Advanced Personal Training

Effective fitness instruction and training programme design require an exercise specialist trainer to
combine professional experience with strategies underpinned by scientific evidence. This is the first
comprehensive fitness instruction and training programme design resource to explore the evidence-base
of effective programme design, drawing on cutting-edge scientific research to identify optimum training
methods and dispel some common myths around fitness training.
Putting clients’ training goals at the centre of the process by focusing on their most common
objectives – such as improving general health, enhancing cardiorespiratory fitness, decreasing body fat
and increasing muscle mass – this book helps the reader develop a better understanding of the
physiological principles at the core of successful programme design. Simple to navigate and full of
helpful features – including applied case studies, example training programmes and guides to further
reading – it covers a variety of key topics such as:

pre-exercise health screening

lifestyle and fitness assessment
nutrition
cardiorespiratory (endurance), resistance and core training
recovery from exercise.

An essential text for fitness instructors, personal trainers and sport and exercise students, this book
provides an invaluable resource for fitness courses, exercise science degree programmes and continued
professional development for exercise professionals.

Paul Hough is a lecturer in health and exercise science at St Mary’s University, Twickenham, UK. Paul is
a British Association of Sport and Exercise Science (BASES) accredited sport and exercise scientist
providing sport/exercise science support to amateur and elite athletes as well as organisations such as
Virgin London Marathon and British Rowing.

Simon Penn is a senior lecturer in health and exercise science at St Mary’s University, Twickenham, UK.
Simon has delivered exercise and rehabilitation programmes to a wide range of populations (e.g. special
populations, service personnel, elite athletes) throughout his career in the fitness industry and higher
education.
Advanced Personal Training
Science to practice

Edited by
Paul Hough and Simon Penn
First published 2017
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

and by Routledge
711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2017 Paul Hough and Simon Penn

The right of Paul Hough and Simon Penn to be identified as the authors of the editorial material, and of the authors for their individual
chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other
means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without
permission in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and
explanation without intent to infringe.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

Names: Hough, Paul, 1974- editor, author. | Penn, Simon, editor, author.
Title: Advanced personal training : science to practice / edited by Paul
Hough and Simon Penn.
Description: Abingdon, Oxon ; New York : Routledge is an imprint of the
Taylor & Francis Group, an Informa Business, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016022890| ISBN 9781138924482 (hardback) | ISBN
9781138924499 (pbk.) | ISBN 9781315684291 (ebook)
Subjects: LCSH: Personal trainers--Handbooks, manuals, etc. | Physical
education and training--Handbooks, manuals, etc. | Physical
fitness--Handbooks, manuals, etc.
Classification: LCC GV428.7 .A48 2017 | DDC 613.7/11--dc23
LC record available at https://lccn.loc.gov/2016022890

ISBN: 978-1-138-92448-2 (hbk)

ISBN: 978-1-138-92449-9 (pbk)
ISBN: 978-1-315-68429-1 (ebk)

Typeset in Berling and Futura

by Saxon Graphics Ltd, Derby
Contents

Cover
Title
Copyright
Contents
List of illustrations
List of contributors
1 Introduction
Paul Hough
2 The components of fitness
Simon Penn and Nicola Brown
3 Pre-exercise health screening
Paul Draper
4 Lifestyle assessment and behaviour change
John Downey
5 Nutrition
John Downey
6 Fitness assessment
Simon Penn and Nicola Brown
7 Fundamental principles of training
Paul Hough
8 Training session design
Paul Hough
9 Long-term training programme design (periodisation)
Paul Hough
10 Warm-up/movement preparation
Paul Draper
11 Cardiorespiratory fitness training
Paul Hough
12 High-intensity interval training
Paul Hough
13 Resistance training
Paul Hough
14 Postural and core training
Simon Penn
15 Cool-down
Simon Penn
16 Recovery from training
Jessica Hill
Index
Illustrations

Figures
1.1 Example health benefits of regular physical activity
2.1 The components of fitness
3.1 PAR-Q
3.2 PAR-Q+ Page 1
4.1 An integrated display of relevant constructs for behaviour change
4.2 The stages of change from the Transtheoretical Model
4.3 Outline of the framework needed for effective motivational interviewing
5.1 Evidence-based components of the diet that support health
6.1 Test validity and reliability
7.1 Schematic of the super-compensation response following a suitable training stimulus and recovery
period
7.2 The threshold for adaptation
7.3 The health-performance training continuum example
7.4 Trainability
8.1 Training session design process
8.2 Example of unbalanced resistance training programme using the muscle group method
8.3 Resistance training exercise order sequencing
8.4 A ten-point perceived exertion scale used to classify the intensity of a training session
9.1 Traditional single-peak periodisation model
9.2 Cyclist case study programme
9.3 Block periodisation: strength and hypertrophy case study
10.1 Main elements of a warm-up
10.2 The benefits of warming-up: summary
10.3 The effects of warming-up: summary
10.4 Dynamic stretch – Hamstring
10.5 Static passive self-stretch – Hamstring
10.6 PNF stretch – Hamstring
10.7 Static passive self-stretch – Pectorals
10.8 Summary guidelines – Structuring a warm-up
10.9 Flow chart – Structuring a warm-up
11.1 The Borg rating of perceived exertion scale
11.2 Schematic of cardiorespiratory training methods
11.3 Examples of physiological adaptations to long-term cardiorespiratory training
11.4 Schematic representation of the dose-response relationship between level of physical activity/CRF
and mortality risk
11.5 The ‘cross-over’ concept
11.6 Fat and carbohydrate oxidation at different exercise intensities
12.1 Interval training intensity classifications
12.2 Example high-intensity interval training protocols
12.3 Change in body fat following a 20-week training intervention
12.4 Examples of physiological adaptations in relation to different high-intensity interval training
protocols
13.1 Example resistance training set sequencing schemes
13.2 The health benefits of resistance training
13.3 The effect of different training modalities on body composition
14.1 Optimal standing posture
14.2 Common postural abnormalities
14.3 Upper crossed syndrome
14.4 The cylindrical definition of the core
14.5 The local muscular group
14.6 Low-load stability tests and exercises
14.7 High-threshold stability and strength exercises
15.1 Cool-down summary
Tables

4.1 Commonly used behaviour change theories/models

5.1 Dietary intake assessment methods
5.2 The impact of fat by category on blood lipids
5.3 Overview of the main micronutrients and accompanying sources and signs of deficiency and toxicity
8.1 Resistance training exercise selection methods
8.2 Training zones based upon percentage of maximum heart rate
8.3 Quantifying resistance training volume: repetition volume and volume load
9.1 Periodisation v. random variation: advantages and disadvantages
9.2 Example of a traditional periodisation model for a 5-km runner
9.3 Training residuals: the approximate duration before components of fitness decline following the
cessation of training
9.4 An example of an undulating periodisation training week
10.1 Examples of recent study findings: effect of warm-up stretches on performance
11.1 Cardiorespiratory training intensity domains
11.2 Example metabolic equivalents of different physical activities
11.3 Maximum heart rate prediction equations
11.4 Heart rate training zones
11.5 Using the talk test during cardiorespiratory exercise
11.6 Fat oxidation and energy expenditure measured at different running speeds
12.1 High-intensity interval training protocols for improved health outcomes
12.2 High-intensity interval training protocols for performance outcomes
13.1 Neurological adaptations to resistance training
13.2 Resistance training classifications
13.3 Advanced resistance training methods
13.4 Advanced resistance training tempo techniques
13.5 Example fat loss resistance training sessions
14.1 Anatomical landmarks
14.2 Muscle imbalances of common postural abnormalities
16.1 Recovery strategies and populations most likely to benefit from the use of each strategy
Contributors

Nicola Brown, St Mary's University, Twickenham UK

John Downey, St Mary's University, Twickenham UK

Paul Draper, St Mary's University, Twickenham UK

Jessica Hill, St Mary's University, Twickenham UK

Chapter 1
Introduction

Paul Hough

The profession of fitness instruction and personal training has evolved dramatically since the
introduction of mandatory qualifications and set codes of practice outlined by national governing bodies.
These measures have improved the quality of fitness practitioners as well as providing assurance to
clients and employers that trainers are appropriately qualified and have the knowledge and skills to
perform their role effectively. The Internet and social media provide an infinite source of health and
fitness information, enabling trainers to broaden their knowledge in a number of fields. However, the
majority of mass media sources of information (websites, social media and magazines) are not subjected
to a peer review process, whereby the accuracy of the information is checked. This can lead to ineffective
and possibly unsafe exercise and nutrition recommendations being applied. Furthermore, inaccurate
information can easily become widespread amongst clients and trainers leading to a number of exercise
and nutrition misconceptions, some of which will be addressed throughout this book.
Effective fitness instruction and training programme design require the trainer to develop an exercise
philosophy, applying professional experience with exercise strategies that are underpinned by scientific
evidence. Although anecdotal evidence and experience can be useful in formulating ideas and creating
effective training programmes, exclusively using this approach lacks objectivity and often yields
inconsistent results. Conversely, objective information generated from scientific studies are unclouded by
opinion or bias. Developing a solid understanding of exercise science empowers the trainer to evaluate
and create effective exercise programmes instead of merely copying them. The objective of this book is to
provide a framework for fitness professionals to design, deliver and evaluate exercise programmes, which
are underpinned by scientific evidence. ‘Real world’ case studies and guidelines to achieve common goals
(e.g. improving health and body composition) are included and explained.
Physical Activity and Exercise

The terms ‘physical activity’ and ‘exercise’ are often used interchangeably, but they are not the same and
this inconsistency in terminology can cause confusion amongst clients. Physical activity (PA) has been
defined as ‘any bodily movement produced by skeletal muscles that results in energy expenditure’
(Caspersen et al., 1985). Therefore, PA encompasses a wide range of daily activities such as walking,
stair-climbing, lifting objects, etc. Exercise is a sub-set of PA; the distinguishing factor is that exercise is
planned and structured, and has the objective to maintain or improve a component of fitness (see
Chapter 2). This is an important distinction given that clients sometimes associate PA with a structured
exercise programme and/or a gym-based environment. Although the purpose of this book is to provide a
scientific framework for designing effective exercise programmes, trainers should also promote the
benefits of daily PA outside the gym environment.
The potential health benefits of daily PA were noted over 2,500 years ago by the Greek physician
Hippocrates. Over the past six decades a large amount of scientific evidence has amassed which supports
this notion. Regular PA has consistently been associated with lower rates of all-cause mortality and
chronic disease (Booth et al., 2008). Furthermore, regular PA has been shown to improve numerous
components of health, examples of which are presented in Figure 1.1. These benefits can be achieved
outside conventional gym-based programmes through adopting an active lifestyle (see page 3).

Adherence

Figure 1.1 Example health benefits of regular physical activity.

Despite the widely promoted benefits of PA and exercise, one of the biggest issues that trainers encounter
is poor client engagement and exercise adherence. Clients are prone to abandoning an exercise
programme for a number of reasons, for example if exercise does not meet their expectations and/or they
lose motivation (Whaley & Schrider, 2005). Most adults who engage in a diet/exercise intervention
experience improvements in health, fitness and body composition. The problem, which has yet to be
solved, is improving long-term adherence of positive behaviours (e.g. regular exercise, good quality diet).
A potential reason for poor adherence/lack of engagement with PA and healthy living advice is because
the relationship between the fitness professional and client can be too didactic, whereby the professional
provides specific advice in the hope that the client will adhere to this guidance, i.e. ‘you need to do this,
to achieve … ’. Providing accurate and relevant advice is obviously a fundamental role of the fitness
professional. However, clients must be empowered to take an active role in their own health/fitness
rather than passively following advice, which is unlikely to be an effective long-term strategy. Thus, the
exercise programme is only ‘part of the puzzle’ in improving health, fitness and performance (see
Chapter 4).
The majority of guidelines presented within this book are based on evidence gathered from scientific
studies. However, the exercise professional must consider that the strategies only work if the client
engages with the exercise programme, i.e. exercise programmes do not work if they are not done! This
seemingly obvious point is often overlooked when trainers devise exercise programmes which have a
strong rationale, but fail to gauge the practicality of the approach or the client's feedback. For example,
perceived enjoyment of exercise is an important determinant of exercise adherence (Hagberg et al., 2009).
Continuous cardiorespiratory training (e.g. cycling for 30 minutes, five days per week) is an effective
strategy for improving cardiorespiratory fitness, but it is unlikely to be an effective long-term strategy
for a client who dislikes the training method. Health and fitness interventions have to include strategies
that encourage a permanent change in positive self-selected and self-motivated behaviours to be truly
effective (see Chapter 4). An example of one of these strategies is to promote an active lifestyle.
Active Lifestyle Promotion

A common reason people give for not exercising on a regular basis is ‘lack of time’ (Trost et al., 2002).
This is possibly because of misconceptions associated with exercise. For example, some clients may
believe that exercise must be performed in a gym and each session must last around an hour. One of the
issues of promoting exercise instead of PA is that exercise can be more difficult to incorporate within a
client's lifestyle based on the ‘time barrier’. This is not an issue for ‘fitness enthusiast’ clients who are
engaged with their fitness programmes, as these clients will typically modify other areas of their life,
such as social or leisure activities, to maintain their fitness routine. However, a large majority of the
clients a trainer will work with will not fall into this category. This is evident in the high attrition rates
within exercise programmes (Wilson & Brookfield, 2009). Therefore, trainers should provide ‘active
lifestyle’ guidance alongside their exercise programme to enable the client to work towards their
health/fitness goals outside the gym environment. Active lifestyle guidance is a simple and effective
means of increasing regular PA within a daily routine (Barr-Anderson et al., 2011). There are a number
of methods to achieve this, such as using stairs instead of escalators, active commuting, standing desks
and walking meetings. Unlike exercise within a gym, monitoring PA levels has historically proved
difficult for trainers and clients. However, the development of technological devices, such as activity
trackers, enables the client and trainer to objectively monitor daily PA levels, which can improve
adherence to PA-based interventions (Lyons et al., 2014).

Sedentary time

The term sedentary is derived from the Latin ‘sedere’ meaning ‘to sit’ and is used to describe periods of
inactivity outside sleep. The majority of people in non-physical occupations (e.g. office workers) spend
most of their waking day doing seated activities, for instance using the computer and watching television
(Matthews et al., 2008). This sedentary lifestyle trend is concerning, as long periods of sedentary
behaviour are associated with a number of negative health consequences, such as poor metabolic health
(Healy et al., 2008). Therefore, the promotion of regular PA may be a feasible approach in reducing the
negative health consequences of excessive sedentary time. An active lifestyle approach is recommended
for clients with sedentary occupations regardless of how active they are outside their occupation. This is
because long periods of sitting can have deleterious health effects, even amongst adults who engage in
regular exercise (Biswas et al., 2015).
Exercise for Weight Loss

One of the most common motives for clients to engage with an exercise programme and/or dietary
intervention is to reduce body mass. This is more commonly known as ‘weight loss’. Therefore, a
number of chapters within this book will address this subject. Before reading these chapters it is
important to establish some basic concepts regarding exercise and body mass weight. Clients wishing to
reduce body mass intuitively focus on changes in their body mass (regular weigh-ins) to monitor their
progress. This approach implies that all body mass is equal and any reduction in body mass is a positive
outcome. However, all body mass is not equal in the context of health and performance. Body
composition can broadly be defined as the proportion of fat and fat-free mass (muscle, tendon, bone, etc.)
in the body. A healthy body composition is one that includes a lower proportion of body fat and a higher
proportion of fat-free mass. Muscle mass serves a number of important functions within the body, which
are essential for health and longevity (see Chapter 13). As conventional body mass scales measure body
mass alone, a decrease in muscle mass (and subsequent total body mass) could be perceived as a positive
outcome when this is clearly not the case.
Body fat has a number of essential roles, such as providing insulation and protection to internal
organs. However, excess body fat (i.e. overweight/obesity) has a negative impact on health and mortality
(McGee, 2005), and is associated with a number of conditions that contribute directly and indirectly to
the development and progression of cardiovascular disease (Dorresteijn et al., 2012; Krauss et al., 1998;
Todd Miller et al., 2008). When working with overweight and obese clients a reduction in body mass can
provide a crude indication of fat loss. However, based on the health benefits of maintaining/increasing
muscle mass (see Chapter 13) and reducing body fat, the emphasis of conventional ‘weight loss’
orientated programmes should be shifted towards fat loss, not total body mass (i.e. body composition).
Consequently, throughout this book the term ‘fat loss’ will be used instead of the conventional ‘weight
loss’.

Is exercise effective for decreasing body fat?

Energy balance is the relationship between energy consumed (calories from food and drink) and energy
expended (calories used by the body). Energy balance is often cited as the main determinant of body
composition, whereby a positive energy balance (more calories consumed than expended) leads to an
increase in body/fat mass. Conversely, a negative energy balance (more calories expended than
consumed) results in a decrease in body/fat mass (Hall et al., 2012). However, this simple concept is
difficult to accurately apply in practice, as there are numerous physiological and psychological factors, as
well as health issues, that interact to influence body composition (Morton et al., 2006).
Many clients engage in an exercise programme in order to reduce body fat with the premise that
performing regular exercise will create a negative energy balance and lead to a reduction in body fat.
However, a number of studies have demonstrated that exercise and PA interventions alone only have a
modest or no effect in reducing body and/or fat mass (Cook & Schoeller, 2011; Rosenkilde et al., 2012;
Villareal et al., 2011). A possible explanation for this occurrence is that some individuals experience
energy balance compensatory mechanisms following exercise, such as being less active throughout the
rest of the day or sub-consciously increasing calorific intake (see Chapter 11). A number of physiological
and psychological factors seem to influence these compensatory mechanisms, which is possibly why
exercise performed without any dietary modification has inconsistent effects on fat loss between
individuals. Therefore, basic nutritional guidance must be presented alongside an exercise programme in
order to induce a significant and consistent reduction in body fat. However, it is essential that trainers
are aware of their scope of practice when discussing nutrition with clients (see Chapter 5).
The conflicting evidence to support exercise for decreasing body/fat mass has led some authorities to
proclaim that exercise is unnecessary or ‘does not work’ in terms of decreasing body/fat mass
(Harcombe, 2011; Malhotra et al., 2015). These statements may attract media and public attention, but are
unhelpful from a health promotion perspective given that obese individuals are less likely to engage in
regular exercise (Smith et al., 2015). As a result, the message that exercise ‘does not work’ may
discourage individuals from engaging in regular PA or exercise meaning they will not experience the
numerous health benefits that regular PA can provide. Whilst it is important that public health messages
accurately reflect the current scientific research, the evaluation of a PA intervention or exercise
programme must not purely be based on reductions in body/fat mass. Rather, fat loss orientated training
programmes should focus on improving health and generating a physiological stress to induce chronic
metabolic adaptations (see Chapter 13) instead of focusing solely on energy balance. Moreover, whilst it
is technically correct that/fat loss can be achieved without exercise, there are a number of issues with
this ‘diet only’ approach.

The problems with a ‘diet only’ approach to body composition

All clients must be encouraged to engage in regular PA and exercise regardless of their primary
health/fitness goals, as many of the health benefits (see Figure 1.1) are independent of changes in body
composition (Pedersen, 2007; Woo et al., 2013). Indeed, the protective effect of cardiorespiratory fitness
(CRF) on mortality is independent of age, ethnicity, adiposity, smoking status, alcohol intake and health
conditions. This fact has led some authorities to suggest that improving CRF should be emphasised over
body composition, as improving CRF will substantially reduce the negative effects of obesity on
morbidity and mortality. This is known as ‘the fitness-fatness hypothesis’ (Fogelholm, 2010; Hainer et al.,
2009). The highest risk of mortality is observed in individuals who are both obese and have poor CRF.
Hence, regular PA is essential for clients in this category, irrespective of changes in body fat.
Adopting a calorie restriction diet without any exercise intervention can result in a loss of muscle
tissue and a decrease in resting energy expenditure (Ross et al., 1996). Both of these factors can have a
negative impact on metabolic health and actually lead to increases in body fat if the calorie restriction
diet is not sustainable. This effect is evident in clients who go through cycles of increasing and
decreasing body fat following a period of calorie restriction – the so called ‘yo-yo dieters’. Therefore,
performing exercise, particularly resistance training, alongside a dietary modification strategy is highly
recommended in order to preserve muscle mass/strength, and maintain a healthy metabolism (see
Chapter 13). Indeed, research indicates that improvements in body composition are best achieved with a
combination of diet and exercise interventions (Johns et al., 2014).
The Client as An Individual

Throughout this book scientific evidence is used to formulate recommendations in order to achieve
positive outcomes within the context of health, fitness and performance. The majority of exercise and
nutrition studies are conducted on a group of participants and the measured responses to the
intervention are usually described in general terms as a group average. For example, a hypothetical study
investigating the effects of a dance based exercise programme on body fat and cardiorespiratory fitness
(CRF) might perform the same dance intervention on 20 participants for 12 weeks. Body fat and CRF
would be measured at the start and end of the intervention. The results of the body fat and CRF tests
would be expressed as a group average with the assumption that this average represents a typical
response for most individuals. However, any experienced exercise professional will recognise that clients
do not always respond to an exercise or nutrition intervention in the same way due to a number of
influences, such as genetics and lifestyle factors (e.g. psychological stress, sleep). Some clients will
achieve greater improvements than others despite engaging in the same intervention; this is the
phenomenon of ‘high and low responders’. Consequently, although the scientific evidence enables us to
form robust exercise recommendations, exercise professionals must always be aware that each client has
unique physiological and psychological characteristics which will determine how they respond to PA
and exercise. Thus, all exercise programmes must be carefully individualised (see Chapter 7).
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Chapter 2
The components of fitness

Simon Penn and Nicola Brown

Fitness is a generic term that can be used to describe the ability to perform activities of daily living
without undue fatigue, or the ability to cope with the demands of an athletic event or sport. Therefore,
when designing training programmes to improve fitness, it is important to identify and understand the
components of fitness related to the client's goals.
Health Related Fitness

Health is an individual's ability to self-manage and restore integrity, equilibrium and a sense of well-
being relative to physical, mental and social health (Huber et al., 2011). Five components of fitness
commonly targeted within health focused training programmes include: cardiorespiratory fitness,
muscular strength, muscular endurance, flexibility and body composition.

Cardiorespiratory fitness

Cardiorespiratory fitness is the ability of the cardiovascular and respiratory systems to receive and
deliver oxygen to the working muscles to be used for aerobic respiration during activity.
Cardiorespiratory fitness is vital in athletic events where the majority of energy is supplied by the
aerobic energy system (e.g. distance running).
Increased physical activity and cardiorespiratory fitness have been shown to reduce the risk or
symptoms of obesity, type 2 diabetes (Colberg et al., 2010), dyslipidaemia (Kokkinos et al., 2013),
hypertension (Kokkinos et al., 2014), cardiovascular disease (Myers et al., 2015), site specific cancers
(Kruk & Czerniak, 2013) and prevent all-cause mortality (Kodama et al., 2009).

Muscular strength/Muscular endurance

Muscular strength (the ability of a muscle, or a group of muscles, to exert a force) is paramount in
athletic events requiring heavy lifting, pulling, pushing or explosive movement. Muscular endurance (the
ability of a muscle, or a group of muscles, to contract repeatedly or maintain a continual contraction
without fatigue) is important in athletic events of continuous activity requiring the repetition of
muscular contractions.
Individuals require a minimum level of muscular strength and endurance to perform daily activities
(e.g. opening jars, climbing stairs, and carrying shopping) without undue fatigue or risk of injury.
Additionally, muscular strength and endurance training can increase muscle mass and improve many
health markers including body fat mass, insulin sensitivity, blood lipid profiles and blood pressure
(Westcott, 2012). Therefore, increased muscular strength and endurance reduces the risk of type 2
diabetes, hypertension, cardiovascular disease and all-cause mortality (Artero et al., 2012; Colberg et al.,
2010).

Flexibility

Flexibility is the ability of a joint, or combination of joints, to move through full range of motion.
Flexibility is influenced by the skeletal structure of a joint, the mechanical properties of the surrounding
muscular and connective tissue, environmental factors (internal/external temperature, clothing), and
individual factors (age, gender).
Flexibility should play an integral part in most training programmes. Joint degradation and reduced
elasticity of muscular and connective tissue cause a decline of flexibility with age. Therefore, flexibility
training should be encouraged throughout the lifespan to minimise muscle imbalance, improve posture,
maintain biomechanical efficiency, aid activities of daily living and reduce the risk of injury.

Body composition

Body composition describes the fat and fat-free mass (muscle, bones, organs and water) components of
the human body. Fat mass includes both essential fat and storage fat and is often termed ‘percentage
body fat’. Essential fat is crucial for normal, physiologic functioning. Storage fat is stored in adipose
tissue under the skin (subcutaneous fat) and around major organs in the body (visceral fat). Healthy
body composition involves a high proportion of fat-free mass and an acceptably low level of fat mass,
adjusted for age and gender. Excessive accumulation of body fat has a negative impact on an individual's
overall health and well-being (Wang et al., 2011). Therefore, body fat percentage should be kept within a
healthy range. Distribution of body fat varies between gender and ethnic groups and is also an important
determinant of health risk, thus indices of body shape should also be monitored.
Skill Related Fitness: Motor Skills

Motor skills are considered to be skill/performance related components of fitness. These include: power,
speed, balance, agility, coordination and reaction time. Although each component of fitness is vital in
mastering a specific skill, each component can also contribute to an individual's health and improved
quality of life.

Power

Power is the ability to exert a maximum force explosively (strength × speed). Power, is calculated as the
product of force generated, divided by the time required to apply the force (work/time). Exerting a force
or moving a weight quickly is important within athletic events that require explosive movement
(sprinting, jumping and lifting). Originally classified as a skill related component of fitness, power is now
becoming recognised as both a skill and a health related component of fitness (Corbin & Le Masurier,
2014; Pate et al., 2012). Muscle power is used for most activities of daily living and increased levels of
power have been associated with enhanced functionality, fall prevention and quality of life particularly
in the elderly (Granacher et al., 2011; Reid & Fielding, 2012).

Speed (distance/time)

Speed is the ability to move limbs or the body rapidly over a distance. Acceleration (time to reach peak
speed), absolute speed (peak speed) and speed endurance (ability to maintain peak speed) are vital in
explosive athletic events. Furthermore, speed endurance plays a major role in distance based events.

Balance

Balance is the maintenance of the body's centre of gravity above the base of support whilst stationary
(static) or during movement (dynamic). Balance requires the vestibular and sensory systems to
coordinate muscle activity to maintain spatial awareness within gravity. Balance is essential in athletic
events and plays a major role in the quality of life for the elderly. Poor balance has been associated with
an increased risk of falls, morbidity and mortality (Ambrose et al., 2013).

Agility

Agility is the ability to change body position or direction quickly in a controlled manner. Agility and
balance are essential in athletic events requiring rapid direction changes (to move into position or avoid
opponents) and should not be overlooked in a training programme.

Coordination

Coordination relies on the senses to move two or more body parts in unison, or combine multiple parts
of a skill in a controlled and efficient manner. Coordination, similar to balance and agility, requires the
adequate processing of kinaesthetic and proprioceptive information (where the limbs and body are in
space) to perform basic daily activities and sport specific skills successfully.

Reaction time

Reaction time is the time period between a stimulus and the motor response of the musculoskeletal
system. Sensory neurons of the neurological system detect the stimuli and transit the signal to the central
nervous system for processing to initiate an action from the motor neurons. Reaction time is important
within most athletic events and can be affected by many intrinsic (fatigue, age, gender and practice) and
extrinsic (type of stimulus and number of stimuli) factors.
Exercise Programming

Exercise programmes should be designed to improve the components of fitness related to the client's
health/fitness goals. However, adopting a more holistic approach and training all components of fitness
will achieve a number of health and performance benefits (see Figure 2.1).

Figure 2.1 The components of fitness.

References

Ambrose, A.F., Paul, G., & Hausdorff, J.M. (2013). Risk factors for falls among older adults: a review of
the literature. Maturitas, 75(1), 51–61.
Artero, E.G., Lee, D.C., Lavie, C.J., España-Romero, V., Sui, X., Church, T.S., & Blair, S.N. (2012). Effects of
muscular strength on cardiovascular risk factors and prognosis. Journal of Cardiopulmonary
Rehabilitation and Prevention, 32(6), 351.
Colberg, S.R., Sigal, R.J., Fernhall, B., Regensteiner, J.G., Blissmer, B.J., Rubin, R.R., & Braun, B. (2010).
Exercise and type 2 diabetes. The American College of Sports Medicine and the American Diabetes
Association: joint position statement. Diabetes Care, 33(12), e147–e167.
Corbin, C.B., & Le Masurier, G. (2014). Fitness for Life, Sixth Edition. Champaign, IL: Human Kinetics.
Granacher, U., Muehlbaue, T., Zahner, L., Gollhofer, A., & Kressig, R.W. (2011). Comparison of traditional
and recent approaches in the promotion of balance and strength in older adults. Sports Medicine,
41(5), 377–400.
Huber, M., Knottnerus, J.A., Green, L., van der Horst, H., Jadad, A.R., Kromhout, D., & Smid, H. (2011).
How should we define health? British Medical Journal, 343, d4163.
Kodama, S., Saito, K., Tanaka, S., Maki, M., Yachi, Y., Asumi, M., & Sone, H. (2009). Cardiorespiratory
fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men
and women: a meta-analysis. Journal of the American Medical Association, 301(19), 2024–2035.
Kokkinos, P.F., Faselis, C., Myers, J., Panagiotakos, D., & Doumas, M. (2013). Interactive effects of fitness
and statin treatment on mortality risk in veterans with dyslipidaemia: a cohort study. The Lancet,
381(9864), 394–399.
Kokkinos, P., Faselis, C., Myers, J., Kokkinos, J.P., Doumas, M., Pittaras, A., & Fletcher, R. (2014). Statin
therapy, fitness, and mortality risk in middle-aged hypertensive male veterans. American Journal of
Hypertension, 27(3), 422–430.
Kruk, J., & Czerniak, U. (2013). Physical activity and its relation to cancer risk: updating the evidence.
Asian Pacific Journal of Cancer Prevention, 14(7), 3993–4003.
Myers, J., McAuley, P., Lavie, C.J., Despres, J.P., Arena, R., & Kokkinos, P. (2015). Physical activity and
cardiorespiratory fitness as major markers of cardiovascular risk: their independent and interwoven
importance to health status. Progress in Cardiovascular Diseases, 57(4), 306–314.
Pate, R., Oria, M., & Pillsbury, L. (eds). (2012). Fitness measures and health outcomes in youth. National
Academies Press.
Reid, K.F., & Fielding, R.A. (2012). Skeletal muscle power: a critical determinant of physical functioning
in older adults. Exercise and Sport Sciences Reviews, 40(1), 4.
Wang, C.W., McPherson, K., Marsh, T., Gortmaker, S.L. & Brown, M. (2011). Health and economic burden
of the projected obesity trends in the USA and the UK. Lancet, 378(9793), 815–825.
Westcott, W.L. (2012). Resistance training is medicine: effects of strength training on health. Current
Sports Medicine Reports, 11(4), 209–216.
Chapter 3
Pre-exercise health screening

Paul Draper
Importance of Health Screening

The health benefits of regular exercise have been demonstrated in many studies (Blair, 2009; Sallis, 2009;
U.S. Department of Health and Human Sciences [USDHH], 2008; Warburton et al., 2006). Public health
policies therefore generally aim to increase levels of physical activity (e.g. Brown et al., 2012; Haskell et
al., 2007; UK Department of Health, 2011; USDHH, 2008). However, certain types of exercise, such as
high-intensity exercise, or in some cases any exercise at all, may present a risk to some clients who have
pre-existing health conditions such as cardiovascular disease (CVD) (Thompson et al., 2007). Risks can
include injury, deterioration of health, or in extreme cases, death. Pre-exercise health screening is
therefore widely used to protect the client from harm, and to help protect the trainer from possible legal
action.
Depending on the outcome of health screening, it may be necessary to seek advice from the client's
doctor, or other healthcare professional. The healthcare professional may advise against exercise, or make
specific recommendations on the exercise type or intensity. Therefore it is important that medical advice
is sought and followed. A personal trainer may need to refer some clients to an exercise professional
with a higher level of training and qualifications. This may include specific knowledge about adapting
exercise for particular medical conditions (American College of Sports Medicine [ACSM], 2014; Register
of Exercise Professionals [REPs], n.d.).
Physical Activity Readiness Questionnaire (PAR-Q)

Overview

One of the most widely used health screening tools is the Physical Activity Readiness Questionnaire
(PAR-Q) developed by the Canadian Society for Exercise Physiology (CSEP) and most recently revised in
2002. This tool is used by an estimated 50 million people each year (Warburton et al., 2011). It is a short,
simple form designed to identify major symptoms of CVD, pulmonary disease, metabolic diseases,
orthopaedic conditions, and other conditions which may be aggravated by exercise. It has been widely
adopted in North America, Europe, Australia and other countries. The PAR-Q is shown in Figure 3.1.

Figure 3.1 PAR-Q. Permission granted. Copyright Canadian Society for Exercise Physiology (2002).

Using the PAR-Q

If the client is between 15 and 69 years of age, and answers ‘No’ to all questions, it is generally
considered to be safe to proceed with fitness testing and a graduated exercise programme. The
programme should start at low to moderate intensity, must be properly designed (see Chapter 8) and take
into account the client's current fitness level, lifestyle, goals and necessary behavioural changes (see
Chapter 4).
Clients who answer ‘Yes’ to one or more questions should seek advice from their doctor before fitness
testing, or increasing activity levels. If the trainer has any doubt as to whether his or her own
qualifications and experience are suitable for training the particular client, a more experienced fitness
professional, or the relevant professional body, should be consulted (ACSM, 2014; REPs, n.d.).

Case study 3.1 Referrals

Jenny is a 42-year-old senior executive in a manufacturing company. Over the past five years she
has had hardly any time for exercise, but has decided now is the time to improve her health and
fitness. During her initial consultation, she answered ‘No’ to all but one question in the PAR-Q. She
answered ‘Yes’ to the question ‘Is your doctor currently prescribing drugs (for example, water pills)
for your blood pressure or heart condition?’
Before conducting any fitness tests with Jenny, or asking her to embark on a fitness programme,
her trainer should write a brief letter to her doctor. This should clearly identify the patient (full
name and date of birth), provide contacts details of the fitness professional, very briefly outline the
type of exercise programme proposed, indicate the level of intensity (low, moderate, or vigorous),
and the level of supervision to be provided (if any). The letter should ask the doctor to indicate
whether or not Jenny should participate, and to provide any recommended restrictions or
limitations to her exercise.
Before the letter is sent, Jenny must give her permission. It may be best for Jenny to deliver the
letter to the doctor herself. Even if the doctor gives clearance for Jenny to exercise, if she has a
condition which is outside the scope of the trainer's training and qualifications, she may need to be
referred to an exercise professional with additional qualifications and experience.

Limitations of the PAR-Q

Although the PAR-Q can be used to assess whether it is safe to increase activity levels, it does not give
any indication of the level of risk of developing chronic health conditions, such as coronary heart disease
(CHD). It does not collect information on medications the client may be using which may have side
effects, other implications, or contraindications for exercise. The PAR-Q also does not ask about
pregnancy, which clearly has an impact on exercise capability/capacity. The PAR-Q is deliberately
conservative, possibly leading to a large number of false positives and hence to unnecessary medical
referrals (Warburton et al., 2011). Therefore, the clients who most need to increase activity levels, the
PAR-Q could create a barrier to exercise.
It is important to note that, although the CSEP gives general permission for its PAR-Q to be copied
and used for screening, it explicitly states that no changes to the questionnaire are permitted (CSEP,
2002). Therefore, fitness professionals and facilities should not include additional questions, or waivers.
Any additional information gathering agreements, or waivers should be carried out separately from the
PAR-Q.
The PAR-Q is not suitable for children or adults aged 70 or above. It is only designed for people aged
15 to 69 (CSEP, 2002). However, in research studies it has often been used to screen individuals aged 70 or
above for participation (e.g. Anderson et al., 2011; Liu-Ambrose et al., 2004; Manini & Pahor, 2009). This
is not appropriate, as demonstrated by a study assessing the diagnostic accuracy of the PAR-Q in elderly
women, which found that it generated a high number of false positives and false negatives, making it
unsuitable in this age group (Maranhao-Neto et al., 2013).
Other Health Screening Approaches

PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone

In order to help to overcome some of the limitations of the PAR-Q, the PAR-Q+ Collaboration has
developed a more sophisticated questionnaire, known as PAR-Q+ (Warburton et al., 2014). The PAR-Q+
comprises 4-pages which aim to identify restrictions or limitations on physical activity. If the answer is
‘No’ to all questions on the first page, the client is considered to be low risk and cleared for general
physical activity guidelines. If the client answers ‘Yes’ to one or more questions on the first page,
additional questions need to be answered to determine whether the client is cleared to proceed, or should
be referred to a doctor. Proper use of the PAR-Q+ could lead to as few as 1 per cent of clients being
referred for additional medical screening (Bredin et al., 2013). The first page of the PAR-Q+ is shown in
Figure 3.2. Online and downloadable versions can be accessed at www.eparmedx.com.

Case study 3.2 Completing the PAR-Q+

James is a 38-year-old IT consultant. Owing to poor diet and a lack of PA, he is slightly overweight.
With the summer coming, he has decided to start an exercise programme in order to reduce body
fat. Five years ago he was diagnosed with high blood pressure. However, he is not currently taking
any medication, and his doctor recently told him that his blood pressure is normal. When
completing page 1 of the PAR-Q+ he answered ‘No’ to all but one question. He answered ‘Yes’ to
the question ‘Has your doctor ever said that you have a heart condition OR high blood pressure?’.
On pages 2 and 3 of the PAR-Q+ he answered ‘No’ to all questions.
As James answered ‘Yes’ to one of the questions on page 1, he was required to answer the
questions on pages 2 and 3. However, he is cleared to exercise because he answered ‘No’ to all the
questions on pages 2 and 3.
Figure 3.2 PAR-Q+ Page 1 (Reprinted with permission from the PAR-Q+ Collaboration and the authors of the PAR-Q+ (Dr. Darren
Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin)).

Risk stratification

Another approach to overcoming the limitations of the PAR-Q is ‘risk stratification’, or ‘risk
classification’. This concept has been incorporated into approaches recommended by the ACSM (2014)
and Sports Medicine Australia (SMA, 2005). The aim of risk stratification is to estimate the likelihood of a
client suffering illness or injury as a result of starting exercise. High-risk clients are usually considered
unsuitable for an exercise programme, unless they have medical clearance and are supervised by a
suitably qualified professional. Moderate risk clients may require medical clearance, depending on the
intensity of the anticipated exercise programme, and exercise intensity is likely to be restricted. Low risk
clients generally do not require medical clearance, and may gradually progress over time to higher
intensity exercise. The ACSM and SMA approaches are briefly described below.

American College of Sports Medicine

The ACSM (2014) has published guidelines and processes for health screening and risk stratification. The
ACSM's screening tools include the PAR-Q (CSEP, 2002) and the AHA/ACSM Health/Fitness Facility Pre-
Participation Screening Questionnaire (ACSM, 2014), which has been adapted from a similar
questionnaire previously published jointly by the ACSM and the American Heart Association (Balady et
al., 1998). The ACSM's screening tools also include a ‘pre-participation screening logic model for risk
classification’, and ‘exercise testing and test supervision recommendations based on risk classification’
(ACSM, 2014). It also recommends that clients should provide written informed consent to exercise, and
provides guidance for this. For full details, refer to the relevant ACSM documentation (ACSM, 2014).

Sports Medicine Australia

In 2005 SMA published, and made available on its website, a pre-exercise screening system. Stage 1 of the
SMA system involves 17 questions designed to identify clients at high risk of exercise-related
complications from cardiovascular, cerebrovascular, respiratory or metabolic diseases. These high-risk
individuals need medical clearance before fitness testing, or beginning an exercise programme. Clients
who answer ‘No’ to all questions in stage 1 can begin low to moderate physical activity. Those wishing
to exercise at vigorous intensity need to undertake stage 2 of the screening process.

Box 3.1 ‘Yes’ answers on a PAR-Q

Fitness professionals are often unclear what to do when a client answers ‘Yes’ to just one question
on the PAR-Q, and indicates that the condition is only mild. In such situations, the procedure
associated with the chosen health screening tool must be used. For example, the instructions
embedded in the CSEP PAR-Q (CSEP, 2002) specify that all clients answering ‘Yes’ to one or more
questions should seek advice from their doctor. If a fitness facility, or independent fitness
professional, adopts a different screening tool such as the PAR-Q+ (Warburton et al., 2014), or a risk
stratification approach (ACSM, 2014; SMA, 2005), fewer referrals may be indicated.

UK Active – Health Commitment Statement

The ‘Health Commitment Statement’ (HCS) is a different approach, which does not use questionnaires,
or risk stratification. UK Active is a not-for-profit body comprising over 3,000 member organisations
across the active lifestyle sector (UK Active, 2015). In 2014, in conjunction with EIDO Healthcare Ltd, it
launched a template HCS. UK Active encourages its members to use this as an alternative to health
screening tools such as the PAR-Q. The HCS sets out the standards that health and fitness centres and
clients can expect from each other, with regard to the health of the client, and aims to place the primary
responsibility with the client. The HCS is designed for use in health and fitness facilities, and is not
suitable for personal trainers working independently.
References

American College of Sports Medicine (2014). Screening and risk classification. In ACSM's Resources for
the Personal Trainer (pp. 281–300). China: Lippincott Williams & Wilkins.
Anderson, H.S., Kluding, P.M., Gajewski, B.J., Donnelly, J.E., & Burns, J.M. (2011). Reliability of peak
treadmill exercise tests in mild Alzheimer disease. International Journal of Neuroscience, 121, 450–
456.
Balady, G.J., Chaitman, B., Driscoll, D., Foster, C., Froelicher, E., Gordon, N., Pate, R., Rippe, J., &
Bazzarre, T. (1998). Recommendations for cardiovascular screening, staffing, and emergency policies
at health/fitness facilities. Circulation, 97, 2283–2293.
Blair, S.N. (2009). Physical inactivity: the biggest public health problem of the 21st century. British
Journal of Sports Medicine, 43(1), 1–2.
Bredin, S.S., Gledhill, N., Jamnik, V.K., & Warburton, D.E. (2013). PAR-Q+ and ePARmed-X+ – new risk
stratification and physical activity clearance strategy for physicians and patients alike. Canadian
Family Physician, 59, 273–277.
Brown, W.J., Bauman, A.E., Bull, F.C., & Burton, N.W. (2012). Development of evidence-based physical
activity recommendations for adults: 18–64 years. Australian Department of Health. Available online
at www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-
guidelines/$File/DEB-PAR-Adults-18-64years.pdf.
Canadian Society for Exercise Physiology (2002). PAR-Q & You. Available online at
www.csep.ca/cmfiles/publications/parq/par-q.pdf.
Haskell, W.L., Lee, I.M., Pate, R.R., Powell, K.E., Blair, S.N., Franklin, B.A., … Bauman, A.B. (2007).
Physical activity and public health: updated recommendations for adults from the American College
of Sports Medicine and the American Heart Association. Circulation, 116, 1081–1093.
Liu-Ambrose, T., Khan, K.M., Eng, J.J., Janssen, P.A., Lord, S.R., & McKay, H.A. (2004). Resistance and
agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized,
controlled trial. Journal of the American Geriatrics Society, 52, 657–665.
Manini, T.M., & Pahor, M. (2009). Physical activity and maintaining physical function in older adults.
British Journal of Sports Medicine, 43, 28–31.
Maranhao-Neto, G.A., Luz, L.G., & Farinatti, P.T. (2013). Diagnostic accuracy of pre-exercise screening
questionnaire: emphasis on educational level and cognitive status. Archives of Gerontology &
Geriatrics, 57(2), 211–214.
Register of Exercise Professionals (n.d.). UK level 4, European qualifications framework level 4,
occupational descriptor: fitness instructor/personal trainer. Available online at
www.exerciseregister.org/about-reps/job-roles-in-our-industry.
Sallis, R.E. (2009). Exercise is medicine and physicians need to prescribe it. British Journal of Sports
Medicine, 43(1), 3–4.
Sports Medicine Australia (2005). Sports Medicine Australia pre-exercise screening system 2005.
Australian Department of Health and Ageing. Available online at http://sma.org.au/wp-
 content/uploads/2009/05/new_pre_screening.pdf.
Thompson, M.D., Franklin, B.A., Balady, G.J., Blair. S.N., Corrado, D., Estes, M.N., … Costa, F. (2007).
Exercise and acute cardiovascular events: placing the risks into perspective. Circulation, 115, 2358–
2368.
UK Active (2014). The Health Commitment Statement. UK Active and EIDO Healthcare Ltd. Available
online at www.ukactive.com/membership/raising-standards/ukactive-information-
notes/more/7796/page/1/health-commitment-statement-hcs.
UK Active (2015). UK Active's Members and Partners. Available online at www.ukactive.com/about-
us/ukactives-members-and-partners.
UK Department of Health (2011). Physical activity guidelines for adults: 19–64 years. London: Chief
Medical Officer. Available online at www.gov.uk/government/publications/uk-physical-activity-
guidelines.
U.S. Department of Health and Human Sciences (2008). 2008 Physical activity guidelines for Americans.
Washington D.C.: Department of Health and Human Sciences. Retrieved from
www.health.gov/paguidelines/guidelines/.
U.S. Department of Health and Human Sciences (2008). Physical activity guidelines advisory committee
report 2008. Washington D.C.: Physical Activity Guidelines Advisory Committee. Available online at
www.health.gov/paguidelines/report/.
Warburton, D.E., Nicol, C.W., & Bredin, S.S. (2006). Health benefits of physical activity: the evidence.
Canadian Medical Association Journal, 174(6), 801–809.
Warburton, D.E., Jamnik, V.K., Bredin, S.S., Burr, J., Charlesworth, S., Chilibeck, P., … Gledhill, N. (2011).
The 2011 physical activity readiness questionnaire for everyone (PAR-Q+) and the electronic activity
readiness medical examination (ePARmed-X+). Health & Fitness Journal of Canada, 4(2), 24–25.
Warburton, D.E., Jamnik, V.K., Bredin, S.S. & Gledhill, N. (2014). The 2014 Physical Activity Readiness
Questionnaire for Everyone (PAR-Q+) and electronic Physical Activity Readiness Medical
Examination (ePARmed-X+). Health & Fitness Journal of Canada,7(1), 80–83.
Chapter 4
Lifestyle assessment and behaviour change

John Downey

Lifestyle assessment refers to the collection of data on a person's daily choices and attitudes in the
context of health and fitness. An appropriate lifestyle assessment and relevant plan are essential to the
long-term obtainment of goals. The initial meeting allows the practitioner to collect information on
expectations, preferences, current and past lifestyle, and beliefs about physical activity (PA) and exercise.
This information will not only allow tailoring of the exercise prescription but also the communication
style and behaviour change practice (Nigg, 2014).
The trainer has a role in facilitating behaviour change and increasing the independence of a client
(Davies, 2011). The increasing importance of this skillset is reflected in practice recommendations that
highlight the competencies needed for exercise professionals in communication and behaviour change
(British Association of Cardiovascular Prevention and Rehabilitation, 2016).

Rapport

The effectiveness of any health/exercise intervention is based on the ability and skill set of the
practitioner (Moyers & Miller, 2013). Some typical practices in the fitness industry promote a relationship
between the client and trainer that increases a client's resistance to change, fear, discomfort and
embarrassment. For example, a trainer may want to help clients by illustrating what is wrong with the
client's current lifestyle and what they should do to correct it. However, this approach may not inspire
motivation. Typically most people will be aware of the benefits of PA but some individuals lack the
behavioural skills required to manage and overcome the barriers to PA. It is imperative that trainers take
the time to explore clients' circumstances, individual definitions of health and PA along with their
motivations for change. In this way, a trainer must make no assumptions or judgements prior to the
initial discussion. A genuine desire to understand the client and a collaborate approach to support their
exercise goals helps to develop a rapport and relationship that facilitates growth and personal change.

Barriers

People undertake various behaviours because of a complex integration of social, environmental,

psychological and individual characteristics (Trost et al., 2002). Therefore, the trainer must understand
the evidence-based variables that can lead to behaviour change (see Table 4.1), and how to identify and
target these in practice (Michie et al., 2011).

Table 4.1 Commonly used behaviour change theories/models

Theory Overview Constructs

Self-efficacy is the task specific

confidence one perceives.
Outcome expectancy is the
perceived likelihood of an
outcome and the value placed on
it.
Social
Behaviour is a reciprocal interaction between Self-regulation is the capacity to
Cognitive
personal social and environmental elements. control behaviour in line with
Theory
values and long-term goals.
Social support and modelling
refers to the social environment
the person is immersed in and the
opportunity to experience the
relevant behaviour.

Attitude relates to the positive or

negative evaluation of a
behaviour.
Theory of
Intentions will precede single level behaviours, Subjective norms are the
Planned
e.g. attending the gym. perceived social pressure related
Behaviour
to behavioural choice.
Perceived control over a
behaviour.

Three basic psychological needs:

Explains behaviour in achievement domains. Competence is the need to master

Self Humans are motivated on a spectrum from tasks.
Determination intrinsic (for enjoyment) to extrinsic (rewards), Relatedness is the need to feel
Theory where a behaviour is completed in a negative connected to others.
light. Autonomy is the independence to
make your own decisions.
 Perceived benefits.
Perceived severity and susceptibility of health Perceived barriers.
Health Belief
implications of certain behaviours will dictate Cues to action relate to a signal
Model
choices. to perform a certain way.
Self-efficacy is the task specific
confidence one perceives.

Transtheoretical
See stage-based models (see page 25)
Model

Barriers to exercise can be real or perceived obstacles to participation. Many elements known to
impact behaviour can manifest themselves in the form of perceived barriers. For example, people who
report environmental barriers also have increased negative psychological constructs (self-efficacy,
intentions) (Van Dyek et al., 2014). This demonstrates that values, self-efficacy, preference, priorities, and
beliefs may impact reported barriers. However, even motivated clients will face barriers impacting PA
maintenance. The ability to self-regulate (capacity to control habitual behaviour for a long-term benefit)
is as an important factor for long-term adherence (Teixeira et al., 2015). Intention to adhere, although
linked to action, does not fully predict compliance (see Case study 4.1). Action and coping planning have
been highlighted as potent self-regulation tools. Therefore, a trainer should work with all individuals,
even the motivated, to create coping plans to address potential barriers. These behavioural skills are
paramount in long-term change (Godinho et al., 2013).

Case study 4.1 Beginning an exercise programme

Kate is a new mum and recently joined the gym and planned to attend three times a week. She has
always had a positive relationship with exercise and believes exercise can help control her weight
and improve her mood. Her husband regularly exercises and cycles to work. When she joined the
gym, she booked ten spinning classes and some personal training sessions. In recent weeks, Kate's
attendance has been sporadic and she has cancelled some sessions at the last minute. Upon talking
with Kate she articulated that exercise had ‘fallen down’ her list of priorities: the kids are off school
due to the holidays and she has family staying with her. She stated that she has failed to complete
any exercise because she has struggled to know what to do when her time is required elsewhere.
A trainer should continually work with the client to identify barriers and solve problems in order
to develop behaviour regulation skills. This will help reduce the intention action gap. Kate would
benefit from support on planning, exploring internal motivation, and relapse-prevention
ideas/contracts.

Adherence
Voluntary, consistent lifestyle choices will precede achieving goals. The vast array of literature is
worthless unless a client adheres to a programme. Furthermore, rarely will a client have the luxury to
exercise with a trainer on a daily basis. Therefore, the trainer has a role in inspiring motivation,
enjoyment and adherence. Research consistently shows high attrition and regression when practitioner
support ceases, especially in voluntary behaviours (Eysenbach, 2005). Consequently, each client contact
provides an opportunity to support behaviour change (Davies, 2011). Optimal practice should identify
and target known elements that can impact change (see Figure 4.1 and Table 4.1). Practice should consult
with theory that provides predictors of change. Theory allows for the trainer to alter the application of
this evidence in their own way, e.g. text messages, self-monitoring, action plans.
The Role of Theory

A behaviour theory is a framework that identifies key variables, known as constructs, that
impact/predict behavioural outcomes. Behaviour theories streamline the process of understanding what
variables are most prudent in predicting behaviour. Extensive literature exists on behaviour and how to
optimise change; however, methodological flaws have limited interpretation of the data (Michie et al.,
2009). Therefore in practice, tools to facilitate behaviour change may be more relevant. Comprehensive
taxonomies (tool/strategy classifications) are now available that highlight techniques for behaviour
change (Michie et al., 2011). It is beyond the scope of this chapter to detail relevant theories but trainers
are advised to familiarise themselves with common frameworks (see Table 4.1). Understanding each
theory enables a trainer, at the initial screening, to identify what constructs are most relevant to a
specific client.
Integrating theory as part of interventions improves health and fitness outcomes. Nevertheless,
research has yet to identify one theory that is the ‘gold standard’ or that can account completely for the
complexity of a behaviour (NICE, 2007). This seems logical, as a single theory may be too simplistic to
account for the diverse impact of contributing factors on behaviour. Figure 4.1 illustrates key factors that
contribute to behaviour, in order to support clients with a unified approach.

Stage based models (SBM)

Figure 4.1 An integrated display of relevant constructs for behaviour change (note this is not a hierarchy matrix) (adapted from Jennings et
al., 2009).

Stage based models (SBM) appreciate that behaviour change does not usually happen at one point in
time. The Transtheoretical Model (TTM) has gained popularity due to the practical framework it
provides to support people at various stages in their ‘readiness to change’. The model details elements
and processes that need to be addressed depending on the stage the client is in. The TTM outlines key
stages in the nature of behaviour change (see Figure 4.2). The important constructs that alter through the
stages are self-efficacy, processes of change and decisional balance (pros v. cons). By using this method
practitioners can tailor lifestyle support based on the stages of change. Stage specific interventions have
shown inconsistent results, especially in the long term, mainly due to study design and intervention
flaws. Others have questioned whether it is the changes in these constructs alone that are predicting the
behaviour change (Hutchison et al., 2009; Marshall & Biddle, 2001). Nevertheless, evidence for improved
outcomes does exist and the TTM provides a blueprint to identify how ready a client is to change and
what support may progress them through the stages. The TTM gives the trainer tangible tools to address
behaviour and should be used as part of a comprehensive assessment.

Figure 4.2 The stages of change from the Transtheoretical Model (Prochaska, DiClemente & Norcross, 1992).
Supporting Change

The client's well-being should be central to a trainer's work. As a trusted source of information there is a
risk of ‘social positioning’ which creates a relationship that discourages self-management and ultimately
does not inspire change (Jennings et al., 2009). The approach that will support a productive relationship,
and behaviour change, is one that allows the client to make choices, supports self-efficacy, builds a
shared agenda, challenges perceptions and beliefs, explores motivations/barriers and requests
conversations around education and raising awareness.
Communication is defined in various ways. Relevant key phrases include information exchange and a
mutual understanding. Considering this, optimal communication should have investment from both
parties in order to shape understanding and build mutual respect (Robinson et al., 2008). This style of
communication allows for client-centred care, in which there is a joint investment and understanding
built. A popular theory proposes that as humans we have an innate drive to display competence (the
ability to achieve an outcome), autonomy (in control of our own actions), and relatedness (feeling
connected) (Deci & Ryan, 1985). Motivational interviewing (MI) facilitates these needs and the self-
determination theory has been used as a framework to describe the success of this communication style
(Markland et al., 2005).

Motivational interviewing

Client-centred care takes into consideration the client's preferences, values and experiences. This
approach has been shown to give superior outcomes in behaviour change (Robinson et al., 2008) and
research suggests that adherence to interventions increases if an individual invests in the programme
(Morton et al., 2008).
A key counselling style to promote client-centred care is MI. Telling or persuading people to change
has poor outcomes; MI works to explore personal perspectives and barriers in order to identify internal
motivation. Individuals often believe that although a behaviour change will be beneficial, the negative
cost of that change may outweigh the benefit causing ambivalence (contradictory feelings). Using MI
requires a practitioner to fully understand and empathise with the client and to challenge the
ambivalence in the correct manner. Motivational interviewing is flexible, but does have a structure that
interviewers should follow along with key principles to ensure the practice is optimal (see Figure 4.3).
Reviews have shown that MI significantly improves behaviour change and exercise adherence
(O'Halloran et al., 2014). However, there is some concern over the implementation of MI in applied
settings and trainers must practise, reflect and undertake continued training on MI to ensure good
application of this approach (McGrane et al., 2015).
The spirit and philosophy of MI is central to impacting ambivalence to change. This is primarily
expressed through collaboration and empathy. A trainer should demonstrate empathy to show that a
client's display of emotions has been recognised, both through emotional and verbal responses.
Expressing empathy alone has been shown to predict a high proportion of behaviour change (Miller &
Baca, 1983). Although defining empathy is difficult, important characteristics include honesty, mutual
respect, warmth and understanding (Moyers & Miller, 2013).

Figure 4.3 Outline of the framework needed for effective motivational interviewing (adapted from Breckon, 2015).

Motivational interviewing should empower the client to co-create plans and coping strategies rather
than a practitioner enforcing restrictions and autocratic programmes. This non-confrontational approach
allows for an environment that supports clients expressing feelings about their current lifestyle habits
and their difficulties with change. Effective MI will be empathetic but also build sufficient discrepancy so
that clients recognise a mismatch between their values, goals and their current behaviour (Rollnick &
Miller, 1995). Clients will often ask a trainer ‘What should I do?’ which reinforces a reliance on the
trainer to provide all of the answers. The practitioner should be sensitive to avoid the ‘expert–client trap’
simply dispensing factual information. Instead, an exploration of beliefs, attitudes and motivations
should take place. A non-judgemental style is required whereby the trainer must remain unbiased and
not attempt to address misconceptions with facts: a directive-guiding conversation should try and
develop contradictions in thoughts and actions (Nigg, 2014) (see Case study 4.2).

Case study 4.2 Motivational interviewing

Trainer (T): Hi, Mr Smith, how are you today?
Mr Smith (S): I am okay, can't complain too much. The doctor told me to come along today as
exercise will be good to fight off these health issues. Apparently I am developing type 2
diabetes.
T: So the doctor asked you to come along today? Can you tell me what you know about diabetes?
S: Well, the doctor explained that my lifestyle may be impacting on how well my body deals with
sugar.
T: What are your thoughts on how you can influence this?
S: Well, I think the main thing for me is in the last few years I have not done much activity.
T: Okay and that lack of activity concerns you?
S: If I am honest, I think that has been the main thing that has led to the weight gain and these
health issues.
T: Do you mind if we chat about your activity levels and how this might help?
S: Yes, please, that would help a lot.
T: So tell me about your physical activity and what you enjoy.
S: Well I used to exercise a lot and have always loved sport. I also had an active job but since
retiring I have done nothing. Since then the weight has crept on.
T: So exercise was a big part of your life, but the retirement started a cycle which led to weight
gain?
S: Yeah, I just fell out of the routine. I am keen to get into the gym and start again. What should I be
doing? Do I need to be in here every day?
T: It sounds like you have made a decision to really take control of your lifestyle. Exercise is not a
one-size-fits-all programme. At the minute tell me what you think would be manageable.
S: Oh I am walking two days a week and take a long 30-minute bike ride on a Sunday. I love being
outside. I hate the gym but will do whatever you tell me.
T: So what I am hearing is you are motivated to exercise and are currently active especially in the
outdoors but the gym is not something you enjoy.
S: Yeah, this place is like torture – it is so boring. But the doctor said to come to you.
T: You spoke about how sport is a passion of yours. Have you thought about getting involved in
sport again?
S: Actually a friend of mine has started a veteran's football league in this facility but I thought I had
to come here.
T: Finding something you enjoy is key. Could you see yourself playing again?
S: Oh yeah, I would love to reintroduce that into my life.
Assessment

Before trainers can decide what methods to implement to lead to a behaviour change, they must assess
the client. By appreciating the needs of a client in a certain context, appropriate elements of various
theories will become apparent. Once established, the most prudent strategies can be used. Applying
multiple behaviour change techniques is a highly effective approach in most cases (Cugelman et al.,
2011).
The following is not a prescription, but an example of how to gather information to develop a
behaviour change plan:

Collaboratively set an agenda.

Explore beliefs, values, barriers and current lifestyle.
Exchange information.
Assess readiness to change (stages of change).
Assess motivation using scaling questions (importance and confidence).
Promote autonomy and self-efficacy.
Explore social support.
Obtain a visual list of pros and cons of adopting an exercise plan (decisional balance).
Evidence-Based Tools

Below is a list of techniques which are known to impact both behavioural constructs and behaviour
change. The list is not exhaustive, but details important tools that target antecedents of PA which has
come from the taxonomy collated by Michie and colleagues (2011, 2013).

Goal-setting (GS)

Goal-setting is now recognised as an essential part of any behaviour change intervention. The SMART
principle works to increase focus, motivation, self-efficacy, and value along with increasing resilience.
The acronym stands for: Specific, Measurable, Achievable, Relevant and Time-Centred. In using this
method, ambiguity is reduced providing a more tangible outcome, which helps to increase persistence.
Literature shows that using self-regulatory tools like GS improves behaviour change outcomes (Greaves
et al., 2011). This is particularly important for clients who have an intention to adopt an exercise plan.
For unmotivated clients it may not be sensible to use this tool initially, instead consciousness-raising and
providing education can be more beneficial.

Self-monitoring

Self-monitoring is deemed a self-regulatory tool and involves the client keeping a behaviour log. This
increases awareness, responsibility and consequences of behaviour. Goal attainment literature has shown
that monitoring progress, especially in a public setting and in a physical form, decreases the intention
behaviour gap and improves behaviour performance (Harkin et al., 2016). Monitoring behaviour allows
for a more regular self-evaluation of performance which an individual will respond to accordingly. This
strategy increases awareness of automatic behaviour where an examination of performance can be
undertaken and compared against values and goals.

Feedback and rewards

Tailored feedback and reinforcement increases behaviour change (Michie et al., 2013). When changing
behaviour, if clients note a discrepancy between their current behaviour and their goal they will be
driven to change, given the right environment (motivation, opportunity and ability). Feedback allows for
a review of behavioural performance and may increase a more conscious appraisal of habits (Hermsen et
al., 2016). A feedback session can also be motivational as a client can assess their progress and
accompanying emotions. Decreasing the discrepancy, mentioned earlier, provides a more pleasurable
emotive state, hence further increasing motivation (Carver & Scheier, 2011). Self-rewards provide an
opportunity to acknowledge change and promote continual encouragement. If clients create the reward
from the outset they will invest more in the process of change.

Action plan and relapse-prevention

Long-term adherence requires more than positive intentions. Action planning and relapse prevention
allow for future planning and identification of potential barriers along with the cues to initiate strategies
to maintain change (Godinho et al., 2013). These tools work best in conjunction and when the individual
makes the plans specific and tangible (de Hoog et al., 2016).

Reviews and prompt practice

A review offers the opportunity for the practitioner to reinforce messages and prompt practice of the
new behaviour, which will contribute to new habit formation. Moreover, the contact increases the client's
perceived responsibility and also improves adherence (Michie et al., 2011).

Summary
The initial meeting with a client is an essential time to build rapport and explore the client's
motivations, values, lifestyle and psychological characteristics. Without the client's adherence to a
programme, little progress will be made. Therefore, a trainer needs to be equipped to understand
behaviour and how to promote change. Behaviour change theory provides the blueprints in order to
shape practice. Central to change is a relationship that portrays empathy and collaboration; this is
known as client-centred care. Motivational interviewing is a potent communication style which is
underpinned by a genuine desire to support a client. Many evidence-based tools are available and a
trainer should choose and apply these within a behavioural and lifestyle assessment. This is
paramount to empower the client, support self-learning and facilitate the obtainment of goals.
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Chapter 5
Nutrition

John Downey

Nutrition plays a vital role in improving health and fitness, as well as maximising athletic performance.
Interventions combining physical activity (PA) and diet have been shown to yield better health outcomes
than exercise alone (Clarke, 2015). Therefore, PA and nutrition should be considered in conjunction to
optimise a health/fitness programme. Research has demonstrated that clients expect nutritional advice
from fitness professionals and often request in-depth nutritional analysis (McKean et al., 2015) and
exercise professionals have been considered the ‘gatekeepers’ of health and exercise information
(Santana et al., 2007). However, many exercise qualifications only superficially addresses nutrition.
Despite no rigorous guidelines for nutrition practices, it is unwise to neglect the impact nutrition can
have in optimising a variety of health/fitness outcomes.
Professional Boundaries

Nutrition is not an exact science and it is known that individuals respond differently to various foods.
Trainers must appreciate that the majority of work should be centred on increasing the client's
knowledge, self-regulation of food intake and food preparation/planning (Michie et al., 2011). Trainers
should understand the limitations of their qualification, know what guidelines to recommend and be
well informed to offer advice and know when to refer the client to a qualified nutrition expert.
Prescribing clients specific diets or food modifications is outside of the trainer's scope of practice.
This chapter provides a basic overview of nutrition and explores the research that has been conducted
within common diets and supplements. This chapter is not a toolkit for prescription; the aim is to prepare
trainers to support, educate and advise client's on these matters. As with exercise prescription, dietary
advice should adhere to the principle of individualisation (see chapter 7) whereby any nutrition
discussions must be based on the status and needs of the client.
Nutrients

There are six key nutrients that food provides to maintain normal bodily functioning (fat, carbohydrates,
protein, vitamins, minerals and water). No single macronutrient (fat, carbohydrate, protein) possesses a
superior function compared to another. In order to ensure optimal health there needs to be a sufficient
delivery of these nutrients to the body's tissues. A diet high in natural, unprocessed food along with
copious variety is vital to this nutrient balance. An extreme priority on any one of the macronutrients
should be discouraged. Focus for clients should be on the overall diet pattern they adopt and the quality
of their food intake, as this is most prudent for optimal cardiometabolic health (Mozaffarian, 2016).
Figure 5.1 illustrates the evidence-based components that should form the majority of a client's dietary
pattern to optimise health.

Figure 5.1 Evidence-based components of the diet that support health (adapted from Mozaffarian, 2016).
Energy

Energy balance refers to the relationship between the energy we obtain from food and drink and the
energy expended through physical activity and bodily function (e.g. digestion, temperature regulation).
The body has a complex regulatory system to sense changes in available energy which can drive or
suppress hunger (see chapter 11). Energy requirements depend on several factors including age, genetics,
body size and gender. Basal metabolic rate contributes to the majority of daily energy expenditure (60
per cent to 75 per cent) and represents the energy required to maintain normal bodily functioning.
Physical activity is the most variable element of daily energy expenditure (15 per cent to 30 per cent).
Lastly the energy needed to digest and absorb food (thermogenesis) contributes to the remaining
proportion of daily energy expenditure (7 per cent to 10 per cent).
A number of equations are available to estimate energy requirements; however, it should be noted that
these recommendations are guides with inherent error. Nonetheless, assessing diet is useful to estimate
current energy (calorie) intake, identify poor eating patterns and open conversations to educate clients
and empower them to adopt dietary changes. Table 5.1 highlights methods of dietary assessment.
Trainers should also be aware that foods with the same calorie content may impact hunger, glycaemia
and disease risk factors differently. Therefore, adopting a ‘counting calories’ approach may not be
optimal. Sugar-sweetened drinks, for example, give poor relief from hunger and can drive appetite
leading to overeating and excessive consumption may also increase the risk of developing type 2 diabetes
and cardiovascular disease (Imamura et al., 2015; Shearrer et al., 2016). Additionally restricting energy by
using equation estimates may paradoxically increase body weight through loss of lean tissue causing a
subsequent decrease in metabolic rate (see Chapter 13). In this way addressing diet patterns and the
‘low-hanging fruit’ will aid a client's goals and improve adherence.

Table 5.1 Dietary intake assessment methods (adapted from Jennings et al., 2009)

Tool Description Advantages Disadvantages

Cheap and
quick.
Standard
protocols Only provides
available. a snapshot of
A validated protocol where the interviewer Assesses meal the client's diet.
explores the client's food and drink intake in patterns and An interviewer
24-hour recall food choice.
the past 24 hours. Prompts are used to needs the
ascertain valid information. Low client specific skillset.
burden. Relies on
Does not alter client's recall.
habitual feeding.
 Does not require
literacy skills.

Excess work to
validate.
Cheap and
Can be
quick.
imprecise and
Uniform
Self-administrated list of foods and drinks reliant on foods
Food administration.
with options regarding frequency of included in the
Frequency Good for large
consumption, usually over a long period of questionnaire.
Questionnaire groups of
time. Client burden.
people.
Requires
Can examine
literacy skills.
dietary patterns.
Relies on
client's recall.

Useful for
examining food
Participant
patterns.
burden.
Good to
May alter the
examine trends
normal food
in
intake of a
mood/symptoms
client.
Food record that varies from 3–7 days. Clients with food
Un-weighted High burden
record all they ate and drank and estimated intake.
food diary for the
the weight using household items. Can gain food
practitioner to
intake data over
analyse.
a number of
Client requires
days.
literacy skills.
Can also be used
Poor
as a behaviour
compliance.
change tool, e.g.
self-monitoring.
Carbohydrates

There are various types of carbohydrate in the human diet which are typically categorised by the
number of sugar molecules in their structure (monosaccharide, disaccharide, polysaccharide). Complex
carbohydrates require greater digestive action which slows down the rise in blood sugar levels.
Consuming wholegrain, complex carbohydrates may potentially have a positive impact on hunger,
mood, energy levels, weight gain and cardiovascular disease compared to diets that minimise
wholegrains (Ye et al., 2012). Simple carbohydrates tend to be calorie dense; typical sources include
confectionary, jams and energy drinks. These should be minimised due to their negative impact on
glycaemic control, cardiometabolic health and satiety (feeling of fullness). Fibre is a carbohydrate that is
resistant to breakdown and is typically abundant amongst plant food sources, as plants have a cell wall
which prevents chemical breakdown. For this reason these foods have a positive role in gut health, blood
pressure control, blood glucose and lipid control (Anderson et al., 2009).
Carbohydrates have an important role in exercise, especially high-intensity training. Moreover,
following a bout of high-intensity exercise the immune system is suppressed and carbohydrate intake
can decrease the impact of this immunosuppression (Nieman, 2007). Carbohydrate requirements will
vary between clients based on preferences, individual responses, health/fitness goals and activity levels.
In general, clients should be advised to base their carbohydrate choices around wholegrain and complex
carbohydrates and to limit simple sources. Diet quality and the overall proportion of the different food
groups are more relevant for health than generic figures (Public Health England (PHE), 2014). Low
carbohydrate diets have become increasingly popular (see page 45). However, constraining clients to eat
a certain way, or follow a specific diet, may not suit their lifestyle or genetics.
Fat

Fat has the highest calorie density of the macronutrients yielding nine calories/gram compared to protein
and carbohydrate yielding four calories/gram. This high energy density also increases the satiety
properties. However, fat contained in foods with high sugar content (pastries, chocolate) does not provide
the same satiating effect. This highlights the need to advise clients to cook and select natural foods.
There are two main types of fats: saturated fats (SFA) and unsaturated fats (UFA) defined by the
magnitude of carbon double bonds they possess. SFA are generally solid at room temperature and have
no double bonds (e.g. animal fat, butter and lard). Monounsaturated and polyunsaturated fats have one
and multiple double bonds, respectively and are generally liquid at room temperature (e.g. peanut oil,
rapeseed oil, olive oil, sunflower oil). Trans fats are a branch of UFA that have been manipulated through
processing or hydrogenation, which alters their structure. There is substantial evidence that trans fats are
detrimental to health and should be avoided (Teegala et al., 2009). Each category of dietary fat has an
influence on the cholesterol/lipid profile in the blood (see Table 5.2).
Omega 3 and Omega 6 fatty acids are known as essential fatty acids as humans lack the enzymes to
create them. Omega 3 is commonly deficient in the modern diet, as the main source is oily fish, a low-
priority in food choice (PHE, 2014). Western diets are also high in Omega 6; this imbalance of essential
fatty acids promotes inflammation and disease (Lazic et al., 2014).

Table 5.2 The impact of fat by category on blood lipids

Low-density lipoproteins High-density liporproteins

Fat Triglycerides Sources
(LDL) ‘bad’ cholesterol (HDL) ‘good’ cholesterol

Lard, butter,
SFA ↑ ↑ ↑
animal fat

Olive oil,
MUFA
↓ ↑ — rapeseed oil,
(monounsaturated)
seeds, nuts

Oily fish,
PUFA
↑ ↑ ↓ flaxseed,
(polyunsaturated)
safflower

Fried foods,
Trans ↑ ↓ ↑ processed
foods
 Box 5.1 Cholesterol, a confusing history
Cholesterol is a sticky substance produced by the liver which is involved in several bodily
functions, including hormone synthesis. Throughout the history of nutrition science, dietary
cholesterol has received a bad reputation, for example for a long time it was considered unhealthy
to consume eggs. It is now recognised that dietary cholesterol (e.g. shellfish, liver) intake seems to
have a small impact on blood lipid levels except in hyper-responders who represent 15 per cent to
20 per cent of the population, therefore a strict reduction in dietary cholesterol is not warranted for
the majority of the population (Djousse & Gaziano, 2008).

United Kingdom (UK) guidelines promote a moderately high fat intake with a goal to reduce SFA (total
fat 35 per cent of total energy) (Department of Health, 1994; Public Health England [PHE], 2014).
Traditional guidelines have been critiqued due to lack of robust evidence at the time of implementation
and subsequent reviews have demonstrated a lack of association between the risk of cardiovascular
disease and total fat or SFA intake (Griffin, 2015). Additionally, exchanging fat intake for refined
carbohydrate intake actually worsens health. However, there is still a relationship between SFA intake
and low-density lipoprotein (LDL), which is a major risk factor for cardiovascular disease. Others note
that SFA types are heterogeneous (not the same) with various implications on disease markers
(Mozaffarian, 2016). For example, one study showed that SFA from dairy products were health protective
whereas excessive consumption of animal fats was associated with increased cardiovascular disease risk.
(Otto et al., 2012). Conversely, hard outcomes including stroke and heart attacks, when examined
singularly, have shown unclear results in relation to SFA intake (Hooper et al., 2015). Nevertheless, a
review of interventions demonstrated that reducing total SFA decreased combined cardiovascular events
by 17 per cent (Hooper et al., 2015) which is why current fat consumption guidelines are based around
replacing SFA with polyunsaturated fats.
Protein

There are 20 amino acids (protein components), nine of which the body cannot manufacture. Biological
value relates to the quality of protein sources and presence/absence of all the essential amino acids.
Sources of proteins with high biological values are typically animal-based with plant sources yielding a
poorer amino acid profile. The need for protein intake increases following periods of increased levels of
PA and exercise, particularly resistance training.
Current protein intakes for the general population in the UK exceed the recommendations (0.75 g/kg
body mass) which are based on the amount needed to avoid deficiency in the vast majority of the
population (PHE, 2014). Higher protein intakes than the recommended have been shown to have positive
outcomes in weight management and physical functioning in older adults (Bauer et al., 2013; Johnstone,
2012;). The long-term literature has failed to show any impact of total protein intake on cardiometabolic
health.

Box 5.2 Protein and kidney health

Previous UK recommendations provided caveats about excessive protein intake and kidney
function. However, contemporary research does not support this hypothesis amongst healthy
populations (Bauer et al., 2013). High protein intakes may accelerate renal dysfunction in
individuals with severe renal issues, yet conversely these patients have higher protein requirements
(Schwingshackl & Hoffmann, 2014). In healthy populations the structural kidney changes seen in
people with a high protein diet are reversible and do not present a pathological strain (Bie &
Astrup, 2015).

The definition of a high-protein diet is varied and the safe upper limit is difficult to define. Some have
explored the impact of high-protein diets on gut fermentation and gastrointestinal disease outcomes. A
higher protein intake, in particular red meat, has been reported to alter gut bacteria and may increase
toxic metabolites compared to a diet consisting of a higher proportion of carbohydrate and fibre, yet
long-term studies do not support these trials (Windey et al., 2012). Carbohydrate is known to positively
influence gut fauna and as such should not be eliminated in the place of protein. As mentioned
previously, the sources of these nutrients also need consideration as advice to limit processed red meats
is recommended due to the potential increased risk of disease (Aston et al., 2012). Acceptable levels of
protein intake range between 10 and 35 per cent of total daily energy (Johnstone, 2012). Therefore, for a
70 kg female, with a requirement of 2,000 calories/day, protein intake could range from 50 g to 175 g
depending on various factors, primarily activity levels and the client's goals.
Fluid Intake

Water intake is an overlooked element of client assessment. The prevalence of sweetened beverages,
alcohol, tea and coffee contributes to the majority of fluid intake in most countries (Gibson & Shirreffs,
2013). It is difficult to set one recommendation for water intake due to the copious factors impacting
requirements. Using urine colour is a reasonable indicator of hydration status with a pale straw colour
indicating good hydration (if the client is not taking vitamin/mineral supplements or medications). A
snapshot of a general American population showed that chronic levels of dehydration range from 16 to
28 per cent (Stookey, 2005). This is a concerning trend as emerging evidence indicates a link between
dehydration, chronic disease and cognitive performance (Popkin et al., 2010). Approximately 30 per cent
of fluid in the diet is obtained through food. Therefore, a trainer should promote the utilisation of fruit
and vegetables when educating clients on fluid intake.
Evidence is now present on the health risks of regularly consuming sweetened and diet beverages,
especially type 2 diabetes risk (Imamura et al., 2015). Sports drinks have integrated their way into normal
culture and most of these beverages have some evidence to support improved endurance performance.
However, positive outcomes after consuming sports drinks have generally been reported during long
endurance events (Jeukendrup, 2011). Therefore, the use of sports/energy drinks containing large
amounts of sugar should not be universally recommended. Moreover, many energy drinks advertised to
promote performance contain numerous stimulants and calories that could affect a client's goals (see
caffeine and carbohydrate sections).
Vitamins and Minerals

Vitamins and minerals are known as micronutrients as they are required in smaller amounts and do not
provide energy. These elements are essential for normal metabolism and bodily function. It is beyond the
scope of this chapter to detail each micronutrient's function or specify recommended levels of intakes.
Trainers are urged to invest time in increasing their knowledge within this area of nutrition. For
example, in developed countries vitamin deficiency is rare, yet trainers should be aware of the clinical
signs and symptoms of deficiency/toxicity (see Table 5.3).
The vitamin and mineral supplementation industry was worth £670 million in 2009 (National Health
Service, 2011). One-third of the UK population take supplements with the main motivation to improve
health and well-being. Evidence shows that supplementation of vitamins and minerals does not provide a
therapeutic effect in non-deficient adults (Desai et al., 2014). Consequently, healthy clients should be
encouraged to consume a consistent and varied diet as this is likely to provide the required levels of
micronutrients.

Table 5.3 Overview of the main micronutrients and accompanying sources and signs of deficiency and toxicity (adapted from Bushman et
al., 2014)

Vitamin/Mineral Key functions Deficiency/Toxicity signs Food sources

Deficiency: poor night vision, unhealthy

Vision
Vitamin A skin and infections Liver, butter, bright and
Reproduction
(retinol) Toxic: headaches, vomiting and bone dark leafy vegetables
Immunity
abnormalities

Energy release
from food (co-
enzyme)
Vitamin B Deficiency: cracked lips, swollen tongue Wholegrains, meats and
Nutrient
family and sensitivity to light legumes
metabolism
DNA synthesis
Nerve conduction

Antioxidant
Vitamin C Iron absorption Deficiency: bleeding gums, fatigue, Fresh fruit and
(ascorbic acid) Collagen muscle pain and depression vegetables
formation

Calcium Deficiency: rickets in children,

Vitamin D absorption Sunlight, small amounts
osteomalacia in adults
(cholecalciferol) Phosphorous Toxic: renal damage and calcium deposits in eggs and fish
absorption

Antioxidant Deficiency: dry or loss of hair, age spots

Vitamin E (α- Nuts, seeds and green
Immunity and premature breakdown of red blood
tocopherol) leafy vegetables
Skin health cells

Green leafy vegetables,

Vitamin K Clotting Deficiency: poor clotting gut bacteria
fermentation

Bone and teeth

health
Dairy, canned fish and
Nerve Deficiency: reduced bone density and
Calcium dark green leafy
transmission fracture easily vegetables
Muscle
contraction

Meats and a less

Oxygen transfer
Iron Deficiency: easy fatigue and anaemia absorbable form in
Oxidative systems
vegetables

Immunity
Wound healing Deficiency: poor growth and frequent Seafood, organ meat and
Zinc
Multiple enzymes infections yeast
activities

Energy
metabolism
Wholegrains, seeds and
Magnesium Protein synthesis Deficiency: weakness
legumes
Muscle
contraction

Component
needed for energy
(ATP)
Phosphorous Part of many Rare Meat, dairy and grains
vitamin B co-
enzymes
Acid-base balance
Supplementation

Whey protein

Health

Whey protein is a by-product of cheese making; it has a high biological value and rapid absorption rate.
Independent of the increased total protein intake, whey protein is proposed to have health benefits. The
majority of health literature has focused on immunity and metabolic functioning. Dairy proteins possess
bioactive peptides which are similar in structure to peptides in the body and may provide therapeutic
effects (Hernández-Ledesma et al., 2014). For example, whey has been shown to decrease blood pressure
in hypertensive patients (Pins & Keenan, 2006). Literature also states that whey supplementation
improves glucose clearance in diabetic patients (Ma et al., 2015). Interestingly, in studies of higher protein
intake without whey supplementation, disease markers are unaffected which may highlight a specific
health enhancing effect of whey (Chiu et al., 2014). Whey may also improve immunity; animal models
and groups of patients supplemented with concentrated whey have shown improved resistance to
infection, yet little is known about this impact in the general population (Micke et al., 2001).
Doubt remains about the delivery of the peptides in whey to the target organs and some have
demonstrated structural changes in peptides during consumption (Standstrup et al., 2014). Others have
commented that the magnitude of peptides in a whey powder is not sufficient to be therapeutic
(Krissansen, 2007). Whey seems to provide benefits (see below) for exercising populations along with
overweight/obese and pre/diabetic groups (Tahavorgar et al., 2015).

Body composition

Whey supplementation during calorie restriction improves body composition outcomes (Verreijen et al.,
2015). Maintaining skeletal muscle is important during fat loss interventions and even one 20 g serving of
whey has been shown to promote protein synthesis in older adults, potentially limiting muscle
breakdown (Breen & Phillips, 2011). The high absorption of whey and the ratio of leucine are responsible
for initiating protein synthesis. Moreover, older and overweight adults may have a blunted anabolic
response which whey supplementation has been postulated to overcome (Breen & Phillips, 2011). Satiety
increases on high-protein diets and whey has a greater impact compared to other forms of protein
(Westerterp-Plantenga et al., 2012). Regardless of these potential benefits this would contribute a small
benefit compared to adherence to a well-rounded diet.

Performance
A body composition favouring higher lean mass is beneficial in many sports. Whey has been shown to
improve muscle accretion and strength when combined with appropriate training loads (Pasiakos et al.,
2015).Whey in conjunction with carbohydrate has mixed results on endurance performance and a recent
review concluded protein ingestion did not improve endurance performance (van Loon, 2014). However,
ingestion prior to both resistance and endurance exercise may provide increases in exercise adaptation
(van Loon, 2014). Although whey is known to initiate regeneration following exercise, there is still no
clear consensus on whey providing tangible recovery of muscle function (Pasiakos et al., 2015).

Caffeine

Health

Caffeine is a natural chemical compound found in over 60 plants; however, the main consumption comes
from coffee which has over 100 other bioactive ingredients. Caffeine intake and health is a controversial
topic with various conflicting studies (de Mejia & Ramirez-Mares, 2014). Research has shown coffee
consumption can potentially protect against cognitive decline and some cancers (Cano-Marquina et al.,
2013; Panza et al., 2014). Conversely, evidence suggests that in some individuals coffee consumption can
accelerate the onset of mental health issues (Ryung et al., 2015). This contradiction is replicated in
cardiovascular health. Caffeine has a negative effect on several cardiovascular disease risk factors;
however, the additional ingredients in coffee seem to negate this relationship (O'Keefe et al., 2013). The
literature on diabetes shows similar contradictions in which caffeine reduces insulin sensitivity, yet
regular coffee consumption (including decaffeinated) is associated with a reduction in the onset of type 2
diabetes, which may highlight the protective nature of the various ingredients (Cano-Marquina et al.,
2013). One must also consider the addictive properties which impact daily living, present withdrawal
symptoms and increase the desire to consume caffeinated products (e.g. chocolate, energy drinks)
(O'Keefe et al., 2013). Moderate coffee consumption has a null effect on health. However, due to its
addictive properties, individual variance and impact on mood following withdrawal, clients must be
made aware of the impact caffeine consumption may have on daily living.

Body composition

Caffeine has been shown to acutely increase resting energy expenditure by 4 per cent and increase fat
breakdown (Miles-Chan et al., 2015). However, little evidence exists for long-term maintenance of this
increase in energy expenditure or any increases in overall fat loss. The literature available tends to
combine caffeine with other stimulants and to date it has not been accepted to significantly reduce levels
of body fat (Li & Cheung, 2011).

Performance
Caffeine has been extensively researched in athletic performance. The majority of the research shows
that a moderate to high (5–13 mg/kg) dose ingested prior to activity increases many measures of athletic
performance (Momaya et al., 2015). It seems that additional factors like daily consumption may not
impact the effect, although studies are dated and a call to define ‘normal drinkers’ is needed (Andre et
al., 2015; Graham & Spriet, 1991). Traditional mechanisms of action are thought to be metabolic yet small
doses can produce improved performance without the associated metabolic alterations, such as an
increase in catecholamines (Spriet, 2014). This suggests that the caffeine has an effect on the central
nervous system. There is a large distribution in caffeine response in athletes as even lower doses can
cause side effects. Therefore, client's using caffeine as an ergogenic aid must adopt an individualised
approach.

Creatine

Health

Creatine is a naturally occurring compound which is synthesised in the liver and found primarily in fish
and meat. The strongest evidence for creatine and health is focused on older adults and degenerative
disease (Agharkar & Gonzales, 2014). Creatine supplementation has been demonstrated to increase
strength and preserve muscle mass (in conjunction with resistance training) in older adults, and
independently in diseased patients it decreases morbidity (Candow et al., 2014; Wilkinson et al., 2015).
There has been increasing interest in the benefits of creatine supplementation amongst individuals with
neuromuscular issues such as Parkinson's and Huntington's disease. Literature is yet to indicate
conclusive long-term benefits, despite plausible biological mechanisms and reported improvement in
symptoms (Agharkar & Gonzales, 2014; Owen & Sunram-Lea, 2011; Salomons & Wyss, 2007; Terjung et
al., 2000).
Studies in situations of sleep deprivation and oxygen deprivation show better cognition with creatine
supplementation (Owen & Sunram-Lea, 2011). Although long-term supplementation does not impact
cognitive function there is some data to suggest that older individuals may benefit in cognitive measures
(McMorris et al., 2007). Alzheimer's disease has known disruptions in bioenergetics in which creatine
may help, which invites future clinical trials (Salomons & Wyss, 2007). The link to brain physiology also
associates creatine to mood disorders; however, literature is sparse at present (Klinedinst & Regenold,
2014; Levental et al., 2015).
Some individuals experience adverse side effects when using creatine, which are mostly related to
gastrointestinal issues (Chilibeck et al., 2015). Although no serious health issues have been produced
(Terjung et al., 2000). It is recommended to avoid its use with renal patients at this time.

Body composition

Creatine is traditionally used by athletes looking to increase muscle mass and/or sports performance.
Very little evidence has examined its role in fat loss. Acute administration increases body mass due to
increased water retention. Fatigue resistance and body composition changes can occur during
supplementation and may be beneficial during a fat-loss scheme (Candow et al., 2014; Rawson et al.,
2011). However, this has yet to be tested and may be met with poor adherence if an individual's body
mass increases.

Performance

Creatine supplementation increases performance of repeated high-intensity exercise bouts (Momaya et

al., 2015). Literature shows the largest performance increase is in multiple, high-power output activities
with short breaks (Terjung et al., 2000). Creatine does not improve isometric strength nor is it responsible
for specific adaptions to training (Terjung et al., 2000). Creatine may increase the ability for higher
workloads, highlighting the importance of programming to utilise this ergogenic effect. Supplementation
increases muscle mass with ingestion post exercise yielding slightly improved responses (dose is typically
5 g/day but some have shown improvements independent of dose) (Lanhers et al., 2015). Creatine does
not improve aerobic performance per se, although it has been shown to improve cognition when oxygen
is low (Turner et al., 2015). Moreover, it has been shown to play a role in increasing glycogen storage, a
traditionally important predictor of endurance performance, although this is not fully understood (van
Loon, et al., 2004). The magnitude of ergogenic effects is variable between individuals and is probably
due to individual differences in baseline muscular creatine content (Lemon, 2002).
Common Diets

Low carbohydrate diet

Health

A standardised definition of a low carbohydrate diet (LCD) has yet to be agreed; generally any
restriction below recommendations is deemed an LCD. Low carbohydrate diets are low calorie diets and
any restriction of major food groups will lead to an overall decreased energy intake. Decreased energy
yields weight loss and an accompanying positive change in health markers (e.g. low density lipoprotein
cholesterol) but, when examining carbohydrate intake independently the changes in health markers are
less clear; for instance the changes in insulin and blood pressure are similar on isocaloric low-fat diets
(Naude et al., 2014). However, most LCD literature reproduces favourable blood lipids in comparison to
low-fat diets (Bazzano et al., 2014; Tay et al., 2015).
A diet that cannot be sustained or is not flexible is unlikely to impact population health (Katz &
Mellor, 2014). The majority of calorie intake comes from carbohydrates in today's society; therefore it
seems doubtful that extreme LCDs (<30g/day) are sustainable. The recognised benefits of fibre,
wholegrains and vegetables have initiated a shift in many LCDs to include such foods. In this way the
type of carbohydrate is highlighted as an area of importance. During an isocaloric (the same calorie
amount) weight (fat) loss protocol, the low glycaemic index (GI) (complex carbohydrates) group had
similar weight loss but significantly improved vascular function (Buscemi et al., 2013). Furthermore, low
GI foods have evidence for reduced risk of breast cancer, cardiovascular disease and type 2 diabetes
(Barclay et al., 2008).
Decreased carbohydrate intake has been linked to higher mortality in a worldwide review (Noto et al.,
2013). The mechanisms are unclear but may involve increased meat consumption and decreased intake of
nutritious foods (e.g. vegetables). Others have shown conflicting results with evidence of positive and
negative outcomes available. Authors have recently commented on a potential ‘U’ shaped relationship in
relation to intake and mortality illustrating how extreme carbohydrate restriction, and consumption may
be both associated with higher mortality rates (Jovanovski et al., 2015).

Body composition

Low carbohydrate diets have consistently been demonstrated to decrease body mass amongst a variety of
populations (Nordmann et al., 2006). Although the body mass changes can be similar on different diets
(e.g low fat diets) (Hu et al., 2012). Research indicates that a long term (12 month) LCD coupled with a
higher protein intake can yield a significant reduction in body fat (Clifton et al., 2013). However,
compliance rates must be considered, as typically people cannot mainatin a LCD indefinitely. In one
study incorporating dietary counselling alongside a lower LCD (30 per cent of total energy) resulted in
the LCD group losing more body mass than a control group (Bazzano et al., 2014). Others have shown
the importance of behavioural support in this field (Saslow et al., 2014). Carbohydrate reduction per se
has not been accepted as the principle reason for body mass reductions; at this time it seems that
behavioural support and habitual decreases in calories explain the results.

Performance

Carbohydrates have a long established role in sporting performance and recovery. However, low
carbohydrate diets have become increasingly popular in sports nutrition but the implementation of LCDs
in athletic populations has taken place without rigorous studies to underpin practice. Endurance training
in a fasted state can induce positive adaptations (Hawley & Burke, 2010). Additionally, during periods of
low carbohydrate intake there is a shift in fuel utilisation improving an individual's ability to utilise fat
for energy (Spriet, 2014b). Conversely, if a LCD is maintained it can induce metabolic inflexibility
(unable to use carbohydrates when needed). Although there may be some use for LCDs in longer, low
intensity, events (e.g. ultra marathons), in team sports or intermittent events it is counterintuitive to limit
an individual's capacity to repeat high intensity work periods. Currently it seems that chronic LCD will
negatively impact performance in most sports and a rational periodisation of nutrition is recommended.

Paleo diet

Health

The Paleo diet aims to recreate the diet of our ancestors. With no standardised definition, much of the
debate is in relation to the ratios of macronutrients and foods prescribed. This inconsistency makes it
difficult to draw conclusions about the diet. Moreover, it would be impossible to match the diet of our
ancestors as much of the flora and fauna of that time are now extinct (Katz & Mellor, 2014). Modern
societal context is also a world away from hunting and gathering. Some recommendations may not be
practical and are hypothesised to show poor compliance. Therefore, more socially acceptable practices
may need adaptation from rigorous definitions (Bligh et al., 2015). While extreme proponents argue over
minor details of the diet, the pattern of eating does have potential health benefits. Advice to eliminate
processed foods and base most food intake on plants, lean meat and nut sources is known to promote
health. Research has shown that a short-term Paleo approach improves cardiovascular risk factors and
long-term research has demonstrated sustained outcomes (Boers et al., 2014; Masharani et al., 2015;
Mellberg et al., 2014). The main mechanism may be related to insulin sensitivity and glycaemic control
(Tarantino et al., 2015). Glucose metabolism has known links to obesity, type 2 diabetes and a host of
metabolic dysfunctions. As mentioned in LCDs, attendance to support sessions predicts beneficial
outcomes and sustained improvements (Allen et al., 2015). These regimes are typically prescribed in
overweight/diseased patients. However, this approach should be applied with caution, as research has
shown that a healthy group on an unrestricted Paleo diet, experienced negative changes in blood lipids,
thus highlighting the variance in free living, versus research Paleo dieting (Smith et al., 2014).
An interesting topic is how the Paleo diet impacts gut bacteria which may impact obesity, gastric
disorders and age-related disease. It is suspected that the original Paleo diet was rich in nutrients
prompting the expression of genes to protect against disease (Pall & Levine, 2015). Therefore, if an
ancestral pattern is followed it may positively impact these important gene expressions. A clearer insight
may become available in time.

Body composition

Short-term Paleo diets promote a decrease in body mass compared to other interventions that allow
unlimited food intake (Young, 2014). This may be due to increased satiety, as a single Paleo meal has
been demonstrated to induce greater satiating responses and alterations in gut hormones compared to a
standard recommendation meal (Bligh et al., 2015). Furthermore, other factors such as a higher protein
intake and restricted food choice may also promote positive changes in body composition.
A person's habitual diet can alter gut microbes and subsequently eating behaviour and mood (Alcock
et al., 2014). The typical Western diet (high fat/high sugar) is known to impact negatively on
gastrointestinal inflammation and microbe communities. It is postulated that a Paleo diet may increase
microbe activity and, potentially, prevent obesity (David et al., 2014). As with all dietary interventions,
despite short term success the practicalities and skills required to sustain a Paleo diet must be considered
(Jönsson et al., 2013).

Performance

There is a high prevalence of athletes following the Paleo diet without much evidence for the effect it has
on performance (Rosenbloom, 2014). The Paleo diet is not primarily a LCD, yet it is postulated that this
regime may not adequately fuel training and the elimination of grains and dairy may increase
inadequacies of calcium and B vitamins (Rosenbloom, 2014). Importantly for intermittent sports, a
reduction of carbohydrate-rich food will have a detrimental effect on performance and, potentially,
health. Although the label of Paleo is commercially attractive there is discrepancy between athletes self-
reporting diet and actual adherence. There are many misconceptions, and athletes may adopt this diet
based on hype without a clear understanding of how it might affect their performance.

Intermittent fasting

Calorie restriction by any means improves risk factor profile for chronic disease and longevity in animals
(Rizza et al., 2014). Intermittent fasting (IF) involves periods of normal feeding interspersed with fasting
(e.g. the 5:2 diet). Intermittent fasting may augment disease outcomes, yet robust human clinical trials
are lacking (Horne et al., 2015). Study design, sparse human research and varied fasting methodologies
make conclusions impossible. Moreover, the lack of constraint on the normal feeding days may cancel
out the potential health advantages. Others have commented that the frequency of IF, food composition
and timing are all important for health benefits (Rizza et al., 2014). While no consensus can be made at
this time there is evidence that IF can promote changes in fuel utilisation and increase the cells' resilience
to aging (Mattson et al., 2014). Again, the actual transfer to human clinical endpoints is lacking.
Researchers have discussed that it may not be the calorie restriction per se but an accompanying high
intake of quality foods in the specific populations that have been observed to date (Johnstone, 2015).
Interestingly, IF can improve lifespan in mice without calorie restriction which may highlight a
particular metabolic adaption that needs further investigation (Hatori et al., 2012). Conversely in human
trials, the changes in risk factors for disease are similar to traditional calorie restriction (Barnosky et al.,
2014).

Body Composition

Intermittent fasting has been postulated to increase adherence to calorie restriction as individuals only
limit food on fasting days. Clinical trials show similar body mass reductions in the short term compared
to traditional methods (Barnosky et al., 2014). In obese populations perceived fullness remains low
throughout trials which could have negative long-term implications (Johnstone, 2015). The proportion of
people dropping out in studies is inconclusive when comparing continuous calorie restriction and IF.
Two trials that categorised reasons for not adhering showed that ‘inability to stick to the diet’ was higher
in the continuous group (Harvie et al., 2013 cited in Seimon et al., 2015). The data on appetite lacks
comparison to other diets; however there does not seem to be an overfeeding response on the non-fasting
days to counteract the calorie deficit on the fasting days, despite the feelings of hunger (Johnstone, 2015).
However, these studies were generally controlled within laboratory settings limiting understanding of
subsequent feeding in free living (real life) conditions.

Performance

Most literature examining IF and performance comes from religious practices. Performance shows
modest negative changes in Ramadan studies and others have shown conflicting changes in cognitive
function (Benau et al., 2014; Chaouachi et al., 2012). Apart from acute periods of low energy availability
training and potential changes to body composition there is no logical reason for an athlete to undertake
IF. Although some evidence exists that body composition improves, little research adjusts for total
energy reductions (Johnson & Morton, 2013). Some researchers hypothesise that IF may attenuate losses
in lean mass during calorie restriction; however, approximately half the literature observed showed a
decrease in fat-free mass and little change was seen in lean subjects (Siemon et al., 2015). Little is known
about the impact IF has on measures of athletic performance.

Summary
With the plethora of easily accessible dietary information now available, in print and on-line
publications, clients are faced with conflicting and often confusing recommendations. Therefore,
trainers must be aware of what dietary principles will best impact health and performance in order
to offer basic advice within their scope of practice. Ultimately, whole foods based mostly on plant
sources, elimination of processed ‘Western’ foods and, most importantly, adherence to this dietary
pattern will provide optimal health and performance. There is considerable debate on minor aspects
of single nutrients. These debates often lack an appreciation that changing any aspect of diet in the
absence of a long-term behaviour changes yields poor outcomes (see Chapter 4). The search for a
‘magic bullet’ diet without considering individual preference and situation is misguided.
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Chapter 6
Fitness assessment

Simon Penn and Nicola Brown

Fitness assessments can be used to screen clients to ensure that they are fit to exercise, and assess
strengths and weaknesses to identify training needs for the prescription of exercise. They can also be
used for goal setting, providing motivation during training and evaluating the effectiveness of training
programmes over time.
Selecting a Fitness Test

Numerous tests have been developed to measure each component of fitness and these can be classified as
direct or indirect. Direct measures usually take place in a laboratory setting requiring specialist
equipment and often involve complex protocols. However, they measure the component of fitness
directly, without using any assumptions or estimates. For example, a maximal oxygen uptake (
max) laboratory test measures the volume of oxygen consumed during exercise, providing a direct
measure of max. In a gym setting, a number of indirect measures may be used to predict
max: heart rate, distance or time. Prediction equations are then applied to estimate max from these
indirect measures. Indirect measures are based on the linear relationship between heart rate, oxygen
consumption and intensity of exercise. There are many equations available in the literature and these
equations are specific for predetermined population groups (e.g. age, gender, activity status). To enhance
test validity, the equation selected must be derived from a population with similar characteristics to the
client being tested. Laboratory based testing is generally considered to be the most valid and reliable way
of measuring components of fitness.

Validity

Validity refers to the extent to which a measurement is representative of a particular characteristic i.e.
does it measure what it claims to? The validity of a test may only be valid for a specific purpose, or for a
specific group. For example, the YMCA cycle ergometer test would not be a valid assessment of a
runner's aerobic fitness because cycling does not replicate the specific energy demands and movement
patterns of running.

Measuring validity

A method of quantifying the validity of a fitness test is to calculate the relationship between two items
or test scores using correlation coefficients; typically an indirect measure (e.g. Bruce protocol treadmill
test) against a direct criterion measure (laboratory max test). The obtained ‘r’ value is known as
the validity coefficient. Correlation coefficients range in absolute value from 0 to 1.00. The closer the
value is to 1.00, the stronger the validity of the test and the lower the error in estimating the criterion.
Fitness tests with validity coefficients ≥ 0.80 are generally considered valid (Heyward & Gibson, 2014).
For example, the Bruce protocol treadmill test has been shown to have good validity (r = 0.865–0.92)
when predicting max (Akalan et al., 2008).
A standard error of estimate (SEE) can also be used to indicate the validity of an indirect test. For
example, when testing healthy males aged 20–54 years, the YMCA submaximal cycle ergometer test (an
indirect measure of max) has been shown to have a SEE of +/− 9.8 ml/kg/min when compared to
the Astrand-Saltin cycle ergometer test with oxygen uptake measured via expired gas collection (a direct
criterion measure of max) (Beekley et al., 2004). If the direct criterion max measure was
recorded as 51 ml/kg/min, the indirect method may give a result between 41.2 and 60.8 ml/min/kg. A low
SEE is associated with increased validity (Heyward & Gibson, 2014).

Reliability

Reliability is how consistent a test is over consecutive tests (test-retest reliability), or how reliable a
single rater (intra-rater reliability), or multiple raters (inter-rater reliability) are in performing the same
tests. Reliability can be heavily influenced by systematic and random error. A systematic error is an error
that is added to a true score in a systematic way. An example of systematic error might be using
weighing scales that are incorrectly calibrated and consistently weigh someone as 2 kilograms heavier
than they actually are. If these scales continue to be used without being changed, the error is systematic
and is always produced. The error will affect every measurement of body mass in the same way. Random
error is error that adds to the true score that occurs randomly. For example, incorrectly counting the
number of repetitions a client completes during a press-up test.

Measuring reliability

Reliability of fitness tests can be assessed by determining the coefficient of variation (CV), which is
calculated as the standard deviation of the data, divided by the mean and multiplied by 100 to give a
percentage score. The CV allows comparison of the reliability of different measurement tools, as it is unit
independent. For example, when assessing body composition, the coefficient of variation for measuring
height and mass may be very small (e.g. 1–2 per cent), but may be greater for other measures such as
circumferences (e.g. 5–10 per cent) and skinfolds (e.g. up to 20 per cent). A small CV indicates a more
reliable measurement; however, it is more important to consider how much error is acceptable with
regard to practical relevance (Hopkins, 2000).
Figure 6.1 Test validity and reliability.

Similar to the validity coefficient, a reliability coefficient can be used to estimate the reliability of a
test by correlating two sets of test scores. The test scores may be obtained by single or multiple raters.
Fitness tests with reliability coefficients ≥0.90 are generally considered to have a high degree of
reliability, with a minimum threshold for acceptance set at ≥0.70 (Baumgartner et al., 2015).
It is important to note that a test can be reliable, but invalid. That is, a test can give reliable, consistent
results, but not measure what it is supposed to. However, a test cannot be valid if it is not reliable (see
Figure 6.1).
Administering a Fitness Test

The fitness test selected must be appropriate for the age and physical limitations of the client and should
only be considered for use if the necessary equipment is available and the testing environment is
appropriate (Burnstein et al., 2011). All testing equipment should be standardised and regularly
calibrated. Test protocols should be standardised to ensure that when tests are repeated, the same
procedures are followed:

Pre-test guidelines: A client's pre-test physical state may influence their performance. Factors such
as their dietary intake and when they last exercised may impact the results they achieve on a
particular test. Clear, standardised guidelines should be provided for clients to adhere to prior to
testing.
The environment: Tests should be conducted in similar conditions so that fair comparisons can be
drawn between results obtained. Changes in climate, type of clothing worn, or training surface may
all influence a client's performance.
Test familiarisation: Clients can improve in a test just from having experienced the testing process.
Generally, two to three familiarisation trials are required to ensure a true measurement has been
obtained.
Test protocol: Measurement techniques, equipment, and procedures followed should all be
standardised. For example repeating tests at the same time of day, providing the same length of rest
breaks between tests and giving standardised motivation statements.

When deciding which health/fitness test to use, it is important to consider the validity and reliability
of the test to ensure accuracy of results (see Case study 6.1). To improve validity and reliability,
standardised test protocols should be followed. When using indirect tests, the formulae and normative
data used should represent the population being assessed.

Case study 6.1

Maria, a 35-year-old female, is currently inactive and wants to begin a training programme to
improve her strength. One-repetition maximum (1RM) tests are considered to be the most valid
method of measuring muscular strength. However, testing maximal strength using a 1RM test is not
suitable for untrained clients due to an increased risk of injury. Although fewer test repetitions are
associated with increased validity and reliability to the 1RM, a 20-repetitions maximum (20RM)
equation (1.5471 (20RM) + 3.834, R2 = 0.955, SEE = 7.36 kg) can provide an acceptable estimate
(Reynolds et al., 2006). However, the highlighted 20RM equation is only valid for individuals (aged
18–69 yrs) performing a bench press. Therefore, additional equations are required for other
exercises.
References

Akalan, C., Robergs, R.A., & Kravitz, L. (2008). Prediction of VO2max from an individualized submaximal
cycle ergometer protocol. Journal of Exercise Physiology Online, 11(2), 1–17.
Baumgartner, T.A., Jackson, A.S., Mahar, M.T., & Rowe, D.A. (eds) (2015). Measurement for Evaluation in
Kinesiology, Ninth Edition. Burlington, MA: Jones and Bartlett Learning.
Beekley, M.D., Brechue, W.F., Dehoyos, D.V., Garzarella, L., Werber-Zion, G., & Pollock, M.L. (2004).
Cross-validation of the YMCA submaximal cycle ergometer test to predict VO2max. Research
Quarterly for Exercise and Sport, 75(3), 337–342.
Burnstein, B.D., Steele, R.J. & Shrier, I. (2011). Reliability of fitness tests using methods and time periods
common in occupational management. Journal of Athletic Training, 46(5), 505–513.
Heyward, V.H. & Gibson, A.L. (2014). Advanced Fitness Assessment and Exercise Prescription, Seventh
Edition. Champaign, IL: Human Kinetics.
Hopkins, W. (2000). Measures of reliability in sports medicine and science. Sports Medicine, 30, 1–15.
Reynolds, J.M., Gordon, T.J., & Robergs, R.A. (2006). Prediction of one repetition maximum strength from
multiple repetition maximum testing and anthropometry. Journal of Strength & Conditioning
Research, 20(3), 584–592.
Chapter 7
Fundamental principles of training

Paul Hough

The field of sport and exercise science has improved health and fitness practitioners' understanding of
exercise physiology and psychology leading to the creation and optimisation of numerous training
methods. For example, the extensive research into high intensity interval training (HIIT) has informed
practitioners of how the strategy can be incorporated within a training programme to optimise health,
fitness and performance outcomes (see Chapter 12). With copious training programmes available on the
Internet, in magazines and books, etc., it is tempting for trainers to experiment with ‘the latest’ training
programme. However, this approach will invariably produce inconsistent and often unsatisfactory
results. A more effective approach involves the trainer evaluating training programmes using scientific
evidence alongside their professional experience. Moreover, exploring the research behind many training
techniques will enable the trainer to apply the findings of scientific studies to design and implement
effective, individualised training programmes. In order for this to occur trainers must develop an
understanding of the fundamental principles of training.
Adaptation

The purpose of any training programme is to induce adaptations. An adaptation is a change in a

structural, physiological or behavioural characteristic that enables a living organism to survive. In
humans, biological adaptations occur within the body to meet the demands that are placed upon it. In
the context of exercise, a biological system (e.g. cardiorespiratory) must be subjected to a stress (physical
activity or exercise) to stimulate adaptation. Therefore, training can be regarded as physical exercises
designed to stimulate biological adaptations in order to improve health, fitness and performance
outcomes.
Adaptations can be classified as acute (short-term) or chronic (long-term). For example, when a
muscle is required to produce force to overcome a load (resistance training) there is an immediate
increase in muscle activation and blood flow. Following the exercise, the muscles might feel tired and
‘heavy’ due to fatigue. These are acute adaptations that diminish shortly after the exercise. However,
repeated exposure to the exercise provides a consistent stimulus to the muscle, causing it to adapt (e.g.
become stronger). This process of adaptation is known as the General Adaptation Syndrome (GAS)
(Seyle, 1956). In the context of exercise, the GAS states that exercise stresses biological systems, which
initiates an ‘alarm phase’ where there is a temporary decrease in performance/physical capacity. The
alarm phase initiates a compensation effect causing the system's physical capacity to return to, or exceed
the initial capacity (see Figure 7.1). This enhancement of the system's capacity is termed super-
compensation and is the desired outcome of all exercise programmes.

Figure 7.1 Schematic of the super-compensation response following a suitable training stimulus and recovery period (adapted from
Yakovlev, 1967).

Improvements in fitness occur when there is an exposure to a repeated training stress. Provided the
stimulus creates a sufficient overload (see below), each training session initiates acute physiological
adaptations that induce a cycle of stress and super-compensation during the recovery periods. Repeating
this cycle of stress and recovery (i.e. consistent training) induces chronic adaptations.
Progressive Overload

In order to achieve super-compensation a progressive overload must be applied. This is achieved through
applying a systematic increase in the physical demands placed upon the body. Progressive overload is
commonly achieved by systematically manipulating acute training programme variables:

volume (quantity of work)

intensity (rate of work)
frequency (number of training sessions within a set period)
exercise selection
order of exercises
rest periods.
Adaptation Threshold

The goal of all training programmes is to consistently meet the client's adaptation threshold by
implementing an appropriate training stimulus and recovery period to induce super-compensation.
However, this threshold is dependent on a number of individual factors (e.g. training status, recovery
capacity, psychological stress levels). Therefore, the adaptation threshold is different between individual
clients. As a client's fitness improves, the exercises must provide an adequate overload to meet the
client's new adaptation threshold (Ratamess et al., 2009). If this threshold is not met, fitness will not
significantly improve. Conversely, if the threshold is dramatically exceeded this will induce a high
degree of fatigue which will significantly decrease physical capacity and increase the duration of the
required recovery period (see Figure 7.2). If the adaptation threshold is consistently exceeded without
adequate recovery, the client's fitness will actually decrease due to an accumulation of fatigue (see Case
study 7.1).
Recovery

The super-compensation effect occurs when the exercise stress is removed, highlighting that fitness
improves during recovery following exercise. Many clients often overlook this important post-exercise
recovery period, but it is fundamental to the adaptation process. Without adequate recovery, fitness can
stagnate or even decline due to an accumulation of fatigue (see Chapter 16). This can have negative
physical outcomes (e.g. muscle soreness, joint pain) as well as negative psychological outcomes, such as
mood disturbances (Piacentini et al., 2015). Therefore, improving fitness can be perceived as a ‘balancing
act’, whereby optimal adaptation takes place when the training programme incorporates an appropriate
exercises stimulus (meeting the adaptation threshold) and affords a suitable amount of recovery time (see
Figure 7.2).

Figure 7.2 The adaptation threshold.

Case study 7.1 ‘Go hard or go home’

Terry has rekindled his passion for resistance training (RT) following a three-year break. He has
started to train with his friend who adopts the mantra ‘go hard or go home’ for every session. This
involves using advanced RT methods and training to failure on every exercise (see Chapter 13).
After three sessions Terry has started to experience severe muscle soreness and joint pain, and he is
unable to train again for three days. Terry is significantly exceeding his adaptation threshold, which
is not enabling him to recover adequately between sessions. Terry needs to reduce his training
volume/intensity and avoid advanced methods until his body has adapted to an introductory period
of RT.
Individualisation

A fundamental aspect of any training programme is that it is tailored to suit the individual client. The
programme must be designed based on the client's health/fitness status, training background, and
health/fitness goals (see Chapter 8). All clients will have different needs, indicating that there is no place
for a ‘one-size-fits-all’ training programme. For example, if two clients (A and B) were performing a
similar RT programme and the intensity was increased by 10 per cent, client A may barely notice the
overload whereas client B may feel more fatigued and require a longer recovery period. Programme
variable guidelines must be refined based on the individual client's response to the training and the
trainer's professional judgement. This is why successful training programme design can be seen as an art
as well as a science.

Figure 7.3 The health-performance training continuum example.

The health-performance continuum (see figure 7.3) is a framework that can be used to prescribe
exercise based on the individual client's training status and objectives. Clients will vary in their starting
position on this continuum and the training programme should be designed accordingly. For example, in
the context of cardiorespiratory fitness, a sedentary client would be at the health end of the continuum
and advanced training methods, such as HIIT, may not be required. Conversely, a keen amateur runner
would be towards the performance end of the continuum, meaning their exercise goals are performance
related (e.g. faster race times) and require a greater volume and intensity of exercise.
Accommodation

If the training stress remains at the same magnitude (i.e. there is no overload) the body is not forced to
adapt and will accommodate to the training stress. This will result in no further improvements in
physical fitness, which is also known as a ‘training plateau’. In order to prevent accommodation, the
training programme must incorporate progressive overload and variation.
Variation

Variation is the systematic process of varying one or more programme variables over time to ensure the
training stimulus remains challenging and accommodation is avoided. Variation can be applied through
implementing a long-term training programme design process known as periodisation (see Chapter 9).

Case study 7.2 The law of diminishing returns

Colette is a gym enthusiast who has been training regularly for two years. She focuses on running
whereby she runs 5 km three times per week. Her strategy has been to improve her best 5 km time
by 5–10 seconds every week (i.e. increasing average speed). However, her best time is no longer
improving. Colette is focusing on one programme variable (intensity). Although adaptation requires
a progressive overload, it is important that a variety of programme variables are modified over time
(variation), rather than focusing on one. If one variable is increased while others remain constant,
the client will reach a point where the training yields progressively smaller improvements in fitness
– this is the law of diminishing returns. Therefore, Colette should systematically change other
programme variables, such as volume (distance).
Specificity

The principle of specificity dictates that training adaptations are specific to the exercise stimulus applied.
Components of fitness can be improved using general programmes, but these programmes will not
achieve specific outcomes. For example, the load used during a RT programme has a specific effect on
the physiological adaptations and performance outcomes achieved. Training with moderate-heavy loads
induces greater improvements in maximal strength compared to using light loads. However, using light
loads and high repetitions induces aerobic adaptations, which improves muscular endurance (Campos et
al., 2002).
The physiological adaptations achieved following a period of training are influenced by the acute
programme variables (see page 60) as well as specific factors related to each individual exercise, such as
the speed at which the exercise is performed and the range of movement that is used (Verkhoshansky,
1977). For example, a client who usually performs squats to a knee flexion angle of 90 ° will improve
strength within this range of motion. However, the client will find the exercise more challenging if they
attempt to squat to a greater depth (80 ° knee flexion) as this is outside the ROM where the strength has
been developed.

Case study 7.3 Fitness cross-over effect

John plays football three times per week (two training, one match). He plays in midfield and scored
the highest result when his team performed the Multistage Fitness Test, which measures
cardiorespiratory fitness. John recently entered a 20-minute cycling fitness challenge at his gym;
however, he was beaten by three of his team mates. This demonstrates that fitness is specific to the
type of exercise performed. Although John has a superior level of cardiorespiratory fitness when
running, this does not directly translate to another mode of exercise (cycling) due to the different
nature of the exercise. Thus, the principle of specificity must be considered when selecting training
exercises and fitness assessments (see Chapter 6).
Trainability

Trainability refers to the magnitude of adaptations that have been achieved through exercise training
and the theoretical capacity a client has for improvement. In general, the longer a client has been
training the less trainability they have. This is because physiological adaptations occur rapidly at the
onset of a training programme, but the rate of improvement declines as physiological systems become
more adapted to the training stress. For example, untrained individuals have been demonstrated to
experience a twofold greater increase in relative isometric strength compared to trained individuals,
following a 21 week RT programme (Ahtiainen et al., 2003). As clients become more trained they reach a
level of fitness closer to their ceiling of adaptation (see Figure 7.4). This ceiling represents a theoretical
point where no further adaptation takes place (i.e. a genetic limit). In reality this point is rarely reached,
as even world-class athletes experience small improvements in fitness during their careers. Nevertheless,
as a client accrues more training experience they become closer to their ceiling of adaptation and a
greater overload is required to augment fitness. However, if the balance of training and recovery is
incorrect the client may experience no improvement, or even a decline, in fitness and/or injury. This
balance between overload and recovery becomes exceptionally intricate amongst highly trained clients,
meaning training programme design becomes more challenging for the trainer. demonstrates why
trained clients require a very different approach to training programme design than novice clients.

Figure 7.4 Trainability.

Detraining

When exercise training is ceased for extended periods the diminished physiological demand on the body
causes a decline in the physiological adaptations achieved through previous training – this is also known
as ‘reversibility’. The magnitude of detraining is dependent on the training status of the client, specific
fitness component, and the length of time training has been ceased or reduced for. For example, a study
on trained endurance athletes reported a 7 per cent reduction in maximal oxygen uptake, a measure of
cardiorespiratory fitness, after 12 days without training (Coyle et al., 1984). Training status also has a
large effect on the magnitude of detraining, whereby the fitness of clients with a long training history
declines at a slower rate compared to novice clients (Mujika & Padilla, 2000). Decreasing the magnitude
of detraining during periods of reduced training can be achieved by maintaining training intensity where
possible. Clients who are unable to perform their typical exercise routine (e.g. injury, lack of equipment)
can use a technique called cross-training. This involves performing an alternative mode of training that
stimulates the same physiological system, for example a runner training on a cycle or rowing ergometer.

Summary
There are numerous training methods and techniques that trainers can apply to achieve various
health, fitness, and performance outcomes. However, in order for a programme to be successful and
enable clients to achieve the maximum benefits from their training, the fundamental principles of
training have to be considered. Moreover, having a clear understanding of these principles enables
the trainer to create, implement and evaluate a range of training programmes based on the needs of
the client.
References

Ahtiainen, J.P., Pakarinen, A., Alen, M., Kraemer, W.J., & Häkkinen, K. (2003). Muscle hypertrophy,
hormonal adaptations and strength development during strength training in strength-trained and
untrained men. European Journal of Applied Physiology, 89(6), 555–563.
Campos, G.E., Luecke, T.J., Wendeln, H.K., Toma, K., Hagerman, F.C., Murray, T.F., … Staron, R.S. (2002).
Muscular adaptations in response to three different resistance-training regimens: specificity of
repetition maximum training zones. European Journal of Applied Physiology, 88, 50–60.
Coyle, E.F., Martin, W.H., Sinacore, D.R., Joyner, M.J., Hagberg, J.M., & Holloszy, J.O. (1984). Time course
of loss of adaptations after stopping prolonged intense endurance training. Journal of Applied
Physiology: Respiratory, Environmental Exercise Physiology, 57(6), 1857–1864.
Issurin, V. (2008). Principles and Basics of Advanced Athletic Training. Michigan, IL: Ultimate Athlete
Concepts.
Mujika, I., & Padilla, S. (2000). Detraining: loss of training-induced physiological and performance
adaptations. Part II: Long term insufficient training stimulus. Sports Medicine, 30(3), 145–154.
Piacentini, M.F., Witard, O.C., Tonoli, C., Jackman, S.R., Turner, J.E., Kies, A.K., … Meeusen, R. (2015).
Intensive training affects mood with no effect on brain-derived neurotrophic factor. International
Journal of Sports Physiology & Physical Performance [Epub ahead of print].
Ratamess, N.A., Alvar, B. A., Evetoch, T. K., Housh, T. J., Kibler, W. B., Kraemer, W. J., Triplett, N. T.
(2009). American College of Sports Medicine: Progression models in resistance training for healthy
adults: Position stand. Medicine & Science in Sports & Exercise, 41, 687–708.
Selye, H. (1956). The Stress of Life. New York: McGraw-Hill.
Verkhoshansky, Y.V. (1977). Fundamentals of Special Strength-Training in Sport. Moscow: Fuzkultura I
Spovt.
Chapter 8
Training session design

Paul Hough

A systematic approach should be adopted when designing a training session to ensure that the session is
appropriate for the client's current level of fitness, exercise experience and health/fitness goals. Following
the initial client consultation, a selection of important information will have been gathered by the
trainer, which should be used to formulate appropriate training sessions (see Figure 8.1).

Figure 8.1 Training session design process.

Goals

Specific and relevant goals should be set with the client at the beginning of any exercise programme (see
Chapter 4). The goals that have been agreed by the client and trainer form the foundation of the short
and long-term training programme design and dictate the training methods that will be implemented.
For example, if the client's primary goal involves improving cardiorespiratory fitness then the principle
of specificity (see Chapter 7) dictates that the training programme must incorporate cyclical exercises
which stress the cardiorespiratory system. Occasionally, a client's goals or motivation for engaging in an
exercise programme may be ambiguous or not align with a specific training modality. In these instances
the trainer must be able to interpret the client's goals and make appropriate recommendations (see case
study 8.1 and 8.2).

Case study 8.1 ‘Toning up’

Aaron is a 36-year-old office worker who has not engaged in regular exercise for three years. He
states that his main goal is to ‘tone up’ his arms and waist. The term ‘tone’ is widely used within
the fitness industry, often inaccurately, by clients and trainers. Muscle tone, also termed tonus, is
the normal state of tension developed within the muscle, which is maintained continuously even
when a muscle is at rest. Although there are certain pathologies that can decrease muscle tone, a
lack of muscle tone generally indicates a deconditioned muscle/group of muscles. In
overweight/obese clients, an excessive layer of subcutaneous fat tissue will also surround the
muscles. Consequently, these muscle groups will appear and feel soft. Therefore, in most cases,
when a client cites a goal to ‘tone up’ or ‘improve firmness’ this can be interpreted as a decrease in
subcutaneous fat and an increase in the density of the muscle (hypertrophy). Once the goal has been
correctly interpreted an effective training programme can be designed.

Case study 8.2 ‘Putting on size’

Tim is a 22-year-old student who has a body mass index of 20 and runs on a regular basis. However,
he has limited resistance training experience. His main goal is to ‘put size on his arms and legs’.
Very few clients will seek to increase body fat, which would increase body size and mass. Therefore,
the common goal of ‘putting on size’ or ‘getting bigger’ can be interpreted as increasing muscle
mass (hypertrophy). Once clarification has been sought that hypertrophy is Tim's primary goal, the
trainer can design an appropriate programme and select relevant body composition and strength
assessments to monitor his progress.
Time

One of the most frequently cited barriers to participating in regular physical activity is ‘lack of time’
(Sallis et al., 1992; Trost et al., 2002). Therefore, the first step to take when designing a training session is
to consider the client's availability to train, as this will dictate the prescription of exercise. When
ascertaining the training time available, it is essential that the client provides a realistic session duration
that they are able to commit to. The time they can afford should account for logistics such as travel to
the training location and changing into exercise clothing. A suitable session can then be designed within
the time frame provided by the client. If a client is unable to commit to regular time periods, the trainer
must provide solutions to overcome this. For example, increasing levels of daily activity through an
active lifestyle approach (see chapter 1).
Resources

Each training session should be designed with consideration of the resources available to the client for
that particular session. Evidently, a training session that has been designed within a commercial gym
may not be achievable at home or in environments not designed for exercise (e.g. hotel rooms).
Therefore, the trainer must establish where the client will be training and design each session
accordingly.
Session Structure

Depending on the client's goals, time demands and level of fitness, a training session may incorporate a
number of forms of training within a single session, such as cardiorespiratory, resistance and flexibility
training. Alternatively, the session may just focus on one component. It is important to note that all
sessions should begin with some form of warm-up in order to prepare the client physiologically and
psychologically for the training session (see Chapter 10). The strength/conditioning phase of the training
session, where the main objectives of the training session are focused on, comes after the warm-up.
During the strength/conditioning phase the acute training programme variables (see Chapter 7) must be
considered to ensure the training session stresses the desired physiological systems and induces the
required adaptations. Therefore, it is important that the goal of the training session is clear, as this
ultimately dictates the prescription of the acute programme variables.
Concurrent Training

Training sessions often incorporate a number of training methods which focus on different components
of fitness (e.g. cardiorespiratory fitness and strength). This type of mixed training approach is known as
concurrent training (CT) and is a common structure for beginners or general health orientated
programmes. Whilst the CT approach is effective in improving a number of components of fitness in
untrained clients (Kazior et al., 2016), it can potentially compromise improvements in strength or
endurance in trained clients (Hickson, 1980; Kraemer et al., 1995; Rhea et al., 2008; Wilson et al., 2012).
This possible decrement/stagnation in a fitness component as a result of CT is known as the ‘interference
effect’. A number of theories have been presented to explain the interference effect such as the molecular
hypothesis, which suggests that CT may simultaneously activate competing intracellular pathways
which weaken the specific strength or endurance training adaptations (Coffey & Hawley, 2007; Fyfe et
al., 2014).
When working with trained clients, in order to reduce or avoid the interference effect, it is necessary
to prioritise the primary fitness goal. This can be achieved through careful long-term planning (see
Chapter 9) and also by focusing on the most important fitness components immediately after the warm-
up, so that residual fatigue does not impact the intensity of the key exercises. Another strategy is to
separate the different types of training into individual sessions, for example cardiorespiratory training in
the morning and resistance training in the evening, ensuring at least six hours between training sessions
(Murach & Bagley, 2016; Sporer & Wenger, 2003). However, this approach may not be practical for most
clients.
Exercise Selection

Cardiorespiratory training exercise selection

In order to stress the cardiorespiratory system, continuous and rhythmic exercises that involve major
muscle groups should be selected (American College of Sports Medicine [ACSM], 2011). For example,
walking, running and cycling all match this description, are straightforward to perform, and can be
modified depending on the fitness level of the client. Although it is common to programme traditional
cardiorespiratory exercises such as running and cycling to improve cardiorespiratory fitness (CRF),
research has also demonstrated that performing a series of resistance training (RT) exercises to repetition
failure can induce a number of physiological adaptations that lead to an improvement in CRF with
simultaneous improvements in strength and power (Steele et al., 2012). This form of RT to failure is often
performed during circuit training sessions. Indeed, Myers et al. (2015) demonstrated that a circuit-based,
whole-body aerobic RT programme produced a greater CRF response and similar muscular strength
gains, with less time commitment, compared to a combined cardiorespiratory and RT exercise
programme. This finding makes circuit training attractive for clients wishing to improve a number of
fitness components in a short period of time. However, the training status of the client must be taken into
consideration, as circuit training may not provide an effective training stimulus (overload) for clients
with a high level of CRF (Steele et al., 2012).

Resistance training (RT) exercise selection

A variety of exercises should be selected within and between RT sessions in order to create a balanced
approach, whereby all muscle groups are trained within a training week. This prevents an overemphasis
on particular muscle groups or movements, which could result in overuse injuries and/or muscle
imbalances (see Case study 8.3). A number of exercise sequencing methods can be adopted to ensure
there is a sufficient balance of exercises between training sessions. Two common approaches are the
muscle group method and the push-pull method.

Case study 8.3 Unbalanced programme

Steve has been performing regular RT for three years, adopting a muscle group training split
consisting of three sessions per week (see Figure 8.2). He has recently started to experience some
shoulder pain and his physiotherapist has indicated he has tight pectorals and weak
rhomboids/lower trapezius. This has created a postural imbalance known as ‘upper crossed
syndrome’ (see Chapter 14). Although adopting a poor daily posture can cause this condition,
 Steve's RT programme has likely contributed to this issue. This is because Steve performs five
exercises that target the pectorals and anterior deltoids, but only one exercise (seated row) that
targets the back musculature and posterior deltoids. Therefore, in combination with physiotherapy,
Steve should introduce more pulling exercises to target the neglected back musculature and
temporally reduce the number of exercises that target the pectorals and anterior deltoids.

Muscle group method

This exercise sequencing method involves dedicating each training session to specific muscle groups,
ensuring all the major muscle groups are targeted within a training week. When applying this method
the target muscle groups will dictate the exercises that are selected (e.g. deltoids: shoulder press).

Figure 8.2 Example of unbalanced resistance training programme using the muscle group method.
Note: bold text denotes anterior chain (pectorals and anterior deltoid) dominant exercises.

Push-pull method

In this method, exercises are selected based on their actions: pushing (moving away from the body) or
pulling (moving towards the body). Selecting a balance of exercise actions will usually ensure that
agonist and antagonist muscles are trained equally. For example, horizontal pushing exercises will
involve anterior muscles (e.g. pectorals, anterior deltoids) and horizontal pulling exercises will involve
the posterior muscles (e.g. trapezius, rhomboids). This method works effectively for the upper body, but
can become complicated with the lower body, as the same muscle groups are often worked during
pushing and pulling exercises. For example, the dead-lift (pulling) and squat (pushing) both work
posterior muscles (e.g. hamstrings, gluteals, etc.). To solve this issue, lower body exercises can be
classified as knee or hip dominant (see Table 8.1). Hip dominant exercises involve flexion/extension
around the hip joint (e.g. dead-lift), with less movement around the knee joint than knee dominant
exercises (e.g. squats).

Table 8.1 Resistance training exercise selection methods

Muscle group method Push-Pull method

Session Example Exercises Session Example Exercises

Bench press Bench press

Chest and back Horizontal push and pull
Bent over row Bent over row

DB curls DB shoulder press

Biceps and triceps Vertical push and pull
Triceps pushdown Pull-up

DB shoulder press BB lunges

Shoulders and abdominals Knee dominant
Plank Leg press

Romanian deadlift Deadlift

Hamstrings and quadriceps Hip dominant
Front squat Good mornings

BB hip thrust Plank

Glutes and calves Trunk
DB calf raise Bird-Dog
Note: DB = dumbbell BB = barbell

The selection of specific RT exercises will be influenced by the acute programme variables (volume,
intensity and rest periods). Additionally, specificity is an important training principle that should be
considered to ensure the RT programme achieves the required physiological adaptations (see Chapter 2).
In general, RT exercises can be classified as multiple-joint (MJ) or single-joint (SJ). MJ exercises, also
termed compound exercises, involve movement at more than one joint during the exercise and involve a
number of muscle groups working concurrently. For instance, a back squat is classified as a MJ exercise
as movement occurs at the hip, knee and ankle and involves the recruitment of a large number of muscle
groups. Conversely, SJ exercises, also termed isolation exercises, only involve visible movement at one
major joint and fewer muscles are recruited. For example, when performed correctly, a biceps curl
involves visible movement only at the elbow joint. During MJ exercises a number of muscle groups are
recruited to initiate the required movement; this requires a greater level of neuromuscular coordination.
i.e. the ability of the nervous system to efficiently recruit muscles in order to perform a specific task.
Therefore, when considering the principle of specificity, utilising MJ exercises may result in a greater
transfer to full body actions such as those performed in everyday activities and sports (Folland &
Williams, 2007).
Multiple-joint exercises are conventionally performed first in a RT session followed by SJ exercises
(see Figure 8.3). This structure ensures the client is fresh for the more technically demanding exercises
and also allows the total work done by the large and small muscle groups to be equalised during a
training session (Fleck & Kraemer, 2014). Performing MJ exercises before SJ exercises also results in a
greater long-term improvement in strength in the MJ exercise, as performing MJ exercises at the end of a
RT session results in significantly fewer repetitions compared to when the same exercises are performed
early in the session (Simão et al., 2007; Spineti et al., 2010). Therefore, based on the goals of the RT
session, it is important to consider which exercises should be performed at the start of the session by
adopting the ‘priority method’ where appropriate.

The priority method

This method of exercise ordering involves performing the exercise of primary focus at the beginning of
the RT session in order to perform the exercise with maximal volume and/or intensity and also to ensure
the exercise is executed with good technique (Gentil et al., 2007).

Muscle activation exercises

As with any generic training guidelines, there are often exceptions. For example, low intensity SJ
exercises can be included within a warm-up to address muscle imbalances/ weaknesses and target
specific muscle groups, which may not be optimally recruited during the MJ exercises (Distefano et al.,
2009). However, these exercises should be performed at a low intensity to prevent excessive fatigue.

Figure 8.3 Resistance training exercise order sequencing.

Case study 8.4 ‘Priority training’

Martin is a healthy male (age 24) who has been resistance training for one year. He has become
stronger and increased muscle mass, but his strength gains have plateaued over the past two
months. His main training goal is to increase strength in the back squat. Performing the barbell
 back squat first, following the warm-up, should enable the completion of more repetitions at a
higher intensity when compared to performing the exercise at the end of a full body RT session
(Spreuwenberg et al., 2006). Therefore, as Martin's primary goal is to improve lower body strength,
particularly in the back squat, it would be advisable to adopt the priority method and perform the
squat early within the session.

The pre-exhaust method

In contrast to performing MJ exercises followed by SJ exercises, a technique known as ‘pre-exhaustion’

(PE) is sometimes implemented. The PE method is typically employed by bodybuilders, whereby SJ
exercises are performed prior to a MJ exercise. For example, a PE sequence for training the pectorals
would be performing dumbbell flys, an isolation exercise, prior to performing a bench press. The
objective of this method is to fatigue the smaller, synergistic muscles so that during the MJ exercise the
larger muscles are required to generate greater forces to compensate for the fatigued smaller muscles
(Fisher et al., 2014). However, this hypothesis has yet to be conclusively proved. For example, a study
demonstrated the activation of the rectus femoris and vastus lateralis muscles during a leg press exercise
was significantly decreased and fewer repetitions were performed when knee extensions (the PE
exercise) were performed beforehand (Augustsson et al., 2003). Therefore, the PE method may
compromise exercise volume and muscle activation in the MJ exercise. With this in mind, it is prudent to
avoid adopting the method with clients with a limited background in RT. The PE method may have other
beneficial applications such as promoting muscle hypertrophy via increased muscle damage and
metabolic stress (see Chapter 13) both of which are important in the process of hypertrophy (Schoenfeld,
2010).
Training Volume and Intensity

Volume

The term ‘volume’ is used to describe the total quantity of work performed or amount of energy
expended. Volume is expressed in different units depending on the training modality. For example,
volume in RT typically refers to the number of repetitions performed during an exercise or training
session, whereas in CRT the volume is typically expressed in distance or training time.

Density

Training density is the combination of training volume and duration (i.e. how much work is performed
in a given time frame). There are two methods that can be used to increase training density: performing
the same amount of work in less time, or performing more work in the same amount of time. Increasing
training density is a useful method to provide progressive overload and prevent an ineffective use of
training time.

Intensity

Exercise intensity is defined in several ways; the most valid and reliable measures of intensity involve
physical and physiological metrics that can be precisely measured (e.g. power, velocity, heart rate and
oxygen consumption). However, intensity is often defined as the psychological effort (rating of perceived
exertion) when performing an exercise. Clearly, this later definition is subjective and makes comparisons
within and between clients problematic. Therefore, it is recommended that physical and physiological
measures are used alongside rating of perceived exertion methods (see Chapter 11). Similar to training
volume, the terminology used to quantify intensity is dependent upon the exercise modality.
Calculating Intensity and Volume in Cardiorespiratory Training
Programmes

Cardiorespiratory training intensity

There are a number of methods for measuring and prescribing intensity during CRT exercises. One of the
most common methods involves the measurement of heart rate (HR). During cardiorespiratory exercise
there is a linear relationship between exercise intensity and HR. Subsequently, the HR response provides
a valid indication of exercise intensity (Karvonen et al., 1957). Heart rate is affected by a number of
factors such as CRF and gender. Age also has a significant effect on HR because there is a gradual decline
in the maximum HR (HRmax) throughout adulthood (Christou & Seals, 2008). Consequently, when using
HR as a marker of exercise intensity, it must be expressed relative to the client's maximum capacity. For
example, prescribing training zones as a percentage of HRmax (see Chapter 11).
Another common CRT intensity metric is the metabolic equivalent (MET). A MET is the amount of
oxygen consumed while sitting at rest. One MET is equal to an oxygen uptake of 3.5 mL O2/kg/min or an
energy expenditure of 1 kcal/kg/hour. Metabolic equivalent units (METS) are often used to quantify
physical activity (PA), for example an activity of 6 METS involves expending six times more energy
compared to seated rest (see Chapter 11).

Cardiorespiratory training volume

Previous epidemiologic and clinical studies have used measures of energy expenditure such as MET
minutes/week and kilocalories/minutes per week to quantify PA and exercise volume (Jetté et al., 1990;
Melanson & Freedson, 1996). These metrics can be useful in approximating the gross energy expenditure
of a client using published activity tables (Ainsworth et al., 2000). However, this approach is not widely
used within a practical setting as it can be arduous for the client and trainer and is associated with a
number of limitations, such as inaccurate reporting of PA.
In performance-related CRT programmes, a common unit to express training volume is distance.
However, using distance alone does not take into account the intensity and therefore the physiological
demand of the training. For example, running at a relatively easy pace for a long distance imposes a
different physiological stress compared to running a shorter distance at a fast pace. Therefore, both
volume and intensity should be considered when comparing or evaluating CRT programmes. Combining
volume and intensity enables the calculation of the training load or training impulse (TRIMP), which can
then be used during the planning and monitoring of a CRT programme (Banister et al., 1975). Rating of
perceived exhaustion (RPE) and HR measures are commonly used to calculate the training load.
The TRIMP rating of perceived exertion method

The simplest method to quantify the TRIMP involves the client rating the difficulty of a session using a
RPE scale (see Figure 8.4). The perceived exertion score is selected 30 minutes following the training
session and is then multiplied by the duration of the training session to produce a TRIMP score (Foster et
al., 2001). For example, if a client performed a 20-minute, high-intensity circuit training session and
selected a session perceived exertion rating of 7 (see Figure 8.4), the TRIMP would be calculated as: 20 × 7
= 140 TRIMP units.

Figure 8.4 A ten-point perceived exertion scale used to classify the intensity of a training session.

Heart rate and exercise duration TRIMP

The TRIMP can also be calculated using training time and average HR recorded during the session,
which can be recorded with a basic HR monitor. A simple equation (training time [minutes] × average
HR [B/min]) is applied to calculate the TRIMP. For example, 30 minutes cycling at an average HR of 160
B/min = 30 × 160 = 4,800 TRIMP units. However, this method does not account for the increased
physiological load of training at higher intensities (Bannister et al., 1991). For example, cycling for 45
minutes at an average HR of 130 B/min produces a TRIMP score of 5,850. However, cycling for 30
minutes at an average HR of 175 B/min produces a lower TRIMP score (5,250). The shorter session is
performed at a higher intensity, which involves a greater physiological stress, but this is not reflected in
the TRIMP scores. Consequently, a TRIMP method which applies a weighting factor is recommended for
clients who train at a variety of intensities.
Five-zone TRIMP method

The five-zone method, devised by Stagno and colleagues (2007), uses HR as a marker of exercise
intensity. However, a weighting factor (see Table 8.2) is applied to each HR zone, with higher HR zones
corresponding to a greater weighting score. The formula (time in HR zone × weighting factor) produces
an exponential weighting of HR, instead of a linear scale. For example, exercising for 20 minutes at an
average intensity of 90% HRmax is recognised as being more demanding than exercising for 30 minutes
at 75% HRmax (72.2 v. 51.3 TRIMP units). Therefore, this system recognises that as HR increases, the
imposed physiological stress increases exponentially.

Training impulse limitations

The key advantage of calculating a training load or TRIMP using HR or RPE is the simplicity in
recording the client's physiological and/or psychological responses to the training intensity, which can
then be used to adjust the current training programme and plan future training sessions. However, it is
important to recognise the limitations associated with the methods, such as the influence of
psychological factors (e.g. motivation, stress) on HR and RPE. For example, using an average HR to
calculate TRIMP has limitations with individuals competing in intermittent sports such as football or
rugby, as short maximal sprints place a high physiological load on the individual, but do not necessarily
produce large increases in HR (Foster et al., 2001). For example, a rugby player might complete 30 short
sprints within a game, placing a high physiological stress on the nervous and musculoskeletal system,
but if their average HR during the game was recorded as 71 per cent of HRmax this would only
correspond to a weighting of 1.25, suggesting (misleadingly) the average exercise intensity was moderate.

Table 8.2 Training zones based upon percentage of maximum HR

Zone % Maximum heart rate Weighting factor

5 93–100 5.16

4 86–92 3.61

3 79–85 2.54

2 72–78 1.71

1 65–71 1.25
Adapted from Stagno, Thatcher & van Someren (2007).
Case study 8.5 Marathon training
Aaron is training for a marathon and during continuous runs he records HR and time in order to
calculate the TRIMP. The running intensity is calculated using the average HR zones presented in
Table 8.2, with zone five being the highest intensity zone and one being the easiest. The intensity of
resistance training sessions are quantified using the session RPE method, whereby Aaron provides
an evaluation of the intensity of the session using a RPE scale which is multiplied by the duration of
the training session.
Aaron’s HRmax = 180 B/min.

On Monday, Aaron runs for 45 minutes at an average HR of 155 B/min (86 per cent HRmax). This
corresponds to zone 4 (weighting 3.61).
45 minutes × 3.61 = 162.5 TRIMP units

On Wednesday Aaron does a 90 minute run at an average HR of 130 B/min (72 per cent HRmax).
This corresponds to zone 2 (weighting 1.71).
90 minutes × 1.71 = 153.9 TRIMP units

Although Aaron performed double the volume of training on Wednesday, the shorter run produced
a higher TRIMP score as it was performed at a higher intensity and was, therefore, more
physiologically demanding.
Calculating Intensity and Volume in Resistance Training Programmes

Resistance training intensity

In RT the intensity for a given set of an exercise can be prescribed based on the load lifted relative to the
client's strength – this is the relative load (Tan, 1999). There is an inverse relationship between the
intensity and the volume of RT exercises: as the load/resistance of an exercise increases, the number of
repetitions that can be performed decreases (Richens & Cleather, 2014). Therefore, the training load that
is selected will determine the number of repetitions that can be performed within a set.
In RT the intensity of an exercise is typically expressed as a percentage of the one repetition maximum
(% 1RM), which is the maximal load that can be lifted for one repetition. This method allows intensity to
be calculated relative to the client's strength (relative load). For example, if a client had a back squat 1RM
of 100 kg and was recommended to lift 65 per cent of this 1RM, this would equate to 65 kg. Using a %
1RM as a measure of intensity has been questioned, as this metric may not accurately indicate the
amount of effort the client is applying during the RT exercise (Fisher et al., 2013). For example, the %
1RM approach implies that two clients who perform four repetitions at 80 per cent of 1RM have worked
at an identical relative effort. However, this might not be the case, as there is a large variation in the
number of repetitions that can be completed for the same % 1RM (Shimano et al., 2006). To overcome this
issue, intensity can be calculated using the repetition maximum (RM) method. The RM corresponds to
the number of complete repetitions that can be successfully accomplished with a given load before
repetition failure occurs. For example, if a client could not perform more than six repetitions with a load
of 80 kg in a bench press, 80 kg would represent their 6RM in this exercise.
Regardless of the classification of intensity (% 1RM, RM or % RM), the intensity used in a RT exercise
has a profound effect on the physiological adaptations that occur following a repeated exposure to the
exercise (Stone & Coulter, 1994). Therefore, the intensity of RT exercises should be selected depending on
the training goal (see Chapter 13).

Resistance training volume

Intensity and volume are key variables for planning and evaluating RT programmes. A useful method to
quantify RT is the volume-load method, which combines the volume (total repetitions) and intensity
(load). The total number of repetitions is multiplied by the total number of sets, which is then multiplied
by the load lifted. For example, if the client performs 3 sets of 10 repetitions of a chest press using 50 kg,
the calculation of the volume-load would be:
3 × 10 repetitions = 300 repetitions.
300 repetitions × 50 kg = 15,000 kg

Table 8.3 Quantifying resistance training volume: repetition volume and volume load
Using the volume-load method is practically more useful than just reporting the total number of
repetitions (repetitions × sets) in quantifying RT sessions. In the example presented in Table 8.3, both
clients have performed the same volume of training in terms of the repetition volume (144). However,
when factoring the load of the exercise, using the volume-load method, it is apparent that client A has
performed a greater volume-load. Furthermore, by dividing the volume-load by the repetition volume,
the average intensity of an individual exercise or training session can also be calculated (average
intensity = volume-load (kg) / total repetitions).
Rest Periods

Cardiorespiratory training rest periods

In order to impose the desired physiological stress, rest periods must be carefully selected when non-
continuous training sessions (e.g. high-intensity intervals) are performed. Specific recommendations are
addressed in Chapters 11 and 12.

Resistance training rest periods

As with the prescription of volume and intensity, the time spent recovering between sets of an exercise
should be recommended based on the goals of the training session, the exercise being performed, and the
client's training status. Specific recommendations are addressed in Chapter 13.
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Chapter 9
Long-term training programme design
(periodisation)

Paul Hough

In order to achieve consistent improvements in health and skill-related components of fitness, a long-
term fitness programme design strategy should be adopted which incorporates planned, systematic
variations in intensity, volume, frequency and exercise selection (Matveyev, 1972; Plisk & Stone, 2003;
Siff, 2003). Manipulating training variables as part of a long-term training strategy to enhance
performance is known as periodisation. The main goals of periodisation are to optimise training
adaptations and prevent accommodation (see Chapter 7). The contemporary concept of periodisation can
be traced back to the 1960s based on the experience of elite sport coaches and findings of scientists in the
former Soviet Union (Matveyev, 1964). Periodisation was formulated for elite athletes to achieve specific
adaptations and performance outcomes at exact time points; for example, a 1500-metre runner achieving
peak fitness for a major championship. Periodisation also allowed coaches to manage athletes' fatigue
and reduce the likelihood of the athletes experiencing an injury, illness or a decline in performance.
Periodisation involves organising the training plan into specific interconnected periods of time known
as ‘cycles’. Each of these cycles have specific goals and prepare the individual for the subsequent cycle.
The largest cycle is the macrocycle, which typically lasts one year, but can be shorter or longer (up to 4
years for an Olympic macrocycle). The macrocycle is sub-divided into mesocycles that last 4–6 weeks
(Plisk & Stone, 2003). Finally, the microcycle consists of a number of days, usually 1 week. All
periodisation strategies involve manipulating volume and intensity over a period of time (see Figure 9.1).
However, other programme variables can also be changed. For example, different exercises can be
performed as the programme progresses, or training density could be modified (see Chapter 13).
Who is Periodisation For?

Although periodisation was originally created for athletes, the strategy is practically useful for clients
engaging in a variety of exercise programmes. General exercise interventions for recreationally active or
sedentary individuals often focus on achieving a minimum volume of exercise followed by a progressive
increase in intensity/volume over time, with no specific periodisation strategy (Straight et al., 2012).
Non-periodised programmes can improve health and fitness outcomes in the short-term, but long-term
adherence to non-periodised programmes can be modest (Middleton & Perri, 2013). Therefore,
periodisation may enhance the effectiveness of training programmes for a variety of clients and should
not be reserved solely for athletes (Souza et al., 2014; Strohacker et al., 2013).

Non-periodised programmes

There are cases where periodisation may not be adopted, such as at the onset of a sedentary client's
programme. In these cases, the first 4–6 weeks might focus on increasing levels of physical activity,
learning exercise techniques and establishing an exercise routine. All of these factors are important in
building levels of confidence and adherence (see Chapter 4). Following this introductory period, a
periodised plan is recommended. However, it is essential to select an appropriate periodisation strategy
based on the client's goals and circumstances (see table 9.1). For instance, clients who have irregular
working patterns (e.g. frequent travelling) may benefit from flexible undulating periodisation (discussed
later), or a random variation (RV) approach that allows them to train as and when they are able to.
The RV approach is in contrast to periodisation, as the method does not conform to a systematic plan;
instead the programme variables can be randomly changed at any time, or even on a daily basis. Over
the past decade, generic cross-training training methods which employ the RV approach have become
increasingly popular. These training systems often implement a RV approach whereby a wide variety of
different training techniques are performed in order to improve a number of fitness components
concurrently. The RV approach means the client does not necessarily specialise in one specific fitness
component and there is no rigid structure to the training programme. The RV method can be suited to
clients who find a structured approach monotonous or incompatible with their lifestyle. However, a daily
RV approach may not be appropriate for novice clients, as the large variation in exercises does not allow
the mastery of exercise techniques and may potentially cause excessive delayed onset of muscle soreness
(DOMS) (see Chapter 16). Furthermore, RV is not recommended for clients who are training for a specific
performance goal as, by nature, the approach is too generic and lacks specificity.

When should periodisation be used?

Improvements in various fitness components can be made without the application of periodisation.
However, non-periodised programmes can lead to accommodation (see Chapter 7) and become less
effective after 6–8 weeks (Fleck, 1999; Willoughby, 1993). Indeed, periodised training programmes have
been demonstrated to achieve more consistent improvements in fitness compared to non-periodised
programmes (Monteiro et al., 2009; Stone et al., 2000). Therefore, the application of a periodised plan is
recommended, particularly when the client has specific performance goals (e.g. increasing strength). A
number of periodisation models have been developed; each has its own advantages and limitations,
which must be considered when designing a long-term programme. Including elements of each model to
create a hybrid periodisation plan can reduce these limitations. In all cases, periodised programmes
should be designed based on the individual client's level of fitness and health/fitness goals.

Table 9.1 Periodisation v. random variation: advantages and disadvantages

Periodisation

Advantages Disadvantages

Scientifically proven method to achieve continual

Requires knowledge and experience to design
improvements in fitness and performance outcomes
an appropriate long-term plan.
(Fleck, 1999).

Most models require a high level of

Training adaptations and improvements in fitness can be
commitment and adherence (i.e. few missed
achieved on a predictable basis.
sessions).

Systematic structure allows fitness to be objectively Some clients may find a lack of daily
assessed over time. variation monotonous.

An appropriate increase in volume or intensity should Some sessions may require specific
reduce the risk of injury. equipment and/or facilities.

Fatigue can be carefully managed.

The long-term plan ensures accountability, which may

increase adherence.

Random variation

Advantages Disadvantages

Incorporates a high level of variability which can be Inappropriate strategy for clients with
physiologically and psychologically stimulating. specific fitness or performance goals.
 The high level of variability makes the
Highly flexible. mastery of exercise techniques more
challenging.

An inappropriate increase in volume or

Sessions can be performed in a variety of environments.
intensity could increase the risk of injury.

Difficult to manage fatigue due to the high

level of variability.

Limited accountability may reduce

adherence.
Traditional Periodisation

Traditional periodisation (TP) is structured so that the training load progresses from high-volume, low-
intensity to low-volume, high-intensity over time until a peak in intensity is reached at an exact time
point. Initially, the model was formulated to achieve one fitness peak for athletes focusing on a single
competition (see Figure 9.1). However, as competitions became more frequent, the model was refined to
include three peaks (Fleck, 1999; Issurin, 2010).

Figure 9.1 Traditional single-peak periodisation model.

The TP model involves the progression from general to specific training exercises/actions i.e. the
incorporation of technique/sport-specific actions increases as the programme progresses and competition
nears (Fleck, 1999; Issurin, 2010). The TP approach is designed to elicit a cumulative training effect
whereby improvements in physiological adaptations and technical skills are built over a progressive,
long-term training programme.

Box 9.1 Traditional and linear periodisation

 Traditional periodisation is often referred to as ‘linear periodisation’ because intensity gradually
increases over the course of a mesocycle. However, this is a misnomer as all periodisation methods
involve variations in volume and intensity within and between training cycles. Therefore, all forms
of periodisation are technically non-linear in nature (Stone & Wathen, 2001).

The TP macrocycle is typically divided into three major phases: the preparatory phase, the competitive
phase and the transition/active recovery phase (Issurin, 2010). A slight variation of the TP model was
later adapted to include a ‘first transition phase’ to designate a small period of time to recover before the
competition phase (see Figure 9.1). The first step when implementing the TP model is to establish phases
of the macrocycle and determine the number of mesocycles that will be dedicated to each phase. The
number of mesocycles devoted to each phase within the TP model is dependent on the sport/event being
trained for (see Case study 9.1).

The preparatory phase

The focus of the preparatory phase is to improve the individual's work capacity (fitness base) and
maximise physiological adaptations in preparation for future mesocycles (Bompa & Buzzichelli, 2015).
The mesocycles within this phase typically involve a wide range of exercises and high volumes of
training at low intensities to develop a foundation/base level of fitness (Issurin, 2010; Matveyev, 1977).
This structure applies to both cardiorespiratory and resistance training. Training intensity is gradually
increased whilst volume decreases as the preparatory phase progresses towards the competitive phase. To
accomplish this, the preparatory phase is usually sub-divided into a general and specific phase. The
general phase consists of high training volumes in all the fitness components required for the
sport/event. In the specific phase the volume decreases and intensity increases as exercises become more
specific to the sport/event. Table 9.2 demonstrates an interpretation of the TP model for a 5 km runner.

First transition phase

The first transition phase focuses on increasing intensity dependent fitness components such as maximal
strength and power (if applicable). Following a period of training it can take a short period of time for
physiological adaptations to manifest and performance outcomes to be achieved; this is known as ‘the
delayed training effect’ (Verkoshansky, 1988). Therefore, training intensity and/or volume are decreased
during the final week of this phase to allow recovery time where improvements in fitness are attained
(see Chapter 7). This planned reduction in training volume and intensity in order to achieve peak
physical condition is known as ‘tapering’. This phase can also overlap into the competitive phase.

The competitive phase

The competitive phase is focused on specific exercises to achieve specific adaptations, which are highly
related to the event/competition. During this phase the volume of training is markedly reduced and
intensity from the first transition phase is maintained or increased depending on the duration of the
phase. The objective of this phase is to prepare the individual for the specific demands of the
event/competition (Bompa & Haff, 2009; Fleck, 1999). This phase requires careful balancing of sufficient
training to maintain the adaptations achieved from the previous mesocycles coupled with appropriate
periods of recovery. If the previous cycles have been programmed correctly, the individual will achieve
peak physical condition for a small period of time (1–2 weeks) during this phase (Issurin, 2008a).
Consequently, TP is not appropriate for clients who are preparing for an event/competition with a long
competitive phase (e.g. team sports).

Second transition phase

The second transition phase or ‘off-season’ is dedicated to recovery from the competition phase and
typically involves a marked reduction in training load and periods of complete rest. This phase allows
the individual to recover physically and mentally and allows time for the rehabilitation of any injuries
that may have arisen during the previous phases. This phase must be sufficient in length to allow
recovery, but not too long so that significant detraining occurs (see Chapter 7). Therefore, this phase will
usually last 2–4 weeks (Bompa & Haff, 2009).

Advantages of traditional periodisation

The TP approach is simple to plan and implement and allows the client to establish a ‘base’ level of
fitness before progressing to higher intensity training. This makes the TP strategy appropriate for clients
that have low levels of fitness, provided the volume is programmed carefully. The TP model is also
highly appropriate for clients wishing to achieve peak condition at a specific time point (see Case study
9.1).

Limitations of traditional periodisation

The principle of detraining dictates that a fitness component declines when the training stimulus is
removed for a period of time (see Chapter 7). Therefore, the adaptations from higher intensity training
cycles may be markedly reduced during preparatory (low-intensity, high-volume) cycles. The TP strategy
is not appropriate for clients with specific, short-term, performance goals, as the initial high-volume
preparatory phase can detract from the main training objective (Siff, 2003). Additionally, training a
number of fitness components concurrently may increase the interference effect and blunt the adaptive
response to a particular form of training (see Chapter 8). Finally, any exercise programme must be
motivating and practical in order to promote adherence (see Chapter 4). Some clients may find the
uniform workloads within TP mesocycles monotonous, which may reduce compliance. Block
periodisation (BP) evolved from TP to address these issues (Bondarchuk, 1988; Verkhohansky, 1998).
Table 9.2 Example of a traditional periodisation model for a 5-km runner

Case study 9.1 Cycling programme

Nicola is an inexperienced cyclist (6 weeks experience) who has been preparing for a 100-mile
charity bike ride. However, she would like advice regarding the organisation of her training
schedule. Her goal is to complete the ride within 8 hours, which will mean maintaining an average
speed of 12.5 m/h. Applying a variation of the TP format ensures that Nicola will be at peak fitness
for the event. The TP format typically involves high volumes at the onset of a programme.
However, as an inexperienced cyclist, a gradual increase in volume has been programmed to
prevent overuse injuries. A 6-week mesocycle is dedicated to the general preparation phase. The
objective of this mesocycle is to improve cardiorespiratory fitness and condition the musculoskeletal
system. This is achieved through a gradual increase in training volume (mileage). The following 5
weeks are dedicated to the specific preparation phase. Volume is decreased initially to allow
training intensity to be increased to the target average speed during long training sessions.
Following this, there is a gradual increase in volume, peaking at week 11. A first transition
microcycle begins at week 12 where volume is reduced. At week 13 there is a marked reduction in
training volume to allow physiological recovery (tapering) before the ride.
Figure 9.2 Traditional periodisation: cyclist case study.
Block Periodisation

In contrast to training a number of fitness components concurrently (TP method), BP involves training a
minimal number of fitness components within concentrated periods (2–4 weeks) known as ‘blocks’.
Therefore, BP is highly appropriate for clients who have a specific fitness component they wish to
improve (e.g. strength). The training blocks are performed in a logical order so that the current block
prepares the individual for the next block (Siff, 2003). Training blocks that include more than one
ability/fitness component only incorporate fitness components that are physiologically compatible. For
example, speed training and maximal strength training are compatible as they both target adaptations
within the nervous system. This sequencing is done to avoid conflicting physiological responses, also
known as the ‘interference effect’ (see Chapter 8). A number of BP models have been proposed, but BP is
commonly structured around three types of focused mesocycle blocks: accumulation, transmutation
(transformation) and realisation (Issurin, 2010).

Accumulation

These blocks focus on developing a general fitness base in components such as cardiorespiratory fitness
(Issurin, 2010). This is achieved through using high training volumes.

Transmutation

The objective of this phase is to convert the adaptations from the accumulation phase into specific
objectives. Therefore, the blocks within this phase focus on developing specific components of fitness
performed at higher intensities. Techniques that are highly related to the fitness/performance goals are
introduced. For example, specific interval training methods might be incorporated for a client who plays
football in order to enhance cardiorespiratory fitness (Hoff, 2005).

Realisation

This phase is designed as a pre-competitive training phase where the main focus is specific exercises
required for the event/competition. However, these blocks are not required if the client is not preparing
for a specific event/competition.
The three blocks specified above form a training cycle that lasts 8–10 weeks and concludes with an
event/competition. Therefore, unlike TP, the BP system allows 5–6 training peaks to be achieved within a
year. The frequent variation also means that training monotony is likely to be reduced, which may
improve adherence.
 Case study 9.2 Block periodisation
Ian has been resistance training for a year using a simple linear progression approach (i.e. weekly
increases in intensity and/or volume). His main goals are to increase strength and muscle
hypertrophy. However, he is no longer experiencing improvements in either of these, as he is unable
to lift heavier loads or perform more reps on a number of exercises. The essence of periodisation is
to avoid this accommodation (training plateau), which is common amongst many clients adopting a
similar linear approach. Therefore, the BP system has been implemented to target specific
adaptations during each block (see Figure 9.3). For example, block 1 incorporates moderate loads
and high volumes to stimulate hypertrophy, whereas block 2 incorporates higher loads to induce
adaptations within the nervous system to enhance strength. Block 3 incorporates high training
volumes, performing exercises to repetition failure, as this technique has been demonstrated to
enhance hypertrophy (see Chapter 13). As with all training programmes, periods of recovery should
be implemented to avoid excessive fatigue, which may cause injury or prevent adaptation. Thus, a
small period of recovery, also known as a ‘de-load week’, has been included at week 7.

Figure 9.3 Block periodisation: strength and hypertrophy case study.

 In BP, the training blocks are carefully organised so that the training programme exploits the
cumulative and residual training effect. The residual training effect is the retention of physiological
adaptations for a period of time after the cessation of a particular form of training (Counsilman &
Counsilman, 1991; Verkhohansky, 1998). The rate at which a component of fitness declines following a
reduction or cessation of training is known as ‘training residuals’ and is dependent on the component of
fitness (Issurin, 2010). In general, aerobic adaptations have a longer residual effect (i.e. they last longer)
than anaerobic adaptations (see Table 9.3). It is important to be aware that the decline in any fitness
component is more rapid than the time taken to achieve the level of fitness. However, the BP method
exploits the residual training effect so that fitness components are not significantly diminished between
training cycles. Indeed, the interaction of the training residuals allows one training block to compliment
the next. For example, performing a strength block has been demonstrated to have a positive effect on
power (Seitz et al., 2014).
Implementation of the BP system requires careful planning and a sound understanding of exercise
physiology to ensure each cycle is sequenced correctly to exploit the residual training effect. For
example, programmes focused on improving components of anaerobic fitness, such as speed and power,
must target these components on a regular basis, as anaerobic adaptations have shorter training residuals
and are more susceptible to reversibility (McMaster et al., 2013).

Advantages of block periodisation

The BP method focuses on a minimal number of abilities within concentrated ‘blocks’ of time. This
makes this form of training appealing to clients that have 1–2 highly specific goals. For example, a client
who wishes to improve their back squat performance would benefit from BP (Bartolomei et al., 2014).
The frequent manipulation of volume and intensity can also prevent the decay of fitness making this
strategy attractive for clients that need to achieve peak levels of fitness 5–6 times per year; for example,
clients involved in sports such as athletics, boxing and bodybuilding.

Table 9.3 Training residuals: the approximate duration before components of fitness decline following the cessation of training

Residual
Component of fitness Physiological adaptations
duration (days)

Cardiorespiratory ↑ Aerobic enzymes, mitochondria, muscle capillaries,

30 ± 5
(aerobic) fitness hemoglobin, glycogen storage, fat metabolism

↑ Neuromuscular interactions and motor control,

Maximum speed 5±3
phosphocreatine storage capacity
Adapted from Issurin, V. (2008). Block Periodization: Breakthrough in Sport Training. Muskegon, MI: Ultimate Athletes Concepts.

Disadvantages of block periodisation

Although BP may allow components of fitness to be maintained over longer periods than TP, the
approach still requires concentrated periods of high-volume (accumulation) or intensity (transmutation)
training to be programmed. This could be problematic for clients involved in long-season sports (e.g.
football, rugby) as fitness must be maintained across the course of a season and the blocks may be
incompatible with the competitive demands of the sport. Additionally, high-intensity (transmutation)
blocks may also be inappropriate for clients with limited levels of fitness.
Undulating Periodisation

Undulating periodisation (UP), also known as ‘non-linear periodisation’, involves the alternation of
training variables on a daily or weekly basis (see Table 9.4). The variation in volume and intensity is
usually programmed between training sessions within the same training week (daily undulating
periodisation) and is in contrast to TP where the training sessions within the same week will have the
same focus according to the training cycle (e.g. strength, hypertrophy, power etc.).

Table 9.4 An example of an undulating periodisation training week

Some studies have indicated that UP is more effective than TP (Prestes et al., 2009; Rhea et al., 2002;
Simão et al., 2012). The reason for this remains unknown, but it has been speculated that UP could
potentially reduce neural fatigue and the potential for overtraining (Stone et al., 1996). Additionally,
increased variation in physiological stress could promote greater adaptations and optimise the balance
between stress and recovery (Peterson et al., 2008; Poliquin, 1988). However, these suggestions have yet
to be conclusively proven. Indeed, other studies have reported UP is less effective than TP (Apel et al.,
2011; Hartmann et al., 2009) or that there is no difference between the two methods (Baker et al., 1994;
Buford et al., 2007; Hoffman et al., 2009; Kok et al., 2009). The disparity within the literature is likely due
to the differences in the design of each periodisation study (discussed later).
Advantages of undulating periodisation

Although the literature comparing TP and UP is equivocal, the frequent variation in training volume and
intensity employed in UP is likely to reduce training monotony (Kraemer & Fleck, 2007; Simão et al.,
2012). Furthermore, UP can also be structured to accommodate the client's physical/psychological
readiness to train on a particular day, which is also likely to promote exercise adherence. This form of UP
is termed ‘flexible undulating periodisation’ (FUP). For example, if the client is feeling fatigued, a high-
intensity session can be substituted for a lower intensity session. Few studies have investigated FUP,
although it has been shown to improve strength compared to non-flexible UP, which suggests the
strategy can be effective (McNamara & Stearne, 2010). Additionally, FUP allows a number of fitness
components to be trained concurrently (McNamara & Stearne, 2013). Therefore, FUP might be
appropriate for clients involved in long-season sports (e.g. football, rugby), as the training sessions can be
programmed to maintain different fitness components, and the flexible nature allows the programme to
be modified based on the readiness of the client to train following competition (Kraemer & Fleck, 2007).

Limitations of undulating periodisation

The regular changes in volume and intensity may not be appropriate for untrained clients, as the
frequent exposure to a novel training stress may increase the delayed onset of muscle soreness between
sessions (see Chapter 16) (Hoffman et al., 2009). This could increase fatigue and potentially interfere with
long-term adaptations (Apel et al., 2011; Rhea et al., 2002). Consequently, the use of UP must be applied
with caution with untrained clients.
Which Periodisation Method is Optimal?

The periodisation literature indicates a number of strategies can be effective and no method has been
conclusively proven to be superior (Harries et al., 2015). By definition, periodisation is a long-term
strategy, which is problematic to research. The disparity within the literature is due to varied study
durations and dissimilar outcome measures that have been focused on (e.g. strength, power, endurance).
Moreover, the large number of variables involved within periodisation studies adds to the complexity of
this area (e.g. participant's training status, adherence to the programme, nutrition). Caution must be
taken when extrapolating the results of studies to health and fitness training programmes, as the
majority of the literature has focused on resistance training performance outcomes (strength and power).
This makes it difficult to generalise the findings of these studies with non-performance outcomes, such
as improvements in health or body composition. Consequently, it is not possible to provide a definitive
answer to the question ‘which periodisation method is optimal?’ This question is context specific,
meaning a periodisation strategy must be selected based on the individual client's training status and
health/fitness goals. Moreover, a key factor in the efficacy of any training programme is adherence
(Sherwood & Jeffery, 2000). Hence, it is essential to implement a periodisation strategy that is both
practical, sustainable and enjoyable for the client.
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Chapter 10
Warm-up/movement preparation

Paul Draper

The warm-up is the first part of the training session, during which the body gradually adjusts to the
demands ahead. The objectives of a warm-up are to prepare the client for exercise, improve performance
and reduce injury risk. Common examples of warm-up activities include cycling, jogging, calisthenics
and stretching (American College of Sports Medicine, 2014; Bishop, 2003; Fradkin et al., 2010; Woods et
al., 2007). The major elements of a warm-up are listed in Figure 10.1, and explained in the remainder of
this chapter.

Figure 10.1 Main elements of a warm-up.

The Benefits of Warm-Up

The evidence

Research provides valuable insight into the effectiveness of warming-up, suitable warm-up activities, and
how a warm-up should be structured. However, reviews of literature relating to the impact of warm-up
on performance and injury risk have highlighted considerable variations in findings between studies, and
changes in the consensus view over time (Bishop, 2003; Fradkin et al., 2010; Herbert & Gabriel, 2002;
Woods et al., 2007). These differences may be due in part to some historical studies having used few
participants, including poor controls, or not undertaking statistical analysis. The authors of these
literature reviews also found wide variation between studies in the warm-up protocols used. Another
consideration is that many studies have used recreational or elite athletes as participants (Magnus et al.,
2006; Thompsen et al., 2007). Therefore, some of their findings may not be applicable to de-conditioned
or sedentary individuals. Research provides important evidence for warm-up prescription. However, the
implications for best practice in health and fitness training for the general population are not clear-cut,
and may change as new evidence emerges.

Injury risk

Although the evidence for a warm-up reducing general injury risk is weak, it may reduce the specific
risk of muscle injuries (Lewis, 2014). Herbert and Gabriel (2002) found a consensus in research that
stretching before exercise did not reduce injury risk. However, five years later a literature review by
Woods et al. (2007) reached a different conclusion, finding that warm-ups including stretching reduced
injury risk, at least for muscle injuries.
Most studies addressing the effect of warming-up on injury risk have focused primarily on the effects
of pre-exercise stretching, as opposed to other warm-up modalities. There may be some injury
prevention benefits of a more general warm-up. For example, in a study that investigated the effects of
temperature on the tensile properties of rabbit skeletal muscle, it was found that at high temperatures
greater forces were required to cause a tear (Noonan et al., 1993). Therefore, an increase in muscle
temperature may contribute to reduced risk of muscle injuries. Another study found that joint-position
sense acuity in soccer players was significantly improved by a comprehensive warm-up, which may help
to reduce injury risk (Salgado et al., 2015). However, when the effects of different warm-up protocols on
dynamic balance were tested, none were found to have any significant effect (Kim et al., 2014). Hence,
there is significant scope for more research in this area.

Delayed onset muscle soreness (DOMS)

An active warm-up may slightly reduce DOMS, and static or dynamic stretching before exercise may
reduce eccentric exercise-induced muscle damage (Chen et al., 2015; Law & Herbert, 2007; Wang et al.,
2015). In a randomised controlled trial a 10-minute uphill treadmill walking warm-up resulted in a small
reduction in DOMS (Law & Herbert, 2007). Another study found the markers for eccentric exercise-
induced hamstring muscle damage were reduced by static and dynamic stretching before exercise,
indicating the potential for a reduction in DOMS (Chen et al., 2015). This was supported by the findings
of another study showing that dynamic contract-relax stretching significantly reduced DOMS symptoms
in the gastrocnemius muscle (Wang et al., 2015). Although dynamic stretching appears to reduce the
severity of DOMS (Herbert & Gabriel, 2002), static stretches appear to be less effective. A systematic
review of literature concluded that DOMS was not reduced by static stretching before or after exercise
(Herbert & Gabriel, 2002).

Performance

Improved performance in training sessions may be an important benefit of warming-up. In a review of

literature, a consensus was found around active warm-up enhancing performance for short (10 seconds),
intermediate (10 seconds to 5 minutes) and long (5 minutes) duration tasks (Bishop, 2003). However,
these benefits only occurred when warm-up intensity and duration was sufficient to significantly elevate
the rate of oxygen consumption ( ), but not so excessive as to cause fatigue. Another systematic
review also found that a suitable warm-up could lead to performance improvements (Fradkin et al.,
2010). For inclusion in the latter review, studies needed to adopt warm-up protocols including elements
in addition to stretching (e.g. jogging, cycling, and/or calisthenics). Of the 32 studies included, 79 per cent
found that warm-ups improved performance across a wide range of activities (e.g. running, cycling,
swimming and jumping). In 3 per cent of studies no change in performance was found, while in 17 per
cent the warm-up was found to be detrimental to performance. In some cases where a warm-up was not
beneficial, Fradkin et al. (2010) hypothesised that warm-up protocols were not sufficiently specific to the
subsequent activity. In other cases, the authors concluded that the warm-up may have been of such high
intensity that participants became fatigued.
The case for warm-ups improving performance has been strengthened by more recent research. For
example, Aguilar et al. (2012) found that quadriceps strength and hamstring length improved after an
active warm-up, and Adamczyk et al. (2012) also observed performance improvements. Andrade et al.
(2015) found improvements in various aspects of performance after different types of warm-up.
The current consensus on the benefits of the warm-up is summarised in Figure 10.2.
Figure 10.2 The benefits of a warm-up: summary.
The Effects of Warming-Up

Increased muscle temperature

Increased muscle temperature is an important aspect of warming-up, but not the only factor. A passive
warm-up uses an external heat source (e.g. heat pads, saunas, hot baths or showers) to warm muscle
tissue. An active warm-up is more common, where the heat is generated by friction between sliding
muscle filaments, and as a by-product of metabolism (Krustrup et al., 2003; Tawada & Sekimoto, 1991).
Many of the effects of warm-up described below have been attributed to this increase in muscle
temperature (Bishop, 2003; Febbraio et al., 1996; Gray et al., 2002; Starkie et al., 1999). However, when
Gray and Nimmo (2001) compared the effects of active and passive warm-ups on cycling performance,
they found that passive heating alone did not deliver all the short-term performance benefits of an active
warm-up. In two reviews of literature, Bishop (2003) also found that a passive warm-up brought
performance benefits for activities lasting up to five minutes, while an active warm-up brought benefits
over all durations of activity. Therefore, an active warm-up appears to deliver benefits in addition to
passive heating. Hence, some of the factors described below may be the result of muscle heating, while
others may be the result of additional processes involved in an active warm-up.

Reduced joint and muscle stiffness

Warming-up has been demonstrated to increase joint range of motion and reduce muscle stiffness
(Aguilar et al. 2012; O'Sullivan et al., 2009; Page, 2012; Woods et al., 2007). A contributing factor may be
reduced stability of actin-myosin bonds at higher temperatures, thus reducing muscle tissue viscosity
(Woods et al., 2007). However, acute increases in muscle flexibility after stretching may not be due to
structural changes in the muscle-tendon unit, but to an increase in stretch tolerance (Konrad & Tilp,
2014).

Increased oxygen delivery to working muscles

When muscles are heated, vasodilation allows increased blood flow, resulting in more rapid transport of
oxygen and nutrients to working muscles, and facilitating transport of by-products of metabolism away
from those muscles. As the warm-up progresses, deeper and more rapid breathing helps to increase
pulmonary gas exchange, and hence the rate of oxygen delivery increases. Furthermore, a warm-up may
induce a greater dissociation of oxygen from haemoglobin at higher blood temperatures, thereby
facilitating release of oxygen into warmer muscles (Bishop 2003; McCutcheon et al., 1999).
Enhanced capacity for aerobic metabolism

Baseline may be increased through warming-up, thereby enabling more work to be completed
aerobically. This may leave greater anaerobic capacity for later activity (Bishop 2003). This hypothesis
was supported by Gray et al. (2002), who found less accumulation of blood and muscle lactate when an
active warm-up was performed before intense exercise, as opposed to passive muscle heating. This
indicated less reliance on anaerobic metabolism after an active warm-up, and that this was not entirely
due to muscle heating. The additional factor may have been increased .

Greater speed and force of muscle contractions

Successive studies have shown an increase in the speed and force of muscle contractions after a warm-up
(Adamczyk et al., 2012; Aguilar et al., 2012; Andrade et al., 2015). This may be due to acceleration of
metabolic processes and reduced muscle internal viscosity (Woods et al., 2007), and the so called ‘treppe
effect’ in which more muscle motor units are recruited each time an exercise is repeated (Burkett et al.,
2005).

Increased muscle contraction speed and reduced reaction time

The increased speed of muscle contractions, and reduced reaction times, observed in many studies after a
warm-up may be attributable to faster neurotransmission at higher temperatures (Bishop, 2003). Faster
muscle conduction appears to be the important factor. For example, after a running warm-up, muscle
conduction time has been demonstrated to be significantly reduced in the abductor pollicis brevis and
gastrocnemius (Pearce et al., 2012).
The effects of warming-up are summarised in Figure 10.3.
Figure 10.3 The effects of warming-up: summary.
Stretching

Types of stretch

The ACSM (2014) provided definitions of six different types of flexibility exercises, which can be
summarised as follows:

Ballistic stretches: ‘Bouncing’ movements using momentum of a moving body segment to drive
the stretch. Often considered contraindicated, but the ACSM suggests these may be considered for
adults involved in activities including ballistic movements (e.g. jumping sports), provided they are
performed properly.
Dynamic or slow movement stretches: Gradual transitions between body positions, repeated
several times, with a gradual increase in range of motion as more repetitions are completed.
Static stretches: Slow stretch of a muscle-tendon unit, before holding that position for a specific
period. May be active or passive:

∘ Active static: Achieving the stretch position by actively contracting the opposing muscle group.
∘ Passive static: Holding the limb in the stretch position. The client may do this (e.g. by holding
the stretched limb), or it may be done by a partner or device (e.g. elasticated band).
∘ Proprioceptive neuromuscular facilitation (PNF): Usually involving isometric contraction of
the target muscle group, followed by static stretching of the same target muscle group.

For safety and effectiveness, stretches should only be conducted after an active warm-up (ACSM, 2014;
Coburn & Malek, 2012). Examples of dynamic, static and PNF stretches for the hamstrings are shown in
Figures 10.4, 10.5 and 10.6.

Injury risk

The European College of Sports Sciences took the position that there was no clear evidence that
stretching during the warm-up reduces injury risk (Magnusson & Renstrom, 2006). Although this may be
true for overall injury risk, the more specific risk of muscle injuries does appear to be reduced. Woods et
al. (2007) published a review of literature, which concluded that muscle injury risk may be reduced
through stretching during the warm-up. This review took account of a wide range of sources, including a
randomised controlled trial (RCT) by Pope et al. (2000) which tracked injuries in 1,538 male army recruits
over a 12-week period. Woods et al. (2007) also considered a literature review by Herbert and Gabriel
(2002), which concluded there was no significant effect of pre-exercise stretching on injury risk.
However, Herbert and Gabriel (2002) were influenced by the work of Pope et al. (2000), who had used a
method for classification of injuries that may have resulted in participants with relatively minor injuries
being excluded (Woods et al., 2007). Woods et al. (2007) therefore gave less weight to Pope et al. (2000)
and took account of additional studies which found pre-exercise stretching reduced the risk of muscle
injuries (Amako et al., 2003; Verrall et al., 2005).

Figure 10.4 Dynamic stretch – Hamstring.

Figure 10.5 Static passive self-stretch – Hamstring.
Figure 10.6 PNF stretch – Hamstring.

More recent systematic reviews have been broadly consistent with the findings of Woods et al. (2007).
These reviews have concluded that the overall rate of overuse injuries was not affected by pre-exercise
stretching, but that the risk of muscle strains may be reduced (McHugh & Cosgrove, 2010; Small &
McNaughton, 2008). Stretching during the warm-up does not appear to reduce overall injury risk
significantly, but it may reduce the more specific risk of muscle and/or tendon injuries. However, further
research is still required to establish the link between stretching before exercise and injury risk.

Box 10.1 Static stretching before exercise

Many fitness professionals, and clients, believe that stretching as part of a warm-up (especially
static stretching) may be detrimental to subsequent performance (Cramer et al., 2005; Kimoto et al.,
2015; Magnusson & Renstrom, 2006). However, current consensus is that in most cases static
stretching before exercise has no effect on performance, provided stretches are not held for
excessive durations, and are preceded by a suitable active warm-up (Kay & Blazevich, 2012; Table
10.1).
Performance

In most cases, short duration (<30 seconds) static stretching before exercise generally has no effect on
performance. A systematic review of the effects of static stretching on maximal muscle performance
concluded that stretches of less than 30 seconds had no detrimental effect (Kay & Blazevich, 2012). As
summarised in Table 10.1, this has been broadly supported by the findings of more recent studies.

Table 10.1 Examples of recent study findings: effect of warm-up stretches on performance
Study Summary findings

Andrade
Specific warm-up required to improve explosive performance. Static stretches (holds of 20
et al.
seconds) not detrimental to explosive performance.
(2015)

Fortney
Neither power or fatigue during cycling affected by active warm-up, or static stretching
et al. (
beforehand.
2015)

McCrary
Power outcomes not affected by short-duration (holds of less than 60 seconds) static stretches
et al.
during warm-up.
(2015)

Mascarin Static stretching (holds of 30 seconds) before maximal throwing exercises detrimental to
et al. performance if performed in isolation. When static stretches preceded by active warm-up, no
(2015) detrimental effect.

Sim et al. Isokinetic muscle torque and muscle power of the quadriceps and hamstrings not affected by
(2015) warm-up including static stretches (holds of 20 seconds).

Pinto et Static stretching detrimental to countermovement jump performance, but only when stretches
al. (2014) held for more than 30 seconds.

Lim et al. No significant decrease in muscle activation after static stretching (holds of 30 seconds) or
(2014) PNF stretching.

Aguilar
No significant effect on muscle flexibility, strength, power, or vertical jump performance, from
et al.
5 minutes cycling warm-up, followed by static stretches (holds of 20 seconds).
(2012)

The conclusion that static stretching need not be detrimental to performance even appears to be true
for maximal muscle strength and explosive power. For example, in a study investigating the effects of
static stretching and PNF stretching on muscle strength, only PNF stretching was found to have a
detrimental effect (Gomes et al., 2011). Very similar findings have been made in relation to quadriceps
peak torque production, possibly due to changes in mechanical muscle properties (e.g. the muscle-tendon
unit becoming more compliant), altered reflex sensitivity (e.g. reduced muscle spindle sensitivity) or a
central nervous system inhibitory mechanism (Siatrus et al., 2008). Similar results have been found for
explosive power. For example, static stretching has been shown to be detrimental to countermovement
jump performance, but only when stretches were held for more than 30 seconds (Pinto et al., 2014).
Although some studies have shown an acute effect of static stretching to be reduced muscle strength, this
may have been due to excessive stretch duration (e.g. Kimoto et al., 2015; Nakamura et al., 2014). In the
last two examples, the protocol used by Kimoto et al. (2015) involved holding each static stretch for 60
seconds, and Nakamura et al. (2014) did not specify stretch duration.
An active warm-up before stretching is important. For example, it has been found that static stretching
before maximal throwing exercises was only detrimental to performance if done in isolation (Mascarin et
al., 2015). When static stretches were preceded by an active warm-up there was no significant
performance deficit. Conversely, another study reported that dynamic stretching reduced hamstring and
quadriceps peak torque, (Costa et al., 2014). However, the warm-up protocol used in the latter study may
not have raised or muscle temperature sufficiently to achieve the full benefits of an active warm-
up. A more vigorous, or longer, active warm-up might have mitigated the negative effects observed. It
appears that, without a suitable active warm-up, stretching before some forms of exercise may be
detrimental to performance.

Muscle flexibility

A lack of muscle flexibility may restrict movement, which could clearly be a problem for those
participating in activities requiring a high degree of flexibility (e.g. dance or gymnastics). However, it
may also present difficulties for the general population in a gym environment. For example, proper
exercise technique may be compromised, injury risk may be increased, or it may be impossible for a
participant to complete certain exercises. Stretching on a regular basis has been shown to increase
muscle flexibility over periods of several weeks (Davis et al., 2005). When planning a warm-up, it is
therefore important to consider whether stretching immediately before exercise can bring client-specific,
or activity-specific, benefits through improved short-term muscle flexibility.
Static stretching appears to cause a short-term increase in static muscle flexibility, whereas dynamic
stretching increases the ability of muscle to lengthen dynamically. Dynamic stretching has been found to
have no significant acute effect on hamstring flexibility, whereas hamstring flexibility was increased by
static stretching (O'Sullivan et al., 2009). Another study appeared to contradict this by showing that
dynamic stretching increased range of motion in kicking follow-through, whereas static stretching had
no effect (Amiri-Khorsani et al., 2011). However, the important difference between these two studies is
that the first measured static hamstring flexibility, whereas the second measured dynamic range of
motion. Provided the type of stretch is chosen to match the subsequent activity, there appears to be
flexibility benefits from stretching before exercise in certain cases (see case study 10.1 and 10.2).
Case study 10.1 Ankle flexibility
Susan has poor flexibility in the ankle plantarflexor muscles. This limits her ability to dorsiflex her
ankles, which in turn restricts her ability to lower her pelvis when squatting. As a result, she has a
tendency to flex her lumbar spine and hips excessively during a squat. In order to help improve
Susan's squat technique, she should perform dynamic stretches for the ankle plantarflexors as part
of her warm-up.

Case study 10.2 Chest flexibility

James lacks flexibility in the pectoralis major, and therefore has limited ability to retract the
shoulder girdle and externally rotate the shoulders. This limits his ability to hold the bar in the
correct position for a barbell squat. In order to improve his upper body posture when squatting,
James is advised to perform static stretches for the pectoralis major as part of his warm-up. A
suitable static stretch for the pectoralis major is shown in Figure 10.7.
Figure 10.7 Static passive self-stretch – Pectorals.
Structuring a Warm-Up

Exercise prescription is usually structured according to the principles of Frequency (how often), Intensity
(how hard), Time (how long) and Type (selection of exercises) (ACSM, 2014). This FITT principle is used
below in relation to structuring a warm-up. A summary of major guidelines for structuring a warm-up is
shown in Figure 10.8.

Figure 10.8 Summary guidelines – Structuring a warm-up.

Case Study 10.3 Concurrent training warm-up structure

Sarah is about to warm-up. The conditioning phase of her exercise session will include treadmill
running and cycling on a cycle ergometer. This will be followed by lower body resistance training
with the objective of building muscular strength (squats, lunges and calf raises). Sarah is well
conditioned to this type of exercise, having been involved in gym-based exercise sessions 3 to 4
times per week for the past four months. A suitable warm-up would be:
 Frequency: At the start of every session.
Intensity: The warm-up should start at low intensity (e.g. 30 per cent of max, 30 per cent
of HRR or RPE of 7–9; Borg Scale), steadily rising to moderate intensity (e.g. 60 per cent of
max, 60 per cent of HRR or RPE of 11 or 12). If resistance exercises are included in the
warm-up, these should be performed at 30 per cent to 70 per cent of the 1RM.
Time: 5 to 10 minutes, ensuring the warm-up is long enough to build to the required level of
intensity, but not longer than 10 minutes, as this could cause excessive fatigue.
Type: The conditioning phase consists only of lower body exercise. Hence, the ‘general’ phase
of the warm-up should focus on the lower body (e.g. treadmill walking/jogging, cycle
ergometer and/or stepper).

Optionally, light–moderate resistance exercises may be included as a ‘specific’ phase of the warm-
up. These should be some of the same exercises used in the conditioning phase.
The conditioning phase includes resistance training, which requires strength and power.
Therefore, unless there is a particular reason (e.g. restricted muscle range which might be
detrimental to technique) Sarah should leave flexibility training until after the cool down.

Frequency – How often?

As discussed above, an appropriate warm-up delivers performance benefits and may reduce the risk of
muscle injuries. A warm-up should therefore be completed at the start of every exercise session (ACSM,
2014; SMA, 2011).

Intensity – How hard should it be?

Warming-up is only beneficial when the intensity and duration are sufficient to significantly elevate
, but not so excessive as to cause fatigue (Bishop, 2003; Fradkin et al., 2010). If warm-up intensity is
too low, it is unlikely to generate a sufficient response. If the intensity is too high, this may cause
muscular fatigue due to a number of metabolic factors (Bishop, 2003; Fradkin et al., 2010). Warm-up
intensity should gradually build until it is sufficient to cause a mild perspiration and increase
heart/breathing rate without fatigue (SMA, 2011; Woods et al., 2007).
Warm-up intensity is measured using the same methods as other cardiorespiratory training (CRT)
exercises. For example, using Borg's ratings of perceived exertion (RPE) scale, percentage of maximum
heart rate (per cent HRmax) or percentage of heart rate reserve (HRR) (ACSM, 2014; Borg, 1998; Chen et
al., 2002). In a review of literature addressing performance benefits from warming-up, Bishop (2003)
found that optimal warm-up intensity before activities lasting less than 10 seconds (e.g. explosive
jumping, or maximal lifting) was between 40 per cent and 60 per cent of max. The same review
concluded that before activities of longer duration, warm-up intensity should gradually build towards 60
per cent to 70 per cent of max. A later review reported that warm-ups building to between 40 per
cent and 60 per cent of max were suitable before most activities (Woods et al., 2007). The
conclusions of these reviews are broadly consistent with guidelines from the ACSM (2014) that warm-up
intensity should be between 30 per cent and 60 per cent of max or HRR, which approximates to an
RPE of 9 to 13 on the Borg scale.
Where resistance training (RT) exercises are included in the warm-up, the ACSM recommends that
these should be performed at 30 per cent to 70 per cent of one repetition maximum (1RM). This is
consistent with the resistance-based warm-up intensities typically used in research studies (Abad et al.,
2011; Barroso et al., 2013; Ribiero et al., 2014).
Cardiorespiratory and resistance warm-ups for poorly conditioned clients should be towards the lower
end of these ranges (ACSM, 2014; Bishop, 2003; Woods et al., 2007). Stretching intensity should be
sufficient to generate a sensation of muscle stretch or tightness, but not sufficient to cause pain or
discomfort (ACSM, 2014).

Time – How long should it last?

A warm-up of between 5 and 10 minutes is usually appropriate. The ACSM (2014) and SMA (2011) both
recommend a warm-up duration of 5 to 10 minutes. This is consistent with research findings. For
example, a study found that a warm-up of 5 to 10 minutes was sufficient for to become elevated
and reach a steady state (Ozyener et al., 2001). This was consistent with much earlier findings that
during the first 3 to 5 minutes of exercise muscle temperature rises rapidly, before reaching a plateau
after 10 to 20 minutes (Saltin et al., 1968). It is therefore recommended that the warm-up should not
exceed 10 minutes, due to the possibility of decreasing muscle glycogen stores or exercise capacity
(Bishop, 2003; Gregson et al., 2005).
The ACSM (2014) recommends holding each static stretch for 10 to 30 seconds, and repeating each two
to four times, resulting in 60 seconds of total stretching time per muscle group. It suggests a stretching
routine of at least 10 minutes, performed after the warm-up, or after cool down. Guidelines from SMA
(2011) are similar, at 20 seconds per stretch, repeated 2–3 times per muscle group. These
recommendations are in line with studies supporting the view that stretches of 10 to 15 seconds are
sufficient to be effective, that holding stretches for more than 20 seconds may be detrimental to
subsequent performance, and that there is no further beneficial effect after 3 or 4 repetitions (Aguilar et
al., 2012; Kay & Blazevich, 2012; Page, 2012; Siatrus et al., 2008).

Case Study 10.4 Cardiorespiratory exercise warm-up structure

Charles is about to warm-up before a cardiorespiratory exercise session, including treadmill
running and rowing on a rowing ergometer. Charles has been sedentary until 1 week ago when he
started a new gym programme. A suitable warm-up would be:
 Frequency: At the start of every session.
Intensity: The warm-up should start at low intensity (e.g. 30 per cent of max, 30 per cent
of HRR or RPE of 7–9). Because Charles is de-conditioned, intensity should be carefully
monitored and controlled. The intensity of the warm-up should be steadily increased to a
moderate level (e.g. 50 per cent of max, 50 per cent of HRR or RPE of 10 or 11).
Time: 5 to 10 minutes.
Type: The conditioning phase consists of upper and lower body exercise. Hence, examples of
suitable equipment for the warm-up include the rowing ergometer and/or cross-trainer.

The conditioning phase does not include resistance training. Flexibility training after the warm-up
is therefore suitable. Alternatively, Charles could leave this until after the cool down.

Type – Which exercises should be included?

The warm-up should include a general cardiorespiratory element (e.g. treadmill walking/jogging, cycle
ergometer, cross-trainer or stepper) aimed at elevating , and increasing the temperature of working
muscles (ACSM, 2014). SMA (2011) recommends that the major muscle groups and movements to be
used in the main exercise session should be addressed by the warm-up, and that movements to be used
in subsequent activity should be included.
There is strong evidence that, for optimum benefit, the warm-up should include elements appropriate
to the subsequent activity (Andrade et al., 2015; Bishop 2003; Samson et al., 2012; Woods et al., 2007).
However, it may not be necessary to directly mimic the activities of the main exercise session. For
example, a study found no difference in sprint performance after a non-specific warm-up (running,
coordination exercises, stretching and acceleration runs), compared with one including specific
‘functional’ exercises (Sander et al., 2013).
A ‘general’ (cardiorespiratory) warm-up is beneficial before CRT or RT (ACSM, 2014; Coburn &
Malek, 2012; Ribiero et al., 2014). Before RT a ‘specific’ warm-up (e.g. light warm-up sets) is also often
recommended, because it can improve maximal lifting performance (Abad et al., 2011; Coburn & Malek,
2012). However, it appears to have no significant beneficial or detrimental effect on submaximal
muscular endurance performance in RT (Ribiero et al., 2014). There is also very little evidence for or
against a ‘specific’ warm-up phase affecting injury risk. The ‘specific’ element of a warm-up targets
muscle warming towards the relevant muscle groups, and provides mental and neuromuscular rehearsal.
Therefore, the logic for this approach is strong. However, the evidence for including a ‘specific’ element
is contentious.
Dynamic Stretches

Dynamic stretches are appropriate as part of the warm-up, especially when demands of the main
exercise session will include repeatedly moving a muscle group through a large range of motion, as in
CRT, or RT (Adamczyk et al., 2012; Aguilar et al., 2012; Amiri-Khorsani et al., 2011; Turki et al., 2011).
Where static muscle length restrictions may be detrimental to technique (e.g. case study 10.2) targeted
static stretching during the warm-up may be beneficial (O'Sullivan et al., 2009).
Static Stretches

As part of long-term flexibility training, static stretches can be included in the warm-up or cool down,
and the evidence for static stretches being detrimental to subsequent performance is controversial (see
page 107) (Adamczyk et al., 2012; Aguilar et al., 2012; Andrade et al., 2015; Kay & Blazevich, 2012;
Samson et al., 2012). Therefore, static stretching should be performed after exercise, if strength and power
are important performance elements (ACSM, 2014).
A flow chart illustrating an approach for structuring a warm-up is shown in Figure 10.9.

Figure 10.9 Flow chart – Structuring a warm-up.

Case Study 10.5 Resistance training warm-up structure

Adam is about to warm-up. The conditioning phase of his exercise session consists of upper body
resistance training with the objective of hypertrophy (e.g. bench press, seated row, lat pulldown,
biceps curl, triceps extension, lateral raise, overhead press). A suitable warm-up would be:

Frequency: At the start of every session.

Intensity: The warm-up should include a ‘general’ phase, starting at low intensity (e.g. 30 per
cent of max, 30 per cent of HRR or RPE of 7–9), steadily rising to moderate intensity (e.g.
 60 per cent of max, 60 per cent of HRR or RPE of 11 or 12). If resistance exercises are
included in the warm-up, these should be performed at 30 per cent to 70 per cent of the 1RM.
Time: 5 to 10 minutes.
Type: The conditioning phase consists only of upper body exercise. Hence, the ‘general’ phase
of the warm-up should include upper body work. Examples of suitable equipment for the
warm-up include the cross-trainer and/or rowing ergometer.

Light-moderate resistance exercises may be included as a ‘specific’ phase of the warm-up. These
should be some of the same exercises used in the conditioning phase. Compound exercises utilising
multiple joints and muscle groups are best suited for this (e.g. bench press and seated row). Adam
should leave flexibility training until after the cool down.
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Chapter 11
Cardiorespiratory fitness training

Paul Hough

Cardiorespiratory fitness (CRF) refers to the capacity of the cardiovascular and respiratory systems to
provide muscles with oxygen during physical activity (PA). As discussed in Chapter 2, CRF is an
important component of physical fitness due to its strong association with health and performance.
Cardiorespiratory training (CRT) is any form of exercise designed to enhance CRF. This chapter will
explore the importance of monitoring CRT intensity accurately and the training techniques that can be
used to improve CRF. The chapter will also focus on designing CRT programmes to achieve the
following common goals:

improving health
reducing body fat
improving performance.

All CRT programmes should be designed based on the client's current level of CRF, health/fitness goals,
medical conditions and motivation. In order to induce the cardiorespiratory adaptations which lead to
improvements in CRF (see Figure 11.1), an appropriate overload must be consistently applied through the
correct prescription of training intensity and volume. The overload required to achieve the desired
outcomes is based on the client's genetics, training age and current level of CRF. Thus, it is important to
recognise that every CRT programme must be tailored to the specific needs of the client
(individualisation).
Cardiorespiratory Exercise Intensity

Before prescribing CRT it is essential to have a good understanding of how the body produces and
transfers energy (bioenergetics). In short, all metabolic processes are fuelled by an energy rich molecule
called adenosine triphosphate (ATP). As there are limited stores of this molecule within the body, ATP
must be continually resynthesised through one of three energy systems:

Anaerobic: ATP-Phosphocreatine system.

Anaerobic: The glycolytic system (anaerobic glycolysis).
Aerobic: The oxidative system (oxidative phosphorylation).

The energy systems do not work independently, they interact to meet the required energy demands of
the exercise. The contribution of the energy systems to produce ATP is dependent on the exercise
intensity and duration (see Table 11.1). As the exercise intensity increases, the anaerobic systems become
more dominant in providing the required ATP (Gastin, 2001). However, as exercise duration increases
and the intensity decreases the aerobic system provides more of the ATP. For instance, a 100 m sprint
predominantly relies on the anaerobic systems, whereas a marathon is almost entirely dependent on the
aerobic (oxidative) system.

Table 11.1 Cardiorespiratory training intensity domains

Exercise Maximum exercise Energy system
Dominant energy systems Training methods
domain duration demand

Light –
Aerobic oxidative 3 hours + Continuous
Moderate

Moderate – Aerobic oxidative and

∼ 3 hours Continuous
Heavy anaerobic glycolytic

Continuous
Heavy – Aerobic oxidative and (Tempo/threshold)
20–45 minutes
Severe anaerobic glycolytic Aerobic interval
training

Extreme ATP-PCr and Anaerobic Sprint interval

2–3 minutes
(maximal) glycolytic training
Adapted from Burnley and Jones (2007); Coates et al. (2003).

In order to stress the aerobic energy system, and induce improvements in CRF, it is important to
exercise at the correct intensity for appropriate durations. Cardiorespiratory exercise can be categorised
into intensity domains to simplify exercise prescription (see Table 11.1). If the CRT intensity is too high,
the anaerobic contribution to energy production increases and the exercise becomes non-sustainable (i.e.
the client will have to stop or reduce the intensity) due to a combination of fatigue mechanisms.
Conversely, if the exercise intensity is very low, or below the client's adaptation threshold (see Chapter
7), there will not be a sufficient overload on the cardiorespiratory system to induce improvements in
CRF. Therefore, the intensity of CRT must be carefully monitored.
Monitoring Intensity During Cardiorespiratory Training

Some CRT recommendations for improving health and avoiding disease have prescribed exercise
intensity based on the absolute energy demands of the activity, using measures such as metabolic
equivalents (METs) and energy expenditure (kcal/min) (American College of Sports Medicine [ACSM],
2011; Kodama et al., 2009). As discussed in Chapter 8, METs can be used to classify the intensity of an
exercise, relative to the resting metabolic rate, using published MET values (see Table 11.2). Metabolic
equivalents can also be used to quantify CRT volume. For example, if a client performs PA at an intensity
of 4 METs for 20 minutes, this corresponds to 80 MET-minutes (4 METs × 20 minutes). This method is
useful when calculating an appropriate dose of CRT for clients with generic health related goals, as the
current recommended volume of PA for the attainment of health benefits is ≥500–1,000 MET/min/wk
(ACSM, 2011).

Table 11.2 Example metabolic equivalents (METs) of different physical activities

Activity METs

Sitting quietly 1

Walking/jogging at 3.2 km/h 2.5

Golf, walking and carrying clubs 4.5

Walking/jogging at 8 km/h 8

Bicycling, general 8
Adapted from Ainsworth et al. (2000) and The American College of Sports Medicine (2011).

Case study 11.1 Starting an exercise programme

Teresa (64 years) is currently sedentary and has been advised by her doctor to increase her levels of
PA in order to improve her general health. She prefers to exercise outdoors and would like to know
how much exercise she needs to perform in order to improve her health. Based on the current
guidelines, Teresa needs to accumulate a minimum 500 MET/min/wk. This could be achieved by
walking at 4.8 km/h (∼3.3 METs) for 30 minutes, six times per week.
3.3 METs × 30 minutes = 99 MET/min.
99 × 6 = 594 MET/min/wk
 Although the MET approach of exercise prescription is simple to administer, it has limitations
concerning accuracy. Individual factors (gender, CRF level and body mass) are not usually taken into
account meaning the MET values (presented in Table 11.2) can vary considerably between individuals.
Therefore, it is prudent to prescribe the intensity of CRT relative to the client's maximum capacity – this
is known as relative exercise intensity.
As discussed in Chapter 8, there are a number of metrics that can be used to prescribe and monitor
CRT intensity, such as measures of workload (e.g. watts, speed, or resistance level). Unfortunately,
commercial fitness equipment is not always calibrated to a high standard and consequently these metrics
can vary considerably between machines. Therefore, it is recommended that heart rate (HR) and rating
of perceived exhaustion (RPE) are used alongside other metrics.

Heart rate

During incremental cardiorespiratory exercise, such as gradually increasing running speed, there is a
linear increase in HR that mirrors the increase in cardiac output. Therefore, maximum heart rate
(HRmax) is often interpreted as the upper limit in central cardiorespiratory function. Consequently,
knowing a client's HRmax enables the intensity of CRT to be monitored and prescribed relative to the
client's maximal capacity. However, it is important to recognise the limitations of using HR to prescribe
and monitor CRT intensity. For example, the validity of HR monitoring methods is compromised in
clients taking certain medications that affect HR (e.g. ß-blockers). Other non-exercise factors that can
affect HR include:

Psychology: emotional factors such as stress and anxiety can elevate HR.
Environment: temperature, humidity, etc.
Time of day: HR is typically lower in the morning.
Pregnancy.
Medical conditions such as arrhythmia.

Calculating heart rate maximum

The most valid method to establish a client's HRmax is to perform an incremental exercise test to
exhaustion. However, as maximal exercise testing is not always practical, HRmax is often estimated
using prediction equations (see Table 11.3). The most commonly applied HRmax prediction equation is:
220 – age (Fox et al., 1971). However, the validity of the equation has been questioned. In addition to a
total error of estimate of 20.1 beats per minute (B/min), the equation has also been shown to
overestimate HRmax in the young and underestimate HRmax in older subjects (Nes et al., 2013). In 2001,
Tanaka and colleagues formulated a more valid equation (208 – [0.7 × age]) using a meta-analysis, which
was cross-validated by a laboratory study of 514 participants. Tanaka's equation was accepted by a
longitudinal follow up study as an accurate method of estimating HRmax (Gellish et al., 2007). Therefore,
it is recommended that the 208 – (0.7 × age) equation is used when the direct measurement of HRmax is
not feasible. Nonetheless, estimated HRmax equations should be used as a broad guideline, as the
equations can still have a standard error of 10.8–11.4 B/min (Arena et al., 2016; Nes et al., 2013).

Percentage of heart rate maximum

After either measuring or estimating HRmax it is possible to formulate HR training zones. One of the
most common methods of calculating HR zones is to prescribe exercise at a fixed percentage of HRmax.

Table 11.3 Maximum heart rate prediction equations

Population Equation Study

Sedentary women and men 208 – (0.7 × age) Tanaka et al. (2001)

Healthy men (28–54 years) 207 – (0.64 × age) Froelicher & Myers (2000)

Healthy men (>20 years) 209.3 – (0.72 × age) Arena et al. (2016)

Healthy men (19–73 years) 199 – (0.63 × age) Graettinger et al. (1995)

Women (19–69 years) 216 – (0.88 × age) Sheffield et al. (1978)

Healthy women (20–49 years) 201 – (0.63 × age) Jones et al. (1985)

Healthy women (20–70 years) 206 – (0.597 × age) Hossack and Bruce (1982)

Active women and men 207 – (0.7 × age) Tanaka et al. (2001)

Trained women and men 205 – (0.41 × age) Lester et al. (1968)

Endurance trained women and men 206 – (0.7 × age) Tanaka et al. (2001)

Example Target HR zone: Vigorous intensity (77–95% HRmax):

31-year-old male
Estimated HRmax (Tanaka et al., 2001): 208 – (0.7 × age) = 186 B/min
Target HR zone: 77–94% HRmax
77% HRmax: 186 × 0.77 = 143 B/min
95% HRmax: 186 × 0.95 = 177 B/min
A limitation of this method is that it does not take into account resting HR. Regular CRT increases stroke
volume, thus trained clients who have a high level of CRF tend to have a lower resting HR (bradycardia)
in order to maintain a normal cardiac output and blood pressure (Spina, 1999). Therefore, it is preferable
to calculate the client's HR reserve (HRR), which takes into account resting HR.

Percentage of heart rate reserve

The HRR method, also known as the Karvonen method (Karvonen et al., 1957), factors in the client's
resting HR and HRmax to identify the HRR in the following equation: heart rate reserve = HRmax −
Resting HR.
Example Target HR zone: Vigorous intensity (60–89% HRR) for improving CRF
31-year-old male, resting HR: 58 B/min
Estimated HRmax: 186 B/min
Heart rate reserve (HRmax − Resting HR): 186−58 = 128 B/min

Following the calculation of the HRR, the percentage of the HRR zones can be calculated

60% HRR: 128 × 0.60 = 77 B/min + 58 (Rest HR) = 135 B/min

89% HRR: 128 × 0.89 = 114 B/min + 58 (Rest HR) = 172 B/min

The required training zones can be used to prescribe a suitable intensity of exercise for the client, with
less experienced clients beginning in the light or moderate HRR training zone (see Table 11.4). The HRR
method is often used to estimate an exercise intensity that is equivalent to the percentage of maximal
oxygen uptake (%VO2max). However, there is typically a small discrepancy between %HRR and
%VO2max.

Rating of perceived exertion (RPE)

A RPE scale is a psychophysiological scale, which is used to rate an individual's perception of effort
during physical work. The scale measures feelings of effort and/or fatigue experienced based on an
incremental, numerical scale. Unlike objective measures (e.g. HR or oxygen uptake), RPE is subjective
and relies on the client to evaluate their level of exertion based on a number of intrinsic physiological
factors (e.g. HR, oxygen uptake, respiration rate) as well as psychological factors (e.g. mood and
motivation) (Borg, 1982; 1998).

Table 11.4 Heart rate training zones

 A widely used RPE scale is the 15 point (6–20) ‘Borg RPE Scale®’ developed by a professor of
Perception and Psychophysics named Gunnar Borg in the 1970s (see Figure 11.1). The scale is based on
the assumption that physiological strain is coupled with perceptual strain, i.e. as the exercise intensity
increases, physiological and perceptual strain increase together. The scale begins at six as it was
formulated to approximately correlate with a HR within the range of 60–200 B/min (Borg, 1982; 1998).
Borg also developed a general intensity category scale, with ratio properties (0–10), for a number of
experiences (dyspnea, angina, fatigue) – this is known as the Borg CR10 scale. This scale is conceptually
different to the 15 point scale and requires careful administration using the correct guidelines (refer to
www.borgperception.se/).

Figure 11.1 The Borg rating of perceived exertion scale. Reproduced with permission from Borg (1998), Borg's Perceived Exertion and Pain
Scales. Campaign, IL: Human Kinetics.

In some cases RPE scales can produce unreliable information due to a number of factors including
whether the scale is visible and how the scale is explained (Abadie, 1996). A common problem when
using RPE scales is client misinterpretation. For example, the client may assign a very low rating to
vigorous exercise because they have misunderstood the scale. Therefore, in order to use RPE scales
reliably it is recommended that the scale is carefully explained to the client using a standardised script
(refer to Borg, 1998). For example, ‘I would like you to rate how heavy and strenuous this exercise feels
to you on this scale (show visual scale) from 6 to 20. A rating of 6 corresponds to no exertion, i.e. not
doing anything, and 20 represents your maximal exertion’. By anchoring feelings to the numerical values
the client is able to put the scale into context and provide accurate feedback. To improve accuracy and
avoid confusion, it is also important to use a consistent scale, which is visible to the client.

The talk test

The talk test is a simple method whereby the trainer speaks with the client during a CRT exercise to
gauge exercise intensity (Persinger et al., 2004). In general, the client is able to hold a conversation with
infrequent pauses during light–moderate exercise (see Table 11.5). Vigorous intensity exercise generally
corresponds to the point where the client is unable to maintain a conversation and frequently pauses for
breaths – this provides a reasonable estimation that the client is working close to the heavy exercise
domain (Carey et al., 2005).

Table 11.5 Using the talk test during cardiorespiratory exercise

Client's response to questions Approximate exercise intensity Energy system demand

Can hold a conversation without pausing Light

Infrequent pauses Moderate
Unable to talk without regular pauses Heavy
Only 2–3 words between breaths

Unable to talk Extreme (maximal)

Cardiorespiratory Training Methods

Exercise selection

Rhythmic exercises involving large muscle groups should be selected for CRT. Examples of common gym
based CRT exercises include treadmill walking/running, cycling, elliptical (cross) trainer and rowing. As
discussed in Chapter 7, the principle of specificity must be considered so that the improvement in CRF is
specific to the client's goals. For instance, a client who wishes to improve CRF for playing football should
perform running based CRT.
When selecting exercises it is also important to consider the experience and CRF level of the client. For
novices, low-skill exercises, such as cycling, are recommended to encourage adherence and reduce the
likelihood of injury. Exercises involving both upper and lower body musculature, such as rowing, should
be avoided for severely deconditioned clients, as these types of exercise induce a greater
cardiorespiratory stress due to the increased demand for oxygen. This is why athletes competing in
sports such as cross-country skiing have exceptionally high levels of CRF (Losnegard et al., 2014).

Continuous exercise training

Continuous exercise training (CET) involves continuous exercise for extended periods (15 minutes – 4
hours + ) and is the most common form of CRT. This method is used to establish a foundation or ‘base’
level of CRF and typically involves exercising in the light–moderate intensity domain (Martin & Coe,
1997). High volumes of CRT can be performed using this method, which induces a number of
physiological adaptations (see Figure 11.3) that improve CRF such as increased mitochondrial content
(Dudley et al., 1982). Therefore, CET is an appropriate training method for a range of clients from
novices to elite athletes. This type of training is often referred to as ‘long, slow distance’ which may
imply a leisurely pace; however, as with all CRT methods, the intensity must be selected based on the
client's current level of CRF (relative intensity). For instance, a club level runner's CET might be
performed at 14–16 km/h, whereas walking at 5 km/h may provide a suitable training stimulus for a
sedentary client.

Fartlek training

Fartlek is a Swedish term meaning ‘speed play’. This method involves alternating the intensity of the
exercise throughout the session, combing CET and interval training techniques. The changes in intensity
can be either planned or random. For instance, a runner may plan to run at a light intensity for 15
minutes, perform five minutes at a severe intensity, and finish with 20 minutes of moderate intensity
running. Alternatively, random changes in intensity can be applied throughout a CRT session; however,
the random method can make the monitoring of a CRT programme problematic. Fartlek training can be
used to develop the aerobic and anaerobic energy systems. This is advantageous for certain clients, such
as those who compete in team sports which involve intermittent bouts of high-intensity running. Some
clients may also find the varied nature of Fartlek training more psychologically stimulating and less
monotonous than CET.

Tempo/threshold training

Tempo training is a form of CET that involves exercising at a higher (heavy) intensity (see Figure 11.2),
which corresponds to the maximal lactate steady state (MLSS). The MLSS represents the highest exercise
intensity where there is balance between lactate production and lactate removal – i.e. lactate does not
significantly increase (Faude et al., 2009). In theory, this point represents an exercise intensity that can be
maintained without a significant contribution from anaerobic metabolism, hence, this point has also
been termed the ‘anaerobic threshold’ (Stegmann et al., 1981). The objective of tempo training is to
improve physiological mechanisms that determine the MLSS, such as the oxidation rate of lactate in
active muscles and volume of proteins that transport lactate between cells (Brooks, 2000; Evertsen et al.,
2001; Green et al., 2002).
Intensity is the distinguishing factor between CET and tempo training; whilst CET training can be
performed for hours, tempo training imposes a greater physiological stress, meaning the intensity can
only be maintained for a maximum of 45–60 minutes (Daniels, 2014; Urhausen et al., 1993). Indeed, if the
intensity is increased slightly beyond the MLSS, the exercise becomes non-sustainable due to a
combination of fatigue mechanisms (see Box 11.1).

Determining the tempo intensity

The gold standard for identifying the MLSS and prescribing the correct tempo intensity is to perform a
laboratory based exercise test. However, laboratory testing is not always a feasible option. The correct
tempo exercise intensity should feel manageable, but difficult. As an approximate guide, the following
criteria can be used to gauge an appropriate intensity for tempo training:

The client should be able to sustain 30 minutes at the selected intensity if they were required.
Talk test: the client is unable to hold a conversation.
RPE: 13–16 (Borg RPE Scale).
80–90% heart rate reserve.

Box 11.1 Lactic acid and fatigue

A common theory that has been proposed to explain fatigue during exercise is that lactic acid
(which disassociates to lactate) and hydrogen ions accumulate within the muscles/blood causing
 acidosis (excessive acidity) and a disruption of cellular homeostasis (Fitts, 1994). This theory, known
as the ‘lactic acid hypothesis’, was originally proposed due to the association between high levels of
lactate and hydrogen ions which are produced during fatiguing exercise. However, debate persists
as to whether lactic acid and/or hydrogen ions cause fatigue or are merely associated with it.
Indeed, research indicates that lactate is used as a fuel source during exercise (Philp et al., 2005) and
may have protective effects during muscle fatigue (Pedersen et al., 2004). Consequently, it is
currently contentious if lactic acid does have a significant impact on muscle fatigue. Furthermore,
fatigue is an incredibly complex phenomenon, which acts at numerous sites within the central
nervous system (Noakes, 2007) and skeletal muscle (Allen et al., 2008), and is also highly dependent
on the type and intensity of exercise performed (Abbiss & Laursen, 2005). Thus, muscular fatigue
cannot solely be attributed to lactic acid.

Extended interval training

Extended interval training involves exercising within the heavy intensity domain used for tempo
training and should not be confused with high-intensity interval training (see Chapter 12). Instead of
performing a continuous tempo session, small rest/recovery periods (30–90 seconds) are incorporated to
split the session into work periods of 5–10 minutes (see Figure 11.2). The rest periods must be kept short
to prevent physiological responses (HR and oxygen uptake) declining towards resting levels. The
advantage of this form of training is that the small breaks allow endurance athletes (e.g. runners, cyclists,
etc.) to train at intensities similar to race pace without accumulating excessive fatigue. Additionally, the
small rest periods can make the sessions more manageable than tempo sessions from a psychological
perspective (Bartlett et al., 2011).
Figure 11.2 Schematic of cardiorespiratory training methods.
Cardiorespiratory Training for Health

The importance of cardiorespiratory fitness

Cardiorespiratory fitness has been consistently demonstrated to be an independent predictor of

cardiovascular disease (CVD) risk, CVD mortality, and all-cause mortality (Lee et al., 1999; Lee et al.,
2010). Cardiorespiratory fitness is influenced by genetics, age, gender and health status. However, the
principal modifiable determinant of CRF is an individual's habitual levels of PA. Therefore, CRF is also
used as a marker of habitual PA and exercise habits (Lee et al., 2010).
Worldwide, physical inactivity has been estimated to cause 6–10 per cent of major non-communicable
diseases and up to nine per cent of premature deaths (Lee et al., 2012). A small (1 MET value) decrease in
CRF can increase mortality risk by 13 per cent (Kodama et al., 2009). A study in 2015 evaluated 160
randomised clinical trials, to investigate the effect of exercise interventions on CRF and various cardio-
metabolic outcomes, concluded that regular PA significantly improves CRF and markers of CVD risk (Lin
et al., 2015). Therefore, regular CRT is an essential element of a structured exercise programme. However,
clients should also be encouraged to perform regular PA outside of a structured exercise programme (see
Chapter 1), as excessive sedentary time is associated with greater mortality (Matthews et al., 2012). The
following guidelines will focus on CRT for improving health, lowering susceptibility to disease
(morbidity) and decreasing premature mortality.

Volume for health related cardiorespiratory training programmes

The term ‘dose-response’ is used within medicine to describe the relationship between the quantity and
effect a drug has. The dose-response is studied in order to formulate an appropriate threshold and
optimal dosage. This concept has been applied in a number of PA cohort studies to explore the
relationship between PA and health, specifically to address the questions: ‘What is the minimal amount
of PA that can be performed to establish health benefits?’ and ‘Is there an optimal dose (volume) of PA
for improving health and avoiding disease?’
Figure 11.3 Examples of physiological adaptations to long-term cardiorespiratory training.

Figure 11.4 Schematic representation of the dose-response relationship between level of physical activity/CRF and mortality risk. Adapted
from Department of Health (2004). At Least Five a Week: Evidence on the impact of Physical Activity and Its Relationship to Health. A
Report from the Chief Medical Officer. London: Department of Health.

The data collected from numerous randomised controlled trials and epidemiological studies indisputably
demonstrate there is a dose-response relationship between the volume of PA and mortality risk (see
Figure 11.4): as the volume of PA increases, mortality risk decreases and health/fitness improves (Church
et al., 2007; Williams, 2001). In general, achieving the minimum PA recommendations (see Box 11.2) will
improve health outcomes amongst sedentary clients. However, the health benefits associated with
regular PA increase as the volume of PA increases i.e. more PA is better, up to a point (see Box 11.3).
An exercise volume relating to an energy expenditure of approximately 1,000 Kcal/week (143 kcal/day)
is required for a significant reduction in mortality risk (ACSM, 2011; Kokkinos, 2012). However, even PA
doses below this recommendation are beneficial (Church et al., 2007; Hupin et al., 2015; Merino et al.,
2014). For example, a study involving over 55,000 adults (18 to 100 years) found that running for 5–10
minutes/day at slow speeds (<9.7 km/h) was associated with markedly reduced risks of death from all
causes and CVD (Lee et al., 2014). In support of this, Arem et al. (2015) complied data from six studies
involving 661,137 men and women (age 21–98 years) to quantify the dose-response association between
leisure time physical activity (LTPA) and mortality. The authors concluded that:

Achieving the current recommended quantity of LTPA (see Box 11.2) provides most of the longevity
benefits.
The benefit threshold was approximately 3 to 5 times the recommended LTPA minimum, i.e.
exercising for more than five times the recommended amount offers no greater health benefits.

Box 11.2 General cardiorespiratory PA/exercise recommendations

The ACSM (2011) recommends that most adults engage in weekly cardiorespiratory PA/exercise,
which can be structured in one of three ways:

Moderate intensity PA/exercise performed on at least 5 days per week, accumulating a total of
≥150 minutes/week. The 150 minutes can be accumulated in single blocks (e.g. 5 × 30 minutes)
or accrued in bouts of ≥10 minutes over the course of a day.
Vigorous intensity PA/exercise for ≥ 20 minutes/day, accumulating ≥ 75 minutes or more
vigorous PA/exercise per week.
A combination of moderate and vigorous intensity PA/exercise to achieve a total weekly
energy expenditure of ≥500–1,000 MET/min/wk which is approximately 1,000 kcal/week.

Box 11.3 What is moderate and vigorous activity?

Physical activity guidelines are frequently based on two distinct classifications of intensity:
moderate and vigorous (ACSM, 2011, 2014). Moderate intensity PA can be defined as PA that
corresponds to 3–5.9 METs, whereas PA corresponding to ≥6 METs is considered vigorous (ACSM,
2011; Ainsworth et al., 2000). These moderate and vigorous descriptors have also been expressed
relative to HR training zones, based on age (see Table 11.4). However, caution should be applied
when using standardised training zones, as percentages of HRmax and HRR vary in relation to
 individual metabolic threshold levels, such as the ‘anaerobic threshold’ (Meyer et al., 1999). Thus, it
is recommended that metrics such as HR and METs are used in conjunction with measures of RPE
to individualise the intensity of CRT exercises.

Cardiorespiratory training for health structure

The ACSM (2011) guidelines presented in Box 11.2 stipulate that cardiorespiratory PA can be performed
as one continuous session per day (e.g. 5 × 30 minutes), or split into 10-minute bouts over the course of
the day to accumulate the minimum 150 minutes/week. Although it has been demonstrated that
accumulated bouts of PA/exercise enhance CRF to a similar degree as the continuous approach, it is
unknown if the accumulative approach produces the same positive effects on physiological and
psychological health outcomes, such as increased psychological well-being and improved blood lipid
profiles (DeBusk et al., 1990; Murphy et al., 2009). Given that a lack of time is a frequently cited barrier to
regular exercise, clients should be encouraged to adopt the accumulated approach. This can be achieved
by embracing an active lifestyle, which involves performing PA whenever possible (see Chapter 1).
However, at present, the evidence to support the accumulative approach for enhancing CRF is not
extensive. Subsequently, it is prudent to recommend clients dedicate a time-slot to perform CRT when
possible (i.e. an exercise session), alongside the accumulative approach.

Box 11.4 Is too much physical activity bad for you?

The aforementioned study which investigated the link between leisure time physical activity and
mortality also investigated if there is an upper limit to PA, whereby too much PA might be
detrimental to health (Arem et al., 2015). The researchers concluded that performing high levels of
PA does not have a negative impact on health, even when ten or more times the recommended (150
min/wk) minimum is performed. This finding is in contrast with studies that suggest substantial
volumes of CRT performed over a long period by athletes may have negative effects on the
structure and function of the heart (Andersen et al., 2013; Eijsvogels et al., 2016; Wilson et al., 2011)
and lead to orthopaedic issues such as osteoarthritis (Michaëlsson et al., 2011). The discrepancy
between the findings is possibly related to the different types of study design. Arem et al. (2015)
used pooled data from a range of studies involving individuals between 21 and 98 years to establish
the relationship between high levels of PA and potential negative health outcomes, whereas studies
which suggest substantial volumes of CRT are detrimental to health have focused on specific
cardiovascular and orthopaedic health outcomes amongst groups of athletes. The findings of these
studies can only be applied to similar populations (i.e. individuals of a similar age, performing the
same activity at comparable exercise volumes). Therefore, CRT performed in the range of 150–1,500
min/wk does not appear to have negative health outcomes amongst the general population. Thus,
clients who perform volumes of CRT that significantly exceed the minimum 150 min/wk should not
be discouraged. However, exceptionally high volumes of CRT routinely performed by some athletes
 may have negative health outcomes in the long-term (Eijsvogels et al., 2016). The volume of CRT
that induces negative effects is unknown and likely differs between individuals.

Intensity for health related cardiorespiratory training programmes

Research suggests there is a larger reduction in the risk of CVD in individuals who partake in regular
vigorous intensity PA compared to light-moderate intensity PA (Batacan et al., 2015; Swain & Franklin,
2006). However, an optimum CRT intensity to reduce premature mortality or improve CRF has not been
defined, as the intensity of exercise required to influence these factors is dependent on the client's
current level of CRF. Initially, sedentary clients with low levels of CRF may benefit from light intensity
CRT, within the 30–39 per cent HRR zone, whereas recreationally active clients would benefit from
moderate (40–59 per cent HRR) or vigorous (60–89 per cent HRR) intensity CRT. In accordance with the
progressive overload training principle (Chapter 7), as a client's CRF improves, a higher intensity of CRT
should be prescribed. Therefore, trained clients benefit from exercising at higher intensities through
utilising training techniques such as tempo and extended interval training (Swain & Franklin, 2002).

Training methods for the health related cardiorespiratory training programme

In general, the CET approach is recommended for clients with health related goals as this method is
simple to prescribe and monitor and has been demonstrated to be effective in enhancing CRF across a
range of populations (Church et al., 2007; Hupin et al., 2015). However, as the client's CRF improves,
other methods such as Fartlek, extended interval, and high intensity interval training can be
incorporated to provide a sufficient overload and prevent monotony.

Progressing the health related cardiorespiratory training programme

The rate of progression of any training programme is based on the client's response to the previous
training stimulus and programme goals. The CRT programme can be progressed by increasing one of the
acute programme variables (e.g. volume, intensity) and following a systematic, long-term approach (see
Chapter 9). For health related CRT programmes, it is practical to gradually increase the training volume
to ensure the client is consistently achieving or exceeding 150 minutes/week. This can be achieved
through increasing the frequency of training sessions or increasing the duration of sessions. Whilst there
is no accepted universal recommendation, a 10 per cent increase in CRT volume applied every 2–3 weeks
is a sensible and realistic guideline. However, if the client is unable to increase training frequency or
time, it is necessary to increase the training intensity with caution. Gradual increases in intensity should
be made using one of the aforementioned intensity monitoring methods. When progressing a CRT
programme it is prudent to increase one variable at a time (i.e. volume or intensity) to avoid an
inappropriate overload, which may cause injury or reduce adherence.
Case study 11.2 Achieving the minimum CRT guidelines
Tony is a 40-year-old entrepreneur, who has not exercised regularly for 15 years. He runs his own
business and spends most of his working day at a desk. He does not exercise at all due to a lack of
time. As Tony does not currently meet the minimum recommended cardiorespiratory PA guidelines,
the first priority is to address this issue. Tony has been prescribed to walk (continuously) at an RPE
of 10–12, for 20 minutes/day, 5 days/week. This will accumulate 100 minutes of cardiorespiratory
exercise. In order to improve compliance, Tony has been advised that he can multi-task and use this
exercise time to either listen to music or make phone calls. Following the first three weeks Tony will
increase the duration of the walks to 25 minutes. This gradual progression will increase the total
CRT volume towards the recommended minimum (150 minutes/week).
Although this exercise recommendation seems modest for a 40-year-old male, Tony is not
currently undertaking any regular PA due to a lack of time. It is, therefore, important to address the
issue of adherence through the gradual incorporation of exercise within his daily routine. This very
basic exercise prescription has a small time commitment and does not require any facilities or
equipment, which should promote adherence (see Chapter 4).
Cardiorespiratory Training for Fat Loss

Professional organisations have historically focused exercise guidelines on CRT for fat loss and
maintenance of a healthy body mass (ACSM, 2009; Haskell et al., 2007; Smith & Zachwieja, 1999). The
basic underpinning theory for this is that regular PA increases energy expenditure, which (provided
energy intake does not increase) should create a negative energy balance resulting in a decrease in
body/fat mass. Although some studies have supported the use of CRT to achieve body composition
related goals (e.g. a decrease in body mass), the evidence to support this widespread approach is
surprisingly unclear.

Volume for fat loss cardiorespiratory training programmes

Existing evidence indicates that 150–250 min/wk moderate intensity PA is effective in preventing
increases in body mass, but will provide only modest reductions in body mass (Donnelly et al., 2009;
Murphy et al., 2002; Thorogood et al., 2011). In order to achieve clinically significant reductions in body
mass it is recommended that >250 min/wk PA is performed (Donnelly et al., 2009; Laskowski, 2012). This
recommendation suggests there could be a dose-response relationship between PA and body mass
reduction i.e. a larger volume of PA should result in a greater reduction in body mass. Whilst there is an
abundance of evidence to support the dose-response relationship between PA and positive health
outcomes (ACSM, 2011), a dose-response relationship between PA and decreasing body and fat mass is
less clear, as increasing PA volume does not always lead to further decreases in body mass (Thomas et
al., 2012). Indeed, many CRT programmes have not been as effective in reducing body mass as prediction
models would suggest (Ross & Jannssen, 2001; Slentz et al., 2004; Wing, 1999). For instance, similar
reductions in body fat have been reported between two groups during a 13 week exercise programme,
despite one group performing a greater volume of exercise (Rosenkilde et al., 2012). Even if the dose-
response relationship between PA and fat loss exists, it is not necessarily a useful concept as part of a
long-term body fat reduction strategy given that a lack of time is one of the most commonly cited
barriers to regular PA (Trost et al., 2002). Therefore, once a client is consistently achieving 150–250
min/wk of PA, methods to increase the intensity and energy expenditure of CRT sessions should be
implemented (see Chapter 12). Exercise professionals also have to recognise the importance of diet (see
Chapter 5) when working towards body composition goals; this is because a combination of exercise and
dietary changes have consistently been demonstrated to be more effective in achieving positive body
composition outcomes than exercise alone (Donnelly et al., 2009; Schwingshackl et al., 2014; Wing, 1999).

Why do some individuals lose more fat than others?

Due to the numerous variables that influence body composition (e.g. genetics, environment and
psychological factors) it is currently unknown why an increase in CRT alone does not always lead to a
significant decrease in body or fat mass. Pontzer (2015) proposed that humans developed an evolutionary
protective mechanism, known as ‘constrained total energy expenditure’ (CTEE), to ensure total energy
expenditure remains relatively stable despite large increases in energy expenditure through PA. The
CTEE served as a survival mechanism during periods of restricted food availability (Pontzer, 2015). This
hypothesis suggests that physiological compensatory mechanisms (see below) interact to defend total
energy expenditure when PA is significantly increased and presents an interesting theory as to why
exercise alone may not present an optimal strategy for decreasing body fat. The following compensatory
mechanisms have been demonstrated during periods of increased PA:

Compensatory mechanisms following increased PA levels

The equivocal findings between studies investigating the effects of exercise on body/fat mass can be
attributed to the large variability in the body/fat mass loss between participants following an exercise
programme. It is likely that physiological and behavioural compensatory mechanisms, designed to
defend total energy expenditure, interact to varying degrees between individuals, which may explain
why some clients experience greater reductions in body/fat mass than others during an exercise
programme.

↑ Secretion of hormonal mediators of appetite causing increased energy intake (Sumithran et al.,
2011).
↑ Metabolic efficiency of exercise: i.e. burning fewer calories for the same volume/intensity of
exercise (Doucet et al., 2003).
↓ Resting energy expenditure (Heilbronn et al., 2006).
↓ Non-exercise activity thermogenesis – less PA apart from exercise (Redman et al., 2009).

Intensity for fat loss cardiorespiratory training programmes: ‘The fat burning zone’

The ‘fat burning zone’ is a common term used within the fitness industry to describe an intensity of
exercise where the body oxidises (burns) fat as a primary fuel. During light–moderate exercise, fat is
oxidised at a high rate. However, as intensity increases the rate of carbohydrate oxidation increases
whilst fat oxidation decreases (Jeukendrup, 2002). In some individuals there is specific exercise intensity
where there is a relative increase in carbohydrate oxidation and a decline in fat oxidation (see Figure
11.5). This is known as the ‘cross-over’ concept (Brooks & Mercier, 1994). The exercise intensity where
the maximal rate of fat oxidation occurs has been termed the ‘FATmax’ (Achten et al., 2002). FATmax
typically occurs at an exercise intensity corresponding to 60–65 per cent max (Achten et al., 2002;
Achten & Jeukendrup, 2003). However, a number of factors such as age, diet and training status affect
this, which means the FATmax intensity is variable between clients and can occur at 50–85 per cent
max (Achten & Jeukendrup, 2003). Thus, although it is probable that an exercise intensity
corresponding to approximately 65 per cent max will involve a high oxidation of fat, this can only
be accurately determined during a metabolic assessment, requiring specialist equipment and expertise.

Figure 11.5 The ‘cross-over’ concept.

Is exercising in the fat burning zone better for fat loss training programmes?

Exercising within the ‘fat burning zone’/FATmax involves a high oxidation of fat, which intuitively
seems like an appropriate intensity for clients wishing to reduce body fat. Additionally, a high capacity
to oxidise fat appears to be beneficial for metabolic health (Robinson et al., 2015). Nonetheless, fat loss
requires a negative energy balance to be achieved, which involves expending more energy than is
consumed through the diet (Flatt, 1993; Strasser et al., 2007). Although exercising at a higher intensity,
above the ‘fat burning zone’ decreases the rate of fat oxidation, it also increases energy expenditure,
which potentially creates a larger negative energy balance. The data presented in Figure 11.3 was
measured during a metabolic profile of a recreational distance runner. When comparing two training
sessions (one at FATmax v. one above FATmax) the session performed above the FATmax running speed
induces a greater energy expenditure (see Table 11.6). Consequently, it is prudent to focus on total energy
expenditure when devising a fat loss orientated training programme, as the fundamental component of
fat loss is achieving a long-term negative energy balance rather than the source of the calories used
during exercise.
Figure 11.6 Fat and carbohydrate oxidation at different exercise intensities.

Table 11.6 Fat oxidation and energy expenditure measured at different running speeds

Fat Total fat Total energy expenditure Weekly (3 sessions) energy

(g/min) oxidation (g)* (kcal)* expenditure (kcal)

FATmax:
0.59 17.7 326 978
10km/h

>FATmax:
0.48 14.4 361 1083
11km/h
* Total fat oxidation/energy expenditure during a 30-minute run.

Training methods for the fat loss related cardiorespiratory training programme

Traditionally CET has been implemented in fat loss orientated exercise programmes due to the ‘fat
burning zone’ concept discussed previously. However, as total energy expenditure is a fundamental
determinant of fat loss over time, the use of higher intensity training methods such as Fartlek and high-
intensity interval training can be appropriate (see chapter 12). Nonetheless, when working with clients
with limited CRF or exercise experience, it is sensible to incorporate an introductory period of CET
before introducing higher intensity training methods (see Case study 12.1).
Cardiorespiratory Training for Performance

Athletes competing in a number of sports require a high level of CRF. This is particularly important for
athletes competing in endurance sports (e.g. cycling, running, triathlon). Typically, clients wishing to
improve CRF for a particular sport or event will have some CRT background. If this is not the case they
should be prescribed a basic CRT programme, following the previously discussed health related
guidelines. As with any form of training, a progressive overload must be applied in order to achieve
further improvements in CRF. There is no specific reference point when a client should transition from a
health-focused programme to a performance orientated programme. However, in general, a six-week
period of regular CRT will prepare the client for more performance focused CRT.

Needs analysis

Assuming the client has achieved an appropriate base level of CRF, the focus of the programme should
gradually transition to achieve the client's performance related goals. Firstly, a needs analysis of the
client's sport/event should be conducted. This involves a systematic approach in identifying the
physiological requirements of the sport/event in order to design an appropriate training programme,
ensuring the client is working within the appropriate intensity domains (see Table 11.1). The following
example outlines a basic needs analysis for a client with a specific performance goal: running a
marathon.

Step 1: What is the marathon?

The marathon is a long-distance running event. The objective of the athlete competing in the marathon
is to complete 26.2 miles in the quickest possible time. Oxidative phosphorylation is the primary energy
producing metabolic pathway that is utilised (Coyle, 1995). Therefore, marathon performance is
dependent on a number of physiological variables related to the aerobic energy system.

Step 2: What are the physiological demands of the marathon?

The key physiological variables that are related to marathon performance include: max, running
economy (RE), fractional utilisation (FU), and the lactate threshold (LT) (Coyle, 1995; Jones & Carter,
2000; Tanaka & Matsuura, 1984). Research has suggested that max, RE and the LT explain >70 per
cent of the between-subject variance in long-distance running performance (Di Prampero et al., 1986).
Consequently, these physiological variables must be addressed within a marathon-focused CRT
programme (Jones & Carter, 2000; Pate & Branch, 1992). Furthermore, RE is proportional to body mass,
meaning the programme must also focus on achieving and maintaining a low body mass (Bergh et al.,
1991).

Step 3: Fitness assessment

The client's current level of fitness should be assessed using an appropriate test (see Chapter 6). In the
case of a performance CRF programme, this can be gauged through a recent personal best time alongside
specific tests to establish the client's strengths/weaknesses.

Step 4: Programme design

Following steps 1–3, the trainer can now design an appropriate training programme using the approach
outlined in Chapters 8 and 9.

Volume for performance related cardiorespiratory training programmes

As with CRT for health, there appears to be a dose-response to CRT for performance: higher training
volumes lead to greater improvements in fitness and performance, up to a point (Costill, 1986). Indeed, a
progressive increase in training volume is fundamental in endurance sports such as distance running
(Daniels, 2014). As discussed in Chapter 7, the client's trainability dictates that the rate of improvement
in fitness declines as the client engages in more training (i.e. a novice client will experience a faster
relative improvement in CRF than an experienced client). Furthermore, as training volume and intensity
are increased, appropriate recovery periods and techniques are required to facilitate adaptation (see
Chapters 7 & 16). There is scarce literature regarding the optimal training volume or intensity for
improving CRF amongst trained individuals, but observational studies have presented guidelines for
specific sports. For example, the volume threshold for endurance runners has been suggested to be in the
range of 60–90 miles/week or 10–15 hours of training (Costill, 1986). However, this only represents a
theoretical threshold for improving CRF amongst runners and not performance (e.g. race time).
Excessive training volumes and/or insufficient recovery can hinder performance (Halson &
Jeukendrup, 2004; McKenzie, 1999). Conversely, an insufficient training stimulus and excessive recovery
periods can lead to lack of progress or detraining (Neufer, 1989). Therefore, as a client's CRF improves,
successful exercise prescription involves the manipulation of training sessions that combine long
duration, low-intensity periods with phases of high-intensity training and suitable recovery. Achieving
the correct balance between overload and adequate recovery requires intricate and highly individualised
programming in order to gain further improvements in performance. Hence, training programme design
can be considered an art as well as a science.
If an increase in training volume is deemed necessary, the trainer must prescribe the increments in
accordance with the client's training availability and also factor in sufficient recovery periods. In general,
each increase in training volume should not exceed more than 10 per cent of the current training volume.
For example, a cyclist who completes 100 miles/week should limit any increase in weekly volume to 10
miles.

Intensity for performance related cardiorespiratory training programmes

Higher intensity CRT is required for trained clients to sufficiently overload the cardiorespiratory system
(Londeree, 1997). Indeed, improvements in physiological adaptations, such as increased max, do
not occur through increasing CRT volume alone in highly trained athletes (Londeree, 1997). Therefore,
methods of increasing exercise intensity, such as tempo and high-intensity interval training, must be
carefully programmed. However, as with CRT volume, any increases in intensity should be carefully
planned using a suitable periodisation strategy (see Chapter 9), which takes into account the demands of
the client's sport, competition period and lifestyle. For example, when designing a CRT programme for a
team sport athlete, any increases in CRT intensity should be considered alongside the demands of other
physical and technical training to ensure other sessions are not adversely affected and the risk of injury
due to fatigue is minimised (Bompa & Haff, 2009).

Training methods for performance related cardiorespiratory training programmes

Following the needs analysis process, the CRT methods should be selected based on the requirements of
the client's sport/event and the required physiological adaptations. A number of the CRT methods can be
used depending on the client's sport/event. These should be prescribed as part of a periodised training
programme (see Chapter 9).
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Chapter 12
High-intensity interval training

Paul Hough

High-intensity interval training (HIIT) is a form of exercise that involves brief, intermittent bouts of
high-intensity exercise, interspersed by periods of rest or low-intensity exercise. Athletes competing in
sports such as running and cycling have traditionally used this form of training to enhance athletic
performance (Billat, 2001). However, over the past decade a vast amount of research has been conducted
into HIIT in non-athletic populations. Traditional cardiorespiratory exercise recommendations have been
based on the continuous exercise training (CET) method (World Health Organization, 2010). Whilst this
form of training is highly effective at enhancing cardiorespiratory fitness (CRF), it can be time intensive.
Indeed, up to 250 minutes physical activity/week has been recommended to prevent increases in body
mass (American College of Sports Medicine [ACSM], 2009). Conversely, HIIT involves short duration
exercise sessions, with some studies utilising protocols as short as 15 minutes (Gibala & McGee, 2008).
The short duration format of HIIT is attractive from an exercise promotion perspective, as one of the
commonly cited barriers to engaging in regular exercise is ‘lack of time’ (Trost et al., 2002).
A number of HIIT studies have demonstrated similar and occasionally superior improvements in
health parameters and performance indicators, in up to half the time commitment of CET methods,
amongst trained and untrained individuals (Gibala et al., 2012; Kessler et al., 2012; Milanović et al., 2015;
Weston et al., 2013). In addition to the positive findings reported in untrained, healthy individuals, HIIT
has also been demonstrated to be an effective exercise strategy in various clinical populations: type 2
diabetes, coronary artery disease, heart failure, metabolic syndrome and obesity (Gibala et al., 2012).
General Benefits of HIIT

Increased cardiorespiratory fitness.

Improved exercise performance.
Increased skeletal muscle oxidative capacity.
Improved insulin sensitivity.
Reduced body fat.
Types of HIIT

HIIT relies on the careful manipulation of exercise intensity. Therefore, it is important to classify what
constitutes ‘high intensity’ exercise. In the following discussion, the term ‘maximal’ is used to define
exercise that elicits the maximum oxygen uptake ( max). The term ‘supra-maximal’ corresponds
with any exercise intensity performed above max (see Figure 12.1).
As with a number of training techniques, there is often confusion amongst practitioners regarding
terminology. The term ‘high-intensity’ may be interpreted as supra-maximal or ‘all-out’ work periods.
However, not all HIIT involves supra-maximal exercise. To distinguish the difference between protocols
it is practically useful to classify HIIT into two categories: sprint interval training and aerobic interval
training (see Figure 12.2).

Figure 12.1 Interval training intensity classifications.

Sprint Interval Training (SIT)

A number of studies have employed 3–4 repetitions of the Wingate test, which involves 30 seconds of
cycling against a high braking force on a cycle ergometer. This form of HIIT is characterised by supra-
maximal (all-out) work periods lasting 10–30 seconds with long recovery periods of ≥5 times the
duration of the work bout (Sloth et al., 2013). This form of HIIT is also known as low-volume HIIT due
to the short periods of high-intensity exercise.
Aerobic Interval Training (AIT)

The key distinguishing factor between SIT and aerobic interval training (AIT) is the exercise intensity.
Whereas SIT protocols involve supra-maximal work periods, which predominantly stress the anaerobic
energy system, AIT uses longer work periods, which place a greater demand on the aerobic energy
system (Withers et al., 1991). It is also important to consider the rest/recovery interval between work
periods, as a short (1–2 minutes) recovery time following a supra-maximal effort may not allow
complete recovery of the anaerobic energy systems. Thus, the ability to produce adenosine triphosphate
(ATP) rapidly will decline causing a reduction in exercise intensity (Bogdanis et al., 1996). As
rest/recovery time decreases, the demand on the aerobic energy system to supply the required ATP
increases (Parolin et al., 1999).

Long AIT

Long AIT can be broadly defined as extended work periods of 3–4 minutes of high-intensity exercise
performed at an intensity equivalent to 80–95 per cent max interspersed with 3–4 minutes of
active recovery for a total of 4–6 work periods (Kessler et al., 2012).

Short AIT

The short AIT approach involves shorter work periods of 15–60 seconds performed at 90–170 per cent
max. Unlike SIT, these work periods are not performed ‘all-out’ (i.e. not sprinting) and the
rest/recovery periods must be equal or slightly less than the work period. This allows cardiorespiratory
responses such as heart rate and oxygen consumption to remain elevated and the aerobic contribution to
ATP resynthesis to remain high (Zuniga et al., 2011). An early example of this type of HIIT was
implemented in a classical study by Tabata et al. (1996), whereby the participants performed 7–8
intervals of 20 seconds interspersed with 10 second recovery periods. This seminal study gave rise to the
popular ‘Tabata training’ protocol.
HIIT for Health

Low levels of CRF are associated with higher incidents of all-cause mortality, cardiovascular disease,
type 2 diabetes, and some cancers (LaMonte et al., 2005; Sui, LaMonte & Blair, 2007) and improvements
in CRF amongst sedentary individuals can reduce all-cause mortality risk by up to 40 per cent (Blair et
al., 1995). Furthermore, amongst individuals over 45 years, there is a gradual decline in CRF of around 8
per cent per decade, which corresponds with a decline in health and functional capacity (Jackson et al.,
2009). Therefore, as recommended by health organisations across the world, in order to increase and
maintain CRF throughout the lifespan it is essential to regularly participate in physical activity that
stresses the cardiorespiratory system (ACSM, 2009).

Figure 12.2 Example HIIT protocols.

Sprint interval training

Both SIT and AIT have been demonstrated to improve CRF (usually assessed through max)
amongst trained and untrained individuals, as well as clinical populations (Milanović et al., 2015;
Rognmo et al., 2004). Interestingly, improvements in max have been reported following 2–6 weeks
of SIT, despite the short duration of work periods involved (Astorino et al., 2012; Whyte et al., 2010). A
study which compared the effects of SIT against CET demonstrated similar improvements in muscle
oxidative capacity and exercise performance despite the significantly decreased training duration
involved in the SIT (135 minutes) group compared to the CET (630 minutes) group (Burgomaster et al.,
2008). The mechanism behind improvements in CRF following a period of SIT is likely due to the
bioenergetics of supra-maximal exercise. During a single supra-maximal 30 second sprint on a cycle
ergometer, the majority of the ATP is produced by anaerobic metabolism: approximately 25–30 per cent
of the ATP is resynthesised from the phosphagen system and the remaining 65–70 per cent is derived
from glycolysis (Bogdanis et al., 1995, Withers et al., 1991). However, as the number of work periods
increase, the contribution of ATP from aerobic metabolism significantly increases, even with long (4-
minute) recovery periods (Bogdanis et al., 1996). This may explain how, despite short exercise durations,
improvements in CRF have been reported following a period of SIT (see Table 12.1).

Aerobic interval training

Aerobic interval training protocols have also been demonstrated to be equally or often more effective in
improving max compared to CET. In an 8-week study both the short (15 seconds at 90–95 per cent
HRmax interspersed with 15 seconds of active recovery at 70 per cent HRmax) and long (4 minutes at
90–95 per cent HRmax interspersed with 3 minutes active recovery at 70 per cent HRmax) protocols
produced greater improvements in max than the CET method (45 minutes at 70 per cent HRmax)
(Helgerud et al., 2007). These improvements in CRF have been replicated in a number of studies (see
Table 12.1). Although a number of protocols have been demonstrated to be effective, the current evidence
suggests that exercise intensity is a critical factor in achieving health related physiological and
performance adaptations (Helgerud et al., 2007; Okura et al., 2003). For example, a lower-intensity (70 per
cent peak aerobic power) protocol was demonstrated to be less effective compared to a higher-intensity
(100 per cent peak aerobic power) protocol in enhancing CRF (Boyd et al., 2013). However, an optimal or
minimal volume of high-intensity exercise has not been identified, as this is dependent on the individual
(i.e. training status, CRF, adherence, etc.).

Case study 12.1 Establishing a cardiorespiratory fitness ‘base’

Tom is a sedentary, 40-year-old male (28 per cent body fat). He has been classified as pre-diabetic
and his doctor has advised him to participate in regular exercise. However, he has little exercise
experience and does not have much time to train due to a hectic work schedule. Due to Tom's lack
of time, the use of HIIT seems attractive. However, studies that have implemented HIIT with
sedentary and clinical populations have been conducted within a controlled and supervised
environment. The majority of studies have reported the training modality is safe and highly
 effective for a variety of populations. However, caution must be applied when prescribing HIIT for
sedentary populations within non-supervised settings, as initially the client may find it difficult to
regulate the required exercise intensity, which could pose potential safety issues. Consequently, Tom
is prescribed a 6-week introductory CET programme consisting of 3 × 20–30 minutes cycling
sessions p/w performed at 70–75 per cent of HRmax. Performing CET at the start of the programme
will enable Tom to engage with regular exercise, establish a routine and improve CRF. Following
this introductory period, an AIT protocol will be gradually introduced. The protocol will consist of
2-minute repetitions (80–85 per cent HRmax) separated by 3 minutes active recovery (50 per cent
HRmax), repeated for 4–5 repetitions. This type of protocol has proven to be effective amongst a
similar demographic (Boudou et al., 2003).

Table 12.1 High intensity interval training protocols for health outcomes

Health related physiological adaptations

Performing SIT and AIT can induce a number of adaptations similar to those achieved through CET
methods (Little et al., 2011). The possible mechanisms for improvements in max may be due to
both central and peripheral adaptations, such as an increase in stroke volume (Trilk et al., 2011) and up-
regulation of mitochondrial enzymes, which may improve the oxidative capacity of muscle (Burgomaster
et al., 2008; Gibala & McGee, 2008). The physiological adaptations that occur following HIIT are likely to
be dependent on the HIIT protocol used (see table 12.1). For example, the high level of type II muscle
fibre recruitment during SIT may produce greater oxidative adaptations in these fibres compared to AIT
(Bailey et al., 2009; Burgomaster et al., 2008; Ma et al., 2013). Whereas AIT may provide a greater
stimulus for central adaptations, such as enhanced cardiac output (Macpherson et al., 2011).
In addition to the cardiorespiratory benefits of HIIT, a number of studies have reported improvements
in metabolic health outcomes, such as enhanced glycaemic control and insulin sensitivity (Jelleyman et
al., 2015; Little et al., 2011). These benefits can be achieved following as little as six SIT sessions (Babraj
et al., 2009). Furthermore, studies in patients with cardiac and metabolic diseases have consistently
shown that 8–12 week HIIT programmes, performed on a cycle ergometer or treadmill, are safe and can
result in similar improvements in cardiometabolic risk factors (e.g. blood lipid profile, blood pressure,
body composition) in comparison to CET (Kessler et al., 2012).
Both SIT and AIT can be implemented to significantly improve CRF, metabolic health, and some
cardiometabolic risk factors. However, it is unclear if HIIT is more effective than other CRT techniques
(see Chapter 11) in improving these outcomes over a long period (>12 weeks). For instance, a study
involving 81 untrained males reported similar improvements in cardiometabolic risk factors and CRF
following a 16-week CET and HIIT intervention (Kemmler et al., 2014). Nevertheless, there may be a
psychological advantage in performing HIIT compared to CET.

The psychology of HIIT

As well as offering a number of health benefits, research also indicates that HIIT offers a number of
psychological advantages over CET, which may improve exercise adherence (Bartlett et al., 2011;
Kilpatrick et al., 2015). For example, a study in 2011 reported higher levels of perceived enjoyment
following HIIT compared to CET (Bartlett et al., 2011). The study also found that the participants
reported lower ratings of perceived exertion during and after a training session when compared to CET.
It is thought that the frequent rest periods of HIIT allow cognitive and physical recovery, although this
positive psychological benefit is reduced as work periods are extended (Price & Moss, 2007).
Consequently, if exercise adherence is a primary goal, it might be prudent to avoid AIT protocols
involving 3–4 minute work periods. (Kilpatrick et al., 2015).

HIIT safety

There has been a suggestion that the the high intensity nature of HIIT (particularly SIT) imposes some
potential health and safety concerns (Kessler et al., 2012). Indeed, injuries have been reported during a
12-week SIT intervention study in a cohort of overweight/obese participants (Lunt et al., 2014) and
during a 12-week running based AIT study (Nybo et al., 2010). Therefore, caution should be applied
when implementing HIIT amongst clients with limited HIIT experience. For these clients it might be
prudent to reduce the volume of the work periods (Helgerud et al., 2007). For untrained and sedentary
clients it is sensible to gradually progress the CRT programme by incorporating an introductory CET
period (4–6 weeks) before transitioning into AIT protocols (see case study 12.1). This approach can be
programmed using the traditional or block periodisation method (see Chapter 9). As with all forms of
exercise, the trainer must be aware of the following contraindications:

unstable angina pectoris

uncompensated heart failure
recent myocardial infarction (4 weeks)
recent coronary artery bypass graft or percutaneous coronary intervention (12 months)
heart disease that limits exercise (valvular, congenital, ischaemic and hypertrophic cardiomyopathy)
complex ventricular arrhythmias or heart block
severe chronic obstructive pulmonary, cerebrovascular disease or uncontrolled peripheral vascular
disease
uncontrolled diabetes mellitus
hypertensive patients with blood pressure 180/110 (or uncontrolled)
severe neuropathy.

(Weston et al., 2013)

HIIT practicality

Although HIIT has been demonstrated to induce a number of health benefits within experimental
laboratory conditions, less is known about its effectiveness in a ‘real-world’ setting. Indeed, the use of
SIT for sedentary populations has been strongly opposed by some (Hardcastle et al., 2014). One of the
reasons for this opposition is that high-intensity exercise has been associated with negative feelings and
poor exercise adherence (Ekkekakis et al., 2008). Lunt et al. (2014) conducted a controlled feasibility
walking/jogging HIIT study within a community park setting and found that the improvements in CRF
were modest within the HIIT group compared to the improvements observed in previous laboratory
studies. The authors speculated that the small improvement in CRF compared to previous studies was
due to a reduced adherence to the training programme (Lunt et al., 2014). Therefore, although HIIT is
highly effective under strict, supervised conditions, there is a possibility that the high-intensity nature of
the exercise might reduce adherence during a long-term unsupervised training programme. Finally, the
long-term benefits or potential disadvantages of HIIT are currently unknown in sedentary and clinical
populations, as most of the health orientated HIIT studies have been conducted over a period of 6–12
weeks.
HIIT for Decreasing Body Fat

As discussed in Chapter 11, conventional exercise programmes designed for fat loss have typically
focused on CET (Donnelly et al., 2009). Moderate intensity exercise in bouts of 30 minutes or more are
typically prescribed (Jakicic et al., 2001) with higher volumes of exercise being required for significant
reductions in body fat (Friedenreich et al., 2015). Whilst this approach has been an effective strategy in
some cases, disappointingly this type of exercise programme is often unsuccessful in reducing body fat
levels (Shaw et al., 2006). This has led researchers to explore the efficacy of different exercise methods,
such as HIIT and resistance training, for reducing body fat.

Body composition physiological adaptations

A number of theories have been proposed to explain how HIIT may reduce body fat. The main theories
revolve around an increased energy expenditure resulting in a negative energy balance (see Chapter 1).
The high-intensity nature of HIIT results in an elevated energy expenditure during the exercise and there
is an increase in energy expenditure for a number of hours following HIIT (LaForgia et al., 2006). This is
due to an excess post-exercise oxygen consumption (EPOC), which is driven by an elevation in metabolic
process, such as the removal of lactate/hydrogen ions and resynthesis of glycogen, all of which may
increase post-exercise fat metabolism (Hazel et al., 2012; Sevits et al., 2013). Indeed, HIIT has been shown
to increase fat oxidation during and after exercise, which may have a positive effect on metabolism and
whole body fat loss over time (Talanian et al., 2007). However, the magnitude of EPOC appears to be
reduced as fitness improves, suggesting clients with limited HIIT exposure may experience greater
relative changes in energy expenditure, fat oxidation and body fat compared to trained clients (Børsheim
& Bahr, 2003).
Another mechanism which may create a negative energy balance is a reduction in appetite following
HIIT. Exercise intensity has been suggested to influence circulating levels of hormones that influence
appetite. For example, cycling at 100 watts has been associated with lower ghrelin (hunger-stimulating
hormone) compared with cycling at 50 watts (Erdmann et al., 2007). High-intensity training also induces
large increases in blood lactate and circulating blood glucose, which may also suppress appetite
following HIIT (Lam et al., 2008). However, it is unclear if this acute suppression of appetite transpires
over a longer period (Bilski et al., 2009; Sim et al., 2015).

Evidence for fat loss following HIIT

One of the first studies to demonstrate a positive effect of HIIT on body composition compared HIIT
against CET during a 20-week intervention (Tremblay et al., 1994). The participants in the CET group
cycled for 4–5 times per week, for 30–45 minutes (60–80 per cent HRR) and the HIIT group performed a
mixed programme of 25 CET sessions (70 per cent HRR); 19 short and 16 long HIIT sessions over the
course of 15 weeks. The authors calculated the mean estimated total energy cost was greater in the CET
protocol (120 MJ) compared to the HIIT protocol (58 MJ). Therefore, when expressed relative to the
energy cost of the exercise, the reduction in body fat in the HIIT group was nine times greater (see
Figure 12.3) than the CET group (Tremblay et al., 1994). This study indicated that HIIT could promote fat
loss to a greater extent than CET. However, the duration of the HIIT protocol was progressively
increased, involved a high training frequency (5 sessions p/w), and the programme also included CET.
This detracts from one of the key advantages of HIIT (reduced time commitment), making the protocol
impractical for most clients, particularly sedentary and clinical populations. To address this issue, Trapp
et al. (2008) conducted a study using sedentary women, which employed a SIT protocol with a total
session duration of 20 minutes (8:12 seconds work:rest ratio). Following the 15-week study the SIT group
experienced a significant reduction in body fat (−2.5 kg) compared to the CET group (+0.44 kg). This
marked reduction in body fat has also been reported following a SIT programme using long (4-minute)
recovery periods between 30 second work bouts (Macpherson et al., 2011). In this study the reduction in
body fat was also greater in the SIT group (−12.4 per cent) compared to the CET group (−5.5 per cent).
Conversely, other studies have not reported significant changes in body fat following SIT (Astorino et al.,
2013) or AIT (da Rocha et al., 2016; Keating et al., 2014).

Figure 12.3 Change in body fat following a continuous exercise training programme vs. a high intensity interval training programme (20
weeks). (Adapted from Tremblay, Simoneau & Bouchard, 1994).
 Currently, the evidence to support the effectiveness of HIIT (without a concomitant dietary
intervention) for decreasing body fat is inconclusive. This discrepancy within the literature is probably
due to the numerous confounding factors between studies (i.e. dissimilar populations, protocols and
different levels of dietary control applied during the interventions). Despite this discrepancy within the
literature, HIIT is widely promoted within the fitness industry as an optimal fat loss strategy (Spira,
2015). Indeed, the protocol from the aforementioned Tabata et al. (1996) study is commonly promoted for
fat loss despite the fact that body fat was not measured in the study. Studies involving participants with
high levels of fat mass have typically resulted in a greater reduction in body fat (example: figure 12.3),
suggesting the amount of fat loss experienced after a period of HIIT may be greater in overweight/obese
clients (Gillen et al., 2013; Sijie et al., 2012; Trapp et al., 2008). Although there are reports of HIIT
decreasing body fat amongst trained athletes, it is not clear if the decreases are greater than those
achieved through CET (Shing et al., 2013). At present there is limited empirical evidence to support the
efficacy of HIIT in reducing body fat amongst trained individuals.
HIIT for Performance

As a client accrues more training experience improvements in performance become more gradual and
increasingly more difficult to achieve (see Chapter 7). Indeed, it is possible that there is a threshold
whereby simply increasing the volume of CET becomes ineffective amongst well trained clients (Turner
et al., 2003). Therefore, alternative training approaches are required to achieve greater physiological
effects and performance gains. The careful implementation of HIIT can enhance performance amongst
well trained athletes in endurance, multiple sprint and power sports (Laursen & Jenkins, 2002; Taylor et
al., 2015).

Performance related physiological adaptations

The performance improvements following HIIT have been attributed to changes in physiological
parameters such as max, anaerobic threshold and exercise economy (Billat et al., 2001; Paton &
Hopkins, 2004). Other physiological adaptations to HIIT, which may enhance performance, are
summarised in Figure 12.4. In accordance with the principle of specificity (see Chapter 7), the type of
HIIT protocol has a profound effect on the physiological adaptations that occur (Ross & Leveritt, 2001).

Aerobic interval training for performance

One of the fundamental physiological determinants of successful performance in endurance and many
team sports is a high max (Jones & Carter, 2000; Stolen et al., 2005). Previous research indicates
that the use of high-intensity training methods is optimal in improving max (Daniels, 2014;
Wenger & Bell, 1986), hence the popularity of HIIT amongst athletes. Although it is unclear if there is an
optimal HIIT training protocol for enhancing max, there is compelling evidence that training at
intensities near an intensity that elicits max (e.g. velocity at max) are optimal (Billat et al.,
2000; Daniels, 2014; Denadai et al., 2006). In practice, this equates to training at an intensity
corresponding to 90–100 per cent max.
Figure 12.4 Examples of physiological adaptations in relation to different HIIT protocols.

An accurate measurement of max is required in order to precisely train at an intensity

corresponding to 90–100 per cent of max. The gold standard is a laboratory based test to
exhaustion; however, this method often lacks practicality. To overcome this problem, heart rate (HR) can
be used as a proxy of oxygen consumption (i.e. training close to HRmax). This is because during
incremental exercise oxygen consumption and heart rate both share a similar linear relationship.
However, HR does not immediately respond to changes in exercise intensity, meaning the use of HR to
gauge the intensity of short (10–120 seconds) work periods during HIIT is problematic. To overcome this
issue, various pacing guidelines can be used. A popular approach is the ‘VDOT system’, which was
developed by exercise physiologist and running coach Jack Daniels (1998). This system was developed
based on physiological data collected from a large cohort of runners of differing abilities to construct
VDOT tables. These tables estimate race times based on an athlete's personal best times across a range of
distances (1500 m – Marathon). The VDOT tables can also be used to prescribe specific intensities at
which to perform different types of training, such as high-intensity intervals (Daniels, 1998). For further
information see Daniels (2014).

Sport-specific HIIT

In untrained clients, a non-specific HIIT intervention can have a positive effect on performance
(Denham et al., 2015). However, when implementing HIIT within the training programme of a trained
client competing in a particular sport it is essential to analyse the physiological demands of the sport.
This must be done in order to prescribe an appropriate intensity and work:rest ratio that will enhance
sport-specific CRF and performance outcomes (Walklate et al., 2009; Wenger & Bell, 1986). Driller and
colleagues (2009) conducted a HIIT study using trained rowers whereby the athletes were split into HIIT
and CET groups. The HIIT protocol involved 8 × 2.5 minute intervals at 90 per cent of the velocity
maintained at peak, as this allowed the athletes to train close to competition intensity for a
prolonged period of time without experiencing excessive fatigue. This protocol proved to be effective, as
the HIIT group experienced greater improvements in 2000 m time and relative peak compared to
the CET group who performed 55–60 minute CET sessions. Similar findings have also been reported in
trained cyclists (Lindsay et al., 1996), runners (Esfarjani & Laursen, 2007), soccer players (Gunnarsson et
al., 2012) and ice hockey players (Naimo et al., 2015) following a period of HIIT.
In addition to the intensity of the work periods, it is also important to consider the volume of HIIT
sessions, as implementing an appropriate volume of HIIT can reduce overall cardiorespiratory training
volume, which may reduce general stress and improve recovery in highly trained individuals (Elbe et al.,
2015). Therefore, achieving the correct balance of volume and intensity is fundamental when devising
HIIT programmes for trained clients. To investigate this issue Seiler et al. (2013) compared the effects of
three different HIIT programmes in trained cyclists: 4 × 4 minutes (at 94 per cent HRmax), 4 × 8 minutes
(at 90 per cent HRmax) and 4 × 16 minutes (at 88 per cent HRmax). The researchers found that the 4 × 8
minutes (at 90 per cent HRmax) protocol produced the greatest improvements in physiological
performance indicators ( peak, absolute and relative power), suggesting that there is an interaction
between volume and intensity in trained cyclists.
As highlighted in Table 12.2, HIIT is a proven method for enhancing CRF and performance in trained
individuals. However, to improve sport-specific performance, the typical activity profile of the client's
sport must be considered (Buchheit & Laursen, 2013). Typically, HIIT is structured using set work:rest
ratios, but this does not reflect the sporadic activity patterns of sports such as football or tennis.
Therefore, sport-specific conditioning activities, which blend physical, technical and tactical training,
should also be implemented within the general training programme. For example, Fartlek training
sessions (see Chapter 11) can be designed to reflect an activity profile of a particular sport which
involves irregular work:rest periods.
The bioenergetics (energy systems) of the client's sport must also be considered when designing HIIT
protocols (Linossier et al., 1993). For example, the use of SIT might be more applicable to sports/events
which rely heavily on anaerobic metabolism (e.g. long jump), whereas AIT may be more applicable to
sports which are dependent on aerobic metabolism (see Case study 12.2). Therefore, sport-specific HIIT
sessions should be prescribed based on the activity profile and the desired physiological adaptations that
are required (see Figure 12.4).

Table 12.2 High intensity interval training protocols for performance outcomes
Case study 12.2 Aerobic interval training
Jenny is a 32-year-old endurance runner whose specialist distance is 10 km. She typically performs
three steady (CET) sessions per week and one shorter tempo (race pace) session. As Jenny does not
routinely perform HIIT, this training method will impose a novel training stress, which should
induce improvements in the physiological determinants ( max and running economy) of 10 km
running performance (Evans et al., 1995). Although improvements in max can be achieved
with various HIIT protocols (Laursen et al., 2002; Rodas et al., 2000), it is important to consider the
distance and average velocity involved in the client's sport. In the case of 10 km the average
intensity typically corresponds to 90–94 per cent of max (Daniels, 2014). Therefore, in order to
accumulate training time close to max and optimally stress the aerobic energy system, Jenny
has been prescribed AIT incorporating 3–4 minute work periods (Esfarjani & Laursen, 2007). As the
competitive phase approaches (see Chapter 9) SIT (e.g. 20 seconds work, 2 minutes recovery) will be
incorporated to provide variation by reducing training volume and increasing intensity. Moreover,
the SIT may also improve Jenny's anaerobic capacity, which is important for when maximal efforts
are required (e.g. a sprint finish).
HIIT Programme Design

Numerous scientific studies demonstrate that HIIT is a time efficient training method for a variety of
clients from clinical populations to elite athletes. In general, the current research demonstrates:

Long and short AIT protocols improve CRF, cardiometabolic risk factors and performance outcomes
amongst a variety of populations across the health-performance training continuum (see Chapter 7).
SIT protocols consisting of 20–30 seconds work periods interspersed with long (3–4 minutes)
recovery periods can improve cardiometabolic risk factors, anaerobic performance and (in some
cases) promote fat loss.
Both SIT and AIT can improve sports performance outcomes provided sport-specific work:rest
ratios are used.

Numerous protocols have been applied within the HIIT literature (with a variety of populations)
meaning it not possible to deduce if there is an optimal protocol for a certain population or training goal.
The exercise intensity appears to be the most important variable when devising a HIIT programme and
should be carefully monitored (Boyd et al., 2013; O'Donovan et al., 2005). The trainer must also interpret
and implement the findings from the HIIT literature in respect to their client's capabilities and goals.
Whilst a number of studies have demonstrated HIIT can be effective in sedentary and clinical
populations, it is important to consider the client's base level of CRF before implementing a HIIT
programme. There is a positive relationship between CRF and recovery from high-intensity work
periods, whereby individuals with higher levels of CRF are generally able to recover more quickly from
periods of high-intensity exercise and thus maintain higher average exercise intensities (Aziz et al., 2000;
Hoffman, 1997). There are a number of physiological mechanisms responsible for this, such as a faster
rate of phosphocreatine resynthesis and recycling of metabolites during the recovery period (Tomlin &
Wenger, 2001). With this in mind, when working with clients with low levels of CRF, it is prudent to
perform CET or conservative AIT initially (see Case study 12.1). Finally, as with all training methods,
there exists an individual response to HIIT. Consequently, caution must be applied when applying
protocols used within short-term intervention studies to individual clients.
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Chapter 13
Resistance training

Paul Hough

Resistance training (RT) is a form of exercise which is universally performed by a range of individuals
from clinical populations to elite athletes. A well-implemented, long-term RT programme leads to a wide
range of positive effects including: increasing strength, muscle size (hypertrophy), power, and improving
various health outcomes. A primary adaptation of any RT programme is an improvement in muscle
strength (i.e. the ability of a muscle to produce external force), hence why RT is also known as ‘strength
training’. The improvement in strength following RT is achieved through a combination of adaptations
within the muscular, nervous and endocrine systems and the type of adaptation that occurs is highly
dependent on the training stimulus. Programme variables such as volume, intensity and rest periods can
be manipulated in order to bring about specific adaptations based on the goals of the RT
session/programme.
Resistance Training Adaptations

Muscle adaptations

Skeletal muscle is composed of a diverse range of fibre types, which have different contractile and
metabolic properties. These fibres can be broadly categorised into two domains: type I and type II fibres.
Type I fibres (slow twitch) have high concentrations of mitochondria and aerobic enzymes, meaning they
are resistant to fatigue and are used extensively during endurance type activities, such as long distance
running. Type II fibres have faster shortening and relaxation speeds, and anaerobic properties. These
fibres can produce higher levels of force compared to type I fibres and are involved in high-intensity
activities, such as sprinting and weightlifting. Every individual has a different combination of type I and
type II fibres, which partly explains why some individuals are more suited and successful at certain
activities (MacArthur & North, 2007). For example, athletes who succeed in strength/power sports have a
greater number of specific type II fibres (Fry et al., 2003). Although muscle fibre type composition is
hereditary, it is possible for the characteristics of the fibres to be modified through training (Fry, 2004;
Häkkinen & Keskinen, 1989), but the fibres cannot change from one type to another (i.e. a type I fibre
cannot become a type II fibre). The degree to which the fibres can be modified is dependent on the
training programme and genetic profile of the client.

Table 13.1 Neurological adaptations to resistance training

Adaptation Meaning

↑ Motor unit An increase in the number of motor units that can be recruited (Folland &
recruitment Williams, 2007)

↑ Motor unit An increase in the probability of motor units firing at a near-simultaneous

synchronisation discharge rate (Felici et al., 2001)

An increase in the motor unit firing rates (action potentials per unit of time)
↑ Rate coding
(Leong et al., 1999)

Neural adaptations

Strength gains can be made without structural changes in muscle due to various adaptations that occur
within the nervous system (Carroll et al., 2001; Ploutz et al., 1994). Indeed, the initial strength
improvements at the onset (1–8 weeks) of an RT programme predominantly occur due to neural
adaptations (see Table 13.1) (Cote et al., 1988; Hoffman et al., 2009). Following this initial period there is a
gradual increase in hypertrophic factors (see page 180), which are associated with improvements in
strength (Häkkinen & Komi, 1983; Seynnes et al., 2007).

Genetics

In order to manage client expectations and design effective RT programmes it is important to recognise
that the adaptations to a RT programme will vary between clients based on non-modifiable genetic
factors. For example, the variance in maximal strength (one-repetition maximum) gains has been shown
to range from zero per cent to 250 per cent between participants following the same RT programme
(Hubal et al., 2005). This demonstrates that the effect of a particular RT programme will not be uniform
between clients. For example, clients with a greater proportion of type II muscle fibres might experience
larger improvements in strength than clients dominant in type I muscle fibres despite following an
identical RT programme. Therefore, a ‘one-size-fits-all’ approach should not be adopted when designing
and implementing RT programmes.
Resistance Training Terminology

In RT the load/resistance lifted has a profound effect on the acute and chronic physiological adaptations
that occur. Clearly, absolute training load (i.e. specific load) recommendations cannot be made and must
be selected based on the client's training status, body size and goals. Consequently, RT load is expressed
relative to the client's strength, which is usually assessed using a 1RM or repetition maximum (RM)
approach (see Chapter 8). Training load zones have been broadly defined within the RT literature as ‘low,
moderate or heavy’ (American College of Sports Medicine [ACSM], 2009). However, the exact
classification of these zones often varies between practitioners. This is also the case for rest periods,
which are typically defined as ‘short’ or ‘long’. The RT zones and rest periods which will be referred to
within this chapter are summarised in Table 13.2.

Table 13.2 Resistance training classifications

Training status
The amount of time the client has been consistently (2 + sessions per week) training for

Novice (untrained) Intermediate (trained) Advanced (trained)

< 6 months experience 6–12 months experience >12 months experience
Absolute load
The amount of load/resistance used for an exercise

Relative load
The load used relative to the client's strength

Low load Moderate load Heavy load

<65% 1 RM 65–85% 1RM ≥85% 1RM
≥12 RM ≥6–12 RM ≤6 RM

Volume: the total amount of load lifted during a RT session

Repetition volume: the total number of repetitions performed during a RT session

Volume-load: combines the intensity (load) and volume (total repetitions)

E.g. 3 sets of 10 repetitions with 60 kg
3 × 10 x 60 = 1800 kg

Rest periods
Short Moderate Long
 < 1 minute 1–2 minutes >2–5 minutes

Muscle actions
Concentric Isometric Eccentric
The muscle shortens The muscle length does not change The muscle lengthens under tension
Resistance Training Methods

The most common system of structuring RT is the straight set method, which involves performing a
defined number of repetitions (a set) followed by a rest period before the subsequent set. There are
numerous set schemes that can be employed, whereby the load/repetitions can remain constant or varied
between sets. The prescribed load will vary depending on the RT goals. Examples of different set
schemes are presented in Figure 13.1.

Figure 13.1 Example resistance training set sequencing schemes.

Exercises can also be performed consecutively as part of an advanced RT method (see Table 13.3) or as
a circuit. The circuit approach involves performing a sequence of consecutive RT exercises for a defined
number of repetitions or set amount of time. This approach is often used to save time and can also
provide a cardiorespiratory training stimulus due to the minimal rest periods between exercises (Steele et
al., 2012). However, the circuit approach can compromise intensity and be impractical in certain
scenarios (e.g. individual circuit training in a busy gym).

Progression

Over a period of time a progressive overload must be applied in order to achieve further adaptations (see
Chapter 7). This can be achieved by modifying one or more acute programme variables (e.g. volume,
intensity etc.). In a periodised programme these variables are systematically modified over long periods.
However, a monitoring strategy is required between sessions to enable the trainer to decide if the client
is able to make short-term progressions.

When and what to progress?

A general recommendation is to apply a 2–10 per cent increase in load when the client can perform the
current workload for one–two repetitions over the desired number on two consecutive training sessions
(ACSM, 2009). However, the size of the increment will vary depending on the exercise, client training
status, and equipment. For example, larger increments in the range of 2.5–5 kg (5–10 lbs) are usually
possible in multiple-joint exercises, such as a dead lift. Conversely, exercises involving smaller muscle
groups require smaller increments in the region of 1.25–2.5 kg (2.5–5 lbs). Moreover, as a client accrues
RT experience and less trainability (see Chapter 7), the load progression will typically become smaller.
Novice clients may be able to increase resistance by 5 per cent to 10 per cent, whereas 2 per cent to 5 per
cent increments may be more appropriate and realistic for advanced clients.
Another progression approach is the ‘two repetitions for two sets’ method whereby the training load is
increased when the client can perform two or more repetitions above the prescribed number of
repetitions for two consecutive sets (without compromising technique). For example, if a client was
prescribed 3 × 10 repetitions and they were able to perform 1 × 10 and 2 × 12, a higher load could be
prescribed. Alternatively, the training volume for subsequent sessions could be increased (i.e. 3 × 11
instead of 3 × 10). The programme variable that is progressed will depend on the training goal. For
example, intensity is important for strength focused programmes, whereas hypertrophy programmes
favor a higher training volume.

Advanced methods

In addition to a basic increase in load or repetitions, a number of methods can be implemented to

increase RT volume and/or intensity, creating an additional overload. These methods are often referred
to as ‘advanced methods’ (see Table 13.3). All of these methods should be implemented based on a
client's fitness status and goals. The methods are not recommended for untrained clients.

Table 13.3 Advanced resistance training methods

Method Description Primary purpose

↑ volume (sets)
Supersets/paired Two exercises for opposing muscle groups performed in succession ↑ density (more
sets without rest (e.g. bench press and barbell row) work within a set
time)

↑ volume (sets)
Two exercises for the same muscle group performed in succession ↑ density (more
Compound sets without rest (e.g. bench press and dumbbell flys) work within a set
time)

↑ volume (sets)
Three exercises for the same muscle group performed in succession ↑ density (more
Tri-sets
without rest work within a set
time)

↑ volume (sets)
Four–five exercises for the same muscle group performed in ↑ density (more
Giant sets
succession without rest work within a set
time)

Forced/assisted A spotter provides the lifter with enough assistance to overcome the ↑ volume
repetitions sticking point in the repetition (repetitions)

↑ Intensity
Repetitions performed within a lesser range of motion than typically
Partial (relative load)
performed (e.g. achieving 70 ° knee flexion instead of 90 ° during the
Repetitions ↑ volume
squat)
(repetitions)

↑ Intensity
(relative load)
Cheating Breaking strict exercise form to continue to perform an exercise
↑ volume
(repetitions)

Drop sets/strip Decreasing the resistance used immediately after reaching ↑ volume
sets repetition failure to allow the performance of additional repetitions (repetitions)

Focussing on the eccentric component of an exercise using a load

Eccentric
greater than can be lifted concentrically (i.e. > 1RM) ↑ Intensity
training/heavy
This usually requires a spotter to assist with the concentric (relative load)
negatives
component of an exercise

Alternative methods of progression

It is important to recognise that the body adapts to a stress, not a specific number (load or repetitions).
Most RT programmes are based on providing an overload quantitatively (i.e. more load and/or
repetitions). However, there are other methods that can be applied to increase the physiological stress.
Frequency

Training frequency refers to the number of sessions performed within a set time frame (e.g. one week).
The weekly training frequency should be based on a client's fitness status, availability and training goals.
As a client's fitness improves they will be able to tolerate a higher frequency of RT. To improve health,
individuals are recommended to perform RT twice a week (ACSM, 2009, 2014). Novice clients will
experience improvements with two RT sessions per week, whereas intermediate and advanced clients
will require a higher training frequency of three to six sessions per week. Increasing training frequency
is a simple method to increase weekly (total) training volume.

Rest periods and training density

Managing time effectively within an RT session increases training density (i.e. more work completed in
the same time, or the same work completed in less time). An example method to increase training
density is to perform exercises as a ‘super-set’ (see Table 13.3). This reduces the total session duration due
to a decrease in the rest periods between sets and is a productive strategy for clients who are restricted
on training time.

Tempo

Tempo is the speed at which a repetition of an exercise is performed and is dictated by the load: as the
load becomes heavier the muscles require more time to produce force, so the concentric portion of the
exercise naturally becomes slower. The concentric duration is also increased towards the end of a set due
to fatigue. Tempo is often conveyed as a three-number sequence; each number represents time in seconds
(e.g. 1–1–3). The first number is the time taken to complete the concentric action; the second number is
the transition (isometric) phase between the concentric and eccentric actions (e.g. the bottom of a squat);
the third number is the time to complete the eccentric action. In most cases, a general tempo of 1–1–2 or
1–1–3 is recommended for the majority of RT exercises. This general tempo recommendation ensures the
muscles are fully activated throughout the exercise. The tempo of an exercise can be changed to increase
the time the muscles are under tension during an exercise and provide an overload (see Table 13.4).
However, advanced tempo techniques are not recommended for untrained clients.

Table 13.4 Advanced resistance training tempo techniques

Tempo (seconds) (concentric-

Technique Purpose
isometric-eccentric)

↑ Time under
Slow eccentric: a deliberately slow eccentric tension
1–1–4 or 1–1–5
action ↑ Muscle
damage
 ↑ Time under
Isometric pause: one extended pause after the tension
1–3–2
concentric action ↑ Exercise
technique

↑ Time under
Eccentric pauses: two pauses during the eccentric tension
1–1–2–2
action ↑ Muscle
damage

During the concentric action of an exercise the goal should be to lift the load as quickly as possible. If the
concentric portion of the lift is performed intentionally slowly this can reduce muscle activation,
resulting in sub-optimal adaptations (Keogh et al., 1999; Schuenke et al., 2012). When using very light
loads (50 per cent 1RM) a slightly slower (2 seconds) concentric action may be required to ensure the
load is fully under control. In most RT exercises, a 1-second isometric pause is recommended at the end
of the concentric action to maintain good exercise form. The eccentric action should be performed at a
slower speed (1–3 seconds). This encourages the eccentric action to be performed under control. If the
eccentric action is performed rapidly, muscle activation is decreased resulting in a sub-optimal technique
and potential injury. If the eccentric action is repeatedly performed slower (>3 seconds), the client is
likely to experience greater levels of muscle damage and delayed onset of muscle soreness.
Resistance Training for Health

Traditionally, health related exercise programmes have focused on cardiorespiratory training. However,
regular RT is now recommended by leading health organisations due to the numerous positive health
outcomes that can be achieved amongst a variety of populations (see Figure 13.2). One of these outcomes
is a reduction in the loss of muscle mass that occurs with aging. A decrease in muscular strength and
muscle mass are two of the most significant changes that occur with aging. Indeed, elderly adults who do
not perform RT can experience up to a 50 per cent reduction in type II muscle fibres (Larsson, 1983).
Skeletal muscle is important for carrying out activities of daily living, such as climbing stairs and lifting
heavy objects. Subsequently, a loss of muscle mass and strength is predictive of functional limitation and
physical disability in older people. Several longitudinal studies have documented that RT increases
muscle mass (hypertrophy) resulting in an improvement in physical capacity (Bouchard et al., 2009;
Rantanen et al., 2002). Moreover, muscle is a metabolically active tissue that contributes to the resting
metabolic rate (Bosy-Westphal et al., 2004; Reeds et al., 1982). Therefore, preserving muscle mass can also
reduce the age decline in resting energy expenditure; this may also reduce the increase in body fat that
occurs with aging, as well as improving metabolic function.
Figure 13.2 The health benefits of resistance training.

Metabolism

Aging is associated with a number of biochemical alterations that increase the risk of developing
cardiovascular and metabolic diseases – these changes are accelerated by lifestyle factors (e.g. lack of
physical activity and poor diet). Skeletal muscle influences a variety of metabolic risk factors (Strasser &
Schobersberger, 2011) and regular RT has been demonstrated to improve a number of metabolic health
markers, such as C-reactive protein (an inflammation biomarker) and blood lipids (Olson et al., 2007;
Phillips et al., 2012; Williams et al., 2011). One of the most promising metabolic effects of RT is improving
glucose and insulin metabolism. Insulin is a hormone that allows cells throughout the body to absorb
glucose from the blood. When the cells do not respond adequately to insulin (insulin resistance) this
causes elevated levels of blood glucose (Khan & Flier, 2000). Chronically elevated blood glucose levels are
the predominant symptom of individuals suffering from diabetes mellitus and can increase the risk of
cardiovascular and other metabolic diseases. Muscle tissue is the largest disposal site for ingested glucose
and plays an important role in glucose metabolism (Holloszy, 2005). Therefore, increasing muscle mass
can improve glucose metabolism. Studies have shown that improved glucose uptake is not purely a
consequence of an increase in muscle, but is likely a result of favourable metabolic changes within
muscle, such as enhancement of insulin action (Ishii et al., 1998; Ribeiro et al., 2016).

Resistance training for health recommendations

Due to the positive impact RT can have on health, at least two RT sessions per week are recommended
for all clients without contraindications (ACSM, 2009). Untrained clients will benefit from a range of
exercises that target the major muscle groups. The use of resistance machines, focusing on multiple-joint
(MJ) exercises (e.g. leg press) is recommended at the onset of an RT programme to build strength and
condition the joints. Following these exercises, single-joint (SJ) free-weight exercises should be
performed to target the smaller muscle groups. Free-weight MJ exercises can be gradually introduced as
the client's strength and exercise competency improves.

Intensity for health RT programmes

A number of RT protocols are effective in improving strength and hypertrophy amongst untrained
clients (Souza et al., 2014). Light loads of approximately 45–50 per cent of 1RM may increase dynamic
muscular strength in previously untrained clients due to neurological adaptations, such as improved
motor learning and coordination (Anderson & Kearney, 1982; Rutherford & Jones, 1986). In some cases
the use of light loads may also improve cardiorespiratory fitness (CRF) due to physiological adaptations
that affect muscular endurance, such as an increase in capillary and mitochondrial density (Holloszy &
Coyle, 1984; Stone & Coulter, 1994). For novice clients, low loads (50–65 per cent 1RM) can be used to
improve strength and achieve health benefits. The use of moderate loads (65–85 per cent 1RM) can be
introduced as clients develop RT experience. However, heavy loads (≥85 per cent 1RM) are not
recommended for novice clients as this can increase the difficulty of developing the correct exercise
technique, particularly with free-weight exercises.

Volume for health RT programmes

Performing one set of each exercise is sufficient to enhance muscle function and physical performance in
untrained clients (Galvão & Taaffe, 2005). However, multiple sets (2–3) will lead to greater strength gains
than one set in both trained and untrained clients (Krieger, 2010).

Rest periods for health RT programmes

In general, untrained clients will require moderate recovery (1–2 minutes) periods between sets of MJ
exercises as they are more metabolically and technically demanding than SJ exercises (Elliot et al., 1992).
Trained clients, using moderate–heavy loads, may require long rest periods between MJ exercises to
achieve sufficient recovery and maintain exercise volume. In both untrained and trained clients, short
rest periods are usually sufficient following low-intensity, SJ exercises (e.g. bicep curls).

Summary
Novice clients should perform RT for a minimum of two days per week using loads
corresponding to 50–65 per cent 1RM, for two to three sets per exercise.
Multiple-joint exercises should be performed where possible.
Moderate (1–2 minutes) rest periods are recommended between sets.
Where appropriate, load and volume should be gradually increased over the course of a
programme.
Resistance Training for Hypertrophy

Muscular hypertrophy is an increase in muscle cross-sectional area (CSA) and mass. Many individuals
who engage in an RT programme do so to increase muscle size for aesthetic or functional reasons.
Hypertrophy is advantageous for clients wishing to increase strength, as there is a strong relationship
between muscle (CSA) and strength (Häkkinen & Komi, 1983; Seynnes et al., 2007). Novice clients can
experience 10–15 per cent increases in muscle CSA after only 10–14 weeks of RT (Holm et al., 2008;
Rønnestad et al., 2007). However, there is a large variance between individuals in the level of muscle
hypertrophy that occurs following RT. This is due to a number of factors such as genetics, age, gender
(see Box 9.1) and nutritional practices (Van Etten et al., 1994). Consequently, some clients will experience
greater levels of hypertrophy than others despite engaging in the same RT programme. Large differences
also exist in respect to the hypertrophy rate/magnitude between different muscles. Indeed, at the onset of
an RT programme the upper extremities tend to experience hypertrophy at a faster rate than the lower
extremities (Tesch, 1988). Although hypertrophy is particularly important to athletes competing in sports
that require high levels of strength and/or muscle mass (e.g. rugby players, wrestlers, bodybuilders), it is
also important from a health perspective (see page 178).

What causes hypertrophy?

The primary mechanism responsible for skeletal muscle hypertrophy is a net increase in the number of
myofibrillar proteins within a muscle (MacDougal et al., 1984; Phillips, 2014; Schoenfeld, 2010). When
muscles experience a mechanical load during RT, a number of sensory receptors (mechanosensors)
located within the soft tissues are activated; the activation of the mechanosensors is influenced by by the
size of the load as well as the duration the tissues are exposed to the load (time under tension). The
mechanical forces within the muscle initiate a cascade of intracellular molecular events, which increase
anabolic and catabolic processes. This involves a series of complex interactions between signalling
agents, hormones, growth factors and myokines (Coffey & Hawley, 2007; Nader et al., 2014; Ogasawara
et al., 2016; Roux & Blenis, 2004). When the rate of muscle protein synthesis exceeds muscle protein
breakdown, this results in an increase in muscle cross sectional area (CSA) (Glass, 2005; Morkin, 1970).
However, the precise mechanisms that initiate an increase in protein synthesis and decrease in protein
degradation following RT are extremely complex and yet to be fully clarified.
Three fundamental factors have been identified for initiating the hypertrophic process: mechanical
tension, metabolic stress and muscle damage (Ozaki et al., 2015; Schoenfeld, 2010). Whilst all three
factors play a role in the hypertrophic process, research indicates that mechanical tension and metabolic
stress are fundamental mediators (Adams & Bamman, 2012; Ozaki et al., 2015).

Mechanical tension
During an RT exercise the active muscles are required to generate force to overcome a resistance or load.
This leads to the development of mechanical tension (MT) within the muscles. The MT increases in
parallel with the amount of force required to overcome the resistance (i.e. MT increases as the resistance
is increased). Both the magnitude of MT and duration that the muscles are under MT (time under
tension) are important stimulators of muscle hypertrophy (ACSM, 2009; Fry, 2004).

Metabolic stress

Metabolic stress during exercise occurs when the energy demand of the working muscles is supplied by
anaerobic glycolysis, which is typically accompanied by increased cell swelling, a decrease in venous
return, and the accumulation of metabolites, such as lactate (Tesch et al., 1986). In order to induce high
levels of metabolic stress it is necessary to perform exercises for a sufficient duration to induce muscle
hypoxia (lack of oxygen) and the build-up of metabolites, hence why loads corresponding to 8–12RM are
often recommended for hypertrophy.

Muscle damage

Case study 13.1 ‘No pain, no gain’

Jane has been performing RT for a year and has improved her strength and overall fitness. However,
she believes that her trainer is no longer pushing her hard enough during her sessions because she
does not feel sore the next day as she used to. Exercise-induced muscle damage (EIMD) is often
experienced after RT leading to feelings of soreness for up to 2 days following the training session.
The degree of soreness tends to be worse in novice clients or following unaccustomed exercise, as in
either case the muscles become damaged due to a novel stress. However, as muscles adapt they
become less susceptible to EIMD following repeated exposure to the same exercise. This is known as
‘the repeated bout effect’ and explains why EIMD and subsequent muscle soreness decrease as a
client accrues RT experience (Nosaka et al., 2003). Therefore, it is unwise to judge the effectiveness
of an RT session based on feelings of soreness, as physiological adaptations take place in absence of
muscle soreness.

Exercise training often causes damage to the muscle fibres and muscle cell architecture. This
phenomenon is referred to as exercise-induced muscle damage (EIMD) and is more severe following
unaccustomed exercise (see Chapter 16). Exercise-induced muscle damage temporarily disrupts cellular
processes and decreases muscle function (Allen et al., 2005). It has been hypothesised that EIMD caused
by RT influences gene expression, which results in structural changes that strengthen and enlarge muscle
fibres. This has led to some hypertrophy RT programmes aiming to create high levels of muscle damage
– the so-called ‘no pain, no gain’ mentality (see Box 13.1). EIMD has been identified as a factor in the
hypertrophic process (Evans & Cannon, 1991; Schoenfeld, 2012), but it is difficult to determine exactly
how fundamental EIMD is, as mechanical tension and metabolic stress both contribute to EIMD.
Furthermore, hypertrophy can occur in the absence of EIMD suggesting that mechanical tension and
metabolic stress may be more important in the hypertrophic process (Schoenfeld, 2012).

Hypertrophy intensity

Skeletal muscle hypertrophy occurs in both type I and type II fibres. However, type II fibres have the
greatest potential for growth (Wagner, 1996). During RT, motor units (MUs) are selectively recruited
depending on the amount of force required to move a given load (Enoka, 2015; Looney et al., 2015). The
size principle of motor unit recruitment states that when lifting a light load the small MUs, with the
lowest firing frequencies, are recruited and the larger MUs are recruited as the demand for force
production increases (Henneman, 1957; Sale, 1987). Therefore, loads above 60 per cent of 1RM (8–12RM)
are typically recommended to recruit type II fibres and maximise hypertrophy (ACSM, 2009; Tan, 1999).
These recommendations are based on the premise that lighter loads (<60 per cent of 1RM) are insufficient
to impose high levels of mechanical tension and activate the full spectrum of muscle fibre types,
particularly the type II fibres with the largest MUs. However, the findings of RT research indicate that a
large individual difference exists in hypertrophy and strength improvements following both low load
(<65 per cent of 1RM) and higher intensity (65–85 per cent of 1RM) RT programmes. Studies have
demonstrated that significant hypertrophy can occur when using low loads, provided the exercises are
performed to repetition failure (see training to failure). Therefore, in order to enhance hypertrophy, a
number of loading protocols can and should be applied within a periodised RT programme.

Training to failure for hypertrophy

The point at which an individual can no longer lift a load during an RT exercise is known as repetition
failure (RF). The RF usually occurs during the concentric phase of the repetition when the muscles fail to
produce an adequate amount of force to move the resistance past a specific joint angle. Reaching RF is a
common practice in both athletic and recreational RT programmes, but the rationale and
recommendations for using the approach remain diverse within the literature (Fleck & Schutt, 1985; Tan,
1999). Studies have demonstrated that performing an exercise to RF significantly increases metabolic
stress, which has been thought to increase the recruitment of high-threshold MUs (Burd et al., 2010;
Loenneke et al., 2011; Rooney et al., 1994). However, the increased muscle activation theory is
contentious (see page 188). The associated metabolic stress caused by performing exercises to RF can also
induce a number of cellular and biochemical processes which can increase the hypertrophic response
(Burd et al., 2013).
Burd and colleagues (2010) investigated the effect of RT on markers of muscle hypertrophy using two
different loading strategies performed to RF (30 per cent of 1RM v. 90 per cent of 1RM). The results
demonstrated that hypertrophic responses were significantly greater in the 30 per cent of 1RM group
suggesting that low-load RT performed to RF can induce a larger acute hypertrophic response compared
to high-load RT. This study demonstrated that hypertrophy is not entirely dependent on load, but
appears to be related to exercise volume, as the 30 per cent of 1RM group was able to perform a
significantly greater number of repetitions than the 90 per cent of 1RM group. However, the results of
short-term (one training session) training effects may not necessarily translate to greater increases in
muscle hypertrophy over a longer period. To address this issue Mitchell et al. (2012) implemented a 10-
week study comparing hypertrophy following a single exercise (knee extension) RT programme. Two
groups performed three sets using a low (30 per cent of 1RM) and high (80 per cent of 1RM) load and one
group performed a single set using 80 per cent of 1RM. At the end of the study the multiple-set groups
experienced similar increases in hypertrophy of the vastus lateralis. The single-set group did demonstrate
hypertrophy, but this was half that of the multiple set groups. Muscle fibre analysis demonstrated that
the 30 per cent of 1RM group displayed greater hypertrophy of type I fibres, whereas the 80 per cent of
1RM group displayed greater hypertrophy of type II fibres, thus supporting the principle of specificity
(see Chapter 7). Low-load RT performed to RF has also been demonstrated to increase hypertrophy
amongst trained individuals. Schoenfeld et al. (2015a) conducted an 8-week study, where the participants
were allocated to a high-load (8–12 repetitions per set) or low-load (25–35 repetitions per set) group.
Each group performed three sets of seven different exercises to RF and both groups experienced similar
improvements in hypertrophy. Consequently, a number of loading strategies can be used to promote
hypertrophy, including low loads (<60 per cent of 1RM) when sets are performed to RF.
Although training to RF can produce a hypertrophic response similar to/greater than that of training
with heavier loads, the approach must be applied with caution when additional fitness goals are sought
alongside hypertrophy. Training to RF on every set with short– moderate rest periods could decrease the
total training volume due to an accumulation of fatigue (Benson et al., 2006; Willardson & Burkett, 2006).
This reduction in volume may have a negative long-term effect on strength adaptations. Furthermore,
training to RF on a regular basis may induce greater fatigue and muscle soreness, which could reduce the
quality of other aspects of a client's training programme, such as cardiorespiratory fitness and sports
specific training (Izquierdo-Gabarren et al., 2010; Stone et al., 1996). Therefore, training to RF must be
carefully periodised (see Chapter 9) to achieve a balance of providing an increased metabolic and neural
overload, whilst allowing adequate recovery between RT sessions.

Volume for hypertrophy

Training volume is a fundamental programme variable that effects increases in strength and hypertrophy
(Baker, 1998; Bird et al., 2005; Rhea et al., 2003; Schlumberger et al., 2001). There is a dose-response
between RT volume and hypertrophy, whereby higher volumes of training have been demonstrated to be
more effective than lower volumes (Rønnestad et al., 2007; Sooneste et al., 2013). Total work performed
(volume-load), in combination with mechanical loading, is important for improving strength and
hypertrophy. This is due to the muscles being exposed to the hypertrophic stimulus for longer durations
(time under tension). Thus, multiple-set programmes are more effective in enhancing hypertrophy than
single-set programmes (Krieger, 2010; Radaelli et al., 2014; Rønnestad et al., 2007). As a general
recommendation, 8–12 repetitions are recommended per set and each session should incorporate 3–8 sets
per muscle group (Krieger, 2010; Peterson et al., 2005).
 There are a number of approaches that can be applied to increase training volume (e.g. increased
repetitions, sets and advanced methods). However, it is likely that a ‘volume threshold’ exists whereby a
plateau in hypertrophy occurs once a certain training volume has been reached within a specific time
frame (day, week, month). This is because excessive training volumes may cause undue fatigue and not
permit sufficient recovery between sessions (Souza et al., 2014). The hypertrophy volume threshold will
differ between clients, with trained clients being able to tolerate higher volumes compared to untrained
clients. This threshold will increase as the client becomes more trained until they reach their (undefined)
volume threshold.

Box 13.1 ‘Lifting weights will make me bulk up’

A common misconception amongst novice clients is that RT will cause a large increase in muscle
mass. This is often a concern for female clients who may not want to become ‘overly muscular’.
Whilst it is true that RT can induce significant hypertrophy, the degree to which this occurs varies
dramatically between individuals, with males tending to experience greater absolute levels of
hypertrophy compared to females (Fry, 2004). Although women can experience hypertrophy, the
magnitude is usually lower compared to males following a similar RT programme (Hubal et al.,
2005). A principal reason for this is due to differences in testosterone levels. Testosterone is a potent,
naturally secreted anabolic hormone, which stimulates muscle hypertrophy and is typically ten
times higher in males compared to females (Vingren et al., 2010). Furthermore, it is possible to
increase muscle strength without significant hypertrophy. Indeed, this effect is apparent at the onset
of an RT programme where increases in neural adaptations are responsible for strength
improvements (see page 170).

Hypertrophy rest periods

When the training goal is muscular hypertrophy, moderate (1–2 minutes) rest periods have been
recommended (ACSM, 2009; Kraemer & Ratamess, 2004; Kraemer et al., 1993). These recommendations
have been based on the findings that rest periods of less than 2 minutes induce greater acute
concentrations of anabolic hormones such as testosterone and growth hormone (Kraemer & Ratamess,
2004; Kraemer et al., 1993). However, contemporary research indicates that acute increases in anabolic
hormone concentrations do not have a substantial effect on hypertrophy (Henselmans & Schoenfeld,
2014; West & Phillips, 2010). Instead, other physiological mechanisms caused by the high metabolic stress
itself are thought to be more critical (Schoenfeld, 2010). Therefore, a moderate rest period is
recommended when training for hypertrophy to prevent full recovery and increase metabolic stress. A
short rest period of 30–60 seconds may increase the metabolic stress, but will compromise intensity and
volume, as the increase in fatigue will reduce the number of repetitions that can be completed on
subsequent sets if the load is not reduced (Willardson & Burkett, 2006).
Metabolic stress will be high when moderate rest periods are used, but 1–2 minute rest periods may
not allow adequate recovery following MJ (compound) exercises (e.g. back squat with an 8RM load) as
these exercises are more metabolically and technically demanding than SJ (isolation) exercises.
Therefore, it is prudent to implement moderate or long rest periods (2–3 minutes) for MJ exercises,
whereas short-moderate (30 seconds – 2 minutes) rest periods can be selected for SJ or low-intensity
exercises. This system allows a combination of hypertrophic factors to be achieved: mechanical tension
and metabolic stress.

Advanced hypertrophy methods

The regular exposure to the same training stimulus will lead to accommodation (see Chapter 7). This is
particularly true in the case of RT for hypertrophy, whereby the relative increase in muscle CSA becomes
smaller as exposure to the RT stimulus increases over time (Maughan et al., 1984). To prevent/overcome
accommodation, a variety of specialised training methods can be used to provide additional overload to
stimulate the mechanisms responsible for hypertrophy (see Table 13.3).

Hypertrophy summary
A wide spectrum of loading strategies can be implemented to induce hypertrophy. Using
moderate loads (65–85 per cent of 1RM) is effective due to inducing a combination of
hypertrophic factors, particularly mechanical tension and metabolic stress.
Low-intensity RT (<65 per cent of 1RM) can also induce hypertrophy when the sets are
performed to RF.
High training volumes are important (up to a point) for increasing hypertrophy, although
increases in volume should be programmed carefully to ensure recovery is not compromised.
Rest periods should be selected based on the RT exercise and intensity, with 2–3 minute
periods for MJ/heavy-load exercises and 1–2 minutes for SJ/moderate–low-load exercises.
To maximise hypertrophy, a number of loading strategies and training to RF should be
implemented within a periodised programme.
Resistance Training for Strength

The fundamental adaptation from any RT programme is an increase in the ability of a muscle to produce
external force (strength). Indeed, an increase in strength is the crucial adaptation which underpins
improvements in health, performance and aesthetic (hypertrophy) outcomes. Increases in strength are
often achieved alongside muscle hypertrophy, but this is not a perfect relationship, as increases in
hypertrophy do not always result in equivalent strength gains and vice versa (i.e. a bigger muscle is not
always a stronger muscle). This is because the adaptations (see page 170) achieved from a hypertrophy
focused RT programme are different from those attained following a RT programme focused purely on
strength (Fry, 2004; MacDougal et al., 1984; Zatsiorsky & Kraemer, 2006). There are cases where certain
clients may wish to improve strength without a significant increase in hypertrophy (e.g. weight category
sports). In these instances the goal of the RT programme is to increase strength relative to body mass
(relative strength). The efficacy of these programmes is assessed based on improvements in maximal
strength measures (1RM, RM) instead of muscle size.

Strength training intensity

To maximise gains in muscular strength it is necessary for trained clients to consistently train with
heavy relative loads (Ogasawara et al., 2013). This is because repeatedly lifting heavy relative loads
enhances a number of neural adaptations (see Table 13.1), which increase force production (Akima &
Saito, 2013; Sundstrup et al. 2012). However, these adaptations can be achieved using different relative
loading strategies, depending on the client's RT experience. Novice clients can experience maximal
strength gains using an average intensity of 60 per cent of 1RM (approximately 12 RM) (Rhea et al.,
2003). However, amongst trained individuals, RT programmes using moderate and high loads have
consistently demonstrated greater improvements in maximal strength compared to low-load
programmes (ACSM, 2009; Campos et al., 2002). For example, a moderate load (8–12 repetitions) training
programme has been demonstrated to increase back squat strength (1RM) by almost twofold compared
to a low-load (25–35 repetitions) protocol (Schoenfeld et al., 2015a).

Strength training volume

Due to the inverse relationship between intensity and volume, strength-orientated programmes (using
loads ≥ 85 per cent of 1RM) will be lower in volume than hypertrophy programmes (using loads < 85 per
cent of 1RM), as fewer repetitions can be performed per set. Higher volume (multiple-set) RT
programmes are understood to produce greater strength gains than low-volume (1 set) programmes in
both trained and untrained individuals (Krieger, 2009; Rhea et al., 2003). This can be attributed to a
greater enhancement of neural adaptations and hypertrophy. Consequently, clients should use a
multiple-set strategy to optimise strength gains. However, a single-set protocol can be effective for
strength improvements if training time is restricted (Baker et al., 2013).
A volume threshold (i.e. optimal number of sets) for strength improvements has not been identified, as
most studies have compared one set of an exercise versus three sets, despite RT routines frequently
incorporating a higher number of sets per exercise. However, researchers have speculated that the
benefits of performing more than four sets significantly decrease (the law of diminishing returns)
amongst trained and untrained individuals (Rhea et al., 2003).
A volume threshold likely exists whereby further increases in volume do not enhance strength or
could actually be counterproductive due to hindering the recovery process or causing overuse injuries.
This threshold will vary between clients, as demonstrated by a study which reported individual
differences in relative strength improvements using different (one, four or eight) set protocols (Marshall
et al., 2011). Therefore, training volume should be gradually increased based on the client's strength
improvements and available training time.

Training to failure to improve strength

As mentioned previously, classic RT for strength recommendations are based on the premise that low
loads (<65 per cent of 1RM) are insufficient in activating the full spectrum of muscle fibre types.
However, researchers have speculated that training with loads below 65 per cent of 1RM can achieve
maximal levels of muscle activation provided the exercise is performed to RF (Burd et al., 2010; Loenneke
et al., 2011; Rooney et al., 1994). This theory has been supported in untrained individuals performing a
lateral raise exercise performed to RF with a light (15 RM) resistance (Looney et al., 2015). Conversely,
maximal muscle activation has not been reported amongst trained individuals when training using low
intensities (30–50 per cent of 1RM) to RF (Schoenfeld et al., 2014).
The scientific evidence suggests that training at low intensities to RF achieves maximal muscle
recruitment amongst untrained but not trained individuals. However, exercise selection is also likely to
influence the degree of muscle activation, whereby isolation exercises (Looney et al., 2015) may achieve
greater muscle activation compared to compound exercises, such as a squat (Schoenfeld, 2014).
Consequently, to achieve maximal muscle activation, training with loads ≥65 per cent of 1RM is prudent
for MJ (compound) exercises. Whereas, maximal muscle activation can conceivably be achieved during
SJ (isolation) exercises using light–moderate loads.
Previous studies have suggested that training to RF does not provide greater improvements in strength
(Kraemer et al., 1997; Stowers et al., 1983). However, these studies did not control for volume and
intensity, which both influence strength gains. Although training to RF with low loads may not achieve
maximal levels of muscle activation in compound exercises, it is possible that training to RF enhances
other physiological mechanisms that may increase strength. Izquierdo et al. (2006) conducted a 16-week,
periodised training study in male athletes with limited RT experience. The RF and non-repetition failure
(NRF) groups experienced similar improvements in 1RM bench press and squat performance, suggesting
that performing exercises to RF is not required for maximal strength improvements. However, this study
used untrained participants who typically experience rapid improvements in strength regardless of the
RT programme. Drinkwater et al. (2005) reported that a 6-week bench press RF programme significantly
improved strength and power compared to a NRF programme amongst junior athletes with previous RT
experience. The authors speculated that muscle activation improved in the RF group, although this was
not measured.
Although a short-term (six weeks) training to RF approach may impose a novel training stress
amongst trained individuals, resulting in improvements in strength and power (Drinkwater et al., 2015;
Sundstrup et al., 2012), the general consensus within the RT literature is that training to RF is
unnecessary to maximise muscular strength (Davies et al., 2015). The potential benefits of training to RF
for improvements in strength should be considered alongside the possible negative consequences
discussed previously (see page 184).

Rest periods

Training for improvements in maximal strength requires the use of moderate–heavy relative loads,
which places a high demand on anaerobic energy metabolism, particularly the ATP-phosphocreatine
system. Consequently, when lifting heavy loads a 3–5 minute rest period is recommended between sets
to replenish phosphocreatine stores so that high levels of force can be reproduced (Dawson et al., 1997).
Short or moderate rest periods are not recommended when the primary outcome is improving strength,
as the decreased recovery time will compromise training volume and intensity (de Salles et al., 2009;
Rahimi, 2005; Schoenfeld et al., 2015b).

Strength summary
Advanced clients should use heavy relative loads (85–100 per cent of 1RM) to maximise
strength, whereas novice/intermediate clients will benefit from using moderate loads (65–85
per cent of 1RM).
For optimal results, a multiple-set ( > one set) strategy should be adopted in both trained and
untrained clients. An optimal number of sets has not been identified to improve strength.
Trained clients may benefit from performing a higher (four to eight) number of sets, whereas
two to three sets are adequate for untrained clients.
Training to failure should be used with caution, as there is limited evidence that the technique
is required for improvements in strength.
Long (3–5 minute) rest periods are recommended to allow adequate recovery between sets.
Resistance Training for Fat Loss

Cardiorespiratory exercise is typically recommended for fat loss and the maintenance of a healthy body
mass, despite the conflicting evidence to support this strategy (see Chapter 10). In recent times RT has
also been recommended to reduce body fat and maintain a healthy body and mass (Donnelly et al., 2009;
Tumminello, 2014). However, the evidence to support this strategy is also equivocal. A period of RT has
been demonstrated to decrease total body fat mass independent of dietary caloric restriction in some
studies (Hunter et al., 2002; Schmitz et al., 2003), but not others (Bouchard et al., 2009; Castaneda et al.,
2002; Ribeiro et al., 2016). A study conducted in 1996 investigated the effects of CRT and RT by
comparing the responses to diet alone and diet combined with a CRT or RT modality in obese men (Ross
et al., 1996). All three groups lost significant amounts of body fat, particularly fat within the abdominal
cavity (visceral). The reductions in visceral fat were similar between the RT and CRT groups (40 & 39 per
cent, respectively). Interestingly, the diet-only group experienced a 32 per cent decrease in visceral fat
supporting the notion that a dietary modification strategy has a greater relative impact on fat loss than
exercise.
In 2012, Willis and colleagues conducted a study to investigate the effects of three different training
programmes (CRT, RT and combined CRT/RT) on body composition in overweight/obese adults (age 17–
70 years). The participants performed the designated programme for 8 months and body composition
was compared (summarised in Figure 13.3). The results indicated that a combined CRT/RT programme
was most effective in reducing body fat. However, this finding was confounded by the fact that the
combined group training sessions were almost twice the duration as the other groups. When comparing
the CRT and RT groups the CRT resulted in a larger reduction (−1.4 kg) in fat mass. However, the RT
group experienced a 1.1 kg increase in lean body mass compared to the CRT group (−0.1 kg).
Consequently, the CRT and RT groups demonstrated similar changes in total body fat percentage. This
study suggests that CRT is more effective than RT for fat loss in the overweight/obese. However, the
increase in lean mass experienced by the RT group is positive from a health perspective. Thus, a
combined CRT and RT approach is recommended when fat loss is a main objective (Dâmaso et al., 2014;
Lopes et al., 2016).
The majority of studies investigating the impact of RT on fat loss have focused on untrained and
clinical populations that typically have limited RT experience. Therefore, Martins et al. (2016) conducted
a study using male and female participants (age 22–34 years) with 1 year of RT experience. The
participants performed three RT sessions per week consisting of nine exercises (3 × 8 repetitions with 85
per cent of 1RM). Following the intervention the subjects' abdominal fat, assessed by skinfolds and waist
circumference, significantly decreased suggesting RT can enhance fat loss in individuals with RT
experience. However, this study was limited by a lack of control group and the basic method of body fat
assessment.
Figure 13.3 The effect of different training modalities on body composition (adapted from Willis et al., 2011).

The general consensus within the literature is that CRT is more effective for reducing body/fat mass
than RT amongst overweight/obese (Schwingshackl et al., 2013; Willis et al., 2012) and normal weight
individuals (Lehri & Mokha, 2006). However, there is a lack of studies comparing RT and CRT
programmes for fat loss across various populations due to the difficulty researchers are faced with in
matching exercise intensity and duration between two vastly different types of exercise. The intensity
and energy expenditure of CRT can be assessed using metrics such as heart rate and oxygen
consumption, whereas RT places a large stress on anaerobic metabolism, which is more difficult to
quantify. Furthermore, studies often include a specific dietary intervention making it difficult to draw
conclusions if RT significantly reduces body fat independently of diet (Spillane & Willoughby, 2016). Due
to these issues, it is unlikely that a single study will be able to provide a definitive conclusion as to which
training modality is better for fat loss; therefore, one approach should not be used exclusively. For
optimal fat loss results, a combined CRT/RT programme should be adopted alongside appropriate and
sustainable dietary modifications (see Chapter 5). Regular CRT will improve cardiorespiratory fitness
and RT will achieve physiological outcomes which enhance body composition: an increase in energy
expenditure and muscle mass.

Increased energy expenditure

As with any form of exercise, RT involves expending energy which, provided energy intake does not
increase, should create a negative energy balance (burning more calories than are consumed) and
promote fat loss. However, this simple theory does not transpire amongst all individuals due to the
complex interaction of various compensatory mechanisms that influence energy balance (see Chapter
11). When comparing an RT and CRT session of the same duration, the absolute energy expenditure may
be greater during CRT, but RT may result in greater energy expenditure after the session. This is because
the anaerobic nature of RT means oxygen uptake remains elevated after the training session in order to
restore metabolic processes to the pre-exercise state (homeostasis). This is known as ‘excess post-exercise
oxygen consumption’ (EPOC). The magnitude of the EPOC response is dependent on the training status
of the client and intensity/volume of the RT. For example, modest EPOC values have been reported in
untrained subjects (Binzen et al., 2001; LaForgia et al., 2006), and the duration of EPOC has been reported
to vary between 1 and 38 hours (Melby et al., 1992; Schuenke et al., 2002). As part of the adaptive process,
the magnitude of EPOC also reduces as fitness improves (Børsheim & Bahr, 2003). Evidently, the EPOC
response is highly variable between individuals which suggests that it is unlikely to be the main
mechanism responsible for decreasing body fat following RT.

Muscle mass

Muscle has a higher metabolic rate than adipose (fat) tissue, meaning it requires more energy (Wolfe,
2006). Therefore, increasing muscle mass (hypertrophy) through RT can increase resting energy
expenditure (REE) (Campbell et al., 1994). This increase in muscle mass and REE is often cited as the
primary reason why RT can promote fat loss. However, the magnitude of this effect has possibly been
exaggerated, as a 1 kg increase in trained muscle tissue may only increase REE by 20 calories/day
(Strasser & Schobersberger, 2011). Nevertheless, when sustained over years, even a slight increase in REE
will translate into significant increases in energy expenditure.

Case study 13.2 Lack of ‘weight’ loss

Jane has been making gradual dietary changes alongside a combined CRT and RT programme with
her trainer, training 3 to 4 days per week. Initially she experienced a weekly decrease in body mass
for 6 weeks and her limb circumference measurements have decreased. However, her body mass has
stabilised and she is concerned that the her programme is no longer working.
Using body mass to assess the effectiveness of a training programme that includes RT is not
recommended, as RT can increase muscle mass (Castaneda et al., 2002; Willis et al., 2011). This
increase in total body mass will mask reductions in body fat if a body composition method is not
implemented. Clients often experience a plateau in body mass despite experiencing a decrease in
overall body size. This is because the muscle gained from RT is a denser tissue compared to fat, i.e.
1 kg of muscle will occupy less space than 1 kg of fat. If a client were to gain 1 kg of muscle and lose
1 kg of fat simultaneously, body size (volume) would decrease, but body mass would remain
unchanged.

During diet and/or exercise programmes a reduction in fat is often associated with other changes in
body composition, such as loss in muscle (see Figure 13.3). This reduction in muscle mass induces a
reduction in REE and can also decrease physical activity energy expenditure and total daily energy
expenditure (Sothern et al., 1999). This reduction in total energy expenditure may lead to increases in
body fat over time if the diet is not changed accordingly. However, RT promotes the maintenance (or can
increase) muscle mass, thus reducing this negative effect. Moreover, the maintenance of muscle mass
may also prevent age-associated fat gains by promoting an active lifestyle.
As mentioned previously (see page 178), RT can elicit a number of favourable metabolic adaptations.
In addition to reducing the risk for the development of cardiovascular and metabolic diseases, these
adaptations may enhance the fat burning process. Overweight/obese individuals often suffer with a
condition called insulin resistance, which has been suggested to promote fat storage (Taubes, 2010; Volek
et al., 2010). RT has been demonstrated to improve insulin sensitivity (Shaibi et al., 2006), which
theoretically may promote a more favourable metabolic environment for fat burning.

Types of resistance training for fat loss

As with all RT programmes, a single RT regimen is unlikely to promote optimal fat loss for everyone.
Rather, a variety of customised RT regimens are needed to achieve the desired effects based on the
individual client. The fat loss RT guidance presented is based on maximising energy expenditure during
and after the RT session. However, regardless of the client's training status, it is essential that some
moderate–heavy intensity RT is maintained within an RT programme, especially during periods of
calorie restriction. The purpose of this is to expose the muscles to high levels of mechanical tension in
order to preserve strength and muscle mass (Bryner et al., 1999).

Case study 13.3 Maintain strength and muscle mass

John is going on holiday in 5 weeks and wants to lose body fat. He has increased his CRT volume
and amended his RT programme to include low-load, high-volume circuits. He has also decreased
his daily calorie intake. John risks losing muscle mass and strength due to the large increase in
training volume accompanied by a reduction in energy intake. Not only is this counterproductive
from an aesthetic perspective, it will also cause negative physiological effects such as reducing his
REE. Therefore, John should maintain an element of moderate and heavy intensity RT within his
programme in order to preserve strength and muscle mass.

Fat loss resistance training volume

To achieve high levels of energy expenditure and EPOC, a high volume of work performed within a
small period of time is recommended. This can be achieved by performing a high number of repetitions
(12–15 reps per set, with low loads <65 per cent of 1RM). This could involve performing each exercise as
a straight set or as part of a circuit sequence (see Table 13.5). The circuit approach allows a greater
volume of work to be performed within a short time frame and may increase the EPOC to a greater
extent than straight set RT (Murphy & Schwarzkopf, 1992). For example, a 20-minute RT circuit has been
demonstrated to expend approximately 200 calories during the session and 50 calories for recovery
processes following the session (Haltom et al., 1999).

Fat loss resistance training intensity

The intensity should be selected based on the client's training status. Trained clients can benefit from
using a straight-sets approach with a moderate loading strategy (65–85 per cent of 1RM), as this permits
high volumes of work to be performed, which generates a large metabolic stress, thus maximising energy
expenditure. The use of moderate loads also induces a higher level of mechanical tension and may
conserve strength and muscle mass during periods of calorie restriction (see Case study 13.3). In general,
untrained clients should use low loads (<65 per cent of 1RM) to establish good exercise technique and
allow the prescribed number of repetitions to be completed for each set. Low loads are also
recommended when a circuit approach is adopted for trained and untrained clients. To prevent
accommodation, it is prudent to include both circuit and straight-sets RT sessions within a periodised
programme. In all cases, large increases in training volume during periods of calorie restriction should be
avoided, as this may compromise muscle mass (see Case study 13.3).

Table 13.5 Example fat loss resistance training sessions

 To maximise energy expenditure, multiple-joint exercises involving a number of muscle groups should
be performed, as the energy cost of an exercise is directly related to the volume of muscle involved
(Elliot et al., 1992). Untrained clients may benefit from using MJ machine exercises initially (e.g. leg
press, seated row) whereas free-weight exercises (e.g. squats, bench press) are recommended for trained
clients.

Fat loss rest periods

Short rest periods (45–60 seconds) should be taken between straight sets to increase metabolic stress and
training density. During circuit training, rest periods should be minimised between exercises and a
moderate rest period (1–2 minutes) should be taken between circuits for trained clients, whereas
untrained clients benefit from a longer (2–3 minutes) rest period to allow adequate recovery.

Summary
A combined (CRT/RT) intervention is recommended for decreasing body fat. For optimal
results, the exercise programme should be combined with sustainable and appropriate
nutritional modifications (see Chapter 5).
A circuit training approach using low loads (<65 per cent of 1RM) and multiple-joint exercises
is recommended to increase energy expenditure during and after the session. This will also
promote numerous metabolic adaptations, which may enhance the fat burning process.
Trained clients may also benefit from a straight-sets approach using low–moderate loads and
short rest periods.
During a fat loss programme, all clients should perform some exercises with moderate–heavy
loads to preserve strength and muscle mass.
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Chapter 14
Postural and core training

Simon Penn
Posture

Posture is the alignment of the musculoskeletal system at rest (static) or during movement (dynamic)
(Posture Committee, 1947; Twomey & Taylor, 1987). Therefore, good posture can be defined as the
optimal arrangement of body segments and supporting structures of the spine to minimise energy
expenditure and injury. Kritz and Cronin (2008) defined good posture as a state of equilibrium: muscular
and skeletal balance. Correct structural alignment will ensure that minimal neuromuscular activity and
joint loading (economical advantage) is required to maintain body position against gravitational stresses.
Additionally, a state of musculoskeletal balance allows optimal muscular efficiency for force production
during locomotion and physical activity (Kritz & Cronin, 2008).
Maintaining good posture is essential for musculoskeletal health (Britnell et al., 2005). Minimising
undue stress placed on the supporting structures (muscles, ligaments and joint capsules) of the body will
help to reduce musculoskeletal conditions and pain that are often associated with, or caused by, poor
posture: idiopathic scoliosis, kyphosis, lordosis, reduced lung function, neck, shoulder, mid-thoracic and
low back pain. Furthermore, when musculoskeletal misalignment is prolonged, muscles commonly adapt
by shortening or lengthening to accommodate the displacement (see Case study 14.1). Misalignment and
muscle imbalance can lead to pain and neurological impingement (Novak, 2004). Therefore, postural
assessment should form part of the client-assessment to identify and correct muscular imbalances to
ensure musculoskeletal efficiency during movement and promote good health.

Postural assessment

Postural assessment requires the examination of body segment alignment from anterior, posterior and
lateral perspectives to assess symmetry. Using a plumb line, good posture is indicated from the side when
the plumb line passes anterior to the centre of the ankle and knee joints, and then through the centre of
the hip joint, lumber vertebrae bodies, shoulder joint, bodies of the cervical vertebrae and ear (see Figure
14.1) (Bloomfield, 1998; Norris, 1995; Roaf, 1977). From the lateral, anterior and posterior perspectives,
specific landmarks should be assessed to identify symmetry between the left and right sides of the body
and any postural abnormalities (see Figure 14.1 and Table 14.1).
Figure 14.1 Optimal standing posture.

Table 14.1 Anatomical landmarks

Lateral view (against a plumb line) Anterior view Posterior view

Head position Eye level Ear level

Cervical spine Ear level Shoulder level

Shoulder position Acromion processes Scapula position

Thoracic spine Pelvic tilt Spine

Lumbar spine Lower limb angle/position Gluteal crease

Pelvic tilt Foot angle/position Knee joint crease

Knee joint Foot arch Achilles tendon angle

Figure 14.2 Common postural abnormalities.

Poor posture and muscle imbalances can be identified by an asymmetry of musculoskeletal landmarks. A
musculoskeletal imbalance/misalignment of structural tissues would cause an increase in the energy
required to maintain body position. Whenever an ‘abnormal’ posture is observed in one body part,
invariably other body parts may adapt their posture to compensate. Common postural abnormalities are
shown in Figure 14.2.

Correcting poor posture

A clinical judgement is required to identify whether any tissue shortening or lengthening is the cause, or
the effect, of abnormal posture. Therefore, clients with large or irregular postural deficiencies should be
referred to appropriately qualified practitioners. Muscle imbalances associated with common abnormal
postures are detailed in Table 14.2. Exercise prescription should focus on correcting the musculoskeletal
imbalances to return optimal posture before progressing to other forms of training (Norris, 1995).

Table 14.2 Muscle imbalances of common postural abnormalities

Postural abnormalities Overactive/Tight musculature Elongated/Weak musculature

 Pectoralis major Rhomboid minor
Kyphosis Upper trapezius Rhomboid major
Levator scapula Serratus anterior

Iliopsoas
Rectus femoris Rectus abdominus
Lordosis Tensor fascia latae Internal obliques
Quadratus lumborum External obliques
Lower erector spinae

Quadratus lumborum
Rectus abdominus
Lower erector spinae Iliopsoas
Flat back Internal obliques
Rectus femoris
External obliques
Tensor fascia latae

Pectoralis major
Lower/mid trapezius
Rectus abdominus
Lower erector spinae
Sway back Bicep femoris
External obliques
Semimembranosus
Iliopsoas
Semitendinosus

Case study 14.1

A common postural abnormality in office workers is called ‘upper crossed syndrome’ (Janda, 1979).
Office workers often repeatedly sit in a kyphotic (hunched) posture with their head tilted back for a
prolonged period of time (see Figure 14.3). Therefore, the musculature in the mid-upper back
(rhomboid minor, rhomboid major and serratus anterior) will become lengthened and weakened
over time. In contrast, the muscles of the chest will become shortened and tight. Due to the
extended head position, the neck flexors (e.g. sternocleidomastoid) will become lengthened and the
posterior neck muscles (e.g. upper trapezius and levator scapulae) will become short and tight.
Therefore, to re-educate the postural position of the office worker, the short, tightened musculature
would require massage or stretching to release the tone and lengthen the muscle before
strengthening the elongated muscles to correct the muscle imbalance and posture. Following the
correction of muscle imbalances, postural and core training could be completed simultaneously, to
promote optimal muscle recruitment and synergy to minimise future postural inefficiencies.
Figure 14.3 Upper crossed syndrome.
Core Training

Core exercise has become a common modality of training to prevent injury (in particular low back pain),
improve posture and enhance performance. The origins of core stability are unclear. In 1996, Hodges and
Richardson identified a delay in the timing of the anticipatory contraction of the transverse abdominals
to achieve motor control in participants with low back pain. The results stimulated further studies to
examine the effect of core exercises on improving the anticipatory contraction delay to treat low back
pain. The assumption that strengthening the core, and re-establishing correct timing would prevent low
back pain led to the establishment of a new training modality in the fitness industry: core stability
training. However, since the original work by Hodges and Richardson (1996), the concept of core stability
and the prescription of core training have been misunderstood and used inconsistently within the health
and fitness industry (Allison & Morris, 2008; Lederman, 2010; McNeill, 2010).
Definitions of the core, core stability, core strength and the optimal exercise prescription are still
debated and scientific reviews on the effect of core training on injury rate and performance have
highlighted conflicting and inconclusive data (Bliven & Anderson, 2013; Hibbs et al., 2008). Therefore, an
improved understanding of what the core is, how it works and how it should be trained is required to
ensure training prescription is successful.

What is the core?

Inconsistent use of the term ‘core’ has led to confusion and debate on creating a scientific working
definition that can be applied to prescribe exercises to healthy, unhealthy and athletic populations. The
anatomical definition of the core includes all muscles and soft tissues (muscles, tendons, ligaments,
cartilage and fascia) that originate from the axial skeleton (Behm et al., 2010). Therefore, the anatomical
definition of the core incorporates a multitude of muscles.
A simpler, more common, definition of the core describes the core as a cylinder of musculature
surrounding the lumbar spine (Akuthota & Nadler, 2004; Bliss & Teeple, 2005; Richardson et al., 1999).
The rectus abdominis provides support anteriorly. The transverse abdominis, internal and external
obliques support the cylinder laterally. The multifidis, paraspinals and quadratus lumborum reinforce the
posterior. The diaphragm and pelvic floor provide the superior and inferior components respectively (see
Figure 14.4).
The core aims to provide optimum neuromuscular coordination and muscle recruitment to achieve
intra-abdominal pressure to stabilise the spine. Furthermore, during locomotion or physical activity, the
objective of the core is to maintain a stable base to transmit force between the upper and lower limbs
(Norris, 2009). A more concise and working definition of the core would be the lumbo-pelvic hip
complex, consisting of the lumbar spine, pelvis and hip joints, and the active and passive tissues that
produce or restrict motion of these segments (Willson et al., 2005). Therefore, depending on which
definition is adhered to (anatomical, cylindrical or working), core training can incorporate a variety of
muscles.

Figure 14.4 The cylindrical definition of the core.

What is core stability?

Despite the inconsistencies within research, a common understanding is that core stability refers to the
ability to maintain control of the torso at rest or during movement (Majewski-Schrage et al., 2014). The
core muscles work in unison to prevent unwanted movement of the lumbar spine (stabilisation) by
contracting to increase intra-abdominal pressure and restrict motion (Behm et al., 2010; Hodges et al.,
2001). The vertebrae provide a structural protection to the spinal cord and nerves. However, the spine is
also required to participate in movement, carry load and dissipate force (Panjabi, 1992). Therefore, to
maintain the stability and integrity of the spine, the surrounding structures work to ensure that range of
motion is not exceeded and that the transmission of force can occur.
Panjabi (1992) described three subsystems that provide spinal stability: active, passive and neural. The
active subsystem comprises the skeletal muscles and tendons encompassing the spine. The passive
subsystem includes the vertebrae, joints, intervertebral discs and ligaments of the spine. The neural
subsystem comprises of the communication between the proprioceptors (nerve sensors detecting
positional, length and force changes) and the brain, which analyses the information and responds to
what is required. Therefore core stability training needs to address the communication between all three
subsystems to achieve the desired stability.

Which muscles provide stability?

Bergmark (1989) classified the core musculature according to their anatomical position, size and
characteristics. The ‘local’ group are muscles that originate or attach to the lumbar vertebrae, are short in
stature and create inter-segmental stiffness through isometric contraction, often in anticipation of
movement (see Figure 14.5). The local group includes intertranvsersaii, interspinales, multifidi, rotatores,
medial parts of quadratus lumborum, iliocostalis lumborum, transverse abdominis, diaphragm and pelvic
floor muscles (Behm et al., 2010; Bergmark, 1989).
The ‘global’ system includes muscles that have a proximal attachment to pelvic girdle and a distal
insertion into the thoracic cage. Bergmark (1989) stated that the global muscles produce isokinetic
contractions (muscle contraction at a consistent rate/speed) to transmit force between the pelvis and
thoracic cage. Mottram and Comerford (1998) extended the classification of local and global muscle
groups to include muscle function. The local group muscles were classified as local stabilisers due to
their responsibility to work continuously under a low load to maintain segmental stiffness and postural
control. Classified by function, the internal obliques were included with the local stabilisers (Akuthota et
al., 2008; Behm et al., 2010; Mottram & Comerford, 1998). The global group was subdivided into global
stabilisers and global mobilisers (Mottram & Comerford, 1998). The global stabilisers (gluteus medius,
spinalis, subscapularis, internal and external obliques) generate force through eccentric contraction to
restrict range of motion. The global mobilisers (iliocostalis, latissimus dorsi, rectus abdominis and
sternocleidomastoid) are responsible for generating movement and increasing functional stability under
load using phasic contractions (Comerford & Mottram, 2001a; Gibbons & Comerford, 2001).Therefore,
recruitment of the core muscles is dependent on the loading, intensity and speed of the task. However, no
individual muscle should be the focus of core training as the core muscles and groups work in unison to
achieve stabilisation.
Figure 14.5 The local muscular group.

Testing the core

To maximise stability and function for most populations, core training should take place in the optimal
postural position with pelvic neutral (see Figure 14.1). Pelvic neutral maintains the natural curve of the
lumbar spine, minimises spinal loading and reduces the energy expenditure of supporting tissues.
Furthermore, pelvic neutral optimises core muscle activation and contraction (O'Sullivan et al., 2002).
Therefore, a postural assessment is essential before prescribing core exercise. Muscular imbalances and
postural or movement deficiencies should be identified and inadequacies in the kinetic chain corrected to
maximise the effectiveness of core exercises.
Following a postural assessment, the initial stage of core training should test motor control to identify
if training should focus on stability or strength. Core stability testing (low-load, isometric hold exercises),
using abdominal hollowing or bracing (see Box 14.1), can identify and potentially retrain motor
recruitment dysfunctions in the stabilising musculature (Barr et al., 2007; Liebenson, 1998; Tsao et al.,
2010). Additionally, core tests (see Figure 14.6) can be used to re-educate the client on the natural posture
that should be maintained throughout all core exercises.
 Box 14.1 Abdominal hollowing vs abdominal bracing
Abdominal ‘hollowing’ and ‘bracing’ are two key terms used in the delivery of core training.
Hollowing describes the pulling/drawing in of the abdominal area toward the lumbar spine and
favours the recruitment of transverse abdominis whilst minimally recruiting the other local
stabilising muscles (Key, 2013). Tsao and Hodges (2007) demonstrated that abdominal hollowing can
improve the delayed recruitment of transverse abdominis in patients with low back pain. In
contrast, abdominal bracing is the co-contraction of all abdominal/core musculature.
Both techniques have been suggested to increase lumbar stiffness. However, bracing has
demonstrated 32 per cent more lumbar stiffness (stability) in comparison to hollowing using
unilateral loading (Grenier & McGill, 2007). Abdominal bracing can significantly increase stability
by up to 64 per cent through increased muscular compression force and intra-abdominal pressure
(Granata & Marras, 2000; Grenier & McGill, 2007). Despite creating greater stability, bracing is
associated with a higher injury risk as spinal compression can increase by 12–18 per cent (Granata
& Marras, 2000). Therefore, abdominal hollowing should be promoted in a rehabilitation setting to
re-educate motor control and the recruitment of transverse abdominis. However, for core stability
and strength training, where spinal stability is key, the abdominal bracing technique should be
adopted.

Stability testing should assess the function of the local and global stabilisers to maintain spinal segment
stiffness during low-load, low-threshold control of limb movements. The anterior, posterior and lateral
cylindrical muscles of the core can be assessed on their ability to maintain a neutral pelvis position under
a low load. Stability muscles are regularly required to maintain sustained contraction under a low load
during daily activities (Comerford and Mottram, 2001b). Therefore the tests offer a muscular endurance
capacity assessment of the local and global stabilisers.
To test stability, optimal posture should be held in the positions identified in Figure 14.6 for 10
seconds, for ten repetitions (Comerford and Mottram, 2001b). During the 10 seconds contraction, the
participant should be working under a low threshold/load (≤40 per cent of maximal voluntary
contraction) and there should be no uncontrolled motion. Although the perceived effort may be
increased initially, the aim should be to perform the exercise at a low threshold (perceived effort of ≤ 4
out of 10). Irregular and uncontrolled movement patterns or higher workloads are often evidence of
motor control dysfunction and usually present during pain or injury (Comerford and Mottram, 2001b).
Muscle imbalances and low back pain can alter the recruitment and efficiency of the stability muscles to
maintain spinal segmental stiffness and stability.
Research has shown that when pain or injury is present, the recruitment order may be altered. Global
mobilisers are recruited first and correspondingly there is a reduction in stability due to the delayed
recruitment of the stabilising muscles (Comerford & Mottram, 2001a, 2001b). Performing low-load, low-
threshold exercises should reset the motor recruitment process (Comerford & Mottram, 2001b). Motor
control dysfunction, muscle imbalances and poor postural control lead to low back pain (Comerford &
Mottram, 2001a; Norris, 1995; Novak, 2004). Therefore, despite the lack of functional transfer to daily
activity, these exercises assess the presence of dysfunction and the ability to maintain stability under a
low load. Following the successful completion of these tests, core strength exercises can be performed to
assess the ability to maintain neutral spine during high-load, functional exercises (e.g. during a squat –
see Figure 14.7).

Figure 14.6 Low-load stability tests and exercises: a) Hook lying leg raise; b) Bird-Dog; c) Modified side plank; d) Side lying clam.

Core stability training (low threshold)

Core stability training uses low-load training to maximise the coordination of the three subsystems of
spinal stability. When designing training programmes to enhance core stability, emphasis should be
placed on the muscles responsible for stability: local and global stabilisers. High repetitions using a low
load should focus on developing muscular endurance. Exercises used in the stability-testing phase can be
progressed to low-load exercises by incorporating limb movements. Simple, controlled exercises in the
hook lying, quadruped and lateral positions (see Figure 14.6) should educate maintaining optimal
posture, neutral spine and abdominal bracing to achieve muscle recruitment and stabilisation during
limb loading movements. Optimal core stability exercises should pose minimal spinal loading whilst
training the core stabilisers (McGill, 1999, 2001). Once good posture and stabilisation can be maintained,
instability or load (for example, combining opposite arm and leg in the Bird-Dog exercise) should be
increased to ensure progressive overload.
 Low-load, low-threshold training may not provide any benefit to the healthy individual. Despite
realigning the neural subsystem by coordinating muscle activity, the low-load exercises provide limited
training transfer to activities of daily living and sporting performance. However, the aim of this first
phase of training (motor control and stability) is to educate the participant on the correct motor patterns
and postural positions in preparation for leading onto the functional training of core strength. Therefore
core stability training should only be prescribed to beginners or individuals rehabilitating from injury.

Core strength training (high threshold)

Core strength training focuses on maintaining stability of the lumbar spine to allow the transmission of
forces through the kinetic chain during functional and high-load exercises (Akuthota & Nadler, 2004).
Therefore core strength training utilises higher loads to strengthen the global mobilisers whilst still
enhancing the recruitment and coordination of the local and global stabilisers.

Figure 14.7 High-threshold stability and strength exercises: a) Anti-flexion exercise – Squat; b) Anti-extension exercise – Plank; c) Anti-
lateral flexion exercise – Side Plank; d) Anti-rotation exercise – Pall of Press.

Functional exercises (see Box 14.2) increase the difficulty of maintaining spinal stability and challenge
the body in all three planes of motion. Core anti-flexion, anti-extension, anti-lateral flexion and anti-
rotation exercises (see Figure 14.7) all train the global muscles' ability to maintain neutral spine whilst
transmitting forces between the upper and lower limbs. For example, during the squat (anti-flexion
exercise) the natural biomechanical action is to cause lumbar flexion and posterior tilt of the pelvis.
However, this position would create excessive load on the vertebrae and spinal supporting tissues.
Therefore, local and global stabilisers prevent the natural movement of lumbar spine flexion and
maintain pelvic neutral. For the squat, and other anti-flexion exercises, the muscles responsible for
preventing posterior pelvic tilt (e.g. erector spinae, quadratus lumborum, gluteus maximus) are
strengthened. Following anti-movement exercises focusing on stabilisation, core strength exercises can
then be progressed by increasing the instability, speed and load of the exercise to resemble more physical
and sporting demands to improve the transfer of training.

Box 14.2 Functional exercises

The term ‘functional’ is used excessively within the health and fitness industry and often describes
a wide variety of exercises from low-load core exercises (Bird-Dog) to high-load core strength
exercises (squats on an unstable surface). To be functional, means to provide a purpose. Therefore,
all exercises can be classed as functional.
From an exercise training perspective, a functional exercise is an exercise that creates specific
physiological adaptations that will directly transfer into activities of daily living, exercise or
sporting movements. For example, a squat will strengthen the quadriceps, hamstrings and gluteal
muscles using the same movement pattern initiated when sitting and standing. Additionally, a
squat will replicate the neuromuscular coordination, biomechanical and strength requirements
involved in the triple extension movement of jumping. Therefore, a squat is a functional exercise
for an individual needing to improve their ability to sit down, and any individual wishing to
improve a jumping aspect of their sport. In contrast, most low-load core exercises are classed as
non-functional. Very few activities of daily living or sporting movements require the core to be
stabilised in a supine, prone or quadruped position and there will be minimal training transfer from
these activities to performance based skills. However, in a rehabilitation setting where individuals
are retraining motor control, the same exercises will provide a functional purpose.
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Chapter 15
Cool-down

Simon Penn

A cool-down (also referred to as a warm-down) is the period at the end of an exercise session where the
exercise intensity is gradually or constantly reduced in an attempt to accelerate the body's return to
homeostasis: optimal resting levels of physiological and psychological parameters. The cool-down aims
to replenish energy stores, reduce metabolic by-products (e.g. lactate and hydrogen ions), reduce
sympathetic nerve activity, reduce the susceptibility to delayed onset of muscle soreness (DOMS), and
reduce cardiorespiratory parameters (e.g. heart rate, blood pressure, respiration) gradually to minimise
the risk of any cardiovascular complications following exercise (e.g. syncope and postural hypotension).
A cool-down also allows for a post-exercise period of reflection on the positive elements of the session,
which may increase exercise adherence.
Unfortunately, there is a lack of scientific evidence to identify the optimum intensity, duration and
type of exercise to facilitate the accelerated return to homeostasis. The general consensus for cool-down
activity is to follow the brief and generic guidelines recommended by the American College of Sports
Medicine (ACSM): 5–10 minutes of reduced intensity exercise followed by a period of stretching (ACSM,
2013). A longer duration of cool-down is recommended for older adults, clients suffering from
cardiovascular related conditions and the recovery from high-intensity exercise. The aims and
mechanisms of acute recovery from exercise warrant further investigation to understand the rationale
for reducing intensity, and increasing the duration of a cool-down.
Energy Substrates and Metabolites

Following the cessation of exercise, restoration of the energy systems' substrates (chemicals that
resynthesise adenosine tri-phosphate (ATP)) and the removal of certain metabolites/by-products of high-
intensity exercise (e.g. inorganic phosphate, hydrogen ions and lactate: a by-product of anaerobic
glycolysis) are vital in re-establishing homeostasis. Active recovery (exercising as part of the cool-down)
has been suggested to be superior to passive recovery in facilitating increased glycolysis, phospho-
creatine resynthesis, decreasing metabolic acidosis (increased acidity in the blood and tissues), and
muscle/blood lactate (Tokmakidis et al., 2010).
During dynamic exercise, aerobic and anaerobic energy pathways use muscle glycogen to produce
ATP (energy) and glycogen stores are often depleted following strenuous exercise. Muscle glycogen
content restoration begins immediately following exercise with lactate oxygenation: the conversion of
lactate to pyruvate (Fournier et al., 2004). Enhanced muscle blood flow during active recovery increases
lactate oxidation in skeletal muscle where pyruvate is transported to the Krebs cycle for oxidation.
Therefore, reducing the contribution of muscle glycogen to energetic demands and facilitating
replenishment. Additionally, increased blood flow enhances the transport of lactate to the liver where
lactate becomes resynthesised to pyruvate and then glucose: the Cori-cycle (Gollnick et al., 1986;
Hermansen and Vaage, 1977).
Following exercise and during active recovery, blood flow, glucose availability and sensitivity are all
increased which may lead to an overall increase in glucose uptake (Richter & Hargreaves, 2013).
Therefore, moderate intensity (64–76% of maximum heart rate (HRmax)) active recovery for prolonged
durations, may attenuate muscle glycogen replenishment and delay the return to homeostasis in
comparison to passive recovery (Raine et al., 2001). However, studies have identified that a low-intensity
(<64% of HRmax) active recovery of 10 (Bangsbo et al., 1994) or 15 (McAinch et al., 2004) minutes does
not reduce muscle glycogen resynthesis. Therefore, cool-downs should be restricted to 15 minutes if
muscle glycogen resynthesis is a priority.
During high-intensity exercise, there is a build-up of lactate. Although lactate may not independently
cause fatigue (see Chapter 11), reducing high levels of lactate is still encouraged in a cool-down to
facilitate the return of muscle homeostasis. Many studies have identified that active recovery, of varying
intensities, is significantly superior to passive recovery in reducing muscle and blood lactate
concentration (Baldari et al., 2005; Devlin et al., 2014; Greenwood et al., 2008; Menzies et al., 2010). Low–
moderate aerobic intensities will enhance blood flow without producing further lactate. However, active
recovery just above moderate intensity at approximately 67 per cent of max (≈79% of HRmax
(Londeree & Ames, 1975)) has consistently demonstrated the greatest level of lactate removal within 9
minutes in comparison to lower intensities or passive recovery (Baldari et al., 2005; Devlin et al., 2014).
Utilising the same exercise as performed in the main exercise session (Krukau et al., 1987) and exercising
large muscle groups (McGrail et al., 1978) during active recovery have also been shown to enhance
lactate removal and are recommended following high-intensity exercise. The magnitude and speed of
lactate removal will depend on the level of muscle and blood lactate, muscle fibre type and muscle
glycogen content (Tokmakidis et al., 2010). For example, higher concentrations of lactate will increase the
length of time required for the removal/recycling process.
In addition to the production of lactate, high-intensity exercise will also elevate hydrogen ion
concentration and produce intramuscular metabolic acidosis. During periods of high-intensity exercise,
the body metabolises a large number of ATP molecules to meet the energetic demands of the exercise.
During the metabolism of ATP, an acidic proton (hydrogen) is released. The increased demand for ATP
metabolism during high-intensity exercise causes an accumulation of protons and an acidic environment:
intramuscular metabolic acidosis. Metabolic acidosis is considered to be one of the mechanisms for acute
muscle soreness; the ‘muscle burn’ that is felt during high-intensity exercise. Therefore, following high-
intensity exercise, the cool-down should focus on reducing proton accumulation. Ten minutes of low-
intensity active recovery has been shown to restore muscle pH balance and homeostasis (Tokmakidis et
al., 2010). Therefore, cool-downs should include a minimum of 10 minutes of low-intensity, exercise-
specific active recovery to optimise muscle substrate replenishment and metabolite removal.
Blood Pressure

Following exercise, sympathetic nerve activity and circulating catecholamines (adrenaline and
noreadrenaline) are decreased leading to the reduction of active muscle contraction which causes heart
rate (HR) and mean arterial blood pressure (BP) to quickly return to resting levels (MacDonald, 2002).
Aerobic exercise beyond 10 minutes (Bennett et al., 1984; MacDonald et al., 2000), above an intensity of
50% max (MacDonald et al., 1999a), and performing resistance exercise (utilising loads ≥ 65% of one
repetition maximum) for 15 minutes or longer (MacDonald et al., 1999b), may also elicit a temporary
reduction in BP, to below resting values for the minutes or hours beyond exercise. This phenomenon is
termed post-exercise hypotension (PEH).
Post-exercise hypotension, occurs independent of gender or age and has been identified in individuals
with borderline hypertension (Floras et al., 1989; MacDonald et al., 2000) and hypertension (Hagberg et
al., 1987; Rueckert et al., 1996). However, in normotensive (normal blood pressure) individuals, PEH is
less consistent and usually of a lower magnitude (MacDonald, 2002). Research has suggested that the
baroreflex, a homeostatic system of the body that aims to restore blood pressure to resting levels, is more
effective in the normotensive population (MacDonald, 2002). The exact duration of PEH is still unclear
and may vary between populations and exercise modes. In some studies, PEH has been documented 12
hours post-exercise. Despite the need for closer observation of at-risk individuals following exercise, PEH
has been shown to have positive reductions on long-term BP in borderline hypertensive and
hypertensive individuals (Hecksteden et al., 2013; Liu et al., 2012). Therefore, exercise that elicits PEH
may reduce the incidence or level of hypertension.
Reduced skeletal muscle vascular resistance is considered to be the main mechanism of PEH (Halliwill
et al., 2013; MacDonald, 2002; Raine et al., 2001). However, a number of mechanisms may be responsible
or contribute to the reduction in BP post-exercise. Decreased sympathetic stimulation (Floras et al., 1989;
Halliwill et al., 1996), reduced peripheral resistance, and increased hyperaemia (excess blood) have also
been suggested to contribute to PEH (Halliwill et al., 2013; MacDonald, 2002). Following moderate
intensity exercise, previously active skeletal muscles can remain dilated beyond two hours due to the
activation of specific receptors (histamine H1 and H2). Hyperaemia in the vasodilated tissues can last
from seconds up to 20 minutes post-exercise dependent on the type, duration and intensity of the
exercise (Halliwill et al., 2013).
The effect of exercise intensity on PEH remains inconsistent. Some studies have shown no effect of
intensity (Cornelissen and Fagard 2004; MacDonald et al., 1999a; Pescatello et al., 2004) on PEH. In
contrast, others have identified that higher-intensity exercise elicits greater or prolonged PEH (Forjaz et
al., 2004; Quinn, 2000; Simão, 2005). Additionally, the magnitude of PEH may vary depending on the
recovery position: supine, sitting or standing. In upright positions (sitting or standing), the dilated
vascular beds are below the heart, increasing the risk of blood pooling (the accumulation of blood in the
lower extremities) and decreasing venous return. Furthermore, the gravitational stress elicited by upright
postures may exaggerate PEH (Kenney & Seals, 1993). However, systolic BP has been shown to reduce
more gradually in a seated rather than supine position (Raine et al., 2001). During active recovery, the
continued skeletal muscular contraction prevents venous pooling, assists venous return and therefore
allows a more gradual return of blood pressure to resting levels. Passive recovery fails to promote venous
return and may contribute to the magnitude of PEH. Therefore active recovery in a seated position
should be encouraged for populations at risk of PEH.
Post-exercise hypotension should be understood and monitored in at-risk populations (borderline
hypertensive and hypertensive) during a cool-down. A significant drop in BP in the period following
exercise may lead to an insufficient supply of oxygen to the brain causing syncope (a loss of
consciousness) (Krediet et al., 2004). Exercise-induced syncope is considered to be a sign of underlying
cardiovascular complications (Krediet et al., 2004). Therefore, for high-risk individuals an extended
gradual cool-down of 15 minutes followed by a period of observation is recommended to slowly return
cardiorespiratory parameters to resting levels and ensure no cardiovascular symptoms/complications are
present post-exercise.
Heart Rate

Active recovery using very low intensities (25–28% of max) has been shown to reduce HR quicker
than passive recovery (Takahashi & Miyamoto, 1998; Takahashi et al., 2000). Immediately following the
cessation of exercise, the restoration of HR to resting levels occurs in two phases. An initial, significant
drop in HR is followed by a period of gradual HR reduction (Furlan et al., 1993; Takahashi & Miyamoto,
1998). The restoration of HR is largely regulated by responses within the parasympathetic nervous
system (PNS), such as a reduction in sympathetic neural drive and a reinstatement of cardiac vagal tone
(the division of the PNS responsible for regulating homeostasis). Heart rate can remain elevated above
resting levels post-exercise to maintain muscle blood flow, increase oxygen availability, and assist in the
resynthesis of the energy systems and removal of muscle metabolites. Furthermore, when PEH is present,
the reduction in venous return, venous pressure, cardiac preload and cardiac output may be compensated
by an elevated HR. Therefore, HR recovery to resting levels may be elongated in the presence of PEH
(Halliwill et al., 1996; Isea et al., 1994). A gradual reduction of exercise intensity and HR is recommended
in the cool-down to minimise blood pooling and any deleterious effects on cardiac function (Dimsdale et
al., 1984). Cool-downs for older adults should be extended because they are at an increased risk of blood
pooling and PEH.
A more rapid return of HR to resting levels is achieved by trained v. untrained individuals due to an
enhanced cardiac autonomic nervous system (Darr et al., 1988). Heart rate recovery has been identified
as a useful tool for predicting all-cause mortality in both healthy and clinical populations (Buchheit et
al., 2007; Cahalin et al., 2013; Johnson & Goldberger, 2012). Various methods of calculating HR recovery
have been used. For example, HR can be taken immediately post-exercise and then repeated either one or
two minutes later. The difference between the two readings can then predict the incidence and risk of ill
health. A low HR recovery (a reduction of ≤ 12 B/min after one minute post-exercise) has been associated
with a dramatic increase in mortality risk (Cole et al., 1999; Nishime et al., 2000; Watanabe et al., 2001).
Parasympathetic activation is the main contributor to HR decay in the initial 30 seconds post-exercise
and therefore a reduced activation of this system is suggested to be the cause of poor HR recovery (Imai
et al., 1994).
Muscle Soreness

As discussed in Chapters 13 and 16, unaccustomed or strenuous exercise may cause exercise induced
muscle damage (EIMD) and accompanying muscle soreness. Acute muscle soreness occurs during or
immediately following unaccustomed/strenuous exercise and may be caused by a reduction in adequate
oxygen to the working muscle, a build-up of metabolites or a combination of the two (Clarkson & Hubal,
2002). Delayed onset of muscle soreness, occurs 12 hours following strenuous exercise (particularly
eccentric activity) and usually lasts for 48–72 hours, but can last longer (Dierking & Bemben, 1998;
Francis, 1999). Exercise induced muscle damage, leading to DOMS, causes site-specific muscle pain,
decreased range of movement and reduced force production/performance (Law & Herbert, 2007; Tella et
al., 2012).
A cool-down, incorporating active recovery and stretching, has often been recommended to reduce the
prevalence or severity of DOMS. Active recovery increases blood flow, replenishes nutrients and
decreases noxious metabolites within the muscle cell, which were thought to reduce the incidence and
severity of DOMS (Cheung et al., 2003). However, research has identified that increased blood flow and
the reduction of metabolites are not associated with attenuated DOMS (Schwane et al., 1983). Therefore,
active recovery has minimal or no effect on DOMS (Bhatia, 2011; Law and Herbert, 2007; Olsen et al.,
2012).

Stretching

Although post-exercise stretching is commonly advocated to reduce muscle soreness, post-exercise

stretching does not effectively reduce DOMS (Herbert et al., 2011; Thacker et al, 2004). Furthermore, as
an efficient cool-down facilitates acute recovery and restores homeostasis, stretching will only play a
minor role in restoring physiological or psychological parameters. Adaptation and super-compensation
to the training stimulus are vital during recovery from exercise (see Chapter 7). However, stretching has
not been shown to improve adaptation to training. Therefore, the use of stretching as a recovery tool
may be unwarranted. Stretching should only be included as part of a cool-down, or as a separate
component of exercise, if the aim is to restore or enhance range of movement (see Chapter 10).

Alternative modalities for reducing muscle soreness

Warm-ups

In contrast to a cool-down, an effective warm-up (see chapter 10) consisting of 10–20 minutes of aerobic
activity has been shown to be more effective at reducing the onset and severity of DOMS in comparison
to a cool-down and passive recovery (Law & Herbert, 2007; Olsen et al., 2012). Warm-ups will increase
the temperature and elasticity of muscles prior to exercise, which will increase the length that muscle
tissue can stretch to before causing the muscle damage that leads to DOMS (Noonan et al., 1993; Safran
et al., 1988).

Myofascial release

An alternative modality that can be used in the cool-down to attenuate DOMS is myofascial release.
Fascia is a connective tissue, composed of collagen and elastin fibres, that surrounds the soft tissues of
the body (muscles, bones, nerves, arteries, veins and internal organs). Trauma and injury can cause fascia
to become restricted, lose pliability and reduce normal muscle mechanics. Myofascial release is a manual
technique used by therapists to restore the length of the myofascial tissue by applying pressure and a
stretch through the tissue. Self-myofascial release follows the same principle but can be applied by self-
massage or using a foam roller.
Recent studies have identified that 20 minutes of foam rolling (2 × 45–60 seconds per muscle group)
immediately after exercise, and 24 and 48 hours post-exercise, effectively reduces the magnitude of
DOMS (MacDonald et al., 2014; Pearcey et al., 2015). Foam rolling is suggested to decrease muscle
tenderness and improve connective tissue recovery (MacDonald et al., 2014; Pearcey et al., 2015).
Therefore, foam rolling could be employed as part of a cool-down following unaccustomed or strenuous
activity. However, foam rolling research is still in its infancy and optimum durations, intensities and
protocols for reducing DOMS are yet to be elucidated.

Exercises to avoid

Another method of reducing the onset of DOMS is to avoid eccentric activity in the cool-down. Eccentric
activity, such as the deceleration phase in running as the foot impacts the floor, increases the risk of
muscle damage and DOMS (Armstrong, 1984). Therefore, although active recovery may not attenuate
DOMS, cycling or other modalities only using concentric activity are recommended for cool-downs
following strenuous activity (Olsen et al., 2012).

Summary
The recommended length and intensity of a cool-down is dictated by the population and the type,
intensity and duration of the exercise performed within a training session. A cool-down aims to
achieve physiological and psychological homeostasis in the body by gradually returning energy
systems, heart rate and blood pressure back to resting levels (see Figure 15.1).
Figure 15.1 Cool-down summary.
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Chapter 16
Recovery from training

Jessica Hill
Introduction

Achieving the highest levels of physical fitness and performance is only possible through an ordered,
well thought-out training process designed to stimulate structural and metabolic adaptations within the
systems of the body (Smith, 2003; Stone et al., 2007). A bout of hard training is followed by a temporary
decrease in muscle function resulting in reduced performance at a given task; however, if a period of
recovery follows training then super-compensation and performance improvements occur (Smith, 2003).
It is well known that adaptation and performance enhancements occur following progressive overload
(see Chapter 7). In general an individual who is able to complete higher training loads will achieve
greater performance improvements; however, high training loads and not enough recovery can lead to a
reduction in physical performance (Stone et al., 2007). Optimal adaptation to training, characterised by
growth, adaptation and improved performance, occurs when the training load is appropriately
sequenced, alternating increasing loads with recovery (Siff, 2003; Smith, 2003). Recovery is a necessary
part of the training process, important in reducing the experience of fatigue and inducing adaptation
(Smith, 2003). Recovery and growth of the systems exposed to training stress occurs in the rest phases
that follow exhaustive training; for this reason, rest periods and temporary decreases in training are vital
(Siff, 2003). If a client has not recovered sufficiently before the next training bout is imposed then
adaptation fails to occur and decrements in performance, injury and stagnation may be observed (Siff,
2003).
It is clear that attaining an appropriate balance between training and recovery is important in
maximising performance, and a multitude of recovery strategies are now being practised amongst
athletes in order to facilitate this balance (Barnett, 2006). In particular there is a growing interest in
strategies that counter the effects of exercise induced muscle damage (EIMD) and aid the process of
recovery (Barnett, 2006; Smith, 2003).
What is Recovery?

The term ‘recovery’ means different things to different people; several definitions for recovery have been
outlined, but essentially recovery can be defined as ‘the ability to meet or exceed performance at a
particular task’ (Bishop et al., 2008).
The term recovery has been used to describe many different situations within the sporting arena. For
example, it has been used to describe the return from illness or an injured state, the short rest periods
between movements during interval training (Bishop et al., 2008), and the period between successive
exercise sessions or competition (Bishop et al., 2008). This chapter will focus on recovery between
successive exercise sessions.
Recovery from Exercise

The impairment in performance following a training bout can be temporary, lasting just a few minutes to
several hours; this decrease in performance is probably due to metabolic factors such as depletion of
muscle glycogen, decreased pH and fatigue. Adequate rest and appropriate nutrition can facilitate
recovery from metabolic fatigue. Impairment that lasts longer than 24 hours is likely to be due to damage
to the muscle fibres and muscle cell architecture. This phenomenon is often referred to as exercise-
induced muscle damage (EIMD) and is characterised by a number of signs and symptoms including pain,
strength loss, stiffness, swelling and an increase in blood circulation of intra-muscular enzymes such as
creatine kinase (CK). These symptoms follow individual time responses, with some symptoms, such as
elevated CK, presenting slowly and becoming more prominent 24–48 hours following the damaging
exercise bout whereas others, such as decreases in muscle function, peak immediately after exercise and
persist for several days after (Allen, 2001).
The severity of EIMD depends on a number of factors including exercise familiarity, intensity and
duration (Connolly et al., 2003). Unaccustomed exercise or exercise that is prolonged in nature can cause
damage to the muscle fibres resulting in ultra-structural changes and delayed onset muscle soreness
(DOMS) (Armstrong, 1986, 1990). Whilst EIMD can occur from concentric, isometric or eccentric
exercise, activities that include an eccentric component, (e.g. downhill running or lowering a weight)
have been found to result in a greater manifestation of symptoms (Clarkson & Sayers, 1999; Enoka, 1996).
Eccentric muscle contractions occur during every day activities; one example can be found in the
normal gait cycle where the lower limb extensor muscles eccentrically contract when the foot strikes the
ground (Fridén & Lieber, 2001; Lieber et al., 1996). Whilst eccentric contractions are associated with
greater tissue damage, these actions are often incorporated into training programmes in order to induce
structural adaptations and to enhance neural commands (Enoka, 1996). These adaptations also occur
following concentric exercise, but not to the same extent (Enoka, 1996). Thus, despite the potentially
damaging effects of eccentric contractions they are important in maximising adaptations. In addition, the
low metabolic cost of eccentric contractions and the ability of eccentric exercise to induce adaptation
from low-intensity exercise make this type of exercise beneficial to elderly and diseased populations
(Hortobagyi, 2003; Hortobagyi & DeVita, 2000).

Case study 16.1 Recovering from resistance training

David is a 26-year-old driving instructor who has not done much exercise in the last 2 years. He
decides he would like to embark on a resistance training programme in order to help reduce body
fat and increase muscle mass. As David has not undertaken any resistance training in the last few
years, if he began a training programme that incorporated a large number of eccentric actions, he
would experience a large amount of muscle damage and consequent soreness. To minimise the
severity of this muscle damage and soreness David should begin with a low volume of eccentric
actions and progressively increase the level of eccentric activity each week.
Strategies to Enhance Recovery

The experience of exercise induced muscle damage brings about a series of undesirable symptoms which
result in the impairment of physical performance in everyday tasks and training (Connolly et al., 2003).
The negative symptoms experienced can have a deleterious effect on subsequent training sessions due to
the occurrence of residual muscle pain, stiffness and a reduced capacity to perform at the desired
intensity (Howatson & Van Someren, 2008). This may also affect adherence to exercise, particularly in an
elderly population (Chao et al., 2000).

Box 16.1 Muscle soreness and lactic acid

It is a common belief that the delayed onset muscle soreness experienced after eccentric or
unaccustomed exercise is due to lactic acid; this is not correct. Several theories have been proposed
to explain the onset of muscle soreness. These include (1) damage to the connective tissues
associated with muscle, (2) mechanical damage that has occurred to the structures within the
muscle fibres, and (3) the inflammatory response associated with muscle damage (Cheung et al.,
2003).

It is recommended that individuals wait for the symptoms associated with EIMD to reduce before
returning to training; however, this is not always possible amongst athletes due to the scheduling of
competition and training (French et al., 2008). It is becoming increasingly more common for individuals
to exercise whilst experiencing some of the negative symptoms associated with muscle damage and, in
addition, it is a concern that the experience of muscle damage may lead to more serious injuries (Cheung
et al., 2003). It is thought that many individuals are now adopting a ‘no pain, no gain’ mentality rather
than resting, and the impact of this behaviour could have detrimental effects (Cheung et al., 2003; Smith,
1992). An inaccurate perception of bodily impairment resulting from EIMD may result in clients
returning to training before they have adequately recovered, and this may cause further injury to the
weakened tissue (Cheung et al., 2003; Smith, 1992). Therefore, optimising recovery has an important role
in both training and competition.
Achieving appropriate recovery between training sessions may enable clients to tolerate higher
training loads in the form of volume, frequency or intensity (Barnett, 2006). Due to this, manipulation of
the recovery time frame is becoming increasingly more important, particularly amongst athletes. Thus,
any modality that may prevent or reduce the negative symptoms associated with muscle damage may be
beneficial (Howatson & Van Someren, 2008). A multitude of strategies have emerged claiming to either
prevent or reduce symptoms associated with muscle damage; these strategies include massage,
stretching, cryotherapy and adequate nutrition.
Nutrition

Adequate post-exercise nutrition is fundamental to effective recovery and will vary depending on the
type of training session and the length of the rest period between training sessions. Depletion of muscle
glycogen occurs during high intensity exercise and affects an athlete's capacity to perform; therefore
refuelling glycogen stores following exercise is important for recovery. In addition, amino acids and
energy are diverted away from protein synthesis during exercise. This combined with damage to the
muscle proteins makes post-exercise protein intake essential for recovery (Levenhagen et al., 2001).
The timing of post-exercise nutrient intake has a significant influence on the speed of glycogen and
protein re-synthesis, therefore individuals who are completing a high training load are encouraged to
consume food as early as possible after the cessation of exercise. With adequate carbohydrate intake
athletes can replenish their carbohydrate stores within 24 hours (Costill et al., 1981). Thus, when the
period of recovery between training sessions is greater than 24 hours the early consumption of food
following exercise is less important.
Stretching

Stretching is defined as the application of force with the desire of achieving increased flexibility and
joint ROM (Weerapong et al., 2004), and is a common practice in sporting scenarios due to the belief that
it can reduce the risk of injury and improve performance (Barnett, 2006; Behm & Chaouachi, 2011;
LaRoche & Connolly, 2006). Stretching is indicated to be effective in the recovery process with research
observing reduced experience of soreness and a reduction in muscle stiffness (Gremion, 2005; Torres et
al., 2007).
Several reviews have indicated that changes in length and stiffness of the musculo-tendonous unit
(MTU) brought about by stretching lead to an improved ROM (Behm & Chaouachi, 2011; Reisman et al.,
2005; Weerapong et al., 2004). These suggestions are supported by LaRoche and Connolly, (2006) who
observed that a 4-week stretching protocol was able to maintain ROM and stretch tolerance following
eccentric exercise; however, there was no effect on soreness. In addition to this, research has also
indicated that a bout of passive stretching can elevate concentrations of neutrophils (a type of white
blood cell, with a role in inflammatory processes) without causing any other symptoms of EIMD (Pizza
et al., 2002).
Whilst stretching is perceived to be beneficial to recovery, several studies have failed to observe any
benefit (Herbert & Gabriel, 2002; Johansson et al., 1999; Lund et al., 1998). Lund et al. (1998) observed that
an 8-day stretching protocol consisting of three 30 second passive stretches of the quadriceps muscle
group did not affect markers of muscle damage to include CK, soreness or strength. It is possible that the
stretching protocol of just 90 seconds per day implemented in this study was of an insufficient duration
to elicit a benefit. However, these findings are in accordance with a meta-analysis investigating the
effects of stretching before or after exercise, using the pooled results from 12 studies, the study indicated
no beneficial effects of stretching on DOMS (Henschke & Lin, 2011). These findings are consistent with
an earlier systematic review conducted on the findings of five studies (Herbert & Gabriel, 2002). Based
upon the current literature, it would appear that stretching has little effect on easing symptoms
associated with EIMD.
Sleep

Sleep has been anecdotally described as the single best recovery strategy available (Halson, 2008;
Walters, 2002). The restorative effects of sleep are reported to facilitate physiological and psychological
recovery and may reduce the risk of unexplained underperformance (Halson, 2008). It is well known that
sleep deprivation increases the experience of fatigue, affects mood state and increases the amplification
of pain (Halson, 2008; Reilly & Edwards, 2007) all of which have a negative impact on health and
performance. In addition, sleep deprivation is likely to impair function of the immune and endocrine
systems (Halson, 2008; Reilly & Edwards, 2007). During sleep all but the most basic of bodily functions
slow down and in addition the endocrine system increases the secretion of growth hormone in order to
facilitate growth and repair (Walters, 2007). Thus, high-quality sleep is fundamental to facilitating
recovery and adaptation to exercise stress. Research has identified that individuals undertaking regular
physical activity sleep for increased durations at night. Therefore, trainers must educate clients regarding
the importance of sleep following exercise.
Historically it has been perceived that exercising close to bedtime disturbs sleep; however, the majority
of research evidence suggests that this is not the case. In a survey carried out to investigate factors that
promote and disturb sleep, exercise in the early evening was generally reported to have a positive impact
on sleep (Vuori et al., 1987). A more recent study investigating vigorous late night exercise observed that
heavy exercise that ends 30 minutes before bedtime did not disrupt sleep (Youngstedt et al., 1999). These
authors suggest that prior assumptions that exercise before bed disturbs sleep may not be valid.
Nevertheless, the timing of exercise should be monitored if clients experience periods of disturbed sleep.
Massage

Massage is used by a variety of practitioners in the treatment and rehabilitation of soft tissue injury. It is
also reported to have a number of psychological benefits to include reduced levels of anxiety and
improved relaxation (Weerapong et al., 2005). Research has also focused on the efficacy of massage as a
treatment for the symptoms associated with EIMD (Tiidus, 1999; Weerapong et al., 2005). It is widely
believed that massage can provide a number of positive benefits to the body. These include: alterations in
blood flow and skin temperature, reduced tension and stiffness, and an improved sense of wellbeing;
however, there is a lack of evidence to support these beliefs (Field et al., 2007; Tiidus, 1999; Weerapong et
al., 2005).
Reductions in muscle soreness following massage have been extensively reported (Farr et al., 2002;
Hilbert, 2003; Zainuddin et al., 2005). Research has indicated that 10 minutes of massage performed 3
hours after eccentric exercise is able to reduce muscle soreness and swelling (Zainuddin et al., 2005). The
reduction in swelling may indicate that massage was able to reduce the inflammatory response. It is
possible these effects were caused by an enhanced blood and lymph flow which resulted in a decreased
accumulation of fluid in the affected area (Zainuddin et al., 2005). In addition, it is thought that the
mechanical action of massage is able to increase blood flow, reducing oedema and the sensitisation of
nerve endings that stimulate pain.
Whilst studies have observed decreases in soreness and swelling following massage, no changes in
muscle function have been observed (Farr et al., 2002; Hilbert, 2003; Lightfoot et al., 1997; Zainuddin et
al., 2005). It is likely that decrements in strength arise from architectural changes resulting from
mechanical damage. The fact that massage has not been demonstrated to have an effect on muscle
strength indicates that massage is not able to reduce the level of muscle damage or improve its recovery
time frame (Farr et al., 2002). The physiological benefits of massage on recovery appear to rely on
alterations in blood flow. Whether massage is able to enhance blood flow is questionable, with research
failing to demonstrate changes in limb blood flow following massage (Shoemaker et al., 1997; Tiidus &
Shoemaker, 1995). If elevation in blood flow is the desired effect then light exercise may be more
effective than massage (Tiidus, 1997).
Massage may be effective in reducing perceptions of soreness; however, the evidence supporting the
use of massage on physiological markers of recovery is lacking (Tiidus, 1997). This is likely due to
differences in the type and duration of massage administered, and the timing of massage application
(Howatson & van Someren, 2008). In sporting scenarios where the focus of recovery is on performance,
massage may not have a place; however, in clinical settings where the reduction of pain is key, massage
may provide a valuable tool (Farr et al., 2002). More scientific knowledge is required to elucidate the
benefits of massage, if any (Weerapong et al., 2005).
Cryotherapy

Cryotherapy is defined as the therapeutic application of cold (Howatson & Van Someren, 2008; Meeusen
& Lievens, 1986). This treatment can include immersion in cold water and ice massage. The use of cold
water immersion (CWI) as a recovery strategy is growing in popularity (Barnett, 2006; Leeder et al., 2012;
Wilcock et al., 2006). Evidence for its efficacy as a recovery strategy comes from the treatment of acute
soft tissue injury (Eston & Peters, 1999; Paddon-Jones & Quigley, 1997).
Immersion in cold water is thought to provide benefits following intensive exercise in two ways. First,
the application of cold is thought to reduce the inflammatory response to tissue damage by promoting
constriction of the blood vessels, therefore reducing swelling and oedema (Meeusen & Lievens, 1986).
Second, during water immersion the body experiences compression from the hydrostatic pressure of the
water (Wilcock et al., 2006). This pressure is greatest at the ankle and decreases towards the surface of
the water. The compression received from the water can displace fluid from the lower limb towards the
thorax, causing a number of physiological changes to include improved removal of metabolites from the
muscle, improved delivery of substrates and enhanced cardiac output (Wilcock et al., 2006).
Studies have found CWI to have some effect in alleviating symptoms of EIMD (Bailey et al., 2007;
Eston & Peters, 1999; Leeder et al., 2012; Yanagisawa et al., 2003). Bailey et al. (2007) observed a reduced
decline in force production 24 and 48 hours post-exercise and reduced perceptions of muscle soreness 48
hours post. Eston and Peters (1999) observed a reduction in muscle stiffness and decreased
concentrations of CK following 15 minutes of CWI at 15 °C. Contrasting this research, Paddon-Jones and
Quigley (1997) observed no differences in soreness, peak torque and limb volume following five bouts of
20-minute CWI, each separated by 1 hour. However, the participants who took part in this study were
well-trained subjects. It is well known that training experience affects the magnitude of EIMD following
strenuous exercise. Thus, it is possible that CWI does not work in trained individuals. These findings are
consistent with Goodall and Howatson (2008), who observed no changes in strength, soreness,
concentrations of CK and thigh circumference.
It is difficult to control for the placebo effect when conducting studies on CWI. This may explain some
of the inconsistency in findings. To address this issue Broatch et al., (2014) conducted a study where,
following a high-intensity exercise session, participants were assigned to one of three 15-minute
treatment groups: (1) CWI (10.3 ± 0.2 °C); (2) thermo-neutral water immersion placebo (34.7 ± 0.1 °C); or (3)
thermo-neutral water immersion control (34.7 ± 0.1 °C). The only difference between the two thermo-
neutral groups was the addition of bubble bath which participants were led to believe was a substance
that would benefit their recovery. Recovery of strength in the CWI and thermo-neutral placebo group
was significantly better than recovery in the thermo-neutral control group. It was identified that CWI
provided no more benefit than a placebo treatment in a thermo-neutral water immersion.
The efficacy of CWI as a recovery strategy is still unclear. This is largely due to variations in the
treatment modality, including timing, duration, frequency of application and temperature, as well as the
type of exercise protocol and training status of the participants. Research has yet to determine an optimal
duration and temperature range. Furthermore, long periods of immersion time is problematic as some
individuals struggle to withstand temperature (Wilcock et al., 2006). Research has also indicated that the
chronic use of CWI may impair adaptive responses to training (Fröhlich et al., 2014); however, further
research is needed to clarify this.

Summary
In summary, recovery is an important part of the training programme. Individuals vary in their
ability to recover and the use of recovery strategies can provide valuable benefits to clients
struggling to recover or to clients looking to accelerate the recovery period. However, it is important
to note that not all clients will benefit from each recovery strategy; some strategies are more
applicable to clients with advanced levels of fitness i.e. trained athletes. (see Table 16.1).

Table 16.1 Recovery strategies and populations most likely to benefit from the use of each strategy
Beginner Intermediate Advanced

Nutrition ✓ ✓ ✓

Stretching ✓ ✓ ✓

Sleep ✓ ✓ ✓

Massage ✗ ✓ ✓

Cryotherapy ✗ ✗ ✓
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Index

Page numbers in italics refer to figures and tables

1RM tests 58, 79, 172
5:2 diet see intermittent fasting (IF)
24-hour recall dietary assessment 36

abdominal hollowing versus abdominal bracing 210, 211

accommodation (training plateau) 63, 74, 83, 84, 92, 186, 193
ACSM see American College of Sport Medicine (ACSM)
active commuting 3
active lifestyle promotion 2, 3–4, 69, 133–4, 192
adenosine triphosphate (ATP) 120–1, 151, 152, 153, 189, 217, 218
adherence 2–3, 24; action plan and relapse prevention 30; and cardiorespiratory fitness training 127, 135, 136; client reviews 31; and cool-
down 217; to dietary plans 36, 48, 49; and high-intensity interval training (HIIT) 155, 156–7; motivational interviewing (MI) 27; and
periodisation 49, 84, 85, 88, 91, 95, 96; and recovery from training 229
aerobic energy system 141, 163, 217–18; see also aerobic interval training (AIT); cardiorespiratory fitness training (CRT)
aerobic exercise: adaptations 64, 70, 93; and blood pressure 219; and warm-up 102–3, 222
aerobic interval training (AIT) 150, 151, 153, 155, 160, 161, 164; case study 163; for performance 159–60
age factors see aging; children
agility 11
aging: balance 11; cardiorespiratory fitness training case study 122; and creatine 44; heart rate 75; injury and adherence to exercise 229; and
intermittent fasting (IF) 48; muscle power 11, 42; and Paleo diet 47; and PAR-Q 17; post-exercise guidelines 217, 220; and protein intake
39; and resistance training (RT) 177, 178; and whey protein 42
Alzheimer's disease 44
American College of Sport Medicine (ACSM): cardiorespiratory fitness training recommendations 133, 149; cool-down guidelines 217; FIIT
principle (frequency, intensity, time, type) 110; health screening guidelines 19, 20; resistance training recommendations 172, 174, 176, 179,
182–3, 185; stretching exercise definitions 104; warm-up guidelines 112, 113
amino acids 39, 230
anaerobic energy system 217–18; anaerobic threshold 128, 133, 159; see also adenosine triphosphate (ATP); cardiorespiratory fitness training
(CRT); resistance training (RT); sprint interval training (SIT)
ankle flexibility 109
appetite: and carbohydrates 37; and intermittent fasting (IF) 48; and physical activity 137, 157; and sweetened drinks 35; see also satiety
(feeling of fullness)
Astrand-Saltin cycle ergometer test 56
back pain 207, 211, 212
balance 11
behaviour change see lifestyle assessment and behaviour change
bioenergetics see adenosine triphosphate (ATP); aerobic energy system; anaerobic energy system
block periodisation (BP) 88, 91–4, 156; advantages 93; disadvantages 94; strength and hypertrophy case study 92
blood lipids see cholesterol/blood lipids
blood pressure: and diet 37, 42, 45; and exercise 9, 10, 124, 155, 156; and health screening 16, 17; post-exercise hypotension (PEH) 217, 219–20,
223
blood sugar levels 37; see also diabetes, type 2
body composition: and cardiorespiratory fitness training (CRT) 136, 137; and combined CRT/RT training 190, 190, 191, 192; definition of 10;
and diet 5–6, 46, 47, 48, 137; and high-intensity interval training (HIIT) 155, 157–9, 158; measuring 56–7; and supplements 42, 43, 44; and
weight loss 4–6
Bruce protocol treadmill test 56

caffeine 43–4; see also energy drinks

calorie intake 4–5, 6; see also diets; nutrition
Canadian Society for Exercise Physiology (CSEP) 14, 15, 17
cancer 9, 151; and caffeine 43; and low carbohydrate diet (LCD) 45
carbohydrates 37, 42; burning of 138, 138, 139; and digestive system 39; intake post-exercise 230; low carbohydrate diet (LCD) 45–6
cardiorespiratory fitness (CRF): and detraining 65; and mortality risk 5–6, 9; and resistance training (RT) 179; see also cardiorespiratory
fitness training (CRT); high-intensity interval training (HIIT)
cardiorespiratory fitness training (CRT) 70, 120–43; ACSM recommendations 133; adherence 127, 135, 136; and aging 122; calculating
intensity and volume 75–8, 76, 78; combined with resistance training (RT) 189–91, 190, 192, 195; and diet 137; for fat loss 136–40; for
health 130–6, 131, 132; intensity of training 120–6, 121, 135; moderate and vigorous activity levels 133, 134–5; for performance 140–3; rest
periods 80; training methods 127–30, 130, 135; warm-up 112
cardiovascular disease: and body fat 4; and caffeine 43; and cardiorespiratory fitness 9, 130, 131, 134, 151; and cool-down 217, 220; and diet 35,
37, 38, 39, 45, 47; and fat consumption 38–9; health screening 14, 19; and muscular strength 10, 178–9, 192; post-exercise guidelines 217
ceiling of adaptation 64, 65
chest/pectoral flexibility 109, 109
children, and PAR-Q 17
cholesterol/blood lipids 9, 10, 37, 38, 45, 47, 133, 155, 178
circuit training 70, 76, 173–4, 173, 193, 194, 195
clients: individual needs 6, 9, 12, 34–5, 58, 62–3, 64, 84, 96, 171; rapport with personal trainer 22, 31; see also adherence
cognitive function: and caffeine 43; and creatine 44, 45; and fluid intake 40; and intermittent fasting (IF) 49
cold water immersion (CWI) see cryotherapy
commuting to work 3
concurrent training (CT) 69–70, 111
constrained total energy expenditure (CTEE) 137
continuous exercise training (CET) 127–8, 130, 135, 140, 149; comparisons with high-intensity interval training (HIIT) 150, 152, 153, 155, 157,
 158, 158, 159, 161, 164; complement to high-intensity interval training (HIIT) 153, 156, 163; see also fartlek training; tempo/threshold
training
cool-down 214–23; ACSM recommendations 217; blood pressure 219–20; energy substrates and metabolites 217–19; heart rate 220–1; muscle
soreness 221–2; summary 223
coordination 11
core training 207–14; core stability 209–12, 210, 212; definition of core 208; functional exercises 214; training methods 212–14, 212, 213; see also
posture
Cori-cycle 218
C-reactive protein 178
creatine 44–5
creatine kinase (CK) 228, 231, 233
cross-over concept 138, 138
cross-training 65, 84; case study 64
cryotherapy 232–3
cumulative training effect 86, 93

degenerative diseases 44
dehydration 40
delayed onset of muscle soreness (DOMS) 84, 100, 101, 217, 221, 222, 228, 231
desks, standing 3
detraining 65, 88, 142
diabetes, type 2: and caffeine 43; and diet 35, 45, 47; and exercise 9, 149, 151, 155, 178–9, 192; and muscular strength 10; and sweetened drinks
40; and whey protein 42
diets 34–49; and cardiorespiratory fitness training (CRT) 189; dietary assessments 35–6, 36; dietary patterns 35; diet drinks 40; evidence
based components of 35; high protein diets 39; intermittent fasting (IF) 48–9; low carbohydrate (LCD) 37, 45–6; Paleo 46–8; and
resistance training (RT) 189; without exercise 5–6; yo-yo dieters 6; see also nutrition
digestive system: and carbohydrates 37, 39; and energy expenditure 35; and Paleo diet 47; and protein intake 39
dose-response relationship 131, 132, 132, 136–7, 141, 184
dynamic balance 100
dyslipidaemia see cholesterol/blood lipids

endocrine system 170, 231

endurance training 9, 11; and cardiorespiratory fitness training (CRT) 140, 141, 142; and detraining 65; and extended interval training
129–30, 130; and high-intensity interval training (HIIT) 159, 160, 163; and low carbohydrate diet (LCD) 46; muscle fibres 170; and
supplements 40, 42–3, 45; training session design 76, 78, 90
energy balance and expenditure 1, 4–5, 35–6; constrained total energy expenditure (CTEE) 137; and fat burning zone 137–40, 140; measuring
74, 75, 76, 121, 132; negative energy balance 136, 139, 157; resting energy expenditure 6; resting energy expenditure (REE) 43, 177, 191,
192, 193; substrates and metabolites 217–19, 233
energy drinks 37, 40; see also caffeine
essential fatty acids 37–8
excess post-exercise oxygen consumption (EPOC) 157, 191, 193
exercise 2
exercise induced muscle damage (EIMD) 182, 221, 227, 228, 229–30, 231, 232, 233
explosive power 107
extended interval training 129–30, 130, 135

fall prevention 11
fartlek training 128, 130, 135, 140, 161
fasting see intermittent fasting (IF)
fat/body mass see body composition
fatigue: and creatine 44; and lactic acid hypothesis 129, 218; and muscle types 170; and periodisation 83, 85, 92, 95; and vitamin/mineral
deficiencies 41; and warm-up 111, 112; see also rate of perceived exhaustion (RPE); recovery from training
fat loss: and caffeine 43; and cardiorespiratory fitness training (CRT) 136–40; and creatine 44; diet only approach 5–6; and exercise 4–5; fat
burning zone 138–40; and high-intensity interval training (HIIT) 157–9, 163; resistance training (RT) 189–95, 194; and whey protein 42;
see also diets
FATmax 138, 139, 140
fat (nutrition) 37–9; essential fatty acids 37–8; saturated fats (SFA) 37, 38; UK guidelines 38; unsaturated fats (UFA) 37, 38
fibre see carbohydrates
fish oil 37–8
fitness assessments 55–8, 141; administering 57–8; reliability of 56–7, 57; validity of 55–6, 57
fitness, components of 9–12
fitness-fatness hypothesis 6
fitness professionals see personal trainers
FITT principle (frequency, intensity, time, type) 110, 110, 111–14, 116
flexibility 10; see also stretching
flexible undulating periodisation (FUP) 95
fluids 35, 40, 43–4
foam rolling 222
food diaries 36
food frequency questionnaire 36
fruit and vegetables and fluid intake 40; see also vitamins and minerals

General Adaptation Syndrome (GAS) 59–60

genetics: and cardiorespiratory fitness 120, 130, 137; and resistance training (RT) 170, 171
glucose, blood 37, 157, 178–9, 218; see also diabetes, type 2
glycaemic index (GI) 45
glycogen 45, 112, 157, 217–18, 228, 230
goal-setting (GS) 29–30
gut fermentation see digestive system

hamstring: injury 100; stretches 101, 105, 106, 108

health belief model 23
health-performance training continuum 62–3, 62
health related fitness 9–10; and cardiorespiratory fitness training (CRT) 130–6, 131, 132; and high-intensity interval training (HIIT) 151–7, 152,
154; and resistance training (RT) 177–80, 178
health screening 14–20; ACSM guidelines 19, 20; physical activity readiness questionnaire for Everyone (PAR-Q+) 17, 18, 20; physical activity
readiness questionnaire (PAR-Q) 14–17, 15, 19, 20; ‘risk stratification’ 19, 20; SMA guidelines 19, 20; UK Active - Health Commitment
Statement (HCS) 20
heart disease see cardiovascular disease
heart rate measurement (HR) 75, 76, 160; and cool-down 220–1; heart rate and training zones 125; heart rate maximum 123–4, 124, 153; heart
rate reserve (HRR) 124–5, 134–5; heart rate training zones 133; TRIMP method 77, 78; and warm-up 112, 113
high and low responders 6
high-intensity interval training (HIIT) 149–64; aerobic interval training (AIT) 150, 151, 153, 155, 159–60, 160, 161, 163, 164; benefits of 149;
and carbohydrates 37; and creatine 45; for fat loss 140, 157–9, 158; for health 151–7, 152, 154; for performance 159–63, 160, 162; practicality
of 156–7; psychological benefits 155; safety of 156; sport-specific 160–3; sprint interval training (SIT) 150, 152–3, 155, 156, 158, 160, 161,
164; training programme design 59, 63, 163–4; types of 150, 150
Hippocrates 2
hunger see appetite; satiety (feeling of fullness)
Huntington's disease 44
hyperaemia 219
hypertension see blood pressure
hypertrophy: and periodisation 92, 92, 94, 94; pre-exhaust method (PE) 74; putting on size 68; and resistance training (RT) 170, 174, 177, 179,
180–6, 191; toning up 68; and warm-up 116
hypotension see blood pressure

ice baths see cryotherapy

immune system: and carbohydrates 37; and sleep deprivation 231; and whey protein 42
injuries: and core training 207, 211; delayed onset of muscle soreness (DOMS) 84, 100, 101, 217, 221, 222, 228, 231; and detraining 65; exercise
induced muscle damage (EIMD) 182, 221, 227, 228, 229–30, 231, 232, 233; and high-intensity interval training (HIIT) 156; and
periodisation 83; and random variation approach (RV) 84; reducing risk of 99, 100, 104, 106; and resistance training (RT) 62, 70, 71, 182
insulin levels see diabetes, type 2
interference effect 70, 88, 91
intermittent fasting (IF) 48–9
Internet, accuracy of information 1
isolation exercises see resistance training (RT)

Karvonen method (HRR) see heart rate measurement (HR)

kidney function: and creatine 44; and protein intake 39
Krebs cycle 218

lactate 103, 141, 157, 181, 217–18; lactic acid hypothesis 129, 229; maximal lactate steady state (MLSS) 128, 129
LDL Cholesterol see cholesterol/blood lipids
legal action 14
lifestyle assessment and behaviour change 22–31; barriers to behavior change 23–4; change theories and models 23, 25–6, 25; evidence based
tools 29–31; supporting and assessing change 26–9
linear/traditional periodisation (TP) 85–90, 86, 89, 90
long term training programme design see periodisation
low back pain 207, 211, 212
low carbohydrate diet (LCD) 45–6

marathon running see endurance training

massage 222, 232
maximal lactate steady state (MLSS) 128, 129
meat consumption 39, 45–6
medical advice 14
meetings, walking 3
mental health 43
metabolic acidosis 218
metabolic equivalent (MET) 75, 76, 121–2, 122, 131, 133
metabolic health: and caffeine 44; and diet 6, 35, 36, 37, 39, 40, 46, 47, 48; and fat burning zone 139; and high-intensity interval training
(HIIT) 149, 155, 157, 163; and resistance training (RT) 177, 178–9, 192; and sedentary lifestyle 4; and whey protein 42
metabolites and substrates 39, 164, 181, 217–19, 220, 221, 233
minerals see vitamins and minerals
monounsaturated fats see unsaturated fats (UFA)
mood: and diet 37, 43, 44, 47; and exercise 24; and fatigue 61, 125, 231
mortality risks: body fat 4, 6; low carbohydrate diet (LCD) 45–6; poor balance 11; poor cardiorespiratory fitness 130, 131, 132, 151; and post-
exercise heart rate measurement 220–1; and too much physical activity 134
motivational interviewing (MI) 26–9, 27, 31
motor skills 10–11
multiple joint exercises (MJ) 72, 73, 74, 179, 180, 185, 186, 188, 195; see also single joint exercises (SJ)
muscle cross-sectional area (CSA) see hypertrophy
muscle fatigue 59, 129
muscle flexibility, and stretching 108–9
muscle imbalance 70, 71, 203, 205, 206, 207, 210, 211–12
muscle injuries: delayed onset of muscle soreness (DOMS) 84, 100, 101, 217, 221, 222, 228, 231; exercise induced muscle damage (EIMD) 182,
221, 227, 228, 229–30, 231, 232, 233; lactic acid hypothesis 129, 229; see also warm-up
muscle mass 4, 6, 10, 68, 179; and aging 177; and creatine 44, 45; and fat loss 191–2, 193, 195; see also hypertrophy
muscles: fatigue 59, 129; imbalances 70, 71, 203, 205, 206, 207, 210, 211–12; muscle burn 218; power 11; strength/endurance 9–10, 42–3; toning
up 68; see also muscle injuries; resistance training (RT); warm-up
musculoskeletal health see posture
myofascial release 222

nervous system: and block periodisation 91, 92; and caffeine 44; and cardiorespiratory fitness training (CRT) 131; and fatigue 129; and MJ
 exercises 73; parasympathetic (PNS) 220; and reaction times 12; and resistance training (RT) 170, 171; and static stretching 107
neutrophils 231
no pain, no gain mentality 182, 229
nutrition 5, 34–49; carbohydrates 37, 39; dietary assessment 35–6, 36; energy balance 35–6; evidence based components of diet 35; fat 37–9;
intermittent fasting (IF) 48–9; low carbohydrate diet (LCD) 45–6; nutrients 34–5; Paleo diet 46–8; and physical activity 34; protein 39–40;
and recovery from training 230; supplements 40, 42–5; vitamins and minerals 40–1, 41

obesity 4, 5–6, 9; and high-intensity interval training (HIIT) 149, 156, 159; and intermittent fasting (IF) 48; and Paleo diet 47; and resistance
training (RT) 192; and toning up 68; and training programme comparisons 189–91; and whey protein 42; see also fat loss
office workers 3–4, 206–7, 207; see also sedentary lifestyle
Omega 3 & 6 37–8
one-repetition tests see 1RM
oxygen deprivation 44, 45

Paleo diet 46–8

Parkinson's disease 44
PAR-Q (physical activity readiness questionnaire) 14–17, 15, 19, 20
PAR-Q+ (physical activity readiness questionnaire for Everyone) 17, 18, 20
perceived exhaustion rate (RPE) see rate of perceived exhaustion (RPE)
‘percentage body fat’ see body composition
performance: and cardiorespiratory fitness training (CRT) 76, 140–3; and core training 207; and diet 34, 46, 47–8, 49; and high-intensity
interval training (HIIT) 159–63, 160, 162; and sports drinks 40; super-compensation response 60, 61; and supplements 42–3, 43–4, 45; and
warm-up 101, 102, 106, 107–8, 107, 111, 112, 113–14; see also periodisation; recovery from training
periodisation 63, 83–96; block periodisation (BP) 88, 91–4, 156; flexible undulating periodisation (FUP) 95; non-periodised programmes 84;
random variation training (RV) 84, 85; traditional/linear periodisation (TP) 85–90, 86, 89, 90; undulating/non linear periodisation (UP)
94–5, 94; when to use 84–5; who is it for? 83–4
personal trainers: advice to client 2; legal action 14; nutritional advice 34, 40, 49; professionalism 1; rapport with clients 22, 31; role in
facilitating behaviour change 22, 24, 26–31; see also training methods, principals of
physical activity (PA): active lifestyle promotion 3–4; and cardiorespiratory fitness 130–1; definition 1–2; and diet 34; dose-response
relationship 131, 132; and energy expenditure 35; evening exercise effect on sleep 231; and fat loss 5; health benefits 2, 2; time barriers 3,
69, 133–4; upper limits to 134
physical activity readiness questionnaire for Everyone (PAR-Q+) 17, 18, 20
physical activity readiness questionnaire (PAR-Q) 14–17, 15, 19, 20
planned behaviour theory 23
plateau, training see accommodation
polyunsaturated fats see unsaturated fats (UFA)
post-exercise see cool-down
post-exercise hypertension (PEH) 219–20
post-exercise oxygen consumption (EPOC) 157
posture 203–7; assessment of 204–5, 204, 210; common abnormalities 205, 206–7, 206, 207; correcting poor posture 205–7; see also core
training
power 11
pre-exercise health screening see health screening
processed foods 39, 47, 49
protein 39–40; intake post-exercise 230; whey protein 42–3
public health policies 5, 14

quadricep strength 101, 107, 108, 214

Ramadan 49
random variation training (RV) 84, 85
rate of perceived exhaustion (RPE): and cardiorespiratory fitness training (CRT) 122, 125–6, 125, 126, 129, 133, 136; and training impulse
(TRIMP) method 76, 77, 78; and warm-up 110, 111, 112, 113, 116
reaction time 12
recovery from training 227–34; adaptation threshold 61–2, 61; cryotherapy 232–3; definition of recovery 227–8; massage 232; nutrition 230;
and periodisation 87, 88, 90, 92, 95; resistance training (RT) 229; sleep 231; strategies to enhance recovery 229–34, 234; see also rest
periods
recovery times 142
red meat see meat consumption
reliability coefficient 57
renal function: and creatine 44; and protein intake 39
repetition failure (RF) 62, 70, 92, 183–4, 188, 189
repetition maximum method (RM) 79; see also 1RM tests
residual training effect 93, 93
resistance training (RT) 170–95; adaptations 59, 63–4, 170–1, 171; and aging 177, 178; and block periodisation 92; and blood pressure 219;
calculating intensity and volume 79–80, 80; combined with cardiorespiratory fitness training (CRT) 179, 189–91, 190, 192, 195; for fat loss
189–95, 194; for health 177–80, 178; for hypertrophy 170, 174, 177, 179, 180–6, 191; injuries 62, 70, 71, 182; and protein 39; recovery from
training 229; repetition failure (RF) 182–3, 188; rest periods 80, 172, 176, 180, 185, 188, 195; for strength 186–9; terminology and
classifications 171–2, 172; training methods 70–5, 71, 72, 73, 173–7, 173, 175, 177; and warm-up 112, 113–14, 116; for women 185
resting energy expenditure (REE) 6, 43, 137, 177, 191–2, 193
rest periods: and cardiorespiratory fitness training (CRT) 80; and resistance training (RT) 80, 172, 176, 180, 185, 188, 195; see also recovery
‘reversibility’ 65
reviews and prompt practice 31
risk assessments see health screening
‘risk stratification’ 19, 20

satiety (feeling of fullness) 37, 42, 47, 48; see also appetite
saturated fats (SFA) 37, 38–9, 38
scientific evidence 1, 3; diet only approach 6; group based studies 6; health benefits of exercise 14; reduction of body/fat mass 5
sedentary lifestyle 3–4; and cardiorespiratory fitness training (CRT) 122, 128, 131, 132, 134–5, 136; and high-intensity interval training (HIIT)
63, 151, 153, 156, 157, 158, 163–4; and periodisation 83–4; and warm-up 100, 113
self determination theory 23, 27
self-monitoring 30
single joint exercises (SJ) 72, 73, 74, 179, 180, 185, 186, 188, 195; see also multiple joint exercises (MJ)
sitting see sedentary lifestyle
skill related fitness 10–12
sleep 44, 231
SMART method 29–30
social cognitive theory 23
specificity 63–4, 68, 72, 73, 84, 127, 159, 183
speed (distance/time) 11
sports drinks 37, 40
Sports Medicine Australia (SMA): health screening guidelines 19, 20; warm-up guidelines 112, 113
sprint interval training (SIT) 150, 150, 151, 152–3, 155, 156, 158, 160, 161, 163
squat exercises 213–14
stage-based models (SBM) 23, 25–6, 25, 26
stair climbing 3
standard error of estimate (SEE) 56
standing desks 3
stimulants: caffeine 43–4; energy drinks 40
strength training see resistance training (RT)
stretching 104–9; ballistic stretches 104; and cool-down 217, 221; definition of 230; dynamic stretches 104, 105, 108, 109, 114; and muscle
flexibility 108–9; proprioceptive neuromuscular facilitation (PNF) 104, 106, 107; recovery from training 230–1; static stretches 104, 105,
106, 107–8, 109, 109, 112, 114; see also warm-up
strokes see cardiovascular disease
subcutaneous fat 10, 68
substrates and metabolites 39, 164, 181, 217–19, 220, 221, 233
sugary drinks 35, 40
super-compensation response 60, 61
supplements: caffeine 43–4; creatine 44–5; vitamins and minerals 40; whey protein 42–3
‘supra-maximal’ exercise 150, 151, 152; see also sprint interval training (SIT)
sweetened drinks 35, 40
syncope 217, 220
Tabata training protocol 151, 159; see also high-intensity interval training (HIIT)
talk test 126–7, 127, 129
tempo/threshold training 128–9, 130, 142, 150
testosterone 185
thermogenesis 35
time barriers to training 3, 69, 133–4
tiredness see fatigue
toning up 68
traditional/linear periodisation (TP) 85–90, 86, 89, 90
training impulse (TRIMP) 76–8, 76, 78
training methods, principals of 59–65; accommodation/training plateau 63; adaptation 59–60; adaptation threshold 61, 61; detraining 65; for
fat loss 140; for health 135; individualisation 62–3, 62; for performance 142; progressive overload 60; recovery 61–2; specificity 63–4;
trainability 64, 65; variation 63
training plateau see accommodation
training residuals 93, 93
training session design 67–80; cardiorespiratory fitness training (CRT) 70, 74, 75–8, 80; concurrent training (CT) 69–70; goals 68; high-
intensity interval training (HIIT) 163–4; intensity and volume 74–80; process diagram 67; resistance training (RT) 70–4, 79–80; resources
69; rest periods 80; session structure 69; time barriers 69; see also periodisation; warm-up
training to failure 62, 70, 92, 183–4, 188, 189
transfats see unsaturated fats (UFA)
transtheoretical model (TTM) see stage-based models (SBM)
‘treppe effect’ 103

UK Active – Health Commitment Statement (HCS) 20

undulating/non linear periodisation (UP) 94–5, 94
unsaturated fats (UFA) 37, 38, 39
un-weighted food diary 36
upper-crossed syndrome 71, 206–7, 207
urine colour 40

validity coefficient (CV) 56–7

VDOT system 160
vegetables see fruit and vegetables and fluid intake
visceral fat 10, 189
vitamins and minerals 40–1, 41, 47
VO2max 55, 56, 125, 138, 138, 142, 151, 152, 153, 155, 159, 160, 163

walking meetings 3
warm-up 69, 99–116, 222; active 102; benefits of 99–101, 101; effects of 102–3, 103; passive 102; stretching 100, 104–9, 112, 114; structuring of
110–16, 110, 115; see also cool-down
water intake 40
weight loss see fat loss
weight training see resistance training (RT)
whey protein 42–3
white blood cells 231
Wingate test 150
work environment 3–4, 206–7, 207; see also sedentary lifestyle

YMCA cycle ergometer test 55, 56

yo-yo dieters 6