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ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2010 • VOLUME 20:3 1ACSM’S CERTIFIED NEWS • JANUARY-MARCH 2010 • VOLUME 20:1 1

NEWS

Continuing Education Self-Testspage 15

Are Your AssessmentsProviding The InformationYou Need? page 3

Is Functional TrainingReally Functional? page 5

New Thoughts OnWhat Really CausesHeart Disease page 7

Resistance, Repetitionsand Results page 10

A Perspective OnLower ExtremityPeripheral ArterialDisease and Exercise

page 12

The Evolution ofWorksite Wellness

page 14

ACSM’S CERTIFIED

A Perspective OnLower ExtremityPeripheral ArterialDisease and Exercise

page 12

The Evolution ofWorksite Wellness

page 14

SHUT

TERS

TOCK

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

CNews20.final:ACSM template 10/26/10 9:08 AM

2 ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2010 • VOLUME 20:3

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IInn tthhiiss IIssssuueeFitness Assessment and Exercise Prescription:

Are your assessments providing theinformation you need? .......................................... 3

Is Functional Training Really Functional?.............. 5New Thoughts on What Really Causes

Heart Disease and How Exercise HelpsBeyond Traditional Risk Factors .......................... 7

Coaching News........................................................... 9Resistance, Repetitions and Results ...........................10A Perspective on Lower Extremity Peripheral

Arterial Disease and Exercise ................................12The Evolution of Worksite Wellness: Enhancing

Quality of Life from 9 to 5 and Beyond .............14Self-Tests ........................................................................15

CCoo--EEddiittoorrssPaul Sorace, M.S.; James R. Churilla, Ph.D., M.P.H.

CCoommmmiitttteeee oonn CCeerrttiiffiiccaattiioonnaanndd RReeggiissttrryy BBooaarrddss CChhaaiirr

Madeline Bayles, Ph.D., FACSM

CCCCRRBB PPuubblliiccaattiioonnss SSuubbccoommmmiitttteeee CChhaaiirrPaul Sorace, M.S.

AACCSSMM NNaattiioonnaall CCeenntteerr CCeerrttiiffiieedd NNeewwss SSttaaffffNational Director of Certification

and Registry ProgramsRichard Cotton

Assistant Director of CertificationTraci Sue Rush

Professional Education CoordinatorShaina Miller

Publications ManagerDavid Brewer

EEddiittoorriiaall BBooaarrddChris Berger, Ph.D.

Clinton Brawner, M.S., FACSMBrian Coyne, M.Ed.

Avery Faigenbaum, Ed.D., FACSMYuri Feito, M.S., M.P.H.

Tom LaFontaine, Ph.D., FACSMPeter Magyari, Ph.D.Thomas Mahady, M.S.

Jacalyn McComb, Ph.D., FACSMPeter Ronai, M.S.

Larry Verity, Ph.D., FACSMStella Volpe, Ph.D., FACSMJan Wallace, Ph.D., FACSM

For More Certification Resources Contact theACSM Certification Resource Center:

1-800-486-5643

IInnffoorrmmaattiioonn ffoorr SSuubbssccrriibbeerrss

Correspondence Regarding Editorial ContentShould be Addressed to:

Certification & Registry DepartmentE-mail: [email protected].: (317) 637-9200, ext. 115

For back issues and author guidelines visit:www.acsm.org/certifiednews

Change of Address or Membership Inquiries:Membership and Chapter Services

Tel.: (317) 637-9200, ext. 139 or ext. 136.

ACSM’s Certified News (ISSN# 1056-9677) is publishedquarterly by the American College of Sports MedicineCommittee on Certification and Registry Boards (CCRB). Allissues are published electronically and in print. The articlespublished in ACSM’s Certified News have been carefullyreviewed, but have not been submitted for consideration as, andtherefore are not, official pronouncements, policies,statements, or opinions of ACSM. Information published inACSM’s Certified News is not necessarily the position of theAmerican College of Sports Medicine or the Committee onCertification and Registry Boards. The purpose of thispublication is to provide continuing education materials to thecertified exercise and health professional and to inform theseindividuals about activities of ACSM and their profession.Information presented here is not intended to be informationsupplemental to the ACSM’s Guidelines for Exercise Testing andPrescription or the established positions of ACSM. ACSM’sCertified News is copyrighted by the American College ofSports Medicine. No portion(s) of the work(s) may bereproduced without written consent from the Publisher.Permission to reproduce copies of articles for noncommercialuse may be obtained from the Rights and Permissions editor.

ACSM National Center401 West Michigan St., Indianapolis, IN 46202-3233.

Tel.: (317) 637-9200 • Fax: (317) 634-7817© 2010 American College of Sports Medicine.

ISSN # 1056-9677

PERSONAL TRAINING —A BROAD PROFESSION

By Julie Downing, Ph.D., FACSMHealth & Human Performance Department

Central Oregon Community College

The professional Personal Trainer performsmany different jobs when working with theirclients.

How do we know that the profession of Personal Training has such a broad list of job tasks?We (the ACSM Personal Training Committee) took a very simple approach and recently surveyedPersonal Trainers about what their job entails and the importance/frequency of each task. This isthe second time we have conducted such a survey. Our first one was conducted in 2004 whenACSM introduced its Personal Training certification. This time, we had nearly 2,100 survey respon-dents and what we found was not necessarily surprising but instead confirmed what we stronglysuspected to be the case in the world of Personal Training — Personal Trainers do it all. They areinvolved in many different tasks in helping clients achieve goals and objectives.

Job Task Analysis Survey highlights illustrated that Personal Trainers:• work with all populations (provided that they have been medically cleared for exercise)

with a multitude of goals and require knowledge to modify exercise prescription/assessment based on clients needs.

• must possess knowledge of proper spotting techniques for various exercises.• coach/counsel clients and are using several different health behavior change models, as

well as motivational techniques.• require business/marketing knowledge in order to be successful.• must be able to communicate effectively in-person, on the phone, and electronically.• earn clients trust by ensuring safety and helping clients achieve their goals. So with this valuable insight from the Job Task Analysis, our ACSM certification exam prepara-

tion materials, textbooks, and exam content will more closely reflect what today’s trainer needsto know. Our certification exam blueprint will now have the following four content domains (per-centages shown are the proportion of the exam questions from each area):

I – Initial Client Consultation & Assessment 26%II – Exercise Programming & Implementation 27%III – Exercise Leadership & Client Education 27%IV – Legal/Professional/Business/Marketing 20%So in summary, the ACSM Personal Training Certification exam will include more content on:

behavior modification (found in domain III and goes beyond the six stages of change transtheoret-ical model), strength training, spotting techniques, business/marketing, effective communication,and finally working with special populations who have been medically cleared for exercise.

The ACSM’s Resources for the Personal Trainer, 3rd Edition text is extremely helpful inreviewing for the ACSM Personal Training Certification. For more information on ACSM’sPersonal Training Certification, visit www.acsm.org/certification.

Thanks to all of you who helped us out by completing the recent Personal Trainer job taskanalysis survey. We could not have done this valuable work without your feedback.


mailto:[email protected]

http://www.acsm.org/certifiednews

http://www.acsm.org/certification

ACSM’S CERTIFIED NEWS • JULY–SEPTEMBER 2010 • VOLUME 20:3 3

IT IS WELL DOCUMENTED AND

UNDERSTOOD THAT THE FIRST FOUR

TO SIX WEEKS OF ANY RESISTANCE

TRAINING PROGRAM INVOLVES

STIMULATING AND DEVELOPING

MOTOR PATHWAYS.2

As fitness professionals, part of our job is to help facilitate thedevelopment of these motor pathways by collecting the necessaryinformation through client assessment, evaluating this information,and prescribing exercise that reflects this information.

Properly trained fitness professionals are well prepared and eagerto design exercise prescriptions based on a client’s needs, goals,health history, and initial fitness assessment. There does, however,exist a need to examine the process by which fitness professionals goabout collecting this information. Testing protocols often becomeroutine practice, utilizing the same health related fitness assessmentsfor all clients as a starting point. This use of routine testing is due tothe validity and reliability of the assessments proven over time, whichis to be respected as these assessments provide information thathelps us when prescribing exercise. However, we need to evaluateour assessment choices and offer a variety of ways to assess ourclients that would better represent the individual’s needs beyond thebasic components of fitness. The ability to assess a client’s motorlearning needs could certainly be part of this process.

In preparation of administering a fitness assessment and followinga review of a client’s health history and exercise experience, a fitnessprofessional should ask themselves the following questions. What aremy options for testing the basic components of fitness? Does the facil-ity provide the space, equipment and time to offer the client theseoptions? How do I offer those choices to my client? Is there anythingelse that exists outside of the basic components of fitness that I canoffer a client as part of their initial assessment? Testing for a motorlearning skill that is specific to the needs of the client could possiblybe part of this assessment. This would be in addition to and not inplace of the testing of the basic components of fitness.

Motor Learning as a basis for fitnessassessment and program development

Most people possess a certain amount of basic motor skills. Dayto day motor abilities enable an individual to navigate their way

through the world. A basic skill such as brushing your teeth is so welllearned through childhood that the thought behind the act of brush-ing is non-existent, except for the motivation to initiate the move-ment. Therefore, motor learning is a part of person’s natural growthand internal processes that determine a person’s ability to performmotor skills well and with good technique.7 Motor skills for athleticperformance, however, are very different and require an assessmentprocess that is planned and systematic.

The following are five important questions to review before begin-ning a motor skills assessment:6

1. Why assess?2. What variables should I assess?3. Which test will assess the most important variable?4. How will you prepare the client for the assessment?5. How will you utilize the results?For example, a male client presents with a goal of improving his

tennis game. After a short conversation with this client, together youestablish that he would like to improve his return game from thebaseline. In addition to the basic components of fitness, you decide toconduct a baseline speed and agility forehand and backhand test.3 Toprepare your client you would describe the test and the proceduresleading up to the actual test. Provide a visual demonstration prior totesting along with specific instructions regarding the testing proce-dure and all beginning and ending parameters. Begin with a properwarm-up, and following a proper cool-down period, share the resultsof the assessment with your client. This would include relating yourclient’s performance to any norms generated from prior testing andresearch, and then relate the results to future strategies for training.6

There exists a plethora of tests related to motor performance.Choosing the proper test requires a little research and the ability toapply it to the needs and goals of the client. Fleishman and colleagues4

have developed taxonomy of motor abilities with two main categories;perceptual motor abilities and physical proficiency abilities. Someexamples of Fleishman’s physical proficiency abilities include staticstrength, dynamic strength and explosive strength. Some examples ofFleishman’s perceptual motor abilities would include response orienta-tion and reaction time.1,4 Using this taxonomy as a guide (see Table),a fitness professional analyzing the client’s needs should be able tochoose an ability that most closely relates to the client’s need and con-duct a test that will support that choice. It would be important to

HEALTH & FITNESS FEATURE

Fitness Assessment and Exercise Prescription:

BY DIERDRA BYCURA, Ed.D., ACSM HFS AND THOMAS P. MAHADY, M.S., CSCS

ARE YOUR ASSESSMENTS PROVIDINGTHE INFORMATION YOU NEED?



assess those physical abilities either in a generic fashion or by recreat-ing the goal task as part of a pre/post type assessment.

Utilizing Fleishman’s Taxonomy of Motor Abilities, the baselinespeed and agility drill cited above would be an example of recreatinga gross body coordination test that is task specific to the baseline playthat is common during a tennis match, whereas an example of ageneric test would be the timing of a client in the 40 yard dash.When deriving assessments to measure particular abilities, it is neces-sary to record the specifics of the assessment to maintain the reliabil-ity of the post-test.5

ConclusionKnowing how the body works and best adapts to stimuli is vital to

the client/fitness professional relationship. Understanding the acqui-sition of motor skills is an integral part of fitness professional’s train-ing skill. A fitness professional who can integrate these concepts intohis program assessment, exercise prescription and subsequent train-ing will help facilitate the client’s goals more effectively.

About the Authors

Dierdra Bycura, Ed.D., ACSM-HFS, CPT is an assis-tant clinical professor at Northern ArizonaUniversity in Flagstaff, Arizona. Dierdra also is amember of the ACSM Exam Development Team forcredentialing and certification.

Thomas P. Mahady, M.S., CSCS is the senior exercisephysiologist for The Cardiac Prevention andRehabilitation Center at Hackensack UniversityMedical Center in Hackensack, NJ. He also is anadjunct professor at William Paterson University inWayne, NJ.

References1. Coker, CA. Motor Learning & Control, 2nd Ed. Scottsdale, AZ:Holcomb Hathaway, 2009, pp. 16-17.

2. Essentials of Strength Training and Conditioning, 3rd Ed.Baechle, TR, Earle, RW, editors. Champaign, IL: Human Kinetics,2008., pp.94-96.

3. Etcheberry, P. Etcheberry certification for tennis. Available at:http://etcheberryexperience.com/en/info/tennis_certification.Accessed September 17th, 2010.

4. Fleishman, EA. Structure and measurement of psychomotor abili-ties. In R.N. Singer (Ed.), The psychomotor domain: Movementbehavior. Philadelphia, PA: Lea & Febiger, 1972, pp. 78-106.

5. Magill, RA. Motor Learning & Control: concepts and applica-tions, 9th Ed. New York, NY: McGraw-Hill, 2011, pp. 55-59.

6. Payne, V. G., and L.D. Isaacs. Human Motor Development: ALifespan Approach. Mountain View, Calif.: Mayfield, 1987, pp. 433-435.

7. Schmidt, RA, Wrisberg, CA. Motor Learning and Performance: Asituation-based learning approach, 4th Ed., Champaign, IL: HumanKinetics, 2008, pp. 11-12.

Table. Fleishman’s Taxonomy of Motor Abilities

Abilities Definition ExampleControl precision Highly controlled movement adjustments, especially those

involving larger muscle groups Dribbling a soccer ballMulti-limb coordination Coordinate numerous limb movements simultaneously Volleyball spikeResponse orientation Select a response rapidly from a number of alternatives,

as in choice reaction time situations Tail back trying to find an openingSpeed of limb movement Make gross rapid limb movement without regard for reaction time Hockey slap shotRate control Make continuous speed and direction adjustments with precision

when tracking Mountain bikingManual dexterity Control manipulations of large objects using arms and hands Water poloFinger dexterity Control manipulations of small objects primarily through the use of fingers Dialing a cell phoneArm-hand steadiness Make precise arm-hand positioning movements where involvement

of strength and speed are minimal DentistryWrist finger speed Move the wrist and fingers rapidly Blackjack dealingAiming Direct hand movements quickly and accurately at a small object in space Marksmanship

Physical Proficiency AbilitiesStatic strength Ability to generate maximum force against weighty external object Pushing car out of snow bankDynamic strength Muscular endurance or ability to exert force repeatedly Rock climbingExplosive strength Muscular power or ability to create maximum effort by combining force

and velocity Throwing javelinTrunk strength Dynamic strength of trunk muscles Pole vaultExtent flexibility Ability to move trunk and back muscles through large range of motion Circus contortionistDynamic flexibility Ability to make repeated, rapid flexing movements Diving, aerial ski jumpingGross body coordination Ability to coordinate numerous movements simultaneously while the body

is in motion Slalom skiing, synchronized swimmingGross body equilibrium Ability to maintain balance without visual cues Tightrope walking while blindfoldedStamina Cardiovascular endurance or ability to sustain effort Climbing Everest

Information obtained from 1, 4.


http://etcheberryexperience.com/en/info/tennis_certification


“Functional fitness” has been defined as having the physical capacityto perform activities of daily living in a safe and independent mannerwithout undue fatigue.3 Some fitness professionals refer to this as“strength you can use.” One of the most popular techniques touted toimprove functional fitness is the use of unstable surface training. Trainingimplements employed to induce instability include wobble boards, foamrollers, stability balls, balance discs, and BOSU devices, among others.

According to proponents, training on an unstable surface imposes agreater challenge to the neuromuscular system, thereby eliciting maxi-mal improvements in human function. Indeed it has been shown thatunstable surfaces are valuable in rehabilitation settings, particularly inhelping to alleviate symptoms associated with lateral ankle sprains.19, 15

There also is a substantial body of research showing that performingabdominal and lumbar exercises on unstable implements increases activ-ity of the core musculature compared to similar movements performedon a stable surface.17, 4, 16, 6 And there is some evidence that training in anunstable environment may help to improve proprioception in the lowerbody musculature,11, 8 potentially by enhancing sensory perception.Whether these enhancements translate into better performance ofactivities of daily living, however, is open for debate.

A problem with the practical application of unstable surface trainingis that it often fails to take into account the concept of specificity. The“Specific Adaptation to Imposed Demands” (SAID) principle dictatesthat optimal transfer of the exercise benefit is achieved when move-ments most closely match those of a given task. Considering that thevast majority of everyday activities are carried out in a stable environ-ment, it therefore follows that functional transfer will be optimized bytraining on stable surfaces. This is consistent with research by Yaggie andCampbell,20 who found that although training on a BOSU® ball improvedsubjects’ ability to stand quietly, it failed to improve functional markersof strength, balance, and power.

Moreover, it is important to note that people commonly lose func-tional ability due to a loss of muscle tissue and thus an associated loss ofstrength.13, 7, 10 Accordingly, improving muscle hypertrophy and strengthwill result in substantial improvements in functional ability. In a study byFiatarone et al.,7 six women and four men (mean age = 90 ± 1 years)were recruited from a nursing home population to evaluate the effectsof strength training on functional capability. Subjects trained three daysa week, performing three sets of eight repetitions on a machine legextension apparatus. After eight weeks, subjects increased their lower

body strength by 175% and their functional scores on a test of walkingand balance improved by approximately 48%. Two of the participantswere actually able to walk without the assistance of their canes! Theseimprovements in function were attained by training solely on a resist-ance machine — an implement that functional training proponents oftendismiss as developing “non-functional” strength.

Alternatively, unstable surface training has been found to be subopti-mal for increasing strength. Behm, et al.2 studied the EMG response toexercise when training on both stable and unstable surfaces. Eight phys-ically active males performed maximal voluntary contractions of theknee extensors and plantar flexors while either seated in a chair (stablesurface) or on a Swiss ball (unstable surface). Results showed that train-ing on the unstable surface resulted in a 44% reduction in muscle activ-ity and a 70% decrease in force output compared to the same activitiesperformed on the stable surface. Similar findings have been reported inmany other studies, with results holding true in the performance of bothupper body and lower body exercises.18, 9, 14, 1 A decrease in muscle forceoutput during training mitigates increases in muscular strength, whichwould seemingly attenuate functional transfer.

Further, the functional benefits of unstable surface training also maybe limited in athletic populations. Cressey et al.5 investigated the use ofunstable surface training on athletic performance in elite athletes.Nineteen recruits (ages 18 to 23 years) from a National CollegiateAthletic Association Division I college soccer team were randomly divid-ed into one of two groups, where ten subjects supplemented their usualexercise program by performing various lower body exercises on inflat-able rubber discs while the nine others performed the same exerciseson a stable surface. Performance was assessed by a variety of testsincluding the bounce drop jump, countermovement jump, 40- and 10-yard sprint times, and T-test. After 10 weeks, the stable surface groupdisplayed greater performance improvements in all measures studiedcompared to the unstable surface group, leading the authors to con-clude that use of unstable surfaces may not be optimal for athletic per-formance improvements in healthy, trained individuals. It was surmisedthat diminished results in the unstable surface group may be due to areprogramming of neuromuscular patterns that chronically impairsstretch-shortening cycle function essential for the performance of sport-ing activities.

In conclusion, commonly accepted training tenets need to be reex-amined with respect to the concept of functional fitness. Central to thedesign of any fitness program is the principle of specificity, where exer-cise routines are matched to an individual’s needs, abilities, and goals.Based on available research, it would seem that functional improvementsare best achieved when a majority of training is carried out on stable sur-faces. In certain circumstances, it is possible that the addition of unstablesurface exercises to a routine may provide a synergistic benefit to func-

IS FUNCTIONAL TRAININGREALLY FUNCTIONAL?

BY BRAD SCHOENFELD, M.S., CSCS

WELLNESS ARTICLE

The term "functional training" has become apopular buzzword in the fitness field — somuch so that several leading fitnessorganizations now call it one of the biggestcurrent industry trends. The question is, doesthe concept live up to the hype?

CNews20.final6.0 10/29/10 8:16 AM


tional capacity. McKeon et al.12 posited that a combination of approxi-mately 75% stable and 25% unstable surface training may be ideal foroptimizing static and dynamic balance. Further research is warranted toshed more light on this topic.

Moreover, it can be misleading to refer to exercise as either “func-tional” or “non-functional” because functional transfer from trainingexists on a continuum. For those who are very unfit, a routine using onlymachines may be all that is required to sufficiently improve an individual’sability to carry out desired activities of daily living. As fitness levelsimprove and/or functional demands increase, exercises that challengethe body in three-dimensional space will be necessary to realize greaterperformance enhancements.

About the AuthorBrad Schoenfeld, MS, CSCS, is the president of

Global Fitness Services in Scarsdale, NY. He is an

adjunct professor at Lehman College in the

Department of Health Sciences, and serves as an asso-

ciate editor for the NSCA’s Strength and

Conditioning Journal.

References 1. Anderson KG, Behm DG. (2004). Maintenance of EMG activity andloss of force output with instability. Journal of Strength andConditioning Research, 18(3): 637-40.

2. Behm, D.G., Anderson, K., and Curnew, R.S. (2002). Muscle forceand activation under stable and unstable conditions. Journal ofStrength and Conditioning Research, 16: 416-422.

3. Collins K, Rooney BL, Smalley KJ, Havens S. (2004). Functional fit-ness, disease and independence in community-dwelling older adultsin western Wisconsin. Wisconsin Medical Journal, 103(1): 42-8.

4. Cosio-Lima, L.M., Reynolds, K.L., Winter, C., Paolone, V., and Jones,M.T. (2003). Effects of physioball and conventional floor exerciseson early phase adaptations in back and abdominal core stability andbalance in women. Journal of Strength and ConditioningResearch. 17(4): 721-725.

5. Cressey EM, West CA, Tiberio DP, Kraemer WJ, Maresh CM. (2007).The effects of ten weeks of lower-body unstable surface training onmarkers of athletic performance. Journal of Strength andConditioning Research, 21(2): 561-7.

6. Duncan M. (2009). Muscle activity of the upper and lower rectusabdominis during exercises performed on and off a Swiss ball.Journal of Bodywork and Movement Therapies,13(4):364-7.

7. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, EvansWJ. (1990). High-intensity strength training in nonagenarians.Effects on skeletal muscle. JAMA, 13;263(22): 3029-34.

8. Hoffman, M. and Payne, V.G. (1995). The effects of proprioceptiveankle disk training on healthy subjects. JOSPT. 21(2): 90-93.

9. Kohler JM, Flanagan SP, Whiting WC. (2010). Muscle activationpatterns while lifting stable and unstable loads on stable and unsta-ble surfaces. Journal of Strength and Conditioning Research,24(2): 313-21.

10. Lord SR, Ward JA, Williams P, Anstey KJ. (1994). Physiological fac-tors associated with falls in older community-dwelling women.Journal of the American Geriatric Society, 42(10), 1110-7.

11. Mattacola, C.G. and Lloyd, J.W. (1997). Effects of a 6-week strengthand proprioception training program on measures of dynamic bal-ance: a single-case design. Journal of Athletic Training, 32(2): 128-135.

12. McKeon, P.O. et al. (2008). Balance training improves function andpostural control in those with chronic ankle instability. Medicineand Science in Sports and Exercise, 40(10): 1810-1819.

13. Melton LJ 3rd, Khosla S, Crowson CS, O’Connor MK, O’FallonWM, Riggs BL. (2000). Epidemiology of sarcopenia. Journal of theAmerican Geriatric Society, 48(6), 625-30.

14. Nuzzo JL, McCaulley GO, Cormie P, Cavill MJ, McBride JM. (2008).Trunk muscle activity during stability ball and free weight exercises.Journal of Strength and Conditioning Research. 22(1): 95-102

15. Osborne MD, Chou LS, Laskowski ER, Smith J, Kaufman KR. (2001).The effect of ankle disk training on muscle reaction time in subjectswith a history of ankle sprain. American Journal of SportsMedicine, 29: 627–632.

16. Sternlicht E, Rugg S, Fujii LL, Tomomitsu KF, Seki MM. (2007).Electromyographic comparison of a stability ball crunch with a tra-ditional crunch. Journal of Strength and Conditioning Research.21(2): 506-9.

17. Vera-Garcia FJ, Grenier SG, McGill SM. (2000). Abdominal muscleresponse during curl-ups on both stable and labile surfaces. PhysicalTherapy, 80(6): 564-9.

18. Wahl MJ, Behm DG. (2008). Not all instability training devicesenhance muscle activation in highly resistance-trained individuals.Journal of Strength and Conditioning Research. 22(4): 1360-70.

19. Wester JU, Jespersen SM, Nielsen KD, Neumann L. (1996). Wobbleboard training after partial sprains of the lateral ligaments of theankle: a prospective randomized study. JOSPT, 23: 332–336

20. Yaggie, J.A. and Campbell, B.M. (2006). Effects of balance trainingon selected skills. Journal of Strength and Conditioning Research.20(2): 422-428.

Editor’s Note regarding the Wellness Article,“Piriformis Syndrome: A Real Pain in the Butt”in the April–June 2010 issue of ACSM’s Certified NewsSeveral figures in the article show the hip being placed in external rotation.The piriformis muscle is an external rotator and weak abductor of the femurat the hip joint and internal hip rotation is an important component of a pir-iformis stretch. Shortening of the piriformis muscle may limit internal rotation.They might experience discomfort during and/or a difficulty achieving muchfemoral internal rotation. As an alternative to internally rotating the femur,the benefits of femoral internal rotation can be achieved by rotating the trunkipsilaterally (to the same side) and by flexing the trunk slightly (in a support-ed manner). Piriformis stretches are often performed in conjunction withstretches for the gluteus maximus, hamstrings, and iliotibial band because oftheir collective effects on hip joint motion and stability. A supine piriformisknee-hug stretch can become a gluteus maximus stretch by eliminating thefemoral internal rotation.

Knee should be pulledgently towardcontralateral shoulder(opposite) to initiatefemoral internalrotation and tostretch the piriformis.

Seated piriformis stretch(notice slight adductionand internal rotation).

THE CO-EDITORS OF ACSM’S

CERTIFIED NEWS WOULD LIKE TO

THANK PETER RONAI, MANAGER

OF COMMUNITY HEALTH FOR

AHLBIN REHABILITATION CENTERS

IN BRIDGEPORT, CT AND DR. RUSTY

SMITH, CHAIR OF THE DEPARTMENT

OF CLINICAL AND APPLIED

MOVEMENT SCIENCES IN THE

BROOKS COLLEGE OF HEALTH AT

THE UNIVERSITY OF NORTH

FLORIDA FOR PROVIDING THIS

ERRATUM.

Another alternative.Notice slight adduc-tion and internal rota-tion. The quadripedposition might not bewell tolerated by orappropriate for allclients.

This is technicallystretching the piri-formis too.



BY JANET P. WALLACE, Ph.D., FACSMAND BLAIR JOHNSON, M.S.

CLINICAL FEATURE

The endothelium, the single most inner layer of the artery, is thesite of origin for atherosclerosis development. The endothelial pro-duction of nitric oxide (NO) is how the endothelium protects theartery from atherosclerosis. Nitric oxide controls the antiatherogenicactivities of platelet aggregation, coagulation, adhesion, fibrinolysis,and vascular tone in the artery. The left panel of Figure 1 illustratesNO synthesis and function. The synthesis of NO from L-arginine, oxy-gen, and electrons carried by nicotinamide adenine dinucleotide phos-phate (NADPH) is catalyzed by endothelial nitric oxide synthase(eNOS), and dependent on other cofactors. Endothelial nitric oxidesynthase can be activated by shear stress from arterial blood flow,

insulin, and acetylcholine (ACh). Insulin’s stimulation of eNOS andsubsequent NO production is dependent on insulin sensitivity, whichcould be a mechanism of why patients with diabetes are at higher riskfor cardiovascular diseases.10

The right panel of Figure 1 illustrates how the NO role in protect-ing the endothelium is compromised in oxidative stress. Superoxideradicals (O2

-) can accumulate as a result of excess oxidative stress.Nitric oxide is used up as an antioxidant scavenger of O2

-. The reac-tion between O2

- and NO not only contributes to loss of NO avail-able for the antiatherogenic functions of the endothelium, but it alsoresults in formation of peroxynitrite (ONOO-), itself a potent oxi-dant. Furthermore, O2

- and ONOO- oxidize a cofactor necessary fornormal production of NO by eNOS, which leads to loss of eNOSfunctioning. This dysfunctional eNOS produces O2

- instead of NO,thus resulting in a vicious cycle of more oxidative stress. Taken togeth-er, oxidative stress results in what we call reduced NO bioavailabilitywhich compromises all the protective functions of the endothelium.

Among the sources of oxidative stress for any individual is a high-fat meal.6 A high-sugar meal also is a direct source of oxidative stressfor patients with diabetes. Atherosclerotic cardiovascular disease wasproposed to be a meal-related (postprandial) phenomenon as early as1979 and has grown in acceptance, more so in other countries. In fact,postprandial lipemia (fat in the blood) is now been considered an inde-pendent risk factor for atherosclerotic cardiovascular disease.4 Theaverage diet of a healthy North American man consists of approxi-mately 50 to 100 g of fat per day, consumed during three to six eat-ing events. Depending on the size and composition of the meal, thepostprandial lipemic response can last up to eight hours, and thereforethe typical North American diet results in continuous exposure topostprandial lipemia. As illustrated in Figure 2, each exposure increas-es the lipemia. When cells utilize the fats oxidative stress results, lead-ing to endothelial dysfunction. The NO mediated protective mecha-nisms for the endothelium are compromised as illustrated in Figure 1(right panel) causing endothelial dysfunction. Sedentary and over-weight adults tend to have higher fat intake, exacerbating this athero-

sclerotic oxidative cycle by pro-longing and magnifying theadverse absorptive state.Consecutive high-fat meals pro-duce greater endothelial dysfunc-tion and higher oxidative stressfor each consecutive meal. Thus,recurring postprandial oxidativestress initiates a nearly continuouscycle of endothelial dysfunction.

The classic study by Vogel andcolleagues reported a decline inendothelial function following ahigh-fat meal in 10 healthy adultsin 1997.7 Figure 3 illustrates theendothelial response to high-fatand low-fat meals. The low fat

Figure 1. Left Panel: Normal protective functions of nitric oxide (NO). Right Panel:Oxidative stress compromises the protective functions of NO to create the environ-ment for the etiology of atherosclerosis

How many times have you heard that only 50% of thepatients who have a cardiac event have elevated choles-terol or that only 50% of the people with elevated cho-lesterol develop heart disease? These types of incon-stancies have led medical research to find other etiolo-gies for atherosclerosis. More recently you have proba-bly heard of the inflammation etiology. Inflammation hasalways been implicated in atherosclerosis even when theResponse to Injury Hypothesis was the dominant theo-ry. What is down played in both theories, however, isthe source of the inflammation. After all, the immunesystem needs to respond to an allergen or irritant ofsome kind. What initiates the immune response thatleads to heart disease or stroke?

NEW THOUGHTSON WHAT REALLYCAUSES HEART DISEASEAND HOW EXERCISEHELPS BEYONDTRADITIONAL RISKFACTORS



meal had no effect on theendothelium (blue line),whereas the high-fat mealexhibited a decline in functionthroughout the postprandialperiod (red line). The lowestpoint in endothelial function isat four hours following themeal, returning to baseline atsix hours. The decline inendothelial function was inresponse to the increase intriglycerides (lipids). Laterresearch found the increase intriglycerides increased oxida-tive stress. Thus, the lipemicload produced the oxidativestress which resulted in endothelial dysfunction.

In a recent review article,9 we found that approximately 45% ofcalories from fat is the minimum amount of fat that causes endothe-lial dysfunction; which also is contingent on the type of fat consumed.Most saturated fats, including monounsaturated fats, are capable ofimpairing endothelial function. Transfats and foods cooked in re-useddeep-frying oil generate even further damage to the endothelium.However, polyunsaturated fats have been found not impair endothe-lial function.

How can we prevent the consequencesof a high-fat meal?

Interventions targeting a lower lipemic load or oxidative stresshave been designed to counteract the consequences of a high-fatmeal. Lipemic load has been managed through the use of insulin andexercise, whereas oxidative stress has been manipulated with statins,exercise, and diet, including antioxidant vitamins, or supplementation.

In exercise interventions, the exercise stimulus has been eitherone single exercise session or the effects of training/detraining. Werepeated the classic study by Vogel and colleagues, but added a 40minute session of treadmill walking two hours after the high-fat meal.3

As illustrated in Figure 4, we found that the exercise not only coun-teracted the decline in endothelial function, but improved it. Then we

observed how active and inactive adults responded to the high-fatmeal and found the active adults had no decrease in endothelial func-tion at four hours after the meal, whereas the inactive adultsdecreased 31%. See Figure 5. We also found the active adults to havea lower triglyceride response, lower oxidative stress response, andhigher antioxidant response to the high-fat meal.

Exercise has several ways of affecting endothelial function.Exercise can act through an improvement in insulin sensitivity,decrease in postprandial lipemia, increase in NO,2 and/or an increasein antioxidant defense. A single session of most types of exercise,including resistance exercise is sufficient to increase insulin sensitivity,in healthy, obese, and type 2 diabetic adults. Similarly, exercise train-ing improves insulin sensitivity regardless of age, in healthy, obese, andtype 2 diabetic adults; even with no change in

.VO2max. Changes in

insulin sensitivity associated with exercise vanish within three to fivedays; and can be regained after a single exercise session.1

Dynamic exercise (acute or chronic) causes a significant, moder-ately large decrease in postprandial lipemia. There appears to be noinfluence of exercise intensity, duration, or time between exerciseand the meal on the attenuation of postprandial lipemia. Thesequence of the exercise, before or after the meal, does not affectthe decrease in postprandial lipemia. Even the accumulation of inter-mittent physical activity throughout a single day is as effective in

Figure 3. The classic response of the endothelium toa high-fat meal (red). The lowest point of function isfour hours following the meal. (figure adapted fromVogel et al (Vogel, Corretti et al. 1997))

Figure 4. The typical response to a high-fat meal(red) is counteracted by exercise (blue). (figureadapted from Padilla et al(Padilla, Harris et al. 2006))

Figure 5. Exercise appears to counteract the harmfuleffects of a high-fat meal by reducing the lipid loadand oxidative stress in addition to increasingantioxidant defense.

NNeeww TThhoouugghhttss (continued on page 11)

Figure 2. The eventsleading to endothelialdysfunction and atherosclerosis.



IN HEALTH CARE, EXPERTS ARETYPICALLY IN THE DRIVER’S SEATWHEN IT COMES TO PATIENT CARE. ASWELLNESS COACHES, WE ARE KEENLYAWARE THAT THIS APPROACH IS NOTEFFECTIVE IN FOSTERING LONG-LASTING BEHAVIORIAL CHANGE. FORCLIENTS TO THRIVE AND ACHIEVEOPTIMAL HEALTH AND WELL BEING,THEY MUST GET INTO THE DRIVER’SSEAT, BOTH IN COACHING SESSIONSAND, ULTIMATELY, IN LIFE.

Why Take the Wheel?

According to proponents of the self-determination theory, navigating frombehind the wheel is the most natural placefor humans. We are self-determining beings,innately inclined towards psychologicalgrowth and development. We are happiestand most productive when we are in controlof our lives. Richard M. Ryan, Ph.D., andEdward L. Deci, Ph.D., (2000) at theUniversity of Rochester write, “The fullestrepresentations of humanity show people tobe curious, vital, and self-motivated. At theirbest, they are agentic and inspired, striving tolearn; extend themselves; master new skills;and apply their talents responsibly. Thatmost people show considerable effort,agency, and commitment in their livesappears, in fact, to be more normative thanexceptional, suggesting some very positiveand persistent features of human nature”(p. 68).2

Please Drive MeYet many of our clients surrender the

wheel to others, causing them to becomestuck, unable to move toward their desireddestination. They take what appears be to anattractive but unproductive detour, seeing itas the “easy way out,” avoiding responsibilityfor the direction of their own lives. Somechoose to ride in the passenger seat, while,even worse, some sit in the back seat.Veering off course, they are no longer trueto their own internal compass, and soon feellost and discouraged.

It is not difficult for coaches to differenti-ate between the drivers and the passengers.We have all seen clients who readily comply,doing what others say is good for them, suchas taking their medications or eating broc-coli. Others defy by resisting a request oradvice. Either way, these clients are not act-ing autonomously. A coach will often hear:“My doctor is in charge, my genes are incharge, the experts and their prescriptionsare in charge, my wife makes the health deci-sions, my job is in charge.” When other peo-ple or external forces are in the driver’s seat,failure is ultimately likely, especially for thosewho are trying to lose weight, get fit, oradopt any new habit. The best way for ourclients to achieve their goals is to help themtake their rightful place behind the wheel.We must encourage them to tap into self-motivation, which according to Deci andRyan, “is at the heart of creativity, responsi-bility, healthy behavior, and lasting change(p. 9).”1

Our Core DrivesDeci and Ryan’s theory of human motiva-

tion asserts that human thriving results fromsatisfying three motivational drives: thedesire to be autonomous (making choicesthat are true to one’s core, not imposed byothers or one’s inner critic); to be competent(using one’s strengths, becoming skilled in lifetasks); and to be connected (doing thingsthat support others). These core drives arealive in our clients when it comes to takinggood care of their mental and physical health.As coaches, it is our job to help our clientsrecognize, enliven, and strengthen them.

Coaxing Clients into theDriver’s Seat

We can learn valuable lessons from thework of Deci and Ryan. First, it is importantto acknowledge that, even as coaches, weare not able to motivate our clients. We canonly create the conditions in which they willmotivate themselves. Fostering choice will

increase our clients’ intrinsic motivation.Taking our clients’ perspective not our own,we must encourage our clients to initiate,experiment, and assume responsibility. Wemust be willing to set limits while still sup-porting our clients’ autonomy — helpingthem discern where their rights end and therights of others begin, while making sure thelimits are as wide as possible and allow forchoice. In addition, we must help themrecruit sources of autonomy support outsidethe session. We also must be attuned to facil-itating feelings of competence, which are cru-cial for intrinsic motivation.

Look, I’m Driving!According to Deci and Ryan, humans

have an innate need to feel competent. Yet,we may be driven by a negative belief wehave constructed about ourselves and beswayed by our inner critic: “I am a loser or afailure or inadequate because I cannot loseweight, stay on a fitness routine, meditatelonger than a few nanoseconds, or avoiddoughnuts when they are put on a plate infront of me.” To combat feelings of inadequa-cy, our clients must be encouraged to beproactive, taking on optimally challengingtasks with our enthusiastic support.Cheering on our clients to success, weenable them to feel competent, energized,and motivated. According to Deci and Ryan,feelings of competence are crucial and, whenaccompanied by autonomy, lead to increasingaccomplishment and learning throughout life.

ConclusionIf our clients are to achieve optimal health

and well being, they must take charge of thewheel, figuring out what works for them asunique individuals so that it becomes part ofwho they are and non-negotiable. Coachesshould encourage clients to act as thoughthey are in the driver’s seat — to be the bosswho solicits advice from the experts, thenexperiments, reflects, adjusts, and experi-ments again to arrive ultimately at the best

COACHING NEWS:WHO’S IN THE DRIVER’S SEAT?

CCooaacchhiinngg NNeewwss (continued on page 13)

By Margaret Moore (Coach Meg), MBA



While 8 to 12 exercise repetitions is a generally accepted guide-line for beginning trainees, most fitness professionals have heard thatmuscle strength is best developed by training with lower repetitions(e.g., 4 to 8 reps per set), muscle hypertrophy is best developed bytraining with moderate repetitions (e.g., 8 to 12 reps per set), andmuscle endurance is best developed by training with higher repeti-tions (e.g., 12 to 16 reps per set),). However, the 2006 ACSMguidelines for resistance exercise prescription state that “Thus, forany common range of repetitions (3 to 6, 6 to 10, 10 to 12, etc.)there is little evidence to suggest a specific number of repetitions willprovide a superior response relative to muscular strength, hypertro-phy, or absolute muscular endurance” (page 156).1 These guidelinesrecommend that strength training participants “…choose a range ofrepetitions between 3 and 20 (e.g., 3 to 5, 8 to 10, 12 to 15) that canbe performed at a moderate repetition duration…” (page 158).1

One study that compared low-repetition and moderate-repetitiontraining was conducted by Chestnut and Docherty5 with previouslyuntrained young men (mean age 24 years). The low repetition groupperformed 6 sets of 4 repetitions each, and the moderate repetitiongroup performed 3 sets of 10 repetitions each. This volume-equatedtraining protocol was practiced three days a week for a period of tenweeks. At the conclusion of the training program, both the low-rep-etition exercisers and the moderate-repetition exercisers experi-enced similar increases in muscle strength and muscle cross-sectionalarea, indicating similar effects on muscle strength and muscle hyper-trophy from both exercise protocols in previously untrained youngmen.

A study by Bemben and others4 examined the effects of moder-ate-repetition and high-repetition training on muscle strength and sizein previously sedentary women between 41 and 60 years of age. Themoderate-repetition trainees performed 8 repetitions per set and thehigh-repetition trainees performed 16 repetitions per set. Both exer-cise groups trained three days a week for a period of six months. Atthe conclusion of the training program, both the moderate-repetitionexercisers and the high-repetition exercisers attained similar improve-ments in muscle strength and muscle cross sectional area, suggestingsimilar effects on muscle strength and muscle hypertrophy from bothexercise protocols in previously untrained middle-aged women.

Behm and colleagues3 incorporated a different approach to exam-ine the muscle activation response to low, medium, and high-repeti-

tion resistance training. Using electromyograph (EMG) technology,these researchers monitored 14 trained young men (mean age 21years) as they performed five repetitions with their five-repetitionmaximum resistance, 10 repetitions with their 10-repetiton maximumresistance, and 20 repetitions with their 20-repetition maximumresistance. The results revealed no significant differences in muscleinactivation, strength loss, or antagonist/agonist EMG activitywhether training to muscle fatigue with 5, 10, or 20 repetitions.These findings indicated that trained young men experience similarmuscle responses to low, medium, and high-repetition strength exer-cise that terminates in tissue fatigue.

A 2009 study by Wilborn and others6 investigated the effects ofmoderate-repetition and high-repetition training on several key regu-lators of muscle development and hypertrophy. The subjects were 13previously untrained young men (mean age 21.5 years) who per-formed two strength training sessions separated by two weeks, serv-ing as their own controls in a cross-over research design. During onesession the participants performed four sets of 18 to 20 repetitionswith 60% to 65% of their maximum resistance, and during the othersession they performed four sets of eight to 10 repetitions with 80to 85% of their maximum resistance. After each exercise session,muscle biopsies were obtained (at four time periods) to assesschanges in gene expression and myogenic activity. Both exercise pro-tocols produced the same effects with respect to the expression ofvarious genes that are involved in muscle hypertrophy. Theresearchers concluded that strength exercise between 60% to 85%of maximum resistance (8 to 20 repetitions) is effective for elicitingsignificant changes in the hypertrophic and myogenic regulators asso-ciated with training-induced muscle development.

Based on the result of these repetition studies, it would seem thattraining to muscle fatigue with sets of 4 to 20 repetitions is effectivefor increasing muscle strength and hypertrophy, with no significant dif-ferences among low, moderate and high-repetition exercise protocols.These findings seem to support the 2006 ACSM1 resistance trainingstatement that a range of 3 to 20 repetitions per set may be effectivefor enhancing muscle strength and size.1

The number of repetitions performed with a given percentage ofmaximum resistance may differ due to muscle fiber composition(ratio of Type 1 and Type 2 muscle fibers), which varies among indi-viduals and muscle groups, and changes with age. However, it would

BY WAYNE L. WESTCOTT, Ph.D.

Both the 20061 and 20102 American College of Sports Medicine’s Guidelines for ExerciseTesting and Prescription recommend a standard strength training protocol that involves eightto 12 repetitions with an appropriate resistance. Of course, there is an inverse relationshipbetween the exercise resistance and the number of repetitions that can be completed.Although there is considerable variability among individuals and muscle groups, 8 to 12repetitions can typically be completed with approximately 75% of maximum resistance.

RESULTSRESISTANCE, REPETITIONS AND

HEALTH & FITNESS COLUMN



appear that for most people, improvements in muscle strength, size,and endurance may be attained with a range of repetitions, as long asthe exercise set is continued to muscle fatigue. That is, the key to mus-cle development seems to be high-effort resistance exercise thatfatigues the target muscles within the anaerobic energy system. Froma practical perspective, the application of this information may renderstrength training a more interesting activity through greater variationof exercise protocols and progressions.

About the AuthorWayne L. Westcott, Ph.D., teaches exercise science and conducts fitnessresearch at Quincy College in Quincy, MA.

References1. American College of Sports Medicine (7th edi-tion). ACSM’s Guidelines For Exercise Testingand Prescription. Philadelphia: Lippincott,Williams and Wilkins, 2006. pp. 156-158.

2. American College of Sports Medicine. ACSM’sGuidelines For Exercise Testing and Prescription(8th edition). Philadelphia: Lippincott, Williamsand Wilkins, 2010. p 172.

3. Behm, D. G., G. Reardon, J. Fitzgerald, and E. Drinkwater. The effectof 5, 10, and 20 repetition maximums on the recovery of voluntaryand evoked contractile properties. Journal of Strength andConditioning Research, 16(2): 209-218, 2002.

4. Bemben, D. A., N.L. Fetters, M.G. Bemben, et al. Musculoskeletalresponse to high and low intensity resistance training in early post-menopausal women. Medicine and Science in Sports and Exercise,32(11): 1949-1957, 2000.

5. Chestnut, J. L.., and D. Docherty. The effects of 4 and 10 repetitionmaximum weight training protocols on neuromuscular adaptations inuntrained men. Journal of Strength and Conditioning Research, 13:353-359, 1999.

6. Wilborn, C. D., L. W. Taylor, M. Greenwood, et al. Effects of differ-ent intensities of resistance exercise on regulators of myogenesis.Journal of Strength and Conditioning Research, 23(8): 2179-2187,2009.

reducing postprandial lipemic load as one session of continuous exer-cise. The exercise-induced reduction in postprandial lipemia also isindependent of the metabolic substrate utilized during exercise.5

Oxygen uptake, essential to sustained physical activity, producesreactive oxygen species crucial for energy production; often resultingin oxidative stress, depending on exercise intensity and training. High-intensity physical activity produces greater oxidative stress; whereastrained populations exhibit less oxidative stress due to higher antiox-idant defense to a given intensity. More recently, exercise-inducedoxidative stress has been considered to have a beneficial impactrather than compromise health. A major benefit of moderate intensi-ty exercise is to induce a moderate oxidative stress which stimulatesexpression of antioxidant enzymes.8

Summary The postprandial period creates a harmful environment in the

endothelium leading to atherosclerotic cardiovascular disease, includ-ing heart attack, stroke and claudication. We have always knownexercise to have a role in the prevention and treatment of these dis-eases, but the role of exercise may not be simply reducing risk factorslike high cholesterol or high blood pressure. Exercise may act bestthrough reducing postprandial lipid load, improving insulin sensitivity,increasing antioxidant defense and/or increasing nitric oxide. Perhapswe should broaden our perspective in our approach to prevent ortreat atherosclerotic cardiovascular disease through the classic riskfactors.

About the AuthorsJanet P. Wallace, Ph.D., FACSM, has been involvedin ACSM certification since 1975 when she partici-pated in the first ACSM Exercise SpecialistWorkshop and earned ES certification #19. Sheserved on the CCRB from 1981-1994 and 2000-2009. She also served on the ACSM Board ofTrustees from 1994-1997 and the Committee on theAccreditation of the Exercise Sciences from 2003-2006. After creating and operating one of themost recognized clinical programs at Indiana University (1986-2005),she is now leading an endothelial function research group. Please visither research at: http://www.iub.edu/~afp/research.html.

Blair Johnson, M.S., is currently pursuing a doc-torate in exercise physiology at Indiana University.His focus is on postprandial endothelial functionand how various blood flow patterns affectendothelial function. In 2007, he received hisMaster of Science degree from the University ofWisconsin-La Crosse in Human Performance afterworking as a research associate for the CooperInstitute. He has been an ACSM member since 2001.

References 1. Eriksson, J., S. Taimela, et al. (1997). "Exercise and the metabolic syn-drome." Diabetologia 40: 125-135.

2. Maeda, S., T. Miyauchi, et al. (2001). "Effects of training of 8 weeksand detraining on plasma levels of endothelium-derived factors,endothelin-1, and nitric oxide, in yount healthy humans." LifeSciences 69: 1005-1016.

3. Padilla, J., R. A. Harris, et al. (2006). "The effect of acute exercise onendothelial function following a high-fat meal." European Journalof Applied Physiology 98: 256-262.

4. Patsch, W., H. Esterbauer, et al. (2000). "Postprandial lipemia andcoronary risk." Current Atherosclerosis Reports 2: 232-242.

5. Petitt, D. S. and K. J. Cureton (2003). "Effects of prior exercise onpostprandial lipemia: A quatitative review." Metabolism 52: 418-424.

6. Sies, H., W. Stahl, et al. (2005). "Nutritional, dietary and postprandi-al oxidative stress." Journal of Nutrition 135: 969-972.

7. Vogel, R. A., M. C. Corretti, et al. (1997). "Effect of a single high-fatmeal on endothelial function in healthy subjects." American Journalof Cardiology 79: 350-354.

8. Vollard, N. J. B., J. P. Shearman, et al. (2005). "Exercise-induced oxida-tive stress: Myths, realities and physiological relevance." SportsMedicine 35: 1045-1062.

9. Wallace, J. P., B. D. Johnson, et al. (2010). "Postprandial lipemia,oxidative stress, and endothelial function: A review." InternationalJournal of Clinical Practice 64: 398-403.

10. Wheatcroft, S. B., I. L. Williams, et al. (2003). "Pathophysiologicalimplications of insulin resistance on vascular endothelial func-tion." Diabetic Medicine 20: 255-268.

NNeeww tthhoouugghhttss continued from page 8


http://www.iub.edu/~afp/research.html


Individuals with PAD are typically over age 50, many have diabetes,many are current or former smokers, and the disease can have pro-found affects on the ability to ambulate. The prevalence of PAD, as withmost chronic diseases, is anticipated to increase over the next twodecades in conjunction with the aging of the population. PAD often goesundetected because many patients do not recognize symptoms. Thisemphasizes the need for appropriate clinical and community basedscreening for PAD. Unfortunately in both diagnosed and undiagnosedpatients, and in those who are not treated appropriately, PAD can pro-foundly affect quality of life. And importantly, those with PAD are at anincreased risk for developing cardiovascular disease, chronic angina, andhave a reduced life expectancy.5 These persons also typically self-imposean increasingly sedentary lifestyle as a method to remain asymptomatic.This in turn increases health risks associated with inactivity.

Standard treatments for symptomatic PAD include medication(Pletal and antiplatelets), revascularization (percutaneous angioplasty orbypass), and exercise training. Although each of these treatments isshown to be effective, it is unknown in which patients any one of thesetreatments is most effective. Also it is unknown if there is synergismamong these treatments. An important study titled Claudication:Exercise Vs. Endoluminal Revascularization (CLEVER), sponsoredby the National Heart, Lung and Blood Institute of the NationalInstitutes of Health,6 is currently addressing the treatment issue. This

study is designed to assess the effect of the three aforementioned stan-dard PAD treatments on maximal walking duration. The premise of thisstudy is that there is equipoise between these treatment modalities,meaning that although there is improvement with each of the modalities,it is not clear which treatment is best in a given patient. The CLEVERstudy is attempting to determine which of these treatments is best forpatients with PAD located in the aorto-illiac region, with respect to theirefficacy (measured by walking time and quality of life questionnaires),safety, and cost-effectiveness. This is an excellent example of compara-tive-effectiveness research. Currently there are more than 100 patientsrandomized and study enrollment closure is anticipated some time in2011, with results to be reported in 2013.

The CLEVER study has the potential to impact the use of supervisedexercise training as a treatment therapy for these patients. Several yearsago a Current Procedural Terminology (CPT) code was established forPAD rehabilitation. The code (93668) was developed in response to apreponderance of efficacy data in favor of supervised exercise training.7

Specifically the code refers to exercise training being performed in arehabilitation setting. However, to date this CPT code is not reimbursedby Medicare. This is despite excellent data on the cost-effectiveness ofsupervised exercise versus percutaneous transluminal angioplasty (PTA)with respect to the cost of treatment relative to the gain in meterswalked at six months post intervention.7

Importantly, the CPT code is specific to supervised exercise. In fact,supervised exercise totaling 30 to 45 minutes performed at least 3times per week for 12 weeks has a Class IA rating for lower extremityPAD rehabilitation in the most recent ACC/AHA Guidelines on thetreatment of PAD.5 A Class IA rating means that supervised exercisetraining is shown consistently in randomized, controlled studies to beeffective as a means of improving PAD symptoms during exercise andallowing individuals to walk further without pain. A meta-analysis of 21studies showed that supervised exercise improves pain free walking dis-tance by 180% and total walking distance by 120%.3 Unfortunately,there is little evidence to support the common physician recommenda-tion of “go home and walk” and no evidence that this approach is supe-rior to supervised exercise training.5 It is possible a primary hindranceof home exercise for improvement in patients with symptomatic PAD isassociated with the necessity to endure pain while walking. The typicalPAD exercise training protocol calls for ambulation to modest or mod-

The most recent American Heart Associationfact sheet on lower extremity peripheralarterial disease (PAD) reports that about 8million Americans are afflicted.2 About 10% to15% of these individuals become symptomatic(i.e., intermittent claudication) when theywalk.4

LOWER EXTREMITY

PERIPHERAL ARTERIAL

DISEASE AND EXERCISE

BY JONATHAN K. EHRMAN,Ph.D., FACSM, CES

A PERSPECTIVE ON CLINICAL COLUMN

CNews20.final6.0 10/29/10 8:19 AM


erate pain to a level 1 or 2 on the claudication scale (see Figure) and isfollowed by rest until the pain is alleviated. This process is repeated until30 to 60 minutes of walking time is completed.1 It is possible that super-vision allows for encouragement of the patient to tolerate the painwhich is necessary for improvement. Other factors such as patient edu-cation and the social atmosphere of a supervised exercise setting alsomay play an important role.

Currently it is unknown if exercise training in patients with sympto-matic PAD will improve associated chronic disease risk profiles orreduce the risk of mortality. For instance, in those with concomitant dia-betes, will exercise training reduce the risk of future chronic limbischemia and amputation? Theoretical data exists that daily exercisetraining can improve blood pressure control, the lipid profile, andglycemic control in patients with PAD.5 At this time supervised exercisetraining should be a goal of every patient with symptomatic PAD to alle-viate symptoms and improve quality of life. In fact, regular walkingshould be a goal for all individuals. The Phase III cardiac rehabilitation set-ting is optimal for PAD exercise rehabilitation as these programs are typ-ically low-cost and provide a level of supervision. In those enrolled inPAD rehabilitation it is important to apply the PAD rehabilitation CPTcode in the billing process. This will allow important information to beaccrued for use in future determinations of potential reimbursement forPAD rehabilitation.

About the AuthorJonathan K. Ehrman, Ph.D., FACSM, CES, is theassociate program director of PreventiveCardiology at Henry Ford Hospital, Detroit MI.He also is the director of the hospital’s ClinicalWeight Management Program. He has served onACSM’s Committee of Certification and RegistryBoard since 2000, was chair of the ClinicalExercise Specialist Committee and is certified bothas an ACSM Clinical Exercise Specialist and a Program Director. He isthe senior editor of the 6th edition of ACSM’s Resource Manual forGuidelines for Exercise Testing and Prescription and is the UmbrellaEditor for the next editions (2013 release date) of the ACSM certifica-tion texts.

References1. American College of Sports Medicine. ACSM’s Guidelines for ExerciseTesting and Prescription. 8th ed. Baltimore: Lippincott Williams &Wilkins, 2010. ps. 120 and 260.

2. American Heart Association. Heart Disease and Stroke Statistics-2009Update. Dallas, TX; American Heart Association; 2009. p. 21 Available athttp://www.americanheart.org/downloadable/heart/1240250946756LS-1982%20Heart%20and%20Stroke%20Update.042009.pdf.Accessed August 23, 2010.

3. Gardner AW, Poehlman ET. Exercise rehabilitation programs for thetreatment of claudication pain: a meta-analysis. JAMA 1995;274:975-80.

4. Hirsch AT , Criqui MH, Treat-Jacobson D, et al. Peripheral arterial dis-ease detection, awareness, and treatment in primary care. JAMA.2001;286:1317-1324.

5. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for theManagement of Patients with Peripheral Arterial Disease (LowerExtremity, Renal, Mesenteric, and Abdominal Aortic): A CollaborativeReport from the American Association for Vascular Surgery/Societyfor Vascular Surgery, Society for Cardiovascular Angiography andInterventions, Society of Interventional Radiology, Society for VascularMedicine and Biology, and the American College ofCardiology/American Heart Association Task Force on PracticeGuidelines (Writing Committee to Develop Guidelines for theManagement of Patients With Peripheral Arterial Disease). J Am CollCardiol 2006;47;e1-e192.

6. Murphy TP, Hirsch AT, Ricotta JJ, et al. The Claudiation: Exercise Vs.Endoluminal revascularization (CLEVER) study: Rationale and methods. JVasc surg 2008;47(6):1356-1363.

7. Treesak C, Kasemsup V, Treat-Jacobson D, et al. Cost-effectiveness of exer-cise training to improve symptoms in patients with peripheral arterial dis-ease. Vasc Med 2004;9:279-285.

Figure. Claudication ScaleRating Description1 Definite discomfort or pain, but only at

initial or modest levels (established, butminimal)

2 Moderate discomfort or pain from which thepatient’s attention can be diverted (e.g., byconversation)

3 Intense pain (short of grade 4) from whichthe patient’s attention cannot be diverted

4 Excruciating and unbearable pain* reprint from 1

choice for them. For example, “I want to walk three days a weekbecause I can fit it in (the five days recommended by my trainer istoo much). I am more relaxed and that helps me be more presentand productive at work and home. I do not want to miss out on thebenefits of my walks and I have backup strategies in place.”

Seizing the wheel leads to authenticity and increased self-motiva-tion. It fosters competence. It helps our clients build and sustain theenergy and strength to handle whatever life throws their way—lead-ing to a life of thriving and well-being.

About the AuthorMargaret Moore/Coach Meg, MBA, is thefounder & CEO of Wellcoaches Corporation, astrategic partner of ACSM, widely recognized assetting a gold standard for professional coachesin health care. She is co-director, Institute ofCoaching, at McLean Hospital/ Harvard MedicalSchool. She co-authored the ACSM-endorsedLippincott, Williams & Wilkins CoachingPsychology Manual, the first coaching textbookin health care. (www.wellcoaches.com • www.instituteofcoaching.org• www.coachmeg.com• [email protected])

References 1. Deci, E.L. & Flaste, R. (1995). Why we do what we do: Understandingself-motivation. New York: Penguin Books.

2. Ryan, R. M. &. Deci, E. L. (2000). Self-determination theory and thefacilitation of intrinsic motivation, social development, and well-being. American Psychologist, Vol. 55, No. 1, 68-78.

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123456TEST 1:BBDAC—TEST 2:DABBA—TEST 3:TRUETRUEBACCTEST 4:BDACB—


http://www.americanheart.org/downloadable/heart/1240250946756LS-1982%20Heart%20and%20Stroke%20Update.042009.pdf

http://www.americanheart.org/downloadable/heart/1240250946756LS-1982%20Heart%20and%20Stroke%20Update.042009.pdf

http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]

http://www.wellcoaches.com%E2%80%A2www.instituteofcoaching.org%E2%80%A2www.coachmeg.com%E2%80%[email protected]

With health care costs on the rise, and employeewellness at the forefront of most benefits discus-sions, more and more companies are seeking outworkplace Wellness Specialists to provideemployee education and increase presenteeism,while helping companies improve their bottomline. In 2007, the International Health, Racquet &Sportclub Association (IHRSA) introduced theWorkforce Health Improvement Program (WHIP)Act, in an effort to make employee wellness andexercise programs tax-free and more widely rec-ognized as a needed benefit. For more informa-tion on the WHIP Act, log onto IHRSA’s home-page at www.ihrsa.org

According to the U.S. Centers for Disease Control and Prevention(CDC), people who participate in moderate-intensity or vigorous-intensity physical activity on a regular basis lower their risk of coronaryartery disease, stroke, non-insulin dependent (type 2) diabetes, highblood pressure, and colon cancer. Yet, according to a 2009 CDCresearch study on physical activity,3 more than 50% of American adultsdo not get enough physical activity to provide health benefits.

A recent study on presenteeism4 notes that the top 12 health con-ditions that unfavorably impact work productivity were allergies,arthritis, asthma, cancer, depression, diabetes, heart problems, hyper-tension, headaches, respiratory disorders, skin conditions, andback/neck/spinal injuries.

Many organizations continue to be concerned with the number ofemployees who are affected with these conditions and how thatimpacts not only days/time spent out of work, but how it translatesin to overall productivity. The data published below, adapted fromresearch collected by the International Journal of WorkplaceHealth Management5 address health risks as well as healthy behav-

iors, further illustrating the relationship between healthy lifestylehabits and productivity (see Figure).

Wellness Specialists are health professionals with diverse back-grounds; such as Registered Dieticians, Certified Personal Trainers,Clinical Exercise Specialists, and Certified Well Coaches. As dedicat-ed certif ied health and fitness professionals, it has always been ourmission to teach, coach, and educate our clients on the benefits ofregular physical activity, proper diet, and healthy habits. We have thepower to address and help modify and or correct many if not all ofthe above mentioned factors that are affecting individuals in theworkplace. Why then, as of late, are companies suddenly labeling“wellness” a hot-button issue? Recent studies conducted by theNational Safety Council have shown that at least 25% of the healthcare costs incurred by working adults can be attributed to modifiablehealth risks, such as increased stress, inadequate physical activity lev-els and poor nutritional habits (www.nsc.org).

According to the National Institute for Occupational Safety andHealth (www.cdc.gov/niosh) stress-related disorders are fast becom-ing the most prevalent reason for worker disability, costing between$20 billion and $30 billion annually due to worker absenteeism. Arecent meta-analysis conducted out of Harvard1 suggests that medicalcosts can decrease by about $3.27 for every dollar spent on worksitewellness and disease prevention, and that absenteeism costs can bedecreased by about $2.73 for every dollar spent. These return oninvestment findings suggest that the implementation of employeewellness programs could prove beneficial for budgets as well as over-all health outcomes. By becoming more familiar with the ever-grow-ing list of career opportunities that are emerging in corporate well-ness, we as health and fitness professionals are able to expand our tal-ents in areas that compliment our expertise. These opportunitiesarising in our industry are exciting for both the newly certified andexperienced professional. Certified Health, Fitness, and NutritionSpecialists are being called upon to design motivating initiatives suchas smoking cessation programs, walking programs, heart healthy aer-obic classes, ergonomics awareness programs, and mind/body relax-ation classes such as stretching and Yoga. In addition, city agenciessuch as police and fire departments, government offices, publicschools, and universities also are hiring health and fitness profession-als to facilitate wellness and educational programs. In 2006, 19% ofcompanies with 500 or more employees reported offering employeewellness programs, with that number increasing to 77% of largercompanies who offered some form of worksite wellness related initia-tive in 2008.2 According to a recent article in the New York Times,6

titled “Carrots, Sticks and Lower Premiums” by Steve Lohr; the busi-ness of worksite wellness programs is starting to boom, and somecompanies are offering incentives to their employees based on theirinvolvement. In fact, a fledgling “pay for prevention” industry is begin-ning to emerge, offering employers ways to reward workers with

WELLNESS ARTICLE

ENHANCING QUALITY OF LIFEFROM 9 TO 5 AND BEYOND

BY Nikki Carosone M.S., ACSM CPT

THE EVOLUTION OF WORKSITE WELLNESS

EEvvoolluuttiioonn (continued on page 16)

Figure.



http://www.ihrsa.org

http://www.nsc.org

http://www.cdc.gov/niosh


SSEELLFF--TTEESSTT ##11 ((11 CCEECC))::The following questions arefrom “Fitness Assessment and Exercise Prescription: AreYour Assessments Providing the Information YouNeed?” published on page 3.

1. Which two points regarding the role of fitnessassessments were discussed?a. Following club protocols and motor learningb. Individualizing assessments and motor learningc. Following industry standards and individualizingassessments

d. Motor learning and physical conditioningassessments

2. The primary adaptation during the first 4 to 6 weeksof a muscular training program is the development of__________________.a. motor sufficiency b. motor pathwaysc. muscle hypertrophy d. muscle hyperplasia

3. Which of the following are components of Fleishman’sphysical proficiency abilities? a. Reaction time, extent flexibility, and explosivestrength

b. Trunk strength, multi-limb coordination, anddynamic flexibility

c. Gross body coordination, stamina, and reactiontime

d. Explosive strength, extent flexibility, and grossbody coordination

4. Which of the following are components of Fleishman’sperceptual motor abilities?a. Reaction time, multi-limb coordination, and ratecontrol

b. Multi-limb coordination, trunk strength, anddynamic flexibility

c. Gross body coordination, reaction time, andcontrol precision

d. Static strength, dynamic strength, and rate control

5. Fitness professionals would benefit from some fine-tuning of their fitness assessments with respect toalignment with the client’s ________.a. goals, health history, and current desire to exerciseb. current desire to exercise and willingness to

participatec. goals, health history, and prior physical activityexperience

d. prior physical activity experience and currentdesire to exercise

SSEELLFF--TTEESSTT ##22 ((11 CCEECC)):: The following questionsare taken from “Is Functional Training ReallyFunctional?” published on page 5.

1) A study by Fiatarone et al. found that nursing homepatients improved their functional scores on a test ofwalking and balance improved by approximately ___after performing 3 sets of 8 repetitions on a machine

leg extension apparatus for 8 weeks.a) 10% b) 26%c) 39% d) 48%

2) A study by Cressey et al. attributed a decrease inperformance improvements in elite soccer playerswho performed exercises on an unstable surface to:a) a reprogramming of neuromuscular patterns that

chronically impairs stretch-shortening cyclefunction.

b) a reduction in muscle hypertrophy.c) an inhibition of calcium release from the

sarcoplasmic reticulum.d) an increase in soft tissue injuries to the knee joint.

3) According to a study by Behm et al., a limitation ofunstable surface training is that:a) it reduces core activation.b) it reduces force output in muscles of the

extremities.c) it increases the potential for injury.d) it does not allow for optimal range of motion

about a joint.

4) The “Specific Adaptation to Imposed Demands”(SAID) principle dictates that:a) multi-joint movements should be performed

before single joint movements.b) optimal transfer of the exercise benefit is achieved

when movements most closely match those of agiven task.

c) muscles must be constantly challenged beyondtheir present capacity.

d) program variables should be varied over time toprevent plateau.

5) According to McKeon et al., incorporatingapproximately ________ unstable surface exercises intoa routine may be ideal for optimizing static and dynamicbalance.

a) 25% b) 35%c) 50% d) 75%

SSEELLFF--TTEESSTT ##33 ((11 CCEECC)):: The following questions aretaken from “New Thoughts on what Really CausesHeart Disease and How Exercise Helps BeyondTraditional Risk Factors” published on page 7.

1. Postprandial is that period of time following a meal.True False

2. Endothelial function includes those activities thatprotect the artery from developing atherosclerosis.True False

3. The substance produced in the endothelial cells thatprotects arteries from developing atherosclerosis is

a. eNOS. b. NO.c. L-Argenine. d. ONOO-.

4. A high-fat meal harms the endothelium bya. Increasing oxidative stress from elevated fats.b. Increasing NO.c. Decreasing insulin.d. Increasing lipemia which decreases eNOS.

5. Nutrients that are harmful to the endothelial lining(of a healthy adult) include:a. Polyunsaturated fats. b. Carbohydrates.c. Transfats. d. Simple Sugars.

6. Exercise can reduce atherosclerosis developmentthrough what mechanisms?a. Decreasing insulin sensitivityb. Increasing oxidative stressc. Decreasing lipemiad. Decreasing NO

SSEELLFF--TTEESSTT ##44 ((11 CCEECC)):: The following questionswere taken from “The Evolution of Wellness...”published in this issue on page 14.

1. According to the U.S. Centers for Disease Controland Prevention, what percentage of American adultsare not getting enough physical activity?a. 40% b. 50%c. 25% d. 15%

2. According to the National Safety Council which ofthese health risks are considered modifiable?a. Increased stress levelsb. Inadequate physical activity levelsc. Poor nutritional habitsd. All of the above

3. Medical costs can fall by as much as this amount forevery dollar spent on worksite wellness and diseaseprevention. a. $3.27 b. $2.50c. $3.10 d. $2.77

4. In 2006, 19% of companies with 500 or moreemployees reported offering employee wellnessprograms. In 2008, that number increased to _____. a. 57% b. 68%c. 77% d. 72%

5. In 2007, IHRSA introduced this Act, in an effort tomake employee wellness and exercise programs tax-free and more widely recognized as a needed benefit.a. Health Improvement Prevention Program (HIPP)Act

b. Workforce Health Improvement Program (WHIP)Act

c. Wellness Health Improvement Benefit (WHIB)Act

d. Workplace, Homeplace, Integration PreventionProgram (WHIPP)

July–September 2010 Continuing Education Self-TestsCCrreeddiittss pprroovviiddeedd bbyy tthhee AAmmeerriiccaann CCoolllleeggee ooff SSppoorrttss MMeeddiicciinnee •• CCEECC OOffffeerriinngg EExxppiirreess SSeepptteemmbbeerr 3300,, 22001111

To receive credit, circle the best answer for each question, check your answers against the answer key on page 13,and mail entire page with check or money order payable in U.S. dollars to: American College of Sports Medicine, Dept 6022, Carol Stream, IL 60122-6022

ACSM Member (PLEASE MARK BELOW) Please Allow 4-6 weeks for processing of CECs[ ] Yes-$15 TOTAL $_________________

[ ] No- $20 ($25 fee for returned checks)

ID # __________________ (Please provide your ACSM ID number)PLEASE PRINT OR TYPE REQUESTED INFORMATION

NAME

ADDRESS

CITY STATE ZIP

BUSINESS TELEPHONE E-MAIL

July–September 2010 Issue EXPIRATION DATE: 09/30/11• SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED • Federal Tax ID number 23-6390952

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

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cash or reduced insurance premiums for participating in these pro-rams and leading healthier lifestyles. Among the industry leaders areRedBrick Health, Tangerine Wellness, and Virgin HealthMiles. And,some big companies, like Safeway and General Electric, are experi-menting independently with financial incentives to encourage employ-ees to adopt healthy habits and to eliminate unhealthy ones. Forexample, General Electric employees who smoke, pay an extra $625a year for health insurance.6

The benefits from these programs are becoming more and moreobvious, with side effects such as heightened alertness, fewer injuries,and visible improvements in appearance and overall well-being. It is nowonder that more and more employers are trying to provide moreaccess to health and wellness programs to their employees.According to a recent study conducted by MetLife,7 37% of employ-ers now offer some type of wellness-based program, which is up from33% in 2008 and 27% in 2005.

In light of these recent studies, it is becoming easier to illustratethe need for worksite wellness programs. A new finding in this years’MetLife study on leveraging health and wellness programs showsstaggering satisfaction results on both the employee and employerfront. Results showed that in companies where health and wellnessprograms are offered, nearly half of employers (48%) and a whop-ping 58% of employees reported that these programs translate intoincreased productivity and employee satisfaction.7 These are veryexciting times for us as health and wellness professionals. We havethe opportunity to help companies keep their employees healthier,happier and more productive!

ABOUT THE AUTHORNikki Carosone, M.S. ACSM cPT, is a generalmanager and wellness specialist with Plus One HealthManagement in New York City. Nikki also is anassociate professor of Exercise Physiology andExercise Prescription at Long Island University,Brooklyn Campus. Her expertise is focused in the areasof wellness, physical activity, and, health promotion.

References 1. Baicker, K, Cutler, D, Song, Z in Health Affairs; Workplace WellnessPrograms Can Generate Savingshttp://content.healthaffairs.org/content/vol29/issue2/index.dtl(February 2010)

2. Capps, K, of Health2 Resources and Harkey, J. Pd.D., of HarkeyResearch for Employee Health & Productivity Management Programs:The Use of Incentives; A Survey of Major U.S Employerswww.incentone.com/files/2008-surveyresults.pdf (June 2008)

3. Centers For Disease Control And Prevention; Physical ActivityResources For Health Professionalshttp://www.cdc.gov/physicalactivity/professionals/data/index.html

4 Econtech Pty Ltd. Economic modeling of the cost of Presenteeism inAustraliahttp://www.econtech.com.au/information/Social/Medibank_Presenteeism_FINAL.pdf (May 2007)

5. Internation Journal of Workplace health Management Voloume 1,Issue 1 http://www.emeraldinsight.com/journals.htm?issn=1753-8351&PHPSESSID=5bc3muejulenmbj75ta3vm66f6

6 Lohr Stephen ; Carrot Sticks and Lower premiums for The New YorkTimes March 26, 2010

7. MetLife : The 8th Annual Study of Employee Benefit Trendshttp://www.metlife.com/assets/institutional/services/insights-and-tools/ebts/Employee-Benefits-Trends-Study.pdf (April 2010)

EEvvoolluuttiioonn continued from page 14


http://content.healthaffairs.org/content/vol29/issue2/index.dtl

http://www.incentone.com/files/2008-surveyresults.pdf

http://www.cdc.gov/physicalactivity/professionals/data/index.html

http://www.econtech.com.au/information/Social/Medibank_Presente

http://www.emeraldinsight.com/journals.htm?issn=1753-8351&PHPSESSID=5bc3muejulenmbj75ta3vm66f6

http://www.emeraldinsight.com/journals.htm?issn=1753-8351&PHPSESSID=5bc3muejulenmbj75ta3vm66f6

http://www.metlife.com/assets/institutional/services/insights-and-tools/ebts/Employee-Benefits-Trends-Study.pdf



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