Physical Training

Healthcare professionals may be called upon from time to time to advise people who wish to undertake physical training. The advice will vary according to the current state of fitness of the individual and what he or she is trying to achieve. It might be a young person who wishes to run a marathon, a person who is overweight and severely unfit or possibly an older person who has heart or lung disease. Neither age nor illness is a bar to activity although both may produce certain caveats. Exercise does not have to be vigorous and it may include activities such as walking or dancing. The advice should also take account of the ability and motivation of the person.

There are 4 questions to be asked at the outset.

• Where are you now? This means answers to:
  What is the current level of fitness?
  • What is the current weight and BMI?
  • When was he or she last exercising regularly and fit?
• Where do you want to be? That is:
  • What is the individual trying to achieve? It may be running a marathon. It may be weight loss. It may be looking and feeling better. It may be reduction of risk factors for disease.
• How do you plan to get there? For example:
  • Perhaps the individual has joined a gym or plans to do so.
  • Perhaps the plan is training at home or going out jogging.
  • Perhaps the individual plans to pursue a particular sport or join a sports club.
• Why do you want to do this?
  • This gives insight into the motivation.
  • The question must not be misinterpreted as, "Why on earth do you want to do that?"

There are many reasons why an individual may wish to take up physical training. For example:

• To achieve an ambition such as running a marathon
• To take up a sport and join a team with the social benefits attached
• To reach entry standards for certain careers such as the armed forces, police or fire service
• To lose weight
• To feel better
• To look better (This may help the person feel better and to be more self confident and happier)
• To reduce risks factors for disease (particularly when there is a family history)

Benefits of exercise

Physical exercise is beneficial for health in a number of ways:^1,2

• It improves cardiovascular and respiratory reserve
• It is helpful in controlling weight
• It tends to reduce blood pressure and may reduce the risk of hypertension
• It has a beneficial effect on HDL and LDL cholesterol and cardiovascular risk
• It reduces the risk of type 2 diabetes
• It benefits mental health with relief of stress and aggression³
• Weight bearing exercise reduces the risk of osteoporosis
• People who indulge in serious physical activity are less likely to smoke and moderate exercise can reduce the craving to smoke⁴
• Exercise improves balance and in the elderly reduces the risk of falls and fractures
• It may reduce dementia

There is some evidence that those who are active in old age suffer less from dementia.⁵ However it should be remembered that those who are dementing are less able to partake in physical activity.
Enquiry about the motivation for taking up exercise permits other factors to be discussed. For example taking up swimming to reduce the risk of osteoporosis is misguided as swimming is not a weight bearing exercise. Other risk factors such as family history, smoking and alcohol consumption should be discussed.

Training for sport involves a number of aspects:

• Stamina or endurance training. The nature of this will depend upon the sport. The requirements of a 400 metres runner are different from those of the test cricketer.
• Speed training is essential in all sport as rapid movement of some type is usually required.
• Strength may be upper or lower body and the nature will depend upon the sport.
• Flexibility is required in all sports although more obviously in some. It reduces the risk of strains and facilitates movement.
• Sport-specific skills are many and varied. These include for example ball skills or techniques in martial arts.

Pre-existing medical conditions are rarely a total bar to exercise but they may impose limitations. It is a good idea for other people (gym or swimming pool staff, team members, coaches) to know of any medical problems.

Asthma

• Asthma is a very common problem and affects children as well as adults.
• Good control should be achieved.
• As mentioned in the article on Drugs and Sport, beta agonists are banned substances but are permitted if a doctor will certify that they are taken by inhaler for asthma. This is only relevant for those who compete at relatively high levels and may be subject to drug testing.
• If asthma continues to be a problem, the introduction of a steroid inhaler or a cromoglycate inhaler may be beneficial. This includes exercise induced asthma.
• Asthma may also influence the choice of sport. It tends to be more troublesome in sports that involve running. It is less troublesome in cycling and least troublesome in swimming.

A more limited programme for COPD can also increase exercise tolerance.

Angina pectoris and intermittent claudication

• Pain should be seen as a warning sign and should not be ignored.
• Exercise may be beneficial and enable the person to extend the time before the pain of angina or claudication demands cessation.
• Exercise should be unhurried and attempts to increase the distance should not be too ambitious.
• GTN may be used before exercise.
• Beta blockers may extend the duration of exercise in angina although for most people wishing to exercise, they are an impediment because they slow the heart rate response to exercise.

Other heart disease

• Exercise training is often used in rehabilitation programmes after myocardial infarction.
• Strenuous exercise should be avoided in aortic stenosis and hypertrophic obstructive cardiomyopathy (HOCM) as it can cause sudden death.
• Hypertension is only a contraindication to exercise if it is severe and uncontrolled. Once reasonably controlled, exercise is beneficial.

Diabetes

Exercise metabolises glucose and increases tissue sensitivity to insulin. This is usually only a problem with vigorous exercise and especially in those who take insulin. When vigorous exercise is anticipated, the diabetic should reduce his dose of insulin before it and should eat some carbohydrate about 20 minutes before exercise.⁶ He should also have some "fast glucose" available in case he develops symptomatic hypoglycaemia. It is also important to remember that alcohol depresses blood glucose and so after the exercise, whilst the rest of the team are rehydrating with a pint of beer or two, he may prefer a pint of shandy and a packet of crisps.

Arthritis

As a general rule, arthritis benefits from exercise although goals should be realistic. The notable exception is an acute inflammatory arthritis that needs rest.

Depression

There is some evidence that mild depression in young people may benefit from an exercise programme⁷ but the evidence is not very strong.

When joining a gym, there will usually be an induction with a suitably qualified person who will show the new recruit how to use the equipment safely. They may work out a training programme together. Someone who does not have such help needs to work out their own plan. As well as the advantages of exercising safely and 'out of the elements' gyms can provide a wide range of equipment. These can be used to build both strength and stamina. Variety should mitigate against overuse injury but if it occurs alternative exercise routines can be used until the injury resolves.

Often men are quite keen to build upper body strength whilst women concentrate on cardio-respiratory fitness. Both men and women should do both but adapted to the individual.

Frequency of training

It is said that if a person trains once a week, the benefit accrued from that session has worn off by the following week and the status quo is maintained. Excessive training is also a problem. Vigorous aerobic sessions on consecutive days will not permit the muscles to replenish the glycogen. Under-training leads to under-achievement but over-training can cause injury and be counterproductive. For the enthusiastic, variety is essential. A person may go jogging one day, swimming the next and weight training the following day. Weight training on consecutive days is also not recommended.

Equipment is important but for the beginner a great outlay is not usually required. In the beginning the most important item is often footwear.
Trainers should give adequate support and have good cushioning. They should be the correct size as shoes that are too large or too small will rub. Feet swell a little on exercise and so they may need to be slightly large when tried on cold. A pair of sports socks gives extra protection and absorbs sweat.

Be comfortable whilst training. For some sports, protective equipment is important.

For some people, loss of weight will be the prime objective of physical training. For others it will be a secondary but important gain. Indeed trying to lose weight without exercise is extremely difficult. Exercise is more than burning extra calories during training. Nevertheless, diet must not be forgotten and alcohol is also a potent source of "empty" calories.

Insulin is strongly antilipolytic whilst catecholamines facilitate lipolysis.⁸ This means that it is a potent force in preventing the breakdown of fat. Exercise suppresses insulin secretion and so facilitates the metabolism of fat. As a general rule, it is said that it takes 20 to 30 minutes of exercise before "fat burning" starts. This is only a rough guide. It may be sooner or later depending upon the intensity of the exercise and whether it is taken after a meal or before breakfast. This may seem like the final knell for the type 2 diabetic who is overweight and has high basal insulin levels. However, the redeeming feature is that not only do they have high resting levels of insulin but lipolysis will occur in them at higher levels of insulin.⁹ Hence type 2 diabetics can successfully exercise and burn fat.

The rate at which fat is metabolised is dependent upon the rate of exercise. Exercise is often measured by the percent of maximal heart rate that is achieved as this is much easier to measure than percent of VO₂ max (the maximum amount of oxygen in millilitres, one can use in one minute per kilogram of body weight). If a person exercises at a rate of about 80% of maximum heart rate, most of the energy is provided by carbohydrate whilst only a minority is derived from fat. This can be calculated by the ratio of oxygen consumed to carbon dioxide produced provided that the subject is not exercising at an anaerobic level. At 60% of maximal heart rate, the ratio is reversed and most energy comes from fat rather than carbohydrate. If maximum heart rate in beats per minute is 220 - age in years, calculation will show that 80% of maximum is not exceptionally onerous whilst 60% of maximum is a very leisurely pace.

These calculations show that the slower rate of exercise burns a larger fraction of fat but the total amount of energy consumed at such a leisurely pace may be low. Suppose that a person may spend 1 hour in the gym, during which he expends 800 calories and leaves exhausted. Alternatively he may slow down and spend 2 hours during which he expends 1200 calories. Not only is the total number of calories higher for the longer session, although at a lower rate per hour, but the amount of fat metabolised will be much higher. Some people discount the concept of "the fat burning zone". More intense exercise may burn a lower percentage of fat but a higher total amount of fat. There are other variables such as an enhanced ability to metabolise fat with physical training.¹⁰

When people go on a diet alone they often lose weight quite fast at first and then it slows and they become disheartened. With exercise this early loss may be less or weight may even rise as fat is replaced by muscle and with it stronger and heavier bones. Vigorous exercise is followed by about 36 hours of a higher basal metabolic rate that is not seen after lower levels of exercise. The basal metabolism of muscle is rather higher than the fat that it replaces. Even if the scales do not reinforce the message, the person should look and feel better.

There are many reasons for doing weight training.

• Individuals may choose to use light weights to keep their muscles looking trim and toned.
• Men especially may do weight training to enhance muscle mass for the sake of appearance.
• Strength training is important for very many sports.
• Building muscle groups may be important to prevent injury or as rehabilitation to prevent recurrence. Muscle building is important after injury to knees, shoulders and backs.
• Strength training as part of general physical fitness helps to stem the reduction in basal metabolic rate with advancing years and enhances the metabolism of fat.

There are certain rules or guidelines for weight training:

• Always do some warm up on the cardiovascular equipment before moving on to weights. Some would advocate stretching too.
• An exercise programme for one set of muscles (agonists) should be accompanied by a programme for the opposing set of muscles (antagonists), eg biceps and triceps, quadriceps and hamstrings.
• Do not try to lift excessive weights or injury will result and set back training.
• As a general rule, using heavy weights that can be lifted just once before needing to rest is a less effective method of training than having less iron on the bar but doing more repetitions. This may not be true for power-lifting but it applies for most weight training. Repetitions should start at 8 to 10, working up to 12 before starting with a little more weight next time.
• Weight training sessions should not take place on consecutive days. Muscle building session should be at least 48 hours apart although it is possible to do upper body work on one day and lower body work the following day.

Fitness training may also be called stamina or endurance training. It comes in various forms and needs are varied. To run 400 metres requires the ability to drive on through anaerobic exercise whilst blood lactate levels are very high. The 10,000 metres and longer races are essentially aerobic although a fast finish may possibly bring a final anaerobic flourish. It is a different ability to run at a slower pace but for substantially longer. Field sports such as football, rugby and hockey involve sprinting interspersed with a slower pace at irregular intervals over a long period of time. It requires the ability to go anaerobic but with a rapid recovery.

All this may be simulated in the gym or outdoors. Runners need both speed and stamina and so a 400 metres runner may train over 300 metres for speed and 500 metres for stamina. Even a 100 metres runner may train over 80 and 120 metres. Field sport athletes who need rapid recovery may train with sprint, jog, sprint, jog around the edge of the pitch. In the 1970s there was a vogue for very high milage training and distance runners may have trained by running 50 to 80 miles a week. This is no longer recommended. It leads to exhaustion and overuse injury.

The person who just wants to "get fit" may start with some distance training, then insert some brief anaerobic training and finally aim for rapid recovery training. However, many people will be content to function at a much lower level.

Diet is an important component of training. If weight loss is an aim consumption, especially in the evening should be reduced. In extreme exercise taking in adequate calories can be a problem. Competitors in the Tour de France may be using 9,000 calories a day and taking in that level of energy can be problematic.

People who aim to build a great deal of muscle eat a considerable amount of protein to do so. Protein is essential to build muscle and even animal protein will not build muscle on a 1:1 basis for weight consumed and muscle built. However, there is a tendency to eat vastly more protein than can be used to build muscle and even lean meat is quite high in fat. The tradition of eating steak that is very rare or even raw has no logic. People who eat a lot of fat and do little aerobic exercise (and even perhaps in some cases take anabolic steroids) put their health at serious risk.

Just a few decades ago steak and chips would be served at Twickenham to international rugby teams about to compete. Such a high fat diet before exercise is ill-advised. Fat delays gastric emptying. Nowadays most teams and athletes have pasta before exercise. Marathon runners like to "pack pasta" including pizza the night before an event. If a top level football team is competing with a kick-off at 3pm, they will have a largely carbohydrate lunch at about 11.30 and plates will be cleared away at midday.

A more scientific approach towards diet is one of the many reasons for improved standards in modern sport.

Hydration

Nutrition includes adequate hydration. Even a fairly moderate level of dehydration has a significant effect on performance and this is an aspect that is much better appreciated nowadays. However, for many people the intake of fluid during rather moderate exercise is excessive and it has become an affectation rather than a physiological need.