NEWSACSM’S CERTIFIED

The IncrementalShuttle WalkingTest PAGE 3

Behavioral Theory andCounseling Techniquesfor Increasing PhysicalActivity Participation

PAGE 4

Enhancing MentalHealth ThroughResistance Exercise

PAGE 9

LungSounds

page 10

ExerciseTraining forOverweightYouth:Why Weight? PAGE 6

O C T O B E R — D E C E M B E R , 2 0 1 2 • V O L U M E 2 2 : I S S U E 4

2 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

ACSM’S CERTIFIED NEWSOctober–December 2012 • Volume 22, Issue 4

In this IssueThe Incremental Shuttle Walking Test ..................... 3Behavioral Theory and CounselingTechniques for Increasing PhysicalActivity Participation ................................................ 4Exercise Training for Overweight Youth:Why Weight? ............................................................. 6Coaching News........................................................... 8Enhancing Mental Health ThroughResistance Exercise ................................................... 9Part 3: Lung Sounds ....................................................10

Co-EditorsPeter Magyari, Ph.D.

Peter Ronai, M.S., FACSM

Committee on Certificationand Registry Boards ChairDeborah Riebe, Ph.D., FACSM

CCRB Publications Subcommittee ChairPaul Sorace, M.S.

ACSM National Center Certified News StaffNational Director of Certification

and Registry ProgramsRichard Cotton

Assistant Director of CertificationTraci Sue Rush

Publications ManagerDavid Brewer

Editorial ServicesLori Tish

Angela Chastain

Editorial BoardChris Berger, Ph.D., CSCS

Clinton Brawner, M.S., FACSMJames Churilla, Ph.D., MPH, FACSMTed Dreisinger, Ph.D., FACSMAvery Faigenbaum, Ed.D., FACSMRiggs Klika, Ph.D., FACSM

Tom LaFontaine, Ed.D., FACSMThomas Mahady, M.S.Paul Sorace, M.S.Maria Urso, Ph.D.David Verrill, M.S.

Stella Volpe, Ph.D., FACSMJan Wallace, Ph.D.

For More Certification Resources Contact theACSM Certification Resource Center:

1-800-486-5643

Information for SubscribersCorrespondence Regarding Editorial Content

Should be Addressed to:Certification & Registry DepartmentE-mail: certification@acsm.orgTel.: (317) 637-9200, ext. 115

For back issues and author guidelines visit:http://certification.acsm.org/certified-news

Change of Address or Membership Inquiries:Membership and Chapter Services

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

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

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

Tel.: (317) 637-9200 • Fax: (317) 634-7817© 2012 American College of Sports Medicine.

ISSN # 1056-9677

FAREWELLSAND WELCOMES

By Peter Magyari, Ph.D., andPeter Ronai, M.S., FACSM

AS CO-EDITORS OF ACSM’s CERTIFIED NEWS, WE WISH TO THANK PAULVISICH, PHD, MPH, FOR HIS VALUABLE SERVICE TO US AND TO READERS OFACSM’s CERTIFIED NEWS.

We have been privileged to have Paul as our clinical columnist and we have all enjoyed read-ing and learning from his Clinical column articles over the last year. His article series on heartsounds was an excellent reference for exercise professionals. Regretfully, Paul’s term as clinicalcolumnist has ended and we must say farewell. Paul will continue to educate us however. Heand his colleagues, John Ehrman, PhD, FACSM; Steven Keteyian, PhD, FACSM; and Paul Gordon,PhD, FACSM, have been editing a third edition of their textbook, Clinical Exercise Physiology.The third edition promises to be an excellent learning resource for clinical exercise professionalsas the first two editions have been. We wish you much continued success and thank you for yourdedication and service to us. Paul also will continue to serve as the chair of the exercise sciencedepartment at the University of New England in Biddeford, Maine.

Finding a successor for Paul has been challenging. He is a difficult act to follow. After carefulconsideration, we have selected a new clinical columnist to continue enhancing the quality of clin-ical information we are able to offer our readers. We are pleased and fortunate to announceGregory B. Dwyer, PhD, FACSM, as the new clinical columnist for ACSM’s Certif ied News. Heis a clinical exercise physiologist and full professor in the Department of Exercise Science at EastStroudsburg University (ESU) of Pennsylvania. Dr. Dwyer has been at ESU since 1997. Prior toESU, Greg was an associate professor for eight years in the School of Physical Education at BallState University in Muncie, Indiana.

He is certified by the American College of Sports Medicine (ACSM) as an ACSM Exercise TestTechnologist, ACSM Exercise Specialist, and ACSM Program Director. In addition, Dr. Dwyer isan ACSM Registered Clinical Exercise Physiologist (RCEP). Dr. Dwyer has been involved in ACSMcertification efforts for more than 13 years most currently serving as the senior editor for theupcoming (4th edition) of the ACSM Certif ication Review.

His main research interests are in exercise testing and training responses of apparently healthyand chronic disease populations, and the reliability of various physical fitness test measurements.

He has authored and co-authored numerous peer-reviewed and refereed articles and will besharing his clinical knowledge and expertise with us and readers of ACSM’s Certif ied News. Weare thrilled to have him as our new clinical columnist.

Good Luck Greg!!

Shuttle Walking Test (continued on page 13)

ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4 3

A recent article in ACSM’s Certif ied News (Volume 21, issue 4,2011) discussed issues regarding the use of the 6-minute walk test asa tool to assist the clinical exercise physiologist (CEP) in assessing: 1)submaximal functional capability, 2) need for supplemental oxygen oroxygen titration, 3) exercise prescription from peak heart rate, rat-ing of perceived dyspnea/exertion, and estimated METS, 4) physio-logical responses to exertion, and 5) the physiological response tomedical interventions with pulmonary patients.11 The 6-minute walktest is a clinically-based field test which has been widely used toaccomplish these objectives.1

The incremental shuttle walk test (ISWT) was developed by Dr.Sally J. Singh and her associates8 as a tool to assess functional capaci-ty in patients with chronic obstructive pulmonary disease (COPD). Itis relatively fast and easy to administer. Performance on the ISWTcorrelates strongly with direct measures of peak oxygen consumption(V02P) allowing the prediction of peak V02.9 Results can be used toevaluate the efficacy of an exercise and/or rehabilitation programand to measure outcomes and progress over time.2,8 The object ofthe ISWT is to simulate a cardiopulmonary exercise test using a fieldwalking test.2 The ISWT also has been validated for elderly peoplewith and without airflow limitations,3 people being assessed for hearttransplant,5 people with intermittent claudication from peripheral vas-cular disease12 and people with congestive heart failure (CHF).6 TheISWT has been shown to be more accurate than the 6-minute walktest in the evaluation of maximal exercise capacity and in the degreeof ventilatory impairment in COPD patients.7 The 6-minute walk testremains the assessment of choice if the clinical outcome in COPDpatients is exercise endurance.7

The ISWT is a performance-based test that assesses exercise per-formance levels by measuring walking distance in meters. Longer walk-ing distances signify better performance.8 According to Singh et al.“improvements of 47.5 meters and 78.7 meters in the ISWT indicat-ed that patients felt slightly better and better respectively and are con-sidered minimal clinically significant improvements or differences.”10

AdministrationStandard instructions for the ISWT are given on a pre-recorded

CD (2, 8) and a level walking course of at least 12 meters and aportable CD player are required to administer it.2,8 Prior to testing,patients/clients should rest in a seated position and then have theirresting heart rate (HR), blood pressure (BP) oxygen saturation(Sp02) and dyspnea (shortness of breath) measured/recorded.Patients prescribed bronchodilator medications should take themwithin one hour of testing or as soon as they arrive for testing.2,8

Subjects walk back and forth around two cones placed nine9

meters apart.* The actual distance of each shuttle (laps between thecones) is 10 meters. Subjects keep pace with a pre-recorded audito-ry signal so that they complete a turn as each sound beeps. The audiosignal or beep sounds at increasingly shorter intervals each minute

(each stage is one minute long). One beep indicates the length of oneshuttle and three (3) beeps indicate an increase in speed and changeof stage. Initially, walking speed is very slow (0.50 meters/second),but each minute the required walking speed progressively increasesto potentially a 2.37 meters/second speed during the 12th and finalstage (there are 12 stages). The test is measured in meters andunlike the 6-minute walk, no verbal encouragement is provided.Patients/clients may use ambulatory assistive devices (single pointcane, rollator walker, or standard walker) but must pull or carry theirsupplemental oxygen themselves.2,8

StandardizationExercise professionals should follow instructions given on the CD.

They should instruct patients/clients to walk faster each time thebeep sounds, and tell patients that they are not walking fast enoughand that they should speed up to make up the speed this time if theyare less than 0.5 meters from the cone when the beep sounds.Exercise professionals also should record each shuttle as it is complet-ed. Two test trials are given with 30 minutes rest between trials. Thebest distance between the two trials is recorded. Test trials can beadministered on separate days for debilitated patients/clients butshould not occur more than one week apart. A comfortable ambienttemperature and humidity must be maintained and the same walkingcourse should be used for all tests.2,8

Test TerminationThe test should be terminated if the patient/client is more than

0.5 meters away from the cone when the beep sounds (allow one lapto catch up), reports they are too breathless to continue, reaches85% of predicted maximum heart rate using the formula[210–(0.65 x age)], or has the following symptoms:

• Chest pain that is suspicious of/for angina• Evolving mental confusion or lack of coordination• Evolving light-headedness• Intolerable dyspnea (shortness of breath)• Leg cramps or extreme leg muscle fatigue• Persistent Sp02 <85% (Oxygen saturation)• Any other clinically warranted reason2

In addition, number of shuttles completed and HR, BP, shortnessof breath (immediately post-test and two minutes post-test) shouldbe measured and recorded respectively.2,8 Exercise professionalsshould ask patients/clients, “What do you think stopped you fromkeeping up with the beeps?”

SummaryThe ISWT is a valid, reliable, and efficient means of assessing func-

tional capacity, exercise program efficacy and long-term outcomes inpatients/clients with COPD.

CLINICAL ARTICLE

THE INCREMENTAL SHUTTLEWALKING TEST By Peter Ronai, M.S., FACSM, RCEP, CES, CSCS-D

4 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

The benefits of physical activity are well recognized. Unfortunately,participation in physical activity (PA) is generally low and dropoutrates are high.6-8 Whether an individual has decided to start an exer-cise program for personal reasons, or has been told by a health pro-fessional to be more active, the participant needs to learn a newbehavior. The challenge for the exercise professional is to help a clientdevelop the motivation and skills to start, and stick with a programof regular physical activity.

A number of theories have been used to describe the process ofbehavior change. Each theory is characterized by specific constructsor correlates which are thought to influence behavior. The purposeof this article is to provide an overview of some popular behavioraltheories. Having an understanding of these theories may enable theexercise professional to guide a client through the process of makingPA part of a healthy lifestyle.

The Health Belief ModelThe Health Belief Model (HBM) suggests that people will modify

behavior to prevent or control undesirable health conditions if they

regard themselves as susceptible to the condition.10 The four maincomponents of the model include perceived susceptibility to a condi-tion, perceived severity of a condition, perceived benefits to takingaction, and perceived barriers to taking action. Cues/strategies totake action and self-efficacy also have been associated with thismodel. Proponents of this theory would suggest that all of thesecombine to influence a person’s motivation to take action to improvethe health condition.14 For example, a person who believes he is atrisk of developing heart disease or diabetes, and believes that thoseare serious health risks, may be prompted to increase PA to reducethe threat of disease. In this scenario, the HBM also would suggestthat the person must believe that PA would be an effective means ofcombating the disease, and that the benefits outweigh any potentialdisadvantages to exercise participation. Cues to action may come inthe form of information from a physician or the media suggesting thatPA is an effective means of preventing heart disease/diabetes; andself-efficacy means that the person has confidence that he is capableof overcoming any barriers that might get in the way of the plannedexercise program.

WELLNESS FEATURE

BEHAVIORAL THEORY AND COUNSELINGTECHNIQUES FOR INCREASING PHYSICALACTIVITY PARTICIPATION

By Sherry Barkley, Ph.D., CES, RCEP, FACSM

Behavioral Theory (continued on page 12)

Theory of Reasoned Action/Theoryof Planned Behavior

The Theory of Reasoned Action (TRA) suggests that the mostimportant determinant of behavior is intention, and intention is influ-enced by a person’s “attitude toward the behavior” (based on per-ceived value of the behavior) and “subjective norm” (i.e., beliefs aboutwhether others approve of the behavior).12 The TRA assumes that asindividuals receive and interpret information, they identify reasons(and develop intentions) for performing (or not performing) a behav-ior. Later, the Theory of Planned Behavior (TPB) was proposed as amodification of the TRA when the construct of “perceived behavioralcontrol” (the participant’s belief that they have a choice to participatein a behavior) was added to the model.1,2 These control beliefs aredescribed as being comparable to self-efficacy beliefs. Control beliefsacknowledge that some factors influencing behavior are out of theindividual’s control and are affected by a person’s confidence in hisabilities to make a change in spite of the barriers that may be encoun-tered. Applying TPB to PA, when a person believes that PA is valu-able and can contribute to a desirable result, the “attitude toward thebehavior” is positive. At the same time, if the participant believes thatfriends or significant others approve of PA participation and is moti-vated to do what others think is appropriate, the rating of “subjectivenorm” is high. Finally, the individual who believes that it will be easyto overcome any barriers to PA participation will have high “per-ceived behavioral control.” The sum of the three constructs con-tributes to the person’s intention to participate in PA; this, in turn,leads to the adoption of the exercise behavior.

The Transtheoretical ModelThe Transtheoretical Model (TTM) proposes that a person goes

through five stages of change (pre-contemplation, contemplation, prepa-ration, action, maintenance) in the process of lifestyle modifications. Thepremise is that people must be in motivationally ready to make behav-ior changes or the change won’t occur. People may move back and forththrough the stages (not always linearly), and a number of variables affectmovement between stages. Those variables include decisional balance(weighing of pros and cons), self-efficacy (confidence) and ten cognitive

and behavioral processes of change.13 The TTM initially emerged in treat-ment of addictive behaviors such as smoking, but also has been appliedin settings to increase physical activity.11 A person in the pre-contempla-tion stage is not participating in PA and has no intention of starting inthe next six months. In the contemplation stage, the client is still onlythinking about exercise, but intends to start a program within sixmonths. When someone has reached the preparation stage, the individ-ual has taken steps to get ready to change behavior (e.g., has purchasedexercise clothes, looked into fitness club membership, made arrange-ments to go walking with a friend) and plans to initiate the programwithin the next month. Additionally, someone participating in PA irreg-ularly, or at a level below that prescribed in ACSM’s guidelines,9 is desig-nated as being in the preparation stage. Action is the stage where theperson is participating in PA at a level at or above the current guidelines,but has maintained the program for less than six months. The personwho has continued in a PA program for more than six months, is meet-ing the recommended levels, has a high level of confidence in the abilityto continue with the program, and has reached the maintenance stage.

Social Cognitive TheoryThe Social Cognitive Theory (SCT) uses the idea of “reciprocal

determinism” to describe how environmental, personal, and behav-ioral factors interact to influence each other.4 Environment refers tofactors that are external to the person and can include both social(e.g., family and friends) and physical aspects (e.g., places like home,neighborhood, or a workout facility). Personal factors include knowl-edge (cognitions), perceptions, values, and experiences. Constructsof SCT include observational learning (watching others), behavioralcapability (having the knowledge and skill to perform a behavior),outcome expectations (anticipated benefits from participating in abehavior), reinforcement (positive consequences that promote con-tinuation of behavior), self-efficacy (confidence to perform a behav-ior), and others. Bandura, who first described SCT, has suggestedthat self-efficacy is the most important predictor of behavior change.3

Self-efficacy indicates a person’s confidence in the ability to succeed ata specific task in specific difficult situations. The strength of that con-fidence influences whether a task is attempted, how much effort isexpended to complete the task, and how persistent a person will bewhen faced with obstacles. Because self-efficacy perceptions are task-specific, individuals may have a high level of confidence in one area,such as eating a low-fat diet, but have low self-efficacy for anothertask, such as maintaining a regular exercise program.

Self-efficacy is derived from four sources: mastery, vicarious expe-rience, verbal persuasion, and cognitive interpretation of physiologicalstates.3 These four sources combine to determine a person’s confi-dence. Mastery refers to feelings of accomplishment experienced bythe person who succeeds at a given task. Vicarious experience pro-motes confidence as someone pays attention to the successes of sim-ilar others. Verbal persuasion is used when another individual pro-vides words of encouragement to reinforce a person’s capabilities andaccomplishments. Finally, the understanding of normal physiologicalresponses to a situation will minimize the stress of participating in anew behavior. The exercise professional is well-positioned to helpbuild self-efficacy by providing verbal encouragement to a client, help-ing establish appropriate goals which a client can master, pointing outthe successes of other participants with suggestions that “you can do

ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4 5

Primary Constructs of Specified Behavioral Theories

Health BeliefModel

Theory ofPlanned Behavior

TranstheoreticalModel

Social CognitiveTheory

Behavior change isdriven by:•Perceived

Susceptibility•Perceived Severity•Perceived Benefits•Perceived Barriers•Cues to Action•Self-Efficacy

Intentions driveBehavior

Intentions areinfluenced by:•Attitude Toward

Behavior•Subjective Norm •Perceived

BehavioralControl

Behavior change isa process whichgoes throughstages:•Pre-

Contemplation•Contemplation•Preparation•Action •Maintenance

Movementbetween stages isinfluenced by:•Decisional Balance•Self-Efficacy•Processes of

Change

ReciprocalDeterminism—thefollowing factorsinteract to influenceeach other:•Environmental •Personal•Behavioral

A number ofconstructs influencethe behavioralresult:• Observational

Learning•Behavioral

Capability•Outcome

Expectations•Self-Efficacy

6 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

EXERCISE TRAINING FOROVERWEIGHT YOUTH: WHY WEIGHT?

HEALTH & FITNESS FEATURE

The global epidemic of pediatric obesity and associated co-morbidi-ties has become a critical public health threat for the 21st century withfar-reaching health, economic, and social consequences.14 While thereis not one program of proven efficacy to manage this, multifacetedinterventions including behavioral counseling, nutrition education, fam-ily support, and physical activity promotion offer the best chance forsuccess.2 Of these components, regular physical activity is critical forweight maintenance and the prevention of abnormal weight gain.22

Understanding how sensible lifestyle choices such as regular physi-cal activity can improve body composition and enhance health andwell-being of youth is a growing area of interest. An increasing numberof fitness centers now offer programs for youth and health-consciousparents who are becoming more aware of establishing healthy habitsat an early age. Fitness professionals who have an understanding ofpediatric exercise science and genuinely appreciate the physical andpsychosocial uniqueness of youth are in an inimitable position to devel-op safe, effective, and enjoyable physical activity programs.

In addition to aerobic forms of exercise (e.g., cycling and sustainedgames), new insights indicate that resistance training can be a safe,effective, and worthwhile method of conditioning for all youth regard-less of body size.10, 12 This article examines the potential benefits ofresistance exercise for overweight children and adolescents and pro-

vides suggestions for designing resistance training programs, definedas a specialized method of physical conditioning that involves the pro-gressive use of a wide range of resistive loads and training modalitiesdesigned to enhance muscular fitness. Youth and pediatric are broad-ly defined to include children and adolescents.

Potential Benefits of Resistance Trainingfor Overweight Youth

Although some once considered resistance training unsafe andpotentially injurious to the developing musculoskeletal system, evi-dence related to the safety and efficacy of youth resistance exercisehas increased over the past decade.3, 4, 12 In addition to enhancing mus-cular strength, regular participation in a resistance training programhas been linked positively to cardiorespiratory fitness, bone mineraldensity, blood lipids, and psychosocial well-being.3, 11 Of note, the posi-tive effects of resistance training on body composition and metabolichealth in overweight youth have received increased attention by clini-cians and researchers.16, 18, 19

Although aerobic exercise is typically prescribed to decrease bodyfat, a decrease in fatness among overweight youth who participated ina structured resistance training program has been reported in the lit-erature.5, 9, 16, 18, 20 Of interest, Shaibi et al. found that body fat decreased

By Avery D. Faigenbaum, EdD, FACSM, and Jill A. Bush, PhD, FACSM

Why Weight? (continued on page 12)

and insulin sensitivity increased in overweight adolescent males partic-ipating in a progressive resistance training program.18 The increase ininsulin sensitivity remained significant after adjustment in total fat andlean mass. Thus due to resistance training, it was speculated that thequalitative changes in skeletal muscle contributed to enhanced insulinaction.18 Other researchers have identified muscular strength as anindependent and powerful predictor of better insulin sensitivity inyouth age 10 to 15 years,6 and a recent cross-sectional study showedthat muscular fitness was negatively associated with fasting insulin lev-els in male adolescents.15 The potential benefits of resistance trainingfor overweight youth are summarized in table 1.

These important findings highlight the clinical relevance of resistancetraining in overweight youth who are less willing and often unable toparticipate in prolonged periods of moderate to vigorous aerobic exer-

cise. Excess body weight not only hinders the performance of weightbearing physical activity such as jogging, but the risk of musculoskeletaloveruse injuries also should be considered. A notable finding from aprospective study of 9 to 12 year old children was that low levels ofphysical activity significantly increased injury risk.7 While youth shouldbe encouraged to accumulate at least 60 min of moderate to vigorousphysical activity daily in the context of school, community, and familyactivities,23 fitness programs for overweight youth need to be carefullyprescribed and professionals need to realize that overweight youthtend to perceive physical activity more negatively and tend to findsedentary activities more reinforcing than normal-weight youth.17

Program Design Considerationsfor Overweight Youth

Most overweight youth find resistance training activities enjoyablebecause it is not aerobically taxing and provides an opportunity for allyouth �regardless of body size �to experience success and feel goodabout their performance. Since youth tend to be more physicallyactive when in the presence of peers and when positive, rewardingrelationships exist,17 resistance training provides an unique opportuni-ty for companionship and recreation. This is important for overweightyouth who spend more time alone and tend to be more sensitive toany type of peer interaction than non-overweight youth.17 Youthinvolved in fitness classes with group activities enhance muscular fit-ness, promote social networking, and gain confidence in their abilitiesto be physically active. Thus, the first step in encouraging overweightyouth to exercise regularly may be to increase confidence to be phys-ically active in a socially supportive environment which may lead to anincrease in regular physical activity, an improvement in body composi-tion and, hopefully, exposure to a form of exercise that can be lifelong.

Youth resistance training programs need to be carefully prescribedbecause unsupervised and poorly performed strength testing andtraining may be injurious. While there is no minimal age requirementfor participation in a resistance training program, it is important thatall children understand training procedures and safety rules. Closesupervision, age-appropriate instruction, and a safe environment areparamount. In short, it is always better to underestimate the physicalabilities of youth and increase risk of negative consequences (e.g.,dropout or injury). Overweight youth should be seen by their physi-cian or health care provider before beginning any exercise program. Inaddition, youth with pre-existing medical conditions including hyper-tension or seizure disorders should be withheld from resistance train-ing until medical clearance is obtained.1

A variety of training modalities, sets, and repetitions have providedan adequate stimulus for strength enhancement and favorable changesin body composition in youth.13 Weight machines, free weights, elas-tic bands, and medicine balls have been used by normal weight andoverweight youth in clinical- and school-based exercise programs. Sincedifferent combinations of sets and repetitions may be needed to pro-mote long-term gains in muscular fitness, the best approach for over-weight youth to start resistance training is with 1 or 2 sets of 8 to 12repetitions on a variety of exercises, and then systematically vary thetraining intensity and volume in order to avoid training plateaus andoptimize adaptations. Of interest, McGuigan et al. reported favorablechanges in body composition in overweight/obese children who par-ticipated in a resistance training program including strength and powerexercises.16 Since type IIb muscle fibers are the most insulin resistantand seem to be more prevalent in obese cohorts,21 high force/highvelocity muscle actions may be needed to optimize training adapta-tions. Although additional research is needed, it is possible that differ-ent resistance training velocities may provide the most effective stim-ulus in overweight youth.

Overweight youth tend to be the strongest students in class andoften receive unsolicited positive feedback from their normal weightpeers who are often impressed with the increased amounts of weightlifted. In support of this, Davis et al. reported a 1 repetition maximumload of 596 lbs (271 kg) leg press in an overweight male youth.8

Unlike other types of exercise, participation in resistance training pro-gram gives youth with a high percentage of body fat a chance to shinewhile creating a favorable impression from their peers. This is wherethe art and science of developing a youth resistance training programexists because training specificity and progressive overload need to bebalanced with individual needs, realistic goals, and positive social inter-actions in order to optimize gains, prevent boredom, and promoteexercise adherence.

ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4 7

Table 1. Potential Benefits of Resistance Training for OverweightYouth

• Increase muscular fitness• Increase bone mineral density• Improve blood lipid profile• Improve body composition • Improve insulin sensitivity • Improve motor performance skills• Increase resistance to injury • Promote positive social interactions • Enhance mental health and well-being • Stimulate a more positive attitude toward lifetime physical activity

Table 2. General Youth Resistance Training Guidelines

• Provide qualified instruction and supervision• Ensure the exercise environment is safe and free of hazards• Begin each session with a dynamic warm-up • Perform to 1 to 3 sets of 6 to 15 repetitions on a variety of exercises• Include exercises for the upper body, lower body, and midsection• Focus on the correct exercise technique instead of the amount of weight lifted• Review fundamental resistance training principles• Sensibly progress the training program as strength improves• Resistance train 2 to 3 times per week on nonconsecutive days• Use individualized workout logs to monitor progress• Cool down with less intense activities• Systematically vary the resistance training program

THIS COLUMN CONTINUES THE NEW FORMAT FOR OUR COACHING

NEWS COLUMN. WE ARE EXPLORING A VARIETY OF CLIENT SCENAR-

IOS, ONE SCENARIO FOR EACH COLUMN. I DESCRIBE A FEW TIPS FROM

MY SCIENCE-BASED COACHING TOOLBOX TO HELP YOU HELP YOUR

CLIENTS ENGAGE FULLY IN A FIT LIFESTYLE THAT ALLOWS THEM TO

THRIVE, WHATEVER THRIVING MEANS IN THEIR LIVES.

Today we explore how to work with a client who has a strongdesire to lose weight and has agreed to track her daily caloricintake and energy expenditure over the past two weeks. You sitdown to review her chart she sent you before your next sessionand quickly suspect she is under reporting her daily caloricintake and over reporting her daily energy expenditure.

Clients more often than not engage fitness professionals to help them lose

weight, a primary reason for getting fit, strong, and flexible. In our larger world,

where we face a tidal wave of weight gain, the exception, not the rule, is for a

client to succeed in losing weight and keeping it off. So let’s first acknowledge that

this is a very challenging goal for you and your clients. Start with a beginner’s

mind, assuming that you truly have no idea about what will work or whether

your client will be successful.

One method that has been proven helpful to those who have lost weight is

daily journaling of eating and exercise activities, online or by hand on a printout

you provide.1 The starting point in a weight loss endeavor is often to help a client

get a snapshot of the balance of intake and expenditure, raise self-awareness of

eating patterns, and help you spot obvious areas for tweaking and improvement.

Approximately 5% of human beings were born with a “signature” character

strength of self-regulation, which means this group is talented at self-monitoring,

self-managing, and self-adjusting rapidly when needed. Some of them are aligned

with a movement called “the quantified self,” gaining self-knowledge through num-

bers according to the tag line at www.quantifiedself.com. The left prefrontal cor-

tex, the brain’s CEO, of a good self-regulator enjoys collecting and evaluating data,

and loves to make decisions based on solid analysis.

I happen to be one of those precious few as I weigh myself daily using a scale

with 0.1 lb increments, and immediately change my eating habits if my weight rises

by a half-pound, even if that day happens to be a family celebration. For people

like me, perhaps you, tracking and recording information like energy balance is an

interesting and engaging challenge; we take pride in doing it accurately, checking

calorie charts carefully, asking lots of questions, and we enjoy reporting our

results and observations. The simple act of recording our intake and expenditure

can lead us to lasting changes in our eating and exercise patterns as well as sus-

tainable weight loss. Unfortunately 5% is a small minority.

What happens to those of us who aren’t good at self-regulation, who dread

tracking and reporting things like eating habits, medical information, and finances?

When you are asked or decide yourself to take on a task that you aren’t good

at, it’s not fun, it drains your energy, you are easily distracted, and your perform-

ance isn’t great. The polar opposite of self-regulation is the strength of living in the

moment, indulging your impulses, eating what you want, being spontaneous,

being creative, and relying on your “gut” to make decisions.

Someone who is not good at self-regulation, or whose self-regulating brain

region is exhausted or stressed out with life demands, may not pay close attention

to filling out your beautiful energy balance chart, may take shortcuts, or miss

recording important information, make mistakes, or even hide the real data from

you and/or themselves.

Hence you find yourself in a difficult situation. You don’t want to start down

a negative path by questioning or criticizing your client’s tracking and recording

skills and efforts. Yet you can’t really trust the data as a basis for your recommen-

dations. A part of you feels frustrated and impatient because your client didn’t

deliver what you hoped, and make it easy for you to provide an exercise pre-

scription based on established evidence based practices. So how do you move

this partnership forward?

1. LET GO OF IMPATIENCE AND FRUSTRATION

First get yourself into a positive, curious, and non-judgmental mindset, and set

aside any frustration or impatience that will instantly impair your partnership

with your client. If you show even a speck of judgment or disappointment,

your client will withdraw, perhaps already feeling badly that she didn’t do a

great job on her tracking homework and now you made her feel worse.

2. GET INTO A MINDFUL, CURIOUS, AND OPEN-MINDED MINDSET

Explore your client’s experience with completing the energy balance chart in

order to help her gain self-awareness. View it as a starting experiment, an

opportunity to figure out what the best next step would be. Was it a helpful

exercise? Was it challenging? Was it boring? Did she do it immediately or wait

for a few days and try to remember all the food she ate and activities she com-

pleted? Did she take her time or rush to put something, anything, in each of

the boxes? What did she learn? What might work better?

Who knows what your client will say and where she will land, but she will

appreciate that you were totally focused and engaged, without assumptions and

judgment, on her welfare, her efforts, her strengths and weaknesses, and what

would work best as next steps. The outcome is a mystery until it emerges. Maybe

she will realize that she forgot about recording important information such as her

snacks, or miscalculated the number of calories in a food type, and decide to have

another go at filling in your chart. Or maybe she’ll decide that instead she’d like

to replace her junk food snacks with fruit and nuts, or eat oatmeal and a boiled

egg instead of a doughnut for breakfast, as a simple starting point.

One of the best things about being a coach is that it is never boring and pre-

dictable. Everyone finds his/her own path with our intent and creative input. It

would be great if the research gave us the answers, such as completing energy

balance charts as an essential starting point. Yet, how dull our work would be if

a standard formula worked every time.

About the AuthorMargaret Moore (Coach Meg), M.B.A., is thefounder & CEO of Wellcoaches Corporation, astrategic partner of ACSM, widely recognized assetting a gold standard for professional coachesin healthcare and wellness. She is co-director ofthe Institute of Coaching, at McLean Hospital, anaffiliate of Harvard Medical School and co-directs the annual Coachingin Leadership & Healthcare Conference offered by Harvard MedicalSchool. She co-authored the ACSM-endorsed Lippincott, Williams &Wilkins Coaching Psychology Manual, the first coaching textbook inhealthcare and the Harvard Health Book published by Harlequin:Organize Your Mind, Organize Your Life.

References1. Hollis JF, Gullion CM, Stevens VJ, Brantley PJ, Appel LJ, et al. Weightloss during the intensive intervention phase of the weight-lossmaintenance trial; Am J Prev Med. 2008 August; 35(2): 118–126.

COACHING NEWS

8 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

By Margaret Moore (Coach Meg), M.B.A.

HEALTH & FITNESS COLUMN

ENHANCING MENTAL HEALTH THROUGHRESISTANCE EXERCISE By Wayne L. Westcott, Ph.D.

A 2012 research review paper published in ACSM’s Current Sports Medicine

Reports 25 presented 15 well-documented benefits of regular resistance training

(see Table 1). Although most of the reviewed research addressed physiological

factors, some studies demonstrated that strength training may have a direct

effect on three aspects of mental health and an indirect effect in at least two relat-

ed areas. With respect to direct impact, resistance exercise has been shown to

improve cognitive ability, to enhance self-esteem, and to reduce symptoms of

depression.18 With respect to indirect influence, resistance exercise has been

shown to reduce low back pain and to ease arthritic discomfort.18

Cognitive Ability

In an excellent review titled, “Strength Training as a Countermeasure to

Aging Muscle and Chronic Disease,” Hurley, Hanson, and Sheoff described four

studies that demonstrated an inverse relationship between muscular strength

and mental decline/Alzheimer disease.14 In three of the studies, lower grip

strength was associated with higher risk of cognitive decline,1 dementia,13 and

Alzheimer’s disease.8 In a study that assessed 11 muscle groups, higher overall

muscle strength was associated with lower risk of both mild cognitive impair-

ment and Alzheimer’s disease.6

Although associations do not necessarily confirm cause-and-effect, O’Connor,

Herring, and Caravalho’s 18 comprehensive review of the mental health benefits

of strength training identified four studies that attained significant improvements

in memory as a result of resistance exercise.9,10,15,19 In addition to improving cog-

nition when practiced alone,16 strength training has been shown to enhance the

cognitive benefits of aerobic exercise when both activities are addressed in a fit-

ness program.11 A 2012 study by Nagamatsu and associates actually found resist-

ance exercise to be more effective than aerobic activity for improving mental per-

formance in 70 to 80 year old women with mild cognitive impairment.17

Self-Esteem

Self-esteem may be defined as an individual’s perception of himself or herself

from a specific or general perspective. Although specific components of self-

esteem may be more responsive to exercise, O’Connor and colleagues have sug-

gested that overall self-esteem is relatively stable and may present a greater chal-

lenge to large-scale changes.18 It is therefore encouraging that research has

revealed enhanced self-esteem resulting from resistance training among younger

adults,23 older adults,24 women,7 and cancer patients.12 Based on their research

review, O’Connor and colleagues concluded that “strength training alone is asso-

ciated with improvements in overall self-esteem.”18The effects of resistance exer-

cise on various psychological measures have been studied by Annesi and co-work-

ers.2,3,4 Their research has demonstrated significant improvements in physical self-

concept, total mood disturbance, fatigue, positive engagement, revitalization,

tranquility, and depression among adults and older adults following 10 weeks of

combined strength and endurance training. Participants in each of these studies

performed approximately 25 minutes of resistance exercise (10 weight stack

machines for 1 set of 8 to 12 repetitions each) and 20 minutes of aerobic activi-

ty (treadmill or cycle at 70% to 75% of predicted maximum heart rate). In one

of the studies the group that emphasized exercise instruction experienced

greater improvements in physiological assessments, whereas the group that

emphasized social interaction experienced greater improvements in psychological

assessments.3 The authors therefore suggested that beginning exercisers may

have better overall results and increased training compliance when fitness instruc-

tors effectively address both exercise instruction and social interaction.

Depression

Depression is an increasingly prevalent and serious mental health problem that

frequently leads to reduced functionality, particularly in older adults.26 O’Connor

and colleagues reviewed more than 20 studies that examined the effects of resist-

ance exercise on symptoms of depression in different populations of people,

including individuals diagnosed with clinical depression.18 Based on the evidence,

the authors concluded that “strength training alone is associated with both large

reductions in symptoms of depression among depressed patients and moderate

reductions in depression symptoms among patients with fibromyalgia.”18

Research by Singh and associates has revealed beneficial effects of resistance

exercise on older adults who experience depression.20,21,22 In one of their studies,

strength training was more effective than a targeted health education program.

More than 80% of the initially depressed elders in the resistance exercise group

no longer met the criteria for depression after 10 weeks of training, compared

to 40% of those in the health education group over the same time period.20 The

authors concluded that progressive resistance exercise reduces depression in

depressed older adults, while concurrently improving muscle strength, morale,

and quality of life.20

Mental Health (continued on page 14)

ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4 9

Table 1. Fifteen research supported health benefits of resistancetraining.

1. Increased lean weight2. Increased resting energy expenditure3. Decreased fat weight4. Reduced low back pain5. Reduced arthritic discomfort6. Increased functional independence7. Enhanced movement control8. Increased insulin sensitivity9. Improved glucose control

10. Reduced resting blood pressure11. Improved blood lipid profiles12. Increased bone mineral density13. Improved cognitive ability14. Enhanced self-esteem15. Reversed aging factors in skeletal muscle

As a clinical exercise physiologist that may

be working in pulmonary rehabilitation, diag-

nostic testing, or cardiac rehabilitation, it is

important to have a general understanding of

pulmonary sounds. It takes practice listening

to normal and abnormal sounds to become

proficient in identifying their significance. A

thorough pulmonary examination includes

inspection, palpation, and percussion of the

chest wall and thorax and auscultation of the

lungs. The purpose of this article is to focus

on the basics of lung sounds.

Abnormal lung sounds give us information that may relate to conditions such

as; narrowing airways due to inflammation and excess mucus secretions (asthma,

emphysema, chronic bronchitis), pulmonary edema (CHF), abnormal collection of

fluid in the pleural space (pleural effusion), and intrinsic lung diseases (pulmonary

fibrosis).

Auscultation of the lungs requires the use of a stethoscope using the

diaphragm side. The clinician should work from the top of the anterior chest,

(the apex), side to side to make comparisons between both anterior lung fields

and then work posteriorly down to the bases. Physical examination of the lungs

should ideally be in the seated position so that all lung fields can be accessed. The

patient is asked to take a full breath, (inspiration and expiration) with an open

mouth and the clinician listens at each location.

When assessing lung sounds it is important to determine if you hear abnor-

mal sounds early or late in the breathing cycle. Hearing an abnormal sound in

the beginning of inspiration would suggest an abnormality exists in the big airways

(trachea, bronchi), whereas hearing sounds at the end of inspiration would sug-

gest an abnormality exists in smaller airways (terminal bronchi and alveoli). As

clinicians, we need to develop an ear for the intensity (how loud), pitch (frequen-

cy of a single sound) and duration of inspiration and expiration, which will vary

based on the area of the lung you are listening to.

Vesicular sounds represent the soft sounds of normal breathing heard by aus-

cultation over most of the lung fields and where the inspiratory phase is usually

longer than the expiratory. Bronchovesicular sounds represent intermediate

sounds and pitch where inspiration and expiration are fairly equal and typically

heard in the first and second anterior intercostal spaces and between the scapu-

lae. Bronchial sounds are loud and the pitch fairly high and expiration is longer

than inspiration and primarily heard over the manubrium. Tracheal sounds are

very loud, pitch is fairly high, inspiration and expiration are equal and they can be

heard over the trachea.

Some of the more common abnormal lung sounds include crackles (also

referred to as rales), wheezes, and rhonchi. Crackles can be considered as fine

(soft, high pitched, and brief) or course (louder, low pitch, and longer). The exact

mechanism for crackles is not clearly understood, but may be related to the pop-

ping open of small airways or the result of air bubbles flowing through secretions.

Crackles can be heard at different times in the respiratory cycle. Hearing crack-

les at the end of inspiration is indicative of interstitial lung disease such as fibrosis,

CHF, and infections of the lung (i.e., pneumonia). Crackles heard at the beginning

of inspiration are more associated with

chronic bronchitis or asthma. Wheezes are

heard when air travels through restricted

airways and is associated with a high pitch

sound. Wheezing is commonly heard in

patients with COPD (emphysema and

chronic bronchitis), asthma and possibly

CHF. Wheezing may be heard in the entire

respiratory cycle or in either the inspirato-

ry or expiratory phase. Rhonchi, in con-

trast to wheezing, are lower pitched

sounds that are heard in the larger airways

usually caused by an accumulation of mucus. Typically, if one hears wheezing

and/or rhonchi, asking the patient to cough can temporarily clear the passage-

ways in individuals with chronic bronchitis. It also should be noted that if wheez-

ing is accentuated during inspiration it is referred to as stridor, and if louder in the

neck versus the chest region it can be indicative of a partial obstruction of the tra-

chea and larynx and requires immediate attention.

Lastly, when there is an absence or decrease in lung sounds there are several

conditions that should be considered, pleural effusion, and pneumothorax. A

pleural effusion is caused by the accumulation of fluid in the pleural space. There

can be many causes, CHF being the most common cause. The fluid separates

the chest wall from the air-filled lung, decreasing the ability to hear air movement,

however, when listening over the bronchi or higher, lung sounds may be heard.

A pneumothorax causes air leaks into the pleural space and the lung collapses or

recoils (usually unilateral) creating a space between the lungs and the chest wall,

which leads to a reduction or absence of sound. Suspected pleural effusion and

pneumothorax require immediate medical attention.

Mastering auscultation and the associated lung sounds is important in the eval-

uation of your patients that may have different pulmonary conditions. Listed are

several websites that may be helpful to increase your knowledge and develop an

ear for different lung sounds:

• www.wilkes.med.ucla.edu

• www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

• www.easyauscultation.com/cases.aspx?CourseCaseOrder=5&courseid=201

• www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep29.htm

About the AuthorPaul Visich, Ph.D., MPH, is the current chair andprofessor of the Exercise and Sports PerformanceDepartment at the University of New England inBiddeford, Maine. Paul served as a team editor ofthe textbook, Clinical Exercise Physiology, publishedby Human Kinetics. Paul served as a member of thePractice Board for ACSM’s Registered ClinicalExercise Physiologist (RCEP) credential, thechairperson of the ACSM Professional EducationCommittee, and a member of ACSM’s Committee on Certification andRegistry Boards (CCRB).

CLINICAL COLUMN

LUNG SOUNDS By Paul Visich, Ph.D., MPH

10 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

12 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

Teaching youth about their bodies, promoting safe training proce-dures, and providing a stimulating program that gives youth a morepositive attitude toward resistance training and physical activity areequally important. Since there is not one “optimal” combination of sets,repetitions, and exercises that will promote favorable adaptations inmuscular strength and body composition in all youth, program variablesneed be altered over time to achieve desirable outcomes. Clearly,resistance training programs for overweight youth need to be individu-alized and based on health history, training experience, personal goalsand time available. Table 2 summarizes general resistance trainingguidelines for youth.

As fitness professionals continue to embrace the challenge ofworking with overweight youth, creative interventional techniquesand effective motivational strategies will be needed to increase thelikelihood for successful outcomes. Our observations suggest thatresistance training gives overweight youth an opportunity to feelgood about performance and improve health, fitness, and quality oflife while fostering new social networks. While additional research isneeded to substantiate the effects of resistance training on cardiovas-cular disease risk factors in overweight youth, current findings indi-

cate that resistance training may offer observable health and fitnessvalue to youth regardless of body size provided the exercise programis well-designed, sensibly progressed, and super-vised by qualified fitness professionals.

About the AuthorsAvery D. Faigenbaum, EdD, FACSM, is a professor inthe Department of Health and Exercise Science atThe College of New Jersey, where his researchfocuses on the role that resistance exercise plays inthe health and fitness of children and adolescents.

Jill A. Bush, PhD, FACSM, is an associate professorin the Department of Health and Exercise Science atThe College of New Jersey, where she researches therole of physical activity and dietary intake on riskfactors for chronic diseases and obesity andhealthy eating habits in children and young adults.

References 1. American Academy of Pediatrics. Strength training by children andadolescent. Pediatrics 121: 835-840, 2008.

it too,” and helping the client understand normal physiologicalresponses to PA (e.g., increased heart rate and blood pressure dur-ing activity) so that the client sees these responses as positive reasonsto continue the program rather than debilitating reasons to quit.

SummaryThe Health Belief Model, Theory of Planned Behavior,

Transtheoretical Model, and Social Cognitive Theory are some of thetheories which have been used to describe behavior, including PA partic-ipation. Each of the theories is defined by specific constructs which mayoverlap from one theory to another. It is unlikely that one theory canfully explain PA behavior, and it has been suggested that it may be mosteffective to integrate factors from several behavioral theories to facilitatebehavioral change.5 The exercise professional who understands the psy-chological processes which influence behavior will be better prepared tohelp a client initiate and maintain a program of physical activity.

(Part 2 will discuss client-centered counseling and practical tech-niques which support the theoretical basis of behavior change.)

About the AuthorSherry Barkley, Ph.D., CES, RCEP, FACSM is anassistant professor and chair of the HPERDepartment at Augustana College, Sioux Falls, SD.Sherry is past-president of the NACSM. Her interestin behavioral theory and motivational techniques istriggered by many years of experience in the clinicalsetting, working with clients to make positivelifestyle changes.

References1. Azjen I, Driver, BL. Prediction of leisure participation from behav-ioral, normative, and control beliefs: an application of the theoryof planned behavior. Leisure Studies 13: 185-204, 1991.

2. Azjen I, Madden TJ. Prediction of goal-directed behavior: attitudes,intentions, and perceived behavioral control. Journal ofExperimental Social Psychology 22: 453-474, 1986.

Behavioral Theory (continued from page 5)

3. Bandura, A. Self-efficacy: toward a unifying theory of behavioralchange. Psychology Review 84(2): 191-215, 1977.

4. Bandura, A. Social Foundations of Thought and Action: A SocialCognitive Theory. Englewood Cliffs, NJ: Prentice-Hall, Inc. 1986.

5. Blanchard CM. Heart disease and physical activity: looking beyondpatient characteristics. Exercise and Sport Sciences Reviews 40(1):30-36, 2012.

6. Centers for Disease Control and Prevention (CDC). Behavioral riskfactor surveillance system survey data. Atlanta, Georgia: U.S.Department of Health and Human Services, Centers for DiseaseControl and Prevention, 2011.http://apps.nccd.cdc.gov/brfss/page.asp?yr=2011&state=All&cat=EX#EX Accessed October 30, 2012.

7. Dishman RK. Exercise adherence: it’s impact on public health.Champaign (IL): Human Kinetics; 1988.

8. Ham SA, Kruger J, Tudor-Locke C. Participation by U.S. adults insports, exercise, and recreational physical activities. Journal ofPhysical Activity and Health 6: 6-14, 2009.

9. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, et al. Physicalactivity and public health: updated recommendation for adults fromthe American College of Sports Medicine and the American HeartAssociation. Medicine & Science in Sports& Exercise 39(8): 1423-1434, 2007.

10. Janz NK, Champion VL, Strecher VJ. The health belief model. In:Glanz K, Rimer BK, Lewis FM (Eds.). Health behavior and health edu-cation, theory research and practice. San Francisco, CA: JohnWiley and Sons. 45-63; 2002.

11. Marcus BH, Forsyth LH. Motivating people to be physically active.

2nd ed. Champaign, IL: Human Kinetics, 2009.12. Montano DE, Kasprzyk D. The theory of reasoned action and thetheory of planned behavior. In: Glanz K, Rimer BK, Lewis FM (Eds.).Health behavior and health education, theory research and practice.San Francisco, CA: John Wiley and Sons. 67-98; 2002.

13. Prochaska JO, Redding CA, Evers KE. The transtheoretical modeland stages of change. In: Glanz K, Rimer BK, Lewis FM (Eds.). Healthbehavior and health education, theory research and practice. SanFrancisco, CA: John Wiley and Sons. 99-120; 2002.

14. Woodard CM, Berry MJ. Enhancing adherence to prescribed exer-cise: structured behavioral interventions in clinical exercise pro-grams. Journal of Cardiopulmonary Rehabilitation 21(4): 201-209,2001.

Why Weight? (continued from page 7)

Why Weight? (continued on page 13)

2. American Dietetic Association. Position of the American DieteticAssociation: Individual-, family-, school-, and community-based inter-ventions for pediatric overweight. Journal of the American DieteticAssociation 106: 925-945, 2006.

3. Behm D, Faigenbaum A, Falk B, and Klentrou P. Canadian Societyfor Exercise Physiology position paper: resistance training in chil-dren and adolescents. Appl Physiol Nutr Metab 33: 547-561, 2008.

4. Behringer M, vom Heede A, Yue Z, and Mester J. Effects of resist-ance training in children and adoelscents: A meta-analysis.Pediatrics 126: e1199-e1210, 2010.

5. Benson AC, Torode ME, and Fiatarone Singh MA. The effect ofhigh-intensity progressive resistance training on adiposity in chil-dren: a randomized controlled trial. Int J Obes (Lond) 32: 1016-1027, 2008.

6. Benson AC, Torode ME, and Singh MA. Muscular strength andcardiorespiratory fitness is associated with higher insulin sensitivi-ty in children and adolescents. Int J Pediatr Obes 1: 222-231, 2006.

7. Bloemers F, Collard D, Paw M, Van Mechelen W, Twisk J, andVerhagen E. Physical inactivity is a risk factor for physical activity-related injuries in children. British Journal of Sports Medicine 46:669-674, 2012.

8. Davis J, LK, Lane C, Ventura E, Byrd-Williams C, Alexandar K, AzenS, Chou C, Spruijt-Metz D, Weigensberg M, Berhane K, and GoranM. Randomized control trial to improve adiposity and insulin sensi-tivity in overweight Latino adolescents. Obesity 17: 1542-1548,2009.

9. Davis J, Ventura E, Shaibi G, Byrd-Williams C, Alexander K, Vanni A,Meija M, Weigensberg M, Spruijt-Metz D, and Goran M.Interventions for improving metabolic risk in overweight Latinoyouth. International Journal of Pediatric Obesity 5: 451-455., 2010.

10. Dietz P, Hoffmann S, Lachtermann E, and Simon P. Influence ofexclusive resistance training on body composition and cardiovascu-lar risk factors in overweight or obese children: a systematic review.Obesity Facts 5: 546-560, 2012.

11. Faigenbaum A, Kraemer W, Blimkie C, Jeffreys I, Micheli L, Nitka M,and Rowland T. Youth resistance training: updated position statementpaper from the National Strength and Conditioning Association.Journal of Strength and Conditioning Research 23: S60-S79,2009.

12. Faigenbaum A and Myer G. Pediatric resistance training: Benefits,concerns and program design considerations. Current SportsMedicine Reports 9: 161-168, 2010.

13. Faigenbaum A and Westcott W. Youth Strength Training.Champaign, IL: Human Kinetics, 2009.

14. Institute of Medicine. Accelerating progress in obesity prevention:solving the weight of the nation. Washington, DC: The NationalAcademies Press, 2012.

15. Jimenez-Pavon D, Ortega F, Valtuena J, Castro-Pinero J, Gomez-mar-tinez S, Zaccaria M, Gottrand F, Molnar D, Sjostrom M, Gonzalez-Gross M, Castillo M, Moreno L, and Ruiz J. Muscular strength andmarkers of insulin sensitivity in European adolescents; the HELENAstudy. European Journal of Applied Physiology 112: 2455-2465,2012.

16. McGuigan MR, Tatasciore M, Newton RU, and Pettigrew S. Eightweeks of resistance training can significantly alter body composi-tion in children who are overweight or obese. J Strength Cond Res23: 80-85, 2009.

17. Salvy S, Bowker J, Germeroth L, and Barkley J. Influence of peersand friends on overweight/obese youths’ physical activity. Exerciseand Sport Science Reviews 40: 127-132, 2012.

18. Shaibi GQ, Cruz ML, Ball GD, Weigensberg MJ, Salem GJ, CrespoNC, and Goran MI. Effects of resistance training on insulin sensi-tivity in overweight Latino adolescent males. Med Sci Sports Exerc38: 1208-1215, 2006.

19. Van der Heijden G, Wang Z, Chu Z, Toffolo G, Manesso E, SauerPJ, and Sunehag A. Strength exercise improves muscle mass andhepatic insulin sensitivity in obese youth. Medicine and Science inSports and Exercise 42: 1973-1980, 2010.

20. Velez A, Golem D, and Arent S. The impact of a 12-week resistancetraining program on strength, body composition, and self-conceptof Hispanic adolescents. Journal of Strength and ConditioningResearch 24: 1065-1073, 2010.

21. Venojärvi M, Puhke R, Hämäläinen H, Marniemi J, Rastas M, RuskoH, Nuutila P, Hänninen O, and Aunola S. Role of skeletal muscle-fibre type in regulation of glucose metabolism in middle-aged sub-jects with impaired glucose tolerance during a long-term exerciseand dietary intervention. Diabetes Obes Metab 7: 745-754, 2005.

22.Watts K, Jones TW, Davis EA, and Green D. Exercise training inobese children and adolescents: current concepts. Sports Med 35:375-392, 2005.

23.World Health Organization. Global recommendations on physicalactivity for health. Geneva: WHO Press, 2010.

ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4 13

*The ISWT kit is available by contacting Sally J. Singh, PhD at:Department of Respiratory Medicine, Glenfield Hospital NHS

Trust, Groby Road, Leicester LE3 9Qp, UK or by email at:leslie.shortt@uhl-tr.nhs.uk.

About the AuthorPeter Ronai, M.S., FACSM, RCEP, CES, CSCS-D, is aclinical associate professor in the Exercise ScienceDepartment at Sacred Heart University in FairfieldConnecticut. He is a clinical exercise physiologistand previously was manager of Community Health atthe Ahlbin Rehabilitation Centers of BridgeportHospital in Connecticut. He is a Fellow of the American College ofSports Medicine (ACSM). He is past-president of the New EnglandChapter of ACSM (NEACSM), past member of the ACSM RegisteredClinical Exercise Physiologist (RCEP) Practice Board, ContinuingProfessional Education Committee, and current member of the ACSMPublications sub-committee. He is also the special populations column edi-tor for the National Strength and Conditioning Association’sStrength and Conditioning Journal (SCJ) and a co-editor ofACSM’s Certified News. He is also ACSM Program Director certified.

References1. Ambrosino, N. Field tests in pulmonary disease. Thorax. 1999;54:191-193

2. Australian Lung Foundation and Australian Physiotherapy Association.Pulmonary Rehabilitation Toolkit (2009).

3. Dyer CAE, Dyer, SJ Singh, RA Stockley, AJ Sinclair, SL Hill. The incre-mental shuttle walking test in elderly people with chronic airflow limita-tion. Thorax. 2002;57:34–38.

4. Gross NJ. Chronic obstructive pulmonary disease outcome measure-ments what’s important? what’s useful? Proc Am Thorac Soc. 2. 2005,pp 267–271.

5. Lewis ME, Newall C, Townend JN, Hill SL, Bonser RS. Incremental shut-tle walk test in the assessment of patients for heart transplantation.Heart 2001;86:183–187.

6. Morales FJ, Martínez A, Méndez M , Agarrado A, Ortega F,Fernandez-Guerra J, Montemayor T, and Burgos J. A shuttle walk testfor assessment of functional capacity in chronic heart failure.American Heart Journal. 1998; 138(2): 191-386.

7. Onorati P, Antonucci R, Valli G, Berton E, De Marco F, Serra P, andPalange P. Non-invasive evaluation of gas exchange during a shuttlewalking test vs. a 6-min walking test to assess exercise tolerance inCOPD patients. Eur J Appl Physiol. 2003, 89:331–336.

8. Singh SJ, Morgan MD, Scott S, Walters D, and Hardman AE.Development of a shuttle walking test of disability in patients withchronic airways obstruction. Thorax. 1992;47:1019-1024.

9. Singh SJ, Morgan MDL, Hardman AE, Rowe C, and Bardsley PA.Comparison of oxygen uptake during a conventional treadmill test andthe shuttle walking test in chronic airflow limitation. Eur Respir J. 1994;7:2016-2020, 1994.

10. Singh SJ, Jones PW, Evans R, and Morgan MDL. Chronic obstructivepulmonary disease: minimum clinically important improvement for theincremental shuttle walking test. Thorax. 2008;63:775-777.

11. Verrill D. Issues for clinical exercise physiologists: the 6-minute walktest in pulmonary rehabilitation. ACSM’s Certified News. 2011; 24(4):8-11.

12. Zwierska I, Nawaz S, Walker RD, Wood RFM, Pockley G, and SaxtonJM. Treadmill versus shuttle walk tests of walking ability in intermittentclaudication. Med. Sci. Sports Exerc. 2004; 36,(11): 1835–1840.

Shuttle Walking Test (continued from page 3)

Why Weight? (continued from page 12)

14 ACSM’S CERTIFIED NEWS • OCTOBER—DECEMBER 2012 • VOLUME 22: ISSUE 4

Conclusion

Compared to the numerous studies of resistance training effects on physical

health, there are relatively few studies of resistance training effects on mental

health. However, an extensive review of the available literature led O’Connor,

Herring, and Caravalho to conclude that the mental health benefits associated

with strength training include reduced anxiety symptoms in healthy adults,

increased cognition in older adults, decreased symptoms of depression in patients

diagnosed with depression or fibromyalgia, and improved self-esteem.18 It would

appear that there is indeed a mind/body connection, and that the positive effects

of resistance exercise on physiological factors and physical health may extend to

psychological factors and mental health.

About the AuthorWayne L. Westcott, Ph.D., teaches exercise scienceand conducts fitness research at Quincy Collegein Quincy, MA.

References1. Alfaro-Acha A, Al SS, Raji Ma, et al. Handgrip strength and cognitivedecline in older Mexican Americans. J Gerontol A Biol Sci Med Sci.2006; 61:859-865.

2. Annesi, J, Westcott W. Relationship of feeling states after exercise andtotal mood disturbance over 10 weeks in formerly sedentary women.Percept. Mot. Skills. 2004; 99:107-115.

3. Annesi J, Westcott W. La Rosa Loud R, Powers L. Effects of associationand dissociation formats on resistance exercise-induced emotionchange and physical self-concept in older women. J. Mental HealthAging. 2004; 10:87-98.

4. Annesi J, Westcott W. Relations of physical self-concept and muscularstrength with resistance exercise-induced feeling states in olderwomen. Percept. Mot. Skills. 2007; 104:183-190.

5. Beniamini Y, Rubenstein JJ, Zaichowsky LO, Crim MC. Effects of highintensity strength training on quality of life parameters in cardiacrehabilitation patients. Am. J. Cardiol. 1997; 80:841-846.

6. Boyle PA, Buchman AS, Wilson RS, et al. Association of musclestrength with the risk of Alzheimer disease and the rate of cognitivedecline in community-dwelling older persons. Arch Neurol. 2009;66:1339-1344.

7. Brown RD, Harrison JM. The effects of a strength training programon the strength and self-concept of two female age groups. Res. Q.Exerc. Sport. 1986; 57:315-320.

8. Buchman AS, Wilson RS, Bienias JL, et al. Change in body mass indexand risk of incident alzheimer disease. Neurology. 2005; 65:892-897.

9. Busse AL, Filo WJ, Magaldi RM, et al. Effects of resistance trainingexercise on cognitive performance in elderly individuals with memoryimpairment: results of a controlled trial. Einstein. 2008; 6:402-407.

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Mental Health (continued from page 9)

ACSM’s ContinuingEducation Self-TestsNow Online!As ACSM strengthened its certification program,

we knew that continuing education would beparamount. Health and fitness professionals

need to keep up with the latest in their field, and wehave provided two outstanding resources. Startingdecades ago with ACSM’s Certified News, then addingACSM’s Health & Fitness Journal ®, we have beenproviding cutting edge articles and CECs to thousandsof eager participants around the world. We areextremely excited to announce that we will now beoffering the convenience of gaining instant creditsthrough our new online learning platform. This will makeall of your re-certification efforts easy and fast!

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Instructions:To take the CEC quiz(zes) for instant results and aprintable certificate that you can immediately use foryour certification(s), please do the following:

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• Read the designated feature issue carefully.• Take the online test• Print your certificate(s) for your files

*If accessing a self-test from ACSM’s Health & Fitness Journal® youwill need an access code that can be found printed in each issue ofthe journal. A subscription to the journal is required.

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