelines
for cancer rehabilitation programs are defined clearly in the ACSM
roundtable guidelines for cancer survivors.7 These guidelines should be
seen as the minimum level of physical activity needed for the cancer survivor with alterations made for each individual based on their unique cancer history, current health status, and/or undulating energy levels if currently undergoing cancer treatment. Ideally, we encourage cancer survivors to engage in five days of aerobic activity per week for 30 minutes
per session at moderate-to-vigorous levels. These levels should be established by a trained exercise professional who critically understands the
distinctive health needs/fluctuations of a cancer survivor. Additionally,
most cancer survivors will benefit from a twice-a-week strength training
program designed to increase posture, mobility, and stability. Even if this
14
prescription appears rather aggressive, we have
found the diagnosis of cancer, while startling, is
often a life altering opportunity for individuals to
start and continue working towards health and
longevity.
About the Author
Riggs Klika, Ph.D., FACSM is director of the Cancer
Survivor Center. He is a clinical exercise physiologist 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 introduction. 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 postsurgical 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 oxidation and blood lactate responses. Integr Cancer Ther. 2011;10(1):6-15.
11. Winters-Stone KM, Schwartz A, Nail LM. A review of exercise interventions to improve bone health in adult cancer survivors. J Cancer Surviv.
2010;4(3):187-201.
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July – September 2011 Continuing Education Self-Tests
Credits provided by the American College of Sports Medicine • CEC Offering Expires September 30, 2012
SELF-TEST #1 (1 CEC):The following questions are
2. Benefits of regular exercise for cancer survivors
include all the following EXCEPT:
a. Improved aerobic capacity depending on health
status
1. Which of the following is an important amino acid in
b. Improved muscular strength
skeletal muscle growth?
c. Decreased depression and anxiety
a. Phenylalanine
b. Leucine
d. Increased lymphedema in breast cancer patients
c. Tyrosine
d. Valine
3. According to this article, aerobic exercise for cancer
2. True or false: Signal transduction proteins activate
patients is beneficial because
downstream sensor proteins
a. it increases cardiorespiratory fitness (and
a. True
b. False
functionality).
3. AMPK works as a(n) _______ in the cell:
b. it aids in stimulating immune system function.
a. Energy sensor
c. it increases red blood cell count.
b. Nucleic Acid
d. it may augment peripheral circulation.
c. Carbohydrate
e. All of the above
d. Forkhead transcription factor
f. None of the above
4. True or False: Antioxidant supplementation is
4. Treatment for cancer (surgery, chemo- and
important and highly effective in improving skeletal
radiotherapy) can cause all of the following problems
muscle adaptation:
EXCEPT:
a. True
b. False
a. Osteopenia
b. Sarcopenia
5. The most important component of strength training
c. Increased range of motion (ROM)
that induces cell signaling for protein synthesis is:
d. Alopecia (hair loss)
a. Muscle endurance
e. Neutropenia
b. The number of repetitions completed
f. None of the above
c. The number of exercises geared towards small
5. Loss of cardiorespiratory fitness in individuals
muscle groups
diagnosed with cancer is primarily related to
d. The load placed on the muscle
a. Anemia
b. Fatigue
c. Decreased physical
d. Sarcopenia
SELF-TEST #2 (2 CEC): The following questions are
activity during the
treatment phase
taken from “Surviving Cancer: Physical Realities”
e. Altered sleep patterns f. Nausea
published on page 7.
from “Building Muscle: Signals Induced by Exercise,
Nutrition, and Supplements” published on page 5.
2. Clinical Exercise Physiologists who possess either an
active ACSM Clinical Exercise Specialist® (CES), or
Registered Clinical Exercise Physiologist® (RCEP®)
certification satisfy the professional eligibility
requirement for the Certified Diabetes Educator
(CDE®) certification.
a. True
b. False
3. The scope of practice for a Certified Diabetes
Educator® (CDE®):
a. allows ALL diabetes educators to prescribe and
adjust insulin doses.
b. continues to follow the licensure and job
description of the candidate.
c. prohibits integrating Diabetes Self-Management
Education into program curriculums.
d. prevents diabetes educators from developing an
education plan in collaboration with the patient.
4. The eligibility requirements, examination application
process, and examination administration of the
Certified Diabetes Educator® (CDE®) certification are
managed by the
a. American Diabetes Association (ADA).
b. American College of Sports Medicine (ACSM).
c. American Association of Diabetes Educators
(AADE).
d. National Certification Board for Diabetes
Educators (NCBDE).
5. The professional practice experience requirement for
initial Certified Diabetes Educator (CDE®)
certification includes
1. According ACSM’s Roundtable on Exercise Guidelines
SELF-TEST #3 (1 CEC): The following questions are
for Cancer Survivors, cancer survivors in the
a. mandatory employment as a full-time diabetes
taken from “The Clinical Exercise Physiologist (CEP) as a
rehabilitation phase should:
educator for five (5) years.
Certified Diabetes Educator® (CDE®)” published on page
a. Strive for 150 min of moderate-intensity
b. mandatory participation in the Diabetes Educator
14.
exercise/week
Mentorship Program.
1. The Certified Diabetes Educator® (CDE®) certification
b. Strive 75 minutes of vigorous-intensity
c. a minimum of two (2) years, 1,000 hours and 0
is
exercise/week
hours of continuing education.
a. not an option for the Clinical Exercise Physiologist.
c. Strive 2-3 weekly strength session that includes
d. a minimum of two (2) years, 1,000 hours and 15
exercises for major muscle groups
hours of continuing education.
b. required to provide Diabetes Self-Management
Education.
d. Participate in stretching sessions on days that
other exercises are performed.
c. available only to Registered Nurses and Registered
Dietitians.
e. All of the above
d. a mastery credential available to multi-disciplinary
f. None of the above
candidates.
ACSM’S
CERTIFIED
NEWS®
To receive credit, circle the best answer for each question, check your answers against the answer key on page 13,
and mail this entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine,
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July–September 2011 Issue EXPIRATION DATE: 9/30/12• SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED • Federal Tax ID number 23-6390952
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CONTRIBUTE TO ACSM'S CERTIFIED NEWS AND EARN VALUABLE BENEFITS
Readers of the American College of Sports Medicine’s (ACSM)
Certif ied News can make significant contributions for students and
exercise professionals while earning valuable benefits.
The purpose of ACSM’s Certif ied News is to provide continuing
education material to the certified exercise and health professional and
inform these individuals about activities of ACSM and their profession.
All materials submitted to and subsequently published in ACSM’s
Certif ied News have been carefully reviewed by an editorial board
comprised of content experts from a number of disciplines from within
the exercise sciences. Articles appearing in ACSM’s Certif ied News
include health and wellness, clinical, wellness features, clinical features,
and a number of ongoing columns. ACSM’s Certif ied News readers
receive helpful information, which they can immediately apply in their
practice as exercise professionals. They also can earn up to four (4) continuing education credits (CECs) per quarterly issue by taking and passing continuing education quizzes appearing in each issue of ACSM’s
Certif ied News . This is particularly important for those who hold
ACSM certifications in either the health and fitness or clinical tracks.
Authors can earn 10 CECs per article appearing in ACSM’s
Certif ied News . Professionals who teach in academic institutions can
provide mentorship to their students by co-authoring articles with them
in ACSM’s Certif ied News . Students can develop good professional
writing skills while sharing useful information with other exercise professionals. Those interested in submitting articles to ACSM’s Certif ied
By Peter Ronai, M.S., FACSM, RCEP, CES, PD, CSCS-D
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 content
experts to serve as reviewers on the editorial board. Terms are for a
two (2) year commitment. Members of the editorial board help enhance
the quality of all articles and their value to readers of ACSM’s Certif ied
News . They can receive “service points” toward earning recognition as
a Fellow of the American College of Sports Medicine.
Professionals can earn ACSM Fellowship service points by contributing to ACSM’s Certif ied News in the following ways:
• Publishing one or more articles in ACSM’s Certif ied News : 1
ACSM Service Point
• Serving a full, two-year term on the Editorial Board: 2 ACSM
Service Points
• Serving a full, two-year term as a co-editor of ACSM’s Certif ied
News : 2 ACSM Service Points
Those professionals interested in serving on the editorial board
should contact the co-editors, Peter Ronai ([email protected])
and Peter Magyari ([email protected]).