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J A N U A R Y ­ M A R C H , 2 0 11 · V O L U M E 2 1 : I S S U E 1

Making Sense of METs

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Building Muscle: Understanding the Building Blocks known as Genes Strength Training and Multiple Sclerosis page 7 Resistance Training Sets: Effects on Muscle Strength page 10 The Clinical Exercise Physiologists Expanding Role for Those with Type 2 Diabetes page 12 Online Tips and Tools For Exercise Professionals

Continuing Education Self-Tests page 15 page 14





January­March 2011 · VOLUME 21, ISSUE 1

In this Issue

Making Sense of METs .............................................. 3 Building Muscle: Understanding the Building Blocks known as Genes....................... 5 Strength Training and Multiple Sclerosis .............. 7 Coaching News........................................................... 9 Resistance Training Sets: Effects on Muscle Strength ...............................................10 The Clinical Exercise Physiologists Expanding Role for Those with Type 2 Diabetes.....................12 Online Tips and Tools For Exercise Professionals............................................14 Self-Tests ........................................................................15 Co-Editors James R. Churilla, Ph.D., MPH. Peter Ronai, M.S. Committee on Certification and Registry Boards Chair Madeline Bayles, Ph.D., FACSM CCRB Publications Subcommittee Chair Paul Sorace, M.S.



William F. Simpson, Ph.D., CES, FACSM

The American College of Sports Medicine (ACSM) Clinical Exercise Specialist (CES) certification was developed in 1975. It is the oldest of its current certification and has recently undergone a number of changes. In this brief article I wish to highlight the major changes that have taken place over the past 24 months. The most obvious change is in the name. Originally the credential was named ACSM Exercise Specialist. However market surveys were conducted and the results indicated the perception of education for an Exercise Specialist was less than a personal trainer. Given this perception in concert with focus group feedback, the identifier "Clinical" was added to give the credential a more accurate job definition and title. The other changes to the credential involve exam eligibility and internship hours. These are more controversial; however, it must be clear that these changes were made after an intensive survey of certified professionals, focus group feedback, a public comment period and hours of discussion and debate within the Committee on Certification and Registry Boards (CCRB) at both the Exercise Specialist subcommittee and Executive Committee level. Based on these intensive discussions over a 24-month period, the following changes have now been implemented: As of January 1, 2011, the eligibility for CES is a Bachelor's degree in Allied Health to an Exercise Science based degree only. Our survey results indicated that the number of non-exercise degreed professionals sitting for the exam accounted for less than five percent. Therefore to better define an exercise professional at this level, one must come from the exercise discipline. Examples of acceptable major titles include: Exercise Science or Physiology, Human Performance, Kinesiology, or Physical Education/Exercise Science. Also the following courses must be within the major: Anatomy and Physiology, Exercise Physiology, Conditioning, Kinesiology/Biomechanics, Nutrition, and Exercise Testing/Assessment/Prescription. Each undergraduate program also must require the completion of an internship. Until this January, the required number of hours traditionally had been 600 hours. Our research indicates that this particular requirement was more arbitrary therefore not demonstrating best practice nor was the degree requirement. The minimum required hours were reduced to 400 hours for an accredited Commission on the Accreditation of the Exercise Sciences (CoAES) program and 500 hours for a non-accredited program. This aligns much more with most academic programs giving the student a 10 to 13 week experience within a typical college/university semester. Finally, the CES committee has recently completed a Job Task Analysis (JTA) that serves as the blueprint for the job a CES performs. This is a practice-based process, which supersedes the contentbased Knowledge, Skills and Abilities now known as Knowledge and Skills (KS's) that were developed at the time certification programs were introduced. All examination questions for the CES exam are based on the JTA. The performance domains for the CES are: Domain I: Patient/Client Assessment ­ 20% Domain II: Exercise Prescription ­ 20% Domain III: Program Implementation and Ongoing Support ­ 20% Domain IV: Leadership and Counseling ­ 20% Domain V: Legal and Professional Considerations ­ 20% The committee spent countless hours reviewing job task statements as well as necessary KS's to develop this JTA, which was reviewed by a psychometrician. At the present time there are 2,703 certified clinical exercise specialists. There were more than 500 candidates who sat for the exam in 2010. I would like to acknowledge the committee for their hard work and dedication in developing these changes within the profession: Ken Harkins, M.S.; Amy Jo Sutterluety, Ph.D., FACSM; Mark Zaleskiewicz, M.S.; David Seigneur, M.S.; and Shel Levine, M.S.

ACSM National Center Certified News Staff

National Director of Certification and Registry Programs Richard Cotton Assistant Director of Certification Traci Sue Rush Professional Education Coordinator Shaina Miller Publications Manager David Brewer Editorial Services Department Lori Tish Angela Chastain

Editorial Board

Chris Berger, Ph.D. Clinton Brawner, M.S., FACSM Avery Faigenbaum, Ed.D., FACSM Tom LaFontaine, Ph.D., FACSM Peter Magyari, Ph.D. Thomas Mahady, M.S. Peter Ronai, M.S. Larry Verity, Ph.D., FACSM Stella Volpe, Ph.D., FACSM Jan Wallace, Ph.D., FACSM 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: 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











Although common terminology for the well-trained exercise professional, MET values are not widely used by the lay person. Given that MET values are displayed on most commercial cardiovascular equipment, trainers are often asked by clients, "What is a MET?" This article provides a simplified view of METs and suggests some useful tips to help your client understand and use METs in their exercise program.

Table 2. Simple hands-on demonstration using the treadmill's* electronic display.

1) Start your client at a comfortable walking pace at 0% grade and program the display to show METs. 2) As you slowly increase the incline, show your client how the MET level simultaneously increases. 3) Return the incline to 0% and direct their attention to the calories display. 4) Slowly increase the incline again and show your client how energy expenditure increases with an increase in MET level.

*If a treadmill is not available or appropriate for your client you can replicate this process on another piece of cardiovascular equipment by adjusting level (elliptical trainer) or resistance (cycle ergometer).

What is a MET?

. A MET is a simplified unit for estimating oxygen consumption ( VO2). One MET is defined as the estimated metabolic cost of rest, which is . -1 -1 equivalent to a VO2 of 3.5 mLkg min or calorically to .0175 -1 -1.4 kcalkg min In other words, METs provide information about both . the approximate VO2 and caloric expenditure associated with that activity. Any increase in the metabolic needs above rest results in increased oxygen consumption, energy demand and hence, MET level. As shown in . Table 1, METs are expressed as a multiple of VO2 above rest. This background information, along with a mastery of metabolic equations (refer to ACSM's Guidelines for Exercise Testing and Prescription 8th Edition, table 7.2) and some basic algebra skills are useful when designing a scientifically sound exercise prescription and determining its caloric cost. The correlation between METs, oxygen demand, and caloric expenditure will most likely not be straightforward for your client and should be simplified to terminology that they can understand and apply. A good starting point is to review with your client the basic definition of physical activity: Skeletal muscle contractions that result in a substantial increase in energy expenditure above rest. 5 Explain to your client that as physical activity intensity increases (i.e., speed, incline, ped. aling resistance) more oxygen ( VO2) is needed to supply energy for the contracting muscles. Acute energy demand is reflective of the amount of physical work being performed. Since METs are a short-hand repre. sentation of VO2, they represent the amount of energy required to perform the physical activity at hand. Therefore, the higher the MET level, the more physical work is being performed (Table 1). Table 2 provides a sample tutorial you can use with your client to help them grasp this concept. Using this description is more tangible for the client because they can feel increases in physical work through increased respiration, rating of perceived exertion (RPE) (subjective, quantified physical exertion rating by the client), and muscular fatigue. Another useful resource for teaching this idea is the Compendium of Physical Activities,1 which is a list of several physical activities and their approximate MET values. By using these tools you can empower your clients to quantify their physical activity, track the progress of their cardiovascular routine, and achieve their exercise goals.

Prescribing Physical Activity Using METs.

The most utilized method of prescribing cardiovascular exercise intensity is the target heart rate method, typically 60%-90% of agepredicted maximal heart rate [206.9 ­ (.67 x age)].2 Although this method is effective at prescribing relative exercise intensity, it does not truly quantify the actual amount of physical work being performed during exercise for reasons including the variability of predicting maximal heart rate as well as the influence of environmental factors on heart rate (exercise mode, air temperature, sweat loss, hydration status). In contrast, METs estimate the metabolic demand of the activity itself and therefore better depict the absolute intensity of physical activity. A bout of exercise prescribed at a specific MET level will require the same -1 -1 kcalkg min regardless of heart rate. Prior to exercise prescription, a well-trained exercise professional should perform a sub-maximal cardiovascular test to estimate their client's maximal cardiovascular capacity (refer to ACSM's Guidelines for Exercise Testing and Prescription 8th Edition for proper screen. ing procedures and protocols). Once a VO2max value has been obtained, . METmax can be determined by the equation METmax=( VO2max /3.5 mL -1 -1 kg min .) Then, exercise intensity can be prescribed by using a modi f i e d K a r v o n e n f o r m u l a f o r M E Ts w h e r e Target METs = [ (METmax - 1) % intensity] + 1.

Table 1. Correlating METs, VO2 and Calories

A c t iv it y M ETs . V O2

( m l/ g / in ) k m


Ca lo r ic Co s t *

( k c a l/ g / in ) k m

Resting Walking, 1.3 mph Walking, 3.9 mph Jogging, 5.2 mph Running, 9.1 mph

1 2 4 9 14

M ETs X 3 .5 3.5 7 14 28 49

.0175 .035 .070 .1575 .245

Using METs After Prescription

Once a client understands the relationship between their own physical activity intensity, energy expenditure, and METs, their exercise prescription will make more sense to them, and it may motivate them to choose activities that will help achieve their goals. Below are a few examples of how your client can use METs to make their exercise program

*Derived from the given that 1 MET is .0035 L/kg/min and 1 L of O2 consumed utilizes ~5 kcal



more effective. They then should understand that as their fitness level improves, they will be able to perform more physical work and burn more calories with seemingly less effort (i.e., "easier breathing" and less muscular fatigue.) Interpreting current physical activity guidelines. Current physical activity guidelines suggest that adults accumulate 30 minutes of moderate activity 5 days/week, 20 minutes of vigorous activity 3 day/week, or a combination of both.6 Although these guidelines are fairly clear, it is not uncommon for terms "moderate" and "vigorous" to be misinterpreted. For example, an unfit individual may consider a slow paced walk vigorous because they feel out-of-breath and an increase in their heart rate. Relative to their fitness level, they may truthfully feel that the activity is vigorous . However, according to the Physical Activity Guidelines for Americans (adults aged 18-64),6 vigorous activity is considered >6 METs which is equivalent to a 4.5 -5 mph walk/jog. Clearly, this misinterpretation could result in one overestimating their physical activity participation level. Using teaching tools such as the example in Table 2 or the Compendium1 will allow you to teach clients to more accurately gauge the quantity and intensity of their activities of daily living. Quantifying Physical Activity Volume and Caloric Expenditure. METs also are useful for calculating the total volume of physical activity performed and the calories utilized during the activity. The product of multiplying METs by duration (i.e., minutes) results in a variable indicative of the total volume of activity. For example, exercising at 3 METs for 20 minutes (3 x 20 = 60 MET-minutes), is the same volume of physical activity (hence, caloric expenditure) as exercising at 6 METs for 10 minutes (6 x 10 = 60 MET-minutes).6 Adding body mass as a variable, total caloric cost can be computed by using the formula, kcalmin-1 = (METs 3.5 kg)/200 (see Table 3 for an example.) Using these simple calculations in collaboration with the Compendium1 is especially useful for clients that have specific energy expenditure goals but want to vary their physical activity type or intensity. Self-monitoring. Self-monitoring is an effective strategy for longterm behavioral change.3 MET values provide your client with an easy variable that allows them to monitor and progress their cardiovascular exercise program accordingly. As the client's fitness level improves, their RPE and/or heart rate at a given MET level decreases. They can then systematically increase their MET workload. This results in improvements in cardiovascular fitness and ultimately increased energy expenditure per session. In addition, direct feedback also has been shown to be important for successful behavior change.3 Each progression provides direct feedback that they are performing more physical work and their fitness level is improving. Table 3 provides a sample progression plan using METs. Notice when the client's RPE drops to12, the MET level is systematically increased by 10%. "Matching" Exercise Intensity. Varying cardiovascular exercise modalities reduces the risk of overuse injury, decreases boredom, and improves exercise adherence. However, "matching" exercise intensity from machine to machine may be difficult considering the variability of heart rate and RPE. Since METs designate an absolute measure of intensity, they afford your client the ability to replicate a prescribed intensity regardless of the mode of exercise performed. For example, treadmill walking at 4 METs for 15 minutes will result in the same approximate caloric expenditure as stationary cycling at 4 METs for 15 minutes. The same could not be said if heart rate or RPE was used as the controlled intensity because both would vary based on the client's fitness level, environment, and exercise experience.

Table 3. Sample Cardiovascular Exercise Progression (Three sessions/week)

70 k g p erso n w ith a n estim a ted M ETma x o f 7.0. In itia l w o rk lo a d is 50% o f M ET reserve. Week 1 2 3 4 5 6 7 8 Target METs Duration Caloric Cost (minutes) (kcal/session) 4 30 147 4 30 147 4 30 147 4.4 30 162 4.4 30 162 4.8 30 176 4.8 30 176 5.2 30 191 Average RPE 15 14 12 13 12 13 12 13


The role of an exercise professional is to not only prescribe and implement effective exercise programs, but also to educate their clients regarding sound principles of exercise training. Ideally, an effective practitioner will provide their client(s) with adequate knowledge and practical skills to eventually exercise safely and effectively on their own. By teaching and incorporating METs as an integral part of the exercise prescription, the fitness professional can implement effective strategies to help achieve client goals in addition to providing the client with knowledge that can be applied throughout a lifetime.

About the Authors

Tony Musto, Ph.D. is the associate director of Fitness Programs at the University of Miami Herbert Wellness Center and adjunct professor in the Department of Kinesiology and Sports Sciences. He is also an ACSM Certified Clinical Exercise Specialist and Health Fitness Specialist Workshop site coordinator. Kimberly S. Perez, M.A., is ACSM Certified Health Fitness Specialist since 2003. She earned her Master's degree in Applied Physiology from Teachers College, Columbia University where she discovered her passion for teaching fitness professionals. She currently serves as the Head Instructor at the Focus Personal Training Institute in New York City.


1. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Medicine & Science in Sports and Exercise. 2000; 32 (9): S498-516. 2. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 8th ed. Baltimore: Lippincott Williams & Wilkins, 2010. 3. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation. 2010; 122: 406-441. 4. Bouchard C, Blair SN, and Haskell WL. Physical Activity and Health.1st ed. Champaign: Human Kinetics, 2007. 5. Casperson CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports. 1985; 100 (2): 126-131. 6. United States. Dept. of Health and Human Services. 2008 physical activity guidelines for Americans [electronic resource] : be active, healthy, and happy! U.S. Dept. of Health and Human Services: For sale by the Supt. of Docs., U.S. G.P.O., [Washington, D.C.]:2008.






Skeletal muscle strength is a key component of physical fitness, critical to athletic performance, and a significant factor that reduces incidence of injury, particularly with advancing age. Therefore, the use of resistance training regimens to increase fitness, performance, and overall health is endorsed by athletic trainers and clinicians, as well as various health and wellness organizations.1 It has long been recognized that the first measurable effect of a resistance training program is an increase in the neural drive stimulating muscle contraction, and within several days, strength increases as an individual becomes more efficient at activating skeletal muscle.9 Over the next few weeks of training, as the muscle continues to receive increased demands, the actual contractile machinery is upregulated, which stimulates muscle hypertrophy (growth) via increased protein synthesis. Indeed, the concept of skeletal muscle hypertrophy as a result of resistance training is not novel. What is novel, however, are the advances in molecular biology techniques over the past decade that have allowed scientists to evaluate alterations in gene expression and protein synthesis in skeletal muscle in response to exercise. These advances have provided scientists with a better understanding of the molecular basis of skeletal muscle hypertrophy. As clinicians, coaches, and exercise specialists, it is important to have a basic understanding of how skeletal muscle hypertrophy is induced at the cellular level. This knowledge will ensure that practitioners and athletes are able to make informed decisions regarding interventions targeted at promoting skeletal muscle hypertrophy. Increased awareness is imperative with the advent of more aggressive markets for anabolic drugs, gene therapies, and costly supplements. Over the next few issues of ACSM's Certif ied News, we will

Figure 1. Schematic representing the central dogma of biology.

Specifically, coded genetic information hard-wired into DNA in the nucleus is transcribed (copied) into messenger RNA (mRNA) for transport into the cytoplasm. However, in RNA the nucleotide Thymine (T) is replaced with Uracil (U). Each mRNA strand is made up of codons that contain the program to synthesize a particular amino acid.

Table 1. Common Terms and Definitions

Common Terms


explore the basics of gene expression and protein synthesis as a foundation for skeletal muscle hypertrophy. The objective of this first commentary is to introduce the basic concepts of gene expression and protein synthesis and how they are generally influenced by increased load and nutrition. Future commentaries will take a closer look at ways to manipulate hypertrophy from the cellular level. To facilitate understanding of this commentary, Table 1 provides a synopsis of the common molecular terms used throughout, as well as their definitions.


Deoxyribonucleic acid. DNA contains the genetic code to make proteins. DNA is a long sequence of nucleotides strung together in a double-stranded helix. There are four nucleotides: adenine (A), thymine (T), guanine (G), and cytosine (C). Ribonucleic Acid. mRNA =messenger RNA. Single-strand of nucleotides (Uracil (U) takes the place of thymine (T)) which are copies of a strand of the DNA back-bone. mRNA carries genetic information from DNA residing in the nucleus to the ribosomes outside of the nucleus. A unit of DNA which contains information to build a specific protein. The process of using information in a gene to synthesize a protein.

Genes and DNA: The Base-ics

Each skeletal muscle fiber is a multinucleated cell and represents the smallest complete contractile system within a muscle. Each nuclei contains combinations of four bases, known as nucleotides, which comprise deoxyribonucleic acid (DNA). These bases include adenine (A), guanine (G), cytosine (C), and thymine (T). Unique combinations of these nucleotides provide the genetic information necessary to make all structural and functional proteins of the muscle fiber. The relationship between the nucleotide sequence of each gene and the amino acid sequence encoding its respective protein product is known as the genetic code. The genetic code consists of sequences called codons, which are formed from a sequence of three nucleotides, with each codon representing a specific amino acid (Figure 1). Since there are four bases (A, G, C, T) that can be arranged in three-letter combinations, there are 64 possible codons that encode 20 amino acids, with most amino acids having more than one possible codon. Since DNA cannot leave the nucleus, it must transport its genetic code out of the nucleus in the form of ribonucleic acid (RNA). RNA is a single-stranded copy of a segment of DNA as is shown in


Gene Gene Expression Upregulation An increase in the amount of gene expression due to a stimulus (e.g., nutrition or exercise). A series of three bases (e.g., AGe) which code for a specific amino acid. Codon(s) One codon codes for one amino acid. Transcription The transfer of genetic information from DNA to mRNA by RNA polymerase. Stop Codon Signals the RNA polymerase to stop transcribing the genetic code from DNA to mRNA. Stop codons are TAG, TAA, and TGA. The process of decoding information from mRNA into amino acids. This Translation is done by the ribosome. During translation a string of amino acids are formed into a polypeptide chain which codes for a specific protein.



Figure 1. However, in RNA, Uracil (U) is substituted for Thymine (T). For example, the codons GCU, GCC, GCA and GCG encode the amino acid Alanine, while the codons UUA, UUG, CUU, CUC, CUA, and CUG encode the amino acid Leucine. In addition, there are also three "stop" or "nonsense" codons. These are TAG, TAA, and TGA. These codons indicate the end of the coding region and to stop the translation of a strand of DNA into a protein. Ultimately, unique arrangements of these amino acid sequences form together to make a polypeptide chain. The fundamentals of this process, known as translation, are discussed in a subsequent section.

Figure 3.

Transcription: Explaining Gene Expression

The basic mechanism of synthesizing muscle-building proteins begins with the transcription of DNA into messenger RNA (mRNA), which is then translated into protein (Figure 2). In transcription, RNA polymerase is an enzyme which constructs RNA chains from DNA genes that are used as templates. Essentially, the codons of each gene are copied into mRNA by RNA polymerase. RNA polymerase functions to unravel DNA strands and produce corresponding mRNA. In the case of resistance training, when the muscle experiences increased tension or load, transcription begins by activating transcription factors. Transcription factors are proteins that bind to regulatory regions of DNA and control the expression of numerous genes. By binding to promoters/enhancers and silencers, respectively, transcription factors can turn on or turn off the genes they control. For example, increased load on a muscle may stimulate the binding of transcription factors to promoter regions of genes that encode actin or myosin. At the same time, transcription factors also may bind to silencer regions of genes that encode myostatin, which is a negative regulator of muscle growth. The rate, magnitude, and time course of changes in gene expression are dependent upon the nature and duration of the exercise, intensity of loading, and frequency of the loading stimulus. Figure 3 provides an example of how loading patterns associated with endurance-type exercise differ from those associated with resistance exercise. Ultimately, the amount of protein synthesis is correlated with the stimulus driving changes in gene expression.

Translating the Importance of Protein Synthesis

Figure 2.

The term tra nsla tion is used to describe the phase of protein synthesis where mRNA is translated into a protein. Specifically, mRNA carries genetic information (coded as an RNA sequence) from the chromosomes inside the nucleus to the ribosomes outside the nucleus. The ribosomes read the RNA sequence, translating it into groups of amino acids, which are formed into a polypeptide chain. RNA polymerase is the ribosomal enzyme that transfers a specific active amino acid to a growing polypeptide chain. Since the amount of mRNA dictates how much protein will be made, the magnitude of gene expression impacts the amount of protein each skeletal muscle fiber is able to synthesize. However, the transcription:translation ratio is not 1:1.7 Many factors such as the rate at which RNA sequences are processed, the stability of mRNA molecules (i.e., the rate at which they are degraded), and overall ribosomal efficiency affect the rate of translation. Therefore, even if the genetic information for a protein is transcribed into mRNA, it is not guaranteed that the mRNA will be translated into a protein. This process affects protein turnover. Protein turnover is the relationship between protein synthesis and protein breakdown. Research has shown that resistance exercise causes a rapid increase in protein synthesis within one to two hours of a single bout, and this increased rate of synthesis typically persists for 24 to 48 hours, depending on an individual's training status.2, 6, 8 Although protein synthesis outweighs protein breakdown resulting in an anabolic state, protein breakdown is still a critical cellular function, as it serves to degrade and remove damaged proteins within the muscle fiber so that they can be replaced with new proteins.4 This is of particular importance as many nutritional supplements designed for resistance training claim to reduce protein breakdown. If protein breakdown is reduced beyond homeostatic levels, there would be an accumulation of damaged muscle proteins, which may prevent the synthesis of new muscle proteins.2 Consequently, new proteins are not available for tissue repair, which is a critical step in skeletal muscle hypertrophy.

Feeding your genes

In addition to the known effects of exercise training, the impact of nutrition on hypertrophy has been clear since the original use of the word, as the word hypertrophy is derived from the Greek words hyper (more than normal), and trophe (nutrition). Because protein is the predominant muscle building material, it is not surprising that for Building Muscle (continued on page 11) 6




Multiple Sclerosis (MS) is thought to be an autoimmune disease that damages the myelin that helps insulate the central nervous system.

This loss of myelin adversely affects the rapid, smooth conduction of impulses along the pathways in the nervous system and interferes with coordinated movement, leading to loss of strength, sensation, balance, and to visual, cognitive, and affective deficits.1, 6, 7, 8 The exact etiology still is not known, but it is generally accepted that MS involves an abnormal immune response within the central nervous system.8 MS is the most common disabling neurologic disease in young adults in the United States. The condition is usually first diagnosed anytime from the late teens to 60 years old, but most people are diagnosed between 20 and 40 years of age. Women are more likely to develop MS than men.1, 7, 9


ently healthy individuals. This increased energy expenditure can be attributed to spasticity and ataxia.6

Benefits of Exercise on Multiple Sclerosis

Exercise has been shown to be effective in enhancing quality of life through improved fitness, strength, and functional performance measures (strength, endurance, aerobic fitness, fatigability, and mobility). Evidence suggests that exercise in persons with MS also has the same effect and benefits for those who are not experiencing an exacerbation,8 but has no effect on the prognosis or progression of MS.1-4, 6, 8, 9 The benefits of strength training include improved scores on tests which quantify well-being, physical function, walking speed, strength, flexibility and balance. When individualized and prescribed carefully, there is no convincing evidence that strength training at moderate intensities has any deleterious effects for patients with MS.2, 8 It is important to increase functional reserve early in the disease process by maintaining and/or even increasing underlying physical fitness levels.6 Over time, disability can accumulate from repeated exacerbations. Although the focus of this article is on strength training, cardiovascular training also has been shown to be an effective means of improving measures of fitness and health. These include aerobic threshold, health perception, increased levels of activity, reduction of fatigue, and even better bowel and bladder function.1, 5, 9

How Multiple Sclerosis Effects Exercise

Patients with MS often have been advised to avoid exercise because neurological symptoms can be brought about by physical activity and, can induce fatigue and thermo-sensitivity.3, 6, 7 A variety of symptoms and physical impairments, which are related to disease severity, can negatively effect the exercise response. Common symptoms and effects may include spasticity, ataxia (loss of coordination), impaired balance, fatigue, muscle weakness, partial or full paralysis, and heat sensitivity. In addition, autonomic nervous system dysfunction can blunt heart rate and blood pressure, which can limit cardiorespiratory work capacity.1 Furthermore, in order to produce the same amount of force, persons with MS require greater cortical drive to motor neurons. Altered patterns of muscle innervation and de-conditioning of muscles are possible explanations. Decreased efficiency of motor-unit activation and increased central fatigue appear to be critical factors contributing to impaired motor performance in patients with MS.6 Ultimately, patients moderately affected by MS exhibit a greater metabolic cost of exercise at a given work rate compared with appar-

Resistance Exercise Prescription

Resistance training programs must reach a threshold of intensity and volume necessary to elicit muscular strength adaptations without causing neuromuscular conduction blocks (blockage in a nerve that prevents impulses from being conducted across a given segment although the nerve beyond is viable), which can cause sudden weakness and numbness. The National Center on Physical Activity and Disability (NCPAD)4 suggests the following: · Using an initial workload intensity of 70% of the patient's 10repetition maximum. · Increasing weight/resistance by 10% when it can be lifted for 25 repetitions for two consecutive sessions. · Performing these exercises two to three days a week, · Performing three sets of 8 to 12 repetitions per exercise · Avoiding strength training sessions with the same muscle groups on two consecutive days. Studies by Dalgas3 and White9 evaluated similar exercise regimens and found significant increases in strength (37% to 52% improvement) and functional capacity (8% to 21% improvement). Changes in MS disease related symptoms can warrant frequent modifications in the exercise prescription. Table 1 describes the

Table 1: Muscular Fitness Pyramid

Beneficial for those without motor deficits and can be designed similarly to those for healthy adults without MS (3x/week, three sets of 10-12 repetitions through a full range of motion). This may differ slightly from suggestions from NCPAD, but are generally similar. Address specific disabilities, exercises may need to be adapted to the specific disability. Considerable work should be done to improve balance /coordination, strength, and fatigue. Consider patient's comfort and motivation when selecting specific equipment. Elastic bands, sandbag weights, and water exercises would be appropriate/acceptable modalities. Activities like Tai Chi, yoga, and Swiss Ball exercises can all help Active improve active range of motion. Body-weight exercises can be added Flexibility and Resistive once patients demonstrate significant improvements in strength and activity tolerance. Number of repetitions should be assigned without Exercises increasing fatigue. Passive Range Generally prescribed for participants with severe paresis. This can help to reduce and prevent further contractures and also can mainof Motion tain joint function. Integrated Strength Training Program Specific Muscle Strengthening *Adapted in part from: Petajan JH and White AT 1999, NCPAD Web site



About the Author

"Muscular Fitness Pyramid" developed by Petajan and White.4 Table 2 describes the "functional classification chart" for persons with MS.

Mark A. Patterson, M.Ed., RCEP, is the chair for continuing education for the Clinical Exercise Physiology Association. He works as a clinical exercise physiologist for Kaiser Permanente of Colorado. He currently runs a program for both Cardiovascular Services and the Department of Vascular Therapy, which provides one-on-one consultations, evaluations, exercise prescription and follow up for patients with multiple chronic conditions. He has been president of the Rocky Mountain chapter of ACSM and is currently a member of the ACSM RCEP Practice Board.

Table 2. Functional Classification Chart

N o r m a l ­ No fatigue or thermal sensitivity N o r m a l w i t h Fa t i g u e ( w i t h o r w i t h o u t t h e r m a l s e n s i t i v i t y ) -- Fatigue may consist only of malaise or include a motor component with a decrement in strength occurring with continued activity. M i l d t o M o d e r a t e M o t o r Di s a b i l i t y ­ Aids may be required for ambulation. A hemiparetic or paraparetic syndrome may be present or there may be ataxia. S e v e r e M o t o r Di s a b i l i t y ­ Motor function is lost so that activities of daily living are no longer possible in certain areas, unable to walk or transfer, unable to dress or feed independently. *Functional MS Classifications - Adapted from: Petajan and White 1999


1. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd Edition, Human Kinetics. 2009. 2. Cakit, BD et al., Cycling Progressive Resistance Training for People with Multiple Sclerosis, Am J Phys Med Rehabil 2010; 89: 446-457. 3. Dalgas U, et al., Resistance Training Improves Muscle Strength and Functional Capacity in Multiple Sclerosis, Neurology, 2009; 73: 1478-1484. 4. National Center of Physical Activity and Disability Website ( Updated 3/2/2007. 5. National Multiple Sclerosis Society Web site ( Information accessed 12/10/2010 6. Petajan JH and White AT, Recommendations for Physical Activity in Patients with Multiple Sclerosis, Sports Med 1999; 27 (3): 179-191. 7. Ponichtera-Mulcare, JA, Exercise and Multiple Sclerosis, Med Sci Sports Exerc, 1993; 25 (4): 451-465, 1993. 8. Rietberg, MB, et al., Exercise Therapy for Multiple Sclerosis (Cochrane Review), The Cochrane Library, Issue 1, 2006. 9. White, LJ et al., Resistance Training Improves Strength and Functional Capacity in Persons with Multiple Sclerosis, Multiple Sclerosis 2004; 10: 668-674.

Final Thoughts

It is essential when creating exercise programs for this population to listen and truly understand their needs. Make sure you gain an understanding not only of their exercise and strength needs, but their resources, support system, and daily life environment. Patients with MS have a sense of losing control over their bodies. This fear and symptoms such as fatigue create problems with motivation and adherence to exercise programs. It is helpful to create exercise programs that are fun, interesting, and that get them involved in community and peer support groups. To help ensure success, frequent follow up either by phone or with multiple supervised exercise sessions and evaluations is of value.

Table 3. Common Terms and Definitions


M e d ic a t io n s -- There are multiple medications that are used to treat MS. Ca rd io va s c u la r Dy s a u t o n o m ia -- Irregular function of the autonomic nervous system leading to a blunted heart rate and blood pressure response to exercise, which may require alterations in exercise prescription.4 This also may be partly responsible for heat intolerance. Fa t ig u e -- Can often be severe and affects about 85% of patients.6 It can interfere with daily activities and may not be noticed at rest but can progress in a short duration to total paralysis of a muscle group such as the hip flexors.6


Side effects can include swelling in the legs, cough, shortness of breath, fatigue, joint pain, depression, muscle weakness, and reduced sweating.1, 6 This may require prolonged warm-up and cool-down periods, and use of perceived exertion ratings may be preferred over use of heart rate to guide intensity of exercise.

Exercise a n d Temp era tu re -- An increase of 0.9°F (0.5°C) in body temperature will slow and ultimately block nerve-impulse conduction in demyelinated fibers, resulting in clinically worsening symptoms.6

B a la n c e a n d Co o rd in a t io n -- Falls are common in this population and can be dangerous. Exe rc is e a n d Exa c e r b a t io n s o f M S

In c o n t in e n c e Sp a sticity/Tremo rs

For those with symptoms of fatigue, a balance between regular physical activity and rest are preferred to being sedentary for reduction of fatigue.6 White et al. 9 demonstrated improvements of up to 24% in various measures of fatigue and well being resulting from exercise. Some methods to help combat fatigue include taking 15-minute naps prior to exercise, performing exercises during times when energy levels are at their peak, and alternating between higher and lower intensity level activities during a workout. In addition, performing an extended warm-up and taking 10 to 15-minute breaks during exercise sessions also can reduce fatigue levels.5 Pre-exercise cooling with a cool bath and using misting devices or even commercial cooling garments can be helpful in reducing heat-related MS symptoms and increasing exercise tolerance in certain individuals.6 Periods of exercise should be timed carefully to avoid the hotter periods of the day and prevent excessive fatigue.5 Air temperature should be between 72° (22° C) and 76° F (24.5° C), and pool temperatures between 80° (27° C)and 85° F (29° C).4 Other methods include wearing lightweight shoes to keep feet cooler, drinking plenty of water, dressing in layers to remove as exercise progresses, and running some cold water on your wrists for a few minutes before and after exercise.5 Choose exercise that provides support: in-water exercise, exercise bikes, weight machines vs. free weights, etc.4 Exercises that have patients shift their center of gravity and react to external cues may be of benefit to this population such as simple eye-hand coordination exercises while seated on a Swiss Ball.6 Should an exacerbation occur (may last two to three months), an exercise prescription may need to be modified or even discontinued. If corticosteroid treatment is required, then exercise also should be discontinued.6 Depending on the severity of the exacerbation, slow, gentle stretching, walking, or water exercises can be performed.4 Void the bladder before exercise, and use sports drinks during exercise instead of water.4 Avoid placing feet in plantar-flexion, this can worsen or trigger spasticity in the lower extremity, focus on areas of muscle imbalance, rhythmical/active flexibility prior to exercise and more static stretching post exercise, and focus on flexibility in tight areas.4




BRINGING WHAT'S HIDING TO LIGHT By Margaret Moore (Coach Meg), M.B.A.


Having the Best of Intentions Is Often Not Enough

Statistics show that a large number of New Year's Resolutions are never realized. While the numbers vary from study to study, one thing is clear, people start the New Year with the best of intentions. Some write them down, others proudly announce them to friends and family because they feel certain in their hearts that they will be triumphant. Yet by year's end, success has not been achieved. If they have the motivation and the confidence to succeed but do not, what is missing?

underlying meanings that give rise to behavior, it is very difficult for an individual to sustain new behaviors. Which is why behavioral change takes more than motivation and confidence.

Overcoming Immunity to Change

In their most recent book, Immunity to Change, Kegan and Lahey address the conundrum of unfulfilled New Year's resolutions. They write, "When we make a New Year's resolution, we look at the behaviors we seek to extinguish as bad; we look at the behaviors we want to amplify as good. But until we understand the commitments that make the obstructive behaviors at the same time brilliantly effective, we have not correctly formulated the problem."1 According to the authors, desire and motivation are not enough. The only way to move forward towards lasting change is to discover the hidden commitments we have that obstruct our behaviors--in short, the underlying agenda that is driving us when we should be in the driver's seat. The authors argue that, in addition to our physiological immune system that works to preserve our biological equilibrium, we have a second kind of immunity--an immunity to change, which works to preserve the status quo. Our immunity to change is made up of hidden commitments that drive our behavior. We become "subject to" them to the point where they "have us" in their grip rather than their being an "object" of our thoughts. The authors believe that we must identify these underlying commitments,

Explaining the Gap between Aspiration and Goal Achievement

Harvard psychologists Robert Kegan and Lisa Lahey have spent years studying why our sincere best efforts to change often go awry. The authors are advocates of a theory called constructive-development. The constructive-developmental approach is a combination of two theories--constructivism and development--and describes how we make meaning or interpret our experiences over time. In his book, The Evolving Self, Kegan emphasizes the importance of meaning making in human development. Contending that making meaning is a physical, social, and survival activity, he states, "well-fed, warm, and free of disease, you may still perish if you cannot `mean.'" Kegan and Lahey employ this theoretical scaffolding to address why there is a gap between our aspirations and our ability to effect lasting behavioral change. They maintain that, without significant changes in the

which they call big assumptions, and objectify them, so that we are no longer subject to them. Only then can we achieve lasting behavioral change. How might this work in practice? An example is a client who may complain that no matter how hard she has tried, she cannot lose weight and that her weight is preventing her from finding an intimate partner. In reality, she may have a fear of losing the spontaneity of enjoying food that drives her to eat in an undisciplined fashion. Her underlying commitment to eat with abandon and pleasure trumps her conscious desire to lose weight. When this big assumption is brought to light, then she is free to choose which commitment she wishes to uphold. Now she can proceed towards lasting change by testing her assumption, such as eating a smaller portion size slowly and noticing that she does not feel deprived.

Coaching for Change Tool

In Immunity to Change, Kegan and Lahey offer a valuable approach that can be used by coaches to pinpoint and uproot issues to overcome immunity to change, thus releasing their clients' potential for growth and success. They offer a five column chart that can be used with clients to determine: visible commitment, doing/not doing instead, hidden competing commitments, big assumptions, and a first S.M.A.R.T. test--preparing to test the big assumptions. The authors write, "Our purpose is to put in your hands a new conceptual and practical means to Coaching News (continued on page 13) 9






Over the past 50 years, hundreds of studies have been conducted to determine the optimum number of exercise sets for increasing muscle strength, with much of the research focused on comparisons of single-set and multiple-set training protocols. Although many studies have examined the effects of varying exercise sets on strength development, the results have been equivocal and the professional literature lacks consensus on training recommendations. Even when we look to an authoritative source such as ACSM 's Guidelines for Exercise Testing and Prescription, we see somewhat different directives over the past decade.

In the sixth edition, published in 2000, the guidelines call for apparently healthy adults to, "Perform a minimum of 1 set of 8 to 12 repetitions of each of these exercises to the point of volitional fatigue" (page 160).1 This statement would seem to suggest that single or multiple sets of a resistance exercise may produce similar results with respect to muscle and strength development, which is consistent with "Evidence Category A level of support" in the ACSM 2009 Position Stand: Progressive Models in Resistance Training for Healthy Adults (pages 691 and 694).4 The seventh edition of ACSM's Guidelines for Exercise Testing and Prescription, published in 2006, recommends that healthy adult populations, "Perform one set of each exercise to the point of volitional fatigue" (page 158).2 This statement would seem to indicate that a single set of each resistance exercise is sufficient for muscle/strength development. In the eighth edition, published in 2010, the recommendation for exercise sets is expanded as follows, "Each major muscle group (chest, shoulders, abdomen, back, hips, legs, arms) should be trained with two to four sets. These sets may be of the same exercise or from different exercises affecting the same muscle group" (page 172).3 Although this training guideline does not exclude single-set exercise protocols (e.g., one set of bench presses and one set of incline presses would provide two sets of exercise each for the pectoralis major, anterior deltoids and triceps muscles), it clearly supports multiple sets of the same exercise. During the same time period (1998 to 2010), several large-scale analyses have examined hundreds of studies that compared single-set and multiple-set strength training protocols. Some of the most prominent of these research reviews and meta-analyses are presented in this column. In a review article, Carpinelli and Otto5 examined studies comparing single and multiple set strength training through 1998. These included 13 studies of 1 set versus 2 sets of resistance exercise, 16 studies of 1 set versus 3 sets of resistance exercise, and several studies of more than 3 sets of strength training. Based on their analyses, the authors concluded that, "In fact, the preponderance of evidence suggests that for training durations of 4 to 25 weeks there is no significant difference in the increase in strength or hypertrophy as a result of training with single versus multiple sets." They further stated that, "there is little scientific evidence, and no theoretical physiological basis, to suggest that a greater volume of exercise elicits greater increases in strength or hypertrophy." In other words, according to Carpinelli and Otto, one set of resistance exercise is as effective as multiple sets of resistance exercise for increasing muscle strength and hypertrophy. In 2003, Rhea et al. 8 conducted a meta-analysis of 140 studies to determine the dose-response relationship for strength development. Based on the effect size data calculated in these studies, the authors determined that, "additional strength increases accompany training beyond single-set protocols." Specifically, the effect size data indicated that two sets were more effective that one set, that three sets were more effective than two sets, and that four sets were more effective than three sets. Their analysis led Rhea and associates to state that, "both trained and untrained individuals experience the greatest gains (~twice the treatment effect of single sets) with a mean training volume of four sets per muscle group." In contrast to Carpinelli and Otto's conclusion, Rhea and associates reported that single-set strength training was not as effective as multiple exercise sets, with four sets per muscle group eliciting the greatest gains in strength. More recently, Krieger7 performed a meta-regression of 14 studies (with 30 treatment groups and 92 effect sizes) that compared the effects of single and multiple sets of resistance exercise on muscular strength. Like Rhea and associates, Krieger found that multiple-set training was associated with a larger effect size than single-set training. However, unlike their findings, Krieger's analyses revealed no significant difference between one set per exercise and four to six sets per exercise. Furthermore, Krieger did not find any significant difference between two to three sets per exercise or four to six sets per exercise. However, Krieger did report that two to three sets per exercise were associated with a significantly greater effect size than one set per exercise. Specifically, Krieger's analysis led him to conclude that, "two to three sets per exercise are associated with 46% greater strength gains than one set, in both trained and untrained subjects." Based on these findings, it would appear that there is research support for three different protocols of resistance exercise. The first review5 seemed to favor single-set training, the second review8 indicated that four sets were preferable to fewer training sets, and the third review7 reported that two to three exercise sets (but not four sets) were more effective than one exercise set. From a practical perspective, it may make sense to select a resistance exercise protocol based on a client's training objectives (e.g., maximum strength gains, improved muscular fitness, improved body composition, etc.) and personal factors (e.g., enthusiasm for strength training, time availability, physical condition, etc). In their review of sin-



Building Muscle (continued from page 6) gle-set versus multiple-set resistance training, Galvao and Taaffe6 suggested that the use of single or multiple sets is dependent on the goals of the program and the time available for training. They state that "single-set programs also result in substantial improvements in strength, albeit not to the same level as that for multiple sets, and are recommended when exercise time is limited." In their quantitative analysis of single versus multiple-set resistance exercise protocols, Wolfe et al. ,9 examined program duration (6 to 16 weeks vs. 17 to 40 weeks), and found that multiple sets were superior to single sets over longer training periods. Their data analysis led them to conclude that "single-set programs for an initial short training period in untrained individuals result in similar strength gains as multiple-set programs. However, as progression occurs and higher gains are desired, multiple-set programs are more effective." This statement is consistent with "Evidence Category B level of support" in the ACSM 2009 Position Stand: Progression Models in Resistance Training for Healthy Adults (page 691).4 These would appear to be appropriate guidelines for addressing training sets with new participants. It makes sense to start with 1 set of 8 to 10 resistance exercises, then progress to additional training sets if the client has the desire and time availability to do so. resistance exercise to elicit optimal gains in muscle mass, adequate protein intake is essential.3 For this reason, research has focused on nutritional strategies that may enhance the acute anabolic response to resistance exercise through the stimulation of muscle protein synthesis. Adequate protein ingestion during resistance training programs provides the building blocks for structural components and also organelles that serve as machinery in the protein synthesis process. Because skeletal muscle mass growth is dependent on an increase in the machinery responsible for protein translation (e.g., ribosomes), insufficient dietary protein decreases translation.5 Despite potential increases in mRNA due to increased load, these mRNAs are not efficiently translated into peptides by ribosomes, thereby reducing size gains.


This commentary identifies the cellular basis of muscle growth from gene expression to protein synthesis (DNA mRNA Protein). Molecular pathways have been identified that regulate muscle size, a key determinant of strength. These pathways can be regulated at many different levels, including transcriptional regulation, translational regulation, and protein modification. The next commentary in this series will review the factors that contribute to and modify muscle size, such as exercise training, diet, and supplement use, specifically emphasizing key molecular pathways involved in these processes.

About the Author

Wayne L. Westcott, Ph.D., teaches exercise science and conducts fitness research at Quincy College in Quincy, MA.

About the Author References

1. American College of Sports Medicine (6th edition). ACSM's Guidelines For Exercise Testing and Prescription. Philadelphia: Lippincott, Williams and Wilkins, 2000. p 160. 2. American College of Sports Medicine (7th edition). ACSM's Guidelines For Exercise Testing and Prescription. Philadelphia: Lippincott, Williams and Wilkins, 2006. p 158. 3. American College of Sports Medicine (8th edition). ACSM's Guidelines For Exercise Testing and Prescription. Philadelphia: Lippincott, Williams and Wilkins, 2010. p 172. 4. American College of Sports Medicine Position Stand. Progression models in resistance training for healthy adults. Medicine & Science in Sports & Exercise. 2009; 41: 687-708. 5. Carpinelli, RN and Otto, RM. Strength training: Single versus multiple sets. Sports Medicine, 1998; 26(2): 73-84. 6. Galvao DA and Taaffe DR. Single- vs. multiple-set resistance training: Recent developments in the controversy. Journal of Strength and Conditioning Research, 2004; 18(3): 660-667. 7. Krieger, J.W. Single versus multiple sets of resistance exercise: A meta-regression. Journal of Strength and Conditioning Research, 2009; 23(6): 1890-1901. 8. Rhea MR, Alvar BA, Burkett LN, and Ball SD. A meta-analysis to determine the dose response for strength development. Medicine & Science in Sports & Exercise, 2003. 35(3): 456-464. 9. Wolfe BL, LeMura LM, and Cole PJ. Quantitative analysis of single- vs. multiple-set programs in resistance training. Journal of Strength and Conditioning Research, 2004; 18(1): 35-47. 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.


1. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009; 41: 687-708. 2. Biolo G. Increased rates of muscle protein turnover and amino acid transport after resistance exercise in humans. American journal of physiology. 2009; 268: E514-E520. 3. Fujita S, Dreyer HC, Drummond MJ, Glynn EL, Cadenas JG, Yoshizawa F, Volpi E, and Rasmussen BB. Nutrient signalling in the regulation of human muscle protein synthesis. J Physiol. 2007; 582: 813-823. 4. Goldberg AL, Etlinger JD, Goldspink DF, and Jablecki C. Mechanism of work-induced hypertrophy of skeletal muscle. Medicine and science in sports. 1975; 7: 185-198. 5. Lemon PW, Tarnopolsky MA, MacDougall JD, and Atkinson SA. Protein requirements and muscle mass/strength changes during intensive training in novice bodybuilders. J Appl Physiol. 1992; 73: 767-775. 6. Macdougall JD, Gibala, MJ, Tarnapolsky MA. The time course for elevated muscle protein synthesis following heavy resistance exercise. Can J Appl Physiol. 1995; 20: 480-486. 7. Nader GA, Hornberger TA, and Esser KA. Translational control: implications for skeletal muscle hypertrophy. Clin Orthop Relat Res: 2002; S178-187. 8. Phillips SM, Tipton KD, Aarsland A, Wolf SE, and Wolfe RR. Mixed muscle protein synthesis and breakdown after resistance exercise in humans. Am J Physiol. 1997; 273: E99-107. 9. Sale DG. Neural adaptation to resistance training. Med Sci Sports Exerc. 1988; 20: S135-145.







The current high, and ever increasing, prevalence of type 2 diabetes mellitus (T2DM) is well publicized both to the general p u b l i c a n d t o h e a l t h c a re professionals. The relationship between being overweight and the risk of T2DM diabetes is solid. And the positive effect of regular supervised exercise training on both reducing the risk of diabetes and for diabetes control is well documented. However, there are no reliable sources today to determine the rate of use of clinical exercise physiologists (CEP) to guide exercise for diabetes treatment.

Anecdotally, the use of CEPs in the treatment protocol for those with T2DM appears to be low. Recently a number of articles have been published that are important to the practicing CEP who works with patients attempting to avoid developing diabetes or those who are trying to better control their diabetes. Additionally, these articles can and should be used to promote the value of the CEP. A Joint Position Stand titled "Exercise and Type 2 Diabetes" was published by the American College of Sports Medicine and the American Diabetes Association in December of 2010.1 This replaces the previous Position Stand published in 2000. A primary difference between the previous and current versions of this Position Stand is the current focus upon the necessity of proper supervision during exercise training. The good news for the CEP is that the following statement is directly from the ACSM Position Stand on "Exercise and Type 2 Diabetes:" Individuals with T2DM engaged in supervised training exhibit greater compliance and blood glucose control than those undertaking exercise training without supervision. This ACSM Evidence Statement received a category B level, which indicates that it is supported by a limited number of randomized, controlled trials. Of the six studies used to support this statement, all but one is more recent than the last Position Stand update in 2000. As with other chronic diseases, such as peripheral arterial disease and obesity, supervised exercise training tends to provide the best results versus exercise "on your own." The not so good news from this ACSM Position Stand is the term used for the exercise professional recommended to work with the type 2 diabetes population. They call this person a "qualified exercise trainer." This statement is vague and does not clearly point to any specific qualified professional. It can and should be argued that both the ACSM Clinical Exercise Specialist and the ACSM Registered Clinical Exercise Physiologist are the bestqualified exercise professionals to guide exercise in those with T2DM. In fact, in a study noted within this same Position Stand,3 which used both cardiovascular and resistance training when attempting to mod-



ify cardiovascular risk factors in those with T2DM, exercise specialists were specifically used. The rationale was to use these professionals to improve "efficacy and safety" as well as adherence to the exercise training regimen. While non-clinical exercise professionals would most likely do well with this population, when maximal safety in conjunction with obtaining exercise benefits are critical, using an ACSM credentialed clinical exercise professional is likely the best choice. In 2009 the American Heart Association published a scientific statement titled "Exercise Training for Type 2 Diabetes Mellitus.2" This important document provides an excellent section on exercise training guidelines. Within this section the writing committee specifically states that first line providers (i.e., physicians, nurses, diabetes educators) should refer these patients to a CEP qualified to work with those who have T2DM. Currently the best qualified individuals are those certified by ACSM as Clinical Exercise Specialists and Registered Clinical Exercise Physiologists. Interestingly, this document also states that supervision of exercise training by exercise physiologists in other countries is a standard part of chronic disease management plans. So the United States may be a little behind the curve on utilizing clinical exercise physiologists in these roles. Another important study is the Look AHEAD trial.4 Recently, the four year results of this very important trial were released. This is an 11.5 year study investigating the effects of weight loss on cardiovascular disease risk in those with T2DM. Obviously an important component of the weight loss and maintenance intervention is exercise training. Patients in this study performed both supervised and homebased exercise. Importantly, both supervised sessions and counseling for home-based exercise were provided by exercise specialists. In the best study to date assessing the effectiveness of using a clinical exercise professional (exercise specialist) in those with T2DM, the aforementioned study3 utilizing a combination of cardiovascular and resistance training suggests that supervised exercise is superior to advice and home-based exercise. In this study the improvement of HbA1c was superior during supervised exercise. The authors propose that larger amounts of exercise are required for benefits in this population, suggesting that supervised exercise delivered by a clinical exercise professional is recommended. Based on this information the stage appears to be set for the clinical exercise physiologist to become an important part of the treatment regimen of those with T2DM. And with an ever increasing focus on lifestyle improvement and other preventive health measures the corner may be turning toward an ever increasing presence of clinical exercise professionals associated with these interventions. So you might consider brushing up on your diabetes and exercise knowledge!.

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 has served on ACSM's Committee of Certification and Registry Board from 2000 to 2010 and was chair of the Clinical Exercise Specialist Committee. He also is the senior editor of the 6th 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.


1. American College of Sports Medicine and the American Diabetes Association. Exerices and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12);2282-2303. 2. American Heart Association. Exercise training for Type 2 Diabetes Mellitus: impact on cardiovascular risk. Circulation. 2009;119(25); 3244-3262. 3. Balducci S, Zanuso S, Nicolucci A, et al. Effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus. Arch Intern Med. 2010;170(20):1794-1803. 4. Look Ahead Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus. Arch Intern Med. 2010;170(17):1566-1575.

Coaching News continued from page 9 unleash capabilities in yourself and your colleagues." Their model delivers on their promise.


Behavior change is difficult, even with the best of intentions. A large majority of New Year's resolutions are never realized. Yet, if we look beyond motivation and confidence to the hidden commitments that "have us," and work to fulfill the marvelous visions and goals we have, we can make a fresh start for the New Year.

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 health care and wellness. She is co-director, 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 health care.


1. Kegan R. The Evolving Self: Problem and Process in Human Development. Cambridge: Harvard University Press, 1982. 2. Kegan R. and Lahey LL. Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization. Boston: Harvard Business Press, 2009.



SELF-TEST ANSWER KEY FOR PAGE 15 ------------------------------------------ QUESTION ------------------------------------------ 1 2 3 4 5 D A C A B A C B D B A A A C C C C A B D





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

Exercise practitioners interested in obtaining current health, medical, and science information have a number of reputable, electronic resources and tools available to them. Two extremely useful resources include and the ACSM member Weekly Literature Update. This article will briefly describe these two resources and explain how to access them. is a web resource service of the National Library of Medicine and the National Institutes of Health.1 Users can obtain information on health and diseases, medications and supplements, and on medical diagnostic and surgical procedures. The three major search tabs on the home page include: Health Topics, Drugs and Supplements, and Videos and Cool Tools. Selecting the "health topics" tab enables users to learn about symptoms, causes, treatment, and prevention for more than 800 diseases, illnesses, health conditions, and wellness issues. These topics are reviewed regularly and links are updated daily. The health conditions search area is indexed by body system and location. Readers can access peer reviewed journal articles, information on clinical treatment trials, patient education materials, and general educational material for professionals. Direct access to Web sites for a number of professional, scientific, medical, research, and health organizations is available. There are also sections on "fitness and exercise" for every health condition. Users also gain access to other health and medical search engines. Selecting the "drugs and supplements" tab enables users to perform an alphabetic search of common medications and supplements by both their generic and trade names. Users can learn about drug and supplement uses and indications, actions, side effects and precautions, and storage, emergency action, and dietary instructions. Selecting "cool tools and videos" enables users to watch tutorial videos on anatomy, diagnostic, and surgical procedures and to use a number of self-tests and calculators. Some of these tools enable users to calculate disease risks, track calorie intake and expenditure, and evaluate health information. On exercise professionals are welcome to link to MedlinePlus ( and to any of its health topic pages. Please indicate that the link is to We recommend that you link to: the MedlinePlus homepage ( or MedlinePlus en español ( In addition, users of can access PubMed. PubMed comprises more than 20 million citations for biomedical literature from MEDLINE, life science journals, and online books.2 Exercise professionals also can access PubMed at American College of Sports Medicine (ACSM) members can develop personalized topic searches and access journal articles by using the "Weekly Literature Update."3 This feature is free to ACSM members and includes links to journal articles via the search engine "Medline." Weekly Literature Update also includes book reviews, frequently referenced articles and a health and medical topic article search function. Every Friday, members receive the "Weekly Literature Update," an email that contains reviews of just-published books, e-books, and software in subject areas you have selected. The service offers full access to the Web's most comprehensive database of more than 100,000 book, e-book, and software titles in the health sciences, including expert, timely reviews on more than 25,000 titles. It allows seamless access to Internet bookstores, where you can instantly check price and availability of titles before ordering. The service also provides citations and abstracts for journal articles, as well as links to the full-text when it is available for free (the full text of 10% to 15% of all articles is available for free). Once at the Web site, the subscriber can access the citations and abstracts of all articles added to Medline in the last 52 weeks with a variety of search, browse, and filter tools. If you are an ACSM member and do not currently receive the "Weekly Literature Update," visit acsm/default.aspx to sign up. Users can refine and modify their topic searches as often as they wish. Exercise practitioners have access to free, online services, which can provide them with valuable resources and a wealth of practical and valuable information.


Peter Ronai, M.S., RCEP, CES, PD, CSCS-D, is clinical assistant professor in the Exercise Science Department at Sacred Heart University in Fairfield Connecticut. He is a clinical exercise physiologist and previous Manager of Community Health at the Ahlbin Rehabilitation Centers of Bridgeport Hospital in Connecticut and an adjunct professor in the Exercise Science Department at Southern Connecticut State University. He 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. He is also the "Special Populations" column editor for the National Strength and Conditioning Association's (NSCA) Strength and Conditioning Journal. He is the coeditor of ACSM's Certified News. He also is ACSM Program Director Certified.


1. MedlinePlus: A Free Service of the National Library of Medicine of the National Institutes of Health. ( Accessed January 3, 2011. 2. PubMed: A Service of the National Library of Medicine of the National Institutes of Health. 3. "Weekly Literature Update." A free service to American College of Sports Medicine (ACSM) Members. Accessed January 3, 2011.



January­March 2011 Continuing Education Self-Tests

Credits provided by the American College of Sports Medicine · CEC Offering Expires March 31, 2012

2. Which of the compounds below are linked together to make polypeptides? a. mRNA 1. According the article, METs are a short-hand b. Transcription factors representation of ______ and a quantifier of ______. c. Amino acids a. physical work; heart rate d. DNA b. oxygen utilization; heart rate 3. If "words" are "codes" for amino acids, how many c. heart rate; pulmonary function "letters" make up a "word" of the genetic code? d. oxygen utilization; physical work a. 64 b. 3 2. The ______ is a list of several activities and their c. 9 d. 1 approximate MET values. 4. What is the name of the process where a a. Compendium of Physical Activities polypeptide chain is made? b. Compendium of Metabolic Equivalents a. Transcription c. Physical Activity Guidelines for Americans b. mRNA d. ACSM's Guidelines for Exercise Testing and c. Ribosomal Polymerase Prescription, 8th edition d. Protein synthesis 3. Using MET values, vigorous physical activity for adults 5. Where does mRNA go once it leaves the nucleus? aged 18-64 years is considered to be: a. Cytoplasm a. > 3.5 METs b. Ribosomes b. > 5.0 METs c. Mitochondria c. > 6.0 METs d. None of the above, mRNA remains in the nucleus d. > 7.0 METs from "Making Sense of METs" published on page 3. 4. When designing a program with specific energy expenditure goals, using METs allows for varying duration and intensities because the caloric cost will be equal. For example: 6 METs for 20 minutes is the same as exercising at 4 METs for 30 minutes. a. True b. False 5. Given a certain MET value, a person's RPE and heart rate will not decrease as their fitness improves because METs are absolute. a. True b. False

SELF-TEST #1 (1 CEC):The following questions are

5. According to Petajan and White's Functional Classification of MS, the following describes what classification of disability of MS? Aids may be required for ambulation. A hemiparetic or paraparetic syndrome may be present or there may be ataxia. a. Normal b. Normal with fatigue c. Mild to Moderate Motor Disability d. Severe Motor Disability

SELF-TEST #4 (1 CEC): The following questions were taken from "Online Tips and Tools For Exercise Professionals" published in this issue on page 14.

1. is a service of the: a. U.S. Centers for Disease Control and Prevention (CDC) b. American Cancer Society (ACS) c. National Institutes of Health (NIH) d. National Arthritis Foundation (NAF) 2. How many information tabs appear on the homepage? a. One b. Two c. Three d. Four 3. Which tab on would provide users with health and fitness information? a. Health Topics b. Medications and Supplements c. Cool Tools and Videos d. Interactive Tools 4. According to the article, ACSM members can access article links through which search engine? a. OVID b. Medline c. Sport Discuss d. Index Medicus 5. The service "Weekly Literature Update" is made available by the: a. National Institutes of Health (NIH) b. National Library of Medicine (NLM) c. National Health Information Clearinghouse (NHIC) d. American College of Sports Medicine (ACSM)

SELF-TEST #3 (1 CEC): The following questions are taken from "Strength Training and Multiple Sclerosis" published on page 7.

1. An increase of 0.5°C will slow and ultimately block nerve-impulse conduction in demyelinated fibers, resulting in clinically worsening symptoms. a. True b. False 2. Room air temperatures should be kept between ___ and ___ degrees Fahrenheit during exercise sessions for persons with MS. a. 72-76 b. 70-74 c. 68-70 d. 78-80

SELF-TEST #2 (1 CEC): The following questions are 3. When individualized and prescribed carefully, there is taken from "Building Muscle: Understanding the no convincing evidence that strength training at moderate intensities has any deleterious effects in Building Blocks known as Genes" published on page 5.

1. What is a segment of DNA that stores genetic instructions called? a. Gene b. mRNA c. Codon d. Leucine patients with MS. a. True b. False

4. MS patients with severe paresis should undergo this type of exercise/activity to reduce and prevent further contractures and maintain joint function. a. Isometric Strength Exercises b. Active Range of Motion Exercises c. Passive Range of Motion Exercises d. Moderate intensity aerobic exercise





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, Dept 6022, Carol Stream, IL 60122-6022 ACSM Member (PLEASE MARK BELOW) Please Allow 4-6 weeks for processing of CECs

[ ] Yes-$15 TOTAL $_________________ [ ] No- $20 ($25 fee for returned checks) ID # __________________ (Please provide your ACSM ID number)








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



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