ACSM’S CERTIFIED
NEWS
S E C O N D
Q U A R T E R
2 0 1 4
•
V O L U M E
2 4 :
I S S U E
2
The Exercise is Medicine
Professional Credential:
A Trusted Community-based
Resource for Health Care
®
Page 2
Issues for Clinical Exercise
Physiologists Part I: Resistive
Exercise Testing in Pulmonary
Rehabilitation
Page 3
Part 2: Suggested Lifestyle
Interventions for Sarcopenic
Obesity
Page 4
Circuit Strength Training
Page 6
Coaching News
The Gallon Jug Shelf Test:
An Assessment of Moderately
Heavy Object Transfer
Page 9
Online Tips and Tools for
Exercise Professionals
Page 10
Thinkstock Images/Stockbyte/Thinkstock
Page 8
ACSM’S CERTIFIED NEWS
Second Quarter 2014 • Volume 24, Issue 2
In This Issue
The Exercise is Medicine® Professional Credential
A Trusted Community-based Resource for Health Care........2
Issues for Clinical Exercise Physiologists Part I: Resistive
Exercise Testing in Pulmonary Rehabilitation......................3
Part 2: Suggested Lifestyle Interventions for
Sarcopenic Obesity.....................................................4
Circuit Strength Training..................................................6
Coaching News...........................................................8
The Gallon Jug Shelf Test: An Assessment of
Moderately Heavy Object Transfer..................................9
The Exercise is Medicine Professional Credential
®
A trusted communitybased resource for
health care
Online Tips and Tools for Exercise Professionals.................10
Co-Editors
Peter Magyari, Ph.D.
Peter Ronai, M.S., FACSM
Committee on Certification
and Registry Boards Chair
William Simpson, Ph.D., FACSM
CCRB Publications Subcommittee Chair
Gregory Dwyer, Ph.D., FACSM
ACSM National Center Certified News Staff
National Director of Certification
and Registry Programs
Richard Cotton
Assistant Director of Certification
Traci Sue Rush
Certification Coordinator
Kela Webster
Publications Manager
David Brewer
Editorial Services
Lori Tish
Barbara Bennett
Editorial Board
Chris Berger, Ph.D., CSCS
Clinton Brawner, M.S., FACSM
James Churilla, Ph.D., MPH, 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.
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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Correspondence Regarding Editorial Content
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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,
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ACSM’s Certified News is not necessarily the position of
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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 ACSM’s Guidelines for Exercise Testing and
Prescription or the established positions of ACSM. ACSM’s
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E
xercise is Medicine® (EIM) is a global health initiative to establish physical activity as a standard in health care. Launched in 2007 as a joint effort by ACSM and
the American Medical Association, EIM has evolved to a boots-on-the-ground
initiative. Leading the way are fitness professionals who seek to elevate their careers by
positively impacting the health of those who lack physical activity and require chronic
disease prevention and management. These professionals are the credentialed EIM professionals.
More at-risk individuals are entering the health care system who are sedentary, obese, and
suffer with chronic diseases. In response, health care is adopting the Population Health
Management (PHM) care model to identify at-risk individuals into population groups.
PHM is a proactive application of strategies and interventions to defined at-risk population groups in an effort to improve the health of the individuals within the group. EIM
professionals fill the role of applying engagement strategies for participation in physical
activity (PA) intervention programs.
The credentialing process includes EIM study materials on the EIM solution for health
care, behavioral modification strategies, and chronic condition management. The study
materials are available online and also are accessible through onsite workshops. The exam
for credentialing is available through PearsonVUE testing centers and can be proctored
at convenient locations across the country.
After credentialing, EIM professionals working within the EIM Solution will be trained
to receive health care referrals, maintain engagement, and deliver PA intervention programs. Structured physical activity, health education, and lifestyle behavioral change
strategies are delivered as “move and learn” sessions designed to address population-specific barriers with credible engagement strategies for retention.
EIM professionals are building a bridge of trust between clinical health care and nonclinical health care resources in the community. This trust building provides referrals
to EIM professionals from health care potentially at every level: providers, payers, and
community outreach. This means that patients, employees, eligibles, beneficiaries, and
underserved community residents can be referred to EIM professionals.
For more information about the prerequisites and procedures to become a trusted community-based resource for health care as a credentialed EIM professional, go to:
acsmcertification.org/exercise-is-medicine-credential
Phil Trotter, Exercise is Medicine®
Community Solution Development
Email: ptrotter@acsm.org
ACSM National Center
401 West Michigan St.,
Indianapolis, IN
46202-3233
Tel.: (317) 637-9200 • Fax: (317) 634-7817
©2014 American College of Sports Medicine.
ISSN # 1056-9677
2
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
Clinical Article
ISSUES FOR CLINICAL EXERCISE PHYSIOLOGISTS
PART I: RESISTIVE EXERCISE TESTING IN
PULMONARY REHABILITATION
By Dave Verrill, MS, RCEP, PD, CES, FAACVPR
(This is the first in a two-part series of resistive exercise testing and
training in pulmonary rehabilitation).
Introduction
C
hronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death in the United
States and projected to be the third leading cause of
death by 20201. Participation in pulmonary rehabilitation (PR)
is essential for patients with chronic lung disease to help them
perform their activities of daily living (ADLs) most effectively
and improve their overall quality of life (QOL)1-4. Developing
and maintaining overall body muscular strength and endurance
is critical for the pulmonary patient due to the muscle atrophy
and weakness that often accompany both COPD and restrictive lung disease. The Joint ACCP/AACVPR Evidence Based
Clinical Guidelines4 state that the addition of a strength training
component in PR increases both muscular strength and muscle
mass with a strength of evidence rating of 1A (high). The ever-increasing pool of research in this area shows multiple benefits
for the pulmonary patient following resistive exercise training
(RET). Studies now show that even heavier or more vigorous
resistive exercise is safe and produces positive outcomes in pulmonary patients up to 80 years of age5. Thus, every PR program
should incorporate some form of formal resistive exercise training
for its patients with chronic lung disease. The clinical exercise
physiologist (CEP) in PR must be able to design, develop, and
supervise the resistive exercise component with documentation
of individual strength improvements over time for exercise prescription modifications and patient outcomes6.
While studies have shown that RET is highly beneficial for the
pulmonary patient, many PR programs do not offer a structured
resistive training period devoted solely to this modality. This is
often due to the time limitations of PR sessions (typically 50 to
70 minutes) or the lack of funds for purchase of resistive exercise
equipment. Practitioners in PR also may be concerned about potential medical complications that could occur with RET. The
major focus of PR has traditionally been aerobic exercise training,
breathing retraining, patient education, and relaxation training.
Thus, with all of these necessary pulmonary interventions, RET
often gets put on the “back burner” in the PR session. Nevertheless, with the advent of recent RET studies that show this form
of exercise to be both safe and highly beneficial for the pulmonary patient, it is now more important than ever for the CEP to
develop and incorporate structured RET protocols into their PR
policies and procedures for daily program operation.
Musculoskeletal Changes Associated
With Lung Disease
Chronic lung disease causes dramatic and detrimental deterioration to human skeletal muscle tissue. Muscle atrophy and
weakness resulting from prolonged hypoxia and/or hypercapnia
may decrease myofibrillar mass, mitochondrial density, and muscle fiber capillarization. The end-result of this disease-induced
myopathy often includes the following adverse side-effects: 1,4,5,7
• impaired exercise tolerance
• peripheral muscular atrophy
• weakened thoracic muscles that impair breathing ability
• a decrease in Type I (fatigue resistant) muscle fibers
• altered muscle enzyme levels
• muscle tendon rupture
• muscle tears and strains
Steroid-induced myopathy and bone degeneration are also
common in the pulmonary patient, as the patient is often prescribed steroidal medications to help reduce lung inflammation
for extended periods of time. This type of therapy may further
exacerbate any of the above conditions, as well as decrease the patient’s overall energy expenditure, basal metabolic rate, muscular
strength, bone density, breathing abilities, and daily activity levels.
Risk of falls and becoming injured from these adverse changes
often leads to sedentary living and further disability for the pulmonary patient. Thus, it is up to the CEP to incorporate specific
strength training regimens that are individualized for their patients, based upon individual needs, to help alleviate this chronic
vicious cycle of muscle and bone degeneration and disability.
Research Findings on the Effects of Resistive
Exercise Training in COPD
While many recent investigations have conducted whole-body
resistive training protocols in patients with COPD, much more
research needs to be conducted in both men and women with
varying types of chronic lung diseases. Current findings show
that resistive training protocols using both free and machine
weights can increase the pulmonary patient’s upper and lower
body strength from 8% to 140%7-13, ADLs4,11, and QOL7. A
mild improvement in cardiovascular endurance also has been observed with research protocols that combine resistive exercise with
lower body aerobic training10,12,13. The aforementioned resistive
training studies (and similar investigations) have not presented or discussed any significant cardiopulmonary or orthopedic
complications within experimental study groups, thus providing
further evidence that resistive exercise training is indeed a very
safe modality in PR programs if performed correctly under the
Resistive Exercise Testing (continued on page 11)
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
3
Clinical Feature
Part 2: Suggested Lifestyle
Interventions for Sarcopenic Obesity
By Elizabeth O’Neill and Richard Wood
I. Introduction
A
s exercise science professionals, it is important that we
are familiar with the challenges associated with aging.
As presented in Sarcopenic Obesity Part 1: Definitions
and Consequences, sarcopenic obesity was identified as a complex
condition involving the age-related changes in body composition:
increases in fat mass with a concomitant loss of muscle mass26.
Evidence and concern are mounting regarding sarcopenic obesity and its associated complications: decreased muscle quality,
functional limitations, and increased inflammation. Thus, as sarcopenic obesity threatens the health and functional ability of
older adults, there is a need for evidence-based interventions and
recommendations for treatment. This second and final article is
designed to examine the challenges in treating sarcopenic obesity
and the potential lifestyle interventions that can address the consequences of sarcopenic obesity.
II. Challenges Associated with Treatment
Approximately 32% of people age 65 and older are classified as
obese, utilizing Body Mass Index (BMI) criterion2. The typical
course of action for treating obesity involves weight-loss therapy.
However, traditional methods of inducing weight loss in older
adults also may increase the loss of muscle mass and increase
frailty. This approach is counterproductive when trying to avoid
exacerbating sarcopenia. Therefore, treating sarcopenic obesity
becomes more complex than trying to treat each condition independent of the other. Suggested lifestyle interventions must not
only address weight loss, but also must function to maintain or
even increase muscle mass in order to reduce sarcopenic processes. The following section contains three sub-sections: nutritional
recommendations, diet and exercise interventions, and exercise
considerations.
III. Lifestyle Interventions
Nutritional Recommendations
The loss of muscle mass associated with aging (sarcopenia) is of
concern due to the subsequent consequences to functional ability and poor muscle quality. While many factors are thought to
contribute to sarcopenia, insufficient protein intake is frequently
recognized as an important variable4,8. The Institute of Medicine’s Food and Nutrition Board established the recommended
dietary allowances (RDA) for protein (0.8g/kg/day) based on
nitrogen balance studies utilizing younger populations14-15. Some
researchers suggest that the nitrogen balance studies and subsequent RDA for protein may not accurately reflect the need for
muscle preservation with aging and, therefore, may be inadequate
for older adults4,8,18.
Some of the most convincing findings regarding protein requirements for older adults have been documented in longitudinal
studies. These studies have consistently found significant asso-
4
ciations between protein consumption and maintenance of lean
mass. The Health ABC study examined the protein intakes of
community-dwelling older adults (n = 2066; ages 70-79)8. Subjects in the higher quintile of protein intake (1.1g/kg/day) lost
43% less total lean mass and 39% less appendicular lean mass
(aLM) compared to subjects in the lowest quintile for protein
intake (0.7g/kg/day) over the period of 3 years. Meng et al.11
and Scott et al.18 found similar results to The Health ABC study.
Meng et al. determined whole body lean mass, aLM, and upper
arm muscle mass area were maintained better by subjects (n =
862 females; 75 + 3 yoa) in the highest tertile of protein intake
over a 5-year period. Additionally, protein was found to have the
strongest relationship to whole body lean mass compared to other
macronutrients (fat or carbohydrate). Scott also reported a positive association between protein intake and aLM in older adults
(n = 740; 62 + 7 yoa). Subjects failing to meet the recommended
dietary intake for protein at baseline (12%) and at the follow-up
(14%) had significantly lower aLM. Scott concluded that protein
intake was a positive predictor of aLM changes over the course
of the 2.6-year study and suggested that age-associated loss of
muscle may be reduced with higher protein intake.
These and other studies have led researchers to suggest that higher protein RDA ranging between 1.0 and 1.5 g/kg may be more
appropriate to address sarcopenia13. Additional guidelines have
been proposed regarding the amount of protein per meal to optimize anabolic efficiency. Symons et al.19 examined the protein
synthesis when manipulating the amount of protein consumed
(30g versus 90g) in a single serving. The 30g serving was found
to be as effective for protein synthesis as was the 90g serving.
Thus, Paddon-Jones and Rasmussen suggest that consumption
of high-quality protein equaling 25g to 30g per meal should be
utilized to optimize protein synthesis15.
Diet and Exercise
Several weight-loss studies have been conducted utilizing an
older adult population, which has helped provide practitioners
insight regarding the most effective interventions for addressing
sarcopenic obesity. Most of these studies incorporate caloric restriction, exercise, or caloric restriction combined with exercise
in an effort to induce weight loss. These studies and others have
helped characterize the complex nature of sarcopenic obesity
treatment.
In an attempt to examine body composition and functional
changes in obese older adults, Villareal et al.20 randomized subjects into two groups: control group (n = 10) or treatment group
(n = 17). The treatment group was directed to follow a balanced
diet (30% fat, 50% carbohydrate, 20% protein) with an energy deficiency of 750 kcal/d and completed a 90 min exercise program
(15 min warm-up, 30 min endurance exercise, 30 min strength
training, 15 min balance exercises) three times per week for 26
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
weeks. While the control group maintained their body weight,
the treatment group lost on average 8.2 kg, with significant losses
occurring in fat mass. Fat-free mass, however, was maintained at
a similar level to the control group.
Frimel et al.5 utilized a similar study design as Villareal20; however, comparisons were made between a dietary-only group (n
= 15) and a diet-plus-exercise group (n = 15) after a 6-month
intervention with older adults (70 + 5 years old). Similar losses
were seen in both groups for body weight and fat mass; however,
the diet-plus-exercise group did not lose as much fat-free mass
as the diet-only group. Subsequent to these two studies, Villareal
et al.21 added an exercise-only condition, utilizing a very similar
design as the previous two studies and creating four comparisons:
control (n = 27), diet (n = 26), diet plus exercise (n = 28), and
exercise (n = 26). The intervention length for this study, however,
was 12 months. Both the diet and diet-plus-exercise groups had
significant losses of body weight and fat mass. However, the diet
group had greater decreases in lean body mass as compared to the
diet-plus-exercise group. The exercise group was the only group
to see increases in lean body mass.
Wood et al.24 compared changes in fat-free mass for a low-fat diet
(LFD; < 30% of energy from fat; energy intake goal of 1800kcal/
day) versus a carbohydrate-restricted diet (CRD; < 50g of carbohydrates per day; energy consumption ad libitum) with and
without progressive resistance training. The study was conducted
over a 12-week period with a supervised whole-body resistance
training program being completed three times per week by those
subjects randomized into one of the two diet (LFD or CRD)
and resistance training groups. Subjects in the LFD group without exercise had the greatest loss of fat-free mass compared to
all groups. The outcomes of this study are similar to those of
Layman et al.10 and provide some evidence that diets based on
carbohydrate restriction should be further examined as an alternative to traditionally used diets based on fat restriction.
Miller et al.12 conducted a systematic review examining randomized, controlled trials designed to measure body composition
changes during weight loss. All studies examined contained both
diet-only and diet-and-exercise groups. Notable to the current article, participants in the studies were not always older adults and
what percentage of them were sarcopenic is unknown. It appears
that adding exercise to energy restriction will likely not enhance
overall weight loss, but will play a critical role in maintaining fatfree mass. Both aerobic and resistance exercise programs appear
to preserve fat-free mass similarly, but future research is needed
to examine resistance training programs with a higher intensity
and a higher volume.
The outcomes demonstrated by these studies and similar studies
point to the conclusion that we must be mindful of the impact
caloric restriction alone can have on body composition changes in
older adults. In order to address both the need for reducing body
weight and fat mass, as well as preserving or increasing muscle
mass, a combined approach of diet and exercise may be most
prudent. Additionally, the type of dietary manipulation may be
a critical factor for optimizing the impact of a diet and exercise
intervention to preserve lean mass.
Exercise Considerations
Exercise modalities should be selected to counter the physiologi-
cal effect of sarcopenic obesity on skeletal muscle and to optimize
functional ability. Optimally, exercise should assist in reducing
body fat while maintaining or improving lean mass, help prevent
reductions in strength and power, and reduce inflammation. For
combating sarcopenic obesity, the literature points to combining
both aerobic training and resistance training modalities to target
the condition in a multifaceted approach.
While resistance training has shown the potential to reduce fat
mass, the ACSM Position Stand “Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of
Weight Regain for Adults” concluded that resistance training is
not likely to cause weight loss1. Willis et al.23 argue that most
studies that found resistance training to alter fat mass compared
resistance training to control populations. In the recent “Studies
of Targeted Risk Reduction Intervention through Defined Exercise-Aerobic and Resistance Training” (STRRIDE-AT/RT)
study, Willis and colleagues attempted to determine which mode
of training was most beneficial to reducing fat mass and positively impacting lean mass, utilizing overweight or obese adults.
Subjects were randomized into one of three training groups:
resistance training (RT; n = 44), aerobic training (AT; n = 38),
and aerobic + resistance training (AT/RT; n = 37). The AT and
AT/RT groups had significant losses in fat mass, body weight,
and waist circumference. The RT group did not see any significant changes in body fat, weight loss, or waist circumference.
However, the RT group and the AT/RT group had significant
improvements in lean body mass and thigh muscle area, while
the AT group did not. Willis indicated aerobic exercise, not resistance exercise, was the critical factor for generating body fat and
weight loss. However, combining aerobic and resistance training
may provide the most appropriate means by which to induce reductions in body weight and fat mass to address obesity, while
still improving lean mass that is so critical for sarcopenia.
The loss of skeletal muscle mass with age is associated with a
decline in muscle strength and power. Progressive resistance
training has been found to be effective at improving strength
in older adults. However, in a systematic review by Latham et
al.9, interventions incorporating standard progressive resistance
training (PRT) protocols found less consistent improvements
in functional assessment scores. Activities of daily living (ADL)
and functional assessments are thought to rely more heavily on
muscular power7. With sarcopenia, power appears to decline
more rapidly than strength, due to the greater loss of fast-twitch
fibers22. Therefore, power or high velocity training may be a modality that warrants consideration with older adults.
Researchers have compared the benefits of high-velocity (power) training versus traditional resistance training for improving
power and functional ability. Bottaro et al.3 examined the difference in strength, power, and functional fitness (Rikli and Jones
Functional Fitness Test) in older adults (60 to 76 years old) who
completed either a 10-week strength (TST) or power (PT) based
training program 2 days per week. The resistance exercises and
work output were kept consistent between groups, with three sets
of 8 to 10 repetitions at increasing intensity (40% 1 RM week
1 and 2; 50% 1 RM week 3 and 4; 60% 1 RM weeks 5-10).
However, the power training (PT) group was to complete the
concentric portion of the movements as fast as possible with a 2
Suggested Lifestyle Interventions (continued on page 7)
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
5
Health & Fitness Column
Circuit Strength Training
By Wayne L. Westcott, Ph. D.
diovascular adaptations (aerobic conditioning). Research clearly
indicates that circuit strength training provides effective exercise
protocols for improving both muscular strength and cardiovascular endurance.
Beginning in the late 1970s, Larry Gettman and his colleagues
conducted considerable research on circuit strength training. One
of their first studies compared a circuit strength training program
with a standard strength training program2. In this study, the
standard strength training program produced greater strength
gains than the circuit strength training program (+30% vs. +20%).
However, both training protocols produced equal increases in
lean weight (+2%) and equal decreases in fat weight (-2%). Additionally, the circuit strength training participants experienced
a 10% improvement in aerobic capacity (
) compared to no
significant change for the standard strength training participants.
C
Wavebreak Media Ltd/ Wavebreak Media/Thinkstock
ircuit strength training provides productive resistance
exercise protocols for experiencing time-efficient workouts that enhance muscular strength and cardiovascular
endurance. Both circuit strength training and standard strength
training typically involve about 10 to 15 exercises that cumulatively address the major muscle groups. The American College
of Sports Medicine recommendations call for 2 to 4 sets of resistance exercise for each major muscle group in a standard strength
training program (page 182)1. Training in this manner is highly
effective, but requires varying amounts of recovery time (generally 2 to 3 minutes – page 182)1 between successive exercises or sets
for the same muscle groups.
On the other hand, circuit strength training requires a single set
of each exercise, with the exercises sequenced to work different
muscle groups. For example, in the sample circuit training program presented in Table 1, successive exercises address different
(fresh) muscle groups and therefore can be performed with minimal transition time between work stations.
Consistent with this protocol, circuit strength training has been
defined as “a conditioning program in which you perform one set
of exercise for a given muscle group (e.g., quadriceps) followed
closely by one set of exercise for a different muscle group (e.g.,
hamstrings), and so on for all of the major muscle groups, typically 10 to 15 different exercises in close succession”11. While one
circuit of 10 to 15 resistance exercises provides a relatively comprehensive strength training session, a higher volume workout
may be attained by repeating the circuit a second or third time. In
this manner, two or three sets of each exercise can be completed
without the rest periods required for doing successive sets of the
same exercise.
Although each set of resistance exercise is completed within 30
to 60 seconds to stimulate muscular development (anaerobic conditioning), performing 15 to 30 minutes of relatively continuous
circuit strength training activity also may elicit beneficial car-
6
Table 1: Sample Circuit Strength Training Program
Work Station
Exercise
Major Muscle Groups
Leg Extension
Leg Curl
Chest Press
Seated Row
Hip Adduction
Hip Abduction
Shoulder Press
Lat Pulldown
Low Back Extension
Abdominal Curl
Quadriceps
Hamstrings
Pectoralis Major, Triceps
Latissimus Dorsi, Biceps
Hip Adductors
Hip Abductors
Deltoids, Triceps
Latissimus Dorsi, Biceps
Erector Spinae
Rectus Abdominis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
A follow-up study by Gettman and his associates compared a
circuit strength training program (3 circuits of 10 exercises at
30 seconds each) with a combined circuit strength training and
running program (3 circuits of 10 exercises at 30 seconds each alternated with 30 seconds of running on an adjacent indoor track)3.
The circuit strength training group exercised for 22.5 minutes
per session and attained a 17% increase in muscle strength, a 3%
decrease in percent body fat, and a 12% improvement in aerobic capacity (
). The circuit strength training and running
group exercised for 30 minutes per session and attained a 22.5%
increase in muscle strength, a 3.6% decrease in percent body fat,
and a 17% improvement in aerobic capacity. Statistically, both of
these circuit strength training programs produced similar results.
A 1987 study by Harris and Holly6 showed that circuit strength
training (3 circuits of 9 exercises at 45 seconds each) produced
significant increases in muscle strength (+32.5%), lean weight
(+2.2%), and aerobic capacity (+7.8%). This program, conducted
with borderline hypertensive subjects, also resulted in a significant reduction in resting diastolic blood pressure (-4.7%).
Research by Messier and Dill10 compared a running program (30
minutes, 3 days/week), a standard strength training program (50
minutes, 3 days/week), and a circuit strength training program
(20 minutes, 3 days/week). After 10 weeks of training, the mean
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
increase in exercise resistance was 23% for the standard strength
training group and 38% for the circuit strength training group.
With respect to aerobic capacity, both the running group, and
the circuit strength training group had similar and significant
improvements in
(11.7% and 10.8%, respectively). The
authors concluded that circuit strength training was as effective
as standard strength training for increasing muscle strength, and
as effective as running for increasing aerobic capacity.
More recently, Westcott and associates12 conducted a comparison study between the standard Air Force conditioning program,
(60 minutes of aerobic activity) and a combined circuit strength
training and cycling program (1 circuit of 10 exercises at 60 seconds each, alternated with 60 seconds of stationary cycling) for
improving fitness test scores in poorly conditioned Air Force personnel. Participants in the combined circuit strength training and
cycling program achieved significantly greater improvements in
all of the Air Force fitness assessment measures (1.5 mile run
time, push-ups, abdominal crunches, waist girth, and total fitness
score) than participants in the standard conditioning program.
Based on these and other studies, 3 to 4 months of circuit
strength training has been shown to concurrently increase muscular strength and cardiovascular endurance2, 3, 6, 9,10, reduce resting
blood pressure6, lower total cholesterol8, improve body composition2, 3, 6, 9, 10, and increase post-exercise oxygen consumption4.
Circuit strength training also has elicited beneficial physiological adaptations in patients with metabolic syndrome7 and heart
disease5, 9.
Therefore, it appears that circuit strength training (alone or in
combination with aerobic activity) offers effective and timeefficient exercise protocols for improving muscular strength,
cardiovascular endurance, body composition, and other health/
fitness parameters such as resting blood pressure and total blood
cholesterol. There are no specific requirements for designing
circuit strength training programs, but the protocols should generally include 10 to 15 exercises that address the major muscle
groups, with relatively brief transition times between exercise
stations. Training durations are typically between 30 and 60 seconds per exercise, and 15 to 30 minutes per session.
About the Author
Wayne L. Westcott, Ph.D., teaches exercise science and conducts fitness research at
Quincy College in Quincy, Massachusetts.
He is an active member of the New England
Chapter of the American College of Sports
Medicine.
References
References available at acsmcertification.org/cn-Q2-2014
Suggested Lifestyle Interventions (continued from page 5)
to 3 sec. eccentric phase. The traditional strength training (TST)
group had matching concentric and eccentric phases of 2 to 3 sec.
Significantly greater improvements were seen in functional performance. Arm curl improved 50% versus 3%, 8-Ft up-and-go
improved 15% versus 0.8%, and 30-s chair stand improved 43%
versus 6% for the PT and TST groups respectively. Although
muscular strength gains were similar between these groups, muscular power improved significantly more in the PT group than in
the TST group. While this and other studies demonstrate the potential benefits of power/high-velocity training with older adults,
researchers need to provide practitioners with more information
regarding safety and effective implementation to reduce the risk
of injury.
ronutrient distribution to aid in the preservation of lean mass.
Additionally, there is evidence to suggest that a variety of modes
of exercise are necessary to target the diverse health challenges
associated with sarcopenic obesity. Although additional research
is still needed, a balanced exercise program incorporating aerobic,
strength, and potentially power training may be most prudent to
generate weight and fat-mass losses while also helping to maintain or reduce inflammatory markers, and minimize declines in
muscle mass, strength, power, and functional ability. Thus, an
appropriate diet, as well as balanced exercise prescription, has the
potential to reduce sarcopenic obesity and its associated health
issues.
Inflammation has been recognized as a potential factor mediating the loss of skeletal muscle, which subsequently can impact
strength and power. Both aerobic and resistance exercise have
been found to have a positive impact on reducing inflammatory
markers in older adults6,25. Additionally, as caloric expenditure
increases, inflammatory markers have been found to decline6,17.
Reducing the loss of skeletal muscle through exercise-induced
regulation of inflammatory markers can potentially help prevent
strength and power losses observed with sarcopenic obesity.
Elizabeth O’Neill, DPE, M.S., is an associate professor
of Exercise Science and the program director for the
undergraduate Applied Exercise Science program at
Springfield College in Springfield, MA. She has served
as the Massachusetts state representative for the New
England Chapter of the American College of Sports
Medicine for the past year.
Conclusion
With the increasing demographic of the older adult population,
sarcopenic obesity has become an important health concern.
Practitioners must consider the complexity of sarcopenic obesity
when trying to develop treatment plans. According to the literature, it appears that the older adult can benefit from higher protein
intake and, potentially, from modification of the traditional mac-
About the Authors
Richard J. Wood, Ph.D., M.S., is an associate professor of Exercise Science at Springfield College in
Springfield, Massachusetts. He also serves as director
of the Center for Wellness Education and Research at
Springfield College, which promotes physical activity
and good nutrition for school-aged children and their
families.
References
References available at acsmcertification.org/cn-Q2-2014
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
7
Coaching News
By Margaret Moore (Coach Meg), MBA
Clients Response to Health Coaching: Health coaching has
received high marks from our clients in engaging employees and
improving health outcomes. These ingredients make for success
within CHS. We have placed health coaches at various clinics
and are showing positive return on investment for clients offering
health coaching services.
Coaching is Catching Other Clinicians’ Interest: Our clinic
staffs have noticed the benefits of adding health coaching to the
mix of services provided by our onsite clinics. One PA in particular mentioned that health coaching changes the atmosphere of
the clinics to the point that she wondered why she wasn’t taught
coaching as a part of her curriculum at medical school. She is
now talking to her physician about it because she sees daily how
coaching engages both patients and clinicians alike.
BlueMoon Stock/BlueMoon Stock/Thinkstock
This article shares two stories of health and wellness coaches making a
difference in a variety of settings and demonstrates the growing career
opportunities for well-trained health and wellness coaches.
CHS Health Services: Putting
Wellness Coaches to Work
Debra Reid CWC
Who We Are: CHS Health Services, Inc. (CHS) is a health and
wellness organization with employer-dedicated onsite health
centers designed to provide meaningful, effective, and higher
quality health care to employees and their dependents across the
country. We build and staff health clinics on large company campuses based on the staffing model the client desires. We might
place nurse practitioners, registered nurses, registered dietitians,
physician assistants, physicians, and health coaches at their site.
Our health coaches are any one of these experts and can also be
fitness specialists. For the last five years, we have worked with
a partner to provide health and wellness coach training for our
coaching staff. When we hire new coaches, we let them know
that they will be required to go through our preferred training
and certification program in order to maintain their employment
with us. We use the organization’s model as the foundation for
training and blend that together with our CHS Health Services,
Inc. methodology, protocol, and philosophy to provide the most
comprehensive training program possible.
8
Utilizing Coaching to Reach Beyond the Episodic Visit:
Through our health management and wellness coaching
programs, we provide health management education, personalized health coaching, and coordinate patients’ medical care and
referrals, all from one location. Even if someone comes into our
clinic for an episodic visit, we provide coaching and information
to ensure he or she gets the best possible care, and we address any
other health concerns he or she has. Improving a patient’s health
means changing behavior, and we know that health coaching is
the catalyst to that change.
The Value of Wellness Coaching
at Hilton Head Health
Jeffrey Ford
Who We Are: Hilton Head Health was founded in 1976 as a
4-week weight-loss spa retreat center. Over the past 30 years,
the center has evolved so guests are able to stay and participate
in our Healthy Lifestyle™ program for up to 3 months. They
can be submerged in the triad of health — fitness, nutrition, and
SELF (Stress management, Empowerment, Longevity, Fulfillment). We offer a 1,200 to 1,500 calorie per day meal plan in
which guests eat six meals throughout the day. We provide daily
educational lectures on fitness, nutrition, emotional eating, and
personal responsibility. Throughout the day we offer a variety
of fitness classes; we offer six to seven chances to participate in
flexibility, strength training, and cardio classes. We also offer a
variety of recreational activities, such as kayaking, biking, paddle
boarding, and more. Finally, cooking demonstrations and handson classes teach our guests how to cook quick, healthy meals to
prepare them for their return home. Our schedule is designed for
guests to experience an entire week engulfed in making balanced,
healthy changes in their lives, while still having a good time.
Coaching News (continued on page 13)
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
Health & Fitness Feature
THE GALLON JUG SHELF TEST: AN
ASSESSMENT OF MODERATELY HEAVY
OBJECT TRANSFER
By Joseph F. Signorile, Ph.D.
Through needs assessments (or diagnoses, as they may be
termed, using the medical model), the recent American College
of Sports Medicine’s Exercise is Medicine® initiative has increased the awareness that true exercise prescription should be
preceded by a testing battery that allows training to be provided
in a targeted and structured, pattern to most effectively address
individuals’ specific needs. Unfortunately, all diagnostic methods
have shortcomings associated with their administration and interpretation. In the case of object transfer tasks, two confluent
problems confound the process. The first is the confusion that
persists between measures of physical performance and measures
of daily activities, the lines of which are admittedly somewhat
blurred. The second is the failure to apply the theory of biomechanical specificity to the assessment methods8.
Table 1: Basic and Instrumental Activities of Daily Living
Instrumental
Basic Activities Instrumental Activities Activities of Daily
of Daily Living10 of Daily Living5
Living (AOTA)7
Figure 1. The Gallon Jug Shelf Test. Reprinted from Bending the Aging Curve.
Champaign: Human Kinetics Publishers, 20118 with permission.
I
n their 1989 position statement, “Measuring the Activities
of Daily Living among the Elderly: A Guide to National
Surveys,” the U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office
of Disability, Aging and Long-Term Care Policy stated that
the prevalence of disability is associated with reduced ability to
perform basic (ADL) and instrumental activities of daily living
(IADL)10. This is evidenced by the inclusion in ADL and IADL
questionnaires5 and testing batteries1 activities such as shopping,
food preparation, housework, and doing laundry, which by necessity require the transfer of moderately heavy objects as part of
most assessment batteries. While it may be tempting to attribute
successful performance levels during moderately heavy object
transfers to upper body strength and range of motion, in reality,
the majority of these tasks actually incorporate the sequential firing of lower, core, and upper body muscles in a “kinetic chain” to
produce a viable performance.
Bathing and
Ability to use a
showering
telephone or other
form of communication
Dressing
Shopping for
groceries or clothing
Eating
Food preparation
TransferringHousekeeping
Personal hygiene Laundry
Toileting
Transportation within
the community
Ability to handle
finances
Responsibility for
one’s own medications
Care of others
(including selecting
and supervising
caregivers)
Care of pets
Child rearing
Communication
management
Community mobility
Financial
management
Health management
and maintenance
Home establishment
and maintenance
Meal preparation and
cleanup
Religious observances
Safety procedures and
emergency responses
Shopping
Two tests which are each well-established measures of upper
limb strength, handgrip strength dynamometry3,4 and the 30s
arm curl test6, can be used to illustrate the problems of performance versus ADL measurement and biomechanical specificity.
First of all, neither handgrip dynamometry nor the 30s arm curl
test is an assessment of object transfer as a component of IADL
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
The Gallon Jug Shelf Test (continued on page 14)
9
Wellness Column
Online Tips and Tools for
Exercise Professionals
By Peter Ronai, M.S. ACSM RCEP, CES, PD, CSCS-D, FACSM
E
Milenko Bokan/iStock/Thinkstock
xercise practitioners interested in selecting clinically oriented tests to assess physical function in their elderly
clients and clients with chronic diseases and disabilities
can find them in the Rehabilitation Measures Database web site,
Rehabmeasures.org. The Rehabilitation Measures Database web
site is described as “the rehabilitation clinician’s place to find
the best instruments to screen patients and monitor their progress ”¹. The content of this web site and database is developed
under a grant from the Department of Education and was developed by the Rehabilitation Institute of Chicago, Center for
Rehabilitation Outcomes Research, Northwestern University
Feinberg School of Medical Social Sciences Informatics Group¹.
This database is made available through a National Institute of
Disability Rehabilitation Research grant number H133B090024.
The Principle Investigator is Allen Heinemann, Ph.D.
Exercise and rehabilitation practitioners can search for measurement tools by:
• assessment area–construct(s) or variable(s) measured
• diagnosis–disease(s) or condition(s) for which the assessment is most appropriate and valid
• length of test–approximate time to complete a specific assessment cost
Section tabs on this website include:
• “home”
• “complete list of instruments”–a comprehensive list of all
tools within the database/ directory
• “statistics review”–definition of research terms and statistics
and their significance/relevance
• “ links”–links to organizations and specific assessment tools
• “take a tour”–a preview of all features of the website
• “about us”–additional information about the Rehabilitation
Institute of Chicago services
• “contributors”–other institutions assisting through either research and/or funding
The “complete list of instruments” tab is a comprehensive index of population-specific evaluation tools. Tools range from
practitioner supervised performance test batteries and physical
examination tools to disease-specific quality of life and health
10
risk assessments. Assessments can serve as a means to measure program outcomes. The “complete list of measurements”
provides users with the name of specific tests, test acronym(s), organization’s links to the assessment(s), assessment duration (time
to administer the test), diagnostic groups or populations in which
the test(s) can accurately and reliably be used, area of assessment
(functional mobility, strength, flexibility, pain, spasticity, balance, aerobic capacity, ability to perform activities of daily living
(ADLs), upper extremity function, cognition, depression, quality of life, and others). Users are able to access the evaluation
and learn how the test was developed and how to administer and
score the assessment. Peer-reviewed research articles describing
the development, administration, scoring, and interpretation of
many of the assessments in this database are available in this
section. An explanation of test reliability, validity, amount of
training, and resources necessary to conduct specific tests are included in this section.
Viewers can access information regarding:
• minimal detectable change (MDC) (the smallest amount of
change that can be detected by a measure that corresponds
to a noticeable change in the ability)1,
• minimal clinically important difference (MCID) (represents
the smallest amount of change in an outcome that might
be considered important by the patient/client or clinician/
practitioner)1,
• predictive validity (indicates that the outcomes of an instrument predict a future state or outcome, like a fall) as well as
a number of other clinically relevant statistics1
Some organizations in this directory provide links to instructional videos of specific assessment procedures, like manual muscle
testing, and musculoskeletal injury screening.
The “statistics review” section provides viewers with a comprehensive explanation of common yet important research/statistical
terms, definitions, and measurements. Examples of ideal numeric ranges for a number of statistical variables are provided to help
viewers understand the strengths and/or limitations of specific
tests as assessment tools for different populations. Some terms
reviewed in this section include:
• predictive validity (ability of the outcomes of an assessment
to predict future events, like a myocardial infarction or a
fall)1
• concurrent validity (ability of a test to obtain similar results
as a “Gold Standard” test/assessment)1
• cut-off scores (designates a positive or negative test score.
Scores below this value typically indicate a client/patient
being at a greater risk of acquiring a specific condition or
encountering a specific event like a fall)1
Online Tips and Tools (continued on page 13)
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
Resistive Exercise Testing (continued from page 3)
guidance of an ACSM certified Clinical Exercise SpecialistSM or
Registered Clinical Exercise Physiologist®.
Program Requirements for Resistive Exercise
Testing in Pulmonary Rehabilitation
Incorporation of resistive exercise testing for the PR patient is
also important from an overall program perspective. Presented
below are just a few requirements for optimal PR program operation with regard to resistive exercise outcomes documentation,
patient education, and exercise prescription:
• Pre- and post-rehabilitation strength testing measures for
outcomes documentation of upper and lower body muscular
improvements are necessary. Muscular strength and endurance testing should be performed under the same testing
conditions at 3, 6, 12, 18, and/or up to 24 months or at program-specific standardized intervals.
• Outcomes documentation is required for AACVPR PR program certification1, as well as for the upcoming AACVPR
Pulmonary Rehabilitation Outcomes Registry.
• I t is important to let the PR participant know how they
“stand up” compared to those in their particular age and gender group with periodic strength testing.
• The PR participant needs to be kept abreast as to how much
they are improving (or regressing) over time throughout
their PR participation with regard to strength gains or loss.
• The CEP should thoroughly address the muscular strength,
muscular endurance, and neuromotor needs of the patient
to assist with the resistive exercise prescription and evaluation of vocational responsibilities and performance of home
ADLs (e.g., walking, dressing, picking up items, housework,
squatting).
•R
esistive testing (and training) should be performed to
measure and compare individual success with validated population-specific norms. If normative data is unavailable for
specific pulmonary populations, the CEP may choose to
compare the patient’s testing results to data from geriatric or
frail populations until such pulmonary normative strength
testing data becomes available.
•C
hronic resistive exercise training may help to boost the PR
participant’s confidence level, self-efficacy, and self-image.
•P
osture and balance issues for the PR participant may be
assessed through resistive testing to assist in the prescription
of posture and balance exercises.
•F
inally, resistive exercise testing should be performed to help
assess and determine the individual needs of the patient with
respect to their unique overall muscular weaknesses.
Muscular Strength and Endurance Testing
Traditionally, it has been difficult to design resistive exercise
training protocols for the PR participant, as there is a lack of
validated testing protocols designed specifically for those with
chronic lung disease in the literature. Thus, many CEPs have
successfully used (or adapted) many common muscular strength
and endurance testing protocols designed for geriatric patients,
cardiac rehabilitation participants, and the elderly. With regard
to oxygen supplementation and pulse oximeter monitoring, the
CEP typically need do nothing different than would normally
be performed in a regular exercise session. Oftentimes, resistive
exercise testing and training does not produce the same meta-
bolic demand and oxygen requirement as does aerobic exercise.
Thus, the patient may or may not need to use their supplemental
oxygen during resistive testing, depending upon their fitness level
and disease profile.
It is important that each selected testing protocol be able to be
performed by the PR participant safely and be previously tested
for validity and reliability. Ideally, normative values also should
be available for the test. Resistive exercise testing in PR does not
require expensive equipment and can often be successfully performed with items that are commonly used in PR programs, such
as dumbbells and chairs. Other testing items can often be built
out of wood by patients or patient family members who have carpentry skills. Commonly used muscular strength and endurance
testing protocols taken from the Senior Fitness Test Manual (and
associated research)14-16 and others17-19 meet the above criteria and
are summarized as follows:
1. The 30-second Arm or Biceps Curl Test: The subject performs
as many arm curls as possible on both the right and left
arms with a dumbbell (8 lbs. men, 5 lbs. women) for 30
seconds in a seated position.
2. The 30-second Chair Stand Test: The subject completes as
many full stands as possible in 30 seconds from a seated
position in a chair that is placed against a wall or ceiling
support beam.
3. The 8-Foot Up and Go Test: As a test of lower body muscular strength/endurance, motor performance, and dynamic
balance, the subject stands from a chair and quickly walks
around a cone placed 8 feet in front of the chair for the best
of two trials, timed to the nearest 1/10 of a second.
4. The Signorile Gallon Jug Shelf Test17: As a measure of upper
body power and strength, five (5) one-gallon jugs are filled
with water and are moved from the bottom shelf of a bookcase to the top shelf. The subject is timed to the nearest
1/10 of a second, and percentile rankings are available by
age group and gender.
5. T
he 6-Minute Peg Board and Ring Test18: As a test of unsupported upper body muscular endurance, the subject moves
a series of 10 lightweight wooden rings from an upper level
of 10 wooden pegs to a lower level of pegs as many times as
possible in 6 minutes. This test has shown excellent test-retest reliability in pulmonary patients.
6. T
he Seated Medicine Ball Throw Test19: From a seated position, the patient performs a basketball chest pass with
medicine balls that weigh 1.5 kg and 3 kg each for 3 trials, with a 3-minute rest between trials. The distance is
measured from the spot where the patient drops the ball
in front of them initially on a piece of masking tape to the
furthest point where the ball lands on a taped line with a
typical chest pass.
The CEP may be able to accurately calculate measures of work
rate and power in watts and kilogram-meters/minute from some
of the tests described above. These types of calculations may
aid in the development of the resistive exercise prescription and
outcomes documentation over time for the patient. While other
muscular strength and endurance tests have been presented in the
literature, few are designed or validated specifically for patients
with chronic lung disease.
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
Resistive Exercise Testing (continued on page 12)
11
Resistive Exercise Testing (continued from page 11)
Using Machines and Free Weights for Resistive
Exercise Testing
Free weights and machine weights also may be used as resistive
testing modalities in PR programs. Unfortunately, as stated there
has been little research on the development of resistive testing
protocols using these modalities in pulmonary populations, resulting in a lack of normative strength testing data for patients
with chronic lung disease. This lack of normative data makes it
difficult for the CEP to determine what is an optimal level of
resistance to be lifted in order for a patient with COPD to be
classified as “normal.” The AACVPR1 and ACSM20 have provided general recommendations for resistive exercise training in
pulmonary populations, but little if any information on resistive
exercise testing. This is due to the lack of evidenced-based research in this area. ACSM recommends using exercise training
protocols for resistive training as those prescribed for healthy
adults and/or older patients (discussed further in Part II of this
article in the next issue of ACSM’s Certified News). Therefore, the
CEP in PR has to rely on previously published research as well as
his or her own intuition and knowledge of each individual patient
to select the best resistive testing modality and protocol suitable
for that particular patient or group of patients.
One-repetition maximum (1 RM) testing and variations thereof
have been shown to be safe and effective in pulmonary populations. Kaelin et al.21 examined older male and female PR
participants with 1 RM testing consisting of parallel squat and
incline bench press exercises. These investigators concluded that
a properly supervised and screened PR population can perform
1 RM testing without significant muscle soreness, injury, or abnormal cardiopulmonary responses. While this is one of very few
investigations that have studied 1 RM testing in pulmonary patients, this is an encouraging study that hopefully promotes on
further strength testing research in pulmonary populations.
Many variations of machine and free weight initial strength
testing have been used in geriatric, cardiac, and pulmonary populations over recent years. These variations include the following
protocols and adaptations:
1. An initial weight load is determined that allows 5-10 reps
at ~ 30% to 40% of 1 RM for upper body and 50% to 60%
for the lower body20,22.
2. Using a rating of perceived exertion (RPE) assessment, the
patient starts with a light weight and performs 12 to 15
repetitions to an RPE of light to somewhat hard (12 to 13)
on the Borg Category Scale23.
3. For novice and intermediate clients, it is recommended that
moderate loading be used at 70% to 85% of 1 RM for 8 to
12 repetitions24.
4. Using a titration technique, where the patient begins at a
level of 10 reps with lighter machine weights and progresses
to 15 reps/session. At this time, the resistance is increased 2
to 5 pounds, and the patient falls back to 10 reps/machine.
5. The patient performs a traditional 1 RM assessment, the
resistance is progressively increased to see how much can be
lifted once with proper warm-up and technique25.
6. The patient performs a 3-repetition maximum (3 RM) test,
which has been shown to be safer and more reliable than a
traditional 1 RM test26.
Regardless of the initial strength testing assessment modality or
protocol utilized, the CEP has to always put patient safety at
the forefront of all testing. Hopefully with further research in
this area, strength testing protocols will be designed specifically
for patients with chronic lung disease who participate in PR
programs.
Handgrip Dynamometer Testing
The handgrip dynamometer has been used to test grip strength
as an indicator of overall body strength and physical function status in older populations27-30 and in cardiac patients31. While this
device may have practical applicability for strength assessment in
these populations, the ability of this device to assess overall body
strength in cardiac patients has been questioned32. Nevertheless,
the handgrip dynamometer would appear to be an excellent modality for assessment of grip strength in most PR participants as
this modality requires little training, is lightweight and portable,
and provides a low-risk assessment of grip strength with only a
brief isometric component. Research has shown that handgrip
muscle strength decreases as FVC and FEV1.0 decreases33 and
BODE Index (a rating scale used to stage disease severity in
persons with COPD) values increase34 in patients with COPD.
While there is a lack of normative handgrip data for pulmonary
patients, these have been published for older populations35,36.
Proper techniques to perform the handgrip dynamometer test
have been presented elsewhere36.
Summary
Resistive exercise testing is an important component in PR. This
form of testing should be performed routinely on all patients at
periodic time intervals for patient outcomes documentation of
strength improvements, as well as for the development of the
resistive exercise prescription. While there is a current lack of
research that presents optimal resistive exercise testing protocols
for the PR participant, the CEP can rely on validated muscular
strength and endurance testing techniques that have been previously performed in older and frail populations. Obviously, not all
PR participants are elderly or frail, but patient safety is paramount
and testing with validated low risk protocols for older patients is
prudent. With the ever-expanding exercise and pulmonary disease research base, it is hoped that the CEP will soon be able to
refer to standardized pulmonary strength testing protocols with
associated normative data to assist in long-term patient outcomes
documentation and the development of the ideal individualized
resistive exercise prescription.
About the Author
Dave Verrill, MS, FAACVPR, is a clinical exercise
physiologist, laboratory director, and lecturer in the
Department of Kinesiology at the University of North
Carolina at Charlotte (UNCC). He is certified as an
ACSM Exercise SpecialistSM, ACSM Program DirectorSM, and ACSM Registered Clinical Exercise
Physiologist®. Dave is currently chair of the committee for state licensure for CEPs in North Carolina and
is past-president of the Clinical Exercise Physiology
Association (CEPA) and North Carolina Cardiopulmonary Rehabilitation
Association (NCCRA). He has co-written chapters for ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, ACSM’s Resources for the
Clinical Exercise Physiologist, and ACSM’s Certification Review. He also has
published a number of journal articles, abstracts, and book chapters in the field
of cardiopulmonary rehabilitation and resistive exercise training and has presented at many regional and national ACSM and AACVPR meetings.
References
References available at acsmcertification.org/cn-Q2-2014
12
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
Coaching News (continued from page 8)
What Was Missing From Our Program: I have been with Hilton Head Health for just over two years and was hired to create a
continued support program for our guests. H3@Home Wellness
coaching offers a component that was missing from our program
before. Upon returning home, guests now have the option for
continued, structured support from one of our trained wellness
coaches to ensure the tools and knowledge gained during their
stay are not just being put into practice, but are actually sticking.
We were all very excited when H3 fitness director Adam Martin
started throwing around the idea of at-home coaching and came
across the highly recommended and leading-edge coach training
program. Adam and I shared the same vision for our guests, and
he trusted me to bring that vision to life. We are so excited that
we are sitting here today with the program successfully put into
action.
How We Began: We made the decision that we were not going
to start a coaching program at Hilton Head Health until we had
a viable certification. We found that the coach training program
we selected was a perfect fit and the focus went hand-in-hand
with what we wanted to do here. We began the training with
our entire program staff in June 2011 and we went through the
training classes together and studied together. Learning about
motivational interviewing and non-violent communication were
particularly impactful to me. The format for structuring the
coaching calls that the program uses has been huge for getting
our program off the ground. I was the first coach to become
certified, and right away we launched our H3@Home Wellness
Coaching program.
Implementing Coaching: We now offer a few different types
of coaching programs, all of which are based on what we learned
in coach training. These are follow-up programs, and our goal
is for our guests to sustain success in living the healthy habits
they learned here. All of our programs offer an initial 90-min-
ute coaching session to get started. Then to create a group feel,
we send weekly group e-mail messages, weekly text messages,
and challenges that we give our guests at home. Guests have
30-minute calls with their coach once a week for 3 months. At
the end of the 3 months, they either continue with the coaching
or feel ready to move on.
Coaching’s Impact: The biggest impact of coaching for our
guests has been accountability! We felt the need to implement
a coaching program to become certified because although many
of our guests are successful at home, we find several guests come
back to our facility and need continued education and assistance.
The difference today with the implementation of coaching is that
these guests are coming back 50 to 60 lbs. lighter, with new sustainable habits, such as reducing work hours, exercising regularly,
improved nutrition, planning, and journaling. Coaching has been
a great way for guests to use the motivation that they get from
staying a week with us and really focus on those habits as they go
home. We have definitely seen more successful outcomes with
our guests because of coaching. A little bit of accountability goes
a long way!
About the Author
Margaret Moore (Coach Meg), MBA, is the founder and CEO of Wellcoaches Corporation, a strategic
partner of the ACSM, widely recognized as setting a
gold standard for professional coaches in health care
and wellness. Wellcoaches has trained 8,000 health
professionals as coaches in 47 countries. Moore is
co-director of the Institute of Coaching at McLean
Hospital, an affiliate of Harvard Medical School,
and co-directs the annual Coaching in Leadership &
Healthcare Conference offered by Harvard Medical School. She co-authored
the ACSM-endorsed Lippincott, Williams & Wilkins Coaching Psychology
Manual, the first coaching textbook in health care and, the Harvard Health
Book, published by Harlequin: Organize Your Mind, Organize Your Life.
Online Tips and Tools (continued from page 10)
This section of the rehabmeasures.org website and database
provide viewers with a better understanding of how to use
specific measurements. And it enables them to select the best
measurement instruments for each patient or client on an individual basis. Viewers can access the Rehabmeasures.org database at
http://www.rehabmeasures.org/default.aspx
Exercise practitioners can search for and access physical assessment tools that best meet the individual needs of each of their
patients and clients on the Rehabilitation Measures Database.
Resources
The Rehabilitation Measures Database Website [Internet]. Chicago, (IL):
Rehabilitation Institute of Chicago: [cited 2013 Sept. 1]. Available from
http://www.rehabmeasures.org/default.aspc.
About the Author
Peter Ronai, MS, RCEP, CSCS-D, FACSM,
is a clinical associate professor in the department of physical therapy and human
movement science at Sacred Heart University in Fairfield Connecticut. He is a Fellow
of the American College of Sports Medicine.
Ronai is past-president of the New England
Chapter of the American College of Sports
Medicine (NEACSM), past member of the ACSM Registered
Clinical Exercise Physiologist (RCEP) Practice Board, Continuing Professional Education Committee and current member of
the ACSM Publications sub-committee. Ronai is co-editor of
ACSM’s Certified News and also the Special Populations column
editor for the National Strength and Conditioning Association’s
(NSCA) The Journal of Strength and Conditioning Research (SCJ).
He is also ACSM Program Director Certified.
ACSM’S CERTIFIED NEWS • SECOND QUARTER 2014 • VOLUME 24: ISSUE 2
13
The Gallon Jug Shelf Test (continued from page 9)
performance. Rather, both are measures of a neuromuscular performance measure — strength. Second, these measures assess
strength production by the flexor muscles of the hand and forearm (grip strength) or the elbow flexors (30s arm curl). While
the strength of these muscles is important to performance of the
overall task, these measures cannot be considered complete assessments of this complex task which incorporates the sequential
operations of multiple joints in a skilled movement pattern.
In contrast, the Gallon Jug Shelf Test (GJST) has been shown
to be a valid, reliable, inexpensive, safe, and easily administered
clinical test of moderately heavy object transfer. Briefly described,
the test requires the participant to sequentially transfer five
one-gallon jugs (weight app 3.9 kg) as quickly as possible from a
shelf set at the level of the participant’s patella to a shelf aligned
with the top of the participant’s shoulder (see Figure 1)9. Three
Table 2: The Gallon Jug Test Methodology
Equipment
• Bookshelf 84” H x 42” W x 12” D with adjustable shelves
• 5 one-gallon water-filled milk jugs
• 1 Stopwatch
Set-up
• Align the lower shelf with the participant’s patella.
• Align the upper shelf with the top of the participant’s shoulder.
• Place the 5 one-gallon jugs on the bottom shelf.
• Provide detailed instructions prior to testing.
• Demonstrate the test.
Test Procedure
1. H
ave the participant stand comfortably in front of the bookcase.
2. I nstruct the participant to keep the back as straight as possible,
keep the head up, not lean forward, use the legs as the primary
source of power for the lift, and abort the task if there is any
feeling of stress or discomfort.
3. P
rovide a test trial, evaluate form, correct form, and provide
another practice if necessary.
4. R
emind the participant to move only one jug at a time, not to
alternate hands, and begin the test standing straight up.
5. B
egin the trial with a “ready” command to prepare the participant,
followed by a “go” command.
6. B
egin the timing with the “go” command and stop when the fifth
jug is placed on the top shelf.
7. I f multiple trials are used, allow a 1-minute recovery between
attempts.
explicit directions provided in preparation for the test are to keep
the back as straight as possible, to not alternate hands, and to use
the legs to help with the task. Obviously these instructions are
designed to put limits on performance strategies and to increase
safety during test performance. But more germane to the current
discussion, the last direction, to use the legs to help with the task,
reflects the developers’ recognition of the importance of force
transfer from the lower body through the core and to the upper
body in the performance of transfer skills involving moderate to
moderately heavy objects (see Figure 2).
In agreement with current arguments favoring the use of
task-specific exercises to maximize improvements in daily activities2, the GJST provides the researcher and clinician with an
assessment that evaluates a skill critical to independence — the
controlled transfer of moderately heavy objects.
Figure 2. Kinetic Chain Utilization during the Gallon Jug Shelf Test. Reprinted
from Bending the Aging Curve. Champaign: Human Kinetics Publishers, 2011
with permission8.
About the Author
Dr. Signorile is a Professor of Exercise Physiology at
the University of Miami with a joint appointment at the
University of Miami Center on Aging. He have been
involved in research using exercise to address independence and fall prevention for over 20 years, has over 65
refereed manuscripts and 200 national and international scientific presentations. He have been a pioneer in
applying the diagnosis/prescription model for tailored
exercise to improve function and reduce falls in older
persons and continues to work on new technologies for improving independence. Within the context of prescriptive exercise he has organized and led a
series of studies that produced and published refereed articles detailing novel
tools to assess and improve independence. He has chaired over 20 doctoral
dissertations and served as a committee member on countless more. Dr. Signorile is the coauthor of SouthBeach Diet Supercharged and recently released his
definitive book on aging exercise prescription entitled Bending the Aging Curve
recently translated into Cantonese.
References
References available at acsmcertification.org/cn-Q2-2014
14
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