(PDF) The scope of practice for the personal trainer

PERSONAL TRAINING QUARTERLY

PTQVOLUME 1

ISSUE 1

PERSONAL TRAINING QUARTERLY

PTQVOLUME 1

ISSUE 4

ABOUT THIS PUBLICATION

Personal Training Quarterly (PTQ)

publishes basic educational

information for Associate and

Professional Members of the

NSCA specifically focusing on

personal trainers and training

enthusiasts. As a quarterly

publication, this journal’s mission

is to publish peer-reviewed

articles that provide basic,

practical information that is

research-based and applicable to

personal trainers.

Strength and Conditioning

Disclaimer: The statements

and comments in PTQ are

those of the individual authors

and contributors and not of

the National Strength and

Conditioning Association. The

appearance of advertising in this

journal does not constitute an

endorsement for the quality or

value of the product or service

advertised, or of the claims made

for it by its manufacturer or

provider.

NSCA MISSION

As the worldwide authority on

strength and conditioning, we

support and disseminate research-

based knowledge and its practical

application, to improve athletic

performance and fitness.

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from you. Write to Personal

Training Quarterly (PTQ) at NSCA

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CONTACT

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Reproduction without permission

is prohibited.

ISSN 2376-0850

EDITORIAL OFFICE

EDITOR:

Bret Contreras, MA, CSCS

PUBLICATIONS DIRECTOR:

Keith Cinea, MA, CSCS,*D, NSCA-CPT,*D

MANAGING EDITOR:

Matthew Sandstead, NSCA-CPT

PUBLICATIONS COORDINATOR:

Cody Urban

EDITORIAL REVIEW PANEL

Scott Cheatham, DPT, PT, OCS, ATC, CSCS

Mike Rickett, MS, CSCS

Andy Khamoui, MS, CSCS

Josh West, MA, CSCS

Scott Austin, MS, CSCS

Nate Mosher, DPT, PT, CSCS, NSCA-CPT

Laura Kobar, MS

Leonardo Vando, MD

Kelli Clark, DPT, MS

Daniel Fosselman

Liz Kampschroeder

Ron Snarr, MED, CSCS

Tony Poggiali, CSCS

Chris Kennedy, CSCS

John Mullen, DPT, CSCS

Teresa Merrick, PHD, CSCS, NSCA-CPT

Ramsey Nijem, MS, CSCS

PERSONAL TRAINING QUARTERLY

PTQ

PTQ 1.4 | NSCA.COM

VOLUME 1

ISSUE 4

TABLE OF CONTENTS

PTQ 1.1 | NSCA.COM

PTQ 1.4 | NSCA.COM

04

10

HIGH HORMONE CONDITIONS FOR HYPERTROPHY

WITH RESISTANCE TRAINING: A BELIEF—NOT

EVIDENCE-BASED PRACTICE IN STRENGTH

AND CONDITIONING

STUART PHILLIPS, PHD, CSCS, FACSM, FACN, ROBERT

MORTON, CSCS, AND CHRIS MCGLORY, PHD

SMALL GROUP TRAINING UTILIZING CIRCUITS

CHAT WILLIAMS, MS, CSCS,*D, CSPS,

NSCA-CPT,*D, FNSCA

THE SCOPE OF PRACTICE FOR

PERSONAL TRAINERS

JUSTIN KOMPF, CSCS, NSCA-CPT, NICK TUMMINELLO,

AND SPENCER NADOLSKY, MD

EXERCISE BEFORE AND AFTER

BARIATRIC SURGERY

CINDY KUGLER, MS, CSCS, CSPS

GETTING THE MOST OUT OF A CERTIFICATION IN

PERSONAL TRAINING

ROBERT LINKUL, MS, CSCS,*D, NSCA-CPT,*D

THE SHARED ADAPTATIONS OF THE TRAINING AND

REHABILITATION PROCESSES

CHARLIE WEINGROFF, DPT, ATC, CSCS

HOW SAFE ARE SUPPLEMENTS?

DEBRA WEIN, MS, RD, LDN, NSCA-CPT,*D, AND

JENNA AMOS, RD

30

26

24

20

16

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM

4

JUSTIN KOMPF, CSCS, NSCA-CPT, NICK TUMMINELLO, AND SPENCER NADOLSKY, MD

T

h

e persona

l

trainer can p

l

a

y

a vita

l

ro

l

e in t

h

e overa

ll

h

ea

l

t

h

and well-bein

g

in each of their clients. The purpose of this

article is to define the role of the

p

ersonal trainer. This

article will also explore the extent o

f

their scope and will identi

f

y

when a referral to a healthcare

p

rovider would be a

pp

ro

p

riate.

Out of the major, recognized certif

y

ing bodies, the American

Colle

g

e o

f

Sports Medicine (ACSM) and the National Stren

g

th and

Con

d

itioning Association (NSCA) are t

h

e on

ly

two organizations

that have attempted to delineate the speci

f

ic

j

ob description o

f

t

h

e

p

ersona

l

trainer.

Accor

d

in

g

to t

h

e ACSM (1):

The ACSM Certified Personal Trainer

(

CPT

)

works with

apparent

ly

h

ea

l

t

hy

in

d

ivi

d

ua

l

s an

d

t

h

ose wit

h

ea

l

t

h

c

h

a

ll

enges w

h

o are a

bl

e to exercise in

d

epen

d

ent

ly

to en

h

ance

qualit

y

of life, improve health-related ph

y

sical fitness,

performance, mana

g

e health risk, and promote lastin

g

health

b

e

h

avior c

h

an

g

e. T

h

e CPT con

d

ucts

b

asic pre-participation

h

ea

l

t

h

screenin

g

assessments, su

b

maxima

l

aero

b

ic exercise

tests, and muscular strength

/

endurance, flexibilit

y

, and

bod

y

composition tests. The CPT facilitates motivation and

a

dh

erence as we

ll

as

d

eve

l

ops an

d

a

d

ministers pro

g

rams

designed to enhance muscular strength

/

endurance, flexibilit

y

,

cardiorespirator

y

fitness, bod

y

composition, and

/

or an

y

of the

motor skill related components of ph

y

sical fitness (i.e., balance,

coor

d

ination, power, agi

l

it

y

, spee

d

, an

d

reaction time).

Li

k

ewise, accor

d

in

g

to t

h

e NSCA (13):

P

ersonal trainers are health

/

fitness professionals who, using an

in

d

ivi

d

ua

l

ize

d

a

pp

roac

h

, assess, motivate, e

d

ucate, an

d

train

clients regarding their health and

f

itness needs. The

y

design

sa

f

e and e

ff

ective exercise pro

g

rams, provide the

g

uidance to

help clients achieve their personal health

/

fitness

g

oals, and

respon

d

appropriate

ly

in emergenc

y

situations. Recognizing

their own area of expertise, personal trainers refer clients to

other healthcare

p

rofessionals when a

pp

ro

p

riate.

Personal trainers should fulfill a s

p

ecific role within the healthcare

s

y

stem an

d

as a

h

ea

l

t

h

care provi

d

er. Trainers s

h

ou

ld

h

ave a strong

k

now

l

e

d

ge

b

ase in

k

inesio

l

og

y

, ps

y

c

h

o

l

og

y

, injur

y

prevention,

nutrition, and knowled

g

e of simple medical screenin

g

tests.

Because of this, the

y

ma

y

share certain roles with other healthcare

provi

d

ers suc

h

as

d

ietitians, p

hy

sica

l

t

h

erapists,

d

octors, an

d

ps

y

c

h

o

l

ogists.

Be

f

ore divulging into the scope o

f

the practice, it is necessar

y

for personal trainers to identif

y

two major components of their

profession; research and practical experience, more specificall

y

the application o

f

research to practice. In a review b

y

English et

al., the author defines evidence-based training for strength and

conditioning professionals as a s

y

stematic approach to the training

of

a

thl

e

t

e

s

a

nd

c

li

e

nts b

a

s

e

d

o

n th

e

c

urr

e

nt b

e

st

e

vid

e

n

ce

f

r

o

m

peer-reviewed and professional reasoning (6). Evidence-based

practice is a five step s

y

stematic process. The five steps are to

develop a question,

f

ind evidence, evaluate the evidence, inte

g

rate

t

h

e evi

d

ence into

p

ractice, an

d

reeva

l

uate t

h

e evi

d

ence.

THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM 5

The question should be de

f

ined precisel

y

; the authors provide

t

he acron

y

m “PICOT,” which stands

f

or population, intervention,

com

p

arison, outcome, an

d

time (6). T

h

e

q

uestion t

h

at trainers

ask should contain all of these com

p

onents. For exam

p

le, is a

resistance trainin

g

pro

g

ram (intervention) of pull-ups or

c

h

in-ups (comparison) a

b

etter

b

iceps musc

l

e

b

ui

ld

er (outcome)

in health

y

college-aged males (population) over the course o

f

12 wee

k

s

(

time

)?

Evidence can be obtained through a variet

y

of sources. Some

sources persona

l

trainers s

h

ou

ld

consi

d

er usin

g

inc

l

u

d

e aca

d

emic

searc

h

en

g

ines as we

ll

as we

b

sites

l

i

k

e t

h

e Nationa

l

Stren

g

t

h

an

d

Conditionin

g

Association website (www.nsca.com). Pro

f

essional

experience can a

l

so

b

e counte

d

as anec

d

ota

l

evi

d

ence a

l

t

h

ou

gh

it is not as stron

g

as a form of evidence as peer-reviewed studies.

T

h

e a

b

i

l

it

y

to eva

l

uate evi

d

ence an

d

weig

h

it against ot

h

er

evidence is an im

p

ortant skill

f

or the success o

f

a

p

ersonal trainer.

The Journal of Bone and Joint Surger

y

introduced a s

y

stem for

rankin

g

levels of evidence. The levels of evidence in order from

l

owest to

h

i

gh

est are: expert opinion; case series (no contro

l

group); case-contro

l

stu

dy

, retrospective co

h

ort stu

dy

, an

d

s

y

stematic review o

f

level-III studies; prospective cohort stud

y

,

poor qualit

y

randomized controlled trial, s

y

stematic review of level

II stu

d

ies, an

d

non

h

omo

g

eneous

l

eve

l

I stu

d

ies; an

d

ran

d

omize

d

controlled trial and s

y

stematic review of level I randomized

contro

ll

e

d

tria

l

s

(

19

).

If the evidence presented is strong, then a training modalit

y

s

h

ou

ld

b

e inte

g

rate

d

into practice. For examp

l

e, it

h

as

b

een proven

t

hat Ol

y

mpic-st

y

le lifting improves explosive power (3,18). If a

persona

l

trainer is wor

k

in

g

wit

h

an at

hl

ete t

h

at requires exp

l

osive

power, t

h

en t

h

e

y

s

h

ou

ld

consi

d

er integrating some O

ly

mpic-st

yl

e

wei

g

htliftin

g

. If the evidence is weak or inconsistent, then perhaps

t

ime wou

ld

b

e

b

etter spent on ot

h

er trainin

g

practices (6)

.

Bein

g

a

bl

e to eva

l

uate researc

h

means

k

eepin

g

an open min

d

,

as t

h

e evi

d

ence-

b

ase

d

persona

l

trainer wi

ll

c

h

an

g

e t

h

eir practice

w

h

en new an

d

b

etter evi

d

ence

d

eman

d

s are

p

resente

d

. Once t

h

e

personal trainin

g

field as a whole understands how to evaluate

evidence, the scope of practice ma

y

expand; however, for now,

personal trainers should focus specificall

y

on exercise screening

an

d

prescription. Persona

l

trainers can a

l

so

h

o

ld

some

g

roun

d

in injur

y

management, ps

y

c

h

o

l

og

y

, an

d

nutrition. Given t

h

e

appropriate e

d

ucationa

l

b

ac

k

groun

d

, persona

l

trainers ma

y

also pla

y

a role in working with populations with speci

f

ic

me

d

ica

l

im

p

airments.

EXERCISE ASSESSMENT AND PRESCRIPTI

O

N

Persona

l

trainers provi

d

e resistance trainin

g

exercise prescription

which ma

y

improve cardiovascular

f

unction, reduce the risk

of coronar

y

heart disease and noninsulin dependent diabetes,

p

revent osteo

p

orosis, reduce the risk of colon cancer, enhance

weig

h

t

l

oss w

h

i

l

e preserving musc

l

e mass, improve

dy

namic

stabilit

y

, and maintain functional capacit

y

and ps

y

chological

we

ll

-

b

ein

g

(17). T

h

e persona

l

trainer s

h

ou

ld

h

ave an esta

bl

is

h

e

d

screening protoco

l

inc

l

u

d

ing a p

h

ysica

l

activity rea

d

iness

q

uestionnaire as we

ll

as a movement screen, w

h

ic

h

s

h

ou

ld

b

e

conducted before resistance trainin

g.

T

h

e P

hy

sica

l

Activit

y

Rea

d

iness Questionnaire (PAR-Q) is a

screening test

d

esigne

d

to

d

etermine an in

d

ivi

d

ua

l

’s ris

k

s in

participating in p

hy

sica

l

activit

y

(7). T

h

e PAR-Q a

ll

ows t

h

e

personal trainer to identif

y

clients with cardiovascular disease

or risk factors for disease. If a client is identified as “at risk” the

y

should be re

f

erred to a medical pro

f

essional who will provide a

medical evaluation be

f

ore beginning an exercise program (11).

While there are a variet

y

of movement screens available to the

personal trainer, the

y

all provide similar outcomes and offer

insi

g

ht as to which exercises can be performed in a safe and

non-pain

f

ul wa

y

.

Pe

rs

o

n

a

l tr

a

in

e

rs sh

o

uld b

e

a

bl

e

t

o

t

a

k

e

th

e

in

fo

rm

a

ti

o

n

f

r

o

m th

e

ir

screenin

g

process to create an exercise pro

g

ram for each client

based on their current ph

y

sical capabilities. Effective strength

training programs inc

l

u

d

e mu

l

ti-

j

oint movements w

h

ic

h

ave

b

een

grouped in a variet

y

o

f

di

ff

erent wa

y

s. For example, Kritz et al.

states that there are seven fundamental patterns: squat, lun

g

e,

upper

b

o

dy

pus

h

, upper

b

o

dy

pu

ll

,

b

en

d

, twist, an

d

sing

l

e-

l

eg

patterns (9). If a trainer screens a client and discovers that the

y

are new to exercise an

d

possess

l

imite

d

h

ip mo

b

i

l

it

y

, t

h

e persona

l

trainer ma

y

want to prescri

b

e a

k

ett

l

e

b

e

ll

h

inge exercise rat

h

er

than a conventional deadlift for the bend categor

y

of movement.

T

h

e ina

b

i

l

it

y

to app

ly

t

h

e screening resu

l

ts to an exercise program

could lead to frustration and

/

or injur

y

.

A persona

l

trainer s

h

ou

ld

a

l

so

b

e competent in coac

h

in

g

an

d

teaching a variet

y

of exercises. Trainers should be able to coach

a

b

asic

h

inge an

d

b

o

dy

weig

h

t squat to t

h

eir c

l

ients. In t

h

at, t

h

e

j

ob of the personal trainer is to find the safest and most effective

means of helpin

g

clients achieve their performance and

/

or

ph

y

sical goals (e.g., become stronger, bigger, leaner, and

f

aster).

The job of the personal trainer is to help their client achieve these

goa

l

s w

h

i

l

e wor

k

ing aroun

d

an

y

ac

h

es, pains, or

l

imitations.

T

HE PERS

O

NAL TRAINER’S R

O

LE WITH

INJ

U

RED

C

LIENT

S

In regards to the specific job description of the ph

y

sical therapist,

accor

d

ing to t

h

e Maine P

hy

sica

l

T

h

erap

y

Practice Act (16):

T

he practice o

f

ph

y

sical therap

y

includes the evaluation,

treatment, and instruction of human bein

g

s to detect, assess,

prevent, correct, a

ll

eviate, an

d

l

imit p

hy

sica

l

d

isa

b

i

l

it

y

,

b

o

d

i

ly

malfunction, and pain from injur

y

, disease, and an

y

other

b

o

d

i

ly

con

d

ition; t

h

e a

d

ministration, interpretation, an

d

evaluation of tests and measurements of bodil

y

functions and

structures for the purpose of treatment plannin

g

; the plannin

g

,

administration

,

evaluation

,

and modification of treatment and

instruction; and the use of ph

y

sical agents and procedures,

activities, and devices

f

or

p

reventive and thera

p

eutic

p

ur

p

oses;

and the

p

rovision of consultative, educational, and other

advisor

y

services for the purpose of reducing the incidence

and severit

y

of ph

y

sical disabilit

y

, bodil

y

malfunction, and pain.

6PTQ 1.4 | NSCA.COM

Additionally, the Florida State Physical Therapy Practice Act

describes what a physical therapy assessment entails (14):

Physical therapy assessment means observational,

verbal, or manual determinations of the function of

the musculoskeletal or neuromuscular system relative

to physical therapy, including, but not limited to, range

of motion of a joint, motor power, postural attitudes,

biomechanical function, locomotion, or functional abilities,

for the purpose of making recommendations for treatment.

Based on these above job descriptions provided by the certifying

bodies in each profession, it is clear and obvious that the

assessments of muscle imbalances, compensations, movement

impairments, and other orthopedic issues and the attempt to

correct these issues using specific exercise interventions, is the

job of the physical therapist and/or orthopedic specialist, not of

the personal trainer. Physical therapists and orthopedic specialists

work specifically to fix what is broken or severely injured, whereas

personal trainers and coaches work to enhance what is not broken.

Put simply, training consists of assessing what they currently have

and using general exercise to improve on what they currently

have while working around what is broken or severely injured. On

the other hand, treatment, which is in the realm of the physical

therapist and/or orthopedic specialist, is the diagnosing of what is

broken and using specific corrective measures to fix it in order to

bring the clients back to what they previously had. When it comes

to performing the exercises provided in a way that best fits the

client, there are two simple criteria:

1. Comfort: Movement is pain-free, feels natural, and works

within the client’s current physiology

2. Control: The client can demonstrate the movement

technique and body positioning as provided in each

exercise description (e.g., when squatting, the client

displays good knee and spinal alignment throughout, along

with smooth, deliberate movement)

It is important to keep in mind that “comfort” does not mean the

sensation associated with muscle fatigue or “feeling the burn.”

Discomfort refers to aches and pains that exist outside the gym

or flare up when the client performs certain movements. To allow

for comfort and control, personal trainers may have to modify (i.e.,

shorten) the range of motion or adjust the hand or foot placement

of a particular exercise to best fit the client’s current ability and

anatomy.

THE PERSONAL TRAINER’S ROLE IN PSYCHOLOGY

AND NUTRITION COUNSELING

The personal training profession has a solid base not just in

exercise, but in nutrition as well (2). However, a personal trainer is

not qualified like a Registered Dietitian (RD), who can write meal

plans for clients. Nutrition is related to psychology in that most

clients have a fair and very general understanding of what they

need to do to improve their eating habits. The real question, and

the one personal trainers can help with, is why do they not take

the steps to become healthy? Personal trainers should be able

to disseminate information on nutrition, serve as counselors to

behavior change, and act as a motivator for health change. This

can all be done without writing a specific meal plan for a client.

Trainers can implement an effective change protocol to be used

to hasten behavior change. Chip and Dan Heath, the authors of

the book “Switch: How to Change Things When Change is Hard,”

identify two factors that can be modified to help people change

(8). The authors talk about the environment which includes the

person’s network and the path to change, discussing how small

changes are more lasting than big changes. For example, one

longitudinal study showed that if a close, same-sex friend became

obese, that person has a 71% risk of becoming obese as well (4).

Changing environmental habits linked to eating can also help a

client lose weight. Successful behavioral modification interventions

have worked by limiting the place overweight people eat to one

location, which may prevent binge eating or random snacking

(15). The book also explains how to direct the client analytically

and how to get them on board for long-term goals emotionally

(8). Some initial questions a personal trainer may ask a client

could include (8):

1. How ready are you to change on a scale of 1-10?

2. How important is it for you to change on a scale of 1-10?

3. How confident are you that you can change on a scale of

1-10?

4. Of your five closest friends, spouses, partners, and siblings,

how many of them place a strong emphasis on healthy

living?

5. Name the people that do and your relationship with them.

6. Are there any people that are close to you that you feel

negatively affect your health goals? If so, who are these

people and what is your relationship to them?

THE PERSONAL TRAINER’S ROLE IN MEDICAL CARE

Practicing medicine is not within the scope of practice for the

personal trainer. However, there are certain conditions that could

be easily screened by a personal trainer especially if a client does

not spend much time with their physician or even go to their

physician regularly. Personal trainers push a healthy all-around

lifestyle, which includes diet, exercise, and even sl eep. As the

obesity epidemic continues, so do the comorbid conditions that

accompany it, including osteoarthritis, diabetes, hypertension, and

obstructive sleep apnea (OSA) (10). Even through physician visits

are typically short, hypertension and diabetes can be easily and

regularly screened.

Osteoarthritis is a very common complaint that a patient will see a

doctor for due to pain. OSA, on the other hand, may be missed in

a quick doctor visit. While a personal trainer cannot diagnose OSA,

it would benefit the client if the personal trainer could recognize

the signs of OSA, so that it might not go unnoticed. Personal

trainers could ask questions from validated questionnaires to

THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS

NSCA.com

PTQ 1.4 | NSCA.COM 7

NSCA.com

know when to refer to a doctor. One such questionnaire, the STOP

questionnaire, is an easy way to assess if a client is at risk of

having OSA (5):

1. Snoring: Do you snore loudly? (louder than talking or

heard through closed doors) Y/N

2. Tired: Do you often feel tired, fatigued, or sleepy during

the day? Y/N

3. Observed: Has anyone observed you stop breathing during

your sleep? Y/N

4. Pressure: Do you have or are being treated for high blood

pressure? Y/N

5. Body mass index (BMI): Is your BMI greater than 35 kg/

m2?

6. Age: Are you over the age of 50?

7. Neck circumference: Is your neck circumference greater

than 40 cm?

8. Gender: Is your gender male?

High risk for OSA = 3 or more questions answered “yes”

Low risk for OSA = less than 3 questions answered “yes”

Figure 1 provides some basic examples of scenarios that a personal

trainer may encounter to help decipher whether it is within the

scope of practice or not. It is important for all personal trainers to

be familiar with local bylaws on scope of practice, as they may be

different depending on where the personal trainer lives. Personal

trainers play a vital role in the general health and well-being of

their clients, but it is important for the personal trainer to clearly

understand the extent of their influence to avoid legal implications

and potential injuries to their clients.

FIGURE 1. BASIC EXAMPLES OF A PERSONAL TRAINER’S SCOPE OF PRACTICE (11,12)

INJURED CLIENTS NUTRITION AND PSYCHOLOGY MEDICINE

Within the Scope of Practice

Chronic low back pain and local Facilitation of habit change

Practicing medicine is not

within the scope of practice;

however, trainers may have

knowledge of screens to use

to make appropriate referrals

Pain comes and goes Dissemination of

nutrition knowledge

Minor acute pain Motivational interviewing and

abetment of change talk

When a Referral is Necessary

Unmanageable pain

with movement Eating disorder PAR-Q indicates potential

cardiovascular disease

Unable to complete activities

of daily living Metabolic disease

Positive screen for OSA

or other conditions

Radiating low back pain Client has been following

healthy habit changes but

is not losing weight

8PTQ 1.4 | NSCA.COM

REFERENCES

1. American College of Sports Medicine. ACSM Certified Personal

Trainer job task analysis. ACSM.org. 2010. Retrieved 2014 from

http://certification.acsm.org/files/file/JTA%20CPT%20FINAL%20

2012.pdf.

2. Carter, L. The personal trainer: A perspective. Strength and

Conditioning Journal 23(1): 14-17, 2001.

3. Channell, BT, and Barfield, JP. Effect of Olympic and

traditional resistance training on vertical jump performance

improvement in high school boys. The Journal of Strength and

Conditioning Research 22(5): 1522-1527, 2008.

4. Christakis, NA, and Fowler, JH. The spread of obesity in large

social network over 32 years. N Engl J Med 357(4): 370-379, 2007.

5. Chung, F, Yegneswaran, B, Liao, P, Chung, SA, Vairavanathan,

S, Islam, S, Khajehdehi, A, and Shapiro, CM. STOP questionnaire:

A tool to screen patients with obstructive sleep apnea.

Anesthesiology 108: 812-821, 2008.

6. English, KL, Amonette, WE, Graham, M, and Spiering, B. What

is “evidence-based” strength and conditioning? Strength and

Conditioning Journal 34(3): 19-24, 2012.

7. Evetovich, TK, and Hinnerichs, KR. Client consultation and

health appraisal. In: Coburn, JW, and Malek, MH (Eds.), NSCA’s

Essentials of Personal Training. (2nd ed.) Champaign, IL: Human

Kinetics; 147-200, 2012.

8. Heath, C, and Heath, D. Switch: How to Change Things When

Change Is Hard. New York, NY: Broadway; 2010.

9. Kritz, M, Cronin, J, and Hume, P. Screening the upper body

push and pull patterns using bodyweight exercises. Strength and

Conditioning Journal 32(3): 72-82, 2010.

10. Kushner, R. Roadmaps for Clinical Practice: Case Studies in

Disease Prevention and Health Promotion-A Primer for Physicians;

Communication and Counseling Strategies. Chicago, IL: American

Medical Association; 2003.

11. McNeely, E. Prescreening for the personal trainer. Strength

and Conditioning Journal 30(5): 68-69, 2008.

12. Mikla, T, and Linkul, R. Drawing the line: The CPT’s scope of

practice. National Strength and Conditioning Association National

Conference, July 2012.

13. National Strength and Conditioning Association. NSCA

Certified Personal Trainer (NSCA-CPT). NSCA.com. Retrieved 2014

from http://www.nsca.com/Certification/CPT/.

14. Official Internet Site of the Florida Legislature: Online

Sunshine. The 2014 Florida statutes. 2014. Retrieved 2014

from http://www.leg.state.fl.us/statutes/index.cfm?App_

mode=Display_Statute&Search_String=&URL=0400-0499/0486/

Sections/0486.021.html.

15. Penick, SB, Lilion, R, Fox, S, and Stunkard, AJ. Behavior

modification in treatment of obesity. J Behav Med 33: 49-56, 1971.

16. Public Laws: 123rd Legislature First Regular Session. Section

N-2 32 MRSA 3111-A: Scope of practice. Retrieved 2014 from

http://www.mainelegislature.org/ros/LOM/lom123rd/PUBLIC402_

ptN.asp.

17. Ratamess, NA, Alvar, BA, Evetoch, TK, Housch, TJ, Kibler, WB,

Kraemer, WJ, and Triplett TN. Progression models in resistance

training for healthy adults. Med Sci Sports Exerc 41: 687-708, 2009.

18. Suchomel, TJ, Wright, GA, Kernozek, TW, and Kline, DE.

Kinetic comparison of the power development between power

clean variations. The Journal of Strength and Conditioning

Research 28(2): 350-360, 2014.

19. Wright, JG, Swiontkowski, MF, and Heckman, JD. Introducing

levels of evidence to the journal. J Bone Joint Surg Am 85(1): 1-3,

2003.

ABOUT THE AUTHOR

Justin Kompf is the Head Strength and Conditioning Coach at

the State University of New York at Cortland. He is a Certified

Strength and Conditioning Specialist® (CSCS®) and a Certified

Personal Trainer® (NSCA-CPT®) through the National Strength and

Conditioning Association (NSCA).

Nick Tumminello is the owner of Performance University, which

provides practical fitness education for fitness professionals

worldwide, and is the author of the book “Strength Training

for Fat Loss.” Tumminello has worked with a variety of clients

from National Football League (NFL) athletes to professional

bodybuilders and figure models to exercise enthusiasts. He also

served as a conditioning coach for the Ground Control Mixed

Martial Arts (MMA) Fight Team and is a fitness expert for Reebok.

Tumminello has produced 15 DVDs, is a regular contributor to

several major fitness magazines and websites, and writes a very

popular blog at PerformanceU.net.

Spencer Nadolsky is a licensed practicing family medicine resident

physician. After a successful athletic career at the University of

North Carolina at Chapel Hill, Nadolsky enrolled in medical school

at the Virginia College of Osteopathic Medicine with aspirations to

change the world of medicine by pushing lifestyle changes before

drugs (when possible). Proper lifting, eating, laughter, and sleeping

are medications he advocates.

THE SCOPE OF PRACTICE FOR PERSONAL TRAINERS

NSCA.com

PTQ 1.4 | NSCA.COM 9

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM

10

CINDY KUGLER, MS, CSCS, CSPS

A

s reports

f

rom the Centers

f

or Disease Control and

Prevention in

d

icate, o

b

esit

y

continues to remain

h

ig

h

an

d

is associate

d

wit

h

ig

h

mor

b

i

d

it

y

an

d

morta

l

it

y

rates (3).

The increase in obesity results in a higher volume o

f

bariatric

s

ur

g

eries bein

g

performed (10). This increases the likelihood that

exercise professionals workin

g

in various settin

g

s will encounter

patients w

h

o are pre- or post-

b

ariatric surger

y

. T

h

is artic

l

e wi

ll

address exercise-related issues and pro

g

rammin

g

needs specific

to t

h

e

b

ariatric sur

g

ica

l

c

l

ient

.

T

YPES

O

F SURGERY

Bariatric surger

y

falls into two main categories, restrictive

p

rocedures and malabsor

p

tive

p

rocedures. Both of these

t

y

pes can

b

e

d

one eit

h

er

l

aparoscopica

lly

or wit

h

an open,

l

ar

g

er incision. Restrictive proce

d

ures inc

l

u

d

e

g

astric

b

an

d

an

d

s

l

eeve gastrectom

y

. T

h

ese proce

d

ures

d

ecrease t

h

e size

o

f th

e

st

o

m

ac

h r

e

s

e

rv

o

ir s

o

a

s t

o

limit f

oo

d int

a

k

e

.

Ma

l

a

b

sor

p

tive

p

roce

d

ures inc

l

u

d

e

b

i

l

io

p

ancreatic

d

iversion,

in which a

p

ortion of the stomach is removed and a

p

art of

t

h

e sma

ll

b

owe

l

is

by

passe

d

; t

h

us, causing weig

h

t

l

oss

by

decreased absorption of food. The Roux-en-Y gastric b

y

pass

p

roce

d

ure is anot

h

er ma

l

a

b

sor

p

tive

p

roce

d

ure w

h

ic

h

a

l

so

includes a restrictive com

p

onent

.

PRE-S

U

R

G

I

C

AL ASSESSMEN

T

Due to the possible complications and risks of surger

y

, a

mu

l

ti

d

iscip

l

inar

y

pre-operative assessment is

d

one to

d

etermine

appropriate surgica

l

can

d

i

d

ates (11,13). T

h

e patient s

h

ou

ld

h

ave a

compre

h

ensive me

d

ica

l

, p

hy

sica

l

, an

d

ps

y

c

h

o

l

ogica

l

assessment.

See Table 1 for pre-screenin

g

criteria examples

.

T

h

e primar

y

exercise o

b

jectives pre-surger

y

are to assess t

h

e

client’s abilit

y

to

f

ollow the li

f

est

y

le change necessar

y

f

or long-

term success an

d

to

d

ecrease t

h

e surgica

l

ris

k

s

by

increasing

cardiorespirator

y

fitness (3,16). After surger

y

, not onl

y

is exercise

essential

f

or lon

g

-term wei

g

ht loss, it has also been shown to be

critica

l

in re

d

ucin

g

h

ea

l

t

h

ris

k

s (5)

.

PRE-S

U

R

G

I

C

AL TESTIN

G

Exercise testin

g

is beneficial to assist in exercise prescription

(

initial and on

g

oin

g

), monitorin

g

pro

g

ress and

g

ivin

g

feedback

to t

h

e c

l

ient, trainer, an

d

p

hy

sician. Initia

l

testing s

h

ou

ld

b

e

d

one

pre-surger

y

and repeated at regular intervals—a minimum of ever

y

t

h

ree mont

h

s post-surger

y

is recommen

d

e

d

. Prior to testing an

d

exercise, medical clearance from the patient’s surgeon or primar

y

p

hy

sician s

h

ou

ld

b

e o

b

taine

d

(1). I

d

ea

lly

,

y

et rare

ly

avai

l

a

bl

e,

having results of a ph

y

sician-supervised stress test to assist in

pro

g

ram desi

g

n and risk assessment would be beneficial (7).

Additional beneficial tests include

(

8,17

):

• Cir

c

um

fe

r

e

n

ce

m

ea

sur

e

m

e

nt

s

• Bod

y

composition (using dual-energ

y

x-ra

y

absorptiometr

y

[DEXA] or bod

y

fat assessment

)

•

6

-min w

alk

t

e

st

•

Sit and reach

(

modified if indicated

)

EXERCISE BEFORE AND AFTER BARIATRIC SURGERY

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM 11

•

Grip

dy

namometer

•

M

odi

f

ied push-up (wall i

f

indicated

)

•

M

eta

b

o

l

ic testing (in

d

irect ca

l

orimetr

y

to

d

etermine resting

meta

b

o

l

ic rate

)

PRE-S

U

RGICAL EXERCISE

P

hy

sica

l

activit

y

recommen

d

ations s

h

ou

ld

ta

k

e into account

muscu

l

os

k

e

l

eta

l

issues, activit

y

to

l

erance, a

l

ong wit

h

persona

l

preferences. Adherence will decrease if the pro

g

ram is not

practica

l

, easi

ly

accomp

l

is

h

e

d

, an

d

a

bl

e to

b

e integrate

d

into an

individual’s li

f

est

y

le. A gradual progression o

f

aerobic exercise

based on tolerance, as well as resistance training and

f

lexibility

t

rainin

g

is recommen

d

e

d

. In or

d

er to meet t

h

e pre-sur

g

ica

l

exercise goals of predicting long-term success via lifest

y

le change

an

d

ecreasin

g

sur

g

ica

l

ris

k

s, exercise s

h

ou

ld

b

e

g

in 8 – 12 wee

k

s

prior to surger

y

. T

h

ose wit

h

weig

h

t

b

earing

l

imitations s

h

ou

ld

f

ocus on low-impact exercise such as recumbent bic

y

cles, chair

exercise, and water exercise. With water exercise, findin

g

an

environment the client will feel comfortable in will be im

p

ortant.

Uti

l

izing assistive

d

evices suc

h

as canes, grocer

y

carts, or wa

lk

ing

sticks along with an

y

needed supportive devices such as braces

/

sleeves, orthotics, or abdominal binders ma

y

assist in success

f

ul

am

b

u

l

ation. T

h

e overa

ll

g

oa

l

is to esta

bl

is

h

a consistent routine

of cardiovascular exercise 3 – 5 times

p

er week at low levels.

Often this population begins with ver

y

low exercise tolerance.

Man

y

will need to start at 5 – 10 min o

f

exercise and progress to

30 min. T

h

is may inc

l

u

d

e intermittent

b

outs wor

k

ing towar

d

s t

h

e

recommen

d

e

d

150 min

p

er wee

k

(16).

Resistance trainin

g

should include one set of 12 – 15 repetitions 2 –

3 times per week utilizing bands, tubing, and

/

or bod

y

weight with

8 – 10 exercises

f

or a total body workout. Important in exercise

s

e

l

ec

ti

o

n is t

o

in

c

lud

e

x

e

r

c

is

e

s f

o

r th

e

a

bd

o

min

a

l mus

c

ul

a

tur

e

.

T

h

is wi

ll

assist in post-surgica

l

movement an

d

recover

y

. Exercises

ma

y

need to be designed to be performed primaril

y

in a sitting

position, wit

h

l

imite

d

stan

d

in

g

positions as to

l

erate

d

. See Ta

bl

e 2

f

or a sample resistance trainin

g

pro

g

ram

.

P

O

ST-SURGICAL EXERCISE PRESCRIPTI

ON

Qualit

y

of life can be greatl

y

improved after successful bariatric

surger

y

(5). Exercise is one o

f

the ke

y

tools

f

or achieving weight

l

oss an

d

preventing weig

h

t gain post-surger

y

(14). Resistance

exercise ma

y

a

l

so

h

e

l

p

by

preventing musc

l

e

l

oss associate

d

wit

h

rapi

d

wei

gh

t

l

oss, increasin

g

b

one stren

g

t

h

, an

d

ecreasin

g

t

h

e

chance o

f

osteo

p

orosis (8,9)

.

Immediate post-surgical exercise ma

y

also reduce the risk of

bl

oo

d

c

l

ots an

d

ot

h

er

p

ost-o

p

erative com

pl

ications. In a

dd

ition,

it can

h

e

lp

p

atients to

l

erate t

h

eir

p

ost-o

p

erative

d

iet, assist in

a

ll

eviating nausea, an

d

ai

d

in getting t

h

e

d

igestive s

y

stem moving

again. Post-

b

ariatric surger

y

exercise is consistent wit

h

gui

d

e

l

ines

p

rescribed for obese clients (15)

.

CARDI

O

RESPIRAT

O

RY EXERCISE

Initia

l

in-

h

ospita

l

exercise t

h

roug

h

two wee

k

s post-surger

y

s

h

ou

ld

consist o

f

low-level exercise such as walking, seated marching,

c

h

air

b

oxing, or stationar

y

recum

b

ent

b

ic

y

c

l

ing as to

l

erate

d

(

usua

lly

5 – 10 min sessions) 3 – 4 times per

d

a

y

. Increasing

d

uration s

l

ow

ly

to 20 – 30 min, using mu

l

tip

l

e

b

outs is accepta

bl

e

t

o assist in pro

g

ress

.

D

uring t

h

e next 2 – 4 wee

k

s post-surger

y

, a

dd

itiona

l

mo

d

a

l

ities

can be added alon

g

with water exercise if the incision has healed

f

ull

y

. Continue progression toward 30 – 40 min sessions

f

or 5 – 6

times per week. A

f

ter one month, progress toward 40 – 60 min

f

or

5 – 6 times per wee

k

. T

h

e initia

l

g

oa

l

s

h

ou

ld

b

e to o

b

tain 150 tota

l

min per week with a lon

g

er term

g

oal of 300 total min per week

(15). Intermittent, interva

l

, an

d

circuit trainin

g

exercise protoco

l

s

can be use

f

ul in aiding this progression. A t

y

pical progression is

p

resente

d

in Ta

bl

e 3.

RESISTAN

C

E EXER

C

ISE

P

rior to starting post-surger

y

resistance training, c

l

earance

f

rom the surgeon is required to ensure the abdominal muscles

have healed

f

ull

y

. Abdominal exercises are important to include,

b

ut s

h

ou

ld

wait unti

l

eit

h

er 3 – 6 mont

h

s post-surger

y

or upon

obtainin

g

sur

g

eon’s clearance. The len

g

th of healin

g

time before

b

e

g

innin

g

a

bd

omina

l

exercises is

d

epen

d

ent on w

h

et

h

er t

h

e

surger

y

was done laparoscopicall

y

or open. Clearance

f

or general

resistance training can t

y

pica

lly

b

e o

b

taine

d

in a

b

out 4 – 8 wee

k

s

post-surger

y

. Due to a

b

ariatric c

l

ient’s initia

l

size, t

h

e

y

usua

lly

d

o

not fit comfortabl

y

in selectorize d equipment; therefore, the use

of bands, tubing, free weights, and bod

y

weight exercises ma

y

be

more suitable alternatives (17). Guidelines

f

or resistance trainin

g

follow those recommended for obese clients (15). A t

y

pical

resistance trainin

g

pro

g

ression is presente

d

in Ta

bl

e 4

.

P

roviding variet

y

and time efficient workouts ma

y

assist the

c

l

ient’s pro

g

ress an

d

in

k

eepin

g

t

h

e c

l

ient’s interest

l

eve

l

s

h

i

gh

.

One met

h

o

d

t

h

rou

gh

w

h

ic

h

t

h

is can

b

e accomp

l

is

h

e

d

is to

create a circuit trainin

g

pro

g

ram incorporatin

g

bikin

g

for

approximate

ly

5 min or trea

d

mi

ll

wa

lk

ing wit

h

30 s interva

l

s

of resistance trainin

g

stations

.

FLEXIBILITY EXER

C

ISE

As recommended for joint mobilit

y

, stretching is indicated for a

well-rounded fitness pro

g

ram. Li

g

ht stretchin

g

can be done after

the initial warm-up. To increase flexibilit

y

, stretch post-exercise

a

f

ter muscles are warm. Flexibility exercises should be done 2 – 3

times per wee

k

, 3 – 4 repetitions per musc

l

e

g

roup an

d

static

stretc

h

es s

h

ou

ld

b

e

h

e

ld

15 – 60 s

(

15

).

P

O

PULATI

O

N-SPECIFIC C

O

NSIDERATI

O

NS

Several special concerns ma

y

affect exercise programming,

inc

l

u

d

ing exercise se

l

ection, intensit

y

, an

d

instruction. Specia

l

considerations include ps

y

chological/emotional status,

comor

b

i

d

ities, size an

d

econ

d

itionin

g

, s

k

in issues, an

d

post-

sur

g

ical concerns (6,8,15,17). See Table 5

f

or special consideration

a

n

d

r

eco

mm

e

n

da

ti

o

ns.

Studies have shown that modern societ

y

has little respect for

mor

b

i

dly

o

b

ese in

d

ivi

d

ua

l

s (19). Stigmatization ma

y

l

ea

d

to a

limited number o

f

riends and social involvement, alon

g

with

d

epression (3). Or

g

anizations an

d

persona

l

trainers wor

k

in

g

wit

h

the obese should identif

y

if the

y

have an

y

weight bias and include

sensitivit

y

training. Sensitivit

y

training s

h

ou

ld

inc

l

u

d

e

k

now

l

e

d

ge

on the complex etiolog

y

of obesit

y

, compassion and empath

y

trainin

g

, an

d

environmenta

l

awareness an

d

a

d

aptation nee

d

e

d

to create an atmos

p

here o

f

acce

p

tance (9). It can o

f

ten be

helpful if an or

g

anization or personal trainer can refer a client

to a

q

ualified individual within their

p

rofessional network for

a

pp

ro

p

riate assistance.

12 PTQ 1.4 | NSCA.COM

EXERCISE BEFORE AND AFTER BARIATRIC SURGERY

CONCLUSION

Bariatric surgery is not the “easy way out” or a cosmetic

procedure. It creates a forced lifestyle change, which can be

lifesaving in some cases. Bariatric surgery is one tool to assist

in weight loss for those that meet the requirements. For long-

term success, healthy eating habits, stress management, social

support, regular exercise, and increased daily activity are essential.

Personal trainers play a critical role in helping clients to adopt the

lifestyle that is needed for both recovery and long-term success

by addressing proper exercise protocols and providing appropriate

recommendations. As personal trainers, working with bariatric

clients can be challenging, yet also very rewarding.

REFERENCES

1. Abbott, A. Personal training – litigation insulation. ACSM’s

Health and Fitness Journal 15(5): 40-44, 2011.

2. Barbalho-Moulim, C, Miguel, G, Forti, E, Campos, F, and Costa,

D. Effects of preoperative inspiratory muscle training in obese

women undergoing open bariatric surgery: Respiratory muscle

strength, lung volumes, and diaphragmatic excursion. Clinics

66(10): 1721-1727, 2011.

3. Bond, D, Evans, R, DeMaria, E, Wolfe, L, Meador, J, Kellum,

J, Maher, J, and Warren, B. Physical activity and quality of life

improvements before obesity surgery. Am J Health Behav 30(4):

422-434, 2006.

4. Brzozowska, M, Sainsbury, A, Eisman, J, Baldock, P, and

Center, J. Bariatric surgery, bone loss, obesity, and possible

mechanisms. Obesity Reviews 14: 52-67, 2013.

5. Chapman, N, Hill, K, Taylor, S, Hassanal, M, Straker, L, and

Hamdorf, J. Patterns of physical activity and sedentary behavior

after bariatric surgery: An observational study. Surg Obes Relat Dis

10(3): 524-530, 2014.

6. Cheifetz, O, Lucy, S, Overend, T, and Crowe, J. The effect of

abdominal support on functional outcomes in patients following

major abdominal surgery: A randomized controlled trial.

Physiotherapy Canada 62: 242-253, 2010.

7. deJong, A. Cardiopulmonary exercise testing in assessing the

risk of bariatric surgery, implications for allied health professionals.

ACSM’s Health and Fitness Journal 12(4): 38-40, 2008.

8. Drew, K. Exercise and bariatric surgery. ACSM’s Certified News

22(3): 11-15, 2012.

9. Kushner, R. Roadmaps for Clinical Practice: Case Studies in

Disease Prevention and Health Promotion-A Primer for Physicians;

Communication and Counseling Strategies. Chicago, IL: American

Medical Association; 2003.

10. Manchester, S, and Roye, G. Bariatric surgery, an overview for

dietetics professionals. Nutrition Today 46(6): 264-273, 2011.

11. McCullough, P, Gallagher, M, deJong, A, Sandberg, K, Trivax,

J, Alexander, D, Kasturi, G, Jafri, S, Krause, K, Chengelis, D, Moy,

J, and Franklin, B. Cardiorespiratory fitness and short-term

complications after bariatric surgery. Chest 130: 517-525, 2006.

12. McMahon, M, Sarr, M, Clark, M, Gall, M, Knoetgen III, J, Service,

F, Laskowski, E, and Hurley, D. Clinical management after bariatric

surgery: Value of a multidisciplinary approach. Mayo Clinic

Proceedings 81(10 suppl): s34-s45, 2006.

13. Owens, C, Abbas, Y, Ackroyd, R, Barron, N, and Khan, M.

Perioperative optimization of patients undergoing bariatric

surgery. Journal of Obesity 81(10 suppl): s25-s33, 2012.

14. Richardson, W, Plaisance, A, Periou, L, Buquoi, J, and Tillery, D.

Long-term management of patients after weight loss surgery. The

Ochsner Journal 9: 154-159, 2009.

15. Smith, D, and Fiddler, R. In: NSCA’s Essential of Personal

Training (2nd ed.) Champaign, IL: Human Kinetics; 489-505, 2012.

16. Sorace, P, and LaFontaine, T. Lifestyle intervention: A priority

for long-term success in bariatric patients. ACSM’s Health and

Fitness Journal 11(6): 19-25, 2007.

17. Sorace, P, and LaFontaine, T. Personal training post-bariatric

surgery patients: Exercise recommendations. Strength and

Conditioning Journal 32(3): 101-104, 2010.

18. Tessier, A, Zavorsky, G, Jun Kim, D, Carli, F, Christou, N, and

Mayo, N. Understanding the determinants of weight-related quality

of life among bariatric surgery candidates. Journal of Obesity Epub

Jan 12, 2012.

19. Vartanian, L, and Novak, S. Internalized societal attitudes

moderate the impact of weight stigma on avoidance of exercise.

Obesity 19(4): 757-762, 2011.

20. Wollner, S, Adair, J, Jones, D, and Blackburn, G. Preoperative

progressive resistance training exercise for bariatric surgery

patients. Bariatric Times 7(5): 11-13, 2010.

ABOUT THE AUTHOR

Cindy Kugler is currently employed by the Bryan Health System in

Lincoln, NE. She has worked as an exercise specialist for cardiac/

pulmonary rehabilitation, a department manager, and is currently

the LifePoint Clinical Liaison. She has assisted with lifestyle

modification for those with chronic disease and worksite health

promotion for her organization and others. She obtained her Master

of Science degree in Exercise Physiology from the University of

Nebraska Omaha and is currently the Chair of the National Strength

and Conditioning Association (NSCA) Certified Special Populations

Specialist® (CSPS®) certification committee.

NSCA.com

PTQ 1.4 | NSCA.COM 13

TABLE 1. SCREENING POTENTIAL SURGICAL CANDIDATES (10)

• Adults

• Body mass index (BMI) ≥ 40 kg/m2 with no comorbidities

• BMI ≥ 35 kg/m2 with obesity-associated comorbidities

• Weight loss history

• Failure of previous nonsurgical attempts at weight reduction, including nonprofessional programs

• Commitment

• Expectation that patient will adhere to post-o perative care

§Follow-up visits with physician and team members

§Recommended medical management, including the use of dietary supplements

§Instructions regarding any recommended procedures or tests

• Exclusions

§Reversible endocrine or other disorders that can cause obesity

§Current drug or alcohol abuse

§Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes

required with bariatric surgery

§Caution must be used when language or literacy issues are present

§Severe food allergies or intolerances must be addressed before surgery

TABLE 2. SAMPLE PRE-SURGERY RESISTANCE TRAINING PROGRAM

Upper body

Wall push-ups Bodyweight

Biceps curls Tubing or dumbbell

Triceps push-downs/kick backs Tubing or dumbbell

Shoulder presses/raises Tubing or dumbbell

Lower body

Seated rows Tubing

Chair squats Bodyweight

Calf raises Bodyweight

Leg presses Tubing

Abdominals Seated crunches Tubing

Standing core twists Tubing or dumbbell

14 PTQ 1.4 | NSCA.COM

EXERCISE BEFORE AND AFTER BARIATRIC SURGERY

TABLE 3. POST-SURGERY CARDIORESPIRATORY EXERCISE PROGRESSION

TIME POST-SURGERY FREQUENCY DURATION

Weeks 0 – 2 3 – 4 x/day As tolerated; 5 – 10 min per bout

Increase daily activities

Weeks 2 – 4 5 – 6 x/week

20 – 30 min; in minimum of

10 min increments, if needed

Focus on increasing duration

(increase by 2 – 3 min every 2 – 3 days)

Weeks 4+ 5 – 6 x/week 40 – 60 min

Increase intensity and utilize intervals

TABLE 4. POST-SURGERY RESISTANCE TRAINING PROGRESSION

TIME POST-CLEARANCE SETS/REPETITIONS FREQUENCY MUSCLE GROUPS

Weeks 1 – 4

(4 – 8 weeks post-surgery) 1 set/12 – 15 reps 2x/week* 8 – 10 exercises; all major muscle groups

No abdominal exercises

Weeks 4 – 8 2 sets**/12 – 15 reps 2 – 3x/week* 8 – 10 exercises; all major muscle groups

Abdominal exercises, if clearance is given

Weeks 8+ 3 sets**/8 – 12 reps 2 – 3x/week*

8 – 10 exercises minimum;

all major muscle groups

Add more functional, postural, balance,

and abdominal exercises

* Allow 48 hours between sessions

** Approximately 1-min rest intervals

NSCA.com

PTQ 1.4 | NSCA.COM 15

TABLE 5. SPECIAL CONSIDERATIONS (3,6,8,9,12,16, 19)

CATEGORY CONCERNS RECOMMENDATIONS

Psychological/

Emotional Status

Stigma Sensitivity training

Decreased self-esteem Establish excellent rapport

Depression Refer to physician or counselor

Embarrassment Empathy and listening skills

Give home exercise and equipment options

Common

Comorbidities

Obstructive sleep apnea/fatigue Refer to physician

Timing of exercise session with rest

Orthopedic/pain (e.g., knees,

back, hips, and feet)

Choice of appropriate exercise modality

(e.g., water, non-weight bearing, etc.)

Use of supportive devices (e.g., orthotics, braces/sleeves, etc.)

Use of thick large mats

Refer to physician for pain control and treatment

Instruction in use of rest, ice, and compression

Diabetes mellitus Utilize appropriate guidelines for checking blood glucose and exercise

Size/Deconditioning

Shortness of breath Utilize intermittent exercise and/or interval protocols; utilize dyspnea

scale with exercise

Panniculus interference Abdominal binder and supportive clothing

Exercise fatigue

Utilize ratings of perceived exertion scale with exercise, intermittent,

and/or interval protocols

Chairs available for rest

Self-consciousness

Awareness of environmental needs such as use of chairs without arms,

ability to get up and down off the floor, alternatives to machines they do

not fit into, and an exercise area that is more private

Give home exercise and equipment options

Overheating Cooler environment, fans, wicking clothing, and cooling towel

Skin Issues Chafing, yeast, and fungus Use of commercial products according to individual preference

Excess skin Use of tighter, supportive, wicking clothing

Post-Surgical Changing body size/mass Awareness of changing balance and having support when including

balance exercises

Concerns

Low energy due to

low calorie diet

Timing of exercise with meal or snack

Utilizing lower intensities and/or intervals

Refer to dietitian for nutrient and caloric recommendations

Dehydration

Consume a minimum of 64 oz of water per day in 1 oz increments

Continuous sipping before, during, and after exercise

Take water breaks

Refer to dietitian as needed

Changing relationships with food,

family, and friends

May sabotage their new lifestyle

Need support, encouragement, and empathy

Refer to physician and/or counselor as needed

Bone loss and osteoporosis

Include resistance training and weight bearing exercises

Encourage compliance with prescribed supplements

Refer to physician and/or dietitian as needed

16 PTQ 1.4 | NSCA.COM

CHAT WILLIAMS, MS, CSCS,*D, CSPS, NSCA-CPT,*D, FNSCA

SMALL GROUP TRAINING UTILIZING CIRCUITS

I

am often asked the following questions by students and other

individuals who are starting a profession in personal training:

“What could be changed?” “What could be done differently?”

“What population should I work with?” “Is there a specific area

of focus to study?” My answer always discusses the benefits of

incorporating small group training into their training protocols. I

have witnessed many fads and fitness trends over the last 18 years

and the one concept that seems to be growing steadily is personal

training in a small group setting. How is small group training

defined? Here are some differences associated with other types of

training in the strength and conditioning industry.

Personal Training: In the traditional sense, personal training is

performed in a one-on-one setting and typically ranges from 30 –

60 min.

Semiprivate: Personal trainer will work with 2 – 3 individuals

during the same session for 30 – 60 min.

Small Group: Personal trainer will develop a training program for

4 – 10 individuals at the same time.

All of these training methods have benefits associated with

them; it will depend on the individual’s personal goals, schedule

availability, fitness level, and comfort level training with other

people. Here are some potential benefits to consider with small

group training.

FINANCIAL INVESTMENT

One of the first questions during the initial inquiries about

personal training is “How much does it cost per session?” Many

times, individuals may not be able to hire a personal trainer due

to a limited budget. For example, a one-on-one session may cost

50 dollars an hour, but in a small group setting a lower rate of 15

dollars per hour may be more realistic. Plus, the total revenue per

hour increases for the personal trainer. Using the same example

with a small group of eight people, the personal trainer will

generate about 120 dollars an hour as opposed to 50 dollars an

hour. The small group concept can be a “win-win” for both parties

as it generates more revenue and time efficiency for the personal

trainer and breaks down the cost barrier for the client.

SUPPORT AND MOTIVATION

Being part of a group instantly develops a support network

for the individuals. This could be family, friends, or coworkers.

Working out with like-minded individuals creates the

competiveness that may push them to a higher level, while

recognizing their own individual fitness strengths. Motivating,

encouraging, and driving one another during workouts develops

a positive environment and camaraderie amongst the group.

Plus, there is accountability that each person must have in a

group setting. The people in the group are typically supportive

in a positive manner and have a tendency to “call out” those who

are missing sessions. People in the group count on individuals to

show up, especially when partner-based training and circuit-type

training are a part of the overall program design.

ADHERENCE, FUN, AND GROUP STRUCTURE

Teamwork, group motivation, and encouragement must also be

supported by the personal trainer to create fun and challenging

workouts. Exercise adherence can be difficult for any individual

participating in a fitness program, but it is especially crucial for a

beginner. A more dynamic program may lead to higher adherence

rates for the individual and the group. Groups can be categorized

by assigned, mixed, and team (e.g., coworkers) depending on

fitness levels and schedule availability. Beginners and individuals

that need programs with a little less intensity can be assigned to

the same group. Individuals with prior fitness experience can be

assigned to a mixed group where the personal trainer can modify

the training within the sessions to meet some of their specific

goals. Team groups can develop their own goals as a group and

individually. For example, they may want to lose a specific amount

of weight as an organization. All three of these groups can set

goals as a group and as individuals every 8 – 12 weeks to maintain

success and motivation.

DEFINITIONS, RESEARCH, AND PROGRAM DESIGN

Circuits, supersets, compound sets, and complex sets are great

ways to keep workouts fast-paced, fun, challenging, and energetic.

Circuits typically utilize 10 – 15 exercises and can either be grouped

together as one big circuit or grouped together focusing on upper

body, lower body, or core. To incorporate greater challenges with

a circuit, programming may include supersets, compound sets,

PTQ 1.4 | NSCA.COM 17

and complex sets. A superset consists of two exercises involving

opposing muscle or action of the muscles (e.g., pairing bench

press with lat pull-down). A compound set involves two exercises

utilizing the same muscle group or action of the muscle (e.g.,

pairing single-arm dumbbell row and bodyweight inverted row).

A complex set combines a power movement with a strength

movement (e.g., pairing countermovement vertical jump and

squat) and usually flow from one movement to the next in terms

of the finishing position (3). The frequency, intensity, rest intervals,

volume, and exercise selection will depend on the overall objective

of the group (2).

Circuit training has been shown to improve multiple fitness

components including time to lactate threshold and increased

endurance (2). Increased maximal oxygen consumption (VO2max),

functional capacity, improved pulmonary ventilation, reduced

body fat, and overall improved body composition are some of

the improvements that may be elicited when incorporating circuit

training where lighter loads are lifted with minimal rest (1). In one

study where heavier loads of six repetition maximum (6RM) were

used comparing traditional strength training to heavy resistance

circuits in resistance trained males showed similar strength and

muscle mass improvements to traditional strength training (1).

Other findings included similar improvements in power, reductions

in body fat, and an increased performance on the 20-meter

shuttle run (1).

PROGRAM EXAMPLES

Here are a couple of examples including different types of circuits

that can be incorporated into the training program design. Each

workout should begin with a warm-up and end with a cool-down

and/or stretching.

10 STATION CIRCUIT (TABLE 1)

This circuit includes 10 different exercises targeting the full body.

This may be useful for a beginner training program that has

10 participants. Each individual can rotate through three times

completing 10 – 15 repetitions for each exercise. Rest between

each exercise should be approximately 30 s or just enough time to

move to the next exercise.

3 MINI-CIRCUITS (TABLE 2)

This circuit includes three mini-circuits which all contain

four exercises. These mini-circuits will include supersets,

compound sets, and complex sets. This full body workout is

not recommended for beginners as it contains intermediate

level exercises.

REFERENCES

1. Alcaraz, P, Perez-Gomez, J, Chavarrias, M, Blazavich, A.

Similarity in adaptations to high-resistance training vs. traditional

strength training in resistance trained men. Journal of Strength and

Conditioning Research 25(9): 2519-2527, 2011.

2. Waller, M, Miller, J, and Hannon, J. Resistance circuit training:

It’s application for the adult population. Strength and Conditioning

Journal 33(1): 16-22, 2011.

3. Williams, C. Complex set variations: Improving strength and

power. Personal Training Quarterly 1(3): 20-25, 2014.

ABOUT THE AUTHOR

Chat Williams is the Supervisor for Norman Regional Health Club.

He is a past member of the National Strength and Conditioning

Association (NSCA) Board of Directors, NSCA State Director

Committee Chair, Midwest Regional Coordinator, and State Director

of Oklahoma (2004 State Director of the Year). He also served on

the NSCA Personal Trainers Special Interest Group (SIG) Executive

Council. He is the author of multiple training DVDs. He also runs his

own company, Oklahoma Strength and Conditioning Productions,

which offers personal training services, sports performance

for youth, metabolic testing, and educational conferences and

seminars for strength and conditioning professionals.

18 PTQ 1.4 | NSCA.COM

SMALL GROUP TRAINING UTILIZING CIRCUITS

TABLE 1. 10 STATION CIRCUIT SAMPLE

MOVEMENT AREA TARGETED SET/REPETITIONS

Bench presses Upper body 3/10

Leg presses Lower body 3/10

Single-arm dumbbell rows Upper body 3/10

Seated leg curls Lower body 3/10

Stability ball abs

(modify for group ability) Core 3/15

Seated overhead presses Upper body 3/10

Cable cross posterior deltoids

(modify for group ability) Upper body 3/10

Calf raises Upper body 3/10

Dumbbell curls Upper body 3/10

Triceps extensions Upper body 3/10

TABLE 2. 3 MINI-CIRCUITS SAMPLE

Circuit 1

EXERCISE TYPE SETS/REPETITIONS

Box jumps Complex set 3/5

Leg presses Complex set 3/10

Leg extensions Superset 3/10

Leg curls Superset 3/10

Circuit 2

EXERCISE TYPE SETS/REPETITIONS

Seated chest presses Compound set 3/10

Push-ups Compound set 3/10

Lat pull-downs Compound set 3/10

Pull-ups Compound set 3/10

Circuit 3

EXERCISE TYPE SETS/REPETITIONS

Hanging leg raises Compound set 3/12

Crunches Compound set 3/15

Straight-bar curls Superset 3/10

Overhead triceps extensions Superset 3/10

NSCA.com

PTQ 1.4 | NSCA.COM 19

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FEATURE ARTICLE

PTQ 1.4 | NSCA.COM

20

STUART PHILLIPS, PHD, CSCS, FACSM, FACN, ROBERT MORTON, CSCS, AND CHRIS MCGLORY, PHD

T

h

e a

b

i

l

it

y

to maintain or increase s

k

e

l

eta

l

musc

l

e mass

(hy

pertrop

hy

)

h

as c

l

ear a

d

vantages in t

h

e at

hl

etic setting.

An increase in the cross-sectional area

(

CSA

)

of skeletal

muscle

f

ibers ultimately occurs when the net rate o

f

muscle

protein s

y

nthesis (MPS) exceeds that of muscle protein breakdown

(

MPB) (16). Bot

h

resistance exercise an

d

protein in

g

estion

s

timulate a si

g

ni

f

icant increase in the rates o

f

MPS over and above

rates of MPB and, when combined, are s

y

nergistic in their effects.

Hence,

f

re

q

uent resistance exercise and

p

rotein consum

p

tion

s

upport increases in MPS an

d

ma

y

in

d

uce s

k

e

l

eta

l

musc

l

e

remo

d

e

ll

ing an

d

hy

pertrop

hy

(2).

Despite the wealth of information pertainin

g

to the impact

o

f

resistance exercise and

p

rotein consum

p

tion on MPS,

t

h

e exact ce

ll

u

l

ar an

d

mo

l

ecu

l

ar mec

h

anisms t

h

at un

d

er

p

in

resistance exercise-in

d

uce

d

c

h

an

g

es in MPS remain unc

l

ear.

Man

y

hy

pot

h

eses

h

ave

b

een propose

d

b

ut some are wit

h

l

itt

l

e

s

upporting evi

d

ence an

d

empirica

l

d

ata. One suc

h

hy

pot

h

esis

is that hi

g

her elevated concentrations of exercise-induced

sy

stemic “anabolic” hormones are needed for attaining optimal

hy

pertrop

hy

wit

h

resistance training (RT); a t

h

esis terme

d

t

h

e

“h

ormone

hy

pot

h

esis.” T

h

e

h

ormone

hy

pot

h

esis seems compe

ll

ing

based on the well-documented knowled

g

e that resistance

exercise is followed b

y

a transient (approximatel

y

30 min)

sy

stemic elevation of hormones, some of which are “anabolic”

(

12,26). Notabl

y

there are increases in free and protein-bound

forms of testosterone (T),

g

rowth hormone (GH), and insulin-like

g

rowth factor-1 (IGF-1). While there is indisputable evidence to

s

how that exogenous supraph

y

siological doses of testosterone

augments musc

l

e

hy

pertrop

hy

an

d

strengt

h

, t

h

ere is not

convincin

g

data for GH or for IGF-1 (1,3,10,18). The link between

th

e

tr

a

nsi

e

nt in

c

r

ea

s

e

in

co

n

ce

ntr

a

ti

o

n

o

f th

e

s

e

h

o

rm

o

n

e

s

a

nd

h

ypertrop

h

y

h

as

b

een exp

l

icit

l

y examine

d

in primary researc

h

p

a

p

ers (1,13,21,24,25,26,27,28,29). However, the aim of this article

is to address the followin

g

questions: 1) is the transient post-

exercise

h

ormona

l

response p

l

a

y

ing a ro

l

e in s

k

e

l

eta

l

musc

l

e

h

y

pertroph

y

? If so, then 2) should hormonal changes influence RT

pro

g

ram

d

esi

g

n an

d

perio

d

ization aime

d

at maximizin

g

musc

l

e

h

y

pertroph

y

? If the answer to the first question is no, then the

secon

d

q

uestion is moot.

It h

a

s b

ee

n kn

o

wn f

o

r s

o

m

e

tim

e

th

a

t GH s

ec

r

e

ti

o

n in

c

r

ea

s

e

s

b

one an

d

musc

l

e mass in

g

rowin

g

anima

l

s an

d

c

h

i

ld

ren (8,14,15).

It is un

d

enia

bl

e t

h

at exogenous suprap

hy

sio

l

ogica

l

GH stimu

l

ates

co

ll

agen protein s

y

nt

h

esis,

b

ut t

h

e notion t

h

at suprap

hy

sio

l

ogica

l

GH a

d

ministration

d

irect

ly

increases s

k

e

l

eta

l

musc

l

e mass is

wit

h

out

d

irect support (3,24). A p

l

ausi

bl

e ar

g

ument is t

h

at t

h

e

exo

g

enous GH-me

d

iate

d

increase in connective tissue wou

ld

allow for more loadin

g

, but such a thesis awaits experimental

confirmation. Alternativel

y

, increases in GH ma

y

exert an indirect

anabolic influence via IGF-1, which is s

y

nthesized b

y

the liver.

O

f

ten recognized

f

or its relation with GH, IGF-1 is also transientl

y

elevated

p

ost-exercise (28,29). The GH

/

IGF-1 axis is involved with

musc

l

e

g

rowt

h

d

urin

g

a

d

o

l

escence w

h

ere,

l

i

k

e T an

d

GH,

l

eve

l

s

o

f

IGF-1 reach their

p

eak (6). The assertion that IGF-1 is anabolic

comes from selective rodent data in which the IGF-1 rece

p

tor

in skeletal muscle was knocked out and the rates of MPS

,

in

response to 50 “repetitions” in rats (stan

d

in

g

on t

h

eir

h

in

d

l

e

g

s),

HIGH HORMONE CONDITIONS FOR HYPERTROPHY

WITH RESISTANCE TRAINING: A BELIEF—NOT

EVIDENCE-BASED PRACTICE IN STRENGTH

AND CONDITIONING

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM 21

was reduced (4). In contrast, removal of the IGF-1 rece

p

tor from

s

k

e

l

eta

l

musc

l

e in mice

d

i

d

not

h

in

g

to attenuate

l

oa

d

-in

d

uce

d

s

k

e

l

eta

l

musc

l

e

hy

pertrop

hy

(21). However, it is important to

acknowledge that rodents exhibit marked di

ff

erences in rates

of

p

rotein turnover as com

p

ared to humans. Moreover, insulin

is

k

nown to stimu

l

ate t

h

e p

h

osp

h

or

yl

ation (an

d

presuma

bly

activation) of the IGF-1 rece

p

tor, resistance exercise does not (9).

Given that insulin pla

y

s onl

y

a permissive role in the regulation o

f

human MPS, these data suggest that IGF-1 exerts a minimal, i

f

an

y

,

im

p

act on resistance exercise-induced increases in MPS (7). In fact,

one

y

ear of IGF-1 administration was shown to have no noticeable

impact on

b

one or

b

o

dy

composition in o

ld

er women (10).

An o

f

ten-used, but categoricall

y

incorrect, argument in support o

f

t

he hormone h

y

pothesis is the marked potenc

y

of T when given

as an exogenous ana

b

o

l

ic agent (1). T

h

ere are,

h

owever, critica

lly

important differences between pharmacolo

g

ical doses (or

pharmacological suppression) o

f

T and the comparativel

y

minor

and

f

leeting increases in post-exercise T. For example, when

y

oung

men are administered 600 mg weekl

y

for 10 weeks, bringing total

T concentrations from approximatel

y

500 ng/dl (nanograms per

deciliter) to 3,000 n

g/

dl, there is an increase in both muscle mass

an

d

strengt

h

(1). We a

l

so

k

now t

h

at w

h

en T is p

h

armaco

l

ogica

ll

y

supressed to one tenth of normal levels, the trainin

g

response is

attenuate

d

(13). Stu

d

ies a

d

ministering T to

hy

pogona

d

a

l

e

ld

er

ly

men (60 or more

y

ears old) found increased muscle protein

ana

b

o

l

ism

(

5

)

. T

h

e exercise-in

d

uce

d

increases in T concentration,

which are no greater than the daily diurnal

f

luctuation o

f

the

h

ormone, are simp

ly

not compara

bl

e in magnitu

d

e (usua

lly

1

/

10th to 1

/

100th of the pharmacolo

g

ic dose) or duration

(

approximate

ly

30 min versus constant e

l

evation

d

epen

d

ent on

d

osin

g

in p

h

armaco

l

o

g

ic mo

d

e

l

s) to w

h

at is seen wit

h

exo

g

enous

su

ppl

ementation (20).

An interesting finding for the hormonal h

y

pothesis is that, despite

t

he lower acute increases in T

p

ost-resistance exercise, females

d

emonstrate t

h

e same re

l

ative

hy

pertrop

h

ic response to resistance

exercise (11). A common misconce

p

tion is t

h

at t

h

e re

l

ative

hy

pertrop

h

ic response to RT is

l

ower in women compare

d

to men.

For exam

p

le, des

p

ite a 45-fold lower exercise-induced T res

p

onse

in women, (com

p

are

d

to men), women ac

h

ieve simi

l

ar re

l

ative

MPS

p

ost-exercise (26). Hubal et al. also

f

ound that women, who

had roughl

y

about one tenth of the resting T levels as men, had

t

he same relative h

y

pertrophic response (11). If the post-exercise T

response were a determinant of MPS and subsequent h

y

pertroph

y

,

th

en women wou

ld

h

ave a

l

ower re

l

ative

hy

pertrop

h

ic an

d

MPS

res

p

onse,

b

ut t

h

at is not t

h

e case. T

h

is im

p

ortant consi

d

eration is

frequentl

y

overlooked when evaluating the hormone h

y

pothesis.

In contrast to the belief that the

p

ost-exercise hormonal res

p

onse

is an important mediator of h

y

pertroph

y

, published studies have

y

ie

ld

e

d

l

itt

l

e mec

h

anistic support or va

l

i

d

c

l

inica

l

d

ata to up

h

o

ld

t

his proposition. In fact, in most studies that have investi

g

ated

w

h

et

h

er t

h

e repeate

d

increase in s

y

stemic “ana

b

o

l

ic”

h

ormones

promote

hy

pertrop

hy

, it seems as t

h

oug

h

none

h

ave provi

d

e

d

an

y

unequivocal support

f

or this assertion. In a lar

g

e cohort (n = 56) o

f

young men, associations were examine

d

b

etween acute increases

in T, GH, and IGF-1 with lean bod

y

mass,

f

iber CSA, and leg press

stren

g

th followin

g

a 12-week RT protocol (25). The exercise

-

in

d

uce

d

h

ormona

l

response was not corre

l

ate

d

wit

h

g

ains in

l

ean

bod

y

mass,

f

iber CSA, or strength (25).

In another stud

y

, h

y

pertroph

y

and strength gains of limbs

w

e

r

e

x

a

min

e

d within th

e

s

a

m

e

individu

a

l und

e

r tw

o

diff

e

r

e

nt

h

ormona

l

environments (28). Twe

l

ve

y

oung men traine

d

eac

h

o

f

their elbow

f

lexors every 72 hr with one arm being grouped

into a

l

ow

h

ormona

l

(LH) environment an

d

t

h

e ot

h

er into a

h

i

gh

hormonal (HH) environment for the duration of the stud

y

. Despite

15 weeks of RT with limbs in a LH or HH environment

,

there

were no di

ff

erences between groups in muscle CSA or strength

f

ollowing training (28). It was concluded that muscle h

y

pertroph

y

and strength with RT in

y

oung men was unaffected b

y

exposure

to exercise-in

d

uce

d

e

l

evations in GH, IGF-1, or T (Fi

g

ure 1) (28).

In

g

enera

l

, t

h

ese stu

d

ies provi

d

e evi

d

ence t

h

at exercise-in

d

uce

d

hy

pertrop

h

ic a

d

aptation in s

k

e

l

eta

l

musc

l

e occurs in

d

epen

d

ent

ly

o

f

exercise-induced endo

g

enous anabolic hormone concentrations

(25,28). Nonetheless, the lack of bona fide RT trial data to su

pp

ort

the hormone h

y

pothesis has not prevented the propagation of

do

g

matic belie

f

s that are not evidence-based recommendations

f

or “e

ff

ective” RT leading to hypertrophy.

In summar

y

, it appears as if there is little evidence to support

t

h

e assertion t

h

at transient

p

ost-exercise increases in

h

ormones

are causative in normal RT-stimulated h

y

pertroph

y

. If how one

respon

d

s to RT is not

h

ormona

ll

y

d

riven, t

h

en w

h

at

d

rives it?

One theor

y

is that h

y

pertroph

y

is facilitated via local muscle-

m

ed

i

a

t

ed

m

echa

nisms t

ha

t

a

r

e

intrinsi

c

t

o

t

he

s

kele

t

al

mus

cle

(24). Instea

d

, t

h

e post-exercise increase in

h

ormones is a

g

eneric

stress response seen after man

y

forms of high-intensit

y

exercise,

many o

f

which do not lead to hypertrophy (i.e., middle distance

runnin

g

) (23). Thus, in

f

ailin

g

to establish a direct causal,

or even associative,

l

in

k

b

etween

p

ost-exercise

h

ormona

l

concentrations

d

irect

ly

ca

ll

s into question t

h

eir measurement

as a driver o

f

an

y

kind o

f

decision making or planning o

f

RT

pro

g

rams or periodization o

f

trainin

g

. It is recommended that the

attainment o

f

RT-induced h

y

pertroph

y

based on measurement

of s

y

stemic hormone concentrations is a belief, and not an

evi

d

ence-

b

ase

d

practice.

22 PTQ 1.4 | NSCA.COM

HIGH HORMONE CONDITIONS FOR HYPERTROPHY WITH RESISTANCE

TRAINING: A BELIEF—NOT EVIDENCE-BASED PRACTICE IN STRENGTH

AND CONDITIONING

REFERENCES

1. Bhasin, S, Storer, T, Berman, N, Callegari, C, Clevenger, B,

Phillips, J, Bunnell, T, Tricker, R, Shirazi, A, and Casaburi, R. The

effects of supraphysiologic doses of testosterone on muscle size

and strength in normal men. The New England Journal of Medicine

335(1): 1-7, 1996.

2. Burd, N, Tang, J, Moore, D, and Phillips, S. Exercise training

and protein metabolism: Influences of contraction, protein intake,

and sex-based differences. Journal of Applied Physiology 106:

1609-1701, 2009.

3. Doessing, S, Heinemeier, K, Holm, L, Mackey, A, Schjerling, P,

Rennie, M, Smith, K, Reitelseder, S, Kapplegaard, A, Rasmussen,

M, Flyvbjerg, A, and Kjaer, M. Growth hormone stimulates the

collagen synthesis in human tendon and skeletal muscle without

affecting myofibrillar protein synthesis. Journal of Physiology

588(2): 341–351, 2010.

4. Fedele, M, Lang, C, and Farrell, P. Immunization against

IGF-1 prevents increases in protein synthesis in diabetic rats after

resistance exercise. American Journal of Physiology, Endocrinology

and Metabolism 280: E877-E885, 2001.

5. Ferrando, A, Sheffield-Moore, M, Yeckel, C, Gilkison, C, Jiang,

J, Achasoa, A, Lieberman, S, Tipton, K, Wolfe, R, and Urban,

R. Testosterone administration to older men improves muscle

function: Molecular and physiological mechanisms. American

Journal of Physiology 282(3): E601-607, 2002.

6. Goldspink, G, Wessner, B, Tschan, H, and Bachl, N. Growth

factors, muscle function and doping. Endocrine and Metabolism

Clinics 39(1): 169-181, 2010.

7. Greenhaff, P, Karagounis, L, Peirce, N, Simpson, E, Hazell, M,

Layfield, R, Wackerhage, H, Smith, K, Atherton, P, Selby, A, and

Rennie, M. Disassociation between the effects of amino acids

and insulin on signaling, ubiquitin ligases, and protein turnover in

human muscle. American Journal of Physiology - Endocrinology

and Metabolism 295(3): E595-604, 2008.

8. Gregory, J, Greene, S, Jung, R, Scrimgeour, C, and Rennie,

M. Changes in body composition and energy expenditure after

six weeks’ growth hormone treatment. Archives of Disease in

Childhood 66: 598–602, 1991.

9. Hamilton, D, Philip, A, MacKenzie, M, and Baar, K. A limited

role for PI(3,4,5)P3 regulation in controlling skeletal muscle mass in

response to resistance exercise. PLOS One 5(7): e11624, 2010.

10. Hoffman, A, Marcus, R, Lee, S, Matthias, D, Yesavage, J,

Friedman, L, Holloway, L, Pollack, M, Grillo, J, Moynihan, S,

Butterfield, G, and Friedlander, A. One year of insulin-like growth

factor 1 treatment does not affect bone density, body composition,

or psychological measures in postmenopausal women. Journal of

Clinical Endocrinology and Metabolism 86(4): 1496-1503, 2001.

11. Hubal, M, Gordish-Dressman, H, Thompson, P, Price, T,

Hoffman, E, Angelopoulos, T, Gordon, P, Moynga, N, Pescatello, L,

Visich, P, Zoeller, R, Seip, R, and Clarkson, P. Variability in muscle

size and strength gain after unilateral resistance training. Medicine

and Science in Sport and Exercise 37(6): 964-972, 2005.

12. Kraemer, W, and Ratamess, N. Hormonal responses and

adaptations to resistance exercise and training. Sports Medicine

35: 339-361, 2005.

13. Kvorning, T, Anderson, M, Brixen, K, and Madsen, K.

Suppression of endogenous testosterone production attenuates

the response to strength training: A randomized, placebo-

controlled, and blinded intervention study. American Journal of

Physiology, Endocrinology and Metabolism 291(6): 1325-1332,

2006.

14. Lissett, C, and Shalet, S. Effects of growth hormone on bone

and muscle. Growth Hormone and IGF Research 10: S95-101, 2000.

15. Pell, J, and Bates P. The nutritional regulation of growth

hormone action. Nutrition Research Reviews 3: 163-92, 1990.

16. Phillips, S. Protein requirements and supplementation in

strength sports. Nutrition 20(7-8): 689-695, 2004.

17. Pritzlaff, C, Wideman, L, Weltman, J, Abbott, R, Gutgesell, M,

Hartman, M, Veldhuis, J, and Weltman, A. Impact of acute exercise

intensity on pulsatile growth hormone release in men. Journal of

Applied Physiology 87: 498-504, 1999.

18. Rennie, M. Claims for the anabolic effects of growth hormone:

A case of the Emperor’s new clothes? British Journal of Sports

Medicine 37: 100-105, 2003.

19. Rosen, C. Growth hormone and again. Endocrine 12: 197-201,

2000.

20. Schroeder, E, Villanueva, M, West, D, and Phillips, S. Are

acute post-resistance exercise increases in testosterone, growth

hormone, and IGF-1 necessary to stimulate skeletal muscle

anabolism and hypertrophy? Medicine and Science in Sport and

Exercise 45(11): 2044-2051, 2013.

21. Spangenburg, E, Le Roith, D, Ward C, and Bodine, S. A

functional insulin-like growth factor receptor is not necessary

for load-induced skeletal muscle hypertrophy. The Journal of

Physiology 586: 283-291, 2008.

22. Staron, R, Karapond, D, Kraemer, W, Fry, A, Gordon, S, Falkel,

J, Hagerman, F, and Hikida, R. Skeletal muscle adaptations during

early phase of heavy-resistance training in men and women.

Journal of Applied Physiology 76(3): 1247-1255, 1994.

23. Vuorimaa, T, Ahotupa, M, Hakkinen, K, and Vasankari, T.

Different hormonal response to continuous and intermittent

exercise in middle-distance and marathon runners. Scandinavian

Journal of Medicine and Science in Sports 18(5): 565-572, 2008.

24. West, D, and Phillips, S. Anabolic processes in human

skeletal muscle: Restoring the identities of growth hormone and

testosterone. The Physician and Sportsmedicine 38(3): 97-104,

2010.

25. West, D, and Phillips, S. Associations of exercise-induced

hormone profiles and gains in strength and hypertrophy in a

large cohort after weight training. European Journal of Applied

Physiology 112: 2693-2702, 2012.

NSCA.com

PTQ 1.4 | NSCA.COM 23

26. West, D, Burd, N, Churchward-Venne, T, Camera, D, Mitchell,

C, Baker, S, Hawley, J, Coffey, V, and Phillips, S. Sex-based

comparisons of myofibrillar protein synthesis after resistance

exercise in the fed state. Journal of Applied Physiology 112(11):

1805-1813, 2012.

27. West, D, Burd, N, Staples, A, and Phillips, S. Human exercise-

mediated skeletal muscle hypertrophy is an intrinsic process. The

International Journal of Biochemistry and Cell Biology 42: 1371-

1375, 2010.

28. West, D, Burd, N, Tang, J, Moore, D, Staples, A, Holwerda,

A, Baker, S, and Phillips, S. Elevations in ostensibly anabolic

hormones with resistance exercise enhance neither training-

induced muscle hypertrophy nor strength of the elbow flexors.

Journal of Applied Physiology 108(1): 60-67, 2010.

29. West, D, Kujbida, G, Moore, D, Atherton, P, Burd, N,

Padzik, J, De Lisio, M, Tang, J, Parise, G, Rennie, M, Baker, S,

and Phillips, S. Resistance exercise-induced increases in putative

anabolic hormones do not enhance muscle protein synthesis or

intracellular signalling in young men. The Journal of Physiology

587: 5239-5247, 2009.

ABOUT THE AUTHOR

Stuart Phillips is a Fellow of the American College of Sports

Medicine (FACSM) and the American College of Nutrition

(FACN). He is a professor at McMaster University in the

Kinesiology Department and is also an Associate Member of

the School of Medicine at McMaster. Phillips’ research is focused

on the interaction between skeletal muscle contraction and

nutritional support in the regulation of muscle mass. He has

more than 200 published papers and has delivered more than

120 public presentations.

Robert Morton is a graduate student working with Dr. Stuart Phillips

at McMaster University. He is a personal trainer, rugby player, and

strength and conditioning coach possessing a strong passion for

the application of science in sport. Having interned with Hockey

Canada, the University of Louisville, the Ontario Soccer Association,

the Hamilton Bulldogs of the American Hockey League (AHL), and

McMaster University Athletics, Morton hopes to work within high-

level sport organizations. His goal is to be an industry-leader in

sport science and to bridge the gap between science and sport.

Chris McGlory is a Postdoctoral Research Fellow and a graduate of

Liverpool John Moores University (where he attained his Master of

Science degree) and the University of Stirling (where he completed

his PhD). He competed in high-level rugby until injury forced a

premature exit from the game. McGlory is very interested in the

link between muscle contraction and mechanisms leading to

hypertrophy in human skeletal muscle.

Panel A: Hypertrophy of the biceps brachii after a 15-week RT program under high hormone (HH) or low hormone (LH) conditions.

Panel B: Aggregate exposure (mean area under the curve [AUC] post-exercise before and after training) for free testosterone (fT).

Panel C: Mean increase in maximal elbow flexor strength – one repetition maximum (1RM); values are means ± standard error of

the mean.

Figures redrawn with data from West et al. with permission (28).

FIGURE 1. HIGH AND LOW HORMONE CONDITIONS ON HYPERTROPHY, AGGREGATE EXPOSURE, AND STRENGTH

24 PTQ 1.4 | NSCA.COM

DEBRA WEIN, MS, RD, LDN, NSCA-CPT,*D, AND JENNA AMOS, RD

HOW SAFE ARE SUPPLEMENTS?

Supplement use in the United States has been steadily

increasing over the last several decades. Consumers spent

almost 34 billion dollars on herbal and dietary supplements

in 2007 alone, which was an increase of almost seven billion

dollars, or 25%, since 1997 (4). As of 2010, approximately half of

all adults in the United States reported taking an herbal dietary

supplement (HDS) (4). These adults generally care about their

health; they cite health maintenance and improvement as two of

the main reasons for beginning a regimen of HDS (1). Interestingly,

of the almost 50% of adult consumers who report taking HDS,

less than half of those do so because of a healthcare provider’s

recommendation (1). This may be related to consumers commonly

perceiving supplements as generally safe (4).

While consumers may perceive supplements as safe, the

regulatory standards set forth by the Dietary Supplement Health

and Education Act of 1994 require less evidence of safety than

medications require (3). The act allows the sale of HDS without

prior approval of their efficacy or safety by the Federal Drug

Administration (FDA) or other regulatory bodies (5). Consumers’

increasing use of supplements coupled with the industry’s lax

standards has triggered research to investigate possible negative

side effects of supplement use.

Previous research by Navarro et al. attempted to quantify negative

outcomes, specifically hepatotoxicity (chemical induced liver

damage) and associated liver transplant or death, related to HDS

and medication use (4). The study recruited individuals from eight

United States Drug Induced Liver Injury Network referral centers

between 2004 and 2013. The researchers grouped the 839 patients

who met inclusion criteria into three categories: liver injury caused

by bodybuilding supplements, non-bodybuilding supplements, and

medications. The study showed that 130 patients (15.5%) had liver

injury related to HDS. The study’s results mirrored the national

trend of increasing supplement use as liver injury from HDS

increased from 7% at the beginning of the study to 20% at the end

of the study. In addition, participants with liver injury from HDS

took a total of 217 different products. It is worth noting that 42

of these products had unidentifiable ingredients and 21 products

contained more than 20 ingredients.

In the same study, patients with liver injury resulting from

bodybuilding and non-bodybuilding HDS were younger than those

with liver injury resulting from medications (5). Patients with liver

injury from HDS had a significantly higher proportion of severe

cases, including those that required liver transplant or resulted

in death (4). This is interesting considering that comorbidities

such as diabetes and heart disease were more common among

the medication associated liver injury group. A total of 13 patients

in the non-bodybuilding HDS-related liver injury group died or

received a liver transplant while no patients in the bodybuilding

HDS-related liver injury group died or required a transplant.

However, patients with liver injury related to bodybuilding HDS

experienced increased latency (time between the start of the

supplement and the onset of injury) and prolonged jaundice

compared to the other two groups (4).

Previous case studies and research findings support the possible

association between hepatotoxicity and supplement intake.

Timcheh-Hariri et al. investigated case studies of individuals

who had taken three specific supplements (6). The study

concluded possible causality between the supplement use and the

hepatotoxicity in the otherwise healthy individuals. Interestingly,

liver injury resolved in all cases within one month of stopping

supplement intake.

Another study by Martin et al. found that 48 military personnel

who required evacuation from a military facility had drug-

induced liver injury. Of those 48, 12 military personnel (25%) were

associated with a pre-workout supplement (2).

Consumers and healthcare providers should remain aware that

the supplement industry has fairly loose regulation, rendering

supplement use risky at times. Studies have shown the harm and

dangers that certain supplements can cause to otherwise healthy

individuals. This suggests a need for more research on the topic to

understand the potential problems better. Ultimately, a consumer

should always discuss the use of HDS with a physician, pharmacist,

or Registered Dietitian (RD) for important information on dosing

and possible drug interactions prior to implementation.

PTQ 1.4 | NSCA.COM 25

REFERENCES

1. Bailey RL, Gahche JJ, Miller PE, Thomas PR, and Dwyer JT.

Why U.S. adults use dietary supplements. JAMA Intern Med 173(5):

355-61, 2013.

2. Martin, DJ, Partridge, BJ, and Shields, W. Hepatotoxicity

associated with the dietary supplement N.O.-XPLODE. Ann Intern

Med 159(7): 503-504, 2013.

3. National Institutes of Health Office of Dietary Supplements.

Dietary Supplement Health and Education Act of 1994. Public Law

103-417: 103rd Congress. 1994. Retrieved 2014 from http://ods.

od.nih.gov/About/DSHEA_Wording.aspx.

4. Navarro, VJ, Barnhart, H, Bonkovsky, HL, Davern, T, Fontana,

RJ, Grant, L, et al. Liver injury from herbals dietary supplements

in the U.S. Drug-Induced Liver Injury Network. Hepatology 60(4):

1399-1408, 2014.

5. Stickel F, Kessebohm K, Weimann R, and Seitz HK. Review of

liver injury associated with dietary supplements. Liver Int 31(5):

595-605, 2011.

6. Timcheh-Hariri A, Balali-Mood M, Aryan E, Sadeghi M,

and Riahi-Zanjani B. Toxic hepatitis in a group of 20 male

bodybuilders taking dietary supplements. Food Chem Toxicol

50(10): 3826-3832, 2012.

ABOUT THE AUTHOR

Debra Wein is a recognized expert on health and wellness and

designed award-winning programs for both individuals and

corporations around the United States. She is the President and

Founder of Wellness Workdays, Inc., (www.wellnessworkdays.com)

a leading provider of worksite wellness programs. In addition, she

is the President and Founder of the partner company, Sensible

Nutrition, Inc. (www.sensiblenutrition.com), a consulting firm of

registered dietitians and personal trainers, established in 1994, that

provides nutrition and wellness services to individuals. She has

nearly 20 years of experience working in the health and wellness

industry. Her sport nutrition handouts and free weekly email

newsletters are available online at www.sensiblenutrition.com.

Jenna Amos is a Registered Dietitian (RD). She is a graduate

of Boston University’s undergraduate dietetics program

and of Virginia Commonwealth University Health System’s

dietetic internship.

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PTQ 1.4 | NSCA.COM

26

CHARLIE WEINGROFF, DPT, ATC, CSCS

R

ehabilitation and per

f

ormance enhancement trainin

g

are

often classified and tau

g

ht as two distinct processes. In the

best-case scenario, the rehabilitation and

p

erformance staff

wor

k

toget

h

er c

l

ose

l

y to manage t

h

e at

hl

ete t

h

roug

h

t

h

e stages

of recover

y

. These situations utilize common communication

methods to create an eas

y

transition for an individual that is

no longer in need o

f

rehabilitation and ma

y

be in need o

f

more

advanced performance training for optimal recover

y

(17). Despite

what ma

y

appear to be use

f

ul teamwork leading to a return to

s

port and performance trainin

g

, this sometimes is not the case.

In rea

l

it

y

, t

h

is process is on a continuum t

h

at encompasses t

h

e

s

ame laws o

f

neurological and ph

y

siological principles (7,17).

Understanding these principles ma

y

allow for even further overlap

of the rehab and performance trainin

g

processes leadin

g

to

potentia

lly

quic

k

er resu

l

ts

.

In the s

p

orts rehabilitation and

p

erformance field, often “worlds

collide” based on semantics and definitions. Man

y

practitioners

have a vision of what the rehab and trainin

g

processes looks

l

i

k

e (16). As a common

d

enominator,

b

ot

h

p

rocesses are a

b

out

changing the bod

y

. Changes in the bod

y

’s performance, whether

it is movement skills or performance measures can usuall

y

be

tracked to a common res

p

onse of ada

p

tation to stress (7). This

is known as s

p

ecific ada

p

tation to im

p

osed demands, or the

SAID Princi

pl

e

.

When the intent is to chan

g

e the perception o

f

pain or chan

g

e

motor control, the focus is neurological or neuromuscular,

respectivel

y

. If the intent is to change or improve measures of

flexibilit

y

, speed, power, and

/

or endurance, the focus of the

stressor is o

f

ten neuroph

y

siological or neuroendocrine. Regardless

of the

g

oal of the stressor or the desi

g

nation of the professional,

t

h

e

b

o

dy

is stresse

d

an

d

require

d

to a

d

apt. Viewing t

h

e

a

d

aptation process t

h

roug

h

t

h

is

l

ens may

b

egin to

b

ring t

h

e

b

asic

processes of rehab and trainin

g

much closer to

g

ether

.

W

h

en viewe

d

t

h

rou

gh

t

h

e re

h

a

b

i

l

itation process, t

h

e su

gg

estion

is t

h

at t

h

e

b

o

dy

is

b

ro

k

en or

h

as negative

ly

a

d

apte

d

to some

form of stress (21). The bod

y

is injured, and the goal is to restore

it to normal levels. This negative stress ma

y

be in the form of an

i

ll

-a

d

vise

d

t

h

erap

y

p

l

an, repetitive motions, overuse s

y

n

d

romes

from dail

y

life or fitness activities, or trauma. The stress can be in

man

y

different forms, but if the adaptation is not desirable, the

individual will o

f

ten seek medical intervention (7). I

f

the bod

y

has

respon

d

e

d

negative

ly

to stress, one answer to injur

y

prevention

is resistance to stress (1,6,8). Some

k

e

y

b

o

d

i

ly

a

d

aptations can

y

ield resilienc

y

to overloading, overtraining, and certain levels of

trauma. Performance training ma

y

help improve this resilienc

y

and

progress toward injur

y

prevention, if applied properl

y

. Although

rarel

y

applied, sometimes it could be beneficial to expedite the

rehabilitation

p

rocess via concurrent a

pp

lication of

p

erformance

trainin

g

usin

g

movements an

d

exercises t

h

at

d

o not exp

l

oit t

h

e

injur

y

or pain (8). These performance training processes manage

qualities of the bod

y

that are alread

y

at normal or above normal

levels and aim to create ada

p

tations that are above normal. If

the trainin

g

process intends to restore or improve qualities of the

bod

y

based on general and specific applications of stress, there

wou

ld

potentia

lly

b

e

l

ess

d

iscor

d

an

d

improve

d

outcomes in

both

p

rocesses with

p

rofessionals of both ends of the s

p

ectrum

workin

g

off the same premises and

g

oals.

THE SHARED ADAPTATIONS OF THE TRAINING AND

REHABILITATION PROCESSES

FEATURE ARTICLE

PTQ 1.4 | NSCA.COM 27

Pro

p

er stress a

ppl

ication is t

h

e common t

h

rea

d

b

etween

rehabilitation and performance trainin

g

processes, and there is

a lot o

f

scienti

f

ic research behind each

f

ield o

f

stud

y

. Matching

t

he correct practitioner to the appropriate stage o

f

the training

process is

l

ess science-

b

ase

d

an

d

more p

h

i

l

osop

h

ica

l

. C

h

an

g

in

g

semantics ma

y

help make this process easier. If there is injur

y

,

it ma

y

be acceptable to sa

y

that there has been failure of the

bod

y

to adapt appropriatel

y

at some level (10,15). The

f

ailure

ma

y

be an

y

where

f

rom a local tissue

f

ailure to a general injur

y

or an inabilit

y

to train or compete. Failure from the performance

t

raining process is

l

i

k

e

ly

an in

d

icator t

h

at t

h

e in

d

ivi

d

ua

l

’s p

hy

sica

l

adaptations are not at a hi

g

h enou

g

h level to be successful in

competitions o

f

the sport (19,20).

There are four

p

otential areas of failure where s

p

ort coaches,

p

erformance coaches, and healthcare

p

rofessionals can all be

legitimate entr

y

points with the common goal of performance

t

raining. The

f

irst area

f

or potential injur

y

is the equipment. The

equipment being used in sports ma

y

be out o

f

date in terms o

f

t

echnolog

y

, inappropriatel

y

sized, or poorl

y

chosen for the t

y

pe of

surface or weather

(

14

)

.

Th

e

s

eco

nd

a

r

ea

of

co

n

ce

rn is

o

n

e

of

t

ec

hni

ca

l skills.

Of

t

e

ntim

e

s

th

e

b

est tec

h

nica

l

a

pp

roac

h

to at

hl

etics is one t

h

at em

ph

asizes

positions of the bod

y

that are possible injur

y

mechanisms (4).

Ot

h

er times, simp

ly

poor

ly

practice

d

tec

h

nique ma

y

l

imit power or

cause injur

y

(11). In t

h

ese areas, t

h

e sport coac

h

ma

y

b

e t

h

e

b

est

in

d

ivi

d

ua

l

to mo

d

u

l

ate t

h

e stressors t

h

at may potentia

ll

y

l

ea

d

to

injur

y

or

l

imitations in output

.

The third area of potential failure can be termed “biolo

g

ical

power.” It is conventiona

l

to su

gg

est t

h

at

l

imitations in power,

endurance, speed, or mental

f

ocus are tar

g

ets to improve

p

er

f

ormance. However, as the u

pp

er thresholds o

f

these

q

ualities

are reac

h

e

d

or excee

d

e

d

, it is ver

y

reasona

bl

e t

h

at in

d

ivi

d

ua

l

s ma

y

nee

d

to resort to poor execution or

h

i

gh

er t

h

res

h

o

ld

tec

h

niques

th

at ma

y

create joint wear (1,6,13). W

h

i

l

e operating un

d

er

l

actic-

g

eneratin

g

conditions, and

g

iven poor conditionin

g

f

or the

se

l

ecte

d

sport, t

h

e

b

o

dy

b

ecomes more suscepti

bl

e to injur

y

,

particularl

y

if acute or prolonged rest is not provided (2).

Operatin

g

un

d

er

l

actic-

g

eneratin

g

con

d

itions, an

d

g

iven poor

conditioning for the selected sport, the bod

y

becomes far more

susceptible to injur

y

, particularl

y

if acute or prolonged rest is

not provi

d

e

d

(2). An

y

l

imitations in capacities

l

iste

d

a

b

ove

ma

y

lead to compensator

y

strategies as well as function under

un

f

avorable allostasis

f

or per

f

ormance or injur

y

. Identi

fy

ing the

ideal joint positions, tonic and phasic muscle function of the

sport, allostatic recover

y

, and the most efficient work capacit

y

are

a

ll

k

e

y

management strategies t

h

at t

h

e

h

ea

l

t

h

care provi

d

er an

d

performance coach can appl

y

(4,8,11,13)

.

Power can be develo

p

ed, and this falls under the

p

erformance

coach. Carr

y

over to sport is paramount during training as much as

it is im

p

ortant to se

l

ect vo

l

umes an

d

intensities t

h

at com

pl

ement

t

he current status and develo

p

ment of the individual. There is a

lot o

f

leewa

y

in training the general population with this in mind;

however, trainin

g

at intensities that

f

ar exceed the individual’s

current capa

b

i

l

ities is a potentia

lly

d

angerous process. C

h

oosing

movements that do not degrade technical proficienc

y

due to lactic

energ

y

suppl

y

ma

y

take a program awa

y

from personal preference

or ideal sport specificit

y

. In general, movement selection ma

y

be less important, but carr

y

over efficienc

y

is more important in

trainin

g

competitive at

hl

etes (10,13).

While the per

f

ormance coach ma

y

be too aggressive and cause

injur

y

via overtraining, t

h

e c

h

ec

k

an

d

b

a

l

ance to t

h

is process,

for example, ma

y

come from the healthcare provider training in

manua

l

t

h

erap

y

or ot

h

er recover

y

met

h

o

d

s t

h

at ma

y

expe

d

ite

acute levels o

f

recover

y

(3,12). No neurological recover

y

technique

can outrun poor

ly

manage

d

p

hy

sio

l

ogica

l

training approac

h

es,

b

ut

in a well-crafted team-based approach, injur

y

ma

y

be limited, and

performance ma

y

be enhanced if executed properl

y

. This is where

some re

h

a

b

i

l

itation tec

h

niques are a

l

so

d

ou

bl

ing as recover

y

tec

h

niques (3,12). Usin

g

t

h

e stress app

l

ication t

h

ou

gh

t process,

injur

y

can

b

e viewe

d

as t

h

e recover

y

process t

h

at

h

as gone awr

y

so t

h

at t

h

ere ma

y

b

e pain or compensator

y

movement strategies,

suc

h

as auto

g

enic in

h

i

b

ition or tone (21)

.

While the third area o

f

potential injur

y

is traditionall

y

governed

b

y

the performance coach, the fourth has more to do with the

rehabilitation professional; this area is movement. Simpl

y

, when

all other cate

g

ories are exhausted and do not mana

g

e the failure

o

f

injur

y

or per

f

ormance, the assumption is that the bod

y

simpl

y

cannot get into t

h

e positions, mec

h

anica

lly

or neuro

l

ogica

lly

, to

a

b

sor

b