Trainer Academy CPT Full Textbook 1st Edition May 2023

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©2023
2

Chapter 1
The Skeletal System

Anna D’Annunzio, MS
Chapter 1
Certified Personal Trainer
The Skeletal System
Textbook
TABLE OF CONTENTS
The Skeletal System 4
The Nervous System 25
The Muscular System 38
The Cardiorespiratory System 50
The Endocrine System 67
Biomechanics and Kinesiology 90
Communication Skills for Fitness Professionals 110
Applied Elements of Behavioral Coaching 125
Health History and Anthropometric Assessments 146
Posture, Movement,
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and Performance Assessments 161
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Cardiorespiratory Fitness Assessments 188
Principles of Aerobic Training Programs 207
Principles of Flexibility Training Techniques 224
Adaptations to Resistance Training 251
Resistance Training Protocols and Systems 267
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ResistanceChapter 1
Training Technique 287
The Skeletal
Program Design System 324
Periodization 338
Principles of Plyometric Training 347
Principles of Speed, Agility, and Quickness Training 372
Principles of Balance Training 398
Corrective Exercise 425
Special Populations Considerations 468
Basic Nutritional Concepts 516
Macronutrients and Hydration 537
Micronutrients568
Supplementation 586
Exercise, Mental Health, and Lifestyle Considerations 616
Legal and Professional Guidelines for Personal Trainers 632
Client Safety, Injuries, and Emergency Situations 640
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Chapter 1
TheCHAPTER
Skeletal1System
The Skeletal System
5
T he Ske le tal Syst em
Chapter 1
Introduction
The Skeletal System to the Skeletal System
Introduction
Fitness professionals
tounderstanding
must have a basic the Skeletal System
of skeletal system anatomy due to the
key role it plays in all aspects of human life, including all movement and exercise. The bones,
ligaments,Fitness
tendons, and joints
professionals mustare allakey
have basicstructures in anatomy.
understanding of skeletal Additionally,
system anatomy professionals
due to the must
key role it plays in all aspects of human life, including all movement
understand how disease and resistance training impacts these structures. and exercise. The bones,
ligaments, tendons, and joints are all key structures in anatomy. Additionally, professionals must
understand how disease and resistance training impacts these structures.
The skeletal system is an integral part of the human body. It supports body movement and protects
TheItskeletal
vital organs. servessystem
as anisattachment
an integral part of the
site forhuman body.
muscles andIt supports bodyIn
ligaments. movement
addition,andthe skeleton
protects vital organs. It serves as an attachment site for muscles and ligaments. In addition, the
stores calcium, which is necessary for many body functions including cardiac function. Bones
skeleton stores calcium, which is necessary for many body functions including cardiac function.
are alsoBones
the primary production site for some types of blood cells.
are also the primary production site for some types of blood cells. 1
1
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Human infants are born with approximately three hundred bones. As each person grows and
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develops, that number reduces due to bone fusion. Once a person reaches adulthood, their total
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number of bones drops down to two hundred and six.1

6
Human infants are born with approximately three hundred bones. As each person grows and
Chapter
develops, that 1 due to bone fusion. Once a person reaches adulthood, their total
number reduces
The human
number skeleton
of bones dropsdivides
down tointo
twotwo mainand
hundred parts
six.–1 the axial and the appendicular skeleton.
The Skeletal
TheThe human
axial skeleton
skeleton System
divides
contains into two
central main
bones parts
such – the axial and the appendicular skeleton.
as the:
• Anna
The axialD’Annunzio,
Vertebrae MS bones such as the:
skeleton contains central
• •Ribs
Vertebrae
• Ribs
•Sternum
• Sternum
•Skull
• Skull
It makes up eighty bones in all. The axial skeleton’s primary function is to protect organs in the
It makes up eighty bones in all. The axial skeleton’s primary function is to protect organs in
body’s systems. These bones also contain attachment sites for muscles that assist with global
the body’s systems. These bones also contain attachment sites for muscles that assist with global
support and balance.
support and balance.
TheThe
appendicular
appendicular skeleton
skeletonis is
made
madeofofone
onehundred
hundred twenty
twenty six
six bones thatcreate
bones that createthe
theupper
upper and
lower
and limbs.
lower These
limbs. bones
These alsoalso
bones include those
include of of
those thethepelvis and
pelvis andthe
theshoulders.
shoulders.Their
Theirmain
main function
is to support
function movement
is to support in the in
movement extremities and serve
the extremities as theasattachment
and serve sitesite
the attachment for for
muscles. 1 1
muscles.
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7 The Skeletal System
T he Ske le tal Syst7em
Chapter 1
Bone
The Types
Skeletal System
Bone Types
Bones are separated into categories based on their appearance. The four main types of bone are:
Bones are separated into categories based on their appearance. The four main types of bone
• Long
are: bones
• Short bones
Long bones
• Flat• bones
• Short bones
• Irregular bones
• Flat bones
• Irregular bones
The names used reflect the appearance of each bone category.3
The names used reflect the appearance of each bone category. 3
Surrounding every bone is a tissue called periosteum, which covers most of the bone except for
Surrounding every bone is a tissue called periosteum, which covers most of the bone except
the locations where bones connect at a joint.
for the locations where bones connect at a joint.
The periosteum is a membrane

The periosteum mademade
is a membrane of two layers
of two – an–outer
layers layer
an outer made
layer madeof of
connective
connectivetissue
tissueand
an inner layer
and an that
inner contains
layer bone stem
that contains bone cells.
stem Blood vessels
cells. Blood and nerves
vessels run through
and nerves thisthis
run through membrane.3
membrane.3
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Chapter 1
Long Bones
The Skeletal System
Long bones have a greater length than they do width or height. Most of the limb bones are long
bones.
Each long bone has a diaphysis. The diaphysis is a shaft that makes up the middle length of the
long bone.
On each side of the diaphysis sits the epiphysis. The epiphysis is the end of the long bone, so
each long bone has two epiphyses.3
During childhood, long bones contribute to height increase and limb lengthening through
epiphyseal plates. These growth plates are located in between the diaphysis and epiphysis and
are made of cartilage that is replaced by bone as the plate grows. They allow for the lengthening
of the long bones.
Once a person reaches their maximal height and limb lengths in adulthood, the epiphyseal plates
become epiphyseal lines that no longer actively contribute to the lengthening of the bones.3
Examples of long bones:
• Phalanges in the fingers

• Ulna and radius in the forearm
• Humerus in the arm3
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Chapter 1
The Skeletal System

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Chapter 1 The Skeletal System 10
Short Bones
The Skeletal System
Short Bones
Short bones are cuboid in shape. Their measurements run similarly in length, height, and width.
Short bones are cuboid in shape. Their measurements run similarly in length, height, and
Examples:
width.
• Wrist Examples:
bones
• Ankles Wrist bones
•
• Ankles
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The Skeletal System T he Ske le tal Syst
11 em
Chapter 1
Sesamoid Bones
The Skeletal System
Sesamoid Bones
Sesamoid bones are short bones specifically found in tendons. Many of the sesamoid bones vary
Anna
in size and D’Annunzio,
Sesamoidlocation from
bones are person
short MS
bones to person. They
specifically foundeven range in
in tendons. number
Many of thefrom person
sesamoid to person.3
bones
vary in size and location from person to person. They even range in number from person to
person.3
Example:
Example:
• Patella in the kneecap
• Patella in the kneecap
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Chapter 1
Flat Bones
The Skeletal System
Flat bones are relatively flat as their name implies. Sometimes they have a curve to them, such
as Anna D’Annunzio, MS
in the ribs.
Examples:
• Scapulae in the shoulders

• Cranial bones in the skull:
• Frontal
• Parietal
• Occipital
• Temporal3
Irregular Bones
Irregular bones are bones that do not fit into the category of long, short or flat bones. They have
varying shapes depending on their specific function.
Examples:
• Cervical vertebrae
• Thoracic vertebrae
• Lumbar vertebrae3
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In addition to categorizing individual bones, scientists also categorize the types of markings
found on bones.
There are three main kinds of bone markings:
• Depressions
• Projections
• Surfaces

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Chapter 1
The Skeletal System

Depressions
Depressions
Depressions are spaces on the bone through which nerves or blood vessels run through.
Depressions
These are spaces
are further dividedon thecategories
into bone through which nerves or blood vessels run through. These
such as:
are further divided into categories such as:
• Foramen – holes or openings for nerves and blood vessels to pass through
Fissure– –holes
• •Foramen openorslits, grooves,
openings forornerves
depressions typically
and blood housing
vessels to passnerves
through and blood vessels
Fossa– –open
• •Fissure broad andgrooves,
slits, shallowor depressions
depressionsin typically
the bone housing
surface nerves and blood vessels
Sulcus
• •Fossa – a furrow
– broad or fissure
and shallow that in the
depressions in case of bones
the bone typically traces the length of nerves
surface
or vessels–also
• Sulcus – a furrow orcalled grooves
fissure when
that in the specifically
case of bonesdiscussing
typically sulci
tracesonthe
bones
length of nerves or
vessels–also called grooves when specifically discussing sulci on bones
Projections
Projections
ProjectionsTrainer
areAcademy
the attachment sites of tendon and ligament to bone. Categories of projections
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include:
Projections are the attachment sites of tendon and ligament to bone. Categories of projections
include:
• Processes
• Condyle
• •Processes
Epicondyle
• •Condyle
Process
• Epicondyle
• Process
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Chapter 1
Surfaces
The Skeletal System
Surfaces are the parts of the bone that attach to another bone to make a joint. These include
Anna
facets D’Annunzio,
and heads. MS projections, and surfaces found on bones have standard
Many depressions,
names anatomists use to recognize their location in the body.3
Bone Tissue Creation

Bone tissue is composed of many types of cells, including some that are specialized for the
skeletal system. Two essential cell types found in the bone tissue are osteoblasts and osteoclasts.
Osteoblasts are cells that help build bone. Osteoclasts help break down bone. These two cell
types are important, because the body needs to build and break down bones throughout its
lifetime.1
Wolff ’s Law
Wolff ’s Law is an important theory of the skeletal system related to bone creation.
This theory states that bone adaptations occur in response to the outside environment and the
external forces the body experiences. According to Wolff ’s law, bone tissue changes over time
by being built or broken down into different shapes, structures, and densities based on the
environmental stresses placed on the bone.
For example, someone who becomes sedentary after trading their dog walking career for a new
office job now primarily spends their day sitting at a desk. Since the bones now put much less
stress on their bones, they begin to be broken down by osteoclasts. The body does not need as
much bone toTrainer
continue
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individual’s bones will become thinner and smaller.2
For another example, consider a professional soccer player who spends her day training for her
sport. She strength trains at her gym, practices agility with her personal trainer, and does practice
drills with her team. These environmental stressors trigger the skeletal system to react as her body
is constantly supporting itself against many and varied outside forces.

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Chapter 1
Osteoblasts in the bone tissue are busy at work building stronger, denser bones. She needs these
The Skeletal System

strong dense bones to protect her organs as she runs across the soccer field and to support powerful
movements like kicking the ball into the goal.2
Connective Tissue in the Skeletal System
While bone tissue makes up a lot of the skeletal system, ligaments and tendons are also part of
this body system.
Ligaments and tendons are made of connective tissue rather than bone tissue. Connective tissue
differs from bone tissue in that it is more elastic and flexible. It primarily consists of type I
collagen fibers surrounded by a mesh of loose connective tissue.4 This allows for mobility and
range of motion at each joint.1
Ligaments
Ligaments are connective tissues that connect one bone to another bone. They aid in holding
the bones together while allowing a range of motion between the two bones.
Tendons
Tendons are connective tissues that attach muscle to bone, allowing the muscle to stretch without
immediately tearing.1
Joints
Non-synovialTrainer
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of protection. The sutures of the skull bones (these bones protect the brain) and the fused vertebrae
of the lower spine (these bones protect the spinal cord) are examples of non-synovial joints.1
Synovial Joints
In exercise science and personal fitness training, synovial joints are the main type of joint to focus
on, as virtually all movement in the human body occurs around synovial joints.

16
Chapter 1
Synovial joints are also the most common type of joints found in the body. They allow for large
The Skeletal System

range of motion while protecting the bones that make up the joint. Between the bones at this
type of joint, is a synovial capsule filled with fluid, conveniently named synovial fluid.
Anna
This capsuleD’Annunzio,
cushions the bones,MS preventing potential injury from two bones rubbing directly
against each other. In addition to the synovial capsule, ligaments are also often found at synovial
joints for added stability of the joint.1
Synovial joints have many different structures allowing for many different functions. Therefore, it
makes sense to classify the synovial joints into subtypes based on their structures and functions.
The subtypes of synovial joints are:
• Gliding joints
• Ball-and-socket joints
• Pivot joints
• Hinge joints
• Saddle joints
• Condylar joints1,2,3
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• Pivot joints
• Hinge joints
17
• Saddle joints T he Ske le tal Syst em
• Condylar joints1,2,3
Chapter 1
The Skeletal System

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Gliding Joints ©2023
These are also known as plane joints. They move using a gliding movement as the name suggests
– two bones are “gliding” against each other. They only allow for movement in one axis. This type
of joint is found in the wrists and in ankles.3
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Pivot Joints
Pivot joints create rotating movements. Like ball-and-socket joints, there are only a few joints
in the body that display this kind of movement. The joints in the forearm composed of the ulna
and radius are an example. When one places the palm of their hand on a surface in front of them
and then flips the hand over so they can see their own palm, they are performing a movement
using the pivot joints in their forearm.

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Chapter 1
Hinge Joints
The Skeletal System
Hinge joints create a hinge movement – think of a hinge that connects a door to a doorway.
Anna
They D’Annunzio,
only allow for movement MS
in one axis. Examples of these joints include the elbows, fingers,
and toes.3
Ball-and-Socket Joints
Ball and socket joints have movements in many axes. Ball-and-socket joints have lots of mobility
The Skeletal
but contain much less stability. These System
joints are often the location of injury due to this lack of18
stability. Ball-and-socket joints include those in the hip joint and shoulder joints.3
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Saddle Joints
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Chapter 1
Saddle Joints
The Skeletal System
Saddle joints allow for movements in two axes. The joint is named because it looks like a saddle
onAnna
a horse,D’Annunzio, MSsurrounding the other. An example of a saddle joint is the
with one bone surface
saddle joint found in the thumb allowing for special opposable movements.3
Condyloid Joints
Condyloid joints also allow for movements in two axes. The easiest way to differentiate condylar
joints from saddle joints is by their appearance. While saddle joints are shaped like saddles,
condyloid joints look like two connected ovals. Each bone surface contributes an oval shape to
this joint. Examples of condyloid joints include theSystem
The Skeletal joints in the knuckles, some joints in the 19
wrist, and the knee joint.3
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Bone and Joint Disease

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Chapter 1
Bone
The and Joint
Skeletal Disease
System
The skeletal system can be affected by disease like every other body system. Some of the main
Anna
bone D’Annunzio,
and joint diseases relevantMS
to personal training are:
• Osteoporosis
• Arthritis
• Osteoarthritis
• Rheumatoid arthritis
Osteoporosis
Osteoporosis is a disease that causes bone mass to become critically low, increasing the risk of
bone breaks. Osteoporosis happens more commonly in women post-menopause, although it can
affect anyone at any age. The Skeletal System 20
Proper nutrition can assist in the prevention of osteoporosis. This includes intaking enough dietary
calcium under the supervision of a registered dietician and building bone through weight bearing
Proper nutrition can assist in the prevention of osteoporosis. This includes intaking enough
exercise. Treatment
dietary calciumfor osteoporosis
under includes
the supervision both medications
of a registered dietician and and weight-bearing
building exercise to
bone through weight
rebuildbearing
some of the lost
exercise. bone. for osteoporosis includes both medications and weight-bearing
Treatment
1
exercise to rebuild some of the lost bone.1
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21
Chapter 1
Arthritis
The Skeletal System
Arthritis is a common disease found in the joints characterized by pain and inflammation at
theAnna
locationD’Annunzio, MSThere are two kinds of arthritis commonly encountered on
of each affected joint.
the gym floor: osteoarthritis and rheumatoid arthritis. Both diseases cause damage to the joint.1
Osteoarthritis
Osteoarthritis is the more widespread form of the disease and more frequently seen in older
populations; however, individuals of any age are susceptible. Cartilage at the affected joint site
has worn down leading to bone injury at the surfaces of the bones. Osteoarthritis is treated with
medication and exercise. However, osteoarthritis pain can sometimes increase with sustained
activity, so exercise should cease the moment if it becomes too painful.
Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune disease where the body’s immune system attacks the
joints. It can affect anyone at any age, but disproportionately affects women. Rheumatoid arthritis
is also treated with medication and exercise. Typically, rheumatoid arthritis pain lessens with
sustained activity.
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22 is also treated with medication and exercise. Typically, rheumatoid arthritis pain lessens
arthritis T he Ske le tal Syst em
with sustained activity.
Chapter 1
The Skeletal System

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23 The Skeletal System 22
Chapter 1
Exercise
The and
Skeletal the Skeletal System
System
Exercise and the Skeletal System
The theory of Wolff ’s Law applies to exercise as it does any other external stressor. Any weight-
Anna
bearing D’Annunzio,
Theexercise
theory ofadds outside
Wolff’s MStotothe
Law stress
applies body. as
exercise Therefore, progressing
it does any with
other external any form
stressor. Anyof weight-
weight-bearing
bearing exerciseexercise adds outside
will increase stress to the body. Therefore, progressing with any form of
bone mass.
weight-bearing exercise will increase bone mass.
Cardiovascular exercise such as running or walking also adds outside stress to the body and can
Cardiovascular exercise such as running or walking also adds outside stress to the body and
increase bonebone
can increase massmass
when performed
when performed consistently
consistentlyover
overtime.
time. Strength trainingis is
Strength training oneone
of of
thethe most
effective stimulistimuli
most effective to increase total bone
to increase massmass
total bone due toduethe
to ability to load
the ability thethe
to load axial spine
axial very
spine effectively.
very
effectively.
The degree of bone mass increase will vary based on the type of exercise and how much stress it
The
places ondegree of bone
the bones. 3 mass increase will vary based on the type of exercise and how much
Any weight-bearing exercise helps prevent osteoporosis and bone breaks,
3
especially as clients age. The Any
stress it places on the bones. weight-bearing
denser exercise
the bones, the morehelps prevent
difficult it isosteoporosis
for bones toandbreak.
bone1,3
breaks, especially as clients age. The denser the bones, the more difficult it is for bones to
break.1,3
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Chapter 1
Summary
The Skeletal System
The adult skeletal system consists of 206 bones of various sizes, shapes, and structures that support
andAnna
protectD’Annunzio,
the body. The systemMS is divided into the axial and appendicular skeleton.1 The main
types of bones are long bones, short bones, flat bones, and irregular bones. Each of these bones
has markings that include depressions, projections, and surfaces.3
Each bone is covered by periosteum. Long bones contain a diaphysis that separates two epiphyses.3
All bones adapt to outside stressors through the work of osteoblasts and osteoclasts as described
by Wolff ’s Law.1
Tendons and ligaments also help make up the skeletal system. Joints made of two or more bones
(and sometimes ligaments) connect the skeletal system and allow for range of motion. Non-
synovial joints help protect organs while synovial joints such as gliding, ball–and–socket, pivot,
hinge, saddle, and condylar joints allow for movement.1,2,3
Diseases affecting the skeletal system include osteoporosis, osteoarthritis, and rheumatoid arthritis.1
As predicted by Wolff ’s Law, the skeletal system will increase bone mass as an adaptation to
many different types of exercise, since exercise causes external stress on the body.3
Improvements to bone mass and the subsequent ability of bones to withstand more force before
breaking are key benefits of exercise that occur within the skeletal system in response to training
with external resistance.
References
1. Sayler, Mary Harwell. The Encyclopedia of the Muscle and Skeletal Systems and Disorders. Facts
on File, Inc; 2005.
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2. Anderson DM, Novak PD, Jefferson K, Elliott MA, eds. Dorland’s Illustrated Medical Dictionary.
30th ed. Philadelphia, PA. Elsevier; 2003.
3. Marieb, R.N., Ph.D., Elaine N., Hoehn, M.D., Ph.D., Katja. Human Anatomy and Physiology. 11th
ed. Pearson; 2019.
4. Zschäbitz A. Anatomie und Verhalten von Sehnen und Bändern [Structure and behavior of tendons
and ligaments]. Orthopade. 2005;34(6):516-525. https://doi.org/10.1007/s00132-005-0799-4

Chapter 1
TheCHAPTER
Skeletal2System
Anna
TheD’Annunzio,
NervousMS System
26
T he Ne rvous Syst em
Chapter 1
Introduction
The to the Nervous System
Skeletal System
The nervous system offers three main functions:

1. Senses conditions inside and outside the body, which allows it to take in sensory information.
Introduction to the Nervous System
2. Integrates the information by sorting it out and forming a response.
3. Carries out the response through glands, muscles, and other organs via its motor function.3
The nervous system offers three main functions:
A special function
1. Senses of theinside
conditions nervous system
and outside theimportant
body, which to fitness
allows andinexercise
it to take is proprioception.
sensory information.
Proprioception, or kinesthetic
2. Integrates perception,
the information by sorting allows theforming
it out and body to detect its location in the environment.
a response.
Proprioception also assists in detecting the locations of the different limbs and other areas in
3. Carries out the response through glands, muscles, and other organs via its motor function. 3
relation to one another.2
A special function of the nervous system important to fitness and exercise is proprioception.
Proprioception, or kinesthetic perception, allows the body to detect its location in the
The receptors that provide this information are called proprioceptors. They are found in the
environment. Proprioception also assists in detecting the locations of the different limbs1 and
tendons, joints,
other areasand muscles
in relation asanother.
to one well as2 parts of the ear (the vestibular system). It is important
for the body to have this awareness when exercising in order to perform movements correctly
and avoid The receptors
injury. 2 that provide this information are called proprioceptors. They are found in the
1
tendons, joints, and muscles as well as parts of the ear (the vestibular system). It is important for
the body to have this awareness when exercising in order to perform movements correctly and
If a person
avoidstands
injury.2 on one foot, their nervous system intakes information via proprioception to
keep them balanced. Proprioceptors in the joints, muscles, tendons, and ears take in information
If a person stands on one foot, their nervous system intakes information via proprioception to
to locate the body for proper balance. Through the nervous system’s awareness of location in
keep them balanced. Proprioceptors in the joints, muscles, tendons, and ears take in information
relationtoto the the
locate environment and
body for proper the body’s
balance. Throughparts in relation
the nervous toawareness
system’s one another, balancing
of location in on one
foot becomes possible.
relation to the environment and the body’s parts in relation to one another, balancing on one foot
becomes possible.
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27
Chapter 1
Divisions
The Skeletal of the Nervous System
System
Divisions of the Nervous System
Two biggest divisions of the nervous system are the central nervous system and the peripheral
Anna
nervous D’Annunzio,
system.
Two biggest
MS
divisions of the nervous system are the central nervous system and the
peripheral nervous system.
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28
Chapter 1
Central Nervous System (CNS)
The Skeletal System
The central nervous system, or CNS, includes the brain and spinal cord.1 The brain is located
Anna
inside D’Annunzio,
the skull.1 MSbrain on average weighs a little more than three pounds.3 The
The human adult
spinal cord is found inside the vertebrae.
It sends messages to the brain or participates in reflexes in which the brain is not required.1 The
central nervous system is where the nervous system performs its integrative functions.
Peripheral Nervous System (PNS)

The peripheral nervous system, or PNS, contains neurons and neuroglia outside the brain and
spinal cord.1 The peripheral nervous system allows the CNS to communicate with the rest of the
body and vice versa. It is the location for the sensory and motor functions of the nervous system.3
Sensory Division
The peripheral nervous system divides into sensory and motor divisions. The sensory division of
the peripheral nervous system is also known as the afferent nervous system. It sends messages
from receptors to the central nervous system via axons.3
Motor Division
The motor division of the peripheral nervous system sends messages from the central nervous
system to glands, muscles, and other organs. It is also referred to as the efferent nervous system.
This motor division divides even further into the somatic and autonomic nervous systems.3
Somatic Nervous System

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The somatic nervous system transmits impulses to the musculoskeletal system as well as the
eyes, skin, and ears.1 It controls voluntary muscle, which describes muscle that is controlled by
conscious thought.3
For example, the somatic nervous system tells the muscles to contract and relax, allowing a person
to perform a biceps curl. The somatic nervous system is important especially in the function of
muscles during exercise and activity.

29
Chapter 1 Autonomic Nervous System

The
The Skeletal System
Autonomic Nervous System
autonomic nervous system deals with glands as well as involuntary muscle, also
as smooth muscle
The autonomic and cardiac
nervous muscle.
system deals 1
Theasautonomic
with glands nervous
well as involuntary system
muscle, does as
also known not functio
Anna D’Annunzio,
smooth muscle and cardiac MS
themuscle.
heart The
rateautonomic nervous system does pressure
not functiontoconsciously.
1
consciously. It allows to change or the blood go up and down a
It allows the heart rate to change or the blood pressure to go up and down along with many
withother
many other unconscious body adaptations.
unconscious body adaptations.
Therefore,
Therefore, this this system
system is also
is also very very important
important during
during exercise. exercise.
It is divided It issympathetic
into the divided into the
sympathetic nervous
nervous system and thesystem and thenervous
parasympathetic parasympathetic
system.3 nervous system.3
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Sympathetic
Sympathetic Nervous System (SNS) Nervous System (SNS)
The sympathetic nervous system (or SNS) helps the body focus on physical activity. It tells the
Thetosympathetic
body focus blood onnervous
the muscles system (orrather
and heart SNS) helps
than the Itbody
the skin. focus
also helps on physical
increase airflow activity
the to
body to focus
the lungs blood
and allows theon
liverthe muscles
to release andfrom
glucose heart rather than
its glycogen stores.the skin.many
It creates It also
morehelps incre
airflow to the
responses lungs to
in addition and allows
those the liver
just mentioned. 2
to release
Essentially, theglucose from
sympathetic its system
nervous glycogen stores. It c
primes
the body for “fight or flight” responses, including during exercise. 2
many more responses in addition to those just mentioned. Essentially, the sympathetic
system primes the body for “fight or Academy
Trainer flight” ©responses,
2023 including during exercise.
30
Chapter 1
The Skeletal System

Parasympathetic Nervous System (PNS)
The parasympathetic nervous system (or PNS) is also known as the “rest and digest” nervous
Anna
system. ThisD’Annunzio, MS system that controls certain unconscious body functions
is the part of the nervous
when the body is at rest. It promotes digestion. Some of its other effects include a lowered heart
rate and bronchoconstriction (an effect in the lungs that decreases airflow).2
Neurons
The two basic units of the nervous system are neurons and neuroglia. Neurons send messages
via electrical impulses throughout the body. They are also known as nerve cells. Neuroglia, also
known as glial cells, are the supporting cells of the neurons. Often they also have special functions
depending on their specific type.3 Neurons have the most direct effect on the body’s functioning
during exercise.
Neurons generally cannot regenerate; therefore, they have long lifespans. Many survive as long as
the human they reside in. However, this also means if someone injures their neurons, permanent
damage could occur.
Because they are constantly sending messages, neurons require lots of oxygen and energy. They
quickly die if oxygen supplies deplete.3 Neurons contain a cell body and processes. The cell body
receives messages from other neurons or receptors and holds the nucleus of the cell and most
other organelles. Sometimes the cell body is referred to as the soma or perikaryon.3
Processes are extensions of the cell. These include dendrites and axons. Dendrites collect the
impulses to convey to the cell body, whereas axons send the message from the cell body to other
cells. Often, axons send messages to another nerve and sometimes they send messages to a muscle
or a gland or another
©2023 type of tissue. The neuron axon can be surrounded by a myelin sheath. The
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myelin sheath both protects the axon and allows for quicker conduction of impulses.3
Types of Neurons
There are multiple ways scientists classify neurons. One distinction scientists use to classify is the
number of poles or processes the neuron has. All neurons only have one axon, but the number
of dendrites varies.

31
Chapter 1
The Skeletal System

Multipolar Neuron
A multipolar neuron contains one axon and multiple dendrites. This is the most common type
of Anna D’Annunzio,
neuron. Motor neurons are MS
usually multipolar.3 For example, a nerve controlling latissimus
dorsi muscle movement is multipolar.
Bipolar Neuron
A bipolar neuron has one axon and one dendrite. It is found in organs that pertain to special
senses such as the nose.3
Unipolar Neuron
A unipolar neuron has one axon with two branches. It does not contain dendrites. Most unipolar
neurons are sensory, especially sensory neurons in the peripheral nervous system that extend into
the central nervous system.3
Sensory Neuron
A sensory neuron takes in information and transmits the information to the central nervous
system. Most sensory neurons are unipolar, however sometimes they are bipolar. A sensory neuron
includes a nerve such as one that senses pain, or a nociceptor, like those on fingertips that sense
a coffee cup that is too hot upon touch.3
Motor Neuron
A motor neuron sends information from the central nervous system to organs such as the muscle.
Most are multipolar neurons.3 The latissimus dorsi muscle described above as multipolar is
classified as a motor neuron.
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Interneuron
An interneuron conveys information between the sensory nerves and motor nerves. Like motor
neurons, most interneurons are multipolar.3 One can think of the interneurons as the necessary
middlemen for most body responses to the environment.

An interneuron conveys information between the sensory nerves and motor nerves. Like
32 most interneurons are multipolar.3 One can think of the interneurons as the
or neurons, T he Ne rvous Syst em
ssary middlemen for most body responses to the environment.
Chapter 1
The Skeletal System

Sensory Receptors Trainer Academy

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Sometimes instead of having just a simple sensory neuron, the body uses sensory receptors to
sense the internal or external environment. These receptors input to the central nervous system
or they have mechanisms for more local reflexes.3 These special sensory receptors act in ways
specific to exercise and fitness.
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Muscle Spindles
Muscle spindles are specialized fibers running parallel to muscles that are stimulated when
stretched and serve to recognize the length and rate of change in a muscle and trigger a muscle
contraction in response. They are designed to protect muscles from being overstretched and they
also assist in plyometric activities.

Muscle spindles are specialized fibers running parallel to muscles that are stimulated when
33
stretched and serve to recognize the length and rate of change in a muscle and trigger a muscle
contraction in response. They are designed to protect muscles from being overstretched and they
Chapter
also assist in plyometric 1
activities.
The Skeletal System

If a muscle spindle recognizes the muscle is overstretched, a reflex occurs when the
If a muscle spindle recognizes the muscle is overstretched, a reflex occurs when the overstretched
overstretched muscle contracts to protect from injury and to keep muscle 2tone.2 Muscle spindles
muscle contracts to protect from injury and to keep muscle tone. Muscle spindles are located
are located in perimysium to allow for a quick local response. 3
in perimysium to allow for a quick local response. 3
Golgi Tendon Organs Trainer Academy

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Golgi tendon organs sense excessive tension in the muscles and trigger a relaxation response.2 They
are located where the muscles attach to tendons and protect the muscles and tendons from tearing
due to excessive muscular tension. If there is too much stress placed on the muscles, the Golgi
relaxation reflex results in involuntary muscular relaxation.3
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Joint receptors are found in synovial joints.3 They react to pressure which allows the body to sense
how the joint is positioned, aiding in proprioception.2 For example, a joint receptor will aid in
allowing the body to know where the elbow is located throughout a golf swing.

Joint receptors are found in synovial joints.3 They react to pressure which allows the body to
34
sense how the joint is positioned, aiding in proprioception. 2 For example, a joint
T he Nereceptor
rvous willSyst
aid em
in allowing the body to know where the elbow is located throughout a golf swing.
Chapter 1
The Skeletal System

Physical Activity and the Nervous

Physical Activity and the Nervous System
System
The nervous system participates in physical activity and the way in which the body adapts to
The nervous
movement system participates
immediately in physical
and over time. Motoractivity andthe
units are thekey
waycomponent
in which the
ofbody adapts tosystem
the nervous
movement
that allowsimmediately
all humanand over time.The
movement. Motor unitsunit
motor are the key component
includes one motorof neuron
the nervous
plussystem
the muscle
that allows all human movement. The motor unit includes one motor neuron plus the muscle
fibers it innervates. One neuron in a motor unit can innervate four or more muscle fibers.
fibers it innervates. One neuron in a motor unit can innervate four or more muscle fibers.
Motor units
Motor unitsininsmaller
smaller muscles thatperform
muscles that performmore more meticulous
meticulous movements
movements (such(such as threading
as threading
aaneedle)
needle)often
often contain
contain a neuron
a neuron that that is attached
is attached to fewer
to fewer musclemuscle fibers
fibers than than
those those attached
attached to to
larger muscles. Larger muscles contain motor units with a large number of muscle fibers per
motor neuron.2 Trainer Academy
Trainer Academy ©2023
©2023
Motor neurons discharge an action potential across the neuromuscular junction, stimulating
muscular contraction in all muscle fibers within the motor unit.

larger muscles. Larger muscles contain motor units with a large number of muscle fibers per
motor neuron.2
35
Motor neurons discharge an action potential across theTneuromuscular
he Ne rvous Syst
junction, em
stimulating
muscular contraction in all muscle fibers within the motor unit.
Chapter 1
The Skeletal System

This contractionThis contraction

process follows process follows the all-or-nothing
the all-or-nothing principle,
principle, which which
states thatstates
when thata when
motora motor
neuron its
neuron discharges discharges
potential,its every
potential, every
single single
muscle muscle
fiber in itsfiber in itsunit
motor motor unit contracts
contracts withoutwithout
any any
possibility of fractional stimulation. The motor unit is either completely stimulated or does not
possibility of fractional stimulation. The motor unit is either completely stimulated or does not
contract at all.2
contract at all.2
In order to move a muscle, the recruitment of motor units must occur. Motor unit recruitment
In order to move
is the asequence
muscle, of
theactivation
recruitment
of a of motor units
particular patternmust occur.units
of motor Motor
for aunit recruitment
movement. The is
the sequenceefficiency
of activation of aunit
of motor particular pattern
recruitment of motor
is one units forfactors
of the multiple a movement. The
that affect efficiency
how much force the
of motor unit recruitment
muscle is one of the multiple factors that affect how much force the muscle
can develop. 4
can develop.4
Recruitment of motor units begins with those that contain slow twitch muscle fibers. If a
large enough force is required, fast-twitch muscle fibers are then recruited. Even at maximum
Recruitment of motor units begins with those that contain slow twitch muscle fibers. If a large
muscle force, not all muscle fibers in a muscle typically join in in order to avoid injury in both
enough force is required, fast-twitch muscle fibers are then recruited. Even at maximum muscle
the tendon and muscle.2
force, not all muscle fibers in a muscle typically join in in order to avoid injury in both the tendon
and muscle.2 More recruitment is required for shortening muscle than lengthening muscle with the same
amount of force.4 In terms of the strength of overall motor recruitment, the muscles can increase
both theisnumber
More recruitment of motor
required units recruited
for shortening and than
muscle improve the efficiency
lengthening in thewith
muscle pattern
theofsame
fibers
recruited.
amount of force. 2
In terms of the strength of overall motor recruitment, the muscles can increase
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both the number of motor units recruited and improve the efficiency in the pattern of fibers
Another major factor that determines acute muscle force is rate coding. Rate coding refers to
recruited.2
the frequency at which the action stimulates the motor unit. Increased rate coding results in
Another major factor that determines acute muscle force is rate coding. Rate coding refers to
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the frequency at which the action stimulates the motor unit. Increased rate coding results in
©2023
increased muscle force development and is one of the nervous system adaptations that improve
muscle force capability.4

36
Chapter 1
The
likely Skeletal System
Over time, rate coding changes based on adaptations to training. Strength training is more
to increase the rate coding in the muscles being trained. Endurance training is likely to
decrease rate coding because improved muscular conditioning means fewer muscle contractions
areAnna
requiredD’Annunzio,
to maintain a givenMS
intensity.
Essentially, the rate coding increases in strength training to allow for an increase in maximal force
whereas the rate coding may decrease in some cases in endurance training as the body becomes
more efficient at endurance movements.4 If a person decreases their activity level, their muscles
will decrease their rate coding over time.4
Motor unit synchronization happens when multiple motor units activate at the same time. This is
another factor that affects the neuromuscular system. Studies have shown that strength training
increases motor unit synchronization. This most likely benefits the rate of force production as
well as allowing for better coordination.5
For example, when an athlete practices weighted lunges over a training period, their motor
units begin to synchronize with each other, allowing them to lunge more effectively and with
coordination. Their movement becomes more refined and their muscle fibers engage more
collectively. They may also be able to lift more weight in the movement thanks to the improved
synchronization.
Overall, the increased recruitment, rate coding, and improved synchronization are all nervous
system adaptations that lead to improved strength and performance in physical activity, independent
of adaptations in other body systems.
Summary
The nervous system senses, integrates, and responds to stimuli both internally and externally.3 One
of its main functions
©2023 in relation to exercise includes proprioception, allowing the body to sense
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where it is in relation to the outside and inside environment.1,2
The nervous system contains multiple subdivisions starting with the central and peripheral
divisions.1 The peripheral nervous system is further divided into the sensory and motor divisions.
The motor division is then divided into the somatic and autonomic divisions.3
Finally, the autonomic division is divided into the sympathetic and parasympathetic nervous
system.2

37
Chapter 1
The Skeletal System

The nervous system contains neurons that send messages throughout the body, and neuroglia, that
support the neurons. Each neuron is made up of a cell body and processes that allow messages
to be received and sent through electrical impulses. The neurons can be classified by number of
Anna
poles as wellD’Annunzio,
as their function. MS
Sometimes, multiple nerves and other supporting cells make up special receptors. These include
muscle spindles, Golgi tendon organs, and joint receptors.2 These receptors help the body function
during exercise.
The nervous system allows movement to occur via motor units that innervate the muscle. These
motor units are recruited in different numbers and different patterns for different forces.2 There
is some evidence that the recruitment motor unit number changes with different forms of
exercise.5 Rate coding is the frequency at which the motor units are stimulated. Rate frequency
appears to increase with strength training and decrease with endurance training.4
Motor unit synchronization allows multiple motor units to fire at the same time. Strength
training potentially increases the level of motor unit synchronization, as well as rate coding and
recruitment, which are among the key performance adaptations that occur in the nervous system
in response to resistance training.5
References
1. Anderson DM, Novak PD, Jefferson K, Elliott MA, eds. Dorland’s Illustrated Medical Dictionary.
30th ed. Philadelphia, PA. Elsevier; 2003.
2. Kent, Michael. Oxford Dictionary of Sports Science and Medicine. 3rd ed. New York, NY. Oxford
University Press; 2006.
3. Marieb, R.N.,
TrainerPh.D.,
Academy Elaine N., Hoehn, M.D., Ph.D., Katja. Human Anatomy and Physiology. 11th ed.
©2023
Pearson; 2019.
4. Duchateau, J, Enoka, RM (2017). Rate coding and the control of muscle force. Cold Spring Harbor
Perspectives in Medicine, 7(10). 10.1101/cshperspect.a029702
5. Gardiner, P. (2011). Advanced neuromuscular exercise physiology. Human Kinetics.

Chapter 1
TheCHAPTER
Skeletal3System
Anna
TheD’Annunzio,
Muscular MSSystem
Tyler Kettle, MS
39
T he Muscular Syst em
Chapter 1
Introduction
Introduction
The to
to the
Skeletal System theMuscular
MuscularSystem
System
The architecture of skeletal muscle is composed of both macro- and microstructures that interact
The Anna
during D’Annunzio,
architecture
muscle of skeletal
contract MSthe
muscle
to shorten is composed
length ofof
theboth macro-
muscle, and micro-
pulling on thestructures thatthe joint,
bone across
interact duringinmuscle
resulting contract
movement to shorten
of the bone withthe the
length of as
joint thethe
muscle,
pivot pulling
point. on the bone across the
joint, resulting in movement of the bone with the joint as the pivot point.
Having a strong grasp of the structure and function of skeletal muscles is important for fitness
Having a strong grasp of the structure and function of skeletal muscles is important for
professionals to understand the biological processes behind resistance training, including
fitness professionals to understand the biological processes behind resistance training, including
muscle contraction. This knowledge both helps guide programming considerations as well as
muscle contraction. This knowledge both helps guide programming considerations as well as
competently
competently explain
explain to a to a curious
curious client
client exactly
exactly whatwhat
goesgoes on behind
on behind the the scenes
scenes in the
in the human body
human
bodyduring
duringmotion.
motion.
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40
Chapter 1
Muscle Macrostructure
The Muscle
Skeletal Macrostructure
System
Closer examination reveals that muscle consists of a series of grouped bundles.
Anna
Closer D’Annunzio,
examination MS consists of a series of grouped bundles.
reveals that muscle
A layer of connective tissues surrounds the entire muscle, called the fascia, with the outer layer
Acalled
layer the
of connective tissues
epimysium. surrounds
This fascia the entire
surrounds muscle,
a series called known
of bundles the fascia, with the outer
as fascicles.
layer called the epimysium. This fascia surrounds a series of bundles known as fascicles.
Each of these fascicles creates the main belly of the muscle. Outside individual fascicles is another
Each of these fascicles creates the main belly of the muscle. Outside individual fascicles is
outer layer of connective tissue called the perimysium.
another outer layer of connective tissue called the perimysium.
InInskeletal
skeletal muscle,
muscle, muscle
muscle fibers
fibers contain
contain a nucleus
a nucleus andand striations,
striations, giving
giving themthem
their their
sinewysinewy
appearance.
appearance.
Musclestructure
Muscle structurealso
alsoincludes
includesmitochondria,
mitochondria, thethe sarcoplasmicreticulum,
sarcoplasmic reticulum, and
and thethe endoplasmic
reticulum.
endoplasmic These organelles
reticulum. live inside live
These organelles the sarcolemma, a layer of cellamembrane
inside the sarcolemma, directly
layer of cell underneath
membrane
theunderneath
directly endomysium. 3
the endomysium. 3
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41
Muscle Microstructure
Chapter 1
Muscle
The Microstructure
Skeletal System
Inside the sarcolemma, several microstructures exist that help and allow the muscle fiber to
Inside
operate asthe sarcolemma,
a functional unit.several microstructures
The mitochondria helpexist that help
facilitate and creation
energy allow theinside
muscle thefiber to operate
body, and
the as Anna
ability D’Annunzio,
a functional unit.
for muscles toThe
contract. MS
mitochondria help facilitate
Striated muscles energy
also contain creation
nuclei. inside
Nuclei thecontrol
act as body, and the
ability
centers forfor muscles cells.
individual to contract. Striated muscles
Without a nucleus, alsomuscle
skeletal containhas
nuclei. Nuclei
no action act as control
potential and no centers
for individual cells. Without a nucleus, skeletal muscle has no action potential and no contraction.
contraction.
Along the
Along the sarcolemma
sarcolemma isis aa channel
channelknown
knownasasthe
thet-tubule, or or
t-tubule, transverse tubule,
transverse which
tubule, which releases
releases
calcium into the sarcoplasmic reticulum in response to motor unit stimulation. TheThe
calcium into the sarcoplasmic reticulum in response to motor unit stimulation. calcium ions
calcium ions play a key role in triggering muscle
play a key role in triggering muscle contraction. contraction.
These structures are all located around the long cylindrical structure known as myofibrils.
These structures are all located around the long cylindrical structure known as myofibrils. Bundled
Bundled myofibrils create muscle fibers. Contractile units called sarcomeres make up the
myofibrils create muscle fibers. Contractile units called sarcomeres make up the myofibrils.
myofibrils.
The
The sarcomeres
sarcomeres themselves
themselves contain
contain the
the smallest muscular structures,
smallest muscular structures, protein
protein filaments
filaments known as
actinasand
known myosin.
actin WhenWhen
and myosin. forcesforces
pull actin and myosin
pull actin together,
and myosin the the
together, distance
distanceshortens between
shortens
ends of
between sarcomeres,
ends known
of sarcomeres, as “Z”aslines,
known creating
“Z” lines, a muscular
creating contraction.
a muscular 3
contraction. 3
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42
Chapter 1
Sliding
The Filament
Skeletal System Theory
The sliding filament theory describes the mechanisms of muscular contraction. As mentioned
Anna
above, D’Annunzio,
contractile proteins actinMS
and myosin live within the sarcomere of a muscle fiber.
Actin, the thin filament, is primarily located in the I-Band. Myosin filaments, which are
thicker, are primarily located in the A-Band. These two bands sit in an area from Z disc to Z
disc. These Z-discs correspond to the end of each sarcomere. When these filaments pull together
within the sarcomere, this creates the H-Zone, the area of overlap.2, 3
In a resting state, the filaments are blocked from binding to one another by a protein called
tropomyosin. Wrapped around actin, tropomyosin prevents cross bridges from forming by blocking
myosin tails from reaching up and binding with actin.
When a motor neuron discharges its action potential, a series of steps occur that result in the
shortening of the sarcomere. This action potential travels from the brain to the desired muscle,
signaling for contraction. At this point, the sarcoplasmic reticulum releases calcium ions into
the sarcomere. The calcium binds with troponin sites and causes a rotation of the tropomyosin
or actin. When these are rotated, new attachment sites become available for myosin to create a
cross bridge.
ATP, adenosine triphosphate, is the energy source at the cellular level. If enough ATP is present
in the sarcomere, the tails of the myosin filament now attached to actin at the cross bridge site
will pull on the actin filament, causing a shortening of the I-Band, bringing the Z-discs closer
together.
When this action repeats it creates a larger H-zone, the area of overlap, until no more calcium or
ATP is present, requiring another action potential to release more if needed.2 During this process,
the ATP loses a phosphate group and becomes adenosine diphosphate (ADP). The ADP can
provide an additional phosphate group as well, further reducing it to adenosine monophosphate.
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However, the bulk of the phosphate required for muscle contraction comes from ATP.
This overall process of cross bridging results in shortening across the sarcomeres in the muscle
that is contracting. The result is a shortening of the overall muscle, a pulling force on the bone,
and the resulting movement about the corresponding joint.

43
Chapter 1
Energy
The Systems
Skeletal System
ATP is required for all muscular actions and gets broken down during the course of muscle
Anna D’Annunzio,
contraction. MS
As such, the replenishment of ATP is the primary goal of the energy systems in
the human body.
The body’s energy systems include both anaerobic and aerobic methods of ATP replenishment.
Anaerobic methods do not require oxygen and typically supply energy for higher-intensity
activities. Anaerobic energy production is limited in duration and requires rest between bouts of
activity to sustain the high intensity.
Aerobic energy requires the presence of sufficient oxygen in the muscle cell to metabolize glucose
and fat and break down ATP. Aerobic energy production is limited by the ability of the body
to use and supply oxygen to working tissues. When the work capacity exceeds the availability
of oxygen in working tissues, the muscles shift to anaerobic energy. While the aerobic system
cannot supply ATP for very high intensity exercise, it can sustain ATP virtually indefinitely if
oxygen and either glucose or fat are present in the cell.
The three main systems of the body are the ATP-PC, glycolytic, and aerobic systems. The ATP-
PC system is entirely anaerobic. The glycolytic system has the ability to function anaerobically or
aerobically depending on intensity. The aerobic system depends on the presence of oxygen to function.
In every human activity, each system contributes to ATP production to some degree. The intensity
of the activity will determine which energy system plays the biggest role in replenishing ATP.
ATP-PC System
The ATP-PC system supplies energy for high intensity, short duration activities. It relies on
limited intramuscular
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©2023 supply of phosphocreatine (PC) as a rapid source of ATP. The PC supplies
the phosphate to rephosphorylate ADP into ATP, and becomes free creatine in the process.
This energy system rapidly yields a high quantity of ATP until PC stores are depleted. At this
point, the body must reduce intensity to allow the glycolytic or oxidative systems to replenish
ATP and rephosphorylate the free creatine back into phosphocreatine.
The ATP-PC system supplies the vast majority of energy during maximal intensity exercises
lasting less than 10 seconds such as Olympic lifting, powerlifting, and short-distance sprints.

44
Chapter 1
The Glycolytic System
The Skeletal System
The glycolytic system relies on glucose and glycogen for the energy to replenish ATP. Anaerobic
Annaoccurs
glycolysis D’Annunzio,
when the bodyMS breaks down glucose or glycogen without any oxygen present.
The glycolytic system is capable of fast glycolysis and slow glycolysis. Fast glycolysis occurs when
insufficient oxygen is present relative to the exercise intensity and can quickly replenish ATP
stores during high-intensity exercise.
While anaerobic glycolysis can rapidly replenish ATP stores during high intensity exercises
lasting 10-30 seconds, lactate and H+ ions are produced as a result and cause a drop in cellular
pH, which is associated with muscle fatigue and the need to reduce intensity. Lactate itself is not
responsible for the burning sensation associated with muscle fatigue, but the buildup of lactate
occurs concurrently with the fatigue.
Following intensity reductions or muscle failure, oxygen levels can rise enough to allow clearance
of lactate and reliance on aerobic energy.
In this case of lower intensity, slow glycolysis can occur. Slow glycolysis occurs if there is sufficient
oxygen in the mitochondria to metabolize the byproducts of glycolysis before lactate accumulation
occurs.
The Mitochondrial Respiratory System (Oxidative)

For exercise lasting longer than 30 seconds, the body will begin a shift to slow glycolysis, also
referred to as aerobic glycolysis, and the aerobic system. This energy system can sustain ATP
replenishment for much longer because the body can use oxygen to metabolize the by-products
of glycolysis before they convert to lactate and drop cellular pH.
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The extra metabolic steps mean the rate of ATP production is lower than in anaerobic glycolysis.
However, the avoidance of lactate buildup means that aerobic glycolysis can be sustained for longer.
Exercise that lasts longer than 3 minutes will be fueled almost entirely by the aerobic energy system.
Trained athletes can exercise at absolute intensities much higher than the general population while
still relying on aerobic energy. As such, fitness level plays a large role in determining whether a
certain absolute intensity will require the addition of anaerobic energy.3

45
Chapter 1
The metabolism of fats and glucose via oxidation has the greatest capacity for ATP production,
The Skeletal System

although it is also the slowest and cannot occur at high intensity.
Muscle Fiber Types
Skeletal muscles in the human body are typically classified into two main muscle fiber types:
type I and type II. Different muscles throughout the body will display different muscle fiber
types.
Each of these types of muscles will be classified with three types of criteria:
1. Movement rates
2. Responses to neural signaling
3. Metabolic styles
Type I (Slow Twitch)

Type I muscle fibers are classified as such because they rely on oxidative or aerobic metabolism.
Type I muscles thrive on the ability to use oxygen to resupply energy, meaning that type I muscle
fibers are primed to perform exercise or physical activity at a much slower rate.
This means type I muscle fibers do not fatigue as quickly and can perform muscular action for
much longer. The act of walking is an excellent example. From an early age, most humans can
walk for extended periods of time without the muscles of the legs fatiguing. This is due to the
slow twitch nature of the muscles in the leg and the body’s ability to utilize oxygen as an energy
source.
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Type II (Fast Twitch)

Type II muscle fibers rely first-and-foremost on the ATP-PC and glycolytic systems. Type
II muscle fibers generally have a greater maximal force output when compared to type I
fibers but are quicker to fatigue. Type II fibers are further broken down into type IIa and type
IIx fibers.

46
Chapter 1
Type IIa
The Skeletal System
Typefiber
Type IIa muscle fibers are an intermediate IIatype. Type IIa muscles have a high capacity for
anaerobic energy but have greater aerobic and glycolytic capacity than type IIx fibers.
Type IIa muscle fibers are an intermediate fiber type. Type IIa muscles have a high capacity
for anaerobic energy but have greater aerobic and glycolytic capacity than type IIx fibers.
Type IIx
Type IIx muscle fibers rely primarilyType IIx system for energy. They are capable of the
on the ATP-PC
greatest force production but also have the least resistance to fatigue.5, 3
Type IIx muscle fibers rely primarily on the ATP-PC system for energy. They are capable of
the greatest force production but also have the least resistance to fatigue.5, 3
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47
Chapter 1
Muscular
The Skeletal Adaptations
System to Exercise
Adaptations to exercise occur in the muscular system over time based on the type and intensity
Anna Anaerobic
of activity. D’Annunzio,
activities MS
lead to adaptations within the muscle tissue that further improve
their ability to produce force anaerobically.
Aerobic training, on the other hand, leads to adaptations that improve the oxidative capacity
of muscles due to the duration and intensity of an exercise. These muscles require continuous
training to adapt over time and can be reversed with inactive states.6
Resistance Training Muscular Adaptations

The typical change expected from resistance training is a change in the force production capability
and cross-sectional size of the muscles. Resistance training causes a series of micro-tears at the
level of the sarcomeres.4 The healing of those tears is how the muscle cells specifically adapt
strength and size in response to resistance training.
Cross-Sectional Area
In resistance training one of the main adaptations is increased cross sectional area. This occurs
over time when the series of microtears seen in the sarcomere of a muscle fiber heal and that
healing compacts on itself. The body has the ability to build up the areas of frequent breakdown
to handle the stress put on the muscles by an external weight. This build up over time increases
cross sectional area, making muscles larger and more defined.7
Strength
Another definable adaptation that occurs with resistance training is increase in force production.
Increases in strength
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sectional area. With a larger cross-sectional area, more area becomes available to overlap the
protein filaments actin and myosin, resulting in a greater potential for force production.
Aerobic Training Muscular Adaptations
Muscular adaptations to aerobic training improve the fiber’s ability to supply and use oxygen
during aerobic exercise.

48
Chapter 1
Increased Capillary Density
The
After Skeletal System
consistent, progressive aerobic training, the body increases the number of capillaries that
surround a muscle. Capillaries are the body’s exchange site for blood and other crucial nutrients.
Anna
These D’Annunzio,
extremely thin exchange MS
vessels wrap around the skeletal muscle, providing a dropoff site
for the muscles to receive and utilize delivered nutrients.
This effect provides increased blood flow and increased surface area. With a larger surface area, a
greater area of the muscle is covered by capillaries, creating a shortened travel distance for blood
and nutrients to be utilized. This also upregulates the body’s ability to use more oxygen and to
use it more effectively.6
Increased Mitochondrial Density
An increase in cellular mitochondria occurs with frequent aerobic training. This increase allows
for the body’s aerobic system to function at an increased rate, with more mitochondria able to
function, creating an increased rate of fatty acid oxidation and energy production along with
biochemical adaptations at the cellular level. Increased mitochondria also promote a more stable
environment for type I muscle fiber endurance.6
Shared Adaptations
There are several adaptations that occur as a result of both resistance and aerobic training.
• Increased blood volume

• Increased cardiac output
• Lower resting heart rate
• Reduced symptoms of anxiety
• Reduced symptoms of depression
• Weight loss
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49
Chapter 1
Summary
The Skeletal System
Skeletal muscle is comprised of macro- and microstructures which create movements where
Anna
joints D’Annunzio,
interact MS
with bone. Sliding filament theory describes how the actin and myosin filaments
cross, creating a shortening of the muscle. ATP is required for all muscle actions and is used
through three different types of energy systems (ATP-PC, glycolytic, oxidative).
Different muscle fiber types correspond to these systems to produce movements over different
time frames. Finally, the muscles adapt to both resistance and aerobic training modalities in
specific ways to facilitate improvements for future stresses.
References
1. Cherry, K. (2020, December 8). All Or None Law for Nerves and Muscles. Retrieved from verywell
Mind: https://www.verywellmind.com/what-is-the-all-or-none-law-2794808#:~:text=The%20
all%2Dor%2Dnone%20law,or%20muscle%20fiber%20will%20fire.
2. Krans, J. L. (2010). The Sliding Filament Theory Of Muscular Contraction. Retrieved from Scitable: https://

www.nature.com/scitable/topicpage/the-sliding-filament-theory-of-muscle-contraction-14567666/
3. Martini Ph.D, F. H., Nath Ph.D, J. L., Bartholomew M.S, E. F., Ober M.D, W. C., Garrison R.N,
C. W., Welch M.D, K., & Hutchings, R. T. (2009). Fundamentals of Anatomy and Physiology. San
Francisco: Pearson Benjamin Cummings.
4. Proske, U., & Morgan, D. (2001). Muscle damage from eccentric exercise: mechanism, mechanical
signs, adaptation and clinical applications. National Library of Medicine, 333-345.
5. Talbot, J., & Maves, L. (2016). Skeletal muscle fiber type: using insights from muscle developmental
biology to dissect targets for susceptibility and resistance to muscle disease. Wires Developmental
Biology, 518-534.
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6. Terjung, R. L. (1995). MUSCLE ADAPTATIONS TO AEROBIC TRAINING. SPORTS
SCIENCE EXCHANGE.
7. The Strength Institute of Australia. (2017, 12 1). The Physiological Responses to Resistance
Training. Retrieved from The Strength Institute of Austrailia: https://www.thestrengthinstitute.
com/articles-and-podcasts/2017/12/1/the-physiological-effects-of-resistance-training

Chapter 1
TheCHAPTER
Skeletal4System
Anna
TheD’Annunzio, MS
Cardiorespiratory
System
Beau Bernardo, MS
51
T he Cardiore sp iratory Syst em
Chapter 1
Introduction
The to
Skeletal System the Cardiorespiratory
System
Fitness professionals must have basic working knowledge of the cardiorespiratory system for
a number of reasons. Program design principles are all based on the underlying anatomy of
the human body. As such, knowledge of anatomy allows fitness professionals to make better
programming decisions, and explain those decisions more effectively with the client.
Furthermore, anyone working with clients must understand the acute and chronic responses of
the cardiorespiratory system to ensure they can safely train clients, monitor intensity, and respond
to any emergencies.
This chapter covers the basic anatomy and function of the cardiorespiratory system and its
responses to exercise. The cardiorespiratory system (CRS) plays an integral role in meeting the
demands of the body. The cardiorespiratory system consists of two main pieces: the pulmonary
system, which consists of the airways and lungs, and the cardiovascular system: the heart, blood
vessels, and blood.3
In totality, the cardiorespiratory system pumps oxygenated, nutrient-rich blood through miles of
blood vessels. Tissues take in the nutrients and oxygen from blood while excreting waste, which
is then transported by the blood for excretion.
During physical activity, the increased demand for oxygen can prompt the cardiorespiratory system
to work harder by increasing breath, heart rate, and blood flow. Exercise can elicit a physiological
response to the CRS so that it meets the needs of the activity.
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52
Chapter 1
Components
Components of ofCardiorespiratory
the the Cardiorespiratory
The Skeletal System
System System
Heart Heart
The heart is located within the mediastinum. This is a cavity within the thorax. It rests just
The heart
aboveisthe
located within posterior
diaphragm, the mediastinum. This is aAbout
to the sternum. cavitytwo-thirds
within the ofthorax. It rests
the heart liesjust above
to the left side
the diaphragm, posterior to the sternum. About two-thirds of the heart lies
of the sternum line. The heart is enclosed by a double-walled sac called the pericardium.3 to the left side of the
sternum line. The heart is enclosed by a double-walled sac called the pericardium.3
The superficial sac is the fibrous pericardium. This is a tough layer that anchors to
The superficial
surrounding sacstructures
is the fibrous pericardium.
and protects This The
the heart. is a tough
serouslayer that anchors
pericardium to surrounding
is a thin, slippery layer that
structures
acts asand protects to
a lubricant theprevent
heart. sticking.
The serous Thepericardium is a thin,these
fluid used between slippery
twolayer
layersthat acts asserous
is called a
lubricant
fluid to
andprevent
helps the sticking. The fluidinused
heart operate between these
a low-friction two layers is called serous fluid and
environment.
helps the heart operate
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©2023 in a low-friction environment.
The three layers of the heart are the epicardium, myocardium, and endocardium. The
epicardium
The three layers of is the
the heart
layer are
of serous pericardium.
the epicardium, This layerand
myocardium, canendocardium.
be replaced with The fat as individuals
epicardium
is theget older.
layer The myocardium
of serous pericardium.isThisconsidered
layer canthe
be muscle
replacedofwiththe heart, while the endocardium
fat as individuals get older. Thelines
the insideis walls
myocardium of thethe
considered heart and blood
muscle of thevessels.
heart, while the endocardium lines the inside walls
of the heart and blood vessels.
Cardiac muscle forms the bulk of what is considered the heart. Cardiac muscle is much
different
Cardiac muscle thanformsskeletal muscle.
the bulk Myocardium
of what cells
is considered theareheart.
heldCardiac
togethermuscle
by connective tissue that
is much different
thancrisscrosses.
skeletal muscle. TheMyocardium
muscle is arranged
cells areasheld
bundles that connect
together the entire
by connective heart.
tissue thatThis ensures that
crisscrosses.
when the heart contracts, the most amount of blood possible is ejected from the heart.
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53
Chapter 1
The muscle is arranged as bundles that connect the entire heart. This ensures that when the heart
The Skeletal System

contracts, the most amount of blood possible is ejected from the heart.
Lastly, the endocardium covers the entire inside walls of the heart, including the valves, chambers,
Anna
arteries, andD’Annunzio,
veins. MS
Chambers and Vessels
The heart consists of four chambers: the left and right atria and left and right ventricles. The
chambers are separated by flow specific valves that open and close in perfect coordination during
each cardiac cycle.
The atria are the chambers of the heart that receive blood. They are small appendages that are
somewhat smooth on the outside.3 The right atrium has bundled up muscle tissue that forms
ridges called pectinate which look like small comb bristles.
The two vessels are smaller and not as muscular as the ventricles because they only need to push
blood downward into the ventricles. The ventricles on the other hand need to push the blood out
to the entire body and to the lungs. Blood enters the right atrium via three veins: the superior
vena cava, the inferior vena cava, and the coronary sinus.
The superior vena cava returns blood from the body region that is above the diaphragm. The
inferior vena cava returns blood from the body region that is below the diaphragm. Lastly, the
coronary sinus collects the blood that drains from the myocardium.
The ventricles are known as the discharging chambers. The ventricles are lined with trabeculae
carneae, which look like irregular ridges. The walls of the ventricles are much thicker than the
atria. The right ventricle pumps blood into the pulmonary trunk which takes the blood to the
lungs. This is where carbon dioxide is offloaded and oxygen is loaded onto the hemoglobin.
Hemoglobin is located on a red blood cell (erythrocyte).
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Valves
Blood flows from the atria to the ventricles in one specific direction which is made possible by
the four valves within the heart. These valves open and close in response to different pressures
on either side.3 The AV or atrioventricular valve is located where the atria meet the ventricle.
The right AV valve is known as the tricuspid valve. The AV valve has three flaps of endocardium
and connective tissue to give it rigidity. The left AV valve has two cusps and is also referred to
as the bicuspid or mitral valve.

54
Chapter 1 The Cardiorespiratory System 55

Attached to the flaps of the AV valves are the chordae tendineae. These are also known as the
The Skeletal System

heart strings. These strings anchor the cusps and connect to the papillary muscle, which consists
of two bands of muscle that protrude from the ventricle wall.
The aortic and pulmonary valves, also known as the semilunar valves, are located at the base
Theofaortic and
the aorta andpulmonary valves,
pulmonary trunk and also known
prevent as 3the
backflow. Eachsemilunar valves,
valve has three are
cusps andlocated
is at the base
of the aorta
shaped likeand
a halfpulmonary trunk
moon. Like the and prevent
AV valves, backflow.
the semilunar 3
Each
valves open andvalve has
close in threetocusps and is
response
intraventricular pressure.
shaped like a half moon. Like the AV valves, the semilunar valves open and close in response to
intraventricular pressure.
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Because of ©2023
the way blood flows through the heart, the right ventricle only pumps blood to the
lungs for oxygenation. Since the lungs are near the right side of the heart, the muscle wall of the
Because of the way
right ventricle blood
is thinner flows
than through
that of the heart, the right ventricle only pumps blood
the left ventricle. to the
lungs for oxygenation. Since the lungs are near the right side of the heart, the muscle wall of the
The left ventricle has a very thick wall to sustain high pressures. This is because the left
right ventricle
ventricle mustispump
thinner thanthrough
the blood that ofthethe leftvalve
mitral ventricle.
into the aorta, ultimately dispersing the
blood to the entire body.
The left ventricle has a very thick wall to sustain high pressures. This is because the left ventricle
must pump the blood through the mitral valve into the aorta, ultimately dispersing the blood
to the entire body.
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55
Chapter 1
Nodes
The Skeletal System
The heart is equipped to depolarize and contract even when outside the body. Nerve fibers
Annathe
innervate D’Annunzio, MS based on oxygen needs.3 Heart rhythm can also be altered
heart to alter its rhythm
when the autonomic nervous system elicitsNodes
its fight or flight response.
Specific cells
Thewithin
heart isthe hearttocalled
equipped cardiac
depolarize pacemaker
and contract even cells
when can depolarize
outside usingfibers
the body. Nerve potassium and
innervate the heart to alter its rhythm based on oxygen needs. 3
Heart rhythm can
sodium ions (K+ and Na+). The Sinoatrial (SA) node is also known as the pacemaker. The SA also be altered
when the autonomic nervous system elicits its fight or flight response.
node generates impulses that are sent to the AV node.
Specific cells within the heart called cardiac pacemaker cells can depolarize using potassium
The atrioventricular
and sodium ions node
(K+ andorNa+).
AV Thenode then receives
Sinoatrial (SA) nodethe signal
is also knownabout
as the 0.1 seconds
pacemaker. Thelater. This
SA node generates impulses that are sent to the AV node.
delay is critical in heart contraction because it allows the atria to contract and then enables the
ventricles to contract.
The After node
atrioventricular the signal is received
or AV node at thetheAV
then receives node,
signal aboutit 0.1
then goes later.
seconds to the AV bundle.
This
This branches
delay is out into
critical in the
heartmyocardium. The itsignal
contraction because allowsthen travels
the atria into the
to contract and subendocardial
then enables the network
ventricles to contract.
which depolarizes the cellsAfter
andthe signal
gets themis received
ready atforthea AV node, it then goes to the AV bundle.
contraction.
This branches out into the myocardium. The signal then travels into the subendocardial network
which depolarizes the cells and gets them ready for a contraction.
Electrocardiogram (ECG)
Electrocardiogram (ECG)
An electrocardiogram (ECG) is a graphic representation of heart activity. An ECG shows
An electrocardiogram (ECG) is a graphic representation of heart activity. An ECG shows the
the action potential that is generated by nodes. 3
It does not show the physical actions that are
action potential that is generated by nodes. It does not show the physical actions that are
3
happening in theinheart.
happening An An
the heart. ECGECGappears visuallyasaslines
appears visually lines
onon a graph
a graph that
that go up go
andup andThere
down. down. There
are threearewaves that are
three waves that very distinguishable
are very inaanormal
distinguishable in normal ECG.
ECG. Thewave
The first firstiswave
the P is the P wave.
wave.
This typically happens when the atria depolarize. After that there is the QRS complex. This is
This typically happens
typically when
the large, the atria
tall section depolarize.
of the line. ThisAfter
is whatthat thereonisan
happens theECGQRS complex.
when This is typically
the ventricle
the large,depolarizes
tall section
andofthen
theproceeds
line. Thisto is what happens
contract. on of
The last part anthe
ECGwavewhen
is the the ventricle
T wave. This isdepolarizes
when and
then proceeds to contract.
the ventricle The last part of the wave is the T wave. This is when the ventricle repolarizes.
repolarizes.
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56
Chapter 1
Cardiac Output
The Skeletal System
Cardiac output or CO is the amount of blood pumped out of the heart in one minute. To find
outAnna
what theD’Annunzio,
volume per minuteMS (CO) is take the total volume per stroke, and the stroke volume,
and multiply it by the heart rate.
The formula is as follows: CO = HR X SV.
Cardiac output is dependent on heart rate and stroke volume. If one variable is manipulated, then
cardiac output will change. Cardiac reserve is the difference between cardiac output maximally
and at rest.3
Stroke volume is found by taking the end diastolic volume and subtracting the end systolic volume.
Diastolic volume is the amount of blood left in the heart in a resting state. Systolic volume is the
amount of blood left in the ventricle after it has contracted.
The contraction phase happens when blood is ejected and is known as systole. The relaxation phase,
where the chambers refill with blood, is called diastole. It should be noted that there’s a small
amount of blood left in the ventricles after the heart has contracted called end-systolic volume.
Blood
Blood is the bodily fluid that runs through the cardiovascular system and delivers nutrients and
removes waste, among other functions.
Blood is composed of three main parts: plasma, red blood cells, and platelets.3
Plasma is a fluid that consists primarily of water with proteins, mineral salts, fats, sugars, hormones,
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and vitamins dissolved or contained in it as well. Plasma transports the other components of
blood, which make up around 55 percent of blood volume.
Red blood cells, or erythrocytes, make up 44 percent of total blood volume and are the densest
component in blood. White blood cells (leucocytes) and platelets (thrombocytes) make up most
of the final 1-2 percent of blood volume.

57
Chapter 1
The Skeletal System

Blood has many functions in our bodies including:

Blood has many functions in our bodies including:
• Transporting oxygen and nutrients for uptake in cells
• Removing metabolic waste for excretion
• Transporting oxygen and nutrients for uptake in cells
• Regulating body temperature
• Removing metabolic
• Preventing wasteloss
further blood for via
excretion
clotting
• Regulating body temperature
• Preventing infection via antibodies and cells carried in blood
• Preventing further blood loss via clotting
Red blood cells
• Preventing are also
infection viacalled erythrocytes.
antibodies Thesecarried
and cells are microscopic
in blood discs that use hemoglobin
to transport O2 and CO2. Red blood cells are made within red bone marrow that is stimulated by
the kidney.
Red blood cells are also called erythrocytes. These are microscopic discs that use hemoglobin to
transport O2there
Finally, and are
COwhite
2
. Red blood
blood cells
cells, areare
which made withindefense
the body’s red bone marrow
against thatThese
bacteria. is stimulated by
the kidney.
cells increase during bacterial infections. White blood cells are also attracted to inflammation.
The following are a few of the major specific functions of blood:

Finally, there are white blood cells, which are the body’s defense against bacteria. These cells
1. Blood
increase delivers
during oxygen infections.
bacterial and nutrientsWhite
from both the cells
blood lungsare
andalso
digestive track.to inflammation.
attracted
2. The blood oversees transporting metabolic waste products from cells to the lungs or kidneys
which will are
The following thenabe excreted
few of theasmajor
urine.specific functions of blood:
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3. Blood helps ©2023
maintain homeostasis by maintaining body temperature. This occurs as blood
1. Blood
bringsdelivers
heat fromoxygen andbody
inside the nutrients
towardsfrom both
the skin forthe lungs
better and digestive
dissipation into the track.
environment.
2. 4. The blood
Blood oversees
transports transporting
hormones metabolic
from organs wastedestination.
to the target products from cells to the lungs or kidneys
which will then be excreted as urine.
5. Blood helps maintain normal pH levels in body tissue by providing buffers to keep things
3. Blood helps too
from getting maintain
acidic. homeostasis by maintaining body temperature. This occurs as blood
brings heat from inside the body towards the skin for better dissipation into the environment.
6. Blood helps prevent blood loss from wounds by initiating clot formation.
4. Blood transports hormones from organs to the target destination.
5. Blood helps maintain normal pH levels in body tissue by providing buffers to keep things
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58
7. Blood helps prevent
Chapter 1 infection by delivering antibodies and white blood cells to infecte
6. Blood helps prevent blood loss from wounds by initiating clot formation.
tissue.
The Skeletal System
7. Blood helps prevent infection by delivering antibodies and white blood cells to infected tissue.
Blood Vessels Blood Vessels
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8.
There are three major types of blood vessels:
There are three major types of blood vessels:
• Arteries
• Arteries
• Capillaries
• Capillaries
• Veins
• Veins
As the heart contracts, it pumps blood into large arteries that leave the ventricles of th
3
59
Chapter 1
As the heart contracts, it pumps blood into large arteries that leave the ventricles of the heart.3 After
The Skeletal System

the blood leaves the main arteries, it is pumped into smaller arteries, which are called arterioles.
Arterioles then feed into the capillary beds, which are found in the organs and tissues.
Anna
Once D’Annunzio,
the oxygen and carbon MS dioxide exchange takes place, the blood travels to the venules.
Once the oxygen and carbon dioxide exchange takes place, the blood travels to the venules.
Venules are considered the smallest veins. As the blood travels toward the heart, it merges into
Venules are considered the smallest veins. As the blood travels toward the heart, it merges into
larger and larger veins. Once the deoxygenated blood meets the heart, it enters the atrium.
larger and larger veins. Once the deoxygenated blood meets the heart, it enters the atrium.
Every
Every artery andartery
veinand vein consist
consist of a tunica
of a tunica intima,
intima, whichisisthe
which the inner
inner layer
layerofof
thethe
vessel, tunica
vessel, tunica
media (found in the middle), and tunica externa (the outermost
media (found in the middle), and tunica externa (the outermost layer). layer).
One major structural difference between veins and arteries is that veins contain valves to
One major structural
prevent difference
Trainer Academy
the backflow
©2023 between
of blood into the veins
tissue and arteries isblood
and encourage that to
veins contain
travel towardvalves to prevent
the heart.
the backflow
Arteriesofdoblood into
not need the tissue
valves becauseand encourage
the pressure fromblood to travel
the heart toward
contraction the the
pushing heart.
bloodArteries
do not need valves
towards because
the organs and the pressure
tissues preventsfrom the heart contraction pushing the blood towards
any backblow.
the organs and tissues prevents any backblow.
Healthy arteries can handle the intense pressure of blood being pumped from the
heart. Arteries can develop issues because of lifestyle factors and genetics, which results in
Healthyplaque
arteries can handle
buildup the intense
and hardened arteries.pressure of blood
Also known being pumped
as atherosclerosis, from theofheart. Arteries
the hardening the
can develop issues
arteries posesbecause of lifestyle
serious health factors and
risks, including genetics,
stroke which results in plaque buildup and
and death.
hardened arteries. Also known as atherosclerosis, the hardening of the arteries poses serious
Some common causes of the start of atherosclerosis include blood-borne chemicals,
health risks, including stroke and death.
hypertension, bacterial infections, and smoking. Once the arterial wall is damaged, it forms a
fatty streak, which then turns into a fibrous plaque and then the plaque can become unstable.
Once the plaque becomes unstable it may rupture.
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Chapter 1
Some common causes of the start of atherosclerosis include blood-borne chemicals, hypertension,
The Skeletal System

bacterial infections, and smoking. Once the arterial wall is damaged, it forms a fatty streak, which
then turns into a fibrous plaque and then the plaque can become unstable. Once the plaque
becomes unstable it may rupture.
AtherosclerosisAtherosclerosis is especiallyfor
is especially problematic problematic for someone
someone with with hypertension.
hypertension. The hypertensive
The hypertensive pressure
beats on the plaque and can cause it to come loose from the wall. This commonly results in theresults
pressure beats on the plaque and can cause it to come loose from the wall. This commonly
formation in
of the formation
a blood of a blood clot. accounts
clot. Atherosclerosis Atherosclerosis
for aboutaccounts fordeaths
half the about in
half
thethedeveloped
deaths in world.
the
developed world.
Lungs
Lungs & Respiratory
& Respiratory Pump
Pump Structures
Structures
The respiratory system
The consists
respiratory of theconsists
system airways,
of lungs, and respiratory
the airways, lungs, andmuscles andmuscles
respiratory provides oxygen
and provides
to the body whiletoexpelling
oxygen carbon
the body while dioxide.
expelling The respiratory
carbon dioxide. Thesystem has system
respiratory four major functions:
has four major
providing functions:
pulmonaryproviding pulmonary
ventilation, externalventilation,
respiration,external respiration,
transport transport
of respiratory of respiratory
gasses, gasses,
and internal
and
respiration. 3 internal respiration. 3
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Pulmonary ventilation (breathing) is the process of air moving in and out of the lungs. Air is
Pulmonary ventilation (breathing) is the process of air moving in and out of the lungs. Air is
first drawn through the nostril down through the nasal cavity, then it travels to the pharynx. The
first drawn through the nostril down through the nasal cavity, then it travels to the pharynx. The
pharynx leads into the trachea, then the carina of trachea, which splits the airway and leads air to
pharynx leads into the trachea, then the carina of trachea, which splits the airway and leads air
the left and right bronchi.
to the left and right bronchi.
External respiration is the process of oxygen diffusing into the blood and carbon dioxide
External respirationinto
diffusing theprocess
is the lungs. Once oxygen
of oxygen diffusesinto
diffusing into the
the blood
blood, and
the cardiovascular
carbon dioxidesystem takes
diffusing
over toOnce
into the lungs. transport the oxygen
oxygen diffusesto into
the specific tissuethe
the blood, where it is needed. system takes over to
cardiovascular
transport the oxygen to the specific tissue where it is needed.
Lastly, internal respiration happens when oxygen diffuses from the blood to the tissue and
carbon dioxide diffuses from the tissue to the blood. The main anatomical structures that are part
of the respiratory system include the nose, the nasal cavity, the paranasal sinuses, the pharynx,
larynx, trachea, bronchi, and the alveoli.
61
Chapter 1
Lastly, internal respiration happens when oxygen diffuses from the blood to the tissue and carbon
The Skeletal System

dioxide diffuses from the tissue to the blood.The
TheCardiorespiratory
main anatomical System
structures that are part of the 62
respiratory system include the nose, the nasal cavity, the paranasal sinuses, the pharynx, larynx,
trachea, bronchi, and the alveoli.
The respiratory system is split into an upper and lower section. The lower respiratory system
The respiratory system is split into an upper and lower section. The lower respiratory system
starts at starts
the larynx and ends at the alveoli. The alveolar sac is where the capillaries line the sac
at the larynx and ends at the alveoli. The alveolar sac is where the capillaries line the sac to
to get blood as close
get blood as to thetoairthe
close as air
possible. The alveoli
as possible. are theare
The alveoli location in theinhuman
the location bodybody
the human where
where gas
gas exchange from the blood to the air takes place.
exchange from the blood to the air takes place.
Muscles of RespirationMuscles of Respiration

The diaphragm
Theisdiaphragm
one of theismain muscles
one of used
the main in inspiration.
muscles The diaphragm
used in inspiration. The has a natural
diaphragm cone
has a natural
shape. Inspiratory
cone shape. Inspiratory muscles called intercostals are located between the ribs which rib
muscles called intercostals are located between the ribs which help lift the help lift
cage andthe
lower the rib
rib cage andcage during
lower expiration.
the rib cage during expiration.
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During inspiration, the diaphragm is drawn downward, and the rib cage is drawn upward. As
During inspiration,
the thoracic the diaphragm
cavity is drawn the
volume increases, downward,
pressure and thetheriblungs
inside cagedecreases.
is drawn Airupward. As into
then flows
the thoracic cavitybecause
the lungs volumeof increases, the pressure
the pressure gradient.inside the lungs decreases. Air then flows into
the lungs because of the pressure gradient.
When someone breathes out, the inspiratory muscles lower the rib cage by relaxing, and the
diaphragm
When someone moves out,
breathes inferiorly. This reduces
the inspiratory the lung
muscles cavity
lower thevolume
rib cagewhich then raises
by relaxing, andthethe
inside
diaphragmlung pressure,
moves forcing
inferiorly. thereduces
This air out the
of the lungs,
lung through
cavity volumethe respiratory
which tract,the
then raises andinside
into the
lung
environment.
pressure, forcing the air out of the lungs, through the respiratory tract, and into the environment.

62
Chapter 1
Cardiorespiratory
The Skeletal System System Function
To initiate the entire process of delivering oxygen to the body, the diaphragm contracts and
Anna
moves D’Annunzio,
downward. MScreated by the diaphragm contraction also increases the lung
The extra space
capacity.
This increase in capacity decreases the pleural pressure in the lung. Because air moves from high
pressure to low pressure, air from the environment moves into the lungs. Air then passes through
the nostril, enters the nasal cavity, and gets passed down the pharynx, through the larynx and
then into the trachea. Once through the trachea, the air is passed into the right and left lungs
by the bronchi and bronchioles.
The air ultimately ends up in the alveoli, which are terminal branches of the lung with thin
membranes separating the air from blood in the capillary bed of the lungs. The alveoli are grouped
into alveolar sacs, and capillaries wrap around each alveolus.
Oxygen from the air then diffuses across the membrane and into the blood, while carbon dioxide
diffuses into the lungs to be exhaled.
Air passes into the bronchioles, which end in a terminal bronchial and a respiratory bronchial.
Air passes into the alveolar duct, which fills the alveoli. A group of alveoli is called an alveolar
sac. This is where the capillaries are wrapped around each alveolus.
The oxygen has been extracted from the air and diffuses across the membrane onto a red blood
cell. Once the red blood cell leaves the capillary beds of the lungs, it travels through pulmonary
veins which then leads into the left atrium.
Note that pulmonary veins contain oxygenated blood which flows into the left atrium, unlike
normal veins which take deoxygenated blood from the body into the right atrium.
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Once in the left atrium, the blood travels through the mitral (bicuspid) valve. It flows to the left
ventricle and then when the heart contracts the blood is pushed through the aortic valve which
leads to the aorta.
The aorta and other supporting arteries are considered elastic arteries or conducting arteries. The
elastic arteries then flow into muscular arteries or distributing arteries. Once in the muscular
arteries, the blood then flows into the arterioles.

63
Chapter 1
Arterioles are the smallest artery branch. The blood moves through the arterioles into the capillaries,
The Skeletal System

which are arranged in capillary beds.
Capillaries are very thin and in some cases one endothelial cell makes up the circumference of the
Annawall.
capillary D’Annunzio,
This is where theMSred blood cell delivers its oxygen because of the oxygen gradient
across the cell membrane.
Red blood cells have a natural affinity for carbon dioxide, which gets loaded onto the red blood
cell to replace the oxygen, with some carbon dioxide dissolving directly into the blood. The blood
then carries red blood cells heads from the capillaries to the venules when leaving the tissue.
Venules form veins that get larger as they get closer to the heart. Veins do not have as much
smooth muscle as arteries therefore veins rely more on pressure gradient.1
Once the deoxygenated blood reaches the heart it enters through the superior vena cava or the
inferior vena cava. The superior vena cava collects all the deoxygenated blood from the upper
body. The inferior vena cava collects all the deoxygenated blood from the lower half of the body.
The blood flows into the right atrium and then through the tricuspid valve which brings the
blood into the right ventricle. Once the blood is in the right ventricle it is then pumped through
the pulmonary valve which then enters the left pulmonary artery and the right pulmonary artery.
The pulmonary arteries head back to the lungs where carbon dioxide is exchanged with oxygen
via the alveoli to start the cycle again.
Cardiorespiratory System Responses to

Exercise
As stated above the SA node and AV node can initiate the electrical impulse and thereby cause
the heart to beat. All of this keeps the heart beating at a consistent rate. The sympathetic and
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parasympathetic nervous system as well as a few hormones can speed up or slow down the
heart rate.1
The sympathetic nervous system stimulates the release of catecholamines: epinephrine and
norepinephrine. These act to increase SA node activity which will increase heart rate.
The parasympathetic nervous system stimulates the vagus nerve which releases acetylcholine.
This is a hormone that has a depressing effect on the SA node, which decreases its firing activity.

64
Chapter 1
With a decreased firing activity this will decrease the heart rate. A decreased heart rate is known
The Skeletal System

as bradycardia. An increase in heart rate is known as tachycardia.
Typically, high performing athletes have a low resting heart rate. In the clinical sense, when a
Anna
patient has D’Annunzio, MS
a low heart rate it can be an indication of some sort of cardiac problem.1 In a healthy
athlete a low resting heart rate can indicate increased levels of efficiency on the heart, nervous
system, and lungs.
Acute Responses to Exercise

During acute bouts of exercise oxygen consumption (V̇O2) increases to meet the high demands of
working muscle and other tissues.1 As exercise intensity increases there will be a greater demand
for energy and therefore a greater demand for oxygen.
As mentioned above, cardiac output is the product of heart rate and stroke volume. To meet the
demands of an acute exercise bout, the body must increase cardiac output. During the early stage
of exercise, heart rate and stroke volume will increase to increase cardiac output. In this state,
most of the circulating blood is diverted from things like digestion to working muscles where
it’s needed most in that moment.
Chronic Adaptations to Exercise

If an individual stays compliant with an exercise program for a long period of time they
may experience long-term adaptations to the cardiorespiratory system. With a prolonged
cardiorespiratory exercise program, adaptations include increased stroke volume, higher cardiac
output, a decrease in systolic and diastolic blood pressure, and an increase in left ventricular
muscle mass.1
It should be noted that the respiratory system is not usually a major limiting factor in increasing
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exercise efficiency. This is because, in general, lung capacity changes very little from exercise.
Long term endurance training tends to simulate hypervolemia. This is where the body increases
blood volume to help the cardiorespiratory system become more efficient by being able to supply
more oxygen. Most of the blood volume increase comes from plasma and very little comes from
red blood cells.
Improvements to V̇O2 max occur with prolonged aerobic training and reflect improvements in

the ability of the heart to pump blood and the ability of the muscles to use the oxygen provided.

65
Chapter 1
Environmental Factors Affecting CRS
The Skeletal System
Severe environmental conditions can cause the cardiorespiratory system to work harder to meet
theAnna D’Annunzio,
body’s oxygen MS in the heat causes the body to shuttle more blood to the
demands. Exercising
skin to help dissipate body heat.
This is typically shown when someone gets hot, they end up turning a shade of pink or red. As blood
flow to the skin is increased, vasculature can become engorged and cause blood pooling.2 Blood
pooling reduces the venous return and can pause the cardiovascular system in order to work
harder in filling the heart.
Dehydration caused by extreme heat can result in a decreased amount of plasma volume. This
means less blood is available for working muscles and to maintain normal body functions. The
body copes with this by increasing the heart rate which may not be enough to maintain cardiac
output.
Exercising in a cold environment can cause heat loss during exercise. Long duration of exercise in
the cold can increase the risk of hypothermia. This is especially true when core body temperature
lowers.
To counteract this, the body tries to create heat by shivering and through the vasoconstriction of
blood vessels in the skin. The respiratory rate is usually higher and maximal oxygen consumption
may be slightly lower.
Altitude is another factor that can affect the cardiorespiratory system.
When someone increases their elevation the pressure of oxygen becomes reduced.2 This makes it
harder for oxygen to diffuse into the tissue because of the lack of pressure gradient. To compensate
for this, breathing rate is usually increased with altitude.
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66
Chapter 1
Summary
The Skeletal System
The cardiorespiratory system contains the pulmonary system and the cardiovascular system. The
Anna D’Annunzio,
pulmonary system contains theMSlungs and airways and is responsible for providing oxygen to the
body while expelling carbon dioxide. It also provides ventilation, respiration and exchange of gases.
The cardiovascular system contains the heart, blood vessels, and blood. The heart pumps blood
throughout the body, which helps to deliver nutrients and oxygen and to remove waste alongside
many other functions.
During exercise the consumption of oxygen increases to meet the energy needs of the body
and cardiac output goes up. Regular cardiovascular training will increase V̇O2 max, because of
improved performance in cardiorespiratory efficiency.
Fitness professional should also be aware that environmental factors can impact the cardiorespiratory
system, like dehydration and altitude, and prepare accordingly with monitoring fluid intakes or
modulating exercise intensity to ensure sessions are safe and productive.
References
1. Chandler TJ, Brown L. Conditioning for Strength, and Human Performance. Routledge; 2019.
2. Magyari P. ACSM’s Resources for the Exercise Physiologist: A Practical Guide for the Health Fitness
Professional. Philadelphia: Wolters Kluwer; 2018.
3. Marieb EN, Hoehn K. Human Anatomy & Physiology. Pearson; 2016.
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Chapter 1
TheCHAPTER
Skeletal5System
Anna
TheD’Annunzio,
Endocrine MS System
Kira Spreenberg-Bronsoms, MS
68 The Endocrine System 69
T he Endocrine Syst em
Chapter 1
Introduction
The to the Endocrine System
Skeletal System
Introduction to the Endocrine System
The endocrine system plays a key role in exercise in both acute responses and long-term adaptations.
Anna
This systemD’Annunzio,
consists of hormones, MSthe glands that produce them, and the receptors in the body
The endocrine
that respond to hormones. system
Fitness plays a key role
professionals mustinhave
exercise in both
a basic acute responses
knowledge and long-term
of the endocrine
system given adaptations. Thistosystem
its importance consists
exercise of hormones,
science theunderstanding
for properly glands that produce them, and thethat
the adaptations receptors in
the body
occur in the body that respond
in response to hormones. Fitness professionals must have a basic knowledge of the
to exercise.
endocrine system given its importance to exercise science for properly understanding the
adaptations that occur in the body in response to exercise.
The endocrine system is a three-part system composed of endocrine glands, hormones, and
receptors. Glands are scattered
The throughout
endocrine system is athe body and
three-part in specialized
system composed of brain areas. glands,
endocrine The cells in
hormones,
these glands carry out functions
and receptors. Glandsby
aresecreting
scatteredspecific chemicals
throughout the bodycalled
and inhormones.
1,2
specialized brain areas. The cells
in these glands carry out functions by secreting specific chemicals called hormones. 1,2
Hormones are chemical messengers released in the blood that causes a change in the target cell
when binding to Hormones areReceptors are
receptors.1,2 chemical messengers
dockingreleased
1,2
in the
molecules blood
in the that cell
target causes
thata change in the target
get activated
cell when binding to receptors. Receptors are docking molecules in the target cell that get
when a hormone binds to it, triggering a cascade of biochemical reactions that eventually modify
activated when a 1,2
hormone binds to it, triggering a cascade of biochemical reactions that
the cell’s function or activity. 1,2
eventually modify the cell’s function or activity.
For the body to For

function,
the bodyit to
requires interdependent
function, communication
it requires interdependent and close
communication andcoordination
close coordination
between all seven systems
between in the
all seven human
systems body.
in the The endocrine
human system evolved
body. The endocrine systemasevolved
a mechanism to
as a mechanism to
communicatecommunicate
and regulateand
signals within
regulate thewithin
signals body. the body.
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Trainer Academy
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69
The Endocrine System T he Endocrine Syst
70 em
Chapter 1
The endocrine system is a complex network of glands, hormones, and receptors that works
The Skeletal System

harmoniously with the nervous system to control and coordinate energy, reproduction, growth,
The endocrine system is a complex network of glands, hormones, and receptors that works
immunity, and behavior.1 To ensure that a constant internal environment (i.e., homeostasis) is
harmoniously with the nervous system to control and coordinate energy, reproduction, growth,
maintained, theand
nervous system allowsthatrapid transmission of information from the brain to the
immunity, behavior.1
To ensure a constant internal environment (i.e., homeostasis) is
nervesmaintained,
in the body. 1,2
the nervous system allows rapid transmission of information from the brain to the
nerves in the body.1,2
Conversely, the endocrine system relies on producing and releasing hormones from various glands
Conversely, the endocrine system relies on producing1,2and releasing hormones from various
and transporting those hormones via the bloodstream. Thus, the two communication systems
glands and transporting those hormones via the bloodstream. 1,2 Thus, the two communication
work systems
in tandem
worktoincomplement each other.
tandem to complement each other.
Major Endocrine
Major Endocrine GlandsGlands and
and Hormones
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Hormones
©2023
Most hormones are produced by endocrine glands. In response to a stimulus, hormones are
released from the gland directly into the bloodstream until they reach the target organ.2 An
example Most hormonesendocrine
of a classical are producedgland
by endocrine glands. Ingland,
is the thyroid response to a stimulus,
which functionshormones are
to synthesize and
released from the gland directly into the
release thyroid hormones into the bloodstream. bloodstream
2 until they reach the target organ. 2
An
example of a classical endocrine gland is the thyroid gland, which functions to synthesize and
release thyroid hormones into the bloodstream.2
On the contrary, exocrine glands release hormones through a duct or opening to a body
surface.3 Examples of exocrine glands include sweat glands, lacrimal glands, salivary glands,
mammary glands, and digestive glands in the stomach,
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pancreas, and intestines.3

70 On the contrary, exocrine glands release hormones through a duct or opening to a body
surface.3 Examples of exocrine glands include sweat glands, lacrimal glands, salivary glands,
Chapter
mammary glands, 1
and digestive glands in the stomach, pancreas, and intestines. 3
The following table shows the major endocrine glands and the hormones they secrete:
The Skeletal System

The following table shows the major endocrine glands and the hormones they secrete:
Functions
Functions of of
thethe Hormones
Hormones in thein the
Human BodyHuman Body
Hormone Regulation
Hormone Regulation
Maintaining a stable physiological equilibrium (homeostasis) requires tight control of hormone
Maintainingand
production a stable physiological
regulation. Hormone equilibrium
regulation(homeostasis)
begins in therequires tight control
hypothalamus, theofmaster
hormone production
switchboard gland and regulation. Hormone regulation begins in the hypothalamus, the2 master
©2023that sits at the base of the brain and is about the size of an almond. Below
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2
switchboard gland that
the hypothalamus sitssits
theatpituitary
the basegland
of the brainresponds
which and is about
to thethe size of an
commands of almond. Below the
the hypothalamus. 2
hypothalamus sits the pituitary gland which responds to the commands of the hypothalamus.2
When the endocrine system perceives stimuli, it regulates hormones through a negative feedback
WhenWhen
loop. the endocrine
an endocrine system
glandperceives stimuli,
senses high it regulates
concentrations hormones
of one hormone through a negative
in the body, it changes
feedback loop.the
to decrease When an endocrine
production of thatgland sensesand
hormone high concentrations
bring of one hormone
a stable equilibrium in the This
in the system. body,
it changes
three-wayto decrease
communication the production
method of that in
begins hormone and bring a followed
the hypothalamus, stable equilibrium in thegland
by the pituitary
system.
until This three-way
it reaches the targetcommunication
organ.2 method begins in the hypothalamus, followed by the
pituitary gland until it reaches the target organ.2

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71
Chapter 1
When the circulating hormones have reached the target cells and levels are sufficiently high, the
The Skeletal System

hypothalamus and pituitary gland cease release, thereby turning off the cascade.2 In some cases,
the sensitivity of the feedback systems alters based on physiological states or stages of life.
ForAnna
example,D’Annunzio, MSthe concentration of growth and sex hormones is the highest
in fetal development,
and culminates in adulthood when the sexual glands have acquired total reproductive capacity.4 On
the contrary, positive hormonal feedback is possible in the case of ovulation in the menstrual cycle.
Behavior Regulation
Hormones play an important role in influencing the nervous system. Over time, they have
evolved to influence body systems in paths that elicit the appropriate behavior or social cue. In
all mammals, the interacting components of the behavioral system include:
1. Inputs (sensory systems)

2. Integrators (central nervous system)
3. Outputs (tissues and organs)
Because endocrine glands produce hormones that can enter target cells and change gene expression,
specific behaviors can occur in the presence of signals, stimuli, and receptor interactions.2
For example, estrogens, the female hormones associated with reproduction, growth, and onset
of puberty, show similarities with the regulation of female sexual behaviors. Interestingly, the
reciprocal relation can occur where behavior affects hormone concentrations. For example, high
testosterone concentrations are associated with aggression, while cortisol and serotonin act
antagonistically to reduce the effects of testosterone.5
As previously discussed, the hypothalamus is the primary center for communication between
the nervous and endocrine systems. One way hormones regulate mood and behavior is through
the hypothalamus-pituitary-adrenal
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©2023 axis (HPA-axis).2 For example, HPA axis overstimulation
and chronically high cortisol levels are associated with depression, anxiety, mood swings, and
irritability.6
Another way the brain can regulate emotions is by releasing certain chemicals called neurotransmitters.
Neurons release neurotransmitters to communicate between different brain areas and influence
human moods, emotions, and behavior.7 Four main chemicals are associated with behavior
regulation, including serotonin, dopamine, adrenaline, and oxytocin.

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1. Serotonin is the neurotransmitter responsible for pleasure, happiness, and stability.7
The Skeletal System

2. Dopamine is the neurotransmitter responsible for reward, joy, and happiness.7
3. Norepinephrine is the neurotransmitter responsible for fear and anger emotions that trigger
a “fight or flight” response.7
4. Anna D’Annunzio,
Oxytocin is MS responsible for love and attachment.8
the neurotransmitter
Sex-Related Differences
Humans, like most animals and plants, present with one obvious anatomical difference, the
existence of two biological sexes. According to biologists, sex is the trait that differentiates males
or females based on reproductive and sexual organs, chromosomes (XX for female and XY for
male), gene expression, hormone levels, and physiological features.9 Gender refers to the range
of socially constructed roles, behaviors, expressions, and identities used to categorize male and
female differences.9
Reproductive Organs
The reason why two distinct sexes, males, and females, are commonly necessary for life to reproduce
is one of the oldest biological enigmas. One prominent theory is that sex evolved to produce
variation, an adaptative trait that gives organisms an advantage in changing environments.10
The main distinction between males and females is the way DNA is packaged into the sex cells
that make new organisms, called gametes.2 The female sex is capable of producing large gametes
(ovules), whereas the male sex produces small gametes (spermatozoa).2
Gonads and Sex Hormones
The second characteristic differentiating males and females are the presence of endocrine glands
and sex hormones. First, gonads are specialized reproductive glands that produce germ cells.2 The
ovaries are theTrainer
female
Academy
©2023 gonads that produce ova, and the testes are the male gonads that produce
spermatozoa. Second, sex hormones synthesized by gonads play an important role in physiological
2
distinctions between males and females.2
While males and females generally have the same hormones (i.e., estrogens, progesterone, and
testosterone), their production sites, blood concentrations, and interactions with different organs
are different.11 Males predominantly produce testosterone and lesser amounts of estrogen and
progesterone.2 Female ovaries mainly synthesize estrogen and progesterone and produce lesser
amounts of testosterone.2

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In the last decade, medical advancements have broadened the understanding of the influence
The Skeletal System

gender has on both human physiology and the pathogenesis of diseases. The most common
anatomic-physiological difference between male and female athletes is that males commonly
present with stronger bones, greater muscle mass and strength, and greater aerobic capacity.
In contrast, females exhibit less muscle fatigue and faster recovery during endurance
exercise.12 Beyond that, conditions such as thyroid disease, diabetes mellitus, osteoporosis, obesity,
and sarcopenia show sex-specific patterns in disease prevalence, pathogenesis, outcomes, adverse
events, and responses to medical treatment.13 Thus, when working with individuals with medical
conditions, it is crucial to tailor exercises considering sex and gender in every disease element,
from the causes to the treatment.
Hormones and Exercise

Several environmental stressors affect an organism’s biology and endocrine system. Engaging in
strenuous forms of exercise and training for sports competitions are examples of situations that
trigger a stress response in the body and impact hormone homeostasis. This section will focus on
understanding the role testosterone, estrogen, GH, insulin, glucagon, catecholamines, cortisol,
and thyroid hormones play in response to exercise.
Testosterone
Testosterone (T) is the main androgenic steroid hormone, abundantly produced in the testes
and in lesser amounts in the ovaries and adrenal cortex.2 As an androgen, its primary role is to
stimulate the development of male characteristics.2 The specific functions of testosterone vary
during different developmental stages.
For example, Trainer

during
©2023 fetal development, testosterone is most elevated to support the growth of
Academy
male genitalia.2,14 Until then, males and females have similar amounts of testosterone production.
However, during puberty, there is an approximately 30-fold increase in testosterone production in

males, resulting in changes in mood and behavior, and anatomical traits such as height, deepening of
the voice, growth of facial, pubic, axillary, and body hair; and increase in muscularity and strength.2, 15
As a result of this higher testosterone production, boys gain considerably more lean body mass
than girls.16 In adult life, testosterone maintains libido and regulates sperm production.2

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Chapter 1
In addition, testosterone plays an essential role in regulating muscle protein synthesis and muscle
The Skeletal System

hypertrophy. New research suggests that chronic increases in testosterone levels can significantly
increase hypertrophy and strength, whereas decreases in basal testosterone levels result in the
opposite effect.17
For both sexes, the typical pattern of testosterone release commonly follows a diurnal rhythm,
with peak concentrations in the morning and a progressive decline over the day.18 In women,
testosterone concentrations can also fluctuate as a function of the menstrual cycle.19
Estrogen
Estrogen (E) is a steroid hormone that virtually exists in the body as estradiol and is associated
with the female reproductive organs.2 In females, estrogen is mainly produced in ovarian androgens,
whereas in males, testes produce only 20% of circulating estrogens, with the rest deriving from
peripheral organs like adipose, brain, skin, and bone, which convert testosterone to estrogen.20
The main function of estrogen is to coordinate the normal development and functioning of the
female genitalia and breasts.2 Serum estrogen concentrations are highest during female pregnancy
than during the rest of the female life cycle. In practice, estrogen is a reliable indicator for assessing
fetus injury and early prevention of chronic placental insufficiency.21
During puberty, estrogen concentrations increase to stimulate the growth of the uterus, breast,
and vagina; coordinate fat deposition and distribution in the body; regulate the pubertal growth
spurt and cessation of growth at adult height, and control the development of secondary sexual
characteristics.2 In adult women, estrogen controls the menstrual cycle, pregnancy, and lactation
and maintains female libido.2
Later in life, the ovaries will stop producing estrogen (i.e., menopause) and are accompanied by
symptoms such as changes in monthly cycles, hot flashes, sweating, heart palpitation, increased
irritability, anxiety,
©2023depression, and brittle bones (i.e., osteoporosis).
Trainer Academy 2
While the effects of aging on women are associated with several negative outcomes, including
a decline in sex hormone production, an increase in injuries, and muscle wasting, estrogen is
known to have a protective effect on musculoskeletal function.
There is evidence to suggest that estrogen stimulates muscle repair and the regenerative processes
by improving the structure and function of musculoskeletal tissues like muscles, tendons, and
ligaments, increasing muscle mass, strength, and collagen content.22

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In turn, these effects influence muscle contractile properties and aid in post-exercise muscle
The Skeletal System

damage.22 During exercise women generally exhibit a greater increase in serum concentrations
of estrogen than males.23
AsAnna D’Annunzio,
a result, female MS
athletes that permanently show low levels of female sex hormones, accompanied
by menstrual cycle perturbations, are more prone to stress fractures and ligament injuries.24,25,26
Growth Hormone
Growth Hormone (GH) is the most abundant hormone produced by the pituitary gland.2 As
the name implies, GH regulates the growth and development of reproductive organs, adipose
tissue, connective tissue, endocrine glands, muscle, and bones.2
The specific functions of growth hormones vary during different life stages of development. GH
levels peak in early childhood to support tissue growth and decline afterward.2
Nevertheless, GH production in adult life is still important as its commonly associated with
symptoms of aging.2 In addition, GH gets released by stress, low blood sugar levels (i.e.,
hypoglycemia), strenuous exercise, and deep sleep.
Ultimately, GH plays an important role in macronutrient metabolism as seen below:
• Glucose: GH lowers uptake by muscle cells, raising glucose levels in the blood and promoting
glucose production from non-glucose molecules (i.e., gluconeogenesis) in the liver.2
• Amino acids: GH enhances the uptake of amino acids from the blood into cells and incorporates
them into proteins.2
• Fat: GH stimulates the breakdown of lipids (i.e., lipolysis) and lipid oxidation in adipose
tissue, suppresses glucose uptake, and consequently increases plasma glucose.2,23
GH is involved in development and maturation and is associated with skeletal muscle growth
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and function. Some research findings suggest that the anabolic action of GH is mediated by
circulating insulin-like growth factor 1 (IGF-1) that comes from the liver and inhibits protein
breakdown.27
Another way is by enhancing muscular and extra-muscular sites and increasing muscle mass
without affecting contraction or muscle fiber composition.27 However, the literature on growth
hormones contributing to tissue growth and strength remains controversial.

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Additionally, there is a lack of consensus regarding sex-related differences in growth hormone
The Skeletal System

response to exercise. So far, most research studies report similar results between both sexes in
which men and women experience an increase in growth hormone levels in response to exercise.27
TheAnna D’Annunzio,
only difference MS
has been seen in the duration of GH release.23 For example, females experience
GH peaks sooner than males, whereas men sustain longer responses.23 The attributable factors to
this response are the lack of testosterone in women and the compensatory mechanism of having
higher concentrations of resting basal level of GH and estradiol.23 Ultimately, the sex differences
in growth hormone response to exercise immediately impact blood glucose control.23
Insulin
Insulin is one of the main hormones produced in the pancreas and the only blood-lowering
hormone in the body.2 It is in the beta cell of the Islets of Langerhan and is released to lower
blood glucose levels after ingestion. Insulin plays an important role in all storage forms of energy
and works on target organs specializing in energy storage, such as the liver, muscles, and adipose
tissue as described below:
• Glucose: Insulin stimulates glucose uptake into cells, glucose breakdown, and inhibits
gluconeogenesis.2
• Protein: Insulin promotes amino acid transport and protein synthesis in muscle cells, and
inhibits gluconeogenesis in the muscles.2
• Fat: insulin increases fat synthesis in the liver and adipose tissue, and inhibits glycerol
breakdown which also can serve as a starting material for gluconeogenesis.2
Insulin release is regulated by various factors including eating patterns, and hormones such as
GH, glucocorticoids, and thyroid hormones.2 The influence of exercise on insulin has long been
studied as an example of favorable adaptive change from two opposing metabolic regulatory
forces. While insulin is an anabolic hormone that is secreted to increase glucose and fat storage
after eating, exercise
©2023 is a condition that suppresses and oxidizes the fuel storage effects of insulin.
Trainer Academy 28
During exercise, serum insulin concentrations decrease by inhibiting the release of insulin from
the pancreas.28 In turn, glucose uptake from glycogen reserves stored in muscles and the liver
increases and produces ATP to fuel contracting muscles.29 As a result, blood sugar levels decrease
up to 24 hours or more after a workout resulting in higher sensitivity to insulin.30
As an anabolic hormone, insulin stimulates the cellular pathway that regulates muscle growth.
For example, patients with uncontrolled diabetes and type 2 diabetes are known to have a relative

77
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deficiency of muscle mass and quality, presumably due to insulin resistance.31 In one study, insulin
The Skeletal System

administration in diabetic patients induced the expression of two muscle growth factors: MyoD,
and myogenin.32 However, most studies showing positive associations are only seen in animal
studies, and whether it directly stimulates muscle protein synthesis in humans remains unclear. 28
Insulin response to exercise is also highly sensitive to sex differences. Males preferentially use
glucose as primary fuel during exercise, whereas females use fat as the major energy source.31 One
suspected explanation for this theory is that women are more efficient at conserving energy and
storing fat, based on body fat mass and other anatomical characteristics.33
Ultimately, engaging in physical activity stabilizes blood glucose levels during and after the
training session, supporting the evidence that exercise improves insulin resistance in individuals
with Type 2 diabetes.
Glucagon
Glucagon is the second most prominent blood glucose-regulating hormone in the body. Produced
in the alpha cells of the Islets of Langerhans in the pancreas, glucagon works to counterbalance
the actions of insulin.2 Its main role is to raise blood glucose levels during fasting, exercise, and
hypoglycemia conditions and oppose the effects of insulin mainly in the liver as shown below:
• Glucose: Glucagon promotes glycogen breakdown and formation of glucose from non-
glucogenic sources through the gluconeogenesis pathway in the liver.2
• Protein: Glucagon increases amino acid catabolism in the liver, uptake of amino acids by
skeletal muscle, and increased excretion of free amino acids.2
• Fat: Glucagon stimulates the fat breakdown of triglycerides into fatty acids and glycerides
for energy utilization which also can serve as a starting material for gluconeogenesis.2
As a catabolic hormone, glucagon’s role is to suppress skeletal muscle protein synthesis, irrespective
of sex differences. During exercise, glucagon stimulates the liver to break down glycogen. Then,
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new glucose production from non-glucogenic precursors increases blood glucose, leading to
hyperglycemia.34
However, arterial glucagon during exercise is incrementally delayed and dampened compared
to the increase in glucose released from the liver.34 Depending on the duration and intensity
of exercise, arterial glucagon may not increase.34 As energy demands from the muscle increase,
glucose is released from the muscle in a glucagon-dependent manner.34

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Chapter 1
Catecholamines
The Skeletal System
Catecholamines are physiologically active compounds that act both as neurotransmitters and
Anna 35D’Annunzio,
hormones. The adrenal glandsMS are responsible for releasing dopamine, norepinephrine, and
epinephrine (adrenaline) in response to physical or emotional stress. This is also known as the
body’s “fight-or-flight” response.35
The significance of circulating catecholamines and their possible roles at birth is used to support
neonatal adaptation.36 During early development and birth, plasma catecholamine concentrations
are remarkably higher than those in adult life, primarily to maintain glucose supply to the heart
and brain and to prepare the lung for ventilation.36
Regarding sex differences in catecholamine levels, young females exhibit a lower adreno-
sympathetic maturity than males. However, both sexes reach full maturity of the adrenergic
sites near the fifth year of age.37 In adult life, women tend to secrete and clear epinephrine out
of the body at lower levels than men. Nevertheless, this change is not dependent on adrenergic
maturity but rather is from the increased rate of catecholamine removal.37
Exercise increases catecholamine concentrations in athletes, specifically adrenaline and noradrenaline

in a sex-dependent manner.38 One study found that men’s epinephrine and norepinephrine levels
were higher throughout the training period than those of women.38
This occurs by stimulating hepatic glycogenolysis and gluconeogenesis, increasing blood glucose
levels during activity, and potentially decreasing glucose levels post-exercise when glycogen stores
are being replenished.23
Therefore, the catecholamine spike seen in men who exercise could have resulted in a higher
mobilization and utilization of muscle glycogen. Ultimately, studies on women remain scarce
and the effects of exercise on catecholamine response remain to be specified.
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Cortisol
Cortisol, also known as the stress hormone, is a steroid hormone synthesized from cholesterol
by the adrenal cortex and regulated by the hypothalamus-pituitary-adrenal (HPA) axis.39
As one of the principal glucocorticoids released from the adrenals, cortisol has many functions
in the body and can affect nearly every organ system. The primary functions of cortisol include

79
Chapter 1
mediating the stress response, regulating carbohydrate, protein, and lipid metabolism, inflammatory
The Skeletal System

response, and immune function.39
Cortisol is a hormone secreted to regulate the 24-hour cycles of the body’s internal clock, also known
Anna D’Annunzio,
as circadian MS is lowest during the early night, increases several hours before
rhythms.40 The secretion
awakening, and peaks in the morning within 30–45 min after awakening.40 In addition, the cortisol
awakening response (CAR) is a separate process that works in harmony with the body’s circadian
rhythms, and it’s associated with the anticipation of stressors for the upcoming day.40
Like other endocrine hormones, cortisol levels play a role in the stages of growth and development.
During pregnancy, maternal cortisol levels increase by two to four times to support neural
development and fetal growth.41,42 Throughout puberty and adolescence, cortisol concentrations
increase significantly to function as a synchronizer for the entire circadian system.43 Additionally,
cortisol production stabilizes between ages 20 to 60 and progressively increases after 60 years.44
Cortisol is released during a “fight or flight” response to optimize bodily functions and improve
alertness in physically or psychologically demanding events. First, it mobilizes energy by releasing
glucose from its storage sites and raising blood glucose levels.39 Second, glucose uptake decreases in the
muscle and adipose tissue and increases glycogenesis and gluconeogenesis in the liver. This effect results
in muscle growth inhibition.39 In adipose tissues, cortisol increases lipolysis. Lipolysis is a catabolic
process that releases glycerol and free fatty acids.40 Lastly, cortisol facilitates the pancreas to decrease
insulin and increase glucagon and enhances the activity of epinephrine, and other catecholamines.39
It’s theorized that repeated exercise can habituate or sensitize the physiologic stress system or
HPA axis.45 While most studies show that exercise intensity correlates with cortisol release
above resting levels, high cortisol levels can inhibit protein synthesis resulting in skeletal muscle
protein breakdown.46
However, serum cortisol levels decrease shortly after exercise and suppress cortisol release at night,
subsequently diminishing cortisol responses to psychosocial stressors.45 Ultimately, continuously
engaging in physical
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©2023 activity mediates the stress response and endorphin release resulting in
feelings of relaxation and mood improvement.
Thyroid Hormone
The thyroid hormone is composed of two structurally related hormones produced by the thyroid
gland: thyroxine (T4) and triiodothyronine (T3). Thyroid hormones increase the metabolism of
almost all body tissues.2

80
Chapter 1
This includes heat regulation, energy metabolism, growth and maturation, and development of the
The Skeletal System

central nervous system, tissues, and bones.2 Ultimately, the thyroid gland is virtually responsible for
maintaining and regulating all body systems required for life, including the nervous, cardiovascular,
and gastrointestinal systems.
As the regulator of several systems, the thyroid hormone significantly contributes to the body’s energy
metabolism in skeletal muscle functioning. First, thyroid hormones increase the basal metabolic rate
and favor metabolic reactions such as lipid and carbohydrate breakdown and anabolism of proteins.2
Second, thyroid hormones regulate changes in the demand and synthesis of ATP in the skeletal
muscle.47 Third, thyroid hormones act on several gene targets that result in the expression of genes
responsible for fast-twitch fibers, muscle development, homeostasis, and regeneration.47 Finally,
thyroid hormone availability influences contractile and relaxation reflexes of the skeletal muscle.47
The influence of exercise on thyroid function increases the release of thyrotropin-releasing hormone
(TRH) that stimulates the secretion of TSH in the pituitary gland. While basal metabolic rate
increases with exercise and provides several benefits in different body systems, strenuous exercise
may be associated with transient alterations in thyroid hormones.48
For example, an underactive thyroid (hypothyroidism) reduces cardiopulmonary function, fatigue,

muscle stiffness, and exercise intolerance.47 In contrast, hyperthyroidism caused by increased thyroid
gland function manifests as weight loss, heat intolerance, diarrhea, fine tremor, and muscle weakness.47
Interestingly, thyroid diseases affect individuals in a sex-dependent manner, with a prevalence

approximately ten times higher in women than men.49 For athletes, these symptoms can negatively
impact their ability to effectively train, compete, and recover. For example, a side effect of
overtraining in female athletes is secondary amenorrhea which can lead to thyroid dysfunction.49
In addition, athletes with low growth hormone, cortisol, and thyroid-stimulating hormone levels
are at risk for diminished tissue growth, repair, and other neuromuscular disorders.47 Nevertheless,
consistency inTrainer
training
Academy
©2023 is not associated with thyroid function improvement among individuals
with thyroid disorders.
While there is a decrease in serum concentrations of TSH, T3, and T4 in periods of increased
physical activity, these changes are minor and have the potential for physiologic adaptation.48
Therefore, individuals with thyroid alterations should seek advice and pharmacological treatment
from a medical professional and pursue exercise training as a lifestyle modification rather than
treatment.

81
Chapter 1
Acute
The and Chronic
Skeletal System Adaptations to Exercise
Acute responses are those that occur immediately after training and in the subsequent hours and
Anna
days. These D’Annunzio, MS
effects may dissipate relatively quickly.
Chronic responses involve long term changes associated with resistance training. These changes
are more long lasting, although inactivity can result in reversal.
As previously seen, hormonal adaptations naturally result from engaging in physical activity. This
section will examine the acute and chronic responses of the endocrine system from various forms of
exercise, taking a closer look at the effects of modality, duration, and intensity of a training session.
Testosterone
Testosterone concentrations are positively associated with exercise modality and duration. Total
testosterone concentrations acutely increase in most men and young women during a training
session, while no changes appear in middle-aged and elderly women.50
While this mobilization of testosterone is brief, the effects of testosterone can last from 15 minutes
to several hours and support favorable adaptive responses to muscle gain.17 Interestingly, the acute
elevation is higher in resistance-trained men than in endurance-trained men.50
Additionally, one study assessing weight distribution found that testosterone and muscle strength are
higher if lower-body exercises are performed before upper-body training.51 Ultimately, moderate-
load, high-volume training with short rest periods produces a more significant testosterone
response than high-load, low-volume training with long rest periods.51
Chronic testosterone changes during and post-resistance training have been inconsistent in the
literature on both men and women. While some studies have demonstrated a chronic increase
in basal testosterone,
©2023 others have failed to find an adaptation to regular resistance exercise.
Trainer Academy 50
For example, significant elevations have been reported in pubertal boys, whereas no difference
exists in resting concentrations between untrained and elite athlete females.50
On the contrary, most reports show that resting concentrations of testosterone decrease when
there are reductions in volume and intensity of the training period, leading to the speculation that
perhaps higher volumes are needed to alter resting levels of testosterone.50 Ultimately, chronic
adaptations from resistance training are associated with increases in lean mass and strength.

82
Chapter 1
Growth Hormone
The Skeletal
Growth System
Hormone acutely increases after resistance training in both men and women. Particularly,
concentrations are elevated through 30 minutes post-exercise in both sexes, although the resting
Anna D’Annunzio,
concentrations of GH are higherMS in women.52
Additionally, programs of moderate to high intensity, high volume, and short intervals are most
successful with the responses compared to conventional programs using high loads, low repetitions,
and long intervals.50
Chronic concentrations of GH are not affected by traditional resistance training programs as seen in
both men and women.50 This data is also supported by research demonstrating similar concentrations
in elite Olympic athletes and strength athletes compared with non-trained individuals.50
Insulin
Insulin is affected by blood glucose concentrations and dietary intake. Not taking protein or
carbohydrate supplementation before, during, or post-acute resistance training show a significant
decrease in insulin.50 During aerobic exercise, insulin levels decrease and counter-regulatory
hormones (i.e., glucagon, cortisol, growth hormone, norepinephrine) increase to keep blood
glucose levels steady.53
Whereas in anaerobic exercise, insulin levels do not fall as much as during aerobic exercise, and
glucose levels tend to rise secondary to counter-regulatory hormones.53 After training, insulin
sensitivity also increases and remains high for about 24 hours, and with prolonged strenuous
exercise, insulin sensitivity increases for up to 48 hours.53
Insulin adaptations can also be related to insulin-like growth factors (IGF-1) given their
importance in protein synthesis during resistance training and muscle hypertrophy.50 However,
the acute responses of this hormone remain unclear in the literature. In general, acute elevations
following short resistance training periods may be delayed until GH-stimulated synthesis and
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©2023
secretion from the liver take place.50
Chronic adaptations are often evaluated in the context of IGF-1 rather than pancreatic insulin
hormone. Similarly, IGF-1 shows no chronic adaptations in response to resistance training.50 In
general, resistance-trained men had higher resting IGF1 than non-trained men.50
In women, higher serum elevations of resting IGF-1 during high-volume training are seen in
studies with longer protocols.50 It also appears that the volume and intensity of training are

83
Chapter 1
important for chronic adaptations of IGF1, as one report showed reductions in IGF1 during
The Skeletal System

strenuous training.50
Catecholamines
Catecholamine changes after exercise have mainly been studied in the context of acute
adaptations. An acute bout of resistance training increases plasma concentrations of epinephrine,
norepinephrine, and dopamine.50 In addition, before a strenuous exercise, the plasma concentration
of catecholamines also increases.50
Similar effects also occur when endurance-trained individuals are compared to sedentary subjects
in response to the same relative intensity exercise. This phenomenon is described as the “sports
adrenal medulla”, a long-term adaptation of an endocrine hormone to physical training.54 However,
chronic adaptations remain unclear, although research findings show that training reduces the
catecholamine response to resistance exercise.50
Cortisol
Cortisol concentrations significantly increase during an acute bout of resistance training in both

sexes. The research shows that this response is independent of training status in the adolescent
population.50 Particularly, metabolically demanding protocols of moderate to high intensity,
high volume, and short rest periods report the greatest acute cortisol response.50 Similarly, the
number of sets per exercise appears to influence responses as well, with four to six sets of resistance
exercises resulting in significant results compared to two sets.50
Cortisol resting levels reflect long-term training stress. Chronic resistance training is not a factor
that produces consistent patterns of cortisol secretion either. The evidence consensus determines
that acute cortisol responses are associated with metabolic stress, whereas chronic adaptations
are related to protein metabolism and tissue homeostasis.50
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Other Hormones
Estrogen
Estrogen concentrations acutely increase in most women after endurance and resistance exercises
and usually decrease by the 30-minute recovery.55 In premenopausal females, similar results
exist.56 Another study assessing postmenopausal females found that anaerobic exercise significantly

84
Chapter 1
improved estradiol level and lean mass than aerobic exercises, despite having more than twice as
The Skeletal System

many aerobic sessions throughout the study.57 The effects of acute estrogen release may relate to
reducing exercise-induced muscle damage and improved recovery.58 Furthermore, inconclusive
data remain on chronic responses to exercise and training on estrogen.
Glucagon
Acute bouts of exercise can lower blood glucose concentration for 2 to 48 hours post exercise
and improve insulin sensitivity for up to 72 hours after cessation of any given exercise bout.53
When plasma glucose declines, the sensitivity of the liver to glucagon also improves.53 In response to
prolonged exercises, the decrease in insulin and increase in glucagon also attenuates.53 Additionally,
acute aerobic exercises show significant increases in glucagon concentrations irrespective of
metabolic state.53
Thyroid Hormones
Exercise intervention studies report that thyroid hormone levels decrease in response to resistance
and endurance training.59 Several analyses indicate that physical activity modulates both circulating
TSH and T4 and the magnitude of TSH response to lower T4 levels.59 At low levels of T4,
physically active adults appear to produce less TSH.59 Previous studies also reported that aerobic
exercise increases total serum T3 and T4.60
Consequently, moderate-intensity exercise can increase T4 concentration in the blood.61 Aerobic

exercise is associated with a progressive decrease or an improvement in serum thyroid stimulating
hormone (TSH).62 On the contrary, 12 weeks of aerobic exercise show insignificant changes in
the plasma level of TSH, T3, and T4 hormones among sedentary women.63
Summary Trainer Academy

©2023
The endocrine system includes hormones (estrogen, testosterone, etc.), the glands that produce
them (hypothalamus, pituitary, etc.), and the receptors in the body that respond to hormones.
Hormones have a strong role in influencing the body’s nervous system and exercise stimulates
hormones dues to system stressors for both men and women, although there are hormone
differences between the genders due to physical differences.

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Chapter 1
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57. Hansen System
M. Female hormones: do they influence muscle and tendon protein metabolism? Proc Nutr
Soc. 2018;77(1):32-41. https://doi.org/10.1017/S0029665117001951
58. Klasson CL, Sadhir S, Pontzer H. Daily physical activity is negatively associated with thyroid hormone
levels, inflammation, and immune system markers among men and women in the NHANES dataset.
PLoS One. 2022;17(7):e0270221. Published 2022 Jul 6. https://doi.org/10.1371/journal.pone.0270221
59. Ciloglu F, Peker I, Pehlivan A, et al. Exercise intensity and its effects on thyroid hormones [published
correction appears in Neuro Endocrinol Lett. 2006 Jun;27(3):292]. Neuro Endocrinol Lett.
2005;26(6):830-834.
60. Barari RA. Endurance training and ginger supplement on TSH, T3, T4 and testosterone and cortisol
hormone in obese men. Iran J Basic Med Sci 2016;3:96–103
61. Krotkiewski M, Sjöström L, Sullivan L, et al. The effect of acute and chronic exercise on thyroid
hormones in obesity. Acta Med Scand. 1984;216(3):269-275. https://doi.org/10.1111/j.0954-6820.1984.
tb03804.x
62. Onsori M, Galdari M. Effects of 12 weeks aerobic exercise on plasma level of TSH and thyroid
hormones in sedentary women. Eur J Sport Sci 2015;4:45–9.
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Skeletal6System
Anna D’Annunzio, MSand
Biomechanics
Kinesiology
Elias Malek, MS
91
Biomechanics and Kine siolo gy
Chapter 1
Introduction
The Skeletal System
The word kinesiology stems from the Greek words Kinesis “to move” and –ology “to study.”
Anna D’Annunzio,
Kinesiology MS study of human movement and how physical activity,
is defined as the scientific
sport, and exercise affect quality of life and sports performance.
Kinesiology focuses on the physiology behind the adaptations that are created as a result of chronic
and acute physical activity or exercise. Kinesiology covers a broad range of topics, ranging from
cardiovascular adaptations to single bouts of exercise to the effects and adaptations to exercising
at altitude.1
As a personal trainer, it is important and necessary to understand both the gross anatomy and
the intricacies of the physiology of the body.
Properly coaching and designing exercise programs for clients requires a basic understanding
of biomechanics and kinesiology to ensure you select the best exercises for each client and keep
them safe while they perform each exercise technique.
Anatomical Terms
These terms are used to describe the different positions of specific anatomical structures, anatomical
locations, movements, and positions.2,3
• Anatomical position – standing upright, facing forward, hands to the side of the body with
the palms facing forward, legs parallel with the feet flat on the floor facing forward
• Anterior – towards the front of the body
The sternum is anterior to the spinal column
• Posterior – towards the back of the body
The hamstrings
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• Midline – the imaginary median line that spans from the head to the foot and serves as a
reference point in the body
• Medial – towards the midline of the body
The sternum is medial to the rib cage
• Lateral – away from the midline of the body
Bending the neck to either side of the head is lateral flexion
• Superior – toward the head, above
The head is superior to the neck

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• Inferior – toward the feet, below
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The diaphragm is inferior to the heart
• Proximal – closer to or toward the torso
The elbow is proximal to the hand
• Distal –D’Annunzio,
Anna away from the torsoMS
The toes are distal to the knee
• Cephalad – toward the head
The cervical vertebrae move cephalad from C7 to C1
• Caudal – toward the tail or feet
The cervical vertebrae are caudal from C1 to C7
• Superficial – toward the surface or skin of the body
The skin is superficial to the muscles
• Deep – toward the inside or core of the body
The organs are deep to the skin
• Origin – the proximal attachment of a muscle
The biceps brachii originates on the coracoid process
• Insertion – the distal attachment of a muscle
The quadriceps insertion point is the patella
• Prone – lying flat, facing downward, laying on one’s stomach
The patient was in a prone position for the spinal surgery
• Supine – lying flat, facing upward, laying on one’s back
The patient was sleeping in a supine position
Planes of Motion
The human body is divided into three planes of motion: the sagittal plane, the frontal plane, and
the transverse plane. Most movements occur in multiple planes of motion to varying degrees,
with the majority of the movement occurring in the primary plane.
The sagittal plane divides the body into left and right sections. Movements in the sagittal plane
include squats, deadlifts,
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The frontal plane divides the body into front and back sections. Movements in the frontal plane
include side steps, lateral lunges, and lateral dumbbell raises. Virtually all lateral movement occurs
in the frontal plane.
The transverse plane divides the body into upper and lower sections. Movements in the transverse
plane include Russian twists, golf swings, and rotational chest passes. Most athletic movements
that involve rotational movement occur in the transverse plane.

93 Biomechanics and Kinesiology 94
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Open-Chain vs Closed-Chain Motion
The Skeletal System
Open-Chain vs Closed-Chain Motion
Open-chain motion refers to the movement of the distal segment of a bone about a fixed proximal
AnnaAnD’Annunzio,
segment. MS movement would be doing a bicep curl with a dumbbell.
example of an open-chain
Open-chain motion refers to the movement of the distal segment of a bone about a fixed
proximal segment. An example of an open-chain movement would be doing a bicep curl with a
A closed-chain movement refers to the movement of the proximal part of a bone about a fixed
dumbbell.
distal segment. An example of a closed-chain movement would be a push-up.
A closed-chain movement refers to the movement of the proximal part of a bone about a
fixed distal segment. An example of a closed-chain movement would be a push-up.
Coaching Application
Coaching Application
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The Skeletal System

An understanding of the planes of motion and anatomical reference points is important for
personal trainers for several reasons.
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Breaking down complex movements into an understanding of the muscle actions, including both
movement and stabilization, allows a coach to have a more nuanced understanding of technique
observation and coaching when demonstrating, cueing, and correcting movements.
Furthermore, when designing exercise programs, coaches should generally include exercise
movements in all planes of direction – this can include both isolated exercises as well as compound
movements with multiple planes of motion.

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Finally, an understanding of biomechanics is important for a trainer explaining to their clients
The Skeletal System

why they selected specific exercises in the event their client asks about that aspect of the exercise
program.
Muscle Actions and Muscle Action

Spectrum
Every muscle in the body has an origin and an insertion. The origin of a muscle is the fixed
end of the muscle. The origin of a muscle attaches to the bone, and this end of the muscle does
not move. 2, 3 The insertion of a muscle is the site at which the muscle connects to the bone
that moves.
When referring to muscles and the movement they create, they are classified as either primer
movers/agonists, antagonists, or synergist muscles. The prime mover or agonist muscle is
the primary muscle responsible for a given movement. The antagonist muscle performs
the opposite movement as the prime mover, and in some cases will resist the action of the
agonist muscle. The synergist muscle or muscles will assist or help the agonist muscle with
movement.
Muscle contractions are categorized by the changes in the length of the muscle during
the contraction. A muscle fiber creates tension through myosin and actin cross-bridge
cycling. When a muscle is under tension, the muscle can remain the same length, shorten,
or lengthen. When referring to a muscle contraction, the assumption is that the muscle is
shortening, but the contraction only means that the individual is generating tension within the
muscle fiber.
Muscle contractions can be categorized into 5 actions:

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1. Isotonic contraction
2. Concentric contraction
3. Eccentric contraction
4. Isometric contraction
5. Isokinetic contraction

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Isotonic Contraction
The Skeletal System
An isotonic contraction maintains constant tension in the muscle while the muscle lengthens or
AnnaAnD’Annunzio,
shortens. MS
isotonic contraction can only occur when the maximal force of contraction exceeds
the total load on the muscle.
For example, during a bicep curl, the biceps muscle will only isotonically contract if the weight
is not too heavy.
Examples of isotonic exercises include dumbbell bicep curls, barbell squatting, push-ups, and
most traditional resistance exercises using weights.
Isotonic contractions are further categorized as concentric or eccentric.
Concentric Contraction
Concentric contraction occurs when the muscle action produces a force that can overcome an
external load. To generate a concentric contraction, the muscle force produced must be greater
than the load that it is carrying.
Consider the upward thrust during a bench press. In this case, the barbell acts as the external
resistance against the pectoralis muscle. During the upward thrust, the sum of the force produced
is greater than the resistance of the barbell pushing downward.
This results in the bar being moved upward or lifted by a concentric contraction.
Eccentric Contraction
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An eccentric contraction is generated when the muscle is lengthened or elongated while still
generating force. During an eccentric contraction, the resistance applied to the muscle is greater
than the force generated by the muscle, thus lengthening the muscle.
Cross-bridge cycling still occurs in this example. During exercise, the eccentric contraction is
often referred to as the negative. For example, during a bicep curl, trainers may coach their client
to focus on slowing down during the negative action of the bicep curl.

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They are instructing their client to stay in the eccentric action longer to increase the time
The Skeletal System

under tension. Post-exercise muscle soreness is produced mainly by eccentric contractions. In
fact, muscle tension is higher during an eccentric contraction than in isometric or concentric
contractions.
Isometric Contraction
The word isometric means “same length.” The key aspect to note here is that the muscle length
is not what is staying the same. The joint angle remains constant. The word contraction means
shortening so an isometric contraction does involve internal processes that shorten the muscle
fibers.
The purpose of isometric contractions in exercise is often stabilizing the joints and spine so that
prime movers can safely and effectively apply muscle force to the resistance. For example, during
a squat the hip adductors and abductors contract isometrically to prevent unwanted movement
in the frontal and transverse planes.
Isometric exercises can be done with or without weights. Isometric exercises are useful because
they require relatively minimal equipment and can be done by most of the general population
regardless of physical activity levels.
The elbow plank is a classic example of an isometric exercise. During a plank, the client is resisting
gravity using their body weight. Resisting the pull of an elastic band without additional movement
is another common example of isometric muscle action.
Isokinetic Contraction
An isokinetic muscle contraction occurs when the speed of the muscle contraction remains
constant whileTrainer
the length of the muscle changes. During an isokinetic contraction, the force that
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is produced by the muscle does not remain constant. The force of the contraction is modulated
by the position of the joint in its range of motion and the participation effort of the subject.
An isokinetic contraction differs from an isometric contraction in that an isokinetic contraction

retains a constant speed while an isometric contraction has a constant muscle length. Isokinetic
muscle loading is similar to isometric contractions in that they can be either concentric or eccentric.
In an isokinetic concentric contraction, the muscle shortens or lengthens while under load.

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An interesting application of isokinetic contractions comes in the form of very expensive
The Skeletal System

biomechanical equipment. An isokinetic dynamometer is a machine that is used to control the
speed of a muscle contraction.
Anna
These D’Annunzio,
devices are typically usedMS
in research settings as well as rehabilitation settings. The ability
to modulate and control the speed of contraction of any joint in the body allows practitioners
and researchers to determine things such as muscle fiber type, create a force velocity curve, and
determine the optimal length of a joint angle for force production.
Most isokinetic exercises require an isokinetic dynamometer or other specialized equipment to

keep the speed of the contraction constant.
There are some bodyweight exercises that can be performed such as squats where the individual
focuses on moving through the exercise at a constant speed. However, most of the time, isokinetic
exercises are going to be performed as part of a rehabilitation or recovery program.
Biomechanical Definitions
Force, Muscle Force, and Power
To standardize terms for the measurement of energy, force, work, and power, scientists use System
International (SI) units. Force is a simple way to represent load in biomechanics and can be
defined as the action of one object to another.
Force can be external or internal. Force is measured as the product of the mass of an object
in kilograms and acceleration in meters per second squared. When calculating force in most
traditional resistance exercises, the acceleration used is going to be gravity, which is commonly
approximatedTrainer
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9.81m/s
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.

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The Skeletal System

There are multiple types of force that can act on the human body. These include:
There are •multiple

Motion types
forces of force that can act on the human body. These include:
•Internal forces
• External forces
• Motion forces
• Reactionary forces
• Internal forces
• External forces focuses both on how the different forces act on the musculoskeletal system as
Biomechanics
well as howforces
• Reactionary the body tissue responds to these forces.
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forces are produced by muscle action within the body and create movement. External
Biomechanics focuses
forces act on both
the body andon
in how theterms
practical different forces the
are typically actground
on theforce
musculoskeletal system as well
acting on the body
during ground contact as well as the external
as how the body tissue responds to these forces. resistance of weights. In the case of swimming,
running, and cycling, fluid resistance from the water or air, respectively, adds another
measurable external force.
Internal forces are produced by muscle action within the body and create movement. External
forces act on the body and in practical terms
Trainerare typically the ground force acting on the body
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during ground contact as well as the external resistance of weights. In the case of swimming,
running, and cycling, fluid resistance from the water or air, respectively, adds another measurable
external force.

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Internal movements cannot cause a change to the motion of the center of gravity of the human
The Skeletal System

body without the assistance of external forces. What this means is that the human body is only
able to change direction of movement if it is in contact with another external object. For example,
a goalkeeper jumping to catch a penalty kick cannot change direction after the first jump until
Anna
they make D’Annunzio, MS Upon landing, the goalkeeper can then push against the
contact with the ground.
ground and change the direction of motion.
In this case, the ground is the external force that will allow the goalkeeper to change the direction
of motion. The same internal muscle forces activated without the ground present cannot result
in a change of motion.
Internal Forces
Internal forces are the result of muscle actions, specifically the cross-bridges formed by actin and
myosin during muscle contraction, that result in muscle force generation. The outcome of this
tension is an internal force within the human body. This internal force ultimately acts on the
bones of the skeletal system via the tendons, resulting in angular motion about a joint.
External Forces
External forces are the forces that result from the human body interacting with its environment.
They can be categorized into contact forces and non-contact forces. From a biomechanics
perspective, most forces humans encounter will be external contact forces occurring at the site
of contact as the limbs interact with the ground.
The prime example is foot contact with the ground that occurs with any standing or walking-
based activity. The most common non-contact external force is gravitational force, which acts
on all objects on Earth via the Earth’s gravitational field. Gravity affects objects even if they are
not in direct contact
©2023 with the ground.
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Power
The definition of power in the context of biomechanics is the rate at which mechanical work is
performed. Power is measured in watts (W). A watt represents 1 joule per second rate or energy
production or consumption.

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To find the amount of energy consumed in joules, one would multiply the power output in watts
The Skeletal System

by the number of seconds that output was sustained. The power produced when lifting an object,
such as a piece of resistance equipment, can also be calculated if the mass of the equipment,
vertical distance lifted, and time to complete the movement are known.
When analyzing a movement as simple as moving a dumbbell vertically, an individual must oppose
the force of gravity that is acting on the mass of the dumbbell through a specific displacement,
or change in height, during a duration of time.
To determine power from this, one would take the product of the force and the displacement to
determine the work in joules which could then be divided by the time it took to complete the
movement to determine the power in watts.
The simplest equation to determine power is as follows: power = force x velocity.
Power is typically used to determine output across time. For example, when on a cycle ergometer, power
is measured in watts as a metric as well as total work done in joules. Overall, power output is a useful
metric when prescribing exercise intensity and measuring improvements in cardiorespiratory fitness.
Length-Tension Relationship
The length-tension relationship explains the difference in tension production as a product of the length
of the muscle changes. As a muscle increases in length, the force that the muscle is producing will
also increase. This happens because of the interaction between the cross-bridges of our muscles. At
shorter lengths, there are fewer cross-bridge interactions, resulting in reduced tension development.
At higher lengths, it’s possible to lengthen too much and decrease the number of cross-bridge
interactions, reducing the potential for contractile protein binding and decreasing the muscle’s
force-generating capacity.
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At the optimal length of the muscle, there is a maximal number of cross-bridge interactions,
which results in maximal tension or force development.
Force Velocity
The link between force and velocity is illustrated by the force-velocity curve. Because of the inverse
nature of this connection, the force will decrease as velocity rises. For specific adaptations, a coach

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must be aware of the physiological and biomechanical distinctions between recommending a
The Skeletal System

1RM deadlift and a 5RM jump squat.
Understanding this relationship is crucial since one exercise will result in larger forces and lower
Annathan
velocities D’Annunzio, MS in the amount of time available for cross bridges to form is
the other. A decrease
assumed to be the cause of this trade-off between force and velocity. More time results in more
cross-bridges, and more cross-bridges mean a greater contractile force.
Slower-paced activities, therefore, enable the athlete to create more cross-bridges and generate more
force. Exercises performed at a higher velocity give cross bridges less time to develop, resulting
in less force being produced. As a result, distinct exercises and intensities have been divided into
different force-velocity curve segments.
Levers
A lever system is a rigid rod that moves at a fixed point called a fulcrum when a force is applied to it.
Movement in the human body is possible using lever systems formed by the muscles and joints working
together. Understanding levers in the body helps a coach understand how movement is possible.
Muscles are attached to bones by tendons. The bones of the skeleton act as lever arms, with the
joints as pivot points, allowing muscles to produce movement. Any lever system consists of three
parts: effort, load, and fulcrum. The effort to move weight is provided by the muscle, the load is
provided by the weight of the body and any added resistance, and the fulcrum is the joint itself.
In a first class lever, the fulcrum is the middle component and lies between effort and load. There
are few exercises that use a first-class lever system in the body; triceps extension at the elbow
is one example. Elbow extension is seen during a throwing motion or tennis stroke, as well as a
triceps cable extension.
In a second class lever system, the load is the middle component and lies between the fulcrum
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and the effort exerted. Exercises involving plantarflexion at the ankle (raising the heels) are
second class lever systems. Examples include calf raises or plantarflexion when jumping upwards
while performing a layup in basketball. The second class leverage system tends to increase effort
effectiveness. That means it’s more effective at overcoming resistance than it is at creating speed.
Most of the movements of the human body fall into the third class lever system. In a third class
lever system, the force is the middle component, lying between the fulcrum and the load. There
are many examples of lever systems that involve flexion and extension at the knee joint.

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These movements are involved in running, jumping, and kicking. During flexion of the knee,
The Skeletal System

the point of insertion of the hamstrings on the tibia is the point of effort, the knee joint is the
fulcrum, and the weight of the leg is the load. The third class lever system is used to increase
fulcrum, and the weight of the leg is the load. The third class lever system is used to increase
body speed and allow for a wide range of motion.
bodyAnna D’Annunzio,
speed and MS of motion.
allow for a wide range
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Torque and Rotary Motion

Torque and Rotary Motion
Torque is another key biomechanical concept. In physics, torque is defined as the rate of
Torqueof
change is another keyangular
an object’s biomechanical concept.
momentum. In physics,will
The following torque is defined
explain as the
what this rate when
implies of change
of an object’s
applied angular momentum.
to biomechanics The following will explain what this implies when applied to
and kinesiology.
biomechanics and kinesiology.
Since all human movement occurs around a pivot point, the rate of movement is most
accurately expressed as the rate of change
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angular momentum.
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An object will move in the same linear direction as the force if a force is applied to it in a
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Since all human movement occurs around a pivot point, the rate of movement is most accurately
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expressed as the rate of change in angular momentum.
An object will move in the same linear direction as the force if a force is applied to it in a linear
Annaand
direction D’Annunzio,
the object is notMSfixed at any point. For instance, when someone pushes a book
across a desk, it will glide in the same direction as their hand, if they were to push close to the
center. Linear motion is the name given to this kind of motion. Forces that push or pull cause
linear motion.
The body can also move in a way known as rotational motion. When a force is given to one part
of an object while another part remains immobile, the object rotates. When a muscle pulls on
one end of a bone while the other end is fixed, rotational motion occurs in the body.
The non-fixed end moves as a consequence. For instance, there is rotary motion at the knee joint
when the proximal end of the hamstring muscles is held stationary at the pelvis while the distal
end pulls on the tibia and fibula during knee flexion.
A force that is created by rotating motion is known as torque. Torque is mathematically defined
as the product of multiplying the force exerted on the object by the distance of the force from
the fulcrum or pivot point.
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109
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Summary
The Skeletal System
Biomechanics and kinesiology are key topics to understand as a fitness professional.
Understanding the planes of motion allows for better exercise programming in terms of both
performance and injury prevention. Furthermore, being able to recognize the movement in the
different planes aids in technique observation and cueing for fitness clients.
Basic physics, as it applies to the human body, also assists personal trainers in understanding the
various forces involved in exercise and their implications in terms of progress tracking, athletic
performance, and preventing injuries.
References
1. Wilson Dl. The Kinesiology Activity Book. Boston (MA): McGraw-Hill, 2011.
2. Hall S. Basic Biomechanics. 6th ed. Boston (MA): McGraw- Hill; 2011.
3. Winter DA. Biomechanics and Motor Control of Human Movement. 4th ed. New York (NY ):
Wiley; 2009.
4. Delorme TL, Watkins AL. Techniques of progressive resistance exercise. Arch Phys Med. 1948;29:263-
73.
5. Holland T. Ten important personal training guidelines. Am Fitness. 2001;19 (l) :42.
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Communication Skills for
Fitness Professionals
Quentin Washington, MS
111 COMMUNICAT ION SK I L L S
FOR F IT NE SS P ROF E SSIO N AL S
Chapter 1
Introduction
The Skeletal System
Communication skills are vital for all fitness professionals. From closing sales with prospective
Anna
clients, D’Annunzio,
to instructing techniqueMS
and guiding clients through behavioral changes, interpersonal
communication is a constant aspect of being a great personal trainer.
Personal trainers, instructors, and coaches with good communication skills give vital information
to their clients in training sessions and process feedback from those clients seamlessly. Effective
communication between client and trainer continuously loops back and forth: the trainer provides
information, and the trainee provides feedback, which allows the trainer to consider and make
proper adjustments.
Fitness professionals need to keep that loop open by developing their communication skills to
encourage discussion and openness. In addition, effective communication between coach and
client expands outside of training. This chapter will cover communication skills that will provide
success for a trainer.
The Importance of Communication Skills

Healthcare industry research shows that better relationships between clients and healthcare
professionals lead to better health outcomes. Warmth, positivity, and clear listening lead to greater
patient satisfaction with their healthcare professional.1
Communication has two components: non-verbal and verbal.
Nonverbal Communication
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Nonverbal communication describes messages that are conveyed outside of words. Information
delivered by a trainer hunched over with a sullen face may be interpreted differently than that
from a trainer standing up tall carrying a confident look on their face.
Nonverbal communication also includes the small things the body conveys as well, such as where
an individual looks when they deliver information. For example, whether the individual is looking
into the other person’s eyes or looking away when they are speaking makes a big difference in
the effectiveness of the communication.

112 COMMUNICAT ION SK114
Communication Skills for Fitness Professionals ILLS
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The way in which a fitness professional’s body language and other forms of nonverbal communication
The way in which a fitness professional’s body language and other forms of nonverbal
The Skeletal System
are interpreted
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continues
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abilities to communicate openly.3
Active listening vitally builds up relationships and trust between individuals. Active listening
Active listeningrepeating
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information, making eyeand trust between
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on the other Active
person listening
as
includes nodding, repeating information, making
well as other facets like displaying care for the client. eye contact, focusing on the other person as
well as other facets like displaying care for the client.
By actively listening, the client can see that their coach cares about what they have to say and
by extension, cares about them. Active listening has four main components that coaches will find
effective: Trainer Academy © 2023
1. Listening to the spoken statements of the client

Chapter 1
By actively listening, the client can see that their coach cares about what they have to say and by
The Skeletal System

extension, cares about them. Active listening has four main components that coaches will find
effective:
Listening MS of the client
to the spoken statements
2. Observing nonverbal communication
3. Listening to the context of the client’s apprehensions
4. Listening to the context of the client’s statements that may need to be challenged4
The first part is simple enough: listen to the spoken statements of the client. This means the trainer
pays attention to what the client is saying. The next part, observing nonverbal communication,
can take time to master. However, with some practice, fitness professionals can start to pick up
on the subtleties of body language.
A client with a hunched back and arms crossed may be displaying apprehension and closed off
to suggestion. In this case, the coach or trainer should focus on developing the relationship so
the client feels like he or she can trust the coach.
The third part requires the trainer to pay attention to the spoken and the deeper emotional
connotations the client is displaying. Often spoken words do not convey the entire picture and
the client may not be able to communicate their apprehension effectively or they might be hiding
something they’re embarrassed about.
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On the other side of that coin, sometimes, a trainer or coach needs to challenge an opinion of
a client.
On the other When
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them to describe what they know, which will give the professional a chance to understand
a client. When this happens, the client must feel seen and respected. The trainer should the allow
client’s current beliefs.
them to describe what they know, which will give the professional a chance to understand the
client’sOnce
current beliefs.positively affirms the correct beliefs, the coach can then address whatever
the trainer
Trainer Academy
myths or misinformation
©2023 the client has described, during either that session or on subsequent
Once the trainer
workout positively
days. Also, affirms
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and concerns. the client has described, during either that session or on subsequent workout
days. Also, the trainer should give the client an opportunity to bring up their hesitations and
The next step of effective active listening requires empathy. The ability to share and
concerns.
understand each other’s feelings builds a more effective relationship. Both parties share. Both
parties hear one another and feel heard.
The next step of effective active listening requires empathy. The ability to share and understand
each other’s feelings builds a more effective relationship. Both parties share. Both parties hear
one another and feel heard.
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©2023 © 2023
Chapter 1
When the coach shows they care about what their client has to say and feel, the client responds
The Skeletal System

openly to the trainer. This enables both sides to speak directly. The trainer is the leader in this
relationship, but the client should also be encouraged to take an active role as well.
Annaobviously
A coach D’Annunzio,
needs to askMStheir clients questions but different kinds of questions can have
a different effect on the relationship between client and coach. Close-ended questions, such as
“what is your name” are unavoidable and provide important information to the coach.
However, open-ended questions allow for more engagement between the client and the coach.
The kinds of interactions that open-ended questions allow for help build a healthy collaborative
relationship that makes for a successful coach-client relationship.
How to Build Rapport

Rapport is a close relationship where both parties can communicate well. Developing rapport
is a multifaceted process that uses important communication skills to help improve the client-
coach relationship.
By creating rapport, a trainer and a client more easily address and solve problems that may arise.
Building rapport requires a trainer’s empathy and self-awareness. To build and maintain rapport,
a trainer should avoid arguments and instead use active listening and reflection, since arguments
can be damaging to the trainer/client rapport.5
The coach needs to be able to incorporate previous experience when appropriate and understand
when their previous experience does not apply. Reflection is another powerful tool that involves
expressing the meaning in a reply to the speaker to show them their words are understood. In
the context of personal training, this offers a chance for the client to correct the trainer if they
misunderstood the meaning of their words or a chance to confirm if the trainer is correct.
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It may take some time for the trainer to become fluent with reflection, but in time, it can be a
powerful tool. It should be noted that reflection, while a powerful tool, can be ineffective based
on certain individuals.6
The natural evolution of reflecting is summarizing. Summarizing involves a series of reflections that
highlight important parts of the conversation. It shows a deep understanding of the conversation
and offers another chance for the client to correct or clarify any information.

Chapter 1
A trainer must convey compassion and respect for the client’s differences while appreciating their
The Skeletal System

similarities. A trainer should be able to discuss differences in opinion without arguing with the
client and ultimately respecting the client’s opinion.
TheAnna
trainer D’Annunzio,
should also be ableMSto discuss why something may not be working for the client in
a manner that is still respectful and criticizes the actions of the client, not the client themselves.
The trainer should motivate their clients with the knowledge they have accrued over time as well
as leveraging their communication skills noted in this chapter to improve rapport.
The Initial Client Interview

Clientele will come into the initial interview with certain expectations. While many of those
expectations will be different between clients, many overlap. The client expects their coach or
trainer to be knowledgeable and confident, which is best conveyed through both verbal and non-
verbal communication. In almost every case, the first impression will determine if the trainer will
be allowed the opportunity to train their prospective client.
A good first impression has many components: making eye contact, smiling, a friendly greeting
with a firm handshake followed by the trainer introducing themselves and then getting the
prospective client’s name, using the client’s name, and displaying confident and open body
language.
While most of these are self-explanatory, using confident and open body language may require
practice from trainers who do not naturally possess this skill. Confident body language requires
the trainer to be relaxed and stand up straight with their shoulders back and the head pointed
forwards and the trainer should keep a smile or neutral facial expression.
Trainers who present the appearance of giving the client their full attention when they are
speaking as well as refraining from closing their chest, as in crossing their arms in front of their
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chest, will be more successful. This last part is crucial for open body language. It displays to the
client that the trainer is open and receptive to them and what they have to say.

FOR F IT NE SS P ROF E SSIO N
Communication Skills for Fitness Professionals 119AL S
Chapter 1
The Skeletal System

In addition to body language, clients will also notice the trainer’s appearance. While a suit or
business casual
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to body is not necessary,
language, beingalso
clients will well-groomed
notice theand havingappearance.
trainer’s clean clothes While
can havea asuit or
positive impression on the client.
business casual wear is not necessary, being well-groomed and having clean clothes can have a
positiveThroughout
impressiontheoninterview,
the client.
the trainer should be fully engaged in the conversation, asking
both general and specific questions to better understand the client. Examples of general questions
Throughout the interview,
Trainer Academy
include asking about injuries
©2023 theortrainer should
conditions be fully
or how muchengaged
experiencein the
theclient
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has while asking
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specifically whatinjury
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motivated them to start
their fitness journey originally facilitates finding out information that will be integral to the
training process. This will show the client that the trainer cares enough to dig deeper and that the
Asking the client what kind of movements irritate their injury or what motivated them to start
trainer listens to them.
their fitness journey originally facilitates finding out information that will be integral to the
trainingIf process.
the clientThis will
has no showinthe
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listens to them.
TrainerTrainer
Academy © 2023
Academy
©2023
Chapter 1
If the client has no interest in sharing deeper information outside of training, the trainer should
The Skeletal System

respectfully understand and continue to focus on health and fitness concerns.
Fitness Sales Process
Once a personal trainer or fitness coach establishes themselves, they need to be able to sell and
market their services in order to be successful individually or as a part of a company or training
facility. A trainer needs to be able to generate leads and take prospective clients through the sales
process so that the trainer has clients to train.
Lead Generation
For many trainers, lead generation is the most difficult part of the sales process. Every
personal trainer and coach at some point has to determine where they will find clients. Some
independent trainers may start by offering free training to close friends and family initially before
charging them.
In terms of growth, some trainers may choose to rely on word of mouth. Many satisfied clients
will promote their trainer without a push from their trainer. Other clients may need their trainer
to communicate with them that it would be helpful if the client told their friends, family, and
co-workers about their services. Overall, it’s advisable to wait until the client is satisfied with
their progress and results before asking to be recommended.
Trainers who work in gyms, whether as a part of the gym’s team or as an independent contractor,
are walking advertisements for their business. Some trainers may choose to offer complimentary
services to promote their work. Some gyms may market their trainers through their front desk
services while other trainers may join a professional network that may include other healthcare
providers andTrainer
retailers.
Academy
©2023 In a professional network, trainers will need to build relationships with
others in the network so the other professionals can refer to the trainer and vice versa.
Finally, the last major method to generate leads is through the internet and social media. Having
a significant presence on the internet, especially on social media, leads to opportunity. Producing
content, such as videos, informative posts, blog posts, or whatever the trainer excels at making,
will help grow their internet presence. It is paramount that all social media accounts and websites
remain professional if they are used for personal trainer marketing.

Chapter 1
Initial Contact
The Skeletal System
After a prospective client has taken interest in a trainer’s services, it is important to move on
to Anna
the initialD’Annunzio, MS
contact, which then leads to the initial consultation. This can take the form of an
in-person consultation, over the phone consultation, or an online consultation, which can be
through video calls, emails, text, or any other digital communication method. Keep in mind, the
initial contact and initial consultations can happen at different times or all at once. The trainer
should be prepared for either situation.
The initial contact is an opportunity for the trainer to make a positive first impression and to
gather important information. As mentioned previously, there are many factors to consider
when making a positive first impression, such as body language, a warm greeting, and making
sure the prospective client feels cared for. In the online environment, especially in text or email
consultations or initial contacts, body language no longer matters but nonverbal communication
skills are still important.
Active listening, or reading in text format, will still apply, especially using open and closed questions
along with reflecting. Every trainer does this differently, but here are key points to keep in mind:
1. The trainer should discuss the client’s fitness and health goals, physical limitations, and current
experience and knowledge.
2. Trainers should have an application process for prospective clients to fill out so a trainer
will have that information on file before the initial consultation or for future reference as
appointments and programming go on.
3. Trainers must be aware of the limits of their scope of practice and refer to qualified professionals
when appropriate.
Initial Consultation
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The initial consultation comes after the initial contact, either immediately or as a follow-up
appointment. The trainer should inform the client of when the consultation will be, what to wear
and bring, and how much time the consultation will take. The initial consultation should take
place in a relatively quiet area that allows for a reasonably private conversation.
If this is done online or over the phone, then it is less important to be secluded as long as it is
confidential and communication is clear. After greeting the client warmly, the consultation begins
with the trainer-client agreement. This is when expectations are established or re-established. This

Chapter 1
could include monetary consequences for no-shows or cancellations for both parties to receive,
The Skeletal System

a refund policy, and everything in between.
The client must understand what is expected from them and what the client can expect from
trainer. The trainer will keepMS
records of all of these agreements and a copy should be sent or
given to the client.
First, the trainer needs to discuss health and medical history with the client. Intake forms
should include medical/health history sections in addition to basic information and fitness goals.
Additionally, clients with serious underlying conditions should obtain medical clearance from
a doctor.
If the trainer concludes a medical clearance form is needed, training should not start until the
form is filled, signed, and provided by the client so the trainer knows what a physician deems
acceptable for the client’s current state.
Informed consent is the next important step. From a legal, and ethical, standpoint, the client
should know the potential risks and benefits of engaging in a guided exercise program. This
provides the client an opportunity to understand what may or may not result from the training.
Informed consent should be documented and the trainer and client should each have a copy.
Once all of the business, health, and legal information is documented and taken care of, the client’s
goals should be revisited. As mentioned earlier, the client’s goals should have been discussed in
the initial contact or put on the application form. The trainers should ask additional questions
to clarify the client’s input on their form or to add context to provided information. This is a
chance for the trainer to paint a clear picture of what the client wants, can and cannot do, and
what the client will need to learn.
Physical Assessment and Trial Session

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After the goals have been revisited, a physical assessment and trial session is the next step.
While the documentation provides the trainer with initial information, a physical assessment
may reveal other limitations or places to improve, such as mobility restrictions, cardiorespiratory
deconditioning, and muscular imbalances.
Each assessment should be clearly explained to the client and demonstrated so the client knows
how to perform the assessment and the trainer will have accurate assessment information.

Chapter 1
Some trainers may decide to offer a trial session. This session may be free or at a reduced cost.
The Skeletal System

The trial session will take the client through a training session to get a preview of what they can
expect when they sign up for training.
AtAnna
the end D’Annunzio, MSfitness professional should immediately attempt to make the
of the trial session, the
sale. If the client declines or does not commit to training at that time, a follow-up should be
performed within the next few days.
A well-executed initial interview using effective communication skills combined with a professional
training experience during the trial session offers the best chance to close the sale and acquire
a new client.
Follow Up
After both the initial consultation and the assessment/trial session, the trainer should follow up
with the client by expressing appreciation for their time and effort.
A note, email, or call thanking the client for their time, expressing how good it is that they are
taking a positive step in their health and fitness journey, and showing eagerness for the next
session or training period will go a long way in keeping clients and reducing those who do not
end up continuing their training with the trainer.
It is also helpful to remind the client of their next session and how to prepare for it. For online and
in-person trainers, explaining what the next steps will look like will also be beneficial to keeping
clients.
Closing the Sale

If all goes well, the
©2023client will communicate with the trainer after the trial period or the follow-
Trainer Academy
up. At this point, it is time for the trainer to close the sale. Closing sales is a major topic in
any business and is the bottom line when it comes to actually earning money as a personal
trainer.
Every fitness professional develops their own methods for closing the sale. Ideally, by the time
the potential client is sitting down with pricing in front of them, the fitness professional will have
learned enough about the client and established enough rapport that the sale comes naturally.

Chapter 1
If the client has made it this far into the process, they are likely going to make a purchase.
The Skeletal System

Nevertheless, there are still objections that the client may bring up. Budget restrictions are one of
the most common reasons a prospective client will cite when delaying making the final purchase.
It isAnna D’Annunzio,
certainly MS sessions are entirely out of the person’s budget. However,
possible that the training
if they mention budget concerns, the professional can direct them to the most affordable option
while also reminding them of the value it will have on their life to reach their fitness goals. This
is a good time to reference any pertinent information from the initial interview.
It is important for the trainer to be professional and understanding when a client decides not to
go further with the trainer. The trainer should thank the client for their time and recommend
them to someone who might be more suitable.
If the client does choose to continue working with the trainer, the trainer should offer gratitude
and enthusiasm to work with the client further.
For trainers who are independent contractors or work on their own, it is also important not to
undersell their training. Underselling their training can lead to clients devaluing what the trainer
is offering. The price for independent trainers will vary depending on what is being offered,
location, and competition.
In the case of a client who has already decided they will be purchasing training sessions before
the final discussion, closing the sale does not involve pitching specific packages or overcoming
objections. In this case, closing is just a matter of agreeing on payment methods, scheduling the
sessions, and collecting payment.
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©2023

In the case of a client who has already decided they will be purchasing training sessions
COMMUNICAT ION SK I L L S
123 before the final discussion, closing the sale does not involve pitching
FOR F IT NE specific packages
SS P ROF or N AL S
E SSIO
overcoming objections. In this case, closing is just a matter of agreeing on payment methods,
Chapter
scheduling the sessions,1and collecting payment.
The Skeletal System

Trainer Academy
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©2023

Chapter 1
Summary
The Skeletal System
Communication skills are vital for every personal trainer to develop. Skills such as active listening
andAnna D’Annunzio,
reflection MS
help the client feel like they are being listened to when they talk to their trainer.
Also, nonverbal communication such as body language can make or break the chance that a
client will stick with that trainer.
Trainers need to be aware of verbal and nonverbal cues from their clients and themselves. The
trainer who can marry communication skills with the sales process will have a strong opportunity
to be successful.
The sales process includes being able to generate leads, conducting a successful initial consultation,
providing a trial session if needed, following up with the client, closing the sale if the trainer can,
or referring the client to a professional or resources that will better help them towards their goals.
Communication skills and a mastery of the sales process are key tools that all successful fitness
professionals need to develop over time.
References
1. Henry SG, Fuhrel-Forbis A, Rogers MA, Eggly S. Association between nonverbal communication
during clinical interactions and outcomes: a systematic review and meta-analysis. Patient Educ Couns.
2012;86(3):297-315. doi:10.1016/j.pec.2011.07.006
2. Mast MS. On the importance of nonverbal communication in the physician-patient interaction. Patient

Educ Couns. 2007;67(3):315-318. https://doi.org/10.1016/j.pec.2007.03.005
3. Cornelius, T. L., Alessi, G., & Shorey, R. C. The effectiveness of communication skills training with
married couples: does the issue discussed matter?. The Family Journal. 2007; 15(2), 124-132.
Trainer Academy
©2023
4. Davidson JA, Versluys M. Effects of brief training in cooperation and problem solving on success in
conflict resolution. Peace Conflict. 1999;5(2):137-48
5. Emmons KM, Rollnick S. Motivational interviewing in health care settings. Opportunities and
limitations. Am J Prev Med. 2001;20(1):68-74.
6. Weger H, Castle GR, Emmett MC. Active listening in peer interviews: the influence of message
paraphrasing on perceptions of listening skill. Int J Listening. 2010;24(1): 34-49.

Chapter 1
TheCHAPTER
Skeletal8System
Anna D’Annunzio,
Applied MS
Elements
of
Behavioral Coaching
Jessica Thomas, MS
126 AP P LIE D E LE ME N TS O F
BE HAVIORAL COAC H I N G
Chapter 1
Introduction
The to Behavioral Coaching
Skeletal System
It is no surprise that most Americans today do not exercise as recommended. According to
theAnna
Center D’Annunzio,
for Disease ControlMSand Prevention, only 23.2% of Americans actually meet the
recommended amount of aerobic and muscle-strengthening activity.1 This is despite the fact
that exercise has been proven to enhance sleep, increase energy, boost strength, manage weight,
reduce stress and anxiety, and improve mood.2
Furthermore, having a regular exercise routine can help to manage and prevent diseases such
as type 2 diabetes, high blood pressure, osteoporosis, arthritis, heart disease, and stroke.2 While
many folks would like to be active, it is often the habit formation and change in routine that can
make it challenging to get started and stick with an exercise routine.
This is where knowledge around behavior change and habit formation can serve as a catalyst
for exercise professionals to better support their clients. This chapter is specifically intended to
explore how fitness professionals can work with their clients to understand where they are, and
how they can work toward reaching their goals.
Some of the concepts and ideas that will be discussed include the transtheoretical model for stages
of change, motivational interviewing, working through barriers, strategies to improve exercise
adherence, social influences on exercise, and psychological benefits.
Stages of Change Model

There are five stages of change when looking at behavioral modification: precontemplation,
contemplation, preparation, action, and maintenance. Relapse is also something to consider
when thinking about the stages of behavior change and will be addressed in this chapter as well.
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For the most effective behavioral change coaching, exercise professionals must meet clients where
they are in their current stage and help them process through it as opposed to trying to force
change. Ultimately, the client must feel empowered to pursue and maintain their fitness goals,
and thoughtful behavioral coaching is one of the more reliable methods to achieve this state.

Applied Elements of Behavioral CoachingBE HAVIORAL COAC H I N
129
G
Chapter 1
The Skeletal System

Precontemplation Precontemplation
People
Peoplewho areare
who in this stage
in this of change
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trainer.However,
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awareness.
Basic, easy-to-follow resources are the best type of educational material for clients in the
Basic, easy-to-follow resources are the best type of educational material for clients in the
precontemplation stage. In addition to educating clients, fitness professionals should inquire
precontemplation stage. In addition to educating clients, fitness professionals should inquire
further with theTrainer
client regarding their feelings about exercise. This type of conversation is also a
further with the©2023
client
Academy
regarding their feelings about exercise. This type of conversation is also a
good time to debunk any myths the client may have about exercise.
good time to debunk any myths the client may have about exercise.
The following are a few questions that may be helpful to ask individuals in this stage:
The following are a few questions that may be helpful to ask individuals in this stage:
• What comes up for you when you think about exercise?
Are comes
• • What you open
up to
fortalking about
you when yousome of about
think the benefits of exercise?
exercise?
What
• • Are you have
openyou heard about
to talking aboutexercise
some of that
the stands
benefitsout
ofto you?
exercise?
• What have you heard about exercise that stands out to you?
The fitness professional should never attempt to force the client to become interested or
ready to begin exercising. The coach’s primary roles during this stage of change are providing
education through credible resources and fostering
Trainer self-awareness.
Academy © 2023
Chapter 1
The fitness professional should never attempt to force the client to become interested or ready to
The Skeletal System

begin exercising. The coach’s primary roles during this stage of change are providing education
through credible resources and fostering self-awareness.
Contemplation
Individuals in the contemplation stage are not exercising yet, but they are interested in getting
started within the next six months. This stage gives fitness professionals a great opportunity to
have a meaningful impact on the client’s decision to move forward with their exercise routine.
At this stage, the fitness professional must ask questions to get closer to understanding where
the client’s remaining ambivalence lies.
At the contemplation stage, the client typically has some level of motivation to exercise and
likely understands the benefits of exercise to a certain extent. However, they still have some
misunderstandings about what it means to be active or a continuing belief in one or more myths
about exercise.
To best support people in the contemplation stage of change, the fitness professional must
continue providing education. In this stage, individuals benefit from information and resources
that support the positive thoughts they have around exercise and a gentle education that helps
to redefine any misconceptions they may have.
The following are a few questions that may work well for clients in the contemplation stage
of change:
• What do you see being a positive result of exercise?

• What seems to be a negative result of exercise?
• What do you already know about exercise?
Understanding where the client’s ambivalence lies will inform the exercise professional’s next
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steps. At that point, the exercise professional can provide education and credible resources, along
with a positive attitude and motivating presence that keeps the client wanting to come back.
Gaining this understanding will help the exercise professional to work with the client from the
contemplation stage and into the preparation stages.

Chapter 1
Preparation
The Skeletal System
People in the preparation stage of change are exercising but may not have a strong habit or plan
Anna D’Annunzio,
established. At this point, they MS
know the benefits of exercise and are motivated to work towards
their fitness goals. People in this stage likely need some support in managing expectations and
determining realistic goals.
The best way to support people in this stage varies based on the client’s activity, however all
support from the exercise professional should focus on the positive outcomes of exercising and
help them to build self-efficacy within their exercise plan.
Strategies that are most helpful for people in the preparation stage include the following:
• Goal setting
• Affirming positive behaviors and thoughts about exercise
• Normalizing differences across exercise plans for individuals
• Tapping into previous positive experiences with establishing habits
• Discussing social support
• Generating awareness around potential barriers
• Encouraging a balance of exercise that supports the client’s current capabilities
Action
People in the action stage are active and may have been active for a few weeks or months. They
are engaging in a regular, healthy exercise habit, but have not yet reached the 6 month mark. It
is important for the exercise professional to help clients in this stage to continue building on
what is going well and recognize where there may be barriers or challenges.
The exercise professional

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©2023 can continue to educate clients about the benefits of exercise and build
on what they already know and believe. Emphasizing the client’s strengths to further grow that
self-efficacy will keep clients feeling motivated and positive about their efforts.
Exercise professionals must learn to adjust the exercise program as needed during the action stage
based on the client’s barriers to exercise, as well as to ensure appropriate workout intensity. This
requires an understanding of the client current’s challenges on the part of the exercise professional.

Chapter 1
Maintenance
The Skeletal System
At the maintenance stage, clients have been able to maintain their exercise habit for six months
or Anna D’Annunzio,
more. They MS
have likely figured out what works well most of the time, but still may slip into
previous sedentary habits. Fitness professionals should continue to affirm the clients in this stage,
give them regular kudos, and check in on their plans.
Goals can be set to last a bit longer than in previous stages and should be specific to what the
client is experiencing at the present time, and what they expect down the line. The exercise
professional can work on keeping the exercise programming in line with the clients’ changing
goals and plans, and should take progression into account.
How to Assess Stage of Change

Assessing a client’s stage of change can be done through asking questions that will help to inform
what and how much thought the client has or has not already put into their activity goals.
Below are some examples:
• How do you feel about exercise?

• What success have you had with reaching your activity goals?
• What has gotten in the way of exercise in the past? In the last 6 months?
• What has helped you to stick with activity goals so far in your experience?
• What have your best exercise routines looked like?
• By learning more about what the client is doing currently, or what they have done in the
past, the exercise professional can think through which stage of change they are in currently.
• Is the client lacking interest in starting activity at all? They may be in the precontemplation
stage.
• Is the client thinking about starting an exercise plan in the next several months? They may
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be in the contemplative stage.

• Is the client getting started and experimenting with exercise occasionally? They may be
preparing to dive into their goals.
• Is the client already exercising regularly and working through challenges as they come up?
This would be a client in the action stage.
• Has the client already been exercising for 6 months or more? This would be a client in the
maintenance stage.

Chapter 1
Motivational
The Interviewing
Skeletal System
Motivational interviewing is a directive, client-centered counseling style for eliciting behavior
Anna
change D’Annunzio,
by helping MS and resolve ambivalence.3 With an understanding of the
clients to explore
stages of change, motivational interviewing is the next key skill that coaches can use to elicit
positive behavior change.
The following are the four main principles of motivational interviewing:
• Express Empathy
• Roll with Resistance
• Develop Discrepancy
• Supporting Self-Efficacy4
Expressing Empathy
Expressing empathy means relating to a client’s experience wholly. This is done by validating their
experience, and clearly communicating an understanding of that experience. This is an important
skill to leverage when working with individuals who are feeling challenged.
For example, the client can benefit substantially when their coach helps them understand their
experience is normal and help them stay positive and feel free from judgment.
Rolling with resistance is about avoiding direct head-on arguments and demonstrating to an
individual that they have been heard. At this point, the exercise professional can promote the client’s
autonomy to make decisions about their goals versus what the exercise professional thinks is best.
The exercise professional should refrain from the ‘righting reflex.’ This is where the professional
in a working relationship
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often made with good intentions, this advice or suggestion that is contrary to what the clients
feels is best for them can create resistance against that advice or suggestion. This is natural human
behavior. In this case, it would be more helpful to ask questions that allow the client to develop
discrepancy.
Developing discrepancy is where the professional in the working relationship asks questions that
allow the client to see how what they are saying or planning on does not necessarily align with
their goals or values.

Chapter 1
An example where this may come up would be a client sharing that they are motivated to continue
The Skeletal System

with their exercise programming to achieve improved aerobic capability, but then they avoid
incorporating aerobic activity in their exercise program. Developing discrepancy here would help
the client see how they may be getting in their own way of reaching their goals.
Lastly, building on self-efficacy is where the professional supports the client in not only following
through on their goals but also recognizing their own strengths and behaviors that allow them to
do so. This can be done by leveraging affirmations and asking clients to reflect on what strengths
they used to achieve their goals.
Active Listening
This is at the heart of motivational interviewing. Active listening lets the client know that their
trainer or coach stays with them, tracking in the conversation, and curious to learn more. Using
verbal cues such as “Hmm”, “Yes”, “Uh-huh” and “Ah” can be one way for a professional to show
clients that they follow what the client shares, but to go beyond surface level will also include
body language and building on the conversation.
Body language should mirror the client and maintain a welcoming presence. Some of the basics
on body language would include not crossing arms or legs, maintaining appropriate eye contact,
and head nodding. Next, is the exploration of building on the conversation by examining a few
other key techniques.
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Chapter 1 Applied Elements of Behavioral Coaching 135
The Skeletal System

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Chapter 1
Building
The SkeletalRapport
System with OARS
This is an acronym for Open Ended Questions, Affirmations, Reflections, and Summaries. Using
Anna
these D’Annunzio,
four techniques reassuresMS
the client that their trainer is fully present.
Open Ended Questions

Open ended questions are inquiries that go beyond ‘yes’ or ‘no’ answers. These questions should
require the client to think through their responses. Generally, open ended questions begin with
‘what’, ‘where’, and ‘how.’ Take note that questions beginning with ‘why’ are not included here.
Questions that begin with ‘why’ can make the recipient of the question feel as though they are
being judged, so are very important to avoid in a trainer-client relationship. The open ended
questions used in conversations with clients should build off of what the client has already been
sharing.
Affirmations
Statements of what the client is doing well and what behaviors or strengths they are exhibiting
will help to bolster their self-efficacy. These statements should go beyond a simple ‘Good job’
and should really encompass specific language about what the client did. For example, “You
accomplished your goal of 4 workouts last week! You’re dedicated.”
Reflections
Reflections are statements reiterating what the client is telling the exercise professional in a way
that shows the client
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their coach actively listens to them and comprehends what they are saying. This goes beyond
regurgitating the client’s words.
For example, in response to their client saying “I just want to feel like I am strong again. I haven’t
been able to stay consistent for a long time,” their coach might respond with, “you’re ready to
feel like yourself again.”

Applied Elements of Behavioral CoachingBE HAVIORAL COAC H I137
NG
Chapter 1
Summaries
The Skeletal SystemSummaries
This technique can be used to move the conversation forward while letting the client know that
Anna
their D’Annunzio,
This technique
exercise
can be used MS
professional tracks
to move the conversation forward while letting the client know
what the client is saying. Summaries differ from reflections in
that their exercise professional tracks what the client is saying. Summaries differ from reflections
that they simply summarize what the client tells the trainer. This is in contrast to a reflection,
in that they simply summarize what the client tells the trainer. This is in contrast to a reflection,
where
wherethethe trainer shares their
trainer shares theirinterpretation
interpretationofof what
what thethe client
client is saying.
is saying.
Summaries helphelp
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clients heard
to feel and
heard andare
areananimportant
important step tokeep
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moving
forward
forwardwhile
while demonstrating activelistening.
demonstrating active listening.
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Chapter 1
Overcoming
The Common Barriers to Exercise
Skeletal System
At some point during a client’s time adhering to their exercise program, they are going to run into
Anna
barriers D’Annunzio,
or other challenges thatMSmake it difficult to move forward. Overcoming these obstacles
will be much easier if the trainer and client address some of the common barriers to starting and
adhering to exercise plans.
Time
Lack of time is the most common barrier to participating in exercise.5 As the exercise professional,
it can be meaningful to support the client in discovering some awareness around this perceived
barrier to achieving goals. Inquiring around the client’s schedule and self-reflection tend to lack
the level of detail needed for gaining this type of self-awareness.
People often are not unaware of how much time is spent on social media, browsing the web, or
even watching TV. To help clients to gain a higher level of awareness around where their time
is being spent, the exercise professional may have them do a ‘time audit.’
This would request that the client takes note of how they are spending their time for a designated
period, such as a week. Doing this is meant to help the client to have a clear picture of how they
are currently spending their time and may help them to see where they have room to add in a
new routine.
Unrealistic Expectations or Goals

Many clients starting out with a new trainer do not have recent experience with an exercise routine.
With the best of intentions and eagerness to grow, they may tend to set goals for themselves that
are not quite realistic,
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build confidence, self-efficacy, and motivation.
Goals should be challenging enough to keep clients interested and inspired, but realistic enough
that they are attainable. It is key for the exercise professional to work with clients to understand
why this is important, and how to apply the concept.

Chapter 1
Lack of Confidence
The Skeletal System
For those who are just getting started with exercise, or who have not engaged in an exercise
Anna
routine in aD’Annunzio, MS to lack confidence around getting active, and the ability
gym setting, it is common
to get active.6
For clients who are lacking confidence, the exercise professional may work with these clients to
start with exercise routines that are within their comfort zone to start, such as a walking program.
Once the client starts reaching their ‘starter goals’, they will start to gain confidence and feel
more comfortable moving forward. This can take some time, and the exercise professional can
support the process by continuing to affirm the client’s strengths and behaviors.
Strategies to Improve Exercise Adherence

Once clients get started with their goals, it will become about working with them to adhere to
the exercise programming. In addition to having discussions about their barriers, the exercise
professional can be proactive about bolstering adherence.
SMART Goal Setting

Working with clients to establish their goals comes up time and time again. At this point, it’s
best to discuss how to start the conversation and what tenets are needed for a meaningful goal.
There is a handy acronym that is used in the behavior change world that makes it easy to remember
the 5 components of a meaningful goal: SMART. These goals should be Specific, Measurable,
Attainable, Relevant, and Time Based.
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Kicking off the goal setting conversation will start off with the big picture, and then will move to
a more granular and specific plan. To start things off and to really understand what is motivating
the client to start an exercise program, the following questions can guide the client to think
through what their outcome goals are:
• What would success look like 6 months from now?

• What would you like to have achieved one year from now?
• What is your ultimate goal for your exercise program?

Chapter 1
• What would you like to be different as a result of your exercise program?
The Skeletal System

• Once the client has shared more about the direction they’d like to go, and what is important
for their success with an exercise program, it will be time to get more specific and determine
action steps.
Specific
Goals should include details that indicate exactly what the action is going to be. This means the
client should be given the opportunity to think through what exactly it is they are looking to
achieve or do via the goal that is being set.
For example, “Going to the gym” is not very specific for an exercise goal, unless the goal is simply
to get to the gym. To make this more specific, it may look like this: “Riding the stationary bike
and completing a strength training routine.”
Measurable
This component should make it easy to know whether the goal has been achieved or not. There
should be some sort of measurable value indicated within the goal, i.e. how many times per week,
an increasing cadence, or a certain amount of time.
To build on the goal that was stated above, this may look like: “Riding the stationary bike for 30
minutes and completing strength training routine 3 times per week.”
Attainable
As mentioned previously, goals should always be attainable for the client. This means the goal
should take into consideration where the client is at currently, and what is achievable for them
to continue to grow. For example, it would not be realistic for someone who hasn’t been running
to set a goal to run a marathon in a month. What may be realistic in this example would be a
5k in 4-6 weeks.
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Relevant
Goals should always be co-created between the client and exercise professional, with the client’s
outcome goals in mind. The SMART goal should be related and relevant to what the client is
looking to achieve. For example, if a client is looking to run a marathon, their SMART goal
should be centered around running, with cross training that supports the sport.

Chapter 1
Time-Based
The Skeletal
To ensure System
the client’s tasks are being prioritized and they are maintaining motivation, it is
important to put a realistic, yet ambitious end date for the goal. For example, to build on the
Annagoal,
marathon D’Annunzio,
if a client wantsMS
to run a marathon next year, they may set a goal for the present
time that has them reaching a 10 mile run within 4 months.
Setting goals that are as close to SMART as possible will help clients to really think through what
Applied Elements of Behavioral Coaching 142
it will look like for them to follow through on their goals. This will lead to improved adherence.
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Chapter 1
Self-Monitoring and Tracking
The Skeletal System
Self-monitoring or tracking are strategies that can help clients to not only see their progress over
Anna
time but canD’Annunzio,
also add a layer ofMS
self-accountability to their routine. Once a client starts writing
down or tracking what they are doing for exercise, they will start to build more self-efficacy. This
creates a record of the success that they are seeing so far. There are several different ways a client
may track: websites, apps, journals, etc.
Manage Expectations
Clients may come to the exercise professional with visions of how they will go from being inactive
to fully integrating exercise into their everyday life. It is important to work toward managing
appropriate expectations for the process of establishing an exercise habit.
Discuss with them the length of time it will take to start seeing progress, normalize barriers and
roadblocks, bring awareness to the importance of consistency, and connect the dots between
where the client is currently and where they’d like to be.
Support
Having the support of an exercise professional, friends, families, or colleagues can be really
meaningful to clients. They may look to an individual ‘gym buddy,’ or a family member who
keeps them accountable to their goals.
Whatever the support looks like, it will likely come into play time and time again throughout
the client’s journey.
A social network can have a profound influence on a client’s physical activity behaviors.7 There
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are a number of different types of support systems that can help a client’s success with their
exercise programming.
Having a positive presence and influence in their corner will add to their feelings of belonging
within the exercise community, provide a level of accountability, and help to build motivation.

Chapter 1
Types of Support
The Skeletal System
Instrumental
Anna
This is the D’Annunzio, MS type of support that makes a client’s success possible. An
service-like or required
example of this type of support would be a client’s spouse watching the kids twice per week so
the client can attend an aerobics class.
Self-Monitoring and Tracking
Self-monitoring or tracking are strategies that can help clients to not only see their progress over
time but can also add a layer of self-accountability to their routine. Once a client starts writing
down or tracking what they are doing for exercise, they will start to build more self-efficacy. This
creates a record of the success that they are seeing so far. There are several different ways a client
may track: websites, apps, journals, etc.
Manage Expectations
Clients may come to the exercise professional with visions of how they will go from being inactive
to fully integrating exercise into their everyday life. It is important to work toward managing
appropriate expectations for the process of establishing an exercise habit.
Discuss with them the length of time it will take to start seeing progress, normalize barriers and
roadblocks, bring awareness to the importance of consistency, and connect the dots between
where the client is currently and where they’d like to be.
Emotional
This support provides a sense of love or care for the client. It is likely to be coming from close
friends or family who may lend an ear, provide validation, and encourage.
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Informational
This support mechanism involves when the client looks for information, advice, and facts. It is
likely that the exercise professional is providing this type of support to clients.

Chapter 1
Companionship
The Skeletal
This type System
of support brings a sense of community or belonging. Clients may have a friend that
they attend an exercise class with, or who they meet at the gym for workouts regularly. Some
of Anna
the socialD’Annunzio, MSare common in the exercise world include family or friends,
support systems that
exercise leaders, and exercise groups. Family or friends can offer up emotional or instrumental
support where they help the client to feel a sense of hope or inspiration to continue going.
Friends or family may also be instrumental supporters in that they are the ones who make it
possible for the client to move forward with their goals: taking responsibility off the client’s plate,
financial support to join a gym or class, or driving the client to or from their workouts.
Exercise leaders would be social connections that have a high level of exercise experience,
knowledge, or engagement. This may be someone that the client knows already, or it could be
the exercise professional working with them to come up with an exercise program.
Finally, exercise groups can be really impactful in creating community and companionship for
clients. This may be through an exercise class, a meet-up group, or some other type of exercise
community that bolsters support in a group setting.
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Psychological Benefits of Exercise

Chapter 1
Psychological
The Benefits of Exercise
Skeletal System
Exercise
Exerciseprovides psychological
Trainer Academy
provides ©2023psychologicalbenefits through
benefits a variety
through of biological
a variety mechanisms.
of biological The following
mechanisms. The
are some
following areof the of
some topthe examples of well-researched
top examples benefits
of well-researched of exercise
benefits when when
of exercise it comes to mental
it comes to
health
mental andand
health psychology.
psychology.
Positive Mood Positive Mood

Exercise
Exercisehas
hasbeen
beenproven
proventotoincrease positive
increase feelings
positive or mood
feelings andand
or mood decrease negative
decrease feelings.8 This
negative
occurs
feelings. 8 both in the moment and holds up over a period of time.
This occurs both in the moment and holds up over a period of time.

Chapter 1
Relieves Stress
The Skeletal System
Exercise of all kinds can be a catalyst for stress management.9 Whether a positive or negative
Anna
stressor, D’Annunzio,
finding ways that workMSwell for each individual to manage stress is an important skill.
While exercise can be a component of a stress management plan, if there is a clinical issue related
to a client’s stress, they should be referred to an appropriate clinician.
Improves Sleep
It is no secret that exercise helps to improve sleep. Not only does regular exercise help to improve
sleep quality, but it can also help to reduce feelings of tiredness during the day as well.2
Reduces Depression / Anxiety

In 2020, an estimated 8.4% of Americans dealt with some type of depression or depressive episode,
and more than 15% of Americans deal with mild, moderate, or severe anxiety.11, 12 Exercise has
been proven to reduce symptoms in both depression and anxiety.13
Summary
Despite the many benefits of exercise, many individuals do not reach the minimum recommended
requirements for weekly activity, so it may be up to the fitness professional to determine where
in the state of change model their clients are and how to move them along it.
They can first build rapport with the client using OARS, deal with overcoming barriers to exercise,
and set SMART goals which help organize expectations into measurable outcomes. All these
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steps act as psychological tools that can be useful in moving sedentary clients towards an active
lifestyle, or they can even help clients who do not currently feel motivated in their fitness pursuits.

Chapter 1
References
The Skeletal System
1. “FASTSTATS – Exercise or Physical Activity.” Centers for Disease Control and Prevention. Centers
Anna D’Annunzio,
for Disease MS June 11, 2021. https://www.cdc.gov/nchs/fastats/exercise.htm.
Control and Prevention,
2. “Real-Life Benefits of Exercise and Physical Activity.” National Institute on Aging. U.S. Department
of Health and Human Services. Accessed August 24, 2022. https://www.nia.nih.gov/health/real-
life-benefits-exercise-and-physical-activity.
3. Rollnick, Stephen, and William R. Miller. “What Is Motivational Interviewing?” Behavioural and

Cognitive Psychotherapy 23, no. 4 (1995): 325–34. https://doi.org/10.1017/S135246580001643X.
4. Schultz, Joshua. “Motivational Interviewing Principles: 4 Steps Explained.” PositivePsychology.com,

July 11, 2022. https://positivepsychology.com/motivational-interviewing-principles/.
5. Lyndall Strazdins, Dorothy H. Broom, Cathy Banwell, Tessa McDonald, Helen Skeat, Time limits?
Reflecting and responding to time barriers for healthy, active living in Australia, Health Promotion
International, Volume 26, Issue 1, March 2011, Pages 46–54, https://doi.org/10.1093/heapro/daq060
6. Hoare, Erin, Bill Stavreski, Garry L Jennings, and Bronwyn A Kingwell. “Exploring Motivation
and Barriers to Physical Activity among Active and Inactive Australian Adults.” Sports (Basel,
Switzerland). MDPI, June 28, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968958/.
7. Dollman, James. “Social and Environmental Influences on Physical Activity Behaviours.” MDPI.
Multidisciplinary Digital Publishing Institute, January 22, 2018. https://www.mdpi.com/1660-
4601/15/1/169/htm.
8. Steinberg, Hannah, Briony R. Nicholls, Elizabeth A. Sykes, N. LeBoutillier, Nerina Ramlakhan,

T.P. Moss, and Alison Dewey. “Weekly Exercise Consistently Reinstates Positive Mood.” European
Psychologist 3, no. 4 (1998): 271–80. https://doi.org/10.1027/1016-9040.3.4.271.
9. Jackson, Erica M. “Stress Relief.” ACSM’S Health & Fitness Journal 17, no. 3 (2013): 14–19. https://
doi.org/10.1249/fit.0b013e31828cb1c9.
10. Connor, Patrick J., and Shawn D. Youngstedt. “Influence of Exercise on Human Sleep.” Exercise and
Sport Sciences Reviews 23 (1995). https://doi.org/10.1249/00003677-199500230-00006.
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©2023
11. “Major Depression.” National Institute of Mental Health. U.S. Department of Health and Human Services.
Accessed September 1, 2022. https://www.nimh.nih.gov/health/statistics/major-depression#part_2562.
12. Terlizzi, M.P.H, Emily P., and Maria A. Villarroel, Ph.D. “Symptoms of Generalized Anxiety Disorder
among Adults: United States, 2019.” NCHS data brief. U.S. National Library of Medicine, September
2020. https://pubmed.ncbi.nlm.nih.gov/33054928/.
13. Carek, Peter J., Sarah E. Laibstain, and Stephen M. Carek. “Exercise for the Treatment of Depression
and Anxiety.” The International Journal of Psychiatry in Medicine 41, no. 1 (2011): 15–28. https://doi.
org/10.2190/pm.41.1.c.

Chapter 1
TheCHAPTER
Skeletal9System
Anna D’Annunzio,
Health History
andMS
Anthropometric
Assessments
147 HE ALT H HISTORY AN D
ANT HROP OME T RIC ASSE SSM EN TS
Chapter 1
Introduction
The Skeletal System
Comprehensive client assessments encompass a variety of subjective and objective assessments
Anna
used D’Annunzio,
to determine a client’s risk MS
factors, goals, and current physiological measurements to establish
a baseline.
The overall resting assessment sequence is as follows:
1. Medical history form including lifestyle questionnaire and PAR-Q

2. Resting heart rate
3. Resting blood pressure
4. Bodyweight
5. Height
6. Circumference measurements
7. Skinfold measurements
While all clients must fill out the medical history and related forms prior to engaging in physical
activity under the trainer’s supervision, the specific additional assessments will vary depending on
client goals and health history, comfort with the assessments, and the availability of equipment.
A comprehensive fitness assessment provides subjective and objective information including

any risk factors relevant to training, resting physiologic measurements, and anthropometric
measurements such as height, weight, and skinfold measurements that allow for objective progress
tracking.1, 2
As a general rule for safety, coaches must advocate that their client see their primary physician
prior to beginning or increasing the intensity of an existing exercise program if needed. However,
clients who select “yes” to any of the questions on the Physical Activity Readiness Questionnaire
(PAR-Q) must obtain medical clearance prior to the trainer beginning an exercise program.1,2
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Medical History Questionnaire

A preparticipation health screening includes a medical history, lifestyle questionnaire, and Physical
Activity Readiness Questionnaire (PAR-Q). Often, these forms are combined into a single intake
form, but they can be separate as well.

Chapter 1
Medical history forms should gather the following information:
The Skeletal
• Current System
medications, especially for metabolic conditions
• Injury history
• Anna D’Annunzio,
Cardiovascular MSvia the PAR-Q
risk assessment
The main pre-existing screen is offered by the Physical Activity Readiness Questionnaire (PAR-Q)
and includes some variation of the following questions:
1. Has your doctor ever said that you have a heart condition or high blood pressure?
2. Do you feel pain in your chest at rest or when performing physical activity?
3. Do you lose your balance because of dizziness or do you ever lose consciousness?
4. Have you ever been diagnosed with another chronic medical condition (other than heart
disease or high blood pressure)?
5. Are you currently taking prescribed medications for a chronic medical condition?
6. Do you have a bone, joint, or soft tissue problem that could be made worse by a change in
your physical activity?
7. Has a doctor ever said that you should only do medically supervised physical activity?
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Chapter 1 Health History and Anthropometric Assessments 152
Cardiovascular
The Disease Risk Factors
Skeletal System
In addition toCardiovascular
the PAR-Q form, intake forms Disease
should also Risk Factorsrisk factors. Based
assess cardiovascular
on the number of risk factors, fitness professionals can make generalized decisions about safe,
In addition to the PAR-Q form, intake forms should also assess cardiovascular risk factors.
optimal programming.
Based on the number of risk factors, fitness professionals can make generalized decisions about
safe, optimal programming.
Additionally,Additionally,
a client with multiple risk factors should also get medical clearance from a qualified
a client with multiple risk factors should also get medical clearance from a
healthcarequalified
professional
healthcareprior to beginning
professional any exercise
prior to beginning program.
any exercise program.The
Thefollowing
following areare
thethe risk factors
risk factors for cardiovascular disease (CVD) to consider on top on the PAR-Q
for cardiovascular disease (CVD) to consider on top on the PAR-Q questionnaire responses: questionnaire
responses:
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Risk Factor Assessment

The following stratification can be used to generalize
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about risk factors and make appropriate
recommendations:
• Low Risk: individuals who do not have any signs or symptoms of cardiovascular, pulmonary,
or metabolic disease and have no more than 1 cardiovascular disease risk factor.

• Low Risk: individuals who do not have any signs or symptoms of cardiovascular,
HE ALT H HISTORY AN D
150
pulmonary, or metabolic disease and have no ANT moreHROP
than 1OMEcardiovascular
T RIC ASSEdisease
SSM ENrisk
TS
factor.
Chapter 1
• • Moderate
ModerateRisk: individuals who
Risk: individuals who dodo not
not have
haveany
anysigns
signsororsymptoms
symptoms ofof cardiovascular,
cardiovascular,
The Skeletal System

pulmonary,
pulmonary,oror metabolic diseasebut
metabolic disease but have
have 2 cardiovascular
2 cardiovascular diseasedisease risk factors.
risk factors.
• • High
HighRisk: individualswho
Risk: individuals who have
have oneone or more
or more signs signs or symptoms
or symptoms of cardiovascular,
of cardiovascular, pulmonary,
or metabolic
pulmonary, ordisease, or
metabolicmore than 2orcardiovascular
disease, more than 2 risk factors
cardiovascular risk factors
Recommendations
Recommendations Based onBased on Risk Levels
Risk Levels
• Low Risk: client may perform moderate or vigorous exercise and no physician is needed for
• Low Risk: client
submaximal may perform
or maximal tests moderate or vigorous exercise and no physician is needed
• forModerate
submaximal or maximal
Risk: client tests moderate exercise but not vigorous without physician
may perform
• Moderate Risk:
approval, and mayclient
take amay perform but
submaximal, moderate V̇Obut
exercise
not maximal, 2
testnot vigorous without
• physician
High Risk: requires a physician’s
approval, and may takeapproval for all exercise
a submaximal, andmaximal,
but not tests VO2 test
• High Risk: requires a physician’s approval for all exercise and tests
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Chapter 1
Lifestyle Factors for Injury Risks
The Skeletal System
Collecting information about a client’s profession and recreational activities helps personal trainers
Anna common
determine D’Annunzio,
movementMS patterns, as well as typical energy expenditure levels during the
course of an average day.
This kind of information helps personal trainers begin to recognize imperative signs about the
client’s musculoskeletal structure and function, potential health and physical limitations, and
boundaries that could affect the safety and value of an exercise program. For example:
• Extended periods of sitting could contribute to muscular imbalances, prolonged periods of low

energy expenditure throughout the day, and potentially poor cardiorespiratory conditioning.
• Repetitive movements can cause musculoskeletal injury and dysfunction. Also, these can create
pattern overload in muscles and joints, which may lead to tissue trauma and eventually kinetic
chain dysfunction, especially in jobs that require a lot of overhead work or awkward positions
such as construction or painting.4, 16
Physiological Assessments
Resting Heart Rate (RHR)
RHR is influenced by factors such as fitness status, fatigue, body composition, drugs/medication,
alcohol, caffeine, and stress.1, 7, 10
The assessment of RHR is an indicator of a client’s overall cardiorespiratory health as well as

fitness status. RHR is a good indication of overall cardiorespiratory fitness, whereas exercise
HR is a strong gauge of how a client’s cardiorespiratory system responds and adapts to exercise.
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Resting Rate Classifications
• Sinus bradycardia: slow HR, anything less than 60 beats per minute.
• Normal sinus rhythm: 60-100bpm.
• Sinus tachycardia: fast heart rate, which is greater than 100bpm.

Chapter 1
Heart rate is either easily recorded at either the base of the wrist (radial), or against the side of
The Skeletal System

the trachea (carotid). To gather an accurate recording, it is best to teach clients how to record
their resting HR on rising in the morning. Clients can test their RHR three mornings in a row
and average the three readings.
Resting Heart Rate Procedure
1. Locate anatomic site

2. Gently press down with two fingers over palpation site
3. Count the number of pulsations for a specific time period (6, 10, 30 or 60 sec)
4. Begin counting the first pulsation as 0 when the timing is initiated simultaneously or, if a lag
time occurs after the start time, begin with the number 1
5. Calculate beats per minute via multiplication based on the time interval
6. 6 second count – multiply by 10
Blood Pressure (BP)

Blood pressure is defined as the outward force exerted by the blood on the vessel walls.
It is measured using an aneroid sphygmomanometer, which consists of an inflatable cuff, a pressure

dial, a bulb with a valve, and a stethoscope. When assessing BP, it is imperative to use calibrated
equipment that meets certification standards and to follow standardized protocol.
Systolic blood pressure (SBP) is the pressure created by the heart as it pumps blood into circulation
via ventricular contraction. Diastolic blood pressure (DBP) represents the pressure that is exerted
on the artery walls as blood remains in the arteries during the filling phase of the cardiac cycle,
or between beats when the heart relaxes.6, 18
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To determine systolic pressure, listen for the first observation of the pulse. Diastolic pressure is
determined when the pulse fades away.

Chapter 1
Blood Pressure Classifications
The Skeletal
• Normal: System
120/80 mmHg
• Prehypertension 120-139/ 80-89
Hypertension MS / 90-99
Stage 1: 140-159
• Hypertension Stage 2: above 160 / above 100
Resting Blood Pressure Measurement Procedure
1. Position yourself to hear the BP and see the manometer scale.

2. Make sure the stethoscope is flat and placed completely over the client’s brachial artery.
3. Client should be seated, with feet flat, legs uncrossed, and the arm free of any clothing and
relaxed. The arm and back should be well supported by furniture.
4. Center the bladder of the BP cuff over the client’s brachial artery.
5. Position the client’s arm so it is slightly flexed at the elbow.
6. Firmly place the bell of the stethoscope over the artery located in the antecubital fossa.
7. Inflate the cuff to approximately 20 mm Hg above the SBP, if known.
a. Up to 140-180 mm Hg for a resting BP
b. Up to 30 mm Hg above disappearance of the radial pulse
3. Deflate the cuff slowly 2 -3 mm Hg per heartbeat by opening the air exhaust valve on the
hand bulb.
4. Record measures of SBP and DBP in even numbers rounding up.
5. Rapidly deflate the cuff to zero after the DBP is obtained.
6. Wait for 1 full minute before repeating the BP measurement.
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Health History and Anthropometric Assessments 157
Chapter 1
The Skeletal System

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Body Composition Testing

There are many methods to assess body composition. Each of these methods gives the trainer
insight in determining the best course of action for a fitness program.
Body composition refers to the relative percentage of body weight that is fat versus fat-free tissue,
more commonly reported as “body fat percentage.”

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Body composition refers to the relative percentage of body weight that is fat versus fat-free
tissue, more commonly reported as “body fat percentage.”
Fat-free mass can be defined as total body weight excluding stored fat, including muscle,
bones, water, Chapterand
connective 1 organ tissues, and teeth, whereas fat mass includes essential fat
Fat-free mass can be defined as total body weight excluding stored fat, including muscle, bones,
The Skeletal System

(vital forwater,
normal body functions
connective such as
and organ tissues, neural
and teeth, pathways
whereas fat and
masshormones) and nonessential
includes essential fat (vital for fat
(storage fat or
normal adipose
body tissue).
functions such13, 16
as neural pathways and hormones) and nonessential fat (storage fat
or adipose tissue).13, 16
Anna D’Annunzio,
Body composition testing can:MS
Body composition testing can:
• Identify client’s health risk for excessively high or low levels of body fat
• Promote
• Identifyclient’s understanding
client’s health of bodyhigh
risk for excessively fat or low levels of body fat
• • Promote
Monitor client’s in
changes understanding of body fat
body composition
• Monitor changes in body composition
• Help estimate healthy body weight for clients and athletes
• Help estimate healthy body weight for clients and athletes
• Assist in exercise program design
• Assist in exercise program design
• Be used
• Be usedasasa amotivational tool(for
motivational tool (for certain
certain clients)
clients)
• Monitor
• Monitorchanges
changesin inthe
the body composition
body composition thatthat are associated
are associated with chronic
with chronic diseases diseases
• • Assess
Assess thetheeffectiveness
effectiveness ofofnutrition
nutritionandand
exercise programming
exercise programming
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Chapter 1
In order to obtain correct calculations, technology has provided many different brands of equipment
The Skeletal System

with different procedures, calculations, and modes of use. The various modes of obtaining results
of body composition include:1, 2, 14
• Anna
SkinfoldD’Annunzio,
measurement: usesMS a caliper to estimate the amount of subcutaneous fat beneath
the skin.
• Bioelectrical Impedance: uses a portable instrument to conduct an electrical current through the
body to estimate fat. This is based on the hypothesis that tissues that are high in water content
conduct electrical currents with less resistance than those with little water (such as adipose tissue)
• Underwater weighing: often referred to as hydrostatic weighing, has been the most common
technique used in exercise physiology labs to determine body composition.
• Air displacement Plethysmography (ADP): the “bod pod” is an egg-shaped chamber that
measures the amount of air that is displaced when a person sits in the machine. Two valves are
needed to determine body fat: air displacement and body weight. ADP has a high accuracy
rate but the equipment is expensive.
• Dual-energy x-ray absorptiometry (DEXA): Ranks among the most accurate and precise
methods. DEXA is a whole-body scanning system that delivers a low-dose x-ray that reads
bone and soft-tissue mass. DEXA has the ability to identify regional body-fat distribution.
• Magnetic resonance imaging (MRI): uses magnetic fields to assess how much fat a person
has and where it is deposited. Since MRIs are located in clinical settings, using an MRI solely
for calculation of body fat is not practical.
• Near-infrared interactance (NIR): uses a fiber optic probe connected to a digital analyzer
that indirectly measures tissues composition (fat and water). Typically, the biceps are the
assessment site. Calculations are then plugged into an equation that includes height, weight,
frame size, and level of activity. This method is relatively inexpensive and fast, but generally
not as accurate as other techniques.
• Total body electrical conductivity (TOBEC): uses an electromagnetic force field to assess
relative body fat. Much like the MRI, it is impractical and too expensive for the fitness setting.
In order to begin body composition testing and related calculations, the following information
is needed: height, weight, and circumferences of selected areas.
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Body Mass Index (BMI)

Body Mass Index (BMI) is one of the commonly used calculations that delineates weight categories
based on
BMI = body mass (kg) divided by the height squared (m2) = (kg / m2).

Chapter 1
The major shortcoming of BMI is that it does not differentiate body fat from fat-free
The Skeletal System

weight and has only a modest correlation with body fat percentage measured via hydrostatic
weighing.
Waist-to-Hip Ratio
Waist-to-hip ratio is a comparison between the circumference of the waist and the circumference
of the hip. This ratio reflects the relative distribution of body fat, which correlates to multiple
metabolic risk factors.
Individuals with more weight or circumference on the waist are at higher risk of hypertension,
type 2 diabetes, hyperlipidemia, and coronary artery disease than individuals who are of equal
weight but have more of their weight distributed on the extremities.1, 2, 4
With the help of formulas and calculations, the Skinfold test with the use of calipers is still used
on individuals who are under 30% body fat and under the care of an experienced personal trainer.
Skinfold Measurements
Skinfold measurements are a more precise way to estimate body fat percentages without expensive
equipment. Skinfold measurements are most reliable on individuals who are under 30 percent
body fat.
Skinfold measurements are taken via handheld calipers and then entered into one of several
formulas depending on which measurements are taken.
While skinfold measurements can be fairly reliable, it takes substantial practice under qualified
supervision to consistently take accurate, reliable measurements.
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Skinfold Measurement Sites
• Abdominal: vertical fold; 2 cm to the right side of the umbilicus

• Triceps: vertical fold; on the posterior midline of the upper arm, halfway between the acromion
and olecranon processes, with the arm held freely to the side of the body
• Biceps: vertical fold; on the anterior aspect of the arm over the belly of the biceps muscle, 1
cm above the level used to mark the triceps site

Chapter 1
• Chest/Pectoral: diagonal fold; one-half the distance between the anterior axillary line and the
The Skeletal System

nipple (men), or one-third of the distance between the anterior axillary line and the nipple
(women)
• Medial calf: vertical fold; at the maximum circumference of the calf on the midline on the
Anna
midline D’Annunzio,
of its medial borderMS
• Midaxillary: vertical fold; on the midaxillary line at the level of the xiphoid process of the
sternum. An alternate method is a horizontal fold taken at the level of the xiphoid/sternal
border on the midaxillary line
• Scapular: diagonal fold (45-degree angle); 1-2 cm below the inferior angle of the scapula
• Suprailiac: diagonal fold; in line with the natural angle of the iliac crest taken in the anterior
axillary line immediately superior to the iliac crest
• Thigh: vertical fold; on the anterior midline of the thigh, midway between the proximal border
of the patella and the inguinal crease (hip)14
Procedures
1. All measurements should be made on the right side of the body with the subject standing
upright.
2. Caliper should be placed directly on the skin surface, 1 cm away from the thumb and finger,
perpendicular to the skinfold, and halfway between the crest and the base of the fold.
3. Pinch should be maintained while reading the caliper.
4. Wait 1-2 sec before reading caliper.
5. Take duplicate measures at each site and retest if duplicate measurements are not within
1-2mm.
6. Rotate through measurement sites or allow time for skin to regain normal texture and
thickness.14
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Chapter 1
Summary
The Skeletal System
Health history, resting, and anthropometric assessments for all new clients are important for
Annareasons.
multiple D’Annunzio,
Health historyMS and PAR-Q is vital to obtain to ensure the client is physically
capable of safely participating in exercise.
Resting assessments further flag risk factors and give a baseline for cardiorespiratory fitness prior
to any performance testing.
Finally, anthropometric assessments give quantitative data about the client’s body composition,
which further assists in designing optimal exercise programs and also allows objective measurement
of progress.
While the specific assessments will vary depending on the individual client and training
environment, all clients must complete the health history and PAR-Q before beginning any
exercise under trainer supervision.
References
1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription.
9th ed. Philadelphia: Lippincott Williams & Wilkins; 2014.
2. Hargens T, Edwards ES, Musto AA, Piercy K. ACSM’s Resources for the Personal Trainer. Philadelphia:
Wolters Kluwer; 2022.
3. Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire
(PAR-Q). Can J Sports Sci.1992;17:338-345.
4. Pate R, Pratt M, Blair S, et al. Physical activity and public health:a recommendation from the
Centers forTrainer
Disease
Academy
©2023 Control and Prevention and the American College of Sports Medicine.JAMA.
1995;273:402-407.
5. Going S, Davis R. Body composition. In Roitman JL (Ed.): ACSM’s Resource Manual for Guidelines
for Exercise Testing and Prescription. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:396.
6. Chobanian, A.V. et al. (2003). JNC 7 Express: The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressu-re. NIH Publication
No. 03-5233. Washington, D.C.: National Institutes of Health & National Heart, Lung, and Blood
lnstitute

Chapter
7. Haskell WL, Lee IM,1 Pate RR, et al. Physical activity and public health: updated recommendation
for adults from the American College of Sports Medicine and the American Heart Association.
The Skeletal System
Circulation. 2007 ;1 1 6 (9): 1 08 1 -9 3
8. Kaminslry LA, editor. ACSM\ Health-Related Physical Fitness Assessment Manual.4th ed.
Anna D’Annunzio,
Philadelphia (PA): LippincottMS
Williams & Wilkins; 2073.192 p.
9. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s recommendations for exercise
preparticipation health screening. Med Sci Sports Exerc. 2075;47 (ll):247 3-79.
10. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement.
Ann Intern Med. 2004;140(7):569-72.
11. Baumgartner, T.A., A.S. Jackson, M.T. Mahar, and D.A. Rowe. 2007. Measurement for Evaluation
in Physical Education and Exercise Science, 8th ed. Boston: McGraw-Hill.
12. Beam, W., and G. Adams. 2011. Exercise Physiology Laboratory Manual, 6th ed. New York: McGraw-
Hill.
13. Eckerson, J.M., J.R. Stout, T.K. Evetovich, T.J. Housh, G.O. Johnson, and N. Worrell. 1998. Validity
of self-assessment techniques for estimating percent fat in men and women. Journal of Strength and
Conditioning Research 12: 243-247.
14. Golding, L.A. 2000. YMCA Fitness Testing and Assessment Manual, 4th ed. Champaign, IL:
Human Kinetics.
15. Harrison, G.G., E.R. Buskirk, J.E. Carter Lindsay, F.E. Johnston, T.G. Lohman, M.L. Pollock, A.F.
Roche, and J.H. Wilmore. 1988. Skinfold thicknesses and measurement technique. In: Anthropometric
Standardization Reference Manual, T.G. Lohman, A.F. Roche, and R. Martorell, eds. Champaign,
IL: Human Kinetics. pp. 55-70.
16. Heyward, V.H. 2010. Advanced Fitness Assessment and Exercise Prescription, 6th ed. Champaign,
IL: Human Kinetics.
17. Morrow, J., A. Jackson, J. Disch, and D. Mood. 2011. Measurement and Evaluation in Human
Performance, 4th ed. Champaign, IL: Human Kinetics.
18. Pickering,Trainer
T.G., Hall, J.E., Appel, L.J., Falkner, B.E., Graves, J., Hill, M.N., Jones, D.W., Kurtz,
Academy
T., Sheps, S.G.,©2023and E.J. Roccella. 2005. Recommendations for blood pressure measurement in
humans and experimental animals. Part 1: Blood pressure measurement in humans. A statement for
professionals from the Subcommittee of Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research. Hypertension 45: 142-161.
19. Prisant, L.M., B.S. Alpert, C.B. Robbins, A.S. Berson, M. Hayes, M.L. Cohen, and S.G. Sheps. 1995.
American National Standard for nonautomated sphygmomanometers. Summary report. American
Journal of Hypertension 8: 210-213.

Chapter 1
TheCHAPTER
Skeletal10System
Anna D’Annunzio,
Posture, MS
Movement,
and
Performance Assessments
John Lindala, MS
162 P OST URE , MOVE ME NT, AN D
P E RFORMANCE ASSE SSMEN TS
Chapter 1
Introduction
The Skeletal System
Posture and movement assessments are crucial steps fitness professionals must use to determine
anyAnna
muscle D’Annunzio, MS issues that should be focused on or corrected during the
imbalances or movement
exercise program.
In the field of personal training, movement assessments are utilized as a baseline tool to determine
injury risk, establish a range of motion patterns, and identify movement dysfunctions in a potential
client.1
Ideally, the movement assessments used for a particular client directly relate to the actions the
client will regularly engage in (squats, push up, etc.), thus providing the most objective indicators
of performance possible.2
Biomechanical Checkpoints
Key points to focus on are around the major joints and will be specific to each assessment. The
primary focal point for the lower body will be the hip complex and, for the upper body, the shoulder
complex. The less mobile joints (knee, elbow, etc.) play a secondary role for most assessments
but still deserve full attention.
Observers should denote asymmetry throughout the range of motion of each assessment. As
the client performs each assessment, they should be viewed from a frontal, lateral, and posterior
position to get a full picture of the client’s kinematic chain.
Denote obvious compensation patterns as a guide for how to build a program to maximally
benefit the client.
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The use of static postural assessment helps to identify muscle imbalances, range of motion
difficulties, and flexibility limitations. A static postural assessment provides excellent indicators
of problem areas that can then be further evaluated so that the trainer can then come up with
an action plan.

Chapter 1
Static
The Postural
Skeletal Assessment
System
This provides a basis for developing an exercise strategy to target contributing factors of incorrect
Anna patterns
movement D’Annunzio, MS inefficiency. This information might provide knowledge
and neuromuscular
for which selection of stabilization exercises and stretching and self-myofascial release strategies
might be used.
There are three common distortion patterns:
1. Pronation distortion syndrome: characterized by foot pronation (flat feet) and adducted
and internally rotated knees (knock knees).
2. Lower crossed syndrome: characterized by an anterior tilt to the pelvis (arched lower back).
3. Upper crossed syndrome: characterized by a forward head and rounded shoulders.19, 20
Postural assessments require observation of the kinetic chain, consisting of:
1. Foot and ankle

2. Knee
3. Lumbo-pelvic-hip-complex (LPHC)
4. Shoulders
5. Head and cervical spine
A static posture assessment may offer valuable insight into:
1. Muscle imbalance at a joint and the working relationships of muscles around a joint.
2. Altered neural action of the muscles moving and controlling the joint – tight or shortened
muscles are often overactive and dominate movement at the joint, potentially disrupting
healthy joint mechanics.
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Posture, Movement, and Performance Assessments 167
Chapter 1
The Skeletal System

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Chapter 1
Overhead
The Squat Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
The squat assessment is a dynamic movement assessment designed to measure the client’s functional
range of motion. It helps determine overall core strength, balance, kinesthetic awareness, and
movement pattern discrepancies.3
Procedure
Have the client start standing with feet comfortably spaced shoulder width apart and toes straight
ahead. Demonstrate a proper squat while instructing the client to perform the move to the best
of their ability.
Have the client perform 10 squats while watching the movement pattern. If performing the
overhead squat, instruct the client to fully extend arms overhead before beginning the squat and
keep them there throughout the movement. A PVC pipe may also be held overhead with a wide
grip if available. During the squats, the trainer can move to slightly different angles if necessary
to determine more information about the movement pattern.
Movement Findings
1. Compensation: Feet turn out. Throughout the squat movement the client’s feet rotate out.
Indications: Overactive soleus, lateral gastrocnemius, and biceps femoris. Underactive

medial gastrocnemius, semimembranosus, semitendinosus, gracilis, and sartorius.
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2. Compensation: Knees cave in. The knee visibly points or tracks inward during the squat rep.
Typically, knees will be seen caving in on the eccentric phase and will circle medially with
the start of the concentric phase of the squat.
Indication: Overactive adductor, biceps femoris, tensor fascia latae, and vastus lateralis
to the dominant side. Target strengthening for the gluteus medius, gluteus maximus,
and vastus medialis oblique.

Chapter 1
3. Compensation: Torso falls forward. Client cannot maintain a neutral spine and their torso
The Skeletal System

flexes forward towards the floor.
Indication: Overactive soleus, gastrocnemius, rectus femoris, psoas, rectus abdominis.

Anna D’Annunzio,
Underactive MS gluteus maximus, and erector spinae.
anterior tibialis,
4. Compensation: Low back arches. Hyperextension of the low back during squat.
Indication: Overactive rectus femoris, psoas, erector spinae, latissimus dorsi. Underactive

gluteus maximus, hamstrings, lower core musculature.
5. Compensation: Arms fall forward (overhead). Arms fail to stay vertical and fall towards
the floor.
Indication: Overactive latissimus dorsi, teres major, and pectoralis group. Underactive

mid/lower trapezius, rhomboids, and rotator cuff.
6. Compensation: Head protrudes forward. Head fails to stay stacked in a neutral position.
Indication: Overactive upper trapezius, sternocleidomastoid, and levator scapulae.

Underactive deep cervical flexors.
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Chapter 1
Single
The LegSystem
Skeletal Squat Assessment
Anna D’Annunzio,
General Purpose MS
The single leg squat assessment is designed to measure lumbo-pelvic hip stability of the client.4
Procedure
Have the client start standing with feet together. They will pick up one foot to a height of 45
degrees of hip flexion while keeping that foot off the ground during the squat. Arms should be
straight out in front of the client with the hands clasped together.
Instruct the client to squat on the standing leg as low as comfortable or to 60 degrees of knee
flexion. Instructor should be able to assess the range of motion within 3 to 5 repetitions then
have the client repeat the test on the opposite leg.
Movement Findings
1. Compensation: Knees cave in. Knee visibly points or tracks inward during the squat
rep. Typically, the knee will be seen caving in on the eccentric phase and circling medially
with the start of the concentric phase of the squat.
Indication: Overactive adductor, biceps femoris, tensor fascia latae, and vastus lateralis
to the dominant side. Target strengthening for the gluteus medius, gluteus maximus,
and vastus medialis oblique.
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Chapter 1
Lunge
The Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
The lunge assessment measures movement asymmetries, lateral stability, and balance.5
Procedure
Position the client into the lunge by having them take one stride forward while leaving their back
foot planted on the ground. With their arms crossed over their chest, have the client attempt to
touch their back knee to the ground bending both knees to 90 degrees. Perform 5 repetitions on
the same leg before switching sides.
Movement Findings Including Tight & Weak Patterns

1. Compensation: Asymmetrical weight shift: client noticeably shifts weight further to one side.
Indication: Potential side dominance with similar indications as the knee caving in on

a squat assessment. Overactive adductor, biceps femoris, tensor fascia latae, and vastus
lateralis to the dominant side. Target strengthening for the gluteus medius, gluteus
maximus, and vastus medialis oblique.
2. Compensation: Excessive knee bend: knee of forward leg drives forward into deep knee
flexion as a sign of quadriceps dominance.
Indication: Overactive quadriceps and hip flexor complex. Underactive gluteal and

hamstring groups.
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3. Compensation: Lack of hip extension: posterior hip doesn’t move into extension and stays flexed.
Indication: Overactive psoas and rectus abdominis. Underactive gluteus maximus and

lower core stabilizers.

Chapter 1
Step
The Up Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
The step-up assessment measures the strength and stability of the gluteus maximus, hamstrings,
and quadriceps as well as the client’s balance.
Procedure
Find a stable and elevated surface for the client to step up onto and have the client stand directly
in front of the surface. Arms should be crossed in front of their chest. Instruct them to place one
foot on the surface and step up into full extension of the planted leg. Opposite leg should be
pulled into hip flexion to 90 degrees. Perform 5 repetitions on the same leg before switching sides.

1. Compensation: Hip dropping upon lifting of foot.
Indication: Overactive psoas, rectus femoris, and tensor fascia latae. Underactive gluteus

maximus/medius, quadratus lumborum, and transverse abdominis.
2. Compensation: Inability to dorsiflex foot. Client cannot lift toes up.
Indication: Overactive gastrocnemius and soleus. Underactive anterior tibialis.
3. Compensation: Forward lean into step. Client leans forward over leg to step up.
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Indication: Lack of strength through the range of motion.
4. Compensation: Failure to flex hip. Client cannot get into 90 degrees of hip flexion.
Indication: Overactive gluteus maximus and hamstring group. Underactive psoas, rectus

femoris, tensor fascia latae, and rectus abdominis.

Chapter 1
Pulling
The Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
Designed to test the strength and range of motion of the posterior shoulder girdle, specifically
the muscles acting on the scapula.6
Procedure
Submaximal assessment in which the instructor will need access to a cable row, suspension trainer,
or resistance band. From a standing or seated position, have the client start with arms extended
and holding resistance in a neutral grip. Torso should begin and remain upright throughout the
assessment. Instruct client to pull handles to their torso as far as they can comfortably. Instructor
should be able to assess client within 5-10 repetitions.

1. Compensation: Low back arches.
Indication: Overactive psoas and rectus abdominis. Underactive lower core stabilizers.
2. Compensation: Shoulders elevate. With concentric motion shoulders elevate rather than

remaining neutral.

Underactive middle/lower trapezius.
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3. Compensation: Head
©2023 protrudes forward. Head fails to stay stacked in a neutral position.

4. Compensation: Shoulder rounding forward: shoulder complex fails to stay inline and rotates
forward during pull.
Indication: Overactive upper trapezius, levator scapulae, and pectoralis major/minor.

Underactive middle/lower trapezius, rhomboids, and rotator cuff.

Chapter 1
Pulling
The Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
Designed to test the strength and range of motion of the posterior shoulder girdle, specifically
the muscles acting on the scapula.6
Procedure
Submaximal assessment in which the instructor will need access to a cable row, suspension trainer,
or resistance band. From a standing or seated position, have the client start with arms extended
and holding resistance in a neutral grip.
Torso should begin and remain upright throughout the assessment. Instruct client to pull handles
to their torso as far as they can comfortably. Instructor should be able to assess client within
5-10 repetitions.


remaining neutral.
Indication: Overactive
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©2023 upper trapezius, sternocleidomastoid, and levator scapulae.


Chapter 1
4. Compensation: Shoulder rounding forward: shoulder complex fails to stay inline and rotates
The Skeletal System

forward during pull.
Indication: Overactive upper trapezius, levator scapulae, and pectoralis major/minor.
Anna D’Annunzio,
Underactive MStrapezius, rhomboids, and rotator cuff.
middle/lower
Pushing Assessment
General Purpose
Designed to test the range of motion for the anterior shoulder girdle and chest.7
Procedure
Submaximal assessment in which the instructor will need access to a cable machine, resistance bands,
or a suspension trainer. Can be performed from a standing or seated position. Have the client start
with an upright torso and resistance handles at chest height with arms wide and elbows bent to 90
degrees. Perform the test by having the client fully extend arms until both handles are directly in front
of the client’s chest and shoulder. Instructor should be able to assess the client within 5-10 repetitions.

2. Compensation: Shoulders
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©2023
remaining neutral.



Chapter 1
Overhead
The Pressing Assessment
Skeletal System
Anna D’Annunzio,
General Purpose MS
The overhead pressing assessment measures range of motion of the upper body, strength of the
elbow, extensors strength of the medial shoulder, and core stability.8
Procedure
Submaximal assessment in which the instructor will need access to a bar. Client starts in either
a seated or standing position. Bar will be brought to shoulder height with hands just outside of
shoulder width apart. Goal for the assessment is to monitor range of motion while the client
extends the bar fully overhead and returns to the starting position.

1. Compensation: Asymmetrical weight shift: weight is clearly shifted towards one arm.
Indication: Side dominance and potential lack of strength in non-dominant limb.

remaining neutral.

3. Compensation: Head
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protrudes forward. Head fails to stay stacked in a neutral position.
©2023

4. Compensation: Bar fails to remain vertical and deviates forward into sagittal plane (sagittal
deviation).
Indication: Overactive latissimus dorsi, teres major, and pectoralis group. Underactive

mid/lower trapezius, rhomboids, and rotator cuff.

Chapter 1
Performance
The Assessments
Skeletal System
While movement assessments determine the quality of movement capabilities of a client,
Anna D’Annunzio,
performance MS strengths and weaknesses of the client.
assessments determine
Performance assessments require clients to directly display their skill in a particular subset (agility,
strength, endurance, etc.) of fitness.
Push Up Test
General Purpose
To test the strength endurance upper body pushing capabilities of a client.9
Procedure
Test can be performed either from toes or knees depending on client’s preference and background.
Contraindications include shoulder, elbow, or wrist injury. If any exist, a modified test may be
performed where the movement only goes to 90 degrees of elbow flexion.
If no contraindications exist, have the client start in the push up position of their choice. Instruct
them that a proper rep involves controlled lowering of the torso until they touch their chest to
the floor then return to full extension of the elbows.
Count all continuous repetitions until the client can no longer perform the movement.
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Chapter 1
Davies
The Test
Skeletal System
Anna D’Annunzio,
General Purpose MS
The Davies test measures the client’s upper body agility and stabilization.11
Procedure
To set up the test, put two pieces of tape or floor marker 36 inches apart on the floor. Have the
client start in a push up position with one hand on each piece of tape. Set a timer for 15 seconds
and explain to the client to bring their left hand to meet their right and back, then their right
hand to meet their left and back.
Continue alternating hand movements during the duration of the 15 second timer. Count every
hand movement back and forth as one repetition. Repeat the test 3 times and take the average
score.
Trial Time Score

1 15 sec
2 15 sec
3 15 sec
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Chapter 1
Shark
The SkillSystem
Skeletal Test
Anna D’Annunzio,
General Purpose MS
The Shark Skill test assesses lower body agility and stability.
Procedure
Create a 3×3 grid on the floor consisting of 9 squares measuring 12” in on all sides. Have the
client start standing in the center square on one foot. In a designed pattern they will jump to a
particular square then return to the center square. They will continue around the grid until all
squares have been touched and then return to the center square.
Let them practice one round with each foot. After practicing, they will perform two rounds per
leg for time alternating legs each round. For each mistake they make, add 10 seconds to their
round time.
Penalty Time
Trial Time Mistake Tally Total Time
(#Mistakes x .1)
(Time + Penalty Time)
Practice

Right
Practice

Left
#1 Right
#1 Left
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#2 Left

Chapter 1
General
The 1 Rep
Skeletal Max Procedures
System
Anna D’Annunzio,
General Purpose MS
The 1 repetition max test is designed to measure absolute strength in one specific motion. It can
be performed through a variety of exercises with the same general construct.
Procedure
Ideally the test will be performed utilizing free weights with the trainer functioning as a spotter
with the option for additional help if necessary.
1. Have the client do a warmup set of 8-10 repetitions at 50-60% of perceived maximum.
2. After allowing a 1-minute rest (longer can be taken if needed), have the client perform a set
of 3-5 repetitions at 60-80% of perceived maximum.
3. Next the first 1 repetition maximum attempt is performed. Add weight based on the client’s
perceived maximum and performance then attempt the first lift.
4. If successful, allow the client to rest 3-5 minutes before adding more weight and performing
a second attempt.
5. Repeat until the client fails a lift or has clearly reached a maximum.
6. Ideally a successful 1 repetition maximum test is completed within 3 attempts.
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Chapter 1
Vertical
The Jump
Skeletal Assessment
System
Anna D’Annunzio,
General Purpose MS
The Vertical Jump Assessment determines a client’s maximal vertical jump power.
Procedure
Test utilizes either a large-unobstructed wall or vertical jump testing device. Have the client first
stand next to the measuring surface with feet flat and arm nearest surface fully extended overhead.
Measure the maximal beginning reach. Then demonstrate a proper jump with arm swing.
Lower body quickly into a partial squat while extending arms behind torso then rapidly extend
entire body vertically into a jump and touching measuring surface at the apex of the jump.
Measure the difference between standing and jumping heights. Allow client 3 attempts to gain
maximal height with a short rest between each.
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Chapter 1
Lower
The Extremity
Skeletal System Functional Test
Anna D’Annunzio,
General Purpose MS
The lower extremity functional test (LEFT) is used as a measure of an athlete’s ability to return
to sport. During the test the athlete will be required to perform every movement pattern that
may occur in sport.
Procedure
A diamond grid is created with four cones, where the vertical cones are placed 30 feet apart.
The trainer place two horizontal cones 10 feet apart halfway between the vertical cones to create
the diamond pattern. Client will then run the following patterns in a continuous motion test.
(Cones labeled A, B, C, D. A is the start, so moving clockwise B would be 15 feet ahead and 5
to the left, C would be 30 feet ahead of A, and D would be 15 feet ahead and 5 to the right.)
1. Forward sprint A-C-A

2. Backpedal A-C-A
3. Side shuffle right leg first A-D-C-B-A
4. Side shuffle left leg first A-B-C-D-A
5. Karaoke right leg first A-D-C-B-A
6. Karaoke left leg first A-B-C-D-A
7. Forward run figure 8’s circling C cone from left to right A-D-C-B-A
8. Forward run figure 8’s circling C cone from right to left A-B-C-D-A
9. 45-degree cuts A-D-C-B-A
10. 45-degree cuts A-B-C-D-A
11. 90-degree cuts (outside leg) A-D-B-A
12. 90-degreeTrainer
cuts (outside leg) A-B-D-A
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13. 90-degree cuts (inside leg) A-D-B-A

14. 90-degree cuts (inside leg) A-B-D-A
15. Backpedal A-C-A
16. Forward Sprint A-C-A

Chapter 1
40-Yard
The Dash
Skeletal System
Anna D’Annunzio,
General Purpose MS
Designed to test a client’s explosive lower body power and maximum movement velocity.
Procedure
This is best if performed on a track, but any level surface will work. Measure a 40-yard space
clearly marked with start and finish lines. Instruct the client on how to position themselves at
the start line. Typical positions include a track stance with one hand on the ground or a standing
start, whichever chosen should best reflect performance needs of the client.
Instructor stands at the finish line with a stopwatch to ensure accurate timing. Instruct the client
to begin when ready. When the client moves, begin the watch and stop when they cross the finish
line. Take the best effort of 2-3 attempts.
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Chapter 1
Yo-Yo
The Intermittent
Skeletal System Recovery Test
Anna D’Annunzio,
General Purpose MS
The Yo-Yo intermittent recovery test assesses a client’s ability to repeatedly perform intervals over
a long period of time. Additionally, it can be used to determine a client’s V̇O2 max.11
Procedure
Instructor will need a flat, non-slip surface, marking cones, measuring tape, recording sheet, and
a pre recorded copy of the test and beep. The cones are layed out in 3 lines that are 20 meters and
5 meters apart respectively. The client starts at the middle line. When prompted by the recorded
beep they will run to the 20-meter line. Another beep will prompt the client to return to the
starting line.
Each round the recorded beeps speed up, lowering the amount of time the client has to complete
a shuttle. There is a 10 second active recovery between shuttles where the client must walk or
jog around the first line 5 meters away and return to the starting line.
The first time a client fails to complete a shuttle they are given a warning. The second failure leads
to the test being completed. An alternative version exists titled the Yo-Yo intermittent endurance
test wherein the active recovery time is lowered to 5 seconds.
To estimate V̇O2 max use the following formulas:
Intermittent Recovery Test (IR1 aerobic):
Yo-Yo Trainer
IR1 test: V̇O2max (ml/min/kg) = IR1 distance (m) × 0.0084 + 36.4
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Intermittent Endurance Test (IR2 anaerobic):
Yo-Yo IR2 test: V̇O2max (ml/min/kg) = IR2 distance (m) × 0.0136 + 45.3

Chapter 1
1-Mile
The Run
Skeletal System
Anna D’Annunzio,
General Purpose MS
The 1-mile run is designed to test a client’s aerobic endurance capacity.
Procedure
Ideally performed on a track without interruption of the run or walk/run effort. The goal of the
test is to have the client complete one mile as fast as they possibly can. Shorter versions can be
introduced for younger children (1/4 mile) and pre-teens (1/2 mile).
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Chapter 1
20-Yard
The Shuttle
Skeletal SystemTest
Anna D’Annunzio,
General Purpose MS
The 20-yard shuttle test (also known as the 5-10-5) is used to test a client’s agility, explosiveness,
overall body control and speed.
Procedure
Three cones are placed in a line 5 yards apart from each other. The client starts at the middle
cone. First, the client sprints to the right cone (5 yards), then all the way to the far left cone (10
yards), and back to pass the middle cone (5 yards).
The instructor begins timing at the start and stop time when the client runs past the middle cone.
Two different variations exist in which the client must touch each cone or simply place their foot
in line with the cone before changing directions. Allow the client sufficient time to rest then
have them repeat the test starting in the opposite direction.
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Chapter 1
Kneeling
The SkeletalChest
SystemLaunch Test
Anna D’Annunzio,
General Purpose MS
The kneeling chest launch test is designed to measure a client’s upper body coordination, power,
and strength.
Procedure
Instructor needs a 2 or 3 kg medicine ball, measuring tape, soft pad to kneel on, and an open
area. The client begins on both knees with an upright torso. Toes should be pointed behind the
client to keep the client from utilizing extra traction from the lower body.
Client starts by holding the ball with both hands directly overhead. Then they lower the ball to
their chest as they sit back towards their heels. In one smooth motion, the client then explodes
up and throws the ball in a pressing motion for maximum distance. Knees should remain on the
ground for the throw, but the client is allowed to fall in front of the starting line upon release.
The client shouldn’t favor one arm over the other in the throw and their spine should not rotate.
Allow the client a practice throw to determine best practice and aim for maximal distance. To
test, allow the client two throws with at least a minute of rest between attempts.
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Chapter 1
Pull
The Up Test
Skeletal System
Anna D’Annunzio,
General Purpose MS
The pull up test is used to measure upper body strength and endurance.
Procedure
This test is performed to the failure of good form. The instructor needs access to a high-horizontal
pull up bar tall enough so that when the client hangs from the bar at full extension, their feet
cannot touch the ground.
Begin by having the client grasp the bar in either an overhand or underhand grip. Grip width
will vary by client but will be approximately shoulder width. Once ready, the client raises body
until their chin clears the top of the pull up bar.
Then, they lower themselves back to full arm extension and repeat until technical failure. The
motion should be smooth without additional bending, kicking, or swinging of the body.
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Chapter 1
Summary
The Skeletal System
Assessments are useful tools for fitness professionals in the field of personal training. Static
Anna
postural D’Annunzio,
assessments MS information to the trainer about which common distortion
give important
pattern a client may be experiencing, movement assessments indicate range of motion and muscle
asymmetries that should be corrected, and performance tests give the personal trainer an idea of
the client’s fitness in a particular area.
Each test should be used for a particular purpose to answer specific questions that need to be
answered to keep the client healthy and moving toward their fitness goals.
References
1. Glaws K, Juneau C, Becker L, Di Stasi S, Hewett T. Intra-and Inter-rater Reliability of the Selective
Functional Movement Assessment. Int J Sports Phys Ther. 2014 Apr; 9(2): 195-207
2. Cook G, Burton L, Hoogenboom B, Voight M. Functional Movement Screening: The Use of
Fundamental Movements as an Assessment of Function – Part 1. Int J Sports Phys Ther. 2014 May;
9(3): 396–409.
3. Myer G, Kushner A, et al. The Back Squat: A Proposed Assessment of Functional Deficits and
Technical Factors That Limit Performance. Strength Cond J. 2014 Dec 1; 36(6): 4–27.
4. Bailey R, Selfe J, Richards J. The Single Leg Squat Test in the Assessment of Musculoskeletal Function:
a Review. Physiotherapy Practice and Research, vol. 32, no. 2, pp. 18-23, 2011.
5. Hartigan E, Lawrence M, Bisson B, Torgerson E, Knight R. Relationship of the Functional

Movement Screen In-Line Lunge to Power, Speed, and Balance Measures. Sports Health. 2014 May;
6(3):197-202.
6. Yoo W. Effects of Pulling Direction on Upper Trapezius and Rhomboid Muscle Activity. Journal
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of Physical Therapy Science. 2017 Jun; 29(6): 1043-1044
7. Trebs A, Brandenburg J, Pitney W. An Electromyography Analysis of 3 Muscles Surrounding the

Shoulder Joint During the Performance of a Chest Press Exercise at Several Angles. Journal of
Strength and Conditioning Research: July 2010 – Volume 24 – Issue 7 – p 1925-1930
8. Kroell J, Jonathan M. Exploring the Standing Barbell Overhead Press. Strength and Conditioning
Journal: December 2017 – Volume 39 – Issue 6 – p 70-75

Chapter
9. Baumgartner 1 O, Hyuk C, Derek H. Objectivity, Reliability, and Validity for a Revised
T, Suhak
Push-Up Test Protocol. Measurement in Physical Education and Exercise Science: 2002 – Volume
The Skeletal System
6 – Issue 4.
10. Goldbeck T, Davies G. Test-Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability
Anna D’Annunzio,
Test: A Clinical MS of Sport Rehabilitation: Volume 9 – Issue 1 – p 35-45
Field Test. Journal
11. Bangsbo J, Iaia FM, Krustrup P. The Yo-Yo intermittent recovery test: a useful tool for evaluation of
physical performance in intermittent sports. Sports Med. 2008; 38(1):37-51
Trainer Academy
©2023

Chapter 1
TheCHAPTER
Skeletal11System
Cardiorespiratory Fitness
Assessments
John Lindala, MS
189 CARDIORE SP IRATO RY
F IT NE SS ASSE SSMEN TS
Chapter 1
Introduction
The Skeletal System
Fitness professionals routinely assess the cardiorespiratory fitness level of clients. Cardiorespiratory
Anna
fitness D’Annunzio,
assessments MS and maximal exercise tests designed to provide baseline
include submaximal
information and progress measurements throughout the duration of the training program.
Cardiorespiratory fitness is the maximal capacity of the body’s circulatory and respiratory systems
to provide oxygenated blood to the muscles during physical activity.1 It is vital to prolong good
health and optimize activities of daily living. Studies have shown a pronounced effect from the
role of cardiorespiratory fitness in chronic disease prevention and as a result, it should be a priority
in any fitness regimen.1, 2
Properly gauging cardiorespiratory fitness can be accomplished through a battery of tests with
data readily available to compare results based on age, gender, and potentially body weight. The
key measurables for most tests include heart rate and breathing rate to determine maximal oxygen
uptake or V̇O2 max.2
The V̇O2 max is the maximum amount of oxygen the body can utilize during intense exercise,
measured in milliliters of oxygen used per kilogram of body weight per minute (ml/kg/min). Overall,
a correct assessment of V̇O2 max is the gold standard in terms of measuring aerobic fitness.
Assessment Sequencing
When determining the optimal sequencing of assessments, the National Strength and Conditioning
Association recommends the following:
1. Resting measures such as heart rate, body composition, and blood pressure.
2. Agility tests
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3. Maximal power and strength tests

4. Muscular endurance tests
5. Fatiguing Anaerobic tests
6. Aerobic tests
The reasoning behind this sequence is based on exercise fatigue and recovery along the energy
metabolism pathway. The earlier tests fatigue the fast-acting metabolic pathways and require a
short rest period to be replenished.

Chapter 1
As the assessments begin taxing the glycolytic pathways, recovery requirements grow to several
The Skeletal System

minutes between tests. The aerobic tests tax the oxidative metabolic pathway and may
Cardiorespiratory Fitness Assessments 192 take up
to 24 hours to fully recover.
Anna
This D’Annunzio,
of tests basedMS
As the assessments begin taxing the glycolytic pathways, recovery requirements grow to
sequencing on energy metabolism is designed to optimize performance
several minutes between tests. The aerobic tests tax the oxidative metabolic pathway and may
throughout every
take up to 24stage
hours of testing.
to fully
3
recover.
This sequencing of tests based on energy metabolism is designed to optimize performance

Optimal test sequencing yields the most accurate results; however, fitness professionals should
throughout every stage of testing.3
know that some flexibility exists when sequencing these assessments depending on the needs of
Optimal
the participant, thetesttiming
sequencing yields the
involved, andmost accurate
access results; however, fitness professionals
to equipment.
should know that some flexibility exists when sequencing these assessments depending on the
needs of the participant, the timing involved, and access to equipment.
Test selection for determining cardiorespiratory fitness depends on the overall status of the
participant Test
andselection
the availability of specific
for determining modalities,
cardiorespiratory asdepends
fitness some may
on theprove
overallto be cost-prohibitive
status of the
participant and the availability of specific modalities, as some may prove to be cost-prohibitive
or hard to access.
or hard to access.
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©2023
Trainer Academy
©2023
Chapter 1
Selecting
The SkeletalAppropriate
System Assessments
Test selection for determining cardiorespiratory fitness will equate to the overall status of the
Anna D’Annunzio,
participant and the availabilityMS
of specific modalities as some may prove to be cost prohibitive
or hard to access.
The relationship between heart rate and oxygen uptake is mostly linear. As a result, relatively
accurate estimates of V̇O2 max can be made employing submaximal testing and ventilatory
thresholds.4,5,6 Usage of submaximal testing, as opposed to maximal testing, is more user friendly
and greatly reduces the risk of injury or harm to the user. Specifically, when thinking of untrained
or sedentary individuals, the risk associated with maximal V̇O2 testing far outweighs the benefit
when a submaximal test can provide a solid estimate.
Submaximal testing can be under predictive of V̇O2 scores when working with highly trained and
athletic participants.7 Therefore, maximal testing is recommended for athletic and well-trained
populations.4
Protocols for Select Cardiorespiratory

Fitness Assessments
V̇O2 Max Testing
The relationship between heart rate and oxygen uptake is mostly linear. As a result, relatively
accurate estimates of V̇O2 max can be made utilizing submaximal testing and ventilatory
thresholds.4, 5, 6
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©2023
The utilization of submaximal testing is more user-friendly and greatly reduces the risk of injury
or harm to the user compared to maximal testing.
Specifically, when thinking of untrained or sedentary individuals, the risk associated with maximal
V̇O2 testing far outweighs the benefit when a submaximal test can provide a solid estimate.
Submaximal testing often underpredicts V̇O2 scores when working with highly trained and athletic
participants.7 Therefore, maximal testing is recommended for athletic and well-trained populations.4

Chapter 1
YMCA 3-Minute Step Test
The Skeletal System
Purpose: Sub-maximal V̇O max test
2
Anna D’Annunzio,
Equipment: 12-inch MS metronome, and optional heart rate monitor
step, stopwatch,
Metronome should be set to 96 beats per minute.
Notes:
• Allow the participant to practice stepping to the beat of the metronome.

• After completion of the 3 minutes, the participant sits down immediately onto the bench
and remains still.
• The score of the test is the participants’ one-minute post-test heart rate.
• Compare the score to the YMCA step test published chart.
A full cycle of 4 beeps equals one complete step. The participant should perform 24 steps per
minute.
Procedure:
1. Demonstrate the alternating step cadence to be performed.

2. Step one foot up onto the bench with the first beat.
3. Step the second foot up with the second beat.
4. Step one foot down onto the floor with the third beat.
5. Step the second foot onto the floor with the fourth beat.
6. Tester starts counting heart rate manually within 5 seconds of completion of test.
7. Continue counting heart rate for one full minute post-test.
8. If using a heart rate monitor, take the heart rate 1-minute post exercise. This is the “score”
used for calculations.
9. Compare Trainer
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score to the YMCA step test published chart.
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Cardiorespiratory Fitness Assessments 195
Chapter 1
The Skeletal System

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Chapter 1
1-Mile Run Test
The Skeletal
Purpose: Aerobic fitnessSystem
assessment and V̇O max estimator.
2
Anna D’Annunzio,
Equipment: MS
Stopwatch, 1.5 mile (2.4 km) flat and hard running course.
Procedure
1. Have the participant complete a proper warmup prior to the start of the test.
2. The goal is to complete the course distance in a run as quickly as possible.
3. Have the participant line up on the starting point and at the testers “go” they will begin
running.
4. Walking is allowed, if necessary, but the goal remains to finish as fast as possible.
5. Have the participant perform a cool-down walk following the completion of the test.
6. Calculate the participant’s V̇O2 max using the formula:
For males:
V̇O2 max = 91.736 – (0.1656 x body mass in kg) – (2.767 x time in minutes)
For females:
V̇O2 max = 88.020 – (0.1656x body mass in kg) – (2.767x time in minutes)
Note: time should be converted to a decimal (9 minutes and 30 seconds = 9.5).
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Chapter 1
12-Minute Run/Walk
The Skeletal
Purpose: The 12-minuteSystem
run/walk test is an easily performed test used to measure aerobic fitness
and estimate a participant’s V̇O2 max. It is the maximum distance a participant can travel in 12
minutes.
Equipment: Level track, stopwatch, cones for marking distance, or a treadmill set to 1% incline
if a running track is not available.
Procedure:
1. Have the participant complete a proper warm up prior to the start of the test.
2. The goal of the test is to complete the maximum possible distance in 12 minutes at either a
run or a walk depending on the participant’s ability level.
3. When the participant is ready, have them start, optional to the participant if time is read
out during the test.
4. Have a cone or other marker ready when time is running out and immediately mark the
participant’s position or notate their distance traveled when the 12-minute timer completes.
Notate the distance traveled in either kilometers or miles then calculate the V̇O2 max using one
of the formulas below:
Kilometers: V̇O2 max = (22.351 x kilometers) – 11.288
Miles: V̇O2 max = (35.97 x miles) – 11.29
Compare the participant’s results to readily available online charts with standardizations for age
and gender.
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Chapter 1
Astrand-Rhyming Cycle Ergometer Test
The Skeletal
Purpose: The System
Astrand-Rhyming cycle ergometer test is a submaximal aerobic fitness test. The
Astrand test uses heart rate and estimated percentage of maximal aerobic capacity to calculate
V̇OAnna
2
max. D’Annunzio, MS
Equipment: Cycle ergometer, stopwatch, heart rate monitor, or optional ECG monitor.
Procedure:
1. Have the participant warm-up on the cycle ergometer for 2 to 3 minutes at a cadence of 50
with no resistance.
2. The goal of the test is for the participant to achieve steady state heart rate over a 6-minute
period of cycling.
3. Ideal heart rate range will fall between 125 and 170 beats per minute.
Initial workload for men and women will fall in the ranges of:
• Unconditioned men- 300-600 kg-m/min

• Conditioned men- 600-900 kg-m/min
• Unconditioned women- 300-450 kg-m/min
• Conditioned women- 450-600 kg-m/min
Note: If needing to convert from watts to kg-m/min multiply the watts by 6.12.
Record the participant’s heart rate every minute during the test.
If the heart rate is not within 5 beats of each other at minutes 5 and 6 continue for an additional
minute.
If the steady state heart rate is not between 125 and 170 beats per minute, adjust the workload
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accordingly and repeat the 6-minute period.
Calculate the participant’s V̇O2 max utilizing the “workload” in kg-m/min, and heart rate steady
state “HRss.”
• Females V̇O2max = (0.00193 x workload + 0.326) / (0.769 x HRss – 56.1) x 100

• Males V̇O2max = (0.00212 x workload + 0.299) / (0.769 x HRss – 48.5) x 100

Chapter 1
Ventilatory Threshold Testing
The Skeletal System
Ventilatory threshold testing is based on the linear relationship of oxygen and carbon dioxide
Anna
during D’Annunzio,
breathing MS the onset of exercise, ventilation will match the cellular
(ventilation). With
demand for oxygen by the body meaning the body will use more oxygen. Initially the body will
increase tidal volume pulling in more oxygen per breath while breathing rate remains relatively
the same.
When exercise nears maximal intensity, breathing rate disproportionally increases compared to
oxygen intake. This increased breathing rate aids in releasing the increased production of carbon
dioxide as a byproduct of switching to anaerobic glycolysis as a primary ATP source.6, 8
Two points to consider with ventilatory threshold hold testing are the first ventilatory threshold
point (VT1) or “crossover point” and the second ventilatory threshold point (VT2) or “compensation
point.”
VT1 is the point at which blood lactate starts accumulating faster than it can be cleared by the
body. This point represents the moment oxygen demands on the body outpace the oxygen delivery
capabilities and lactate buildup begins.6
VT2 represents hyperventilation and the point at which the increased breathing rate can no
longer disperse the carbon dioxide at that rate.
The VT2 can otherwise be described as the onset of blood lactate accumulation.8
• Relative performance intensity of VT1 corresponds to the highest pace someone can sustain
for 1 to 2 hours.
• VT2 represents the maximal sustainable pace for 30 to 60 seconds.
Talk Test Trainer Academy

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Purpose: The purpose of the VT Talk Test is to establish VT1 and the associated heart rate of
the VT1 threshold.
During the test, intensity should be increased incrementally. The purpose of the test is to find
VT1, and if large changes in intensity are made, the exerciser may unintentionally pass VT1,
invalidating the test. As such, the talk test is best performed using machines with adjustable
intensities to allow precise increases in exercise intensity.

Chapter 1
Appropriate increases in intensity include an additional .5 mph, 1% grade, or 15 watts.
The
With Skeletal
each level increase,System
the heart rate steady state should also increase by approximately 5 beats
per minute.
Level increases usually happen every 60-120 seconds depending on when the heart rate steady
state is reached. Ideally, the test can be completed within 8 to 16 minutes overall.
During each level of the test, the exerciser reads or repeats a phrase. Preconstructed cue cards
with long complete sentences can be read off or the exerciser can recite a phrase from memory
such as the Pledge of Allegiance.
When the exerciser reaches an intensity where they are unable to string together 5-10 words
between deep breaths, VT1 has been determined and the test is complete.
This ability will be the determining factor in the duration of the test. At any point while below
VT1, the exerciser should be able to string together 5-10 words between deep breaths. Once
they struggle to reach 5 to 10 words consecutively the test has been completed and VT1 reached.
Equipment: Cardio modality (treadmill, cycle ergometer, elliptical, etc.), stopwatch, heart rate
monitoring equipment (watch and/or strap), cue cards with pre-determined phrases written on them.
Procedure
1. Measure pre-exercise heart rate.

2. Allow the exerciser to warm up on the modality the test will be performed on. The heart
rate should stay below 120 bpm while the tester goes over the predetermined written or
memorized phrases.
3. Once the warmup is completed, increase the intensity to bring the heart rate steady state
up to 120 bpm. On a perceived rating of exertion scale, this level should feel like a 3 or 4.
4. When a steady ©2023state is achieved, have the exerciser talk continuously for 20 to 30 seconds.
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5. Ask the exerciser if speaking was challenging or difficult at this level.

6. Proceed with incremental increases and repeat the steps until VT1 is found.
7. Notate the heart rate at VT1.
8. Allow the exerciser to cool down for 3 minutes at the warmup intensity level.
The heart rate limit established from the VT1 test delineates the base heart rate for sports
conditioning and should operate as a guide for purely aerobic conditioning vs the beginning
stages of anaerobic conditioning.9

Chapter 1
VT2 Talk Test
The Skeletal
The VT2 System
Talk Test will determine the point at which blood lactate rapidly accumulates inside an
exerciser’s body. The VT2 test is optimally performed using lactate analyzers that continuously
Annablood
measure D’Annunzio,
lactate levels. MS
The equipment required is both cost and procedurally-prohibitive for most fitness training
professionals, so VT2 field tests are a practical alternative to estimate VT2.
Equipment: Cardio modality (treadmill, cycle ergometer, elliptical, etc.), stopwatch, and heart
rate monitoring equipment (watch and/or strap).
Procedure
1. Before starting, review the test purpose and discuss the intensity level the test will be performed
at. The goal is maximum sustained intensity for 20 minutes.
2. Have the participant perform a 3–5-minute warmup on the modality being used for the VT2
test. Heart rate should remain at or below 120 bpm.
3. Increase the intensity to the predetermined level.
4. The participant can adjust the intensity as needed during the first few minutes of the test
so they can finish the entire 20-minute test.
5. During the last 5 minutes of the test, record the participant’s heart rate each minute.
6. Once completed, find the average heart rate for the last 5 minutes of the test.
7. Multiply the average heart rate by .95 to determine the VT2 estimate.
VT2 results
The limit established by the VT2 test should mark the maximum efficiency of the individual in
their ability to buffer lactic acid out of the body through oxygen delivery.10
The VT2 limit establishes

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©2023 guidelines for high-intensity interval training (short-duration sprint
repeats) which can improve lactic acid buffering efficiency. The improved efficiency has been
shown to increase V̇O2 max over time.11

Chapter 1
Selecting
The SkeletalaSystem
Testing Modality
Identifying the right cardio modality to use for testing depends on the participant’s profile. Comfort
Anna
with D’Annunzio,
a particular modality due MS
to prior use or application to their chosen sport will typically be
the determining factors.
In certain situations, due to lack of access to equipment or risk of injury, accommodations can
be made.
Below is a breakdown of common modalities with the pros and cons for testing based on a user’s
capabilities and common checkpoints for form while using the modality.
For upper extremity injuries a traditional cycle ergometer and potentially a stair stepper can be
utilized to limit exertion on the injury.
For lower extremity injuries, an upper body only cycle ergometer can be utilized for a
submaximal test.
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Chapter 1
Treadmill
The Skeletal System
Pros
• Direct carryover to real world activities
• Ideal modality for many sports applications
• Ideal for maximal intensity testing procedures
Cons
• High impact modality

• Potentially too intense for beginners above walking speed·
• May be unsuitable for clients with lower extremity injuries
Form Checkpoints
1. Toes pointing straight ahead on foot strike.

2. Foot strike plants directly under the body.
3. Knee points in the same direction as toes.
4. Hips face forward.
5. Torso remains tall without shoulder rounding.
6. Arms swing front-to-back without crossing midline.
7. Eyes stay parallel to the floor with head up.
Coaching Cues
1. Advise the participant to try to utilize a normal stride, not adjusting for being on a machine.
2. Placing the treadmill
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3. Since the belt moves below the participant, remind them to make a full cycle of the legs
and pick heels up with each stride.

Chapter 1
Stair Stepper
The Skeletal System
Pros
• Low impact
• Varied intensity capabilities
Cons
• The learning curve for proper form

• The bulkiness of the machine can make communication and testing procedures difficult
Form Checkpoints
1. Body stays upright throughout use.

2. Lightly hold handrails or let arms swing freely, handrails should not support bodyweight.
3. Hips should stay directly under the torso.
4. Plant and step through the entire foot allowing the heel to drop
Coaching Cues
1. Inform the user to treat the stepper like a real-world stairwell and not rely on the handrail.
2. Fully extend the leg every step in an attempt to drive the stairs down to better simulate
moving up stairs.
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Chapter 1
Elliptical
The Skeletal System
Pros
• Low impact
• Total body exercise
Cons
• Unnatural movement pattern

• Lower overall exertion makes it less ideal for maximal-intensity tests
Form Checkpoints
1. Always maintain a tall upright posture.

2. Shoulders should stay relaxed and depressed.
3. Maintain a small bend in the elbow.
4. Loose grip on the handles.
5. Hips stay neutral under the torso.
6. Toes and knees point forward.
Coaching Cues
1. Remind the participant that the elliptical is a total body combination machine. The lower
and upper body should work in unison.
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Chapter 1
Rowing Machine
The Skeletal System
Pros
• Low impact
• Effective for high-intensity testing
Cons
• Steeper learning curve than other modalities

• Potential users more limited due to injury risk
• Not advised for individuals with a history of lower back injury
Form Checkpoints
1. The starting position is straight arms holding the handle with a prone grip and bent knees
with feet in the stirrups. Shoulders should be slightly in front of hips.
2. In the drive phase, the knees extend near-maximally first, followed by hips hinging and the
torso leaning back with a neutral spine, and finally, the arms follow through and pull the
handle to meet the torso at the lower chest.
3. The recovery phase should be a mirror image of the drive phase.
Coaching Cues
1. The rowing form should activate the gluteal muscle group and feel similar to a deadlift
movement.
2. Maintain a neutral spine throughout the motion.
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Chapter 1
Cycle Ergometer
The Skeletal System
Pros
• Low impact
• High intensity
• Setup facilitates easy monitoring
Cons
• Test results will vary if a client is a trained cyclist independent of CRS fitness
Form Checkpoints
1. On the extension phase the driving leg should near maximal extension.
2. Back should remain flat throughout use.
3. Relaxed grip on the handlebars to ensure the upper body doesn’t perform isometric exercise
and hold tension.
4. Opposing limbs should look symmetrical from in front or back of the ergometer.
Coaching Cues
1. If using an upper body cycle ergometer, the same cues apply to the upper extremities vs lower
extremities on a traditional cycle ergometer.
2. Align the seat height so at full extension the participant’s knees are only slightly flexed.
3. The handlebars are there for balance support and shouldn’t absorb a lot of body
weight. Additionally, keep the feet and legs relaxed for an upper body ergometer.
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Chapter 1
References
The Skeletal System
1. Myers, J.; Kokkinos, P.; Nyelin, E. Physical Activity, Cardiorespiratory Fitness, and the Metabolic
Anna D’Annunzio,
Syndrome. MS
Nutrients 2019, 11, 1652.
2. Shete, A; Bute, S; Deshmukh, P. A Study of VO2 Max and Body Fat Percentage in Female Athletes.
J Clin Diagn Res. 2014 Dec;8(12):BC01-3.
3. Huff, G; Triplett, N. Essentials of Strength Training and Conditioning. National Strength and
Conditioning Association. Human Kinetics, 2016, 10, 256.
4. Marsh, C. Evaluation of the American College of Sports Medicine Submaximal Treadmill Running
Test for Predicting V̇ o2max. Journal of Strength and Conditioning Research: 2012, 26(2), 548-554.
5. Nunes, R; Castro, J; Silva, L; Silva, J; Godoy, E; Lima, V; Venturini, G; Oliveira, F; Vale, R. Estimation
of Specific VO2max for Elderly in Cycle Ergometer. Journal of Human Sport and Exercise, 2017,
12(4), 1199-1207.
6. O’Leary, B; Stavrianeas, S. Respiratory Rate and the Ventilatory Threshold in Untrained Sedentary
Participants. Journal of Exercise Physiology, 2012, 15(4).
7. Jamnick, N; By, S; Pettitt, C; Pettitt, R. Comparison of the YMCA and a Custom Submaximal
Exercise Test for Determining VO2 max. Medicine and Science in Sports and Exercise, 2015.
8. Mezzani, A. Cardiopulmonary Exercise Testing: Basics of Methodology and Measurements. Annals

of the American Thoracic Society, 2017, 14(1).
9. Muñoz, I; Seiler, S; Bautista, J; España, J; Larumbe, E; Esteve-Lanao, J. Does Polarized Training

Improve Performance in Recreational Runners?, International Journal of Sports Physiology and
Performance, 2014 9(2), 265-272.
10. Astorino T; Edmunds R; Clark, A; King, L; Gallant, R; Namm, S; Fischer, A; Wood, KM. High-
Intensity Interval Training Increases Cardiac Output and VO2max. Med Sci Sports Exerc. 2017
Feb;49(2):265-273.
11. Milanović,Trainer
Z; Sporiš,
Academy
G; Weston, M; Effectiveness of High-Intensity Interval Training (HIT) and
Continuous Endurance Training for VO2max Improvements: A Systematic Review and Meta-
©2023
Analysis of Controlled Trials. Sports Med, 2015, 45, 1469–1481.

Chapter 1
TheCHAPTER
Skeletal12System
Anna D’Annunzio,
Principles ofMSAerobic
Training Programs
AJ Mortara, MS
208
Principles of Aerobic Training Programs
Chapter 1
Introduction
The Skeletal System
Proper programming of aerobic exercise is an integral part of any comprehensive fitness plan.
Annawhen
Knowing D’Annunzio, MS different aerobic modalities will help fitness professionals
and how to incorporate
guide their clients toward specific goals and health markers.
In addition, knowing which adaptations aerobic training creates establishes a deeper understanding
of the benefits of aerobic conditioning on a physiological level.
The minimum guidelines for aerobic exercise, created by the American College of Sports Medicine
in 2007, and re-affirmed by the Department of Health and Human services in 2018, are as follows:
1. 150—300 minutes of moderate-intensity physical activity
or
2. 75—150 minutes of vigorous-intensity physical activity per week.
While these are the minimum recommended aerobic exercise total duration each week, more
aerobic activity provides greater proportional benefit.
Most clients will benefit from a combination of aerobic and resistance training. This is referred to
as concurrent training and requires specific programming considerations. The most critical factor
for concurrent training is fatigue management, as overall training volume is high and clients may
not be able to sustain the program for prolonged mesocycles.
Therefore, performing aerobic exercise and strength training in the same session is not advisable
for beginner or intermediate clients. Older research has concluded that aerobic exercise has an
inhibitory effect on muscular strength and hypertrophy adaptations.2 However, newer research
calls this intoTrainer
question.
Academy
©2023
Recent research concludes that the interference effect is nullified if cardio and strength workouts
are not performed in the same session when training volume is equated. Thus, a key programming
question is how to integrate both aerobic and strength training without sacrificing the training
volume or quality of either.

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Acute
The Physiological
Skeletal System Responses to Aerobic
Exercise
Acute responses to aerobic exercise can be divided by system: cardiovascular, respiratory, endocrine,
and metabolic responses. The extent and duration of these responses are linearly related to exercise
intensity.
In laboratory conditions, aerobic exercise intensity is quantified as a percentage of V̇O2 max.

V̇O2 max is defined as the maximum volume of oxygen that can be consumed (utilized by the
tissues) per minute. Another commonly used measurement of intensity is heart rate [HR].
Cardiovascular Responses
The cardiovascular system (heart and vessels) responds to exercise by increasing the delivery of
oxygen to working muscles in order to maintain exercise performance. This includes vasodilation
of the blood vessels and an increase in the work capacity of the heart muscle.
At rest, the sympathetic and parasympathetic nervous systems create a balance between stimulation
and inhibition of the heart respectively. As exercise intensity increases, the sympathetic nervous
system increases stimulation, while the parasympathetic system decreases inhibition. The result
is an increase in heart rate and stroke volume.
Stroke volume describes the amount of blood ejected from the left ventricle per heartbeat. The product
of HR x SV is referred to as cardiac output [CO, Q̇]. Heart rate is measured in beats per minute, and
stroke volume is measured in liters per beat; therefore, the units of Q̇ are liters per minute.
Stroke volume increases as a result of greater stimulation from the sympathetic nervous system
during exercise. However, there is also a mechanical stimulus responsible for the increase in SV.
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The increase in SV results in an increase in the amount of blood which returns to the heart via
the veins: this is referred to as venous return.
The Frank-Starling Mechanism
The increased venous return during exercise results in the expansion of the cardiac muscle tissue.
This results in stored elastic potential energy within the tissue. During heart muscle contraction,
elastic energy is released which increases the amount of blood ejected from the ventricles.

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This increased blood volume ejection due to the increased elastic energy in the heart is known as
The Skeletal System

the Frank-Starling mechanism and assists the body during exercise in providing sufficient oxygen.
Thus far has been a discussion about changes specifically in the heart during aerobic exercise, but
Anna
changes alsoD’Annunzio, MS
occur in the vessels themselves. At the onset of exercise, a vasodilator, nitric oxide,
secretes within the vessel walls, increasing their inner diameter. This increase in inner diameter
reduces the resistance to blood flow; resistance to flow is referred to as total peripheral resistance
[TPR], and also contributes to the overall increase in stroke volume. At the same time, skeletal
muscle contracts around veins; this constricts them, increasing venous pressure. This increase in
venous pressure aids in venous return.
Finally, active respiration (heavy breathing during exercise) increases venous return by creating
a pressure gradient between the thorax and the abdomen, referred to as the respiratory pump.
During exercise, blood flow redirects away from the core of the body, towards skeletal muscle to
aid in exercise performance.
Blood pressure [BP] (measured in mmHg) is the force blood exerts on vessel walls; it is measured
as the ratio of force during contraction (systole) versus relaxation (diastole). During aerobic
exercise, systolic BP increases linearly with exercise intensity. However, in a healthy heart, diastolic
BP changes very little.
As a result, the mean arterial pressure [MAP] increases linearly with exercise intensity. MAP
cannot be calculated as the simple arithmetic average of systole and diastole because the heart
spends more time in diastole than systole. Therefore, the following formula is used:
MAP = DBP + [.333 x (SBP – DBP)]
A metric of the oxygen demand placed on the heart is the rate pressure product [RPP] and can
be expressed as the product of HR x SBP.
Key Formulas:
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• Q̇ = HR x SV
• MAP = DBP + [.333 x (SBP – DBP)]
• RPP = HR x SBP

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Respiratory Responses
The Skeletal System
Respiratory responses to exercise include an increase in breathing rate and depth and are mostly
Anna
linear D’Annunzio,
in nature. MS maximal levels, respiratory rate increases exponentially to
As exercise reaches
help buffer body pH in response to an increasing amount of lactate in the cells and bloodstream.
At rest, the volume of air inhaled and exhaled naturally is referred to as tidal volume, with the
average breathing rate at rest approximately 12 breaths per minute. Breathing frequency reaches as
high as 45 breaths per minute as exercise reaches maximal levels, with breathing depth increasing
steadily until it plateaus at about 70 percent V̇O2 max.9
The Respiratory Exchange Ratio [RER or RQ] describes the ratio of carbon dioxide exhaled
to the volume of oxygen consumed. Metabolic gas analyzers measure the RER at the mouth in
laboratory settings. The ratio is expressed via the following formula:
RER = V̇CO2/V̇O2
The RER is an estimate of fuel utilization at rest and during exercise. At rest, a non-fasted person
with a normal (non-ketogenic) diet has an average RER of .82, which means that 60 percent
of their total energy production derives from fat, while the remaining 40 percent derives from
carbohydrates.7 As exercise intensity increases the preferred energy source shifts from fat to
carbohydrates.
It is important to note that RER values above 1.0 are routinely observed in laboratory testing. This
is due to the fact that RER is measured at the mouth and is therefore affected by breathing
rate. At a certain exercise intensity, ventilation increases exponentially, not linearly with exercise
intensity, this is referred to as the ventilatory threshold (VT).
This does not occur due to oxygen demand. Rather the high breathing rate is necessary to maintain
pH when high levels of lactate are being produced. As a result, RER levels at maximum exercise
are often observed ©2023to be 1.1 or higher.
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Metabolic Responses
During aerobic exercise, the body supplies ATP to working muscles through both aerobic and
anaerobic means, with anaerobic means supplying the majority of ATP at higher intensities. Thus,
the higher the exercise intensity, the greater reliance on anaerobic sources of ATP (phosphocreatine
and glycolysis).

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However, these sources are finite, meaning that high intensity exercise can only be maintained
The Skeletal System

for a relatively short period of time. Ultimately, the onset of fatigue is, at least in part, due to the
availability of carbohydrates and fats for oxidation in working muscles to produce sufficient ATP.
Endocrine Responses
During exercise the endocrine system facilitates fuel availability and uptake by muscle cells.
The hormones of interest include the following: epinephrine, norepinephrine, glucagon, insulin,
cortisol, and growth hormone.
Glucagon and Insulin
The pancreas produces and circulates glucagon and insulin. Glucagon and insulin are regulatory
hormones that control blood glucose levels by moving glucose molecules in and out of cells.
Specifically, insulin lowers blood glucose levels by binding to glucose molecules and transporting
them across cell membranes via specialized channels called GLUT4 transporters. In essence,
insulin lowers blood glucose and increases glucose availability in cells for glycolysis.
Glucagon does precisely the opposite, it increases blood glucose levels by moving glucose molecules
out of cells and into the bloodstream. Glucagon also stimulates the breakdown of glycogen (the
stored form of glucose) into glucose.
During exercise, blood concentrations of insulin decrease, and other mechanisms which move
glucose into cells increase. Furthermore, glucagon levels increase, improving insulin sensitivity.
The combination of the two also leads to an increase in fat breakdown (lipolysis), resulting in
more fatty acids available for fuel.
Cortisol and Growth Hormone
The adrenal cortex releases cortisol, a hormone with wide-ranging effects. In the context of exercise,
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cortisol primarily stimulates the conversion of amino acids into fuel sources and intermediates
for aerobic exercise.
Cortisol encourages the breakdown of muscle proteins in order to facilitate the conversion of
some amino acids into glucose or intermediates for the Krebs cycle. Cortisol concentrations are
directly related to exercise intensity, with higher intensity correlating to higher cortisol levels in
the blood.3 Growth hormone is secreted from the anterior pituitary gland and increases cortisol
and glucagon levels in the blood.

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Epinephrine and Norepinephrine
The
Lastly,Skeletal
epinephrine andSystem
norepinephrine (collectively referred to as the catecholamines) are
stimulatory and inhibitory endocrine responses respectively; they are colloquially referred to as the
Anna
“fight D’Annunzio,
or flight” MS medulla releases these hormones when the body perceives
hormones. The adrenal
stress, such as in physical exercise. They increase heart rate and blood pressure, delivering more
oxygenated blood to working muscles in order to maintain exercise performance.
In summary, exercise leads to increases in glucagon, cortisol, growth hormone, epinephrine, and
norepinephrine concentrations. Plasma concentrations of these hormones directly correlate to
exercise intensity. Their collective effects facilitate the availability of oxygen and other nutrients
necessary for the production of the ATP.
Long-term Adaptations to Aerobic

Exercise
Long-term adaptations to aerobic exercise can be divided into the following categories:
cardiovascular, respiratory, musculoskeletal, metabolic, and endocrine. This section reviews each
of these systems as well as examines the effects on body composition and exercise performance.
Understanding these effects aids the personal trainer as they set long-term goals with their clients,
as well as guide programmatic decisions at the mesocycle and macrocycle level.
Cardiovascular Adaptations
Maximal aerobic power is expressed by the Fick Equation:
V̇O2 (L/min)Trainer
= ©2023
Q̇Academy
x a- O2 difference.
As previously mentioned, cardiac output [Q̇ ] is the product of stroke volume and heart rate,
and measures the amount of blood, in liters, pumped into systemic circulation per minute. The
a- O2 difference is the difference in oxygen concentration in arterial versus venous blood, thus it
measures how much oxygen the cells extract from the blood. The Fick equation represents both
oxygen delivery (Q̇ ) and oxygen extraction (a- O2 difference). Chronic adaptations to aerobic
exercise occur in both oxygen delivery and extraction.

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The primary adaptations in cardiac output occur via increases in stroke volume. Long-term
The Skeletal System

cardiovascular exercise results in hypertrophy of the cardiac muscle cells, specifically in the left
ventricle.
Anna
This results D’Annunzio, MScavity and a stronger contractile function of the ventricle walls.
in a larger left ventricle
Meanwhile, filling time (the period of time in which the bicuspid and tricuspid valves are open)
increases. An increase in blood volume also results from chronic cardiovascular training.11 These
factors combine to increase stroke volume.
Maximal heart rate is largely genetic and age dependent and cannot be changed via exercise.
However, at resting and submaximal exercise, a reduction in heart rate is observed. Three
mechanisms explain this phenomenon:
• Increase in parasympathetic stimulation

• Decrease in sympathetic stimulation
• Lower intrinsic heart rate4
The effect of long-term aerobic exercise on blood pressure varies based upon resting BP and
overall health of the client. For individuals with normal blood pressure, average changes are very
small. On the other hand, in individuals with hypertension (SBP> 140 OR DBP > 90 mmHg)
scientists have observed more substantial reductions.8
Furthermore, the reductions in blood pressure following a bout of aerobic exercise have been
observed and are termed “postexercise hypotension.” Finally, as the left ventricle hypertrophies,
SBP decreases for a given submaximal workload. This demonstrates an improved aerobic capacity
in response to long-term term training.
Respiratory Adaptations
Respiratory adaptations
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in other systems. However, a few changes at both sub-maximal and maximal work rates occur in
minute ventilation, and ventilatory efficiency.
Minute ventilation (V̇E) decreases at submaximal work rates by a significant amount.4 However,

V̇E increases at maximal work rates. This is because at submaximal work rates tidal volumes
increase but breathing frequency either stays the same or slightly decreases. In maximal work
rates both frequency and tidal volume increase.

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Another adaptation to long-term aerobic training is hypertrophy of the diaphragm and other
The Skeletal System

muscles used during active breathing. This results in a decreased oxygen cost of ventilation, thus
an increase in efficiency. This efficiency frees up more oxygen for use in other muscles while still
meeting the oxygen needs of the muscles used in active breathing.
Musculoskeletal Adaptations
Aerobic activity stimulates type I muscle fibers with little to no effect on type IIa or IIx
fibers.11 Research evidence suggests that some mild shifting in fiber type may occur, resulting in
a shift away from IIx and IIa towards type I fiber types.
However, the extent to which this occurs, and the duration of training needed to stimulate it
remain unclear.10 This potential shift would result in a decrease in the maximum velocity of
shortening and peak force production of a muscle fiber along with an increase in fiber efficiency,
aerobic capacity and fatigue resistance.
Bone and Connective Tissue Adaptations

Bone mineral density [BMD] describes the amount of bone mineral content per unit volume
of bone tissue. BMD is the standard measurement of bone strength; it rises through childhood
and early adulthood, plateaus in middle age, and declines later in life.
Resistance training exercises, specifically activities which load the hips and axial skeleton, have
been shown to be the most effective.5 However, aerobic activities, such as running, have also been
shown to improve BMD.5 Lower impact activities such as walking, aquatics, and upper body
cycling have not been found to be beneficial for bone adaptation.
Metabolic Adaptations
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Within type I muscle fibers, numerous adaptations occur that enhance the fiber’s capacity to
produce ATP aerobically. Capillary density, defined as the number of capillaries surrounding one
muscle fiber, increases substantially over a period of a few weeks to two months. This increases
oxygen supply and the rate of waste removal.
There is also an increase in the concentration of cellular myoglobin, a molecule that transports
oxygen from the cell wall to the mitochondria. Other enzymes and molecular transporters increase

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in intracellular concentration as well. Mitochondrial density also increases, albeit more slowly
The Skeletal System

than myoglobin concentrations or capillary density.
In addition to oxidative capacity, type I muscle fibers also increase glycogen storage. Glycogen, the
Anna
stored formD’Annunzio, MS
of glucose, produces ATP via the anaerobic pathway, through glycolysis. Glycolysis
provides a fast means of producing ATP and is used by cells in conjunction with aerobic metabolism
to meet ATP demands.
In summary, long-term aerobic exercise training results in increased capillary density, myoglobin,
oxidative enzymes, and mitochondrial density. The collective effect improves the fiber’s ability to
utilize oxygen to produce ATP.
Measuring Aerobic Intensity

Direct measurement of aerobic power output (V̇O2) is not practical outside of laboratory conditions.
However, heart rate correlates strongly to V̇O2 and is easily measured manually or with optical
or electrical monitors. Maximal heart rate directly relates to age and can be calculated through
various equations, the simplest of which is the age-predicted maximal heart rate formula:
APMHR = 220 – AGE
This equation has been shown to be accurate within approximately 10 – 15 beats.11
A more accurate measurement is the Karvonen formula or heart rate reserve method (HRR),
which incorporates resting heart rate (RHR) instead of using age-predicted max heart rate. The
Karvonen formula is:
HRR = APMHR – RHR
Target HR (THR) ©2023 = (HRR x exercise intensity) + RHR

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To accurately measure resting heart rate, clients must measure their heart rate early in the morning,
typically immediately after waking up naturally, prior to the ingestion of any stimulants such as
caffeine.

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Subjective Measurements of Aerobic Intensity
The Skeletal System
Subjective measurements of aerobic exercise intensity are also available, such as the talk test, the
rateAnna D’Annunzio,
of perceived MS
exertion (RPE), and the Borg scale.
The Talk Test
The Talk Test measures intensity based upon the ease with which the client can carry a conversation
during aerobic exercise.
If a client can carry a full conversation with no difficulty, intensity is likely low. On the other
hand, if they are unable to speak at all, intensity is high, bordering on maximal.
The Talk Test breaks down as follows:
Low intensity: If the client can easily carry on a full conversation, sing, or recite a poem during
exercise, they are likely working at a low intensity level.
Moderate intensity: If the client can still talk comfortably but need to take breaths between
sentences or phrases, they are likely working at a moderate intensity level.
High intensity: If the client can only speak a few words or a short sentence before needing to
catch their breath, they are likely working at a high intensity level.
The Borg Scale
The Borg Scale, also known as the Borg Rating of Perceived Exertion (RPE) scale, is a widely-
used tool for measuring aerobic exercise intensity. Developed by Swedish psychologist Gunnar
Borg in the early 1980s, this subjective scale helps individuals gauge their own level of exertion
during physical activity.
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The Borg Scale ranges from 6 to 20, with each number corresponding to a description of perceived
exertion. The scale breaks down as follows:
• 6: No exertion at all, equivalent to resting.

• 7-8: Very, very light exertion.
• 9-10: Very light exertion, similar to light walking or stretching.
• 11-12: Fairly light exertion, comfortable and easy to maintain.

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• 13-14: Somewhat hard exertion, noticeable but manageable effort.
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•
•
15-16: Hard exertion, challenging and requires a lot of effort.
17-18: Very hard exertion, very strenuous and difficult to maintain.
• 19: Extremely hard exertion, close to maximal effort.
20: Maximal MS
exertion, cannot continue for more than a few seconds.
Modified Borg/RPE Scale
A more common RPE scale is the modified 0—10 scale. In either case, clients subjectively report
their level of exertion, which can be correlated to low, medium, or high intensity.
• 0: No exertion at all, equivalent to resting.

• 1: Very light exertion, barely noticeable effort.
• 2: Light exertion, similar to a slow walk or gentle stretching.
• 3: Moderate exertion, comfortable and easy to maintain, such as a brisk walk.
• 4: Somewhat hard exertion, noticeable effort but still manageable.
• 5: Hard exertion, challenging but sustainable for some time.
• 6: Very hard exertion, very strenuous and difficult to maintain for long periods.
• 7: Extremely hard exertion, near maximal effort, only sustainable for short durations.
• 8-9: Very, very hard exertion, extremely difficult to maintain.
• 10: Maximal exertion, the highest level of effort, cannot continue for more than a few seconds.
Aerobic Training Protocols

As with all exercise programs, the principles of specificity, overload, and periodization apply.
The principle of specificity states that the body will adapt to the stimulus to which it is exposed,
meaning that in order to trigger adaptations in specific muscle groups and systems, they must
be targeted during training.
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The principle of overload states that these muscle groups and systems must be exposed to a
greater level of exertion than normal in order for them to adapt. This can be in the form of greater
intensity, and/or greater duration of the stimulus.
Lastly, the principle of periodization states that overload can only be maintained through specific,
measured, and gradual increases in stimulus over time. Furthermore, periodization also states that
the body must experience periodic reductions in stimulus in order to re-sensitize the adaptive
pathways and allow for sufficient recovery from training.

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The basic variables of exercise program design are: frequency, intensity, and duration. Frequency
The Skeletal System

refers to the number of aerobic sessions per week. Intensity is a measurement of how hard a
training session is, as mentioned it is measured either objectively (APMHR, HRR, etc..) or
subjectively (talk test, RPE). Duration refers to the minutes of actual training, warm-ups and
Anna D’Annunzio,
cool-downs are not included. MS
Frequency of Aerobic Training

The number of aerobic training sessions per week will depend upon client training status and
fatigue management. The minimum recommended guidelines for aerobic exercise are 150—300
minutes of moderate intensity exercise per week or 75—150 minutes of vigorous activity per week.
Beginner clients will focus more on moderate intensity sessions spread evenly throughout the
week. As clients progress, vigorous sessions can be added, replacing moderate sessions. If clients
manage their fatigue well via proper sleep and nutrition, weekly progressions are expected.
Intensity of Aerobic Training

Training zones vary based upon the calculations used to gather intensity data. Using a percentage of
APMHR from between 64 percent to 95 percent will provide an appropriate stimulus to improve
aerobic fitness. If HRR is used, a smaller range, 40 percent to 89 percent should be used. When
creating an aerobic training protocol for clients, calculate a target heart rate range by using either
formula twice, a low end, and a high end. Consider the example below, using the HRR formula.
A.J. is a 42 year old male. His resting heart rate is 80 bpm. If his training zone is between 40
percent and 89 percent of HRR then his training zone is calculated in the following steps:
APMHR = 220 - 42 = 178 bpm

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HRR = 178 – 80 = 98 bpm
THRlow end = (98 x .4) + 80 = 119.2 bpm
THRhigh end = (98 x .89) + 80 = 167.22 bpm
Based on the above, A.J. should have a target heart rate between 119 and 167 beats per minute,
rounded to the nearest digit.

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Most clients will have little familiarity with subjective exercise scales, as a result their initial RPE
The Skeletal System

reports will be quite inaccurate. This is further complicated by the fact that many novice exercisers
have not experienced true maximal or near maximal level exercise, so they cannot accurately say
what a “10 out of 10” feels like.
However, research in the last five years has shown that repeated use of the RPE scale during
the same exercise modality improves its reliability and validity.6 Combining RPE and HR
measurements will accelerate this process.
Heart Rate Zones
Heart Rate Zones are another method of assigning aerobic intensity. They correspond to ranges
of heart rate as a percentage of maximal heart rate. Assigning intensity based on heart rate zones
can be a useful way to map out the right workout intensity for a given workout.
Zone 1: Recovery or Warm-up (50-60% HRmax)
This zone represents low-intensity exercise, typically used for warm-ups, cool-downs, and recovery
sessions.
Zone 2: Aerobic or Base Training (60-70% HRmax)
This zone corresponds to moderate-intensity exercise, where the body primarily uses aerobic
energy systems. Training in this zone can improve endurance and cardiovascular efficiency.
Zone 3: Tempo or Threshold Training (70-80% HRmax)
This zone represents a transition between aerobic and anaerobic energy systems. Training in this
zone can improve lactate threshold, increase aerobic capacity, and enhance overall fitness.
Zone 4: Sub-maximal
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This zone corresponds to high-intensity exercise, where the body relies more on anaerobic energy
systems. Training in this zone can improve speed, power, and muscular strength.
Zone 5: Maximal or Redline (90-100% MHR)
This zone represents maximal or near-maximal effort. Clients will be unable to maintain this
intensity for more than several seconds. Training in this zone can improve neuromuscular
coordination, speed, and power.

221
Chapter 1
Wearable
The Skeletal Aerobic
System Equipment
(Fitness Trackers)
The last two decades have seen a boon in wearable exercise technology including accelerometers,
pedometers, electrical and optical heart rate monitors, and GPS units. The wealth of options has
driven the cost down, making devices practical and affordable for the average consumer.
Accelerometers and pedometers measure activity via a pendulum which swings in time with each
stride, completing an electrical circuit and allowing a microchip to track. They are highly effective
at measuring steps, but less accurate at quantifying other forms of physical activity. Electrical
heart rate monitors measure heart rate via a chest strap, which detects electrical activity in the
heart and then calculates heart beats per minute.
Optical heart rate monitors measure heart rate via infrared measurement of blood vessel perfusion.
These are typically worn on the wrist via smartwatch. They have been shown to be very accurate
for steady state exercise, with a higher error rate during interval exercise. Lastly, GPS trackers
connect to a network of satellites and triangulate position, direction, speed and other kinematic
variables.
Wearable technology, such as those mentioned above, can provide trainers a wealth of quantitative
data regarding clients’ performance, both during sessions and beyond. Quite a few wearables even
track recovery variables such as resting heart rate, sleep quantity and quality. They can also be used
to estimate basal metabolism and therefore provide info for dietary programming. Given their
usefulness they are fastly becoming an essential part of every trainer’s toolkit, although there is
room for error, so consider that when using these devices.
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222
Chapter 1
Summary
The Skeletal System
Aerobic training creates many short and long-term changes in the body.
On an acute basis, the heart increases vasodilation of the blood vessels and an increase in work
capacity, resulting in greater heart rate and stroke volume. Systolic blood pressure goes up along
with respiratory rate, ATP production, epinephrine, norepinephrine, glucagon, cortisol, and
growth hormone, while insulin decreases.
Chronic cardiovascular exercise results in hypertrophy of the cardiac muscle cells, improved
aerobic capacity, an increase in oxygen efficiency, stimulation of type I muscle fibers, some small
strength changes in bone adaptation, increased capillary density, myoglobin, oxidative enzymes,
and mitochondrial density.
When prescribing cardiovascular exercise programs, fitness professionals should be aware of

general exercise principles and be able to set and track target heart rate intensities using the
modern technology available to them.
References
1. Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B. A., Macera, C. A.,
Heath, G. W., Thompson, P. D., & Bauman, A. (2007). Physical activity and public health: updated
recommendation for adults from the American College of Sports Medicine and the American Heart
Association. Medicine and science in sports and exercise, 39(8), 1423–1434. https://doi.org/10.1249/
mss.0b013e3180616b27
2. Hickson RC. Interference of strength development by simultaneously training for strength and
endurance. Eur J Appl Physiol Occup Physiol. 1980;45(2–3):255–63
Trainer Academy
3. Jacks, D., Sowash,
©2023 J., Anning, J, McGloughlin, T, & Andres, F. Effect of exercise at three exercise
intensities on salivary cortisol. J Strength Condit Res 16(2):286-289, 2002.
4. Kenney, W., Wilmore J, & Costill, D. Physiology of Sport and Exercise. 7th ed. Champaign, IL:
Human Kinetics, 2020.
5. Kohrt, W., Bloomfield, S., Little, K., Nelson, M., & Yingling V. American College of Sports Medicine
position stand: Physical activity and bone health. Medicine and Science in Sports and Exercise
36(11):1985-1996, 2004.

223
ChapterJ. M.,
6. Lea, J., O’Driscoll, 1 Hulbert, S., Scales, J., & Wiles, J. D. (2022). Convergent Validity of Ratings
of Perceived Exertion During Resistance Exercise in Healthy Participants: A Systematic Review
The Skeletal System
and Meta-Analysis. Sports medicine – open, 8(1), 2. https://doi.org/10.1186/s40798-021-00386-8
7. McArdle, W., Katch, F., & Katch, V. Exercise Physiology: Nutrition, Energy, and Human Performance. (7th
Anna D’Annunzio,
ed.) Philadelphia: Lippincott MS
Williams & Wilkins
8. Pescatello, L., Franklin, B., Fagard, R., Farquhar, W., Kelley, G., & Ray, C. American College of Sports
Medicine position stand. Exercise and hypertension. Medicine and Science in Sports and Exercise
36(3):533-553, 2004.
9. Power, S., Howley, E., & Quindry, J. (2021). Exercise Physiology: Theory and Application to Fitness and
Performance (11th). McGraw Hill LLC
10. Rico-Sanz, J., Rankinen, T., Joanisse, D., Leon, A., Skinner, J., Wilmore, J., Rao, D., & Bouchard,
C. Familial resemblance for muscle phenotypes in the HERITAGE Family Study. Med Science in Sports
and Exercise 35(8):1360-1366, 2003.
11. Schoenfeld, B. J. & Snarr, R. (2021). NSCA’s Essentials of Personal Training (3rd) Human Kinetics,
Champaign, IL.
12. Schumann, M., Feuerbacher, J. F., Sünkeler, M., Freitag, N., Rønnestad, B. R., Doma, K., & Lundberg,
T. R. (2022). Compatibility of Concurrent Aerobic and Strength Training for Skeletal Muscle
Size and Function: An Updated Systematic Review and Meta-Analysis. Sports medicine (Auckland,
N.Z.), 52(3), 601–612. https://doi.org/10.1007/s40279-021-01587-7
13. U.S. Department of Health and Human Services. Physical Activity Guidelines Advisory Committee
Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018.
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©2023

Chapter 1
TheCHAPTER
Skeletal13System
Anna D’Annunzio,
Principles ofMSFlexibility
Training Techniques
John Lindala, MS
225 P RINCIP L ES O F
F LE XIBILIT Y T RAINING T ECHNI Q UES
Chapter 1
Introduction
The Skeletal System
Flexibility training is a key component of comprehensive fitness training. Flexibility training
Anna encompass
techniques D’Annunzio, MSrange of activities that are best utilized in a specific, progressive
a very broad
fashion.
Flexibility can be defined as the ability of a joint to move through its complete ranges of motion
without injury.1,12 This ability is dependent on the optimal function of the musculature surrounding
a joint, including the ability to both flex and extend without impediment.2
For otherwise healthy individuals, greater flexibility tends to reduce the rate of injuries incurred
in training and day-to-day life.
Ideal flexibility allows muscle tissue to contract, relax, and synergistically work with all muscles
supporting a moving joint or series of moving joints.1,2
The two major concepts of flexibility are elasticity and plasticity.
Elasticity is the ability of the muscle-tendon complex to return to its original state following a
movement pattern.3 Through both lengthening through a stretch phase and contracting under
resistance, fluidity of elastic potential has been shown to reduce potential muscle injury.4 Plasticity
refers to how skeletal muscle adapts to the load and stress placed upon it.5 Muscle tissue will
grow in response to healthy stimuli or deteriorate if it is not utilized.6
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226 Principles of Flexibility Training Techniques
P RINCIP L ES
227
OF
Chapter 1
Factors
The Affecting
Skeletal System Flexibility
Factors Affecting Flexibility
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Chapter 1
Multiple factors have been shown to limit flexibility and someone’s ability to improve their
The Skeletal System

own safe range of motion. The factors most likely to affect overall flexibility include gender,
age, temperature, activity levels of the individual, repetitive motions (pattern overload), body
composition, prior injury, joint structure, and tissue extensibility.7
• Sex: Women demonstrate greater ROM than men while also exhibiting a higher stretch
tolerance, according to research.8, 16
• Age: Regardless of gender, aging has been correlated to a decrease in flexibility.9, 11
• Temperature: Heat increases flexibility and reduces injury through reduced internal friction
and decreases the energy cost of muscular contraction. Cold proves the opposite, decreasing
and limiting flexibility.10
• Activity Level: Regular activity does promote improved flexibility levels.11 Regular participation
in strength training correlates to an increase in overall flexibility in most.
• Repetitive Motions: Research shows the stress of repetitive motions often used by athletes
but not limited to them, correlates with a decrease in flexibility of the associated joints.13
• Body Composition: Greater waist circumference and obesity directly link to a reduction in
flexibility due to mechanical obstruction.9, 14
• Prior Injury: Limitations in flexibility due to injury have been well documented over time.
Reasoning includes joint disfiguration, scar tissue development, and muscular maladaptation.13, 15
• Joint Structure: All the joints of the human body fall into a specific structure wherein they
have a certain natural range of motion.17 Based purely on design, a ball and socket joint will
have a greater degree of range of motion than any other joint.15, 17
• Tissue Extensibility: Healthy muscle tissue exhibiting high extensibility and flexibility allows for
greater flexibility.15, 18 Changes in the mechanical properties of muscle fascia including thickness
and tightness directly impede overall flexibility. Tightness results from an increase in tension
in either active (muscle) or passive (tendon/ligament) structures, limiting extensibility.18,19
Benefits of Flexibility Training

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A flexibility training program has the goal of lengthening the distance between a muscle’s origin
and its insertion.19
Generally, muscle tension is inversely related to muscle length. This means that the longer the
muscle, the less tension it should hold.
The success of a flexibility training program is typically determined by measurable increases in

the range of motion as the program progresses.19

Chapter 1
Increased range of motion offers many performance advantages in sports and other physical
The Skeletal System

activities. Some sports have inherently high flexibility requirements, while other sports do not
require as much flexibility.
Anna D’Annunzio,
Nevertheless, MS sports with a less-than-normal range of motion typically
athletes across many
benefit from improved flexibility.
Another benefit of improved flexibility is injury reduction. One particular study around workplace
injuries had subjects perform a variety of stretching exercises. During the course of the study,
subjects reported reduced discomfort and demonstrated an increased range of motion, thereby
decreasing the likelihood of injury.20
Additional research suggests that both acute and chronic stretching is associated with decreased
injury frequency.33
In addition to muscle lengthening, an additional benefit of stretching lies in the alignment of

collagen fibers within the muscle tissue.
Specifically, in cases of rehabilitation and healing tissue, proper stretching has been shown to
improve recovery.19 Pain relief is another useful application for a stretching program. In certain
cases, studies indicate that stretching has been performed as well as strength training and yoga
for the relief of chronic musculoskeletal pain.19, 21
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collagen fibers within the muscle tissue.
Specifically, in cases of rehabilitation and healing tissue, proper stretchingPhas been shown
RINCIP L ES O toF
229
improve recovery. Pain relief is another useful application
19
for aY stretching
F LE XIBILIT T RAINING program. In certain
T ECHNI Q UES
cases, studies indicate that stretching has been performed as well as strength training and yoga
Chapter
for the relief 1 musculoskeletal pain.19, 21
of chronic
The Skeletal System

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Types of Stretching
Static Stretching
Static stretching involves extending the targeted joint to the point of discomfort at the end range
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of flexibility, then holding the end position for 30 seconds or more for one or more sets.24
The cumulative effect relaxes the stiffness in the targeted muscle and muscle-tendon unit.25 Research
shows that muscle-tendon unit stiffness is commonly linked to soft tissue injury.22, 23
By utilizing a slow and controlled lengthening of soft tissue, static stretching improves flexibility
in a range of motion tests, passive torque, and passive stiffness.23, 28

Chapter 1
Dynamic Stretching
The Skeletal System
Dynamic stretching involves loosening muscle tissue through a series of whole-body active range
Annaexercises.
of motion D’Annunzio, MS
The rhythmic movements of the muscles elevate body temperature, enhance
motor-unit excitation, improve kinesthetic awareness, and improve active range of motion.
Typical exercises used during a dynamic stretch include leg swings, skipping, and jumping.26 The
effects from dynamic stretching have been determined to be limited and only effective in the
acute phase when measuring stiffness and range of motion.26, 27
Ballistic Stretching
Ballistic stretching utilizes the body’s momentum through repetitive bouncing movements at or
near the end range of motion. Immediately post ballistic stretch, an increase in range of motion
has been noted, but the findings are controversial. No long-term benefit around ballistic stretching
has been found.28, 29
Of all the varieties of stretching, ballistic stretching has been shown to be potentially harmful as
a byproduct of the muscle tissue contracting when the muscle spindle is stimulated in response
to rapid stretching in the muscle.28
Proprioceptive Neuromuscular Facilitation (PNF)

Stretchers perform PNF via a series of contractions by the shortened muscle group followed by
a combination of full relaxation, followed antagonistic contraction, which facilitates muscular
inhibition by activating the Golgi tendon organs of the muscle tendon unit.30
PNF stretching performs similarly to static stretching and thus should be used in a similar
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fashion. Both will show an immediate range of motion increase if done correctly. They can both
temporarily reduce muscle strength, power, speed, and agility, especially if performed directly
before these other modalities.31, 32

Chapter 1
Recommendations
The Skeletal System for Flexibility Training
A stretching routine aims to increase the range of motion of the body by systematically targeting
Anna
muscle D’Annunzio,
tightness. The tightnessMS
can occur in two different scenarios.
Tight Muscles
Muscles may be tight because they are overly dominant or active.
The activation of the muscle at its resting length keeps the muscle in a shortened or contracted
position. In this case, the goal of the stretching program is to lengthen the shortened muscle,
thus gaining elasticity and increased potential for both extension and flexion.
Muscle Weakness and Imbalance

Muscle tightness can also occur when a muscle is too weak compared to its dominant counterpart.
In this situation, the muscle is chronically lengthened as it is not strong enough to counteract
the resting tension of the opposing muscle group.
In this scenario, activating and strengthening the weakened muscle can be beneficial, and can
improve the range of motion independent of passively stretching the dominant muscle.
Most often, these two causes of flexibility limitations occur together. As such, the most effective
stretching programs cover multiple areas of the body utilizing a range of stretching types.
Static stretches should be held for a long period of time typically 30 seconds or longer. Static
stretching is a good stretching technique for developing length along the muscle-tendon unit.
As mentioned, their
©2023 effects can be deleterious to strength and power before exercise, so these
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stretches should be placed after those exercise modalities in a training session.
Dynamic stretching is best utilized as a warm-up activity accounting for the number of benefits the
active range of motion exercises create. In the case of overly lengthened muscle tightness, dynamic
stretching proves effective in properly warming up both sides of a force couple, creating elasticity
around vulnerable joints. Dynamic stretching acutely affects tightness and is not considered the
best way to create long term benefits, but is excellent for acute training benefits.

Chapter 1
Ballistic stretching’s benefits are controversial at best and can’t be recommended above the other
The Skeletal System

varieties of stretching in any fashion.
The utilization of proprioceptive neuromuscular facilitation should be used parallel to static

Anna with
stretching D’Annunzio, MSbenefit in immediate range of motion increases.
more pronounced
For tightness created by a dominant muscle group, PNF can create an immediate range of motion
improvement. If used prior to activity ideally it is paired with a dynamic warm up immediately
following the stretching routine.
Warm Up Protocols
General Warm Up
To plan the warm up, trainers should look at the muscles, joints, and systems required within
this exercise session to pick a combination of dynamic stretches along with light movements
that prepare the body for the entire workout.
The general warm up also reveals any particular tightness the athlete is currently experiencing
which may require special attention on the day of training.
Principles of Flexibility Training Techniques 233

Example General Warm Up for Sprinting session
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Specific Warm Up
Now that the client is warmed up Trainer

and mobilized for the workout, they need to perform a
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specific warm up using the first main movement in the session with lower resistance or intensity.
This specific warm up protocol should occur before the ‘working sets’ in most typical resistance
Chapter 1
Specific Warm Up
The Skeletal
Now that System
the client is warmed up and mobilized for the workout, they need to perform a specific
warm up using the first main movement in the session with lower resistance or intensity. This
Anna
specific D’Annunzio,
warm MS
up protocol should occur before the ‘working sets’ in most typical resistance training
programs.
Performing heavy or high intensity resistance exercises requires a greater number of warm up
sets. For example, a bench presser aiming to do a 5 repetition maximum (RM) with 495lbs is
going to need more warm up sets than a novice aiming for a 5RM with 95lbs.
Example Specific Warm Up Before a 100m Sprinting Session
The client completes 3-5 warm up 100 meter sprints with increasing intensity prior to the target
intensity sprints of the same distance.
Techniques for Select Flexibility Exercises

Static Stretches
Neck Rotation (Look Right and Left)
Target muscles:
• Levator scapulae
• Suboccipitals
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Procedure:
1. With an upright torso and eyes fixed parallel to the floor, slowly rotate the head looking to
the right as far as comfortable and hold at the end range of motion for 15-30 seconds.
2. After completing the stretch hold, return to the center then repeat to the left side.
3. Repeat the stretch 3 times per side.

Chapter 1
Neck Flexion
The Skeletal
Targeted muscles: System
• Anna
SpleniusD’Annunzio,
capitis MS
• Cervicis
Procedure:
1. Start with an upright torso.

2. Slowly bring the chin towards the chest trying to tuck the chin to the sternum creating a
stretch on the back of the neck.
3. Hold for 30 seconds then relax.
4. Repeat 3-5 times.
Neck Extension
Targeted muscles:
• Deep neck flexors

• Scalenes
• Sternocleidomastoids
Procedure:
1. Start with an upright torso.

2. Contract the scapulae together while trying to slide them down the back.
3. Bring the back of the head towards the back and spine stretching the front of the throat.
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Lateral Neck Flexion
Targeted muscles:
• Levator scapulae
• Trapezius
• Sternocleidomastoids
• Scalenes

Chapter 1
Procedure:
The Skeletal
1. Start System
with an upright torso, head pointed forward.
2. Take the right hand and gently rest it on top of the left ear with the elbow tilted upwards.
3. Anna
Let the D’Annunzio,
weight of that handMS
slowly pull the right ear towards the right shoulder, stretching
out the muscles running along the side of the neck and shoulder complex.
4. Hold for 30 seconds and then switch sides.
Hands Behind Back
Targeted muscles:
• Biceps
• Anterior deltoid
• Pectoralis major/minor
Procedure:
1. Start standing with fingers interlocked behind the back and arms straight.
2. Slowly lift the arms as high as possible without letting the torso lean forward.
Pretzel
Targeted muscles:
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
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• Obliques
• Paraspinals
Procedure:
1. Start seated on the floor with the legs extended straight out in front.
2. Cross right foot over left leg, planting the right foot outside of the left knee.
3. Cross the left arm over the right thigh while placing the right arm on the floor behind

Chapter 1
the body.
The Skeletal System

4. Rotate the trunk and look over the right shoulder.
6. Switch sides with every repetition.
Repeat 3-5 times per side. MS
Supine Hamstring Stretch
Target muscles:
• Biceps femoris
• Semimembranosus
• Semitendinosus
Procedure:
1. Start lying on the floor adjacent to a doorway or wall.

2. Lift one leg to rest on the doorway or wall while keeping the opposite foot planted on the floor.
3. Extend the elevated leg while pulling the toes towards the body to create the maximally
tolerable hamstring stretch.
Forward Lunge
Target muscles:
• Hip flexors
• Rectus abdominis
Procedure:
1. Start in a Trainer
half kneeling position with shoulders stacked vertically over the knee on the floor.
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2. Opposite foot should be in a forward lunge position with 90-degree knee bend.
3. Squeeze glutes of the kneeling leg to drive the kneeling hip forward into extension while
keeping shoulder stacked over knee.

Chapter 1
Prone Quadriceps Stretch
The
TargetSkeletal
muscles: System
• Anna D’Annunzio, MS
Rectus femoris
• Vastus lateralis
• Vastus intermedius
• Vastus medialis muscles
Procedure:
1. Lie on a mat or the floor, chest facing the ground, legs straight.
2. Bend the knee and grab the ankle with the corresponding hand.
3. Pull the ankle towards the glutes.
4. Hold for 30 seconds, then switch sides.
Lying Knee to Chest
Target muscles:
• Erector spinae
• Latissimus dorsi
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
• Thoracolumbar fascia
Procedure:
1. Start lyingTrainer
on the back with legs extended and heels on the floor.
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2. This stretch can be performed with either one or both legs based on user preference.
3. Pull knee(s) towards chest wrapping arms around tucked knee(s) and hugging leg(s)
towards the chest.

Chapter 1
Semistraddle (Modified Hurdler’s Stretch)
The
TargetSkeletal
muscles: System
Biceps femoris MS
• Semimembranosus
• Semitendinosus
Procedure:
1. Start seated on the floor with one leg extended out in front.
2. Bend the opposite knee so that the bottom of the foot rests on the inside of the thigh of the
extended leg.
3. While trying to keep the back straight, reach for the toes of the extended leg with both
hands allowing the torso to fold over the extended leg.
5. Repeat 3-5 times per side.
Butterfly
Target muscles:
• Adductors brevis
• Adductor longus
• Adductor magnus
• Gracilis
Procedure:
1. Start seated on the floor with both legs out in front.

2. Bend bothTrainer
knees
©2023 to bring the bottoms of both feet together.
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3. The closer the heels pull toward the groin, the more intense the stretch will be.
4. Hold both feet with both hands and allow both elbows to rest on both knees.
5. Keeping the torso upright, allow both knees to fall towards the floor. Additional pressure
can be applied through the elbows.

Chapter 1
Wall Stretch
The Skeletal
Targeted muscles: System
• Anna D’Annunzio, MS
Biceps femoris
• Semimembranosus
• Semitendinosus
• Gastrocnemius
• Soleus
• Additionally, the static wall stretch will utilize gravity to promote thoracic extension through
the upper back via natural compression.
Procedure:
1. Start by lying on the floor with the body perpendicular to a wall.

2. Place both legs vertically on the wall and bring the tailbone as close to the base of the wall
as possible.
3. Engage quads and maintain straight legs to deepen the effect of the stretch.
4. Hold for 1 to 4 minutes.
Forearm Stretch (Flexor and Extensor)
Targeted muscles:
• Carpi ulnaris
• Palmaris longus
• Carpi radialis
• Pronator teres
• Brachioradialis
• Extensor digitorum
• Extensor digiti©2023minimi
Trainer Academy
• Anconeus
Procedure:
1. Come down onto all fours with hands directly under the shoulders and knees directly under
the hips.
2. Spread the fingers as far out as possible with the index finger pointing forward.

Chapter 1
3. Gently rock the hips forward until the stretcher feels a stretch along their flexor muscles.
The Skeletal System

Hold for 15-20 seconds.
4. Move the hips backward until they feel a stretch in the other direction along their extensors.
5. Come back to center and slowly rotate the fingers outward until the thumb is pointing
Anna
forward.D’Annunzio, MS
Repeat the same stretch.
6. Keep rotating the wrists until the fingers are pointed back towards the hips and repeat
the stretch, being mindful of the stretcher’s own mobility restrictions.
Dynamic Stretches
Arm Circles
Targeted muscles:
• Rotator cuff
• Medial deltoid
• Posterior deltoid
• Biceps
Procedures:
1. Start in a standing position with arms straight and feet shoulder-width apart.
2. Raise the arms to the side bringing them up to shoulder height.
3. Move the arms forward in a controlled circular motion.
4. Repeat 20 times then reverse the direction of the circles.
Arm Swings
Targeted muscles:
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• Pectoralis major
• Pectoralis minor
• Rhomboids
• Upper trapezius
• Middle trapezius

Chapter 1
Procedure:
The Skeletal
1. Start System
in a standing position with arms straight and feet shoulder-width apart.
2. Raise the arms to the side bringing them up to shoulder height.
Bring the MS around the upper torso as if hugging the chest.
arms forward to wrap
4. Release the arms back towards the start position in a swinging motion.
5. Maximize the range of motion comfortably in both directions.
6. Repeat 15 times.
Leg Swings
Targeted muscles:
• Psoas
• Iliacus
• Rectus femoris
• Vastus medialis
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
Procedure:
1. Start in a standing position with feet shoulder-width apart.

2. Swing one leg forward up to hip height. The leg should be straight and the toe pointed forward.
3. Swing the leg backward, bring it behind the body to hip height using gravity’s momentum.
4. Repeat 15 times and switch sides.
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Lunge Walk
Target muscles:
• Psoas
• Iliacus

Chapter 1
• Rectus femoris
The Skeletal System

•
•
Vastus medialis
Vastus lateralis
• Anna
GluteusD’Annunzio,
maximus MS
• Gluteus medius
• Gluteus minimus
Procedure:

2. Take one step forward allowing both knees to bend.
3. Forward knee should stay on top of the forward ankle.
4. Back knee should bend to 90 degrees and be directly under the torso.
5. Maximize range of motion throughout the lunge.
6. Step forward to return to the standing position then repeat on the opposite leg.
7. Continue for 20 lunges.
Reverse Lunge Walk
Target muscles:
• Psoas
• Iliacus
• Rectus femoris
• Vastus medialis
• Gluteus maximus
• Gluteus medius
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©2023
• Gluteus minimus
Procedure:

2. Take one step backward allowing both knees to bend.
3. Forward knee should stay on top of the forward ankle.
4. Back knee should bend to 90 degrees and be directly under the torso.

Chapter 1
5. Maximize range of motion throughout the lunge.
The Skeletal System

6. Extend the forward leg to push back into the standing position then repeat on the opposite leg.
7. Perform 20 alternating repetitions.
Anna Lunge
Hockey D’Annunzio,
Walk MS
Target muscles:
• Psoas
• Iliacus
• Rectus femoris
• Vastus medialis
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
Procedure:

2. Keeping one foot planted, rotate and step into a lunge at approximately a 45-degree angle. Allow
planted foot to pivot on toes.
3. Moving leg should bend to 90-degrees with knee above toes.
4. Back leg will bend but doesn’t touch the floor.
5. Extend moving leg to return to standing position.
6. Repeat on the opposite leg.
7. Perform 20 alternating repetitions.
Walking Side Lunge

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Target muscles:
• Psoas
• Iliacus
• Rectus femoris
• Vastus medialis

Chapter 1
The Skeletal System

•
•
Vastus intermedius
Gluteus maximus
• Gluteus medius
• Anna
GluteusD’Annunzio,
minimus MS
• Adductor longus
• Adductor magnus
• Gracilis
Procedure:

2. Take one step laterally into a lunge.
3. Moving knee will bend and torso can lean forward.
4. Sit as low as possible onto the moving leg. Moving foot should point straight ahead and the
knee should point the same direction as the second toe. Hip should be stacked above the ankle.
5. Trailing leg should remain straight.
6. Extend the moving leg to push the body straight up into a standing position. Bring the
trailing leg to meet the moving leg without pushing off the trailing leg.
7. Repeat for 10 lunges then switch to the opposite leg
Walking Knee Tuck
Target muscles:
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
• Biceps femoris
• Semimembranosus
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• Semitendinosus
• Gastrocnemius
• Soleus
Procedure:

2. Take one step forward in a normal walk pattern.

Chapter 1
3. Reach down and grab the trailing knee.
The Skeletal System

4. Pull the trailing knee to the chest while simultaneously fully extending on the planted
leg. Planted hip and knee should be extended with maximal plantar flexion.
5. Release the knee and swing the leg through into the next step.
Repeat for 20 tucks. MS
Walking Knee Over Hurdle
Target muscles:
• Psoas
• Iliacus
• Rectus femoris
• Vastus medialis
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
• Adductor longus
• Adductor magnus
• Gracilis
• Obliques
• Transverse abdominis
Procedure:
1. Set up 2 to 6 hurdles at an equal height that is just below hip height.

2. Stand in front of the first hurdle, throughout the exercise focus should remain on keeping
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the torso upright as well as the hips square and facing forward.
3. The lead leg will drive the knee up and towards the chest then plant on the opposite side
of the hurdle.
4. The trailing leg will then pull through to the knee to chest position and plant on the
ground next to the lead leg.
5. Clear all the hurdles then repeat switching the lead and trail legs.

Chapter 1
Peripheral Neuromuscular Facilitation (PNF) Stretches
The Skeletal System
Hamstrings
Targeted muscles:
• Biceps femoris
• Semimembranosus
• Semitendinosus
Procedure:
1. Start by lying in a supine position with legs straight and feet dorsiflexed.
2. Hold both ends of a yoga strap, belt, or rope and wrap the object around the foot of the
targeted leg.
3. Raise the targeted leg into hip flexion as far as comfortable while keeping the leg straight.
4. The opposite leg should remain flat on the floor.
5. Start the contract phase by contracting the hip extensors and pressing the targeted leg
into the strap and holding for 8 seconds.
6. Relax the hamstrings by contracting the quadriceps and pulling the targeted leg into
flexion, hold for 8 seconds.
7. Repeat 3 to 6 times as needed to relieve the hamstring of the targeted leg and then switch sides.
Deltoid
Targeted muscles:
• Medial deltoid
• Posterior deltoid
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• Stretch will typically be felt through the pectoralis major and latissimus dorsi as well.
Procedure:
1. For PNF stretching of the deltoid, the user will start lying supine on the floor and will need
the assistance of a dowel rod, broom, or other long and light-weight object.
2. The arm intended to be stretched should start completely straight and pointing towards the
ceiling.

Chapter 1
3. Hold the rod with the non-stretching arm and place the end of the rod in the palm of
The Skeletal System

the arm to be stretched.
4. Gently push the stretching arm overhead to a comfortable maximal range of motion.
5. Hold for 8 seconds.
Then contract MSinto the rod by trying to perform a pullover while resisting
stretching arm
with the opposite limb.
8. Repeat the overhead stretch and pullover contract 3-5 times.
9. Switch arms and repeat on the opposite side.
Latissimus Dorsi
Targeted muscles:
• Latissimus dorsi
• Stretch will be felt along the serratus anterior as well.
Procedure:
PNF stretching of the latissimus dorsi will start on the knees and require the use of a tall bench
or box.
1. Place both hands with straight arms on the box then sit back towards the heels trying to get
maximal extension through the torso.
2. Hold the end position for 8 seconds.
3. Contract the latissimus dorsi by trying to push downward the hands through the box
towards the floor.
4. Hold contraction for 8 seconds then relax.
5. Repeat stretch and contract phases 3-5 times.
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Summary
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Flexibility, the ability to take joints through a full range of motions safely, is a key aspect of overall
fitness that most clients will need to spend some time developing. While different intrinsic factors
can influence flexibility such as age, weight, and joint structure, fitness professionals can still help
their clients make improvements by using the correct type of stretching and warm-ups to both
prepare people for exercise movements and increase their overall ranges of motion for daily life.

Chapter 1
References
The Skeletal System
1. Amiri-Khorasani, M; Abu Osman, N; Yusof, A. Acute Effect of Static and Dynamic Stretching on
Anna D’Annunzio,
Hip Dynamic MSDuring Instep Kicking in Professional Soccer Players. Journal of
Range of Motion
Strength and Conditioning Research: June 2011 – Volume 25 – Issue 6 – p 1647-1652.
2. Nelson, R; Bandy, W. An Update on Flexibility. Strength and Conditioning Journal; February 2005
– Volume 27 – Issue 1; p 10-16.
3. Fukashiro, S; Hay, DC. Biomechanical Behavior of Muscle-Tendon Complex During Dynamic

Human Movements. Journal of Applied Biomechanics: June 2006.
4. Witvrouw, E.; Mahieu, N.; Danneels, L.; et al. Stretching and Injury Prevention. Sports Med 34,
443–449 (2004).
5. Lieber, R.L.; Roberts, T.J.; Blemker, S.S.; et al. Skeletal Muscle Mechanics, Energetics and Plasticity.
J NeuroEngineering Rehabil 14, 108 (2017).
6. Pette, D; Vrbová, G; The Contribution of Neuromuscular Stimulation in Elucidating Muscle Plasticity

Revisited. Eur J Transl Myol. 2017 Feb 24;27(1):6368.
7. Hedrick, A. Dynamic Flexibility Training. Strength and Conditioning Journal: October 2000 –
Volume 22 – Issue 5 – p 33
8. Marshall, P.W.; Siegler, J.C. Lower Hamstring Extensibility in Men Compared to Women is Explained
by Differences in Stretch Tolerance. BMC Musculoskelet Disord 15, 223 (2014).
9. McKay, M; Baldwin, J; Ferreira, P; Simic, M; Vanicek, N; Burns., J Normative Reference Values for
Strength and Flexibility of 1,000 Children and Adults. Neurology Jan 2017, 88 (1) 36-43.
10. Petrofsky, J; Laymon, M; Lee, H. Effect of Heat and Cold on Tendon Flexibility and Force to Flex
the Human Knee. Med Sci Monit. 2013, 12(19), 661-667.
11. Stathokostas, L; McDonald, M; Little, R; Paterson, D. Flexibility of Older Adults Aged 55–86 Years
and the Influence of Physical Activity. Journal of Aging Research, vol. 2013, Article ID 743843, 8
pages, 2013.
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©2023
12. Nuzzo, J.L. The Case for Retiring Flexibility as a Major Component of Physical Fitness. Sports Med
50, 853–870 (2020).
13. Daneshmandi, H; Rahmaninia, F; Shahrokhi, H; Rahmani, P; Esmaelli, S. Shoulder Joint Flexibility

in Top Athletes. Journal of Biomedical Science and Engineering , 2010, 3, 811-815.
14. Park, W; Ramachandran, J; Weisman, P; Jung, E. Obesity Effect on Male Active Joint Range of
Motion, Ergonomics, 2010, 53(1), 102-108
15. Alter, M.J. Science of stretching. 1996 Human Kinetics Publishers, Champaign.

16. Kato, E; Chapter 1 K; Kurihara, T; Nagayoshi, T; Fukunaga, T; Kawakami, Y. Musculotendinous

Oda, T; Chino,
Factors Influencing Difference in Ankle Joint Flexibility between Women and Men. International
The Skeletal System
Journal of Sport and Health Science. 2005, Special Issue, 218-225.
17. Knudson, D; Magnusson, P; McHugh, M. Current Issues in Flexibility Fitness. President’s Council

Anna D’Annunzio,
on Physical MS
Fitness and Sports Research Digest, 2000, series 3, n10.
18. Wilke, J; Macchi, V; De Caro, R; Stecco, C. Fascia Thickness, Aging and Flexibility: is there an
Association? Journal of Anatomy, 2019, 234: 43-49.
19. Page P. Current concepts in muscle stretching for exercise and rehabilitation. International Journal
of Sports Physical Therapy. 2012 Feb;7(1):109-19.
20. Gasibat, Q; Simbak, NB; Aziz, AA. Stretching Exercises to Prevent Work-related Musculoskeletal
Disorders – A Review Article. American Journal of Sports Science and Medicine, 2017, 5(2), 27-37.
21. Sherman, K; Cherkin, D; Wellman, R; et al. A Randomized Trial Comparing Yoga, Stretching, and
a Self-care Book for Chronic Low Back Pain. Arch Intern Med. 2011;171(22):2019–2026.
22. Takeuchi, K; Nakamura, M. The Optimal Duration of High-intensity Static Stretching in Hamstrings.
PLoS ONE, 2020, 15(10): e0240181.
23. Matsuo, S; Iwata, M; Miyazaki, M; Fukaya, T; Yamanaka, E; Nagata, K; Tsuchida, W; Asai, Y; Suzuki,
S. Changes in Flexibility and Force are not Different after Static Versus Dynamic Stretching. Int J
Sports Med 2019; 40(14): 941-941.
24. Rogan, S; Wüst, D; Schwitter, T; Schmidtbleicher, D. Static Stretching of the Hamstring Muscle for
Injury Prevention in Football Codes: A Systematic Review. Asian J Sports Med. 2013 Mar;4(1):1-9.
Epub 2012 Nov 20.
25. Nakamura, M; Ikezoe, T; Takeno, Y; Ichihashi, N. Acute and Prolonged Effect of Static Stretching
on the Passive Stiffness of the Human Gastrocnemius Muscle Tendon Unit in Vivo. Journal of
Orthopaedic Research. 2011, 29(11), 1759-1763.
26. Curry, B; Chengkalath, D; Crouch, G; Romance, M; Manns, P. Acute Effects of Dynamic Stretching,
Static Stretching, and Light Aerobic Activity on Muscular Performance in Women. Journal of
Strength and Conditioning Research: September 2009, 23(6), 1811-1819.
Trainer Academy
27. Herman, S; Smith,
©2023 D. Four-Week Dynamic Stretching Warm-up Intervention Elicits Longer-Term
Performance Benefits. Journal of Strength and Conditioning Research: July 2008, 22(4), 1286-1297.
28. Mahieu, NN; McNair, P; De Muynck, M; Stevens, V; Blanckaert, I; Smits, N; Witvrouw, E. Effect
of Static and Ballistic Stretching on the Muscle-tendon Tissue Properties. Med Sci Sports Exerc.
2007 Mar;39(3):494-501.
29. Konrad, A; Tilp, M. Effects of Ballistic Stretching on the Properties of Human Muscle and Tendon
Structures. Journal of Applied Physiology, 2014, 117(1), 29-35.
30. Nagarwal, AK; Zutshi, K; Ram, CS; Zafar, R. Improvement of Hamstring Flexibility: A Comparison

between Chapter 1
Two PNF Stretching Techniques. International Journal of Sports Science and Engineering,
2010, 4(1), 25-33.
The Skeletal
31. Miyahara, System
Y; Naito, H; Ogura, Y; Katamoto, S; Aoki, J. Effects of Proprioceptive Neuromuscular
Facilitation Stretching and Static Stretching on Maximal Voluntary Contraction. Journal of Strength
Anna D’Annunzio,
and Conditioning MS 2013, 27(1), 195-201.
Research: January
32. Lempke, L; Wilkinson, R; Murray, C; Stanek, J. The Effectiveness of PNF Versus Static Stretching
on Increasing Hip-Flexion Range of Motion, Journal of Sport Rehabilitation, 2018, 27(3), 289-294.
33. Behm, D. G., Kay, A. D., Trajano, G., Alizadeh , S., & Blazevich, A. J. (2021). Effects of stretching
on injury risk reduction and balance. Journal of Clinical Exercise Physiology, 10(3), 106-116. https://
doi.org/10.31189/2165-6193-10.3.106
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Chapter 1
TheCHAPTER
Skeletal14System
Adaptations to Resistance
Training
Travis McKinney, MS
252
Adap tations to Re sistance T rai n i n g
Chapter 1
Introduction
The Skeletal System
The body undergoes many different beneficial adaptations in response to prolonged resistance
Anna
exercise D’Annunzio,
training. MS clients, these adaptations are typically the primary reason
For general fitness
for including resistance training as a pillar of fitness.
Fitness professionals must understand the various adaptations and processes to effectively plan,
program, and adjust programs, as well as explain the rationale to clients.
The body undergoes many different beneficial adaptations in response to prolonged resistance
exercise training. For general fitness clients, these adaptations are typically the primary reason
for including resistance training as a pillar of fitness.
Fitness professionals must understand the various adaptations and processes to effectively plan,
program, and adjust programs, as well as explain the rationale to clients.
General Adaptation Syndrome

General Adaptation Syndrome is a theory developed by Dr. Hans Selye in the early-to-mid
20th century. Selye is known to be the first researcher to use the term “stress” in reference to
changes in the body after a stimulus is applied.1 Stress is defined as a “non-specific response of
the body to any demand.”
Through various experiments, Selye concluded that his newly coined term of General Adaptation
Syndrome is “a generalized effort of the organism to adapt itself to new conditions.”
In 1950, Selye publicly adopted the position that “stress is the interaction between damage and
defense. It is Trainer
the©2023rate of wear and tear caused by life.” The term stressor was coined soon after,
Academy
which refers to anything that can produce both stress and specific action.
As knowledge of stress and physiological adaptations continued to develop, so did the understanding
of GAS. It was repeatedly shown that regardless of the stressor being applied, the physiological
processes appeared to follow a similar pattern.
The GAS was later defined in three separate stages:

253
Chapter 1
• Alarm Reaction
The Skeletal System

• Resistance Development
Adaptations to Resistance Training
• Exhaustion
254
alarm phase was the initialMS response to the shock that occurred to the body which elicited
a The alarm phase
resistance, wasofthe
or series initial response
metabolic defenses to the shock
against that occurred
the initial to the
stimuli. If the stimuli
body which elicited
persisted,
exhaustionor
a resistance, would
seriesoccur which would
of metabolic lead to
defenses death the
against in extreme cases. If the stimuli persisted,
initial stimuli.
exhaustion would occur which would lead to death in extreme cases.
Note: original studies tunneled towards physical stressors such as pain or discomfort. It is now
Note: that
known original studies
emotional tunneled
stressors maytowards physical
trigger similar stressors such
physiological as pain or discomfort.
responses. Stressors It is
may include
now known
a job that emotional
loss, break up, financialstressors may
struggles, trigger
poor similar
grades, physiological responses.
or embarrassment. It Stressors
does not require may
extreme
temperatures
include or surgeries
a job loss, break up,tofinancial
trigger GAS. Selyepoor
struggles, was adamant
grades, orthat irrespective ofItthe
embarrassment. nature
does not or
quantity
require of thetemperatures
extreme stressor, the physiological
or surgeries mechanism of response
to trigger GAS. for any
Selye was living organism
adamant always of
that irrespective
theremained
nature orthe same. of the stressor, the physiological mechanism of response for any living
2
quantity
organism always remained the same.2
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254
Chapter 1
Alarm Reaction
The Skeletal System
The Alarm Reaction (AR) is the first stage of GAS when an organism faces a stressor. Selye
Anna itD’Annunzio,
compared MS
similar to the fight or flight reaction, but the AR allowed for chronic responses
leading towards further responses.
Biological reactions during alarm reaction typically include secretion through the adrenal glands
(specifically the adrenal medulla), most commonly are epinephrine and norepinephrine, however,
cortisol is upregulated by the presence of epinephrine.
Other hormones affected include estrogen, testosterone, dopamine and serotonin.3
Cortisol is known as the “stress hormone.” It is present in high concentrations when the body
undergoes stressful situations. When cortisol is upregulated, the response includes an increase
of blood pressure, blood glucose, and the immune system is suppressed.4
Epinephrine and norepinephrine are responsible for acceleration of heart and lung activity,
inhibition of digestion, constriction of many blood vessels to organs, release of lipids and glucose
for energy use, dilation of muscular vessels, dilation of pupils, hearing loss, tunnel vision and
shaking, for an inconclusive list.5
Remember, the primary intent behind these hormones is to survive when faced with imminent
danger, therefore bodily functions that are unnecessary for short term survival (such as digestion,
urination and reproduction) are inhibited until the threat is gone.
Resistance Development
Resistance Development (RD) is the second stage of Selye’s GAS model. This stage is noted by
the body’s attempt ©2023to repair itself after being shocked with an influx of stress through the AR
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phase. There are two paths the body can take in this stage and it depends on the environment
of the individual.
In the first option, hormone concentrations return to homeostatic levels if the threat has subsided.
If the threat persists then the stress hormones will continue to rise, thus increasing the effects of
those hormones. This means digestion continues to slow, vessels to organs continue to contract,
vessels to muscles stay dilated, and heart rate and blood pressure stay elevated.

255
Chapter 1
Recovery and Exhaustion
The Skeletal System
Similar to resistance development, the third and final stage may be split depending on if the threat
Anna D’Annunzio,
is prominent MS
or not. If the threat is not prominent, then recovery begins. If it is still prominent,
by stage three the organism will be reaching exhaustion.
Recovery will begin when the source of stress has subsided, but the previous stages have already
prepared the body to recover. The changes in hormone status from the previous two stages have
upregulated the amount of glucose, lipids, and amino acids that are free floating within the
bloodstream which provide a more readily available source of nutrients. Since the body is reducing
stress levels, the free-floating nutrients may be utilized for recovery and anabolic reactions.7
Exhaustion can be observed when a body has worked itself until it cannot continue further. This is
when energy stores are reaching near depletion of their usable stores. The body is demonstrating
the inability to return to a status of normal functioning.
Personal trainers and fitness professionals must be aware of the overall implication of the General
Adaptation Syndrome. Clients must understand the importance of taking days off to actually
see progress. Coaches must understand how to program the proper amount of exercise to elicit
the body adaptations without pushing the client past the point of exhaustion in the General
Adaptation Syndrome.
Stimulus-Fatigue-Recovery-Adaptation
Theory
The Stimulus-fatigue-recovery-adaptation theory suggests that exercise triggers both fatigue and
adaptation. The magnitude
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©2023 of both depends upon the magnitude of the stimulus. Therefore, the longer
or more intense the training session, the greater amount of recovery time is needed until full recovery.
As the client recovers and adapts to the previous training stimulus, the more fatigue will dissipate.
If the client waits too long to train again, the body will begins to detrain and it loses the
adaptations. With proper programming, full recovery usually occurs before detraining begins.
Then, clients can train continuously with full or near full recovery in between training stimuli for
extended periods of time. This is especially true for novel exercisers, as their total workloads during
sessions are typically low.

256
Chapter 1
Fitness-Fatigue
The Skeletal SystemParadigm
Another way to consider the interaction between stimulus and fatigue is the fitness-fatigue
Anna D’Annunzio,
paradigm. If MSadaptation (fitness) and fatigue, then the sum of the two can
training induces both
be considered the primary driver of a client’s performance referred to as “preparedness.6”
When training loads are high, fitness rises; however, so does fatigue. Therefore, preparedness is
relatively low. This is also true if training loads are very low. Fitness is low, but so is fatigue. Thus,
a balance must be struck, via a structured periodized program, which will dissipate fatigue but
maintain a high level of fitness.
Accumulation vs Deloading vs
Maintenance
Accumulation, deloading, and maintenance are the programmatic applications of GAS and the
other physiological theories behind periodized training.
Accumulation
Periods of hard training, wherein adaptations are stimulated, and fatigue is accrued is referred to
as accumulation. The number of these sessions that an individual can perform continuously (i.e.
the weeks of hard training) without a period of recovery will vary based on a variety of factors
such as training age (experience with exercise), chronological age, dietary status, sleep quality,
stress levels, and training intensity. However, even under optimal conditions, all clients eventually
reach a point where training stagnates. This is the time to deload.
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Deloading
A deload is a period of reduced training volume and intensity to allow the body to recover and
for the adaptative mechanisms to resensitize the body to training. Deloads typically last one
week but must vary based on clients’ needs.

257
Chapter 1
Programming a deload can often be challenging for trainers, especially when working with new
The Skeletal System

clients. There are two variables to consider: the length of deload and the degree to which normal
training volume and intensity are reduced.
Length of Deload
A week has become a standard deload period for many exercisers across a broad spectrum of
training and chronological age. This allows for mental recovery, as well as physiological recovery
of the muscle tissues and joints. However, shorter periods can be employed for clients with
limited training experience, as their exercise-induced muscle damage is lower than intermediate
or advanced clients. Also, older clients may require longer deload periods as their recovery cycle is
often longer. Research is still underway to quantify the optimal range of deload duration, however
anecdotal evidence suggests that no fewer than 3 days and no longer than 2 weeks are best.
Volume and Intensity Reduction

The second variable of the deload: training volume and intensity, has greater variation. The
goal of the deload is to reduce training stress; this can be accomplished by reducing the load
or volume of training, or both. A common strategy is to maintain the training load and reduce
the volume by half. However, if joint stress is an issue, consider reducing the load by half or one
third should also be considered.3 In either case, as long as the goal (reducing training stress) is
met, any strategy can be effective. On the other hand, a week of complete rest, with no training,
is not recommended. It is well established by research that mild amounts of physical activity
actually facilitate recovery; therefore, some level of training is better than none.
Maintenance
Even with regular deloading periods at the end of mesocycles, occasional periods of prolonged
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active recovery, called maintenance cycles, are suggested. Months of prolonged training, even

properly programmed with deloads, lead to significant wear and tear on the joints and substantial
loss of psychological arousal for training. Maintenance cycles can solve these problems before
manifest.
During maintenance clients should train very little, only enough to maintain their current level of
fitness. The focus during this 3—4 week cycle is twofold: mental and physical recovery. Clients
should continue to be physically active and engaging in daily mobility and warm-up activities.

258
Chapter 1
Clients can also engage in several one to two training sessions per week but intensity and volume
The Skeletal System

should be very low.
The relationship between accumulation, deload, and maintenance is cyclical. Clients should engage
in Anna
prolongedD’Annunzio, MS concluding with deloads as needed. When deloads are
periods of accumulation,
no longer effective at reducing fatigue or when overuse injuries begin to occur, a maintenance
phase is necessary.
SAID Principle
The SAID acronym stands for Specific Adaptations to Imposed Demands and applies the concepts
of the General Adaptation Syndrome to reach a given goal.
For a simple example, if an individual is trying to run a marathon, most of their training will
likely be surrounded by endurance-based activities.
A client who is training to complete a marathon will not benefit from max effort bench press
training during their preparation, because the adaptation for a heavy bench press does not improve
lower body endurance.
However, a competitive powerlifter who is preparing for a competition would utilize a heavy bench
press during their training since the one-repetition max bench press is relevant to their sport.
The powerlifter will likely not be running in a way that raises aerobic capacity, as a strategy to
prepare for a bench press contest. The concept of imposing demands similar to that of the goal
that the individual is trying to achieve is utilizing the SAID Principle.
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sport.
259 The powerlifter will likely not be running in a way that raises aerobic capacity, as a strategy
to prepare for a bench press contest. The concept of imposing demands similar to that of the goal
that theChapter
individual is1trying to achieve is utilizing the SAID Principle.
The Skeletal System

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Progressive Adaptations to Resistance ©2023
Training Trainer Academy

©2023
During the training process, there are two ways to induce an adaptation. One is to increase
the training load (intensity, volume), while continuing to employ the same drill, for example,
endurance running, where the length of the run increases.
The other is to change the drill, provided that the exercise is new, and the athlete is not accustomed
to it. If an athlete uses a standard exercise with the same training load over a very long time, there
will be no additional adaptations and the level of physical fitness will not substantially change.”12

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Chapter 1
When this concept is applied to resistance training, the amount of weight being lifted needs to be
The Skeletal System

greater than the normal amount that the person would normally lift, if they want to continuously
see progress. The weight lifted could increase through more total repetitions (between all sets
and repetitions), or through an absolute load (90lbs instead of 80lbs).
If the athlete continues with the same volume scheme each time they perform the exercise, such
as 3x10x80lbs every week on the exact same movement, they will eventually stop progressing
and become stagnant. Variables that can be changed include the weights, repetitions, sets, rest
periods, frequency, and total volume. Additionally, using different variations of movements or
types of exercises is another way to change the stimulus and promote further adaptations.
Skeletal muscle adaptations are achieved through training programs, with the intent to achieve a
specific goal. In the context of resistance training, the main adaptations are muscular endurance,
hypertrophy, strength, and power.
While each of these adaptations has crossover in terms of their effects and benefits, they each
represent distinct changes in the muscle fibers that must be specifically targeted with appropriate
workout programming depending on the client’s goal.
Muscular Endurance
Athletes who specialize in muscular endurance largely participate in exercises that contain
a relatively light-to-moderate resistance, but do not greatly activate the cardiorespiratory
system.
Muscular endurance exercises can be split between maximum repetitions within a set time, such
as 60-second max repetition push up drills, or they can involve a max time that a person can
maintain a specific posture or pace of repetitions, such as in a two-minute plank.
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Remember that absolute strength is not the goal and it’s been shown that when using weight
below 25% of a one-repetition max effort attempt, it is impossible to predict the number of
repetitions an athlete could complete.
Strength and endurance are not closely related. Athletes who train with an endurance intent
will typically work within the 12-25 repetition range, or even a greater number. These athletes
should keep short rest periods in an attempt to increase their rate of lactate buffering.

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Chapter 1
Maintaining rest intervals between 30-60 seconds, or approximately a 1:1 ratio of work to rest,
The Skeletal System

will create an environment that increases blood lactate levels. Clients training under this condition
will more efficient at buffering blood lactate so the individual has an increased ability to sustain
repeated moderate to maximal muscle contractions over a longer period of time.13
Hypertrophy
Hypertrophy at its root is an increase in the size of the muscle cells, resulting in an increase in
muscle cross-section area and volume.
For most general fitness clients, especially those who are deconditioned, improved muscle mass
is generally a beneficial adaptation in terms of health outcomes and obtaining a more muscular
appearance.
During resistance training, mechanical and metabolic stress results in muscle damage and the
subsequent hormonal responses that stimulate hypertrophy.
Hypertrophy generally occurs due to an increase in the size of existing muscle fibers via the addition
of myofibrils and increases in actin and myosin and other muscle cell components. The hormones
secreted in response to resistance training play a major role in driving muscular hypertrophy.
Clients who seek to maximize muscle hypertrophy should use weights equivalent to a 5-12
repetition maximum effort attempt. Clients should perform multiple sets while leaving 1-2
repetitions in reserve and resting between 1-2 minutes to maximize hypertrophy.12
Strength Trainer Academy

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In the context of fitness training, strength is the ability of the body to exert force via muscular
contraction. The purest measure of absolute strength on a given movement or exercise is the
1-repetition maximum. Resistance training activities for improvements in strength typically
utilize a lower number of repetitions, often between 1 to 5, high levels of resistance, and longer
rest periods.
When individuals train towards the goal of maximal strength, adaptations occur within the body
to accommodate for the increased stimuli and demands being placed. These adaptations change

262
Chapter 1
the body and increase its ability to exert force, translating into greater performance on maximal
The Skeletal System

strength activities, as well as the associated beneficial biological adaptations.
Changes within the body that contribute to an increase in strength have to do with both the
Anna
physical sideD’Annunzio, MS
of the body and the neural side of the body such as motor recruitment, covered in
the nervous system chapter.
While strength adaptations do not occur solely as a result of hypertrophy, increased muscle cross-
section results in greater force production capabilities.
When discussing the physical adaptations of hypertrophy, the most noticeable is the increase in
cross-sectional area (CSA) of the muscle fibers and an increase in sarcomere volume.14
As discussed in the skeletal system chapter, bone mineral density, and subsequent bone mass
increase as a progressive response to resistance training. This increases the ability of the skeletal
system to withstand external resistance and resist bone fractures.16
Tendons are another site of adaptation to resistance training. Researchers have found that just
12 weeks of resistance training improved tendon stiffness, reflecting greater tendon strength.17
In the long run, increased strength depends on increasing the size of the muscle fibers, the ability
of the nervous system to fully recruit fibers, and the density and strength of the skeletal system.
For this reason, strength-focused periodization plans usually include hypertrophy-focused training
blocks as well as higher intensity, lower repetition strength blocks to drive neural adaptations.
Similarly, general fitness clients benefit from cycling between programs focused on muscular
endurance, hypertrophy, and strength to elicit the full array of beneficial adaptations to resistance
training. How to structure and cycle workout programs is covered in more depth in the chapter
on periodization.
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Power
Power in the absolute sense is a measurement of the rate of energy production of a given activity. In
the context of physical fitness adaptations, power refers to the ability to create maximal force within
minimal time.12 As such, the rate of force production matters in power considerations alongside
the maximum force exerted. To increase the rate of force development, which is the primary goal
for power training, an individual must train in a manner that increases their ability to move faster.

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Power exercises include explosive lifts such as those in Olympic weightlifting, plyometric activities
The Skeletal System

such as jumping, and maximal effort sprints using traditional aerobic modalities such as running
sprints, cycling, or rowing using short working periods and long rest periods to ensure sufficient
effort on each set.
Most strength-focused training exercises also improve power, especially in novice athletes and the
deconditioned. Since power depends on both speed of movement and the amount of resistance,
increasing the resistance while maintaining the same speed of movement reflects improved power.
As the client gains training experience, continued power focused adaptations will require specific
focus on movement speed.
In the context of aerobic training, power is typically expressed as watts and is used as a way to
measure the absolute output. Activities such as cycling make measuring watts straightforward
compared to running or swimming. While this use of “power” is correct from a physics standpoint,
when it comes to resistance training, power training primarily refers to anaerobic exercises
performed quickly and explosively.
In the context of personal fitness training, power training can include a variety of bodyweight
and equipment-based training methods. Jump squats, Olympic lifting, medicine ball throws, and
any movements performed quickly and explosively are all power training exercises commonly
used to elicit improvements in peak power.
The adaptations to power development are comparable to that of strength adaptations. In a

study by MacDougall that was published in the Journal of Applied Physiology, they observed the
physiological differences in 12 healthy men who participated in a sprint style program on a cycle
ergometer.20 It is important to understand that these are not elite athletes.
These 12 healthy men trained with multiple bouts of 30-second sprints for 7 weeks. On
week 1 the subjects began with 3 sessions per week and performed 3 – 30 second sprints on
week 1 and increased to 10 – 30 second sprints during week 7. Between each bout was a 4
minute rest period©2023for the first 4 weeks. In weeks 5-7, they decreased their rest periods by 30s
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each week.
Significant results from the study showed an increase in 12% mean total power output after
the 4th bout of sprints and approximately a 25% increase in peak power output among the
participants when comparing their 7-week differences. They demonstrated a 7% increase in
V̇O2 max, a 49% increase in phosphocreatine kinase (PFK) activity, 56% increase in hexokinase
activity and 36% increase in citrate synthase (CS) activity.

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Overall, this demonstrates that clients can experience significant beneficial results from a variety
The Skeletal System

of strength and power training modalities.
Fitness professionals should take note that adaptations to resistance training occur primarily on a
Annawhere
spectrum D’Annunzio, MS are more heavily favored within certain repetition, intensity,
certain adaptations
and movement speed ranges as opposed to a hard cutoff point for each adaptation.
For example, training with 3-5 repetitions using appropriate intensity will result in some
hypertrophy alongside the strength adaptation. Hypertrophy would be increased between 8-12
repetitions, while still eliciting some strength gains. Finally, pushing past the 12 repetition range
will cause an increasing shift away from hypertrophy and towards muscular endurance.
Sedentary, deconditioned clients will see the greatest across-the-board adaptations using a variety
of repetition ranges. As training experience increases, training programs must be specific to the
desired adaptations to ensure progress.
Summary
Considering the adaptations caused by different stressors on the body, fitness professionals should
be monitoring the system fatigue in clients throughout a training cycle, as well as choosing specific
exercises to target the changes clients are looking for through an exercise program.
Hypertrophy, endurance, strength, and power all require different loads, rep ranges, rest periods,
and exercises, while blocks of accumulation, deloading, and maintenance may be required to
achieve optimal results based on overall recoverability across a training cycle.
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References
The Skeletal System
1. Jackson M. Evaluating the Role of Hans Selye in the Modern History of Stress. In: Cantor D,
Anna
RamsdenD’Annunzio, MS and Adaptation in the Twentieth Century. Rochester (NY ):
E, editors. Stress, Shock,
University of Rochester Press; 2014 Feb. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/
books/NBK349158/
2. Paul, M. (2020, July 24). The Scientific Legacy of Hans Selye. Nootropics Official. https://
nootropicsofficial.com/the-scientific-legacy-of-hans-selye
3. Walter Bradford Cannon (1915). Bodily Changes in Pain, Hunger, Fear and Rage: An Account of
Recent Researches into the Function of Emotional Excitement.
4. Padgett, David; Glaser, R (August 2003). “How stress influences the immune response”. Trends in
Immunology. 24 (8): 444–448.
5. Henry Gleitman, Alan J. Fridlund and Daniel Reisberg (2004). Psychology (6 ed.). W. W. Norton
& Company.
6. WebMD. (n.d.). Ammonia Aromatic Inhalation: Uses, Side Effects, Interactions, Pictures, Warnings
& Dosing. WebMD. https://www.webmd.com/drugs/2/drug-7536/ammonia-aromatic-inhalation/
details
7. Gozhenko, AI; Gurkalova, IP; Zukow, W; Kwasnik, Z; Mroczkowska, B (2009). Gozhenko, AI;
Zukow, W; Kwasnik, Z (eds.). Pathology: Medical student’s library. Radom University. p. 272
8. Adamsson A, Bernhardsson S. Symptoms that may be stress-related and lead to exhaustion

disorder: a retrospective medical chart review in Swedish primary care. BMC Fam Pract. 2018
Oct 30;19(1):172. https://doi.org/10.1186/s12875-018-0858-7. PMID: 30376811; PMCID:
PMC6208049.
9. Schmidt, R.A. (1988). Motor Control and Learning: A Behavioral Emphasis. 2nd ed. Champaign,
IL: Human Kinetics.
10. Thompson, D. (2001, November 26). Motor teaching and motor learning. Oklahoma University of
Health Science. https://ouhsc.edu/bserdac/dthompso/web/mtrlrng/mtrlrng.htm
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11. Human Kinetics. (n.d.). Vladimir M. Zatsiorsky. Human Kinetics. Retrieved July 27, 2022, from https://
www.human-kinetics.co.uk/author/vladimir-m-zatsiorsky/
12. Zatsiorsky, V., & Kraemer, W. (2006). Science and Practice of Strength Training (2nd ed.).
13. Parsons, D. (2019, January 4). Rest Periods Between Sets. ISSA. https://www.issaonline.com/blog/
post/rest-periods-between-sets–everything-you-ever-needed-to-know-
14. Hughes DC, Ellefsen S, Baar K. Adaptations to Endurance and Strength Training. Cold Spring

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Harb Perspect 1 Jun 1;8(6):a029769. https://doi.org/10.1101/cshperspect.a029769. PMID:
Med. 2018
28490537; PMCID: PMC5983157.
The Skeletal
15. Maughan, R J, Watson,System
J S, Weir, J, (1983), Strength and cross-sectional area of human skeletal muscle.
The Journal of Physiology, 338. https://doi.org/10.1113/jphysiol.1983.sp014658.
16. Anna-Lena Zitzmann, Mahdieh Shojaa, Wolfgang Kemmler, The effect of different training frequency
on bone mineral density in older adults. A comparative systematic review and meta-analysis, Bone,
Volume 154, 2022, 116230, ISSN 8756-3282, https://doi.org/10.1016/j.bone.2021.116230.
17. Bohm, S., Mersmann, F. & Arampatzis, A. Human tendon adaptation in response to mechanical
loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults.
Sports Med – Open 1, 7 (2015). https://doi.org/10.1186/s40798-015-0009-9
18. Alvidrez, L., & Kravitz, L. (n.d.). Hormones Responses Resistance Training. The University of New
Mexico. https://www.unm.edu/~lkravitz/Article%20folder/hormoneResUNM.html
19. Vingren JL, Kraemer WJ, Ratamess NA, Anderson JM, Volek JS, Maresh CM. Testosterone
physiology in resistance exercise and training: the up-stream regulatory elements. Sports Med. 2010
Dec 1;40(12):1037-53. https://doi.org/10.2165/11536910-000000000-00000. PMID: 21058750.
20. Muscle performance and enzymatic adaptations to sprint interval training J. Duncan MacDougall,
Audrey L. Hicks, Jay R. MacDonald, Robert S. McKelvie, Howard J. Green, and Kelly M. Smith
Journal of Applied Physiology 1998 84:6, 2138-2142
21. Barker, D. (2020, October 13). Understanding Reciprocal Inhibition. San Diego Personal
Training. https://sandiegopersonaltraining.com/2020/10/13/understanding-reciprocal-inhibition/
22. US Army Public Health Center. (2020). Strength Tests in Army Fitness Training and Assessment
of a Pilot Program. Tip No. 12-119-0121.
23. U.S. Army. (2012). FM 7-22; Army Physical Readiness Training. Department of the Army.
24. Paul, A. C., & Rosenthal, N. (2002). Different modes of hypertrophy in skeletal muscle fibers. The
Journal of Cell Biology, 156(4), 751-760. https://doi.org/10.1083/jcb.200105147
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Chapter 1
TheCHAPTER
Skeletal15System
Anna D’Annunzio,Training
Resistance MS
Protocols and Systems

Travis McKinney, MS
268 RE SISTANCE T RAI N I N G
P ROTOCOLS AND SYS T EM S
Chapter 1
Introduction
The Skeletal System
Fitness professionals must have in-depth knowledge of the various training protocols and systems
forAnna
improvingD’Annunzio, MS
strength and fitness. Professionals should be particularly familiar with the equipment
in their facility, and the modalities they plan to use with their clients.
Each modality has its pros and cons. While certain populations may benefit from the proper
use of these styles more than others, nearly all populations can find an intelligent use for each
modality and receive positive results. Two of the fundamental parameters discussed here are set
training and exercise implements.
Single Set
Single set training utilizes one set per exercise before moving on to another movement. For
example, if an individual performed one set of 20 repetitions and moved on to another exercise,
that would be considered a single set-style of training.
Single sets are most appropriate for novice clients and can be effective at inducing muscular
development.24 Additionally, single set training can be used as a method to test muscular endurance
and anaerobic capacity.22
Clients who have already completed several months of resistance training will need to add multiple
sets or other means of increasing volume in order to see continued results.
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Multiple set training calls for performing more than 1 set of an exercise in an individual workout.
Multiple set training is one of the most used methods when programming resistance workouts in
order to create the best muscular adaptations. For example, performing three sets of ten (3×10)
for hypertrophy or five sets of five (5×5) for strength would constitute examples of multiple sets.
Research has consistently shown multiple set training to be superior to single set training when
it comes to strength and hypertrophy adaptations.25, 26

Chapter 1
Pyramid
The SkeletalSets
System
Pyramid sets are a common method used by old-school bodybuilders and strength athletes. This
is aAnna D’Annunzio,
style where MS with each set. Typically, as a heavier weight is being used,
the weights increase
the number of repetitions performed will decrease. However, this concept follows the increase
in the weight to reach the “peak” of the pyramid and then back down.
An example of Pyramid Sets may include (reps x % of 1RM):
• 10×50%
• 8×60%
• 6×70%
• 4×80%
• 2×90%
• 1×100% (top of pyramid)
• 2×90%
• 4×80%
• 6×70%
• 8×60%
• 10×50%
Superset
A superset, commonly spelled using one word, is when two exercises are performed back to back.
“Supersetting” exercises is a useful programming method for a multitude of different reasons.
Performing supersets reduces the total time to complete a given number of sets, making it an
effective way to reduce workout time and/or increase workout volume and intensity without
increasing total time.
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The specific training goal will determine the exact superset structure. For strength focused training,
opposing or unrelated muscle groups can be exercised in quick succession followed by a moderate rest
period between each superset. For example, performing lat pulldowns followed by overhead presses.
As the latissimus dorsi muscles recover from the set of pullups, the deltoids are performing their
work on the overhead press. The deltoids then rest during the full rest period and during the pull
up set, before being tasked with the second set of overhead presses.

Chapter 1
Supersets can also be performed using the same muscle group twice in a row with a different
The Skeletal System

exercise, which increases the volume performed by that muscle group. Due to the increased
fatigue and subsequent decrease in total weight required, supersetting the same muscle group is
most appropriate for muscular endurance and hypertrophy.
For example, a person who performs hamstring curls could then follow up with a set of 45-degree
back extensions. By performing the two exercises back to back, the hamstring muscles are being
worked in quick succession and by targeting both of its purposes, flexion at the knee and torso
extension at the hip.
Drop Set
Drop sets are a technique that involves performing a relatively heavy set, then immediately
removing some of the weight and performing another set.
For example, a client performing drop sets on the bench press exercise might perform a set using
80% of their 1-repetition maximum and then immediately reduce the weight to 65% 1RM and
complete the next set. The client repeats the process without resting in between sets until the
target number of drop sets has been reached.
Drop sets are an excellent choice to promote quick exhaustion, hypertrophy and to save time as
little to no rest periods are used. Some lifters will utilize a drop set as a ‘burnout’, which would
be performing as many repetitions as possible (AMRAP) on the very last set of the exercise.
The client could perform a normal 3×10 multiple set method at 75% 1RM on the bench press
and then perform maximal repetitions to failure on a final set, followed by decreasing the weight
to 50% and again performing maximum repetitions. They could then continue by reducing the
weight after the client reaches muscular failure on each set and move on to the next.
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Circuit Training
Circuit training involves performing a single set of one exercise followed by a single set of a
different exercise and continuing on through a series of exercises to complete the full circuit.
At the end of the circuit, the exerciser would then go back and repeat the circuit if performing
another set.

Chapter 1
Circuit training is often constructed using a set time performing each exercise with a submaximal
The Skeletal System

resistance level. A client could perform 30 seconds of goblet squats using 20% 1RM, performing
them as quickly as possible, followed by a quick transition to 30 seconds of V-ups, and continuing
on through a variety of exercises.
Circuit training can improve cardiovascular development, anaerobic capacity, and improve body
composition, depending on the programming in the circuit.27, 28
Peripheral Heart Action (PHA)

Peripheral heart action (PHA) is similar to circuit training and involves performing a series
of exercises in quick succession. Rather than allowing for any exercises in random order, PHA
requires the lifter to alternate from upper body to lower body movements.
The alternation between upper to lower body movements in quick succession causes a dramatic
increase in cardiovascular activity. When exercises are being performed, an influx of blood is
delivered to that body part which has a higher demand for oxygen, energy, and nutrients.
When the movements are alternating between upper and lower body, that flux of blood is rotating
between whichever side of the body is in highest demand, while the previous section of the body
is still recovering.
When performed with high intensity, PHA style training can burn calories at a rapid rate.
Vertical Loading
A vertical loading ©2023routine will utilize multiple supersets in a circuit-like fashion. The intent
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behind this style of routine is to order the exercises by the proximity of the muscles that they
work. For example, a lifter may perform shrugs, dumbbell side raises, dumbbell rows and situps
all in succession to one another, resting in between sets if the goal is hypertrophy or strength.
When the last exercise is completed, repeat the same series of exercises until the desired number
of sets is completed. The intent behind this style of routine is to provide more rest for a muscle
group while other muscle groups are being worked on compared to performing back-to-back
sets of the same exercises.

Chapter 1
In the above example, the athlete would be rotating between the muscles of the trapezius, deltoids,
The Skeletal System

latissimus dorsi, and abdominals prior to restarting the circuit at trapezius or shrugs again.
Horizontal Loading
Horizontal loading is the opposite of vertical loading. While vertical loading rotates the muscles
being worked on each set, horizontal loading ensures that all prescribed sets of an exercise are
completed prior to moving on to another exercise.
This is used in conjunction with the multiple sets method and is most commonly utilized by
strength athletes. Remember that the multiple sets method is simply performing more than one
set on any exercise, whereas horizontal loading specifically prevents the utilization of supersets.
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273 Resistance Training Protocols and SystemsRE SISTANCE T RAI N I N273
G
Chapter 1
The Skeletal System

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Chapter 1
Resistance
The Training Implements
Skeletal System
Anna D’Annunzio,
Bodyweight MS
/ Calisthenics
Using the weight of one’s own body as resistance for exercises is called calisthenics. Many people
refer to this style of exercise as simply ‘bodyweight exercise,’ but the two are synonymous and
can be used interchangeably depending on the populations within the conversation.
Bodyweight-style exercises have been a favorite of an incredibly wide variety of populations due to
the convenience of performing the movements. To achieve an effective bodyweight workout, one
can perform many exercises within the comforts of their own home or outside on a playground,
especially if there is access to an overhead pullup bar of some variety.
Bodyweight training encompasses straightforward movements such as glute bridges, push-ups,

pull-ups, and squats as well as advanced calisthenics such as handstand pushups, high-intensity
plyometrics, and gymnastic-style exercises.
Nearly every population can benefit from bodyweight exercises. The intensity of bodyweight
training depends on the exercises performed as well as the individual body mass of the person
performing the exercise. Bodyweight movements are progressively more difficult if the weight
of the body is heavier.
Bodyweight exercises are common within rehab clinics. Oftentimes these movements are used
to recover from an injury or preserve quality of life. An elderly individual may perform sets
of ‘squats’ by sitting in a chair and standing back up without the use of their hands. Another
individual recovering from an ankle injury may perform calf raises in an effort to rebuild mobility
and coordination.
These movements can also be regressed by using bands to help take off some of the load on the
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body, or with added weight to increase the difficulty of the movements.
Barbell
Barbells are a mainstay of most resistance training equipment setups. A normal bar is referred
to as a “power bar” and weighs a standard 45 pounds or 20 kilograms (44.2 pounds). Entire
training programs can be created by using a straight bar as nearly every muscle in the body can

Chapter 1
be activated with a properly formulated barbell routine. There are aspects of resistance training
The Skeletal System

that can be accomplished more effectively by using other methods of training, but a straight bar
is the bread and butter for many athletes of all levels.
Annasuch
Exercises D’Annunzio, MS
as the squat, bench press, deadlift, snatch, clean and jerk, overhead press and curls
are staples in most strength training regiments, and they all utilize the straight bar. It is common
to have strength programs centered around the squat, bench press, deadlift, and overhead press
where lifters workout several times per week, performing one of those movements at the start
of each workout.
A straight bar has many inherent advantages and disadvantages. Because weight is directly loaded
to the bar it is easy to calculate how much resistance is being used and easy to increase the load
by small increments over time.
One of the major disadvantages to utilizing a straight bar only in training is that over extended periods
of time, barbell training can result in the development of muscle imbalances if coaches do not properly
program a variety of movements using other equipment or even just other styles of barbell.
There are many styles of barbells to use in a training program. Note that for beginner, intermediate,
and even advanced clients, most standard barbells are sufficient when included in a balanced
training program, and specialty bars for each lift are not necessary until the weight being lifted
is substantially beyond the capabilities of most fitness clients. However, it is still important for
personal trainers to have knowledge of the types of barbells given their prevalence in strength and
conditioning programs.
A non-exhaustive list of bars to utilize in training includes:
• the squat bar

• bench press bar
• deadlift bar
• Olympic bar
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• safety squat bar (Hatfield bar)

• cambered bar
• bow bar
• multi grip bar
The squat, bench press, and deadlift bars are specialized for elite level powerlifters who require
bars that accommodate their lifts. Most gyms are equipped with a standard barbell typically
weighing 45 pounds without added weight, with moderate knurling.

Chapter 1
Squat Bar
The Skeletal System
A squat bar is thicker and heavier than a 45 pound bar, with a larger loading sleeve. This allows
bar to hold MS
more plates than a standard bar and reduces the amount of whip, or vibrations
that occur within the bar.
When lifters approach heavy weights, such as 700 pounds or greater, standard bars tend to flex
and bend uncontrollably which can be hazardous for stability and can cause serious injuries. Bars
must be capable of handling the weights that they are put through. Squat bars tend to weigh
between 55 to 65 pounds.
Bench Press Bar

Bench press bars are a medium between a power bar and a squat bar. They can maintain rigidity
with more weight than a power bar, they are thinner than a squat bar, and they have more
loading area on the sleeve than a power bar. The bench press bar isn’t necessary until the lifter is
performing over 800 pounds.
Due to the contact points of the hands on the bar being wider during a bench press than the
shoulders when they support the bar during the squat, bars tend to flex less under equivalent
weight during a bench press as opposed to a squat. A bench press bar typically weighs between
50 to 55 pounds.
Deadlift Bar
Deadlift bars are the opposite to the previous two bars. Deadlifts bars are made slightly longer
and thinner than a standard power bar. They weigh 45 pounds and the intent of them is to flex
more than normal off the floor, while being easier to hold onto.
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If the bar flexes one inch before the end plates break from the floor, that means the range of
motion for the deadlift has decreased by one inch. Utilizing this bar is most helpful for individuals
with an ultra-wide sumo deadlift stance, those with very small hands and people with a short
range of motion to begin with.
Note: Specialized squat, bench press and deadlift bars are only necessary for elite level powerlifters.

Chapter 1
Olympic Bar
The Skeletal System
An Olympic bar has specs modified for Olympic weightlifting, which consists of the snatch and
clean and MS has smaller and softer knurling which reduces the likelihood
jerk. This bar typically
of the skin on the thumbs ripping when forcefully pulling with a hook grip.
Olympics bars do not have a center knurling on them. This smoothness allows for the bar to hit
the thighs during the high-pull portion of the Olympic lifts, without it snagging on the lifter’s
clothing. The sleeves of an Olympic bar use ‘needle bearings’ which when well-greased, allows the
sleeves to spin several seconds longer than a typical power bar – which may not spin at all sometimes.
Lastly, Olympic bars are made with lower tensile strength to allow the bar to flex or whip, much
like a deadlift bar.
Safety Squat Bar

The safety squat bar (SSB) was originally called the “Hatfield Bar” after Dr. Fred Hatfield who
designed the first model. This bar is one that should be utilized by coaches and trainers as their
default, prioritizing it beyond a straight bar for squats.
The SSB is denoted by large, foam pads that sit atop the shoulders and behind the neck. It has
handles that jet forward and two forward facing pads are diagonally facing downward. The bar
has a slight camber to it and the slides sit forward rather than straight down.
The diagonal angle of the handles causes the pads to press into the upper chest of the lifter
while the angle of the sleeves shifts the center of gravity of the bar forward. This combination
encourages the lifter to round their upper back.
The lifter must maintain an upright posture throughout this movement. The advantages to
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squatting with the SSB is that maintaining the upright posture uses the muscles of the upper
back to a much greater degree than a straight bar does. The pads of the SSB sit the bar higher
on the shoulders which shifts the point on the lifter with the most structural stress to be on the
upper back, as opposed to the lower back with a straight bar.
Lastly and arguably most significantly, the SSB allows lifters to squat without applying stress to
their shoulders or elbows like a straight bar does. Consider replacing straight bar squats with
SSB squats. This bar can be used by anyone who is capable of performing a weighted squat.

Chapter 1
Cambered Bar
The Skeletal System
A cambered bar is rarer to find in gyms than a SSB is. The cambered bar is identified by two
Anna
vertical barsD’Annunzio, MS
that drop down from the horizontal centerpiece. The lowered center of gravity means
that this bar stimulates the muscles of the lower back much harder than other bars would.
When using the cambered bar, the plates sway forward and backwards which causes a sense of
instability. This instability forces the lifter to practice proper bracing techniques otherwise the
risk of injury heightens significantly. Lastly, since this bar has vertical uprights along the sides of
it, the lifter may place their hands lower on the uprights to reduce stress on the shoulder joints.
Bow Bar
The bow bar is most commonly called a “Buffalo Bar” named after the first company to create a
curved bar. This bar functions similarly to a straight bar, but has a curve to it. The curve allows
a gradual reduction in height from the peak of the bar, down to the sleeves, and typically has a
4 inch difference in height.
The bow bar is used to mimic a straight bar, but reduce tension on the shoulders. Many lifters
with shoulder mobility issues due to injuries, age or muscle mass will squat with a bow bar instead
of a straight bar.
Dumbbells
Dumbbells (DBs) are weights in the form of short handles with added weight attached to either
side. Dumbbells are arguably the most versatile piece of equipment within a gym.
They are predominantly

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exceptions can be made for exercises such as weighted sit ups or pull ups, where the DB is held
between the feet.
Common exercises with DBs are DB press, DB rows, DB Romanian deadlifts, DB side raises,
DB triceps extensions, and DB curls. There are thousands of exercises that can be performed
with DBs. The largest benefit of using DBs comes from the ability to work muscles unilaterally.
DBs are a consistent tool to utilize for gym goers of all ages and ability levels.

Chapter 1
Machines
The Skeletal System
Machines are a standard class of equipment in any facility that promotes exercise. Machines
Anna
may be pin D’Annunzio, MS Pin-loaded machines have stacks of weights with a hole in
loaded, or plate loaded.
the center, both a vertical hole and a horizontal hole.
A post with horizontal holes is stuck through the center of the weight stack and the holes of
that post align with each hole of the plates in the stack. When a pin is pushed through a plate,
it locks into the center post and the lifter may move the selected amount of weight.
A plate loaded machine is much simpler in design. Rather than moving a predetermined amount
of weight from a convenient stack, the machine has empty sleeves where plates may be put on
to. The number of plates on the sleeve will determine the amount of weight being moved.
There are thousands of different variations of machines to work all the different muscle groups
in the human body and it is impossible to cover them all.
The key constant between every machine is that the machines are built onto a fixed track. There
is one motion that can be used with that machine and when under proper working order,
the machines will not deviate from the predetermined track. This decreases the stabilization
requirements for the movements compared to free-weight exercises.
The biggest notable exception to the fixed motion are cable machines, which offer some instability
as well as a constant angle of resistance across the full range of motion. Common exercises on
the cable machine include lat pulldowns, triceps extensions, face pulls, and cable curls.
Alternative Implements
Alternative implements
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©2023 are effectively any device or tool used to provide resistance for a training
stimulus that falls outside the traditionally used bodybuilding tools such as barbells, dumbbells,
and weight machines.
Nevertheless, alternative implements of a variety of types are becoming increasingly common in

commercial gyms due to their popularity and versatility towards a variety of fitness goals.

Chapter 1
Kettlebells
The Skeletal System
Kettlebells are incredibly versatile and useful to a wide variety of populations. Some athletes
Anna
choose D’Annunzio,
to compete in kettlebell MS
competitions which perform various kettlebell based movements
for maximum repetitions within a set time typically.
Kettlebells may be found in 5-70 pounds typically, but some retailers carry up to 200 pound
kettlebells. The most popular movement is the “kettlebell swing” which is similar to the initial
motion in a Romanian deadlift. The athlete adopts a shoulder or wider width stance, holds the
kettlebell with both hands, and gets a swinging start.
Once a small amount of momentum has occurred, the athlete forcefully pushes their hips back,
and then extends them forward while relaxing the shoulder joint. The force from the hips
at the catch, or bottom position of the kettlebell swing will carry the kettlebell to shoulder
height. When performed correctly, kettlebell swings provide a plyometric-type stimulus for the
posterior chain.
Heavy kettlebell swings can build strength, power, and explosiveness through the glutes, hips and
hamstring muscles. Other common exercises with kettlebells include overhead press, overhead
squats, suitcase carries, Turkish get ups, and overhead throws if performed on grass.
Strongman’s Yoke
The yoke is a standard strongman implement. Yokes look like old style squat stands with a bar
welded in the center. Weights are placed on sleeves that stick vertically on the base of all four
corners. The athlete assumes an athletic position under the center of the yoke, braces properly
and squats the yoke off the ground. The athlete will carry the yoke a predetermined distance. The
instability and bulk of the yoke makes it awkward to carry.
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With light weights the yoke may be used with a normal, healthy adult population as it promotes
abdominal stability and mobility. Due to the swinging of the implement, the yoke can be potentially
dangerous to the lumbar spine of an ill-prepared individual.

Chapter 1
Farmer’s Handles
The Skeletal System
Farmer’s handles are becoming more common within the general population, but especially
Anna
popular D’Annunzio,
within MS
tactical athletes. Farmer’s handles are a pair of handles that allows plates to be
loaded on both the front and back side of the implement.
The handle only has enough room to be gripped with one hand. The athlete carries both handles,
with equal load on either side, and hastily walks the handles a predetermined distance. This
exercise may be used with the general population with light weights but is especially useful for
competitive athletes of nearly all disciplines.
The farmer’s carry promotes trunk stability, grip strength and mobility. Consider using a farmer’s
carry for general preparedness or conditioning with a variety of athletes.
Logs
Logs are a tool that are nearly exclusively used by strongman athletes. A log can be made from a
metal mold or cut from real wood. It is an implement that typically ranges from 8-12” in diameter
and is intended for the log clean and overhead press. There are large holes carved into it where
the handles are solidified in place. The handles span vertically so that the athlete presses overhead
with a neutral, or a hammer style grip.
The Log Clean and Press is a common event within strongman competitions. A log is more of a
niche tool and has specific techniques associated with it. Logs are not typically used by athletes
outside of the strongman sport, however there is merit to overhead pressing with a neutral grip
as opposed to a pronated grip which is used with a typical barbell.
Sandbags
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Sandbags consist of a heavy fabric sack filled with sand that may or may not have handles sewn-
on. Sandbags are a dynamic way to train strength and power. They are frequently used by combat
sports athletes such as MMA fighters and wrestlers.
Sandbags are also used by strength athletes such as strongmen and powerlifters as well as in
obstacle course races. Common exercises with sandbags include throws, where the individual
picks the sandbag off the ground and throws it over their shoulder, sandbag clean and presses,
and sandbag squats.

Chapter 1
Sandbag workouts are often structured around performing the repetitions of each exercise for
The Skeletal System

a set amount of time or completing a certain number of repetitions using a submaximal weight
but can also be done for maximum weight with careful attention to form.
Anna
When D’Annunzio,
the weight MS
is selected appropriately, sandbags are a fun and effective tool for improving
the strength and conditioning of a healthy, adult population.
Suspension Trainers
Suspension trainers are adjustable-length straps suspended from the ceiling or high rack with
handles or loops on the bottom that allow a variety of upper and lower body exercises to be
performed. Suspension trainers effectively add instability to bodyweight movements when an
individual places their feet or hands in the straps. Suspension trainers include gymnastic rings,
TRX equipment, and other similar implements.
Suspension trainers also allow decreased intensity on a variety of bodyweight movements when
gripping the handles with the hands. For example, they can be used for assisted squats in elderly
populations who cannot safely perform standard bodyweight squats.
Common exercises on the suspension trainers include pushups, dips, knees-to-chest in a plank,
planks, rear flies, and assisted squat variations.
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283 Resistance Training Protocols and SystemsRE SISTANCE T RAI282
NING
Chapter 1
The Skeletal System

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Trainer Academy
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Chapter 1
Summary
The Skeletal System
While there are nearly endless varieties of training systems, equipment and modalities available
to Anna D’Annunzio,
fitness professionals, the vastMS
majority of training programs for general fitness clients follow
some variation of the resistance training protocols and equipment discussed in this chapter.
When using equipment, trainers must ensure clients follow proper form protocols and are familiar
with the equipment they are utilizing.
Given the key role of fitness equipment in most training programs, trainers should spend substantial
time using and familiarizing themselves with any and all equipment they use with clients.
References
1. Jackson M. Evaluating the Role of Hans Selye in the Modern History of Stress. In: Cantor D,
Ramsden E, editors. Stress, Shock, and Adaptation in the Twentieth Century. Rochester (NY ):
University of Rochester Press; 2014 Feb. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/
books/NBK349158/
2. Paul, M. (2020, July 24). The Scientific Legacy of Hans Selye. Nootropics Official.
3. Walter Bradford Cannon (1915). Bodily Changes in Pain, Hunger, Fear and Rage: An Account of
Recent Researches into the Function of Emotional Excitement.
4. Padgett, David; Glaser, R (August 2003). “How stress influences the immune response”. Trends in
Immunology. 24 (8): 444–448.
5. Henry Gleitman, Alan J. Fridlund and Daniel Reisberg (2004). Psychology (6 ed.). W. W. Norton

& Company.
6. WebMD. (n.d.). Ammonia
Trainer Academy Aromatic Inhalation: Uses, Side Effects, Interactions, Pictures, Warnings &
©2023
Dosing. WebMD. https://www.webmd.com/drugs/2/drug-7536/ammonia-aromatic-inhalation/details
7. Gozhenko, AI; Gurkalova, IP; Zukow, W; Kwasnik, Z; Mroczkowska, B (2009). Gozhenko, AI;
Zukow, W; Kwasnik, Z (eds.). Pathology: Medical student’s library. Radom University. p. 272
8. Adamsson A, Bernhardsson S. Symptoms that may be stress-related and lead to exhaustion

disorder: a retrospective medical chart review in Swedish primary care. BMC Fam Pract. 2018
Oct 30;19(1):172. https://doi.org/10.1186/s12875-018-0858-7. PMID: 30376811; PMCID:
PMC6208049.

9. Schmidt,Chapter 1
R.A. (1988). Motor Control and Learning: A Behavioral Emphasis. 2nd ed. Champaign, IL:
Human Kinetics.
The Skeletal
10. Thompson, D. (2001,System
November 26). Motor teaching and motor learning. Oklahoma University of
Health Science. https://ouhsc.edu/bserdac/dthompso/web/mtrlrng/mtrlrng.htm
11. Human Kinetics. (n.d.). Vladimir M. Zatsiorsky. Human Kinetics. Retrieved July 27, 2022, from https://
www.human-kinetics.co.uk/author/vladimir-m-zatsiorsky/
12. Zatsiorsky, V., & Kraemer, W. (2006). Science and Practice of Strength Training (2nd ed.).
13. Parsons, D. (2019, January 4). Rest Periods Between Sets. ISSA. https://www.issaonline.com/blog/

post/rest-periods-between-sets–everything-you-ever-needed-to-know-
14. Hughes DC, Ellefsen S, Baar K. Adaptations to Endurance and Strength Training. Cold Spring
Harb Perspect Med. 2018 Jun 1;8(6):a029769. https://doi.org/10.1101/cshperspect.a029769. PMID:
28490537; PMCID: PMC5983157.
15. Maughan, R J, Watson, J S, Weir, J, (1983), Strength and cross-sectional area of human skeletal
muscle. The Journal of Physiology, 338. https://doi.org/10.1113/jphysiol.1983.sp014658.
16. Anna-Lena Zitzmann, Mahdieh Shojaa, Wolfgang Kemmler, The effect of different training frequency
on bone mineral density in older adults. A comparative systematic review and meta-analysis, Bone,
Volume 154, 2022, 116230, ISSN 8756-3282, https://doi.org/10.1016/j.bone.2021.116230.
17. Bohm, S., Mersmann, F. & Arampatzis, A. Human tendon adaptation in response to mechanical
loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports
Med – Open 1, 7 (2015). https://doi.org/10.1186/s40798-015-0009-9
18. Alvidrez, L., & Kravitz, L. (n.d.). Hormones Responses Resistance Training. The University of New
Mexico. https://www.unm.edu/~lkravitz/Article%20folder/hormoneResUNM.html
19. Vingren JL, Kraemer WJ, Ratamess NA, Anderson JM, Volek JS, Maresh CM. Testosterone
physiology in resistance exercise and training: the up-stream regulatory elements. Sports Med. 2010
Dec 1;40(12):1037-53. https://doi.org/10.2165/11536910-000000000-00000. PMID: 21058750.
20. Muscle performance and enzymatic adaptations to sprint interval training J. Duncan MacDougall,
Audrey L. Trainer
Hicks, Jay R. MacDonald, Robert S. McKelvie, Howard J. Green, and Kelly M. Smith
Academy
Journal of Applied
©2023 Physiology 1998 84:6, 2138-2142
21. Barker, D. (2020, October 13). Understanding Reciprocal Inhibition. San Diego Personal Training. https://
sandiegopersonaltraining.com/2020/10/13/understanding-reciprocal-inhibition/
22. US Army Public Health Center. (2020). Strength Tests in Army Fitness Training and Assessment
of a Pilot Program. Tip No. 12-119-0121.
23. U.S. Army. (2012). FM 7-22; Army Physical Readiness Training. Department of the Army.
24. Cunha, Paolo & Nunes et al. (2018). Resistance Training Performed With Single and Multiple Sets

Chapter
Induces Similar 1
Improvements in Muscular Strength, Muscle Mass, Muscle Quality, and IGF-1 in
Older Women: A Randomized Controlled Trial. The Journal of Strength and Conditioning Research.
The Skeletal System
10.1519/JSC.0000000000002847.
25. Krieger JW. Single vs. multiple sets of resistance exercise for muscle hypertrophy: a meta-analysis.
Anna D’Annunzio,
J Strength Cond Res. (2010). MS
Apr;24(4):1150-9. https://doi.org/10.1519/JSC.0b013e3181d4d436.
PMID: 20300012.
26. Fröhlich M, Emrich E, Schmidtbleicher D. Outcome effects of single-set versus multiple-set

training–an advanced replication study. Res Sports Med. 2010 Jul;18(3):157-75. https://doi.
org/10.1080/15438620903321045. PMID: 20623433.
27. Sperlich, B., Wallmann-Sperlich, B., Zinner, C., Von Stauffenberg, V., Losert, H., & Holmberg, H.
C. (2017). Functional High-Intensity Circuit Training Improves Body Composition, Peak Oxygen
Uptake, Strength, and Alters Certain Dimensions of Quality of Life in Overweight Women. Frontiers
in physiology, 8, 172. https://doi.org/10.3389/fphys.2017.00172
28. Ramos-Campo, D. J., Caravaca, L. A., Martínez-Rodríguez, A., & Rubio-Arias, J. Á. (2021). Effects
of Resistance Circuit-Based Training on Body Composition, Strength and Cardiorespiratory Fitness:
A Systematic Review and Meta-Analysis. Biology, 10(5). https://doi.org/10.3390/biology10050377
Trainer Academy
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Chapter 1
TheCHAPTER
Skeletal16System
Anna D’Annunzio,Training
Resistance MS
Technique
Travis McKinney, MS
288
Re sistance T raining T echn i q ue
Chapter 1
Introduction
The Skeletal System
Fitness professionals must have in-depth knowledge of proper exercise technique to ensure client
Anna
safety whenD’Annunzio, MS Overall, proper technique in resistance training exercises
performing movements.
provides the optimal training stimulus while reducing the risk of injury.
When introducing clients to exercises, observing proper form checkpoints at each phase of the
movement is key to both giving proper verbal technique cues as well as identifying potential
muscular imbalances.1
Key Injury Indicators

The most common areas injured during resistance training include the knees, shoulders, and
back.2 Therefore, common visual checkpoints for trainers to look for are proper knee tracking,
shoulder complex alignment, and engagement, along with neutral spine positioning.
Knee valgus (knees caving in) is a risk factor for lower limb injury and a potential indicator of
weakness in the hip abductor group.3
Research attributes scapular muscle strength discrepancy as a common cause of shoulder injury
during resistance training. The typical shoulder muscle imbalances lead to elevation and internal
rotation of the shoulder, which can occur at rest or during movements involving the glenohumeral
joint. This pattern places unneeded pressure on the shoulder joint.4 Therefore, trainers must keep
a strong technical focus on scapular retraction and shoulder depression during pressing exercises.5
A neutral spine should be maintained through most resistance exercises, as it is the optimal
position for power in sports-related movements and protects the muscular alongside the spine
itself.6 For those clients who have difficulty holding this position, fitness professionals should
include properTrainer
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©2023 strengthening exercises which can aid them in the endeavor.
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Resistance Training Technique 289
289
Chapter 1
The Skeletal System

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Trainer Academy
of motion ©2023 the safest
offers and and
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movement
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the arc.
290
Chapter 1
3. Maintain neutral spine
The Skeletal
As mentioned System
above, neutral spine is the safest position for the musculature alongside the spine,
which can be injured if placed underResistance
load andTraining Techniquemove out of position.
the vertebrae 290
In sport-specific movements when the athlete needs to come out of neutral spine under load,
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Breathing During Resistance Training

Breathing is essential for not only correct exercise techniques, but for human life. The
average lungs move around 17 fluid ounces of air with each normal breath, but during exercise
that number shoots up to 101 ounces.
During a workout, levels of carbon dioxide and hydrogen ions increase in the bloodstream,
causing a drop in pH and an increase in breathing rate. The primary trigger to breathe is actually
291
Chapter 1
Breathing During Resistance Training
The Skeletal System
Breathing is essential for not only correct exercise techniques, but for human life. The average
Anna
lungs moveD’Annunzio, MS of air with each normal breath, but during exercise that
around 17 fluid ounces
number shoots up to 101 ounces.
During a workout, levels of carbon dioxide and hydrogen ions increase in the bloodstream,
causing a drop in pH and an increase in breathing rate. The primary trigger to breathe is actually
to remove excess CO2, not more oxygen.
Better breathing will increase exercise output during both cardiovascular and weight lifting
endeavors.
During resistance training movements there are two breathing techniques to consider: when to
breathe, and when to hold the breath.
When to Breathe
For most exercises, breathing in on the eccentric portion of the movement, and out on the
concentric phase will provide the best pattern of breathing to follow.
In the case of a pull up, the lifter breathes out on the way up and in on the way down as they
go through their repetitions.
For a back squat, they would start with a breath in on the way down and then release that breath
on the way up before beginning again.
When Not to Breathe
Sometimes, especially
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©2023 on heavy low repetition sets, it’s helpful to take one deep breath and hold
it while bracing the core and pushing air against a closed glottis throughout the working set. This
is called “the Valsalva maneuver,” and is very effective at creating intense pressure throughout the
body that provides spinal stability, allowing the body to support substantial weight.
Note that this can be a dangerous technique to implement, especially for any set greater than a
few repetitions, because without oxygen, humans can pass out and potentially even suffer greater
negative consequences.

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Chapter 1 Resistance Training Technique

For this reason, the Valsalva maneuver is best used with intermediate and advanced clients
The Skeletal System

training for maximal strength.
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Technique for Selected Resistance

Exercises Trainer Academy © 2023
293
Chapter 1
Technique
The for Selected Resistance
Skeletal System
Exercises
Bodyweight Movements
Push Ups
Safety Checkpoints:
• Keep core braced and maintain neutral spine during movement.

• Shoulders should be pulled back and down to protect joints.
• Make sure to stack wrists under elbows.
• Hand placement will vary based on personal preference.
• Allowing the elbows to flare more increases chest activation, but puts the shoulder in a more
compromised position so consider focusing on pushing elbows back rather than out in the movement.
• If the flattened hand position hurts the wrists, consider using push up stands (or two dumbbells)
to keep wrists straight or limit the ROM of the exercise if needed to 90 degrees.
Exercise Instructions:
1. Start in the plank position, creating a straight line from head to heel. Hands should be directly
outside shoulders with elbows extended, fingers facing slightly outwards.
2. Engage the core and lower the body, by allowing the elbows to flex until the chest lightly
touches the ground, then come back up.
Coaching Tips:
• Observe client’s elbows to ensure they point back at a 45-degree angle while maintaining
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vertical stack©2023
above the wrist during the movement.
• If they are unable to perform a traditional push up, regress the exercise to either push ups
with the hands on an elevated box or push ups on the knees.
Targeted Major Muscle Groups:
• pectoralis major/minor
• triceps brachii
• anterior deltoid

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Chapter 1
Pull Ups
The
SafetySkeletal
Checkpoints: System
Keep active MS
shoulders during movement. Scapula should be pulled back and down.
• Watch for scapular winging during retraction.
• Watch for shoulders shrugging during pull up as it can place excessive pressure on the joint.
• Keep core engaged.
• Control the eccentric portion of the movement and limit excess hip or lower back involvement;
often people use a lot of extra body motion to reach their chin or clavicle above the bar, which
increases potential for injury and limits use of the muscles this movement seeks to target.
1. Start directly under a bar set at a height from which you can hold on to with the elbows fully
extended, without feet touching the floor.
2. Place hands slightly outside shoulders with palms facing forward and feet off the ground.
3. Pull the shoulder blades back and down to initiate movement and bring the body up, bending
the elbows, until the chin (or chest) touches or raises over the bar.
4. Complete the repetition by lowering down to the starting position with the elbows fully
locked out.
Coaching Tips:
• Alternative grips exist at underhand and neutral, changing the associated muscular recruitment
and overall difficulty of the pull up as well as differences in the width distance of the grip.
• If a client is unable to perform a standard pull up or chin up, utilize either a pull up machine
or pull up bands to reduce the weight needed to overload the muscles properly.

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• latissimus dorsi
• trapezius
• rhomboid

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Dips
The
SafetySkeletal
Checkpoints: System
• Anna
Neutral D’Annunzio, MS the range of motion.
head posture throughout
• Elbows stacked above wrists to avoid excessive wrist flexion.
• Maximize ROM while considering mobility restrictions, not everyone will be able to safely
lower all the way.
1. Start with hands planted on parallel bars.

2. Step or jump into position so that arms are supporting the weight of your body while elbows
are fully extended.
3. Lower body until shoulders are below height of elbows.
4. Return to full extension to finish the rep. Knees can remain flexed throughout the movement
if need be.
Coaching Tips:
• A more upright posture with elbows pointed back will emphasize triceps, while a greater lean
forward with elbows flared will emphasize chest (although be careful with flaring the elbows
too much as this can put excess pressure on joints).
• If unable to perform a dip, clients can use a bench or box instead of a parallel bar: Have them
plant hands slightly outside shoulder width with fingers facing forward on the implement.
Elbows begin fully extended with legs straight, resting on heels. Lower body towards the floor
until shoulders are below the height of elbows. Return to full elbow extension to finish the rep.
• pectoralis Trainer
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• triceps brachii

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Air Squats
The
SafetySkeletal
Checkpoints: System
Knees fall MSof toes specifically, second metatarsals.
in line with the path
• Maintain neutral spine and upright posture.
• Make sure knees do not buckle inwards during motion.
1. Stand with feet outside hip width, toes pointed forward or slight out.
2. Push the hips back and down, keeping the chest open (as if sitting down into a chair) until
the hips drop below the knees.
3. Stand back up.
Coaching Tips:
• As the client lowers into the squat, their weight should be positioned toward the midfeet,
right below the ankle.
• Some people may prefer putting their arms out in front during movement to help with balance.
• If the client cannot perform a full squat safely, because of injury or balance or coordination
issues, have them start by squatting onto a box or bench, practicing the correct form. Over
time the trainer can lower the height of the implement until the client can squat safely
without any assistance.
• gluteal muscles
• quadriceps femoris
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Lunges
The
SafetySkeletal
Checkpoints: System
• Make sure knees do not buckle inwards.
• Do not put excess pressure onto the back leg.
1. Stand with feet hip distance apart.

2. Step forward a few feet with one leg and lower the hips, allowing the front knee to bend until
the back knee lightly touches the floor,
3. Rise back up and bring the front forward foot back to the starting position. Finish repetitions
on one side and repeat for the other leg.
Coaching Tips:
• If the client cannot lower into the lunge, have them instead step up onto a box. This movement
is the same as the lunge but in reverse as it begins with the concentric phase of the movement
instead of the eccentric.
• gluteal muscles
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Dumbbell Movements
The Skeletal System
Bent Over Row
Safety Checkpoints:
• Maintain neutral spine.

• Shoulder blades should be pulled back and down as weight comes up.
1. Start standing, holding two dumbbells at sides.

2. Push hips back and lower torso while keeping back flat until dumbbells are at knee height.
3. Pull dumbbells to the torso allowing elbows to flex at a 45-degree angle. Dumbbells will stop
next to either side of the ribcage.
4. Slowly lower back to full extension while keeping the torso stationary.
Coaching Tips:
• This exercise can also be done one arm at a time with the hand and knee of the opposite side
supported on a bench, which reduces lower back load.
• If the dumbbells are pulled higher on the body, like to the chest line, it activates the rhomboids
more. If the dumbbells are pulled lower to the ribcage, that involves more of the lats.
• trapezius
• rhomboids
• posterior deltoid
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Flat Chest Press
The
SafetySkeletal
Checkpoints: System
Maintain MS
head, shoulders and tailbone contact with bench or flat surface.
• Vertical forearms and wrists.
• Shoulder blades pull back and down.
• Keep core braced and torso tight, maintaining a stable base.
1. Lie on a flat bench holding two dumbbells.

2. You can use knees and arms to push the weights up into the starting position over the chest
or have someone help position them there.
3. Lower the weights to the chest. Elbows can open up to 45-degrees of the torso.
4. Once the weights lightly touch the chest, push them back up, extending the elbows.
Coaching Tips:
• For extra power, have the client keep contact with the floor during the entire movement and
push through the legs and feet, while keeping hips on bench to drive the dumbbells up.
• Different elbow angles will work for different people, but a wider elbow has the potential to
aggravate the elbow and shoulder joints.
• triceps brachii
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Incline Chest Press
The
SafetySkeletal
Checkpoints: System
Maintain MS
1. Lie on an incline bench holding two dumbbells.

2. You can use knees and arms to push the weights up into the starting position over the chest
or have someone help position them there.
3. Lower the weights to the chest. Elbows can open up to 45-degrees of the torso.
4. Once the weights lightly touch the chest, push them back up, extending the elbows.
Coaching Tips:
• Bench angle varies from an incline of 15-60 degrees for this exercise. The angle will change
depending on goals and preferences, but for most, a lower degree angle in the 15-30 degree
will suit goals best as it places more emphasis on the pectoralis muscle and less strain on the
shoulders.
• triceps brachii
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Chapter 1
Overhead Press
The
SafetySkeletal
Checkpoints: System
• Anna
UprightD’Annunzio,
torso with neutral MS
spine.
• Push the weights straight overhead, perpendicular to the floor.
• Keep abs braced.
• Make sure mobility is adequate before excessively loading this movement.
1. Dumbbells held at shoulder height.

2. Brace core and press the weights straight over head to full elbow extension, directly over each
respective shoulder.
3. Lower the weights with control.
Coaching Tips:
• Having clients keep elbows tucked in will increase triceps involvement and help maintain
external rotation, while letting elbows open outwards allows more shoulder and chest
involvement but increases the likelihood of impingement.
• This exercise can be performed seated or standing.
• medial deltoid
• triceps brachii
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Chapter 1
Bulgarian Split Squat
The
SafetySkeletal
Checkpoints: System
Keep torso MS stable.
upright and midline
• Forward knee stays in line with second metatarsal during flexion and extension.
• Make sure knee does not buckle inwards.
1. Hold a pair of weights, arms hanging on either side of the torso.

2. Targeted leg will have the foot planted on the floor with the opposite leg elevated and its
foot resting on a bench/block/box at knee height behind the lifter. Planted foot should be in
front of the torso rather than vertically stacked.
3. Begin the movement by lowering the torso to the floor allowing the planted leg to bend.
Avoid the planted knee going past the toes by driving the elevated knee towards the floor.
4. Return to single leg standing to complete the repetition.
Coaching Tips:
• This movement is often done holding two dumbbells at the sides, but can also be done with
one dumbbell held in a front rack position or with a barbell racked on the client’s shoulders.
• The length of the step of the forward leg from the back leg will change the muscle emphasis:
a shorter step recruits more quad musculature and a longer step will focus more on glute
muscles.
• gluteal muscles
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Chapter 1
Goblet Squat
The
SafetySkeletal
Checkpoints: System
• Anna
torso with neutral MS
spine.
• Elbows stack under wrists and tuck tight into the mid section.
• Knees stay in line with second metatarsal.
1. Stand with feet outside shoulder width, holding a dumbbell with both hands at sternum.
Toes pointed forwards or slightly outwards provided knees track with toes.
2. Push hips back and sit tailbone as low as possible (ideally lower than the height of the knees)
while maintaining an upright torso.
3. Return to standing to complete the repetition.
Coaching Tips:
• This is a great movement to teach clients who lean forward too much when they squat, because
the weight is placed on top of the chest and any leaning forward will dramatically increase
the difficulty of the movement.
• While this movement provides many benefits, as clients progress it becomes harder and harder
to load it properly enough to tax the legs, because the weight must be held in place using the
shoulders and arms, which are not as strong.
• gluteal muscles
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Chapter 1
Lateral Raise
The
SafetySkeletal
Checkpoints: System
Torso upright MSmovement.
and static during
• Minimal elbow flexion during ROM.
1. Start standing or seated, holding a pair of weights by the hips.

2. Perform the lateral raise by raising both arms to shoulder height directly to the side of each
respective shoulder. Body should present a “t” at the top of the movement with arms parallel
to the floor and each other.
3. Return arms to the sides of the hips to complete the repetition.
Coaching Tips:
• Have clients use a minimal bend at the elbows during exercise.

• This movement is best done for higher repetitions with lighter weights.
Targeted Major Muscle Groups
• medial deltoid
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Chapter 1
Dumbbell Snatch
The
SafetySkeletal
Checkpoints System
Maintain neutral spine. MS
• Hips are the driving force behind this movement, not arms.
• Weight travels in a straight path.
• Clients need excellent mobility to load this movement.
• This movement requires much more coaching than most other exercises.
Exercise Instructions
1. The goal of this movement is to attempt to lift the dumbbell placed in front of you in one
smooth motion from the ground to overhead. This is accomplished through three phases of
movement: the jump, the transition, and the catch.
2. The jump: squat down to reach the weight with a straight arm. Bring the weight to shin height,
then explode with their lower body using triple extension (extension of the hips, knees, and
ankles) to drive the weight into the air.
3. The transition: as the dumbbell travels through the air, bend your elbow, allowing the weight
to be flipped from the wrist pointing down to the wrist facing up.
4. The catch: immediately after the weight is flipped up, stabilize the weight over your center
of gravity with a straight arm. You can do this by dropping into either a full squat (in the full
snatch) or a quarter squat (in the power snatch).
5. When momentum stops, the weight should be locked out overhead and the body should be
in a squat or dip.
6. Finish the move by standing completely upright with the weight overhead.
7. After this the weight is returned back to the ground.
Coaching Tips
• As clientsTrainer
bring
©2023 the weight down, have them bring their hips back to take the force of the
Academy
movement, instead of the spine.

• Teach this movement in stages, using the three phases separately before integrating them
together in the whole movement.
• A snatch is the fastest way to move a dumbbell from the ground to straight overhead.
• total body power movement

306
Chapter 1
Bicep Curls (supine grip)
The
SafetySkeletal
Checkpoints: System
• Anna
stable torso. MS
• Shoulders retracted and depressed.
• Avoid excessive body movement.
1. Hold weights with a supinated grip (palms out) with straight arms by sides. Weights should
be just in front of the hips.
2. Keeping shoulders retracted and depressed, flex the elbows to bring weights to shoulder
height while minimizing any accessory movement through the body.
3. At the top of the movement, palms should be facing shoulders. Upper arm should remain
in contact with torso.
4. Slowly lower back to the start position to complete the repetition.
Coaching Tips:
• Can be performed standing or seated.

• To help clients do this movement correctly without any extra body motion, you can teach
it while having clients lean against a wall, making sure to keep their back against the wall
during the movement.
• biceps brachii
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Chapter 1
Biceps Curl (hammer/neutral grip)
The
SafetySkeletal
Checkpoints: System
• Anna
stable torso. MS
• Shoulders retracted and depressed.
• Avoid excessive body movement.
1. Hold weights with a neutral grip (palms facing hips) and straight arms. Weights should be
by the side of the hips.
2. Keeping shoulders retracted and depressed, flex the elbows to bring weights to shoulder
height while minimizing any accessory movement through the body.
3. Upper arm should remain in contact with torso and palms should face each other throughout
the repetition.
Coaching Tips:
• Can be performed standing or seated.
• biceps brachii
• brachioradialis
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Chapter 1
Chest Fly
The
SafetySkeletal
Checkpoints: System
Torso stays in contact with MS
bench during movement.
• Slight flex at elbows.
• Weights should start stacked directly above shoulder and at maximal abduction should present
a symmetrical line from right to left wrist.
1. Lie flat on a bench with a pair of weights extended directly above the chest. Maintain a slight
amount of elbow flexion.
2. Slowly abduct the weights to the sides maintaining arm length to spread the chest while
also retracting shoulders. Upper body should be nearly parallel from weight to weight at the
bottom of the movement.
3. Adduct the weights back together over the chest to complete the repetition.
Coaching Tips:
• Have clients arch their back slightly on the bench to help open up the chest, along with
retracting their shoulders.
• There is much more tension at the bottom of the movement than the top, so focus on that
range of motion more for hypertrophy work.
• triceps brachii
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Chapter 1
Barbell Movements
The Skeletal System
Bench Press
Safety Checkpoints
• Maintain head, shoulders and tailbone contact with bench or flat surface.
• Bar should follow a symmetrical range of motion for both right and left sides.
• When using heavy weights, this movement requires a spotter or stable safety pins.
1. Lie on a bench with barbell racked, hands gripping barbell outside shoulder width.
2. Unrack the barbell and bring it over the height of the chest.
3. Pin the shoulder blades back against the bench and lower the weights to the chest. Elbows
can open up to 45-degrees of the torso.
4. Once the bar lightly touches the chest, push it back up, extending the elbows completely.
Coaching Tips:
• For extra power, have clients keep contact with the floor during the entire movement and
push through the legs and feet, while keeping hips on the bench to drive the barbell up.
• A back arch will aid in total body stability and strength during movement, but it makes the
press more of a full body move and can shorten range of motion.

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• triceps brachii

310
Chapter 1
Overhead Press
The
SafetySkeletal
Checkpoints: System
• Anna
UprightD’Annunzio, MS
torso with neutral spine.
• Push the weight straight overhead, perpendicular to the floor.
• Keep abs braced.
• Make sure mobility is adequate before excessively loading this movement.
• Make sure client moves their head out of the way of the bar path.
1. Start with the barbell held at shoulder height with palms facing forward and elbows to the
side of the torso. Grip should be spaced just outside shoulder width.
2. Brace core and press the weights over head to full elbow extension, making sure to move head
out of the way of the bar’s straight path. Keep active shoulders at the top of the movement.
3. Lower the weight with control.
Coaching Tips:
• Can be performed seated or standing.

• Having clients tuck elbows in will increase triceps involvement and help maintain external
rotation, while letting the elbows open outwards allows more shoulder and chest involvement,
but increases the likelihood of impingement.
• medial deltoid
• triceps brachii
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Chapter 1
Incline Press
The
SafetySkeletal
Checkpoints: System
Maintain MS
• Bar should follow a symmetrical range of motion for both right and left sides.
• When using heavy weights, this movement requires a spotter or stable safety pins.
1. Lie on an incline bench with barbell racked, hands gripping barbell outside shoulder width.
2. Unrack the barbell and bring it over the height of the chest.
3. Pin the shoulder blades back against the bench and lower the weights to the chest. Elbows
can open up to 45-degrees of the torso.
4. Once the bar lightly touches the chest, push it back up, extending the elbows completely.
Coaching Tips:
• For extra power, have clients keep contact with the floor during the entire movement and
push through the legs and feet, while keeping hips on the bench to drive the barbell up.
• triceps brachii, anterior deltoid
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Chapter 1
Back Squat
The
SafetySkeletal
Checkpoints: System
• For heavy weights use safety pins in case lifter gets stuck at the bottom.
1. Start with the barbell resting on a squat rack at shoulder height.

2. Bring your body under the barbell, letting the bar rest on the shoulders behind the head.
Barbell should be resting on the upper trapezius across the back without putting any pressure
on the neck’s vertebrae. Hands go just outside the shoulders on the bar.
3. Extend the knees to lift the barbell from the rack and step into free space for the exercise.
4. Begin the movement by pushing hips back and down to lower body towards the floor
allowing knees to bend. Ideally knees track in line with toes while torso remains upright.
5. Control the lowering of the body then when max depth is reached (lower than parallel) drive
the weight back up to a standing position by extending throughout the hips and legs.
Coaching Tips:
• Use the greatest ROM possible with this exercise and then standardize the depth, otherwise
progression will be harder to control.
• gluteal muscles
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Chapter 1
Deadlift (Standard)
The
SafetySkeletal
Checkpoints: System
• Anna
Vertical D’Annunzio,
bar path. MS
• Keep the weight close to body.
• Shoulders remain retracted during movement.
• Hip drive is catalyst for movement, not lower back extension.
1. Bar starts on the floor in front of you.

2. Push your hips back and down and roll the bar in until it’s as close as possible to the shins.
3. Grabbing the bar right outside their knees, extend your hips and stand up with the bar.
4. Return the barbell in the same path to the floor to complete the repetition.
Coaching Tips:
• The goal of the movement is to lift the bar from the floor in as vertical a line as possible by
driving hips forward to a standing position.
• Emphasize a full standing posture without hyper-extension of the low back (which may
require ab and glute activation).
• Grip options are either double overhand, mixed (under and over), or double overhand with
a hook grip. If you clients prefer to use a mixed grip, make sure to alternate which hand is
over and under to avoid muscle imbalances.
• gluteal muscles
• hamstrings
• quadricepsTrainer
femoris
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Chapter 1
Deadlift (Romanian)
The
SafetySkeletal
Checkpoints: System
• Anna
Vertical D’Annunzio,
bar path. MS
• Keep the weight close to body.
• Shoulders remain retracted during movement.
• Hip drive is catalyst for movement, not lower back extension.
• Knees angle stays constant.
1. Starts standing up with the bar held at mid thigh level with minimal knee bend.
2. Push your hips back allowing the bar to travel downwards as far as possible without bending
the knees any more.
3. Once the hips are as far back as possible, loading the hamstrings, contract your glutes and
bring the weight back up.
Coaching Tips:
• Some people will be able to keep the legs completely straight during movement and some
will need a slight bend so vary based on mobility of the client.
• Tell clients to think about, “sitting back” during the movement to emphasize the hip motion
more.
• gluteal muscles
• hamstrings
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Chapter 1
Power Clean
The
SafetySkeletal
Checkpoints: System
• Hips are the driving force behind this movement, not arms.
• Weight travels in a straight path.
• Need to be able to split exercise into 3 phases: pull, dip/transition, catch.
• This movement requires much more coaching than most other exercises.
1. Lift the weight in one smooth motion from the ground to your shoulders. This is accomplished
through three phases of movement: the jump, the dip, and the catch.
2. The jump: squat down to reach the weight with straight arms, grabbing just outside hips.
Bring the weight to shin height, then explode through the lower body using triple extension
(extension of the hips, knees, and ankles) to drive the weight into the air.
3. The transition/the dip: as the barbell travels through the air, bend your elbows, allowing
the weight to be flipped from the wrist pointing down to the wrist facing up. While this is
happening, dive underneath the bar.
4. The catch: immediately after the weight is flipped up, you need to stabilize the weight.
Do this by dropping into either a full squat (in the full clean) or a quarter squat (in the power
clean) under the bar, pulling your elbows up and in so you can catch it.
5. When momentum stops, the weight should be held in a front rack position and the body
should be in a squat or dip.
6. Finish the move by standing completely upright with the weight on the shoulders.
Coaching Tips
• When the client brings the weight back to the ground, coach them to bring their hips back
to take theTrainer
force
©2023 of the movement as the barbell drops off of the shoulders.
Academy
• Teach this movement in stages, using the three phases separately before integrating them
together in the whole movement.
• A clean is the fastest way to move a dumbbell from the group to the shoulders.
• total body power movement

316
Chapter 1
Bent Over Row
The
SafetySkeletal
Checkpoints System
• Shoulder blades should be pulled back and down as weight comes up.
• Arms remain symmetrical throughout the movement.
1. Start standing, holding the barbell with extended hanging arms directly in front of the hips.
2. Push hips posteriorly while keeping back flat until the barbell is just below knee height.
3. Pull barbell to torso with the weight meeting torso at approximately the bottom of the
sternum, allowing elbows to flex out at a 45-degree angle.
4. Slowly lower back to full arm extension to finish the repetition.
Coaching Tips
• Variations of this exercise include the t-bar row, Yates row, and Pendley row. Different variations
will work for different clients as well as different grip positions.
• It’s very easy for the hips to aid in the movement, so choose the load, repetitions, and volume
that allows proper technique for clientele.
• trapezius
• rhomboids
• posterior deltoid
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Chapter 1
Biceps Curl
The
SafetySkeletal
Checkpoints System
Shoulders MS and retracted throughout the movement.
should remain depressed
• Torso remains upright.
• Avoid swaying during exercise.
1. Stand, holding the barbell with a supinated grip (palms out) and straight arms at shoulder
width apart. Barbell should be just in front of the hips.
2. Keeping shoulders retracted and depressed, flex the elbows to bring barbell to shoulder height
while minimizing any accessory movement through the body. At the top of the movement,
palms should be facing shoulders. Upper arm should remain in contact with the torso.
Coaching Tips
• To help clients do this movement correctly without any extra body motion, you can teach
it while having clients lean against a wall, making sure to keep their back against the wall
during the movement.
• Variations of the barbell curl include preacher curls, spider curls, partial repetitions, and curls
utilizing an E-Z bar for more range of motion and better wrist position.
• biceps brachii
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Chapter 1
Machine Movements
The Skeletal System
Lat Pulldown
Safety Checkpoints
• Keep active shoulders during movement. Scapula should be pulled back and down.
• Watch for scapular winging during retraction.
• If elbows flare out to the side during pulldown, it places extra pressure on the shoulders so
watch for this.
1. Set the thigh pad pin so that your knees fit snugly into the opening and the correct weight.
2. Reach or stand up and grab the bar, using your body weight to bring it overhead with straight
elbows as you get into position.
3. Pull the shoulder blades back and down to initiate movement and bring the bar down,
bending the elbows, until the chin (or chest) touches or raises over the bar.
4. Complete the repetition by allowing the bar and cable to return to the starting position with
the elbows fully locked out.
Coaching Tips
• Experiment with different grip widths, but for most clients, directly outside the shoulders
will be best with a pronated or supinated wrist position.
• As the weight travels back up, make sure clients aren’t being pulled out of the seat.
• latissimusTrainer
dorsi Academy
©2023
• trapezius
• rhomboid

319
Chapter 1
Calf Raise
The
SafetySkeletal
Checkpoints System
• Anna
Use fullD’Annunzio, MS
range of motion and control descent.
1. Select the appropriate height on the machine so you can stand or sit and still complete the
entire movement without obstruction.
2. If standing, place the pads on your shoulders, if seated they go above your knees.
3. Push the weight through your ankles and feet and come up as far as you can onto the toes.
4. Lower all the way down and repeat.
Coaching Tips
• Calf raises are best used with high repetitions and lower rest times.
• Have your clients use the most ROM as possible, getting a stretch at the bottom as well as
the top of movement.
• Clients can point their toes forward, in, or out, which may recruit different sides of the calf,
although the best foot position is going to be whichever allows the client to do the most
quality repetitions.
• gastrocnemius
• soleus
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Chapter 1
Leg Curl
The
SafetySkeletal
Checkpoints System
Make sure MSlined up with joints.
machine angles are
• Control eccentric.
1. Set up the machine so pads lie flat against the lower back. Raise your legs and slip them into
the padded lever. The leg pad should sit on the lower calf. Drop the lap pad so that it sits
comfortably tight above the knees.
2. Start each repetition by pulling your legs back toward your glutes as far as possible.
3. Hold for a one second at the finish point and return the weight back to the start.
Coaching Tips
• Most machines will have dots or markings to indicate where the knee joint should line up
with the machine, so double check the machine.
• There are several types of leg curl machines including lying and seated. Both will work well.
• hamstrings
• gluteal muscles
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Chapter 1
Leg Press
The
SafetySkeletal
Checkpoints System
Knees fall MSof toes specifically, second metatarsals during motion.
1. Load the machine with the weight and sit down.

2. Position your feet on the sled slightly outside hip width.
3. Extend your knees and unlock the safety devices.
4. Lower the weight under control as far as possible with the knees tracking over the feet
and the lower back flat against the seat.
5. Pause briefly and then drive the weight back to the initial position by extending the knees.
Do not lock out the knees completely but maintain a slight flex at the top of the movement.
6. Complete the repetitions and then relock the safeties.
Coaching Tips
• The range of motion will be dictated by client’s mobility, but seek to lower the weight past
a 45 degree knee angle.
• Placing feet higher on the sled or lower will be different based on goals and anthropomorphics
of clients, but the main goal should be to put the knee in a safe position.
• gluteal muscles
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Chapter 1
Triceps Pushdown
The
SafetySkeletal
Checkpoints System
Maintain neutral spine, useMS
triceps to control movement, not lower back.
1. Pick either a rope or a v-shaped bar attachment and clip it into the cable system.
2. Raise the height of the rope to eye level using the drop pins.
3. Stand upright leaning very slightly forward with your upper arms close to the body.
4. Grab tightly with both hands on either side of the device, and bring the rope down until
the elbows are fully extended, perpendicular to the floor.
5. Hold for a second and return the rope up to the starting position.
Coaching Tips
• As the client brings the rope or bar down, allow their elbows to open out slightly, which will
help with the muscle contraction.
• triceps brachii
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Chapter 1
Summary
The Skeletal System
Proper exercise technique prevents risk of injury and targets the correct muscles used in the
Anna D’Annunzio,
movement. MS
Additionally, coaching the correct motion pattern requires knowledge, communication
skills, and patience.
Above all, fitness professionals must make sure their clients can perform exercises properly before
adding extra resistance, because as weights increase it becomes very easy for minor changes in
movement to create large impacts on the body in both a positive and negative way.
Generally, stressing the three rules of weightlifting and correct breathing will go a long way,
but each exercise contains specific cues that enhance the movement and aspects to watch out so
correct technique on that exercise is essential.
References
1. Colado, J; Garcia-Masso, X. Technique and Safety Aspects of Resistance Exercises: A Systematic
Review of the Literature. Phys Sportsmed: 2009 Jun;37(2):104-11.
2. Gean, RP; Martin RD; Cassat, M; Mears, SC. A Systemic Review and Meta-analysis of Injury in
Crossfit. Journal of Surgical Orthopaedic Advances: 2020 Jan;29(1):26-30.
3. Wilczynski, B; Zorena, K; Slezak, D. Dynamic Knee Valgus in Single-Leg Movement Tasks. Potentially

Modifiable Factors and Exercise Training Options. A Literature Review. International Journal of
Environmental Research and Public Health: 2020, 17(21).
4. Barlow, J; Benjamin, B; Birt, P; Hughes, C. Shoulder Strength and Range-of-Motion Characteristics

in Bodybuilders. Journal of Strength and Conditioning Research: 2002 Aug;16(3):367-72.
5. Kolber, M;Trainer
Beekhuizen,
Academy
K; Cheng, M; Hellman, M. Shoulder Injuries Attributed to Resistance
Training: A Brief
©2023Review. Journal of Strength and Conditioning Research: 2010 June:24(6):1696-1704.
6. Akuthota, V; Ferreiro, A; Moore, T; Fredericson, M. Core Stability Exercise Principles. Current

Sports Medicine Reports: 2008 Jan:7(1):39-44.
7. Cissik, John. The Role of Core Training in Athletic Performance, Injury Prevention, and Injury
Treatment. Strength and Conditioning Journal: 2011 Feb:33(1):10-15.

Chapter 1
TheCHAPTER
Skeletal17System
Anna D’Annunzio,
Program MS
Design
Quentin Washington, MS
325
Program Des i gn
Chapter 1
Introduction
The Skeletal System
Understanding how to design an effective program seems an easy task; however, it can be an
Annaprocess.
intensive D’Annunzio, MS guide an individual through their training in an organized
Training programs
fashion in order to achieve optimal results.
Anyone can take several exercises and perform them in succession, but it is job of the fitness professional
to use knowledge and common sense to pick the right set of exercises and perform them in the
correct order to both maximize improvements in fitness and minimize risk of injury for the client.
Programs must consider a myriad of variables that may change the design fundamentally. Some
variables involve the actual workouts while others involve the client’s strengths, limitations and
goals. An endurance program will look vastly different compared to a strength program. An older
client’s program will be in stark contrast to a younger client’s program.
This chapter will cover different program variables and their uses as well as giving fitness
professionals a way to organize training schedules to best fit the needs of a client.
Program Design Variables

A training program requires manipulation of multiple variables to be effective. Each variable
carries important factors with it. Each variable’s manipulation may alter how a program affects
a client’s progression. The following will explain important training variables that will be a part
of every training program.
Sets
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A set is a grouping of several repetitions of an exercise or a number of reps performed without

rest.1 Most workout programs include several sets per exercise. However, some may only use one
set per exercise for beginners or one extended set. Exercises will typically have 1-3 warm up sets
followed by 3-5 working sets.
A warm up set uses lighter weights to prepare the body for the working sets, while a working set
is the set using the assigned intensity, reps, and tempo. Usually a rest break is required between
sets, which can vary from a few seconds up to ten minutes depending on the goals of the workout.

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Chapter 1
Reps
The Skeletal System
A repetition, or rep, is one instance of an exercise. One set will have 1-30 reps typically. Different
repAnna D’Annunzio,
ranges are MSof stimulus they typically provide a muscle or muscle group.
related to the type
Each rep range is related to either hypertrophy, strength, power, muscular endurance, or a multiple
other training goals discussed later.
Generally, most reps involve moving the weight to its required destination and then back, although
in some instances reps involve no movement or partial range of motion.
Intensity
The intensity of an exercise typically refers to its percent of a 1 repetition max (%1RM). Intensity
levels correspond to different goals. For example, 90% 1RM or higher is typically related to power,
maximal strength, and for some athletes, a peaking phase.
Different intensity ranges will be discussed later in this chapter. Intensity can also refer to how
challenging a rep or set feels to the individual based on the rate of perceived exertion (RPE).
Tempo
Repetition Tempo, or rep tempo, is the speed at which a rep is performed during a given set. Rep
tempo is often displayed as 3 to 4 digits, such as 2-1-2 or 2-1-2-0. 2-1-2 denotes a 2 second
eccentric phase, 1 second pause at the bottom of the rep, and 2 second concentric phase. The
fourth number would represent the time between finishing one rep and starting the next.
A slower rep tempo has been shown to be more effective than a typical one when it comes to
hypertrophy, but the difference is insignificant when a set is pushed to a similar proximity to failure.
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Volume
Training volume is an accumulation of how much work a trainee performs in a given workout
or program. To find training volume, multiply sets, reps, and the weight used. For example,
a lifter performs 4 sets of 15 reps at 225lb on the back squat. Their training volume will be
13,500lbs of training. It is important to note that 15 sets of 4 reps at 225lb may equal 13,500lbs

327
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Chapter 1
of training volume, but it is not the same stimulus, because of the rep range and relative
The Skeletal System

intensity.
Training volume is also considered on a weekly basis. The total amount of sets performed on a
Anna
body part isD’Annunzio, MS progression.
crucial for hypertrophic
Currently the MV, MEV, MAV, and MRV systems are a common measure for weekly training
volume. MV, or maintenance volume, is the number of weekly sets to maintain current amounts
of muscle. MEV, or minimum effective volume, is the minimum weekly number of sets for a
muscle or muscle group to grow. MAV, maximal adaptive volume is the optimal number of sets
performed in a week for a muscle or body part to grow. Finally, MRV, or maximum recoverable
volume is the maximal number of sets that a client can perform and still recover for that body
part’s next training session.
Rest
A rest interval describes time between sets that is dedicated to acute recovery, or the ability to
recover enough to perform the next set. The rest interval typically lands in between 30 seconds and
180 seconds. Shorter rest periods (30-60 seconds) are linked with greater hypertrophic responses
while longer rest periods (3-5 minutes) are linked with greater maximal strength responses.2
What is more important, is that the trainee takes enough time to fully recover before the next
set without taking so long that they are not prepared for the next set. Some rest periods go as
long as ten minutes or more if needed.
Frequency
Training frequency defines how many times someone trains a body part per week. Beginners
usually start with once a week and high level athletes may train 6-8 times a week, including days
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where they train twice in that one day. Training frequency typically requires an inverse relationship
with training duration in order to accumulate enough training volume per week for growth.
Duration
Training duration describes how long a training session lasts. Typically, a training session lasts
30 minutes up to 2 hours depending on workout structure, rest intervals, training volume, and,

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of course, time wasted. In some cases, training sessions can be shorter than 30 minutes or longer
The Skeletal System

than 2 hours, but this is beyond the scope of this text.
Anna D’Annunzio,
Exercise Selection MS
The exercises a trainer or coach picks change according to goals, time, and equipment available.
A bodybuilder uses certain exercises that differ from a powerlifter. A lifter with a knee injury will
pick different exercises than a lifter with no injuries. A gymnast will perform different exercises
than a football player, and so on. Poor exercise selection can also increase the risk of injury.
Heavy movements paired with explosive movements afterwards can be detrimental

for some lifters, or high rep exercises followed by sprints. Proper exercise selection
can maximize the utility of a training session and should be sports specific.
Selecting Variables for Common

Fitness Goals
A coach or trainer must design a program that focuses on achieving the client’s personal or sports-
related goals. There are five common overall training goals: stability, muscular endurance, hypertrophy,
strength, and power. While several of them have overlap, training for each can be quite different.
Stability
Stability training refers to training with the intention of improving balance and neuromuscular
control, normally handled by type I muscle fibers.
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This kind of training goal commonly includes beginners or people recovering from injuries.
Reps can be moderate or high (15-20) depending on the experience of the client, or reps can
be time based. Loads are typically very low in this category while reps are high or time based.
Coaches often program low training volume because of the nature of this kind of training.
Exercises include use of unstable surfaces or unilateral, or single sided movements.

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New trainees need to build up their stability for heavier lifts later in the training career, so while
The Skeletal System

this is an individual training goal for many, it is also a stepping stone.
Anna D’Annunzio,
Muscular EnduranceMS
Muscular endurance refers to the ability for a muscle to produce force for extended periods of
time. Muscular endurance training focuses on type I muscle fibers. This occurs through long
training sessions that seek to emulate the requirements of endurance events, or for occupations that
require endurance on a day-to-day basis.
There are no specific exercises more conducive to muscular endurance training. Muscular endurance
training usually requires low intensity loading with a high number of reps, such as 15 or more
at below 60% 1RM.3
In some cases, workouts include a higher amount of working sets, but usually, muscular endurance
training will keep working sets on the lower end, usually around three sets per exercise.
Hypertrophy
Hypertrophy refers to the growth of muscle. Hypertrophy training benefits most training goals,
but many trainees are primarily concerned with just increasing muscle mass.
Hypertrophy training involves all muscle fibers, but type II fibers are larger and more conducive
to hypertrophy. Clients seeking this goal range from the typical gym goer who wants to look
better to an aspiring bodybuilder or powerlifter preparing for their next strength phase.
Most resistance training movements are effective for hypertrophy, but many bodybuilders will
opt for machines when applicable to remove some unnecessary fatigue from the stabilization of
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Academy
Hypertrophy can be elicited with sets of 5-30 reps, but more often trainees use sets of 6-12 reps
with medium to high loads and low to moderate rest intervals at or greater than 30% 1RM.4,5
A 1-3 second concentric phase and a 2-4 second eccentric phase is cited to be the optimal rep
tempo for muscle growth.6 A 30-60 second rest interval between sets suits hypertrophy training
in many cases, although this can be individual, exercise, and muscle dependent.

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Hypertrophy blocks often use a higher variety of exercises to train different muscle fibers and
The Skeletal System

high volume training.
Strength
Maximal strength refers to a trainee’s ability to produce maximal force. Maximal strength training
mostly involves type II muscle fibers. Clients interested in strength training fall into two categories:
trainees who want to be generally stronger in their daily life, and strength athletes like powerlifters,
strongmen, and other athletes from mainstream sports.
Maximal strength training typically includes compound movements (movements in which

multiple joints move at once) which involve as many muscle fibers as possible per exercise.
Maximal strength training involves lower volume than hypertrophy training, but high loads
with 1-5 rep sets, but strength increases have been observed at working sets at or below sets
of 20.7 Strength training seems to be optimal when loads are at or higher than 80% 1RM, but
significant strength gains can still be elicited at lower loads.8
3-5 minute rest periods (or longer sometimes) are best for maximal strength training physiologically
and psychologically. Maximal strength training also benefits from high volume training depending
on the trainees current mesocycle (see Periodization for more info).
Power
Power oriented goals center around the ability to produce a high degree of force quickly, handled
by the type II muscle fibers.
Many athletes look into power training to maximize their speed and explosiveness during
competition, but this specific style of training is not not recommended for novice lifters.
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Novice lifters will often increase overall power during a strength or hypertrophy cycle, because
those adaptations will stimulate some power increases in the de-trained. Olympic lifters use
power training because their sport revolves around being explosive.
Like maximal strength training, multi-joint compound movements are preferred to build power.
Power training uses either between 85-100% 1RM to improve force production or 30-40%
1RM to improve speed. Power training typically utilizes low volume, using sets of 1-3 reps with

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medium to high loads as fast as possible with good form. Rest intervals should be between 2-5
The Skeletal System

minutes for proper recovery between sets.9 In many cases, power goals can also be considered
the peaking phase in a program’s periodization.
In Anna
many longD’Annunzio, MS a trainer or coach will take their trainee through all of these
term program designs,
phases at some point in 2 to 8 week periods called mesocycles (see Periodization). The main
takeaway is that there is some overlap with all of these training goals. One will lead into another
or will benefit another.
Subgoals
Subgoals can align with one of two of the more common goals. Many individuals have the desire
to increase bone density, such as women at risk for osteoporosis. Resistance training positively
correlates with improved bone density in randomized control trials.10 In fact, any exercises with
impact such as walking or running will typically benefit bone density.
The only exercises that do not benefit bone density are exercises like swimming or cycling which
have low loads and no impact. While movements with impacts such as running or walking are
beneficial for bone density, resistance training is more potent than cardiovascular exercises in
increasing bone density.11
Clients may be interested in reducing injury. Resistance training has been shown to prevent
acute and overuse injuries.12 Targeted resistance reduces chronic pain more than other exercise
intervention.13 Increased muscle size and strength come with stronger denser bones and
tougher connective tissue. Tendons and ligaments grow at a slower rate than muscle and bone,
but they are benefited by training nonetheless. Strength training also reduces many forms of
chronic pain. Chronic pain is often caused by muscle imbalances, which benefit from correctly
trained muscles. Also, many people have inactive muscles or mobility restrictions from daily
activities like excessive sitting, which can be corrected with a well balanced resistance training
regiment. Trainer©2023
Academy
For athletes of all kinds, speed, agility, and quickness (SAQ) is the focus. Again, all of the common
training goals contribute to SAQ, but power training teaches the body to be explosive with each
step or jump in generating speed. Resistance training improves connective tissue toughness and
bone density to better resist the stresses placed on the body during sudden changes in direction.
Plyometric training, or plyo training, also is benefitted by power training. Both plyo and SAQ
training are explored further in other chapters.

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Possibly the most common goal among most clients is weight loss. The most common strategy for
The Skeletal System

weight loss includes a high degree of cardio, but resistance training can be extremely effective for
long term weight loss and maintenance. Resistance training has been connected with decreases in
obesity related conditions, but may not be the quickest way to reduce visceral body fat.14 Basically,
Anna
aerobic D’Annunzio,
training MS path to weight loss, but resistance training correlates with
may be the quicker
overall better health outcomes in the long-term.
Particularly, as a trainee increases muscle mass, their base metabolic rate (BMR) increases,
which helps long term weight loss and lowers obesity related health risks. The second benefit of
hypertrophy training for weight loss is that the higher volume will burn more calories and help
create the caloric deficit required for weight loss.
Client Type and History

Each kind of client may have different needs that will affect the way a trainer gets them to
their goals. One client may have a knee injury while another may be older and have a heart
condition. The type of client dictates how a program is designed outside of goals.
A client’s program may be dictated by their training age or experience. A program designed for
a beginner will look vastly different to a program designed for a ten year veteran. A beginner
may not understand how their body reacts to training and will usually be better off with a lower
volume program. On the other hand, a training veteran may need a much higher volume training
because that may be needed to stimulate growth.
Biological age is a major factor in designing a program for a trainee. Younger clients may be able
to handle more volume and heavier loads because their body is in its prime. Recovery time for
younger trainees is typically faster than older trainees. Older trainees may not be able to handle
high weekly volume.
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Assigning high volume to an older client may not allow them to recover and risk them developing
injuries. Older clients may also not be able to handle as high an intensity as younger clients in some
cases so it may be better to assign them higher rep exercises.
In conjunction with biological age, recovery capacity is a vital variable to consider. Recovery capacity
includes nutrition habits, sleeping habits, daily stresses, age, and training experience all may affect recovery
capacity. A trainee with high stress may not be able to recover from a high volume or high training
frequency, while a client with all of these factors in order may benefit from a more intense program.

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Injuries plague clients of all kinds and must be considered when designing a program. Injury
The Skeletal System

history may dictate how much volume a trainee may be able to undertake for a certain body part.
A trainee with a history of torn ACLs may not be able to do much, if any at all, leg exercises
requiring high loads or large ranges of leg motion, while a trainee with a history of shoulder
Anna
injuries mayD’Annunzio, MSwith their shoulder work than a trainee with perfectly healthy
need to progress slower
shoulders. Every injury requires its own considerations and adjustments.
As mentioned before, a client’s lifestyle can affect their ability to recover and thus their ability to
handle more intense training programs. However, some clients may have less time to train so this
may affect their workout structure. Circuit training or supersets may be better for CEOs while
pyramid sets may be better for professional athletes. A trainee with no equipment available will
need a different program than one who goes to a gym on a regular basis.
Nutrition is a massive factor in a training program. A training program with an extremely high
training volume will be wasted with poor nutrition. For example, college students often have
poor nutrition habits and may not get the most out of their training programs.
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334 Program Design 335
Program Des i gn
Chapter 1
Example
The Training
Skeletal
ExampleSystem Templates for
Training Templates for
Various Goals
Anna D’Annunzio, MS Various Goals
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335
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Chapter 1
Scheduling
The Workout Splits
Skeletal System
When designing a template for a client or athlete to follow, consider both the client’s scheduling
Anna D’Annunzio,
limitations and their ability to MS
recover from session to session.
The number of days trainees can workout (or want to workout) every week, the amount of time
in those days, and the trainee’s level of experience dictate the number of days in the microcycle
(week of training) and the appropriate volume and muscle split used on those days.
Full Body Routines

Full body workouts are ideal for beginners, for trainees who have little time to train, and for
people who want a low-level of training frequency per week. Clients using a full body routine
can get the appropriate amount of training stimulus to enact big changes in their body with only
2 or 3 workouts per week.
Athletes often use this template, because sports-specific drills and practice takes up much of
their weekly time. Full body splits involve training the entire body, using compound movements
because of time and energy restrictions, each time the trainee works out.
Upper/Lower Splits
Upper and lower splits require the trainee to split up sessions between training their upper and
their lower body. Intermediate-level exercisers often use upper/lower splits, because it allows them
to focus more closely on individual body parts and train more often, although more advanced
trainees may require a further split, like a push/pull/legs or individual body part split to achieve
the maximal results. Exercisers in this model workout 2, 4, or 6 days per week depending on
their goals and time
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Push/Pull/Legs
Push/pull/legs splits the body even further into 3 days of training. On day one, the trainee
exercises the muscles which push (shoulders, chest, triceps), on day two they train the pulling
muscles (back, biceps, forearms) and on day three they train their legs. Day four can either be a
rest day or a repeat day where the client goes back to a push day.

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Most trainers will never use this split with a client unless they train the client every day or trust
The Skeletal System

that the client knows what they’re doing and will workout diligently and safely on their own.
This model requires a 3-days per week exercise cycle or 6-days per week.
Body Part Split
In this split, the exerciser trains individual muscles in every workout. This is a highly variable
template and should only be used by advanced athletes and competitive bodybuilders to achieve
maximal results.
Summary
Programming workouts requires the use of variables such as sets, reps, volume, intensity, rest,
frequency, duration, and exercise selection. Fitness professionals should also consider the client’s
goals, as well as age, injuries, and training history.
Some goals will be able to coexist together in an exercise program as subgoals while others need to
be placed on hold until the client achieves the primary goal. In addition, personal trainers should
factor in the schedule of the client and level of experience when designing weekly templates for
various body parts and movement patterns.
References
1. Schoenfeld BJ. The mechanisms of muscle hypertrophy and their application to resistance training. J
Strength Cond Res. 2010;24(10):2857-2872. https://doi.org/10.1519/JSC.0b013e3181e840f3
Trainer Academy
2. de Salles BF, Simão
©2023 R, Miranda F, Novaes Jda S, Lemos A, Willardson JM. Rest interval between sets
in strength training. Sports Med. 2009;39(9):765-777. https://doi.org/10.2165/11315230-000000000-
00000
3. Schoenfeld BJ, Grgic J, Van Every DW, Plotkin DL. Loading Recommendations for Muscle Strength,
Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel).
2021;9(2):32. Published 2021 Feb 22. https://doi.org/10.3390/sports9020032
Strength Cond Res. 2010;24(10):2857-2872. https://doi.org/10.1519/JSC.0b013e3181e840f3

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5. Schoenfeld BJ, Grgic 1
J, Van Every DW, Plotkin DL. Loading Recommendations for Muscle Strength,
The Skeletal System
Anna
Strength D’Annunzio, MS
Cond Res. 2010;24(10):2857-2872. https://doi.org/10.1519/JSC.0b013e3181e840f3
9. Suchomel TJ, Nimphius S, Bellon CR, Stone MH. The Importance of Muscular Strength: Training
Considerations. Sports Med. 2018;48(4):765-785. https://doi.org/10.1007/s40279-018-0862-z
10. Layne JE, Nelson ME. The effects of progressive resistance training on bone density: a review. Med
Sci Sports Exerc. 1999;31(1):25-30. https://doi.org/10.1097/00005768-199901000-00006
11. Layne JE, Nelson ME. The effects of progressive resistance training on bone density: a review. Med
Sci Sports Exerc. 1999;31(1):25-30. https://doi.org/10.1097/00005768-199901000-00006
12. Lauersen JB, Andersen TE, Andersen LB. Strength training as superior, dose-dependent and safe
prevention of acute and overuse sports injuries: a systematic review, qualitative analysis and meta-
analysis. Br J Sports Med. 2018;52(24):1557-1563. https://doi.org/10.1136/bjsports-2018-099078
13. Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-Chain Resistance Training Compared
to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the
General Population: A Systematic Review and Meta-Analysis. Sports Med Open. 2021;7(1):17.
Published 2021 Mar 8. https://doi.org/10.1186/s40798-021-00306-w
14. Ismail I, Keating SE, Baker MK, Johnson NA. A systematic review and meta-analysis of the effect
of aerobic vs. resistance exercise training on visceral fat. Obes Rev. 2012;13(1):68-91. https://doi.
org/10.1111/j.1467-789X.2011.00931.x
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Chapter 1
TheCHAPTER
Skeletal18System
Periodization
AJ Mortara, MS
339
Pe riodizat i o n
Chapter 1
Introduction
The Skeletal System
The long-term success of a training program depends on progressing through multiple phases of
Anna
training D’Annunzio,
that MS
target different, complimentary fitness goals that cycle over periods of time. Most
large fitness goals cannot be achieved without multiple types of training.
However, this training must be planned and coordinated properly to successfully drive adaptations
and avoid injuries. This long-term planning is called periodization and is a key knowledge
requirement for successful fitness professionals.
Periodization is defined as the systematic manipulation of training variables in order to maximize

training adaptations. This includes changes in exercise selection, loading schemes, sets, reps, and
even exercise order.
Traditionally, periodization has been the domain of strength and conditioning professionals
focusing on athletes, who have a defined “pre”, “mid”, and “off season.” However, the same
principles of progression and periodization used to improve athletic performance apply to the
general population as well.
Failure to properly periodize a client’s program leads to a stagnation of training adaptations at

best and injury at worst. All training programs must balance the stimulus for adaptation with
the level of fatigue acquired.
If the body were able to shed fatigue at a constant rate, while simultaneously adapting at a constant
rate, then an optimal program could be established and practiced without variation indefinitely.
However, the rate of adaptation varies over time.
Furthermore, the rate at which an individual recovers from fatigue is based on a multitude of
factors. Hence the need to periodize programming to manage it optimally. This chapter focuses
on the key physiological
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©2023 concepts related to periodization as well as periodization types and
examples.
Periodization Hierarchy
Periodization is broken down into an organizational framework used to construct short, medium,
and long term goals and plans.

340
Pe riodizat i o n
Chapter 1
The smallest time frame is the individual day or training session. At this level, the fitness professional
The Skeletal System

develops the plan for the day, including exercise selection and daily programming variables.
Periodization 342
Microcycles last several days to one week of training. The most common microcycle length is one
Anna
week. D’Annunzio,
At this MS
level the trainer determines training volumes for the week, the number of sessions
per week for each body
Microcycles part, and
last several daysplanned restofdays.
to one week training. The most common microcycle length
is one week. At this level the trainer determines training volumes for the week, the number of
Thesessions
mesocycle
per ranges from
week for each2—8
bodyweeks, withplanned
part, and the final
restweek
days.being an intentional deload. The trainer
should structure mesocycles around specific goals, such as hypertrophy, strength, or endurance.
The mesocycle ranges from 2—8 weeks, with the final week being an intentional deload. The
trainer should structure mesocycles around specific goals, such as hypertrophy, strength, or
Two to three consecutive mesocycles with the same training goal but a change in training plan
endurance.
are referred to as training blocks. For example, a hypertrophy training block might include two
or three mesocycles.
Two to three consecutive mesocycles with the same training goal but a change in training
plan are referred to as training blocks. For example, a hypertrophy training block might include
Thetwo
longest duration
or three subcomponent of periodization is the macrocycle, which is often an annual
mesocycles.
plan but not necessarily. Macrocycles include several mesocycles and transition from one goal to
The longest duration subcomponent of periodization is the macrocycle, which is often an
another, typically including at least one maintenance period. For example, a typical macrocycle
annual plan but not necessarily. Macrocycles include several mesocycles and transition from one
may have two to three mesocycles of hypertrophy, followed by two to three for endurance, and
goal to another, typically including at least one maintenance period. For example, a typical
lastly a few mesocycles for strength.
macrocycle may have two to three mesocycles of hypertrophy, followed by two to three for
endurance, and lastly a few mesocycles for strength.
Some clients will require multi-year training plans to achieve long-term goals. These plans include
Some
multiple clients willwith
macrocycles require multi-year
repeating training
goals and plans to maintenance
several achieve long-term goals.ItThese
phases. plans to
is important
include multiple macrocycles with repeating goals and several maintenance phases. It is
note that the duration of these periods is fluid, and should logically flow from the clients’ contract
important
duration andtogoals.
note that
Thethe duration
table belowofsummarizes
these periodsthe
is fluid, and shouldhierarchy.
periodization logically flow from the
clients’ contract duration and goals. The table below summarizes the periodization hierarchy.
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Another form of periodization is auto-regulated periodization which allows for individual

sessions within a microcycle to varyTrainer Academy
based on © 2023
client preparedness. Under this model,
programming varies based on feedback from the client. A night of poor sleep or a sudden
341
Pe riodizat i o n
Chapter 1
Another form of periodization is auto-regulated periodization which allows for individual sessions
The Skeletal System

within a microcycle to vary based on client preparedness. Under this model, programming varies
based on feedback from the client. A night of poor sleep or a sudden stressful event 343
Periodization can be
reasons to reduce training volume and/or intensity. On the other hand, if motivation is high and
Anna D’Annunzio,
performance MS increasing volume or load can be warranted. In essence, the
is better than expected,
warranted.
trainer In essence,
must tailor the trainer
the sessions’ planmust
andtailor
goalsthebased
sessions’ planclient’s
on the and goals based
day on the
to day client’s
abilities.
day to day abilities.
This method is vastly superior to forcing a pre-planned program irrespective of the client’s feedback
This method is vastly superior to forcing a pre-planned program irrespective of the client’s
but note that itbut
feedback cannote
getthat
a bitit messy
can getina terms of quantifying
bit messy progressionprogression
in terms of quantifying and overalland
goals if thegoals
overall training
is constantly shifting
if the training and the shifting
is constantly coach does notcoach
and the account
doesfor
notthis when
account forprogramming for the client.
this when programming
for the client.
Traditional vs. Undulating

Traditional Periodization
vs. Undulating
Periodization
Many textbooks and reference manuals title periodization strategies as “linear” and “nonlinear.”
However, in the strictest sense, both are nonlinear in nature due to the varying levels of training
volume throughout
Many textbooksa mesocycle of training.
and reference Therefore,
manuals title the terms
periodization traditional
strategies andand
as “linear” undulating will
be used, as they However,
“nonlinear.” are more in
descriptive.
the strictest sense, both are nonlinear in nature due to the varying levels
of training volume throughout a mesocycle of training. Therefore, the terms traditional and
undulating
Traditional will be used, as
periodization they are more
strategies descriptive.
involve training with the same sets and repetitions per
microcycle, with variations in load per training day, for example a hard, medium, and light day.
Traditional periodization strategies involve training with the same sets and repetitions per
microcycle, with variations in load per training day, for example a hard, medium, and light day.
Each successive microcycle would increase either the load or volume or both, resulting in a mostly
Each successive
linear increase microcycle
in total training would increase
volume over theeither
coursetheof
load
theormesocycle.
volume or both, resulting in a
mostly linear increase in total training volume over the course of the mesocycle.
This would
Thisresult
wouldin a work
result over time
in a work graph
over time similar
graph totothe
similar thechart
chart below:
below:
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An important characteristic of traditional training is that, despite the weekly or session to

Trainer
session variation, the program still has one Academy
focus such©as2023
hypertrophy or strength, but not both.
All training days within the microcycle are still focused on that goal.
342
Pe riodizat i o n
Chapter 1
An important characteristic of traditional training is that, despite the weekly or session to session
The Skeletal System

variation, the program still has one focus such as hypertrophy or strength, but not both. All
training days within the microcycle are still focused on that goal.
Periodization 344
Anna or
Nonlinear D’Annunzio, MS
undulating periodization is similar in so far as there are variations within the
microcycle. However, these variations are larger and focus on different goals. For example, one
day or Nonlinear or undulating
training session periodization
may focus is similar in
on hypertrophy, thesonext
far asday
there
onare variations
strength, andwithin the
so on.
microcycle. However, these variations are larger and focus on different goals. For example, one
day or training session may focus on hypertrophy, the next day on strength, and so on.
Since these goals have distinct programming guidelines, the sets, repetitions, and load ranges all
may change on agoals
Since these session-to-session basis. The resulting
have distinct programming guidelines,changes
the sets, in overall training
repetitions, and load volume
ranges are
drastic. Consider
all may thea example
change on below: basis. The resulting changes in overall training volume
session-to-session
are drastic. Consider the example below:
Programming Periodization for Fitness Clients

Programming a periodized training plan for fitness clients is, in many ways, more challenging
than for athletes. Athletes
Programming havetraining
a periodized a clearly defined
plan preseason,
for fitness in in
clients is, season,
many and
ways,off season, which can
more
simplify the process
challenging than forofathletes.
settingAthletes
goals and creating
have a clearlytimelines.
defined preseason, in season, and off
season, which can simplify the process of setting goals and creating timelines.
General population personal training clients do not have such a rigid structure. However, that
GeneralTrainer
population personal training clients do not have such a rigid structure. However, that
does not mean a©2023
long-term training plan is unnecessary. In fact, it is even more necessary and
Academy
does not mean a long-term training plan is unnecessary. In fact, it is even more necessary and
cancan
serve asasa agoal
serve goalsetting
setting exercise toincrease
exercise to increaseclient
client motivation
motivation and and retention.
retention. There There are a few
are a few
guidelines totoconsider:
guidelines consider:
1. Limit consecutive
1. Limit consecutive mesocycles
mesocycles with identical
with identical goalsgoals to three
to three or fewer.
or fewer.
Varying the training stimulus is a good thing.5 5Training the same movements, at the same
Varying the training stimulus is a good thing. Training the same movements, at the same
intensity, with the same goal for longer than three mesocycles (one training block) will likely
intensity, with the same
lead to monotony goal for
and training longer than three mesocycles (one training block) will likely
staleness.
lead to monotony and training staleness.
2. Follow a strength period with an endurance period.
Training for strength involves relatively high loads with lower training volumes. At the
conclusion of a strength focused training block, the connective tissues have been stressed for
343
Pe riodizat i o n
Chapter 1
2. Follow a strength period with an endurance period.
The Skeletal
Training System
for strength involves relatively high loads with lower training volumes. At the conclusion
of a strength focused training block, the connective tissues have been stressed for several months
would benefit from a periodMS
of light loading to allow for recovery and adaptation. Endurance
training, which involves relatively low loads, is ideally suited to allow for this recovery while
continuing training.
3. Precede a strength period with a hypertrophy period.
As mentioned above, strength training requires relatively high loads, a hypertrophy training
block serves to acclimate the muscles and connective tissues to moderate loading, making the
transition to heavier loading smoother.
4. Following a strength period with a maintenance period is recommended
As mentioned, every two to three training blocks should be followed by a maintenance mesocycle.
A logical placement for a maintenance mesocycle is after a strength block, when fatigue is high,
soft tissues have been heavily taxed, and motivation for training may be low.
5. Fat loss phases can accompany endurance and hypertrophy periods, but not strength
Most personal training clients have fat loss goals, therefore it is the trainer’s job to combine
nutritional and exercise strategies in a way that maximizes the effectiveness of both. The energy
deficit required for fat loss will impact exercise performance, especially when training for strength.
Endurance and hypertrophy training will suffer the least from the caloric deficit and are better
choices to program during a fat loss phase.
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Endurance and hypertrophy training will suffer the least from the caloric deficit and are
344 better choices to program during a fat loss phase. Pe riodizat i o n
Chapter 1
Exampleofof
Example Periodized
Periodized Training
Training Plans
Plans
The Skeletal System
Periodization 346
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345
Pe riodizat i o n
Chapter 1
The Skeletal System

Periodization 347
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Summary
Proper periodization allows clients to progress
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© 2023
remaining injury free. Knowledge of periodization is one of the key skills fitness professionals
346
Pe riodizat i o n
Chapter 1
Summary
The Skeletal System
Proper periodization allows clients to progress towards long-term, larger fitness goals while
Annainjury
remaining D’Annunzio,
free. KnowledgeMS of periodization is one of the key skills fitness professionals must
develop to be successful, particularly when training individual clients for ambitious fitness goals.
References
1. American College of Sports Medicine. (2009) Position stand. Progression models in resistance training
for healthy adults. Medicine and Science in Sports and Exercise 41:687-708.
2. Haff, G., & Triplett, N. (Eds) (2021) Essentials of Strength and Conditioning (4th ed) Human
Kinetis, Champaign, IL
3. Israetel, M., Hoffmann, J., Davis, M., & Feather, J. (2020) Scientific Principles of Hypertrophy Training.
Renaissance Periodization.
4. Plisk, S. & Stone, M. (2003). Periodization strategies. Strength and Conditioning Journal, 25(6) 19—37.
5. Stone, MH, Stone, ME, and Sands, WA. (2007) Principles and Practice of Resistance Training.
Champaign, IL: Human Kinetics, 376.
6. Zatsiorsky, V., Kraemer, W., & Fry, A. (1995) Science and Practice of Strength Training. Human
Kinetics, Chapaign, IL.
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Chapter 1
TheCHAPTER
Skeletal19System
Anna D’Annunzio,
Principles ofMSPlyometric
Training
Darek Velez, MS
348
Princip le s of Plyome tric T rai n i n g
Chapter 1
Introduction
The Skeletal System
Plyometric training encompasses any movement or exercise activity that involves a rapid eccentric
Anna
loading D’Annunzio,
quickly followed by aMSrapid concentric contraction. Generally speaking, plyometric
modalities involve some form of jumping, hopping, or skipping. Due to the range of beneficial
adaptations that occur with proper plyometric training, fitness professionals should be familiar
with the plyometric exercise technique and program design principles to safely and effectively
integrate plyometric training into client programs.
Definition of Plyometric Training

Plyometric training is defined as any rebound activity that take advantage of the neuromuscular
and physiological properties of the musculotendon unit. This rebound activity uses an eccentric
contraction of the muscle that is rapidly followed by a concentric muscle action to increase force
production.1 The goal of plyometric training should be to increase the potential of the muscle to
maximize force production in the shortest time possible.
Benefits of Plyometric Training

Plyometric training has benefits that include improving speed, agility, coordination, running
economy, strength and peak power.2 Studies show that plyometric training has a greater effect
on vertical jump height and agility compared to sprinting.3
Rate of Force Production

Rate of force production is the time it takes to produce force in the muscle through a ballistic
action.4 In many sports and activities there is a need for quick force production to overcome
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an opponent, obstacle, or weight. Therefore, rate of force development (RFD) is an important

variable to understand when considering plyometric training effectiveness and programming.
Ballistic training, speed, and weightlifting at appropriate velocities can all improve RFD.5

349
Chapter 1
Neural Adaptations that Affect RFD
The
WhenSkeletal System
a movement or reflex is initiated, either the motor cortex or the central nervous system
signals the motor unit to activate. At this point the motor neuron discharges, causing the muscle
to Anna
contract.D’Annunzio, MS
Motor units have different sensitivities or thresholds that determine how fast an electrical charge
should be sent to create a contraction.4 High threshold motor units are sensitive to inputs and have
the ability to create rapid muscle contractions. High threshold motor units are more dominant
in type II muscle fibers.4
By utilizing plyometric training, the discharge rate from high threshold motor units and the
efficiency of signals from the central nervous system and motor cortex increases to allow for
rapid muscle activation and contractions.4 The result is an increase in the RFD due to explosive
training. Strength training combined with explosive movements can also greatly increase RFD
in all ages. 4
Reactive Strength Index

Reactive Strength Index (RSI) is a fairly accurate way of identifying the effectiveness of a
plyometric training protocol. RSI is calculated by taking the jump height divided by the time
on the ground or, alternatively, flight time divided by ground contact time.6
Ground contact time, defined as the time from the start of a jump to take-off, is an important
variable to consider because this takes into account the eccentric, amortization, and concentric
phases of a jump.7 It has been found that RSI is highly related to eccentric RFD, peak power,
jump height, and ground reaction forces.7 RSI can be an efficient way to give more information
related to multiple variables in plyometric training than jump height alone. If jump height goes
up then RSI goes up, if ground contact time decreases then RSI increases.
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Stretch-Shortening Cycle
The stretch-shortening cycle (SSC) is a concept described by different mechanical and
neurophysiological models that explains how an eccentric loading or pre-stretch can lead to a
concentric muscle action that has enhanced force production compared to the same movement
performed without a pre-stretch.1

350
Chapter 1
The two widely accepted models used to describe how the stretch-shortening cycle occurs are
The Skeletal System

the biomechanical and neurophysiological model.
Anna D’Annunzio,
Biomechanical MS
Model
In the biomechanical model, the muscle and tendon together are considered the musculotendon
unit. When the musculotendon unit is rapidly and forcefully stretched, like in the pre-stretch
of a counter movement jump, work is being performed through lengthening of the muscle and
tendon. The work performed is then absorbed in the form of elastic energy by the stretched muscle
and tendon.8 This is called “potentiating the muscle.” The concept is similar to pulling a rubber
band and then releasing it. There is elastic energy stored as the rubber band pulls back. When
the rubber band is released from its stretched position, a greater force production is achieved.
Elastic energy releases when a concentric or shortening of the muscle happens following a pre-
stretch. The magnitude, rate, and duration of a stretch will determine the amount of elastic energy
that can be released to increase the force production of a musculo-tendon unit.9 In other words,
the larger and faster the braking force occurs, the more powerful and explosive the movement
will be.
It is important to note that elastic energy from the muscle and tendon decreases the longer it
takes to start a contraction. If a pause lasts more than one second, cross bridging in the muscle cell
detaches and potential energy decreases dramatically.10 When performing a plyometric exercise,
it is important to rebound quickly to maximize the force that can be produced.
Neurophysiological Model
Muscle spindles are located in the intrafusal fibers of the muscle.11 When there is a rapid stretch
on the muscle, a deformation within the muscle spindle occurs.9 The muscle spindle sends an
electrical signal to the spinal cord that is returned to the muscle to generate a reflexive shortening
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or concentric action. The greater the rate and magnitude of the stretch, the greater the concentric
action.8, 10
Another factor to consider is the Golgi tendon organ (GTO). The GTO is in the musculotendinous
unit, which plays a protective role in preventing overstretching by contracting the antagonist
muscle. For example, the quad is stretched rapidly and the hamstring contracts to limit further
rapid stretching or damage to the quadriceps.

351
Chapter 1
In plyometric training, the more the GTO is inhibited or turned off, the more muscle fibers can
The Skeletal System

be utilized to generate force and create stiffness or pre-activation of the agonist muscle to allow
for a greater force return.8 Plyometric training helps to desensitize the GTO.9
Anna
There D’Annunzio,
is a pre-activation MS in the eccentric or stretching phase of a movement. This
that occurs
occurs because as a muscle stretches rapidly, other muscles are activated to slow the stretch and
stiffen a limb for action.10 Time and angle of movement affect how much force pre-activation
of the muscle contributes to the movement.
The stretch shortening cycle contributes to force production due to pre-activation of the leg
muscles before a jump, a stretch-reflex that occurs with the nerves, a recoil of elastic energy of
the musculotendinous unit and the amount of cross bridges in the eccentric phase in the muscles
fiber.12
Phases of the Stretch-Shortening Cycle

There are 3 stages that explain how the stretch shortening cycle is used in explosive movements.
These are the eccentric, amortization, and concentric stages.
Eccentric
An eccentric phase of the stretch shortening cycle requires a pre-stretch, also referred to as a
braking or eccentric action of an exercise. The eccentric phase begins when force is generated
into the ground to prevent a free-fall downward.
During this phase, elastic energy is stored into the muscle and tendon as it is stretched. The
more eccentric or braking force generated, the greater the rate of concentric force for the jump.7
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In addition, at this stage there is a reflex created in response to a rapid stretch on the muscle. This
reflex is a stimulated muscle spindle that sends information to the spinal cord. Think of jumping,
once lowering into the jump, eccentric forces are created to allow for a controlled fall versus a
free fall. The faster and more forceful the drop, the more power is created.9,10

352
Chapter 1
Amortization
The Skeletal System
After the eccentric phase there is a delay in the signaling from neurons before a concentric action
Anna
occurs, D’Annunzio,
known MS
as “amortization.” Amortization is an isometric or static contraction that occurs
before a concentric contraction of the muscle can occur. For example, in a countermovement
jump, this is when the body is as low as possible right before propulsion.
In this stage, pre-activation of the muscle has been created from the eccentric phase to generate
stiffness in the muscle and joint.8,10 The longer the delay in this stage, the more energy that will
be lost towards force production.9 Both leg stiffness and neural feedback enhancements are
critical to increasing performance.
Concentric
A concentric action of the muscle is a shortening of the muscle. If there is a concentric action
immediately following the eccentric action, then an increase in force production occurs to create
propulsion or flight. The increased force production at this stage comes from elastic energy
released from the musculotendinous unit (biomechanical model) and the reflex action of the
muscle spindles (neurophysiological model).9
Plyometric Program and Progression

Guidelines
Plyometric training is used progressively to allow for increased excitation of high threshold motor
neurons, increased leg stiffness prior to a jump, a decrease in GTO sensitivity, and enhanced
feedback from the
©2023 central nervous system (CNS) to create enhanced performance. When
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programming plyometric exercises, manipulation of different variables allows for overload and
increased performance.
Exercise selection, frequency of training, volume of training, recovery of training and intensity
of training are all important considerations.
It has been shown that there is no difference between volume, intensity or a mix of volume
and intensity progressions on countermovement jumps (CMJ), squat jumps, sprinting and

intensity of training are all important considerations.
353 It has been shown that there is no difference between volume, intensity or a mix of volume
and intensity progressions on countermovement Princip le ssquat
jumps (CMJ), of jumps,
Plyome tricand
sprinting T rai n i n g
agility.3 Therefore, if there is progression in volume and intensity using appropriate variable
Chapter 1
recommendations,
agility. 3
Therefore,performance can be improved.
if there is progression in volume and intensity using appropriate variable
The Skeletal System

recommendations, performance can be improved.
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Exercise Selection and Selection Progression ©2023
Plyometric training should start with bilateral and work to unilateral in lower limb exercises as experience
increases.13 There is a greater demand on the body from single leg jumps that require an adequate
amount of strength and biomechanical efficiency.
When considering horizontal plyometric exercises like bounding, adequate technique in vertical
jumps should precede horizontal jumps.13
Some exercises are ideal for the sport or goal. For instance, horizontal plyometric exercises are
more beneficial to improve sprints.14 For an increase in vertical jump, a combination of exercises
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like depth jumps, squat jumps and CMJ seem to be better than one single exercise alone.15
Length of Training
7-12 weeks of plyometric training is recommended to allow for an effective increase in jump
performance, sprint performance, strength, and contact time.16,17

354
Chapter 1
Frequency of Training
The Skeletal System
Plyometric training should be performed 1-2 times per week to increase performance. It seems
Anna
that D’Annunzio,
with moderately MS using high intensity exercises one session per week for
trained athletes,
seven weeks is enough to induce changes, with two per week being optimal.16
Plyometric training volume is based on the number of contacts with the ground. These contacts
can be counted from multiplying sets by the total number of reps. For example, when performing
1×6 tuck jumps and 2×5 hurdle jumps, the total ground contact would be 6 + 10 = 16 ground
contacts.
Technique and experience should be considered when determining the volume needed in a
program. More is not better in plyometric training. There seems to be an optimal amount of
volume that allows adaptations and performance to occur.2
Session Volume Ground Contacts

Beginner
An optimal amount of ground contacts for beginners is 60 ground contacts per session; however,
to generate greater benefits in sprint performance, higher volume is recommended.18
Intermediate
For more intermediate athletes, programming 80-120 contacts per week has been shown to be
effective for increases in performance.19,20
Advanced
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For more advanced athletes it is recommended that 120 or more ground contacts be made per
session.15 It is important to note that more volume does not seem to be beneficial to enhance
performance.2
Extraneous volume may have the same benefits as a lower volume of ground contacts, therefore,
it is advised to stay between 120-198 ground contacts per session for advanced athletes.2,15

355
Chapter 1
Rest Period
The Skeletal System
Research suggests that 240 seconds in between sets and 30 seconds in between repetitions elicits
most beneficial adaptations.MS
19
However, for practical purposes, as little as one minute between
sets and little rest between repetitions has been found to allow sufficient recovery with 3 sets
of 10 using 30% of body weight in a loaded countermovement jump.21 Age may influence the
recovery time of plyometric sets, with adolescents 8 to 14 needing lower rest times between sets
of 30-120 seconds.18
Available training time, volume, intensity and fitness level should all dictate how long recovery
between sets should be.
Recovery
Adequate recovery between plyometric sessions is needed based on the intensity, volume, age,
and experience of the athlete. High intensity sessions should have at least 48 to 72 hours of rest
between sessions and low intensity sessions need at least 24 hours of rest.20
Intensity
Intensity in plyometrics depends upon the amount of ground contact force, the rate of force
development needed to execute the movement, and the torque on the joints during the landing.
Intensity should always be specific to the training goal. For example, a basketball player may
need to increase vertical height, but a runner might need to increase muscle efficiency at lower
intensities to preserve energy.
High intensity plyometric

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©2023 drills include depth jumps, single leg jumps, and broad jumps. Low
intensity plyometrics exercises consist of skipping, double leg bounces, and countermovement
jumps (CMJ).3

Principles of Plyometric Training 358
356
Chapter 1
Example of IntensityExample of Intensity Progression
Progression
The Skeletal
Progressions in trainingSystem
Progressions in training intensity of 9-12% are considered appropriate.
intensity of 9-12% are considered appropriate.
23
23
Anna
increase D’Annunzio, MSthejump
To increase a depth jump difficulty, the height can increase from 20 cm to 22 cm (a 10%
Toincrease). a depth
The jumpofdifficulty,
distance a single leg height
cancan
go increase from
from 3 feet 20 cm
to 3.3 feetto 22 cm
(10% (a 10% increase).
increase).
The distance
Exercises ofA-skips
like a singlecould
leg jump can go from
be progressed 3 feetA-skips
into power to 3.3 where
feet (10% increase).
height Exercises like
is the focus.
A-skips could be progressed into power A-skips where height is the focus.
Use of Weighted Jumps

Use of Weighted Jumps
The purpose of using a weighted jump is to increase power development in the lower limbs,
The purpose of
specifically, using
peak a weighted
power jump
development is to
or the increase
greatest power
amount development
of power that can in
be the lower limbs,
achieved.
specifically, peak
Increasing the power ofdevelopment
intensity or the greatest
jumps using weights amount of
requires proficient power that
technique can unloaded
in jumps be achieved.
Increasing the intensity of jumps using weights requires proficient technique in jumps unloaded
before loaded.
before loaded.
When considering the mode of exercise to use with weighted jumps, greater peak power has
been shown to be generated with a hexagonal barbell or trap bar at arm’s length when compared
When considering the mode of exercise to use with weighted jumps, greater peak power has
to a barbell.24
been shown to be generated with a hexagonal barbell or trap bar at arm’s length when compared
to a barbell.24

With a hexagonal barbell, the weight should be between 10-20% of 1-RM box squat (box
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height set to where
©2023 legs are parallel to the floor).
24
With a hexagonal barbell, the weight should be between 10-20% of 1-RM box squat (box height
set toLoaded jumps
where legs aredoparallel
take away fromfloor).
to the the SSC
24 cycle (stretch-shortening cycle) because of longer
ground contact times.15 Therefore it is highly recommended that there is an intermediate to

advanced level of efficiency in unloaded plyometric training to maximize the effectiveness of
Loaded jumps do take away from the SSC cycle (stretch-shortening cycle) because of longer
weighted jumps.
ground contact times. Therefore it is highly recommended that there is an intermediate to
15
advanced level of efficiency in unloaded plyometric training to maximize the effectiveness of

weighted jumps.
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Academy © 2023
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357
Chapter 1
Plyometric
The Technique for the Select
Skeletal System
Exercises
Squat Jump
Difficulty: low
1. Lower hips to right above the knee line while maintaining an upright torso.
2. Explosively extend ankles, knees and hips until legs are off the ground.
3. On landing, contact the ground with toe to heel landing while keeping torso over the hips
and knees bent to create a soft landing.
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Chapter 1
Butt Kick
The Skeletal System
Difficulty: low
1. Begin running forward or in place.

2. Relax the ankle and “flick” the heel of each foot back towards the glutes. The knee should be
slightly forward of the hips.
3. Landing is based on running mechanics, but usually consists of a toe or mid-foot landing
that is capable of “springing the other foot off the ground.”
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359
Chapter 1
Multiplanar Jump with Stabilization
The Skeletal System
Difficulty: low
1. Stand upright then initiate the movement by bending at the knees and dropping weight
rapidly into a ¼ squat position. Knees and toes face the same direction and knees bend at
the same time the hips drop.
2. Rapidly extend hips, knees ankles to triple extension until feet leave the ground. Look at
90 degrees from your starting position and rotate body into a new direction while in midair.
3. Decelerate body on landing with hips, knees and toes facing the same direction and hold
in the squat landing position for 1-3 seconds.
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360
Chapter 1
Multiplanar Box Jump-Down with Stabilization
The Skeletal System
Difficulty: medium
1. Stand on top of a box.

2. Step one foot off the box and drop without jumping.
3. Toes, knees and hips face the same direction upon landing with knees aligned with hips
and slightly bent over the shoe laces (not faced inward).
4. Hold the landing squat position for 1-3s.
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Chapter 1
Lunge Jump
The Skeletal System
Difficulty: medium (no leg switch in air), high (switching legs midair)
1. Begin with one foot forward, and one foot back. Width between feet should mirror an athletic
stance. Rear foot will be far enough back to allow the rear leg knee to drop underneath the
hip. Rear foot heel will be off the ground and bottom of toes will be pushed into the ground.
Rear foot will have 20% of body weight. Front foot will have 80% of the weight and will have
toes facing forward and heel flat on the ground.
2. Bend at both knees and use hands to rapidly extend knees, ankles, and hip into the air. For
increased intensity switch legs in mid-air. The same foot that was in the front starting should
be in the rear.
3. Absorb the impact of landing by bending the knees as the body touches the ground. A
toe to heel landing of the front foot should occur and the same time the “balls of the feet”
landing on the rear foot happen.
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Chapter 1
Tuck Jump
The Skeletal System
Difficulty: medium
1. Initiate the movement by bending at the knees and dropping weight into a ¼ squat.
2. Rapidly extend ankles, knees, and hips into triple extension until feet leave the ground. As
the body reaches maximal height tuck the knees into the chest.
3. As the body prepares for landing, “unwind” the legs from the chest rapidly and create a
“soft landing” by creating a toe to heel contact with the ground and bending the knees to
“absorb” impact.
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Chapter 1
Repeat Box Jumps
The Skeletal System
Difficulty: high
1. Initiate movement by bending from the knees on the ground in front of the box and rapidly
lowering the body into a ¼ squat.
2. Immediately extend the ankles, knees, and hips into triple extension until propulsion off the
ground is created. Create soft landing contact with the box and do not stand up completely.
3. Use a rapid, spring-like contact with the box to quickly bring feet back off the box back
to the ground where the athlete started. Repeat the desired repetition box jumps as quickly
as possible with no rest.
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Chapter 1
Power Step-Up
The Skeletal System
Difficulty: high
1. Initiate the movement by bouncing or hopping on one foot while simultaneously flexing the
contra-lateral hip (opposite side of the body from flexed hip) to 90 degrees. The opposite arm
chops up simultaneously with hip flexion.
2. Drive flexed hip down and underneath the hips until both feet bounce off the ground at the
same time. Simultaneously both arms extend toward the floor.
3. Forcefully bounce off the ground for height with the opposite leg while rapidly driving the
contra-lateral leg into hip flexion at 90 degrees. The opposite arm chops up simultaneously
with hip flexion. Repeat the second step.
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Chapter 1
Skaters
The Skeletal System
Difficulty: high
1. Initiate the movement by pushing off the outside leg while simultaneously bending the inside
leg to prepare to jump.
2. Swing the outside leg behind the front leg while preventing rotation of the hip and keeping
shoulders over the hips.
3. Land softly with the front foot in contact with the ground, toes forward, knees aligned
with the toes, and “belly-button” forward. There should be no rotation in the hips.
4. Swing the rear leg behind and forward while simultaneously pushing off the ground.
Landing mechanics are the same as above.
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Chapter 1
Single Leg Power Step Up
The Skeletal System
Difficulty: high
1. One foot will be on a box and the other foot will be underneath the hips on the ground and flat.
2. Using the foot that’s on the box (not the rear foot), forcefully and rapidly extend the hips
and ankle until standing upright. Hips, knees, and ankles should be extended, and rear foot
should be off the ground.
3. Upon landing, absorb the impact by bending the back leg and lower rear foot back to the
ground to the starting position.
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Chapter 1
Depth Jump
The Skeletal System
Difficulty: high
1. Start standing on a box between 4 and 20 inches. Reach one foot out in front and drop onto
the ground. Do not jump off the box.
2. Bend the knees to absorb the landing on the ground, and spring back up as quickly as possible
into a jump with the goal of achieving maximal height.
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Chapter 1
Ballistic Push Up
The Skeletal System
Difficulty: high
1. Initiate the movement by starting into a plank with palms flat on the ground, elbows extended,
knees extended, glutes squeezed, and abs flexed.
2. Drop chest to the ground rapidly and then execute a forceful, powerful push-up with the
goal of both hands coming off the ground.
3. Allow the upper body to be absorbed into the ground to allow for rapid execution of
another ballistic push-up.
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369
Chapter 1
Summary
The Skeletal System
Plyometric training encompasses any rebound activity that take advantage of the neuromuscular
physiological properties ofMS
the musculotendon unit such a rebounding, jumping, hopping.
Plyometric training has benefits that include improving speed, agility, coordination, running
economy, strength and peak power.
It involves the stretch-shortening cycle, and includes eccentric, amortization, and concentric
phases. Intensity, volume, frequency, and exercise selection are all based around the level of trainee.
References
1. Patel NN. Plyometric Training: A Review Article. Int J Curr Res Rev. 2014;6(15).
2. Jeffreys MA, De Ste Croix MBA, Lloyd RS, Oliver JL, Hughes JD. The Effect of Varying Plyometric
Volume on Stretch-Shortening Cycle Capability in Collegiate Male Rugby Players. J Strength Cond
Res. 2019;33(1). https://journals.lww.com/nsca-jscr/Fulltext/2019/01000/The_Effect_of_Varying_
Plyometric_Volume_on.15.aspx
3. Lievens M, Bourgois J, Boone J. Periodization of Plyometrics: Is There an Optimal Overload

Principle? J Strength Cond Res. 2019;Publish Ah:1. https://pubmed.ncbi.nlm.nih.gov/31268999/
4. Maffiuletti NA, Aagaard P, Blazevich AJ, Folland J, Tillin N, Duchateau J. Rate of force development:
physiological and methodological considerations. Eur J Appl Physiol. 2016;116(6):1091-1116. https://
doi.org/10.1007/s00421-016-3346-6
5. Turner AN, Comfort P, McMahon J, et al. Developing Powerful Athletes Part 2: Practical
Applications. Strength Cond J. 2021;43(1). https://journals.lww.com/nsca-scj/Fulltext/2021/02000/
Developing_Powerful_Athletes_Part_2__Practical.3.aspx
6. Walker O.Trainer
Reactive
Academy
Strength Index. Accessed September 24, 2022. https://www.scienceforsport.
com/reactive-strength-index/
©2023
7. Barker LA, Harry JR, Mercer JA. Relationships Between Countermovement Jump Ground
Reaction Forces and Jump Height, Reactive Strength Index, and Jump Time. J Strength Cond Res.
2018;32(1). https://journals.lww.com/nsca-jscr/Fulltext/2018/01000/Relationships_Between_
Countermovement_Jump_Ground.32.aspx
8. CORMIE P, McGUIGAN MR, NEWTON RU. Changes in the Eccentric Phase Contribute
to Improved Stretch-Shorten Cycle Performance after Training. Med Sci Sport Exerc. 2010;42(9).
https://journals.lww.com/acsm-msse/Fulltext/2010/09000/Changes_in_the_Eccentric_Phase_

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Contribute_to.16.aspx
The Skeletal System

9. Davies G, Riemann BL, Manske R. CURRENT CONCEPTS OF PLYOMETRIC EXERCISE. Int
J Sports Phys Ther. 2015;10(6):760-786.
Anna D’Annunzio,
10. Fukutani A, Isaka T, HerzogMS W. Evidence for Muscle Cell-Based Mechanisms of Enhanced
Performance in Stretch-Shortening Cycle in Skeletal Muscle. Front Physiol. 2020;11:609553. https://
doi.org/10.3389/fphys.2020.609553
11. Gregory H, Travis Triplett, eds. Essentials of Strength Training and Conditioning. In: Essentials
of Strength Training and Conditioning. fourth. ; 2016:472-482. https://doi.org/10.1016/s0031-
9406(05)66120-2
12. Seiberl W, Hahn D, Power GA, Fletcher JR, Siebert T. Editorial: The Stretch-Shortening Cycle
of Active Muscle and Muscle-Tendon Complex: What, Why and How It Increases Muscle
Performance? Front Physiol. 2021;12. https://www.frontiersin.org/articles/10.3389/fphys.2021.693141
13. Kossow AJ, Ebben WP. Kinetic Analysis of Horizontal Plyometric Exercise Intensity. J Strength
Cond Res. 2018;32(5). https://journals.lww.com/nsca-jscr/Fulltext/2018/05000/Kinetic_Analysis_
of_Horizontal_Plyometric_Exercise.5.aspx
14. Sáez de Villarreal E, Requena B, Cronin JB. The Effects of Plyometric Training on Sprint
Performance: A Meta-Analysis. J Strength Cond Res. 2012;26(2). https://journals.lww.com/nsca-
jscr/Fulltext/2012/02000/The_Effects_of_Plyometric_Training_on_Sprint.35.aspx
15. de Villarreal ES-S, Kellis E, Kraemer WJ, Izquierdo M. Determining Variables of Plyometric
Training for Improving Vertical Jump Height Performance: A Meta-Analysis. J Strength Cond Res.
2009;23(2). https://journals.lww.com/nsca-jscr/Fulltext/2009/03000/Determining_Variables_of_
Plyometric_Training_for.20.aspx
16. de Villarreal ESS, González-Badillo JJ, Izquierdo M. Low and Moderate Plyometric Training
Frequency Produces Greater Jumping and Sprinting Gains Compared with High Frequency. J
Strength Cond Res. 2008;22(3). https://journals.lww.com/nsca-jscr/Fulltext/2008/05000/Low_and_
Moderate_Plyometric_Training_Frequency.10.aspx
17. Valadés Cerrato D, Palao JM, Femia P, Ureña A. Effect of eight weeks of upper-body plyometric
training during the competitive season on professional female volleyball players. J Sports Med Phys
Fitness. 2018;58(10):1423-1431. https://doi.org/10.23736/S0022-4707.17.07527-2
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18. Ramírez-Campillo R, Andrade DC, Izquierdo M. Effects of Plyometric Training Volume and Training
Surface on Explosive Strength. J Strength Cond Res. 2013;27(10). https://journals.lww.com/nsca-jscr/
Fulltext/2013/10000/Effects_of_Plyometric_Training_Volume_and_Training.10.aspx
19. Slimani M, Paravlic A, Bragazzi N. Data concerning the effect of plyometric training on jump
performance in soccer players: A meta-analysis. Data Br. 2017;15. https://doi.org/10.1016/j.
dib.2017.09.054

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20. Ramirez-Campillo
Jump Training in Soccer: A Review. Sport (Basel, Switzerland). 2022;10(6). https://doi.org/10.3390/
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sports10060094
21. Guan S, Lin N, Yin Y, Liu H, Liu L, Qi L. The Effects of Inter-Set Recovery Time on Explosive
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Power, Electromyography MS and Tissue Oxygenation during Plyometric Training. Sensors
(Basel). 2021;21(9). https://doi.org/10.3390/s21093015
22. Ramirez-Campillo R, Andrade DC, Alvarez C, et al. The effects of interset rest on adaptation to 7
weeks of explosive training in young soccer players. J Sports Sci Med. 2014;13(2):287-296.
23. Watkins CM, Storey AG, McGuigan MR, Gill ND. Implementation and Efficacy of Plyometric
Training: Bridging the Gap Between Practice and Research. J Strength Cond Res. 2021;35(5). https://
journals.lww.com/nsca-jscr/Fulltext/2021/05000/Implementation_and_Efficacy_of_Plyometric.11.
aspx
24. Turner TS, Tobin DP, Delahunt E. Optimal Loading Range for the Development of Peak Power
Output in the Hexagonal Barbell Jump Squat. J Strength Cond Res. 2015;29(6). https://journals.lww.
com/nsca-jscr/Fulltext/2015/06000/Optimal_Loading_Range_for_the_Development_of_Peak.23.
aspx
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Chapter 1
TheCHAPTER
Skeletal20System
Anna D’Annunzio,
Principles ofMSSpeed,
Agility,
and Quickness Training
John Lindala, MS
373 P RINCIP LE S OF SP E E D, AG I L I T Y,
AND QUICKNE SS T RAI N I N G
Chapter 1
Introduction
The Skeletal System
Speed, agility, and quickness (SAQ) are athletic performance-based skills that offer a variety of
Anna
benefits D’Annunzio,
to both MS
athletes and the general fitness population alike.
Fitness professionals must be familiar with the concepts, techniques, and programming guidelines
for SAQ training to offer these modalities as part of a comprehensive fitness program.
In the context of training general fitness clients, SAQ drills can be beneficial for a variety of
client types. SAQ training should not replace resistance training in most situations but can be
included in conjunction with resistance training.
Clients who engage in recreational sports can benefit tremendously from SAQ training, and it
also provides additional variety and stimulus to a client’s training plan, regardless of their fitness
goals.
The sub-skills in SAQ are distinct but related and should be progressed logically and appropriately
to drive desirable adaptations.
SAQ Training Concepts

To understand SAQ training there are key concepts to understand as they will be an influencing
factor in any SAQ training program.
Most SAQ movements can be broken down into three phases: acceleration, maximum speed,
and deceleration.
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Acceleration
In physics, acceleration refers to the rate speed increases with respect to time. In the context of
SAQ, acceleration is the phase of a drill involving going from stopped or low speeds to maximal
velocity.1

Chapter 1
Maximum Speed
The Skeletal System
Maximal speed is the point during a sprint at which maximal power output is generated that
Anna
results D’Annunzio,
in the MS
body moving horizontally at the maximum possible speed the individual can
reach. Maximal speed is not necessarily reached during all SAQ drills, as for certain drills the
2
distance covered is too short to achieve true peak speed.1
Deceleration
In physics, deceleration (also called negative acceleration) refers to the rate at which speed
decreases with respect to time.1 In the context of SAQ, deceleration involves the act of reducing
speed, often in preparation for a change of direction.
Deceleration places a high degree of eccentric force on the body, and can also result in a plyometric
effect when rapidly re-accelerating in another direction.
Ground Reaction Forces

Ground Reaction Forces (GRF) is the force exerted by the ground against the human body when
the body is in contact with the ground.2 In SAQ, contact force is applied by the exerciser’s feet
to the ground, and the ground reaction force pushes back against the feet.
When standing still, the ground reaction force will equal the force of gravity pulling the individual’s
body toward the Earth. During acceleration, sprinting, and deceleration, ground reaction forces
exceed the normal gravitational force on the body.3
Changes of direction occur frequently during most field sports, with professional soccer players
often performing 600-700 changes of direction per day.
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In the context of general fitness, change of direction skills are helpful for clients who engage
in recreational sports to improve performance and reduce injury risks, assuming proper form is
followed.

Chapter 1
Rate of Force Development
The Skeletal System
As discussed in Principles of Plyometric Training, the rate of force development (RFD) is a
Annaof D’Annunzio,
measure MS
how quickly the body can generate force.
RFD is influenced by a variety of factors including muscular strength and neural drive. Timed
performance on SAQ drills will improve if RFD is improved, all factors remaining equal.
Improvements to rate of force development are brought about through progressive SAQ training
as well as resistance training and plyometric training. For maximum improvement to RFD, a
combination of resistance, plyometric, and sprint training should be employed.5
Stretch Shortening Cycle

SAQ has a substantial plyometric component, and the stretch shortening (SSC) cycle plays a
major role in the force production during SAQ activities.5 Improvements to the SSC result in
greater force production when acceleration rapidly follows deceleration.
The deceleration is the eccentric component, the brief isometric contraction during the change
of direction is the amortization phase, and finally, reacceleration forms the final concentric phase
of the SSC during SAQ.
Sprinting
Sprinting refers to the activity of running at maximal speed and its associated training protocols.
Sprinting ability can be improved through a variety of training methods including resistance
training as well as sprinting protocols.
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Given the requisite intensities required to reach maximal speeds, sprinting is a predominantly
anaerobic activity, relying on the ATP-PC and anaerobic-glycolytic systems.
Sprint speed is the result of two factors: stride length and stride rate.
Stride length is the distance covered between two strides. Stride rate is the number of strides
taken with respect to time.6

Chapter 1
Each individual will have an optimal stride length as determined by their individual biomechanics.
The Skeletal System

If a client has proper sprint form, then increasing stride rate, as opposed to stride length, is the
best approach to improve speed.
Annaalso
Research D’Annunzio, MS stride rate with a reduced relative stride length reduces the
shows that increased
risk of many common running injuries.17
Depending on a client’s training experience, improvements to strength and power brought about
via resistance training and plyometric training will result in improved sprint speeds.
As an individual adapts to an initial training program, the training will need to favor speed-
specific activities if continued improvements in sprinting ability are desired.
Sprint Mechanics
Each part of the human body along the kinetic chain has a specific role in allowing the human
body to successfully sprint.
The posterior kinetic chain of the body is responsible for hip extension and acts as the driver for
linear maximal force production, propelling the body forward.
The anterior kinetic chain aids in triple extension with the quadriceps acting on the knee and
hip/pelvic stability through core stabilization.6
More specifically, during a sprint, the foot and ankle act as a spring, absorbing and redistributing
energy while running.8 Additionally the plantar flexors aid in forward propulsion, particularly
during the acceleration phase.11
The knee works as a shock absorber while sprinting by flexing to absorb impact forces and
redistribute them throughout the kinetic chain.9 Additionally, the knee works in concert with
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the ankles and hips creating triple extension or full extension of the 3 joints. Triple extension is
vital in running to optimize stride length and force development.9
The lumbopelvic hip complex produces maximal force through hip extension.10 It further improves
sprint performance by flexing to increase knee drive. The greater the knee drive the higher the
gravitational force that can be produced upon planting the leg.10

Chapter 1
During acceleration, the sprinter will be in a forward leaning position, slowly raising the torso
The Skeletal System

and coming upright as they approach maximal speed.
During the maximal speed phase of a sprint, the head should remain level and in line with the
spine.
This positioning allows for elongation of the spine, prevents injury from potential asymmetry,
and can improve mental performance.12
Change of Direction and Agility

Change of direction and agility are often thought of as interchangeable terms, but they are
distinctly different skills, despite some overlap.
Change of direction refers to the body’s ability to move from one direction to another safely
and efficiently. COD can be broken into phases of deceleration (eccentric contraction), plant
(isometric contraction), and acceleration (concentric contraction).3
Examples of change of direction include turning the corner at a base or taking an otherwise
preplanned route that involves at least one directional change.
Agility involves changing direction in response to a stimulus, such as cutting left in response to a
defender cutting right during field sports. Because agility requires rapid decision making before
action, it has an entirely separate neurological component.
Additionally, recent meta-analysis draws attention to the fact that individuals in live sport scenarios
often change their movement patterns when actively preparing for and responding to opposing
players as opposed to performing pre-planned routes.18
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The change in movement pattern during live play means that performance on pre-planned change
of direction routes may not correspond to relevant neurological agility benefits.
In terms of general fitness training, incorporating a stimulus and response into a change of
direction activity is a straightforward way to add the agility component. This type of training
can be particularly beneficial for older adults when it comes to reducing the risk of falls as well
as many of the other beneficial adaptations associated with resistance training.19

Chapter 1
Examples of agility activities for general fitness include ‘stop-and-go’ activities as well as changes
The Skeletal System

of direction to the left or right depending on a sound or color signal displayed by the coach.
Benefits of SAQ Training
Specific SAQ training is designed to challenge neuromuscular systems and body control.13 This
training enhances not only speed, agility, and quickness but can lead to the following beneficial
adaptations:
• Increased force and power production14

• Injury prevention through increased body awareness and reaction time15
• Increased muscular strength endurance16
• Reduced risk of falls and other injuries in older adults19
• Weight loss
SAQ Training Progressions

For the beginner athlete SAQ designs should initially start with 2-3 repetitions of an exercise with
lengthy rest between repetitions. The exercises should limit the total number of changes of
direction but gradually add variables over time.
1. Fast feet for 30 seconds rest for 60 seconds for 2-3 sets
2. One-ins ladder drill 2 repetitions per side for 2 sets resting for 60 seconds between sets.
3. Two-ins ladder drill 2 repetitions per side for 2 sets resting 60 seconds between sets.
The intermediate fitness participant should have a greater sense of body awareness and overall
fitness allowing for more variables to be included into the programming:
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1. In-in-out-out ladder drill for 4-6 repetitions, 2 sets, and up to 60 seconds rest between sets.
2. Ali shuffle ladder drill for 4-6 repetitions, 2 sets, and up to 60 seconds rest between sets.
3. T-drill for 3-5 repetitions, 2 sets, and up to 60 seconds rest between sets.
4. Box drill for 3-5 repetitions, 2 sets, and up to 60 seconds rest between sets.
5. 5-10-5 drill for 3-5 repetitions, 2 sets, and up to 60 seconds rest between sets.

Chapter 1
The advanced fitness participant could use a program that focuses on power production which
The Skeletal System

necessitates a longer rest interval due to the demands place on the body:
1. Sprints, 40 meters, 4 repetitions, 2 sets with up to 90 seconds rest between sets.

Depth jump to forward run,MS5 repetitions, 2 sets with up to 90 seconds rest between sets.
3. Modified box drill, 4 repetitions, 2-3 sets, with up to 90 seconds rest between sets.
4. Z-drill, 4 repetitions, 2-3 sets, with up to 90 seconds rest between sets.
5. T-drill, 4 repetitions, 2-3 sets, with up to 90 seconds rest between sets.
If introducing SAQ training to special groups certain steps should be taken to maximize the benefits
of SAQ training.
SAQ programs designed for youth participants carry similar benefits in terms of strength increases
and increased body control.14,15
Specific design considerations include:
• Gamifying by playing tag or jumping rope to keep the entertainment value high.
• Consider the youth participant along the lines of the beginner programming by limiting
changes of direction/complexity initially and building as body awareness grows.
SAQ programs for seniors carry the same health benefits as all ages however the focus is different.
For senior populations the focus is less on utilizing speed and power exercises and more so on
training activities that improve activities of daily life. Example exercises include:
• Hurdle step overs.

• Cone obstacle courses at a walking pace.
• Sit-to-stand movements.
SAQ programs designed specifically for weight loss should focus on the high intensity interval
aspect of SAQ.
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High intensity movements for short periods with adequate recovery have been shown to be an
effective weight loss training technique.
Any combination of exercises can be effective following the interval model with a focus of
elevating the heart rate then allowing recovery.

Chapter 1
SAQ Training Technique for Selected Exercises
The Skeletal System
A-Skip
Difficulty: low
1. Begin standing with feet hip-distance apart and torso upright.

2. Raise one leg to hip height while skipping on the ball of the opposite foot.
3. Place raised leg down directly under your center of mass momentarily standing on both
feet while they are slightly staggered.
4. Repeat steps alternating legs while moving forward.
Additional Notes:
• Maintain posture to avoid forward or backward leans.

• Engage arms in opposition of elevated legs.
• Avoid twisting.
• Find a comfortable pace and rhythm.
Agility Addition:
• Add stop and go in response to light or sound signal from coach.
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Chapter 1
Fast Feet
The Skeletal System
Difficulty: low
1. Start standing with feet hip width apart.

2. Pushing through the balls of the feet, run in place quickly.
3. Continue for desired time or repetitions.
Additional Notes:
• Can be performed moving forward by taking as many steps as possible over a set distance.
• Breathe deeply throughout the movement creating a steady rhythm.
• Use your arms in rhythm with your feet.
Agility Addition:
• Add stop and go in response to light or sound signal from coach.
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Chapter 1
Sprints
The Skeletal System
Difficulty: high
1. Following a proper warmup and practice sprints at a lower intensity level prepare for the first
all out sprint.
2. Determine start and finish line for the next sprint.
3. Start position can be standing with feet staggered or in a track stance depending on the
goal of the exercise performer.
4. On the predetermined signal to start, performer takes off in a run at maximum speed and
maintains effort until crossing the finish line.
Additional Notes:
• Run tall with head, neck, and shoulders in line with hips.
• Arms should move only in the sagittal plane avoiding crossing over the body.
• Elbows should be bent to 90 degrees.
• Feet should land directly underneath the torso on the ball of the foot.
• A high heel lift off and knee pull through should be emphasized.
Agility Addition:
• This is not recommended if training for maximal speed.
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Chapter 1
Deceleration Drills
The Skeletal System
Deceleration drills have a single focus on the eccentric phase of a movement or the slowing down
of aAnna D’Annunzio,
concentric movement. Drills MScan be implemented across the kinetic chain for any movement
that requires a change or stop in momentum. Additionally, the difficulty of deceleration drills
can gradually increase by changing or adding planes of movement, progressing from bipedal to
single stance activities, or adding external load/forces.
Example exercises include depth jumps, sprint to backpedal, drop and catch drills, and single
leg lateral hop to balance.
Depth Jumps to Forward Run
Difficulty: high
1. Start standing on an elevated surface.

2. Either step or lightly hop off elevated surface emphasizing landing on two feet in an athletic
stance.
3. Immediately drop into a squat to slow momentum from the drop.
4. As soon as possible, explode forward into a forward run.
Additional Notes:
• Emphasize quick and controlled ranges of motion.

• Maintain good posture and eyes up while landing.
Agility Addition:
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• Run forward, cut left, or cut right upon landing in response to auditory or visual stimulus.

Chapter 1
Speed Ladder Drills
The Skeletal System
Agility Addition for Speed Ladder Drills: stop and go or change drills in response to light or
Anna
sound signalD’Annunzio,
from the coach. MS
One-ins
Difficulty: low
1. Start standing at the beginning of a speed ladder in an athletic stance with feet hip width apart.
2. Movement will begin in a controlled run by quickly placing the first foot inside the first box
of the speed ladder.
3. Continue running, placing the opposite foot inside the second box of the speed ladder.
4. Progress through the ladder in a controlled run placing only one foot inside each box and
alternating feet.
Additional Notes:
• Pump arms in rhythm with the feet.

• Perform at a fast but controlled pace.
• Perform drill multiple times alternating starting foot.
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Chapter 1
Two-ins
The Skeletal
Difficulty: low System
AnnaInstructions:
Exercise D’Annunzio, MS
1. Start standing at the beginning of a speed ladder in an athletic stance with feet hip width apart.
2. Movement will begin in a controlled run by quickly placing the first foot inside the first box
of the speed ladder.
3. Continue running placing the opposite foot inside the same box of the speed ladder so
that both feet are inside the first box.
4. Progress through the ladder in a controlled run placing both feet inside each box.
Additional Notes:

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Chapter 1
Side Shuffle
The Skeletal
Difficulty: low System
AnnaInstructions:
1. Start standing at the beginning of a speed ladder while facing sideways in an athletic stance
with feet hip width apart.
2. Movement will begin in a controlled lateral shuffle by quickly placing the first foot inside the
first box of the speed ladder.
3. Continue moving laterally by placing the opposite foot inside the same box of the speed
ladder so that both feet are inside the first box.
4. Progress through the ladder in a controlled shuffle placing both feet inside each box.
Additional Notes:

• Emphasize upright posture and eye level staying off the floor.
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Chapter 1
In-In-Out-Out
The Skeletal
Difficulty: System
low-medium
Anna D’Annunzio,
Procedure: MS
1. Start standing at the beginning of a speed ladder, with feet on either side of the first box.
2. Movement will begin by quickly placing the first foot inside the first box of the speed ladder
followed immediately by the second foot.
3. Weight and impact should be on the balls of the feet.
4. Step forward and out placing the first foot outside of the second box.
5. Repeat with the opposite foot.
6. Progress through the ladder repeating both feet inside each box then outside the next box.
Additional Notes:

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Chapter 1
Zigzag
The Skeletal
Difficulty: System
low-medium
AnnaInstructions:
1. Start standing at the beginning of a speed ladder, with both feet in front of ladder and off to
one side of the first box.
2. Movement will begin by quickly placing the foot nearest the ladder inside the first box. The
step should be forward and lateral.
3. Immediately follow with the second foot.
5. Step first foot laterally outside of the second box.
6. Repeat with the opposite foot but instead of planting the second foot only tap the toes
on the ground maintaining bodyweight on the first foot.
7. Move the second foot forward and lateral to plant inside the second box.
8. Repeat the above steps to progress through the ladder.
Additional Notes:

• Movements into the ladder should be forward and lateral.
• Movements out of the ladder should just be lateral.
• Add a challenge to the drill by having fitness participant perform the move in reverse.
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Chapter 1
Ali Shuffle
The Skeletal
Difficulty: medium System
AnnaInstructions:
1. Start standing at the beginning of a speed ladder, standing with feet together facing the side
of the first box.
2. Movement will begin by quickly hopping into a staggered stance while placing the lead foot
inside the first box.
3. Trailing foot should be planted slightly behind the body and outside of the first box.
4. Perform another hop moving slightly laterally placing lead foot outside of the second box
and trailing foot inside of the first box.
6. Repeat the above steps to progress through the ladder.
7. Each foot should alternate being placed inside of each box.
Additional Notes:

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Chapter 1
5-10-5 Drill
The Skeletal
Difficulty: System
medium-high
AnnaInstructions:
1. Start with a 5-10-5 grid. Place 3 sets of cones in a row with each set 5 yards from the last. Each
set of cones should be 5 yards apart from its partner.
2. The fitness participant will start at the middle set of cones with their hand touching the line
between the pair of cones.
3. The fitness participant will choose a direction to begin the drill.
4. At the start of the drill, the fitness participant will sprint the 5 yards from the middle
cones towards the outside set of cones they chose to begin with.
5. Once they reach the outside cones, they will touch the line between the pair and immediately
change direction.
6. Then they will sprint the full 10 yards to the opposite set of outside cones.
7. Again, they will touch the line between the second set of outside cones, then immediately
change direction and sprint back towards the opposite set of outside cones.
8. Drill ends when the sprint through the middle cones not stopping to touch the line between
the middle pair.
Additional Notes:
• Perform drill multiple times alternating starting direction.

• Timing begins when the fitness participant starts moving and ends when they cross the
middle cones for the second time.
Agility Addition:
• Change directions in response to auditory or visual stimuli.

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Chapter 1
Modified Box Drill
The Skeletal
Difficulty: high System
AnnaInstructions:
1. Start by creating the modified box grid out of 5 cones. 4 of the cones should create a square
that is 5 yards long on each side with the 5th cone being placed in the center of the square grid.
2. Starting position can vary to adjust difficulty with the start and end drills.
3. The fitness participant will maintain their hips facing forward throughout the drill and
must always repeat the pattern of corner cone-middle cone–corner cone until they cover the
entire box.
4. The participant starts at the front right cone.
5. At the start of the drill, the fitness participant will reverse diagonal shuffle to the middle
cone then forward diagonal shuffle to their starting cone.
6. Next, they will lateral shuffle to the front left cone and repeat the shuffle to the middle cone.
7. Upon returning to the front left cone, they will backpedal to the back left cone.
8. After shuffling to the middle cone and back they will lateral shuffle to the back right cone.
9. After shuffling to the middle cone and back they will sprint to the front right cone and come
to a complete stop at their starting position ending the drill.
Additional Notes:
• Perform drill multiple times alternating starting position.

• Timing begins when the fitness participant starts moving and ends when they return to their
starting position.
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Chapter 1
T-Drill
The Skeletal
Difficulty: medium System
AnnaInstructions
1. Start by creating the T-Drill grid utilizing 4 cones or markers. The first cone will be used at
the starting and ending point. The second cone should be placed 10 yards away in a straight
line from the first cone. The third and fourth cones should be placed 5 yards away to the right
and left of the second cone. The four-cone grid should resemble a capital T.
2. The fitness participant should start in an athletic stance at cone one facing cone two.
3. When the test starts, the fitness participant will run from cone one to cone two as fast as
possible but under control so they can touch cone two with one hand.
4. The fitness participant will then laterally shuffle to cone three again touching the cone
with one hand before changing direction and laterally shuffling to cone four.
5. After touching cone four, the fitness participant will shuffle back to cone two.
6. After touching cone two a second time, the fitness participant will backpedal past cone one
to complete the test.
Additional Notes:
• Perform drill multiple times alternating the order the fitness participant goes left or right.
• Timing begins when the fitness participant starts moving and ends when they return to their
starting position.
Agility Addition:

• Catch and throw a ball from the coach or partner.
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Chapter 1
Box Drill
The Skeletal
Difficulty: System
low-medium
AnnaInstructions:
1. Start by creating the box grid out of 4 cones creating a square that is 5 yards long on each side.
2. Starting position can vary to adjust difficulty with the start and end drills.
3. The fitness participant will maintain their hips facing forward throughout the drill.
4. The participant starts at the front right cone.
5. At the start of the drill, the fitness participant will laterally shuffle to the front left cone.
6. Next, they will backpedal from the front left cone to the back left cone.
7. Then they will laterally shuffle from the back left to the back right cone.
8. Finally, they will sprint from the back right to the front right cone and come to a complete
stop at their starting position ending the drill.
Additional Notes:

• Perform as fast as possible.
• Timing begins when the fitness participant starts moving and ends when they backpedal
passed to their starting position.
• A common variation includes sprinting the entire course requiring the fitness participant to
go around each cone.
Agility Addition:

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Chapter 1
LEFT Drill
The Skeletal
Difficulty: System
medium-high
AnnaInstructions:
1. Start by placing 2 cones 10 yards apart.

2. Starting position is at the first cone in an athletic stance.
3. When the test starts the fitness participant will sprint to the far cone and backpedal back
to the start.
4. Then the participant will turn sideways and shuffle to the far cone and back. They should
face the same direction both ways so that both the right and left leg lead at some point.
5. Then the participant will carioca to the far cone and back making sure to face the same
way both directions again.
6. Finally, the fitness participant will sprint to the far cone ending the test.
Additional Notes:
• Timing begins when the fitness participant starts moving and ends when they run past the far cone.
Agility Addition:

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Chapter 1
Z-Drill
The Skeletal
Difficulty: high System
AnnaInstructions:
1. Start by creating a square grid out of 4 cones that measures 5 yards on each side. Place a fifth
cone in line with the left side of the square but 5 yards farther away.
2. Have the fitness participant start on the right side of the square.
3. At the start, the fitness participant will laterally shuffle from the back right to the back
left cone going behind the back left cone.
4. After shuffling past the back left cone, the participant will change direction without
turning around and they will laterally shuffle forward to the front right cone. Their right foot
should be leading.
5. They will shuffle just past the front right cone then change direction and laterally shuffle
to the front left cone.
6. After shuffling slightly passed the front left cone, sprint passed the fifth and final cone.
Additional Notes:
• Perform drill three times at one starting position then switch for another three repetitions.
• Timing begins when the fitness participant starts moving and ends when they sprint past
the fifth cone.
• The fitness participant’s hips should face forward the entire drill.
Agility Addition:

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Chapter 1
Summary
The Skeletal System
SAQ training has proven to be effective for many fitness populations and should be considered
as aAnna
valuableD’Annunzio, MS coaching athletes and general fitness clients alike.
tool for personal trainers
The benefits include increased speed, agility, quickness, strength, endurance, body awareness, and
with a cumulative overall effect of improved injury prevention.
The exercises used for SAQ training offer much room for progression for clients of all levels and
abilities.
References
1. Cooke, K; Quinn, A; Sibte, N. Testing Speed and Agility in Elite Tennis Players. Strength and
Conditioning Journal: August 2011 – Volume 33 – Issue 4 – p 69-72
2. Kawamori, N; Nosaka, K; Newton, R. Relationships Between Ground Reaction Impulse and Sprint
Acceleration Performance in Team Sport Athletes. Journal of Strength and Conditioning Research:
March 2013 – Volume 27 – Issue 3 – p 568-573
3. Spiteri, T; Newton, R; Binetti, M; Hart, N; Sheppard, J; Nimphius, S. Mechanical Determinants

of Faster Change of Direction and Agility Performance in Female Basketball Athletes. Journal of
Strength and Conditioning Research: August 2015 – Volume 29 – Issue 8 – p 2205-2214
4. Bloomfield, J; Polman, R: O’Donoghue, P. Physical Demands of Different Positions in FA Premier

League Soccer. J Sports Sci Med. 2007 Mar 1;6(1):63-70.
5. Walanker, P; Shetty, J. Speed, Agility, and Quickness Training: A Review. International Journal of

Physical Education, Sports, and Health. 2020; 7(6): 157-159
6. Barr, M; Sheppard, J; Newton, R. Sprinting Kinematics of Elite Rugby Players. Journal of Australian
Trainer Academy
Strength and ©2023

Conditioning. 2013; 21(4): 14-20.
7. Wild, J; et al. A Biomechanical Comparison of Accelerative and Maximum Velocity Sprinting:

Specific Strength Training Considerations. Professional Strength and Conditioning 21 (2011): 23-37.
8. Lai, A; Schache, A; Brown, N; Pandy, M. Human ankle plantar flexor muscle-tendon mechanics and
energetics during maximum acceleration sprinting. J R Soc Interface. 2016 Aug;13(121):20160391.
9. Morin, J; Gimenez, P; Edouard, P; Arnal, P; Jiménez-Reyes, P; Samozino, P; Brughelli, M;

Mendiguchia, J. Sprint Acceleration Mechanics: The Major Role of Hamstrings in Horizontal Force

Chapter
Production. 1 2015 Dec 24;6:404.
Front Physiol.
The Skeletal
during blockSystem
10. Sado, N; Yoshioka, S; Fukashiro, S. Three-dimensional kinetic function of the lumbo-pelvic-hip
complex start. PLoS One. 2020 Mar 12;15(3):e0230145.
Anna D’Annunzio,
11. Sabrina, MS
S; Stephen, J. Built for speed: musculoskeletal structure and sprinting ability. J Exp Biol 15
November 2009; 212 (22): 3700–3707.
12. Almasi, M. Investigating the Effect of Head Movement during Running and Its Results in Record
Time Using Computer Vision. International Journal of Applied Engineering Research, 2018, 13(11),
9433-9436.
13. Azmi, K; Kusnanik, N. Effect on Exercise Program Speed, Agility, and Quickness (SAQ) in Improving
Speed, Agility, and Acceleration. 2018 J. Phys.: Conf. Ser. 947 012043
14. Jovanovic, M; Sporis, G; Omrcen, D; Fiorentini, F. Effects of Speed, Agility, Quickness Training
Method on Power Performance in Elite Soccer Players. Journal of Strength and Conditioning
Research: May 2011 – Volume 25 – Issue 5 – p 1285-1292
15. Devaraju, K. Effect Of SAQ Training On Vital Capacity Among Hockey Players. Journal Impact
Factor. 2014 Jan;5(1):102-5.
16. Arjunan, R. Effect of speed, agility and quickness (SA Q) training on selected physical fitness variables
among school soccer players. International Journal of Research in Humanities, Arts and Literature
(IMPACT: IJRHAL). 2015;3(10).
17. Schubert AG, Kempf J, Heiderscheit BC. Influence of stride frequency and length on running mechanics:
a systematic review. Sports Health. 2014;6(3):210-217. https://doi.org/10.1177/1941738113508544
18. Young W, Rayner R, Talpey S. It’s Time to Change Direction on Agility Research: a Call to Action.
Sports Med Open. 2021;7(1):12. Published 2021 Feb 12. https://doi.org/10.1186/s40798-021-
00304-y
19. Lichtenstein E, Morat M, Roth R, Donath L, Faude O. Agility-based exercise training compared to
traditional strength and balance training in older adults: a pilot randomized trial. PeerJ. 2020;8:e8781.
Published 2020 Apr 14. https://doi.org/10.7717/peerj.8781
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Chapter 1
TheCHAPTER
Skeletal21System
Anna D’Annunzio,
Principles ofMSBalance
Training
John Lindala, MS
399
Princip le s of Balance T rai n i n g
Chapter 1
Introduction
The Skeletal System
Balance is a fundamental skill in daily activity necessary for the safe completion of any type of
Anna or
movement D’Annunzio, MS
activity pattern. Specifically, balance refers to the body’s ability to maintain its center
of gravity over its base of support during a given action. It relies upon a feedback network from
the vestibular, visual, and somatosensory systems for ideal and smooth motor function.
Essentially, balance is the ability of the body to maintain its equilibrium.4 Proper balance not
only aids in injury prevention but is vital for a variety of specific athletic movements.1
Individuals from many different populations benefit from incorporating balance training. Fitness
professionals must have a working knowledge of balance training programming and exercises to
safely and effectively implement balance training into fitness programs when appropriate. They must
know basic balance concepts, how to progress movements, and the correct technique for exercises.
Balance Training Concepts

Center of Gravity
Center of gravity is refers to the point at which the entire weight of a body is concentrated so
that, if supported at this point, the body remains in equilibrium in any position.2, 14
Base of Support
The base of support is the region of ground surface that the body contacts.3, 14
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The center of mass operates perpendicular to the base of support, enabling the body to remain
balanced through static or dynamic postures.3
Limit of Stability
The limit of stability is the maximum distance the body can move while remaining balanced
before having to change the base of support.4

400
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Static Balance
The Skeletal System
The body’s ability to maintain equilibrium without movement.4
Semi-dynamic Balance
Semi-dynamic balance refers to the ability to stay in the same spot with the addition of movement.4
Dynamic Balance
Includes the ability to balance through motion including adjustments made to voluntary movement
and to maintain balance during disruption from an outside influence.4
Vestibular System
The vestibular system resides in the inner ear and relates information relating to acceleration and
guidance continuously, providing movement and positioning feedback.5
This system provides vital information for rapid compensatory movements in response to external
or internal forces being applied to the body.
Somatosensory System
The somatosensory system is a network of neurons that provides direct input to the central
nervous system via muscle and connective tissue receptors. It is largely responsible for aiding
both proprioception©2023 and kinesthesia for sensorimotor feedback, including connecting sensations
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of touch, pain, pressure, movement, and temperature from the tissues to the brain.6, 7
Visual System
The role of the visual system in relation to balance is in the detection of movement. Motion
detected by the retina can be utilized to determine whether the movement is occurring from the
individual or the environment.8, 9

401
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The combination of the vestibular, somatosensory, and visual systems creates the necessary
The Skeletal System

components for a fully functioning system of balance, allowing the individual to operate optimally
at rest or in motion.5, 6, 8
Sensorimotor Function
The sensorimotor system functions to maintain joint stability and equilibrium throughout static
and gait postures. It utilizes the processing information acquired through sensory, motor, and
central integration feedback.10
Neuromuscular Control
Neuromuscular control is used to define the interaction between the neurological and musculoskeletal
systems. As relating to balance, neuromuscular control is responsible for involuntary muscular
contractions to control joint motion and maintenance of joint stability.10
Balance is a necessity for function in everyday life. Accomplishing tasks that involve displacement
in the body while staying upright will involuntarily rely upon the systems that contribute to
overall balance ability.14
Only through continuous and rapid feedback from the vestibular, visual, and somatosensory
systems will the body maintain its center of gravity in dynamic or postural positions.1
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402
Principles of Balance Training le s of Balance T rai n i n
Princip 405
g
Chapter 1
The Skeletal System

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403
Principles of Balance Training 406
Chapter 1
Benefits
The Skeletal ofSystem
Balance Training
Effective balanceBenefits of Balance
training carries a multitude Training
of positive impacts for regular and athletic bodies
Anna
alike. D’Annunzio,
Positive MS to balance training include:
effects directly related
Effective balance training carries a multitude of positive impacts for regular and athletic
bodies alike. Positive effects directly related to balance training include:
1. Greatly reduced risk of bodily harm due to imbalance 1
2. 1. Greatly
Improved reduced and
memory risk of bodilycognition
spatial harm due to
11 imbalance1

3. Optimization of dynamic
2. Improved memory motorcognition
and spatial patterns to improve performance and reduce injury 1,12
11
4. Balance of muscular
3. Optimization asymmetries
of dynamic
13
motor patterns to improve performance and reduce injury 1,12
4. Balance of muscular asymmetries13
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404
Chapter 1
Balance
The Training
Skeletal System Progressions
Balance training requires a linear process that continually progresses from simple and safe exercises
to Anna D’Annunzio,
more complex and unstable MSexercises as the body improves its sense of balance.15
Balance exercises occur in all three planes of motion.
Balance training seeks to introduce controlled instability as a client develops their sense of
balance.15
From a movement plane perspective, exercises progress from sagittal, to frontal, and, finally,
transverse.
Sagittal plane exercises have a high carryover to activities of daily life and thus have a high natural
comfort level for users.
Frontal plane exercises introduce a combination of movements that will occur mostly in the
frontal plane, but also have some interaction in the sagittal plane.
This added layer of complexity challenges the body and the balance by adding additional stress
and dynamics with movement.16
Finally, the transverse plane utilizes a wide range of muscles with crossover to both the sagittal
and frontal planes. The rotational nature of the exercises particularly challenges the visual balance
system.
Creating exercise progressions uses a similar logical progression from comfortable and stable to
challenging and unstable.
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Lower-body progression
Two-Legged Stance:
1. Begin with a two-legged stance with feet shoulder width apart on a firm stable surface.
2. Move to narrow the stance, still on two feet and a stable surface.
3. Finally, progress to a staggered stance or heel-to-toe.

405
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The initial positioning of the two-legged stance creates a wide base of support, making it easy
The Skeletal System

for the user to maintain the center of gravity. With the first progression the base of support is
narrowed reducing the area available to balance the center of gravity.
progression MS
to heel-to-toe maximally reduces the width of the base of support and will likely
accompany postural sway as the user works to maintain their center of gravity.
After successfully completing heel-to-toe exercises, the next progression in balance training is
to move to single-leg stance exercises.
One-Legged Stance, or Unstable Surface:
1. Begin with a single-leg stance on a solid surface.

2. Move to a two-legged stance on an unstable surface or balance modality.
3. Finally, progress to a single-leg stance on an unstable surface or balance modality.
The first progression to a single-leg stance greatly reduces the overall surface area of the base of
support and reduces the number of points of contact with the ground. Reducing contact points
also decreases the number of pressure and touch sensors communicating with the central nervous
system.
Following a single-leg stance, the next progression brings users back to a two-legged stance
but on an unstable surface. Having a floor or modality that is constantly changing challenges
the user’s perception of where they are in space, directly engaging the somatosensory system as
proprioceptive feedback will rapidly change as the surface shifts. The next progression to single-
leg stance again reduces the overall area of the base of support.
External Force:
Up to this point all balance progressions utilized only the internal force of the user’s own body.
After passingTrainer
single-leg
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©2023 and unstable surface exercises, the next progression incorporates an
outside force upon the user.
1. Push or pull in one direction or movement plane.

2. Push or pull in multiple directions or movement planes.
The addition of external forces accompanying the movement challenges the vestibular system
and its ability to counteract force to maintain a center of gravity.

406
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The outside force starts small, for example catching a tennis ball.
The
Then,Skeletal System
the intensity progresses via increased weight, such as using a medicine ball. Additionally,
incorporating additional planes of movement as balancing skills increase will train the entire
Anna
balance D’Annunzio, MS
system.
Additional Variables Principles of Balance Training 409
Beyond adjusting foot positioning andAdditional

the stability of the surface the user is balancing on, a few
Variables
more progressions exist to challenge the ability to balance.
Beyond adjusting foot positioning and the stability of the surface the user is balancing on, a
few more progressions exist to challenge the ability to balance.
1. Closing eyes during exercise. Eliminating the visual system puts greater emphasis on the rest
1. Closing eyes during exercise. Eliminating the visual system puts greater emphasis on the rest
of the balanceof system
the balanceas a full
system as alayer ofofsensory
full layer feedback
sensory feedback is removed.
is removed.
2. Additional2.cognitive
Additional tasks.
cognitivePerforming
tasks. Performingsmall mental
small mental tasks
tasks such
such as basic as basic
math whilemath while attempting
attempting to balance further challenges the brain’s capacity to sort through incoming
to balance further
sensory challenges
feedback. the brain’s capacity to sort through incoming sensory feedback
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407
Chapter 1
Technique
The for Select
Skeletal System Balance Training
Exercises
Tandem Stance
Difficulty: low
1. Start standing next to a wall or chair for safety.

2. Line feet up, heel-to-toe, in a standing stance.
3. Ensure toes of both feet are pointing straight ahead.
4. Hold position for the desired time then switch feet.
5. If needed, place a chair they may hold on to on either side in the event of loss of balance.
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Chapter 1
Single-Leg Balance
The Skeletal System
Difficulty: low
1. Start standing in a comfortable neutral position. Hands can be on hips or floating.

2. Flex one hip pulling foot off the floor and thigh to 90 degrees of hip flexion. Shoulders and
hips should remain neutral.
3. Hold for desired time. Ranges typically vary between 5-30 seconds.
4. Repeat on the opposite side.
Balance can be aided in this position by maintaining full extension of the standing leg.
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Chapter 1
Single-Leg Balance Reach
The Skeletal System
Difficulty: low
1. Start standing in a neutral position with feet hip width apart. Hands can be on hips or floating.
2. Lift one leg while keeping the leg straight and float it directly in front of the body a few inches
off the ground while ‘reaching’ forward with the foot. Maintain all weight on the stance leg.
Do not step down with the reaching foot
3. The exercise can be progressed by abducting the floating leg or opening the leg up into
external rotation.
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Chapter 1
Single-Leg Hip Rotation
The Skeletal System
Difficulty: low
1. Start standing in a comfortable neutral position. Hands can be on hips or floating.

2. Flex one hip, pulling the foot off the floor and thigh to 90 degrees of hip flexion. Shoulders
and hips should remain neutral.
3. Externally and internally rotate elevated leg at a controlled pace, holding briefly at the
end range of motion.
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Chapter 1
Single-Leg Lift and Chop
The Skeletal System
Difficulty: low
1. Start standing in a neutral position while holding a medicine ball to one hip.
2. Lift the opposite leg so that the body balances on a single leg with the medicine ball to that
side.
3. Hips should stay neutral while holding the floating leg is off the ground.
4. Cross the medicine ball from hip of planted leg to the opposite shoulder in a diagonal
pattern with straight arms.
5. Return to the start position and repeat.
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Chapter 1
Single-Leg Arm and Leg Motion
The Skeletal System
Difficulty: low
1. Start standing in a neutral position.

2. Lift one leg off the floor into a single leg balance position with shoulders and hips staying
neutral.
3. Lean forward while simultaneously reaching the floating leg behind them to full extension
and opposite arm (arm of the planted leg) forward to full extension.
4. Adjust the range of motion based on the user’s capability level.
5. Continue performing the pattern for time.
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Chapter 1
Single-Leg Windmill
The Skeletal System
Difficulty: low

neutral.
3. Lean torso forward to 45 degrees while pushing hips back loading weight into the gluteus
muscles.
4. Extend both arms directly out to the sides.
5. While maintaining balance, rotate arms and torso slowly as far as possible in each direction.
6. Continue performing the pattern for time.
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Chapter 1
Single-Leg Throw and Catch
The Skeletal System
Difficulty: low
1. Start standing in a neutral position while holding a medicine ball with both hands.
neutral.
3. Toss the ball to a partner or trainer then catch the return toss while maintaining balance
and alignment.
4. Repeat for time or repetitions.
6. To progress the exercise, increase the distance, velocity, or placement of the throws.
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Chapter 1
Single-Leg Squat
The Skeletal System
Difficulty: medium

neutral.
3. Squat down on the planted leg as if sitting into a chair.
4. Make sure knee stays in line with toes to avoid knee stress or injury.
5. Hold briefly at the bottom of the squat.
6. Fully extend the planted leg extending through the gluteal muscles to return to standing.
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Chapter 1
Single-Leg Squat Touchdown
The Skeletal System
Difficulty: medium

neutral.
3. Squat down on the planted leg as if sitting in a chair.
4. Make sure the knee stays in line with the toes to avoid knee stress or injury.
5. At the bottom of the squat, reach the opposite hand to touch the toes of the planted foot.
6. Fully extend the planted leg extending through the gluteal muscles to return to standing.
9. If unable to reach the toes, adjust the target to the leg or knee and work back down to
the toes over time.
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Chapter 1
Single-Leg Romanian Deadlift
The Skeletal System
Difficulty: medium

neutral.
3. Keep the floating foot off the ground a few inches but next to the planted leg.
4. Hinge forward at the hip of the planted leg, the torso should lean forward while the
tailbone drives backward.
5. Planted leg should remain extended with a minimal amount of knee bend.
6. Reach for the planted foot with the opposite hand trying to touch the toes of the planted
foot.
7. Using the gluteal and abdominal muscles, extend the planted hip to return to an upright
position.
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Chapter 1
Multiplanar Step-Up to Balance
The Skeletal System
Difficulty: medium
1. Start standing in a neutral position directly in front of a stable elevated surface like a box,
platform, or step.
2. For the sagittal plane, lift one leg and place foot directly on top of the elevated surface.
3. Toes and knee of forward foot should be aligned.
4. Shift weight towards the forward foot pushing through the heel and extend the forward
leg through the gluteal muscles and quadriceps to bring the body upright on top of the
elevated surface.
5. Hold top position for balance with opposite leg flexed in front of body to 90 degrees at
both the hip and knee.
6. Return lifted leg to the ground followed by the standing leg.
Progressions include:
• Alternating legs every repetition.

• Incorporate the frontal plane by performing a lateral step-up sideways to the elevated
surface. The lateral step-up focus will be on stacking the hips, knees, and ankles in one vertical
column during the movement.
• Incorporate the transverse plane by performing a rotational step-up from the side of the
elevated surface while rotating to face the surface while placing the stepping foot. The opening
step to place foot on the elevated surface will involve rotating the body to mirror the traditional
step-up. Between the opening and closing rotation from/to start position, the checkpoints
will be the same as the regular step-up.
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Chapter 1
Multiplanar Lunge to Balance
The Skeletal System
Difficulty: medium

2. For the sagittal plane, lift one foot off the ground and step forward into a lunge with knees
and toes pointing forward.
3. Forward foot should be flat on the ground with forward knee directly above the ankle.
4. Back foot will be pivoted onto toes and shoulders should be above the back knee.
5. Both knees should bend to 90 degrees.
6. Drive through the forward foot to extend the forward leg and push the weight back to
the back leg.
7. Come into a standing position on the back leg with the forward leg held in a balance
position at 90 degrees of hip and knee flexion.
• Incorporate the frontal plane by performing a lateral lunge to balance. The initial step will
be to the side and focus on the forward leg will be on stacking the hips, knees, and ankles in
one vertical column.
• Incorporate the transverse plane by performing a rotational lunge. The initial step will rotate
the hips externally, so the user’s forward foot moves laterally and posteriorly to the back foot.
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Chapter 1
Multiplanar Hop with Stabilization
The Skeletal System
Difficulty: hard

2. Lift one leg into a single leg balance stance.
3. To perform in the sagittal plane, hop forward off the balancing leg and land on the opposite
leg in a single leg balance position.
4. Hold the balance position for 3-5 seconds.
5. Hop backwards returning to the start position and landing in single leg balance on the
original leg.
• Incorporate the frontal plane by performing a lateral hop to balance. The start position is
identical, but the hop goes laterally instead of front to back.
• Incorporate the transverse plane by performing a rotational hop to balance. The start position
is identical, but with external rotation of the balancing leg. The initial hop will go laterally and
posteriorly to the side of the elevated leg. The second hop will still return to the start position.
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Chapter 1
Multiplanar Single-Leg Box Hop-Up with Stabilization
The Skeletal System
Difficulty: hard
1. Start standing in a neutral position directly in front of a stable elevated surface like a box,
platform, or step.
3. To perform in the sagittal plane, hop forward off the balancing leg and land on the same
leg, on top of the surface, and in a single leg balance position.
5. Step backwards to return to the start position.
• Hoping off the box as ability level allows.

• Incorporate the frontal plane by performing a lateral hop-up by stepping sideways to the
elevated surface with the balancing leg closest to the surface. The hop onto the elevated
surface will be lateral.
• Incorporate the transverse plane by performing a rotational hop-up by starting at the side of
the elevated surface. The hop onto the elevated surface will incorporate rotating the body to
land in a position that mirrors the sagittal plane hop-up. Between the opening and closing
rotation from/to start position, the checkpoints will be the same as the sagittal hop-up.
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Chapter 1
Multiplanar Single-Leg Box Hop-Down with Stabilization
The Skeletal System
Difficulty: hard
1. Start standing in a neutral position on top of a stable elevated surface like a box, platform,
or step.
3. To perform in the sagittal plane, hop forward off the balancing leg and land on the same
leg, on the floor, and in a single leg balance position.
5. Return to the start position.
• Incorporate the frontal plane by performing a lateral hop-down by hopping laterally instead
of anteriorly.
• Incorporate the transverse plane by performing a rotational hop-up by hopping with an
external rotation instead of moving anteriorly. The landing position should be a 90 degree
turn from the start position.
Summary
Balance training progressions should systematically challenge the neuromuscular system to
produce effective improvements. The overall safety of the user or client is a priority as their ability
to balance improves,
©2023 so as not to overwhelm the balance system creating vulnerability to injury.
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Progression should follow the format of:
1. Easy to hard
2. Simple to complex
3. Stable to unstable
4. Static to dynamic
5. Slow to fast
6. Eyes open to eyes closed

423
Chapter 1
7. Known to unknown (cognitive task)
The Skeletal System

8. Single task to dual-task
Some commonly used pieces of balance equipment that are highly effective at challenging the
Anna D’Annunzio,
neuromuscular system include:MS
1. Floor: utilizing a soft floor surface creates a minimal amount of instability forcing greater
recruitment of balance training systems.
2. Balance beam: a narrow-elevated surface that reduces the base of support available to the user.
3. Half-foam roll: a semi-cylinder where the user stands on the curved surface. The flat surface
is stable to avoid movement but standing on the arc of the roller greatly reduces points of
contact and the base of support for the balancer.
4. Foam pad: dense pad typically between 1-3 inches thick that dramatically reduces the
stiffness of the standing surface. User can be pushed into any direction due to the give of the
foam pad.
5. Balance disc: small disc filled with air that provides greater give than the foam pad. Users
can experience rapid changes in balance or direction.
6. Wobble board: solid board with an attached curvy surface. Typically, user stands on the flat
surface with the curved surface in contact with the solid floor. The combination of materials
makes for rapid changes in direction if weight compensations occur from the user.
References
1. Brachman, A; Kamieniarz, A; Michalska, J; Pawłowski, M; Słomka, K; Juras, G. Balance Training
Programs in Athletes – A Systematic Review. Journal of Human Kinetics, 2017;58(1):45-64.
2. “Center of gravity.” Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-

webster.com/dictionary/center%20of%20gravity.
3. Nam, HS; Kim, JH; Lim, YJ. The Effect of the Base of Support on Anticipatory Postural Adjustment
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and Postural Stability. Journal of Korean Physical Therapy, 2017;29(3):135-141.
4. Ragnarsdottir, M. The Concept of Balance. Physiotherapy, 1996;82:368-375.
5. Purves, D; Augustine, GJ; Fitzpatrick, D; et al. Neuroscience. 2nd edition. Sunderland (MA): Sinauer
Associates; 2001. Chapter 14, The Vestibular System.
6. Ogard, W. Proprioception in Sports Medicine and Athletic Conditioning. Strength and Conditioning
Journal, 2011;33(3):111-118.

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7. Hillier, Chapter
S: Immink,1 M; Thewlis, D; Assessing Proprioception: A Systematic Review of
Possibilities. Neurorehabilitation and Neural Repair. 2015;29(10):933-949.
The Skeletal
8. Redfern, System
M; Yardley, L; Bronstein, A. Visual Influences on Balance. Journal of Anxiety
Disorders. 2001;15(1-2):81-94.
9. Hammami, R; Behm, D; Chtara, M; Othman, A; Chaouachi, A. Comparison of Static Balance and
the Role of Vision in Elite Athletes. Journal of Human Kinetics. 2014;40:33-41.
10. Riemann, B; Lephart, S. The Sensorimotor System, part I: the Physiologic Basis of Functional Joint
Stability.The Journal of Athletic Training. 2002;37(1):71-9.
11. Rogge, A; Röder, B; Zech, A; et al. Balance Training Improves Memory and Spatial Cognition in
Healthy Adults. Scientific Reports. 2017;7:5661
12. McGuine, T; Keene, J. The Effect of a Balance Training Program on the Risk of Ankle Sprains in
High School Athletes. The American Journal of Sports Medicine. 2006;34(7):1103-1111.
13. Sannicandro, I; Cofano, G; Rosa, RA; Piccinno, A. Balance Training Exercises Decrease Lower-
limb Strength Asymmetry in Young Tennis Players. Journal of Sports Science Medicine. 2014, May
1;13(2):397-402.
14. Yaggie, J; Campbell, B. Effects of Balance Training on Selected Skills. Journal of Strength Conditioning
Research. 2006;20(2):422-428.
15. Page, P. Sensorimotor Training: A “Global” Approach for Balance Training. Journal of Bodywork
and Movement Therapies. 2006;10(1):77-84.
16. Cuğ, M; Duncan, A; Wikstrom, E. Comparative Effects of Different Balance-Training-Progression

Styles on Postural Control and Ankle Force Production: A Randomized Controlled Trial. Journal
of Athletic Training. 2016;51(2):101-10.
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Chapter 1
TheCHAPTER
Skeletal22System
Anna D’Annunzio,
Corrective MS
Exercise
Michael Caceci, MS
426
Corrective Exe rc i s e
Chapter 1
Introduction
The Skeletal System
Corrective exercise involves an integrated approach to identifying muscle imbalances and creating
an Anna D’Annunzio,
individualized MS
program of flexibility, isolated strengthening, and functional movements to
restore proper muscle balance, improve movement quality, and reduce injury risk in otherwise
healthy clients.
Fitness professionals with an understanding of corrective exercise and its application can provide
better service and results for clients with underlying muscular imbalances.
While there is some overlap between corrective exercise modalities and physical therapy modalities,
corrective exercise is used by certified trainers to address movement and postural issues in clients
without serious injuries.
Physical therapists utilize similar modalities to address specific injury issues in patients and
rehabilitate them to normal day-to-day activity.
Fitness professionals must understand that while the approaches are similar in many cases,
physical therapists have many years of advanced training, preparing them to deal with medical
rehabilitation. Personal trainers are not qualified to treat medical injuries requiring physical therapy.
Diagnosing and treating injuries falls outside the scope of practice for a CPT, but developing
individualized exercise programs that help someone move better is within the Trainer Academy
CPT Scope of Practice.
Corrective exercise restores the proper function of the kinetic chain which may reduce injury risk
and fatigue. The saying “straighten before you strengthen” emphasizes the importance of proper
movement and the use of corrective exercises to achieve that goal.1
Corrective exercise focuses on improving the qualities of mobility, stability, and common movement
Trainer Academy
©2023
patterns using modalities such as foam rolling, stretching, activation, and integration exercises. The
purpose of corrective exercise is not to increase physiological parameters like aerobic and anaerobic
power, but to restore muscle tone, muscle length, muscle tension, and freedom of movement.2
An appropriately designed corrective exercise program will help to improve stability, proprioception,
timing, and motor control while addressing limitations and asymmetries in basic movement
patterns.

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Chapter 1
To use corrective exercises effectively, the CPT will need an understanding of the proper modalities,
The Skeletal System

when to use them, and how to sequence them in the correct order with progressions.
Corrective Exercise Rationale
Muscle imbalances caused by poor posture, repetitive movements, and prolonged periods of
sitting create shortened and lengthened muscles, which causes weakness and tightness in those
muscles.1, 3, 5 This leads to faulty alignment of joints and alters the physiological and neurological
properties of the muscle that results in movement compensation and dysfunction.1, 2, 3
Joint stability, the ability to maintain and control joint movement and position, and joint mobility,
the range of motion (ROM) around a joint, are maintained by proper length-tension and force-
couple relationships of muscles, proper arthrokinematics, proprioceptors, and mechanoreceptors.2
An optimal length-tension relationship is the length of the muscle where the greatest number
of potential cross bridge sites occurs, allowing for optimal force production of the muscle.
Muscle imbalances alter this relationship and decrease the force output of the muscle.1, 2, 3 Both
the shortened muscle and lengthened muscles on opposite sides of the joint are outside of their
optimal length-tension relationships and do not produce force effectively.
Muscles in a lengthened state can chronically activate muscle spindles. Muscle spindles,
mechanoreceptors located in the muscle belly, detect the length and rate of stretch in the muscle.
When muscle spindles detect an overstretching, they cause the antagonist muscle to contract to
prevent damage. The tension from the antagonist contract discharge of GTOs (Golgi tendon
organs) results in decreased force production.1, 3
Force couples from muscles provide opposing directional or contralateral pulls at joints.1 These
force couples Trainer
maintainAcademy
©2023 proper posture, and joint alignment, allowing for normal movement and
distribution of forces to occur. Tight and weak muscles alter the force couples, causing changes
in posture and arthrokinematics, resulting in compensatory movement and losses in stability
and mobility.1,2,3
Altered force couples and length-tension relationships weaken the muscles on both sides of the
joint. Corrective exercise modalities are an effective way to address muscle imbalances and restore
mobility and stability to allow proper motion and mechanics.

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Chapter 1
Corrective exercise modalities must follow a systematic progression. Performing modalities that
The Skeletal System

address mobility and stability before movement and performance is the best approach for long
term success and injury prevention in clients with non-clinical movement dysfunctions.
Anna without
Exercising D’Annunzio, MS and stability may do more harm than good and does not
regard for mobility
adequately develop an exercise program based on the client’s needs.1
Corrective Exercise Methods

Results from the client’s movement assessments will dictate where to start.
Mobility and stability issues should be resolved before any movement is performed. Initially, the
focus will be on correcting muscle imbalances to restore freedom of movement. Self-myofascial
release (SMR) is used for loosening up tight shortened muscles and relaxing hypertonic muscles
to restore ROM.4
Foam rolling targets tightened areas in muscles called trigger points, which can decrease ROM
by decreasing the elasticity of the connective tissue.3 Commonly performed with a foam roller,
SMR works by stimulating GTOs, causing autogenic inhibition and relaxing the affected area.
Increases in blood flow help alleviate inflammation as well. SMR may be performed alone and
some evidence suggests that it may improve ROM without the decreases in force production
seen with static stretching.1, 3, 4 SMR may be performed before and after exercise, but to enhance
results it should be before any other type of stretching.1,3,5
Along with SMR, passive, active, and PNF stretching can help correct muscle imbalances, increase
joint range of motion, decrease the excessive tension of muscles, relieve joint stress, improve the
extensibility of the musculotendinous junction, maintain the normal functional length of all
muscles, improve neuromuscular efficiency, and improve function.
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©2023
Static stretching reduces the sensitivity of muscle spindles and lengthens connective tissue when
the stretch force is applied.1 Generally, the client performs a brisk aerobic warm-up to increase
core temperature, then applies SMR to loosen up the muscle followed by static stretching.
Restoring ROM and addressing instability are the first concerns. While flexibility techniques are
useful for alleviating shortened muscles, the antagonist is usually lengthened and underactive,
which requires restoring the muscle’s ability to produce force at its resting length. Activation

429
Chapter 1
exercises will address this issue by restoring endurance, strength, and proper recruitment patterns
The Skeletal System

to the underactive muscle.
Restoring muscle imbalances using flexibility and activation exercises will restore the length-
Anna
tension D’Annunzio,
relationships MS
and altered force-couples allowing for the required mobility and stability
needed for functional movement to occur. From there, integration exercises can be used to restore
dynamic balance and proper movement patterns.
To avoid training the muscle in its lengthened state, activation exercises initially involve isometric
movements at joint-specific angles. Supportive devices like the wall, floor, or back of a chair can
be used to provide kinesthetic awareness and allow the client to understand the alignment of
the joints involved.1
To avoid training the muscle in the lengthened state, the exercise can be progressed to greater
ranges of motion, progressing from static to dynamic movements. The goal of corrective flexibility
is to restore the muscle’s force production at normal and resting lengths, not to become flexible
beyond normal requirements.
Once the lengthened and shortened muscles have been addressed and the client demonstrates
the necessary mobility and stability in the area, the progression to dynamic movements happens
though can incorporate integration exercises to work the body in a synchronous and coordinated
fashion.1
After correcting muscle imbalances and restoring mobility and stability to an area, the athlete
must retrain the poor compensatory motor patterns created previously. Integration exercises
will restore and groove proper movement patterns.1, 3, 4 These exercises incorporate multi joint
movements and movements in multiple planes of motion.
A key concept when using the corrective exercise strategies and modalities is that “proximal
stability promotes distal mobility.” This concept states that for distal joints to be mobile, such as
the hips and shoulders,
Trainer Academy
©2023 proximal joints must be stable. Proximal stability revolves primarily around
stabilizing the core and spine. If these areas are unstable, risk of injury goes up and distal joints
and muscles may increase tightness to prevent injury as a response to the instability in the core.
A properly strengthened, stable core is key for improving mobility in the commonly-restricted
areas of the human body.
This is an example of a proper corrective exercise progression:

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Chapter 1
1. Stabilize the lumbar spine
The Skeletal System

2. Restore mobility to the hips and thoracic spine
3. Stabilization of the shoulder girdle and glenohumeral joint1
Anna exercise
Corrective D’Annunzio, MS component of any CPT’s training acumen. Often trainers
is an important
come across common movement dysfunctions such as a client with pronation syndrome due to
tight hip adductors or weak hip external rotators causing knee valgus.
They might have lower crossed syndrome, causing an anterior pelvic tilt due to tight hip flexors
and weak extensors, adding to the excessive lumbar lordosis.
The client might have upper cross syndrome from tight pectoralis muscles and weak middle and
lower trapezius, thus creating rounded shoulders and a kyphotic thoracic spine.3
These common syndromes will inhibit clients from moving safely and effectively, which will
compromise the results of their exercise program while increasing their risk of injury.
CPTs not only need to be able to identify and correct the muscle imbalances associated with
these syndromes, but they should correct the faulty motor patterns to restore proper movement.
Knowledge of the corrective exercise modalities and when to use them is an integral part of the
CPT’s training toolbox.
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431
Chapter 1
Corrective
The Approaches Based on
Skeletal System
Movement Assessments
Overhead Squat, Single Leg Squat, and Lunge/Step Over
Assessments
Knee Valgus
Suspected Tight Muscles:
• Hip adductors, tensor fascia latae (TFL), gastrocnemius, soleus, IT band, short head of biceps
femoris
Suspected Weak Muscles
• Gluteus maximus, gluteus minimus, anterior and posterior tibialis
Self Myofascial Release (SMR)
• Gastrocnemius, soleus, adductors, TFL, IT band, short head of biceps femoris

• Hold each area for a minimum of 30 seconds
Static Stretch
• Gastrocnemius, soleus, adductors, adductors, TFL, biceps femoris

• 30 second hold or 7-10 second isometric contraction and 30 second hold
Isolated Strengthening
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• Gluteus maximus, gluteus medius, anterior tibialis, posterior tibialis

• 10–15 repetitions for each exercise with 2-second isometric hold and 4-second eccentric
contraction
Functional Exercises
• Ball squats, step-ups, lunges, single leg squats

• 10-15 repetitions as an integrated exercise

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Chapter 1
Pronation
The Skeletal
Suspected System
Tight Muscles
Gastrocnemius, MS short head of biceps femoris
soleus, peroneals,
• Tibialis group, medial hamstrings
• Lateral gastrocnemius, peroneals, short head of biceps femoris

Static Stretch
• Gastrocnemius, soleus, short head of biceps femoris

• 30 second hold or 7-10 second isometric contraction and 30 second hold
• Posterior tibialis, anterior tibialis, hamstrings
• Step up to balance, and single leg balance reach for 10-15 repetitions as integrative exercise5
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433
Chapter 1
Arms Falling Forward
The Skeletal
Suspected System
Tight Muscles
Latissimus dorsi, pectoralis,MS
and thoracic spine (T-Spine)
• Middle and lower trapezius, and rotator cuff
• Latissimus dorsi and thoracic spine

Static Stretch
• Latissimus dorsi and pectoralis major

• Hold for at least 30 seconds
• Rotator cuff, middle and lower trapezius
• Squat to row, 10-15 repetitions
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434
Chapter 1
Excessive Forward Lean
The Skeletal
Suspected System
Tight Muscles
Psoas/iliacus, MS
gastrocnemius, and soleus
• Gluteus maximus, anterior tibialis, erector spinae, and core stabilizers
• Gastrocnemius, soleus, and hip flexors

Static Stretch
• Gastrocnemius, soleus, abdominals, and hip flexors

• 30 second hold or 7-10 second isometric contraction followed by a 30 second hold
• Anterior tibialis, gluteus maximus, erector spinae, and core stabilizers
Ball wall squat with overhead press 10-15 repetitions
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435
Chapter 1
Excessive Lower Back Arch
The Skeletal
Suspected System
Tight Muscles
Psoas major MSerector spinae, and latissimus dorsi
and minor, iliacus,
• Gluteus maximus and abdominals
• Hip flexor complex and lats

Static Stretch
• Hip flexor complex, lats, and erector spinae

• 30 second hold
• Ball wall squat with overhead press
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436
Chapter 1
Asymmetrical Weight Shift
The Skeletal
Suspected System
Tight Muscles
Adductors, MS
TFL, IT band on same side and piriformis, biceps femoris, gastrocnemius, and
soleus on opposite side
• Gluteus medius same side, and adductors opposite side
• Adductors, TFL, and IT band on the same side, and piriformis, biceps femoris, gastrocnemius,
and soleus on the opposite side
Static Stretch
• Adductors, TFL on the same side, and piriformis, gastrocnemius, soleus, and biceps femoris
on the opposite side
• Gluteus medius (same side) and adductors (opposite side)
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437
Chapter 1
Excessive Lower Back Rounding
The Skeletal
Suspected System
Tight Muscles
Hamstrings MS
and adductor magnus
• Gluteus maximus, hip flexors, and erector spinae
• Hamstrings and adductor magnus

Static Stretch
• Hamstrings and adductor magnus
• Gluteus maximus, hip flexors, and erector spinae
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438
Chapter 1
Forward Head
The Skeletal
Suspected System
Tight Muscles
• Anna
ThoracicD’Annunzio, MS
spine, sternocleidomastoid, levator scapulae, and upper trapezius
• Deep cervical flexors, cervical erector spinae, and lower trapezius
• Thoracic spine, sternocleidomastoid, levator scapulae, and upper trapezius

Static Stretch
• Sternocleidomastoid, levator scapulae, and upper trapezius

• 30 second hold
• Cervical flexors, cervical erector spinae, and lower trapezius

• 10-15 repetitions with a 2 second isometric hold and a 4 second eccentric contraction
• Ball combo with cervical retraction for 10-15 repetitions
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439
Chapter 1
Push & Pull Assessments
The Skeletal System
Forward Head
Suspected Tight Muscles
• Deep cervical flexors, cervical erector spinae, and lower trapezius

Static Stretch
• Sternocleidomastoid, levator scapulae, and upper trapezius

• 30 second hold
• Cervical flexors, cervical erector spinae, and lower trapezius

• 10-15 repetitions with a 2 second isometric hold and a 4 second eccentric contraction
• Ball combo with

©2023 cervical retraction for 10-15 repetitions
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440
Chapter 1
Excessive Lower Back Arch
The Skeletal
Suspected System
Tight Muscles
Psoas major MSerector spinae, and latissimus dorsi
and minor, iliacus,
Self-Myofascial Release (SMR)
• Hip flexor complex and lats

Static Stretch
• Hip flexor complex, lats, and erector spinae

• 30 second hold
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441
Chapter 1
Scapular Winging
The Skeletal
Suspected System
Tight Muscles
Latissimus dorsi, pectorals, MS
serratus anterior, T-spine
• Middle and lower trapezius
Self-Myofascial Release (SMR)
• Latissimus dorsi and T-spine

Static Stretch
• Lats, pecs, and serratus anterior

• 30 second holds
• Standing 1-arm cable chest press for 10-15 repetitions
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442
Chapter 1
Scapular Elevation
The Skeletal System
Suspected Tight Muscles
• Upper trapezius, levator scapulae, and pectoral muscles
• Latissimus dorsi and T-spine

Static Stretch
• Lats, pecs, and serratus anterior

• 30 second hold
• Single leg Romanian deadlift with PNF pattern for 10-15 repetitions
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443
Chapter 1
Technique
The Descriptions for Select
Skeletal System
Exercises
SMR techniques
Calves
1. Begin in a seated position with legs straight.

2. Place foam roller under calf.
3. Position non-SMR leg on top of the SMR leg to increase pressure.
4. Roll calf area upwards from the ankle until you find a tender spot.
5. Hold tender spot for 30 seconds.
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444
Chapter 1
TFL/IT band
The Skeletal
1. Begin System
lying on one side, the foam roller just in front of the hip.
2. Cross the top leg over lower leg, with foot touching the floor.
Slowly roll MS the knee until you find a tender spot.
from hip joint towards
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445
Chapter 1
Piriformis
The Skeletal
1. Begin seated on the System
foam roller.
2. Cross one ankle over the opposite thigh.
Put weight MScrossed leg.
into the hip of the
4. Slowly roll on the posterior hip until you find a tender spot.
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446
Chapter 1
Latissimus Dorsi
The Skeletal
1. Begin System
lying on one side.
2. Extend the ground side arm with thumb facing upward.
Place the foam roller underMS the armpit, perpendicular to the lat.
4. Roll across area until you find a tender spot.
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447
Chapter 1
Static Stretching Techniques
The Skeletal System
Perform 1-3 sets and hold for a minimum of 30 seconds.
Gastrocnemius
1. Begin standing facing a wall or rack.

2. Step one leg back, maintain a straight knee and hip and ensure heel remains on floor.
3. Lean toward the wall by bending arms, engage glutes and quadriceps while keeping heels
on the floor.
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448
Chapter 1
Tensor Fasciae Latae
The Skeletal
1. Begin in a staggeredSystem
stance, keep slight bend in front knee and back leg straight.
2. Squeeze gluteal muscles while rotating pelvis posteriorly.
Slowly move body forward MS
until you feel the stretch in the front of the rear hip.
4. To increase the stretch, raise the arm up and over to the opposite side while maintaining
pelvis position.
6. Repeat on both sides.
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449
Chapter 1
Hip Flexor
The Skeletal
1. Begin kneeling withSystem
front and legs bent to 90 degrees.
2. Rotate pelvis posteriorly and squeeze gluteal muscles of the back leg.
Move body forward you feelMS a stretch in the front of the back hip.
4. To increase intensity, raise arm and bend to the opposite side.
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450
Chapter 1
Adductor
The Skeletal
1. Begin standing withSystem
legs in a straddled stance, keep feet shoulder-width apart or further
depending on flexibility.
2. Anna
Engage D’Annunzio, MS
core and rotate pelvis posteriorly
3. Move hips sideways by bending at the right leg and shifting to the right, keeping the left
leg straight.
4. Move sidewards until a stretch is felt in the inner thigh of the left leg.
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451
Chapter 1
Latissimus dorsi
The Skeletal
1. Begin System
kneeling in front of a stability ball.
2. Extend both arms in front of you with thumbs upward, keeping a slight bend in the elbow,
Anna D’Annunzio,
and place the blades of yourMS
hand on the ball.
3. Engage core, rotate pelvis posteriorly, and gently round through the back.
4. Slowly extend arms until a stretch is felt in the lat area under each armpit.
Note: this stretch can be performed one arm at a time or both at the same time.
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452
Chapter 1
Pectoralis
The Skeletal
1. Stand System
next to a tall object that will allow you enough room to place your forearm vertically
against the object with elbow and shoulder joints each bent to 90 degrees.
With forearm MS core and slowly lean forward until a stretch is felt in the
in position, engage
anterior shoulder and chest region.
3. Hold the stretch for 30 seconds.
4. Repeat on both sides.
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453
Chapter 1
Upper Trapezius/Scalenes
The Skeletal
an upright posture.
2. Engage core to prevent torso movement.
3. Anna
Retract D’Annunzio, MS on the left side to target the left upper trapezius and
and depress the scapula
scalenes.
4. Slowly tuck chin and laterally flex the neck, by bringing your ear to your right shoulder,
until a stretch is felt in the left neck and trapezius.
5. Hold the stretch position for 30 seconds.
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454
Chapter 1
Strengthening Exercises
The Skeletal System
Perform 1-3 sets of 10-15 repetitions for all exercises
Prisoner Squat
1. Begin standing with upright posture and place hands behind the head with shoulders abducted
and flexed to 90 degrees.
2. Engage core and lower into a squat by extending hips backwards and while lowering.
3. When you reach the target depth, extend through the hips, knees, and ankles to return
to the top position.
4. Repeat for all repetitions.
Note: proper squat mechanics including knees tracking toes, no excessive lean, arched back, or
other compensations should be permitted.
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455
Chapter 1
Multiplanar 3-Way Lunge with Reach
The Skeletal
an upright posture.
2. Engage core and step forward (sagittal plane), and descend into a lunge position while
Anna
reachingD’Annunzio,
forward. MS
3. Use hip and thigh muscles to push up and back to the start position.
4. For the next repetition, perform a side lunge by stepping laterally with the working leg,
bending the knee, and lowering into the side lunge.
5. Push away and down with the working foot to return to the starting position.
6. For the next repetition, step laterally with the left foot while rotating the foot, leg, and
knee 90 degrees so your are now facing left instead of forward.
7. Drive through the floor and return to the start position.
8. Repeat the 3-way lunge flow for the target number of repetitions.
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Chapter 1
Step Up to Balance
The Skeletal
an upright posture and a step or box in front of you. To add resistance,
hold a dumbbell in each hand.
Step onto the box with oneMS
leg, keep foot pointed forward and knee tracking with the toes.
3. Push through the step-up foot to stand straight.
4. Bring the non-step up foot up by flexing 90 degrees at both the hip and knee.
5. At the top, balance for 1-2 seconds with the non-stepping ‘floating’ leg elevated in the
90-90 position.
6. Step back to the floor with the floating leg and return to the start position.
7. Repeat on both sides for target repetitions.
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457
Chapter 1
Single Leg Touchdown Squat
The Skeletal
an upright posture and elevate one foot about 4 inches above the ground
by flexing at the knee and hip.
Bend the MS
ankle, knee, and hip of the standing to perform the single leg squat while reaching
the opposite hand toward the planted foot.
3. Repeat on both sides for the target repetitions.
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458
Chapter 1
Tube Walking Side-Side
The Skeletal
an upright posture.
2. Place resistance tubing around legs either just above or below the knee (easier) or at the ankle
Anna
(harder).D’Annunzio, MS
3. Step laterally against the band resistance. Keep feet pointing forward with a slight bend
in the knee and maintain an athletic position.
4. Step with the trailing foot to complete the repetition movement.
5. Perform lateral walks in both directions for the target repetitions.
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Chapter 1
Medicine Ball Lift and Chop
The Skeletal
an upright posture with knees slightly bent and feet pointing forward.
2. Grab a medicine ball with both hands and extend forward until elbows are fully extended.
With straight arms, lowerMS the medicine ball diagonally towards the floor as you rotate
through the torso.
4. Reverse the diagonal movement, bringing the medicine ball up towards the opposite
shoulder.
5. Perform target repetitions for both sides.
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460
Chapter 1
Marching
The Skeletal
1. Begin System
supine with knees bent at 90 degrees and hips bent at 45 degrees, feet flat with toes
pointing forward, and keep arms by sides.
Slowly lift MSby flexing at the hip while keeping knees bent at 90 degrees.
one foot off the floor
3. Raise the knee as high as possible while maintaining control.
4. Pause at the top position and slowly return to the starting position.
5. Repeat on each side for the target repetitions
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461
Chapter 1
2-Legged Floor Bridge
The Skeletal
1. Begin System
supine with knees bent at 90 degrees and hips bent at 45 degrees, feet flat with toes
pointing forward, keep arms by sides.
Drive through MSengaging glutes until the hip crease is roughly straight.
both feet while
3. Slowly lower pelvis to the floor to return to the starting position.
4. Repeat for target repetitions.
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462
Chapter 1
Prone Cobra
The Skeletal
1. Begin on the floor inSystem
a prone position with arms and legs extended.
2. Engage gluteal muscles and pinch shoulder blades together.
Lift chest and arms off the MSfloor keeping thumbs pointing up.
4. Thighs, knees, feet, chest, arms, and head should all be off the floor during engagement.
5. Hold the position for 1 to 2 seconds, then slowly lower to the start position.
6. Repeat for the target repetitions.
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Chapter 1
Plank
The Skeletal
1. Begin on the floor inSystem
a prone position with forearms on the ground and feet together, elbows
directly under shoulders.
Lift body off the ground by MS
engaging core and glutes while supporting body weight through
the forearms and feet. Keep chin tucked and back flat or neutral throughout.
3. Hold for target time and repeat for target repetitions.
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Chapter 1
Ball Crunch
The Skeletal
1. Begin System
supine with stability ball under the low back, bend knees to a 90 degree angle.
2. Crunch upper body forward by flexing the abdominals and raising the chest and neck.
Slowly return MS
to the start position.
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Chapter 1
Cable Rotation
The Skeletal
1. Begin System
standing facing a cable machine, grasping handle with straight arms. Keep an upright
posture and knees slightly flexed. The angle of pull should be opposite the direction of the
target direction.
2. Keeping arms straight, rotate torso against the angle of pull until facing the opposite direction.
3. Return to the start position.
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Chapter 1
Single Leg Romanian Deadlift
The Skeletal
1. Begin standing with System
an upright posture with feet shoulder-width apart and knee slightly flexed.
2. Lift the non-working leg off of the floor roughly 4 inches.
3. Anna
KeepingD’Annunzio, MSforward at the hip while kicking the floating leg backward
a neutral spine, bend
and reaching towards the planted foot with the opposite hand.
Incorporating Corrective Exercise into

Standard Programs
Once the client is able to perform movement screenings without major dysfunction, they may
begin to transition to a regular fitness program. However, corrective exercise techniques can be
incorporated
Tight overactive areas can be addressed with SMR and other stretching techniques during the
warmup and cooldown.
Exercises that target the stabilizers of the shoulder can be used as warmups for upper body
exercise and exercises that target the hip and abdominal stabilizers can be used to warm up lower
body muscles.
Dynamic stretches that mimic the conditioning exercises can be used to warm up as well. Corrective
exercise can be used as a form of active recovery, or the exercises can be grouped together as a
circuit on their own.
Overall, corrective exercise can be used in the warmup, cool down, and in the main conditioning
component of the workout once the client can safely and competently perform functional exercises.
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©2023
Summary
Corrective exercise refers to a combination of techniques and approaches used to address postural
and muscular imbalances in otherwise healthy clients. Fitness professionals benefit from knowledge
of corrective exercise because it allows them to more effectively bring conditioned clients into a
state of exercising regularly without injury, leading to better health outcomes.

467
Chapter 1
References
The Skeletal System
1. Seidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise
Anna
programD’Annunzio,
improves alignment,MS
muscle activation and movement pattern of men with upper crossed
syndrome: randomized controlled trial. Sci Rep. 2020;10(1):20688. Published 2020 Nov 26. https://
doi.org/10.1038/s41598-020-77571-4
2. Bagherian S, Rahnama N, Wikstrom EA. Corrective Exercises Improve Movement Efficiency

and Sensorimotor Function but Not Fatigue Sensitivity in Chronic Ankle Instability Patients: A
Randomized Controlled Trial. Clin J Sport Med. 2019;29(3):193-202. https://doi.org/10.1097/
JSM.0000000000000511
3. Mehri A, Letafatkar A, Khosrokiani Z. Effects of Corrective Exercises on Posture, Pain, and Muscle
Activation of Patients With Chronic Neck Pain Exposed to Anterior-Posterior Perturbation. J
Manipulative Physiol Ther. 2020;43(4):311-324. https://doi.org/10.1016/j.jmpt.2018.11.032
4. MacDonald, G.Z. et al. (2013). An acute bout of Self-myofascial release increases range of motion
without a subsequent decrease in muscle activation or force. Journal of Strength & Conditioning
Research,27,3, 812-821.
5. Sullivan, K.M. et al. (2013). Roller-massager application to the hamstrings increases sit-and-reach
range of motion within five to ten seconds without performance impairments. lnternational Journal
of Sports Physical Therapy,8,3,22U236.
6. Titcomb DA, Melton BF, Miyashita T, Bland HW. Evidence-Based Corrective Exercise Intervention
for Forward Head Posture in Adolescents and Young Adults Without Musculoskeletal Pathology:
A Critically Appraised Topic. J Sport Rehabil. 2022;31(5):640-644. Published 2022 Feb 16. https://
doi.org/10.1123/jsr.2021-0381
7. Seidi, Foad & Rajabi, Reza & Ebrahimi, Ismail & Alizadeh, Mohammad & Minoonejad, Hooman.
(2013). The efficiency of corrective exercise interventions on thoracic hyper-kyphosis angle. Journal
of back and musculoskeletal rehabilitation. 27. 10.3233/BMR-130411.
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Chapter 1
TheCHAPTER
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Anna D’Annunzio,
Special MS
Populations
Considerations
Dorota Lewandowski, MS
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Sp ecial Pop ulations Cons ide rat i o ns
Chapter 1
Introduction
The Skeletal System
In the context of personal training, special populations refers to any given subset of the general
Anna that
population D’Annunzio, MS
have special considerations when it comes to program design or exercise technique.
While many training principles apply across most populations, there are modifications and
considerations that fitness professionals must make when working with various special populations.
An understanding of these modifications and when to apply them for certain types of clients
greatly improves the fitness professional’s ability to successfully deliver fitness results and prevent
injury.
The main type of special populations client’s fitness professionals must be familiar with are:
• Youth clients
• Older adult clients
• Pregnant clients
• Clients with chronic illnesses
There is always an additional risk factor in training special population clients. For clients with
health conditions, medical clearance should always be obtained ahead of time.
Training Guidelines for Youth

Youth physical exercise typically comes from a combination of structured and unstructured
activities. Considering youth are typically active in school periods or while playing sports, their
ability to perform exercises over a longer period may be lower than that of a structured adult,
due to overallTrainer
fatigue.
Academy1
©2023
When developing a fitness program, individual programming should be considered for each child
as abilities will be vastly different, regardless of similarities in age. Incorporating age-appropriate
sports helps to increase aerobic function. Exercising develops muscle and bone strength in youth
populations.2, 3

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Physiological Differences Between Children and Adults
The Skeletal System
Fitness professionals who train children must understand the physiological differences between
Anna
various age D’Annunzio, MS
ranges and their implications for safely exercising. Children intake more oxygen per
pound of body weight. They also have thinner skin, so dehydration and fluid loss is more prevalent.4
It is vital to ensure children stay well-hydrated, especially when exercising heavily or in a hotter
environment. Though children do respond well to exercise, their bodies adapt somewhat differently
to exercise than adults.5, 6
Youth Flexibility
Flexibility is the ability to move joints through a full range of motion.8 Dynamic stretches help
joints, and muscles move through their full range of motion. Assuming the child is otherwise
healthy and mature enough to follow instructions, youth flexibility guidelines can follow adult
flexibility guidelines.
Frequency
• Before and after each activity or exercise session (or 3 days per week)
Mode
• Static stretches for major muscle groups
Duration
• Hold stretch 10-15 seconds, two times per stretch

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Intensity
• Mild tension or slight muscular discomfort
Special Considerations
• There are no special considerations unless the child has preexisting musculoskeletal conditions

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Youth Resistance Training
The Skeletal System
Based on the latest research, youth resistance training for health and fitness conditioning shows
Anna
a lower riskD’Annunzio, MS to playing traditional sports.8 The most common injuries
of injury when compared
associated with resistance training are strains and sprains, which are largely attributable to poor
technique coaching or lack of adult supervision during the session.
Strength training in prepubescent youths improves muscular endurance and strength, improves
motor skills, protects against injury, has positive psychological effects, and provides a platform
for safe and proper training.9
Frequency
• 2-3 times per week
Mode
• Use of bodyweight for major muscle groups
Intensity
• Very light to begin <40% of maximum effort
Duration
• 1 or 2 sets of 6-12 repetitions
• Main objective©2023 is to introduce resistance training and correct movement patterns before
Trainer Academy
applying more weight
Movement Assessment
• Overhead squat, push, pull, single leg balance, single leg squat

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Chapter 1
Youth Aerobic Training
The Skeletal System
To create an appropriate aerobic training program for children, trainers must consider the maturity
of Anna
the child,D’Annunzio,
medical status, andMS
their previous experience with exercise.
Regardless of age, the exercise intensity should start low and progress slowly. Children should be
physically active every day to create positive habits, expend energy, and develop healthy physical
habits.8 Provided proper technique guidelines are followed, children can safely perform most
forms of aerobic exercise.
Frequency
• 3 times per week
Mode
• Walking/jogging, dancing, recreational biking and swimming
Intensity
Options:
• HR 50%-60% HRmax
• Moderate (beginning to sweat)
• RPE Borg 4- 5
Duration
• 30 minutes
Trainer Academy
©2023
• Make activity fun, part of an active lifestyle

• 30 minutes
473 Special Considerations

• Make activity fun, part of an active lifestyle
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The Skeletal System

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Trainer Academy
©2023

474
Chapter 1
Training
The SkeletalGuidelines
System for Senior & Older
Adult Populations
Current estimates indicate there are over 35 million Americans aged 65 and above.10 Many older
adults do not achieve the recommended amount of daily physical activity. Lack of exercise leads
to lower metabolism, a weaker immune system, and chronic diseases.
Typical chronic diseases that develop are heart disease, stroke, diabetes, lung disease, Alzheimer’s,
hypertension, and certain cancers.11, 12 A main component of aging is frailty with reduced physical
function. Loss of muscular strength can lead to loss of independent living and an increased risk
of developing various chronic diseases. Older adult populations are at a higher risk of developing
osteoporosis, arthritis, low back pain, and obesity.12
Trainers must consider different risks that may require medical clearance and perform movement
assessments to determine any muscle imbalances when designing exercise programs for seniors.
Some normal physiological adaptations that older adult populations experience are a decline in
maximal attainable heart rate, cardiac output, muscle mass, balance, coordination, connective
tissue elasticity, and bone mineral density.13
Aging fundamentally predisposes people to multiple morbidities that compound upon each other,
often to the detriment of function and well-being.
For example, loss of skeletal muscle mass and bone mass accelerates in older populations which
leads to less strength and a subsequent risk increase for falls and fractures.15
Hypertension is common in older populations because aging typically stiffens the arterial walls,
due to the degeneration of elastic fibers and deposition of collagen and calcium in the walls of
the arteries.16Trainer
©2023 Academy
This arterial stiffening raises the systolic blood pressure. Thus, isolated hypertension is commonly
found in the elderly and constitutes a major risk factor. A healthy individual should have a blood
pressure read of 120/80 mmHg and any individual, regardless of age, should be referred to their
physician if their blood pressure reading is 140/90 mm Hg or higher.
Aside from the normal decline in physiological health, healthy older adults adapt to exercise the
way normal, healthy adults would.13 Encouraging older adults to exercise and demonstrating

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proper technique will help build their confidence to participate in resistance training and mobility
The Skeletal System

exercises.
Before initiating any physical training, older adults must complete a Physical Activity Readiness
Anna D’Annunzio,
Questionnaire MS
(PAR-Q) and age-appropriate movement assessment to determine their capabilities
before initiating an exercise prescription.
A flexibility assessment should be conducted with the movement assessment because older adults
lose the elasticity of their connective tissue, which reduces range of motion and increases the
risk of injury.
Older Adult Flexibility

Frequency
• Minimal two times per week
Mode
• Static Stretching
Duration
• 5-30 minutes total with 2 30-second bouts for each muscle group
Intensity
• Moderate intensity (5-6 on 0-10 scale)
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©2023
• Avoid ballistic movements and the Valsalva maneuver during the stretching routine.

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Older Adults Aerobic Training
The Skeletal System
Frequency
• Moderate intensity exercises 5 times per week, or vigorous intensity 3 times per week
Mode
• Walking, cycling, seated recumbent, pool activity, and seated aerobics
Duration
• Moderate intensity exercise for 30-60 minute intervals; targeting 150-300min per week
Intensity
• Moderate intensity at 50%-70% HRR or 5-6 on the 10 point exertion scale
• Muscle strengthening exercises and/or balance training may need to precede aerobic training
among frail older adults.
• Comorbidities such as arthritis, osteoporosis, and heart disease need to be considered.
• Highly deconditioned adults with limited functional abilities should start with a low intensity
and duration of physical activity.
Older Adult Resistance Training

Frequency Trainer Academy
©2023
• Two or more times per week
Mode
• Resistance bands and free weights if multi station machines are not available
Duration

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• 8-12 repetitions for each muscle group
The Skeletal System

Intensity
5-6 (moderate) MS on a 10-point scale
or 7-8 (vigorous)
• Strength training regimens depend on maximum resistance as well as endurance; supervision

and cueing is helpful.
• Proper breathing is important- avoid the Valsalva maneuver for safety.
• Focus on building major muscle groups before challenging balance.
Movement Assessment
• Push, pull, OVH Squat (if possible) or sit to stand

Special Populations in a chair for balance
Considerations 481
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478
Chapter 1
Training
The SkeletalConsiderations
System for Pregnancy
Collaborating with pregnant women to set appropriate and attainable goals will help them focus
onAnna
efficacy, D’Annunzio, MS success. Similar to a PAR-Q, having prenatal clients fill out
efficiency, and achieving
a ParMed-X screening for pregnant women will help determine their level of readiness for an
exercise program.17
Guidelines for Training Pregnant Clients

• If they already have an exercise prescription, continue this during the first trimester or minimum
30-40 minutes per day.
• With little or no previous exercise prescription, begin with 15 minutes of continuous exercise
and slowly increase the duration to 30 minutes.
• During the second and third trimesters, vigorous exercise should be lowered.
• Avoid bouncing while stretching, exercises with risk of falling, sit ups, leg lowering exercises,
and exercises performed in the prone position.
• Focus on hydration.
• Extend warm up and cool downs.
Contraindications to Training Pregnant Women

Some indications may be considered normal so please discuss first with the client. If new to
exercise, pregnant women should be cleared for activity by their physician. These are a few
contraindications to training pregnant women:
• Vaginal bleeding
• Dizziness
• ShortnessTrainer
of©2023
Breath
Academy
• Chest Pain
• Imbalance
• Swelling in outer limbs
• Painful contractions
• Amniotic fluid leakage

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Chapter 1
Aerobic Recommendations for Pregnant Women
The Skeletal System
Frequency
• 3-5 days per week
Mode
• Various weight bearing and non-weight bearing activities
Duration
• Work up to 30 minutes per day
Intensity
• Moderate or vigorous intensity for previously active women
Resistance Training During Pregnancy

Frequency
Mode
• Free weight machines and body weight exercises
Duration Trainer Academy

©2023
• 1-3 sets for major muscle groups
Intensity
• Exercise to moderate fatigue with sub-maximal repetitions

480
Chapter 1
Flexibility Training During Pregnancy
The Skeletal System
Frequency
• At least 2-3 days per week
Mode
Specialusing
• Targeting each muscle and tendon Populations Considerations
active, passive, and dynamic forms of stretching484
Duration
Duration
• 10-30 second holds
• 10-30 second holds
Intensity
Intensity
• Stretch
• Stretch to the
to the point
point of slight
of slight discomfort
discomfort
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481
Chapter 1
Training
System for Obesity
The World Health Organization defines overweight and obese as abnormal or excessive fat
Anna D’Annunzio,
accumulation that may impair MS
health.19 Obesity is a rapidly growing issue in America where 1
out of 3 adults (68%) is overweight and over 31% of the population is obese.
The Task Force on Proposal for Public Actions states that obesity is largely a result of lifestyle.
Short-term intervention has limited effectiveness, while long-term success is rare without an
ongoing care plan or weight loss surgery.18, 19
Though weight loss surgeries can be successful in removing large amounts of fat, the person can
gain it back if they do not commit to a fitness regimen and adequate nutrition planning.
In total, diet, lifestyle change, and exercise are essential components of obesity management.19
Body Mass Index

The common way to determine if a person is overweight or obese is to use body mass index
(BMI). BMI is recommended by the National Institutes of Health to classify overweight and
obesity and to estimate the relative risk of associated diseases.
Though this tool is widely used, it is important to note that BMI does not discriminate between
fat mass and lean tissue. BMI does, however, significantly correlate with total body fat.20 Body
mass index is calculated as weight in kilograms divided by height in meters squared.
There are other tools to measure accurate body fat such as skin fold calipers, but this can become an
uncomfortable situation with overweight clients and often trainers who use calipers need to practice
under someone more experienced before they are able to reliably take skinfold measurements.
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©2023
A good tool to measure is the circumference of the client’s abdomen, arm, buttocks/hips, calf,
forearm, hips/thigh, mid-thigh, and waist. Taking these measurements gives trainers a more
accurate starting point for overweight and obese clients. For a start, measuring just the waist and
hips can often be enough to get a rough idea of where a client is at.
Keeping in mind the inaccuracy of BMI, it is a helpful tool to develop achievable goals with
overweight clients. A BMI of 18.5 to 24.9 is considered within a normal range, 25-29.9 is
considered overweight, and a BMI of 30 or greater is obese.

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As stated above, over 31% of Americans are obese, meaning their BMI falls into a range of 30
The Skeletal System

and above. This population-level increase in BMI leads to a corresponding increase in the various
metabolic conditions associated with obesity.
Obesity and Exercise
Weight loss results derive from calories in versus calories burned and when excess calories are
not expended, they are converted and stored as fat. While traditional advice would have trainers
tell their clients to “eat less, run more,” there are additional environmental factors that contribute
to overeating and decreased activity levels.
The availability of low-cost, calorie-dense, micronutrient-poor foods is a contributing factor

along with a decrease in physical activity in both occupation and recreational activities.21 Personal
trainers should work closely with dietitians to develop a balanced lifestyle that encompasses both
a training program and a nutritional program.
Regardless of muscular strength, overweight and obese individuals tend to exhibit poor balance,
slower gait velocity, and shorter steps.
Training should be focused on energy expenditure, balance, and proprioceptive training to burn
more calories and improve posture, and gait.22
By programming proprioceptive exercises, there is greater potential for caloric expenditure,

stability training, and greater muscle recruitment.23
For weight loss results, obese clients should expend 200 to 300 kcal per exercise session with a
weekly average starting at 1200 kcal expended between physical activity and exercise.
Having clients start on an aerobic workout regimen is ideal for sustainability. Resistance training
should be added into a training program starting at a lower intensity and employing modifications
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©2023
where necessary.
For obese clients who are hesitant to begin resistance training, taking increasingly longer walks
is a good way to begin exercising.
However, incorporating some resistance training is important in a weight loss program because
it helps increase lean body mass, which over time will improve metabolic function and overall
body composition.24

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Recommendations for Training Obese Clients
The Skeletal System
Frequency
• 5+ days per week to maximize caloric expenditure
Intensity
• Moderate to vigorous intensity for aerobic activity- progress to vigorous activity once sustainability
is accomplished
Time
• Minimum 30 minutes, progressing to 60 minutes of moderate, aerobic activity

• Incorporate vigorous exercise only if the client is capable and willing to increase the intensity
Mode
• Primary should be aerobic exercises and weight lifting that involve large muscle groups
Assessment
• Push, pull, squat, single leg balance
• Weight management relies on the relationship between energy intake and energy expenditure.
However, a deeper look into the environmental effects on weight loss are important to note
because sustainable weight loss will only be achieved if relative factors are addressed.
• To achieveTrainer
weight
Academy
©2023 loss, clients should aim to decrease current energy intake by 300-500 kcal,
and progress to a minimum of 150 minutes of moderate intensity aerobic activity to optimize
health. Increase exercise gradually for sustained weight loss.

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485
Chapter 1
Training
System for Diabetes
Diabetes is the seventh leading cause of death in America.25 Diabetes is a metabolic disorder
Anna
that affects D’Annunzio, MSfood into energy. The human body breaks down most food
how the body converts
into sugar (glucose) and releases it into our bloodstream.
When there is an excessive amount of sugar, it signals the pancreas to release insulin and insulin
allows blood sugar into cells to be used as energy. A person with diabetes does not produce enough
insulin (type 1) or the body does not respond to the insulin that is being produced (type 2).
A primary characteristic of type 1 diabetes is insulin dependency while type 2 diabetes is caused
by insulin-resistant skeletal muscle, adipose tissue, and liver, combined with an insulin secretion
deficit. A common cause of type 2 diabetes is excessive body fat with fat distributed in the upper
half of the body.
However, some individuals may not be able to control their glucose levels, thus becoming insulin-
dependent.26 To control the high levels of blood sugar, type 1 diabetics inject insulin to produce
what the pancreas cannot.
Exercise increases the rate at which people utilize glucose, meaning insulin levels may need to
be adjusted when performing the exercise.
It is important to control insulin levels before, during, and after exercise, because when blood
sugar becomes too low, it creates a condition called hypoglycemia (low blood sugar) which can
make the individual feel light-headed, dizzy, and short of breath.
Type 2 diabetes develops gradually and years can pass before severe symptoms arise. This is
often called adult-onset diabetes and accounts for 90-95% of those with diabetes.27 With insulin
resistance, the body cannot effectively use the insulin in the muscles or liver even though it
produces a sufficient
©2023 amount.
Trainer Academy
Over time the pancreas cannot secrete the insulin effectively to compensate for insulin resistance
and hyperglycemia (high blood sugar). Genetic factors are a cause of type 2 diabetes, however,
most people with this type are overweight or obese at the onset of symptoms.

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Exercising with Diabetes
The Skeletal System
The fundamental goal for management of diabetes mellitus is glycemic control using diet, exercise,
Anna
and, D’Annunzio,
in many cases, medicationsMS
such as insulin or oral hypoglycemic tablets.
More specifically, when focusing on individuals with type 2 diabetes, the main goal would be
weight loss. By exercising the skeletal muscle, the body circulates glucose, creating a similar effect
to insulin, thereby reducing insulin requirements.
Hypoglycemia during exercise is the most common and serious problem in individuals with
diabetes, especially for individuals who are taking oral medications or supplemental insulin.
Rapid drops in blood sugar may occur in exercise, even when blood sugars are at a normal level.
Common symptoms associated with diabetes include weakness, dizziness, shakiness, excessive
sweating, anxiety, tingling, and hunger.6 Tracking an individual’s glucose levels throughout the
program is necessary to maintain consistent levels.
Exercise should be scheduled knowing the client’s insulin timing to prevent hypoglycemic episodes
along with adjusting carbohydrate intake before and after the workout to avoid hypoglycemic
episodes.24 Recommend individuals with diabetes to exercise with a snack to avoid lowering
their blood sugar.
Exercise Recommendations for Individuals with Diabetes

Frequency

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©2023
Intensity
• Aerobic goal is 40%-60% maximum heart rate, however better glucose control may be achieved
during higher intensity exercises, so intensity should increase progressively over time.

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Duration
The Skeletal
• 20-60 System
minutes or a minimum of 150 minutes per week
Anna
Mode D’Annunzio, MS
• Low impact activities (walking, cycling, progress into swimming)
Resistance Training
• 1-3 sets of 10-15 repetitions, 2-3 days per week

Assessment
• Push, pull, OVH Squat, single-leg balance, and single-leg squat

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©2023

488
Chapter 1
Training
System for Hypertension
Hypertension, commonly referred to as high blood pressure, is among the most common modifiable
Anna D’Annunzio,
cardiovascular MSBlood pressure is the pressure measured within large blood
disease risk factors.
vessels, especially the arteries.
This pressure fluctuates depending on the strength of the heartbeat, the elasticity of the arterial
walls, the volume and viscosity of the blood, as well as the person’s age, physical condition, and
health. Blood pressure has two categories: systolic and diastolic.
The systolic (top number) measures the maximum pressure the heart exerts while beating, while
the diastolic (bottom number) measures the pressure in the arteries between beats. A normal
resting blood pressure used to read 120/80mmHg, however new guidelines by the American
Heart Association suggest a healthy BP is “less than 120/80 mmHg.” Individuals classified with
hypertension have a resting BP of 140 mmHg or greater or a resting diastolic BP of 90 mmHg
or greater.
Personal trainers should know whether their clients are taking hypertensive medication before
starting any exercise program. Hypertension increases cardiovascular risk factors such as disease,
stroke, heart failure, peripheral arterial disease, and chronic kidney disease. Medications are proven
highly effective. However, lifestyle changes such as increased physical activity, diet, and quitting
smoking have also been proven to decrease hypertension.
Aerobic exercise training leads to reductions in resting BP by nearly 5-7 mm Hg in individuals with
hypertension.27 If personal trainers are able, they should measure their client’s blood pressure and
heart rate before and again after the workout. These results should be logged during each session.
Personal trainers should focus on aerobic activities for clients with hypertension, supplemented
with moderate intensity resistance training.
Body positionTrainer
is©2023
extremely
Academy
important when measuring heart rate or blood pressure. The client
should not talk during measurements. They should sit upright in a chair with both feet flat on
the ground for accurate results. Training regimens should be performed in a circuit-style to
distribute blood flow between the upper and lower extremities. Clients should focus on deep
breaths during exercise and avoid the Valsalva maneuver.

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Exercise Recommendations for Individuals with
The Skeletal System
Hypertension
Frequency
• Aerobic exercise on most, preferably 6-7 days per week, resistance training 2-3 days per week
Intensity
• Moderate intensity aerobic exercise (40-60% MaxHR) supplemented with resistance training
at 60-80% 1-RM.
Duration
• 30-60 minutes of continuous aerobic exercise
Mode
• Emphasis should be placed on aerobic activities such as walking, cycling, or swimming.

Resistance training should utilize free weights, machines, or resistance bands.
Movement Assessment
• Push, pull, OVH Squat, Single leg balance
Flexibility
• Static and active stretches in a standing or seated position

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©2023
• Avoid heavy lifting and the Valsalva maneuver. Do not perform the cardiovascular exercise
if resting systolic BP exceeds 200 mmHg or diastolic BP exceeds 110 mmHg.

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491
Chapter 1
Training
System for Coronary
Heart Disease
Approximately every forty seconds, a person has a coronary infarction (heart attack) in the United
States.28 Fifty percent of all cardiovascular deaths are a result of coronary heart disease (CHD)
making it the leading cause of death in both men and women.
CHD is caused by plaque formation or atherosclerosis. Plaque builds in the carotid, iliac, femoral,
and aortic arteries, causing the narrowing of the blood vessels, which leads to poor perfusion
and ultimately, heart failure.
The rate of progression of atherosclerosis may not be consistent, but there are several causes of
plaque build up such as tobacco usage, low-density lipoprotein cholesterol, hypertension, diabetes
mellitus, and various infectious agents.6, 29, 30
The goal of the fitness trainer in helping clients with CHD is to stabilize the buildup of plaque
through a lifestyle change incorporating exercise, good nutrition, and adequate sleep.
Though moderate exercises are recommended for these patients, research indicates high-intensity
interval training has significant increases on V̇O2 max, improvements in endothelial function,
and lower resting blood pressure.31
Before beginning a training program, clients should be cleared by their physician for exercise. If
the client has had an episode or myocardial infarction, they may have already completed a cardiac
rehabilitation program. Trainers must stay up to date on medications their clients are taking and
learn the signs and symptoms of a heart attack.
It is important for trainers to speak with clients about the benefits of participating in an exercise
and nutritionTrainer
program
Academy
©2023 to improve their condition. A proper lifestyle change that incorporates
exercise and nutrition can lower the risk of death, increase exercise tolerance, raise muscle strength,
reduces CHD, and overall improves physiological health.
The risks of injury are low for individuals with CHD, however clients should be able to track
their heart rate reliably and stay below their maximum allowed exertion as determined by their
physican.

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Signs of CHD vary between individuals. However, if a client experiences chest pain, exercise
The Skeletal System

should be stopped and the client should be assessed. Individuals with CHD may also have
comorbidities, such as diabetes, hypertension, and obesity, so trainers must comprehensively
screen clients to develop proper modifications.
Exercise Recommendations for Individuals with Coronary

Heart Disease
Frequency
Intensity
• Moderate: 40-85% Maximum HR
Duration
• 30 minutes per day of moderate intensity 5 days per week or 20 minutes of vigorous intensity
3 days per week
Mode
• Circuit training for large muscle groups, walking, cycling, group glasses
Movement Assessment
• Push, Pull, OH Squat, Balance

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©2023
Flexibility
• Static or active stretching
• Be aware that individuals with CHD may also have comorbidities such as diabetes, hypertension,
peripheral vascular disease, and/or obesity.

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• Regress exercises if needed, such as training using a chair if necessary.
The Skeletal System

• Encourage regular, adequate breathing— avoid the Valsalva maneuver.
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494
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Training
System for Osteoporosis
Osteoporosis is a skeletal disorder characterized by low bone density and deterioration of bony
Anna
tissue, 32 D’Annunzio,
whereas MS
osteopenia also indicates bone density loss, just at a lower level. In order to
understand osteoporosis, it is first necessary to learn the physiology of bone formation, also known
as bone remodeling. Over a person’s lifespan, bone remodeling maintains the architecture and
structure of bones, regulates calcium level, and prevents fatigue damage.34
Bone mineral density increases during adolescence and begins to decrease after the age of forty.
Bone loss occurs at a greater rate in women than men because women start with naturally lower
bone density and their rate of bone loss increases 3-5 years after menopause. As such, women
develop osteoporosis more often than men. Osteoporosis affects almost 50 percent women at
some point in their life.33
A loss in bone density directly correlates to bone fractures and leads to increased morbidity and
mortality.6 There are two main types of osteoporosis. Type 1 osteoporosis is developed as a result
of natural aging, including lower productions of estrogen and progesterone, both of which are
key components of regulating bone loss.
While type 1 is primarily due to the normal course of aging, type 2 encompasses other medical
risk factors, medications, and lifestyle factors such as tobacco smoking and alcohol consumption.
Both forms of osteoporosis are treatable.
The development of osteoporosis and osteopenia is asymptomatic, which leaves the disease
undetected. Bone mineral density assessments are not always accurate. Often, a fracture is the
first time the disease is detected. Before training a client with osteoporosis, it is imperative to
obtain a history of their fractures and current bone mineral density.
Knowing this information will help develop a proper exercise program and minimize mechanical
stress on the hip, spine, or wrist, which are at the highest risk. Other risk factors associated with
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©2023
osteoporosis development include physical inactivity and low calcium intake.
Fitness professionals must be aware of the contraindications for clients with osteoporosis. The
impact associated with traditional exercise movements may be excessive. As such, spinal flexion,
high impact skeletal loading such as jumping, and stepping should be avoided along with twisting
movements of the neck and spine.24

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Gait and balance will have an effect on individuals with osteoporosis due to spinal fractures
The Skeletal System

and joint impingements from bone deterioration, therefore client programs should include low
intensity exercises.
Anna physical
Increasing D’Annunzio, MS bone mineral density and strength. Additionally, training
activity improves
adaptations typically improve balance, which reduces the risk of falling.
When training a client with osteoporosis, it is important for coaches to learn their client’s abilities
and limitations. Though resistance training has been shown to improve bone density, they must
assess to see if a specific exercise would improve their clients’ conditions or lead to a fracture.
This is also the case when conducting movement assessments.
If a client is capable of standing, then performing exercises such as push, pull, and overhead squat
movements are appropriate. Otherwise using exercise equipment to assist with the movement
assessment will be helpful.
An exercise program for clients with osteoporosis should create variable weight distributions
on the bones and focus on strengthening the main joints that become overloaded like the hips,
spine, wrists, and lower back.35 An exercise program should not be substantially different than
that of a normal individual of the same age.
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©2023

496
Chapter 1
Exercise Recommendations for Individuals with
The Skeletal System
Osteoporosis
Frequency
• 2-5 days per week of aerobic exercise and 2 days per week of strength training
Intensity
• Moderate intensity to begin (40-70% HR Max) or 15 reps of 8-10 exercises for strength
training
Duration
• 30 minutes of aerobic training or 30-60 minutes of resistance training
Mode
• Walking, biking, weight machines, resistance bands, dumbbells
• Avoid jogging and other exercises that increase the risk of falling.
• Avoid spinal flexion and rotation.
• Encourage slow and controlled movements to maintain proper form.
• Focus exercises on strengthening target joints: hips, lower back, wrists, and spine.
• Osteoporosis is not a contraindication to exercise.
• In fact, exercising helps increase bone mineral density and improve quality of life. It is important
to build confidence
Trainer Academy
©2023 in a client’s balance so they feel safe performing everyday duties.
• A health report should be obtained from the individual so the trainer can develop an exercise
program appropriate to their abilities.
• Flexibility should be limited to static and active stretching, using a chair if necessary.
• Develop exercise programs with longevity and progression in mind as it takes time to improve
bone mineral density.

497 Special Populations Considerations 500
Chapter 1
The Skeletal System

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©2023

498
Chapter 1
Training
System for Arthritis
Arthritis is an acute or chronic inflammation in one or more of the joints. There are a wide variety
of Anna
symptoms D’Annunzio, MS such as joint stiffness, pain, decreased range of motion,
associated with arthritis
and joint deformities.36
There are over 100 different forms of arthritis, all varying in degrees of joint mobility, deterioration
of the muscle tissue, and pain.
The two most common types personal trainers will encounter with clients are osteoarthritis
(OA) and rheumatoid arthritis (RA). In both conditions, exercise has a major impact on those
living with the disease. Exercise helps to support the affected joint by building strong supportive
muscles around the joint.
Osteoarthritis
Osteoarthritis involves degeneration of the cartilage within joints, which develops gradually and
particularly affects the articulating bones.
Constant movement with diminishing cartilage causes bone-on-bone rubbing, inflammation

around the joint, and weakening of ligaments and tendons. Symptoms of OA include stiffness,
deformities, crepitus, and bone spurs.
The most affected areas include large weight-bearing joints such as the hips and knees, the hands,
feet, and the spine.
Rheumatoid Arthritis
Trainer Academy
©2023
Rheumatoid arthritis is an autoimmune disorder that begins affecting the small joints first, then
larger joints, and eventually the organs. This disease destroys the cartilage in joints, causes joint
stiffness, inflames the ligaments and tendons, and is very painful for individuals.37
Movement assessments should analyze the joint function and should be reassessed throughout
the client’s exercise program to monitor their arthritis and symptoms.

499
Chapter 1
Pain will be a major barrier when beginning or maintaining a program, therefore the goal should
The Skeletal System

be to avoid painful movements while also keeping the program relevant.
Exercise programs can interact at each stage of arthritis and can help mitigate the effects of the
Anna
disease D’Annunzio,
on the MS development. It is recommended clients follow a program
deterioration of physical
that develops strength and stability to improve balance and joint strength.
Trainers will likely encounter deconditioned individuals with this disease so it is ideal for them
to start their training with flexibility in the seated position before progressing to standing.
Throughout the workout, trainers should ask the client if they are experiencing flare-ups, heat,
or pain and adjust the workout accordingly.
Exercise Recommendations for Individuals with Arthritis

Frequency
• Aerobic exercise 3-5 days/week, resistance exercise 2-3 days/week
Intensity
• 40-60% Max HR- light to moderate intensity- both light and higher intensity both show
improvements in joint function, pain, and strength of the muscle
Duration
• 30 minutes per day
Mode
• Aerobic exercise with low joint stress- walking, cycling, swimming.

Trainer Academy
• Resistance exercise should include all major muscle groups and flexibility exercises for all
©2023
range of motion in all muscle groups.
• Avoid strenuous exercises during flare ups and when highly inflamed.
• Adequate warm up and cool downs help to wake up the joints and invite movement into
the body.
• Avoid heavy lifting to protect the bone structure.

500
Special Populations
Sp ecial Considerations
Pop ulations Cons ide rat i o503
ns
Chapter 1
The Skeletal System

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©2023

501
Chapter 1
Training
System for Cancer
Cancer describes a range of diseases characterized by an uncontrollable growth of abnormal
Anna
cells D’Annunzio,
that divide MS other organ tissues. Cancer management modalities involve
and spread through
surgery, radiation, chemotherapy, hormones, and immunotherapy.39
Clients who are going through any of these treatments during training may experience side effects
that may limit their ability to complete workouts due to a decrease in overall physical function,
muscular strength, and joint range of motion.
In recent years, studies have shown that regular moderate intensity exercise enhances immune
function, which lowers the susceptibility to cancer.
Long term effects of exercise promote anti-inflammatory effects because of the reduction in body
fat and release of catecholamines.40
Personal trainers should have an overall understanding of how to develop an exercise regimen for
this population and should judge their clients abilities in strength, balance, flexibility, and mobility.
Exercise at a moderate intensity for moderate durations has a positive effect on the immune
system and research shows that moderate to high intensity activity is associated with a decrease
in mortality in certain forms of cancer.
Individuals with cancer typically experience fatigue and weakness quicker than healthy individuals.
Exercises should be primarily aerobic based at low- moderate intensity with many breaks. Exercise
duration, frequency, and intensity should be progressed slowly as tolerated by the client.
The American College of Sports Medicine guidelines for cancer survivors does not state any
differences in training individuals that are healthy post-cancer, so an exercise program for otherwise
healthy cancerTrainer
survivors
Academy
©2023 should include flexibility, resistance, and aerobic training.24

502
Chapter 1
Exercise Recommendations for Individuals with Cancer
The Skeletal System
Frequency
Intensity
• 50-85% of Max HR
Duration
• 15-30Duration
minutes per session (start low and slowly progress 30 seconds- 2 minutes per day)
• 15-30 minutes per session (start low and slowly progress 30 seconds- 2 minutes per day)
Mode
Mode
• Walking, stationary bike, free weights, resistance bands
• Walking, stationary bike, free weights, resistance bands
Intensity may need to be adjusted during exercise. If needed, conduct a few exercises
• Intensity may need to be adjusted during exercise. If needed, conduct a few exercises multiple
multiple times per day. Allow for adequate rest between sets.
times per day. Allow for adequate rest between sets.
Trainer Academy
©2023

503
Chapter 1
Training
System for Chronic
Lung Disease
Chronic lung disease includes, chronic obstructive pulmonary disease (COPD), sleep-disordered
breathing, and interstitial lung disease. Smoking is a primary risk factor for developing chronic
lung disease and though cigarette smoking is on the decline, there is significant data that shows
the negative effects of vaping and e-cigarettes on lung function.41
There are two major types of chronic lung disease: restrictive and obstructive. Restrictive lung
disease is categorized by a reduced playability of the lung tissue; compromising lung expansion
by reducing lung volumes, which decreases total lung capacity.
Obstructive lung diseases revolve around blockages in the air passageways that limit ventilation.
Major obstructive lung diseases include asthma, chronic bronchitis, and emphysema. Mucus
builds in the lungs and air passages which leads to chronic inflammation that obstructs the
airway. Chronic lung diseases are developed throughout life, so even though cystic fibrosis is a
lung inflammatory disease, it is also a genetic disorder.
Exercise training has been shown to improve lung function and lung tissue in individuals with
lung disease. Exercise increases functionality and though there is a decrease in ventilation and
gas exchange for these individuals, it is possible to program to their tolerance.
Individuals with lung disease will experience shortness of breath which may then lead to dizziness
so being mindful of intensity levels is key to developing an appropriate resistance and aerobic
workout. Individuals with emphysema typically are underweight and experience shallow breathing
because of a lack of neck and upper back muscles. On the contrary, individuals with chronic
bronchitis are typically overweight with a large chest.6
Trainer Academy
©2023
Training methodologies for individuals with lung disease are similar to that of a healthy
person. Clients exercising with lung diseases will fatigue sooner. Exercising lung function will
strengthen the diaphragm that helps fill the lungs, and decrease symptoms of dyspnea, or shortness
of breath.
Developing an exercise regimen utilizing resistance of the lower body is an excellent starting
point since upper body exercises will require additional support of the muscles in the lungs.

504
Chapter 1
Progress slowly and begin training at a low intensity and breath focus. Clients in this population
The Skeletal System

are typically on medications or inhalers to open the bronchioles and alveoli of the lungs.42, 43 It is
important to know what these medications are, trainers should have them bring their medications
for each session and learn how these medications will affect the training.
There are a few considerations when training individuals with chronic lung disease. Arm exercises
require accessory muscles of inspiration so programming lower extremity exercises will help to
develop lung function but will not fatigue the client preemptively.
A workout regimen aimed at improving lung function through resistance training could benefit
those with obstructive lung disease through training 2-3 days per week at 30 minutes in duration
with low resistance. Another consideration for those with lung disease is deconditioning of the
muscles and lungs.
Depending on which type of lung disease they have, they may be overweight, underweight, or
not active so exercise programming should revolve around the clients’ shortness of breath and
tolerance.
If clients are using supplemental oxygen during a workout, trainers should not adjust their flow.
This is considered a medication and if the client is experiencing shortness of breath, exercise
should stop and their physician should be consulted.6
Exercise Guidelines for Individuals with Lung Disease

Frequency
• 1-2 sessions, 3-5 days per week
Intensity
Trainer Academy
©2023
• 40-60% of Max HR, comfortable pace and endurance (monitor dyspnea)
Duration
• 30 minute sessions

505
Chapter 1
Mode
The Skeletal
• Large System
muscle activities- walking, swimming, cycling and free weights, machines for resistance
training
• Exercise compliance should be considered in the determination of exercise intensity. Shorter

intermittent sessions may be Special
necessary initially.
Populations Respiratory muscle weakness is common.
Considerations 508
Upper body exercises contribute to dyspnea and inspirations muscle may require training.
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©2023

506
Chapter 1
Training
System for Peripheral
Artery Disease
Peripheral artery disease (PAD) occurs as the result of developing atherosclerotic plaque in
the internal walls of the major arteries in the legs. This disease decreases functional capacity
in oxygenated blood flow, increases the risk of cardiovascular diseases, and is associated with a
higher risk of mortality.
Individuals can be asymptomatic or experience symptoms associated with PAD including

intermittent claudication (IC) which encompasses pain, cramping, and aching in the calves,
thighs, or buttocks. It may be difficult to distinguish deconditioning and PAD, so if clients
complain about these symptoms, it is best to have them see their physician first.
Some traditional risk factors associated with PAD include advanced age, smoking, obesity, diabetes,
hyperlipidemia, and hypertension.44 It is important to know that PAD often comes with other
comorbidities and is associated with obesity, coronary heart disease, and diabetes so exercise can
significantly help control and even lower the risk of these morbidities.
A properly developed training program should increase exercise performance by increasing

oxygen consumption by 15-30%, increasing walking ability and quality of life. Regular exercise
increases leg blood flow and reduces blood viscosity, so it does not pool in the lower extremities.
There are several training considerations to follow for individuals with PAD. Beta-blockers
decrease the time to claudication so understanding which medications clients are taking is
important for programming. Cold weather exacerbates pain, so trainers should exercise clients
in a warm environment, when possible.
When clients have a known coexisting coronary disease or diabetes, coaches will have to adjust
the intensity Trainer
and maximum heart rate. Resistance training promotes claudication so it should
Academy
©2023
be in addition to aerobic exercising and always to the client’s pain tolerance.6, 45

507
Chapter 1
Exercise Guidelines for Individuals with Peripheral Artery
The Skeletal System
Disease
Frequency
• At least 3 days per week
Intensity
• 50-85% maximum heart rate
Duration
• Work up to 35-50 minutes
Mode
• Walking exercise, stationary cycling, and/or elliptical trainer
• Begin exercise at 5-10 minutes and increase from there.

• For asymptomatic PAD, IC may not be a duration-limiting factor so the level of exertion
should be used to guide exercises.
• Allow for sufficient rest between sets.
Trainer Academy
©2023

• Begin exercise at 5-10 minutes and increase from there.
• For asymptomatic PAD, IC may not be a duration-limiting factor so the level of exertion
508 should be used to guide exercises.
• Sp ecial Pop ulations Cons ide rat i o ns
Allow for sufficient rest between sets.
Chapter 1
The Skeletal System

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Trainer Academy
©2023 ©2023

509
Chapter 1
Training
System for Nonspecific
Low Back Pain
Nonspecific low back pain (NSLBP) remains a condition that many people in society suffer
from. It is the most musculoskeletal complaint in the world with 85% of people complaining
about NSLBP in their lives. This condition does not only affect individuals physically, but also
mentally and socially. When the symptoms of NSLBP affect ability to move, then someone’s
ability to socialize decreases, and chances of depression significantly increase.
This topic is listed under special populations because each client trainers encounter with NSLBP
may have different symptoms and should always be monitored for inflammation, additional pain,
or new symptoms. NSLBP includes pain in the lumbosacral area that is not attributed to any
known or recognizable disorders such as tumors, osteoporosis, inflammation, deformities, disc
disease, or spinal compression.46
There are three subtypes of NSLBP that account for the duration of the pain:
1. Current: less than 6 weeks

2. Sub-acute: 6-12 weeks
3. Chronic: 12 weeks or more
Treatment to find out the cause of back pain includes medical interventions and screenings such
as x-rays or MRI.
There are many tendons, ligaments, and nerve roots flowing through the lower back that makes
diagnosing difficult to narrow down. Disc deformities can be a factor in NSLBP and a medical
screening should be obtained before beginning an exercise prescription.
A client withTrainer
NSLBP Academy
©2023 may complain of generalized pain in the lumbosacral region. Pain will
differ between individuals in intensity, duration, and frequency. Some may experience radiating
pain with sensory changes, numbness, or lower extremity weakness.
Research states that individuals with NSLBP have decreased activation of certain intrinsic core
muscle groups including the transverse abdominis, internal obliques, pelvic floor muscles, multifidi,
diaphragm, and deep erector spinae.47

510
Chapter 1
In addition to a decrease in core muscle activation, individuals with NSLBP tend to have decreased
The Skeletal System

muscular endurance, and trunk muscle weakness. Promoting exercise to strengthen the lower
back is strongly suggested to help alleviate the pain and avoid bed rest, however weight bearing
activities can increase symptoms in certain planes of motion and postures.
Before executing exercises, it is vitally important to explain and demonstrate how to locally and
globally stabilize the core, because, if not properly addressed, exercises can increase pressure on
the discs and can cause damage to ligaments and supporting vertebrae.
A general rule is to strengthen the muscles of the core first before strengthening to outer extremities.
Strengthening the muscles of the core should be progressive and have longevity in mind.48
Training considerations vary case by case however prevention should be considered for clients
with NSLBP to decrease the chance of the pain returning. If the client is having an acute flare-
up trainers should not perform any exercises and mandate a brief rest period for the client.
Individuals will experience pain in different ways so sitting on a bike may not be comfortable for
some, and walking on a treadmill could cause pain for others. Fitness professionals must work
closely with the client to find exercises that will promote stability and strength in the core.
Adherence to exercise may be difficult to achieve with individuals suffering with chronic NSLBP,
but functionality can improve quickly, and long term benefits begin after only two months of
training. Exercise should be generally tolerable and should only leave clients mildly sore.
Exercise Guidelines for Individuals with Nonspecific Low

Back Pain
Frequency
Trainer Academy
©2023
• 3-5 days per week- progress to everyday
Intensity
• Moderate 40-60% maximum HR

511
Chapter 1
Duration
The Skeletal
• Build System
up to 20-60 minutes, 10-minute bouts throughout the day
Anna
Mode D’Annunzio, MS
• Brisk walk with arm movement, cycling (if possible), swimming
• Low impact is best initially.

• Individuals are typically deconditioned so start low and slow, progress as tolerated.
• Avoid exercising on unstable surfaces (stability ball) early in training.
• Monitor symptoms and pain tolerance levels, adjust workout accordingly.
Trainer Academy
©2023
Summary Summary
Special populations clients are frequently encountered in the personal training setting. Well-
Special populations
trained fitness clientshave
professionals are frequently
the ability encountered
to modify andindeliver
the personal
fitnesstraining
programssetting. Well-trained
to a variety
fitness professionals
of clients. have theofability
As such, knowledge specialtopopulations
modify andtraining
deliverprotocols
fitness programs tocertified
is key for a variety of clients.
As such,
personal knowledge of special populations training protocols is key for certified personal trainers.
trainers.

512
Chapter 1
References
The Skeletal System
1. Bangsbo J, Krustrup P, Duda J, et al. The Copenhagen Consensus Conference 2016: Children, youth,
Anna D’Annunzio,
and physical activity in schoolsMS
and during leisure time. British Journal of Sports Medicine. https://
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2. Hill JO. Dietary and Physical Activity Guidelines for Americans. Obesity Management. 2008;4(6):317-
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interstitial lung disease [synopsis]. Journal of Physiotherapy. 2017;63(4):257. https://doi.org/10.1016/j.
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20. Meeuwsen S, Horgan GW, Elia M. The relationship between BMI and percent body fat, measured by
bioelectrical impedance, in a large adult sample is curvilinear and influenced by age and sex. Clinical
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doi.org/10.1136/bmj.333.7569.640
22. OGITA F, STAM RP, TAZAWA HO, TOUSSAINT HM, HOLLANDER AP. Oxygen uptake in
one-legged and two-legged exercise. Medicine & Science in Sports & Exercise. 2000;32(10):1737-
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WEIGHT CONTROL REGISTRY. Journal of Cardiopulmonary Rehabilitation and Prevention.
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of Diabetes and ©2023Its Burden in the United States Background.; 2020. https://www.cdc.gov/diabetes/
pdfs/data/statistics/national-diabetes-statistics-report.pdf
26. Kim KS, Park SW. Exercise and Type 2 Diabetes: ACSM and ADA Joint Position Statement. Journal
of Korean Diabetes. 2012;13(2):61. https://doi.org/10.4093/jkd.2012.13.2.61
27. Diabetes Report Card. Center for Disease Control (CDC). Published 2019. https://www.cdc.gov/
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Stroke Statistics Subcommittee. Heart disease and stroke statistics—2022 update:a report from

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HH. Kinetics of cellular proliferation after arterial injury II. Inhibition of smooth muscle
growth by heparin. Journal of Vascular Surgery. 1986;4(5):540-541. https://doi.org/10.1016/0741-
5214(86)90401-5
30. Coronary Artery Disease Progression in Patients With Acute Coronary Syndromes and Diabetes
Mellitus. Case Medical Research. Published online March 26, 2019. https://doi.org/10.31525/ct1-
nct03890822
31. Tian D, Meng J. Exercise for Prevention and Relief of Cardiovascular Disease: Prognoses, Mechanisms,
and Approaches. Oxidative Medicine and Cellular Longevity. 2019;2019:1-11. https://doi.
org/10.1155/2019/3756750
32. Christodoulou C. What is osteoporosis? Postgraduate Medical Journal. 2003;79(929):133-138. https://

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33. Cawthon PM. Gender Differences in Osteoporosis and Fractures. Clinical Orthopaedics and Related
Research®. 2011;469(7):1900-1905. https://doi.org/10.1007/s11999-011-1780-7
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37. Bullock, Jacqueline, et al. “Rheumatoid Arthritis: A Brief Overview of the Treatment.” Medical
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gov, 2019, www.cancer.gov/publications/dictionaries/cancer-terms/def/cancer
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39. American Cancer
©2023 Society. “Cancer Facts & Figures 2022| American Cancer Society.” www.cancer.
org, 2022, www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-
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40. Woods, JA, et al. “Exercise and Cellular Innate Immune Function.” Rehabilitation Oncology, vol. 19,
no. 2, 2001, p. 34, 10.1097/01893697-200119020-00043. Accessed 22 Mar. 2020
41. Bhatta, Dharma N., and Stanton A. Glantz. “Association of E-Cigarette Use with Respiratory Disease
among Adults: A Longitudinal Analysis.” American Journal of Preventive Medicine, vol. 58, no. 2,
Dec. 2019, 10.1016/j.amepre.2019.07.028

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ncbi.nlm.nih.gov/books/NBK560880
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al. “Dyssynchronous Breathing during Arm but Not Leg Exercise in Patients
with Chronic Airflow Obstruction.” New England Journal of Medicine, vol. 314, no. 23, 5 June 1986,
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pp. 1485–1490, MS
10.1056/nejm198606053142305. Accessed 6 June 2020.
44. Treat-Jacobson, Diane, et al. “Optimal Exercise Programs for Patients with Peripheral Artery Disease:
A Scientific Statement from the American Heart Association.” Circulation, vol. 139, no. 4, 22 Jan.
2019, 10.1161/cir.0000000000000623.
45. Hackam, Daniel G. “Medical Management of Peripheral Arterial Disease.” JAMA, vol. 296, no. 1,
5 July 2006, p. 41, 10.1001/jama.296.1.41-a. Accessed 6 Jan. 2020.
46. Cassidy, J David, et al. “Incidence and Course of Low Back Pain Episodes in the General Population.”
Spine, vol. 30, no. 24, Dec. 2005, pp. 2817–2823, 10.1097/01.brs.0000190448.69091.53. Accessed
11 Mar. 2021.
47. Hodges, Paul W., and Carolyn A. Richardson. “Inefficient Muscular Stabilization of the Lumbar Spine
Associated with Low Back Pain.” Spine, vol. 21, no. 22, Nov. 1996, pp. 2640–2650, 10.1097/00007632-
199611150-00014. Accessed 7 Apr. 2020
48. McGill, Stuart M. “Low Back Stability: From Formal Description to Issues for Performance
and Rehabilitation.” Exercise and Sport Sciences Reviews, vol. 29, no. 1, Jan. 2001, pp. 26–31,
10.1097/00003677-200101000-00006.
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Chapter 1
TheCHAPTER
Skeletal24System
Anna D’Annunzio,
Basic MS
Nutritional Concepts
Ellen Landes, MS, RDN
517
Basic Nutritional Concepts
Chapter 1
Introduction
The Skeletal System
Knowledge of basic nutritional concepts is important for personal trainers as nutrition plays an
Anna
integral roleD’Annunzio, MS and health of the body. This chapter will review nutrition
in the overall mechanics
and its importance for athletic performance, foundational concepts in nutrition, popular diets,
and general healthy eating guidelines.
Nutrition can be defined as the science of the nutrients in foods and their impact on the body.
Taking the definition of nutrition a step further considers dietary choices and relevant human
behaviors.1
Importance of Nutrition for Health and

Athletic Performance
Poor nutrition is one of the leading risk factors when it comes to both chronic disease as well as
death in the United States.2
Large studies of over 2.88 million patients in total have all provided the same information – that
being overweight or obese greatly increases the risk of death from chronic conditions such as
cardiovascular disease, kidney disease, and diabetes.2
Of course, other factors play a role in the development of diseases.
It’s possible to have a genetic predisposition for conditions such as type 2 diabetes; however,
research supports the concept that a healthy lifestyle can help with prevention of diabetes, despite
any predisposition. 2
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From a fitness standpoint, optimal nutrition can enhance athletic performance as well as provide
proper recovery from exercise.3 It’s clear that nutrition plays a key role in all aspects of health
and personal trainers will need to have a basic understanding of its concepts to be successful in
working with clients.

518
Chapter 1 Basic Nutritional Concepts 520
The
The Trainer
Skeletal Academy CPT Scope of
System
Practice
Anna The TrainerMSAcademy CPT Scope of
D’Annunzio,
Practice
Personal trainers must respect their scope of practice when it comes to nutrition. In most states,
there are laws in place that prevent individuals without the proper licensing and certifications from
providingPersonal
specifictrainers
nutrition
must services, such
respect their as meal
scope planswhen
of practice or recommendations
it comes to nutrition.for specific diseases.
In most
states, there are laws in place that prevent individuals without the proper licensing and
Registered Dietitians
certifications or Registered
from providing specificDietitian Nutritionists
nutrition services, such as (RDs or RDNs)
meal plans are individuals who
or recommendations
for specific degrees
earn bachelor’s diseases. in nutrition and dietetics from accredited colleges or universities, complete
a supervised clinical
Registered practice
Dietitians internship,
or Registered pass aNutritionists
Dietitian national examination,
(RDs or RDNs)and maintain continuing
are individuals
education credits.
who earn bachelor’s degrees in nutrition and dietetics from accredited colleges or universities,
complete a supervised clinical practice internship, pass a national examination, and maintain
continuing
Because education
of their in-depthcredits.
experience and qualifications, only RDs are legally allowed to provide
specific nutrition prescriptions.4
Because of their in-depth experience and qualifications, only RDs are legally allowed to
provide specific nutrition prescriptions.4
However, personal trainers can provide basic nutrition recommendations and cite published dietary
However, personal trainers can provide basic nutrition recommendations and cite published
guidelines without specifically assigning certain foods. Overall, giving nutrition recommendations
dietary guidelines without specifically assigning certain foods. Overall, giving nutrition
within the personal trainer scope of practice may be beneficial for their clients.
recommendations within the personal trainer scope of practice may be beneficial for their clients.
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519
Chapter 1
Basic
The Nutrition
Skeletal SystemConcepts
Anna D’Annunzio,
Metabolism MS
and Bioenergetics
One of the first steps in understanding nutrition and its effects on the body is to learn about
energy balance. This becomes important in the role of the personal trainer, especially when clients
are looking to lose or gain weight.
A calorie is a measurement of heat energy. The energy in food is measured in calories, and
denominated kilocalories. Technically speaking, one kilocalorie is the amount of heat (energy)
that is needed to raise the temperature of 1 kilogram (kg) of water by 1 degree Celsius.
However, most people refer to the energy found in food as simply “calories”. This textbook will
use the abbreviation “kcal,” or the term “calories” moving forward to discuss energy intake and
expenditure.5
Energy balance occurs when energy intake (in the form of calories from food) is roughly equal
to energy expenditure (or the calories burned throughout the day). When energy is balanced,
body weight remains stable. When a negative energy balance exists, meaning energy intake is
less than the energy expended, body weight decreases.
Alternatively, in a state of positive energy balance, when calories eaten (energy intake) are greater
than the calories being burned (energy expenditure), body weight increases.6 It’s worth noting
that while this concept is indeed simple, it’s not always easy for those seeking to gain or lose
weight. Obesity rates have increased over the years in part thanks to an environment with an
abundance of highly palatable foods and societal decreases in physical activity.6
Total Daily Energy Expenditure (TDEE)

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Total Daily Energy Expenditure, or TDEE, is the amount of energy that is expended in a 24-
hour period. It’s a dynamic number that is affected by various factors day to day, including activity
levels, the environment, caffeine, sleep, and other lifestyle factors.1
TDEE consists of three main components: the basal metabolism, physical activity, and the
thermic effect of food.

520
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The thermic effect of food (TEF) is the energy that is required to process the food consumed and will
The Skeletal System

account for about 10% of total energy expenditure.1
When food is ingested, the body needs to use energy to break it down to digest and absorb it.
Anna D’Annunzio,
Interestingly, MS to carbohydrates and fats, has the highest thermic effect on
protein, when compared
food, increasing the metabolism an estimated 15-30% after ingestion. For reference, carbohydrates
cause an increase of about 5-10% and fats just 0-3%.7, 8
Arguably the most variable component of TDEE among different individuals, as well as within
one individual day to day, is physical activity, which can account for anywhere from 30 to 50%
of someone’s energy expenditure.
A person’s physical activity is the amount of voluntary movement they are performing each
day. This includes any form of movement, such as an active day job. For example, a mail
delivery carrier has a certain amount of physical activity he or she performs every day through
their job which contributes to their energy expenditure as well as any formal exercise they
perform.1
NEAT, or Non-Exercise Activity Thermogenesis, is energy burned through day-to-day activities,

aside from intentional exercise. For example, things like housework, getting up and stretching
throughout the day, or even fidgeting, would count as NEAT.9
Lastly, the biggest contributor to TDEE, accounting for 50-65% of total energy expenditure, is
the basal metabolism, which is the energy used to maintain life at a complete rest. This is often
quantified by measuring the BMR (basal metabolic rate) or RMR (resting metabolic rate).1
BMR and RMR are often used interchangeably, but there is a small difference (up to 10%). BMR
is measured in a lab setting via indirect calorimetry, where the individual has slept overnight in
the lab and their values can be measured first thing in the morning.
On the other Trainer

hand,©2023 RMR is also measured in a lab, but the individual did not stay overnight and
Academy
has thus awoken and traveled to the lab setting for the testing. Ultimately, this means BMR will
be slightly more accurate as it’s slightly more controlled.
Such differences are rather small and what’s more, BMR/RMR can change from day to day,
depending on several factors like stressors, the use of caffeine, or the presence of a fever.1 It can
also be increased or decreased over time by changes in lifestyle factors.

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While it’s possible to measure BMR or RMR in a laboratory setting, this is not easily accessible
The Skeletal System

for most individuals. Alternatively, several
Basiccalculations have been developed to provide estimations.
Nutritional Concepts 523
Moving forward, this chapter will simply use the term BMR when discussing these calculations.
Calculations
Calculations
There are many calculations that can be used to estimate BMR, but the Harris-Benedict
equation, which considers an individual’s gender, height, and weight, is commonly used.10
There are many calculations that can be used to estimate BMR, but the Harris-Benedict equation,
which considers an individual’s gender, height, and weight, is commonly used.10
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522
Chapter 1
The result of these equations will be an estimate of an individual’s BMR.
The
From Skeletal
there, the activity System
level of that individual needs to be considered. To factor this in, the next
step will be to multiply the result from the equation above by the appropriate activity factor below:
Energy Expenditure Calculations via BMR
Activity level BMR multiplied by:

Little to no exercise 1.2
Light exercise (1-3 days per week) 1.375
Moderate exercise (3-5 days per week) 1.55
Heavy exercise (6-7 days per week) 1.725
Very heavy exercise (twice per day, daily) 1.9
After multiplying the BMR by the activity factor, the result is an individual’s TDEE, or the
estimated number of calories they need to consume daily to maintain their body weight at their
current activity levels.
While these calculations are used when indirect calorimetry is not available or accessible, it’s
important to note that they are not 100% accurate.10 Increasing TDEE will likely be a goal of
many personal training clients, particularly those looking to lose weight.
As a reminder, weight loss is typically observed when a negative energy balance is achieved,
meaning the energy intake is less than the energy expenditure. Therefore, increasing TDEE
would help promote a negative energy balance and ultimately, weight loss.
The most obvious method of increasing TDEE is to increase the amount of physical activity.
This can be done through NEAT, or increasing overall movements throughout the day, as well as
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formal, structured exercise like sessions with a personal trainer or going for a bike ride or walk.
Another approach to increasing TDEE might be considering a diet higher in protein, as protein
has a higher TEF than carbohydrates or fats. However, while this may lead to modest increases
in TDEE, it’s unlikely to be substantial.7, 8 Lastly, research suggests that an increase in lean body
mass may increase BMR and therefore TDEE, so promoting strength training and muscle
building with clients is recommended.11

lean body mass may increase BMR and therefore TDEE, so promoting strength training and
523 muscle building with clients is recommended.
11
Chapter 1 Calories
Calories
The Skeletal
Changing System
caloric intake is an effective approach to changing body weight. As reviewed in
earlier sections,
Changing calorica negative
intake is energy balance
an effective occurstowhen
approach the calories
changing eaten are
body weight. As fewer thaninthe
reviewed earlier
Anna
calories D’Annunzio,
burned and thus results MS
in weight loss and alternatively, a positive energy balance
sections, a negative energy balance occurs when the calories eaten are fewer than the calories burnedshould
promote
and thusweight gain.
results in weight loss and alternatively, a positive energy balance should promote weight gain.
A low-calorie diet typically involves anywhere from a 500-750 calorie deficit, meaning the
A low-calorie diet typically involves anywhere from a 500-750 calorie deficit, meaning the
difference between an individual’s caloric intake and TDEE is 500-750 calories.1212
difference between an individual’s caloric intake and TDEE is 500-750 calories.
For many, eating this many fewer calories each day is difficult, and a more modest deficit
For
may bemany,
moreeating this While
realistic. many fewer calories
a smaller each
deficit may day is difficult,
lead to slowerand a more
weight lossmodest
results,deficit
it maymay
be
be more
more realistic.
effective While
overall a smaller
as it’s likely deficit mayanlead
easier for to slower
individual to weight
commitlossto. 13results, it may be more
effective overall as it’s likely easier for an individual to commit to. 13
Additional, increasing non-exercise activity thermogenesis (NEAT) by adding just a bit more
Additional,to
movement increasing
the day non-exercise activity thermogenesis
without additional exercise sessions(NEAT) by adding
can help just a bit
individuals morethe
reach movement
target
to the day
caloric without additional exercise sessions can help individuals reach the target caloric deficit.
deficit.
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524
Basic Nutritional Concepts 526
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The success of a diet will rely heavily on an individual’s adherence to the diet. Research suggests
The Skeletal System

thatThe
keeping
effective that
suggests
a food
success log and
of a diet
strategies
will choosing a diet
rely heavily
foraimproving
keeping food log and
on an
adherence.
that
13
fits the individual’s
individual’s adherence food
to thepreferences are both
diet. Research
choosing a diet that fits the individual’s food preferences
are both effective strategies for improving adherence. 13
Anna
Still, while D’Annunzio, MS approaches to weight loss, some of which will be reviewed
there are many different
in aStill,
later while there
section, are many
research has different
found thatapproaches to weight
caloric intake is theloss,
mostsome of which
important will 12
factor. be
reviewed in a later section, research has found that caloric intake is the most important factor. 12
The same principles can be applied for an individual looking to gain weight, though the focus
The same principles can be applied for an individual looking to gain weight, though the focus
should shift to a caloric surplus.
should shift to a caloric surplus.
It is again important for the approach to diet to be realistic and sustainable to achieve
It is again important for the approach to diet to be realistic and sustainable to achieve success.
success.
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Macronutrients Macronutrients
Macronutrients areare
Macronutrients compounds found
compounds foundin in
food that
food thatprovide
providethe
thebody
bodywith
withenergy,
energy,ininthe
theform
formof
calories.
of There
calories. areare
There three macronutrients
three macronutrientspresent
presentininfoods:
foods:carbohydrates,
carbohydrates,fat,
fat,and
andprotein.
protein.
EachEach of these
of these provide
provide a certain
a certain number
number of calories
of calories perper gram,
gram, ultimately
ultimately contributing
contributing toto the
the total
total calories consumed in one’s dietary
calories consumed in one’s dietary intake. intake.
• One gram of carbohydrate contains 4 calories.
• One gram of protein contains 4 calories.
• One gram of fat contains 9 calories.
525
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• One gram of carbohydrate contains 4 calories.
The Skeletal System

• One gram of protein contains 4 calories.
• One gram of fat contains 9 calories.
AsAnna D’Annunzio,
fat contains MS
more than twice the number of calories as carbohydrates and protein, it can be
considered more calorie dense.
When it comes to weight loss, various approaches to macronutrients have been suggested. Research
shows that caloric intake, along with sufficient protein intake, remains the most important factor.12
This means that whether a diet is lower in carbohydrates or fats does not determine the success
of a diet. But, as adherence to a caloric deficit is a huge driving factor, an individual’s preferences
towards foods higher in carbohydrates or fats should be considered.
Additionally, though not technically considered a macronutrient, alcohol also provides energy
in the form of calories.
• One gram of alcohol (ethanol) contains 7 calories.
This can be notable for individuals working on losing weight as calories coming from alcohol
will contribute to overall caloric intake.
Calories in typical alcoholic drinks
Beverage Serving Size Total Calories Calories from Alcohol

Beer 12 fluid ounces 153 96
Light Beer 12 fluid ounces 103 76
Red Wine 5 fluid ounces 125 108
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Spirits 1 fluid ounce
©2023
82 82
The table above indicates that some alcoholic beverages, such as beer and wine, contain calories
in addition to the calories from alcohol, while spirits are 100% alcohol.
This is because beer and wine contain carbohydrates in addition to alcohol.

526
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Hydration and Fluid Needs
The
ProperSkeletal
hydration shouldSystem
be considered an essential part of a nutritional plan, particularly when
exercise is involved.
Water is an essential part of healthy nutrition.
It’s important for transporting nutrients throughout the body as well as carrying away waste
products. It also helps to digest foods and regulate body temperature, especially during exercise.15
Athletes can lose large amounts of water through sweat during exercise. It’s estimated 1.5 liters
or more fluid can be lost during each hour of activity.
To prevent dehydration, which occurs when the body’s output of water exceeds the input,
individuals should focus on drinking plenty of fluids throughout the day, particularly before,
during, and after exercise.1
Dehydration can lead to a rapid heartbeat, muscle weakness, low blood pressure, and other
symptoms.
Recommendations for water intake can vary, but the Adequate Intake set by the DRI committee
suggests 3 liters (about 13 cups) per day for adult men and 2.2 liters (about 9 cups) per day for
adult women.16
It’s important to note that total water here is used interchangeably with total fluid intake, meaning
other liquids, such as milk or fruit juice, and even foods, thanks to their water content, can
contribute to this number.
If an individual is particularly active, they will likely need to increase their amount of total
water. To determine an exact amount of fluids needed, the hourly sweat rate can be calculated
by weighing an individual before exercise and immediately after.
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One pound of weight loss is approximately 2 cups of fluid.1
This means that an individual should focus on consuming a minimum of 2 cups of water (or about
16 ounces) per pound lost to sweat during exercise. Sufficient fluids should also be prioritized
leading up to and during training.

527
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Also, remember that sweat is not simply just water. It also contains electrolytes, which are
The Skeletal System

electrically charged particles that maintain water balance inside and outside of cells, and, therefore,
are essential to hydration.15
Annapotassium,
Sodium, D’Annunzio, MS
calcium, and magnesium are all important electrolytes, but sodium tends to
be lost in the greatest amounts through sweat.
For example, an average individual will lose up to 800mg of sodium in 2 pounds of sweat, but
only 10mg of magnesium.15
Low levels of sodium can lead to something called hyponatremia, which can cause nausea,
confusion, fatigue, and muscle weakness.
Thus, staying on top of both fluids and electrolytes is important for hydration.
Sports drinks containing carbohydrates as well as sodium can be particularly useful during
exercise, especially for heavy sweaters or individuals exercising for extended periods of time,
though they are not necessary for everyone. An approach to hydration before, during, and after
exercise might look like this1:
• Throughout the day: 1 ounce of fluids per 10 pounds of body weight

• 2 hours before exercise: 0.6 ounces per 10 pounds of body weight
• During exercise: Sips of fluids to prevent dehydration
• After exercise: 16 ounces of fluids per each pound of body weight lost during exercise
Popular Diets
Ketogenic DietTrainer Academy
©2023
The ketogenic diet, also known as the keto diet, is a high fat, very low carbohydrate diet that aims
to establish ketosis in the body. In the ketogenic diet, people typically consume less than 10% of
total calories from carbohydrates or fewer than 50 grams of carbohydrates per day.
Ketosis is a state in which the body begins to use fat as fuel, rather than its preferred fuel source
of carbohydrates.12, 17 Originally used to help those suffering from epilepsy, the keto diet has more
recently become popular for those looking to lose weight.18

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Individuals following a keto diet generally see rather fast weight loss in the early stages of
The Skeletal System

implementation. This is due to the diuretic effect of a low carbohydrate diet.17
Some research suggests that a keto diet may help decrease appetite and manage blood sugars
andAnna
insulin D’Annunzio,
levels.12, 19 However,MS
the research overall does not favor a low carb or low fat diet, but
rather calorie restriction for successful weight loss.12, 20
While the keto diet may be effective for some, it may not be realistic or sustainable for others.
Because the biggest factor is calories, thisNutritional
Basic is an example where the individual’s food preferences
Concepts 530
should be taken into consideration when considering a diet approach such as the keto diet.
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Paleo Diet
The Paleolithic diet, or the paleo diet, is a hunter-gatherer style of eating that focuses on
eliminating processed foods, which were not consumed by humans during the Paleolithic era.
529
Chapter 1
Paleo Diet
The Skeletal System
The Paleolithic diet, or the paleo diet, is a hunter-gatherer style of eating that focuses on eliminating
Annafoods,
processed D’Annunzio,
which were not MS consumed by humans during the Paleolithic era.
The diet revolves around consuming foods like meat, vegetables, fruits, and nuts. It eliminates
grains, dairy, and added sugars. Today, the Paleo diet has become extremely popular and there
are several heavily marketed products throughout the fitness industry, claiming to be Paleo.
Some research suggests that the paleo diet may help improve blood lipids and blood pressure,
but stronger, more conclusive research is still needed before these claims can be made.12
Ultimately, there is no conclusive research supporting the paleo diet over other types of diets for
fat loss. It can also be rather restrictive and difficult to sustain for some.
Vegan Diet
Vegan diets, or plant-based diets, eliminate all forms of animal products, including meats as well
as foods derived from animals like dairy and eggs.
Some research does support a vegan diet for fat loss as its emphasis on plant-based foods may
help improve insulin sensitivity, lower caloric intake, lower the risk of some chronic diseases, and
ultimately promote weight loss.21
Some nutrients can become of concern on a vegan diet, including protein, vitamin B12, vitamin
D, iron, and calcium.
It’s possible to consume enough of these nutrients without eating animal products, but individuals
must be educated in plant-based food sources to do so. Some may wish to use dietary supplements
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to cover any gaps in nutrition.22
As with other diets, a vegan diet could be difficult for some to follow, and individuals should
focus on diets that fit their lifestyle and preferences.

It’s possible to consume enough of these nutrients without eating animal products, but
individuals must be educated in plant-based food sources to do so. Some may wish to use dietary
530 supplements to cover any gaps in nutrition.22
As with other diets, a vegan diet could be difficult for some to follow, and individuals should
Chapter 1
focus on diets that fit their lifestyle and preferences.
The Skeletal System

Trainer Academy
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Vegetarian Diet
Vegetarian diets eliminate meat, but often include things like dairy and eggs. This style of eating
can be referred to as a lacto-ovo vegetarian diet. Some vegetarians prefer to follow a lacto-
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vegetarian or an ovo-vegetarian diet, meaning only meat and eggs are restricted, or only meat
and dairy are restricted. Same may also consider themselves pescatarian, meaning they do not
consume meat, but do eat fish and seafood.
Vegetarian diets have been found to offer various health benefits, including a reduced risk for
type 2 diabetes, heart disease, and cancer. Some research supports vegetarian diets for fat loss,
but more conclusive research is still needed on the topic.12

531
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Plant-Based Diet
The Skeletal System
A plant-based diet can be similar to a vegetarian or vegan diet but with a bit more flexibility. It’s
Anna
a diet D’Annunzio,
that emphasizes MSfoods, but it may also include other whole foods, including
plant-based
animal products.23
Plant-based diets have been found to be beneficial in several ways, including lowering the risk
of some chronic diseases, particularly heart disease, as they tend to be lower in saturated fats and
higher in fiber.24 As with other diets, a plant-based diet may be beneficial for fat loss, but the
most important factor in success remains a caloric deficit.12
Intermittent Fasting
Intermittent fasting is a style of eating that involves a certain length of time of fasting, followed
by an “eating window,” during which all of one’s calories are consumed for the day. There are
several different approaches to intermittent fasting, some focusing on a 16 hour fast and 8 hour
eating window, others recommending alternate day fasting, and more.12
Some potential benefits of intermittent fasting include improved insulin sensitivity and blood
pressure.25 There is also promising research that suggests intermittent fasting may be effective
for weight loss, however the research overall remains inconclusive.26
As with many diets, this style of eating can be rather restrictive and difficult to sustain and fasting
can cause feelings of dizziness, weakness, and headaches in some.12
As a reminder, a caloric deficit is essential for weight loss, and some individuals may find that
following an intermittent fasting approach helps them to maintain this deficit, but others may
find fasting for longer periods lead to periods of overeating.
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Summary of Popular Diets

Weight loss does not depend on the specific type of diet but the adherence to a long-term
calorie-deficit.13
There are many different popular approaches to dieting and fat loss. While some may have research
supporting their benefits and some may even have research supporting their effectiveness for
fat loss specifically, the conclusion remains that caloric intake is the biggest driving factor.12, 27

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Additionally, adherence to a specific diet ultimately determines the effectiveness of that diet.
The Skeletal System

Some approaches, such as keeping a food log, setting realistic goals, and a supportive environment,
have been found to improve adherence.13, 28
Anna
Many D’Annunzio,
of these MS a caloric deficit, which is necessary to promote weight
diets work by creating
loss. Individuals should consider their own preferences and lifestyle before choosing to follow
a specific diet.
Healthy Eating Guidelines
General Healthy Eating Recommendations
Despite the limited scope of the personal trainer, some general healthy eating recommendations
can still be made. Before providing any sort of recommendation, consider if it would fall into the
scope of diagnosing, treating, or preventing a specific condition or prescribing specific dietary
approaches.
If the recommendation does fall into any of the latter, it’s best to refer the client to a registered
dietitian.
Some general healthy eating recommendations for a client looking to lose weight or improve
overall health might include:12, 13, 16, 29
• Drink plenty of water throughout the day (9-13 cups)

• Keep a food log
• Focus on high-fiber foods like vegetables, fruits, and whole grains to boost satiety
• Include a source of lean protein with each meal to increase satiety and support lean muscle
mass
• Limit alcohol consumption
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• Limit empty calories and ultra-processed foods

• Keep saturated fats and added sugars in moderation

533 Basic Nutritional Concepts 534
Chapter 1
The Skeletal System

Alternatively,
Alternatively, if a client
if a client is interested
is interested in gaining
in gaining weight,it’sit’s
weight, besttotocontinue
best continue recommending
recommending the
abovethe aboveeating
healthy healthyguidelines,
eating guidelines,
but it’sbut
alsoit’s also important
important to encourage
to encourage the following
the following habits:
habits:
• Increase overall calories (in the form of carbohydrates, protein, and fat) by increasing
portion sizes at meals and snacks
• Increase overall calories (in the form of carbohydrates, protein, and fat) by increasing portion
• Focus onAcademy
protein to support muscle building and recovery
sizes at meals©2023
and snacks
Trainer
• Focus on protein
Alternatively, if atoclient
support muscle building
is interested in gainingand recovery
weight, it’s best to continue recommending
the above healthy eating guidelines, but it’s also important to encourage the following habits:
Alternatively, if a client is interested in gaining weight, it’s best to continue recommending the
• Increase overall calories (in the form of carbohydrates, protein, and fat) by increasing
above healthy eating guidelines, but it’s also important to encourage the following habits:
portion sizes at meals and snacks
• Focus on protein to support muscle building and recovery
• Increase overall calories (in the form of carbohydrates, protein, and fat) by increasing portion
sizes at meals and snacks
• Focus on protein to support muscle building and recovery
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Chapter 1
Summary
The Skeletal System
The role of the personal trainer is centered around exercise and scope of practice must always be
Anna D’Annunzio,
considered MS
before offering any recommendations related to nutrition or other areas of expertise.
An individual’s TDEE can be calculated using equations that consider their gender, height,
weight, and activity levels. This can be used to determine a caloric deficit or surplus that can
support a goal of weight loss or gain.
Hydration is an essential aspect of nutrition and fitness, particularly in heavy sweaters. Clients
should be encouraged to drink 9-13 cups of water, and sometimes more depending on their
sweat rate.
While various weight loss diets exist, research remains steady in support of caloric intake and
adherence being the biggest driving factors in success. An individual should first consider their
own preferences and habits before committing to a restrictive diet.
While personal trainers are limited in their ability to make nutritional recommendations, they
can offer several sound healthy eating recommendations to those looking to improve overall
health. Anything that involves diagnosing, treating, or prescribing specific dietary approaches
should be referred to a registered dietitian.
Trainer Academy
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535
Chapter 1
References
The Skeletal System
1. Eleanor Noss Whitney, Sharon Rady Rolfes. Understanding Nutrition. Cengage; 2018.
2. Kandel S. An Evidence-based Look at the Effects of Diet on Health. Cureus. Published online May
22, 2019. https://doi.org/10.7759/cureus.4715
3. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement.
Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc.
2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. https://doi.org/10.1249/
MSS.0000000000000852
4. What is a registered dietitian nutritionist. EatRightPro. https://www.eatrightpro.org/about-us/what-

is-an-rdn-and-dtr/what-is-a-registered-dietitian-nutritionist.
5. Osilla EV, Safadi AO, Sharma S. Calories. PubMed. Published 2022. https://pubmed.ncbi.nlm.nih.

gov/29763084/#:~:text=Calories%20are%20a%20measure%20of
6. Hill JO, Wyatt HR, Peters JC. The Importance of Energy Balance. European Endocrinology.
2010;9(2):111. https://doi.org/10.17925/ee.2013.09.02.111
7. Calcagno M, Kahleova H, Alwarith J, et al. The Thermic Effect of Food: A Review. Journal of the
American College of Nutrition. 2019;38(6):547-551. https://doi.org/10.1080/07315724.2018.1552544
8. Pesta DH, Samuel VT. A high-protein diet for reducing body fat: mechanisms and possible
caveats. Nutrition & Metabolism. 2014;11(1):53. https://doi.org/10.1186/1743-7075-11-53
9. Levine JA. Non-exercise activity thermogenesis (NEAT). Best practice & research Clinical endocrinology
& metabolism. 2002;16(4):679-702. https://doi.org/10.1053/beem.2002.0227
10. Bendavid I, Lobo DN, Barazzoni R, et al. The centenary of the Harris–Benedict equations: How to
assess energy requirements best? Recommendations from the ESPEN expert group. Clinical Nutrition.
2020;40(3). https://doi.org/10.1016/j.clnu.2020.11.012
11. MacKenzie-Shalders K, Kelly JT, So D, Coffey VG, Byrne NM. The effect of exercise interventions
on resting metabolic rate: A systematic review and meta-analysis. Journal of Sports Sciences.
2020;38(14):1635-1649. https://doi.org/10.1080/02640414.2020.1754716
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12. Kim JY. Optimal diet strategies for weight loss and weight loss maintenance. Journal of Obesity &
Metabolic Syndrome. 2020;30(1). https://doi.org/10.7570/jomes20065
13. Gibson A, Sainsbury A. Strategies to Improve Adherence to Dietary Weight Loss Interventions
in Research and Real-World Settings. Behavioral Sciences. 2017;7(4):44. https://doi.org/10.3390/
bs7030044
14. SELF Nutrition Data | Food Facts, Information & Calorie Calculator. Self.com. Published
2007. https://nutritiondata.self.com/

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15. Clark N. Nancy 1 Sports Nutrition Guidebook. Sports Nutrition Services, Llc; 2020.
Clark’s
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16. Read “Dietary Reference Intakes: The Essential Guide to Nutrient Requirements” at NAP.edu. Accessed
September 10, 2022. https://nap.nationalacademies.org/read/11537/chapter/15
17. Masood W, Uppaluri KR. Ketogenic Diet. Nih.gov. Published March 21, 2019. https://www.ncbi.
nlm.nih.gov/books/NBK499830/
18. Ułamek-Kozioł M, Czuczwar SJ, Januszewski S, Pluta R. Ketogenic Diet and Epilepsy. Nutrients.
2019;11(10):2510. https://doi.org/10.3390/nu11102510
19. Westman EC, Tondt J, Maguire E, Yancy WS. Implementing a low-carbohydrate, ketogenic diet
to manage type 2 diabetes mellitus. Expert Review of Endocrinology & Metabolism. 2018;13(5):263-
272. https://doi.org/10.1080/17446651.2018.1523713
20. Seid H, Rosenbaum M. Low Carbohydrate and Low-Fat Diets: What We Don’t Know and Why
we Should Know It. Nutrients. 2019;11(11):2749. https://doi.org/10.3390/nu11112749
21. Najjar, Feresin. Plant-Based Diets in the Reduction of Body Fat: Physiological Effects and Biochemical
Insights. Nutrients. 2019;11(11):2712. https://doi.org/10.3390/nu11112712
22. Sakkas H, Bozidis P, Touzios C, et al. Nutritional Status and the Influence of the Vegan Diet on the Gut
Microbiota and Human Health. Medicina. 2020;56(2). https://doi.org/10.3390/medicina56020088
23. Storz MA. What makes a plant-based diet? a review of current concepts and proposal for a standardized
plant-based dietary intervention checklist. European Journal of Clinical Nutrition. Published online
October 21, 2021:1-12. https://doi.org/10.1038/s41430-021-01023-z
24. Craig WJ, Mangels AR, Fresán U, et al. The Safe and Effective Use of Plant-Based Diets with
Guidelines for Health Professionals. Nutrients. 2021;13(11):4144. https://doi.org/10.3390/nu13114144
25. Sutton EF, Beyl R, Early KS, Cefalu WT, Ravussin E, Peterson CM. Early Time-Restricted Feeding
Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss
in Men with Prediabetes. Cell Metabolism. 2018;27(6):1212-1221.e3. https://doi.org/10.1016/j.
cmet.2018.04.010
26. S W, R M, T O, et al. Intermittent fasting and weight loss: Systematic review. Canadian family
physician Medecin de famille canadien. Published February 1, 2020. https://pubmed.ncbi.nlm.nih.
gov/32060194/
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27. Freire R. Scientific evidence of diets for weight loss: different macronutrient composition, intermittent
fasting and popular diets. Nutrition. 2019;69. https://doi.org/10.1016/j.nut.2019.07.001
28. Sm F. Obesity: Risk factors, complications, and strategies for sustainable long-term weight management.
Journal of the American Association of Nurse Practitioners. Published October 1, 2017. https://
pubmed.ncbi.nlm.nih.gov/29024553/
29. Cordova R, Kliemann N, Huybrechts I, et al. Consumption of ultra-processed foods associated with
weight gain and obesity in adults: A multi-national cohort study. Clinical Nutrition. 2021;40(9):5079-
5088. https://doi.org/10.1016/j.clnu.2021.08.009

Chapter 1
TheCHAPTER
Skeletal25System
Macronutrients and
Hydration
Kira Spreenberg-Bronsoms, MPS, RDN
538
Macronutrie nts and Hydrat i o n
Chapter 1
Introduction
The Skeletal System
Macronutrients and water are necessary products that fuel the body’s daily processes. This chapter
Anna
defines whatD’Annunzio, MS
an essential nutrient is, how macronutrients function in the human body as well as
hydration requirements and ways to make sure clients maintain the proper fluid intake.
Nutrients
Nutrients are defined as chemical structures found in foods that are necessary for human life
and the growth, maintenance, and repair of body tissues.1 The main nutritional constituents of
food are proteins, fats, carbohydrates, vitamins, and minerals.
Essential Nutrients
The search for the nutrients considered essential for health began in the late 1950s. Scientist
Alfred E. Harper first defined and summarized them in 1999.1 The definition for essential
nutrients includes several aspects.
Firstly, the substance is required in the diet for growth, health, and survival. Without it, or without
the proper amounts of it, human beings exhibit signs of deficiency, disease, and ultimately, death.
For example, salt is required for life. It is essential for nerve and muscle functions and helps
regulate regulate fluids in the body. It is critical.
Another part of the definition for essential nutrients includes the fact that growth failure and
characteristic signs of deficiency are prevented only by the nutrient or a specific precursor of it,
not by other substances. So only this substance or a precursor to it will prevent signs of deficiency.
Arginine is aTrainer
non-essential
Academy
©2023 amino acid that has many profound effects, but can actually be
synthesized from other nutrients rather than just arginine or a precusor.
The human body cannot simply synthesize essential nutrients from other substances.
Also, below critical levels of intake of an essential nutrient, growth response, and severity of signs
of deficiency are always proportional to the amount consumed, meaning a larger deficiency will
lead to further and further symptoms and issues.

539
Chapter 1 Macronutrients and Hydration 541

Examples of essential nutrients include certain carbohydrates, protein, fats, certain vitamins,
The Skeletal System

minerals, and water.
Conditionally Essential Nutrients

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Conditionally Essential
With increasing scientific Nutrients
knowledge of human nutrition, came the understanding that some
nutrients are not essential to maintain life. Defined as conditionally
essential
With or indispensable,
increasing nutrientsofare
scientific knowledge the substances
human nutrition,that
camepartly meet the criteria
the understanding thatforsome
essentiality
nutrients
areyet
notare not required in the diet. The onlyas conditionally
exception to theessential or indispensable, nutrients
norm is specific populations that do are
1
essential to maintain life. Defined
thenot synthesize
substances them
that in adequate
partly meet theamounts.
criteria for essentiality yet are not required in the diet.1 The only
exception to the norm is specific populations that do not synthesize them in adequate amounts.
Non-Essential Nutrients
Non-essential nutrients are substances that cannot be synthesized by the human body but may
be included in the diet given their significant effect on health, although the body can survive
540
Chapter 1
Non-Essential Nutrients
The Skeletal System
Non-essential nutrients are substances that cannot be synthesized by the human body but may
be Anna
includedD’Annunzio, MSsignificant effect on health, although the body can survive
in the diet given their
without them. Examples of non-essential nutrients include biotin, vitamin K, cholesterol, dietary
fiber, certain amino acids, and fatty acids.
Macronutrients
Macronutrients are carbon compounds derived from food sources that provide the essential
energy for growth, maintenance, metabolic functions, and survival. The three main sources of
macronutrients include carbohydrates, proteins, and fats. Alcohol can be considered an alternative
macronutrient because it is its source of energy but it is not essential for survival.
Energy Content and Structure of

Macronutrients
Energy
Energy can be defined as the strength and vitality required for sustained physical or mental
activity. The sun is the main source of energy for all living organisms and is primarily used by
photosynthetic organisms such as plants, algae, and cyanobacteria to make carbon matter from
carbon dioxide and water.3 Human beings require the use of this energy for building metabolic
substances and components that are essential for growth and survival.
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The energy that food produces is directly measured by calorimetry. In chemistry and
thermodynamics, calorimetry is the science that measures the amount of heat that is transferred
by burning a sample of food mass. In biological systems energy in foods is measured in kilocalories
(kcal) or kilojoules (kJ). One kilocalorie (equivalent to 4.184 kJ) is the amount of heat required
to raise the temperature of 1 kg of water to 1°C at standard atmospheric pressure of 760 mm
Hg.4 To simplify the following formula, the field of nutrition uses kilocalories and calories
interchangeably and defines 1 Kcal = 1,000 cal or 1 large calorie.

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The three main macronutrients individually provide a relative energy content that can be measured
The Skeletal System

by kilocalories per gram. Carbohydrates and proteins provide us with 4 kcal per gram and fats
with 9 kcal per gram. Alcohol is not a nutrient but provides 7 kcal per gram as usable energy.
Anna
Certain D’Annunzio,
nutrients MS to digest than others, which reduces the net energy supplied
require more energy
by the nutrient. Fiber, for example, requires significant energy to digest. As a carbohydrate, fiber
technically has 4 calories per gram. However, the net digestion requirements result in roughly 2
calories acquired per gram. Overall, the net energy or caloric value of a food is the energy that
is supplied to the body after each nutrient has been metabolized.
Carbohydrates
Functions
Carbohydrates are the most abundant organic compound in food and the major energy source
for humans, supplying half or more of the total caloric intake for many.5 Carbohydrates exist
as large molecules in the cell walls of bacteria, plants, and the connective tissues of animals to
maintain structure and protection.6 The principal role of carbohydrates is to provide energy and
regulate blood glucose and insulin metabolism.7
Carbohydrates also function as metabolic intermediates in the biosynthesis of fat and protein
and participate in biological recognition and communication processes within cells.7 Different
metabolic states can signal the body to store carbohydrates until further energy is needed or
break down the stores for energy use.
Certain types of carbohydrates also function to supply dietary fiber into the system and promote
good digestive health. Carbohydrates are primarily found in fruits and vegetables, grains, legumes,
commercially-prepared sweeteners, syrups, sugars, and baked goods.
Structure and Properties

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Carbohydrates are structurally made from carbon (C), oxygen (O), and hydrogen (H) atoms. The
general chemical structure for carbohydrates is (CH2O)n where n is the number of carbons in
the molecule.8
Carbohydrates can be classified into two major classes: simple carbohydrates and complex

carbohydrates depending on the number of sugar molecules in the structure. Simple
carbohydrates include monosaccharides (1 single sugar unit), and disaccharides (<2 sugar

542
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units). Complex carbohydrates include oligosaccharides (3–10 sugar units) and polysaccharides
The Skeletal System

(>10 sugar units).
Simple Carbohydrates
Monosaccharides, also termed simple sugars, are the basic units from which all carbohydrates are
built. Monosaccharides differ from complex carbohydrates in that they are colorless crystalline
structures with a sweet taste, solid at room temperature, and soluble in water.8 Simple carbohydrates
are classified using numerical prefixes (tri-, tetra-, penta-…) according to the number of carbon
atoms.8 Following this rule, monosaccharides with three carbons are called trioses, those with
four are carbons tetroses, those with five are carbons pentoses, and so forth. The most abundant
monosaccharide in nature and most important nutritionally is glucose, a six-carbon sugar.8 Other
common monosaccharides found in foods include fructose and galactose.
Disaccharides are composed of two monosaccharides covalently linked by glycosidic bonds.

Disaccharides can be readily broken down (hydrolyzed) or reduced to their constituent
monosaccharides by acidic or enzymatic reactions.8 Similar to monosaccharides, disaccharides
are also colorless crystallized structures with a solid appearance.8 The most significant structures
in this group are sucrose, lactose, and maltose as summarized below:
Sucrose
Also known as table sugar, sucrose is a sugar present in fruits and vegetables, predominantly
sugarcane. Sucrose consists of one glucose and one fructose molecule and is represented by the
molecular formula C12H22O11. Sucrose is characterized by being highly soluble in water and
sweeter than its constituent disaccharides.8 The functional property of the former is partially
influenced by fructose, the monosaccharide with the highest content of sugar. This is why sucrose
is widely extracted to be used as a sweetening agent and to form syrups and nectars.
Lactose
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Lactose is the only sugar that is biologically made in the body, particularly in the breast milk
of lactating mammals. This disaccharide is present in dairy products like milk and cheese and
commercially manufactured for pharmaceutical products and infant formulas. Consisting of one
glucose and one galactose molecule, lactose is also represented as C12H22O11, however, it is
less sweet and soluble than sucrose.8 Compared to milk from other mammals, human milk is
considered unique in its high sugar content; it contains about 70 g/L lactose (7%) contributing
to around 40% of the caloric value.9

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Lactose intolerance is the deficiency or reduced activity of lactase enzymes in the small intestine
The Skeletal System

that develops in some people after the consumption of milk or milk products. When lactose-
containing products are consumed, the undigested lactose remains in the gut. As the bacteria
in the large intestine ferment lactose, they produce hydrogen, methane, and carbon dioxide gas
Anna
that causes D’Annunzio, MS pain. The presence of unabsorbed lactose and products of
bloating and abdominal
fermentation causes an increase in osmotic pressure, attracting water into the bowels, so water
flows in and leads to diarrhea.
Maltose
Maltose is the most limiting sugar found in nature and is rarely consumed in the diet. Sources
of maltose include germinated seeds of plants and grains that are kept in water for a long
time.8 Maltose is a disaccharide that is made of two glucose molecules and also shares the same
molecular formula as that of lactose and sucrose (C12H22O11). Similar to its constituents,
maltose is sweet and soluble in water.
Complex Carbohydrates
Oligosaccharides are carbohydrate polymers that link three to 10 simple sugars by glycosidic

bonds. Oligosaccharides are not as abundant as disaccharides except for maltodextrins and
raffinose.8 Maltodextrins are used in many commercially prepared foods as thickeners, sweeteners,
humectants, and corn syrup, whereas raffinose, also known as “flatulence sugar” is naturally found
in legumes and can lead to excessive flatulence as a result of gut bacteria fermentation.10
Polysaccharides are carbohydrate polymers composed of over 10 sugar units that exist in

linear or branched formations. The properties of polysaccharides depend on their chemical and
conformational structures. In general, highly branched polysaccharides are water soluble and
form relatively nonviscous solutions, whereas linear polysaccharides tend to be insoluble in water
and form viscous solutions.8
Polysaccharides exist as starch, glycogen, cellulose, and hemicellulose and are classified based

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on how readily digestible they are in the human body. The major digestible polysaccharides are
starch, stored mainly in plant cells, and glycogen, stored solely in animal tissues, particularly in
the liver and muscle.8 Plants also synthesize polysaccharides that are non-digestible in the human
gut such as cellulose, hemicellulose, and pectin.

Polysaccharides exist as starch, glycogen, cellulose, and hemicellulose and are classified
based on how readily digestible they are in the human body. The major digestible
544 polysaccharides are starch, stored mainly in plant cells, and glycogen, stored solely in animal
tissues, particularly in the liver and muscle.8 Plants also synthesize polysaccharides that are non-
digestible inChapter
the human1gut such as cellulose, hemicellulose, and pectin.
The Skeletal System

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Protein
Functions
Proteins are the most abundant macronutrient in the body that virtually exists in every cell, with
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over 40% of body protein found in skeletal muscle, over 25% found in body organs, and the rest
found mostly in the skin and blood.8 Proteins are virtually involved in every process that takes
place in cells.
The principal functions of proteins are to act as transcription factors in genetic expression and
to provide building blocks that aid in the growth, structure, and metabolic functions of tissues
and organs in the body.7 More specifically, proteins can act as energy substrates in periods of
starvation or as messengers in storing proteins, forming enzymes, hormones, receptors, signaling

545
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proteins, and antibodies.7 Proteins are present in whole foods of both plant and animal origin
The Skeletal System

and used in the food industry to provide structure, texture, and palatability to food products.
Amino Acid Classification

Amino acids are units of protein in their simplest form made of a central carbon (C) that bonds
at least one amino group (-NH2), at least one carboxyl group (-COOH), and a side chain (R
group). Amino acids can be classified based on structure, net charge, polarity, and essentiality.
What makes protein functions unique is the R group, a side chain that can take on many different
chemical forms and is configured from one of the 20 amino acids that every human body requires
to function.8
In 1957, William C. Rose and his colleagues defined a system of categorizing amino acids based
on essentiality.11 Out of the hundreds of amino acids that the body can build, only nine amino
acids are considered essential or indispensable.11 In other words, essential amino acids cannot be
Macronutrients
synthesized by the body and therefore must be and Hydration
supplied 547
by the diet. The following list identifies
the amino acids that are essential from those that are not essential.11
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Peptides and Proteins
Proteins are chains of over 50 aminoTrainer

acidsAcademy
that fold©into
2023three dimension configurations.
Similar to carbohydrates, amino acids form chains of various lengths held together by amide
546
Chapter 1
Peptides and Proteins
The Skeletal
Proteins are System
chains of over 50 amino acids that fold into three dimension configurations. Similar
to carbohydrates, amino acids form chains of various lengths held together by amide bonds, and
Anna
named afterD’Annunzio, MS in the chain. A polypeptide is a single linear chain made
the number of molecules
of many amino acids, and an oligopeptide is a chain of 2-20 amino acids.8
The naming of oligopeptides uses a similar approach to monosaccharides by using numerical

prefixes (di-, tri-, tetra-, penta-...) to determine the size of the polymer.8 For example, two amino
acid molecules can be covalently joined to yield a dipeptide, three amino acids can be joined to
form a tripeptide, four amino acids can be linked to form a tetrapeptide, and so forth.8
Lipids
Functions
Lipids, also referred to as fats, account for 30% to 35% of total caloric intake for many.5 The
primary function of lipids is to store energy in the human body and form structural components
of cellular membranes.7 Other important functions of lipids include providing lubrication and
conditioning for body surfaces, acting as signaling molecules of receptors, antigens, sensors,
electrical insulators, biological detergents, and membrane anchors for proteins.7
Lipids can act as specialized pigments (retinal and carotene), cofactors (vitamin K), and precursors
for hormones (vitamin D derivatives, sex hormones).8 Dietary sources of lipids predominantly
exist as triacylglycerols (TAGs) in butter, oils, meats, dairy products, nuts, seeds, and many
processed foods. Fats are commercially used as a cooking medium, to increase the tenderness of
baked goods, and add richness and flavor to meals.
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Structure and Properties
Lipids are structurally composed of carbon (C), hydrogen (H), and oxygen (O), but unlike
carbohydrates, they are insoluble in water. The capacity to classify lipids is limited to their solubility
property given that the systematic organic chemical naming of lipid structures is dominated by
trivial names.8 Lipids can therefore be classified based on the products of synthesis and their
structural and functional similarities.

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Triacylglycerols (TAGs) are virtually the most abundant storage form of lipids in the adipose
The Skeletal System

tissue and account for nearly 95% of dietary fat. The structure of TAGs is composed of a glycerol
backbone to which three fatty acids are attached by ester bonds.8 The three fatty acids can be
saturated (SFA), monounsaturated (MUFA), polyunsaturated (PUFA), or a combination.8
Fatty acids are single fat molecules composed of a soluble carboxylic acid head and an insoluble
hydrocarbon acid chain tail. Fatty acids are classified according to the length of the hydrocarbon
chains and their degree of saturation. Typically short-chain fatty acids chains have fewer than 6
carbon atoms, medium-chain fatty acids have 8 to 14 carbons, and long-chain fatty acids have
more than 14 carbons.8 Fatty acids can also be classified as unsaturated or saturated depending
on the number of double bonds in the hydrocarbon chain.
Trans Fatty Acids are chains of fat characterized by trans geometric bonds between a double
bond. The degree of bonding plays an important role in the structure and function of cell
membranes. The more carbon-carbon cis double bonds a chain has, the more pronounced the
bonding effect.8 Trans fatty acids are mainly produced because of partial hydrogenation.8 Partial
hydrogenation is the process commonly used to make frying oils and commercial food products
remain solid at room temperature. The role of trans fatty acids in the etiology of cardiovascular
disease is well established in the literature, indicating the potential risks associated with the
consumption of trans fatty acids in the human diet.12
Unsaturated Fatty Acids are chains of fat molecules with at least one double bond. The main
property of these fats is their ability to stay liquid at room temperature based on their double bond
configuration.8 Unsaturated fats exist as monounsaturated fatty acids (MUFAs) and polyunsaturated
fatty acids (PUFAs). MUFAs such as oleic acid (C18:1, ω-9) are considered omega-9 fatty acids
(C18:1, ω-9) and are not essential in the diet.8
Sources of MUFAs include vegetable oils like olive, avocado, canola, peanut, and sesame oil. PUFAs
such as linoleic and linolenic acid are essential in the diet because the body cannot synthesize
them. Linoleic acid (C18:2, ω-6) is an omega-6 fatty acid that primarily exists as arachidonic
acid (ARA) and can become inflammatory if consumed in a high amount.
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Food sources of omega-6s are corn, soybean, and safflower seed oils. Linolenic acid (C18:3,
ω-3) is an omega-3 fatty acid that appears to play anti-inflammatory roles in the prevention
and treatment of chronic diseases.13,14 Chief among the omega-3 fatty acids are eicosapentaenoic
acids (EPA), and docosahexaenoic acids (DHA), found in whole foods such as cold-water fatty
fish, shellfish, and algae, respectively.

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Phospholipids are composed of glycerol, phosphate, and the appropriate base, such as choline, and
The Skeletal System

show similar solubility properties to fatty acids. Particularly, the soluble head group and insoluble
fatty acyl chains allow phospholipids to form outer layer membranes, structural components of
the brain and nervous tissue, membranes of body tissues, and lipoproteins.8
Phospholipids are classified based on their head group. The five major classes of phospholipids
thus are phosphatidylcholine (PtdCho, also called lecithin), phosphatidylethanolamine (PtdEtn),
phosphatidylserine (PtdSer), phosphatidylinositol (PtdIns), and phosphatidylglycerol.8 Phospholipids
are found in sources of whole foods such as eggs, organ meats, lean meats, fish, shellfish, cereal
grains, and oil seeds.
Cholesterol is a derivative of plant sterols that frequently exist in foods and body tissues esterified
to one fatty acid per molecule. Similar to phospholipids, cholesterol is a membrane component
essential in brain and nervous tissue formation.8
The main function of cholesterol is to form bile acids, steroid hormones, and the precursor
to vitamin D.8 Cholesterol occurs naturally in foods of animal origin, mainly in liver and egg
yolk, red meats, poultry, whole milk, and cheese. Dietary cholesterol, which was once thought
to increase the risk of heart events, is no longer associated with heart disease, ischemic stroke,
or hemorrhagic stroke, and in some cases, appears to improve lipoprotein particle profiles and
HDL functionality.15
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549 Macronutrients and Hydration 550
Chapter 1
The Skeletal System

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550
Chapter 1
The
The Gastrointestinal
Skeletal System Tract
The gastrointestinal tract (GIT) or gastrointestinal system is the tubular structure that extends
Anna
from D’Annunzio,
the mouth to the anus. TheMS
GI system includes the oral cavity, pharynx, esophagus, stomach,
small intestine, large intestine, and rectum, as well as accessory organs (salivary glands, pancreas,
liver, and gallbladder) that provide essential secretions. The main functions of the GI are (1)
digestion of carbohydrates, proteins, and fats from dietary sources, (2) absorption of fluids,
micronutrients, and trace elements, (3) and providing immune protection against pathogens.16
Digestion, Absorption, and Excretion
Digestion
Digestion encompasses all the processes that result in the breakdown of macronutrients into
smaller units. Digestion is assisted by mechanical (physical) and enzymatic (chemical) processes.
Mechanical digestion includes chewing, mixing of food with secretions from the GIT, and
contractility of the stomach and the intestines to allow passage and breakdown of the food.
The process of digestion and absorption of macronutrients begins in the mouth. The mechanical
forces of the oral cavity cut and grind food and mix it with saliva to form a food bolus.16 The
main role of saliva is to initiate the digestion of carbohydrates and fat, neutralize acids in the
mouth, and assist in swallowing food.
Carbohydrates and fats are the only macronutrients that are initially digested in this site, with
the aid of salivary amylase and salivary lipase, respectively. From the mouth, the food bolus is
swallowed by passing from the pharynx into the esophagus. Swallowing is a voluntary reflex
regulated by the brain.16
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Once the bolus enters the stomach, the smooth muscles of the stomach, the gastric acid juices,
mucosa, and enzymes facilitate the transformation of the bolus into a chyme.16 The gastric juice
is highly acidic and creates an acidic environment for carbohydrates, lipids, and protein to break
down. Proteins are broken down into smaller peptides by pepsin, an enzyme that is activated by
the hydrochloric acid in the gastric juice. Lipids containing triacylglycerols (TAGs) are hydrolyzed
first into diglycerides and then fatty acids by the enzyme gastric lipase. Carbohydrates are further
broken down by salivary amylase until it is inactivated by the low pH of gastric juice.

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Absorption
The Skeletal
Absorption is System
the movement of nutrients, including water and electrolytes across the mucosal lining
of the GIT into the blood or the lymphatic system.16 The main organ responsible for complete
Annaand
digestion D’Annunzio,
absorption is theMS
small intestine, which accounts for specialized absorptive cells
that increase the uptake of nutrients across the extracellular compartment.
Once the stomach has acidified the chyme, it enters the small intestine where it is completely
absorbed. The small intestine is composed of three sections, the duodenum, the jejunum, and
the ileum. Absorption is accomplished by structural components called villi and microvilli, hair-
like extensions that project out of the lumen of the intestine and are made of absorptive cells to
transport nutrients out into the blood.16
When predigested macronutrients enter the small intestine, the pancreas releases pancreatic
juice and digestive enzymes to neutralize the acidic chyme and break down the nutrients for
absorption. Pancreatic enzymes are specialized according to each macronutrient and can digest
approximately half of all ingested carbohydrates, half of all proteins, and almost all (80–90%) of
ingested fat.16
Protein peptides are hydrolyzed into amino acids by a group of protein-based enzymes
called proteases that include trypsinogen, chymotrypsinogen, procarboxypeptidase, proelastase,
and collagenase.16 Proteases are formed in the pancreas and must travel to the small intestine to
complete digestion before they are absorbed.
Fat droplets are first hydrolyzed by bile salts before pancreatic enzymes complete the process. Bile
salts are composed of bile, an alkaline solution made and secreted liver that mixes with electrolytes,
pigments, and other substances to emulsify fat.16 This step allows pancreatic lipases made in the
pancreas to completely digest fat for absorption.
Digestion and absorption of disaccharides greatly depend on the availability of enzymes within
the small intestine.
©2023 Disaccharides first move into the duodenum and jejunum where lactase,
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sucrase, and maltase act upon each of their constituents.
Lactase cleaves a lactose molecule to yield one galactose and one glucose, sucrase hydrolyzes
sucrose to yield one glucose and one fructose residue, and maltase hydrolyzes maltose to yield
two glucose units. Once they reach the ileum, pancreatic amylase completes the final digestion
before monosaccharides are absorbed.

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Transport
The Skeletal
Following absorption ofSystem
the smaller constituents by the villi of the ileum, water-soluble nutrients
such as amino acids and monosaccharides, water-soluble vitamins, and electrolytes move across
intestinal MS blood until reaching the liver. The products of fat digestion
mucosa into the portal
such as monoacylglycerols and long-chain fatty acids must become reesterified to water-soluble
molecules before crossing the intestinal barrier. Fatty acids reform to TAGs and combine with
cholesterol and phospholipids to form chylomicrons.
Chylomicrons consist of a lipid core made of hydrophobic chains of fat, and a shell made of
phospholipid heads that can move through water.16 Unlike water-soluble nutrients, fat-soluble
nutrients travel from lymphatic vessels into blood vessels and directly into the heart without
making a first pass through the liver.
Excretion
The undigested material that has not been absorbed in the small intestine must move out from
the ileum into the large intestine. The primary functions of the colon are (1) absorption of water
and electrolytes from the ingesta, (2) microbial fermentation of undigested polysaccharides and
resistant protein, and (3) formation and storage of feces.16 The formation of stool or feces begins
with mixing neutralized chyme with mucus. Organic materials that the body can’t further process
are digested and fermented by bacteria in the colon, and the remaining water left is absorbed.
Normal feces are roughly 70% to 75% water and 20% to 25% solids.16
Metabolism
Metabolism is the sum of chemical reactions, secretions, and changes that occur within cells
of organ tissues to provide vital energy for the body.16 The metabolic processes involved in the
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body include anabolic and catabolic pathways. Anabolism or anabolic reactions are the metabolic
processes that involve the synthesis of macromolecules such as proteins, glycogen, various lipids,
and nucleic acids which promote growth.
Catabolism or catabolic reactions are the metabolic processes involved in the breakdown of
organic compounds to CO2 and H2O with the release and breakdown of energy. The three
organ systems that metabolize nutrients for storage and energy are the liver, the skeletal muscle,
the adipose tissue, and the brain.16

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Chapter 1
Carbohydrates
The Skeletal System
The metabolic fate of monosaccharides depends on the body’s energy needs. In the fed state,
Anna
glucose D’Annunzio,
levels start to rise andMS
signal insulin in the pancreas to absorb glucose into the cells.
Under these conditions, most tissues (liver, skeletal muscle, adipose, brain, and red blood cells)
will increase glucose uptake, oxidation of glucose into energy, and storage for later use.17
The main catabolic pathways that take place in the fed state are glycolysis, tricarboxylic acid
(TCA) cycle or citric acid cycle, and the pentose phosphate pathway (PPP).17
Glycolysis is the pathway that breaks down glucose into pyruvate.17 Glycolysis has two fates
depending on the availability of oxygen. When oxygen is present (aerobic glycolysis), glucose
makes pyruvate enter the mitochondria and be oxidized to acetyl-CoA, which will enter the
TCA cycle.17 When oxygen is limited or energy demands exceed oxygen supply, the cell relies
on anaerobic glycolysis.
In this case, lactate or lactic acid is formed, but the energy produced through this process is much
less than through aerobic oxidation and therefore less favorable.17 If lactic acid levels start to
rise, the Cori cycle takes place, by releasing lactate from the tissue, transporting it to the liver,
and converting it back to pyruvate.17
The TCA cycle, also known as the citric acid cycle or Krebs’s cycle, is the pathway that takes place
in the mitochondria to convert pyruvate into energy.16 This can only take place in the presence of
oxygen and acetyl-CoA, an intermediate breakdown product of carbohydrates, protein, and fat.
This cycle produces 90% of the body’s energy as ATP and results information of carbon dioxide
(CO2) and water (H2O).17
Monosaccharides can also undergo anabolic pathways in the fed state. The most important
pathway is glycogenesis. This process synthesizes single units of glucose into glycogen to serve as
the main storage form of carbohydrates in the liver and skeletal muscle.17 On the contrary, when
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the body is in the fasted state, it will decrease serum glucose levels by the actions of glucagon in
the pancreas and utilize alternative fuels for energy.17
Glycogenolysis is the catabolic pathway that takes place in the fed state and forms glucose from
glycogen stores to maintain blood glucose levels.17

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Chapter 1
Fat
The Skeletal System
The adipose tissue is the main site for fat metabolism and storage. In the fed state, glucose, as
Anna
well D’Annunzio,
as dietary MS(transported as chylomicrons), are taken up by the adipose
fat and cholesterol
tissue.17 Dietary fat undergoes lipogenesis, an anabolic reaction that oxidizes glucose to glycerol
and synthesizes them to triacylglycerols (TAGs).17
The liver can also synthesize fat but should never store fat. To prevent fat accumulation, the liver
is equipped with lipotropic factors that promote the removal of fat from the liver].16 During
a fasting state, the signaling of hormones such as glucagon and growth hormone will
stimulate the activation of lipolysis.17 Lipolysis is a catabolic pathway that releases fatty
acids from stored triacylglycerols and provides an oxidizable substrate for the skeletal muscle
and liver.17
Protein
Protein metabolism mainly takes place in the liver. Since protein can’t be stored in the body, once
protein needs are met, any protein excess is used to make fat and fat storage deposits, and energy,
or is removed by the kidneys in the urine.
In the fed state, protein synthesis is the main anabolic reaction that takes place in the ribosomes
of liver cells to form proteins from amino acids.17 This pathway involves a complex interplay of
many macromolecules including ribosomes, messenger RNA (mRNA), transfer RNA (tRNA),
the genetic code, and protein factors.16
Muscle protein synthesis (MPS) is the metabolic process that describes the incorporation
of amino acids into bound skeletal muscle proteins.18 Muscle proteins can be classified into
contractile myofibrillar proteins (i.e., myosin, actin, tropomyosin, troponin) and energy-producing
mitochondrialTrainer
proteins.
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©2023
Depending on diet and translation needs, excess amino acids will undergo amino acid catabolism
where amino acids split off the nitrogen groups to form free ammonia. Given that ammonia in
the blood can be toxic, it must be converted into urea through the urea cycle, to safely remove it
from the blood and into the kidneys.17 Some of it can be converted into purines, and some are
used to make the nonessential amino acids through transamination. Excess amino acids are not
stored, rather the deaminated carbon skeletons can be stored as glycogen or fat.17

555
Chapter 1
In the fasted state, the main anabolic pathways that take place are gluconeogenesis and ketogenesis
The Skeletal System

in the liver. Gluconeogenesis is an anabolic process that synthesizes glucose from lactate, amino
acids, or glycerol. The glucose produced is released into the bloodstream to maintain blood glucose
and provide energy for the brain and red blood cells (RBC).17
Ketogenesis is the biochemical process through which organisms produce ketone bodies by
breaking down mostly ketogenic amino acids and fatty acids to serve as energy supply for certain
organs, particularly the brain, heart, and skeletal muscle.17 Ketogenesis and gluconeogenesis are
similar in that they are both chemical processes that provide energy to the body when not enough
carbohydrate is present in the diet. However, ketogenesis differs in that it produces ketones to
be used as fuel, rather than glucose.17
Macronutrient Content in Foods

Carbohydrates
Carbohydrate is an umbrella term that encompasses sugar, fruits, vegetables, fibers, and legumes.
Complex carbohydrates (oligosaccharides or polysaccharides) are generally preferred over simple
carbohydrates because they take longer to digest and have a more gradual effect on the increase
in blood sugar, whereas simple carbohydrates (monosaccharides) can rapidly raise blood glucose
levels upon digestion. In some cases quick digesting carbohydrates are needed, but in most
scenarios, slower carbohydrates are preferable, due to longer levels of energy.
The individual effects of food on blood sugar can be measured by the glycemic index scale that
ranks carbohydrates from 0 to 100 based on how rapidly the rise in blood glucose occurs upon
consumption.19 The following lists food items as poor or beneficial sources of carbohydrates in
terms of slow digestion.
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Poor carbohydrates (quick digesting):
• Fruit juice
• White bread
• Crackers and crisp bread
• Breakfast cereals
• Processed grains and pasta
• Sodas

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Chapter 1
• Sweets
The Skeletal System

• Convenience foods
• Sweetened dairy products
Anna carbohydrates
Beneficial D’Annunzio,
(slowMS
digesting):
• Fruits (all whole fruits)

• Non-starchy vegetables (spinach, broccoli, kale, cauliflower)
• Starchy vegetables (potatoes, sweet potatoes, carrots, beets, peas, corn, pumpkin, rutabaga)
• Unrefined whole grains (brown rice, whole wheat, oatmeal, muesli, whole grain pasta)
• Legumes ( lentils, chickpeas, soybeans, baked beans, cannellini beans, kidney beans)
• Dairy products (non-fat, 1% milk, 2% milk, low-fat yogurts)
Protein
Complete protein sources are generally of animal origin except for some plant-based foods. Complete
protein refers to foods that contain all the essential amino acids required in the diet.20 Despite
this, it would be wrong to assume that animal-based foods provide more protein than plant-based
ones.20 Not all plant foods are low in the same amino acids, so eating a variety of plant-based
foods can provide all nine of the essentials.20 Complete animal proteins include eggs, dairy, meat,
and seafood; whereas complete plant-based foods mainly include soy.
High protein foods
• Meat (7g protein/oz)

• Fish and shellfish (7g protein/oz)
• Eggs (7g protein/oz)
• Cow’s Milk (8g protein/cup)
• Goat’s Milk (9g protein/cup)
• Soy Milk Trainer
(7-8 g protein/cup)
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• Plain yogurt (6-7g protein/1/2 cup)

• Greek yogurt: (11-15g protein/1/2 cup)
• Cheese (7g protein/1oz)
• Nut butter (8g protein/2 Tbsp)
• Tofu (4.6 g protein/oz)
• Lentils, cooked (10g protein/1/2 cup)
• Chickpeas, cooked (8g protein/1/2 cup)
• Quinoa, cooked (4g protein/1/2 cup)

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• Teff, cooked (5g protein/1/2 cup)
The Skeletal System

• Chia seeds (5g protein/oz)
Fats
Fats and oils are naturally found in both plants and animal foods, and, most recently, commercially
prepared as hydrogenated oils. Oils are classified by their stability at room temperature and
essentiality.
Particularly trans fats, saturated fats, and some omega-6 vegetable oils have been shown to promote
inflammation, whereas a diet high in monounsaturated fat and essential omega-3 fats have been
shown to inhibit and reduce inflammation by interfering with pro-inflammatory compounds
naturally made by the body.13, 14 Diets supplemented with omega-3 fats have been shown to
reduce post-exercise delayed-onset muscle soreness and inflammation and promote healing.21
Essential Fats
• Seeds
• Nuts
• Legumes
• Fish and shellfish
• Vegetable oils
Non-essential Fats
• Tropical oils
• Vegetable oils
• Peanut oil
• Butters and solid fats
• Red meatsTrainer©2023
Academy
• Dairy products
• Snacks

558
Chapter 1
Macronutrient
The Recommendations for
Skeletal System
Fitness Goals
Dietary Intake Guides

The Recommended Dietary Allowance (RDA), first established in 1941 by the Food and Nutrition
Board of the Institute of Medicine, defined the average daily amount of nutrients to meet the needs
of most healthy people.5 With changes to the food supply and needs of the general population,
the RDAs were adapted into a framework of nutrient recommendations called dietary reference
intakes (DRIs). Included in the DRIs are RDAs, as well as guidance on safe upper limits (ULs)
of vitamins and minerals.
1-based guidelines revised and published every five years by the National Academy of Sciences
Food and Nutrition Board of the Institute of Medicine (IOM) in conjunction with the U.S.
Department of Agriculture.22 The first ever published guidelines were a federal government
response to the increasing national concern for the rise in nutrition-related chronic diseases.19
Today, the DGAs are used by accredited nutrition professionals to assist the public in consuming
a healthy diet.22 For other health and community professionals, including the government, the
information in the DGA can be incorporated into community programs and used to create
educational materials for consumers and health initiatives.22
In 2011 the MyPlate guidelines from the USDA replaced the previous MyPyramid diagram.23 The
MyPlate is designed for the general population and serves as a food guidance system to choose
foods from within and across food groups to meet nutrient needs.23 The amounts vary based on
a person’s gender and age.
Generally, MyPlate ©2023 suggests that adults consume the following each day: at least 2 cups of fruits,
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2 and 1 ⁄ 2 cups of vegetables, a minimum of 3 oz of whole grains, at least 1 and 1 ⁄ 2 cups of beans
and peas weekly, 5 to 6.5 oz of protein, and 3 cups of dairy.

559
Chapter 1
Macronutrient Requirements
The Skeletal System
Carbohydrates
According to the RDAs, healthy adult diets should consume 130 grams of carbohydrates per
day to maintain the most essential functionalities of the brain.5 The Acceptable Macronutrient
Distribution Range (AMDR) suggests including 45 to 65% of daily calories in the form of
carbohydrates, or 225 and 325 grams of carbohydrates based on a daily 2,000 calorie diet.5
Recommendations for daily carbohydrate intake in the athlete population vary by gender, age,
body mass, and training needs. A carbohydrate intake of 5 to 7 g/kg/day can meet the general
training requirements, an intake of 7 to 10 g/kg/day of carbohydrates will likely suffice for
endurance athletes, and for elite athletes training 5 to 6 hours a day, 12 g/kg/day or a range of
420 to 720 g of carbohydrates are appropriate.24
Carbohydrate intake will also vary greatly depending on the training modality. When glycogen
stores drop to critically low levels, the athlete must either stop exercising or drastically reduce the
pace. If athletes experience glycogen depletion after exercise, a carbohydrate intake of 1.5 g/kg body
weight during the first 30 minutes and again every 2 hours for 4 to 6 hours is recommended.19
As a general recommendation, athletes should consume a mixed meal after strenuous training
that provides a balance of all three macronutrients to help build and repair muscle tissue. If the
goal of the client is solely to gain a healthy weight of lean muscle tissue, an additional 500 to
1,000 calories per day can be added in addition to strength training.19
Protein
Protein requirements
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©2023 greatly vary depending on the age, body size, and physiological state, as
well as the level of energy intake of each individual. The RDA of protein for adults (men and
women aged 19 years and older) is set at 0.8 grams of protein per kilogram of body weight to
maintain basic function.5 The AMDR for protein is 10 to 35% of calories for adults or about 50
to 175 grams per day for people consuming 2,000 calories per day.5
The athletic population will have an increased need for protein intake depending on the training
modality that the individual is engaged in. For endurance athletes, nitrogen balance studies in
men suggest a protein recommendation of 1.2g/kg per day.25

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If resistance training is the main modality, protein requirements are higher than endurance
The Skeletal System

exercise, and it has been recommended that experienced male bodybuilders and strength athletes
consume 1.6 to 1.7g/kg/day to allow for the accumulation and maintenance of lean tissue.26, 27
For athletes interested in muscle hypertrophy, it appears that neither the type nor the number
of Anna
proteins D’Annunzio,
matters if the day’sMS
total amount is within the recommended range for resistance-
training athletes of 1.2 to 2 g/kg/day.19
Protein intake after training is essential to help build and repair muscle tissue. Research shows
that a minimum of 30 g of high-quality protein at each meal that contains 2.5 g leucine per meal
optimally stimulates protein synthesis, and when leucine and omega-3 fatty acid are supplemented
there is a reduction in muscle loss for acutely injured athletes.21
Fats
The Food and Nutrition Board of the IOM has not established RDAs for fats.5 The AMDR for
fat is between 20 to 35% of total dietary calories for adults age 19 and older or about 44 to 77
grams of fat per day if consuming a 2,000-calorie diet.5 The AMDRs recommend adjusting the
number of calories coming from fat based on the type of fat.
It is recommended that monounsaturated fats represent 15% to 20% of total calories/day,

polyunsaturated fat 5% to 10% of total calories/day, saturated fat less than 10% of total calories/
day, cholesterol less than 300 mg/day, and completely zero trans fats.5 The IOM also gives
recommendations for the two essential fatty acids: linoleic acid (men, 14–17 g/d; women, 11-I2g/d)
and linolenic acid (men, 1.6 g/d; women, I. I g/d).5
Fat is a macronutrient that should never be disregarded in the dietary pattern of athletes, since
there is no performance difference with less than 15% of energy from fat, compared with 20%
to 25% of energy from fat].28 Fat is also essential in athletes’ dietary intake as it provides energy,
fat-soluble vitamins, and essential fatty acids.
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561
Chapter 1
Hydration
The Requirements and Strategies
Skeletal System
Anna Function
Water D’Annunzio, MS
Water (H2O) is an essential nutrient that makes up the largest component of the body, accounting
for about 73% of lean body mass in adults.19 As a vital nutrient to both humans and plants, water
functions to (1) dissolve nutrients, minerals, gasses, and enzymes, (2) regulate body temperature,
(3) lubricate and moisten tissues, (3) transport nutrients and oxygen into cells and remove excess
waste, (4) maintain blood volume and acid-base (pH) balance.19
Electrolytes
Within fluid systems in the body exist electrolytes, and electrically charged minerals that regulate
fluid balance, movement, and distribution within other compartments. Electrolytes are responsible
for (1) the maintenance of physiologic body functions, (2) cellular metabolism, (3) neuromuscular
function, and (4) osmotic equilibrium.19 The major extracellular electrolytes are sodium (Na+),
calcium (Ca2+), chloride (Cl-), and bicarbonate (HCO3-). Potassium (K+), magnesium (Mg2+).,
and phosphate (PO ₄)³⁻ .19
Dehydration
Water is naturally lost throughout the day by the respiratory tract, skin, gastrointestinal tract,
and kidneys. During physical exercise, the body increases the rate of sweat production leading
to substantial water and electrolyte losses. If sweat water and electrolyte losses are not replaced
then the individual will dehydrate during physical activity.
Dehydration refers to the loss of body water of 2% or more of body weight.19 The typical symptoms
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of dehydration include extreme thirst, decreased urine output, secretion of concentrated urine,
headaches, fatigue, muscle cramps, hypotension, and fever.19
The effects of body water loss ultimately alter the functionalities of the central nervous system,
thermoregulatory system, cardiovascular system, and metabolic functions. Excessive dehydration
can increase the risk for heat exhaustion29, 30, 31 and heat stroke32, 33, 34, 35 In addition, dehydration
has been associated with reduced autonomic cardiac stability36 altered intracranial volume,37 and
reduced cerebral blood flow velocity responses to orthostatic challenges.38

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Chapter 1
Water and Electrolyte Requirements
The
For anSkeletal System
individual to maintain a water balance, the amount of water consumed must equal the
amount lost from the body. The body can maintain a water balance by releasing and regulating
Annaincluding
hormones D’Annunzio,
antidiureticMS
hormone, aldosterone, angiotensin II, cortisone, norepinephrine,
and epinephrine. 39
The minimal amount of daily water to replace obligatory water losses from the respiratory tract,
skin, feces, and urine is about 1.44 L. Calculations of daily water intake are also based on age
group and exercise intensity.
Adults
According to the IOM, the general fluid requirements for adults are based on the formula 35
m/kg or 1mL/kcal of energy expenditure.40 The IOM also recommends adequate intake (AI)
values for total water at levels to prevent dehydration.40 The AI for men aged 19+ is 3.7 liters
each day, and 3 liters (13 cups) of which should be consumed as beverages.40 The AI for women
aged 19+ is 2.7 liters about 2.2 liters (9 cups) which should be consumed as beverages each day.40
Special attention must be given to this population given their increased risk for dehydration. The
EFSA reviewed the literature and recommended an Adequate Intake (AI) of 2.0 L/day for women
and 2.5 L/day for men of all ages (from a combination of drinking water, beverages, and food).41
Pregnancy and Lactation Pregnancy is also at risk for dehydration given the increased needs of
the fetus, and the amniotic fluid. The water requirements for pregnant women are the same as in
non-pregnant women plus an increase in proportion to the increase in energy intake (300 mL/
day) is proposed. For lactating women, adequate water intakes of about 700 mL/day above the
AIs of non-lactating women of the same age are derived.
Physical Activity
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The level of physical activity of adults can also impact water requirements. The following guidelines
can be used to assess fluid requirements before, during, and after physical activity:
Before an activity it is recommended to drink 17 to 20 oz of water 2 to 3 hours before the start

of exercise or during warm-up to maintain normal plasma electrolyte levels.40 Consumption of
sodium in beverages (20-50 mEq/L) and/or small amounts of salted snacks or sodium-containing
foods at meals helps to stimulate thirst and retain the consumed fluids.40 On the contrary,
hyperhydration can lower plasma sodium and increase the risk of dilutional hyponatremia.40

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During activity it is suggested to drink 7-10 ounces of fluid every 10 to 20 minutes to prevent
The Skeletal System

excessive dehydration.40 In prolonged exercise lasting greater than 3 hours, such as for marathon
runners, a possible starting point is to drink ad libitum from 0.4 to 0.8 L/hr.40
Annahydration can
Restoring D’Annunzio, MS by drinking around 1.5 L/kg of body weight loss.40 When
be accomplished
possible, it is recommended that fluids are consumed over time (and with sufficient electrolytes)
rather than being ingested in large boluses to maximize fluid retention .42, 43
Water replacement in the absence of supplemental sodium can lead to decreased plasma sodium
concentrations.19 When plasma sodium levels fall below 130 mEq/L, the individual can experience
lethargy, confusion, seizures, or loss of consciousness.40 Exercise-induced hyponatremia may result
from fluid overloading during prolonged exercise over 4 hours.40
Hyponatremia is associated with individuals who drink plain water above their sweat losses or
who are less physically conditioned and produce a saltier sweat.40 Another important electrolyte,
potassium, can decrease through sweat, but the loss of 32 to 48 mEq/day does not appear to be
significant and is easily replaced by diet.40
Hot Weather Conditions
For individuals performing prolonged physical activity in hot weather, drinking fluid replacements
or also known as electrolyte replacement is suggested. Beverages containing approximately 20-30
mEq/L of sodium (chloride as the anion), 2-5 mEq/L of potassium, and 5-10% carbohydrate
are recommended.44
The sodium and potassium are to help replace sweat electrolyte losses, while sodium also helps
to stimulate thirst, and carbohydrate provides energy.44 These components also can be consumed
by nonfluid sources such as gels, energy bars, and other foods.44
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564
Chapter 1
Summary
The Skeletal System
Macronutrients provide the essential energy for growth, maintenance, metabolic functions, and
AnnaHealthy
survival. D’Annunzio,
adults shouldMSconsume adequate amounts of protein, carbohydrates, and fat
based on their weight and calorie requirements.
Water is a vital nutrient that dissolves nutrients, regulates temperature, lubricates tissues, transports
important products across cells and removes excess waste, along with maintaining blood volume
and acid-base balance in the body. Water and electrolytes are lost throughout the day and must
be replenished, especially with added activity or warm weather conditions.
References
1. Harper, A. E. Defining the essentiality of nutrients. In M. E. Shils, J. A. Olson, M. Shike, & A. C. Ross
(Eds.), Modern nutrition in health and disease (9th ed, pp. 3–10). Baltimore: Williams & Wilkins.
1999.
2. Rudman D, Feller A. Evidence for deficiencies of conditionally essential nutrients during total parenteral
nutrition. J Am Coll Nutr. 1986;5(2):101-106. https://doi.org/10.1080/07315724.1986.10720117
3. Beman, J. Energy Economics in Ecosystems. 2010. Nature Education Knowledge 3(10):13
4. National Research Council (US) Committee on Diet and Health. Diet and Health: Implications for
Reducing Chronic Disease Risk. Washington (DC): National Academies Press (US); 1989.
5. Trumbo P, Schlicker S, Yates AA, Poos M; Food and Nutrition Board of the Institute of Medicine, The
National Academies. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol,
protein, and amino acids. J Am Diet Assoc. 2002;102(11):1621-1630. https://doi.org/10.1016/s0002-
8223(02)90346-9
6. Madigan MT, Brock TD, Parker J, Martinko JM. Brock Biology of Microorganisms: International
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Edition. 10th ©2023

ed. Pearson; 2002.
7. Murray RK, Bender D, Botham KM, Kennelly PJ, Rodwell VW, Weil PA. Harper’s Illustrated
Biochemistry. 29th ed. McGraw-Hill Medical; 2012.
8. Nelson DL, Cox MM. Lehninger Principles of Biochemistry. 8th ed. W. H. Freeman; 2021.
9. Swagerty DL Jr, Walling AD, Klein RM. Lactose intolerance [published correction appears in Am

Fam Physician. 2003 Mar 15;67(6):1195]. Am Fam Physician. 2002;65(9):1845-1850.

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10. Garrett RH, 1 CM. Biochemistry. 4th ed. Brooks/Cole; 2010.
Grisham
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11. Rose, W. C. Feeding experiments with mixtures of highly purified amino acids: I. The inadequacy of diets
containing nineteen amino acids. The Journal of Biological Chemistry. 1931; 94, 155–165.
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12. de Roos D’Annunzio,
NM, Schouten EG, KatanMS MB. Trans fatty acids, HDL cholesterol, and cardiovascular disease.
Effects of dietary changes on vascular reactivity. Eur J Med Res. 2003;8(8):355-357.
13. Massaro M, Scoditti E, Carluccio MA, Montinari MR, De Caterina R. Omega-3 fatty acids,
inflammation, and angiogenesis: nutrigenomic effects as an explanation for anti-atherogenic and anti-
inflammatory effects of fish and fish oils. J Nutrigenet Nutrigenomics. 2008;1(1-2):4-23.
14. Wall R, Ross RP, Fitzgerald GF, Stanton C. Fatty acids from fish: the anti-inflammatory potential
of long-chain omega-3 fatty acids. Nutr Rev. 2010;68(5):280-289. https://doi.org/10.1111/j.1753-
4887.2010.00287.x
15. Blesso CN, Fernandez ML. Dietary Cholesterol, Serum Lipids, and Heart Disease: Are Eggs Working
for or Against You?. Nutrients. 2018;10(4):426. Published 2018 Mar 29. https://doi.org/10.3390/
nu10040426
16. Stipanuk, M. H. Biochemical, physiological, & molecular aspects of human nutrition. 3rd ed. St. Louis:
Saunders Elsevier; 2006.
17. Lieberman, M., A. and Peet, eds. Marks’ Basic Medical Biochemistry: A Clinical Approach. 5th ed.
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 2: The Fed or
Absorptive State, Chapter 3: The Fasted State.
18. Witard OC, Bannock L, Tipton KD. Making Sense of Muscle Protein Synthesis: A Focus on Muscle
Growth During Resistance Training. Int J Sport Nutr Exerc Metab. 2022;32(1):49-61. https://doi.
org/10.1123/ijsnem.2021-0139
19. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11th ed. W B Saunders; 2003.
20. Smith J, Gropper S, Carr T. Advanced Nutrition and Human Metabolism. 8th ed. Wadsworth Publishing;
2021
21. Tipton KD. Dietary strategies to attenuate muscle loss during recovery from injury. Nestle Nutr Inst
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2013;75:51-61. https://doi.org/10.1159/000345818
©2023
22. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary
Guidelines for Americans, 2020-2025. 2020. 9th Edition. https://www.dietaryguidelines.gov/
23. U.S. Department of Agriculture. MyPlate. 201. http://www.choosemyplate.gov/
24. Driskell JA, Wolinsky I, eds. Nutritional Assessment of Athletes, Second Edition. CRC Press; 2016. https://
doi.org/10.1201/b10203
25. Fraser CL, Kucharczyk J, Arieff AI, Rollin C, Sarnacki P, Norman D. Sex differences result in increased
morbidity from hyponatremia in female rats. Am J Physiol. 1989;256(4 Pt 2):R880-R885. https:/doi.

566
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org/10.1152/ajpregu.1989.256.4.R880
The Skeletal System

26. Fraser CL, Arieff AI. Epidemiology, pathophysiology, and management of hyponatremic encephalopathy. Am
J Med. 1997;102(1):67-77. https://doi.org/10.1016/s0002-9343(96)00274-4
AnnaCL,
27. Fraser D’Annunzio, MS pump function in rat brain synaptosomes is different in males and
Sarnacki P. Na+-K+-ATPase
females. Am J Physiol. 1989;257(2 Pt 1): E284-E289. https://doi.org/10.1152/ajpendo.1989.257.2.E284
28. Rodriguez NR, DiMarco NM, Langley S; American Dietetic Association; Dietitians of Canada;
American College of Sports Medicine: Nutrition and Athletic Performance. Position of the American
Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and
athletic performance. J Am Diet Assoc. 2009;109(3):509-527. https://doi.org/10.1016/j.jada.2009.01.005
29. Adolph E.F. and associates. Physiology of Man in the Desert. 1970. Am J Trop Med Hyg;19(3):576-
576. https://doi.org/10.4269/ajtmh.1970.19.3.tm0190030576a
30. McLellan TM, Cheung SS, Latzka WA, et al. Effects of dehydration, hypohydration, and hyperhydration
on tolerance during uncompensable heat stress. Can J Appl Physiol. 1999;24(4):349-361. https://doi.
org/10.1139/h99-027
31. Sawka MN, Young AJ, Latzka WA, Neufer PD, Quigley MD, Pandolf KB. Human tolerance to heat
strain during exercise: influence of hydration. J Appl Physiol (1985). 1992;73(1):368-375. https://doi.
org/10.1152/jappl.1992.73.1.368
32. Carter R 3rd, Cheuvront SN, Williams JO, et al. Epidemiology of hospitalizations and deaths from
heat illness in soldiers. Med Sci Sports Exerc. 2005;37(8):1338-1344. https://doi.org/10.1249/01.
mss.0000174895.19639.ed.
33. Epstein Y, Moran DS, Shapiro Y, Sohar E, Shemer J. Exertional heat stroke: a case series. Med Sci
Sports Exerc. 1999;31(2):224-228. https://doi.org/10.1097/00005768-199902000-00004
34. Centers for Disease Control (CDC). Exertional rhabdomyolysis and acute renal impairment–New York
City and Massachusetts, 1988. MMWR Morb Mortal Wkly Rep. 1990;39(42):751-756.
35. Centers for Disease Control and Prevention (CDC). Hyperthermia and dehydration-related deaths
associated with intentional rapid weight loss in three collegiate wrestlers–North Carolina, Wisconsin, and
Michigan, November-December 1997. MMWR Morb Mortal Wkly Rep. 1998;47(6):105-108.
Trainer Academy
36. Carter R III,©2023
Cheuvront SN, Wray DW, Kolka MA, Stephenson LA, Sawka MN. The influence
of hydration status on heart rate variability after exercise heat stress. J Therm Biol. 2005;30(7):495-
502. https://doi.org/10.1016/j.jtherbio.2005.05.006
37. Strachan A, Watson P. The effects of dehydration on brain volume–preliminary results. Int J Sports Med.
2006;27(4):342. doi:10.1055/s-2006-924007
38. Carter R 3rd, Cheuvront SN, Vernieuw CR, Sawka MN. Hypohydration and prior heat stress exacerbates
decreases in cerebral blood flow velocity during standing. J Appl Physiol (1985). 2006;101(6):1744-
1750. https://doi.org/10.1152/japplphysiol.00200.2006

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39. Kingley Chapter

J: Fluid and 1
electrolyte management in parenteral nutrition, Support Line 27:13, 2005.
The Skeletal
stand. ExerciseSystem
40. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medicine
position and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377-390. https://doi.
org/10.1249/mss.0b013e31802ca597
41. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA). Scientific opinion on dietary reference
values for energy. 2013. EFSA J. 11, 3005.
42. Kovacs EM, Schmahl RM, Senden JM, Brouns F. Effect of high and low rates of fluid intake on post-
exercise rehydration. Int J Sport Nutr Exerc Metab. 2002;12(1):14-23. https://doi.org/10.1123/
ijsnem.12.1.14
43. Wong SH, Williams C, Simpson M, Ogaki T. Influence of fluid intake pattern on short-term recovery
from prolonged, submaximal running and subsequent exercise capacity. J Sports Sci. 1998;16(2):143-
152. https://doi.org/10.1080/026404198366858
44. Institute of Medicine (US) Committee on Military Nutrition Research, Marriott BM, eds. Fluid
Replacement and Heat Stress. Washington (DC): National Academies Press (US); 1994.
Trainer Academy
©2023

Chapter 1
TheCHAPTER
Skeletal26System
Micronutrients
569
Micronutri ents
Chapter 1
Introduction
The Skeletal System
Micronutrients are the compounds necessary to maintain the daily functions of the human body.
Anna
These D’Annunzio,
encompass MS
organic and inorganic compounds such as vitamins and minerals.1 There are
nearly 30 of these nutrients considered to be essential because the body cannot manufacture
them in sufficient amounts.
Thus, these micronutrients must be obtained from the diet in small amounts to maintain essential
functions in the body, human development, disease prevention, and well-being.1 Given the
importance of micronutrients in health and fitness training, fitness professionals should have a
working knowledge of the various key micronutrients required in a complete human diet.
Vitamins
Vitamins are organic compounds and are essential nutrients found in plants and animals
that are only required in the diet in small amounts to maintain fundamental functions of the
body.2 Vitamins are categorized into two groups: water-soluble vitamins (the vitamin B group,
C, folic acid, and biotin) and lipid-soluble vitamins (A, D, E, and K).2
The classification of vitamins is based on their solubility, and biochemical and physiological
roles in digestion, absorption, and transport rather than chemical structures.3 Another important
distinction is that vitamins cannot be transformed into energy to meet metabolic demands nor
used for structural purposes but can be easily broken down by heat, acid, or air. Hence vitamins
are required in much smaller amounts than carbohydrates, proteins, and fats.3
Minerals Trainer Academy

©2023
Minerals, or inorganic nutrients, are essential elements found in the soil and water and classified
into macro and micro minerals. Macrominerals are composed of calcium, phosphorus, magnesium,
sodium, potassium, chloride, and sulfur.
The microelements may be considered in two groups: trace elements (iron, zinc, manganese,
copper, and fluorine) and ultra-trace elements (selenium, molybdenum, iodine, chromium, boron,
and cobalt).3 Other minerals such as arsenic, nickel, vanadium, and silicon have proven some

570
Micronutri ents
Chapter 1
benefits in animal studies but have insufficient evidence to determine their essentiality or benefit
The Skeletal System

for humans.
Role of Micronutrients in the Human Body
Micronutrients play a key role in metabolism, the maintenance of tissue function, and the prevention
of critical illness. Optimal intakes of micronutrients are essential to all individuals, with observable
clinical benefit in those who are severely depleted. Improper dosing of micronutrients carries its own
risks and can be potentially harmful to those who exceed upper limit intakes of vitamins and minerals.4
The four main biochemical functions of micronutrients can be summarized below:
Cofactors
Cofactors are inorganic trace elements whose presence facilitates enzymatic reactions in metabolic
processes.4 For example, zinc is a cofactor for over 100 enzymes, whereas selenium is required in
the form of selenocysteine within the enzyme glutathione peroxidase.4
Coenzymes
Coenzymes are defined as small, organic molecules that are required by an enzyme and that
participate in the chemistry of catalysis.3 In human biology, coenzymes are the vitamins whose
presence is required to facilitate an enzymatic reaction.4 For example, riboflavin and niacin are
vitamins that participate in the electron transport chain by acting as intermediary elements to
ensure the formation of energy, proteins, and nucleic acids.4
Transcription factors
TranscriptionTrainer
factors
Academy
©2023 are minerals that have a key role in genetic control.4 For example, zinc
“fingers” are transcription control factors that bind to DNA and regulate the transcription of
receptors for steroid hormones and other factors.4
Antioxidants
Antioxidants are a class of micronutrients that aid in the removal and protection against mediators
of systemic inflammation such as reactive oxygen species (ROS) or “free radicals.”4 Many vitamins
have antioxidant properties.

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Micronutri ents
Chapter 1
For example tocopherol (Vitamin E) is a lipid-soluble antioxidant known to play an important
The Skeletal System

role in scavenging free radicals that damage cells.5 Wound healing and immune function also
depend on adequate levels of vitamins andMicronutrients
trace elements.6 571
Trainer Academy
©2023
Vitamins: Functions, Sources, Intake

Guidelines, and Deficiencies
Fat-Soluble Vitamins
572
Micronutri ents
Chapter 1
Vitamins:
The Skeletal Functions,
System Sources, Intake
Guidelines, and Deficiencies
Fat-Soluble Vitamins
Like any other fat, fat-soluble vitamins are absorbed into the lymphatic system before they can
travel through the blood in association with protein carriers.7 Fat-soluble vitamins can be stored
within the liver or with other lipids in fatty tissues and tend to be susceptible to building up and
potentially causing toxicity.7 The requirements for fat solubles vary greatly, but periodic dosages
(weeks or even months) are optimal requirements because the body can draw on its stores.7
Vitamin A
Vitamin A (Retinol, Retinoic acid) plays a vital role in vision and skin integrity and is involved
in maintaining bone, teeth, nerves, and membrane integrity and functionality.7, 8 The active form
of vitamin A is present in organ meats, liver, fish oil, fortified milk, and foods such as enriched
cereals. The precursor of vitamin A, beta-carotene, is naturally present in yellow and orange fruits,
and dark leafy green vegetables.
When vitamin A supply runs low, night blindness (nyctalopia) can occur.7, 8 This is a reversible
process that can be corrected with adequate supplementation. If vitamin A deficiency is not
corrected, it can lead to xerophthalmia, a more profound deficiency that results in permanent
and irreversible blindness.7, 8
Populations at risk for vitamin A deficiency include those experiencing malnutrition, anorexia
nervosa, burns, some forms of cancer, cystic fibrosis, and recent obstructions leading to surgery.7,8
Signs of vitamin A toxicity include headaches, weight loss, abdominal pain, blurred vision,
Trainer Academy
©2023
muscle weakness, drowsiness, irritability, and peeling of skin.7, 8 Vitamin A intake that exceeds
the tolerable upper limit can lead to congenital birth defects in the eyes, skull, lungs, and heart.7,8
AI for infants is based on the amount of retinol found in human milk. RDA is 900 mg for men
and 700 mg for women, adjusted for differences in average body size. UL is 3000 mg/d.9 Vitamin
A intake in pregnant women should be restricted if present in supplement form.

573
Micronutri ents
Chapter 1
Vitamin D
The Skeletal
Vitamin D (Calcitriol, System
D3) regulates calcium and phosphorus metabolism to maintain bone
integrity.7, 8 The main sources of vitamin D are sunlight, egg yolks, fortified milk, and supplements,
Anna referred
commonly D’Annunzio, MSD3 (cholecalciferol).
to as Vitamin
Plant sources also contain vitamin D in the D2 form (ergocalciferol) and are equally as absorbable
as Vitamin D3. The precursor of this fat-soluble vitamin is cholesterol, which must travel to the liver
to produce calcidiol, and finally to the kidneys where it becomes metabolically active as calcitriol.7, 8
The prevalence of vitamin D deficiency is especially high in the United States. The 2020-2025
Dietary Guidelines for Americans estimates that more than 90 percent of men and women older
than age 19 years do not consume enough vitamin D.9
The most notable signs of vitamin D deficiency are bowed legs, rickets in children, and osteomalacia
in adults.7, 8 Susceptible individuals, particularly adolescents, people with dark skin, adult
women, housebound elderly people, and many overweight and obese people are at high risk for
insufficiency.7, 8
Vitamin D toxicity is rare, however, symptoms such as headache and nausea, upset stomach, bone
fragility, and growth retardation have been reported in children receiving doses that exceed the
tolerable upper intake.7, 8 The AI for vitamin D recommended is 5-15 ug, UL is 100 mcg (4000
IU)/day, and RDA for individuals 19-50 years old is 600 IU (15 mcg). For those older than 70
years RDA is 800 IU (20 mcg).11
Vitamin E
Vitamin E (Tocopherol, Tocotrienol) acts as a lipid-soluble membrane antioxidant by scavenging

free radicals and reducing inflammation.7, 8 Vitamin E has important roles in muscular, vascular,
nervous, and reproductive systems and acts as an anticoagulant and vitamin K antagonist.7,
8
Vitamin E isTrainer
naturally
Academy
©2023 found in vegetable oils and derived products such as margarine and salad
dressings, whereas animal fats have virtually none.
Vitamin E deficiency is rare, however, reported symptoms include changes in balance and coordination,
muscle weakness, visual disturbances, prolonged blood coagulation, and hemolytic anemia.7, 8
In addition, the toxicity of vitamin E rarely occurs. Excessive doses of vitamin E can lead to
dermatitis, fatigue, acne, vasodilation, hypoglycemia, increased requirement for vitamin K, abnormal
coagulation and bleeding, and muscle damage.7, 8

574
Micronutri ents
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Caution should be taken for individuals taking anticoagulant medication, as interactions with
The Skeletal System

coagulant factors can occur and lead to uncontrolled bleeding and unwarranted brain hemorrhages.12
Intake guidelines for vitamin E increase with the use of PUFAs. The RDA for males and females
Anna
ages D’Annunzio,
14 years MS (22 IU), UL is 1000 mg/day, and AI is 4-12 mg/day based
and older is 15 mg/day
on life stage and gender.9
Vitamin K
Vitamin K’s primary function is to aid in blood clotting, calcium metabolism, and bone
mineralization.7, 8 Vitamin K is the only fat-soluble vitamin that is synthesized by bacteria in
the gut to form prothrombin, a coagulation factor.7, 8
Vitamin K is mainly found in plant foods like dark green leafy and cruciferous vegetables. Smaller
amounts can be found in animal foods such as fish, liver, meat, and eggs.
Vitamin K deficiency can cause bruising and abnormal bleeding due to its critical role in
blood clotting.7, 8 Deficiency may also decrease bone density and as a result, increase the risk of
osteoporosis.
For individuals taking anticoagulants, vitamin K toxicity can also block the effect of these
therapeutic medications.7, 8 However, vitamin K toxicity is rare in healthy populations. Individuals
who take large doses of vitamin A or E may also acquire a vitamin K deficiency due to the
antagonist roles of the respective vitamins.
On the contrary, vitamin K toxicity is rare, but reports have been documented of prolonged
bleeding time and breakage of the red blood cells leading to jaundice.7, 8
Instances in which vitamin K is supplemented in doses higher than normal are during pre-
surgery, or upon birth to prevent hemorrhagic diseases in newborns. Caution must be adverted
to individualsTrainer
taking
©2023 anticoagulant medications.
Academy 7, 8

The RDA and AI are 120 mg/day for men and 90 mg/day for women. No UL has been established,
but data is limited and one should not assume that high vitamin K consumption is harmless.9

individuals taking anticoagulant medications.7, 8
575 The RDA and AI are 120 mg/day for men and 90 mg/day for women. No UL has been
Micronutri ents
established, but data is limited and one should not assume that high vitamin K consumption is
harmless.9Chapter 1
The Skeletal System

Water-Soluble Vitamins
Different from their constituent fat-soluble vitamins, water-soluble vitamins are absorbed directly
into the blood and travel freely in the body through passive diffusion. Water-soluble vitamins
cannot be stored, resulting in easy transportTrainer
through the gut and excretion in the urine.7
Academy
©2023
Vitamin C
Vitamin C (Ascorbic acid) plays an important role in collagen formation and wound healing,
tryptophan toTrainer
serotonin
Academy
©2023 conversion, folic acid metabolism, and iron absorption.7, 8 Vitamin C
can be found in citrus fruits, potatoes, papaya, and dark green and yellow vegetables.
The main signs of vitamin C deficiency are scurvy, poor wound healing, bleeding gums, and petechiae
(brown spots on the skin).7, 8 Vitamin C deficiency is especially high in individuals with severe
trauma, surgical wounds, burns, cancer, chronic diarrhea, alcoholism, and Alzheimer’s disease.7, 8
Excess vitamin C can occur and often manifests with GI distress and diarrhea.7, 8 The RDA for
vitamin C is 75 mg for women 19 years or older and teen boys. Pregnant women need 85 mg/

576
Micronutri ents
Chapter 1
day and lactating women need 120 mg/day. Teen girls need 65 mg/day, men 19 and older need
The Skeletal System

90 mg/day, and smokers need an extra 35 mg daily. The UL for vitamin C is 2000.13
Thiamin
Thiamin (Vitamin B1) is an essential coenzyme in the metabolism of pyruvate, the end product
of glycolysis, and the master fuel input of energy in Krebs’ cycle.7, 8 Other key functions of thiamin
are its role in cell respiration, RNA and DNA formation, protein catabolism, growth, appetite,
normal muscle tone, and digestive and neurologic functioning.7, 8 Sources of thiamin are found in
organ and lean meats, pork, grains, wheat germ, eggs, dried legumes, seeds, and fortified cereals.
The main symptom of thiamin deficiency is beriberi, characterized by a lack of appetite, weakness,
and swollen feet or legs.7, 8 Other signs of deficiency include weight loss, mental confusion, and
tachycardia.7, 8
Health conditions at risk include those suffering from malnutrition, severe alcoholism, cancer,
celiac disease, cardiomyopathies, increased basal metabolic rate, and antibiotic overuse.7, 8 Thiamin
toxicity can lead to respiratory failure and death when doses surpass the tolerable upper intake,
with noted symptoms of headache, convulsions, muscular weakness, cardiac arrhythmia, and
allergic reactions.7, 8
The DRIs for thiamin include AIs for infants as found in human milk; RDAs are based on
levels of energy intake with 1.2 mg/day for men and 1.1 mg/day for women.9 No UL has been
established.9
Riboflavin
Riboflavin (Vitamin B2) is the main coenzyme in redox reactions of fatty acids and is involved
in all macronutrients metabolic reactions to aid in cell respiration and energy formation.7, 8
Other roles ofTrainer

riboflavin
Academy
©2023 are in the maintenance of mucous membranes, and the proper functioning
of niacin and pyridoxine.7, 8
Sources of riboflavin are found in milk, yogurt, cheese, egg whites, liver, beef, chicken, fish,
legumes, peanuts, enriched grains, and fortified cereals.
The most notable symptom of riboflavin deficiency is growth failure and cheilosis (fissures and
scaling of lips). This leads to angular stomatitis (mouth sores), sore throat, and glossitis (magenta,
swollen tongue).7, 8

577
Micronutri ents
Chapter 1
Populations at risk for deficiency are those living in developing countries, those with severe alcoholism,
The Skeletal System

cancers, drug use, and hormone imbalances.7, 8 Riboflavin toxicity is extremely rare. The DRIs for
riboflavin include AIs for infants and RDAs based on the amount required to maintain normal tissue
reserves, RDA is 1.3 mg/day for men and 1.1 mg/day for women, and no UL has been established.9
Niacin
Niacin (Vitamin B3, Nicotinic acid, Nicotinamide) serves as a coenzyme in the metabolism of

carbohydrates, protein, and fat and has an important role in DNA repair and gene stability.7, 8
The precursor of niacin is tryptophan, an essential amino acid, thus, niacin is mainly found in
protein sources such as organ meats, poultry, saltwater fish, peanuts and legumes, enriched bread,
and fortified cereals.
Signs of niacin deficiency include inflammation and swelling of the oral mucosa, esophagitis,
diarrhea, headaches, insomnia, depression, anxiety, tremors, loss of motor function leading to
numbness, and paresthesia in limbs.
Severe niacin deficiency can lead to pellagra, a disease characterized by dermatitis, diarrhea,
dementia, and death if left untreated (the three Ds of pellagra).7, 8
Niacin toxicity is rare; however, cases reported include symptoms of hives, rash (“niacin flush”),
excessive sweating, blurred vision, and liver damage. 7, 8 Intake for infants is established as AIs,
RDA is 16 mg/day for men and 14 mg/day for women, and UL is 35 mg/day for men and women.9
Pantothenic Acid
Pantothenic Acid (Vitamin B5) serves as a coenzyme in the energy synthesis of fatty acid
metabolism. Pantothenic acid is available in all organic forms both in plant and animal tissues,
the most important being organ meats, grains, legumes, egg yolks, milk, and sweet potatoes.
Deficiency ofTrainer
pantothenic
Academy
©2023 acid is rare, but signs can include impaired lipid synthesis and energy
production leading to nerve weakness and burning sensations in the feet, depression, fatigue,
insomnia, and weakness. Toxicity is also rare, with excess B5 causing mild intestinal distress or
diarrhea.7, 8 AI for adult men and women is 5 mg/day. UL is not established.9
Pyridoxine
Pyridoxine (Vitamin B6) is a coenzyme in amino acid metabolism and is known for its role in gene
expression and hemoglobin synthesis. Pyridoxine can be found in organ meats, fortified cereals,

578
Micronutri ents
Chapter 1
legumes, and nuts. Signs of pyridoxine deficiency are rare but may present as anemia, confusion,
The Skeletal System

irritability, peripheral neuropathies, glossitis, and dermatitis. In addition, toxicity is relatively low,
with symptoms reported as limited peripheral sensations, and muscle incoordination.7, 8 The DRIs
for vitamin B6 include AIs for infants. Infants need three times as much vitamin B6 as adults.
RDAAnna D’Annunzio,
is 1.3–1.7 mg/day for menMS and 1.3–1.5 mg/day for women. The UL is established at 100
mg/day for adult men and women.9
Biotin
Biotin (Vitamin B7) is a coenzyme in fatty acid synthesis, and carbohydrate metabolism, and
plays an important role in converting pyruvic acid to oxaloacetate to initiate the Krebs cycle.7, 8
Sources of biotin are present in organ meats, pork, egg yolk, cereals, legumes, and nuts.
Similar to vitamin K, biotin is the only water-soluble vitamin that is synthesized by gut bacteria.
The deficiency of biotin is identified by signs of inflammation on the skin and lips, dermatitis,
alopecia, paralysis, depression, nausea, and glossitis. In contrast, there are no known toxic effects
if supplementation exceeds upper tolerable limits. The RDA is 30 mg/day for adult men and
women, and no UL has been established.9
Folate
Folic Acid (Vitamin B9, Folate) is primarily known for its role in DNA synthesis and red blood
cell formation in the bone marrow and is used to prevent neural tube defects in pregnancy.7, 8
Folate is naturally found in food including fortified cereals, lentils and beans, organ meats, citrus
fruits, and green leafy vegetables; whereas folic acid is the supplemental form and can be found
in fortified foods.
The typical manifestation of folate deficiency is anemia followed by diarrhea, fatigue, irritability,
and dyspnea. Populations at risk of deficiency include pregnant women, individuals with
malabsorption syndromes, alcoholics, teens, and elderly individuals. Neural tube defects such as
spina bifida orTrainer
anencephaly
Academy
©2023 may result when women are folate deficient during the early months of
pregnancy.
There are no reports of toxicity or adverse effects associated with excess intake of folate, although
recurrent use can mask vitamin B12 deficiency symptoms.7, 8 The DRI is described as AIs for
infants. RDA is 400 mcg/day for adults, pregnant women need 600 mcg/day and lactating women
need 500 mcg/day. The UL is 1000 mcg/day.9

579
Micronutri ents
Chapter 1
Cyanocobalamin
The Skeletal System
Cyanocobalamin (Vitamin B12, Cobalamin) plays an important role as a coenzyme in protein
synthesis and the formation of red blood cells. It is attached to intrinsic factors in the stomach
andAnna
is only D’Annunzio, MS the ileum, the main site for fat-soluble vitamin absorption.
absorbed when it reaches
Vitamin B12 is mainly found in products of animal origin such as organ meats, eggs, fish, and dairy.
Similar to folate, Vitamin B12 deficiency also manifests with anemia, followed by constipation,
poor balance, loss of appetite, and numbness and tingling in extremities. Individuals with poor
diets, strict vegetarians, senior citizens, and those with severe chronic malnutrition are at high
risk for this deficiency.7, 8 Vitamin B12 toxicity has not been reported. The RDA is 2.4 mcg for
adults. Pregnant women need 2.6 ug and lactating women need 2.8 ug. No UL was established.9
Minerals
Macrominerals
Calcium
Calcium is one of the most abundant minerals in the body and plays an important role in
bone and tooth formation. Additionally, calcium is an intracellular cation that regulates blood
clotting, cardiac function, nerve transmission, and muscle contractility. Calcium is found in any
dairy and fortified dairy products, legumes, and dark leafy green vegetables. Signs of deficiency
(hypocalcemia) manifest in children as stunted growth and weak bones. In adults, calcium
deficiency can lead to osteoporosis (bone loss), tetany, paresthesia, hyperirritability, muscle cramps,
and convulsions.7, 8 Signs of toxicity (hypercalcemia) usually occur in milk-alkali syndrome,
kidney stones, or renal insufficiency. Calcium absorption tends to decrease with increased age
for both menTrainer
and women, so bone health maintenance must be accomplished with vitamin D
Academy
©2023
along with calcium supplementation.7, 8 The RDA for calcium is 1000 mg/day for most adults
(19–50 year-old men and women; 51–70 year-old men), 1300 mg for teenagers, and 1200 mg
for those over 50 years. The UL is 2,500 mg/day (19–50 years) and 2,000 mg/day (>50 years).9
Phosphorus
Phosphorus is the second most abundant mineral after calcium and plays a vital role in energy, fat,
amino acid, and carbohydrate metabolism, regulation of calcium, and phospholipid transport.7, 8

580
Micronutri ents
Chapter 1
Phosphorus intake can be achieved with virtually any food and is abundant in protein-rich foods
The Skeletal System

such as meat, poultry, fish, and eggs, whole grains, milk and dairy products, chocolate, and soft
drinks.
Anna D’Annunzio,
Phosphorus MS
deficiency (hypophosphatemia) is rare but may occur in malnourished individuals
and those with renal insufficiency taking medications. Toxicity (hyperphosphatemia) is not
common but can promote paralysis, muscular weakness, arrhythmias, heart disturbances, and
even death if it occurs.7, 8 The RDA for adult men and women is 700 mg/day, and UL for adults
varies from 3–4 g/day.9
Potassium
Potassium is known as the main intracellular ion responsible for nerve transmission, muscle
contraction, carbohydrate, and protein synthesis, and water and acid-base balance. Food sources
high in potassium include potatoes, oranges, tomatoes, avocados, bananas, soy products, spinach,
cantaloupe, and dairy products.
Signs of deficiency (hypokalemia) include muscle weakness, cardiac arrhythmia, paralysis, bone
fragility, decreased growth, weight loss, and even death, which is often seen in malnourished
individuals.7, 8 Excess potassium (hyperkalemia) can lead to paralysis, muscular weakness,
arrhythmias, heart disturbances, and even death. For potassium, there are no specific RDA, AI,
or UL.9
Sodium
Sodium is the main extracellular ion along with chloride and its main function is to regulate
blood pressure, and glucose transport into cells, to stimulate nerves, and muscle contractions,
and to maintain acid-base balance.7, 8
Sodium is found in many processed foods in the American diet such as salty snack foods,
condiments, Trainer
and dressings, cured and processed meats, canned products, grains, and pasta.
Academy
©2023
Natural sources include meat, fish, poultry, eggs, dairy products, dark leafy vegetables, and grains.
Sodium deficiency (hyponatremia) can occur from water overload, resulting in nausea, weight
loss, confusion, coma, and even death.7, 8
Excess sodium (hypernatremia) is often seen in individuals with dehydration, malnutrition, and
severe weight loss, and can lead to symptoms of confusion, high blood pressure, heart failure, and
coma.7, 8 There is no specific RDA set for sodium, the UL is 2,300 mg/day for adults.9

581
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Chapter 1
Magnesium
The Skeletal
Magnesium is System
an essential mineral used by more than half of the cells in our body in processes
such as normal muscle contraction, nerve transmission and function, heart rhythms, energy
Anna D’Annunzio,
metabolism, MSMagnesium is present in most foods. Fruits and vegetables,
and protein synthesis.
dairy products, and grains contain the most abundant sources of magnesium.
Signs of deficiency (hypomagnesemia) can occur in malnourished individuals and lead to poor
growth, confusion, loss of appetite, tetany, numbness, arrhythmias, seizures, and even death.
Excess magnesium (hypermagnesemia) can be seen with kidney failure, and cause nausea, osmotic
diarrhea, appetite loss, muscle weakness, respiratory failure, extremely low blood pressure, and
Micronutrients 581
irregular heartbeat.7, 8 The RDA is typically 420 mg for men and 320 mg for women. UL for
supplemental magnesium for adolescents and adults is 350 mg/d.9
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©2023
Trace Minerals
582
Micronutri ents
Chapter 1
Trace Minerals
The Skeletal System
Iron
Iron is the most abundant trace mineral, existing in all animal and plant cells. Functional iron
is composed of two proteins: hemoglobin in red blood cells and myoglobin in muscle cells.7,
8
The main function of iron is to carry oxygen from the lungs to all tissues and cells in the
body and improve cognitive, immunity, and nerve functioning.7, 8 The food sources rich in
iron include meat, poultry, fish, eggs, legumes and beans, enriched grains, fortified cereals, and
dried fruit.
The most notable sign of iron deficiency is anemia, accompanied by fatigue, weakness, pallor,
pale conjunctiva, koilonychia (thin, spoon-shaped nails), impaired learning ability, pica, and
tachycardia.7, 8 Iron toxicity can occur from taking iron supplements daily or recurrent transfusions,
and commonly manifests with vomiting, diarrhea, GI distress, and drowsiness.7, 8
The RDA is 8 mg for men and postmenopausal women; 18 mg for premenopausal women.
Pregnant women need 27 mg/d and breastfeeding women need 9 mg.9 Teenage girls (ages 14–18
years) need 15 mg of iron per day (27 mg if pregnant; 10 mg if breastfeeding). Teenage boys
(ages 14–18 years) need 11 mg of iron per day. The UL for iron is 45 mg/d.9
Iodine
Iodine (Iodide) is part of the hormone thyroxine and aids in the production of T3 and T4 to
maintain proper thyroid functioning, energy metabolism, in normal growth and reproduction,
and the regulation of metabolism and temperature. Iodine can be found in iodized salt, seaweed,
and shellfish. Iodine deficiency and excess can both cause an enlarged thyroid gland. Deficiency
is often associated with weight gain, cold intolerance, thinning hair, cognitive impairment,
decreased metabolic rate, and neuromuscular impairments.7, 8 The RDA is 150 mg/d for both
men and women. UL is 1.1 mg/day.9
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©2023
Copper
Copper is an antioxidant that is vital in skeletal development, formation of red blood cells,
immunity, and energy metabolism.7, 8 Copper is mainly found in grains, enriched cereals, shellfish,
legumes and beans, eggs, potatoes, and dried fruit. Copper deficiency is rare in adults, except in
individuals with celiac disease. Symptoms of deficiency include anemia, decreased skin and hair
pigmentation, and reduced immune response.7, 8 Copper toxicity is also rare, but can occur in

583
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individuals with liver disease, leading to copper deposits in the brain, diarrhea, tremors, and liver
The Skeletal System

damage.7, 8 The RDA is 900 mg daily for men and women and UL is established at 10 mg/d.9
Zinc
Zinc is present in very small quantities in the body and its main function is to protect cell structures
against damage from oxidation, make cells’ genetic material, stabilize DNA and RNA, enhance
insulin action, and increase taste acuity.7, 8 Zinc is found in most protein foods like organ meats,
meat, poultry, fish, and eggs. Deficiency is not common in developing countries, but when it
occurs it can lead to reduced immune function, alopecia, poor wound healing, and decreased taste
acuity (hypogeusia).7, 8 Signs of zinc excess include vomiting, diarrhea, headaches, and exhaustion.
The RDA is 11 mg for men and 8 mg for women. UL is 40 mg.9
Fluoride
Fluoride is the most abundant mineral in water and soil that aids in the formation of bone and
teeth enamel. Sources of fluoride include fluoridated water, tea, mackerel, salmon, and some
infant foods. Signs of deficiency include dental cavities, anemia, and potential bone thinning, and
toxicity may lead to tooth mottling and discoloration, and neurological problems.7, 8 The RDA
is 3–4 mg/d for men and women. UL is set at 10 mg/d.9
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©2023

584 Micronutrients 583
Micronutri ents
Chapter 1
The Skeletal System

Summary
Summary Trainer Academy
©2023
Micronutrients play many vital roles in basic biological functions as well as responses and
Micronutrients play many vital roles in basic biological functions as well as responses and
adaptations to exercise.
adaptations to exercise.
With a working knowledge of micronutrients, fitness professionals are better prepared to
identify
With potentialknowledge
a working symptoms of
of micronutrients,
deficiency or overdose and refer the are
fitness professionals client to anprepared
better appropriate
to identify
healthcare provider.
potential symptoms of deficiency or overdose and refer the client to an appropriate healthcare provider.
Making specific diagnoses or recommendations is outside the Trainer Academy CPT Scope
Making specific diagnoses or recommendations is outside the Trainer Academy CPT Scope of
of Practice.
585
Micronutri ents
Chapter 1
Practice.
The Skeletal System

References
1. Centers for Disease Control and Prevention. Micronutrient facts. Available at: https://www.cdc.

gov/nutrition/micronutrient-malnutrition/micronutrients/index.html. Published February 1, 2022.
Accessed September 26, 2022.
2. Muñoz García M, Pérez Menéndez-Conde C, Bermejo Vicedo T. Avances en el conocimiento del uso
de micronutrientes en nutrición artificial [Advances in the knowledge of the use of micronutrients in
artificial nutrition]. Nutr Hosp. 2011;26(1):37-47
4. Shenkin A. Micronutrients in health and disease. Postgrad Med J. 2006;82(971):559-567. https://doi.

org/10.1136/pgmj.2006.047670
5. Rizvi S, Raza ST, Ahmed F, Ahmad A, Abbas S, Mahdi F. The role of vitamin e in human health and
some diseases. Sultan Qaboos Univ Med J. 2014;14(2):e157-e165.
6. Demling RH, DeBiasse MA. Micronutrients in critical illness [published correction appears in Crit

Care Clin 1996 Oct;12(4): xi]. Crit Care Clin. 1995;11(3):651-673.
7. Sizer FS, Whitney E. Nutrition Concepts & Controversies. 13th ed. Belmont, CA: Wadsworth
Publishing Co; 2014
8. Escott-Stump S. Nutrition & Diagnosis-Related Care. Academy of Nutrition and Dietetics; 2022.
9. National Institutes of Health, Office of Dietary Supplements. Nutrient Recommendations: Dietary

Reference Intakes (DRI). Available at: https://ods.od.nih.gov/Health_Information/Dietary_Reference_
Intakes.aspx. Accessed September 26, 2022.
Trainer Academy
Guidelines for ©2023
Americans, 2020-2025. 2020. 9th Edition. https://www.dietaryguidelines.gov
11. National Institutes of Health. Vitamin D. Available at: https://ods.od.nih.gov/factsheets/VitaminD-

HealthProfessional/ Published February 11, 2016. Accessed September 26, 2022.

Chapter 1
TheCHAPTER
Skeletal27System
Supplementation
587
Chapter 1
Introduction
The Skeletal System
Dietary supplements are widely used by athletes and fitness enthusiasts alike.
The Trainer Academy Scope of Practice prohibits recommending specific dietary supplements.
However, fitness professionals should have basic knowledge of the widely used supplements and
performance-enhancing drugs since many clients take one or more of these substances.
Furthermore, knowledge of the general purpose and proven efficacy of popular supplements, as
well as understanding the regulations in the supplement industry is key for discussing safety and
rationale for supplements when clients inquire.
Dietary Supplementation
A dietary supplement is a product that is intended to supplement the diet, and that contains
one or more of the following: vitamins, minerals, herbs or other botanicals, amino acids, or other
dietary substances for use by a human to supplement their diet by increasing their total dietary
intake or concentrates, metabolites, constituents, extracts, or combinations of these ingredients.14 A
more comprehensive definition can be found below15:
A product other than tobacco, intended to supplement the diet that contains a vitamin, mineral, herb
or botanical, dietary substance, or a concentrate, metabolite, constituent, extract, or combination
of the above ingredients.
• A product that is intended for ingestion, that is not represented as food or as a sole item of
a meal or diet and is labeled as a dietary supplement.
• A product that includes an article approved as a new drug, certified as an antibiotic, or licensed
as a biologic and that was, before such approval, certification, or licensure, marketed as a
Trainer Academy
©2023
dietary supplement or food unless the conditions of use and dosages are found to be unlawful.
• A product that excludes such articles which were not so marketed before approval unless
found to be lawful. Deems a dietary supplement to be a food. Excludes a dietary supplement
from the definition of the term “food additive.”

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Dietary Supplement Regulation

Dietary Supplement Regulation
The regulation of Dietary Supplements (DS) is overseen by two government agencies: the
The regulation of Dietary Supplements (DS) is overseen by two government agencies: the Food
Food and Drug Administration (FDA), and the Federal Trade Commission (FTC).
and Drug Administration (FDA), and the Federal Trade Commission (FTC).
The FDA is the major agency in the United States food supply that ensures food safety,
Themonitoring,
FDA is theand major agencyofinanimal
inspection the United States
products, food supply
sanitation, thatfood
proper ensures food food
labeling, safety, monitoring,
additives,
andgenetically
inspectionmodified
of animal
Trainer Academy
©2023
foods, and pesticides.
products, sanitation, proper food labeling, food additives, genetically
16
modified foods, and pesticides.16

The Federal Trade Commission (FTC) regulates advertising, including infomercials, for
dietary supplements.17 Both the FDA and FTC have the authority to take enforcement actions
The Federal Trade Commission (FTC) regulates advertising, including infomercials, for dietary
against dietary supplements and firms if they identify violations.
supplements. Both the FDA and FTC have the authority to take enforcement actions against
17
dietaryThe
supplements anddietary
FDA regulates firms ifsupplements
they identify violations.
under a different set of regulations than those
covering conventional foods and drug products. In 1994, the Dietary Supplement Health and
The FDA regulates
Education dietarywas
Act (DSHEA) supplements
enacted to under
prohibita dietary
different set of regulations
supplement than those
manufacturers and covering
distributors foods
conventional from making
and drugfalse claims on
products. Insupplement labels, toSupplement
1994, the Dietary prohibit the manufacture
Health and and sale
Education

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©2023
589
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Act (DSHEA) was enacted to prohibit dietary supplement manufacturers and distributors from
The Skeletal System

making false claims on supplement labels, to prohibit the manufacture and sale of adulterated dietary
supplements, and categorized dietary supplements as food instead of drugs or dietary additives.15
Annamany
However, D’Annunzio, MS contain ingredients that have strong biological effects and
dietary supplements
can potentially conflict with a drug or medical condition.14 A more comprehensive list of the
federal law set forth by the DSHEA is listed below:
• It is advised that a company that introduces a new DS must send a notification including safety
information to the FDA 75 days before selling the supplement.18 This is not a requirement given
that DS are classified as food products and not drugs.19 The FDA is not authorized to approve
dietary supplements for safety and effectiveness before they are marketed. In many cases, firms
can lawfully introduce dietary supplements to the market without even notifying FDA.19
• A DS label must contain the product name and a statement that it is a “dietary supplement”
or equivalent term replacing “dietary” with the name or type of dietary ingredient in the
product (e.g., “iron supplement” or “herbal supplement”), all ingredients must be declared, and
the name, place of business of the manufacturer, packer, distributor, and contact information
must be displayed.18
A supplement facts panel defines how ingredients must be listed on the label.18
The label must also include the disclaimer, “This statement has not been evaluated by the Food
and Drug Administration.18 This product is not intended to diagnose, treat, cure, or prevent any
disease,” because only a drug can legally make such a claim. 18
Manufacturers and retailers are not allowed to display product information or technical data
sheets next to products. 18
A DS label is no longer allowed to list disease states or make specific health claims on DS labels
but can make “structure/function” claims and those are not subject to premarket review and
authorizationTrainer
by©2023
FDA.
Academy 1
Dietary Supplement Labeling Claims

Among the claims that can be used on dietary supplement labels, there are three categories
of claims defined by FDA regulations: health claims, structure/function claims, and nutrient
content claims.

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Health Claims
The Skeletal
Health claims describe System
the relationship between a substance (whether a food, food component
or dietary ingredient) and a disease or health-related condition.18 A health claim can mention a
Anna
disease stateD’Annunzio, MS
as long as it has met the significant scientific agreement standard of the FDA and
can exist on foods and dietary supplements.20, 21
An example of a health claim is “soluble fiber from foods such as oat bran, as part of a diet low
in saturated fat and cholesterol, may reduce the risk of heart disease.” All health claims, whether
authorized or qualified, require pre-market review by the FDA.20, 21
Authorized Health Claims
Authorized health claims must be supported by a significant scientific agreement that the

proclaimed benefit of a food or food component on a disease or health-related condition is true.20, 21
An example of an authorized health claim is “low-fat diets rich in fiber-containing grain products,
fruits and vegetables may reduce the risk of some types of cancer, a disease associated with many
factors.”
Qualified Health Claims
Qualified health claims have significant scientific agreement supporting the claim however there
is insufficient evidence to approve them as health claims.20, 21 An example of a qualified health
claim is “consumption of omega-3 fatty acids may reduce the risk of coronary heart disease.”
Structure-Function Claim
Structure-function claims describe the role of a nutrient or dietary ingredient intended to affect

the normal structure or function of the human body.20, 21 In addition, they may characterize how
a nutrient or dietary
©2023 ingredient acts to maintain such structure or function, for example, “calcium
Trainer Academy
builds strong bones,” “fiber maintains bowel regularity,” or “antioxidants maintain cell integrity.”
Structure/function claims for conventional foods focus on effects derived from nutritive value,
while structure/function claims for dietary supplements may focus on non-nutritive as well as
nutritive effects.20, 21
FDA does not require conventional food manufacturers to notify FDA about their structure/
function claims, and disclaimers are not required for claims on conventional foods.20, 21

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Nutrient Content Claims
The Skeletal
Nutrient System
content claims describe the level of a nutrient in food using terms such as free, high,
and low, or they compare the level of a nutrient in a food to that of another food, using terms
Anna
such D’Annunzio,
as more, MS
reduced, and light.20, 21
Nutrient content claims have been authorized by FDA and
are made following FDA’s authorizing regulations.20, 21 An example of a nutrient content claim
is a package of muffins that carries the claim “Low in Fat.”
Vitamin and Mineral Supplements

Supplements Versus Whole Foods
The skyrocketing sales and use of supplements in the United States continue to expand at a
rapid pace. Some of the reasons associated with supplement use in the American population
are speculated to be related to the growing interest in food and nutrition in the maintenance of
health and widespread availability.22, 23
In fact, in the US, over 50% of adults declare supplement use, and in some studies, almost 40%
had taken dietary supplements during the previous 30 days when they were questioned.22, 23
In general, the scientific community and medical providers have come to the consensus that
diversifying intake of whole foods is better assimilated and more effective at treating deficiencies
than supplements alone. The most notable observed benefits in whole foods compared to
supplements are:
1. Food bioavailability: whole foods including dairy, fruits, and vegetables offer greater nutrient
density and micronutrient bioavailability compared to supplements. In simple terms, the
bioavailability of vitamins in food means how much of a micronutrient is absorbed or made
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©2023
available to the body when consumed in the diet.24 In contrast, supplements and fortified
foods typically contain much higher amounts of nutrients than whole foods, but it is not
guaranteed that the body can absorb them and put them all to use.
2. Essential fiber: a big proportion of whole foods such as cereals, fruits, and vegetables contain
dietary fiber. While dietary fiber is derived from one of the macronutrients, it is not considered
an essential macronutrient.25 Given the increasing prevalence of Americans with suboptimal
intakes of fiber, the Scientific Report of the 2020 Dietary Guidelines Advisory Committee
acknowledges that fiber is a “nutrient of a public health concern due to the adverse health

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outcomes relative to its underconsumption.”10 When comparing supplement use to whole
The Skeletal System

food consumption, supplements only provide an isolated source of the nutrient, and generally
lack the fiber component necessary to meet the recommended daily intakes of fiber and
observable health benefits that whole foods offer.
Anna D’Annunzio,
3. Antioxidants MS
and phytochemicals: these compounds are naturally occurring in whole
foods such as fruits and vegetables, whole grains, and legumes and play an important role
in the prevention and treatment of chronic diseases. The main role of antioxidants and
phytochemicals is to scavenge free radicals in the body and act as anti-inflammatory agents,
ultimately protecting against cancer, aging, cardiovascular diseases, diabetes mellitus, obesity,
and neurodegenerative diseases.26
Target Population
The literature has made it clear that the consumers of dietary supplements are mostly middle-
aged and older adults. As it appears, the routine intake of supplements by healthy populations
is not strictly tied to a particular disease state or micronutrient deficiency but rather taken for
preventative reasons. And for this reason, people with healthier diets and lifestyles make it hard to
study and determine whether vitamin and mineral supplementation offer the supposed benefits.
To this point, the literature continues to show that the taking of vitamin and mineral supplements
by healthy people neither lowers their risk of cardiovascular diseases nor prevents the development
of malignancies.27
With some exceptions, there is recognized evidence that omega-3 fatty acids lower blood
triglycerides, but the extent that taking them prevents heart disease is ambiguous.27 Similar
examples follow this pattern for supplements intended to aid in weight loss and cancer prevention.
Populations Who May Benefit from Supplements
Certain special populations may benefit from specific supplementation. While it exceeds the Trainer
Academy Personal ©2023Trainer Scope of Practice to recommend supplements to these populations,
Trainer Academy
individuals in the following categories can benefit from certain supplementation protocols:

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Supplementation Basic Nutritional592Concepts
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Toxicity and Safety
Toxicity
Toxicity and Safety
While it is difficult for food to cause nutrient imbalances or toxicities, supplements can easily
lead to toxicity and adverse effects when routinely ingested in higher doses. The extent of
Toxicity Trainer Academy
supplement toxicity
©2023 in the United States is unknown, but many adverse events are reported each
year from overconsuming vitamins, minerals, essential oils, herbs, and other supplements.
While it is difficult for food to cause nutrient imbalances or toxicities, supplements can easily lead
Several committees, for example, the European Food Safety Authority (EFSA) and Institute
to toxicity and adverse
of Medicine effects
(IOM) have when routinely
set tolerable upper intakeingested in to
levels (ULs) higher
preventdoses. The extent of supplement
micronutrient
toxicity in the United States is unknown, but
Trainer many adverse events are reported each year from
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©2023
overconsuming vitamins, minerals, essential oils, herbs, and other supplements.
Several committees, for example, the European Food Safety Authority (EFSA) and Institute of
Medicine (IOM) have set tolerable upper intake levels (ULs) to prevent micronutrient toxicities.

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The DRI Tolerable Upper Intake Levels define the highest intakes of dietary vitamins and
The Skeletal System

minerals that appear safe for most healthy people.9
This parameter is different from the Estimated Average Requirement (EAR), which assesses the
Anna
average D’Annunzio,
daily MSis estimated to meet the requirements of 50% of the healthy
nutrient intake that
individuals in a group.9
In other words, the EAR assesses nutrient adequacy in groups and ULs prevent the risk of adverse
effects from excessive nutrient intakes.
Dietary supplement toxicity is the umbrella term that encompasses vitamin overdosage, vitamin
overload, and hypervitaminosis. Vitamin overdosage and overload are observed with every vitamin
and produce high blood and tissue levels of the vitamin itself. Vitamin overdosage is obtained
only upon administration of high doses of a vitamin, while vitamin overload may originate from
a variety of factors.28
Hypervitaminosis is a condition of abnormally high blood levels of a specific vitamin, generally,

vitamin A and D, that either manifests as acute or chronic and is characterized by specific
symptomatology.28
Megadoses of fat-soluble vitamins (A, D, E, K) can easily cause toxicity and should be taken with
caution, particularly for individuals with medical conditions and pregnant women. Vitamin A
toxicity is most notable and can cause nausea, vomiting, headache, dizziness, and blurred vision.29
While water-soluble vitamin toxicity is rare, folic acid overdose is common and can cause
adverse events when taken in excessive doses, generally manifesting as reversible neurological
complications.30 Furthermore, some people may experience adverse effects from too much calcium
or iron. In the case of iron toxicity, observable side effects include coma or low blood pressure,
which can sometimes be fatal.
Iron overdosesTrainer
can
©2023have long-term consequences on the intestines and liver, including intestinal
Academy
scarring and liver failure.31, 32 Calcium toxicity is not as fatal as iron, but high calcium levels
can cause serious heart rhythm disturbances, as well as kidney stones and damage to kidney
function. Long-term overuse is often more serious than a single overdose.
Safety
Proving supplement safety is one of the many risks that the FDA bears under the DSHEA. In 2006,
the Dietary Supplement and Nonprescription Drug Consumer Protection Act was signed into

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law, requiring mandatory reporting by manufacturers and retailers of known serious adverse events
The Skeletal System

(AEs) related to dietary supplements and over-the-counter (OTC) medications.33 Serious adverse
events related to dietary supplements and drugs include life-threatening events, incapacitation,
hospitalization, birth defects, and death.
The adverse effects associated with dietary supplements vary consistently in the literature. The
most common supplements with health and safety concerns are those used for weight loss,
performance enhancement (ergogenic aids), and sexual dysfunction.34
According to the FDA, these supplements have the highest risk of contamination and adulteration
with unapproved dietary ingredients and pharmaceutical drugs.35 A nine-year report published
by the CDC found that among young adults aged 20-34, the most common supplements causing
adverse events were weight loss and energy (ergogenic aids) and the most common symptoms
were tachycardia, chest pain, and palpitations.36
For adults 65 and older, adverse events were mostly attributed to choking on micronutrient pills.36 Up
to date, only two dietary supplements have been banned by the FDA, Ephedra sinica in 2004, and
dimethylamylamine (DMAA) in 2013, as being linked to cardiovascular toxicity and death.35
More recently, the FDA announced that N-acetyl-L-cysteine (NAC), used for chronic respiratory
conditions, fertility, and brain health, is no longer included in the definition of a dietary supplement.37
Reporting Adverse Effects
The same year that the DSHEA was enacted, the National Institutes of Health founded the
Office of Dietary Supplements (ODS).41 The purpose of this entity is to increase awareness of
dietary supplements, provide credible information to the public, and alert the public on current
warnings and recalls as well as consumer tips for buying and taking dietary supplements safely.41
On the government website, consumers can find basic consumer information and a Dietary
Supplement Label ©2023Database of dietary supplements used in the United States. This database
Trainer Academy 41
was developed to provide specific information on the ingredients in a supplement, technical data
sheets about dietary supplements and herbs, and FDA warnings.41
In the event of a suspected serious health-related reaction or illness associated with a dietary
supplement, alert a medical provider or healthcare professional knowledgeable in nutrition. In
addition, reporting adverse reactions to supplements directly to the FDA via its hotline or website
(FDA MedWatch) is highly recommended. Adverse event reports are forwarded to the Center
for Food Safety and Applied Nutrition, where they are further evaluated by qualified reviewers.

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Common
The Skeletal General
System Health Supplements
Anna D’Annunzio,
Multivitamin MS
& Mineral Supplements
Multivitamin/mineral Supplements (MVM) have gained public attention over the years and are
considered one of the most popular supplements on the market. The National Health and Nutrition
Examination Survey (NHANES) found that between 2003 and 2006, the most commonly used
supplements were multivitamins and multiminerals with at least half of the men and women 50
years of age or older regularly consuming them.38
In the years 2005–2012, the ten most popular of these, in order of decreasing prevalence of use,
were vitamin D, vitamin C, calcium, cobalamin, vitamin E, folic acid, pyridoxine, niacin, vitamin
A, and riboflavin.38
To date, there is no clear unanimity suggesting that MVMs help prevent chronic disease. In
general, multivitamins from reputable sources without add-ons test free from contamination, and
taking a daily dose of a basic MVM is unlikely to pose a health risk for most people.39
However, caution must be taken if consuming fortified foods and beverages along with dietary
supplements. Reading the Supplement Facts label and percent daily value (% DV) to see what
proportion of daily allotment one gets from taking a vitamin is generally considered safe to
prevent toxicity.39
The biggest contraindication in MVMs use is that they have no standard scientific, regulatory,
or marketplace definitions. Manufacturers determine the combinations and levels of vitamins,
minerals, and other ingredients in them and therefore they have no standard regulations as to
what nutrients they must contain or in what amounts.39
Furthermore, the definition of MVMs and evaluation of potential health effects varies greatly in the
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©2023
scientific literature. This concern and the fact that many dietary supplements are not labeled as MVMs
even though they contain a variety of vitamins and minerals further complicates the study of MVMs.
Botanical and Herbal Supplements

Botanical and herbal supplements are dietary supplements that are increasingly popular among the
public. In particular, athletes’ use of herbal supplements is higher than that of the general public,

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and reasons for intake range from performance enhancement to immune function improvement
The Skeletal System

to the prevention of illness or healing of injuries.40
However, regular ingestion of herbal supplements also raises toxicity and safety concerns among
scientific community. The MSreasons why controversies related to herbal dietary supplement
intake exist include limitations in scientific evidence, premarket approval, and FDA regulation.
In general, most of the common herbs used in the United States do not pose a risk for a drug-
nutrient interaction (DNI).34 Out of the most commonly used herbal supplements, St. John’s
wort is the most problematic and has been shown to reduce the efficacy of many drugs, including
antiretrovirals for HIV, antirejection medications for organ transplants, oral contraceptives, cardiac
medications, chemotherapy, and cholesterol medications.34
Two other herbs have been shown to have a high risk for DNI, including goldenseal and black
pepper in the supplemental form.34
Common Legal Performance Enhancing

Supplements
Performance-enhancing substances (PES) are any substances taken in non-pharmacologic doses
specifically used to improve athletic performance and alter one’s appearance toward a more
muscular and lean body. When surveyed, individuals reported using PES to improve physical
appearance, increase muscle mass, optimize general health, and help meet physical demands on
their bodies.42
Over the years, the literature has shown that PES in the athletic population has steadily increased
and has been estimated internationally at 37% to 89%, with greater frequencies being reported
among elite and older athletes.43
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©2023
Among college athletes and nonathletes, prevalence rates of PES are also relatively high. In a
study from 2008, at least 46% of male nonathletes and 56% of male athletes, as well as 25% of
female nonathletes and 30% of female athletes, were using these substances.44
More recently, PES has become increasingly popular among adolescents and young adults and there
is a growing trend of using PES as cognitive function enhancements for academic performance,
attention, and memory, specifically through the use of neuroactive substances.45

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In particular, a prospective cohort study from the National Longitudinal Study of Adolescent to
The Skeletal System

Adult Health, Waves I to IV (1994–2008) identified 16.1 % of young men and 1.2% of young
women from a sample of 12,133 young adults aged 18 to 26 years who used legal PES in the
past year.46
Along with the increased usage of these products, there is an ever-growing cause for concern
about not only their effectiveness but also safety. Since PES are mostly unregulated by the FDA
and clinical trials lack data and regulation, inconsistencies exist on the legal status of PES in
federal and state laws in the United States and medical outcomes associated with their use.
Legal PES can be classified according to the constituent ingredients, and the timing of the
training. The most common legal PES that will be discussed in this chapter include: creatine,
caffeine, protein and branched-chain amino acids (BCAAs), and beta-alanine.
Pre-Workout Supplements
Pre-workouts are supplements ingested before an exercise session or sporting event intended to
increase mental focus, endurance, blood flow, strength, power, aerobic and anaerobic capacity, or
overall perceived increase in energy level.
While a small amount of evidence exists for potential benefits when consuming a pre-workout
supplement, inconsistencies within the literature remain when considering the specific dosages,
populations, and types of activities performed.
According to the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American
College of Sports Medicine, the ingredients mentioned below are common pre-workout
supplements that have been regarded as safe and have strong evidence to support efficacy.
Beta-Alanine
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Beta-alanine (β-alanine) is a non-essential amino acid commonly found in meat, poultry, and fish.
During exercise, the formation of lactic acid is likely to result if insufficient glucose is present in
the body to be metabolized for energy.
This metabolic reaction lowers muscle pH levels and reduces the muscles’ ability to contract,
causing fatigue.47, 48 The purpose of supplementing beta-alanine is to increase concentrations of
carnosine, a proton that improves muscles and blood pH buffering capacity during high-intensity
exercise, and reduces overall fatigue.

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In addition, beta-alanine can increase time to exhaustion,49 muscular endurance,50, 51 anaerobic
The Skeletal System

capacity,48 and lean mass,52 ultimately enhancing training capacity. The optimal dosage is set
between 4 to 6 g/day for 2–4 weeks and is most effective when complimenting high-intensity
exercises lasting 1–4 minutes, such as high-intensity interval training (HIIT) or short sprints.47
The only reported side effect is paraesthesia (i.e., tingling) but studies indicate this can be attenuated
by using divided lower doses (1.6 g) or using a sustained-release formula.47 At usual doses, beta-alanine
appears to be safe for most healthy populations except for pregnant or breastfeeding individuals.
Caffeine
Caffeine is a central nervous system stimulant ubiquitously found in a variety of food and
beverages such as coffee, tea, energy drinks, pre-workout supplements, over-the-counter diet pills,
and medications. The ergogenic benefits of caffeine as a pre-workout have been documented.
Caffeine can reduce the perception of fatigue and allow exercise to be sustained for longer.53 In
addition, caffeine can increase muscular endurance, glycogen sparing during exercise, intestinal
absorption of carbohydrates, fat utilization, and calcium release.54
The optimal dose of caffeine ranges from 3 to 6 mg/kg, approximately 60 min before exercise,
and is most effective for high-performance athlete improvements.54
The FDA established that 400 mg/day of caffeine is a safe amount of daily consumption for
the general population.55 Higher doses of caffeine (9–13 mg/kg) do not result in an additional
improvement in physical performance and are associated with a high incidence of side effects
such as nausea, anxiety, and insomnia.56
The most commonly reported side effects of caffeine are tachycardia, heart palpitations, anxiety,
headaches, and insomnia quality, and its use should be discontinued for individuals taking stimulant
medications, anticoagulants, monoamine oxidase inhibitors, and quinolone antibiotics.54, 57, 58, 59
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Creatine
Creatine, usually sold as creatine monohydrate is an amino acid produced by arginine and glycine,
two non-essential amino acids. Approximately 2 grams of creatinine can be obtained daily from
dietary sources such as meat and fish.60
Creatine supplementations elevate muscle creatinine levels and increase ATP regeneration by
delaying the onset of muscle fatigue during high-intensity exercise and increasing the capacity

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of the skeletal muscle to perform work during periods of alternating exercise.61 The classical
The Skeletal System

loading protocol consists of ingestion of 0.3 grams/kg/day of CM for 5 – 7 days (e.g., ≃5 grams
taken four times per day) and 3–5 grams/day thereafter.62, 63
performance MS supplementation has been primarily observed in short-
benefit of creatine
duration, maximum-intensity resistance training, and strength training.64
Conflicting evidence appears in studies assessing the effect of creatine on endurance sports. In
healthy individuals, creatine supplements are generally safe when taken both short and long
term and no adverse effects from consuming recommended doses of creatine supplements have
been documented.65
Since supplementation has the potential to raise creatinine levels and mimic kidney disease,
creatine supplementation should not be used by individuals and athletes with pre-existing kidney
disease or those with a potential risk for kidney dysfunction.66
Post-Workout Supplements
Protein
Protein as an ergogenic aid can be found in many foods, from animal and vegetable whole foods,
powders, shakes, gels, and bars. Powdered protein can come from various sources, including eggs,
milk (e.g., casein, whey), and plants (e.g., soybeans, peas, hemp). Some protein powders can
contain protein from multiple sources (e.g., plant-derived).
The ergogenic effects of protein as a post-workout supplement have been well documented in
the literature, claiming that its purpose is to provide sufficient “building blocks” for muscle and
lean tissue growth after the body’s resistance to acute high-intensity training.
As a result, damage©2023 to contractile proteins and muscle soreness occurs, which can last for several
Trainer Academy
days and may impair muscle function. In these circumstances, an adequate intake of protein may
increase synthesis, whereas its absence increases the rates of protein degradation resulting in a
negative net protein balance.
In theory, protein supplementation stimulates protein synthesis that aids in the growth and repair
of contractile proteins, thereby facilitating long-term recovery and muscle remodeling.67, 68, 69, 70

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According to the American College of Sports Nutrition, the Academy of Nutrition and Dietetics,
The Skeletal System

and Dietitians of Canada, there is a lack of evidence from well-controlled studies that protein
supplementation directly improves athletic performance.71
Anna protein
However, D’Annunzio, MS in the presence of adequate carbohydrate intake during
supplementation
the recovery period may delay muscle damage and soreness.71 The extent to which protein
supplementation improves resistance in athletes is contingent on a variety of factors, including
intensity and duration of the training, individual age, dietary energy intake, and quality of protein
intake.71, 72
For athletic individuals engaging in strenuous exercise that seek to build and maintain muscle
mass, the International Society of Sports Nutrition recommends an overall daily protein intake
of 1.4–2.0 g/kg of body weight/day.72 For resistance-trained individuals higher protein intakes
(>3.0 g/kg/d) may have positive effects on body composition (i.e., promote loss of fat mass). These
protein doses should ideally be evenly distributed, every 3–4 h, across the day.72
In addition, it is advised to take protein supplements with caution as they are considered dietary
supplements with no FDA approval for safety or effectiveness. In particular, protein supplements
often contain processed materials and lack other essential nutrients required for the sustenance
of a healthy lifestyle.
It is suggested that the required protein intake be obtained from natural whole food sources and
protein supplementation should be resorted to only if the protein is insufficiently available in
the normal diet.
Protein supplements appear to be safe for the general population, and to date, there is limited
information available concerning the possible side effects of long-term supplementation. To
date, the only adverse effects reported come from protein powders and claim symptoms of
gastrointestinal discomfort, increased risk of weight gain and uncontrolled blood glucose from
added sugars and calories, and contamination with non-protein ingredients.
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A more recent report found that many protein powders sold recently contained heavy metals (lead,
arsenic, cadmium, and mercury), bisphenol-A (BPA, which is used to make plastic), pesticides,
and other contaminants with links to cancer and other health condition.73
Reading the nutrition and ingredient labels and consulting with a physician, sports dietitian,
or athletic staff beforehand is recommended to prevent contamination with banned substances
that are not listed on the label.

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Chapter 1
Branched Chain Amino Acids (BCAAs)
The Skeletal
Branched System
chain amino acids (BCAAs) include leucine, isoleucine, and valine, three essential amino
acids that are chemically structured with a branch side-chain that form one-third of the total
Anna
protein D’Annunzio,
in the body74 and are theMS
only amino acids metabolized by the skeletal muscles.75 BCAAs
must be obtained from external sources such as protein foods like chicken, red meat, fish, and
eggs because the body can’t produce them.
The three BCAAs are unique among the EAAs for their roles in protein metabolism, neural
function, and blood glucose and insulin regulation.72 In the last decade, consumption of BCAAs
in the form of dietary supplements has increased among recreational exercisers and athletes based
on the potentially efficacious effects on reduction in protein degradation, muscle damage, feelings
of soreness, and fatigue after ingestion post-exercise.76, 77, 78
A combination of 3.2 g BCAA and 2.0 g taurine, three times a day, for 2 weeks before and 3 days
after exercise was a useful strategy for reducing delayed muscle soreness and muscle damage.79
While short-term intake of leucine has the potential to improve protein synthesis, long-term
trials do not support BCAAS as useful performance enhancers that accelerate the repair of
muscle damage after exercise.72
In addition, caution must be taken when ingesting high intakes of leucine, as it can potentially disrupt
the normal action of insulin and dysregulate blood glucose, making increased BCAA concentrations
and their metabolites responsible for insulin resistance and complications associated with diabetes.80, 81
The excess of BCAA may lower brain uptake of other neutral amino acids, such as phenylalanine,
tyrosine, HIS, and tryptophan (TRP), which are precursors of dopamine, norepinephrine,
histamine, and serotonin.82
Ethical, Legal, and Health Issues with Illegal

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Performance-Enhancing Drugs
Epidemiology and Use
Performance-Enhancing Drugs (PED) are pharmacological substances that are commonly

used by competitive, professional, Olympic athletes, and non-athlete weightlifters to improve
performance, muscle recovery, and prevent nutritional deficiencies.

603
Chapter 1
The most common PEDs include anabolic-androgenic steroids (AAS), beta 2 agonists, peptide
The Skeletal System

hormones, diuretics, cannabinoids, blood doping, narcotics, beta-blockers, and corticosteroids,
human growth hormone, erythropoietin, diuretics, and stimulants.
TheAnna
use andD’Annunzio,
prevalence of PEDsMS use have increased dramatically over the past decade. To date,
it has been estimated that there are at least 3 million PED users in America, which puts PED
use on a scale similar to commonly encountered diseases such as Type 1 Diabetes and HIV.83, 84
Although steroid use is widespread in many Western countries, the United States appears to be
the leading country in AAS use.83, 84 In addition, a systematic review that sampled between 1976
and 2019 from 35 countries estimated that the rates of doping prevalence in competitive sports
ranged between 0 and 73%, with most falling under 5%.85
The vast majority of PED users are not athletes but rather nonathlete weightlifters, and the
adverse health effects of PED use are greatly underappreciated. Furthermore, the individuals
who are particularly vulnerable for use of performance-enhancing substances are adolescents.
Among athletes who use PEDs, those who play football, baseball, and basketball, who wrestle,
and who are involved in gymnastics and weight training are at increased risk.84
Purpose and Adverse Effects
Androgenic-Anabolic Steroids
Androgenic-anabolic steroids (AAS) are synthetic derivatives of the male hormone testosterone.

Testosterone is a male sex hormone and the most common androgen that helps promote the
development and maintenance of male sex characteristics.
Androgens also have anabolic effects such as an increase in skeletal muscle mass and strength.
Athletes and nonathlete weightlifters take AASs orally, transdermally, or by intramuscular
injection; however, the most popular mode is the intramuscular route.34
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©2023
Oral preparations have a short half-life and are taken daily, whereas injectable androgens are
typically used weekly or biweekly.34
The primary effects of AAS usage include34 :
• Muscle fiber hypertrophy

• Increased tissue net oxygen delivery
• Increased bone mineral density

604
Chapter 1
• Increased blood cell production
The Skeletal System

•
•
Decreased body fat
Increase heart, liver, and kidney size
• Vocal cord changes
Increased libido MS
• Mood and motivation
The main effects of short- and long-term AAS use that athletes most often self-report are an
increase in sexual drive, the occurrence of acne vulgaris, increased body hair, and an increment
of aggressive behavior.34
Adverse effects of PEDs use have also been reported in the literature, particularly, associations
with increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine,
neurologic, infectious, hepatic, renal, and musculoskeletal disorders.83
These drugs have also been implicated in stroke, seizures, and such adverse psychiatric conditions
as anxiety, mood changes, and autonomic hyperactivity.86 “Steroid rage” has been cited as a cause
of aberrant behavior in some adolescent males.87
It also is associated with other high-risk behaviors, such as the use of other illicit drugs, reduced
involvement in school, poor academic performance, engaging in unprotected sex, aggressive and
criminal behavior, suicidal ideation, and attempted suicide.34
Human Growth Hormone
Human growth hormone (HGH) is a naturally occurring metabolic hormone secreted by the
pituitary gland. In healthy adults, HGH enhances carbohydrate and fat metabolism, helps to
maintain sodium balance, and stimulates bone and connective tissue turnover.34
In addition, HGH regulates protein through anabolic effects including protein oxidation sparing,
increasing lean body
©2023 mass, and decreasing fat mass. Despite these physiological effects, there
Trainer Academy 34
is not enough evidence to suggest that HGH administration enhances physical performance or
has adverse effects on HGH.
Therefore, most of the information is anecdotal, and these reports are often confounded by
concurrent use of other PEDs, especially AASs. The potential side effects include edema, excessive
sweating, skin changes, darkening of moles, adverse effects on glucose and lipid metabolism, and
the growth of bones as evidenced by the development of a protruding jaw and boxy forehead.34, 83

605
Chapter 1
Erythropoietin
The SkeletalisSystem
Erythropoietin (EPO) a glycoprotein hormone that regulates red cell production and is produced
by both the kidney and the liver. In adults, the kidneys are the dominant source of circulating
Anna D’Annunzio,
erythropoietin, MSis an important contributor to erythropoietin production in
although the liver
the fetal and perinatal periods.
EPO injections are used in the athletic population to increase the serum hematocrit and oxygen-
carrying capacity of the blood and delivery to the muscle and thereby improving endurance.34
While EPO use as an ergogenic aid is popular in endurance sports, such as distance running,
cycling, and triathlons, it is difficult to detect because it is a hormone produced by the kidneys.
The usage of EPO augments the risk of thrombosis, cardiovascular or cerebrovascular events
(including myocardial infarction and stroke), and hypertension.34 EPO also can cause elevated
blood pressure or elevated potassium levels.34
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©2023

606 Supplementation 604
Chapter 1
The Skeletal System

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©2023

Trainer Academy
©2023
607
Chapter 1
Legality Issues and Regulations
The Skeletal System
The use of PEDs is banned in major sports organizations that regulate sporting competitions to
Anna
protect D’Annunzio,
the health MS
and well-being of athletes and ensure fair play in Olympic sports. In competitive
sports, the term doping is used to define the use of banned athletic performance-enhancing drugs
by athletic competitors.
To prevent that, the World Anti-Doping Agency (WADA) is an international agency that

oversees the implementation of the anti-doping policies in all sports worldwide and maintains
a list of substances (drugs, supplements, etc,) that are banned from use in all sports at all times,
banned from use during competition, or banned in specific sports.88
The WADA’s Anti-Doping Program is based on the WADA Code, a universal core document
that contains anti-doping policies, and rules and regulations for best practices in international
and national anti-doping programs.89 It works in conjunction with eight mandatory international
standards and 12 non-mandatory guidelines.89
The WADA’s Prohibited List is a mandatory International Standard that gets updated at least
annually, with the new list taking effect on January 1st each year.90 Any substance that is added
to the prohibited list is deemed to meet two of the following criteria90:
1. It has the potential to enhance or enhances sport performance

2. Use of the substance or method represents an actual or potential health risk to the athlete
3. Use of the substance or method violates the spirit of sport
Additionally, the list is divided into the substances and methods that are prohibited at all times,
or prohibited only in competition.90 Those substances banned at all times would include (but
are not limited to) hormones, anabolics, EPO, beta-2 agonists, masking agents, and diuretics.90
Those substances prohibited only in competition would include but not be limited to stimulants,
marijuana, narcotics, and glucocorticosteroids.90 Also banned at all times are methods such as
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blood transfusion or manipulation, or intravenous injections in some situations.90
©2023
It is important to remember that not all substances and methods are named on the Prohibited
List.90 Even if not expressly named, a substance and method can be deemed prohibited if90:
• It is not currently approved by any governmental regulatory health authority for human
therapeutic use (e.g. drugs under pre-clinical or clinical development or discontinued, designer
drugs, substances approved only for veterinary use), or
• It has a similar chemical structure or similar biological effect(s).

608
Chapter 1
Above all, athletes are responsible for knowing what substances and methods are considered
The Skeletal System

banned on the Prohibited List. Supplementation 606
Under World Athletics Rules, the presence of a prohibited substance in an athlete’s sample, the
useAnna D’Annunzio,
of aUnder
prohibited
World substance,
MSprohibited method all constitute a doping offense.
and
Athletics Rules, the presence of a prohibited substance in an athlete’s sample,
the use of a prohibited substance, and prohibited method all constitute a doping offense.
It is important that those who work with athletes acquaint themselves with WADA’s List of
It is Substances
Prohibited important thatand
those who work with athletes acquaint themselves with WADA’s List of
Methods.
Prohibited Substances and Methods.
The National Collegiate
The National Athletic
Collegiate Association
Athletic (NCAA)
Association (NCAA)also bans
also the
bans theuse
useofofPEDs
PEDs and
and recreational
drugs to protectdrugs
recreational the health of college
to protect athletes
the health andathletes
of college ensure and
fairensure
play. fair
91
Theplay.
NCAA91
Thetests
NCAA fortests
steroids,
peptide hormones,
for steroids, andhormones,
peptide masking agents year-round
and masking agents and tests for
year-round stimulants
and and recreational
tests for stimulants and drugs
recreational drugs
during championships. during
91 championships. 91
Member schools also may test for these substances as part of their athletics department drug-
Member schools also may test for these substances as part of their athletics department drug-
deterrence programs.91 A positive drug test will result in loss of eligibility and suspension from
deterrence programs.
the sport,
91
Arisk
including the positive drug test
of negatively will result
impacting in 91loss of eligibility and suspension from
health.
the sport, including the risk of negatively impacting health.91
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609
Chapter 1
Summary
The Skeletal System
The popularity of dietary supplements and even performance-enhancing drugs mean that fitness
Anna D’Annunzio,
professionals MS with clients in the context of health and fitness.
routinely discuss them
While making supplement recommendations is outside the Trainer Academy Scope of Practice,
certified trainers can discuss research on the efficacy and safety of supplements, as long as they
do not prescribe them to the client.
References
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2. Muñoz García M, Pérez Menéndez-Conde C, Bermejo Vicedo T. Avances en el conocimiento del uso
de micronutrientes en nutrición artificial [Advances in the knowledge of the use of micronutrients in
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org/10.1136/pgmj.2006.047670
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some diseases. Sultan Qaboos Univ Med J. 2014;14(2):e157-e165.
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bjsports-2018-099027
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performance. Published August 31, 2021. Accessed September 26, 2022
43. Thomas DT, Erdman KA, Burke LM. Position of the Academy of Nutrition and Dietetics, Dietitians
of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance [published
correction appears in J Acad Nutr Diet. 2017 Jan;117(1):146]. J Acad Nutr Diet. 2016;116(3):501-
528. https://doi.org/10.1016/j.jand.2015.12.006
44. Yusko DA, Buckman JF, White HR, Pandina RJ. Alcohol, tobacco, illicit drugs, and performance enhancers:
a comparison of use by college student-athletes and non-athletes. J Am Coll Health. 2008;57(3):281–290
45. Constantinou D, Aguiyi I. Use, Perceptions and Attitudes of Cognitive and Sports Performance Enhancing
Substances Among University Students. Front Sports Act Living. 2022;4:744650. Published 2022 Apr
12. https://doi.org/10.3389/fspor.2022.744650
46. Ganson KT, Mitchison D, Murray SB, Nagata JM. Legal Performance-Enhancing Substances and
Substance Use Problems Among Young Adults. Pediatrics. 2020 Sep;146(3):e20200409. https://doi.
org/10.1542/peds.2020-0409. PMID: 32868471; PMCID: PMC7461208.
47. Trexler ET, Smith-Ryan AE, Stout JR, Hoffman JR, Wilborn CD, Sale C, Kreider RB, Jäger R,
Earnest CP, Bannock L, Campbell B. International society of sports nutrition position stand: Beta-Alanine.
Journal of the International Society of Sports Nutrition. 2015 Dec;12(1):1-4.
48. Hobson RM, Saunders B, Ball G, Harris RC, Sale C. Effects of β-alanine supplementation on exercise
performance: a meta-analysis. Amino acids. 2012 Jul;43(1):25-37.
49. Walsh AL, Gonzalez AM, Ratamess NA, Kang J, Hoffman JR. Improved time to exhaustion
following ingestion of the energy drink Amino Impact. J Int Soc Sports Nutr. 2010;7:14. https://doi.
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org/10.1186/1550-2783-7-14.
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50. Spradley BD, Crowley KR, Tai CY, Kendall KL, Fukuda DH, Esposito EN, et al. Ingesting a pre-
workout supplement containing caffeine, B-vitamins, amino acids, creatine, and beta-alanine before
exercise delays fatigue while improving reaction time and muscular endurance. Nutr Metab (Lond).
2012;9:28. https://doi.org/10.1186/1743-7075-9-28.
51. Gonzalez AM, Walsh AL, Ratamess NA, Kang J, Hoffman JR. Effect of a pre-workout energy supplement
on acute multi-joint resistance exercise. J Sports Sci Med. 2011;10(2):261–6.

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52. HoffmanChapter
JR, Landau 1 G, Stout JR, Dabora M, Moran DS, Sharvit N, et al. Beta-alanine supplementation
improves tactical performance but not cognitive function in combat soldiers. J Int Soc Sports Nutr.
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2014;11(1):15. https://doi.org/10.1186/1550-2783-11-15.
53. Davis JM, Zhao Z, Stock HS, Mehl KA, Buggy J, Hand GA. Central nervous system effects of caffeine
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and adenosine on fatigue. Am JMS
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54. Guest NS, VanDusseldorp TA, Nelson MT, et al. International society of sports nutrition position stand:
caffeine and exercise performance. J Int Soc Sports Nutr. 2021;18(1):1. Published 2021 Jan 2. https://
doi.org/10.1186/s12970-020-00383-4
55. U.S. Food and Drug Administration. Spilling the Beans: How Much Caffeine is Too Much? Available
at: https://www.fda.gov/consumers/consumer-updates/spilling-beans-how-much-caffeine-too-much.
Published December 12, 2018. Accessed September 26, 2022
56. Pasman W.J., van Baak M.A., Jeukendrup A.E., de Haan A. The effect of different dosages
of caffeine on endurance performance time. Int. J. Sports Med. 1995;16:225–230. https://doi.
org/10.1055/s-2007-972996.
57. Grgic J, Mikulic P, Schoenfeld BJ, Bishop DJ, Pedisic Z. The influence of caffeine supplementation on
resistance exercise: a review. Sports Med. 2019;49(1):17–30.
58. Pallares JG, Fernandez-Elias VE, Ortega JF, Munoz G, Munoz-Guerra J, Mora-Rodriguez
R. Neuromuscular responses to incremental caffeine doses: performance and side effects. Med Sci Sports
Exerc. 2013;45(11):2184–92.
59. Ramos-Campo DJ, Perez A, Avila-Gandia V, Perez-Pinero S, Rubio-Arias JA. Impact of caffeine

intake on 800-m running performance and sleep quality in trained runners. Nutrients. 2019;11(9).
60. Brunzel NA. Renal function: Nonprotein nitrogen compounds, function tests, and renal disease. In:
Scardiglia J, Brown M, McCullough K, Davis K, editor. Clinical Chemistry. McGraw-Hill: New
York, NY; 2003. pp. 373–399.
61. Wax B, Kerksick CM, Jagim AR, Mayo JJ, Lyons BC, Kreider RB. Creatine for Exercise and Sports
Performance, with Recovery Considerations for Healthy Populations. Nutrients. 2021;13(6):1915.
Published 2021 Jun 2. https://doi.org/10.3390/nu13061915
62. Williams MH, Kreider R, Branch JD. Creatine: The power supplement. Champaign, IL: Human
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Kinetics Publishers; 1999. p. 252.
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63. Kreider RB, Leutholtz BC, Greenwood M. Creatine. In: Wolinsky I, Driskel J, editor. Nutritional
Ergogenic Aids. CRC Press LLC: Boca Raton, FL; 2004. pp. 81–104.
64. Hall M, Trojian TH. Creatine supplementation. Curr Sports Med Rep. 2013;12(4):240–244
65. Davani-Davari D, Karimzadeh I, Ezzatzadegan-Jahromi S, Sagheb MM. Potential Adverse Effects of

Creatine Supplement on the Kidney in Athletes and Bodybuilders. Iran J Kidney Dis. 2018;12(5):253-260.
66. Vega J, Huidobro E JP. [Effects of creatine supplementation on renal function]. Revista Medica de Chile.

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67. Breen L, Philip A, Witard OC, et al. The influence of carbohydrate-protein co-ingestion following endurance
exercise onmyofibrillar and mitochondrial protein synthesis. J Physiol.2011;589:4011–25.19.
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68. Howarth KR, Moreau NA, MS Phillips SM, et al. Coingestion of protein with carbohydrate during
recovery from endurance exercise stimulates skeletal muscle protein synthesis in humans. J Appl Physiol.
2009;106:1394–402.20.
69. Moore DR, Stellingwerff T. Protein ingestion after endurance exercise: the ‘evolving’ needs of the
mitochondria? J Physiol.2012;590:1785–6.21.
70. Hulston CJ, Wolsk E, Grøndahl TS, et al. Protein intake does not increase vastus lateralis muscle protein
synthesis during cycling. Med Sci Sports Exerc. 2011;43:1635–42.
71. Thomas DT, Erdman KA, Burke LM. Position of the Academy of Nutrition and Dietetics, Dietitians
of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance [published
correction appears in J Acad Nutr Diet. 2017 Jan;117(1):146]. J Acad Nutr Diet. 2016;116(3):501-
528. https://doi.org/10.1016/j.jand.2015.12.006
72. Jäger R, Kerksick CM, Campbell BI, et al. International Society of Sports Nutrition Position Stand:
protein and exercise. J Int Soc Sports Nutr. 2017;14:20. Published 2017 Jun 20. https://doi.org/10.1186/
s12970-017-0177-8
73. Bandara SB, Towle KM, Monnot AD. A human health risk assessment of heavy metal ingestion among
consumers of protein powder supplements. Toxicol Rep. 2020;7:1255-1262. Published 2020 Aug
21. https://doi.org/10.1016/j.toxrep.2020.08.001
74. Mero A. Leucine supplementation and intensive training. Sports Med. 1999;27(6):347–358.
75. Koo GH, Woo J, Kang S, Shin KO. Effects of supplementation with BCAA and L-glutamine on blood
fatigue factors and cytokines in juvenile athletes submitted to maximal intensity rowing performance. J
Phys Ther Sci. 2014;26:1241–1246.
76. Da Luz C.R., Nicastro H., Zanchi N.E., Chaves D.F., Lancha A.H. Potential therapeutic effects of
branched-chain amino acids supplementation on resistance exercise-based muscle damage in humans. J. Int.
Soc. Sports Nutr. 2011;8:23. https://doi.org/10.1186/1550-2783-8-23.
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77. Greer B.K., Woodard
©2023 J.L., White J.P., Arguello E.M., Haymes E.M. Branched-chain amino acid
supplementation and indicators of muscle damage after endurance exercise. Int. J. Sport Nutr. Exerc. Metab.
2007;17:595–607. https://doi.org/10.1123/ijsnem.17.6.595.
78. Blomstrand E. A role for branched-chain amino acids in reducing central fatigue. J. Nutr.
2006;136:544S–547S. https://doi.org/10.1093/jn/136.2.544S.
79. Shimomura Y, Inaguma A, Watanabe S, et al. Branched-chain amino acid supplementation before squat
exercise and delayed-onset muscle soreness. Int J Sport Nutr Exerc Metab. 2010;20(3):236-244. https://
doi.org/10.1123/ijsnem.20.3.236

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80. Bloomgarden 1 and branched-chain amino acids: What is the link? J Diabetes. 2018;10:350–
Z. Diabetes
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81. Yoon MS. The emergingSystem
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2016;8:405. https://doi.org/10.3390/nu8070405.
82. Holeček M. Side effects of amino acid supplements. Physiol Res. 2022;71(1):29-45. https://doi.
org/10.33549/physiolres.934790
83. Pope HG Jr, Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S. Adverse health consequences of
performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341-
375. https://doi.org/10.1210/er.2013-1058
84. Dandoy C, Gereige RS. Performance-enhancing drugs. Pediatr Rev. 2012 Jun;33(6):265-71; quiz 271-
2. https://doi.org/10.1542/pir.33-6-265. PMID: 22659257; PMCID: PMC4528343.
85. de Hon, O., Kuipers, H. & van Bottenburg, M. Prevalence of Doping Use in Elite Sports: A Review of
Numbers and Methods. Sports Med 45, 57–69 (2015). https://doi.org/10.1007/s40279-014-0247-x
86. Agency for Healthcare Research and Quality. Ephedra and ephedrine for weight loss and athletic
performance enhancement: clinical efficacy and side effects. Available at: http://www.ahcpr.gov/clinic/
epcsums/ephedsum.pdf. Accessed September 26, 2022
87. Virtual Mentor. 2005;7(11):764-766. https://doi.org/10.1001/virtualmentor.2005.7.11.oped1-0511.
88. World Anti-Doping Agency. Who We Are. Available at: https://www.wada-ama.org/en/who-we-are.

Accessed September 26, 2022
89. World Anti-Doping Agency. The World Anti-Doping Code. Available at: https://www.wada-ama.

org/en/what-we-do/world-anti-doping-code. Accessed September 26, 2022
90. World Anti-Doping Agency. The Prohibited List. Available at: https://www.wada-ama.org/en/

prohibited-list. Accessed September 26, 2022
91. The National Collegiate Athletic Association. NCAA Banned Substances. Available at: https://www.

ncaa.org/sports/2015/6/10/ncaa-banned-substances.aspx Updated July 14, 2022. Accessed September
26, 2022
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©2023

Chapter 1
TheCHAPTER
Skeletal28System
Anna D’Annunzio,
Exercise, MS
MentalHealth, and
Lifestyle Considerations
Patricia Lininger, MS
617 E XE RCISE , ME NTAL HE ALT H , AN D
LIF E ST YLE CONSIDE RATI O N S
Chapter 1
Introduction
The Skeletal System
There is a reciprocal relationship between mental health, a positive healthy lifestyle, and exercise.
In Anna
additionD’Annunzio, MStraining, fitness professionals can deliver coaching toward
to exercise and fitness
healthy lifestyle practices, which can be highly beneficial for clients.
The effects of such habits as proper exercise, nutrition, and other wellness practices can result in
mental and emotional health improvements.
As with all other aspects of personal training, fitness professionals must be aware of the limits
of their scope of practice when it comes to mental health and lifestyle coaching.
The role of a personal trainer can be broad as the trainer guides a client to a myriad of improvements
in all health and wellness pillars. The benefits of the personal trainer’s guidance include enhanced
quality of life for the client through improved physical condition and fitness levels.
This in turn affects overall physical health but can include facilitating greater confidence, a more
positive outlook, and improved mental and emotional health based on reaching new fitness peaks
These holistic improvements can be achieved through the trainer’s coaching the client to adopt
healthy lifestyle habits, including the following:
• Getting enough quality sleep

• Hydrating adequately
• Practicing good nutrition habits
• Managing stress
• Limiting alcohol
• Quitting smoking
For coachingTrainer
clients to improve their lifestyle habits, personal and in-depth discussions and
Academy
©2023
analysis of the client’s current lifestyle practices must take place.
These discussions are more readily accomplished when a high level of trust is established between
the client and the personal trainer, which precipitates greater compliance with the coaching.
However, with such a level of trust, the definitive line marking the scope of practice boundaries
of a personal trainer can become hazy and a client’s expectations can exceed the scope of practice
limitations.

618 E XE
Exercise, Mental Health, and Lifestyle RCISE , ME NTAL
Considerations HE ALT H ,617
AN D
Chapter 1
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uncommon for aforclient
a client
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their mental
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health counselor, encroaching into the scope of practice for a licensed mental health
health counselor, encroaching into the scope of practice for a licensed mental health professional.
Providing services outside thethe

scope
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resultin in a personal trainer
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accreditation ororeven
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in expensive legalaction
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against thethe trainer.
trainer. 1, 2, 3 1, 2, 3
Trainer Academy
©2023
The boundaries of the professional scope of practice for a personal trainer must be
maintained, yet it is the personal trainer’s responsibility to decipher what might be an overstep
The boundaries of the professional scope of practice for a personal trainer must be maintained,
into a licensed health professional’s scope of practice.
yet it is the personal trainer’s responsibility to decipher what might be an overstep into a licensed
health professional’s scope
To be careful not of practice.
to overstep the boundaries of other licensed professional domains, the
personal trainer should not:
To be careful not to overstep the boundaries of other licensed professional domains, the personal
Trainer Academy
©2023
Chapter 1
trainer should not:
The Skeletal
• Counsel or advise System
• Diagnose
• Anna
AttemptD’Annunzio, MS
to heal disease or treat/rehabilitate an injury
• Prescribe medication, supplements, dietary plans, or other approaches to prevent, treat, or
cure any disease
The personal trainer can avoid the legal liabilities by remembering that they serve as a guide or
facilitator, helping the client reach their own conclusions and helping them problem solve versus
problem-solving for them.
Lifestyle coaching should be a client-led collaborative process that guides the client to analyze,
think, plan, set goals and work towards them.
To guide a client, a personal trainer would be wise to practice coaching techniques which include
active listening, reflective listening, and motivational interviewing, which is not unlike the practice
of a counselor. However, a personal trainer should not directly advise a client on how to handle
problems or manage the personal aspects of their lives.
The trainer should exhibit empathy and compassion, impart no judgment when listening to a client
express their concerns or daily experiences, and acknowledge the client’s feelings expressed. However,
a personal trainer will be outside their professional scope of practice if he or she provides counsel.
The personal trainer can be an educator of evidence-based strategies and techniques for improved
fitness, health and wellness, mental well-being, confidence, self-improvement, and empowerment.
Sharing quality resources from evidence-based sites and publications is one way to begin exposing
clients to new information that may inform their decision making. Allowing the client to be
the decision maker in the collaborative process will be best for the client’s chances for success.
Trainer Academy
©2023
Counseling Referrals
If a personal trainer perceives that a client needs professional counseling, a referral should be made to
a licensed counselor, psychologist, psychiatrist, or social worker in a non-insulting and nonjudgmental
manner.

Chapter 1
The statements above refer to common venting on personal issues from a client who perceives the
The Skeletal System

trainer as a confidant. However, If the situation seems extreme and/or if there is any indication
that the client is in danger of harming themselves or others, a direct question regarding their
intentions for harm should be asked. If the answer affirms such intentions, emergency personnel
Anna
should D’Annunzio,
be contacted. A suicide MS
hotline should be contacted if self-harm is intended.
Similarly, when coaching or training a client with the adoption of healthy nutrition habits, the
personal trainer must not infringe on the scope of practice of a registered dietitian. The personal
trainer should not recommend specific diet plans or quantities of nutrients nor should they offer
advice on supplementation. However, they can help the client track food intake and educate them
on evidence-based healthy nutrition plans and portion control, provide quality science-backed
resources, and help the client analyze and determine healthier choices.2
Likewise, as a personal trainer instructs a client on exercise and designs an effective exercise
plan, they must not infringe on the scope of practice of a physical therapist, medical doctor, or
another licensed practitioner.
The personal trainer cannot decide whether it is safe for the client to exercise and must refer the
client to an appropriate licensed professional if they suspect the client may have an issue that
makes exercise unsafe.
In summary, it is the personal trainer’s responsibility to respect the boundaries between them
and licensed professionals in all overlapping fields.
There is a risk for liability if a personal trainer’s action could be in any way construed to have
contributed to any harm to a client, but any actions that can be interpreted as operating beyond
the scope of practice of a personal trainer can be cause for legal action.
The Benefits of Physical Activity on

Trainer Academy
©2023
Mental Health
Good mental health is often determined by self-reports of positive moods, resilience, a lack
of any significant or consistent anxiety or depressive symptoms and the ability to regulate
emotions.
In an era with high incidence of mental health issues, many health professionals and affected

Chapter 1
individuals are searching for all avenues to assist in improving mental health.4
The
ManySkeletal System
studies link exercise and consistent physical activity with better mental health and even
more studies are being conducted on this topic every year.
In one such study with a large test group of 1.2 million American adults, it was recorded that
those who exercised regularly exhibited better mental health than those who did not, taking in
account other factors such as background and demographics.5
In one of the many meta-analyses, researchers found a correlation between exercise and positive
mental effects for those with mental health disorders, as well as those without. These effects were
most evident in those who had exhibited higher levels of anxiety and depression.6
In this review, the findings concluded that regular rhythmic moderate or low intensity aerobic
exercises delivered the most improvements. In some case improvements in anxiety and depression
were evident after just one bout of exercise of 15-30 minutes in duration.6
According to another meta-analysis on the prevention of anxiety and depression, more than over
80,000 participants across multiple studies showed that participating consistently in physical
activity reduced the chance of suffering higher anxiety levels or developing an anxiety disorder.7
On the other hand, lower activity levels correlated with greater risks of less-than-optimal mental
health.
Another study review including more than 250,000 people across 49 studies showed that
consistently participating in more physical activity reduced the chance of suffering from depression.8
As for improvements in the mental health of those who suffer from more severe mental health
disorders, research concludes that marked symptoms such as adverse moods, difficulties with
focus and concentration, dysfunctional sleep habits and other symptoms of psychosis improve
with physicalTrainer
activity and exercise.9
Academy
©2023
Personal trainers assist their clients not only with improving their physical health, but also their
mental health and well-being, which then, affects every aspect of their lives.

Chapter 1
How
The to Maximize
Skeletal System the Mental Health
Benefits of Exercise
• Encourage clients to exercise outdoors. Time spent in nature was also proven to provide
mental health benefits, so combining the two may provide a double boost.12
• Have clients choose activities they like for exercise/physical activity.
• Let clients choose several short bouts of exercise in a day versus one long one if the single
workout seems daunting. It was proven that several 10-minute bouts were as effective as a
30 minutes single session.13
• Encourage clients to take rest days and listen to their bodies. Exercise can become a dreaded
chore when it creates excessive stress.
• Encourage small celebrations after activities using positive language and expressions. The
feelings that result from a mini-celebration give a boost of dopamine that fosters the desire
to repeat the activity that brought about such feelings.14
• Listen to enjoyable music during exercise. Studies prove music decreases stress and boosts
positive feelings.15
• Practice mindfulness (for example, notice the birds or the plants on a walk or jog outdoors,
listen for the sounds around when taking a swim.) Attune all senses to the experience.26
Helping Clients Identify and Practice

Healthy Behaviors
Clients can often make great leaps in their health and fitness goals once they adopt healthier
lifestyle habits. Trainers can facilitate these changes in all lifestyle pillars. There are many studies
supporting this potential for boosting mental health, moods, cognitive functioning, and more
when improving these four lifestyle habits.
Trainer Academy
©2023
Hydration
Some clients may not recognize the correlation between hydration and mental health, so it is
essential to educate them on the need for water intake and the many benefits it bestows to both
physical and mental health.

Chapter 1
One study revealed that drinking less than 2 glasses of water every day more than doubled the
The Skeletal System

risk of depression for women and increased the risk by more than 70% in men.16
Additionally, links between obesity, metabolic disorder, and inadequate water consumption have
Anna
been D’Annunzio,
established MS
which feeds into the mental health aspect, as those with obesity and other health
issues have higher rates of depression as well.17
There is growing evidence that lack of adequate water consumption is linked with mental health
disorders.16 Research suggests even slight dehydration adversely affects mood and the perception of
the difficulty of a task for women.18 Likewise, a study on healthy young men showed a decrease in
alertness and memory and increased feelings of fatigue and anxiety when moderately dehydrated.19
The first objective as a trainer and coach could be to help the client identify his or her current
hydration habits by tracking them daily, then setting goals to increase the amount of water they
drink in the day.
Awareness of inadequate hydration often prompts extra efforts and tracking can provide both
accountability and awareness.
Examples for a trainer to follow could include having the client determine a small goal of
increasing his or her water consumption and then having them problem-solve as to what they
can employ to prompt the behavior throughout the day.
If they can’t think of solutions, the trainer could provide a list of suggestions and let them choose.
They might put a sticky note on their desk and check off tally marks, they may fill up a water
glass when they get coffee in the morning and then do it again each time they get up to use the
restroom.
They may buy an attractive new water jug and keep it in a prominent place. The trainer can start
the list of suggestions to get them thinking and then ask them to finish it. The idea is for them
to come up with what might inspire them to maintain adequate hydration.
Trainer Academy
©2023
Sleep
Adequate sleep is another healthy habit that should not be ignored for improving both physical
and mental functioning and health. It is, therefore, imperative when working with a client to
discuss their sleep patterns and educate them on the evidence-based value of 7-9 hours of quality
sleep each night.

Chapter 1
Helping a client to identify their current sleep patterns by tracking and analyzing them, and
The Skeletal System

then strategizing on ways to improve these patterns where necessary can greatly improve their
rate of success in reaching health, fitness, and wellness goals.
It isAnna
reportedD’Annunzio, MS
that one-third of US adults report getting less than 7-9 hours of sleep as recommended
by the CDC. Without adequate sleep, both physical performance and mental performance
20
decline. Psychological distress is increased, showing up in the form of anxiety and depression,
low moods and agitation, low energy, fatigue, and even cognitive decline and memory issues.21
Both short sleep duration and poor quality of sleep have associations with depression.21 One study
of over 28,000 people concluded that mental health was negatively affected by both inadequate
quantity and poor quality of sleep.21
Earlier, researchers in the US found that inadequate sleep duration (less than 7-9 hours per night)
and sleep problems within the duration were linked with higher levels of clinical depression.22
It has even been observed that individuals averaging 6 or fewer hours of sleep per night were
approximately 2.5 times more likely to experience frequent mental distress than the participants
who sleep consistently more than 6 hours.20
As with hydration, having clients track to become aware of their current patterns can often
inspire more adherence to the recommendations. Tracking can be done simply with pen and
paper logging bedtime and wake-up time and any waking throughout the night. Many apps are
also available for smartphones and smartwatches and fitness trackers can track sleep time, as
well as the quality of sleep.
Trainer Academy
©2023

inspire more adherence to the recommendations. Tracking can be done simply with pen and
paper logging bedtime and wake-up time and any waking throughout the night. Many apps are
also available for smartphones and smartwatches and fitness trackers ,can
E XE RCISE ME track
NTALsleep HE
time,
ALTas H , AN D
625
well as the quality of sleep. LIF E ST YLE CONSIDE RATI O N S
Chapter 1
The Skeletal System

Exercise can often be a remedy for sleep problems for those who have trouble getting to
Exercise canoroften
sleep staying
beasleep, but iffor
a remedy sleep problems
sleep persist,for
problems collaborate
those who problem-solving
have troublewith clientsto sleep or
getting
stayingregarding otheriflifestyle
asleep, but changes such
sleep problems as stopping
persist, screen time
collaborate in the evening, eliminating
problem-solving with clients regarding
other lifestyleTrainer
changesAcademy
©2023 such as stopping screen time in the evening, eliminating caffeine or alcohol,
taking an evening walk, meditating, listening to Academy
Trainer calming music and other strategies can be tried.
©2023
As always, let the decision-making of strategies be client-led. The personal trainer simply facilitates
problem solving with open-ended questions and active listening.
If sleep problems persist, a referral to a sleep specialist or counselor should be made.

Chapter 1
Nutrition
The Skeletal System
Good nutrition habits can result in more energy and vigor, healthy digestion, greater focus
alertness, improved moods,MS
greater exercise and sports performance, better mental health,
cognitive functioning, and more. In short, good nutrition can affect all bodily functions and is
instrumental to overall good health and wellness.
As a personal trainer, providing evidence-based resources on healthy nutrition plans is expected,

however, as in the previous segment on mental health, it is the responsibility of the trainer to
not overstep the boundaries of the personal trainer’s scope of practice.
The role of a personal trainer is to both help their clients identify and practice the recommendations
for consuming a balanced diet consisting of health-promoting nutrients and to share quality
science-backed resources.
Alcohol limitation and Smoking Cessation

It would be rare to find a client who does not already know that smoking is an unhealthy habit
or that drinking too often or too much is also not good for your physical or mental health either.
Although there are personal trainer scope of practice limitations when it comes to counseling,
fitness professionals can be a source of guidance and support for clients wanting to stop smoking
or those who want to refrain from drinking excessively.
Smoking Cessation
As for smoking cessation, according to a report by the CDC, about 70% of adult smokers have
proclaimed they want to quit, yet only about 1 out of 10 successfully quit each year.24
Trainer Academy
©2023
Dependence on tobacco often takes strong intervention and several tries before success.
With those track records, a personal trainer should consider referring the client to a smoking
cessation practitioner who is highly trained in this specific area and works diligently with the
latest evidence-based practices. The personal trainer can continue supporting the client at the
same time.

Chapter 1
One of the many resources available to share with clients who want to quit is a government “quit
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line” provided by the CDC which uses evidence-based practices and can be called 24 hours per day.
English: 1-800-QUIT-NOW (1-800-784-8669)

Anna1-855-385-3569.
Spanish, D’Annunzio, MS
Mandarin & Cantonese: 1-800-838-8917
Vietnamese: 1-800-778-8440
State Quit-Lines can be found at map.naquitline.org Visit www.cdc.gov/tobacco/campaign/tips/

quit-smoking for additional resources to share.
Additionally, nicotine replacement medications such as the patch, nicotine gum and nicotine
lozenges can be helpful. Although a personal trainer would not be in the scope of practice to
prescribe or recommend a product, they can learn more about these to answer questions and
send the client to the websites that educate on the details including recommended dosage and
duration of use.
Motivational interviewing techniques common in health coaching and behavior change guidance
techniques are again, a great way to allow the client to fully engage and make decisions. These
techniques keep the trainer or coach within the scope of practice by supporting and facilitating,
not advising.
Limiting Alcohol Consumption
Educating a client on the risks and the adverse effects on physical health and mental health of
drinking too much or too often is certainly within the scope and helping a client track, analyze
and define their current drinking habits are as well.
Assist the client in identifying their true perspectives about their habits along with setting goals
first. The client must
©2023 also take note of the triggers that prompt excessive drinking and brainstorm
Trainer Academy
solutions for avoiding or countering them. Finding replacement behaviors is another task for the
client. Again, the client is the one solving the complex problem and the personal trainer cannot
give advice.
Since drinking heavily can be a sign of an addiction, recommending a counselor, a mental health
professional or even a rehabilitative treatment program is usually the best choice. This needs to
be done tactfully and without judgment.

Exercise, Mental Health, and Lifestyle Considerations 626

When Chapter
allowing the1client to explore their present habits, goals, and the barriers to achieving
When allowing
them with openthe client
ended to explorethe
questioning, their present
client mighthabits,
come upgoals,
withand
thisthe barriers
need to achieving
for treatment them
on their
The Skeletal System
with
own.open ended questioning, the client might come up with this need for treatment on their own.
Strategies for Trainers to Encourage

Strategies for Trainers to Encourage
Healthy Lifestyles
Healthy Lifestyles
Trainer Academy
©2023
The following is a list of a few practical tips for fitness professionals to encourage healthy
lifestyles in their clients:
The following is a list of a few practical tips for fitness professionals to encourage healthy lifestyles
in their
• clients:
Model healthy behaviors to help inspire clients to adopt such habits.
• Share resources where healthy lifestyles are modeled and the rewards of those lifestyles
• Model arehealthy
visible, behaviors
which provides a subliminal
to help message
inspire clients that encourages
to adopt others to make healthy
such habits.
• Sharechoices.
resources where healthy lifestyles are modeled and the rewards of those lifestyles are
• Hold the client
visible, which accountable
provides whilemessage
a subliminal utilizingthat
positive approaches.
encourages others to make healthy choices.
• Hold the client accountable while utilizing positive approaches. efforts.
• Acknowledge and celebrate the small wins to encourage continued
Trainer Academy
Trainer Academy
©2023 © 2023
Chapter 1
• Acknowledge and celebrate the small wins to encourage continued efforts.
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• Provide positive yet sincere affirmations encouraging clients to scaffold one small win onto
another.
• Encourage clients to set goals small enough to be reached but big enough to be satisfying,
Anna
and thenD’Annunzio, MSonce each small goal is reached.
build on their success
Summary
The role of the fitness professional includes guiding clients towards improvements in all health
and wellness pillars. Just as exercise creates better physical and mental well-being, further health
and wellness improvements such as proper sleep, hydration, and better nutritional choices can
drastically improve health and fitness outcomes.
Additional lifestyle habits include limiting the use of substances like cigarettes and alcohol, which
is something fitness professionals can discuss with clients.
In all cases of behavioral and lifestyle coaching, it is imperative that fitness professionals stay
within the Trainer Academy Certified Personal Trainer Scope of Practice.
References
1. Herbert, D.L., JD, Services of a Personal Trainer are Not Medical in Nature, THE EXERCISE,
SPORTS AND SPORTS MEDICINE STANDARDS & MALPRACTICE REPORTER, Vol. 3, No.
5 (September, 2014):74, 75.
2. Sass C, Eickhoff -Shemek JM, Manore MM, Kruskall, LJ. Crossing the line: understanding the scope
of practice between registered dietitians and health/fitness professionals. ACSM Health Fitness J.
07; 11(3): 12-19.
Trainer Academy
3. Melton DI, Katula
©2023
JA, Mustian KM. The current state of personal training: an industry perspective
of personal trainers in a small Southeast community. J Strength Cond Res. 2008 May;22(3):883-
9. https://doi.org/10.1519/JSC.0b013e3181660dab. PMID: 18438226; PMCID: PMC4021014.
4. World Mental Health Report: Transforming mental health for hall. Executive summary. Geneva:
World Health Organization; 2022. License: CC BY-NC-SA 3.0 IGO.
5. Chekroud SR, Gueorguieva R, Zheutlin AB, et al. 2018. Association between physical exercise
and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional
study. Lancet Psychiatry 5:739–46

Chapter
6. Guszkowska 1 ćwiczeń fizycznych na poziom leku i depresji oraz stany nastroju [Effects
M. Wpływ
of exercise on anxiety, depression, and mood]. Psychiatr Pol. 2004 Jul-Aug;38(4):611-20. Polish.
The Skeletal System
PMID: 15518309
7. McDowell CP, Dishman RK, Gordon BR, Herring MP. 2019. Physical activity and anxiety: a
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systematic MS of prospective cohort studies. Am. J. Prev. Med 57:545–56
review and meta-analysis
[PubMed] [Google Scholar]
8. Schuch FB, Vancampfort D, Firth J, et al. 2018. Physical activity and incident depression: a meta-
analysis of prospective cohort studies. Am. J. Psychiatry 175:631–48
9. Alexandratos K, Barnett F, Thomas Y (2012) The impact of exercise on the mental health and
quality of life of people with severe mental illness: a critical review. British Journal of Occupational
Therapy, 75(2), 48-60. https://doi.org/10.4276/030802212X13286281650956
10. Fischer S, Cleare AJ. Cortisol as a predictor of psychological therapy response in anxiety disorders-
Systematic review and meta-analysis. J Anxiety Disord. 2017 Apr;47:60-68. https://doi.org/10.1016/j.
janxdis.2017.02.007. Epub 2017 Feb 24. PMID: 28273494.
11. Ng JS, Chin KY. Potential mechanisms linking psychological stress to bone health. Int J Med
Sci. 2021 Jan 1;18(3):604-614. https://doi.org/10.7150/ijms.50680. PMID: 33437195; PMCID:
PMC7797546.
12. Zhang X, Zhang Y, Yun J, Yao W. A systematic review of the anxiety-alleviation benefits of
exposure to the natural environment. Rev Environ Health. 2022 Mar 24. https://doi.org/10.1515/
reveh-2021-0157. PMID: 35334194.
13. Sharma A, Madaan V, Petty FD. Exercise for mental health. Prim Care Companion J Clin
Psychiatry. 2006;8(2):106. doi: 10.4088/pcc.v08n0208a. PMID: 16862239; PMCID: PMC1470658.
14. Fogg,BJ. (2020). Tiny Habits: The Small Changes That Change Everything. Boston, Houghton
Mifflin Harcourt,
15. Koelsch S, Fuermetz J, Sack U, Bauer K, Hohenadel M, Wiegel M, Kaisers UX, Heinke W. Effects
of Music Listening on Cortisol Levels and Propofol Consumption during Spinal Anesthesia. Front
Psychol. 2011 Apr 5;2:58. https://doi.org/10.3389/fpsyg.2011.00058. PMID: 21716581; PMCID:
PMC3110826.
Trainer Academy
16. Haghighatdoost
©2023 F, Feizi A, Esmaillzadeh A, Rashidi-Pourfard N, Keshteli AH, Roohafza H,
Adibi P. Drinking plain water is associated with decreased risk of depression and anxiety in adults:
Results from a large cross-sectional study. World J Psychiatry. 2018 Sep 20;8(3):88-96. https://doi.
org/10.5498/wjp.v8.i3.88. PMID: 30254979; PMCID: PMC6147771.
17. Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx BW, Zitman FG. Overweight,
obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen
Psychiatry. 2010; 67:220–229. [PubMed] Lawrence E. Armstrong, Matthew S.

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18. Ganio, Douglas 1 Elaine C. Lee, Brendon P. McDermott, Jennifer F. Klau, Liliana Jimenez,
J. Casa,
Laurent Le Bellego, Emmanuel Chevillotte, Harris R. Lieberman, Mild Dehydration Affects Mood
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in Healthy Young Women, The Journal of Nutrition, Volume 142, Issue 2, February 2012, Pages
382–388, https://doi.org/10.3945/jn.111.142000
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19. Ganio,M., MS D., McDermott, B., Lee, E., Yamamoto, L., . . . Lieberman,
Armstrong, L., Casa,
H. (2011). Mild dehydration impairs cognitive performance and mood of men. British Journal of
Nutrition, 106(10), 1535-1543. https://doi.org/10.1017/S0007114511002005
20. Blackwelder A, Hoskins M, Huber L. Effect of Inadequate Sleep on Frequent Mental Distress. Prev
Chronic Dis 2021;18:200573. DOI: http://dx.doi.org/10.5888/pcd18.200573
21. Jiang J, Li Y, Mao Z, Wang F, Huo W, Liu R, Zhang H, Tian Z, Liu X, Zhang X, Tu R, Qian X,
Liu X, Luo Z, Bie R, Wang C. Abnormal night sleep duration and poor sleep quality are independently
and combinedly associated with elevated depressive symptoms in Chinese rural adults: Henan Rural
Cohort. Sleep Med. 2020 Jun;70:71-78. https://doi.org/10.1016/j.sleep.2019.10.022. Epub 2019 Dec
16. PMID: 32229420.
22. Chunnan L, Shaomei S, Wannian L. The association between sleep and depressive symptoms in
US adults: data from the NHANES (2007-2014). Epidemiol Psychiatr Sci. 2022 Sep 8;31:e63. https://
doi.org/10.1017/S2045796022000452. PMID: 36073029.
23. MyPlate. www.ChooseMyPlate.gov. Accessed 13 June 2022
24. U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon
General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on
Smoking and Health, 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.
pdf [PDF – 9.8 MB]
25. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html
26. Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of
empirical studies. Clin Psychol Rev. 2011;31(6):1041-1056. https://doi.org/10.1016/j.cpr.2011.04.006
Trainer Academy
©2023

Chapter 1
TheCHAPTER
Skeletal29System
Anna D’Annunzio,
Legal MS
and Professional
Guidelines for Personal
Trainers
Michael Caceci, MS
633 LEGAL AND P ROF E SSI O N AL
GUIDE LINE S FOR P E RSONAL T RAI N ER S
Chapter 1
Introduction
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Fitness professionals and personal trainers must follow a number of legal and professional
Anna when
guidelines D’Annunzio, MS
training clients in any capacity. This includes knowing the scope of practice,
obtaining proper certifications, following proper standards of care, obtaining necessary paperwork
from clients, and ensuring a clean and safe facility.
Healthcare professionals include most individuals credentialed through licenses, certifications,

and registrations in a field relevant to human health. Each of these professionals provides services
which identify, prevent, and treat injuries and diseases.
When an individual needs treatment, they visit with their primary care physician. When that
physician encounters a situation outside of their scope of practice, they refer their patient to
another healthcare professional who can provide specific services (such as a registered dietician
to provide nutritional information or an orthopedist to treat a bone-related issue).
While other professionals may provide general guidelines for physical activity, it is the certified
personal trainer (CPT) that develops exercise programs for healthy individuals to help improve
and maintain their fitness goals. Certified personal trainers are often the bridge between the
medical community and those who exercise. Physicians are often called on to recommend physical
activity to their patients, but only 30% of patients report hearing this advice from their doctor.4
All personal trainers should stay within the scope of practice equivalent to their training and
experience, following the recommendations of other healthcare professionals. When a client is
referred by a physician, it is necessary to get permission from the client to communicate with
their doctor in order to keep the doctor abreast on how the client is doing and to see what
recommendations the doctor may have.
Physician’s orders take precedence over the fitness professional, since they will have a more
complete understanding
Trainer Academy
©2023 of the client’s health and medical history. The trainer must remain
cognizant of their own role in order to avoid any legal problems and provide the right types
of services for which they are qualified. This will also help develop relationships with the other
medical professionals who are linked to this client as well and create good cohesion, and the trust
to refer more clients to the trainer.

Chapter 1
The
The Trainer
Skeletal Academy CPT Scope of
System
Practice
The Trainer Academy CPT scope of practice encompasses working with apparently healthy
individuals or people with health conditions who have been cleared to exercise by an appropriate
healthcare professional.
Scope of Practice for Trainer Academy Certified Personal Trainers:
• Training apparently healthy individuals to improve aerobic and muscular fitness

• Training individuals with medical conditions who are cleared by physician for exercise
• Training 1-on-1 or in small groups
• Coaching clients on developing realistic fitness goals
• Designing appropriate fitness training programs for specific goals
• Instructing safe exercise technique
• Supervising exercise equipment use
• Conducting preparticipation health screenings
• Conducting physiological measurements (heart rate, blood pressure, weight)
• Assessing cardiovascular fitness
• Assessing muscle strength and endurance
• Assessing flexibility
• Providing basic general nutrition information
The Trainer Academy CPT scope of practice prohibits:
• Diagnosing or treating any illness or injury

• Prescribing medications or supplements
• Making specific meal plans or dietary recommendations
• Monitoring medical conditions
• Rehabilitating or providing counseling for any conditions
Trainer Academy
©2023
Liability Guidelines for Personal Trainers

The trainer should understand areas of liability associated with the delivery of their service and
how to minimize these risks by following standards and guidelines established by professional
organizations.

Chapter 1
Along with a comprehension of how to develop safe and effective exercise programs, personal
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trainers must obtain liability waivers from all clients prior to bringing them into the equipment area.
Anna D’Annunzio,
Proper MS
Certification
Although there is no one governing body over exercise and no specific qualifications as far as
education or certification, the primary purpose of each certification is to protect the public from
harm. Becoming certified is the first step prospective trainers must take to minimize the risk for
the client and liability for themselves.
With a certification from a National Commission for Certifying Agencies (NCCA) accredited
organization, fitness professionals prove that they have met minimal competencies and that they
possess the knowledge, skills, and abilities to develop safe and effective exercise programs.
Certification and adherence to industry recognized standards will serve to maintain professionalism,
reduce liability, and give guidance to the client as far as the trainer’s credentials.
Numerous professional organizations recommend hiring trainers who have an NCCA accredited
certification. Certifications will require that trainers achieve continuing education units to maintain
certification.
The Trainer Academy CPT is among the NCCA accredited certifications and has thus gone
through the rigorous process to ensure the information and guidelines provided match the best
practices in the industry.
The Trainer Academy CPT has a continuing education requirement of 20 credit hours every 2
years from a wide range of continuing education providers.
Standard of Care
Trainer Academy
©2023
Personal trainers must act as any reasonable and prudent professional would with the same level
of training. If a lawsuit is brought against them, another professional may testify as to what
they would have done in the same situation. Also, the position statements of prominent exercise
organizations may be consulted to see if they conformed to these standards.

Chapter 1
Confidentiality and Record Keeping
The Skeletal System
Since CPTs collect various health forms, personal information, records of training sessions, and
Annamade
payments D’Annunzio, MSconfidentiality will have to be protected. And in case of any
or due, the client’s
litigation, trainers may need to reproduce documentation to prove that they performed appropriately.
Facilities and Equipment

Facilities that trainers may work in include commercial fitness centers, private studios, outside
locations, or in a client’s home. Regardless of location, trainers have a responsibility to make sure
that they took all reasonable precautions to eliminate any hazards. If training in a gym, CPTs
should make sure the floor is clean and equipment is put in its proper location. They should check
local laws when training outdoors and inform clients of any potential risks.
Ensuring that clients are wearing appropriate clothing and footwear for the workout is another
area of concern that the CPT should be aware of. All precautions that are undertaken should be
documented and kept up to date in case they need to be produced.
Trainers use various apparatuses during workouts. It is important to use equipment from reputable
manufacturers. CPTs should inspect equipment to make sure it is not damaged, it is clean, and
it is safe to use.
Procedures should be in place to document that the equipment receives inspections, maintenance,
and repairs. CPTs must make sure they are knowledgeable about the intended use of the equipment
so that they will use it effectively and appropriately. Using equipment for unintended use will
open the trainer up to liability.
Personal trainers should make sure that the client has been familiarized with the apparatus and
has the physical aptitude to safely use a piece of equipment. They should make sure to have the
appropriate pieces of equipment for the number of people they will be training so nobody is
fighting over itTrainer
and know how to substitute one piece of equipment for another in case something
Academy
©2023
is not available when they go to train a client.
Emergency Response
In the event of an emergency, certified personal trainers should follow the facility procedures.
Since Trainer Academy Certified Personal Trainers are required to maintain a valid CPR/AED
certification, trainers should always respond as trained individuals in those certifications when
responding to potential cardiovascular risks.

637 LEGAL
AND P ROF E SSI636
Legal and Professional Guidelines for Personal Trainers O N AL
Chapter 1
The Skeletal System

Trainer Academy
©2023
Trainer Academy
©2023

Chapter 1
Risk
The Management
Skeletal System
Proper risk management involves having policies and procedures in place as well as following
Annastandards
industry D’Annunzio, MSto show that CPTs took all possible precautions to ensure
and guidelines
safety, minimize risk, and are prepared to handle any foreseeable emergencies.
Risk management plans should be multi-tiered. Written documentation showing that the facility
and equipment is being surveilled for damage, maintenance, and repair should be kept on file,
informed consent and waivers for all participants should be signed and up to date, and liability
insurance should be procured by the CPT. The CPT should uphold all copyright laws as well.1, 3
Liability insurance will help to protect trainers from claims due to such things as accidents or
negligence. When acquiring insurance, the CPT should make sure to check that the insurance
provides proper coverage for the services they will be delivering and the settings that they will
be working in and the amount appropriate to the level of risk.
Though CPTs will take every precaution to minimize any liability, accidents happen. Carrying
liability insurance along with the practice of other risk management strategies are the best ways
for personal trainers to protect themselves and their assets from possible litigation.
Summary
In conclusion, the CPT has many professional responsibilities. They need to understand their
place alongside other healthcare professionals and how their services interact with them.
The CPT must adhere to their scope of practice and refer to the appropriate professionals when
client’s present with conditions that fall outside the Trainer Academy Scope of Practice.
Trainer Academy
©2023
The CPT must also respond appropriately to emergencies, keep detailed records of all client
waivers and incidents, and take steps to protect themselves against potential liability.

Chapter 1
References
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1. IDEA Health and Fitness Association. IDEA Opinion Statement: Benefits of a working relationship
Anna
between D’Annunzio, MSpractitioners and personal fitness trainers. IDEA Personal Trainer.
medical and allied health
2001; 13 (6): 26-31.
2. US Bureau of Labor Statistics. Occupational Outlook Handbook, Fitness Trainers, and

Instructors. Fitness Trainers and Instructors : Occupational Outlook Handbook: : U.S. Bureau of
Labor Statistics (bls.gov). Accessed 1 July. 2022.
3. Archer-Eichenberger S. Reward Carries Risk: A Liability Update. Idea Personal Trainer. 2004; 15
(4): 30-4.
4. Pojednic R, Bantham A, Arnstein F, Kennedy MA, Phillips E. Bridging the gap between clinicians
and fitness professionals: a challenge to implementing exercise as medicine. BMJ Open Sport Exerc
Med. 2018 Oct 16;4(1):e000369. doi: 10.1136/bmjsem-2018-000369. PMID: 30364472; PMCID:
PMC6196940. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196940/
Trainer Academy
©2023

Chapter 1
TheCHAPTER
Skeletal30System
Anna D’Annunzio,
Client Safety,MSInjuries, and
Emergency Situations
Michael Caceci, MS
641 CLIE NT SAF E T Y, INJURIE S, AN D
E ME RGE NCY SIT UATI O N S
Chapter 1
Introduction
The Skeletal System
Keeping clients safe from injury and fitness professionals free from legal issues is paramount
Anna
when D’Annunzio,
training a client in any MS
scenario. Fitness professionals must respond appropriately to
emergency situations, understand the various injuries relevant to personal training, and maintain
a safe training environment.
CPR/AED Importance
All fitness professionals must maintain an up-to-date adult CPR/AED certification, and ideally,
first aid and infant CPR as well. Often, training facilities require all staff to have these certifications,
and may provide certification classes. These certifications cover the steps to take in the event of
a cardiac emergency or other first aid emergency situations.
Dealing with a cardiac emergency, such as a cardiac arrest where the heart stops, or a deadly
arrhythmia such as ventricular fibrillation (VF), requires immediate action. Response time can
mean the difference between life or death. The time between calling 911 to activate the EMS
and the arrival of medical personnel may be longer than the victim will survive.
All training facilities should have an Automated External Defibrillator (AED) available, which
drastically improves the effectiveness of CPR.
Emergency Safety
Before responding to any emergency, particularly when bodily fluids are involved, responders
should wear personal protective equipment (PPE), which includes medical gloves, mask or face
shield, eye protection, and if performing CPR, a CPR facemask. PPE is vital to protect the
responding individual
Trainer Academy
©2023 from various communicable diseases including hepatitis and HIV.
CPTs must wear gloves whenever there is a need to touch anyone to deliver emergency care.
They should have a face shield with a one-way valve to protect themselves when giving rescue
breaths during Cardiopulmonary Resuscitation (CPR). Following the standards of Universal
Precautions and treating all bodily fluids as a biological hazard is imperative. This will
protect CPTs from blood borne pathogens like Human Immunodeficiency Virus (HIV) and
Hepatitis.

Chapter 1
When responding to an emergency, fitness professionals should always call 911 or activate the
The Skeletal System

facility’s emergency procedures, then provide appropriate care within the scope of their training.
The fitness professional should not attempt to give care beyond the scope of any certifications they
have. Since fitness professionals must be CPR certified, responding to cardiac emergencies and
Anna
related D’Annunzio,
conditions is within theMS
Trainer Academy Certified Personal Trainer Scope of Practice.
Acute Injuries
Personal trainers may encounter clients with injuries to various tissues of the body like muscle,
tendons, ligaments, cartilage, and bones. These injuries may be pre-existing, but can also occur
during the exercise session, particularly if the client misses a key form checkpoint or fails a heavy lift.
Pre-existing injuries and risk factors are screened via the health history and PAR-Q forms and
discussed between the trainer and client prior to beginning any exercise.
Clients with a history of soft tissue injury should undergo rehabilitation under the supervision of
a physical therapist prior to working with a fitness professional. However, many clients will have
low grade, nagging injuries that may or may not be rehabilitated. In this case, any movement that
causes pain should be avoided, and corrective exercises should be used to address any obvious
muscular imbalances.
Diagnosing or treating any injury is outside the Trainer Academy Certified Personal Trainer
Scope of Practice, but being able to identify and respond appropriately to common injuries such
as strains, sprains, and fractures is an important skill.
The appropriate response to injuries should be to contact emergency medical personnel, begin
the PRICE treatment, and refer the client to the appropriate healthcare professional once the
acute situation has been addressed.
The PRICE Treatment

Trainer Academy
©2023
The PRICE treatment is an acute process for addressing tissue injuries and consists of the
following:1
• Protection
• Rest
• Ice
• Compression
• Elevation

Chapter 1
Protection involves preventing further injury by removing the stress to the injured area. Rest
The Skeletal System

or restricted activity, especially weight bearing involves inactivity to the injured area, but not
necessarily complete bed rest. Client Safety, Injuries, and Emergency Situations 642
IceAnna
be applied 10-20 minutes MS every hour for 24-72 hours. Ice will reduce pain and
inflammation.IceTrainers
should be should
applied 10-20
not minutes everydirectly
apply ice hour for 24-72
to thehours.
skinIcesurface;
will reduce pain aand
have cloth or some
inflammation. Trainers should not apply ice directly to the skin surface; have a cloth or some
type of barrier between
type of the icetheand
barrier between ice skin. Compression
and skin. Compression isisachieved
achieved by putting
by putting a compression
a compression wrap wrap
that coversthat
above
coversand below
above the the
and below injured
injuredarea. Elevation
area. Elevation is accomplished
is accomplished by raisingbytheraising
injured the injured
body part 6-12” above the heart. This helps to reduce inflammation.
body part 6-12” above the heart. This helps to reduce inflammation.
Trainer Academy
©2023
Trainer Academy
©2023

Chapter 1
Regardless of the type of musculoskeletal injury the tissues will go through 3 stages of healing.
The Skeletal System

The stages are2:
• Inflammation
• Anna
Repair D’Annunzio, MS
• Remodeling
During inflammation, which may last for up to six days depending on the severity of the injury,
the goal is to immobilize the area to prevent further injury and to prepare the tissue for healing
during the subsequent phases. Rest, ice, compression, and elevation are recommended at this stage.
The repair phase begins approximately three days after the injury and may last for up to twenty-
one days. During this stage damaged tissues are healed and replaced, and scar tissue is formed.
New connective tissue is laid down.
Collagen, which is the component of the new connective tissues and strongest when parallel
to the line of stress, is laid down in a transverse alignment, which does not allow for optimal
strength of the new tissue.
The goals during this stage are to prevent muscle atrophy, joint degeneration, promote collagen
resynthesis, and prevent damage to newly formed collagen fibers. During this stage low load
stresses may be used cautiously to prevent loss of joint motion and to promote collagen synthesis.
The phase of remodeling begins around day twenty-one and may last up to two years. The goal
during this phase is to strengthen the newly formed tissue by helping the collagen fibers to align
in parallel. Increased loading may be used to help the newly formed collagen fibers to strengthen
and line up parallel to the line of stress. During this phase clients may continue exercises performed
during the repair phase and activity specific exercise may be added.
The rehabilitation process above is generally beyond the scope of personal training and should
be overseen by a©2023
licensed physical therapist.
Trainer Academy

Chapter 1
Common
The Skeletal Injuries
System and Issues
Tendonitis/Bursitis/Fasciitis
Tendonitis, bursitis, and fasciitis are inflammatory conditions that typically result from repeated
microtrauma caused by overuse.
Tendonitis is an inflammation of tendons, which connect muscle to bone.4,6 Bursitis is an

inflammation of bursa which are fluid filled sacs that act like ball bearings in joints.3,4 Fasciitis
is the inflammation of a band of connective tissue.4,5
These injuries often occur from repeated microtrauma or overuse. The repetitive stress causes
inflammation of the respective tissues. Insufficient warm up, overtraining, and previous injury
can be underlying causes.
General symptoms of these three conditions include localized pain, pain with activity, and
weakness. Proper response and treatment consist of conservative management which includes rest,
avoidance of contraindicated activities, ice, heat, physical therapy, anti-inflammatory medication,
and cortisone injections. Ice should be used initially before heat.
If any of these inflammatory conditions is suspected, the fitness professional should refer the
client to the appropriate professional.
When the injury is stabilized, heat may be used before activity and ice may be used after activity.
If there is severe pain, loss of function, or the injury doesn’t respond to conservative treatments in
2-4 weeks, a doctor referral is recommended. Program modifications to restore strength, muscle
balance, and flexibility along with a proper warm and myofascial release techniques of the area
are recommended.
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Muscle Strain
Muscle strains (or pulled muscles) occur when there is an overstretching or tearing of the muscle.
Strains may be the result of an acute macro traumatic event or microtrauma resulting from
repetitive overtraining. In either case, the result is pain, inflammation, and possible loss of function.7

Chapter 1
The symptoms and grievousness are dependent on the grade of the strain.
The Skeletal
• Grade 1 strains are System
mild with tears occurring to only a few fibers with the muscle being
painful and tender.
• Anna
Grade 2D’Annunzio, MStear with a greater number of fibers being affected. This results
strains are a moderate
in pain, point tenderness, inflammation, bruising, mild swelling, and noticeable loss of function.
• Grade 3 strains are complete tears of the muscle that result in loss of function, extreme pain,
point tenderness and inflammation along with bruising.
Initial response for strains involves the PRICE acronym. A physician’s referral may be warranted
depending on the grade of the strain.
Risk factors for strain in the fitness context include improper warm up, muscle fatigue, muscle
imbalance, poor flexibility, bad posture, and fluid and electrolyte depletion. Painful activities will
have to be avoided and exercise programs will need to be modified to promote strengthening,
muscle balance, and flexibility to the strained muscle.
Since muscles, tendons, and ligaments respond to the stress or lack thereof put on them, long
periods of immobilization are detrimental to healing and can lead to atrophy. Full recovery time
for muscle strain depends on the grievousness of the strain, the muscle injured, and length of
immobilization. Common areas for muscle strains are the shoulder, hamstring, knee, hip, and calf.
Suspected strains should be assessed by a qualified medical professional prior to resuming training
with the injured area.
Ligament Sprains
Ligaments connect bone to bone and provide stability for joints. A sprain is an overstretching
or tearing of a ligament. This may result in a complete displacement (known as a luxation) or a
partial displacement
©2023 (a subluxation). The amount of tearing that occurs will determine the grade
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of the sprain.8
• Grade 1 sprains are minimal tears that result in minor swelling, pain, and loss of function.
• Grade 2 sprains result in the complete tearing of some but not all fibers resulting in moderate
pain, swelling, and loss of function.
• Grade 3 sprains are complete tears and rupture of the ligament resulting in severe pain,
swelling, and loss of function.

Chapter 1
Sprains are serious injuries that require qualified medical care and warrant stopping activity until
The Skeletal System

examined by a surgeon.
Return to activity will be dependent on the grade and location of the sprain. Exercise programs
Anna
be modified to continue MS
progressing what was done in physical therapy. Sprains commonly
occur in the shoulder, knee, and ankle.
Cartilage Damage
Cartilage provides shock absorption, lubrication, improves congruence, and increases the stability
of joints. The primary cartilage structures of concern to fitness professionals are the medial and
lateral menisci of the knee which may become worn from degeneration or damaged by a traumatic
event. Symptoms include medial and lateral instability of the knee, pain, stiffness, and complaints
of hearing a clicking sound with weight bearing activity.9
Chondromalacia a wearing away of the cartilage behind the patella is another source of complaints.
It is the result of improper tracking of the patella on the femoral groove. Pain occurs behind the
patella and walking up and down stairs exacerbates the symptoms.
Cartilage injuries should be assessed by a qualified medical professional prior to resuming training
with the injured area.
Bone Fracture
A partial or complete disruption of bone tissue is known as a fracture. A fracture is classified as
simple (closed) or compound (open). A simple fracture is one where there is no break in the skin
while a compound fracture will result in breakage of the skin. Different types of fractures include
longitudinal, oblique, transverse, and compression.
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Concussions
Concussions are a serious head injury resulting from blows to the head. Loss of consciousness may
occur, and the first signs are confusion and disorientation. Other symptoms include amnesia, headache,
drowsiness, impaired speech, tinnitus, double vision, and sensitivity to light or noise. After a concussion
the person is in a vulnerable state and a second injury could be disabling. A client suspected of having
a concussion should receive immediate medical attention and cease physical activity immediately.11

Chapter 1
Myocardial Infarction
The Skeletal System
Fitness professionals must be very familiar with the signs of myocardial infarction (heart attack)
andAnna
stroke. D’Annunzio, MS
Angina pectoris is pain in the chest described as a crushing and squeezing feeling that is sometimes
mistaken for indigestion. The pain can radiate to the neck, jaw, shoulder, or stomach as well
as down the arms, especially the left arm since the heart is on that side of the chest. Clients
experiencing angina pectoris may be having a heart attack and should be carefully monitored
and receive qualified medical attention. This is particularly true if the client has risk factors for
cardiovascular disease.12
Other symptoms of heart attack include vomiting, nausea, and cold sweats. Dyspnea or labored
breathing that results in shortness of breath is possible as well. The symptoms may occur without
chest pain. Screening clients ahead of time to ensure at-risk clients are carefully monitored is
vital for ensuring client safety.12
Acute Stroke
Stroke is a leading cause of disability. Most strokes are ischemic and result from blockage of a
blood vessel that supplies the brain. The other type of stroke is hemorrhagic and results from
the rupturing of a blood vessel that supplies the brain. This may result from aneurysms, which
are weak spots in the artery that form a balloon like bubble.13
Warning signs to look for include if the person is off-balanced when they walk, if they have
slurred speech, droopy face, weakness, or numbness on one side of the body, partial or total vision
loss, and severe headache.13
Symptoms will also be dependent on which side of the brain is affected. If the right side is
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affected the right side of the face and left side of the body will be affected. Weakness, numbness,
vision, and memory loss may occur. When the left side of the brain is affected, the left side of
the face and right side of the body will be affected. Weakness, paralysis, and speech and language
impairments may be visible signs of stroke.13
An individual suffering a stroke requires immediate medical attention from qualified professionals.

649 CLIE
Client Safety, Injuries, and Emergency NT SAF E T Y,
Situations INJURIE S,
648AN D
Chapter 1
The Skeletal System

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Chapter 1
Gym
The Maintenance
Skeletal System and Hygiene
Client care and customer service are an integral part of personal training services. Fitness
Anna D’Annunzio,
professionals MS to ensure cleanliness and safety. Facilities and equipment
must take all measures
should be clean, maintained and properly functioning. While fitness professionals may not be
tasked with equipment maintenance, any observed malfunction, issue, or defect in equipment
should be promptly reported and the equipment should not be used.
Trainers should make sure to wipe down equipment including mats after use. Hand sanitizer or
wipes should be available to prevent the spread of any infections.
As a precaution it would be wise for coaches to wipe equipment before use too. Gym hygiene is
everyone’s responsibility, but personal hygiene is up to the individual trainer. The first impression
a client gets of their fitness trainer may be based on appearance and demeanor.
A good trainer needs a professional standard and appearance. One way to do that is by being
professionally dressed and groomed. Wiping down and cleaning equipment prevents the spread
of disease, shows that they care and respect the people and place they work at.
Summary
Fitness professionals must be prepared to respond appropriately to a variety of potential emergency
situations that may occur in the personal training environment. Emergency medical personnel
should always be called in the event of a life threatening emergency.
Since Trainer Academy Certified Trainers are required to be CPR certified, they may respond
to cardiac emergencies per their training.
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©2023

Chapter 1
References
The Skeletal System
1. Norton C. How to use PRICE treatment for soft tissue injuries. Nurs Stand. 2016;30(52):48-
52. https://doi.org/10.7748/ns.2016.e10506
2. Essentials of Strength Training and Conditioning. Tissue healing. National Strength and Conditioning
Association(NSCA). https://www.nsca.com/education/articles/kinetic-select/tissue-healing/.
Published December 22, 2021. Accessed November 2, 2022.
3. Williams CH, Jamal Z, Sternard BT. Bursitis. [Updated 2022 Jul 24]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.
gov/books/NBK513340/
4. Huang HH, Qureshi AA, Biundo JJ Jr. Sports and other soft tissue injuries, tendinitis, bursitis,
and occupation-related syndromes. Curr Opin Rheumatol. 2000;12(2):150-154. https://doi.
org/10.1097/00002281-200003000-00009
5. Buchanan BK, Kushner D. Plantar Fasciitis. [Updated 2022 May 30]. In: StatPearls [Internet].
gov/books/NBK431073/
6. Bass E. Tendinopathy: why the difference between tendinitis and tendinosis matters. Int J Ther
Massage Bodywork. 2012;5(1):14-17. https://doi.org/10.3822/ijtmb.v5i1.153
7. Noonan TJ, Garrett WE Jr. Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg.
1999;7(4):262-269. https://doi.org/10.5435/00124635-199907000-00006
8. Yang G, Rothrauff BB, Tuan RS. Tendon and ligament regeneration and repair: clinical relevance
and developmental paradigm. Birth Defects Res C Embryo Today. 2013;99(3):203-222. https://doi.
org/10.1002/bdrc.21041
9. Bhan K. Meniscal Tears: Current Understanding, Diagnosis, and Management. Cureus.

2020;12(6):e8590. Published 2020 Jun 13. https://doi.org/10.7759/cureus.8590
10. Sop JL, Sop A. Open Fracture Management. [Updated 2022 Aug 8]. In: StatPearls [Internet].
gov/books/NBK448083
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11. Tator CH. Concussions and their consequences: current diagnosis, management and prevention.
CMAJ. 2013;185(11):975-979. https://doi.org/10.1503/cmaj.120039
12. Mechanic OJ, Gavin M, Grossman SA. Acute Myocardial Infarction. [Updated 2022 Aug 8]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK459269/
13. Tadi P, Lui F. Acute Stroke. [Updated 2022 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535369/

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The Skeletal System

The Nervous System 25

The Muscular System 38

The Cardiorespiratory System 50

The Endocrine System 67

Biomechanics and Kinesiology 90

Communication Skills for Fitness Professionals 110

Applied Elements of Behavioral Coaching 125

Health History and Anthropometric Assessments 146

Cardiorespiratory Fitness Assessments 188

Principles of Aerobic Training Programs 207

Principles of Flexibility Training Techniques 224

Adaptations to Resistance Training 251

Resistance Training Protocols and Systems 267

Trainer Academy © 2023

Principles of Speed, Agility, and Quickness Training 372

Principles of Balance Training 398

Corrective Exercise 425

Special Populations Considerations 468

Basic Nutritional Concepts 516

Macronutrients and Hydration 537

Exercise, Mental Health, and Lifestyle Considerations  616

Legal and Professional Guidelines for Personal Trainers 632

Client Safety, Injuries, and Emergency Situations 640

Trainer Academy © 2023

number of bones drops down to two hundred and six.1

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The periosteum is a membrane

Examples of long bones:

• Phalanges in the fingers

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The Skeletal System

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Chapter 1 The Skeletal System 10

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• Scapulae in the shoulders

Bone Markings Trainer Academy

There are three main kinds of bone markings:

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The Skeletal System

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Bone Tissue Creation

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The Skeletal System

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The Skeletal System

The subtypes of synovial joints are:

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The Skeletal System

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Bone and Joint Disease

exercise to rebuild some of the lost bone.1

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The Skeletal System

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The nervous system offers three main functions:

The Nervous System 25

The Muscular System 38

The Cardiorespiratory System 50

The Endocrine System 67

Biomechanics and Kinesiology 90

Communication Skills for Fitness Professionals 110

Applied Elements of Behavioral Coaching 125

Health History and Anthropometric Assessments 146

Cardiorespiratory Fitness Assessments 188

Principles of Aerobic Training Programs 207

Principles of Flexibility Training Techniques 224

Adaptations to Resistance Training 251

Resistance Training Protocols and Systems 267

Principles of Speed, Agility, and Quickness Training 372

Principles of Balance Training 398

Corrective Exercise 425

Special Populations Considerations 468

Basic Nutritional Concepts 516

Macronutrients and Hydration 537

Exercise, Mental Health, and Lifestyle Considerations 616

Legal and Professional Guidelines for Personal Trainers 632

Client Safety, Injuries, and Emergency Situations 640